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There may be no wrong answers, but there are wrong questions: Avoiding pitfalls in qualitative interviewing
We always tell our participants that there are no wrong answers, and it’s true. They are the experts, and if we’re not learning what we want from them, the blame is likely on us. Maybe our goals or our expectations for the research are misguided. Maybe we’re making some bad assumptions. Maybe, just maybe, we’re asking the wrong questions. The interviewer has a lot of power over what to ask and when to ask it during open-ended interviews and sometimes even the most experienced interviewer can make poor decisions. This article will cover some key interviewing pitfalls to avoid when conducting a qualitative interview. It isn’t an exhaustive list, so if you have any that I’ve forgotten or anything here that you disagree with, I’d love to hear from you!
Leading questions
Leading questions might be the first thing that comes to mind when thinking about interviews gone wrong, and researchers fall prey to asking leading questions all the time. They can come in a few, devious forms.
Leaning in on an answer. This is what most people think of when they think about leading questions: phrasing the question in a way that assumes the answer and in doing so, influences the participant to respond in a certain way. An example might be, “Do you wear your motorcycle helmet to give you a sense of security?” A better alternative might be, “Why do you wear a motorcycle helmet?” Leading questions shouldn’t be confused with mirroring questions (or “parroting” or “echoing” questions), confirming what the participant just said for clarification or to prompt additional information. The mirroring version would be something like, “What you’re saying is that wearing your motorcycle helmet gives you a sense of security?” That’s perfectly fine as long as you’re not sneaking little assumptions into your confirmations.
Narrowing the possibilities. Another way interviewers can lead a participant is by listing, and thereby limiting, potential responses. Here the interviewer may have the best intentions and funnel their participant unwittingly. Sometimes the participant is struggling with answering, and it can seem helpful to follow up with some possible direction. An example might be, “How do you use your cell phone…Do you text? Surf the web? Play games?”
These follow-up questions are unfortunate. For one, it can be helpful to know their first, top-of-mind answer, indicating it might be their most frequent or most important use. For me, if someone asked how I use my phone, my first answer might be, “I look to see if there are any good Burger King coupons.” If someone attached the list of examples to their question, I might start with “texting” instead and never even make it to my fast food addiction.
If you need specific information about their texting, you might start with an open-ended question (“What do you use your phone for?”) and if they don’t mention it on the first go around, you can follow up with questions about their texting habits.
Social influence. Social desirability bias is also an issue in quantitative research, but it can be especially potent in face-to-face, qualitative research. We often share our own experiences during our interviews and usually this is a totally harmless way to make the relationship more equitable and to build rapport. The danger is that it can key them into how we feel about whatever we’re studying and potentially steer their answers. It isn’t so much about asking the wrong questions as it is about being careful of what personal opinions to share. Studying politics? Don’t go in wearing your MAGA hat or your BLM shirt. Studying snacks? Don’t go in with orange fingers and lips, asking questions like, “I love Cheetos a lot, what do you think about them?”
Clustered questions
Another interview sin is bombarding participants with multiple questions at once. It can be a little overwhelming for the recipient of the onslaught, more like a college exam than a friendly conversation. Often the participant will answer just one of the questions, and maybe the interviewer will remember to return to the others, but maybe not.
Baffling questions
Ethnographers may be more prone to baffling questions than some other qualitative researchers. We are more likely to be looking at things like culture, social structures, and semiotics, and if we’re not careful, our questions can be overly abstract. Sometimes, we make the error of asking participants the same sort of “how the world works” questions that we’re asking ourselves in our analysis.
Questions might baffle participants when we use terms or concepts that only social scientists or marketers would understand. We can get so used to our jargon that we forget that it is jargon. Our questions also might be so removed from our participants’ experiences that they might seem absurd or even laughable to them. Market researchers are always asking people to think deeply about products and behaviors they normally don’t give much thought. “What kind of unmet needs do you have with your sour cream?” “How does taking your pills in the morning impact your sense of self?” Whatever package the baffling question comes wrapped in, the confused look of participants is always the same. Time to rephrase or move on.
Giant leap questions
Sometimes interviewers will change subjects so abruptly that it can throw off the pace and rapport of the interview. A segue can usually save the day but making a major shift in the interview’s direction can signal that you weren’t all that interested in what the participant just said. There will be times when leaps are necessary, e.g., if you have a participant who is bound and determined to talk about everything except what you’re there to talk about. There will also be times where a conversation line will be exhausted, and a new direction will seem natural. For the most part, however, questions should move the conversation along in a steady stride and not giant leaps.
Poorly-timed questions
Sometimes it isn’t about what you ask but about when you ask it. For one, interrupting participants is obviously in bad form, but interviewers might not even realize they’re doing it if they’re used to having to talk over their chatty friends and family. Not only must we wait our turn to talk, but we have to learn to embrace silence. It is a common technique to wait just a bit longer than seems natural to ask your next question with the idea that the discomfort from the silence will prompt the participant to elaborate further. It works, but at the very least, interviewers should give their participants plenty of breathing room to say what they please.
Another example of bad timing is going too deep or too personal with participants too fast. You have to build a little trust before you start asking about sensitive subjects. This includes asking for a home tour too early. Bedrooms and bathrooms can be just as private and personal as talking about your embarrassing health issues or your deepest feelings.
“Normally” questions
It is better to ask someone what they actually do than what they normally do. For example, instead of asking someone, “What do you usually eat for dinner?” You might ask them, “What did you have for dinner last night?” Or, “What’s on the menu for next week?” Afterwards, you might follow up with a question on how that compares to their typical dinners, but this approach promotes detailed answers and specific examples that can give color to your understanding. Or, better yet, skip the questions altogether and ask to join them for dinner or have them record their meals on a video diary!
