Sobre el uso de métodos cualitativos en Salud Colectiva, o, la falta que hace una teoría
Mara H de Andrea GomesI; Cássio SilveiraII
IEscola Paulista de Medicina. Universidade Federal de São Paulo. São Paulo, SP, Brasil
IIFaculdade de Ciências Médicas da Santa Casa de São Paulo. São Paulo, SP, Brasil
The present study problematizes certain uses of qualitative in the field of collective health methods, which are characterized by a lack of theoretical references and gloss over the rationality involved in their use as a technique exclusively. The proliferation and acceptance of such studies probably occur due to the strength of the instrumental rationality with which they have been conducted. Although frequently observed in a careful way, the results are not always supported by a careful presentation of the theoretical framework that underlies the interpretation. The use of "validated" techniques, the discourses constructed, and narratives of the actions of the "subjects" studied do not commit the researcher to the process of investigation, as they are separated from the historical-spatial contextualization and the theoretical-methodological landmark that imprint a historical and social sense to studies.
Descriptors: Qualitative Research. Methodology. Measurements, Methods and Theories. Public Health. Critical thinking.
El artículo problematiza ciertos usos de métodos cualitativos en el campo de la salud colectiva que se caracterizan por la ausencia de referencias teóricas y que ocultan la racionalidad presente en su exclusiva utilización como técnica. La proliferación y aceptación de estos estudios posiblemente ocurren por la fuerza de la racionalidad instrumental con que han sido conducidos. Casi siempre presentados de manera cuidadosa, los resultados no siempre son apoyados por la presentación juiciosa del cuadro teórico que fundamenta la interpretación. El uso de técnicas "validadas", los discursos construidos y las narrativas de las acciones de los "sujetos" investigados no comprometen el investigador en la relación, ya que prescinden de la contextualización histórico-espacial y del marco teórico-metodológico que imprimen sentido histórico y social a los estudios.
Descriptores: Investigación Cualitativa. Metodología. Mediciones, Métodos y Teorías. Salud Pública. Reflexión crítica.
Based on the increasing number of articles published or manuscripts submitted for publication in Collective Health journals, the contributions of socio-cultural reflections to studies that require knowledge about individual and group ways of feeling, thinking and acting are now recognized. In fact, in this field of knowledge, surveys on dimensions that value human actions have pointed to clues and directions for new reflections, especially when considering the fact that they aim to justify proposals of interventions in collective actions included in the area of health.
However, it is important to problematize certain uses of qualitative methods, which are characterized by a lack of theoretical references and gloss over the rationality involved in their use as a technique exclusively, at times deceiving researchers themselves. As a rule, several studies have been conducted in an effort to make an assessment of either the professional qualification required by health programs, the organization or action needed to enable the implementation of programs, or the proposal of models of conduct (technical-health care and/or educational, among others) and behavior.
The contribution, proliferation and acceptance of these studies have probably occurred as a result of the strength of the instrumental rationality with which they have been conducted. In general, studies of this nature describe in detail the procedures used, so that one can rely on the results achieved and believe that possible selection and information biases have been controlled by researchers. With regard to interpretation criteria, those that primarily lack a good and solid theoretical framework are the ones shown in a vague manner, often clouded by a certain understanding of phenomenology, as though there was only one approach that rendered that exclusive interpretation legitimate, which becomes implicitly accepted.
As in quantitative studies, the data collection techniques used in qualitative research are a wide set of possible means to obtain data and information. The discourses constructed to express ways of thinking and feeling, or the narratives of actions of research "subjects" are still collected through interviews that require interpersonal contact and that are performed face-to-face. Thus, these (structured and semi-structured) interview situations commit the researcher to a relationship4 that should be reflective. In addition, they presuppose the fact that researchers will think over themselves in the interview situation and over their own values or, as indicated by Gonçalves6 when one approaches empirical materials, "the researcher comes closer to the object in a sensual way and observes its apparent contours and ways of existence for the first time".
However, when such exposures are thoroughly described and shown to be a natural result of the technical resources used, without an equally strict presentation of theoretical criteria and principles that led to this construction, both the researcher and the reader lose the dimension of values overlapping the relationship. In the absence of argumentation, such reports and discourses could well have occurred in any place or "non-place", using a known expression by Augé1 (1994), as if the researchers' inner experiences, convictions and social inclusions were not involved in the knowledge construction process.
The present study aimed to problematize the use of qualitative methods and their underlying techniques in health studies, and it was motivated by questioning the number of articles submitted to journals in the area of health and which have been published or not.
