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Abstract

Critically-oriented health research often engages participants whose lives are shaped by structural inequities and structural violence. As scholars who engage in critical theoretical, praxis-oriented research, including research with social justice and decolonizing aims, we are cognizant of the histories of exploitation and structural violence often perpetuated through research. To engage in research that effectively promotes health equity, we are increasingly aware of the necessity of critical research approaches that include processes for engaging in data collection that are respectful, affirming, and minimize harm, and that illuminuate unequal relations of power, challenge the status quo, and contribute to social change. The aim of this paper is to explore participant observation as a method of data collection in critical ethnographic health research with people impacted by structural violence and inequity. Our premise is that it is not possible to conduct research that exposes structural violence, marginalization and social injustices without also critically examining our research processes. To illustrate, we weave together our experiences of conducting critical ethnographic work in diverse contexts to examine the complexities of conducting participant observation with people impacted by structural violence, surfacing the tensions between the potential for harm in research, and strategies for promoting equity. Specifically, we present our collective analysis of how observational practices can reproduce stigma, exacerbate harms associated with methodological and academic colonialism, thereby contributing to epistemic violence, and how participant observation can be deployed in ways that prevent and mitigate such harms. Despite the inherent challenges and complexities, we see immense value in critical ethnographic research that includes participant observation, and we join others in advocating for trauma-, violence-, and justice-informed approaches to critical ethnographic research.

Keywords

critical ethnography participant observation health research health equity social justice structural violence epistemic violence

Prologue

We begin by acknowledging our positionality as authors and scholars. We engage in scholarship as able-bodied cisgender women (all), white settlers of European ancestry (TH, HB, KIS, AJB) and of Indigenous and English immigrant ancestry (CV), as registered nurses (all), as academics and researchers (all), and as speakers of English, the dominant language in our culture. We recognize that our positionalities grant us unearned social and economic privilege. Although we write as critical scholars who bring extensive experience working with structurally marginalized populations through clinical nursing practice, research, policy, advocacy, and health systems work, we do not claim to speak for anyone but from our own experiences. We strive to engage in ongoing critical reflexivity, examining our power and privilege, and our complicity in perpetuating structural violence, while challenging others similarly positioned to do the same. We endeavour to be allies to people experiencing social exclusion and structural violence, but take the position that allyship is continually negotiated, and that it is up to those we are attempting to support to determine if we have been allies in any given moment.

Introduction

Critically-oriented health research often engages participants whose lives are shaped by structural inequities and structural violence. First articulated by Galtung, structural violence refers to the effects of social arrangements that prevent people from meeting their basic human needs (Farmer et al., 2006; Galtung, 1969). Farmer et al. (2006) articulate that such social arrangements are “structural because they are embedded in the political and economic organization of our social world; they are violent because they cause injury to people (typically not those responsible for perpetuating such inequalities)” (p. e449). Galtung asserts that structural violence “shows up as unequal power and consequently unequal life chances”, where resources are not evenly distributed, and “above all, the power to decide over the distribution of resources is unevenly distributed” (Galtung, 1969, p. 171, emphasis in original). The effects of structural violence are evident in the intersecting impacts of poverty, homelessness, racism, trauma, discrimination, and stigma frequently associated with mental health challenges and substance use, cognitive impairments, disability, and criminal legal system involvement. Conducting research in the context of structural inequity also invariably involves engaging with people responsible for enacting policies and practices that sustain these inequities, including health and social care providers, police officers, child protection workers, and prison staff. As scholars engaged in critical theoretical, praxis-oriented research, including research with social justice and decolonizing aims, we are cognizant of the histories of exploitation and structural violence often perpetuated through research. We acknowledge how academic research has contributed to harm when engaging with people with lived experience of structural violence. To engage in equity promoting health research, we argue for the necessity of critical research approaches that include processes for engaging in data collection that are respectful, affirming, and minimize harm, while illuminuating unequal relations of power, challenging the status quo, and contributing to social change.

