Ethnographic study: qualitative studies
How to use an ethnographic study to evaluate your digital health product.
This page is part of a collection of guidance on evaluating digital health products.
Ethnography involves observing people in their own environment to understand their experiences, perspectives and everyday practices. This can give in-depth insight into a particular context, group or culture.
Ethnography uses different research techniques, which may include observations, taking field notes, informal conversations, interviews, document analysis, surveys, filming and photography. More rapid approaches have been developed in recent years, some of which include digital methods.
What to use it for
Use ethnography to describe how a particular group or community works. For example, you could focus on the experiences of:
- professionals delivering a digital health service
- changes in routine practices in health services because of digital tools
- patients living with a health condition and using digital tools
Ethnography investigates the whole setting rather than a digital product in isolation. It focuses on exploring experiences (how someone might use the product in practice), not testing hypotheses. It is usually informed by specific research questions and theory. It can involve detailed examination of one or a few cases – these might be people or places.
You can use an ethnography to:
- inform service development (formative or iterative evaluation), by assessing needs or understanding how current systems work
- describe how your service works (summative evaluation)
Pros
Benefits include:
- it can offer a deeper understanding of experiences and local practices than quantitative studies or qualitative studies that only rely on interviewing (what people do versus what they say)
- it can uncover experiences, knowledge and perspectives that other methods miss out because of its real world focus and flexible approach
- it can give a voice to seldom-heard groups and perspectives that have been marginalised or overlooked
- it can uncover unintended consequences of changes made
Cons
Drawbacks include:
- it usually involves extensive field work – this is time-consuming and needs experience, although rapid ethnographic approaches are increasingly being used
- it can be subjective because it’s very dependent on the evaluator’s interpretation and skills
- negotiating permissions and access to carry out observational work can be difficult
How to carry out an ethnography
Ethnography includes a range of specific techniques. You will need to decide which methods to use. This will depend on:
- the evaluation question
- the setting being studied
- the availability of participants and materials
Research may include document analysis – for example, reading all documents from board meetings of a health service, or starting with an organisational chart.
The researcher will place themself in the setting being studied. It’s important that they establish good relations with the group or community and build trust. The researcher may identify knowledgeable informants who can act as a way in to understanding and interacting with the community.
You might select participants to cover the range of different experiences. In ethnography, the researcher can evolve their approach to data collection as the study goes on or collect data opportunistically. The researcher analyses the emerging data flexibly, identifying themes and any gaps or questions that require further study. Often, the researcher will sit in a clinic, spend time in organisations or visit patient’s homes. Digital ethnography can involve interacting with participants in a virtual space. The researcher observes events and talks to participants, either in a more formal way like a scheduled interview, or more informally during observations.
Field notes are usually made by the researcher. These are qualitative notes recorded during or soon after observations. They include both factual information (times, dates, behaviour observed, comments by participant) and reflections and interpretations by the researcher.
Ethnographic research is interpretive, so it can be subjective. To counter this, researchers often try to examine their own reasoning and involvement, recording it and working through any assumptions or difficulties that come up (this is called critical reflexivity). They often involve others in the evaluation team to sense-check their findings. They may validate findings by sharing their interpretations with participants, opening them up for discussion.
Data analysis tends to involve reading and re-reading the research materials using a constant comparison approach, where each finding is compared with existing findings. This is a sense-making process, drawing on the different types of evidence collected. It will often be a form of thematic analysis. Your analysis might draw on existing theory or you may develop a new theory that lets you be more responsive to the data.
Example: a rapid ethnography of patient portal use
Ackerman and others (2017), Meaningful use in the safety net: a rapid ethnography of patient portal implementation at five community health centers in California
The team wanted to examine the implementation of patient portals (also known as Personal Health Records) in US healthcare services for low-income populations. They used what they described as a rapid ethnography. They carried out 4 site visits, each lasting one to one-and-a-half days. They used methods including:
- detailed field notes
- 12 interviews with clinicians and management
- 35 informal focus groups with clinical and IT staff
- observations of sign-up procedures and clinic work
- a brief survey with 45 responses
- a document review of marketing materials for the portal
- quantitative data on portal use
The team also carried out a telephone interview with a programme coordinator at a fifth site.
Observing clinic work involved sometimes observing patients. Patients who were present gave informed consent. A university ethics committee decided that the study didn’t require ethics approval.
The health systems were putting in considerable effort to implement the portals, encouraging staff support and changing work patterns to accommodate portal-related work. They achieved or were close to achieving targets that released central funding, which were focused on registrations.
However, staff were not sure how to achieve real impact in their patients’ lives with a portal that was not necessarily relevant to patients. Patients rarely used the portal and faced many barriers to doing so. For example:
- no internet access at home
- lack of digital and linguistic literacy
- language barriers
- family members or caregivers not able to act on behalf of patients because of privacy restrictions
- purpose of the portal not clear to patients
- not clear how the portal worked, for example, who would see messages sent through the portal
- patients worried that using the portal would lead to government surveillance
- patients preferred face-to-face contact to digital interactions
The authors noted:
- that they could only gain limited insight into patients’ experience with their methods
- a potential form of sampling bias: health centres who took part were probably more advanced in their use of the technology than average
More information and resources
Greenhalgh and Swinglehurst (2011), Studying technology use as social practice: the untapped potential of ethnography. This discusses the value of ethnographic studies for studying health technology.
Policy Lab blog (2020), Lab Long Read: Human-centred policy? Blending ‘big data’ and ‘thick data’ in national policy. A practical example of how ethnography can be used in policy-making.
Pink and Morgan (2013), Short-term ethnography: intense routes to knowing. This article discusses the use of short-term (also called rapid) ethnographic studies.
Vindrola-Padros & Vindrola-Padros (2018), Quick and dirty? A systematic review of the use of rapid ethnographies in healthcare organisation and delivery. This article reviews the use of rapid ethnographies in health care.
Examples of ethnographic studies in digital health
Ventres and others (2006), Physicians, Patients, and the Electronic Health Record: An Ethnographic Analysis. An example of an ethnographic study of how electronic health records change the interaction between patients and physicians.
Sturesson and others (2018), Clinicians’ Selection Criteria for Video Visits in Outpatient Care: Qualitative Study. Following the introduction of video visits with patients in outpatient care in Sweden, researchers conducted an ethnographic study to investigate how clinicians used this new healthcare delivery.
Solvoll and others (2013), Physicians Interrupted by Mobile Devices in Hospitals: Understanding the Interaction Between Devices, Roles, and Duties. This study investigated the impact of interruptions caused by mobile phones to the working practices of physicians in Norway.