The Potential of Grounded Theory for Health Education Research: Linking Theory and Practice* Patricia Dolan Mullen, Dr.P.H. Richard Reynolds, Dr.P.H.** This paper offers a critique of present research methods used in the literature drawn upon by health education practitioners, students, and teachers. Weaknesses of deductive methods and of theory which is highly general are noted in terms of their implications for the advancement of health education theory and practice, and in terms of their consistency with traditional principles of practice. The grounded theory method—an inductive approach usually used with participant observation and interview data—is described, and the major arguments for its value are presented. In particular, the empirical generation of middle-range theory can provide a strong link between more general theory and situations faced by practitioners, and definitions of problems are not prematurely closed to reinterpretation from other perspectives. Several recommendations are given for changing the research orientation of health education.
Are there strong links among theory, research, and practice in community health education? Unfortunately, few health educators would agree that this is the case. This paper will show that the research methods and the generality of theories used in health education help explain these gaps; a rationale and a method will be suggested for developing an empirically-based body of theory
relevant to practice and conceptually linked to formal theory. With the maturation of health education, the usefulness of existing theory and the appropriateness of usual research methods for the needs of practitioners have been called into question.9/18,26/27,32 Health education has relied heavily. upon behavioral and other social sciences and upon related professional fields such as social work and adult education for its theories. While this eclecticism has guaranteed a broad base, there has been movement toward the integration, refinement, and adaptation of these imported theories into a conceptual scheme unique to health education. * Based upon papers presented at a Conference on The Future of Health Education, SiigarloaG Maine. Decerrrber 21, 1977 and the Dorothy B. NysU’ander Symposium, Emeryville. California,
September 1973. * *Dr. Mullen is a Postdoctoral Fellow in the Division of Health Education. Schonl ojNygiene and Public Ifealtla, Johns ttopkins Urriversity, and Dr. Reynolds is a Visiting Professor at the University of New Mexico. Address requests jor reprints to Dr. Afullen, Division of Health Education, School of Hygiene and Public tfealth, bl5 N. Wolfe Street, Baltimore, Maryland 21205. 280
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The favored modes of research in the health education literature have been
deductive and hypothesis-testing; only infrequently, have hypothesis-seeking methods been used. The deductive and hypothesis-testing research ap-
proaches often have not been useful for the development of health education practice and theory for the following reasons: ~ Researchers often have not made a significant commitment to understanding the perspective of the people being studied or to leaving open a redefinition of the &dquo;problem.&dquo; Many studies of compliance with medical regimens illustrate this difficulty. The term connotes an explanation for as well as a description of the ill person’s behavior; and this may have short-circuited the research efforts
~
which as they are depicted in the literature show remarkably little attention to the patient’s point of view.29 Studies generally have been static. They take a snapshot to describe conditions or situations at one or several points in time instead of moving pictures of processes as they vary under different conditions and interact with other variables. The status of attitudes or behaviors, for example, is infinitely easier to measure than the dynamics of attitude change, health habit formation, or the stages of redesigning a ’
lifestyle. ~
~
~
~
~
Variables’ such as demographic characteristics have enjoyed considerable popularity among researchers, but these descriptors provide only a starting point for intervention. A deeper understanding is needed to give greater leverage for change. Concepts and theory often have not been generated from data. They have been deduced on too general a level without an adequate empirical base, and this means that little is being added to health education theory. The focus frequently has been dictated by logico-deductive theoretical concerns rather than empirical questions. In health education terms this is like a program designed by the staff of an agency without the participation of the community or client group to be served. Literature of conceptual relevance to a substantive area of health education theory and practice is sometimes missed. If the theoretical starting point of a deductive study turns out not to be relevant or not to have the best fit, no further literature search is routinely conducted. And without empirically generated concepts, it is difficult to estimate the relevance of new theory or concepts. Relevant concepts often have been oversimplified when they were operationalized for quantitative measurement. (See Blumer~ for an extended discussion of this point.) This can occur, for example, when learning is indicated only by a score on a true-false knowledge test or when prevention is defined solely in Western health care terms for a study of another cultural group. Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
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In an effort to respond to these problems, the advantages of a promising strategy for empirical inquiry, called the &dquo;grounded theory&dquo; method will be discussed. This method especially lends itself to what Roberts26 saw as the alternative to the &dquo;basic-applied&dquo; distinction in research, insofar as it contributes to systematic knowledge and theory and has practical use. THE GROUNDED THEORY METHOD
The grounded theory method, as it will be described here, was developed and refined by Glaser and Strauss. 12,15 It was derived primarily from two research approaches-one associated with the analysis of qualitative data, the other associated with analysis of quantitative data. The dominant parent is comparative analysis, a recognized general research method which has been used in sociology and anthropology (e.g., by Weber, Durkheim, Mannheim, and social anthropologists). Its major approach is comparison of several groups or social units of any size-e.g., individuals, roles, groups, programs,. institutions, or nations. Strauss’ work with George Herbert Mead at the University of Chicago initiated a research career using participant observation and comparative analysis as the major modes of gathering and analyzing data. The second main contribution originated with Lazersfeld and his associates at Columbia University where Glaser was trained to analyze survey data with the goal of generating core variable theories. The concept of core variable refers to a category which accounts for most of.the variation in a pattern of behavior and which helps to integrate other categories that have been discovered in the data. The grounded theory method then, uses comparison as an analytical tool to generate concepts and hypotheses and to interrelate them through core variables which are both parsimonious and broad in scope. The final goal is middle-range substantive theory&dquo; in a specific content area such as dying,’3’’6 pain management,&dquo; recovery after a heart attack , 21 or formal theory, that is theory generalized over a number of specific areas such as status passage, 17
life-style redesign, The procedures
or awareness
context.’4
are systematic and provide for empirical verification of the hypotheses and propositions developed during the research process. Chronologically, these operations are unlike the linear models used to test or verify hypotheses; data gathering, analysis, and conceptual integration go on simultaneously, although their mix at any one time differs over the course of a study. The beginning stage consists of discovering categories into which data can be coded (see Fig. 1). Indicators (indicents and definitions in the data) are inspected with the question, &dquo;Of what concept is this an indicator?&dquo; In the early part of the study, the analyst attempts to discover many categories and to compare them with new indicators to uncover their characteristics and relationships. The data are coded into as many categories as possible. These early codes may be discarded if they lack foundation in the data, and more
282
of this method
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FIGURE I
CODING SAMPLE
may be added as the data gathering progresses. First indicators are compared with other indicators with the purpose of establishing underlying uniformity and its varying conditions. Then concepts are compared to new indicators to generate more theoretical properties af the concept and new hypotheses and to verify the concept. (See example in Appendix.) A third level of comparison is concept with concept. This is to establish the best-fitting concept(s) for a set of indicators and to establish the interrelationships among the concepts. One analyst has described this as follows: I
sought
multiple and varied relationships between and among attempting to prove a linear causal hypothesis between an approach is designed to yield &dquo;molecular&dquo; rather than linear modelS.34 to discover
concepts rather than Such theoretical two.