Questions with one-word answers
Finally, when you’re doing open-ended interviewing, it is good practice to avoid questions that can be answered with one-word replies (unless you’re looking for very specific information). Instead, questions should be framed in a way that prompts as much elaboration as possible. For example, a better option to, “Did cost factor into your purchase?” might be, “Tell me how cost factored into your purchase?” Alternatively, you can follow up your more close-ended questions with something open-ended like, “Tell me more about that.”
In fact, asking someone to “tell me more” is the ultimate open-ended prompt. It isn’t really a question at all but a simple invitation to talk and share. This is the sweet spot of the ethnographic interview, where the interviewer simply provides the fuel for the participant to share themselves and their stories. It’s unrealistic to avoid questions that seek specific information entirely, but the participant exploring their relationship with the research subject while the ethnographer is there only as a delicate guide is at the heart of all good ethnographic interviews. As long as you are conducting your research in that spirit, all of your questions, more likely than not, will be good questions.
Old school ethnographers moving to online research
In early 2019, one of our clients asked us to do an interview and video diary study for them entirely online. We were open to the idea but a little skeptical. We had never done online research before and it seemed almost sacrilege to go against the long tradition of ethnographers immersing themselves, physically, in the research setting. We wondered exactly how far removed it would it be from our typical work. The interviews would lack much of the context of an in-person interview, and that is a real sacrifice. Still, we reasoned that if we weren’t getting much contextual, observational data from the interviews, we’d still be getting it through online video diaries. We had done similar video diaries for years where we send our participants cameras and ask them to document their lives, and we never doubted the soundness of these diaries. After all, Sol Worth and his colleagues were doing similar work over 50 years ago, handing their film cameras over to their participants to make movies. It isn’t much of a stretch to argue that video diaries, whether you’re using film, a camcorder, or a mobile phone, is an established ethnographic method.
After a little hemming and hawing, we decided that although nothing beats doing research in context, we could still get great data online by approaching it ethnographically. Once we actually got the project up and running, we were pleasantly surprised at just how good that data could be. This article will explore some of the practical and methodological challenges we experienced during our first foray into online research, and why we believe that ethnography online is a great option when in-person research may not be practical.
Diving in
Diving into this new way of doing research was a little stressful. With ethnography you want to feel like you’re at least in control of the process since what we’re studying, real life, is often so chaotic. Some of the transition to online research was easy. Participants typically go through a screener prior to the research so we can make sure they’re a good fit for the project. With our in-person research, we do this over the phone and often, at least parts of it, through an online questionnaire. Moving this screener entirely online was just a matter of learning the ins and outs of this new platform’s questionnaire tool. Transitioning to online interviewing was fairly easy too. Some nonverbal cues are different when talking to someone online, but being longtime users of Facetime, Skype, and the like, we adapted quickly.
Other aspects of moving our process online proved a little more challenging. Creating the video diary guide required a reset in our thinking. Where we typically could ask anything in a video diary guide, we had to be a little choosier—the particular platform we were using allowed only a certain number of open-ended video questions so we had to design the questions carefully make sure our data was as rich and as ethnographic as possible. We could fill in the blanks with text-based questions for the more straightforward data, but it took some consideration to construct the guide in a way that produced data that was as full of the vitality we’re accustomed to and that our clients expect from us.
There was a learning curve with the technology too. The vast majority of our sample had never used the platform and despite its general ease of use, tech issues did arise. When participants ran into a snag, they tended to come to us and not the platform’s official support channels. This was fine, but it caused a shift in our communication with participants. Typically, our interactions with diary participants are mostly about what they should be recording and when they should be sending back their memory cards. Although we were still having conversations about content and timing, we also were spending more time providing tech support. We relied on our contact at the platform to help with tech issues at first, but after a while we were able to address most questions ourselves.
The limitations
With the platform we used, each video that participants recorded could only be two minutes long. This limitation can be problematic and was a main reason we had strayed from online video diaries in the past. Our video diaries typically include activities like, “Show us every time you do this,” and this project was no exception. Luckily doing “this” was using our client’s device—something that would typically take less than two minutes to do. In contrast, if we wanted them to show us how they prepare dinner, we might have had an issue (unless a frozen pizza was on the menu). Other online platforms allow you to record more than two minutes at a time, but if we needed a diary that included long stretches of recording whole acts, sending participants camcorders might be the better option.
The other major limitation with doing research online is obvious—you’re not there. Here, having the observational data from the video diaries is a life saver, but if you are just doing online interviews? You can still collect a little contextual data by having your participant do a “show and tell” or take you on a house tour if you’re using a platform that supports mobile devices. There’s also no harm in just relying more on interview data. It’s hard to argue against the value of observational research, but there is a lot of insight to be gained through interviews alone.
The benefits
After getting past the learning curve and getting a handle on some of the limitations, we believe online research provides incredible value. Here are a few of its advantages.
Speed. In theory you could decide to do research in the morning and have data coming in by that afternoon, compared to a traditional, camcorder diary where it takes a participant a couple of days to get a camera, they record for a period of time and then we only get their recordings back a couple of days after they drop their memory cards off at FedEx. Online research is much faster.
Participant progression. Since you can see data as it comes in, you can give participants direction if they aren’t recording the quantity or types of entries you need. You can send them a friendly note offering advice and reminding them to stay on track. Online research also allows for in-the-moment follow-ups on their recordings to dig deeper.
