Philosophical and methodological approaches

At the outset of any research project it is important to make explicit the philosophical perspectives and presuppositions that will inform the knowledge generated by the process of enquiry (Guba & Lincoln, 1994). This chapter outlines my philosophical approach to the research, after the study aims and objectives have been introduced. I provide a rationale for the ontological, epistemological and methodological

decisions made in devising the research strategy, in comparison with available alternatives. Grounded theory is presented as the chosen methodology and alignment with my research philosophy is demonstrated. The chapter concludes with a brief argument for pragmatic pluralistic approaches in studying complex public health issues and interventions.

Aims and objectives

The initial aim of the research was to address the gaps in the existing evidence base by conducting a qualitative exploration of user engagement and health-related behaviour change in the NHS Health Trainers Initiative. Over the course of the study, it became apparent that accessing support from a health trainer was just one element of service users’ efforts to adopt and maintain healthy lifestyles. In order to achieve a fuller understanding of the behaviour change process, my initial aim was refined into two separate but closely linked aims:

i. To explore the processes involved in attempting to make and maintain health-related behaviour changes from the perspectives of people living in socio-economically disadvantaged areas; and

ii. To qualitatively evaluate the contribution of the health trainer role to supporting people in these attempts

More specifically, the study objectives were as follows:

1. To explore the factors that motivate users to access lay-led health improvement interventions such as those delivered as part of the NHS Health Trainers Initiative

2. To identify perceived barriers and facilitators to the engagement of individual users and communities with lay-led interventions

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3. To identify perceived barriers and facilitators to the adoption and

maintenance of health-related behaviour changes by users of health trainer services

4. To compare and contrast the experiences and perceptions of users, managers and health trainers operating within different models of local service provision

5. To inform the future development and evaluation of the NHS Health Trainers Initiative and similar lay-led interventions

By conducting a qualitative comparison of one-to-one and community-level approaches to health trainers, I sought to highlight the underlying mechanisms by which different intervention models might influence outcomes. The following sub- sections describe the study design employed to address the aims and objectives.

Philosophical approach

As shown in figure 9, the process of developing a research strategy begins with the inquirer’s ontological position. Ontology is the philosophical study of the form and nature of reality, and addresses questions about the nature of being (Guba & Lincoln, 1994). The study described here is primarily concerned with participants’ perceptions of the factors that help or hinder in attempting to lead a healthy lifestyle, their experiences of accessing or delivering a health trainer-led intervention, and the perceived impact of these interventions. Reality in this research is viewed from the perspective of the researched and gives primacy to their individual understandings of the NHS Health Trainers Initiative, which are influenced by their experiences of the world and the meanings they place on things. However, it was also recognised that participants would be likely to refer to shared experiences such as material disadvantage, ill-health and disability. The chosen research approach therefore had to acknowledge the existence and value of both the participant’s interpretation and their lived reality. Critical realism has been advocated as both an explanatory and action theory in health promotion, due to its emphasis on the existence and influence of structures that lie beneath the surface of social reality (Archer et al., 1998; Connelly, 2001). Unlike positivism, critical realism argues against the idea that human beings are reducible to passive subjects and, unlike interpretivism, opposes all forms of relativism as inadequate in leading to positive action. Whilst I am in favour of advocacy and activism in public health, a pragmatic approach had to be taken in recognition of the limits of the doctoral project to influence change.

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Subtle realism

My ontological position in conducting this study can be described as a form of subtle realism, which assumes that a social world exists independently from individual subjective understanding but that this is only accessible from my interpretation of the accounts constructed by others (Hammersley, 1992; Hammersley & Atkinson, 1995). The advantage of subtle realism over other forms of realism is that it acknowledges the paradox of only being able to discuss the ‘real world’ in the relativist arena of discourse and representation (Cromby & Nightingale, 1999). As such, it involves attempts to explore and represent this underlying reality, rather than attain ‘the truth’. There exist many truths and multiple realities, resulting from our individual interpretations that simultaneously enable us to understand and construct the social world around us (Grant & Giddings, 2002). In this research I set out to explore these many truths by exploring what meanings people attach to their health-related behaviours and the events of their lives. Hence, the study is informed by symbolic interactionism and, to a lesser extent, social constructionism. The former is concerned with the study of interactions and relationships between individuals and society, and the way in which social structures develop from these repeated interactions (Denzin, 1978). The use of a symbolic interactionist approach in this study was intended to highlight issues that arose from health promoting activities mediated through the symbolic significance of phenomena to individuals (for example, attitudes to food and physical activity) and through others (for example, the language used by health trainers versus professional advice-givers).

