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Global Health Research to Promote Social Justice

A Critical Perspective

Bathum, Mary Elizabeth, PhD, RN

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doi: 10.1097/01.ANS.0000300180.71724.8e
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Abstract

GLOBAL HEALTH research is a complex and daunting undertaking potentially fraught with cultural misunderstandings, simplifications, overgeneralizations, ethnocentric biases, blind prejudices, and cultural paternalism/maternalism. If the global health research is conducted with underprivileged, marginalized, indigenous, and/or oppressed populations of the developing world, the complexities of issues surrounding research become even more problematic. Researchers using a critical perspective consider the historical, political, economic, social, and cultural and gender factors that impact on the people and phenomena being studied. A critical perspective also requires researchers to be self-critical and aware of their own ideological and epistemological foundations and the presuppositions that inform their research and to be as transparent about them as possible.1 This critical analysis can uncover the differences in political understanding, social class, and culture, and access to power between researchers and the people being studied. Not addressing these differences can affect the quality, depth, and breadth of information that is shared, and can lead to research that may further oppress or cause harm to vulnerable populations.

The purpose of this article is to describe why and how a critical perspective was used in designing and implementing research with Aymara women healers in the high plains (altiplano) of Peru. Critical perspective factors that impact on health and healing practices in this culture are discussed. Finally, this article highlights findings from this study to demonstrate the usefulness of a critical perspective in global health nursing to promote social justice.

The critical perspective in inquiry has its roots in critical social theory. Critical theory is credited to have begun with social researchers at the Institute of Social Research in Frankfort, Germany, following World War I.2 There are many terms used in the literature to describe this perspective (critical inquiry, critical analytic stance, critical consciousness), but for this article, I will use critical perspective. Critical perspective researchers regard research as the beginning of social and/or political action, and look toward research findings as a way to help redress social inequalities.2 Participants are considered central collaborators in the research, and by thinking about and acting upon things in the world that need changing, participants' subjective interpretations and objective reality can be changed.3 The overall goal of a critical perspective research approach is social justice, which is achieved through empowered participants working toward societal transformation. Social justice has been defined as the equitable bearing of burdens and reaping of societal benefits.4 Without understanding the complex perspective of the people being studied and fostering their collaboration in research, researchers cannot fully know what empowerment or social justice may mean in another culture.

BACKGROUND

Aymara people

I delivered primary healthcare as a family nurse practitioner and worked in women's leadership and development projects for 10 years with Aymaras, the pre-Incan indigenous people. Aymaras have survived on the harsh, barren high plains of the Andes in Peru and Bolivia for 3500 to 4000 years.5 In the late 20th century, there were almost 2 million Aymara people in the world, and the current Aymara population in Peru is estimated at 750 000 people. Most Aymara people reside in rural areas of Peru as subsistence farmers who grow tubers, quinoa, and barley and herd sheep, cattle, llamas, and alpacas. Innovative, indigenous agricultural technology has allowed them to produce food and maintain animals in a cold, harsh, and high altitude environment. Aymara people still use farm implements and methods of farming and animal keeping that were used before the Spanish conquest.5

Aymara people of Bolivia and Peru have passed through several stages of acculturation into dominant cultures. They were “conquered” by the Inca Viracocha in 1430s, but unlike other conquered people, they maintained their own way of governance and community structure and language.5 During the Spanish Conquest, Aymaras were brutally forced to convert to Catholicism. Today, they remain nominally Catholic with much of their cosmology of a multispirit world functioning in their daily lives.6 In Peru, the Aymara people went through a bloody civil war from 1980 to 1992 when a Maoist-type insurgency group, Sendero Luminoso (The Shining Path), working in both the cities and the countryside, tried to violently overthrow the government.7 Through many violent and destructive historical and political events, the Aymara culture has remained intact and retained its language.

Research with Aymara women

Women have been recognized as the primary health promoters all over the world because of their work in child rearing, food production and preparation, and relational connections to family and community.8 Aymara women play a significant role in their culture in taking care of the health of the family and promoting family and community harmony.9 Aymara women suffer the 3-fold oppression in their societies by being women, economically poor, and indigenous. Indigenous people highly bear the burden of global health disparities.10 Indigenous women, because of poverty and gender health disparities, may be the most affected. Research with indigenous women of another culture needs to consider the history of oppression and marginalization in women's lives, and to promote empowerment, liberation and relief of suffering, and oppression.