Although ethnographers aren’t inclined to like set, structured questions, the structure of online research is another way that ensures that participants are progressing and recording the kinds of data you need them to. These platforms typically have a series of questions for the participants to complete, and the researcher can tell exactly what they’ve done and what they still need to do. It might lead the participant to mentally tick off a box and not record more than they might have otherwise, but it also ensures they tick off that box to begin with.
Client involvement. Clients can be more involved in online studies. Attending in-person research might not always be practical, but online research is more accessible since no travel is required. The data from online video diaries is also immediately available to clients, and they can interact directly with diary participants if that’s something they want to do. As insiders to their business, they’ll have different perspectives and questions than we do as ethnographers. They might see participants use their products in ways or contexts they’ve never seen before and want to learn more about their motives and rationales. Online research makes that easy.
Although nothing can replace in-person research for us, old school ethnographers, we see tremendous value in doing research online. You can still meet real people, hear their stories, and observe them going about their daily lives, even if it might come in shorter snippets. We always say that ethnography is more of an approach to understanding than a specific method, and if online platforms allow us to get a real-life, inductive glimpse into people’s lives, isn’t that the point?
Forming connections in the field: Three case studies on the bonds that ethnography builds
The bonds ethnographers make with their participants can come in unexpected ways. Years ago I was in Australia studying hair loss, and my participant’s apartment looked like it would be walkable from the hotel. This was back when we used paper maps, and I would measure distance by how many thumb-widths point A was from point B. What I thought might be a twenty-minute walk turned out to be more like an hour jog in the Sydney heat, so I showed up late, sweaty, and panting like a dog. Fortunately, the guy was as nice as could be, and it ended up being very rich, surprisingly intimate fieldwork. As much as I’d like to, I can’t really attribute that to my highly refined skills and astute questions. Rather, I think that by arriving a disheveled mess, by showing this very human side of myself, it gave him free rein to do the same.
That day we connected over dripping sweat and blistered toes, but often our bonds with participants are deeper and longer lasting. It’s only natural that ethnographers in academia who spend years with the people they’re studying might build these bonds, but it can happen in business ethnography too, where we might only have a few hours with participants. You don’t always develop intimacy with participants, and it isn’t always necessary in order to walk away with good data, but it’s still great when it happens.
All ethnographers, including my co-workers at Ethnographic Research, Inc. will likely have similar stories of the connections they’ve made in the field. Here are a few of mine, along with a few ideas of how the methods and contexts of ethnography might have fueled the bond-building.
Watching fireworks with the Wilsons
A travel and leisure company hired us to understand families on vacation—a fun topic for sure. We did all of the fieldwork in Orlando, going to both the lesser-known attractions, like the Titanic Museum and the Holy Land Experience (a religious theme park), to the bigger names like Universal and Disney World. Our job was to become ethnographic tourists and temporary members of the families in the sample, popping in for participant observation multiple times throughout their trips. I was “Uncle Steve, the one that keeps staring at us.”
Each family was great, but I really bonded with one in particular, the Wilsons. The mom, Marianne, has a personality that can light up a room and is one of the funniest people I’ve met. The dad, Paul, is much more reserved, the “strong and silent” type. He had fun, but I always got the sense that his biggest joy was seeing his family have a good time. Marianne and Paul have two teenage daughters: both good, smart kids who share their parents’ love of all things Disney. They are the kind of people who would have gotten along with anybody, but we really hit it off. On our last day, together we hung out for hours longer than we were slotted for so they could show me Epcot’s fireworks show, and we’ve kept in touch ever since. We still send each other Disney-themed Christmas cards every year.
Why did we get on well? The Wilsons were very friendly and that’s certainly helpful, but there’s probably more to it. We got along well with all of the families in the sample, probably more so than a typical project. Some of it might have been transference: we were observing one of the happiest times of the year for the families, and those good feelings about their vacations became good feelings about us ethnographers along the way.
The context also provided the families an ideal “looking glass self,” a way of gauging how they think they appear to others. With an ethnographer at your side, you might be more self-reflective, more aware of how this outsider is perceiving you and your kids. Sometimes this can be a good thing, sometimes not so good. On vacation, your family might put aside its typical troubles for a few days, everyone might stop quibbling for a minute. Seeing the ethnographer there, observing you and your family in all of its glory, can feel great. You might think, “Yeah, we are pretty awesome.” Still, not all of the trips were as fun and fancy-free as the Wilson’s trip. Some continued to quibble and some didn’t leave their problems at home—those families don’t send me Christmas cards.
Gaining mana in game shops
A games company wanted to learn about teenage boys who were into collectible card games (CCGs) like Pokémon and Magic the Gathering so we dove headfirst into the fascinating world of the local game shops they hung out at. More than just retail stores, these shops were gathering places where people played all varieties of games: mainly CCGs, strategy games like Warhammer, and tabletop roleplaying games like Dungeons and Dragons. The shops served as many players’ core social hubs, where they went to be with their friends, chill out, and have fun.
Although I didn’t keep in touch with the participants I met during the study, they welcomed me into their world with open arms, and I became a part of their groups remarkably fast. I did the weekly Friday Night Magic events with my pedestrian starter decks and won a game or two. I competed in a Pokémon tournament and lost miserably. Dungeons and Dragons is hard for a newcomer to jump into without grinding everything to a halt, so we just sat in on those sessions. All in all, they enjoyed us being there, and we enjoyed it too, the culture and the games themselves—I still play Magic to this day.
But why did we have these synergies? Simply showing interest went a long way. Collectible card games serve a niche audience and CCG players don’t have many people outside of their inner group willing to talk about games with them. I know I’d be thrilled if someone asked me how my Ooze deck was coming along.
