Grounded Theory
As part of my training in qualitative analysis, I engaged in three studies of the roles which different cultural settings played on personal health maintenance related practices. This process took me about three academic years, and involved my use of anthropological research methodologies, combined with grounded theory methods and the use of several open-close classification system methods designed for use in qualitative data analysis.
Laotian Population Study
The first study was of a church setting servicing a Vietnamese-Cambodian community relocated during the late 1970s due to the Vietnam war. This study, performed throughout the winter and spring of 2000/1, focused on the mental health status of a locally small social group with ties to similar refugees programs established in Seattle and Iowa. The need for this activity was voiced by one of the members of this local ethnic community, whose service to them as a counselor and career advisor led her to request a review of her special needs group to determine what if any additional services could be provided to them by the university, county, state or federal programs. The goal of this program was to document the history of this problem locally, collect and analyze quantifiable qualitative and quantitative information on this special needs group, to analyze this information, and then to develop a plan of action and a series of recommendations pertaining to this community’s public health concerns and community health status.
According to published studies focused on the health of Laotian immigrant populations, forced to remove to the United States, due to the Viet Nam War, the primary health issues these people had to face included infectious disease transmission related problems, and emotional and psychosocial issues they will have to face due to their relocation during the late 1970s. The most important culturally bound syndrome for Laotians is the Diagnostic and Statistical Manual of Mental Disorders IV condition referred to as susto by Latino/a populations, amok by Malaysians, and latah by Laotians. The description typically provided for the amok behavior (i.e. “running amok”) very much has similarities with the emotional and personal behavioral attributes Laotians express whenever they discuss this during the group therapy process as a personal mental health concern. For this study, the focus on latah, in a western medical context, was pretty much focused on by determining the amount of social and public functionality a particular individual demonstrated in the group social meetings engaged in with this study (typically a weekly church-sponsored meeting, church service, peer counseling, followed by dinner setting).
Since the migration of Laotians to the United States, other medical conditions and syndromes have been noted in the medical literature as well, many not culturally-bound and psychosocial in nature, origin and display. The role of folk medicine practices and knowledge sources, such as the practice if Laotian herbology and dietary practices in relation to health status, and the use of Laotian specific acupuncture/moxi practice methods, have been shown to play a role in ongoing Laotian cultural settings in the United States. The availability of a community-centered religious practice setting helps to assist in the acculturation process, to whatever extent this change is allowed to take place by engaged local community leaders and members.
The Laotian Community. The local Laotian community was represented by at least four generations of members from a single family, with the youngest members just a few years in age at most and the family elders approximately 90 years of age or more. Each of the four generations demonstrated different sociomedical issues that had to be dealt with through their social networks, including primarily the church where many of these social gatherings and review sessions related to this study took place, and with the assistance of the local federal social services agencies.
The two youngest populations consisted of children in need of sufficient preventive medical care services, including parental assistance, food and nutritional supervision and assistance programs, and health maintenance activities involving the standard medical services such as child immunization, well-visit activities, family/peer counseling services, and for those attending a local school, school counseling assistance. The youngest children were already well-engaged in local social service programs established for childhood care, and the greatest risk to receiving this care in its fullest form pertained more to the ability of the parent to adhere to appointment scheduling and travelling to the clinical setting. There were limited provisions made by county and state offices in order to attend to this specific health maintenance/disease prevention need. At times, language barriers prevented parents from making their appointments on time due to their reliance and use of local taxi services, more often than public transportation provisions when a social services or family’s member’s assistance was not available.
The children active in local school settings had ample services available to meet their health and education needs. The local school setting health and nutrition programs were more than adequate. There were minimal language barriers when it came to meeting these members’ needs. Parents expressed no criticisms or concerns for any of these services.
The 18-45 year old members were usually actively engaged in some sort of employment-seeking or employment opportunity. Those already employed were working either within their social network setting or working at some storefront or service industry location which involved daily interaction with customers of all ethnic backgrounds and races. A number of the older males in this group actually owned the businesses they were employed with, and on occasion even developed the network needed to exchange, barter or trade these business opportunities freely with other members of their social group or cliché. Cultural-related problems typically involved individual separating from the family by way of seeking outside employment opportunities afforded to them due to their academic experience and contacts.