Many of my well-intentioned health teachings and advice to prevent illness and improve the health of Aymara people did not seem very effective in promoting a long-term change. As my cultural understanding and experience with this culture grew, I realized that there were overriding factors of history, politics, economics, social, culture, and gender that impacted on the ability of people to care for their health and on my ability to provide healthcare and education. A critical perspective assisted me in planning critical inquiry research that took into account these factors and their influence on health and healing in this culture.

Study design and procedures

The research study received approval by the institutional review board of the University of Wisconsin, Madison. This study was an exploratory, descriptive study using the methodology of critical ethnography, more specifically cross-cultural feminist ethnography. Feminist ethnography includes 3 goals: (1) to document the lives and activities of women, (2) to understand the experience of women from their own point of view and perspective, and (3) to conceptualize women's behavior as an expression of political, social, and economic contexts.11,12 Cross-cultural feminist research broadens feminist ethnography as it posits the importance of cultural specificity, necessitates intensive study in the cross-cultural setting, seeks commonalities among women of different cultures and countries, and needs to be subjected to a feminist's critical evaluation of the study materials.12

Individual interviews, focus groups, and participant observation were all used to explore the components of the health beliefs and healing practices of rural Aymara women healers in 3 generations. Twenty Aymara women participated in individual semistructured interviews. Seven intergenerational family groups included participants from 4 triads (12 participants) and 3 dyads (6 participants). The family groups (dyads or triads) were also interviewed in focus groups (7 focus groups). Two other Aymara women healers who were not members of an interfamilial generational group were also interviewed. Fieldwork was completed in Peru in 7 months.

Full participation of the Aymara women from the study's inception was not possible because of the constraints of a dissertational study. For example, I decided on the research questions, the population to be studied, and the timeline, and these were subject to my dissertation research committee's approval. However, my intent was to make this study as close to participant action research as possible and to invite Aymara people to participate in the research as fully as possible. This was done by the formation of a research consulting team, by including local research partners in the study, and by fostering Aymara women's participation in analysis.

Formation of Aymara women research consulting team

An Aymara Women Research Consulting Team (AWRCT), consisting of 3 Aymara women leaders (bilingual in Aymara and Spanish), was formed to help with recruitment of research participants, to check the validity of the translations from Aymara to Spanish, to help with data analysis, and to act as a guide in cultural questions and situations. They received training in the ethical conduct of research, interviewing techniques, and use of the digital recorder and digital camera.

The AWRCT was an essential part of this study of Aymara women healers. Their experience with rural communities and women's organizations made it possible to find and recruit women healers. In a small rural community, a lone non-Aymara outsider could arouse suspicion in the people who lived there. Arriving with a group of Aymara women, I was an object of curiosity, but my presence was not seen as potentially harmful. The AWRCT guided me through decisions about whom to interview first in a generational group, how to most respectfully approach each interviewee, when to listen to a long story, and when to redirect the flow of the interview. They helped carry equipment and foodstuffs up some pretty hard climbs to healers' rural homes! We were able to evaluate each interview on our return trips back to our home community, and this informal evaluation process improved our approach and interviewing skills. There was something intuitively sound about arriving as a community to interview Aymara women healers about community.

The AWRCT made this study participative, but at times the participation of all of the group members during an interview made it chaotic and hard to control. I am barely functional in Aymara, so several women talking in Aymara at one time made it difficult for me to follow the conversation and direct the interview toward the next question. I wondered about selection bias in our sample of healers. Most of the healers shared the same values of service that the AWRCT exemplified in their lives, and we did not interview healers that may use their power to inflict harm. I wondered if the AWRCT chose those healers that they felt had values similar to their own, values they knew I cherished because of our time working together. I am convinced that this study was stronger and culturally more respectful and sensitive because of the formation and utilization of the AWRCT, but in evaluating their participation, I am aware of biases that may have affected the study's results. To enhance the information I was able to generate in my study, I developed relationships with other institutional research partners in the area.