The research was also a great example of something we talk about a lot: the value of letting the participant know they’re the expert. There was a distinct hierarchy at the shops. There were the adults and older teenagers who had been playing these games for years and were often more skilled and had more expendable income to spend on the best cards. The old timers often mentored the younger kids (our primary participants), teaching them the ropes, raising the next generation of CCG players. Our arrival meant that the younger kids could turn the tables. The students became the masters, and we became their students. That sort of role switching can be fun and empowering for a kid.
Henry and his chauffeur
A pharmaceutical company hired us to learn about the experiences of people living with schizophrenia. The plan was to see each participant four times times over the course of a year, but I ended up hanging out with one participant, Henry, for several years (until he passed away). When we met Henry, he was living in a transitional home in a rough part of Kansas City. His thoughts could be hard to follow at times, so we never really did any sort of formal interviewing with him. Instead we learned through observation, experiencing his very unique life alongside him.
Henry was a character: charismatic, a 24/7 Lothario, kind of a hustler, but an all-around good guy. Henry walked most places out of necessity, so when we first showed up, we weren’t so much researchers to him, we were a ride. I couldn’t count how many times I drove him to Dollar General and the smoke shop so he could resupply. As time went by, our destinations expanded, and I never knew what I was in store for when he invited me out to lunch. Cigarettes and snacks continued to be on the docket, but we might go to sell some stuff at the pawn shop. We might go to see one of his girlfriends (who had interesting stories too). One time I even took him to vote (and saw how problematic voter access can be).
With Henry, the bonds of fieldwork might have had an economic origin (I had a car and paid for lunch), but he developed a genuine fondness for not only for me but my co-workers, Melinda and Shalonda too. It was probably a rare treat for someone to be as attentive to him as we were, for someone to really listen and care about what he had to say.
Henry’s situation was unique but regardless of who you are or where you’re from, it is unusual for people to show you the sort of genuine interest that’s central to an ethnographer’s work. Whether we’re asking someone about their life story or how they do their laundry, the “it’s all about you” focus of an ethnographer is refreshing and makes fieldwork wide open to these kinds of bond-building moments. Ethnographers don’t necessarily remove themselves from the environments they work in, rather they work to help others shine, to share themselves in ways they often do not. Part of it is simply people “clicking” with other people, but there is also some special magic in the ethnographic context—our methods produce a setting ripe for the kinds of deep connections that develop between us and the people we learn from.
Analysis at Ethnographic Research, Inc.
Analysis is a sacred and labor-intensive element of our work at Ethnographic Research, Inc. Sometimes we hear about ethnography timelines that have reporting slotted just a couple of days after the end of fieldwork and we aren’t sure how that is even possible. Ethnography is about bringing people and culture to life; it gets to the heart of what’s really going on with a depth that is simply impossible to achieve in a couple of days. Good ethnography offers what Clifford Geertz called “thick descriptions.” More than just reporting some top of mind ideas, it goes much deeper into context and culture. To get there, we rely on (1) analytical rigor, (2) theory, and finally, (3) years and years of experience.
1. Analytical rigor
Doing analysis right takes a lot of work and a lot of time. We spend around six hours doing analysis for every hour of video we collect, and we collect tons of video. We often provide some “early insights” to clients who need something to work from immediately, but to do a complete analysis that makes the most of the data? That takes time.
Still, it doesn’t matter how much time you spend doing analysis if you don’t spend it wisely, so we use methods like Glaser and Strauss’s Grounded Theory, an inductive approach to analysis where data is coded and categorized until insights begin to emerge. People tend to picture analysis as this magical process where a wild-eyed, crazy-haired social scientist is thumbing through notes and watching video until some brilliant idea pops in their head. And yes, there are “Eureka!” moments (and sometimes crazy hair), but in reality, we follow fairly structured steps. If we didn’t, those big ideas might never show up and if they did, we wouldn’t be sure that they were trustworthy.
2. Theory
Our team is academically trained in ethnography, and we learned that using theory to help inform research is not only helpful, it is required. It just makes sense. Brilliant minds have been wrestling with similar topics for years. It would be silly not to take advantage of that, and although we’re all sociologists by training, we also use theory from anthropology, psychology, and sometimes economics and philosophy.
Our use of theory has a meaningful impact on our results. It is vital in making sense of data, and it helps so much in understanding the social and cultural drivers behind the behaviors we observe. Research that ignores culture comes out flat. For social scientists, by definition, if you want to understand people, you have to look at the society and culture they live in: the people they interact with, the institutions they are a part of, the information they consume, and any other outside influence that shapes the way they see the world. Theory provides the scaffolding for organizing and understanding all of that data.
3. Years of experience.
Ethnographic Research, Inc. opened its doors back in 2001, long before the iPhone, long before Facebook. Back when we started, ethnographers didn’t do in-homes, they did in-caves.
We’ve been observing people in-context for nearly twenty years, and we’ve picked up a few things along the way. This gives us a leg up whenever we start a new project—we go in with a strong understanding of how households have evolved over the last couple of decades and can use this to give projects an analytical jumpstart. We can approach new topics with a certain maturity and sophistication that would have been impossible were we just starting out. For instance, we do a lot of work studying how illnesses impact people’s daily lives. We’ve studied the daily lives of people with cancer, heart disease, arthritis, chronic pain, lupus, epilepsy, and many others. When someone comes to us wanting to learn about the patient experience of a condition we haven’t studied, like multiple sclerosis, we have all of this past work to help us learn, right away, what is unique and different about living with MS.
