Judith Green & Nicki Thorogood (2004). Qualitative Methods for Health Research. London: Sage, 262 pages, ISBN 0-7619-4771-X (Paperback), $43.95; 0761947701 (Hardcover), $119.00

Abstract: "Qualitative Methods for Health Research" is a pragmatic introduction to qualitative research in the health sciences. It is written for professional researchers with little knowledge of the social sciences. It serves that audience well. The book provides a comprehensive overview of different epistemologies underlying qualitative methodologies and of a broad range of qualitative methods. It illustrates different approaches with numerous case studies and adds a list of further readings at the end of each chapter. It is an excellent source of information for all those unfamiliar with qualitative research.

Key words: qualitative methods, epistemology, health research, quantitative methods

Qualitative methods play a minor role in health research and are mostly used for exploratory purposes in pilot studies or to illustrate quantitative findings. They are considered descriptive in nature rather than analytic. "Qualitative Methods for Health Research" is another effort to counter those assumptions. The authors, Judith GREEN and Nicki THOROGOOD, ascertain the importance of theory and the complexities involved in qualitative research throughout their book. While it is not the only textbook working on this endeavor (e.g. RICE & EZZY 1999; MURPHY & DINGWALL 2003), it is more easily accessible for those unfamiliar with qualitative traditions and theories. [1]

The stated goal of the book is to be an introduction for those "with considerable professional experience but little prior knowledge of the social sciences" (p.xiii). For those unfamiliar with qualitative research the book provides an excellent source of information. Each chapter ends with "key points" and "suggested further readings." Case studies are presented in boxes separated from the main text throughout the book. The book serves as a useful tool to gain an overview of qualitative research and functions as a reference for other resources to delve into the subject more. [2]

The book is organized following the sequence of a study. It begins with a thorough overview of the theoretical underpinnings of qualitative methodologies and methods. First the authors talk briefly about macro- and middle-range theories that are seldom explicitly acknowledged in publications but that underlie research per se as they determine the scope of questions and analysis of any research project. While they don't go into macro level worldviews in detail, the authors mention materialism, globalization, and gender as examples. Middle-range theories are those that link observable behavior to the macro-level theories such as the health belief model. The authors then turn to theories of knowledge, such as positivism, social constructivism, critical and feminist approaches, and participatory approaches. Each of these is discussed under a subheading, summarizing the assumptions of the approach and giving examples of what types of research studies are conducted. GREEN and THOROGOOD abstain from linking the discussion of the different epistemologies to specific philosophers or debates. This means the theories appear dehistoricized and decontextualized, leading to the impression that theories of knowledge consist of undebatable knowledge and are clear-cut within their frame. [3]

GREEN and THOROGOOD then discuss the type of questions that can be best addressed using qualitative methods and how the aims of such research differ from quantitative research goals. Qualitative research, they argue, starts with the "research subject," asking what they know, how they behave and what logic underlies their behavior. This is different from most research in the health field where the starting point is the logic of the health sciences with an assumption that the research subjects are irrational for behaving in certain ways. Qualitative research wants to find out the how, what and why of a phenomenon (p.5). Questions that warrant a qualitative approach are those that aim to understand the perspectives of participants, to explore the meanings participants give to a phenomena, or to observe a process in depth (p.30). In health research, because of its overall positivistic frame, it is quite important to have a specific research "question" at the onset of a study. The aim of the question should frame what question will be answered and how it will be addressed. [4]

This book then helps the novice researcher refine their research questions. To achieve this, GREEN and THOROGOOD suggest that the researcher should at the outset make explicit the worldviews inherent in the broad question and then deliberately apply alternative perspectives. This will aid in specifying the question. Once the question is precise, the authors go on to discuss what research design will be most appropriate. Specifically they describe experiments, surveys, observational studies, case studies, and action research. Qualitative types of research inquiry have their own ethical implications. In health research, ethical standards have been developed based on medical research. Informed consent and confidentiality are today the most prominent ethical issues in health research. GREEN and THOROGOOD discuss these in relation to observational and interview studies. In observational studies it can be hard to assess who has to be asked for informed consent. For example, at sites where many people are passing through, as in a clinic, it may be hard or unfeasible to inform everybody about the research and the role of the researcher. Confidentiality in the publication of qualitative work can also be a challenge. Qualitative studies are often small, and decisions have to be made on how to disguise the research participants without jeopardizing the analysis of the study. There are no easy answers to these problems. [5]