’
codes are of two kinds: (1) those which are taken were observed or interviewed-such as oneself,&dquo; &dquo;convincing,&dquo; and &dquo;cutting out&dquo;; and (2) implicit codes
Substantive categories from the language of the
&dquo;budgeting
or
people who
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283
such
as
&dquo;social
comparison (as
loss,&dquo; &dquo;conditional dependence,&dquo; and various standards of seen in Fig. I) which are constructed by the researcher
on behavioral science concepts. This mix of comparisons soon begins to make possible the construction of theoretical properties of categories, and the emergence of major categories. Coding thus leads to conceptual reorganization. Core variables provide the organizing focus and are selected on the basis of pervasive and meaningful relatedness to other categories and frequent occurrence in the data. In grounded theory studies, core variables are most often social processes, because qualitative data frequently have a time dimension. The analysis then traces the emerging process to identify its stages, dimensions, and the characteristics and conditions that vary it. The types of social processes refer to two levels of sociological analysis. (1) Structural processes are social structure in the making, usually growth or deterioration’and are exemplified by the concepts of bureaucratization and debureaucratization, routinization and deroutinization, and centralization and decentralization. (2) Social psychological processes are modal patterns of behavior such as becoming, role taking, cultivating clients, leveraging, cutting back and optimizing health. A core variable may also be any other kind of theoretical category, such as the social structural condition, the awareness context (i.e., who knows that the patient is expected to die which explains the social interaction with and around a dying patient.’4 Further data gathering is purposefully directed through theoretical sampling to obtain more comparison groups. The sampling in later stages of a study, after identification of a basic social process or other core variable, is directly focused on the developing theory. For example, after one study was underway, focus narrowed from dying patients in general to awareness contexts in which dying was taking place. The researchers found that the closed awareness or mutual pretense contexts were by far the most common in U.S. hospitals at the time of the study (early 1960s). Thus, the fact of the patient’s impending death was either unknown to . the patient and/ or family or they knew and pretended that they did not. The question which was put forward then was &dquo;what happens in an open context where everyone knows and behaves as if the others know also&dquo; and &dquo;where would one find such examples for study?&dquo; Such lines of inquiry can be pursued through theoretical sampling but not through statistical sampling; this approach helps assure that the developing theory will be rich with variation. Glaser has summarized several important points on the differences between theoretical and statistical sampling strategies:’2
based
284
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The aim of
grounded theory is
logico-deductive;
or
not
complete
coverage in
a
descriptive,
scholarly sense-its goal is theoretical completeness, that
is, the explanation of
a
social
phenomenon
in relevant
terms.
Described
’
another way: Since the field researcher senses the great complexity of social reality and sees the operational relationship between discovery and creativity, he is less inclined quickly to measure or test his findings-not because he fails to appreciate the need for ’nailing things down’...but because he is never quite sure that his latest ’finding’ is critical or is the final one. More important to him than ’nailing it down’ is ’linking it up’ logically, theoretically, and empirically to other findings 8-91 or discoveries of his own and others. Then, he may measure or test it.3c)t Pp
With more data and adequate sampling, major changes in the categories are less frequent. As the categories become saturated, fewer data come to light that are new or that would cause significant alteration of the properties of a category. Later modifications consist of clarifying the logic, removing irrelevant aspects, and simplifying and integrating the outline of the theory. Lastly, memoranda written during the analysis process (e.g., Appendix) are sorted. The original list of categories is greatly reduced. Data are now ordered and become a systematic statement of the matter under study. Abstractions have been formed to explain the underlying complexities of the data. Inconsistencies are- brought to view to be accounted for or explained. The final form of the theory is an integration of the conditions, contingencies, contexts, consequences, and strategies around one or two core variables which are rich in conceptual detail and adequate to develop testable
hypotheses. ADVANTAGES OF THE GROUNDED THEORY METHOD
Applicability by
Practitioners
Presentations of grounded theories to practitioners have shown that they do not require an interpreter to translate the research. The practitioner can hear it, relate it to his or her experience, and apply it. Such conceptual schema Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
285
properties which favor successful application: close fit to the practice area, understandability, generality, and focus on situational structure and dynamics over which users have at least partial control.&dquo; have four
Fit and understandability. Grounded theories generally meet the criteria of fit and understandability by definition because of the means through which they are developed. Only those theories which are thin-built with insufficient data and inadequate theoretical sampling-will fall short of the criteria. Use in grounded theories of imagery, examples, and concepts drawn from the contexts on which these theories are based makes them immediately recognizeable to practitioners and laypersons who are familiar with the area. &dquo;Shifting gears,&dquo;22 a popular guide on making major life changes (and also a grounded theory) has been helpful to many lay readers; &dquo;Taking chances&dquo;2° sheds light on the dynamics of behavior involved in unwanted pregnancies and repeated abortions for a wide range of persons involved in family planning and abortion programs. Generality. A grounded theory meets the criterion of generality, because it is based upon the accumulation of &dquo;a vast number of diverse qualitative ‘facts’ on many different situations in the areas or sampling of variables rather than being based upon sampling of people aimed at representativeness of a population. Seeking out as much variation as possible and developing hypotheses to explain the variation helps to guarantee that the theory can be exported from the locale in which it was developed. All the practitioner has to do is to identify what conditions are present in the new situation to understand how the grounded theory will apply. Disadvantages of many deductive and of most purely descriptive studies are that they rapidly become outdated and yield relatively few general concepts. From the standpoint of practice it is more fruitful to know the types, range, magnitude, and conditions of occurrence of a phenomenon rather than merely the frequency of occurrence. ControL By &dquo;control&dquo; Glaser and Strauss refer to enabling the person applying the theory: ...to
understand and
analyze ongoing situational realities,
to
produce
and
and to predict and control consequences both for the object of change and for other parts of the total situation that will be affected. As changes occur, his theory must allow him to be flexible in revising his tactics of application and in’revising the theory if necessary. &dquo;(PZ45)
predict change in them,
understanding of the social process of cutting back,&dquo; for instance, enables practitioner working with heart patients to understand and predict situational realities. It is possible for more heart patients to reach an appropriate level of physical activity more easily and quickly by assisting them in learning to discriminate among bodily signs and read warning signals and in reinforcing their judgments. Changing the awareness context of surgery patients from closed to open by telling them what is going to happen to them An
a
increases the number of patients who have less severe pain.’° Grounded theories also have practice validity. In the process of the original research the theory is subject to verification by those who are immersed in that 286
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of social life; however, the theory can be modified through experiences gained in applying it (this may be thought of as an extension of theoretical sampling, as described above). Another example from the Mullen study21 will illustrate this process. A practitioner reading her study of heart patients would be sensitized to the propensity of persons confronted with a chronic illness to develop a causal explanation for its occurrence. This is hypothesized to influence the ill person’s choice of subsequent behaviors designed to prevent crises and further damage or other worsening of the condition, so it would seem important to learn how patients with another illness viewed the cause of their problem. A health educator working with a hypertensive black population learned that there were not only the levels of causal theories found among other heart patients (i.e., causes of the condition in the individual and causes of short-term fluctuations), but also a new level which is constructed by black patients to explain the high prevalence of the condition among black This does not make the original hypotheses invalid. It simply leads to the addition of a new condition; (when the disease appears to strike a particular group disproportionately, there will tend to be causal explanations for this). Once these insights are gained, the practitioner needs to explore the consequences of the various levels of causal theories for regimen-related behavior and the proportion of persons subscribing to certain sets of area
people.’