This experience is just as helpful for our other projects too. We have years of experience watching people shop, work, cook, groom, clean, play, parent, travel, and more. This allows us to place our research topic into a much larger database of insights into daily life habits and rituals. It helps us in every aspect of the journey that is ethnography. We can avoid common pitfalls in sampling and recruiting, we can get the most out of our in-home visits, and our analytical processes are refined and streamlined. We have also learned that it is our analytical processes that add the most value for our clients. All of the time and rigor we give to analysis are absolutely necessary when your research aims for deep, rich insights.
Developing empathy and understanding with ethnography
The political divide in the United States has been a stark reminder of how people can experience and interpret the world in very different ways. No matter what side you are on, it can be hard to see where the other side is coming from, what they’re feeling, and what drives them to think and do what they do. Developing this sort of empathy is essential to ethnography and to each part of our research process. We need empathy to ensure that we gather data that is deep and trustworthy. We need empathy to help us organize and sort that data in a way that accurately reflects the experiences and viewpoints of our participants. We need empathy to hold ourselves and our clients accountable and grounded during the reporting phases of our work. Still, maintaining empathy is sometimes easier said than done. Although most of the time we can connect with people and their stories right away, sometimes we just can’t relate to their experiences and viewpoints. Let’s explore some ways that ethnographers can develop empathy and understanding, especially in contexts where those might be hard to come by.
History, physical space, and relationships
Spending time with people is obviously the first step for ethnographers. Developing empathy is typically just a matter of really listening and hanging out with participants, trying to walk in their shoes as much as we can. Usually this goes a long way towards gaining insight into their perspectives. Even if it isn’t directly related to what we’re studying, investing time to learn a little bit about where they come from and about the context of their daily life pays dividends in helping us walk away with an empathetically grounded understanding of our research topic.
Touring a participant’s home or workspace provides another great opportunity to build empathy. Going room to room, sharing stories about their recent purchases and favorite belongings, there’s a good chance that we will run into something that will help us understand what their life is like and what’s really important to them.
We also try to involve our participants’ friends and families in the process whenever we can. They may show a different side of themselves when they’re playing with their kids or when they’re talking shop with a colleague. This can help us see them in a whole new light. People play many different roles in their lives, and the more roles we can observe, the more complete our understanding will be.
Public discourse, media, and marketing
We can also build empathy if we step back and look at the impact of the larger cultural context on our participants’ attitudes and actions. Macro sources of behaviors and beliefs are often ignored, but they can be quite powerful in molding and shaping individuals. Tracing the influences of marketing messages, information sources, government systems, religious structures, and social media all help us gain a better understanding of who our participants are.
We usually do this through “contextual mapping.” This means we examine how what we’re studying is represented in public discourse. If we want to understand cat owners, for example, we’ll dive into social media to see how cat care is discussed. We’ll survey ads about cat care, looking at the messages they convey and the symbols they use. We’ll explore the world of cat care influencers, like Jackson Galaxy, to see what they’re teaching others. We’ll also watch lots of cute cat videos just for the heck of it, but the goal is to understand how all of this background noise impacts and shapes people with cats in their lives. Contextual mapping would help even the most die-hard “dog person” empathize with their cat-loving neighbors.
Colleagues and theory
When we’re having trouble getting our heads around what’s going on with our participants, sometimes it helps to get another perspective. Getting a colleague’s input is great. Sometimes we need someone else to remind us to be more empathetic and to stop letting our own baggage get in the way. Social science theory also helps us reposition our thinking and see our data and our participants from a different angle. As odd as it may seem, reading theory can even help when the theory has nothing to do with the research topic. You can read Foucault when you’re studying paper towels, and it still might spark a big idea. Theory is an ethnographer’s yoga—it resets your mind and leads you straight towards empathy and enlightenment.
Induction and reflexivity
A good ethnographer is always working inductively, but sometimes we put the cart before the horse and start making assumptions. This can prevent us from developing empathy and getting at the heart of what’s going on with our data. If this happens, we need to take a deep breath and brush off those assumptions as quickly as we can.
The whole process requires self-reflection. When what someone thinks or does seems a little confusing, we try to remind ourselves that our thoughts or actions would probably be just as confusing to them. If we continue to have trouble understanding someone’s behaviors or motives, there’s a decent chance that we might be our own roadblock; a prejudice of one sort or another might be standing in our way. It helps to take an inventory of our own beliefs and practices, being critical of their origins and how they shape our viewpoints. This is a key step in developing empathy. If we want to walk in the shoes of the people we’re trying to learn from, we’ve got to take our own shoes off first.
Five challenges ethnographers face in health care settings and how to overcome them
It’s not our imagination—observing health care provider/patient interactions was simpler when Ethnographic Research, Inc. opened its doors in 2001. This was before HIPAA’s Privacy Rule, its Security Rule, and its HITECH Rule all went into effect, and although these are all important and necessary, the required processes and paperwork can be intimidating for our clients, for the HCPs we meet, and for us too.
This article will highlight some of the challenges involved in doing observational research in health care spaces and provide some insights into how we have adapted and continue to do work in these settings. Whether you’re a researcher or you are thinking about hiring ethnographers to observe health care in action, we hope these provide you with some food for thought.
1. Getting your foot in the door is difficult.
HIPAA regulations can make recruiting an enormous challenge; the HCPs have to trust that we, complete strangers, will treat their patient data as sacredly as they do. Even without HIPAA, HCPs would likely be uncomfortable with the idea of folks showing up at their work with cameras. That’s true of any workplace, particularly customer-facing workplaces. By letting us in, they’re vouching for us and that’s a risk for them.
