Scand J Prim Health Care 1986; 4:81-84

Conceptual Problems in Primary Health Care Research

KERSTIN M. ANDERSSON

Institute of Nursing Science, School of Medicine, University of Bergen, Norway

Andemon K MXonceptual problems in primary health care reserueh. Scad J Prim Health care 1% 4 81-4.

Concepts are basic elements in all scientific uork. New fieMs of indgation, We primary health care, haw to adopt new concepts. These may hrm a, more or less, physical appearance or may be phenomenological by M-. Concepts may be defined by description or, more appropriate, by explicption of weessvp and sufficient attributes or ehprpcteristics, or by criteria to be fdlilkd. One model for concept d y s i a contains steps as: (1) detumine the aims of analysis, (2) identify PU uses of the concept, (3) determine the deflniq attributes, (4) construct a model case, and (5) define empirical referents. Another model, desdoped for analysis of phenomenological Coneepe, is based on accumulation of hundreds of explications of the meaning of the concept. Those are elaborated by 1. Grouping, 2. Reduction, 3. Elimination, 4. HypotacticPl identification, 5. Application, 6. F d identification. Methods for concept analysis need to be fnrther emph.sizca in doaorsl progpms. E m expcrieneed scientists may need more trplning in such methods, when entering new tklds. Students need accurate puiacmeC through pasages of conceptual wwk. Concept development should be accepted and encouraged as rcscplch projects in its own capacity. It makes quite a contribu- tion to scientifii knowledge, to elaborate an important concept in PU aspects. In addrrssing new empirical problems, much work shoald be spared, if the rrsepreher could use concepts already studied and described in the literature. Key words: concept anal*, research methods, phenomenology. Kerstin M. Andersson, M t u t e of Nursing Science, Hans Tanksgt 11,5014 Bergen, No-.

Concepts are mental abstractions. They are our attempts to order our environmental stimuli. They are also necessary devices in communication. In daily life a tentative common-sense apprehension of meaning of concepts often serves its purpose. In scientific work, however, there is a demand for clarity and precision, for firm definitions and inter- subjectivity of meaning.

In traditional school medicine, researchers use concepts, established a long time ago and well de- fined like blood pressure, or coagulation. In new medical fields, like primary health care, those con- cepts may be too limited. The researcher may ad- dress problems related to the impact of illness on people’s life and life satisfaction. He may be inter- ested in people’s ability to cope or the way they function in certain roles in life. Life style and health

preserving behaviour may be in focus. In such situ- ations, the investigator may stick to familiar medi- cal concepts and pretend he is studying something new, or he has to adopt new concepts. To do so, he can either borrow from other disciplines, like psy- chology or sociology, or develop his own. In the first case an investigation into the appropriateness of the concept is crucial. In the second case he is embarking upon a dif€icult and time consuming, but very important process.

The purpose of this article is to discuss some of the problems faced in working with concept devel- opment. It addresses basic definitions, the nature of the problems and methodological issues. Further, some examples are used to illuminate the problems and issues focused.

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82 K. M. Andersson

THE NATURE OF CONCEPTUAL purpose, add a new meaning, or invent a new con- PROBLEMS cept for a special use. “Turbulence” has, for exam-

Concepts are formed by generalisations of p d c u - ple, been borrowed from physics to describe work- Pain or anxiety are generalisations of p d c u - ing environments with few routines and high degree

lar experiences in people. In some cases it almost of unexpected tasks. means the same to add meaning to a word and to form a concept. In other cases the meaning comes first and afterwards it gets a label, like in establish-

A BASIC MODEL FOR CONCEPT ANALYSIS

ing diagnoses. Most concepts are not used in a A quite simple step by Step Procedure for concept vacuum, the context or circumstances add certain analysis will be presented and discussed (1, 6). It meaning to them. A concept deliberately and con- gives a Useful @dance, and may even Serve a sciously invented or adopted for scientific purpose check-list for control, when YOU assume YOU master often is called a construct (1, 2). the concepts but need confirm. The steps included

Conceptual problems may arise at different stages of scientific work. Some of them appear initially, in defining the research problem or in stat- ing the hypotheses. Others are exhibited in the planning stage. If the concepts are inconsistent, vague, unclear or self-contradictory no valid and reliable tools for data collections can be made. Tension, logical inconsistency or incompatibility among the results or in comparison to eadier find- ings may be due to conceptual problems (3).

