Health Services Research Methods 2nd Edition Ebook PDF
Health Services Research Methods 2nd Edition Ebook PDF
Definition 165
Types 170
Validity Threats 173
Designs and Threats to Validity 176
Strengths and Weaknesses 185
Summary 186
Review Questions 187
References 187
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viii Contents
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Contents ix
GLOSSARY 443
INDEX 465
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PREFACE
The term health services research (HSR) began to be widely used in the 1960s,
and the field was developing rapidly by 1981, when the Association for Health
Services Research was formed. Since then, HSR has developed into a recognized
discipline by merging health-related methods and results from a number of the
traditional disciplines of inquiry, ranging from sociology, political science or policy
analysis, economics, epidemiology to nursing, medicine, and pharmacology. Typi-
cally health services researchers conduct investigations within different disciplinary
fields: health policy, health systems research, health outcomes research, clinical epi-
demiology, technology assessment, clinical decision analysis, operations research,
health economics, medical sociology, medical anthropology, to name a few. Indeed,
HSR is in part defined by its field of interest rather than by a method, although
methods—and agreement about methods among researchers—are as central to the
creation of this discipline as to any other unique discipline. HSR is also an enter-
prise that is aimed at improving health services: it therefore seeks practical more
than theoretical wisdom.
Despite the extensive literature related to HSR, few textbooks exist that exam-
ine the field of HSR and systematically describe the design, methodology, and
analysis commonly used in HSR. As a student and later a professor in HSR, I
was continually nagged by the lack of a relevant textbook on HSR. The research
methods books I have encountered are primarily written by sociologists with little
health care applications. Students frequently complain about the lack of relevance
of those textbooks. In the course of teaching “Health Services Research Methods,”
I developed the current textbook that integrates HSR applications in the presenta-
tion of research methods and analysis.
AUDIENCE
The major audiences of this book include doctoral- and master-level students in
health services administration programs. Students from nursing administration and
clinical nursing programs can also benefit from this book. These programs may
be offered by schools of public health, nursing, business administration, public
xi
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xii Preface
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Preface xiii
FEATURES
There are a number of features of this book. First, the book intends to be a practi-
cal guide for those interested in HSR. Steps are delineated and illustrated clearly in
the text, tables, and figures. Second, HSR examples are used throughout. Third, the
book integrates research design with analysis. While this is not a statistics textbook,
commonly used statistics are discussed in terms of their use for different levels of
analysis and the nature of the variables. Fourth, the book also provides resources
for students and researchers of health services. For example, the book includes cur-
rent HSR journals, funding sources (public and private), and data sources.
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xiv Preface
The current edition also offers new examples of contemporary and salient HSR
topics, drawn from the HSR literature, government, and other public and private-
sector sources, and updated descriptions of research aids and directories, including
funding sources, primary and secondary data sources, Internet search engines, and
government agencies involved in HSR.
ACKNOWLEDGMENTS
The preparation of this book, both at the initial and later phase, has been greatly
aided by a number of devoted reviewers who themselves are active health services
researchers. The author wishes to thank Patricia Collins who served as my research
assistant and helped with numerous tasks associated with the revision on the first
edition. Similar thanks and gratitudes are extended to all those who have reviewed
either the proposal or selected chapters of the manuscripts and provided comments
and feedback. Their time and effort spent in reviewing the manuscripts are warmly
and graciously appreciated and acknowledged. The author is also grateful to Thom-
son Delmar Learning and former series editor, Stephen Williams, for encouraging
the development and publishing of the original book and the new edition. The di-
rect assistance provided by Thomson Delmar Learning staff Kalen Conerly, Natalie
Pashoukos, Brooke Baker, Jack Pendleton, and Meaghan O’Brien is much appreci-
ated. All suggestions concerning any aspects of this second edition of the book are
welcome and will be acknowledged and incorporated in future editions.
Leiyu Shi
Johns Hopkins University
Bloomberg School of Public Health
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REVIEWERS
and
xv
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ABOUT THE AUTHOR
Dr. Leiyu Shi is Professor of Health Policy and Health Services Research at Johns
Hopkins University’s Bloomberg School of Public Health Department of Health
Policy and Management. He is Co-Director of Johns Hopkins Primary Care Policy
Center. He received his doctoral education from University of California Berke-
ley majoring in health policy and services research. He also has a Masters degree
in business administration focusing on finance. Dr. Shi’s research focuses on pri-
mary care, health disparities, and vulnerable populations. He has conducted ex-
tensive studies about the association between primary care and health outcomes,
particularly on the role of primary care in mediating the adverse impact of in-
come inequality on health outcomes. Dr. Shi is also well known for his extensive
research on the nation’s vulnerable populations, in particular community health
centers that serve vulnerable populations, including their sustainability, provider
recruitment and retention experiences, financial performance, experience under
managed care, and quality of care. Dr. Shi is the author of seven textbooks and
over 100 journal articles.
xvii
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CHAPTER 1
KEY TERMS
anonymity Hawthorne effect positive/direct relationship
applied health services research positivism
assumptions hypothesis process
asymmetrical relationship independent variable proposition
biomedical research inductive process randomized clinical trial
causal relationship informed consent reactivity
clinical research Institutional Review Board replication
concept (IRB) resources
conceptual framework intervening variable right to service
confidentiality linear relationship scientific inquiry
constant multidisciplinary scientific method
construct natural science scientific theory
deductive process negative/inverse relationship small area analysis
dependent variable nonlinear relationship social science
empiricism objectivity spurious relationship
environmental health research operationalization suppressor variable
epidemiological research outcomes research symmetrical relationship
ethical standards paradigm variable
financing peer review voluntary participation
grounded theory placebo
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2 CHAPTER 1
Chapter 1 lays the groundwork for the chapters that follow. By providing an over-
view of the scientific foundations of health services research (HSR), the chapter
serves as a framework on which specific aspects of HSR are based. The nature of
scientific inquiry is discussed, followed by a description of HSR. Since social sci-
entists have made significant contributions to the development of health services
research, the discussion of scientific inquiry centers on social science research.
