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Introduction

In document Health Literacy: (Page 164-169)

Chapter 4 Research Methodology and Method

5.1 Introduction

The previous chapter presented the hermeneutic methodology of this thesis and Ricoeur’s theory of the interpretation of texts. This chapter is the first of two chapters that presents the researchers’ interpretations of the baby boomers’ and primary healthcare professionals’ (PHCPs) understanding of health literacy. These interpretations are made by proceeding through an iterative hermeneutic circle having regard (primarily) to the context of New Zealand healthcare, baby boomers as a generational cohort, and previous knowledge and theories of health literacy.

In today’s health context and healthcare systems, individuals are considered and expected to be active, engaged, and informed consumers (Fox, Ward, & O’Rourke, 2005; Henderson & Petersen, 2002; Hibbert, Bissell, & Ward, 2002; Holmes, 2006; Lupton, 1997; Madison, 2010; Petersen & Lupton, 1996; Rose, 2000;

Savard, 2013; Schneider & Hall, 2009; Shaw & Aldridge, 2003; Shaw & Baker, 2004). Individuals hold complex health beliefs and engage in diverse health-seeking behaviours (Germond & Cochrane, 2010). At the same time, being and acting ‘health literate’ is increasingly demanding in the current context of health with processes emphasising the centrality of self-management of health and illness (e.g., Epstein, Fiscella, Lesser, & Stange, 2010; Fox & Ward, 2006; Petersen, Davis, Fraser, & Lindsay, 2010). Thus, there is an increasing emphasis on an individual’s health literacy to enable effective health behaviours and achieve

‘good’ outcomes. Earlier Chapter 3 highlighted that health literacy research has been predominantly at an aggregate population level, focussing on measurement and intervention with reference to target groups that are at risk or unwell.

Similarly, little research has explored how non at-risk individuals experience and understand health literacy. Chapter 3 concluded by proposing a conceptual

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framework that health literacy be considered as an interactive, dynamic, and contextual phenomenon.

The term health literacy “…has been stretched, squeezed and reshaped to try to cover all of the factors that affect the way consumers relate to the health system and the resulting outcomes” (Australian Commission on Safety and Quality in Health Care, 2013, p. 11). Given the evolving nature of health literacy definitions and the on-going refinement of health literacy measurement, this research uses qualitative in-depth interviews and hermeneutic analysis to develop a conceptual framework that addresses the call from the World Health Organisation for a

“relational whole-of-society approach to health literacy that considers both an individual’s level of health literacy and the complexities of the contexts within which people act” (Kickbusch, Pelikan, Apfel, & Tsouros, 2013, p. ii).

Researchers often examine health literacy in the context of specific illnesses, medical conditions or health behaviours. Notably, this research draws on understandings and perceptions of health literacy roles among a population of individuals, selected according to age rather than according to medical condition.

Furthermore, this research frames health literacy as a resource, not as a risk/deficit, focussing on the patient as an active consumer (Schulz, 2013, IRiSS).

This thesis explores individuals’ behaviours, roles, and relationships in order to deepen the understanding of health literacy as a dynamic and interactive process (more than just cognitive skills and competences) that is contextually situated.

This chapter uses categories of description (Akerlind, 2012; Marton & Pong, 2005) to better understand the complexity of healthcare consumers’ intent (motivation and volition), skills (competencies), and knowledge (bracketed terms taken from Sørensen et al., 2012) in health literacy, without separating the individual from their health context and those contextual processes of communication, relationships, and networks.

This chapter addresses the research question:

How do Baby Boomers experience and practice health literacy? Specifically,

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- How do Baby Boomers as primary healthcare patients perceive their behaviours, roles, and relationships in relation to health literacy?

Although the 46 New Zealand baby boomer participants were characterised according to gender, ethnicity (European, Asian, Māori, and Pacific Peoples), and age (leading edge baby boomers and trailing edge baby boomers), the study purpose was not primarily to investigate differences between these segments. The aim was to explore diverse responses on the phenomenon of New Zealand baby boomers’ health literacy. The research did not seek statistical representation according to gender, ethnicity (although this revealed insights for comparative constructions of health literacy), or baby boomer age sub-group. However, some reflections on these demographic characteristics are offered in developing and interpreting the baby boomers’ understanding and experiences of this phenomenon.

