Reflexão sobre a abordagem etnográfica em três pesquisas

Reflections on the ethnographic approach in three research studies

Reflexión sobre el abordaje etnográfico en tres investigaciones

ARTIGO DE REVISÃO

Reflections on the ethnographic approach in three research studies

Reflexão sobre a abordagem etnográfica em três pesquisas

Reflexión sobre el abordaje etnográfico en tres investigaciones

Neiva Francenely Cunha Vieira^I; Luiza Jane Eyre de Souza Vieira^II; Mirna Albuquerque Frota^III

^IEnfermeira, Professor da Pós-Graduação da Universidade Federal do Ceará, PhD pela Universidade de Bristol - Inglaterra, e-mail: [e-mail]

^IIEnfermeira, Professor Titular da Universidade de Fortaleza, Enfermeira do Instituto Dr. José Frota - Fortaleza - Ceará

^IIIEnfermeira, Professor Adjunto da Universidade de Fortaleza, Enfermeira do Instituto de Prevenção da Desnutrição e Excepcionalidade - Fortaleza - Ceará

ABSTRACT

This paper aims at analyzing three research studies that focused on the effects of the perception in adults´ attitudes with the purpose to improve the health care provided to children. Although each study had a distinct area of investigation, all of them adopted the ethnographic approach on the interaction between the adults and children. This work aimed at reporting the researchers' reflections with respect to: i) the adoption of the ethnographic approach in Nursing studies; ii) the theoretical perspectives that are relevant in the production of themes. Authors considered the value of this reflection after the research and its potential in order to understand how it can contribute to consolidate the health care theoretical frameworks in general, and the nursing care models, in particular.

Descriptors: cultural anthropology; research; nursing; culture

RESUMO

Este trabalho embasa-se em três pesquisas que focalizaram os efeitos da percepção nas atitudes dos adultos, com o objetivo de melhorar o cuidado de saúde da criança. Embora cada estudo pertença a uma área distinta de investigação, todos adotaram a abordagem etnográfica para analisar a interação entre adultos e crianças. Este estudo desenvolveu a reflexão dos pesquisadores com relação a: i) adoção de uma abordagem etnográfica na produção científica de enfermagem; ii) perspectivas teóricas relevantes na análise destes temas. Em suma, este estudo exemplifica o valor da reflexão sobre pesquisas já realizadas e seu potencial para aumentar o entendimento de como as pesquisas podem contribuir para consolidar os modelos de cuidado a saúde em geral e do cuidado de enfermagem, em particular.

Descritores: antropologia cultural; pesquisa; enfermagem; cultura

RESUMEN

Este trabajo involucra tres estudios de investigación que se enfocaron en los efectos de la percepción en las actitudes de los adultos en los intentos por mejorar el cuidado de la salud del niño. Aunque cada estudio tenía un área distinta de investigación, todos adoptaron un abordaje etnográfico en la interacción entre adultos y niños. Este estudio muestra la reflexión de los autores en relación con: i) adopción de un abordaje etnográfico en la producción científica de enfermería; ii) perspectivas teóricas que demuestran ser relevantes en la producción de los temas. Se considera que el valor de esta reflexión post-investigación radica en su potencial para entender como este abordaje puede contribuir en la consolidación de un marco teórico relacionado con el cuidado de la salud en general y del cuidado de enfermería, em particular.

Descriptores: antropología cultural; investigación; enfermería; cultura

INTRODUCTION

The process of reflection in which the three researchers became involved sprang from our desire to address two main criticism aimed at ethnographic approaches in nursing research: insufficient explanation of how the theoretical or conceptual framework (if one is used) is guiding the study; little reflection in the research findings on theoretical perspectives which has formed the basis of the study, or contributed ideas emerged by our studies⁽¹⁾.

It is with these criticisms in mind that we offer our post-research thoughts. We do not claim to have answered the criticisms, we merely wish to communicate the value of the process of reflection.

Firstly, we give our rationale for the adoption of an ethnographic approach. Secondly, we examine the development of the research designs. Lastly, we reflect upon the relevance of existing theoretical perspectives.