Some issues of Brazilian journals in the area of health or with an interface with collective health were analyzed to identify the ways in which published qualitative studies have been conceived and constructed and their purposes. Aiming at a temporary categorization that could guide subsequent readings focused on the research purposes, two major topics related to published qualitative studies were constructed: on the one hand, there were research projects that led to articles aimed at professional qualification assessment and practices required by health programs; on the other, there were research projects whose purpose was to propose models of conduct and behavior, especially through educational proposals that were supposedly more in agreement with or adequate for the technical-health care models.
This dialogue-oriented process of reading and reflecting was guided by the following question: "Why and in what conditions is there consensus on the 'relevance of the use of qualitative techniques in research in the health field?". Evidently, we did not reach the end of possibilities for understanding and reading, but sought to point out the role of theory in research, whether qualitative or not.
The pragmatism in the health field should also be taken into consideration, although this was not the object of the present reflection. This pragmatism is justifiable to a certain extent and it is probably explained by its multi-professional composition, with a strong influence of technical reasoning on the basis of the educational background of the majority of health professionals. Health practices are strongly oriented towards immediately responding to suffering, emergencies and the risk of becoming ill. This reasoning is almost always followed by the search for adequate solutions for the reduction in time and burden of suffering of individuals and populations with health problems, and by the search for measures applied to health prevention actions. Before being a set of types of knowledge constructed upon a solid basis of argumentation, this is the context where theoretical-methodological instruments are turned into application techniques, in which the socio-cultural dimension runs the serious risk of playing a secondary role, rather than the desired applicability of research results.
Thus, the interactions between the use of the technique and public actions, whether state-based or not, give support to the set of actions regulated by types of knowledge that do not problematize the constitutive elements of their origins and analytical developments. On the contrary, they reveal the dangerous conviction of speaking for others.
THEORY AS A PROBLEM
The ethics involved in the relationship between research subjects should also be reflected upon. In a survey conducted by Ramos et al7 (2008), authors debated the recurrent use of the Informed Consent Form as a personification of the ethically required role with regard to things that "must be said":
"Thus, we asked ourselves what this 'unsaid' would mean, as everything beyond the scope of these reference points remains in the realm of what is general and inferred. However, choices about what should be said determine the unsaid and, as a result, the 'unsaid' also 'says much', including the possibilities of their enunciation. (...) Our themes and key words speak of possible choices, commitments and visions of reality."7
The discussion in this study is found precisely in this distancing between the realm of theoretical possibilities and the choice for techniques aimed at the development of forms of intervention in health. Here, the unsaid, which is glossed over by the technique and which remains hidden, involves choices that researchers make throughout the research. They are visions of the world that instigate the choices one makes and follow one's reasoning. Such choices imply the way one views theories and condition choices of methodologies, methods and techniques to which they are related. One's views reflect part of one's history and background.
Historically, the ever-renewed concern about the development of techniques associated with interventions grew substantially in the first half of the 20th century. In 1941, Mannheim5 (1961) wrote "Diagnosis of Our Time". He was a relevant author in the field of sociology, concerned over the world situation and over what he diagnosed as the appearance of mass society, whose governments could not work without a series of inventions and improvements in the field of economic, political and social techniques. With regard to the latter, Mannheim defined them as "a set of methods aimed at influencing human behavior, which act as particularly powerful social control means when in the hands of the government".5
The main characteristic of this theory was to reveal these social techniques not only for the purpose of their being highly effective, but also for the indication that this efficacy emphasized the predominance of a minority. During that same period, marked by the "mechanical dissemination of mass ideas through the press and wireless communication means",5 the organization of behavioral control and maintenance techniques occurred in a broad and vigorous way. Their theoretical development enabled researchers to denounce the greater efficacy of human behavioral manipulation or even the establishment of ways of influencing and determining mass emotions, within certain limits. More objectively, their complaint was aimed at social services, especially the influence of social work on individuals' personal life.
In the political sphere, Mannheim was worried about the construction of democracy and the development of democratic planning, whose main attribution was to define the place and use of such social techniques, contrary to the way followed by totalitarian governments during the 2nd World War. As a new ideal, he proposed planning for freedom, vis-à-vis the increase in the demand for social justice. His project for society was guided by principles of freedom and social justice not only as a matter of ethics, but also as a pre-condition for the functioning of the democratic system itself.
Finally, another important point raised by this author should be emphasized. According to him, the error made by liberalism was that it mistook neutrality for tolerance, because "neither democratic tolerance nor scientific objectivity imply that we should abstain from defending that which we consider to be true or that we should avoid debates on the ultimate values and goals of life". Among the causes of disturbance and shifting of the values of "our time", Mannheim pointed to the fact that responsibility was concentrated on certain social agents: "in a place where there is not a recognized system of values, authority spreads, justification methods become arbitrary and nobody is responsible anymore".5
It is not for another reason that it is precisely these arguments which are emphasized to contextualize the ethos of this reflection, as they reveal what has not been said, the unsaid which turn means into ends and fills the development and purposes of qualitative research in health with utilitarianism, without critical and coherent reflection over the choices.