Imbued with political purpose, ethnography informed by critical theoretical perspectives (referred to hereafter as critical ethography) aims to investigate health and social inequities and injustices with the aim of stimulating social change, advancing equity and fostering justice (Madison, 2005; Thomas, 1993). Health researchers using critical ethnographic approaches share the goal of disrupting the status quo, interrogating taken-for-granted assumptions, and surfacing and redressing power relations and systems of oppression (Baumbusch, 2011; Madison, 2005; Reimer Kirkham & Anderson, 2002; Tang et al., 2015). In the process, critical ethnography aims to explicate the actual, though often invisible, social processes and practices that shape people’s experiences, mediated by social, economic, political and historical forces (Reimer Kirkham & Anderson, 2002). Critical ethnographic researchers conduct intensive fieldwork to analyze the social conditions and their potential for change within a particular area of interest (Madison, 2005). The primary method employed during fieldwork is participant observation (PO), used to bring to light the often-hidden influences of power and ‘culture’ (Allen et al., 2008).

The aim of this paper is to explore participant observation as a method of data collection in critical ethnographic health research with people impacted by structural violence and inequity. Our premise is that we cannot aim to conduct research that exposes structural violence and advances equity without also critically examining our research processes. Weaving together our experiences of conducting critical ethnographic work in diverse contexts, we examine the complexities of conducting participant observation, surfacing tensions between the potential for harm in research with people impacted by structural violence, and strategies for promoting equity. Specifically, we present our collective analysis of how observational practices can contribute to epistemic violence, and how participant observation can be deployed in ways that prevent and mitigate such harms. We draw on our experiences of conducting fieldwork with people experiencing structural violence and inequities in the context of oncology care (Horrill et al., 2023), palliative and end-of-life care (Giesbrecht et al., 2023; Stajduhar et al., 2019), primary health care (Browne et al., 2011b, 2016; Browne et al., 2011a), care in the emergency department (ED) (Tang et al., 2015; Varcoe et al., 2019, 2022a, 2022b), maternity care for rural Indigenous women (Brown et al., 2011; Varcoe et al., 2013) and the health and wellbeing of people who are currently or were formerly incarcerated (Brown & Timler, 2019; Varcoe et al., 2020). We begin with an overview of participant observation in critical ethnography, followed by a brief exploration of the concepts of epistemic violence and equity-oriented healthcare to guide our analysis.

Participant Observation in Critical Ethnography

As the hallmark of critical ethnography, participant observation is a method of data collection characterized by the researcher’s participation in the lives and/or events under study through actively watching, listening, asking questions, and recording observations. In health research, participant observation can occur, for example, by observing interactions between patients and providers in healthcare/clinical settings; in spaces and places where health care encounters can profoundly influence peoples’ health and well being (e.g., in waiting rooms); or in meetings rooms where health care providers meet to discuss plans of care. In the context of critical ethnography, where the goal of inquiry is to understand the influence of power, context, and culture, participant observation can be employed to gain insights that deepen understanding and provide nuance to participants’ experiences beyond what may be evident through individual interviews (Browne et al., 2011b, 2012, 2016; Funk & Stajduhar, 2009; Tang et al., 2015).

In our work, observing people as they access care in diverse settings, the interactions occurring in those clinical encounters, and the wider context in which those encounters are happening, has been instrumental in establishing an evidence base and theoretical understanding of the ways structural inequities and violence manifest to shape experiences of care and the contextual dynamics that sustain such inequities. This has involved attuning to points of conflict, communication strategies, power relations and how they shape interactions; observing healthcare providers ‘behind the scenes’, including the general organizational culture, division of labor; and the physical and clinical spaces of care. In non-clinical settings such as communities, participant observation means engaging with people where their everyday lives are lived to learn about the conditions that sustain inequities, local priorities and community-led solutions (Varcoe et al., 2011).

Epistemic Violence & Participant Observation

Aware that knowledge and processes of knowledge production (i.e., research) are neither neutral nor benign (Potts & Brown, 2015), we draw on the concept of epistemic violence throughout our analysis to illustrate the potential for participant observation to cause harm. First conceptualized by Spivak (1988) as “the remotely orchestrated, far-flung, and heterogeneous project to constitute the colonial subject as Other” (p. 280), epistemic violence can be understood as violence through knowledge or knowledge production. Epistemic violence is a key tool in systems of privilege and oppression (e.g., colonialism, racism, sexim), with its strength lying in its imperceptibility (Perez, 2019). Because it tends to be diffuse, not limited to a particular action or singular point in time, nor easily attributable to a specific agent, epistemic violence is often less obvious than other forms of violence (Perez, 2019). Norman (1999) draws attention to this imperceptibility: “of course, the phenomenon in question would not ordinarily be thought of as violence: it is too respectable, too academic, too genteel for that. It is violence all the same, and deserves to be seen for what it is” (p. 353). The concept of epistemic violence is helpful in understanding the silencing of groups pushed to the margins by structural violence. Examples of epistemic violence and subsequent silencing include: the production of ‘altnerative’ historical narratives, the de-valuing of knowledge that is outside of Euro-centric Western norms, the objectification of ‘marginalized’ groups as ‘other’, and the construction of certain groups as ‘unreliable’ sources of information or knowledge (Dotson, 2011; Perez, 2019). Academic settings, with their emphasis on knowledge production through research and entrenched knowledge hierarchies (Ahenakew, 2016) are particularly prone to perpetuating epistemic violence (Perez, 2019).

