Documents in Health Research_MPH presentation

Qualitative Data analysis

1. Documents in Health Research-Reading Based Presentation ( Lindsay Prior) Presentation By: Sandip Dhungana Roll no: 611 MPH 6 th Batch School of Public Health ( SoPH ) Patan Academy of Health Sciences (PAHS) 1

2. Content of the Presentation Introduction: The Role of Documents in Health Research Four Approaches to the Study of Documents in Health Research Conclusion 2

3. Introduction: The Role of Documents in Health Research Documents tend to enter and to leave the ‘field’ in relative silence in all areas of research. T heir role in empirical research is more often not linked to the use of ‘unobtrusive’ techniques. Unobtrusive techniques share the unique quality that they do not require the researcher to interact with the people he or she is studying. This is mainly because documents are most commonly viewed as containers and carriers of content – divorced and detached from the circumstances in which they are produced and in which they are used . 3

4. Introduction: The Role of Documents in Health Research D ocuments contain data, and the task of the social or health researcher is assumed to involve the extraction of data – as evidence – from the relevant container into which it has been placed. Documents always enter the field in at least two roles : The first is, indeed, as a container for content . The second, however, is as an active agent involved in the configuration of the very settings in which it is found . Written documents have potency as well as capacity than transient verbal communications. ‘A verbal contract isn’t worth the paper it is written on’. Attributed to Sam Goldwyn (film producer) 4

5. Four Approaches to the study of Documents in Health Research Focus of research approach Document as resource Document as topic Content (1) Approaches that focus almost entirely on what is ‘in’ the documents. (2) Archaeological approaches that focus on how document content comes into being. Use & Function (3) Approaches that focus on how documents are used as a resource by human actors for purposeful ends. (4) Approaches that focus on how documents function independently of their producers. Source: Prior, L. (2008) 5

6. Four Approaches to the study of Documents in Health Research A pproaches that fit into Cell 1 have been dominant in the history of sociology, in social science, and in health research generally. In this approach, documents (especially as text) are sourced and coded for what they contain in the way of descriptions, reports, images, representations, and accounts i.e., they are scoured for evidence. Data analysis strategies concentrate almost entirely on what is in the ‘text’ (via various forms of content analysis, thematic analysis, or even grounded theory). 6

7. Four Approaches to the study of Documents in Health Research This emphasis on content is carried over into the approaches described in Cell 2 with the key difference being a focus on how document content comes into being. The attention here is on the origin and social production of written reports , descriptions, statistical data and so forth. Many kinds of discourse analysis reflect such concerns, and so too does the work of ethnomethodologists in so far as they elaborate on how clinical, police, and other reports and records get constructed. 7

8. Four Approaches to the study of Documents in Health Research T he focus in Cell 3 is on how documents are used as a resource by different kinds of ‘readers’. Here, concern with document content or how a document has come into being are marginal. T he analysis concentrates on the relationship between specific documents and their use by identifiable human actors for purposeful ends – such as the use of clinical records in ward settings. 8

9. Four Approaches to the study of Documents in Health Research The approaches that fit into Cell 4 regard content as secondary . The focus here is on how documents, as ‘things’, function in schemes of social activity, and with how such things can drive, rather than be driven by, human activity. 9

10. 1. A focus on content: researching health policy Clinics, hospitals, health centres and their respective bureaucracies are filled with documentations. Forms, cards, reports, procedure manuals, patient charts and records , as well as policy statements are just a few examples of the documentation that can be drawn upon and used as data by a wide range of health researchers. For example: In the United Kingdom, governments and NGOs produce new policy documents in abundance. It was estimated that the UK government published some 228-health policy and guidance documents on its website during 2007 alone. 10

11. 1. A focus on content: researching health policy The content of such documents can often be dealt with in a relatively straightforward manner – beginning with a simple concordance (agreement) – executed via one of the freely available concordance programmes available online. Such a programme provides an identification and count of all of the words us ed in the document, and the resulting listings provide key insights into the concerns and points of emphasis of the document (as well as highlighting issues that are absent). It may also be possible to develop a semantic map from such data – by focusing on co-occurrence rather than the single occurrence of words. 11

12. 1. A focus on content: researching health policy Inevitably as any analysis moves from words to sentences, and on to paragraphs and sections , more sophisticated forms of data analysis need to be considered – these might include thematic analysis, analysis of rhetorical form, or they may be structured in terms of grounded theory. T he method to be adopted has to mesh with the aims of the research project. 12

13. 1. A focus on content: researching health policy Health policy documents can relate to vastly different areas of activity, but they often contain a similar storyline . Roughly speaking, this storyline argues that what has gone on until now is insufficient or not good enough; that the existing state of affairs is bolstered only by people with narrow and sectional interests at heart; that there is a consequent need to transform, modernize, change, and improve services; that the current government is going to achieve that by listening to; by empowering; by working in partnership with; and by enabling the voter – as a consumer, an individual, or whatever, to create things afres h. 13