APPROACH TO RESEARCH: WHAT? WHY?

The three studies involved the experiences of school personnel as implementers of a school-based health education innovation project on sex education for the HIV/AIDS prevention; the experiences of families facing situations involving the accidental poisoning of children in the home and the experiences of adolescents mothers in their attempts to care for undernourished children.

All three studies were undertaken in the North-East of Brazil. In each study, the process of decision-making was based mainly on the desire to provide meaningful, understandable, useful, consistent and believable data from a particular situation where the subjects experience it. There was no desire to pre-determine outcomes, nor manipulate the setting of investigation, but to search for what happened; how things happened based on the actions and interactions of the people engaged in the process itself and what and why change if any occurred^(2-7).

From the outset therefore, we were clearly operating within a qualitative research environment in pursing the aims of understanding a social situation by means of interpreting it into the particular, social, historical context from which it emerges. Thus, we felt that we should pursue a theoretical framework which could help us to get answers from those who feel, experience, and attribute meanings in their natural settings, indeed there are structures, forces and other furniture of the world which are beyond all powers of observation^(8-11).

Our decisions were influences further by researchers^(1,4,12-13) when they point out that the decision-making of which approach to adopt in a research design depends mainly on the kind of data which is required. They advise the examination of the following questions:

1. what will be the nature of the phenomena under the study?

2. will it have an etic or an emic perspective?

3. what form of relationship will be established between the research and its subject/object of study in view of the knowledge will be produced?

4. what role will this subject/object of study play in this knowledge?

THE ETHNOGRAPHIC BASIS TO THE STUDIES

The answers to the above questions emphasised our determination to ensure that our research was giving voice to subject's opinions and thoughts, searching for meaning of everyday life experience of people within their world, in order to better understand the events^(5,13-19). As a result, the studies were placed firmly the ethnographic tradition for the following reasons:

- ethnography rests on the understanding of a particular group based on their cultural influences, and the diversity of responses based on their experiences and perceptions⁽¹⁵⁾. Thus, we understood as one of the best path to become close to the cultural context of the clients and their meanings, feelings, cultural practices, beliefs, taboos, whose are related to health and illness and their attitudes to cope with risk situations;

- the ethnography encompasses the research commitment to the field, personal interest to improve informed decision-making and understanding of each situation to enrich the nursing care based on the subjects' experience and meaning, data classification, codification would emerge from fieldwork, data collection strategies relied on unstructured, semi-structured interviews, observation, fieldnotes, and documentary evidence, the study took a small number of cases in detail, and looked them equally, data analysis are explicitly of research participants' viewpoints presented by researcher;

- within the ethnographic perspective, data presentation is descriptive. The analysis is processed by the identification and observation of group behaviours under norms and rules acting on them^{(8-11,13,15-19)}. With descriptive data are taken from participants perspectives. Patterns and relationships are searched for and grounded in the data;

- the task is to make sense of data, to have it in a legible form which is understandable. This requires work on from the point of verbatim transcription, through to reductions and organisation into themes, and patterns. This is the final stage in a continuum of data analysis, which incorporates interactive process during and between each of this study, from the conceptual framework, until the 'conclusion' of data analysis. The aims is to capture the sense of themes/categories which emerged from data, then to paint the picture of the situation and tell the story^{(3-6,9-11,16-17)};

- within the ethnographic tradition, the three studies embodied a focused ethnographic approach, as illustrate in other research⁽¹³⁾, especially in nursing research. This approach has a pragmatic aim and direction in the design and the conducting of the research. It aims to improve practice, and follows them of exploration before data collection and analysis starts;

- the diversity among people in the world, leads nurses to pursue a view to catch up the perception and understanding how people behave within their social and cultural context. Having said that, nurses would provide better care based upon the people's reaction during the process of being healthy or sick, indeed facing situation such as domestic injuries, undernourished child and school personnel working as implementers of a sex education programme at school.

THE RESEARCH DESIGNS

Now we turn to the research designs and our reflections regarding the development of the theoretical or conceptual framework of these studies.

