Introduction: Bringing health research to practical use

Ajay Bailey, Sjaak van der Geest

Abstract

This introduction to a special issue about translating health research to practice descibes the problems that present themselves when applying research results. The authors emphasise the importance of engagement from all relevant parties during the design, the fieldwork and the reportage of the research. Only if there is a sense of ownership regarding the project among policymakers, health workers and the target population, application is likely to succeed.

In the appendix to his classic ‘Street Corner Society’, William Foot Whyte records his first meeting with Doc, the man who offered to introduce him to the Italian-American slum where he hoped to do his research. It is a fascinating discussion between two people from entirely different backgrounds but who are interested in one another. Whyte explains what he wants to do and how; Doc listens and offers suggestions.

We talked a little how and when we might get together. Then he asked me a question. “You want to write something about this?”

“Yes, eventually.”

“Do you want to change things?”

“Well – yes. I don’t see how anybody could come down here where it is so crowded, people haven’t got any money or any work to do, and not want to have some things changed…. I don’t want to be a reformer, and I’m not cut out to be a politician. I just want to understand these things as best as I can and write them up, and if that has any influence…”

“I think you can change things that way. Mostly that is the way things are changed, by writing about them.” (Whyte 1955: 292-293).

Is Doc right? It is indeed possible – and attractive – to believe that good knowledge will just find its way and bring about the changes it proposes. We are afraid, however, that Doc was too optimistic, that knowledge will not automatically lead to deeper insight and work as a lever to change. The spread of knowledge is whimsical and depends on a complex whole of social, political and symbolic frames. The access to knowledge is uneven and the understanding of knowledge which does arrive differs enormously according to gender, class, social position, age and education. The appropriation of knowledge depends on political control from above and interest from below. Knowledge, moreover, is permeated with cultural and ideological assumptions that may attract some, push off others and leave again others indifferent.

Considering that the practical application of research insights implies seriously considering the ideas and interests of ‘others’, this issue discusses how this gap can be bridged by promoting changes in relation to local and global health research agendas, and dynamics of producing and sharing knowledge. How to bring health research to policy-makers, development practitioners, activists and community members? How, why and for whom is health research being done? The key question is the location of the production of knowledge. If we assume that knowledge in terms of theories or some crucial ideas are produced in the domain of academia and diffused for applications, then we claim more than we ought to.

Ironically, anthropologists have repeatedly pointed at out the social and political nature of producing knowledge (e.g. Geertz 1983, Keesing 1987, Franklin 1995, Boyer 2005), but have given relatively little attention to the cultural and political embeddedness of the ethnographic and theoretical knowledge which they produce. Almost proverbial is the cliché of the research report gathering dust in the drawer of an office: unwelcome, uninteresting or incomprehensible to the policymaker or health practitioner and totally unknown to the people in the community.

It is the researcher’s challenge to get findings to all parties involved and capture their interest. There are different levels of stakeholders to whom research can be ‘returned’ and in a form that is easily identifiable and accessible to them. Those different stakeholders might include the everyday people who participated in the study and grassroots development practitioners, as well as local and international policy makers and the health care providers. Each group requires a different approach in selecting which knowledge can be shared and how it can be conveyed. It is this translation process that needs to be focused upon where one has to also let go of academic language and present information in the language of the intended audience.

The contributions to this special issue describe four ways of getting the message across to different stakeholders. Fuusje de Graaff studied views about and experiences with professional home care for terminally ill cancer patients with a Moroccan and Turkish background in the Netherlands. She compared and contrasted the views of relatives, professional caregivers and general practitioners (huisartsen) and pointed out various miscommunications. In the article she first describes her research approach, particularly how she tried to get all relevant parties interested and involved in the research. The focus of her essay is on the translation of the conclusions and recommendations into ‘practical products’. In five sessions she develops health education materials which appeal to the people who need them. They appeal because, thanks to the attention to translation, they make sense to them and matter to them. The author takes a clear stand about the work of an applied researcher: It does not end with the conclusion of a report. The findings must be delivered to the right addresses and taken to heart.

