The anthropology of health and the health services

Rachael Gooberman-Hill, Research Fellow, Department of Social Medicine, University of Bristol

I work at the Department of Social Medicine at the University of Bristol where I manage, advise and do "qualitative" research. At the moment I work on pain, pain management and osteoarthritis, but I've also worked on and with other projects. For instance I worked on a project to evaluate an educational package for GPs ("family doctors") in the UK and have recently been involved in a Citizens’ Jury project designed to facilitate public involvement in setting priorities for research.  Much of my work uses one-to-one interviews, but other methods have their place too, for instance we also use focus groups and observational research methods.

Before working here I completed a PhD in Social Anthropology at the University of Edinburgh. My doctoral thesis was based on fieldwork in Solomon Islands. That fieldwork entailed a small amount of health-related work, which did not appear in my thesis. During my PhD I thought that I would like to start to apply anthropology in a manner that was practical. It was because of this that I ended up working on health-related topics for the MRC for nearly 7 years before transferring into the University of Bristol in 2007.  At first I was concerned about how such a shift in topic would be for me, but it was fascinating and I feel comfy working in the field of health now. When I started working in applied research I had to regard my previous training as a set of skills. These skills included research planning and organisation as well as skills in hands-on research. Also, I find that in an applied field, especially a multidisciplinary one, it's very important to be able to explain to others how one reaches particular research findings. Within health-related research there's a lot of emphasis on the visibility of the process of research itself. In general I like this, as it encourages more reflection about the process of research itself. However, in health there are now certain expectations about how qualitative research should be done, and these expectations are sometimes based on a very narrow definition of what qualitative research is.

Although my work does tackle policy-related issues, much of my work is still academic in character. For instance, I write papers for journals and attend conferences. I also do some teaching, some of which is for medical students. This work really makes on think about the relevance of anthropology to real world issues. I enjoy the fact that I work alongside people with different disciplinary backgrounds. In the department where I am based there are epidemiologists, statisticians, psychologists, clinicians and sociologists. My work is interesting and challenging. I'm constantly learning about new topics and new ways of doing things. I like the sense that my work might have some influence on policies relating to issues such as research priorities and pain management as well as to our future doctors. Although things can always change, at the moment I'm hoping to keep on the same track for a while yet.

Rachel Gooberman-Hill

Photograph shows Rachael Gooberman-Hill at her desk in Bristol.

Alexandra Greene, Senior Research Fellow and Honorary Lecturer, Department of Social Anthropology, University of St Andrews

Through my training in health education and social anthropology, I have developed a programme of applied research and teaching in the anthropology and sociology of health and illness and qualitative methodology. I am responsible for developing and teaching the anthropology of health and illness curriculum in the Department of Social Anthropology. In addition, I contribute to undergraduate and postgraduate medical courses at the University of Dundee. My research is in the area of client-centred health care and focuses on peoples' perceptions and experiences of health and illness and health care provision. In particular, the relationship between children and young people with a chronic illness, their family and health professionals. This includes issues of identity, risk, ethics, technology and audit. My work aims to promote a forum for interdisciplinary dialogue between social science, medicine and the lay public, and in this way strengthen the link between health policy, substantive knowledge, theory and clinical practice.

My current research programme is multidisciplinary and combines the theoretical and applied expertise of medical anthropology, sociology, health psychology, management, nutrition, public health and clinical medicine both in Scotland and cross culturally. I have conducted research in Guatemala, Italy, Mexico, Scotland and The Netherlands and worked for a number of funding bodies, such as the World Cancer research Foundation, Diabetes UK and The National Asthma Campaign.

The NEXUS Programme:

As an applied anthropologist I established and co-direct the NEXUS Programme (www.st-andrews.ac.uk/~nexus) a collaborative research programme between the universities of St Andrews's Department of Social Anthropology and Dundee's Department of Maternal and Child Health Sciences, within the Social Dimensions of Health Institute (SDHI).

The NEXUS Programme is an interdisciplinary research forum that has established an agenda of novel research in the field of medical anthropology and encompasses a range of topics relating to chronic illness, lifestyles, identity, race, adherence and concordance with therapy.

The core issues of the programme are: CONTEXT, CULTURE, COMMUNICATION AND CONCORDANCE

A particular focus is the investigation of concordance to therapy / clinical standards in relation to health and illness in children, young people, the family and health professionals.

The Programme examines 'ways of knowing' about concordance and involves the bringing together of different experiences and perspectives of client-centre practices (e.g. policy makers, health professionals, community workers and the lay public), and how such data can help to improve health outcome.