The social constructionist view also assumes an emergent reality fundamentally shaped by social interaction. It argues that the social reproduction and

transformation of structures of meaning, conventions and discursive practices principally constitutes both our relationships and ourselves (Cromby & Nightingale, 1999; Edley, 2001). Language is therefore central as the dominant carrier of categories and meanings, although there is some disagreement amongst social constructionists as to whether a real world exists beyond the text. Within the subtle realist perspective it can be argued that phenomena such as poverty, inequality and disease are both socially constructed and real, emerging through social processes that are shaped by influences such as power relationships and material resources. As this approach offers an open-ended and flexible means of studying both fluid interactive processes and more stable social structures, it was deemed highly relevant to the aims of this research (Charmaz, 1990). Taking a subtle realist view also provided tools for linking subjective consciousness and personal choice to

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macro social structures, and brought a critical posture to examining the data. This perspective fosters asking critical questions about how society impinges upon the individual and how individuals reproduce dominant ideas within society (Charmaz, 1990; Hammersley, 1995). These questions have inevitably been addressed in the present study due to its focus on marginalised groups, along with the factors that contribute to their disadvantaged social positions and poor health outcomes.

Interpretivism

A major focus of social constructionism is to uncover ways in which individuals and groups participate in the creation and consolidation of the perceived social reality (Bury, 1986). In the present study, this involved exploring the participants’ stories for the creation of taken-for-granted definitions, ideas and knowledge about health and behaviour. It also involved paying attention to my own social constructions –

influenced by my personal and professional background and experiences – and to the role of power in this process. This highlights the importance of considering the researcher’s epistemological position at the outset of any study. Epistemology is the theory of knowledge and concerns the means of knowledge production (Benton & Craib, 2001). In considering the most appropriate approach to this study, I began by drawing upon my prior experience as a research assistant and my formal training via a recently completed Masters degree in public health. This allowed me to

develop a broad understanding of the main research paradigms and their underlying theoretical assumptions, as well as a working knowledge of historical debates in health and social research. However, I was aware that I also needed to explore in depth the precise position of public health research in the context of rapidly changing health services. In order to appreciate the various perspectives, an exploration of the underlying epistemological and methodological assumptions was undertaken via extensive reading and formal training11.

Through this process I became aware that, although large randomised controlled trials (RCTs) have traditionally been seen as the ‘gold standard’ for investigating health problems, recent decades have seen an increasing recognition of the important role for social sciences and qualitative approaches in understanding complex health issues (Baum, 1995; Watson, Procter & Cochrane, 2004). For some

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During the first year of the PhD, postgraduate modules were undertaken in research philosophies and issues (Northumbria University), public health intervention (Newcastle University), social divisions and inequalities (Newcastle University), and theories, methods and principles of medical anthropology (Durham University). These formed part of the tailored training programme associated with an NIHR doctoral training fellowship.

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time it has been generally accepted that methodologies for public health research should be diverse and selected to suit the problem being investigated. Furthermore, there has been a growing acceptance of the need to take seriously people’s own views about health (Popay & Williams, 1994). Ideological developments such as a move towards more upstream and collaborative approaches have created

conditions for acknowledging the place for lay theories and understandings about health. The epistemological perspective taken in this research is interpretivism, which is founded on the study, expression and interpretation of human experience (May & Williams, 1998). In this approach, knowledge is created through the self- understandings of participants, rather than by the direct observations involved in positivistic methodologies. Furthermore, whilst positivists tend to distinguish between the objects of study and techniques used to research them, interpretivists emphasise the importance of the collaborative relationship between the researcher and subject in co-constructing the data (Guba & Lincoln, 1994; Grant & Giddings, 2002). Hence, the conventional distinction between ontology and epistemology becomes blurred, as that which can be known is inextricably intertwined with the way in which knowledge is created. The researcher’s position must be made explicit to enable them to interpret a participant’s story credibly (Grant & Giddings, 2002). This highlights the need for open-mindedness and reflexivity in order to move beyond a strict problem focus to a more general exploration of social phenomena.