14. 1 . A focus on content: researching health policy As an example, consider the following; it is drawn from a speech made in 1961 by the then British Minister of Health. It was a speech that served as a prelude to the closure of virtually every large psychiatric hospital (‘asylum’) in the United Kingdom between the 1960s and the 1990s . Despite the substantial time lapse between then and now, the speech contains some structural features worthy of study: 14

15. 1 . A focus on content: researching health policy Now look and see what are the implications of [my] bold words. They imply nothing less than the elimination of by far the greater part of this country’s mental hospitals as they exist today. This is a colossal undertaking, not so much in the new physical provision which it involves, as in the sheer inertia of mind and matter which it requires to be overcome. There they stand, isolated, majestic, imperious, brooded over by the gigantic water-tower and chimney combined, rising unmistakable and daunting out of the countryside – the asylums which our forefathers built with such immense solidity to express the notions of their day. Do not for a moment underestimate their powers of resistance to our assault. Let me describe some of the defences which we have to storm… (Enoch Powell, Minister of Health, speech 1961, heralding the closure of the psychiatric hospitals in the United Kingdom). 15

16. 1. A focus on content: researching health policy F rom the standpoint of a researcher, the documents, together with the political speeches to which they are related , and the actions of the politicians who make these speeches and presentations, add up to an analyzable narrative . In the words of Newman and Vidler: ‘[Health policy documents] are presented as part of a story that situates new initiatives, drives or targets into a history, and draws on images of societal change and/or institutional problems to legitimate their proposals. Such an approach views policies and the political speeches that surround their presentation as providing a linguistic repertoire on which managers, professionals, user groups and other stakeholders can draw’. 16

17. 1 . A focus on content: researching health policy The issue with these narratives is not, of course, to judge them as right or wrong – as in accord with the truth (or otherwise) of the historical events to which they invariably refer, or the principles to which they appeal – but to enquire about what is recruited into the policy story and what is being generated as a result of the storytelling. W e can view the speech not simply as fine words from a politician, but as a signal of what was to happen in the coming decades ; how what was to happen could be justified; and how opposition to any plans might be rhetorically countered. The example serves to highlight something rather important about policy narratives, namely that they are represented not just by words on a page, or sentiments expressed in a speech, but are tied into action. The task of the health (policy) researcher in that respect is not to be beguiled by content, but to examine content as a component of a wider network of action. 17

18. 2. A focus on document content: approaching content as ‘topic’ T he World Health Organization (WHO) publishes, on an annual basis, an array of mortality and morbidity statistics which provides data on both the numbers of people who die in any one country during a given year, along with the causes of death. One can take statistics from the online sources and scour them for facts about mortality, or health, or, if one wishes, transpose and integrate the data into a measure of the ‘quality of life’. Of course, to approach the statistics in that spirit would be to approach them as a resource, and whilst that is a perfectly legitimate thing to do in many frames of health research (especially quantitative styles of research), it is always useful to step back from such readily available facts and to ask some questions as to how the facts were generated . Statistics themselves must be treated as a topic. 18

19. 2. A focus on document content: approaching content as ‘topic’ 19

20. 2. A focus on document content: approaching content as ‘topic’ The ICD-10 contains rules about which causes of death should take precedence over other causes. So that when a person dies of many conditions, the people responsible for coding the data on which the health statistics depend, ‘know’ which cause to select as the underlying cause of death. Diseases of the heart, for example, commonly take precedence over diseases of any other organ , and cancers take precedence over infections and so on. These rules also change from decade to decade. Thus, during the early part of the twentieth century, diseases of the liver and lung took precedence over disease of the heart . In the context in which it is here considered, the ICD-10 is an excellent example of what we might call a ‘generative document’. 20

21. 2. A focus on document content: approaching content as ‘topic’ It is not simply a question of differentiating one physiological cause from another, but also of interpreting the social contexts in which the death has occurred (as might be indicated by the deceased’s biography). Treating documents (reports, case-notes, death certificates, etc.) as a topic reveals an entire universe of decision making that is often taken for granted. 21

22. 3. A focus on use and function: medical documents as resource Text, documentation, and images are commonly deployed in the exercise of medical expertise. For any given setting, if we were to ask, ‘where is the medical expertise?’ it is unlikely that we would point to document content as its sole repository. Rather, we would gesture towards the ways in which images, text, and tools were being used by an individual or a group in a clinical environment. In other words, it would be the ways in which human agents called up and manipulated things (including documents) rather than the things themselves that would constitute the focal point of the demonstration . 22

23. 3. A focus on use and function: medical documents as resource For example, in a study of a Norwegian thoracic clinic Måseide (2007) investigated how X-rays are used and drawn upon in everyday clinical discussions – commenting on how the presentation of X-ray images to members of a medical team can form the occasion for a joint and agreed interpretation of what can be ‘seen’, rather than an occasion for presenting the self-evident ‘facts’ of the case. In this sense, the medical images function not simply as containers of data and information, but as focal points for the routine work and display of expertise among medical professionals . 23

