220.127.116.11 Observation to refine or evaluate policy interventions A variant on the triangulation role of observation is to use observation to help refine how policy interventions work in specific settings. Policy has to be implemented and observation/ethnographic study can provide analyses of both how local actors implement policy or how local circumstances require adaptations of policy.
For example,Hewitt's (2005) ethnographic study of urban racism explored policy interventions. He took the line that while theorising of racism is fine, situations differ in different contexts such that, for example, Greenwich is different from Birmingham or Moss Side in Manchester and it is important to ensure that the local context is fully understood if policy interventions are to be effective. Hence the need for detailed understanding of the local context, which observation studies can provide.
Abdoulaye Wade, Catherine Enel and Emmanuel Lagarde (2005) used sentinel observers to check out and log the nature of HIV prevention-related events in rural Senegal. In Africa, Senegal was one country with a low rate of HIV infection in the population. The study explored the mechanisms for HIV prevention messages. Three rural communities of Senegal: Niakhar in centre Senegal, Bandafassi in eastern Senegal, and Mlomp in southern Senegal were studied. In each community, a coordinator recruited and managed a network of what the researchers called sentinel observer, who recorded prevention actions occurring in their living area (11 observers in Niakhar, 9 in Bandafassi and 6 in Mlomp). A standard format was used:
sentinel observers were provided with standardised cardboard sheets that they were asked to fill in each time they witnessed or were reported a prevention-related event. The sheet contained fields for circumstances of the event, subjects addressed, investigator, support used, an estimate of the audience size and demographic characteristics, and the duration. Every 6 months, the coordinator organised a summary meeting with all sentinel informants in one site. All events reported by one or several observers were reviewed for completion and validation. All validated sheets were data captured. From the data file, all events were recoded using new summary variables describing the type of event and subjects addressed. (Wade et al., 2005, p. 253)
The collected information allowed building a descriptive timetable of these prevention actions, which included not only prevention campaigns but also all events related to prevention (meetings involving women, men, youth or chiefs, political or cultural meetings, theatre, radio or television programmes, information provided by health staff, casual discussions between villagers, etc.).
Observation is also used in evaluation studies. For example, Stapleton et al., (2002) used non-participant observation to evaluate the implementation of a recommendation to make childbirth in the UK more 'women-centred'. Observation research augmented a survey to aid understanding of the social context in which Informed Choice leaflets about maternity options were used. Observations were made of antenatal consultations to identify how the leaflets were used and how informed choice and decision-making occurred in practice. The researchers made detailed field notes about the setting, actions, words, and non-verbal cues of health professionals and parents. The evaluative research showed that, although most health professionals initially expressed positive views about the principles underpinning the Informed Choice leaflets, within practice settings, they were seldom used to maximum effect.
Pragmatic usage resulted in many leaflets being withheld from women because staff disagreed with the contents of the leaflet or were concerned because some leaflets promoted choices that were unavailable locally. Some midwives also made assumptions about the ability and willingness of women to participate in decision making. These assumptions were sometimes incorrect. (Stapleton et al., 2002)
The researchers concluded that the leaflets did not, in practice, promote informed choice. Although health professionals were generally positive, the ways in which leaflets were distributed or withheld diluted their potential benefits. Health professionals, pressured by time and concerned about litigation, rarely discussed the content of the leaflets or promoted their difference from other literature. Passive dissemination of information, the authors noted, is ineffective in changing the behaviour of health professionals (NHS, 1999). The lack of opportunities to discuss the content of the leaflets were exacerbated by the organisational and hierarchical structure of the maternity services that resulted in a lack of continuity of care, which precluded the formation of trusting relationships necessary to facilitate informed choice.
Furthermore, technological interventions were presumed to be the norm, and some choices promoted in the leaflets, 'such as whether to have ultrasound scanning or electronic monitoring in labour, were rarely available in practice because the technology had long been integrated into routine care' (Stapleton et al., 2002). There was little diversity in clinical practice between individual practitioners or maternity units and the local obstetric culture tended to maintain the status quo, which made it difficult to promote (informed) choice.
Time pressures on staff working within a culture that supported existing normative patterns of care rather than informed choice. The hierarchical power structures within the maternity services, and the framing of information in favour of particular options, ensured compliance with the "right" choice.... Midwives were observed to "frame" information and "steer" women towards making the "right" decisions to "protect" themselves and their clients from the consequences of inadvertently disrupting the status quo. Informed choice was therefore equated with making the locally defined "right" choice in accordance with the authoritative knowledge and experience of senior obstetricians. Unequal power relations resulted in bias towards the "objective" knowledge of health professionals and marginalised women's subjective knowledge (Stapleton et al., 2002)
The researchers argued that the intention to empower childbearing women had been severely diluted and that the use of the leaflets to promote informed choice in maternity care would need to be part of 'a coherent strategy addressing power imbalances and the ambiguities currently underpinning choice'. They noted also that the barriers they identified 'are unlikely to be unique to maternity care'. Providing information is insufficient without 'considerable cultural change at all levels of the maternity services' (Stapleton et al., 2002).
This study by Stapleton goes beyond a positivist evaluation of whether the pamphlets were used appropriately to adopting a critical approach that digs beneath the surface of professional control of maternity care, (see critical ethnography, Section 18.104.22.168).