An Equity-Oriented Healthcare Framework

Despite potential challenges of conducting participant observation with people impacted by structural violence, when done carefully and thoughtfully, such research can lead to positive change, challenge stigmatizing policies and practices, and provide nuanced perspectives that convey the complexity of health and social issues while creating much needed evidence (Boilevin et al., 2018). As nursing scholars, our programs of research are focused on improving health equity and healthcare accessibility through a framework of equity-oriented healthcare. Browne et al. conceptualize equity-oriented healthcare as an organizational approach to healthcare service design and delivery that takes into account: the impacts of structural inequities, including the inequitable distribution of the determinants of health (such as poverty, lack of affordable housing); the impact of multiple and intersecting forms of racism, discrimination and stigma on people’s access to services and their experiences of care (including stigma related to mental illness, substance use, or non-conforming gender identities); and the frequent mismatches between the usual approaches to care and the needs of people considered structurally vulnerable (2018, p. 2). Our framework for equity-oriented healthcare is based on three key dimensions, which include trauma- and violence-informed care, culturally-safe/anti-racist approaches to care, and harm reduction philosophies, with specific attention to mitigating substance use stigma (Browne et al., 2018; Browne & Varcoe, 2023).

Briefly, trauma- and violence-informed care aims to recognize and limit the effects of trauma and violence (including both structural and interpersonal violence) on peoples’ health and healthcare experiences, emphasizing the provision of care that demonstrates respect and fosters safety, without requiring the disclosure of trauma (Browne et al., 2016; Ponic et al., 2016; Wathen & Varcoe, 2023). Trauma- and violence-informed care within the critical ethnographic research context can also extend to include disrupting epistemic violence created and sustained through practices of constructing the ‘other’ and subverting and erasing diverse knowledges that play a critical role in transforming the hegemonic logics of research. Foregrounded in social justice aims, culturally safe and anti-racist approaches focus on understanding the impacts of racism, discrimination, and colonialism on health and healthcare experiences, and on reducing power imbalances between patients and healthcare providers while establishing trusting relationships (Browne et al., 2016, 2018). From a cultural safety perspective and in the context of critical ethnographic research, we are prompted to develop nuanced analyses of the intersections between micro-level experiences operating at the level of clinical practice (as one example), and the wider social and historical contexts that shape health care relations and access to services. Finally, harm reduction approaches focus on preventing harms from substance use and intersecting forms of stigma (Jiao, 2019; Pauly, 2008). Harm reduction philosophies emphasizes the dignity of each individual, while aiming to accept people as they are, avoid judgment, and demonstrate compassion (Browne et al., 2018; Browne & Varcoe, 2023). In the discussion that follows, we consider the application of these key dimensions of equity-oriented healthcare to participant observation in critical ethnographic health research with people impacted by structural violence (summarized in Table 1).

Table 1.

Summary of Analytical Themes.