Compounding the challenge are gatekeepers, usually office managers, whose job it is to filter the calls that make it to the decision-makers, usually physicians. This is another uphill battle, a kind of modern-day gauntlet. Finally, these are busy places, and they simply don’t have time for us. We have to convince them that we’ll be as little of a bother as possible and that their practice can function almost as efficiently as it normally does.
What is the secret sauce to recruiting health care providers? Persistence and an indestructible will. Also, although it isn’t always practical, we have found that recruiting in-person can go a long way in showing sincerity and resolve. When dealing with a tight timeline, getting the help of a third party recruiter can also be a viable option.
2. Incentives can be complicated.
HIPAA isn’t the only regulatory barrier we contend with doing healthcare research. There’s also the Sunshine Act, and although it sounds very pleasant, it can make incentives for participants a little tricky. The Physicians Payments Sunshine Act is anti-bribery legislation designed to keep pharmaceutical companies and others from incentivizing physicians to prescribe their products. It seems totally removed from ethnography, but we have to make sure that any incentives we pay health care providers don’t top fair market value.
As a result, our incentives are never so much that they will really drive HCPs’ participation. So, again, we need to make sure that participating in our research causes as little inconvenience as possible and that their time with us is, if not loads of fun, at least mildly interesting.
3. Be careful what data you collect.
Once we’re in the door, keeping the data we collect safe and sound is always our top priority. It is essential for everyone involved: the patient, the practice we are observing, our client, and our company. The first step is to only collect patient data when necessary. This can be hard if we’re videotaping the research. Here, video’s greatest strength, that it records everything, becomes its biggest weakness, that it records everything. Like a vacuum cleaner inhales random coins, hairpins, and the occasional sock, the camera is going to record off-camera conversations, random patients walking in front of the camera, and computer screens displaying patient data. We minimize this by:
- Not recording in hallways and waiting rooms whenever possible (where other patients tend to roam).
- Being far enough away from computer screens that they aren’t legible on the recording.
- Only having the camera on and recording when necessary.
- Being careful not to record patient data unnecessarily (e.g., if we don’t really need to record a patient’s face, we don’t record their faces).
Also, we get informed consent from anyone whose data we collect so they know what we’re collecting and how it is going to be used.
4. Be careful how you store and transmit your collected data.
After we’re done with data collection, that data needs to stay safe. It is important to have solid security policies ahead of time—multiple layers of protection in place to prevent unauthorized access. It helps to enlist a professional with a background in information security to make sure that everything is airtight.
5. You may need to take a few extra steps to protect your clients.
All of our clients have different needs when it comes to regulatory compliance, and it is best to discuss their needs from the start. Again, we make sure our planned incentive won’t cause our client any unnecessary hassle. We also see whether our client needs the study to be blinded or double-blinded. Like other industries, it is common for health care clients to want their identity withheld from participants. That might make recruiting more difficult, but it is fairly routine. If they need the research to be double-blinded, for whatever reason, we need to take a few additional steps. We will need to remove names and other information that may identify the practices in anything we give to the client, including initial sample spreadsheets and final reporting. We’ll also need to mask all of the video in the video deliverable. This includes participant faces, ID tags, and any paperwork with the practice’s name on it—it is always surprising how many identifiers need blurring. Understanding a client’s needs from the start is extremely helpful in preventing bumps down the road as the research unfolds.
So those are five things to be thinking about when undertaking in-context research in health care settings. It can be a challenge for sure, but there are ways you can navigate the challenges and get the job done. The insights possible from seeing health care providers in action are very much worth the effort.
Some of our favorite theories for doing ethnography in health care spaces
At Ethnographic Research, Inc., we always emphasize the value of social theory in ethnography and its ability to add depth and nuance to our results. It is like having the ghosts of sociology’s past prodding us to consider looking at our data this way or that way, just in case there might be a big insight around the corner. Research for the health care industry is no exception. In fact, given how challenging in-context observations of health care settings can be, it’s a crying shame not to make the most out of that data. That’s where theory lend a hand. There is a ton out there, but here are a few theories we tend to use the most:
Stigma: Emile Durkheim, Erving Goffman. Stigma is an essential variable to consider when we do projects on living with an illness. Sometimes the stigma is the result of the physical effects of an illness, its accompanying behaviors (like injecting insulin in public), or by just having the illness (like a sexually transmitted disease). The impact of stigma can be as traumatic as the physical effects of the illness itself, and Durkheim and Goffman helped us understand these dynamics.
The sick role: Talcott Parsons. Talcott Parsons’ functionalism hasn’t necessarily stood the test of time, but we still use his idea of the “sick role.” The basic notion is that when we’re deemed “sick” and take on the “sick role,” we’re excused from normal responsibilities while also being required to work towards getting better. For us, we often use it more broadly in examining how having a specific illness impacts a person’s social roles and their engagement with the world around them. Given our long history of studying different conditions, we can then compare the “sick role” of X illness with the many other illnesses we’ve studied in the past.
Gender theory: Simone de Beauvoir. We always make sure to attend to how gender roles impact the interactions and behaviors we observe. You could pick many influential gender theorists, but de Beauvoir was one of the first to draw the line between sex and gender, and this idea of the social construction of gender is arguably the fundamental starting point of most or even all current gender theory.
She also wrote that women and their bodies were the “inessential other,” deemed both alien to and lesser than men and men’s bodies. We can see this in women’s experiences of health care. In a study we did on a rare, difficult to diagnose illness, women, in trying to find out what was going on with them, weren’t taken seriously by the HCPs. Their physicians downplayed their symptoms as “just stress” or “just needing to lose some weight” when they had a condition that would be fatal if left untreated.