The concept analysis approach is governed by the kind of concept and the purpose of analysing it. Some are considered material by nature. They have, more or less, physical appearance (4). “Fe- ver” is like that, or “bed rest” or “handicap”. Other concepts are phenomenological, they are formed not by things themselves, but by the way people experience things (5). Concepts like “loneli- ness” and “pain” are examples of those kinds.

Conceptual problems are non-empirical or theo- retical by nature. If someone asks: “Is colour- blindness a handicap?” he has stated a conceptual question. To answer it, he has to determine the necessary and su&cient characteristics of the con- cept “handicap”. If instead he had asked: “Is co- lourblindness a risk in car driving?” the question is empirical. It can be answered by observing colour- blind drivers or by comparing accidents among drivers with and without colourblindness.

A concept analysis may end in a descriptive defi- nition, formulated by words, with as well defined meaning as possible. It may explicate attributes or characteristics of the concept, or criteria to be ful- filled. Or, it may focus on actions or behaviour expressed b$ or implied in the concept. The result may even be operational, indicating a way to meas- ure the concept. The definition may be stipulative, meaning that you will assign a content for a certain

in the procedure are:

1. Decide about the concept. 2. Determine the aims or purposes of analysis. 3. Identify all uses of the concept that you can

4. Determine the defining attributes. 5. Construct a model case. 6. Construct border-line, related, contrary, invent-

7. Identify antecedents and consequences. 8. Define empirical referents.

In deciding about concepts to be analysed too broad “umbrella” terms are avoided or broken down into more specific concepts analysed one by one. In order to study the problems involved in having a severely handicapped child, an attempt was made to analyse the concept “care load on families”. This, however, appeared to be much too broad to handle.

In identifying all applications, dictionaries, all types of literature may be used, as well as inter- views with knowledgeable persons. All your imagi- nation should be brought into use in tracing sources of information. Initially all aspects are taken into consideration. Later on, they are narrowed down according to the purpose of the analysis. Related and borderline uses of the concept should also be listed. In determining attributes, you should start by reading through all your information about the use of the concept, make lists of characteristics that appear again and again, and from provisional crite- ria. In this way a phenomenon is identifed as dif- ferent from other similar or related ones. A number of possible meanings may turn up, and one has to decide, which one fits in with the purpose. More than one may be appropriate. Alongside with the determination of attributes, a model case is devel-

discover.

ed and illegitimate cases.

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Conceptual problems in primary health care research 83

oped, a real life example of the concept. This should include all the attributes amved at and noth- ing else.

In constructing borderline, related, contrary and invented cases, you should provide examples of concepts that are not the true ones. A borderline case contains some of the attributes, but not all of them. Related cases do not contain the critical attri- butes, but are connected with the true concept. Contrary cases are those which are certainly not an example of the concept. They have none of the critical attributes defined. Invented cases are those in which you use your pure imagination to under- stand the concept, and illegitimate cases are all those in which the term is used improperly. All these other cases are compared with the model case and the attributes are re-examined and refined. The goal is met when there is no overlapping and no contradiction between the defining attributes in the model case.

Antecedents and consequences are well exampli- fied by the concept of pregnancy. Ovulation and conception must occur prior to a pregnancy, and the pregnancy will inevitably end in a delivery.

The last step in the analytical procedure is the important determination of empirical referents. These are sometimes identical to the defining attri- butes. In other cases, the attributes are too abstract to serve as determinants in the real world. You will have to find categories or classes of phenomena which by their presence represent the concept it- self. Thus may the critical attributes of “intelli- gence” be represented by certain problem solving behaviour .

The described procedure has been utilized in an analysis of the concept “suffering” (7). From what I found, it was not possible to arrive at any defining attributes from the nurses’ point of view. Several were suggested, but they were too inconsistent and contradictory to be used.