Analytical Theme	Potential for Harm/Epistemic Violence Through Participant Observation	Equity-Oriented Strategies for Participant Observation
Negotiating Power, Positionality, Representation and Voice	• Potential for harm exists as researchers’ constructions of what is ‘seen’ in participant observation is invariably shaped by ideologies, social constructions, and dominant discourses about structurally vulnerable people. Research participants become ‘objects’ of our ‘gaze’.	• Cultivate and continuously engage in critical reflexivity (as a lifelong process) … goal of understanding how one’s positioning as a researcher is impacting all research processes.
Negotiating Power, Positionality, Representation and Voice		• Include people with lived experience of structural violence (“peers” as members of the research team with the aim of centering subjugated voices, experiences, and knowledges.
Developing Trust, Demonstrating Respect & Reciprocity	• Participant observation may perpetuate stigma, trigger trauma, or undermine communities participating in the research.	• Use language carefully and thoughtfully to demonstrate respect, acceptance and non-judgment. For example, using person-first language in field notes (‘person who is unhoused or living in unstable housing’ instead of ‘homeless’).
	• Researchers’ theoretical and/or interpretive lenses may attune them to ‘read’ inequities (racism or other forms of discrimination, for example) when participants’ themselves do not share that interpretation.	• Position participants as knowledge holders and experts in their own experience.
		• Meaningfully engage with people that work closely with participants.
The Imperative of Context	• Epistemic violence may be perpetuated when observational practices reproduce assumptions about who people experiencing structural violence ‘are’.	• Observations should be carefully and thoughtfully contextualized, drawing attention to the interrelations among and between people, their contexts, the power dynamics and structural drivers at play.
	• Descriptions of events, interactions and experiences without sufficient contextualization carries the potential to perpetuate racism, discrimination and stigma.	• Constant and careful attention to participants’ verbal and nonverbal communication for signs of distress or discomfort is necessary. Supports should be readily available for participants who experience distress.
	• Adding participant observation into healthcare encounters that already carry potential for trauma responses may be harmful.	• Remain flexible – pausing participant observation or adopting an entirely different data collection strategy.
Minimizing Harms in Participant Recruitment	• People experiencing structural violence are already subject to greater scrutiny and participant observation may be experienced as voyeuristic. The more profound the inequities experienced, the higher the likelihood of real or perceived harm through research.	• Invite (‘recruit’) anyone who comes to a health service agency for care rather than targeting people who you may presumed to be ‘marginalized’ or disadvantaged in some way because of their appearance or other characteristic. This also has the advantage of including people who experience less obvious forms of disadvantage.
Minimizing Harms in Participant Recruitment		• Carefully explain why participant observation is being used.

Negotiating the Complexities of Participant Observation in Research With People Experiencing Structural Violence: Toward an Equity-Oriented Approach

Conducting ethnographic fieldwork with those experiencing structural violence and inequities presents specific methodological and ethical complexities (Shaw et al., 2020; Winfield, 2021). Academic debate continues about importance of careful attention to the potential risks and the ethics of using ethnographic methods in research with people or communities impacted by structural violence, as formal research guidelines often do not address these complexities (Bashir, 2018; Pacheco-Vega & Parizeau, 2018). Given the potential of fieldwork to be exploitative or cause harm (Moore & Miller, 1999; Pacheco-Vega & Parizeau, 2018), we present our reflections on conducting participant observation with people experiencing structural violence wherein the potential for harm and epistemic violence (as violence through knowledge and knowledge production) exists. We discuss how to mitigate these harms by prioritizing safety and ensuring research participants feel respected and affirmed, with the goal of avoiding further harm and reducing the perpetuation of stigma and epistemic violence.

Negotiating Power, Positionality, Representation and Voice

As critically-oriented ethnographic researchers, we aim to amplify the often silenced voices of people impacted by structural violence by interrogating the power dynamics at the root of this silencing. Although historically, researchers have questioned whether such participants should be included in research (Moore & Miller, 1999) and in participant observation specifically, the very question of inclusion reflects diverse views that are variously shaped by claims about the critical value of lived experience and subjective knowledge, and paternalistic claims about ‘subject protection’. In many cases, research participants have a strong desire to share their knowledge and experiences, and know their voice matters in stimulating change, requiring researchers to give careful consideration to representation and voice.

As researchers, we occupy positions of power relative to research participants, and this is magnified in the context of research with people experiencing structural violence. While likely to be an uncomfortable process for researchers occupying positions of privilege, cultivating critical reflexivity to understand our positionality in relation to research participants is foundational to an equity-oriented approach. We ourselves, as authors and researchers, are continuously engaging in critical reflexivity, and see this as a lifelong process. Critical reflexivity can be understood as “the active and ongoing analysis of how positionality and ideology are shaping decisions, relationships, and interpretations, rather than a static, formulaic declaration of who we are or what we believe” (Strega & Brown, 2015, p. 9). This reflexive work should facilitate an understanding of how researcher social positioning affects how all study processes are enacted, from conducting fieldwork to how power and privilege shape research decisions and interpretations (Baumbusch, 2011; Strega & Brown, 2015). Moreover, participant observation with people facing structural violence requires that researchers carefully consider how their constructions of what is ‘seen’ can be ideologically shaped through dominant discourses of who structurally vulnerable people ‘are’.