In Brazil, more than 30 years after the publication of Mannheim's diagnosis, Cardosoª indicated the incapacity of Cartesian epistemology to respond to their own criteria in "O Mito do Método" (The Myth of Method): "the method is simply a set of rules that in themselves only guarantee the achievement of the expected results"; thus, identifying itself with the technique. With this reduction, the method itself is characterized by the absence of scientific criteria, leading the researcher to adopt accepted and pre-established standards without the need for critical reflection. According to Cardoso, criticism imposes the condition that one will distance oneself from the entanglement of the method to reach the assumptions on which it is based, thus enabling possibilities to understand the formation of knowledge and the role played by the method in such formation.
In the perspective of social and human sciences, it is practically a truism to think that knowledge results from interpersonal relationships. In the case of studies "involving human beings", it should be considered that this knowledge is the result of a relationship between at least one individual who is engaged in knowing something and something or someone that represents the focus or object of their concern. However, Cardoso warns that, in an "instantaneous epistemology", this relationship takes place between the empirically considered investigator, as a concrete individual, and the space defined by reality, also concrete, which one expects to investigate: "but there are serious limitations in this double empiricism, in relation to both the subject and the object and, consequently, in the orientation of the relationship itself".
"Each individual would be entirely responsible for the formulations they have made and for the explanations they give, because their thought would have been formed from the contact with the object, which could not deceive them as it is concrete and independent from them. All they have to do to succeed is to not let themselves be deceived, i.e. to remain neutral to prevent interferences that deform the object, which should be obtained in all its purity". (Limoeiro, 1971, p. 3)
Thus, the researchers' proposal of recovery of the requirements needed for qualitative studies can be more detailed and what could appear to be obvious becomes the object of the question: who is the researcher after all? If one assumes that a thought cannot exist independently from someone who thinks and that it only exists as something thought of in a given historical-social context, prior to being someone who defines, a researcher is a subject with definitions, because they learn to think within a society even before realizing they were thinkers. This subject researcher also has their own language, originated from a culture that sets their habits, ways to behave, norms to follow and preferences, among other aspects. Thus, it is their responsibility to reflect over the conditions in which their own ideas are created.
The first observation to be made as those who have a project is that this project does not belong to the researcher alone, but rather to their culture and society. Ultimately, this project is based on values shared by their group or social class. The researcher's choices are thus guided by their own sense of socio-cultural belonging. There is not any neutrality in this belonging; on the contrary, it is through it that they make their choices and raise the problems they expect to study.
An almost obvious consequence of this assumption of the subject conforming to society or social group is that the thought-object relationship goes beyond the individual and specific "thinking" subject, because it is based on the partial explanation which is concretely accepted by society. This is why researchers admit that knowledge is always limited, partial, less rich and complex than the reality they refer to; and this is why they accept that the adequacy of a thought to the object is always relative and temporary.
SPONTANEOUS SOCIOLOGY AND SOCIAL THEORY
The argumentation constructed thus far could lead to a spontaneous sociology, a concept developed by Bordieu2 (1990), which is only overcome when theory is included in this relationship.
First, it is important to remember that the effort made by the researchers of this study is aimed at the object, although they do not control the process of their own intelligibility. What enables the knowledge about the object is founded on the theory put into practice, on theorization. In other words, reality only becomes an object as a term of the relationship, as something thought of, as a scientific fact, and as a constructed fact in this relationship with theory and with that which it explains or interprets. Only then can one speak of scientific research. Thus, science is both method and theory, or one is a requirement for the other.
Performing research is undoubtedly a methodical exercise of construction of an object of knowledge, where technique is required at precisely this point: as a way of doing. However, this way of doing depends on who does it and what is done, representing a triple specificity to lead researchers to the real object, to the ontological basis: the theory, the method and the technique.
Just like human actions in general are included in normative fields, research actions also follow more or less permanent and intense standards. These actions become problematic when researchers follow rigid and routine-oriented standards without questioning them, or even without clarifying, even to themselves, the axiological body that constitutes them as such researchers. In the qualitative dimension, they need to combine their views of the world with the theories that provide them with information to develop a research project, in addition to exposing the rationalities that are pertinent to them.
According to Weber8 (1991), one's choices imply making decisions about the values one attributes to the objects studied. By constantly explaining the process that leads researchers to incorporate certain values and to disregard others, they expose their way of constructing the research object. Such exposure must be sufficiently careful to clarify the critical posture that guided each action, enabling the identification and problematization - to convert it into a problem - of that which can be solely guided by actions that have not been reflected over. This suggestive methodological conduct also guided the reading of the articles performed in this study.
