Cross-cultural comparative research methods workshop Kuopio, Sept. 2011

1. Cross-cultural comparative research methods workshopKuopio, Sept. 2011 Prof. Edwin van Teijlingen

2. Is cross-national research possible? “Holland differed enormously from other countries …. also in its arrangements for childbirth… It is difficult, given these factors, to find bases for comparison. In attempting to explain such differences, we are also drawn inevitably into an analysis of Dutch society and economy, educational provisions ... the culture surrounding childbirth …” Lieburg van M.J. & Marland, H. (1989) Medical History33: 296-317

3. Overview Traditional approaches to comparative research / cross-national studies. Decentred Comparative Research

4. Strengths comparative research • You learn to question your own ways of doing things from observing the “strange” ways of others. • You can (may) study approaches which have not been considered in certain countries, for example, “looking at the problems from a different angle, questioning present practices, raising warnings as to possible negative effectiveness” (Collins et al. 2000: 97).

5. Traditional approaches Types of comparisons: • Over time; • Between geographical areas; • Between populations within a community / society • Between countries / cultures

6. Comparisons over time

7. Comparisons by sub-group in population Girls in developing countries are generally disadvantaged in the education system: • less likely in secondary education than boys; • those in rural areas are particularly disadvantaged; • but, today’s adolescent girl is 2 to 3 X more likely to receive an education than her mother.

8. Comparing at different levels Example I comparison between countries Example II comparison between regions

11. Problems with epidemiological data • Data sets differ between areas; • Data are collected for a different reason, often they do no exactly address our research question; • Definitions of topic under research vary between areas; • Cultural differences in interpreting survey questions introduces differences in the data sets; • Data sets are incomplete/ missing data; • Response rates to survey underpinning data sets varies;

12. Overview Traditional approaches to comparative research / cross-national studies. Decentred Comparative Research

13. Introduction / aim of BBD The main goal of this international project was to bring together researchers located on both sides of the Atlantic, who, until that time, had almost exclusively focused on issues pertaining to maternity care within their own academic disciplines and national boundaries.

14. Shaping a Network of Local Researchers BBD brought together researchers from two continents and 9 countries; while some had done two-country comparisons, BBD involved comparisons of up to four countries at a time; examining everything from the training of maternity care providers to public policy, to attitudes of women about desirable care.

15. What is main task of the state in the provision of maternity care? Culture & Society ?

16. Main task of the state? Americans replied: "To ensure that individual women have freedom of choice” and "to make choice available for childbearing women". Europeans: "to ensure that the poorest women in society have access to a reasonable quality of maternity care" and "to ensure that all women have access to good maternity care". ... we were talking from our own culturally colored perspectives. (DeVries et al. 2000: xvi)

17. Cause or effect? “We do not wish to discount the role of clients in the creation of maternity care systems, but we are keenly aware that opinions about health care are as much a productas a causeof that care.” DeVries et al. (2001) ‘What (and why) do women want?’ In: Birth by Design, Routledge, NY, p. 244.

18. Comparative studies in maternity care Structural: • organisation of health care, welfare state, politics, law, economy, etc. Cultural: • attitudes, general views, expectations of a population, ‘the way things are done here’, etc.

19. Lessons BBD • When we began our work together, our natural inclination as sociologists was to look for structural explanations for the variation we discovered – the tradition in the field of medical sociology is to use differences in social structures to explain varied health care delivery systems.

20. Lessons BBD • Structural explanations were insufficient: they simply push the question back one level. For example, our research uncovered important differences in the power of professional groups to influence health care policy – differences that had significant influence on how maternity care was delivered.

21. Problematising Terminology Comparing like with like? • Trained nurse-midwife • Direct-entry midwife (NB: UK vs US meaning) • Midwifery assistant / maternity care assistant • Maternity benefits • Economic migrant • etc.

22. Comparative research Comparative studies • Cross-national research helps one to look at problems from a different angle, questioning current practice, warn against side effects, etc. I.e. there exist ways of doing things which have not been considered in the UK (or Germany or Finland or …..) . • Cognitive psychology recognises that cognition is a situated process and that knowledge is a collaborative, culture-bounded effort.

23. Decentred method I key aspects: • add context to seemingly context-free concepts. • challenge ethnocentrism in cross-national research. • all contexts are perceived as problematic & in need of explanation. • team of scholars rooted in multiple communities.

24. Decentred method II BBD used decentred method to fashion a multilevel framework that used meso level of organization (i.e., health care organizations, professional groups and other concrete organizations) as an analytical point. Our method departs from traditional comparative health systems research that is mostly conducted at the macro level. Macro Meso Micro

25. Decentred method III Decentred comparative research – addresses the often unacknowledged ethnocentrism of traditional comparative research. Decentred cross-national research draws on the socially-situated and distributed expertise of an international research team to develop key concepts & research questions.

26. Decentred method IV “International collaboration, if pursued more systematically, is a strategy for individual researchers to become more cosmopolitan in their reflexivity….”

27. Recent example

28. Salway et al. (2011) I Salway and colleagues adopted: “… frameworks that encompass both national-level contextual specificity and universal patterns or trends [Hantrais 1999; Wrede et al. 2006].” “We adopted approach that did not seek to impose standard concepts or measures (something we felt was neither conceptually nor operationally feasible) but rather to work with the national peculiarities of our three countries.”

29. Salway et al. (2011) II • We worked “with and against the established discourses …to understand …migrant/minority groups and the implications for maternal health. Such an approach offered potential for important new insights. • BUT moving beyond accepted concepts and terms may create problems at a country-level. We … need to engage with local stakeholders and to generate research products that were meaningful and applicable to these actors; suggesting the importance of employing familiar concepts and terminology.”

30. Final Note: Culture Sharing a culture does not mean people are in agreement on specifics, only that they possess a similar understanding of how the world works.

31. References Benoit et al., 2005, Understanding the social organisation of maternity care systems, Sociol Health Illness 27: 722-37. Collins et al. (2000) NHS reforms in UK & learning from developing country experience. J Man Med, 14: 87-99. DeVries, R, et al. (eds..), 2001, Birth by Design: Pregnancy, Midwifery Care & Midwifery in North America & Europe, NY: Routledge. [ISBN 0-4159-23387] Galtung, J., 1981, Structure, culture, and intellectual style, Soc Sci Information 20(6): 817-856. Hantrais L (1999) Contextualisation in cross-national comparative research. Int J Soc Res Meth2(2):93-108 Lieburg van MJ & Marland, H, 1989, Midwife regulation, education, and practice in the Netherlands during the Nineteenth Century. Medical History33: 296-317 Lupton, D, 1994, Medicine as Culture: Illness, disease & the body in Western Societies, London: Sage Payer, L., 1990, Medicine & Culture, London: Victor Gollancz Ltd. Wrede, S., et al. (2006) Decentered Comparative Research: Context Sensitive Analysis of Health Care, Soc Sci & Med, 63: 2986-2997.

32. Cross-cultural comparative research methods workshopThank you! Edwin van Teijlingen