Rachel Gooberman-Hill

  • The Programme offers a non-hierarchical and non-oppositional examination of the attitudes, beliefs and behaviour of both lay-people and health professionals.
  • The programme promotes interdisciplinary dialogue through the translation of multidisciplinary philosophies, approaches and methodologies

The programme welcomes a number of research initiatives, as well as offering a selection of courses for a variety of professionals, practitioners and academics. The courses aim to combine practical skills in innovative qualitative methodologies with techniques to enhance client-centred communication, and the promotion of rigorous multidisciplinary research.

Fiona Harris, Research Fellow, Community Health Sciences, University of Edinburgh

I am employed as a research fellow in Community Health Sciences at Edinburgh University working on a number of projects, which keeps my work life both interesting and challenging. My main job at present is to review the literature on the determinants of suicide funded by the Scottish Executive Health Department, writing up some papers for publication and writing research proposals. I am now consolidating my interests and aim to develop a programme of research around patient experiences of chronic and terminal illness. My interests include the body, emotion, and experience. 
I came to anthropology and university education later than most after a long time of working and travelling both in the UK and abroad. I developed a strong affection for Malaysia over the years and decided to return there for fieldwork when I registered for a PhD in the Department of Social Anthropology at the University of Edinburgh. My initial interests focused on the link between gender, shamanism and power, but like many of my contemporaries, this changed as fieldwork progressed. Returning once again to Sarawak (one of the Malaysian states of Borneo) to conduct this research, it was not long before I realised that the most significant phenomenon to explore was religious change, since many people were in the process of conversion to Christianity. This encapsulated the flow between 'urban' and 'rural' environments, between changing forms of work and economy and generally engaging with a moral geography that included newly emerging folk models of modernity.

After graduating I aimed to secure a lectureship in social anthropology, however I quickly realised that not being either willing or able to travel around the country in pursuit of nine month contracts would almost certainly bar me from that first start on the ladder towards a permanent post. I was then offered a job with a former colleague in Aberdeen whom I had worked for before starting my PhD and also during my postgraduate studies. This marked a return to health research that was to have a huge impact on my future career as an 'applied anthropologist'.

I was employed as a research fellow on a study exploring the training needs of health professionals involved in the provision of 'rural' maternity care in Scotland. This study was both fascinating in its own right and also provided me with a window into working within a multidisciplinary team. During this project I gained skills that have enabled me to continue to work successfully within the health field and enhanced my understanding of research methods. Since then I have been employed on a range of projects that have further developed my research skills and experience. 

Like others in the Applied Anthropology group, I do not see a sharp divide between 'applied' and theoretical anthropology: my theoretical interests continue to develop in response to the research projects that I am involved in. For instance, the rural maternity care project enabled me to present two conference papers: one dealing with emotion, authority and 'rurality'; and another questioning both constructions and representations of the 'rural'. Furthermore, this led to a research project that was a study of methodologies applied to 'end of life' research. This fuelled a new interest in arts-based research methods.

Looking back on the past few years I feel that my career developed out of a mixture of planning, practicality and a good dose of serendipity. I still love theoretical anthropology, but I feel privileged to be in a position now where I am engaged in research that might make a difference, while also allowing me to develop as an 'academic' anthropologist.

Dr Guro Huby, Reader in the School of Health in Social Sciences, University of Edinburgh

I acquired a post as a Reader in the School of Health in Social Sciences, University of Edinburgh in April 2005. The post is part of a Scotland wide initiative to enhance the research capacity among nurses, midwives and allied health professionals in NHS in Scotland. A large part of the job, and the one I enjoy the most, involves helping professionals address practical issues by means of research. Research designs, which bring the research directly into practice are now very much in vogue and this gives this part of my job a 'cutting edge' feel which adds to the enjoyment. I also do my own research work, which at the moment includes finishing off my involvement in an ethnographic study of the effects of the new GP contract on general practice organisations and a study on workforce reconfiguration in English primary care services for respiratory disease.

My main occupation this last year has been to set up a training programme for Scottish managers of integrated health and social care services in use of information (routine data, qualitative information) to understand and manage this very fragmented and complex service system. We aim to help them better support front line staff and develop services in a coherent way. (For more information see Making Integration Work http://www.elib.scot.nhs.uk/CPDintegration) The Health Foundation is supporting an evaluation of this programme and this allows us to address an evidence gap concerning how managers can apply the current abundance of models of change management and Quality Improvement in real and messy everyday NHS contexts.