Research partners

The Institute of Aymara Studies (Instituto de Estudios Aymara), located in Chucuito, Peru, was developed in the late 1970s to help outsiders (at that time mostly Catholic Missioners) working with Aymara people to better understand the culture. Staff members of the Institute of Aymara Studies reviewed, revised, and translated interview questions into Aymara and translated and transcribed the Aymara interviews from Aymara into Spanish. I talked with staff about contextual and cultural questions and healing practices that I was unclear about during my study.

The Institute of Andean Pastoral Work (Instituto de Pastoral Andino), located in Cuzco and Sicuani, is a Catholic Church sponsored organization that coordinates pastoral work in the southern Andean region. It sponsors groups and activities for youth, women, and families. The local Catholic Church diocese, the Juli Prelature, was another valuable research partner and has a long history of working in solidarity with Aymara people. My credibility with rural Aymara women was enhanced by my connection with the Prelature.

Aymara women participation in analysis

Another influence of using a critical perspective in implementing this study was the participation of Aymara women in the preliminary analysis of the data. This was done in the intergenerational focus groups, as women discussed together what they had said about healing and what it meant to them. It was also done with the AWRCT when we spent 3 days together reading all the interview transcripts. They commented on what was striking and/or puzzling to them, and those notes were used in my final analysis. Focus group data and the preliminary analysis were also used to plan for further participatory research with Aymara women.

Other analysis strategies

The analyzed data included the texts of the interviews of the individual healers, the texts of the focus group with the intergenerational family group, the taped interviews with key informants, and the field notes on participants' observation of many daily activities. Data triangulation13 was used, as data from each of these methods were compared and contrasted. In keeping with a feminist ethnography, areas that seem to be of most concern to the lives of the women are emphasized, including their relationship with the Pachamama, their involvement with community maintenance, healing work with women, and domestic violence.

After returning to the United States, the word documents were downloaded into N6, a software used in organizing qualitative data to help in analysis. Through several readings of the interview transcripts, I created a list of themes and organized them into hierarchical nodes.14 My University of Wisconsin–Madison research group, a qualitative analysis expert, and a bilingual Spanish/English nursing professor reviewed the nodes to assure their comprehensiveness. Transcripts of each individual interview were then coded line by line into several node categories. A bilingual Spanish/English nursing professor in the United States reviewed the line-by-line coding.

The individual interview transcripts were then organized into smaller groups of texts that related to certain themes. I used text analysis that aims to identify themes, to describe the themes, and then compare them across individual women and groups15 For example, through N6, I created transcripts of participants' words of anything that was said about “coca,” “the Pachamama,” “economic or social concerns,” and “gender.” These smaller, thematic groups were then organized to include each participant who had spoken on these themes. Pulling these topics together helped in describing what the themes meant from the Aymara women's standpoint and words.

To further the understanding of what the Aymara women were describing, I also used the data organizing functions of N6 to create transcripts of overlapping or intersecting nodes. For example, I created transcripts of how each generational group of healers discussed “medical pluralism” and/or “relationship with the ancestors.” I then asked questions from the smaller text transcripts to better help me analyze the responses, and actually wrote those questions on the transcripts. Examples of some of these questions are: “What are the mental health issues for women in this culture?” “How do women experience blocks to community among groups of women, i.e. criticisms from neighbors, envy, gossip?” “Do older healers share common themes about use of traditional versus allopathic medicine?” “What do Aymara women consider psychological violence?” “How do women express their practice of medical pluralism?” “Where are the social security nets?” These questions helped me delve deeper into understanding the transcribed texts and to analyze the study's findings.

FINDINGS

A critical perspective calls the researcher to critically examine the contextual factors that impact on the people and phenomena being studied. The study's findings are organized under these contextual factor categories. Each category includes words from the interviewed Aymara healers, information from other interviewed sources, historical or situational information that may clarify the importance of the topic, impressions from participants' observation and/or experiences of living in this culture, and a discussion on how all this impacts health and healing practices. For the purposes of this article, factor categories are combined, briefly described, and only the most salient information reported. This section concludes with ideas about future participatory action research that emerged from the use of a critical perspective in research with Aymara women healers.