For the female members, social network and employment-related issues were substantially different. Although most expressed the same desire to work as the males of their age, many seemed to be more housebound due to family and extended family-related problems and concerns. The youngest members of this age group tended to display or express verbally their concerns about specific mental health-related problems of issues pertaining their social interaction skills in the work and/or college setting, and the stresses placed upon them by family members. For this reason, the most needy members of this group were those who were female and not involved in any college-related education programs or not involved in any long-term form of employment. They often tended to reflect back upon their family’s views of their obligations, which typically served as the primary barriers to them developing any social interactions outside the family and church community settings.
Employed individuals between 45 and 60 years of age often expressed their concerns about their heritage and its history, and the lack of this lifestyle since removing to the United States around 1978-1980. The youngest of these members discussed their initial problems of finding adequate income sources soon after their arrival, the memories of which seemed to have more of an effect on their present mindset than their current financial situation and now much better employment history. For the most part, most of the families with a male head in this age group were functioning quite well in the social and work settings, and were the most important contributors to this social networking program as a whole for the region. Likewise, their spouses also played important support roles in the community, and often tended more towards obtaining work primarily within the Laotian social setting. For some, this work was compensated for more so through barter and trade than through the production of a salary or hourly wages form of payment.
The fourth group of people attending these activities were the family elders, members either retired from work since their arrival, or with a limited background in the local workplace since their arrival. These individuals were usually not well-versed in English as a secondary language and usually required a translator to be by their side for much of the time in social settings. In the church meeting setting, these individuals tended to focus heavily upon their heritage and cultural history, commenting often about the impacts this migration had upon self-imagery, their economic status, their self-assigned personal and social values the felt they had to offer their community, and how these problems impacted their traditional lifestyles and intrafamily relationships as a whole.
Methodologies
Survey. As part of this research, a survey tool was developed targeting the university staff and student populations about topics pertaining to the Laotian student experience. This survey was carried out by targeting Laotian/Cambodian members of the campus setting in order for evaluations and comparisons to be made. This survey was also carried out separately by targeting non-Laotian members of the campus community. The primary purpose of this survey was to document on non-Laotian familiarity with Laotian heritage and its place on the map; the second series was developed in order to document how Laotian/Cambodian students felt they interacted with other peers or fellow students of non-Laotian background. This survey was carried out on 35 Laotian/Cambodian students and 15 non-laotian/Cambodian students.
Focus Group. The social worker attending this Laotian social activity introduced their member and fellow student, who in turn introduced the other members of the research group to the church members, leaders and Laotian community members. The purpose of these types of meetings were reviewed, and throughout the activity, passive engagement practices were followed and simple observation-related notes taken. Each researcher had specific tasks at hand and questions about the membership (age-gender-apparent education status or work status, etc.) that had to be asked and evaluated independently, followed by an evaluation o these results by the team as a whole following this activity. Each time we attended these meetings, one or more leaders or important contributors to the activity and social setting were interviewed (including the MSW), and notes taken and shared. Following the first week of activities, certain questions could be developed and then posed at the next meeting. Upon completion of this work, an open-system of analysis was engaged in to review these findings and present them to the population.
As per the grounded theory approach, we initiated this project without posing any questions other than “what role does this community program play in the adaptation of Laotian to the local living requirements” and “how does this effect, impact, alter or improve the physical and mental health of Laotian immigrants?”
Laotian Public Health History. Putting this into a public health perspective, it was readily apparent that the most important concern still in need of care-taking pertained to the mothers of school-age and pre-school-aged children. Historically, the most important issue with the Laotian migration was the prevalence of tuberculosis carriers in many of these families. Due to very active monitoring and prevention programs, tuberculosis is no longer a major threat to this community, although it is important to note that subsequent immigrants and elders known to be carrying tuberculosis for quite some time tend to be a problem every now and then.