The concepts of epistemic violence and epistemic power (Hill Collins, 2019) highlight how research can be both exploitative and harmful when considering whose knowledge and what knowledge is prioritized in critical ethnographic studies and during participant observation fieldwork. For example, epistemic violence can occur during participant observation in prison settings that are ideologically shaped by carceral logics, where punishment and discipline create the context for people who are incarcerated to be known and identified based on their criminologic history. Participant observation in prison is shaped by the dominant narrative of who criminalized peoples “are”, leaving little room for seeing the wider context of structural violence, trauma, poverty and racism that are known correlates of crime. Conducting participant observation studies in carceral settings requires critically analyzing how punitive power casts a dehumanizing gaze that shapes any observational moment. For example, in Brown’s studies with incarcerated men in federal prison, participant observation requires resisting the hegemonic practices of reducing men to their criminologic history, to learn about their lives, their strengths, and their experiences of holistic wellness made possible through their creating and gifting of handmade items to Indigenous communities (Brown et al., 2017, 2022; Brown & Timler, 2019; Varcoe et al., 2020). Reducing the harms of critical ethnographic research in prison settings requires not reproducing the structural violence inherent in everyday carceral practices to open up spaces where the men can be seen as contributing to the wellbeing of others, their families and communities. This means the research aims to remake the ‘logics’ to make space for changing the story of ‘who’ criminalized individuals are and what they need for community re-integration post-release. Extending critical attention to representation and voice in critical ethnographic studies and participant observation means reducing the chance that epistemic violence will occur; in observational moments it means turning toward perspectives and subjectivities of people facing structural violence whose experiences of self may not be represented in current ideological research practices.

One approach to mitigating unequal power dynamics and attending to representation and voice that we frequently use in our projects is the inclusion of people with lived experience (“peers”) as members of the research team. The inclusion of peers as researchers will guide the very research questions asked and methodologies chosen, and shape how participants are engaged in participant observation as partners in the research process rather than as objects of our research ‘gaze’. For example, drawing on principles from literature on participatory action research, there are explicit commitments to relationships among researchers and participants that focus on shared knowledge and power; research participation is guided by principles of democratizing and participatory co-development of knowledge between researchers and people living the realities of structural violence. These practices in research aim to centre subjugated voices, experiences and knowledge.

Developing Trust, Demonstrating Respect & Reciprocity

Research has historically and currently perpetuated harm for structurally vulnerable people, who, as a result, rightly distrust researchers, the institutions we work for, and the normative research approaches we use. Conducted uncritically, research on people experiencing structural violence can perpetuate stigma, undermine initiatives within the communities under study, trigger trauma, devastate people and communities in the absence of reciprocity, exhaust valuable and limited resources, and misrepresent participants or groups (Boilevin et al., 2018). As we began to explore above, through our work to disrupt hierarchical relations of power and deconstruct dominant discourses of ‘who’ people facing structural violence ‘are’, and what is needed to foster health and social equity, we also aim to demonstrate respect and form a foundation for trust. Discourses can be understood as ways of thinking and speaking that provide a common – though often unseen and unspoken – set of assumptions that constitute reality in particular ways (Cheek, 2000). In part, through the use of language, discourses generate social structures and can either perpetuate the status quo or be instrumental in transforming it (Barker & Galasinski, 2001; Phillips & Jorgensen, 2002). Attention to our use of language is critical to demonstrating respect, conveying acceptance and minimizing harm, as language can easily and inadvertently reproduce stigma and stereotypes (Public Health Agency of Canada [PHAC], 2019). Language should be non-judgmental, avoid assumptions, and should not blame people for their health status or personal circumstances (PHAC, 2019). For example, using language that communicates non-judgment and respect can include asking participants about their preferred pronouns (e.g., they/them/theirs; she/her/hers), or using person-first language in observational fieldnotes (e.g., ‘person with substance use challenges’ or ‘person who uses substances’ rather than ‘substance user’ or ‘addict’) (PHAC, 2019). Participant observation offers the opportunity to use language to disrupt the status quo, position people with lived experience as experts, and model destigmatizing language. For example, a graduate student supervised by Varcoe, use alternate language (e.g., ‘people who are unhoused’) when staff in EDs used more labelling language (e.g., ‘the homeless’), and asked people with lived experience of substance use and homelessness for direction regarding what should be observed, leading to her observations of how stigma was passed on, nurse to nurse, chart to chart and “shift to shift” (Wright, 2020, p. 69).

