The holistic perspective

As the community initiative to be evaluated in this thesis was a new service with a minority ethnic group that had been little studied in terms of health status or the effectiveness of healthcare initiatives to date, and so was largely exploratory in nature, I have chosen to use a holistic perspective. A holistic perspective views the whole as greater than the sum of its parts (Patton, 1987). McWhinney (1989) provides a description of a holistic perspective in ‘general systems theory’. How “all an individual’s significant relationships” impact on their health.

According to McWhinney, general systems theory believes nature to be a hierarchical series of dynamic systems, both living and nonliving which interact and impact on one another. Each system is both a whole and part of a greater whole (see figure 3.1). Each system is unique and has features that can only be described in terms of that system. An event that impacts on one system will reverberate through the other systems both up and down in turn. These dynamic systems require equilibrium and therefore if something happens to impact on a system, that system will react to adjust to the change to restore that equilibrium.

Systems Hierarchy

Culture - subculture

Organs Family Universe - biosphere

Society - nation

Community

Person

Nervous System

Cells Two persons

Figure 3.1

Understanding the project as a whole and therefore providing the decision­

makers with the information required to make the decisions about the

effectiveness of the initiative meant seeking to describe those people involved in the community initiative, on several systems levels. On a personal level; by exploring Gypsies’ and Traveller’s perceptions of their identity, on a familial and cultural level; by describing Gypsies’ and Travellers’ culture, lifestyle, and health beliefs, and on a societal level; by exploring how the dominant society views Gypsies and Travellers and how this impacts on their daily lives and the

community health initiative. I also provide a description of the community health initiative, explore the processes involved in the community initiative, and explore its ‘systems’ including the interactions at the personal level and health service level (see figure 3.2 below). Patton (1987) also discusses the importance of

describing and understanding both a program’s social and political context and suggests this is essential for the overall understanding of programs.

Systems Included in the Evaluation

Gypsies and Travellers Health Project Personal

Ethnic Group Health Service

Personal

Society

Family Community Health

Initiative

Figure 3 .2

In order to provide the information needed to fully evaluate the community health initiative, and to provide the kind of in-depth knowledge that is required to look at a program and the context in which activities occur (Patton 1986), its participants’ perspectives and its interfaces, an ethnographic method was used.

In line with an ethnographic approach, a range of methods, both qualitative and quantitative have been used, in particular, participant observation, which is a defining feature of ethnographic enquiry (Savage 2000).

Ethnography has its roots in cultural/social anthropology. One conceptual feature of anthropology is that what is ‘rational’ is seen in its local context to be socially and culturally specific and valid (Lambert 2002). This means in practice, that biomedical concepts and practice are variable and therefore the knowledge and practice of lay-people and that of professionals are both valid for empirical

inquiry. Another feature of anthropology is the acknowledgement that, what people say can differ from what they think and do. To this end, participant observations are particularly informative, bridging the gap between language and actions (Lambert 2002). Ethnography is said to be particularly useful in understanding the organisation of healthcare and allows for comparisons between what people say and what they do (Savage 2000). Anthropology is also concerned with questioning categorisations by focusing on classification and meaning. Therefore, an anthropological approach would be to investigate, not only what people’s beliefs are about a given category but also the category itself, looking at the meanings of the familiar and looking at the construction and maintenance of familiar categories such as medical terminology. Medical

anthropology seeks to improve health outcomes by increasing the

understanding of health issues for people by examining the apparently familiar (Lambert 2002) and ethnography can go beyond that of many approaches by providing a detailed method of witnessing and reporting on both practitioners’

and patient’s worlds (Savage 2000).

Ethnography has been chosen in this study as a method of accessing beliefs and practices, viewing them in the context in which they occur and providing insight into how patients’ cultural practices may impact on health interventions (Savage 2000). In program evaluation, ethnography provides the detailed description of the processes involved in the service in order to gain

understanding of its strengths and weaknesses.

Others, such as Cook (2005) go further by advocating the use of ‘critical ethnography’ in health promotion research, where the primary aim and explicit goals are changing of existing social structures. Where traditional ethnography describes “what is”, critical ethnography attempts to speak on the behalf of the often unheard oppressed by stating “what should be” by confronting the social structures and institutions on grounds of racism, sexism and classism.

Ethnographic research in medical settings can provide ‘the catalyst for reflection and opportunities to feedback to doctors and other healthcare professionals’

(Pope 2005).

When evaluating programmes directed at people from different cultural backgrounds misinterpretations of the ethnographic data can occur through differences in cross-cultural and socio-economic differences between the researcher, participants and other stakeholders. In order to improve sensitivity to cross-cultural differences, insider and outsider perspectives are explored in this study (Patton 2005). The aim was to be reflective of the beliefs and

perspectives of both Gypsies and Travellers and those involved with the community health initiative, both at the personal level and cultural level. By adopting this approach, I was able to explore areas from the ‘insiders’

perspective of the participant, the perspectives of ‘service providers’ and

‘service users’ and also reflect on how my own presence impacted on the

community health initiative and the study as a whole. Several studies have been reported by Sharon Merriam which explored the ‘insider/outsider’ issues in terms of “positionality, power and knowledge construction” and highlights the impact that the interviewees’ beliefs about the researcher can have on what type of information is given to the researcher (Merriam 2000).

However, I am not a Gypsy or Traveller, but a middle-classed, researcher from a university and therefore, an ‘outsider’ to this community. How people

conducted themselves and what they chose to disclose to me will have been moderated because of this. Also, as a female, my perceptions are influenced by my gender as are the experiences I had during this study, such as who I

interacted with and how people interacted with me. All these things have an impact on the data collected and how it is perceived.

Brayboy and Deyhle (2000), exploring the effects of being ‘insiders’ in ethnographic work by being native Americans studying native Americans, discuss the impact of studies that present the insiders’ perspective. They

suggest that although it may be impossible to become a complete insider into a community, the researcher can be positioned as ‘broker’ bringing the ‘insiders’

voices to the ‘outsiders’.

By adopting the ‘insiders/outsiders’ approach within a General Systems Framework, the perspectives of all the key players within the study were

described, a voice was provided for Gypsies and Travellers in Wrexham, and the community initiative judged within a cultural and environmental context.