Adopting a hermeneutic process, the researcher analysed and interpreted the interview data in an iterative cycle of pre-understandings, the interview text, and new (post) understandings of baby boomers’ experiences and perceptions of health literacy. This pull-and-push between text and interpretation, between appropriation and distanciation, occurred until the interpretation illuminated the phenomenon. The interview texts were initially organised by applying descriptive codes through the ATLAS.ti software programme (organising codes and an excerpt from a coded interview are attached as Appendices 17 and 18 respectively). Repeated readings of the texts enabled an appreciation of the dimensions of the phenomenon of health literacy and of the phenomenon as a whole. Applying an on-going reflective application of this researcher’s pre-understandings to the readings of the texts led to a deeper interpretation and new meanings to be reached; Ricoeur (1974b, 1981a, 1990) refers to this as distanciation and appropriation.

Categories of description, adopted from phenomenographic research, are used to denote this interpretation and deeper understanding of the practices and

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experiences of the phenomenon of health literacy (Marton & Pong, 2005).34 Such categories, different from the individual’s awareness of a phenomenon, present a collective voice of experiencing a phenomenon similar to “any symbol system…by which we organise experience into the formal structure of which

‘knowing’ is constituted” (Brown, 1976, p. 169). This thesis adopts categories of description as a means to interpret the participants’ texts, combining participant’s individual awareness and understanding of health literacy into a collective description of the fundamental aspects of the phenomenon.

Flick posits that presenting qualitative research findings can be anywhere between the two poles of where one is “developing a theory from the data and interpretations…At the other end, you will find the ‘tales from the field’…which are intended to illustrate the relations the researcher met” (2009, p. 414). This thesis takes the first approach, presenting the categories of description, first outlining the logic for these, and then supporting these with the textual data interweaved with the researcher’s pre-understandings. The linear presentation belies the cyclical hermeneutic process through which the large amounts of textual data were reduced and (re)interpreted, ending in the new understandings proffered via the categories of description. The interpretations are presented in a linear and structured fashion smoothing out the twists and turns of the interpretation process.

Five categories provide interpretive differentiation for the baby boomers’

experiences and practices of health literacy; these are: seeker, decider, networker, sensemaker, and manager. The process of identifying and selecting the labels for these categories of description is explained earlier in Section 4.8.1. Each of these categories of description is a relatively abstract and complex concept that provides a way of ‘seeing’ the phenomenon of health literacy; each category expresses a qualitatively different aspect of experiencing and understanding health literacy

34 Phenomenography’s ‘categories of description’ are adopted in this hermeneutic interpretation of health literacy as they inform and improve the interpretative capability.

Other outcomes of phenomenographic research (outcome space, dimensions of variation, referential and structural dimensions) are not adopted following the general pragmatist guideline to use “whatever works best” (Huber, 1973, p. 276), borrowing that which offers interpretive potential.

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(Marton & Pong, 2005). Although the categories are interrelated, in describing these categories of description the distinguishing aspects are represented and the non-critical/non-defining aspects are put to one side.

This chapter begins by discussing the five categories of description, interpreted from the baby boomer participants’ data, summarised in Table 5.1. For each category, key meanings are identified; these meanings emerged in the hermeneutic process as the researcher moved between the parts of the texts and the transcripts as a set, and between the various horizons of the researcher’s pre-understandings and the phenomenon of health literacy. In this circular manner, the horizons of the researcher and the horizons of the texts come together to illuminate the phenomenon. After interpreting and discussing each category, baby boomers’

health literacy is conceptualised according to two horizons (Section 5.3) - a self-horizon and an interactivity self-horizon.

The following notes outline the procedures adopted with regard to the interview excerpts used to support the interpretations in this chapter:

1. The baby boomer interview transcripts are identified according to ethnicity, gender, and age, followed by # for the chronological number of the interview schedule, as follows:

Ethnicity: A: Asian, E: European, Mi: Māori, PP: Pacific People Gender: F: Female, M: Male

Age subgroup: L: Leading edge baby boomers born 1946-1955, T: Trailing edge baby boomers born 1956-1965

For example, Transcript AFT #34 refers to a participant who is Asian, female, and in the trailing edge age subgroup. The interview was number 34 of the 46 baby boomer interviews.

2. The transcribed texts have been kept as spoken by the participants. Where limitations in the spoken English prevent a clear understanding of the meaning of the text, added words are included in square brackets.

3. When the transcript excerpts include the interviewer and participant dialogue, the interviewer is identified as INT. These are included when it is necessary to provide some context for the text.

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4. Pseudonyms are added when the dialogue requires the participant to be named for sense and comprehension.

In document Health Literacy: (Page 164-169)