Historical and political factors

Peru is a multicultural country where Andean, African, Amazonian, Asian, and European traditions have interacted and mixed in various and surprising ways.16 A brief overview of Peruvian and Andean history is provided here to place into context the lives of Aymara women within their country and society.

The first human remains in Peru date back 14 000 years ago. Humans were foragers/gatherers/hunters until 4000 years ago when domestication of the camelids (llamas, alpacas, and vicunas), and growing potatoes and possibly quinoa heralded a more horticultural civilization. The Inca civilization, which by 1430 had become the Inca Empire, existed for barely a century. During that time, however, it was able to conquer and incorporate earlier dominant cultures to extend from southern Columbia to northern Argentina. The unification of the empire did not completely extend to the daily lives of people in these cultures. Insurgencies and unrest within the empire are thought to have been a reason why the Spaniards were successful in their invasion and conquest of the Inca Empire in 1532.17 The colonial period in Peru extended from 1535 until 1831 when the republic of Peru, through many battles and wars, gained its independence from Spain.18

Understanding this history of being “conquered” is important to understanding Aymara women. Even in the present time, Aymara women talk of the Inca “conquering” their people. There are folk dances and mock battles that depict the conflicts between Aymaras and Incas. A town in the rural highlands, Chucuito, was given to favored families of the Inca after Aymara territory was invaded, and there is still mistrust expressed between people of that town and people of surrounding towns.

The colonial period and its many wars, insurgencies, and political upheavals, play an important role in the history of Aymara people. Aymara indigenous movements from the early colonial period are still mentioned in the present, and the names of revolutionary heroes and heroines are evident in Aymara daily life. Understanding the historical underpinnings of indigenous revolutions and movements is important in studying the present health and healing practices of these people. Some of their practices may be in response to a history of being oppressed and needing to protect one's culture from a dominating culture. The rural healers expressed a desire to avoid the hospital and government healthcare centers (most often staffed by non-Aymara people), as expressed in the following: “Although we are advancing more and more, we are afraid to go to the hospital. They always ask you questions about your life and family. They do not understand us. It is because of this fear that people do not go-fear of too many questions.”

The violence of the Sendero Luminoso (SL) guerilla war (1980–1992) greatly affected all aspects of political and social organization in the rural areas of Peru's highlands.7 Social programs to help the poor were suspected by SL, as they were seen as helping to maintain a status quo and total destruction of civil society was the goal of the revolution. Many Aymara women abdicated leadership positions during this time. The SL threatened the community leaders with death if they continued in positions of authority. The government regarded organizing as a threat and was suspicious of community activities that could support the guerillas. Left leaning political and development organizations were considerably weakened during this period including organizations aimed at promoting women's rights. The 12 years of political violence are still present in most people's minds. While the terrorism of the war has mostly disappeared; political, social, and psychological repercussions remain. This history of terrorism and violence still influences Aymara women and affects their health, their health-seeking behaviors, and their willingness to risk being seen as leaders in society.

Economic and social factors

Economic and social factors that marginalize Aymara people greatly affect their health and health-seeking behaviors. Privatization, which began in the late 1970s, remains a cornerstone of the government's economic policy, closely following the neoliberal capitalistic economic model and International Monetary Fund guidelines.19 Utilities, mining, and other previously government-run enterprises passed to private, usually foreign, ownership. Income from these sales boosted the Gross Domestic Product (GDP) during the late 1990s and gave the illusion of an improved economy, but the benefits did not “trickle down.” While infrastructure improvements were made throughout the country, there was not a coherent development plan, and there are accusations that much of the money from privatizations may have been stolen. Government officials have estimated that government corruption costs Peru $2 billion a year in lost investment, as well as more than 50 000 jobs a year.20

Poverty rates actually increased during the 1990s. By 2000, about 54% of Peruvians lived in poverty, with insufficient income to meet basic needs, and about 5 million, lived in extreme poverty, unable to satisfy basic food needs. The problem is more acute in rural areas, where as many as 90% of people live in poverty.21