Ajay Bailey in his article uses an autoethnographic lens to examine his own efforts to share results about HIV risk perceptions and behaviour of migrant and mobile men with practitioners such as those in non-governmental organizations in Goa, India. He describes different steps he took to sharing these results and discusses challenges he faced during the process. The paper also highlights the positionality of the researcher and how different stakeholders evaluate him. The paper, though not prescriptive, is an effort to show the learning process in translating results.

Judith van de Kamp tackles the issue of Dutch medical aid to developing countries and grounds her concerns about the ill effects of short-term medical aid. As a pro-active researcher, Van de Kamp mingles with people holding varied opinions and tries to find a common ground for their conflicting views. Her technique of ‘plugging in’ and ‘staying connected’ to all stakeholders helps to keep them alert and interested in the findings of her report. The involvement of the media plays a central role in her approach. Implicitly her essay also shows that the publicity in Dutch newspapers and television programmes surrounding the matter of medical aid does not yet effect changes in medical practices in hospitals in developing countries. Ultimately, the researcher usually has little direct influence on what happens on the ground.

Pauline Oosterhoff‘s essay describes the dual role of researcher and practitioner, which she played in a health setting in Vietnam. She examines how knowledge is produced when the researcher must take both insider and outsider positions and how the boundaries between the two become blurred in a setting where the observer is also expected to contribute to the provisioning of services. Interestingly, she is the only author who succeeds in directly influencing conditions on the ground, thanks to her dual role of researcher and practitioner.

In all four contributions, the success of getting conclusions across to the various stakeholders boils down to ownership. When a researcher succeeds in creating a sense of ownership of the research, locating it in the hands of the participants, the ‘owners’ are likely to act upon the findings. Creating shared ownership between parties which perceive each other as having opposing interests seems to be a contradiction. Overcoming the conflicting positions is a matter of brokerage: applied research rests on cultural, social and political brokering.

It has become somewhat of a platitude among anthropologists to write that they want ‘to give a voice’ to groups of people that are not heard in the wider world. But platitudes can still be true. As brokers, anthropologists transport information about life in one corner of society to other corners where people live who are not aware of those conditions, or pretend they do not know, or do not want to know.

By confronting different categories of people with information about each other we practise cultural and social brokerage. Every society is – in varying degrees – a ‘pluriverse’ of cultures (Weidman, in Van Willigen 2002: 132), or a collection of ‘co-cultures’ (ibid.). Cultural brokerage implies bringing about communication, interaction and – hopefully- mutual understanding and support. If anthropology has usefulness, it is first of all this establishment of respect and understanding between different cultures or different levels of societal organization (Van der Geest et al. 1990). Kinsman’s (2008) study about HIV/AIDS policy in Uganda demonstrates the need for ‘brokerage’. In his critical analysis of how research leads to policy in the fight against HIV/AIDS, he convincingly shows that conflicting views and interests regarding the disease at different levels in the country’s political organization account for ineffective interventions. Better communication and understanding between international agents, ministerial officers, health workers and people suffering from the disease improves the quality of anti-AIDS policies.

An interesting example of social and cultural brokerage can be found in a research experiment with health workers in Bolivia. Initially, the aim of the research was to have an anthropologist explore the views and needs of the community regarding health care and report the findings and recommendations to the health workers. Then it was decided to involve the health workers themselves in conducting the research, thus, directly experiencing the problems of the populations. The experiment proved to be a success. The health workers gained a much better understanding of the patients’ points of view and applied their new insights in a more respectful treatment of the patients (De Boer 2004); an ingenious strategy of cultural brokerage within one and the same person, similar to Oosterhoff’s approach.

Another ingenious way of brokering research findings and establishing shared ownership of the research enterprise is to invite members of the ‘target population’ as co-researchers. In 2001 the Dutch organization PatiëntenPraktijk commissioned Stuart Blume and Geerke Catshoek to write a report about the possibility of including patient organizations in scientific research. Their report suggested three strategies to achieve this objective: (1) Bring about structures for dialogue between scientists and patient organizations; (2) Strengthen the legitimacy of patient participation in research; and (3) Promote and develop new styles of research (Blume & Catshoek 2001, 2003). All three recommendations were already commonly recognised in medical anthropology as valuable elements in research, but in actual practice, anthropologists may encounter difficulties when attempting to involve ‘patients’as research partners.

