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Overview
Whilst the main themes within the book will look very similar to those in many other texts on qualitative research methods, they will:
- Apply the concepts familiar from qualitative methods to health economics issues in a way that is meaningful in this specific context;
- Work within an economic analytical approach where the analytic focus is on issues around scarcity and resource allocation;
Product Details
| ISBN-13: | 9781783485635 |
|---|---|
| Publisher: | Rowman & Littlefield Publishers, Inc. |
| Publication date: | 07/10/2017 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 320 |
| File size: | 5 MB |
| Age Range: | 18 Years |
About the Author
Read an Excerpt
CHAPTER 1
Theoretical and methodological positions and the choice to use qualitative methods
Joanna Coast and Louise Jackson
It is assumed that the main audience for this book comprises (health) economists with an interest in using qualitative methods in their own research; this chapter therefore begins the book with a relatively accessible discussion of issues around ontology, epistemology and methodology. The nature of training in economics (Lawson 1997; Lee, Pham, et al. 2013) means that many economists reading this book may be unaware of these terms and will not have thought about these issues previously (Coast 1999). Indeed, when publishing her first article exploring these issues in a health economics journal in the late 1990s, Coast was asked to include a glossary detailing these terms, as they were deemed to be terms that health economists would generally be unfamiliar with (Coast 1999). It has been noted that economists' training does not tend to provide an understanding of data collection processes or the role of qualitative methods in complementing quantitative research, with Berik stating that 'such training would be an eye-opening and humbling experience – an essential antidote for arrogance – for economists who do not question their data' (Berik 1997, p. 124). Those with an existing sophisticated understanding (e.g., qualitative researchers reading the book because they are working with economists) may want to read this chapter not so much for its content but to become aware of the different understandings of ontology and epistemology that the economists they are working with may have.
This chapter begins by considering theories of knowledge and their application in economics, drawing on Coast's earlier paper (Coast 1999). There is much work of an explanatory nature examining issues relating to the nature of health care systems as well as health more generally. The vast majority of this work is conducted within the neoclassical framework (indeed Murphy and colleagues have noted the 'narrowness of the range of economic thought that is currently being deployed on the problems of health technology and health services' [Murphy, Dingwall, et al. 1998, p. viii]) although explanatory work can also be conducted within alternative frameworks. Normative (welfare or extra-welfare), institutional, behavioural and feminist economics are all briefly considered, as is the potential for approaches based on critical realism. The chapter then details the nature of qualitative research methods as well as the constructivist philosophy with which they are most frequently associated. From this discussion it is apparent that such a philosophy is very different from that usually associated with the discipline of economics. The nature of enquiry associated with qualitative research is briefly examined, covering details of specific data collection methods, sampling, analysis of data and ensuring rigour. Despite differences in philosophy from mainstream economics, it is apparent that qualitative methods are useful to economists, and the use of qualitative methods in health economics is then examined. It is argued that robust qualitative research can provide scientifically valuable contributions to health economic knowledge both through improving quantitative data collection, such as when generating attributes for discrete choice attributes, and through contributing directly to economic theory, particularly in complex areas such as priority setting or developing financial incentives.
UNDERSTANDING RELEVANT TERMINOLOGY
Health economists embarking on qualitative research first need some understanding about the ways in which different types of researchers understand the world. Many are likely to have a view similar to that of Coast when she started work as a junior health economist in 1990. She had completed a first degree in economics and a master's degree in health economics, and throughout these degrees, theories had been largely presented either as self-evident, and thus without the need for any supporting evidence, or in terms of economists developing hypotheses based on deductive thinking and then testing these hypotheses using quantitative data.
An example of the former was the basic underlying principles of demand and supply, and the elaborations on these such as Giffen goods. These were presented as clear, logical and internally consistent interpretations of how the world works. But there was little in the way of evidence for many of these theories, perhaps underlining the views of some that economics is largely a branch of applied mathematics, with little relationship to the world outside (Rosenberg 1992).