Employment is a major concern in Peru. While official statistics show that only about 10% of Peruvians are unemployed, the figures are misleading. The unemployed and underemployed constitute the bulk of the work force, with an income insufficient for survival. About half the labor force is in the “informal” sector of the economy, most working as street vendors. Thousands of people have been laid off as businesses have failed. Privatized companies like mining and oil interests employ very few local people, and about 250 000 educated young people enter the work force each year with little hope of finding jobs.20

These worsening economic conditions have local consequences. Besides the obvious health effects of hunger and malnutrition, Aymara women experience worry and stress when they do not have food and the money to provide for the needs of their children. One of the healers describes this:

In the communities, the women have so many worries. Sometimes we do not have money to buy everything that our children need, the harvest does not go well and the animals get sick. All of this causes worries and this affects our health.

Clearly, Aymara women make strong connections between political decisions, economics and their quality of life:

Women do not have much, we lack economic means, and this is a worry. More than anything, on the part of the government, it should not create more political parties, but should assure that there are social programs. They should create employment opportunities for women … in this way our lives can improve.

The major health problems that affect Aymara people are diseases of poverty, inadequate nutrition, and lack of healthcare infrastructure that influences access to resources. There is a gross inequality in the distribution of wealth in the population that particularly affects women and children.21 The infant mortality rate in 2002 was 30 per 1000 and mortality rate for children younger than 5 years was 39 per 1000, a figure that increases to 62 for males and 90 for females in rural Peru. The adjusted maternal mortality ratio was 410 per 100 000.22 Lack of water and poor sanitary conditions led to the 1991 outbreak of cholera, which has become endemic. Tuberculosis is an increasing problem with some 50 000 new cases per year and yellow fever, with a 50% fatality rate, reappeared in Peru in 1995.20 Better health conditions depend on a better economic situation.

In the last 2 decades, the effects of globalization have intensified in rural Aymara communities. Economic hardship and less available land to sustain increasing family size have caused intense migration from the rural areas to the larger cities in Peru which has a great effect on indigenous women.23 Many times, it is the men and young people who migrate leaving indigenous rural women with the full responsibility of agricultural work, childrearing, and community work. Internal migration also influences how the knowledge of healing practices is passed down through the generations. Several of the older healers described how they would want to share their knowledge and skills with women from the younger generation, but that the younger generation was not interested in learning from them. This lack of interest may be from modernization and/or migration. These words from an older midwife exemplify this:

My grandmother knew a lot about healing and my mother learned how to heal from her, and I learned from my mother. But nobody is learning now. My daughter-in-law has no interest in being a midwife. After me, we will not have a midwife.

Another healer describes this: “It would be good for us here to recuperate the wisdom and knowledge of our grandparents, but perhaps some of the young people here are not interested.” The interviewed healers are acutely aware of the social changes that affect their healing practices.

Cultural factors

There are cultural values that are identified by many writers on Aymara culture.5,6,9 The importance of the community and solidarity within the community, the ability to work hard, to be generous and to promote self-dignity and respect, the importance of the family, and religious celebrations, participation in community celebrations and fiestas are all described as essential cultural values. The valuing of the earth as the Mother Earth (Pachamama), a sacred entity that cannot be bought or sold, is another important relational aspect of Aymara culture.5,9,24,25

All the Aymara women healers discussed the Pachamama and the importance of asking forgiveness and blessing from her to protect and promote health. This earth-centered health cosmology was the most consistent finding in this study. Most of the healers talked about herbal healing and the difference between hot and cold diseases and hot and cold treatments. Most of the healers clearly identified 2 systems (ethnomedical and biomedical) that they chose between or chose to combine in some fashion (medical pluralism). All of the Aymara healers identified the importance of relationships, reconciliation, and being in harmony as a protective and restorative factor for health, as stated by a younger healer: “If we do not relate well with people, with the Pachamama and with our ancestors, little will go well in our lives. We need harmonious relationships to be healthy-this is very important.”