Experiences of school staff as implementers of school-based sex education innovation project for HIV/AIDS prevention

The research design of this study aimed at contributing to further informed action and decision-making in the improvement of health education programme for the HIV/AIDS prevention based in schools. The emphasis was on the exploration of subjects' meanings and understandings about the experienced situation in 'their' particular context.

The ethnography combined the theoretical perspective to form the basis for the research design of this study. Both advocate having orientated question to start with, and evolving to more refined questions, and categorisation as the issues emerged from the data.

The decision about the theoretical underpinnings of this study was based mainly on the following points:

- The focus was on the process rather than the final outcomes of the implementation;

- The study relied on school personnel's perceptions of their experiences in their context;

- The study principally explored how the health education innovation project was implemented in order to effect change not the degree of change.

The research design was developed in two phases: preparatory fieldwork and fieldwork. The first one embraced two stages as follows: approach to literature and pilot study. The literature functioned under a critical perspective. It contribute, as a starting point, to the formulation of the main issues, questions and aims. However, there was no intention to define concepts and themes previously. The pilot study was mainly to examine the semi-structured interviews schedule addressed to the school personnel. It looked at the consistency, adequacy and relevance of the interview schedule, and the standards of answers, and further possible questions could generate from this stage. The first outcomes of the pilot study raised some concerns with regards to how the sexual education programme was conducted within the schools. It showed not only some evidence of what personnel needed in terms of knowledge and skills, but also how they handled and translated this new responsibility into practice.

The fieldwork stage started to pursue the following data from the broad research questions:

a) What kind of sex education for HIV/AIDS prevention was provided by the government to schools, and was it extent?

b) What kind of support did the schools have to implement this theme?

c) How did Education and Health Government Bodies work on this theme?

At this stage, collection of official documents and unstructured interviews were the main source of information.

The findings emerged from this stage of the fieldwork led to further reflection, and the conceptual framework took a more precise form. It was acknowledged at this stage that any positive response to this innovation would be limited or temporary without uncovering the implications for school as implementers of this innovation. Now exploring more closely the research questions, an inner perspective of the implementers within the schools was pursued:

a) What kind of relationship has been established between the school and health promoters and within the school to enhance the implementation?

b) Why have they operated in this way?

c) How do school personnel, as implementers, experience this innovation within their schools?

d) What are the consequences of the implementation for future directions?

After 'concluding' the fieldwork, the next job was to make sense of the data. The findings were composed of a mosaic of themes that tell the story of the implementation of the Health Education Innovation Project. The findings of the study took the form of a narrative story based on the 'real' world of the people who experienced it, where issues could then be addressed in accordance with structured, but flexible framework on which the research had been built.

This research suggests that in fact, the design as implementation of this health education innovation project for the HIV/AIDS prevention was seriously impeded as a result of the following misinterpretations of the highlighted principles:

1. decentralisation - this became interpreted as a physical transference of delivery of the health agenda issues from the central agency to school;

2. participation - this became a transference and enforcement of the health agenda in which staff training was reduced to methods of what to say and what to do in school and in the classrooms;

3. inter-sector collaboration - this became an "official" arrangement at top level only - i.e. at Health and Education Authorities, and the involvement of schools was largely reduced to the transference of task previously defined.

Also, different theoretical and methodological interpretations in the operation of these principles may have been reflected in the way the two parties involved acted and reacted together leading to:

1. poor interaction between people;

2. poor communication;

3. lack of preparedness for team working;

4. lack of preparedness of the support environment.

Experiences of families facing situations involving the accidental poisoning of children in the home

The main aim of this study was to understand how families cope with the accidental poisoning of children in the home. It sought information about families' perceptions, feelings and knowledge with regards to risk in the home environment. Within the ethnography, data collection and analysis were guided by the theoretical underpinnings suggested by some authors^{(1,13-14,16-18)} , such as data presentation is descriptive, and the analysis is processed by the identification and observation of group behaviours under norms and rules acting on them. The authors suggest looking for cultural factors to understand human behaviour. From those factors we can identify those which might influence the process of being healthy or ill. This study in particular, sought to understand how mothers´ perceptions, feelings and experiences within their home context could affect their care for their children.