The second most important pathology with a public health perspective for the Laotians was the Sudden Unexplained Nocturnal Death Syndrome (SUNDS) documented during the early 1980s for this social group. SUNDS was unique to Laotian immigrants at the time, and was originally interpreted as a biological phenomenon brought about due to particular genetic and familial traits linked to cardiac anatomy, histology, electrophysiology and functionality. This biological interpretation of SUNDs has since been replaced by a more combined psychosocial/psychoneuroimmunological state of being that had an effect on the heart during sleep cycles. The current philosophy assigns a fairly strong psychological and emotional component to the cause and effect of SUNDS than any anatomical or physiological components. Throughout this activity, the Laotian population I interviewed did not have the typical stories of elders who died soon after their removal to the United States. This doesn’t mean that SUNDS was not a problem for this particular Laotian community; instead, er it means that the Laotian interpretation of elderly deaths soon after their arrival were not felt to be a mental health or emotional issue.
Local Laotian Public Health Matters. The primary problems the local Laotians had to face seemed to focus on the members who arrived during their childhood years and their children. Based on the social networks established, the preventive medicine activities engaged in by local social services agencies, and the ongoing monitoring programs that exist with Laotian professional and peer counselors and Laotian social workers readily available, parental mental health issues were the most important issue that still has to be faced by this community. Their social ties and regular community gatherings remain their most important health-promoting activity.
New Age Churches and Health
The second study was of a church setting devoted to alternative metaphysical healing practices. This study was carried out over the 15-month period I spent engaged in a qualitative research techniques certification program. Due to my background in alternative/complementary medical philosophy, and my extensive background as a chemist in medical botany, I fit in quite easily with this social group and was able to develop a detailed understanding of how this religious philosophy fit in with other medically-based church- or cult-based disease/health maintenance philosophies including Christian Science, Scientology, 7th-Day Adventism, etc. This project included an ongoing demographics review of participants, a review of the primary purpose or objectives of the church’s teachings, a review of its most important philosophical elements, studies of its numerous teachings (including taped messages and such), and a review of its members on an individual basis through one-on-one and focus group discussion session.
The one-on-one and focus group work was the most important part of this research and defines its qualitative research portion. Before initiating these meetings and discussion, the leader of this church was already approached, interviewed, and the purpose of these interviews with members discussed. Even the members engaged in discussions with me about their practices and beliefs were already aware of the nature of these interactions. These sessions were performed and the topics that were reviewed were open to change. Sessions often began with one or two questions in mind, but quickly and automatically led to valuable material pertaining to the role of this particular religion in well-being and health. The topics reviewed were numerous and included such things as medical beliefs and practices, the purpose of going to the church, comments on the teachings and their reliability/credibility, their perceived purpose of this religion, any related personal medical experiences, how this church’s teachings fit in with other medical religions, what role the church’s goals and beliefs play in regard to regular and alternative medicine, etc..
For the most part, the followers of this church did not recommend their church’s practices over regular medical practices, a behavior typical of several other religious following with strong medical beliefs. They viewed their practice in a very Descartian fashion, respecting the role of the physician as a role important to personal health, and distinct from the role of religion itself (and “God’s fate or decisions) in one’s well-being. They viewed their role more like the role of a metaphysician, teaching “spiritual” practices for individuals to engage in that were in part, Buddhist in nature, in part natural theologian-like in nature, and in part very-Christian in nature. The typical church activity involved all of the parts of a traditional Christian activity in any Catholic or non-Catholic Christian church. The difference was, this following placed a much stronger sense of responsibility on the individual member and his/her role in defining her health-related destiny, including mental health and the role of community involvement and devotion to work as a part of this responsibility. The most common path taken in defining its recommended health promoting activities was the mindbody approach, which they really did not differentiate much into its different forms. Each individual had his/her own philosophy to develop and then follow and adhere to, such as psychosomatics and human psychology, psychoneuroimmunological theory, energy fields theory, Oriental chi theory, quantum theory, vibrational energy theory, etc..