Gender factors

Inequalities between men and women (gender gap) and gender health disparities have dire consequences for women in developing countries. For women in Latin America, especially those that are in the deepest poverty and situations of marginalization, decreasing the gender gap may make the difference between grave harm and basic safety and survival or nonsurvival for themselves and their daughters.26

In many discussions with Aymara men and women on gender discrimination against women, the cultural factor of gender complementarity is mentioned. Complementarity is an important aspect of Aymara culture and cosmovision. It can be defined as the balance, union, and reciprocity that exist between male and female. Men and women are not considered the same, but are 2 equally important forces that are interdependent upon each other.24 Sometimes this is used to negate the existence of gender discrimination.9

Overall, the interviewed women describe many incidences of gender discrimination against women and talk about how societal changes have improved women's awareness of their equal rights. Most of the healers denied that past times were easier for women, as stated by a healer who was working against domestic violence: “From the time before Christ, women have been marginalized, but now our rights are recognized.” The role of women in this rural Aymara culture are changing as women are more involved with proindigenous groups and women's organizations. This change in roles is stated strongly by a young healer who had been involved in a women's organization in her barrio:

Before I was humble, but not now. I have become more rebellious, I raise my voice, I argue. I have changed a lot, it wasn't always like this. Now I am stronger than I was before. Sincerely, I do not tolerate much from anyone. When one is weak, everyone orders them about. So that this doesn't happen, one needs to be strong.

IMPLICATIONS

This implication section integrates some of the findings from this study to illustrate the usefulness of using a critical perspective in global health nursing research. The implications I focus on here are issues surrounding the promotion of social justice and how research can play a part in that, the complexity of fostering empowerment, and the importance of researchers being aware of their ideological stance.

Social justice

One of my hopes for this study was to begin to outline with the rural Aymara women issues and ideas that could lead to participants' action research projects that would somehow promote social justice and improve their lives. This section will describe ideas for projects that developed through the interviews, focus groups, and the reflections.

The Aymara women talked about social justice in concrete, local, nongrandiose ways. They helped me remember that any change that improves lives in even little ways is a work toward social justice. Many of the healers described their healing work, which at times was inconvenient or a risk to themselves, as being of service to those who were less advantaged. They were promoting social justice through their healing services. Being able to continue offering their services to those in need becomes an issue of social justice.

Creating opportunities for further education and employment for their children, especially their girls, was identified as an action point that would improve the lives of the people of the altiplano. This idea came through the analysis of interviews and the gendered effects of the economic, political, and social situation for women. The women expressed ideas to include more young girls in women's leadership groups, to form youth groups that would focus on gender, and to use existing church and civil groups to emphasize the importance of education for girls.

The Aymara women healers identified the need to reaffirm their ethnomedical, traditional medicine including licensing and protection for their practices. Many wanted to study more allopathic or biomedical medicine, but expressed that optimal health and healing comes from having the ability to move between the 2 systems.

Reproductive health rights were mentioned by a few of the healers. In analyzing what was said about contraception and family planning, Aymara women identified the complexity of this issue. There are strong cultural, religious, and ethnomedical beliefs that need to be addressed before culturally sensitive reproduction education can be developed and/or taught.

All of the participants discussed problems with domestic violence and family disharmony. In a cultural context of the importance of harmonious relationships and the role of reconciliation in health and healing, this violence seems especially disruptive, illness producing, and destructive of the culture. Cultural issues of complementarity between men and women, the influence of conquering Spanish culture and imported “machismo,” the reemergence of a stronger indigenous identity and continued economic, political, and social marginalization all play a role in how to address this issue with women in this culture. No specific action plan concerning domestic violence resulted from this study, but there seemed to be a heightened awareness and an urgency to continue to work on this complex problem in the lives of rural Aymara women.

Finally, we identified mental health issues such as depression and hidden suicide attempts by women, issues surrounding self-esteem and cultural transitions, and changing roles of parenting as topics of concern that impact Aymara women at this time in their history. The women who participated in the study proposed the idea of developing a holistic population health assessment/survey of Aymara women that would approach these issues in a culturally acceptable way by using survey questions translated to Aymara and training Aymara women to do the interviewing, collect the information, and participate in analysis.