24. 3. A focus on use and function: medical documents as resource Similarly, Hak (1992) provides an illustration of how a psychiatrist routinely transforms items of patient talk and observed behaviour into a written record . He demonstrates how the psychiatrist – as note taker – highlights essential details of a patient’s conversation, translates the conversation into professional language (of delusions, hallucinations, or other diagnostic terms) and makes suggestions for future action (e.g., entry into a psychiatric unit). In short, Hak demonstrates how the psychiatric notes display the expertise of the psychiatrist and serve to confer identities and qualities to the patient that the hospital or medical service will draw upon to justify the ‘appropriate’ management of the patient’s case. 24

25. 4. A focus on use and function: documents as actors The idea of conceptualizing nonhuman agents as actors was first proposed by adherents of what is often referred to as actor–network theory or ANT. One key plank of the ANT argument is that the traditional distinction – indeed, the asymmetry – between material and human objects be overturned and it is argued that the traditional distinction between subject and object should be discarded. Therefore, when studying schemes of social interaction, material objects are not to be regarded as mere (passive) resources that are important only when activated by human actors, but are seen to play a part in social configurations in their own right i.e., material objects can be seen to instigate and direct as well as be directed. 25

26. 4. A focus on use and function: documents as actors An example in which documents enter into an episode of clinic-based interaction: The episode involves exchanges between a clinical geneticist (designated as CG), and some specialist genetic nurse–counsellors (designated as NC). The aim of their discussion is to assess the degree to which a client of the genetics service might be at risk of expressing an inherited proclivity to breast cancer. 26

27. 4. A focus on use and function: documents as actors 27

28. 4. A focus on use and function: documents as actors 28

29. 4. A focus on use and function: documents as actors H ow the session opens with (and is structured by) a statement of the relevant issues as conveyed in a letter from the patient’s primary care physician (lines 2 to 9). Such letters serve as triggers for consideration by the service, and ‘frame’ the relevant clinical problems. In addition to giving the client’s clinical and biographical details, the letters usually contain a justification as to why the patient has been referred to the service. In this case, it is suggested that the patient is ‘naturally concerned’ about her family history. 29

30. 4. A focus on use and function: documents as actors Between lines 11 and lines 18, the clinical geneticist is examining the patient’s genetic pedigree or family tree. The ‘black lines’ referred to indicate deaths from cancer, and the pedigree will normally be inscribed with the names, ages, and current states of health of people in the patient’s family over as many generations as is possible. Here, the pedigree is brought into the discussion via pointing and looking. It provides a field in terms of which the discussion can proceed. Note how it is recruited as evidence by both NC and CG for variable interpretations of ‘what is important’ (lines 14 and 15). 30

31. 4. A focus on use and function: documents as actors A crucial point is arrived at in line 19, and there is evident disappointment expressed in the talk contained in lines 19–22. The disappointment arises, because an expert computer-based decision-aid has generated a much lower risk assessment for the client than was expected. CG states, ‘I suspect that puts her into a high – oh! – 24.6 percent. (1.0) Mm’. The decision-aid is known as Cyrillic. Cyrillic draws a pedigree for any given family member and on the basis of quite complicated processes that involve data bases and statistical calculations produces a lifetime risk estimate of the onset of breast cancer. 31

32. 4. A focus on use and function: documents as actors Very roughly stated, a low risk would be below 12 percent, a moderate risk between 12 and 24 percent, and a high risk above 25 percent. The difference here is marginal, but sufficient to generate doubt (lines 19–22). Such doubts are overturned in lines 23–24, and in the subsequent discussion – beyond line 24 – a justification for ignoring the results of the decision-aid is provided. T here are various actors inscribed in this setting . These include not merely the human actors , but also the nonhuman referral letter i.e., the pedigree and the Cyrillic print out. How documents – especially in the form of decision-aids – can drive medical decision-making procedures is, at present, a poorly researched field. 32

33. Conclusion There are many manuals and textbooks to instruct us as to how we might capture and analyze speech and behaviour if we wish to study human actors in a rigorous social scientific manner However, few social science research manuals concentrate on the written word and, more specifically, on documents that contain words. W hen documents are put forward for consideration, they are usually approached in terms of their content rather than their status as ‘things’ . 33

34. Conclusion E ach and every document stands in a dual relation to fields of action i.e., as a receptacle (of instructions, commands, wishes, reports, descriptions, etc.), and as an agent that is open to manipulation . As a receptacle of content, one set of questions that a social scientific researcher may ask concern the processes and circumstances that led to the creation of document ‘X’ i.e., the document becomes a topic of investigation rather than a resource. D ocuments emerge in organizational settings in many different ways irrespective of human manipulations. 34

35. Conclusion Therefore, a further route of analysis for the researcher is to ask questions about how documents function in specific circumstances . Naturally, the way in which a document functions is often affected by its content , but the latter is rarely a determinant of the former. In fact, we need to keep in mind that the content of a document is never fixed and static – it is ‘situated’, and therefore, sensitive to context . In fact, the analysis of content, production, and function form the three points around which we can think about how to develop a suitable research strategy for dealing with documents in both their inert and their active/dynamic states. 35

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