The authors see their task in guiding the reader through the important considerations in the research process of a qualitative study. GREEN and THOROGOOD continue with a comprehensive overview of interview techniques, observational methods, and the uses of existing documents as research material. They discuss the methods of analysis most widely used in health research, thematic content analysis, grounded theory, and framework analysis. Finally the authors focus on the specifics of doing qualitative research in the health field: working in interdisciplinary groups in which disciplines are grounded in different epistemologies, and the difficulties of writing up qualitative work conducted in the health field for different scientific and lay audiences. For example, if the findings are to be published in a biomedical journal, the papers often have to follow a prescribed format. Similarly, the methods section has to be more explicit than for most social science journals. [6]

The book is very thorough and touches on all aspects of designing, conducting, publishing, and evaluating qualitative research projects. It impresses by its sheer number of cited studies. It supplies tools for those interested in doing qualitative work in the health sciences and at the same time shows the pitfalls social scientists may encounter in a field dominated by positivism. [7]

If the intent of the book is to give health professionals unfamiliar with the social sciences the tools to set up qualitative research projects, the organization of the book may be misleading. It suggests a linear process in the conduct and analysis of qualitative research, but data analysis, methods, and epistemology cannot be separated. The authors know this and reiterate it throughout the book (e.g. p.20) but the formal structure may speak its own language, clouding the nature of much qualitative work for newcomers. While the same qualitative data can be analyzed using different methodological approaches (COFFEY & ATKINSON 1996), analysis is crucial throughout all phases of a project. Data analysis should always be done alongside data generation, just as "writing up" and analysis cannot be separated in most qualitative work. [8]

While this book does not suggest that "anybody" can do qualitative research, and indeed is an attempt to overturn that assumption, it still seems to feed it by being an introduction for those "postgraduates with considerable professional experience but little prior knowledge of the social sciences" (p.xiii). This dilemma affects the entire book. The authors refrain throughout from historicizing epistemologies, methods, and analyses, making the book easy to understand but doing so at the expense of the depth and complexities of qualitative research traditions and debates. [9]

At stake is the question of how useful the divide into quantitative and qualitative methods is and what this separation entails. GREEN and THOROGOOD acknowledge the debate on qualitative and quantitative methods (p.5) and suggest rather than focusing on methods the goals of a study are the defining moment of the difference. If the aims are related to meanings—to the what, how and why of a phenomenon—then GREEN and THOROGOOD consider it a qualitative study. This suggests that key to the definition are the underlying epistemologies of social science disciplines. It is the theories of knowledge that create the questions to be asked; methods follow from them and may include qualitative and quantitative approaches. [10]

Within the different disciplines of the natural sciences there exists a diversity of methods, some of which are considered qualitative and others quantitative. Still, it seems as if in the natural sciences the differences are not considered so fundamental as to hinder fruitful interdisciplinary collaborations. The reason may be that they agree on the epistemology. Thus the aim—striving for new medications, or finding mechanisms of disease, etc.—bridges the methodological difficulties across the disciplines. At stake in the social and behavioral sciences is the legitimacy of the underlying epistemologies, as the authors rightly point out (p.10). This isn't recognized in some applications of qualitative methods in health research and leads to such assumptions as that qualitative methods are merely descriptive. [11]