ANALYSING PHENOMENOLOGICAL CONCEPTS

I will now address the problem of analysing pheno- menological concepts. These can be defined as “not the things themselves, but the way people experience things”, or “the way things appear sub- jectively in people’s minds” (4, 5). According to Spiegelberg (8), the term phenomenology first oc-

curred in the writings of Lambert in 1764. Since that time a long range of theorists have devoted themselves to the development of the concept. Most recognized is the German philosopher Ed- mund Husserl (9). Before and even more so after his time there have been a variety of schools and much disagreement concerning the issue.

Many methods for approaching phenomenologi- cal concepts are described in the literature. Some of them are purely philosophical. By “open your eyes” concerning the phenomenon one can intu- itively grasp the uniqueness of it. By introspection one’s own experience is utilized. In that process one has to put anything one knows, or thinks, or feels about the phenomeon into brackets, to enable the reach of a pure intuitive sense of it (11). An analysis in order to trace elements and structure of the concept will follow. Finally, the phenomenon is described in a way that provides unmistakable guide-posts and makes a person recognize his own experience of it. The purpose is to find the essence, the very core of a phenomenological concept.

For an investigator trained inside the paradigm of medicine, thoughts of philosophical intuiting must be very new and strange. A systematic and accept- able way of studying phenomenological concepts is described by Van Kaam (12). In his opinion, step- ping back and looking into one’s own experience or awareness is not enough. Such a method has too many pitfalls. For one thing, it is not open to scien- tific control. His alternative is suitable for phenom- ena that are a relative common experience among people, when the human experience is basically identical and expressed under the same label. In his own work he studied the concept “being under- stood”.

A study of “feeling lonely” is about to start at my own department. The method proposed has the following steps:

1. Accumulation of explications from samples of

2. Scientific explication in six operations: untrained subjects

Listing and primary grouping. Reduction. Elimination. Hypothetical identification. Appli- cation. Final identification.

By untrained subject is meant subject with no theo- retical background, but merely with experience of the phenomenon under study. The subjects are asked to describe their feeling in situations in which the experience has occui-red. In the Van Kaam

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84 K. M. Andersson

example 365 high school and college students wrote descriptions of situations in which they felt they really had been understood.

The data are listed into groups created by the materid itself. For that purpose a random sample of cases from the total pool of description is taken. Van Kaam used 80 of the descriptions produced. To ensure validity, more than one person should perform the listing and comparisons.

Reduction means the transformation of concrete, vague, intricate, and overlapping expressions into more precise terms. In elimination the elements that are probably not inherent in the phenomenon under study are removed.

So far crude and preliminary, a hypothetical identification and description of the phenomenon is produced. The next measure is to apply the hypo- thetical description on other random samples out of the material collected, to see if it corresponds. When nothing more is added or removed you may consider your identification to be valid, but only for the group represented by the sample. It will be tested on other groups and remains valid until it can be proven that cases of the phenomenon contain other elements.

REFERENCES 1. Wilson J. Thinking with concepts. London: Cam-

bridge University Press, 1963. 2. Kerlinger FN. Foundations of behavioral research.

2nd ed. New York: Holt. Rinehart and Winston, 1973. 3. Laudan L. hgress and its problems. Toward a the-

ory of scientific growth. Berkeley: University of Cali- fornia press, 1977.

4. Alexandersson C. Amedeo Giorgi's empirical phe- nomenology. University of Giiteborg, Department of Education, 1981; 03.

5. Lauer Q. Phenomenomology. Its genesis and pros- pect. New York: Harper & Row. 1965.

6. Walker LO, Avant KC. Strategies for theory con- struction in nursing. Norwalk, Conn: Appleton-Cen- tury Crofts. 1983.

7. Andersson KM. Suffering. A search for conceptual attributes. (Submitted for publication).

8. Spiegelberg H. The phenomenological movement. A historical introduction. 2nd ed. The Hague: Martinus Nijhoff, 1977; I.

9. Husserl E. Phenomenological psychology. The Hague: Martinus Nijhoff, 1977.

10. Spiegelberg H. The phenomenological movement. A historical introduction. 2nd ec. The Hague: Martinus NijaOff, 1971; II.

11. Schutz A. On phenomenology and social relations. Chicago: University of Chicago Press, 1970.

12. Van Kaam A. Existential foundations of psychology. Pittsburgh: Duquesne University Press, 1%.

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