Norming and De-norming in People’s Use of Local Primary Health Care Facilities

Norming and De-norming in People’s Use of Local Primary Health Care Facilities

Applying Logical Positivist and Postmodernist Approaches

Introduction

The seemingly ideal approach “bringing health closer to the people” has been employed in primary health care services around the world. Yet, one wonders at the interstices of policy and practice that belie the smooth-functioning of primary health care systems.

Looking into approaches under which theories and models may be subsumed is an integral part of the research process, the value being that it “shapes the way practitioners, educators, and researchers collect, analyze, interpret, and disseminate information” (McElmurry et al, 2002:8). “To be effective, we must deconstruct our ways of “knowing” and understanding the influence of the values and philosophies forming the foundation of our practice, teaching, and research” (ibid).

This essay seeks to demonstrate how the research question ‘Why do some people not use local primary health care facilities?’ may be appreciated differently by using a logical positivist and postmodernist research approach. I would like to outline this exposition by first discussing feature tenets of both logical positivism and postmodernism then illustrating the application of some of these major claims of each approach vis-à-vis the conventional medical model¹ applied in primary health care.

The Logical Positivist Approach: Norming health care

Logical positivists tender knowledge as best guess saying that no amount of empirical evidence would justify universal theory, hence, verification is impossible (Siegmann, 2009a). However, it does not preclude the idea that empirical evidence may justify the claim that a universal theory is false, therefore it posits that falsification is possible (Siegmann, 2009b).

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¹The conventional medical model uses a logical positivism philosophy, or empiricism, to verify cause and affect relationships for all human experiences (Wilson-Thomas 1995 in McElmurry, 2008:8).

Karl Popper argues for the falsifiability criterion where “a scientist seeks to discover an observed exception to a postulated rule” (Science Chat Forum, 2007). The absence of contradictory evidence thereby becomes proof of the theory (ibid). There is “therefore a preference for theories whose falsehood has not been established” (Siegmann, 2009c). Thomas Kuhn rejects Popper’s view by proposing that “it is not the products of science that are important, but the way in which scientists conduct their inquiry (Schick, 2000).

Logical positivists believe in an objective reality independent of observation (Siegmann, 2009d). They argue that this reality is reflected in techniques guaranteeing replicability and underline the distance between the researcher and the researched (ibid). They accept that empirical content guarantees testability and propose the exclusion of values due to lack of testability.

I proceed to relating this particular approach to people’s use of local primary health care facilities within the frame of a conventional medical model. The logical positivist may hypothesize that all people make use of local primary health care facilities and proceeds to falsify this universal claim through empirical evidence that proves otherwise. The absence of contradictory evidence proves the strength of the theory while the existence of a case that contradicts it warrants a study on why people do not use local primary health care facilities and thus establish cause and effect relationships “with the goal to describe, predict, and control human responses” (McElmurry, 2002:8).

Researchers subscribing to the idea that reality is independent of the observer may use this approach to “locate the ‘problem’ within the individual and consider the health-care professional as the expert responsible for curing disease and dysfunction and ‘helping’ people to achieve ‘health and normalcy’” (McElmurry, 2002:8; Oliver 1998 in McElmurry, 2002:8). This position suggests that there is a universal notion of “being healthy” and if one deviates from such norm, one is “unhealthy” thereby prescribing the need to seek the closest medical care available, the local primary health care facility. Researchers are also bound to establish causal relations through methods that include “controlled trials, random statistical samples, and structured questionnaires” (McElmurry, 2002:8), in the process, excluding “personal histories and experiences which are not validated, and where dialogue and sharing appear to be irrelevant in the process” (Wilson-Thomas 1995 in McElmurry, 2002:9).

The Postmodernist Approach: De-norming health care

Postmodernists believe that there is not one correct description of reality. It proposes “uncertainty as certainty” which is further explained with the message of the impossibility of knowledge closure on the past or the future as well as the inclination towards contextual relativism, “local rationalities”, thick/rich narratives, and the rejection of all claims to universal knowledge (Cameron, 2009a). “For this reason, postmodernism is highly skeptical of explanations which claim to be valid for all groups, cultures, traditions, or races, and instead focuses on the relative truths of each person” (PBS, 2009a).