’
explanations. Analysis of Processes
Versus
Analysis of Units
are a crucial aspect of health education, and the grounded theory particularly oriented toward understanding them. As such it meets specifications for a strategy which would
Processes
method is
...trace the lines of defining experience through which ways of living, patterns of relations, and social forms are developed, rather than to relate these formations to a set of preselected items,J(Pp138-9) -
Present research strategies are of limited help in this regard, because they focused on units such as persons and their roles, institutions, subcultures, and so forth. These analyses tend to be bound to finite times, places, and people, and as such, are quickly outdated. (Of course, studies of the beliefs, attitudes, and practices related to family planning or other health concerns of programmers provide baselines for evaluations, and they offer suggestions for program development.) In contrast, the grounded theory approach uses social units to study the movement of social life through time. The unit only provides the conditions under which a process varies, so that grounded theories have greater generality because of their transcendance of the specific identities of particular units, and because processes are more basic objects of research. Two grounded theories which resulted from analyses confined to the stages of development and types of actors within single institutions illustrate the generalizability of such products: One was set in an anti-psychiatric treatment center for schizophrenic teenagers, focusing upon the subtle process of maintaining control under conditions of freedom
are
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287
The other
study developed
a
process model of
institution-building
from
historical documents and participant observation which covered the 12-year history of technical assistance to an overseas family planning research and communication center.25 Four stages of development were indicated by the data: initiating, transitioning, consolidating, and enabling. The core variable was role-sharing, by which was meant that at any time several personsadvisors and counterparts alike-were performing acts which in their sum represented the performance of an institutional role, such as manager, social scientist,- or leader. Other process variables which were managed include orientation toward (another cultural world) balancing priorities; pacing change and development; modeling desired behaviors; coaching others on how to act in new roles; sponsoring or vouching for capabilities of one’s counterpart (particularly in public roles); and letting go, which is learning when and how not to act.
Psychological Level of analysis Choice of level of analysis for the study of a substantive problem area has great influence on the range of solutions which might be developed as a result of the study. One view of research recognizes three levels: (I) rates (descriptive, verificational, and distributive); (2) modal patterns of behavior; and (3) personal patterns. While it may be clear that grounded theory is not concerned with rates, it should be stressed that the goal of this approach is to explain modal patterns of behavior, not personal patterns. This distinction is maintained in the definition of the problem by a researcher using the grounded theory approach (see below). With this approach explanations of behavior patterns are viewed as problems with which the individual is coping Social
&dquo;
as inherent within him. The assumption that the individual carries the cause of his problem within himself is common in the literature of deviancy, illness behavior, and mental health. Such work accounts for present behaviors in terms of personality, cultural training, social class, and the like. Lofland has referred to studies which emphasize special, pre-existing proclivities as &dquo;dispositionalist,&dquo; and he notes that this label still applies to work focusing upon &dquo;temporally and geographically remote or diffused variables’ Grounded theory emphasizes the level of analysis in which situational patterns and their personal and social meanings account for behavioral patterns. These are patterns of people, abstracted from personal identities. Thus, an answer to the question, &dquo;Why do juveniles steal stereo sets?&dquo; is &dquo;Because they are easy to pawn.&dquo; (Why a particular boy steals a stereo is not explained.) In typing behavior an actor is a free agent who can walk in and out of the process. The person is not typed one-dimensionally. He is not a deviant-rather, he is someone who engages in deviating. The grounded theory approach contrasts with the tendency of agencies of social control (juvenile courts, schools, health departments, and medical care workers, for example) to rush this person into the role of deviant Such an explanation is illustrated by BVhyte’s33 account of why waitresses
and not
-
288
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cry. He does not discuss the women’s personality traits. Instead, he focuses upon the organization of their work which often subjects them to upsetting cross-pressures. The orders from superiors, orders from impatient and demanding customers, and even requests from co-workers sometimes builds up to a point at which a waitress will break down and cry.
Problem Definition: The Victim’s Perspective In using the grounded theory approach the problem is allowed to emerge from the data and is thus defined by the actors in the situation. This is consistent with the traditional philosophy of health education. However, some established research strategies force pre-structured questions and interview schedules upon people without asking them how they define their situations and problems. Health education researchers sometimes find themselves representing established interests in trying to change the wrong ’
people. Ryan has described a research and program planning formula which is all familiar, and his perspective surely challenges researchers and
too
practitioners: First, identify a social problem. Second, study those affected by the problem and discover in what ways they are different from the rest of us as a consequence of deprivation and injustice. Third, define the differences as the cause of the social problem itself. Finally, of course, assign a government bureaucrat to invent a humanitarian action program to correct the differences.28(P8)
grounded theory approach makes it much less likely that the researcher or recommend solutions which aim to change only the patient, the hard-to-reach, or others who pose problems to health The
will blame the victim
professionals. Several studies4-6,8,23-24,3] using this method bear out an important point about grounded theory as illustrated with the chronically ill. Focusing on the core social psychological problems of those who are chronically ill has greater explanatory power-accounts for more of what goes on behaviorally-than approaches which view the medical problem as central. Actions of the ill person which seem anomalous, inexplicable, or irrational when described in relation to medical objectives, appear quite understandable, appropriate, and predictable when analyzed in terms of the consequences of the illness. Noncompliance could be reconceptualized and re-explained in terms of the patient’s selective utilization of the regimen and other strategies preceived to optimize health in order to maximize areas of functioning which have high priority. Thus, an approach which concerns itself with the meanings, definitions, and interpretations which are made by the subjects of the study has greater potential for depicting their world and priorities more accurately than methods which begin by preconceiving that world and its meaning. And it is this which helps practitioners to see an ill person&dquo;s or community’s situation holistically. Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
289
Theory-Building:
Selection and
Integration
of Social Science Theory Health education could benefit from higher quality decisions about the relevance of existing formal theories, and the grounded approach offers an organizing feature which can bring together a wide range of literature and put the analyst in a better position to judge the usefulness of available theories. The use of a substantive grounded theory as a bridge between data and formal theory largely prevents the distortion, forcing, and neglect of data by a formal theory. As Mullen conducted a study of heart patients,2’ for instance, the important condition of having an invisible physical handicap led to exploration of the deviance literature for work on situations in which people wish to disguisd an aspect of themselves that is socially stigmatized, that is, to &dquo;pass.&dquo; The work of others such as Davis,’ helped to conceptualize aspects of the data; it then yielded ideas for further literature searches--e.g., on the social and psychological effects of successfully passing and on the attendant problems of selective revealment. Further data collection was then undertaken to ascertain the relevance of the new ideas for heart patients. Another example of the ability of a grounded theory to organize a large number of separate studies is the framework developed by Bigus in his study of alcoholiCS;2 this study of the social transformation of alcoholics from persons constrained by normal boundaries of behavior to those engaging in greater and greater deviance has helped to bring together a portion of the diverse literature of alcoholism. The grounded theory method could be helpful in another important aspect of building theory for health education-in the realm of practice theory. Among the many possible subjects are the processes of: ~ organizing persons and units within institutional settings; ~ coordinating the efforts of a variety of programs promulgated by different agencies; ~ establishing health education programs in relatively new settings such as health maintenance organizations under organizational contexts ranging from compliance with federal regulations to strong support by one or more constituencies; and ~ facilitating interdisciplinary cooperation among medical care ’
workers. Further development of theories of practice would be a contribution to program development and evaluation, training educators, and setting new priorities for research.