We continually work to position research participants as knowledge holders and experts in their own experience. Returning again to the concept of epistemic violence, Dotson (2011) conceptualizes ‘testimonial smothering’ as one form of epistemic violence in which the ‘knower’ is unable to speak about their experiences or perspectives because it is unsafe, in the sense that speaking up carries the potential for harm (political, social or material). In the healthcare context, speaking up about racist or stigmatizing treatment risks being labelled as ‘causing trouble’, or ‘at risk of violence’; potential harms of such labels include the construction of those who speak up as ‘undeserving’ of healthcare, or the outright denial of services. Participant observation may offer a mechanism of ‘capturing’ such ‘testimony’ without requiring people to subject themselves to these potential harms, and may also offer an opportunity to intervene when harm is being perpetrated. For example, in Varcoe and Browne’s ED research, one observer intervened to explain to a security guard who was about to remove a patient who had difficulty speaking due to a neurological disorder that the patient was not intoxicated (as he had been presumed to be), and had been told to wait by the physician. Navigating such power dynamics requires researchers to become attuned to the ways people are being harmed, while not causing further harm by antagonizing those in positions of power or engaging in rescue fantasies.

One of the major challenges in critical ethnographic work, and participant observation in particular, occurs when a researcher’s theoretical and interpretive lens attunes them to ‘read’ inequities, for example, those based on racism or other forms of discrimination, where participants (e.g., patients) may not. This requires researchers to mediate between people’s understandings and experiences, and the need to illuminate and critique inequities, without becoming impositional, especially when such insights or analyses are not necessarily shared by research participants (Reimer Kirkham & Anderson, 2002). Similarly, when a participant interprets their experience as shaped by racism or discrimination, we do not minimize it as a ‘mistaken’ interpretation regardless of what observational data might indicate (Tang et al., 2015). Differences in the ways that reality is interpreted are not framed as contradictory; rather, they are held out as exemplars of how our social world, including healthcare, is organized, and how racism and other intersecting forms of power and oppression organize our experiences and interpretations. Thus, from a critical vantage point, participant observation is not about discerning the accuracy or ‘validity’ of peoples’ experiences; rather, it is an opportunity to further deepen understandings of the complexities and tensions that arise in clinical contexts, and (often) unequal power relations that organize experiences, and the interpretation of those experiences for people coming from differing social locations and positions.

Trust and respect can also be fostered through relationships with people surrounding those who experience structural violence. For example, most of Stajduhar’s palliative care research is community-based, with recruitment through housing, outreach, and harm reduction workers (vs. participants coming in to a community health clinic or ED, for example). This means that in doing participant observation ‘in community’, part of our strategy for developing trust includes engaging the people that support and work closely with people experiencing structural violence, gaining their trust and respect, while also paying attention to the fact that many of these workers also live on the poverty line, are low paid, and are likely to be racialized, for example, and as such, are experiencing structural violence themselves.

The Imperative of Context

Mitigating the potential for harm in critical ethnographic research means that data collected through participant observation must be thoughtfully contextualized, with researchers critically examining the lenses through which they are observing, collecting data, and the interpretations of those data (Pacheco-Vega & Parizeau, 2018). Researchers, therefore, have a responsibility to carefully attend to how participants who face structural violence are ‘represented’ in the data. Considering how epistemic violence eradicates perspectives and subjectivities, paying careful attention to how dominant discourses reproduce assumptions about who people facing structural violence ‘are’ can provide an opening to how participants can shape the way they are portrayed in research. We see critical ethnography as a relational approach to research. Not to be confused with relationships, a relational approach draws attention to the interelations among people, and between people and their contexts (Doane & Varcoe, 2021). As such, observations are aimed not only at individuals, including people impacted by structural violence, and those in positions of relative power to them, but also to the interactions among them, and the interactions between people and their contexts.