The findings are presented using the first level of Leininger's theory⁽¹⁶⁾ - Dimension of the Culture and Social Structure in order to broaden understanding beyond the medical implications. Her theory describes the influence of several factors which might explain people's attitudes to health care. The following data emerged from the mothers´ perceptions of the experience of their child being at risk because of poisoning.

The research also identified the feelings of some mothers with regard to the experience of their child being poisoned, feelings of guilt, pain and shame predominated. For example:

There was not any mother who would wish this happen to her child

I will not forget this tragedy in my life

I almost got crazy when I saw my boy in that situation

I never expect to see my boy in a hospital because of poisoning

The theoretical and methodological framework adopted in this research contributes to nursing knowledge and understanding of risk situations within the family and, by adopting a wider perspective than a simply medical model, we can provide better family support and education in preventing further risk to children.

Experiences of adolescent mothers in their attempts to care for undernourished children

This ethnographic study started with the broad question: "How do adolescent mothers care for their undernourished children?" It sought to uncover informants' perceptions, feelings, beliefs and experience in their particular situation and allowed the researcher to be close to the subjects of the study and to participate in their world The setting of this investigation was a clinic for undernourished children where adolescent mothers attended with their children who were suffering from malnutrition.

Data collection and analysis were conducted based on Leininger´s Sunrise model. This encompasses strategies suggested by ethnographic approaches such as observation, listening, participation, reflection, and reconfirmation of findings with informants.

Data analysis proceeded through four stages⁽¹⁶⁾: collecting, describing, and documenting raw data; identification and categorisation of descriptors and components; pattern and contextual analysis; major themes, research findings, theoretical formulations, and recommendations.

The themes which emerged from data as informing the adolescent mothers' world view were:

1. How I take care of my child

2. What is better for my child

3. What I believe

4. I get crazy when they get sick

5. I gave a lot of medicine

The data revealed that there is a strong relationship between the family's beliefs and life-style and the quality of adolescent mothers' care for their children. This is exacerbated by the fact that the majority of the adolescent mothers still live with their own mother due to the poor economic situation within most of these families. At government level there is a lack of policy to support adolescent mothers through health and education provision during and after pregnancy. Consequently adolescent mothers lack knowledge about contraception and how to care for their children. I addition, they tend to delay going to clinics when their child is sick because they tend to look for healing or medication without medical advice.

The theoretical approach which guided this research proved to be effective in promoting understanding of the wider perspective of the world of the adolescent mother and her undernourished child thus challenging the notion that malnutrition can be addressed solely from a clinical perspective.

CONCLUSION: THE JOURNEY PROCESS OF LEARNING

Thus, these research processes identified two pertinent areas: one derived from the theoretical-methodological perspective, and the other the personal engagement, which was derived from feelings, such as reflection and emotional engagement during the process of the investigation, which go beyond the formality of the aims of each study.

These studies relied mainly on what people perceived of the situation they experienced within their culture context without imposing previous themes onto the data collection. The reliance on people's perception causes limitation for both the researcher and the informants because the subjectivity of participants can not be uncovered in deeply. However, the strength of these studies was the participants´ positive reaction to them. Also, this awareness posed some methodological implications in the observance of not imposing our interpretations over the informants'⁽¹⁹⁾.

At the personal level, this research experience has enriched our attachment and commitment to reveal social reality with those who have experienced it, and the need to continue to pursue the understanding of it with an holistic perspective, i.e. people, context, and structural forces. The process orientated research which was adopted for these studies proved to be an important learning experience professionally and personally. It is essential for nurses to plan and implement their care based on peoples' social and cultural understanding of health and illness, as implementers or participants of the process of health education.

ACKNOWLEDGEMENTS

Thanks to Dr. Mary Grant - University of Bristol - England for the revision of this article.

Recebido em: 16.5.2002

Aprovado em: 25.6.2003

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Datas de Publicação

• Publicação nesta coleção
  13 Jul 2004
• Data do Fascículo
  Out 2003

Histórico

• Aceito
  25 Jun 2003
• Recebido
  16 Maio 2002