significant new
health
CONCLUDING REMARKS: ANOTHER RESEARCH STRATEGY FOR HEALTH EDUCATION In summarizing this introduction to the grounded theory approach and its potential for health education, its strengths as a research strategy and its unusual compatibility with the principles of health education practice should be stressed. Substantive grounded theories would flesh out the linkages 290
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theory, research, and practice in community health education to a greater degree. Their empirical roots makes them understandable to those among
who are involved in that substantive area, and they immediately introduce the reader who is unfamiliar with the area to important variables. Existing social science research and theory can be brought to bear on the problem more fruitfully when they are related to the data by the conceptual bridge of a
grounded theory. While one research strategy should not be emphasized to the exclusion of others, greater interest in the grounded theory method is warranted. One needed change is wider recognition within the field of health education of inductive, qualitative research as a legitimate mode of inquiry. Too often the labels &dquo;soft,&dquo; &dquo;lacking rigor,&dquo; and &dquo;not really scientific&dquo; are applied. This appears to be because of exposure to poor examples and/ or because of the perpetuation of the bias favoring deductive, experimental designs as the highest form of research which psychology adopted in its drive to move from a philosophical to a scientific discipline. This limited view of scientific inquiry is one which ironically, the physical sciences do not share at all. In biochemistry, for example, inductive development of models is a major part of research
activity. Health education training institutions ought to include the grounded theory approach in research methodology survey courses, (e.g., 15). As a basis for more advanced training and also as valuable skills for health education practice, systematic participant observation and inductive thinking should be taught (e.g., 30). Faculty members should encourage interested students to take more extensive course work in the method at institutions where this is available (e.g., University of California at San Francisco, Berkeley, Davis, and San Diego; Teachers College; University of Washington; and University of Oklahoma). The second of the grounded theory methodology books is now in press, 12 and that together with careful study of completed studies such as those cited in this paper are helpful for self-teaching. Students and practitioners could also benefit from reading more grounded theory studies. In conclusion, then, health education would be enriched greatly if this research method were given more attention. -
ACKNOWLEDGEMENTS
The authors wish to acknowledge the contributions of Drs. Barney G. Glaser, Lawrence ~’V. Green, Anselm L. Strauss, and Harold Gustafson, and the members of Dr. Glaser’s research seminar 1972-1974. The authors’ training in the grounded theory method was undertaken during their doctoral work at the School of Public Health, University of California, Berkeley, and sponsored by U.S. Public Health Service Traineeships. REFERENCES 1. Arnold GM: A
Question of Control: A Study of Black People’s Perceptions of and Adaptions to Hypertension. Master’s thesis, Department of Health Education, University of Washington, 1978. Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
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2. 3. 4. 5.
6. 7.
8.
9.
Bigus OE: Becoming "Alcoholic": A Study of Social Transformation. Doctoral dissertation, University of California, San Francisco, 1974. Blumer H: Symbolic Interactionism: Perspective and Method. Englewood Cliffs, New Jersey, Prentice-Hall, 1969. Charmaz KC: Shouldering a burden. Omega 3:23, 1972. Charmaz KC: Time and Identity: The Shaping of Selves of the Chronically Ill. Doctoral dissertation, University of California, San Francisco, 1973. Davis F: Passage Through Crisis: Polio Victims and Their Families. Indianapolis, BobbsMerrill, 1963. Davis F: Deviance Disavowal: The Management of Strained Interaction by the Visibly Handicapped. In Becker HS (ed): The Other Side: Perspectives on Deviance. New York, The Free Press of Glencoe, 1964, p 119. Davis MZ: Living with Multiple Sclerosis: A Social Psychological Analysis. Springfield, Illinois, Charles C Thomas, 1973. Derryberry M: Research procedures applicable to health education. J Sch Health 33:215, 1963.
Egbert LD, Battit GE, Welch CE, et al: Reduction of postoperative pain by encouragement and instruction of patients. N Engl J Med 270:825-827, 1964. 11. Fagerhaugh SY, Strauss AL: Politics of Pain Management: Staff-Patient Interaction. Menlo Park, California, Addison-Wesley, 1977. 12. Glaser BG: Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Mill Valley, California, Sociology Press, in press. 13. Glaser BG, Strauss AL: Awareness of Dying. Chicago, Illinois, Aldine-Atherton, 1965. 14. Glaser BG, Strauss AL: Awareness contexts and social interaction. Am Sociol Rev 29 :669679, 1967. 15. Glaser BG, Strauss AL: The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, Illinois, Aldine-Atherton, 1967. 16. Glaser BG, Strauss AL: Time for Dying. Chicago, Illinois, Aldine-Atherton, 1968. 17. Glaser BG, Strauss AL: Status Passage. Chicago, Illinois, Aldine-Atherton, 1971. 18. Hochbaum GM: Research to improve health education. Int J Health Educ 3:141, 1965. 19. Lofland J: Analyzing Social Settings: A Guide to Qualitative Observation and Analysis. Belmont, California, Wadsworth, 1971. 20. Luker K: Taking Chances. Berkeley, California, University of California Press, 1975. 21. Mullen PD: Cutting back after a heart attack: An overview. Health Educ Monogr 6 :29510.
311, 1978. 22. O’Neill N, O’Neill G:
Shifting Gears: Finding Security in a Changing World.
New York, M
Evans, 1974.
Quint JC: Becoming Diabetic: A Study of Emerging Identity. Doctoral dissertation, University of California, San Francisco, 1969. 24. Reif L: Managing a life with chronic disease. Am J Nurs 73:261, 1973. 25. Reynolds R: Institution-Building and the Development Process. Doctoral dissertation, University of California, Berkeley, 1973. 26. Roberts BJ (ed): Health Education in Medical Care: Needs and Opportunities. Berkeley, School of Public Health, University of California, 1962. 27. Roberts BJ: Research in Health Education: Background Paper. Geneva, World Health 23.
Organization, 1968. 28. Ryan W: Blaming the Victim. New York: Vintage, 1972. 29. Sackett DL, Haynes RB: Compliance with Therapeutic Regimens. Baltimore, Johns Hopkins University Press, 1976. 30. Schatzman L, Strauss AL: Field Research: Strategies for a Natural Sociology. Englewood Cliffs, New Jersey, Prentice-Hall, 1973, pp 8-9. 31. Strauss AL, Glaser BG: Chronic Illness and the Quality of Life. St. Louis, Missouri, Mosby, 1975. 32. Steuart GW: Scientist and the professional: The relations between research and action. 292
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Health Educ Monogr 1(29):1-10, 1969. 33. Whyte WF: Human Relations in the Restaurant Industry. New York, McGraw-Hill, 1948. 34. Wilson HS: Infra-Controlling: Social Order Under Conditions of Freedom in an AntiPsychiatric Community. Doctoral dissertation, University of California, Berkeley, 1974.