Empowerment

Empowerment is a desired outcome of research using a critical perspective. While I did not specifically ask women if their participation in this study empowered them, some of their comments suggest elements of empowerment. During the focus groups, older Aymara women did express how important they felt it was to be able to share their knowledge with their younger companions. The knowledge that participants exchanged among themselves concerning healing and how to improve health for rural Aymara women may help improve individual's healing practices. The AWRCT have continued to work with women's groups on issues of self-esteem and small economic projects and have begun to identify Aymara women to help with our next health assessment/survey. They have responded to my queries and questions by e-mail often during my US analysis and seem engaged in what I was writing. However, it would be arrogant for me to claim that it was this study that fostered their participation in improving the lives of the women around them. Our research partnership is a small part of their tremendous work and sacrifice to promote justice in their lives.

Scheper-Hughes27 discussed the classic double-blind trial of critical analysis. A researcher can attribute “great explanatory power to the fact of oppression (but in doing so, one can reduce the subjectivity and agency of subjects to a discourse on victimization).” (p533) Alternatively, a researcher may romanticize or trivialize the very real suffering of the poverty through descriptions of small acts of resistance in the everyday acts of the poor and marginalized. I think I have done both at different times in this study! But, I have seen Aymara people survive acts of brutal discrimination, senseless acts of violence and its ensuing grief, destructive acts of nature such as sudden floods, long droughts, hailing just on the day that the potato flowers, thus destroying the year's subsistent crop, and hunger. I have sat with them as loved ones die of illnesses that could be cured with just a small increase in resources. I have experienced them giving to others out of the very little they have. I have learned from Aymara women as they banded together and stood against tear gas and rifles to call for changes that would promote their rights as indigenous people to exist and develop. Their ability to survive their harsh lives and continue to offer their service of healing has empowered me. Hopefully, my recognition and description of their work and our ongoing research partnership will empower them.

Ideological stance

To conduct global health research with a people and a culture that is not one's own, without considering the contextual factors that have an influence on their lives, narrows the information that is collected and can reduce the effectiveness of work to improve living and social conditions. A critical perspective in global nursing research can also be helpful in overcoming the tendencies in researchers toward ethnocentric biases, or at least help make them more transparent.

I believe that all researchers have an ideological stance. The reason that I am so attracted to the use of a critical perspective is that I recognized early on in my nascent research career that I have a strong ideological stance that colors my interpretations of the world and of this data. A critical perspective calls for the researcher's biases and subjectivity to be explicit. This transparency and self-reflexivity has historically been a part of nursing care and a critical perspective may also encourage those values in nursing research. This is important not only in global health nursing research but also in any research with people of diverse ethnicities.

Limitations to using this method are the amount of time, study, and resources that are needed to conduct research. In global health research, a critical perspective can help uncover and reveal the differences of power, social class, and culture between researchers and those being researched. Recognizing power differences does not necessarily mitigate those differences and may create a false sense of equality that does not exist. Actions to promote social justice in politically unstable or violent countries can be dangerous to people who live and work in these countries. And although empowerment or improving the lives of the people being studied is an expected outcome of research based in a critical perspective, how to measure and claim that outcome is complex and problematic.

CONCLUSION

This article describes how using a critical perspective in global health research can more deeply inform a study of a culture not one's own. The most important usefulness of a critical perspective, however, may be in its ability to help improve life and health conditions in the people being studied. My research perspective as a nurse dictates understanding and promoting actions toward producing health and well-being. Nursing does not have the answers to promote health without help from other disciplines. I studied anthropology, psychology, and sociology to explore and understand the cultural underlying beliefs about health, the things that keep behaviors from changing, and to discover the hidden or subconscious influences that don't allow a person, or a family, or a system to change if that is what is warranted. This is what I wanted to accomplish in my study with Aymara women healers. A critical perspective in this research has given me the basis to begin participatory work that is grounded in this complex and evolving cultural understanding.

An important and anticipated outcome of research in the critical perspective is empowerment of the people being studied and an attempt to transform society. Transforming the political, social, and economic factors that impact on health to improve health and living conditions of people may be the most important work that researchers in global health attempt. Promoting social justice is at the heart of nursing. Using a critical perspective in global health research may help social justice become a reality.

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Keywords:

Aymara; critical perspective; global health; social justice

© 2007 Lippincott Williams & Wilkins, Inc.