The authors stress the importance of the "social science imagination" (p.196). This has to be brought to the data analysis, otherwise the strength of qualitative methods will be lost, and the interpretations will be "thin." For health professionals much more is necessary than to read books on qualitative methods, and a broad reading on theories in social sciences is necessary to produce the rich, informative reports possible through the use of qualitative methods (p.196). This means the difference in methods is only the foreground, and the deeper difference lies in the epistemology. Someone who wants to apply qualitative methods needs to learn more than the technique; they need to review qualitative research theories (RICE & EZZY 1999, p.4). [12]

Finally, GREEN and THOROGOOD provide insights into the challenges of qualitative research in the health field to social scientists in training. The authors know the health field well. They address most of the particular issues faced by qualitative research in the field and offer very good proposals on how to avoid problems associated with them. They give guidance about how to conduct successful research projects in the heath field. Reliability, generalizability, and validity are important concepts in having data analysis accepted as valid in the health field. GREEN and THOROGOOD provide their own understandings of what these concepts mean for qualitative research analysis and how they need to be applied. To the authors, validity in qualitative research projects refers to the rationale behind a proposed interpretation of the presented data. This can be ensured by providing context, giving evidence of how often something occurred in the data, or by including material that contradicts the emerging theories. Discussing generalizability in qualitative studies means thinking through the kind of relationship the study findings have to other groups and settings (p.197). In qualitative research studies what sometimes is transferable (generalizable) is the concepts that have been identified (p.198). [13]

Contrary to other textbooks on qualitative methods in the health field GREEN and THOROGOOD do not discuss the social scientists' debate on postmodernism and constructivism. The book seems to have a stance within "subtle realism" (HAMMERSLEY 1992) but it doesn't engage in trench warfare to defeat postmodernist approaches. It describes all epistemological approaches equally. It is impartial as it discusses where and when to ask questions that warrant qualitative methods within certain epistemological traditions and how to design an appropriate study. It keeps out of quarrels within qualitative research methodologies. This is what makes it an excellent textbook for all those who work in the health fields and who want to expand their research agendas. As such this book is a valuable contribution to the vast literature on qualitative methods in health research. [14]

Coffey, Amanda Jane & Atkinson, Paul A. (1996). Making Sense of Qualitative Data: Complimentary Research Strategies. London: Sage.

Hammersley, Martin (1992). Ethnography and Realism. In Martin Hammersley (Ed.), What's Wrong with Ethnography (pp.43-56). London: Routledge.

Morse, Janice M. & Field, Peggy Anne (1995). Qualitative Research Methods for Health Professionals (2nd edition). London: Sage.

Murphy, Elizabeth & Dingwall, Robert (2003). Qualitative Methods and Health Policy Research. New York: Aldine deGruyter.

Rice, Pranee Liamputtong & Ezzy, Douglas (1999). Qualitative Research Methods. A Health Focus. Oxford: Oxford University Press.

Christine HOLMBERG holds a Dr. phil. in European Ethnology from the Humboldt-University Berlin and a M.P.H. in Epidemiology from the University of Illinois at Chicago. She is currently a fellow at the National Cancer Institute, where she is designing and leading mixed-method studies on the effects of expanding medical technologies on medical practice and on the experience of patients as well as healthy populations. The overarching theme of all of Dr. HOLMBERG's work is the societal and individual consequences of developments in early detection in biomedicine. Questions of the societal and individual cost and benefit for being labeled at risk as well as the influence and determination of scientific concepts of risk on society and on everyday behavior and perception are foundational to her work. Her recent publications include Diagnose Brustkrebs. Eine ethnografische Studie zu Krankheit und Krankheitserleben (Campus-Verlag 2005) and Researching Cancer: Understanding Sameness and Absolute Otherness (2006).

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Holmberg, Christine (2006). Review: Judith Green & Nicki Thorogood (2004). Qualitative Methods for Health Research [14 paragraphs]. Forum Qualitative Sozialforschung / Forum: Qualitative Social Research, 7(2), Art. 7, http://nbn-resolving.de/urn:nbn:de:0114-fqs060274.

Forum Qualitative Sozialforschung / Forum: Qualitative Social Research (FQS)

ISSN 1438-5627

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