An Alternative Medicine Adult Summer Camp
The third extensive combined qualitative-quantitative research project was my review of an adult summer camp devoted to alternative healing practices, primarily those which were exercise-health oriented, diet and lifestyle-based, or philosophical or metaphysical in nature. This involved my employment as a staff member at the camp, during which time I worked in buildings maintenance (repairman, doing building repairs, garbage pick-ups, pest management, etc.). This enabled me to have first hand access to much of the administrative materials related to this facility, which I used to produce a report on its activities, attendees, employed instructors, and special topics covered by the camp. The income generated by this program was about $1 million per month, and typically provided its education classroom and activity services to individuals making more than $100,000 per year. The “hot topics” covered by this camp facility included those very much a core part of the popular culture scene, topics typically supported by famous actors, artisans, and such, including the different forms of Yoga meditation, shamanism, the Native American sweat lodge activity, Sufiism, a number of very famous “world peace” speaker’s activities, psychological alchemy, different forms of color and music therapy, and methods of soul-partner exploration and relationships improvement, etc. Local community members were also interviewed in order to determine whether or not this fairly successful business demonstrated any significant social support practices involving the local (sometimes low-income) populations.
Current Projects
As a result of these past activities, my primary goal has been to develop some research skills that could be used to combine the traditional quantitative analysis techniques with the popular qualitative analytic techniques, the purpose of this being to produce a richer, more detailed review of your projects activities, results and outcomes. This technique was found to be especially helpful for the many small groups-related programs that such programs often engage in. In the Medicaid/Medicare population research setting, we often engaged in focus group activities in which specific members were targeted and asked to engage in a survey designed to provide important insights into how to best engage in certain intervention related events.
The typical PIP and QIA reports I was producing made use of these activities at times as part of the planning process, but often mentioned them in passing as part of a methodology or means of dealing with barriers to change (this information is often reported as part of the last table in a PIP or QIA). This greater focus on the qualitative method makes this an additional measurement tool that can be employed as part of a much larger intervention program. The goal of any of these types of activities I currently engage in several times per year is to develop methods of use in PIPs and QIAs that can add to the weight and value of the project as a whole. This method of combining qualitative and quantitative, parametric and non-parametric measurement techniques, makes for a much more credible research methodology.
Methodology Problems. With small groups, we have the problem of numbers and the possibility that statistical validity will be lacking when the groups involved with a study become exceptionally small. Qualitative research techniques provide us with several ways to correct for this problem of small numbers. In general, the smaller your group, the more lengthy and detailed the data has to be for your study. Individual case studies are sometimes the only way one can effectively evaluate a program for which only a handful of participants responded to its outcomes. A focus group study is the next type of analysis that can be performed, often with slightly more or double the amount of participants. Anthropological/ethnographic studies are next in population size, followed by the Grounded Theory application.
For grounded theory, you need a significant amount of data in order to engage in a comfortable review and summary of your program’s/project’s outcomes. This means that one or two dozen brief essay questions may be employed for some studies involving several dozen participants, or just a few fairly length essay replies provided by just a few people. The point is, you have to analyze whatever data they provide for you. In Grounded Theory, sampling is sometimes allowed in which case you are asked to select the best, most representative examples of outcomes needed to define the overall response population.
For the grounded theory methods I engage in, I typically apply this methodology to small numbers of responses. In theory, this kind of work can be managed in a fairly timely fashion if it involves 75 or less participants, but on occasion can even reach 100 participants depending on the length of the responses given for use in statistical evaluations.
My most recent project involved 150 pre-post Tier 1 population, a 45 detailed text responses Tier 2 population and a Tier 3 (essay response) population of just 12 people. In spite of these numerical differences for each level of this work, a detailed summary could be made for each Tier of this project. These summaries could then be reviewed relative to each other to determine what the overall impacts of the program were. For Tier 1, the numbers were adequate enough for traditional statistical measurement techniques to be employed. For Tier 2, a text analysis in combination with Grounded Theory was applied in order to develop a decent summary of the results that were presented. This evaluation included the use of chi squared analytic techniques (along with several others) due to the low numbers involved. This process made use of every case, every data entry, so no sampling process had to be employed. The Tier 3 results were focused on the benefits of the program, in essay response form. These responses were evaluated for content, and content type or class. Minimal statistical evaluations were made of this data. Instead it was related to Tier 2 results, which in turn were reviewed in relation to Tier 1 results, to determine if some common themes or outcome recur throughout the program thereby demonstrating its Tier 3 (long-term) effects of success. More on this methodology follows.
Brian Altonen, MPH, MS 