My epistemological stance is based on an understanding that the participants in this study are experts in their own lives and that my role was to investigate the socially constructed meanings and behaviours that constitute their realities. This follows from the literature on lay knowledge described in previous chapters, which recognises that people acquire an ‘expert’ body of knowledge through a combination of life experience, circumstances and personal history (Popay & Williams, 1996; Popay et al., 2003). A qualitative approach was used to engage people in active, meaning-making dialogues and challenge their taken-for-granted beliefs and assumptions. Qualitative research involves the use of multiple

methodologies to study real-world settings and generate rich narrative descriptions, in an attempt to make sense of phenomena in terms of the meanings people bring to them (Denzin, 1978; Fraser, 2004). This approach is most appropriate where quantitative methods would not be able to adequately describe or interpret a situation, or where one needs to identify the variables that might be tested quantitatively (Corbin & Strauss, 2008). In the present study, a qualitative

interpretive strategy was employed in a manner consistent with the development phase of the Medical Research Council’s (MRC) framework for the evaluation of

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complex interventions (Craig et al., 2008; MRC, 2008). It also shares the aims of realistic evaluation research, which involve understanding the causal mechanisms of an intervention and the conditions under which they operate to produce specific outcomes (Pawson & Tilley, 1997). Rather than asking “Does the intervention work?”, the question asked in undertaking a realistic evaluation is “What works for whom and under what circumstances?” This approach was deemed suitable for use in the present study as the emphasis is on understanding the mechanisms through which lay-led interventions produce behaviour change, identifying the contextual factors necessary to trigger these mechanisms and predicting the range of likely outcomes (Pommier, Guevel & Jourdan, 2010). Pawson and Tilley (1997) describe this as the context-mechanism-outcome (CMO) framework. The ability to evaluate the effects of health improvement interventions and how they might be replicated means that realistic evaluation is highly relevant to policy development.

Research methodologies

Ontology and epistemology are key components of research paradigms, which provide frameworks of inquiry that define the nature of the world, the researcher’s place within it and what falls within and outside the limits of legitimate inquiry (Guba & Lincoln, 1994). The following sections describe the final component of the chosen paradigm – the research methodology. In this study, the methodology involved the use of grounded theory, delivered through a longitudinal qualitative research approach (abbreviated to QLR in much of the existing literature). See figure 10 for an overview. Alternative options were explored in developing the study proposal; for example, a phenomenological approach could have been utilised to ask questions about the lived experiences of individuals seeking help from a health trainer (VanManen, 1990). However, the emphasis in phenomenology is on the common features of the lived experience, whereas this research was concerned with comparing and contrasting narratives to further understanding of different

interventions. Employing a phenomenological approach would also have involved attempting to put aside or ‘bracket’ my presuppositions and understandings about health trainers in order to get back to the ‘real’ lived experience of the participants. Given my prior research in this area and existing links with the local health trainer teams, bracketing would have been very difficult to achieve. Grounded theory researchers, on the other hand, are recognised as social beings who create and recreate social processes (Charmaz, 1990; Baker, Wuest & Noerager-Stern, 1992). Ideas and assumptions about the situation are not put aside, but are instead used to understand better the processes being observed.

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Figure 10: Overview of the research design

The possibility of using discourse analysis was also considered in order to investigate the way in which stakeholders use language and words to create meaning in relation to health, inequality and behaviour change. Discourse analysis involves examining how language both shapes and reflects cultural, social and political practices, through tracing the historical evolution of language practices (Gee, 2005). Grounded theory, on the other hand, involves inquiring about the ways in which social structures and processes influence the experience of individuals through their social interactions (Starks & Trinidad, 2007). This approach was felt to be most suitable in meeting the study aims and objectives due to the emphasis on identifying structural as well as contextual, symbolic and interactional influences, thereby highlighting the need to take account of both macro and micro influences on the phenomenon under investigation (Subgranon & Lund, 2000; Corbin & Strauss, 2008). Grounded theory has been described as “particularly useful in new, applied areas where there is a lack of existing theory and concepts to describe and explain what is going on” (Robson, 2002, p.90). This approach was considered appropriate for use in the present study as, although there exists a substantial body of literature on behaviour change theories and models, this relates primarily to professional-led interventions. The lack of theoretical and empirical research on the processes involved in lay-led behaviour change interventions was identified in Chapter 3, providing the rationale for the grounded theory methodology described here.

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