When articles based on empirical research describe the methodology used in detail, alluding to a distant phenomenology and/or hermeneutics, researchers can legitimately conduct the reading according to the expectation that the results achieved are associated with these theoretical propositions. For example, when one says that a study seeking the meanings, purposes or perceptions was conducted with the help of a semi-structured questionnaire, including hermeneutics as the "theoretical framework", it is legitimate to expect that argumentation reflects the relationship between language and the researcher's interpretation or orientation, in addition to the values that guided the initial definitions and the choices made throughout the entire research process.
If this argumentation is not clarified, it is also fair to ask what logic and what rationality led to that specific interpretation, instead of another one like the reader's, for example. Especially in the case of hermeneutics, the absence - whether intentional or not - of such argumentation exempts researchers from thinking about and treating the other and themselves in a relational perspective, as both in the world. Apparently, this exempts researchers from the responsibility for the possible consequences of their research projects, especially in the field of health, according to the strong tradition of associating these projects with the applicability of their results.
The so-called "discourses" collected through a technique, reports that resulted in a list of languages - so as to remain in the domain of hermeneutics - which, in its turn, was organized through a different technique, derived from the speech that underwent several cognitive and intellectual mediations until the final presentation or conclusion. Here, the following question becomes relevant: how to establish levels of communication and reliability, if the supra-sensitive realm of senses is not conducted by the history of these senses and concepts that created them? The presentation of perspectives that inform these mediation processes ends up establishing a complete separation between the researcher and their interviewees, as though there was not an implicit rationality, one that does not view them from a relational perspective.
The result is almost always a text that exhaustively describes the technique used to collect the speech of the "other", considered as an object, even when referred to as a subject. One could agree on this aspect, including on that fact that they are indeed the subject in this rationality, although in the sense of being subjected to, subordinate to and dependent on3 an unquestioned rationality.
On the other hand, that way of interviewees' speech being collected and organized was only possible for those who admitted the researcher's inexistent exemption, even from the technical-instrumental rationality that informed them. Based on this absence of questioning, researchers can infer that they themselves are subordinate to, subjected to, as they do not make the criticism required to set them free. This is a reflection that refers to the ultimate purposes that set them face-to-face with their interviewees.
Inevitably, they remain imprisoned in the empirical and ontological realm, accepting a certain reality as final and being strongly supported by the determinism of rules. Research will continue to play against hermeneutics itself, while this determination of technique prevails, while the "conclusion" and "purpose" of research are presented as an unquestionable truth, and while hermeneutics is used in such way, because its appeal for freedom primarily derives from the impossibility of separating the subject from the object.
To look back on texts written by Mannheim5 and Cardosoª so long ago was neither a mere casual event nor pure nostalgia. Recommendations that have long been made in the field of social sciences were intentionally recovered, precisely due to their libertarian nature, when compared to the typical technical-instrumental rationality of modern times.
Likewise, this is not an obsession with critical theory. Instead, it shows the required place of the method in the field of Collective Health, a field which is highly permeable to different disciplines of knowledge and their different approaches towards spaces of professional interaction of a reality which is common to all.
Researchers should be careful and somewhat ceremonious when using qualitative methods. Readers are invited to observe rules that are strictly adequate for critical reflection, otherwise all of whom are under the risk of being subjected.
1. Augé M. Não-lugares: introdução a uma antropologia da supermodernidade. Campinas: Papirus; 1994.
2. Bourdieu P. Coisas ditas. São Paulo: Brasiliense; 1990.
3. Houaiss A. Dicionário Houaiss da língua portuguesa. Rio de Janeiro: Objetiva; 2001.
4. Guesser AH. A etnometodologia e a análise de conversação e da fala. Em Tese. 2003;1(1):149-68.
5. Mannheim K. Diagnóstico de nosso tempo. Rio de Janeiro: Zahar; 1961.
6. Gonçalves RBM. Tecnologia e organização social das práticas de saúde: características tecnológicas do processo de trabalho na rede estadual de Centros de Saúde de São Paulo. São Paulo: Hucitec; 1994.
7. Ramos FES, Finkler M, Gonçalves ER, Caetano JC. A eticidade na pesquisa qualitativa em saúde: o dito e o não dito nas produções científicas. Cienc Saude Coletiva.2008;15(Supl 1):1673-84. DOI: 10.1590/S1413-81232010000700079
8. Weber M. Ensaios sobre a teoria das ciências sociais. São Paulo: Moraes; 1991. Correspondence: Received: 4/15/2011 Authors declare no conflicts of interest.
Mara H. de Andrea Gomes
Rua Borges Lagoa, 1.341
04038-034 São Paulo, SP, Brasil
a Cardoso ML. O Mito do método. [cited 2008 Feb 20]. Available from: http://pt.scribd.com/doc/55481683/Mirian-Limoeiro-Cardoso-O-mito-do-metodo
Authors declare no conflicts of interest.