For example, throughout our research across diverse contexts we pay close attention to how contexts shape interactions among staff. In prisons, observations include attention to how prison guards interact with “program officers” who are responsible for rehabilitation programs, and how those interactions vary with different contextual conditions (such as during“lock down”). In one of our studies conducted in EDs, a 58-year-old woman who identified as First Nations described (and we observed) a persistent feeling of anxiousness when talking to people in positions of authority or power, such as health care providers (Browne et al., 2011b). She described coming to the ED frequently for a variety of chronic health and mental health concerns including anxiety, joint stiffness, chronic pain, asthma, and allergies. In the process of conducting participant observation, she recalled a recent experience at one of the EDs where she sought help:

I had one nurse who said, “You know how many times you’ve been here?” I said, “No.” She said, “Thirty-three times.” And I said, “Well, this is a hospital, right?” I didn’t really need to hear that because I was really having a lot of problems with myself and I didn’t understand it, because of being raised in the residential school. You know, you’re always told to shut up and we didn’t have any opinion about anything. So it was really hard for me to try to converse with doctors or anything. . . And then I said [to the nurse], “Well, I can’t help it.” I said, “I don’t know who to talk to about what’s going on with me. (Browne et al., 2011b, p. 342–343).

In this example, participant observation and discussions with the woman helped to illuminate how the context shaped these interactions, in which providers and patients became caught up in frustrating dynamics. Whereas this woman’s distress stemmed from her concern that she had been repeatedly dismissed, providers can also become frustrated when they fail to see the wider sociohistorical circumstances that give rise to some patients’ repeated visits.

The purpose of critical ethnographic research is to move toward greater equity, thus observation and analysis must go beyond description of peoples’ lived experiences of inequities. As the example above demonstrates, in the absence of analysis of context, participant observation could have the impact of perpetuating racism and stigma, even if unintended. Descriptions of events, interactions and experiences without adequate attention to context – for example, the ways in which racism is bound up with myriad dimensions of systemic inequities such as gender-based violence, lack of adequate housing, high levels of poverty, ongoing economic marginalization – have the potential to divert attention away from the strategies and actions needed at structural levels to counteract the harmful effects of racism (Browne, 2017).

The traumatic effects of structural violence (Quesada et al., 2011; Varcoe et al., 2013), repeated negative healthcare encounters (Browne et al., 2012; Stajduhar et al., 2019), and historically unethical ethnographic research with populations considered vulnerable (Jorgensen, 2020) means there is often significant and warranted distrust towards healthcare providers, institutions, researchers, and research staff among those who may be invited to participate in research. Furthermore, people living with trauma often experience feelings of unsafety and powerlessness that are continuous with structural violence and unequal power relations (Ford Gilboe et al., 2023). Entering into the health and social service systems, often the context of study for health researchers, and accessing services carries potential for additional trauma. For example, one of the hospitals in Varcoe and Browne’s research resembled the Residential Schools that many Indigenous people and their families had been forced to attend, and at which many suffered extensive abuse. In addition to physical examinations or procedures, the layouts of clinical spaces, simply entering into an institutionalized setting can trigger trauma responses (Elliott et al., 2005; Reeves, 2015). Thus, observers must seek to go beyond static description to examine the potential impact of contexts.

Adding participant observation into the healthcare encounter, including the presence of researchers who often hold positions of power relative to research participants, may heighten potential for re-traumatization and create conditions of powerlessness or a lack of control. Conversations with research participants during observations may evoke painful or traumatic memories despite ethical commitments to reduce harm and minimize risk, contributing to the potential for causing distress and additional trauma (Bashir, 2018; Boilevin et al., 2018). Although it may be assumed this is less likely in the context of participant observation, where conversations are informal and occur in response to observations, the types of questions being asked may inadvertently cause harm (Boilevin et al., 2018). For example, we have found that without careful framining, asking about ethnicity can be harmful when people anticipate racism.

A trauma- and violence-informed approach to participant observation requires researchers to continuously critically reflect on the potential harms to participants and possibilities for participant observation to trigger a trauma response or re-traumatization (Boilevin et al., 2018; Winfield, 2021). For example, in our cancer care project, we realized that participant observation of people experiencing structural violence while navigating a cancer diagnosis and treatment (itself a traumatic experience for many), held potential to decontextualize their experiences and chose to focus participant observation on healthcare providers instead (Horrill et al., 2023). Research procedures should be designed to minimize risk of re-traumatization and to provide care to people who may be triggered during observations (Boilevin et al., 2018). During participant observation, we are constantly and carefully observing and attending to participants’ verbal and nonverbal communication for signs of distress or discomfort, and have support readily available in the event that participants experience distress or a trauma-response. For example, in our research on grief among social care workers – some of whom experience inequities themselves – we have recognized how discussions of death and dying in the contexts of inequities have high potential to trigger trauma responses (Giesbrecht et al., 2023). Prioritizing supports in this instance sometimes means placing observational research to the side, focusing on supports required if needed, and ensuring processes of ongoing consent should participant observation continue in this context. Similarly, in our research in EDs, we trained research assistants to constantly observe for distress and pause or refrain from survey data collection as needed, using observation as a safety mechanism within survey research. Thus critical researchers require knowledge and skill in recognizing the impacts of trauma and violence and knowing how to respond in the context of a research relationship.