Presentation of the self: Erving Goffman. Goffman is back for a second round! For Goffman, when we interact with others we act, as if in a play, and our choice of words and our body language are designed to convey a certain image to the person we’re interacting with. This concept is essential when trying to decipher the interactions that patients have with their health care providers. It helps us make sense of how both sides communicate and how those communications are interpreted, which ultimately shapes treatment decisions and patient outcomes.
These interactions usually play out in the exam room, what Goffman would call the “front stage,” the stage that our clients tend to be most interested in. We always argue that we should also observe the “backstage,” their offices, labs, and break rooms, to see what HCPs are doing outside of direct patient care, to see how they interact with other staff members, and to get the entire picture of what’s involved in their day’s work.
This front stage and backstage distinction of Goffman’s is also important when we study the experiences people have with their illnesses away from the doctor’s office. It’s our job to understand how the public face of someone’s experience of an illness might differ from the private, backstage experience they keep to themselves or just share with their closest friends and family. It is often only in this backstage space where we can see what’s really going on.
The quantified self: Deborah Lupton. Just so we can include something from this century, the quantified self has become a more influential theory in the last couple of years in both our health care research and our technology research. It basically explores how we are increasingly measuring the wellbeing of our bodies with numbers. The most common example is fitness tracking (e.g., FitBits and Apple Watches), but you can see it elsewhere, like assessing diabetes status through the numerical output of a glucometer.
The quantified self can be considered a kind of extension or offshoot of the “medicalization of society,” another valuable theory from the previous century, the 70’s. It contends that more and more aspects of our lives are falling under the umbrella of medicine. A classic example of medicalization is giving birth. Where once done with family in the comfort of the home, now having babies in hospitals is the norm. Medicalization comes up periodically in our research too, like a project we did on Restless Legs Syndrome (RLS). Our participants’ friends and family didn’t take RLS seriously; they didn’t believe it was a real condition (rather the result of the medicalization of society). This led our participants to feel the stigma of having a “fake” condition and it impeded their ability to take on the sick role.
Often we combine these theories in our quest to understand and organize our fieldwork, our analysis and our reporting. What are some theories you love to use in your work?
Notes on being a cultural chameleon and a pied piper
In my business it is important to try to blend in. No matter who we are hanging out with, it is essential that we look like we belong and are able to put our participants at ease. Each ethnographer has her/his own way of achieving this goal, but generally we have to be comfortable in a variety of different types of situations and the natural ethnographer does this, well naturally. Most of the best ethnographers I’ve known don’t have to work at blending in, they just do.
At Ethnographic Research, Inc. we started referring to ourselves as cultural chameleons a few years ago, because that is really who we are. We have spent time with doctors as well as people who have been unable to work for years due to chronic pain. We have hung out with academics as well as sex workers. We have worked along side high-end sales folks and inner city social workers. We have learned from people diagnosed with mental illness as well as suburban soccer moms. And in each case, we have usually been invited to come back and hang out again.
It’s true that traditional ethnographic work provides ethnographers longer periods of time to work their way into a setting and into relationships. But for those of us who work in business contexts, the time we get to make others comfortable with our presence is sometimes only a matter of minutes. Hence our cultural chameleon abilities are even more important. And for the most part, I’ve been very successful as a cultural chameleon. But there was that one time. . . .
When I did fieldwork in the Philippines a few years ago, I got to experience what it feels like to really stick out. For starters I am very white, the kind of white that glows in the dark. In fact, my nick-name in high school was Casper. Also, at five foot four, I’m not particularly tall, but compared to the average Filipino woman, I am gigantic. Since I spent most of my time in neighborhoods where most westerners don’t go, I stuck out EVERYWHERE. In many neighborhoods we created such a spectacle that people would lean out of their windows or even come out of their houses to watch us go by. Often they called out ‘Hey Joe!’ (a reference to American GIs). Several times, the neighborhood kids would form a pack and follow us down the street, creating a carnival like atmosphere. I felt like the pied piper.
In this particular setting, there was no ‘blending in’ so I just embraced my status as an outsider and made observations from that vantage point. It was as the pied piper that I did most of my contextual mapping in the Philippines. Walking around from neighborhood to neighborhood, I met up with and had the opportunity to observe hundred of people. I was in Manila trying to understand how moms take care of their babies, so it was convenient for me that many parents brought their children outside to see me as I walked down the street.
In the end, whether we are able to blend in and be a cultural chameleon or whether we stick out like a sore thumb, the skilled ethnographer uses each status to their advantage. The best understandings of any subject or context come from examining and analyzing data from both an insider and outsider perspective, so although ethnographers generally don’t like to stand out, acting as the pied piper once in awhile provides a nice change of pace and a nice change of perspective.
Sociological Theory Comes to Life
When I was earning my undergraduate degree, there was a required class called Sociological Theory. The first time I became aware of the class was when a bunch of my classmates were sitting around, talking about what they were going to take the next semester. They all agreed to avoid Sociological Theory as long as possible. None of them WANTED to take the class. They said it was boring, difficult, and essentially a waste of time. It sounded awful. So, I put the class off too (even longer than statistics). When I couldn’t put it off any longer, I enrolled in the class. Boy was I surprised. I LOVED the class. It was interesting. And so useful.
Imagine that you are trying to solve a difficult puzzle without a picture of what it looks like. You are having trouble getting started. But then suddenly the outer edge of the puzzle comes together and you begin to see how the inside might look. Social theory often provides that type of tool for ethnographers. It gives us a framework or a starting point to organize data or to understand a pattern.