Zonmw, the Dutch national fund for health research, holds meetings for patient organizations and professional researchers to stimulate and inspire patient groups and individual patient-researchers to become directly involved in health-related research. Zonmw has now made participation of patient-researchers as a condition for funding. A team of patient-researchers and non-patient professionals also wrote a handbook for patient participation in scientific research (Smit et al. 2006). It provides a wealth of practical suggestions about how and where the contribution of patient-researchers could be most valuable: evaluation of research proposal, patient information, style of interviewing, mediating between researcher and patient population, monitoring of research, analysing data, and distributing results (Smit et al. 2006: 20). It would be difficult to imagine a better guarantee for the successful application of research than the inclusion of patient-researchers.

Mainstream anthropologists tend to be rather sceptical about applied research, however. They regard applied anthropology as superficial and divested of theoretical reflection and think it is a weak compromise to please the non-anthropological parties that are responsible for policy and practical implications. We agree to some extent: applied anthropology must refrain from long theoretical discourse when it wants to reach policy-makers and other interested parties. But applied anthropology should not be superficial or without theory. Practical recommendations are the outcome of intense theoretical reasoning about positionality vis-à-vis all parties involved in the research and its objectives (see also Bailey’s contribution to this special issue). Applied research is thus heavily endowed with theory and reflexivity about methodologies. Meaningful suggestions for change consequently call upon more ‘theory’ than cultural interpretations of meaning (cf. Van der Geest 2010).

The paradox – and irony – of most policy recommendations is that they are based on insufficient theoretical insight. Many recommendations are naïve, because they do not take into account the complex political and social relations where their recommendations ultimately arrive. Theses of students sometimes end with ambitious recommendations which fill their supervisor with vicarious shame. Due to their naïveté, the statements are implicitly insulting to the intelligence of policymakers, others involved in the issue, and, ultimately to the student. Many times it is better to drop all recommendations to prevent annoyance, or worse, irritating the practice-oriented readers. Allowing readers to draw their own conclusions is often a better route to application than offending them with platitudes. Another irony is that recommendations are offered to those who have little or no interest in changing conditions, while those who would benefit from the changes remain uninformed about the suggestions and without any say in the decision-making process. To ensure application of research results one needs co-researchers who are at the same time practical workers in health care (cf. Varkevisser et al. 2001, De Boer 2004).

It may sound cynical, but we should realize that policy-makers see it as their main task to produce papers that contain designated words and in vogue intentions. Unfortunately, it is often the inclusion of certain words in government documents by which they are evaluated, not by the actual changes taking place on the ground. Anthropologists have to think of ways to circumvent the ‘paper delusions’ of policy-makers and speak directly to those for whom policy change really matters.

In addition, anthropologists owe it to themselves to think in practical terms when they reflect upon their work and position as researchers. By seeing themselves in the web of conflicting interests and contesting parties that constitute their ‘field’, they cannot afford to shrug off the practical implications of their presence in that field. Concern about these implications shows reflexivity and theoretical maturity. Clever reasoning and intricate arguments about cultural and political dilemmas and social inequality without rendering any account about responsibilities in these matters is not only questionable on ethical grounds but also problematic for reasons of theory. Thick description that excludes the epistemological and moral reality of the researcher’s own presence, misses the point.

Anthropologists working in the field of health and health care are always asked what the practical conclusions of their research are. In a triangle of research-funding-policy we are required to provide results that can be brought to those to whom they matter. In this issue of the journal we have brought together papers which address the question how to do this.

Returning to Doc’s optimistic statement that opened this introduction: the route of knowledge from research to practical use is full of pitfalls and obstacles. It requires theoretical and methodological inventiveness, trust in the ingenuity of policymakers and ‘target groups’, social skills, and a discipline in writing for a variety of audiences.

Note

Ajay Bailey is a post-doctoral fellow at the Population Research Centre, University of Groningen. Email: A.Bailey@rug.nl

Sjaak van der Geest is medical anthropologist at the University of Amsterdam. Email: s.vandergeest@uva.nl

The four papers in this special issue were presented and discussed in a panel during the CERES Summerschool 2009 “Where research meets policy and practice.” We are grateful to CERES (the Interuniversitary Research School for Resource Studies for Development) for its subsidy to make this special issue possible. We thank Deanna Trakas for editing this introduction.

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