APPENDIX MEMORANDUM: PROPERTIES OF CAUSAL THEORIES
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293
’
APPENDIX (Co»iinued)
MEMORANDUM: PROPERTIES OF CAUSAL THEORIES
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294
Are there strong links among theory, research, and practice in community health education? Unfortunately, few health educators would agree that this is the case. This paper will show that the research methods and the generality of theories used in health education help explain these gaps; a rationale and a method will be suggested for developing an empirically-based body of theory
relevant to practice and conceptually linked to formal theory. With the maturation of health education, the usefulness of existing theory and the appropriateness of usual research methods for the needs of practitioners have been called into question.9/18,26/27,32 Health education has relied heavily. upon behavioral and other social sciences and upon related professional fields such as social work and adult education for its theories. While this eclecticism has guaranteed a broad base, there has been movement toward the integration, refinement, and adaptation of these imported theories into a conceptual scheme unique to health education. * Based upon papers presented at a Conference on The Future of Health Education, SiigarloaG Maine. Decerrrber 21, 1977 and the Dorothy B. NysU’ander Symposium, Emeryville. California,
September 1973. * *Dr. Mullen is a Postdoctoral Fellow in the Division of Health Education. Schonl ojNygiene and Public Ifealtla, Johns ttopkins Urriversity, and Dr. Reynolds is a Visiting Professor at the University of New Mexico. Address requests jor reprints to Dr. Afullen, Division of Health Education, School of Hygiene and Public tfealth, bl5 N. Wolfe Street, Baltimore, Maryland 21205. 280
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The favored modes of research in the health education literature have been
deductive and hypothesis-testing; only infrequently, have hypothesis-seeking methods been used. The deductive and hypothesis-testing research ap-
proaches often have not been useful for the development of health education practice and theory for the following reasons: ~ Researchers often have not made a significant commitment to understanding the perspective of the people being studied or to leaving open a redefinition of the &dquo;problem.&dquo; Many studies of compliance with medical regimens illustrate this difficulty. The term connotes an explanation for as well as a description of the ill person’s behavior; and this may have short-circuited the research efforts
~
which as they are depicted in the literature show remarkably little attention to the patient’s point of view.29 Studies generally have been static. They take a snapshot to describe conditions or situations at one or several points in time instead of moving pictures of processes as they vary under different conditions and interact with other variables. The status of attitudes or behaviors, for example, is infinitely easier to measure than the dynamics of attitude change, health habit formation, or the stages of redesigning a ’
lifestyle. ~
~
~
~
~
Variables’ such as demographic characteristics have enjoyed considerable popularity among researchers, but these descriptors provide only a starting point for intervention. A deeper understanding is needed to give greater leverage for change. Concepts and theory often have not been generated from data. They have been deduced on too general a level without an adequate empirical base, and this means that little is being added to health education theory. The focus frequently has been dictated by logico-deductive theoretical concerns rather than empirical questions. In health education terms this is like a program designed by the staff of an agency without the participation of the community or client group to be served. Literature of conceptual relevance to a substantive area of health education theory and practice is sometimes missed. If the theoretical starting point of a deductive study turns out not to be relevant or not to have the best fit, no further literature search is routinely conducted. And without empirically generated concepts, it is difficult to estimate the relevance of new theory or concepts. Relevant concepts often have been oversimplified when they were operationalized for quantitative measurement. (See Blumer~ for an extended discussion of this point.) This can occur, for example, when learning is indicated only by a score on a true-false knowledge test or when prevention is defined solely in Western health care terms for a study of another cultural group. Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
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In an effort to respond to these problems, the advantages of a promising strategy for empirical inquiry, called the &dquo;grounded theory&dquo; method will be discussed. This method especially lends itself to what Roberts26 saw as the alternative to the &dquo;basic-applied&dquo; distinction in research, insofar as it contributes to systematic knowledge and theory and has practical use. THE GROUNDED THEORY METHOD
The grounded theory method, as it will be described here, was developed and refined by Glaser and Strauss. 12,15 It was derived primarily from two research approaches-one associated with the analysis of qualitative data, the other associated with analysis of quantitative data. The dominant parent is comparative analysis, a recognized general research method which has been used in sociology and anthropology (e.g., by Weber, Durkheim, Mannheim, and social anthropologists). Its major approach is comparison of several groups or social units of any size-e.g., individuals, roles, groups, programs,. institutions, or nations. Strauss’ work with George Herbert Mead at the University of Chicago initiated a research career using participant observation and comparative analysis as the major modes of gathering and analyzing data. The second main contribution originated with Lazersfeld and his associates at Columbia University where Glaser was trained to analyze survey data with the goal of generating core variable theories. The concept of core variable refers to a category which accounts for most of.the variation in a pattern of behavior and which helps to integrate other categories that have been discovered in the data. The grounded theory method then, uses comparison as an analytical tool to generate concepts and hypotheses and to interrelate them through core variables which are both parsimonious and broad in scope. The final goal is middle-range substantive theory&dquo; in a specific content area such as dying,’3’’6 pain management,&dquo; recovery after a heart attack , 21 or formal theory, that is theory generalized over a number of specific areas such as status passage, 17
life-style redesign, The procedures
or awareness
context.’4
are systematic and provide for empirical verification of the hypotheses and propositions developed during the research process. Chronologically, these operations are unlike the linear models used to test or verify hypotheses; data gathering, analysis, and conceptual integration go on simultaneously, although their mix at any one time differs over the course of a study. The beginning stage consists of discovering categories into which data can be coded (see Fig. 1). Indicators (indicents and definitions in the data) are inspected with the question, &dquo;Of what concept is this an indicator?&dquo; In the early part of the study, the analyst attempts to discover many categories and to compare them with new indicators to uncover their characteristics and relationships. The data are coded into as many categories as possible. These early codes may be discarded if they lack foundation in the data, and more
282
of this method
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FIGURE I
CODING SAMPLE
may be added as the data gathering progresses. First indicators are compared with other indicators with the purpose of establishing underlying uniformity and its varying conditions. Then concepts are compared to new indicators to generate more theoretical properties af the concept and new hypotheses and to verify the concept. (See example in Appendix.) A third level of comparison is concept with concept. This is to establish the best-fitting concept(s) for a set of indicators and to establish the interrelationships among the concepts. One analyst has described this as follows: I
sought
multiple and varied relationships between and among attempting to prove a linear causal hypothesis between an approach is designed to yield &dquo;molecular&dquo; rather than linear modelS.34 to discover
concepts rather than Such theoretical two.