My training in anthropology is very useful in my work because I can identify how practical issues are created by the dynamics of a setting, and how 'whole systems' solutions have to be found to address them. The theoretical and practical grounding I acquired through my PhD training has laid the foundation for this, but I have honed these skills on the job and without formal training.

I arrived here via a chequered career history, which started with field work in the Southern Sudan for an MA in Anthropology from the University of Trondheim, Norway, my home country. I set out to study gender roles and urbanisation and ended up studying production and sale of alcohol and the construction and management of 'drink problems' in urban settings (with the usual amount of participant observation on the consumption side I am afraid). This made me interested in medical anthropology and the anthropology of health care. Since then I have settled in the UK and worked in applied and 'pure' research projects in a variety of areas ranging from management of problem drinking, use of community groups as a resource in primary health care, older people and hospital discharge, GPs use of evidence in clinical care, and the role of pharmacists in primary health care. I obtained my PhD in social anthropology in 1997 from the University of Edinburgh based on an action research project on co-ordination of services for people with HIV and AIDS in Lothian, Scotland. Most of this time I worked in the GP Section of Edinburgh University Community Health Sciences Division. This was a good place to be in terms of collaboration with NHS practitioners and I learned lots about the challenges, techniques and enjoyment involved. I also helped design and deliver the GAPP course 'Professional Practice for Multidisciplinary Research Work in a Health Context.' Between 1996 - 1999.

The last three years before my present post I lead a Scotland-wide initiative concerned with research based development of Scottish Primary Care. This was funded by the Primary Care Trusts with an explicit aim of practice-driven research and dissemination of research evidence. This brought me into very close and productive relationships with practitioners at different levels of Scottish health and social care organisations. I developed my repertoire of collaboration techniques and also acquired new skills. For example, I have now become really excited about routine quantitative service data! This data is important to better understand patterns of service provision and use. More interesting questions concern how this data is constructed, interpreted and used, and how the picture it presents maps on to the complex reality of a health service in change, and to people's - patients, clinicians and managers - experience of this reality.

My last job also brought home to me the realities of NHS 'modernisation' and change. The global economic and political forces which reconstruct health care in anthropologists' more traditional field work sites are also clearly changing health care on U.K. based anthropology's own doorstep. The potential for comparative work and theory building is there in abundance, and anthropology has a lot to contribute in facilitating understanding of the changes in health care and in helping people involved master them.

My future plans are to develop ethnography-based research and practice in the field of service change and 'quality improvement' and to contribute to an anthropological profile in this area. 

Becci Lynch, Independent Researcher

I knew I wanted to take at least one year out to travel before going to university, however, in order to do the year out scheme I wanted I needed to already have a place at university. Rather hastily I decided to go for Social Anthropology at the University of Kent at Canterbury as it seemed to incorporate all the areas I was interested in one way or another (plus it was part of a modular course so I could always swap to do another subject if I wanted!). It turned out to be even more "me" than I expected and I found the time I had spent living with an Arab-Israeli family in Israel during the year out scheme fed into my studies as well as helping me understand more about my time there.

In my second year I realised that I wanted to focus on Medical Anthropology and was, among other things, drawn to the more applied focus this could bring to anthropology. I spent four months working in a hospital in Bihar in India after my degree and then moved to Italy for eight months. These two periods brought about an interest in rituals and notions of fate and luck within healthcare and health beliefs particularly in preventative medicine. I chose to take these ideas further for my MSc. dissertation in Medical Anthropology which I did at University College London (UCL).

I then worked for in a research centre in Cardiff which focuses on largely on public health and health policy (both areas in which I saw a practical and applied use for anthropology). I worked in a multidisciplinary team which was a hugely beneficial (as well as eye-opening and at times frustrating) experience. It was useful to see how other disciplines view the same problem and how approaches can be combined to achieve the same goal. I also had the chance to gain greater understanding and experience of quantitative measures which I'd never come across in my previous studies. I was involved in different research projects while at the institute including designing and carrying out an evaluation of a Welsh Assembly Government healthy food policy in primary schools and looking at community, social cohesion and how where you live affects your mental health in the Welsh Valleys. I worked with and liaised with members of the Welsh Assembly Government, local government and other governmental organisations allowing me to get another perspective on policy and policy making. Hopefully the findings of both these projects will affect future Assembly policy in these areas. Building on this work, I also looked at the ethics of doing research, why people choose to participate in research, how and why research sites and groups are chosen and how they benefit from the work. As well as working for the research group I also taught on the undergraduate Social Research Methods and Introduction to Social Anthropology modules which I very much enjoyed, I tried to get students as excited about the subjects as I was in my first year! As these students are not doing anthropology as their main degree it has also been a useful experience for me to think how I can make the subject relevant to their area and the world around them.