I’m a little bit of a social theory junkie and I’ll admit that sometimes, for fun, I take random experiences and try a few different social theories on for size to see how well they can explain what I have seen. It is very interesting to see how a single event can be understood in a variety of ways. Admittedly, some social theories have more explanatory power and a wider scope of applicability than others. One of my favorites is social exchange theory. You know this one. The premise is that all social relationships are based on exchanges between people and that these exchanges are based on a careful cost/benefit analysis of what each party is getting/receiving. This particular theory is widely applicable and explains a great deal.
A few years ago I saw this theory in action when I was asked to help a client understand the lives of women at high risk for HIV infection. I was spending time learning from a group of women who worked in the sex trade industry, hearing their stories, and learning more about how sex and protection fit into their work lives as well as their personal lives. It was during these conversations and afterwards during analysis that I saw social exchange theory at work. Many of the women I talked to summed up their decisions to not practice safe sex in terms of the costs and benefits they paid and reaped from their sexual exchanges. It turned out that NOT using condoms helped them to shift the power balance of the exchange in their favor. Obviously, at work they could demand more money if they didn’t use a condom. But less obvious was the exchanges that they often made in their private relationships. Not using a condom during sex with their significant others signaled trust, which was an important commodity that they paid into the relationship bank. Using a condom would signal lack of trust and would put them further into the negative when it came to power within the relationship. Although this seems counter-intuitive (i.e., using a condom SHOULD and does generally increase the power position of the woman), within this particular population, there were other, contextual variables at play that impacted the exchange. For example, among this population, there was not a surplus of eligible partners and every potential partner entered into the relationship in a one up position, just by virtue of being scarce. Also, there were cultural biases that made ‘cheating’ normal for men, but unacceptable for women. Cheating was something that female partners were expected to not only accept, but essentially pretend not to see. If they asked their partner to wear a condom, they were violating the agreement by pointing out that there was anything to be concerned about. Finally, because their partners could usually leave the relationship and more easily find a replacement partner than they could, the value of ‘more pleasure’ that not using a condom provided allowed my participants to add another benefit to what they were paying into the relationship.
Social exchange theory provided a framework by which to organize the data and to explain the seemingly counter-intuitive and self-destructive behavior that my participants reported. It also encouraged me to try to understand the motivations for their decisions from a more rational perspective based on their social and cultural context. Although I didn’t spend enough time in the field to really know whether the patterns I saw would be trustworthy in a larger population, social exchange theory provided a very interesting potential explanation for risk-taking behavior within this population and one that would probably indicate less traditional approaches to sex education and STI prevention efforts.
Are you studying me right now?
One of the first things people ask me when they find out I’m a sociologist is ‘Are you studying me right now?’ And if I’m being honest, the answer is usually ‘yes.’ I think people are fascinating and I wonder why everyone doesn’t people watch, all the time. There are so many people data points to ‘study’ in fact, that even if I collected data 24 hours a day, every day for the rest of my life, I would never run out of things to note. So obviously, I can hardly afford to take time off.
When I was in high school and college, I had a part time job at a local grocery store. The store was located in a neighborhood with lots of socio-economic, racial, and ethnic diversity. One of the things that I loved about the job was the opportunity to meet and ‘watch’ so many different people. As I look back on that experience, I realize that I was essentially doing participant observation every day. I wish I had taken field notes!
I learned a lot about people by being a cashier. I got to peek into customer’s daily lives and got to know what happened in their kitchens without ever visiting their homes. Being a teenager who had a working mom who didn’t cook much, I was amazed at the variety of foods that people bought and apparently cooked and ate. During my first several months on the job, I was forever asking customers what a particular produce item was because there were so many things I had never seen or heard of (jicama, kumquats, etc)! And many times as I was introduced to a new food, I was also introduced to a new dish or a new way of cooking or eating. Many of my customers took the time to explain to me how they prepared a particular food or where they had learned about or gotten a particular recipe. Many of these stories told me a lot about the person’s history, subculture, and family traditions.
But it wasn’t just produce, there were tons of other clues to household norms that passed through the grocery store each day. For example, there was a lot of variance in the amount of food people purchased and the frequency with which they visited the store. Some customers came grocery shopping virtually every day and others tried hard to keep their shopping confined to weekly, if not monthly visits. These habits obviously effected what they bought and therefore what they ate. But their habits were often grounded in ideas and values about food and about time. Some customers always came in in a rush and others seemed to never be in a hurry. Some customers bought the same items each visit and others varied their purchasing according to season or occasion. Some customers paid via food stamps and others paid with cash. All of these data points told a story about daily life, routine and ritual.
And each time I interacted with each customer, I learned a little bit more about who they were, where they came from, and what was going on in their lives. Although I had received very little training in sociology at the time, I was always trying to put together their ‘story’ by using the pieces of data that I got during our conversations and also the clues that I got from seeing what they purchased and what their shopping habits were. It was then that I realized how much you could learn about a person by just listening to what they were saying, and paying attention to what they were doing. I was fascinated by their stories and also a little bit surprised by how much I could learn by showing a little interest. I often asked a simple question about a particular produce item and got a very descriptive narrative about daily life.
People tell me a lot that I’m intuitive, but I think it is closer to the truth to say that I’m really curious and a pretty good observer. It is amazing what you can see when you are really looking, and what you can hear when you are really listening. So, if we ever met and you wonder if I’m studying you, the answer is probably yes. BUT don’t be offended, instead ask yourself, ‘when was the last time I had such a captive audience interested in me?’
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