’
codes are of two kinds: (1) those which are taken were observed or interviewed-such as oneself,&dquo; &dquo;convincing,&dquo; and &dquo;cutting out&dquo;; and (2) implicit codes
Substantive categories from the language of the
&dquo;budgeting
or
people who
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283
such
as
&dquo;social
comparison (as
loss,&dquo; &dquo;conditional dependence,&dquo; and various standards of seen in Fig. I) which are constructed by the researcher
on behavioral science concepts. This mix of comparisons soon begins to make possible the construction of theoretical properties of categories, and the emergence of major categories. Coding thus leads to conceptual reorganization. Core variables provide the organizing focus and are selected on the basis of pervasive and meaningful relatedness to other categories and frequent occurrence in the data. In grounded theory studies, core variables are most often social processes, because qualitative data frequently have a time dimension. The analysis then traces the emerging process to identify its stages, dimensions, and the characteristics and conditions that vary it. The types of social processes refer to two levels of sociological analysis. (1) Structural processes are social structure in the making, usually growth or deterioration’and are exemplified by the concepts of bureaucratization and debureaucratization, routinization and deroutinization, and centralization and decentralization. (2) Social psychological processes are modal patterns of behavior such as becoming, role taking, cultivating clients, leveraging, cutting back and optimizing health. A core variable may also be any other kind of theoretical category, such as the social structural condition, the awareness context (i.e., who knows that the patient is expected to die which explains the social interaction with and around a dying patient.’4 Further data gathering is purposefully directed through theoretical sampling to obtain more comparison groups. The sampling in later stages of a study, after identification of a basic social process or other core variable, is directly focused on the developing theory. For example, after one study was underway, focus narrowed from dying patients in general to awareness contexts in which dying was taking place. The researchers found that the closed awareness or mutual pretense contexts were by far the most common in U.S. hospitals at the time of the study (early 1960s). Thus, the fact of the patient’s impending death was either unknown to . the patient and/ or family or they knew and pretended that they did not. The question which was put forward then was &dquo;what happens in an open context where everyone knows and behaves as if the others know also&dquo; and &dquo;where would one find such examples for study?&dquo; Such lines of inquiry can be pursued through theoretical sampling but not through statistical sampling; this approach helps assure that the developing theory will be rich with variation. Glaser has summarized several important points on the differences between theoretical and statistical sampling strategies:’2
based
284
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The aim of
grounded theory is
logico-deductive;
or
not
complete
coverage in
a
descriptive,
scholarly sense-its goal is theoretical completeness, that
is, the explanation of
a
social
phenomenon
in relevant
terms.
Described
’
another way: Since the field researcher senses the great complexity of social reality and sees the operational relationship between discovery and creativity, he is less inclined quickly to measure or test his findings-not because he fails to appreciate the need for ’nailing things down’...but because he is never quite sure that his latest ’finding’ is critical or is the final one. More important to him than ’nailing it down’ is ’linking it up’ logically, theoretically, and empirically to other findings 8-91 or discoveries of his own and others. Then, he may measure or test it.3c)t Pp
With more data and adequate sampling, major changes in the categories are less frequent. As the categories become saturated, fewer data come to light that are new or that would cause significant alteration of the properties of a category. Later modifications consist of clarifying the logic, removing irrelevant aspects, and simplifying and integrating the outline of the theory. Lastly, memoranda written during the analysis process (e.g., Appendix) are sorted. The original list of categories is greatly reduced. Data are now ordered and become a systematic statement of the matter under study. Abstractions have been formed to explain the underlying complexities of the data. Inconsistencies are- brought to view to be accounted for or explained. The final form of the theory is an integration of the conditions, contingencies, contexts, consequences, and strategies around one or two core variables which are rich in conceptual detail and adequate to develop testable
hypotheses. ADVANTAGES OF THE GROUNDED THEORY METHOD
Applicability by
Practitioners
Presentations of grounded theories to practitioners have shown that they do not require an interpreter to translate the research. The practitioner can hear it, relate it to his or her experience, and apply it. Such conceptual schema Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
285
properties which favor successful application: close fit to the practice area, understandability, generality, and focus on situational structure and dynamics over which users have at least partial control.&dquo; have four
Fit and understandability. Grounded theories generally meet the criteria of fit and understandability by definition because of the means through which they are developed. Only those theories which are thin-built with insufficient data and inadequate theoretical sampling-will fall short of the criteria. Use in grounded theories of imagery, examples, and concepts drawn from the contexts on which these theories are based makes them immediately recognizeable to practitioners and laypersons who are familiar with the area. &dquo;Shifting gears,&dquo;22 a popular guide on making major life changes (and also a grounded theory) has been helpful to many lay readers; &dquo;Taking chances&dquo;2° sheds light on the dynamics of behavior involved in unwanted pregnancies and repeated abortions for a wide range of persons involved in family planning and abortion programs. Generality. A grounded theory meets the criterion of generality, because it is based upon the accumulation of &dquo;a vast number of diverse qualitative ‘facts’ on many different situations in the areas or sampling of variables rather than being based upon sampling of people aimed at representativeness of a population. Seeking out as much variation as possible and developing hypotheses to explain the variation helps to guarantee that the theory can be exported from the locale in which it was developed. All the practitioner has to do is to identify what conditions are present in the new situation to understand how the grounded theory will apply. Disadvantages of many deductive and of most purely descriptive studies are that they rapidly become outdated and yield relatively few general concepts. From the standpoint of practice it is more fruitful to know the types, range, magnitude, and conditions of occurrence of a phenomenon rather than merely the frequency of occurrence. ControL By &dquo;control&dquo; Glaser and Strauss refer to enabling the person applying the theory: ...to
understand and
analyze ongoing situational realities,
to
produce
and
and to predict and control consequences both for the object of change and for other parts of the total situation that will be affected. As changes occur, his theory must allow him to be flexible in revising his tactics of application and in’revising the theory if necessary. &dquo;(PZ45)
predict change in them,
understanding of the social process of cutting back,&dquo; for instance, enables practitioner working with heart patients to understand and predict situational realities. It is possible for more heart patients to reach an appropriate level of physical activity more easily and quickly by assisting them in learning to discriminate among bodily signs and read warning signals and in reinforcing their judgments. Changing the awareness context of surgery patients from closed to open by telling them what is going to happen to them An
a
increases the number of patients who have less severe pain.’° Grounded theories also have practice validity. In the process of the original research the theory is subject to verification by those who are immersed in that 286
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of social life; however, the theory can be modified through experiences gained in applying it (this may be thought of as an extension of theoretical sampling, as described above). Another example from the Mullen study21 will illustrate this process. A practitioner reading her study of heart patients would be sensitized to the propensity of persons confronted with a chronic illness to develop a causal explanation for its occurrence. This is hypothesized to influence the ill person’s choice of subsequent behaviors designed to prevent crises and further damage or other worsening of the condition, so it would seem important to learn how patients with another illness viewed the cause of their problem. A health educator working with a hypertensive black population learned that there were not only the levels of causal theories found among other heart patients (i.e., causes of the condition in the individual and causes of short-term fluctuations), but also a new level which is constructed by black patients to explain the high prevalence of the condition among black This does not make the original hypotheses invalid. It simply leads to the addition of a new condition; (when the disease appears to strike a particular group disproportionately, there will tend to be causal explanations for this). Once these insights are gained, the practitioner needs to explore the consequences of the various levels of causal theories for regimen-related behavior and the proportion of persons subscribing to certain sets of area
people.’