As postmodernists argue that neither deduction nor induction can be freed from language and power, it sets on to employ deconstruction as a methodology by both ‘reading’ actively and reflecting on closures, metaphors, and silences in knowledge claims (Cameron, 2009b). When applied in research, there is recognition of the greater presence of the researcher and the reader but at the same time stressing more on the language of the researched rather than of policy agencies as a way of recognizing power relations (ibid). Its methodology gives more importance to the ethical right to inclusion which considers the range rather than the average experience while being open to the inevitability of unintended outcomes (ibid).

My thinking is predisposed towards arguing that the postmodernist would acknowledge that “as we increasingly work with culturally diverse groups, knowledge must be constructed in a manner that accurately reflects the nature of diversities and the consequences on responses to health” (Im & Meleis 1999 in McElmurry, 2002:8) while the logical positivist may “not consider the values embedded in society nor one's social position as an over-arching determinant of health status (Parsons 1999 in McElmurry, 2002:8) and thus fail to explain the social and environmental factors that account for people’s access and use of primary health care facilities such as “skyrocketing medical care costs, decreasing access to health care and increasing disparities in health care status among various groups of people” (McElmurry, 2002:9).

The postmodernist is sensitive to ‘stakeholding’ analysis to ensure inclusion of all testimonies in their own languages (Cameron, 2009c). It would find problematic the narrow construction of health care by the conventional medical model as it ignores differences in cultural attitudes and values such as what clients perceive as health problems. Power inequity exists as the model views people as passive recipients of medical care (McElmurry, 2002:9) there being, less privileged in claiming what for them is health as well as what is good for their health.

Conclusion

I have presented the nuances of the research question at hand by arguing that both approaches have their own epistemological limitations in that the logical positivist is normative in its conception and prescription towards health and access to it while the postmodernist is open to agentive spaces that acknowledge the range of knowledge, values and attitudes that people may have towards health care. Nevertheless, I try to avoid closure by saying that both leave an epistemological space for debate and have the potential to negotiate and challenge understanding of the research question within the realm of philosophy and methodology.

References

Cameron, J. (2009) 4223-0809 Session 6: Philosophy and Methodology of Social Science Research: The Roots of Postmodernist/Structuralist Epistemology Powerpoint Presentation, ISS: Development Research: Comparative Epistemologies and Methodologies

McElmurry, B.J., B.A. Marks, R. Cianelli, (2002) ‘Primary Health Care in the Americas: Conceptual Framework, Experiences, Challenges and Perspectives’, [Online], Available: http://www.paho.org/English/HSP/HSO/HSO07/primaryhealthcare.doc [15 Feb 2009].

Messer, E. (1985) ‘Social science perspectives on primary health care activities: Paper presented at the United Nations University Conference on Nutrition in Primary Health Care held in Bellagio, Italy, 1-6 July 1985’, [Online] http://www.unu.edu/Unupress/food/8F123e/8F123E07.htm [7 Feb 2009].

PBS, (2009) ‘Postmodernism’, [Online], Available: http://www.pbs.org/faithandreason/gengloss/postm-body.html [15 Feb 2009].

Schick, T., C.A. Mountainview eds. (2000) ‘Readings in the Philosophy of Science: From Positivism to Postmodernism’, [Online], Available: http://findarticles.com/p/articles/mi_m2320/is_1_65/ai_78487199/pg_6?tag=content;col1 [10 Feb 2009].

Science Chat Forum (2007) ‘Science and Philosophy Forum Index: Logical Positivism’, [Online], http://www.sciencechatforum.com/bulletin/viewtopic.php?t=5626 [15 Feb 2009].

Siegmann, K. (2009) 4223-0809 Session 5: Philosophy and Methodology of Social Science Research: Logical Positivism Powerpoint Presentation, ISS: Development Research: Comparative Epistemologies and Methodologies

Space and Motion (2009) ‘On Truth & Reality The Spherical Standing Wave Structure of Matter (WSM) in Space: Postmodernism’, [Online], Available: http://www.spaceandmotion.com/Philosophy-Postmodernism.htm [14 Feb 2009].