An example of the latter might be the theories of supplier-induced demand, where economists have developed theories about how medical physicians might act in ways that shift the demand curve for health interventions from its 'true' level (the level that fully informed consumers might choose), perhaps to achieve higher income for themselves (Evans 1984). Hypotheses are then generated based on these theories, and various quantitative econometric techniques might then be utilized to test these theories. For example, the hypothesis might be around physicians not being able to achieve their target income if more doctors arrive in an area and thus choose then to increase their provision of services to achieve this income. This might then be tested using quantitative information about the levels of consumption of medical services alongside data about numbers of physicians working in a location (Evans 1980). The hypothesis can then be accepted or rejected.
In applying economics to health, health economists constantly come up against the problem that theories developed to explain 'the economy' (with varying degrees of success and with varying degrees of acknowledgement of that varying success) will very often not apply readily and simply to the 'health economy'. For Coast, her first job, as a lone health economist in a university department of epidemiology and public health in the United Kingdom, made this abundantly clear, as her relatively 'neat' views of the world did not reflect those of her new non-economist colleagues, nor as she could quickly see for herself the complexities of health care provision in the UK health economy. There was clearly a need for something more, and qualitative methods seemed to have potential in achieving a better understanding of the health economy and how it works. Even a small foray into this different research paradigm, however, suggested a very different perception of the world.
UNDERSTANDING ONTOLOGY, EPISTEMOLOGY AND METHODOLOGY IN (HEALTH) ECONOMICS
Ontology means the view of the nature and form of reality (Lincoln 1992). Epistemology is concerned with the theory and nature of knowledge, in particular the relationship between what is to be known and the researcher (Lincoln 1992). There are very different views of the nature and form of reality, although many health economists are unlikely to have given these issues much thought. Indeed, they may well assume that their own view of reality is universally shared because of the way in which the nature of the discipline is conveyed.
As suggested in an earlier paper (Coast 1999), most health economics explanatory research is achieved within an orthodox neoclassical framework. The standard view of reality within this 'positive' or 'explanatory' economics has had a number of influences including positivism, the notion that there is a single reality that can be researched (Hollis 1994), and the falsificationism of Popper (Blaug 1992; Hausmann 1994). Essentially, within this world view, there is a belief that there is a single, knowable reality and that research can help to find out about this reality. This reality comprises a set of rules that it is possible to determine (Lawson 1997; Graça Moura and Martins 2008).
Methodology is concerned with the means by which the person inquiring tries to find out what is to be known, the practice of research (Lincoln 1992; Creswell 2013). Methods of investigation within explanatory neoclassical economics are long standing (Mill 1994) and start from the individual; that is, assumptions about 'individual' preferences, both from consumers and from firms, are used to generate the behavioural assumptions from which the economic theory is built. This is known as methodological individualism (Hodgson 1986; Dugger 1994; Toboso 2001). In an explanatory research conducted within a neoclassical paradigm, the economist starts with a set of these assumptions, referred to as axioms, which are high-level principles that are regarded as being established and accepted (although the accuracy of these starting assumptions is often seen as less important than the resultant predictions [Friedman 1994]). From these axioms, often concerned with rationality or optimization (Lawson 2006), the economist can infer logically, through a deductive process, what might be predicted, and these predictions can be tested; these predictions then form the basis for explanation.
The testing of these assumptions draws on a particular view of the relationship between the researcher and what he or she is researching, in which it is assumed that the economist tries to be objective. The economist develops and tests hypotheses without allowing himself or herself to influence the findings or be influenced by these findings, so that he or she can confidently accept or reject the hypothesis/hypotheses that have been tested and thus confirm (or not) the accuracy of the theory generated. In general, at least theoretically, it is seen as better to try to test whether hypotheses can be falsified (Blaug 1992). Although the logical sequelae of falsifying a theory is to reject it and move on to generate new theories and test these, it has been noted previously that in economics this may not be the ultimate outcome (Coast 1999), with views expressed that economists may instead try to refine their mathematical expressions (Ormerod 1994), alter assumptions and try to bring more variables into the explanation (Lawson 1997). Indeed, in relation to the example of supplier-induced demand used earlier, it is notable that there has been difficulty in reaching clear conclusions (Labelle, Stoddart, et al. 1994) despite the problem being formulated in a number of different ways.