’
explanations. Analysis of Processes
Versus
Analysis of Units
are a crucial aspect of health education, and the grounded theory particularly oriented toward understanding them. As such it meets specifications for a strategy which would
Processes
method is
...trace the lines of defining experience through which ways of living, patterns of relations, and social forms are developed, rather than to relate these formations to a set of preselected items,J(Pp138-9) -
Present research strategies are of limited help in this regard, because they focused on units such as persons and their roles, institutions, subcultures, and so forth. These analyses tend to be bound to finite times, places, and people, and as such, are quickly outdated. (Of course, studies of the beliefs, attitudes, and practices related to family planning or other health concerns of programmers provide baselines for evaluations, and they offer suggestions for program development.) In contrast, the grounded theory approach uses social units to study the movement of social life through time. The unit only provides the conditions under which a process varies, so that grounded theories have greater generality because of their transcendance of the specific identities of particular units, and because processes are more basic objects of research. Two grounded theories which resulted from analyses confined to the stages of development and types of actors within single institutions illustrate the generalizability of such products: One was set in an anti-psychiatric treatment center for schizophrenic teenagers, focusing upon the subtle process of maintaining control under conditions of freedom
are
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287
The other
study developed
a
process model of
institution-building
from
historical documents and participant observation which covered the 12-year history of technical assistance to an overseas family planning research and communication center.25 Four stages of development were indicated by the data: initiating, transitioning, consolidating, and enabling. The core variable was role-sharing, by which was meant that at any time several personsadvisors and counterparts alike-were performing acts which in their sum represented the performance of an institutional role, such as manager, social scientist,- or leader. Other process variables which were managed include orientation toward (another cultural world) balancing priorities; pacing change and development; modeling desired behaviors; coaching others on how to act in new roles; sponsoring or vouching for capabilities of one’s counterpart (particularly in public roles); and letting go, which is learning when and how not to act.
Psychological Level of analysis Choice of level of analysis for the study of a substantive problem area has great influence on the range of solutions which might be developed as a result of the study. One view of research recognizes three levels: (I) rates (descriptive, verificational, and distributive); (2) modal patterns of behavior; and (3) personal patterns. While it may be clear that grounded theory is not concerned with rates, it should be stressed that the goal of this approach is to explain modal patterns of behavior, not personal patterns. This distinction is maintained in the definition of the problem by a researcher using the grounded theory approach (see below). With this approach explanations of behavior patterns are viewed as problems with which the individual is coping Social
&dquo;
as inherent within him. The assumption that the individual carries the cause of his problem within himself is common in the literature of deviancy, illness behavior, and mental health. Such work accounts for present behaviors in terms of personality, cultural training, social class, and the like. Lofland has referred to studies which emphasize special, pre-existing proclivities as &dquo;dispositionalist,&dquo; and he notes that this label still applies to work focusing upon &dquo;temporally and geographically remote or diffused variables’ Grounded theory emphasizes the level of analysis in which situational patterns and their personal and social meanings account for behavioral patterns. These are patterns of people, abstracted from personal identities. Thus, an answer to the question, &dquo;Why do juveniles steal stereo sets?&dquo; is &dquo;Because they are easy to pawn.&dquo; (Why a particular boy steals a stereo is not explained.) In typing behavior an actor is a free agent who can walk in and out of the process. The person is not typed one-dimensionally. He is not a deviant-rather, he is someone who engages in deviating. The grounded theory approach contrasts with the tendency of agencies of social control (juvenile courts, schools, health departments, and medical care workers, for example) to rush this person into the role of deviant Such an explanation is illustrated by BVhyte’s33 account of why waitresses
and not
-
288
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cry. He does not discuss the women’s personality traits. Instead, he focuses upon the organization of their work which often subjects them to upsetting cross-pressures. The orders from superiors, orders from impatient and demanding customers, and even requests from co-workers sometimes builds up to a point at which a waitress will break down and cry.
Problem Definition: The Victim’s Perspective In using the grounded theory approach the problem is allowed to emerge from the data and is thus defined by the actors in the situation. This is consistent with the traditional philosophy of health education. However, some established research strategies force pre-structured questions and interview schedules upon people without asking them how they define their situations and problems. Health education researchers sometimes find themselves representing established interests in trying to change the wrong ’
people. Ryan has described a research and program planning formula which is all familiar, and his perspective surely challenges researchers and
too
practitioners: First, identify a social problem. Second, study those affected by the problem and discover in what ways they are different from the rest of us as a consequence of deprivation and injustice. Third, define the differences as the cause of the social problem itself. Finally, of course, assign a government bureaucrat to invent a humanitarian action program to correct the differences.28(P8)
grounded theory approach makes it much less likely that the researcher or recommend solutions which aim to change only the patient, the hard-to-reach, or others who pose problems to health The
will blame the victim
professionals. Several studies4-6,8,23-24,3] using this method bear out an important point about grounded theory as illustrated with the chronically ill. Focusing on the core social psychological problems of those who are chronically ill has greater explanatory power-accounts for more of what goes on behaviorally-than approaches which view the medical problem as central. Actions of the ill person which seem anomalous, inexplicable, or irrational when described in relation to medical objectives, appear quite understandable, appropriate, and predictable when analyzed in terms of the consequences of the illness. Noncompliance could be reconceptualized and re-explained in terms of the patient’s selective utilization of the regimen and other strategies preceived to optimize health in order to maximize areas of functioning which have high priority. Thus, an approach which concerns itself with the meanings, definitions, and interpretations which are made by the subjects of the study has greater potential for depicting their world and priorities more accurately than methods which begin by preconceiving that world and its meaning. And it is this which helps practitioners to see an ill person&dquo;s or community’s situation holistically. Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
289
Theory-Building:
Selection and
Integration
of Social Science Theory Health education could benefit from higher quality decisions about the relevance of existing formal theories, and the grounded approach offers an organizing feature which can bring together a wide range of literature and put the analyst in a better position to judge the usefulness of available theories. The use of a substantive grounded theory as a bridge between data and formal theory largely prevents the distortion, forcing, and neglect of data by a formal theory. As Mullen conducted a study of heart patients,2’ for instance, the important condition of having an invisible physical handicap led to exploration of the deviance literature for work on situations in which people wish to disguisd an aspect of themselves that is socially stigmatized, that is, to &dquo;pass.&dquo; The work of others such as Davis,’ helped to conceptualize aspects of the data; it then yielded ideas for further literature searches--e.g., on the social and psychological effects of successfully passing and on the attendant problems of selective revealment. Further data collection was then undertaken to ascertain the relevance of the new ideas for heart patients. Another example of the ability of a grounded theory to organize a large number of separate studies is the framework developed by Bigus in his study of alcoholiCS;2 this study of the social transformation of alcoholics from persons constrained by normal boundaries of behavior to those engaging in greater and greater deviance has helped to bring together a portion of the diverse literature of alcoholism. The grounded theory method could be helpful in another important aspect of building theory for health education-in the realm of practice theory. Among the many possible subjects are the processes of: ~ organizing persons and units within institutional settings; ~ coordinating the efforts of a variety of programs promulgated by different agencies; ~ establishing health education programs in relatively new settings such as health maintenance organizations under organizational contexts ranging from compliance with federal regulations to strong support by one or more constituencies; and ~ facilitating interdisciplinary cooperation among medical care ’
workers. Further development of theories of practice would be a contribution to program development and evaluation, training educators, and setting new priorities for research.
