Eurocentrismo y su influencia en el conocimiento

While many researchers paint mixed methods as a dualism between quantitative and qualitative methods, this is perhaps a poor starting point for this discussion. I say this because methodology is the last piece of the research puzzle based on certain

assumptions that arise much earlier in the research process; methodology (how we find information that can be known) must flow coherently from ontological (a systematic account of existence) and epistemological (what can be known) assumptions about the world (Lincoln, Lynham & Guba, 2011). So, instead of using the quantitative-qualitative terminology, I will draw on Sayer’s (1992) framing of the extensive versus intensive research design, which better speaks to the underlying assumptions and goals of the research, as opposed to just the end product.

These two types of design ask two different types of questions and therefore use “different techniques methods and define their objects and boundaries differently” (Sayer, 1992: 242). Whereas extensive research design seeks to find regularities and common patterns, distinguishing features of a population, or report on how widely certain characteristics or processes are distributed or represented, intensive research design, in contrast, seeks to find how processes work in a particular case or area, what produces change, why change is happening. As noted by Warshawsky (2014:167), Sayer’s extensive-intensive framing is taken by many as a substitute for the quantitative- qualitative framing; it should not be. Instead, the extensive-intensive lens should be understood as less of a question of method and more of a question of the type

generalizability achieved, which is rooted in epistemological and ontological assumptions.

Elliott’s (1999) manuscript bearing the title “And the Question Shall Determine the Method” was the introduction to a focus section in The Professional Geographer that provided an in-depth examination of qualitative approaches in health geography. Elliott points out that as health becomes a social science (the ‘cultural turn’ in health geography – the article was published right in the middle of the medical/health geography debate) and qualitative approaches became more popular, no one was advocating for a

replacement of quantitative approaches. She argues that the guiding principle is

appropriateness given the “purpose of the inquiry and the questions being investigated” (Patton, 1990:39) that determine methodological appropriateness.

The “questions” for my dissertation stemmed from the theoretical foundation upon which it is built. Though there existed information about the NHIS as a whole (national scale), we knew very little about how it was functioning in the UWR, other than the aforementioned Dixon, Luginaah and Tenkorang (2011) study that hinted at

inequalities. Yet, as discussed more fully elsewhere in this dissertation, the need for theoretically driven research was clear, and broader knowledge about access to health care led me to draw on three theoretical foundations to structure this work: first, the behavioural model of access to health care; second, a feminist framework of intra- household bargaining; and third, a political ecology framework which was further developed in the writing process into the political ecologies of health (PEH) framework.

and barriers, each also came with some separate assumptions regarding what can be known and how we may know it. For instance, the behavioral model is rooted in post- positivist notions of truth, focused on individuals and assumes that findings will be generalizable across space and time, where the aim of inquiry is explanation. A caveat: the behavioral model has evolved quite a bit since Andersen first introduced it in the 1960s, and now makes space for localized ‘place’ concepts, as well as interpretive notions of health which feed-back into an individualized propensity to seek healthcare; indeed, the focus of its use in this context is not meant to generate universal laws, but understanding of a place-based context of the UWR (see Keating, 2008 for a richer discussion of the fusion of interpretivist and positivist approaches). Intra-household bargaining, in contrast, draws on a critical paradigm, where a person’s power and access to resources within the household are determined by how they ‘stack up’ compared to other members of the household. This bargaining process is tightly linked to the material reality and social norms that push against it – e.g. gender mediates power within the household. Finally, the PEH framework is rooted in the critical/structural paradigm, namely the recognition of historical, economic, environmental influences on health. Knowledge is gained through a transactional (or “subjectivist”) approach, much like interpretivism, but with emphasis on how value mediates all findings. Thus, knowledge grows dialectically through historical revision, challenges power structures, and research is judged on its ability to erode ignorance (Lincoln, Lynham & Guba, 2011).

A look to this dissertation’s research questions derived from these theoretical perspectives reveals that there are, as to be expected, epistemologically differentiated assumptions:

1. What are the significant patterned differences between those enrolled in, never enrolled in, and those who have dropped out of NHIS?

2. What are the financial, social and bureaucratic barriers to NHIS enrolment?

3. How and why does gender and patriarchy influence enrollment and ability to pay for the NHIS?

4. What are the community perceptions of the NHIS? How is this shaped by the context of rural livelihoods?

Namely, question one, which seeks patterned difference between certain groups, is obviously rooted in post-positivist notions of generalizability (or extensive research, according to Sayer, 1992). Since this type of work had never been done in the UWR before (a unique context) some ‘generalizable’ facts were sensible, as well as

theoretically appropriate when trying to understand the determination individual enrolment status. Thus, coupled with our queries on gender, financial, and social differences in enrolment, a quantitative survey was the logical extension from the first research question. On the other end of the scale, question four, which sought out community perceptions regarding the NHIS especially in the specific rural context (place) of the UWR, aimed not for generalizability, but for depth and personal meaning of the participant’s experience with the larger structural forces that comprise the focus of this study. In line with Sayer’s (1992) notion of intensive research design, this research question begat further questions of ‘why’ and ‘how’ (i.e., to find how processes work in a particular case or area, why change is happening, etc.). These questions could only be answered through the use of qualitative methods (in-depth interviews and focus group

discussions), which provide a forum for exploring the “deeper and more genuine expressions of beliefs and values that emerge through dialogue [and] foster a more accurate description of views held” (Howe, 2004: 54). In sum, the theoretical basis of my dissertation shaped the research questions, which in turn shaped the research methods.

Before proceeding to the next section, I would like to say a few more words on the topic of my dissertation’s theoretical paradigms and why that logically has resulted in mixed methodologies. The undercurrent to this is the so-called “compatibility thesis” where researchers have been debating if the wedding of methods is epistemologically incoherent. A “pragmatism paradigm” has been suggested by some as an alternative theoretical paradigm to explain the use of mixed methods without getting too concerned with the nitty-gritty of epistemologically questions (Biesta, 2010; Johnson &

Onwuegbuzie, 2004; Howe, 1988; Maxcy, 2003; Tashakkori & Teddlie, 1998). I do not believe that the pragmatism paradigm is of relevance here.

While the questions for my dissertation stemmed from three theoretical

foundations, there is a single theoretical thread that runs through this entire dissertation, and its resulting research questions. That is to say, this entire dissertation has been built around a critical/feminist approach to knowledge, which challenges the status quo, and situates the current knowledge within a long history of Ghana and the UWR. Though I may draw on different theories to help explain enrolment in health insurance, the overarching theoretical framework is that of critical/feminist theory. As such, the epistemological and ontological incongruence that may appear above does not really exist. Critical/feminist researchers historically have always drawn on a variety of tools (both quantitative and qualitative) to help provide an intensive and extensive

understanding of the research at hand.