In testing hypotheses, the aim is to eliminate bias and obtain true knowledge about how reality works. Options for achieving this include the randomized controlled trial with which most health economists will be familiar, given the place of this method within health research as the 'gold standard' basis for determining the effectiveness of health interventions (Bennett 2007). Indeed, many health economists will have particular familiarity with this method through their conduct of economic evaluation alongside such randomized controlled trials (Drummond, Sculpher, et al. 2015). Although there are some famous exceptions, particularly around the use of health insurance (Manning, Newhouse, et al. 1987), randomised trials have not generally been used to explore economic phenomena for practical reasons. Instead, economists employ complex statistical and econometric techniques (e.g., instrumental variables [Angrist, Imbens, et al. 1996] or difference-in-difference approaches [Lechner 2010]) with the aim of reducing bias, applying these techniques to observational data for statistically representative samples of the population. A problem faced by economists, however, is that they generally use existing data sets that may have been collected with quite different purposes and intentions and may therefore not have access to good-quality data for answering their particular research question (Leontief 1982).
It is clear that ontology, epistemology and methodology in neoclassical (health) economics is of a particular kind: belief in a single knowable reality that is accessible through rigorous unbiased testing of hypotheses generated through logical inference from accepted axioms. As this chapter goes on to show, however, this set of beliefs and approaches is very different from that common among the broad set of disciplines where qualitative methods are commonly used.
Although most health economists reading this text are likely to have their academic origins in orthodox neoclassical economics, of course, many will also have other aspects to their interests, backgrounds and concerns. Health economists in particular, and in contrast to other economists, very often work within normative economics, where the concern is how policy should proceed rather than explanation. Health economists may be working from either welfarist or extra-welfarist perspectives (Brouwer, Culyer, et al. 2008; Coast, Smith, et al. 2008) which both ally to some extent with neoclassical economics in the extent to which they focus on the concerns of individuals and their values and preferences (Coast 1999) but draw on differing ethical theories that relate to how well-being is identified. For traditional welfarism, this well-being is identified with the satisfaction of individual utility (Hausman and McPherson 1994; Coast, Smith, et al. 2008), while for extra-welfarism in its usual expression as health maximization it is identified with some form of satisfaction of societal preferences for maximizing health gains (Culyer 1989; Coast, Smith, et al. 2008). Although these branches of normative economics undoubtedly rely on philosophical and ethical thinking about what should be maximized and why, there is also huge effort expended on trying to estimate preferences/values from unbiased samples of the relevant patient or general adult population to inform these normative assessments (see, e.g., Brazier, Roberts, et al. 2002; McCabe, Stevens, et al. 2005; Al-Janabi, Flynn, et al. 2011; Flynn, Huynh, et al. 2015; Ratcliffe, Huynh, et al. 2016). In a similar way to explanatory economics, health economists working in this area, at least until recent years, have tended to start with assumptions about what is valuable and then test these assumptions about what attributes/dimensions of wellbeing/health/utility are important to people through estimating the values given to them through some quantitative form of preference elicitation (common methods include time trade-off [Buxton and Ashby 1988; Brazier, Ratcliffe, et al. 2007], standard gamble [Baker and Robinson 2004; Brazier, Ratcliffe, et al. 2007], willingness to pay [Donaldson 1993; McIntosh, Clarke, et al. 2010], person trade-off [Pinto-Prades 1997; Dolan and Green 1998] and discrete choice experiments [Louviere 2000; Ryan 2004; Bansback, Brazier, et al. 2012] including best-worst scaling [Flynn, Louviere, et al. 2007; Louviere, Flynn, et al. 2015]) and testing whether they are significant.
(Continues…)
Excerpted from "Qualitative Methods for Health Economics"
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