These activities did not always relate to my anthropological training and I've had to develop many new skills. As the only anthropologist in the unit I felt I was able to offer a different and useful contribution to our work, also learning much about other approaches to research. As my anthropological background contributed to my work at Cardiff, I hope these other skills will contribute to my future anthropological work.

Never having previously wanted to start a PhD, but having enjoyed my masters and very much maintained my enthusiasm for the subject whilst at Cardiff, I have now left my post to pursue a PhD in Medical Anthropology. After three years experience of working in Public Health research I feel that I have gained many skills and much experience that will assist me in this or in future roles having written and contributed to reports and peer-reviewed publications, presented findings to a range of audiences and managed the day-to-day running of projects from start to finish. I'd like to combine my new knowledge and experience in the field of public health with my anthropological interests in preventative medicine, health beliefs and other socio-cultural beliefs in undertaking my doctorate, again hoping that my anthropological perspective can usefully be applied. What happens after that I'm not sure, but I hope that I can continue to use and further develop my knowledge and skills in anthropology in my work, and just maybe perhaps some of what I do might contribute something to anthropology or beyond!

Christine McCourt, Reader in Health and Social Science in the Faculty of Health and Human Sciences, Thames Valley University, London

My name is Christine McCourt and I am Reader in Health and Social Science in the Faculty of Health and Human Sciences at Thames Valley University, London (TVU).

I originally studied social anthropology at the London School of Economics and after working as a community housing worker for a few years, returned there to study for my PhD. I specifically wanted to get involved in applied research and thought that anthropological perspectives and methodology would have something useful to offer to other disciplines, and to policy related issues at home as well as in other countries. This was still rather unusual at the time, (the late 1980s) and I felt I needed to justify doing doctoral research in my own country. My doctoral research was conducted in and around a Victorian psychiatric hospital which was closing, examining the experience from the perspectives of the patients and staff, and within its social and cultural context. After completing my PhD (well actually, while trying to finish the write up!) I went to work at Brunel University as a research fellow funded by the Department of Health, looking at quality in residential and community care. While at Brunel I had my first experience of teaching, on the BSc and Masters in Anthropology of Medicine and the Masters in Social Policy- a great experience, where I learnt a great deal, about anthropology of health and illness and about teaching. After a short break - more kids, more writing - I started working as a NHS funded researcher focusing on maternity care.

My main area of interest is now childbirth and maternity care and with the Professor of Midwifery and Women's Health, I head up the Centre for research in Midwifery and Childbirth (CeMaC) at TVU. I'm involved in research in this area, particularly focusing on women's experiences, and organisational and cultural issues. I teach on several masters programmes, mainly for health professionals, and lead the module on childbirth and midwifery in history and cross-culturally. My main contribution to undergraduate teaching, since we don't have an anthropology programme, is in critical appraisal and knowledge of research, but I also teach on specific issues related to social sciences. I also supervise a number of PhD students who are working on ethnographic or anthropological studies of childbirth and maternity-related issues, in a range of countries and cultural settings, but also on ethnicity and health or illness and the integration of non-western therapies with biomedicine. This all makes for an interesting and rewarding working life.

I have found my background and skills in anthropology very useful for working in both theoretical and applied health work. I like to think of the role of an anthropologist working in this field as one of critical engagement. Not being a health professional, being an 'outsider' is useful rather than isolating. It makes it easier to bring a fresh eye to bear on practical issues and research questions, to approach things from a different angle, which can be complementary and useful as well as critical. I have found health professionals, especially midwives, very welcoming and keen to involve anthropologists because of this. A number of my students and colleagues have been keen to use ethnographic approaches to research, because they recognise ways in which this approach can help them to address particular types of questions - such as what shapes the experience of illness or health care, the role of the context of practice, why change is difficult. There are contradictory trends presently in healthcare - as in much of life - with moves towards modernisation, centralisation and protocol driven practices, and adherence to a rather rigid hierarchy of knowledge, but also attempts to recognise and integrate different types of knowledge and research, to humanise health services and re-establish community-based and person-centred practices. Although it can sometimes feel like a difficult balancing act - trying to 'keep up with' and understand the language of several different disciplines - it is also continually interesting and challenging in the best of ways.