significant new
health
CONCLUDING REMARKS: ANOTHER RESEARCH STRATEGY FOR HEALTH EDUCATION In summarizing this introduction to the grounded theory approach and its potential for health education, its strengths as a research strategy and its unusual compatibility with the principles of health education practice should be stressed. Substantive grounded theories would flesh out the linkages 290
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theory, research, and practice in community health education to a greater degree. Their empirical roots makes them understandable to those among
who are involved in that substantive area, and they immediately introduce the reader who is unfamiliar with the area to important variables. Existing social science research and theory can be brought to bear on the problem more fruitfully when they are related to the data by the conceptual bridge of a
grounded theory. While one research strategy should not be emphasized to the exclusion of others, greater interest in the grounded theory method is warranted. One needed change is wider recognition within the field of health education of inductive, qualitative research as a legitimate mode of inquiry. Too often the labels &dquo;soft,&dquo; &dquo;lacking rigor,&dquo; and &dquo;not really scientific&dquo; are applied. This appears to be because of exposure to poor examples and/ or because of the perpetuation of the bias favoring deductive, experimental designs as the highest form of research which psychology adopted in its drive to move from a philosophical to a scientific discipline. This limited view of scientific inquiry is one which ironically, the physical sciences do not share at all. In biochemistry, for example, inductive development of models is a major part of research
activity. Health education training institutions ought to include the grounded theory approach in research methodology survey courses, (e.g., 15). As a basis for more advanced training and also as valuable skills for health education practice, systematic participant observation and inductive thinking should be taught (e.g., 30). Faculty members should encourage interested students to take more extensive course work in the method at institutions where this is available (e.g., University of California at San Francisco, Berkeley, Davis, and San Diego; Teachers College; University of Washington; and University of Oklahoma). The second of the grounded theory methodology books is now in press, 12 and that together with careful study of completed studies such as those cited in this paper are helpful for self-teaching. Students and practitioners could also benefit from reading more grounded theory studies. In conclusion, then, health education would be enriched greatly if this research method were given more attention. -
ACKNOWLEDGEMENTS
The authors wish to acknowledge the contributions of Drs. Barney G. Glaser, Lawrence ~’V. Green, Anselm L. Strauss, and Harold Gustafson, and the members of Dr. Glaser’s research seminar 1972-1974. The authors’ training in the grounded theory method was undertaken during their doctoral work at the School of Public Health, University of California, Berkeley, and sponsored by U.S. Public Health Service Traineeships. REFERENCES 1. Arnold GM: A
Question of Control: A Study of Black People’s Perceptions of and Adaptions to Hypertension. Master’s thesis, Department of Health Education, University of Washington, 1978. Downloaded from heb.sagepub.com at UNIV CALGARY LIBRARY on March 19, 2015
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2. 3. 4. 5.
6. 7.
8.
9.
Bigus OE: Becoming "Alcoholic": A Study of Social Transformation. Doctoral dissertation, University of California, San Francisco, 1974. Blumer H: Symbolic Interactionism: Perspective and Method. Englewood Cliffs, New Jersey, Prentice-Hall, 1969. Charmaz KC: Shouldering a burden. Omega 3:23, 1972. Charmaz KC: Time and Identity: The Shaping of Selves of the Chronically Ill. Doctoral dissertation, University of California, San Francisco, 1973. Davis F: Passage Through Crisis: Polio Victims and Their Families. Indianapolis, BobbsMerrill, 1963. Davis F: Deviance Disavowal: The Management of Strained Interaction by the Visibly Handicapped. In Becker HS (ed): The Other Side: Perspectives on Deviance. New York, The Free Press of Glencoe, 1964, p 119. Davis MZ: Living with Multiple Sclerosis: A Social Psychological Analysis. Springfield, Illinois, Charles C Thomas, 1973. Derryberry M: Research procedures applicable to health education. J Sch Health 33:215, 1963.
Egbert LD, Battit GE, Welch CE, et al: Reduction of postoperative pain by encouragement and instruction of patients. N Engl J Med 270:825-827, 1964. 11. Fagerhaugh SY, Strauss AL: Politics of Pain Management: Staff-Patient Interaction. Menlo Park, California, Addison-Wesley, 1977. 12. Glaser BG: Theoretical Sensitivity: Advances in the Methodology of Grounded Theory. Mill Valley, California, Sociology Press, in press. 13. Glaser BG, Strauss AL: Awareness of Dying. Chicago, Illinois, Aldine-Atherton, 1965. 14. Glaser BG, Strauss AL: Awareness contexts and social interaction. Am Sociol Rev 29 :669679, 1967. 15. Glaser BG, Strauss AL: The Discovery of Grounded Theory: Strategies for Qualitative Research. Chicago, Illinois, Aldine-Atherton, 1967. 16. Glaser BG, Strauss AL: Time for Dying. Chicago, Illinois, Aldine-Atherton, 1968. 17. Glaser BG, Strauss AL: Status Passage. Chicago, Illinois, Aldine-Atherton, 1971. 18. Hochbaum GM: Research to improve health education. Int J Health Educ 3:141, 1965. 19. Lofland J: Analyzing Social Settings: A Guide to Qualitative Observation and Analysis. Belmont, California, Wadsworth, 1971. 20. Luker K: Taking Chances. Berkeley, California, University of California Press, 1975. 21. Mullen PD: Cutting back after a heart attack: An overview. Health Educ Monogr 6 :29510.
311, 1978. 22. O’Neill N, O’Neill G:
Shifting Gears: Finding Security in a Changing World.
New York, M
Evans, 1974.
Quint JC: Becoming Diabetic: A Study of Emerging Identity. Doctoral dissertation, University of California, San Francisco, 1969. 24. Reif L: Managing a life with chronic disease. Am J Nurs 73:261, 1973. 25. Reynolds R: Institution-Building and the Development Process. Doctoral dissertation, University of California, Berkeley, 1973. 26. Roberts BJ (ed): Health Education in Medical Care: Needs and Opportunities. Berkeley, School of Public Health, University of California, 1962. 27. Roberts BJ: Research in Health Education: Background Paper. Geneva, World Health 23.
Organization, 1968. 28. Ryan W: Blaming the Victim. New York: Vintage, 1972. 29. Sackett DL, Haynes RB: Compliance with Therapeutic Regimens. Baltimore, Johns Hopkins University Press, 1976. 30. Schatzman L, Strauss AL: Field Research: Strategies for a Natural Sociology. Englewood Cliffs, New Jersey, Prentice-Hall, 1973, pp 8-9. 31. Strauss AL, Glaser BG: Chronic Illness and the Quality of Life. St. Louis, Missouri, Mosby, 1975. 32. Steuart GW: Scientist and the professional: The relations between research and action. 292
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Health Educ Monogr 1(29):1-10, 1969. 33. Whyte WF: Human Relations in the Restaurant Industry. New York, McGraw-Hill, 1948. 34. Wilson HS: Infra-Controlling: Social Order Under Conditions of Freedom in an AntiPsychiatric Community. Doctoral dissertation, University of California, Berkeley, 1974.
APPENDIX MEMORANDUM: PROPERTIES OF CAUSAL THEORIES
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293
’
APPENDIX (Co»iinued)
MEMORANDUM: PROPERTIES OF CAUSAL THEORIES
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294