On the other hand, sometimes participant observation can have a beneficial effect on health care encounters. When we are engaged in participant observation and present with participants in healthcare encounters, we have seen a greater capacity for health care providers to engage respectfully, and hear and address the needs of participants as patients. For example, in Stajduhar’s research with structurally vulnerable people at the end-of-life, the presence of a researcher sometimes facilitated supportive communications between research participants and health care providers and often played a role in facilitating access to health care services that were previously limited (Stajduhar et al., 2019).

Minimizing Harm in Participant Recruitment

Closely related to the potential for trauma is the potential for observations to be experienced as voyeurism. An equity-oriented approach means careful attention to who is included and how they are recruited for observations. That is, people who are marginalized are already subject to greater scruitiny than those in the general population, and often have greater visibility and fewer protections from such scruitiny. For example, people without the protection of homes, people in prison, and those involved with child protection services are subject to intense and often punitive surveillance. The more profound the inequities experienced, the higher the likelihood of harm and perceived harm. Recruiting people based on identities (e.g., Indigenous, living in poverty, using substances) will automatically convey stigma.

One strategy to avoid stigmatizing is to recruit (meaning, extend invitations to participate in research) anyone who comes to a health service agency for care, as was done in a recent study conducted in several EDs, rather than target people who might be presumed to be ‘marginalized’ by virtue of their appearance or other characteristics (Varcoe et al., 2022a; 2022b). This had the advantage of including people who experienced less visible forms of disadvantage, such as invisible disabilities or poverty masked with carefully selected clothing. Secondly, careful explanation as to why we were observing (“we want to help improve how people are treated and would like your advice”) helped respectfully invite people to participate as experts, demonstrated our commitment to their safety, and laid a beginning for trust by conveying that we were not engaging them voyeuristicly, exploitively or judgementally.

Concluding Thoughts

In our respsective programs of research with people experiencing structural violence, we see immense value in critical ethnographic research that includes participant observation, despite the inherent challenges and complexities. Yet, in the absence of also continually critically examining our approaches to our research processes, and to participant observation specifically, we risk causing harm through reproducing stigma, perpetuating trauma, and contributing to epistemic violence. We join others in advocating for trauma-, violence-, and justice-informed approaches to participant observation in critical ethnographic research (Pacheco-Vega & Parizeau, 2018; Winfield, 2021). We do not offer a prescriptive approach; rather, we encourage researchers to engage in critical reflection and dialogue, and advocate for the inclusion of people with lived/living experience of structural violence and inequities to guide research decisions and processes, including participant observation. As scholars engaged in and committed to research with social justice and decolonizing aims, we are continually engaged in critical reflexive practices to better understand our own power, positionality, biases, and assumptions, and in learning from those with lived experience of structural and epistemic violence. In this paper, we have presented our reflections on how we have applied an equity-oriented healthcare framework to our critical ethnographic fieldwork, and what participant observation through the lenses of anti-racism, harm reduction, and trauma- and violence-informed care can offer. Potts and Brown (2015) argue that “knowledge is neighter neutral nor benign…knowledge can be oppressive in how it is constructed and utilized, or it can be a means of resistance and emancipation” (p. 19; emphasis added). Moving beyond participant observation that is equity-oriented, we wonder: how could critical ethnographic research contribute to epistemic resistance and projects of emancipation?

Footnotes

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.

ORCID iD

Tara C. Horrill

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Bringing an Equity Lens to Participant Observation in Critical Ethnographic Health Research

Abstract

Keywords

Prologue

Introduction

Participant Observation in Critical Ethnography

Epistemic Violence & Participant Observation

An Equity-Oriented Healthcare Framework

Negotiating the Complexities of Participant Observation in Research With People Experiencing Structural Violence: Toward an Equity-Oriented Approach

Negotiating Power, Positionality, Representation and Voice

Developing Trust, Demonstrating Respect & Reciprocity

The Imperative of Context

Minimizing Harm in Participant Recruitment

Concluding Thoughts

Footnotes

Declaration of Conflicting Interests

Funding

ORCID iD

References