The chapter concludes with a summary of the stages of health services research,
based on the major components of scientific inquiry. After completing this chap-
ter, readers should be ready to examine some of the more concrete aspects of
health services research related to the delineated stages.
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Scientific Foundations of Health Services Research 3
Positivism
Scientific disciplines, whether physical, natural, social, or medical, are typically
based on the fundamental assumption that there exists a relatively persistent
pattern or regularity in what is being studied. This assumption is particularly
upheld in natural science, which is the rational study of the universe via
rules or laws of natural order. However, the assumption is often challenged in
social science, which studies human behavior and social phenomena. For ex-
ample, Wilhelm Dilthey (1988), a 19th-century sociologist, took the extreme
position that humans had free will, and thus no one could generalize about their
actions. He believed that scientists could only study unique events, not make
generalizations.
The opposite view was held by Émile Durkheim (1974), who maintained that
social phenomena, just like physical phenomena, are orderly and generalizable.
Social scientists could study and explain social phenomena just as well as physi-
cal scientists study and explain physical phenomena. Durkheim’s study of sui-
cide rates in European countries was an example. His work on suicide began
in 1888, and his monumental book Le Suicide was published in 1897 (Lester,
1994). Durkheim (1951) noted that although suicide rates changed over time,
they were consistently and inversely correlated with the degree of social integra-
tion. This finding was later termed “Durkheim’s law of suicide.”
However, most social scientists favor an intermediate approach as espoused
by Max Weber. According to Weber (1949), social phenomena are the prod-
uct of both social laws and human volitional action. The fact that humans have
free will does not mean that their actions are random and totally unpredictable.
Rather, human actions are guided by rational decision making and can be pre-
dicted by understanding the rationale behind the actions.
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4 CHAPTER 1
Although many social scientists agree that social phenomena are orderly
enough to be explained and predicted, they also believe that not all social
phenomena can be explained or predicted with complete accuracy or unifor-
mity. This is because existing theories, methods of data collection, and current
techniques of data analysis are not sufficiently developed to explain social phe-
nomena (Bailey, 1994). In addition, social phenomena can change over time.
Moreover, since to some extent reality is socially constructed, there are often
multiple views of reality. Similarly, although to a lesser extent, not all physi-
cal phenomena can be explained or predicted with complete accuracy. For ex-
ample, most observers agree that the space program is backed by sophisticated
scientific theory and sound engineering application. The explosion of the space
shuttle Challenger, however, showed that physical science can also experience
failure.
The fact that there are exceptions to regularity is insufficient evidence to over-
throw the assumption that regularity exists in both physical and social phenom-
ena, because scientific inquiry is concerned with the study of patterns rather than
exceptions. The pattern that, given the same educational level, men earn more
money than women overall is not problematic when a particular woman earns
more than a particular man. The trend that women live longer than men over-
all is not violated when a particular man lives longer than a particular woman.
Social scientists primarily study social patterns. Regularities and patterns are
probabilistic and do not need to be manifested in every observation.
It is also important to know that a particular pattern may not always persist
(Skinner, 1953). In other words, regularity is not certainty. Scientific “truth” is
based on observable evidence, but that truth is always subject to change when new
evidence is presented that contradicts it. Thus, at some point a scientific proposi-
tion is accepted because it describes or interprets a recurring, observable event.
But just because an event has occurred on several occasions is no guarantee that it
will always recur. Scientific knowledge represents the best understanding that we
have been able to produce thus far by means of current empirical evidence.
Scientific Theory
Scientific inquiry generally works within the framework of scientific theories.
Scientific theories are based on overwhelming evidence and are used to derive
research hypotheses, plan research, make observations, and explain generaliza-
tions and patterns of regularity in life (McCain and Segal, 1988; Zetterberg,
1954). They provide a systematic explanation and make predictions for a par-
ticular phenomenon. A statement that does not seek to explain or predict some-
thing is not a theory. Theories must also be potentially testable. A statement that
is too vague to be understandable is not an adequate theory.
In searching for theories, scientists generally do not start out with a completely
clean slate. Rather, they are influenced by the paradigms of their discipline. A
paradigm is normative in that it reflects a general perspective, a fundamental
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Scientific Foundations of Health Services Research 5
model or scheme that breaks down the complexity of reality and organizes our
views. As such, paradigms are deeply embedded in the socialization of research-
ers and tell them what is important, legitimate, and reasonable (Patton, 2002).
Thomas Kuhn (as cited in Neurath, Carnap, and Morris, 1970) was respon-
sible for popularizing the term paradigm, which he described as essentially a
collection of beliefs shared by scientists, a set of agreements about how problems
are to be understood. According to Kuhn, paradigms are essential to scientific
inquiry, for “no natural history can be interpreted in the absence of at least some
implicit body of intertwined theoretical and methodological belief that permits
selection, evaluation, and criticism.” Indeed, a paradigm guides the research ef-
forts of scientific communities, and it is this criterion that most clearly identifies
a field as a science. A fundamental theme of Kuhn’s argument is that the typical
developmental pattern of a mature science is the successive transition from one
paradigm to another through a process of revolution. When a paradigm shift
takes place, “a scientist’s world is qualitatively transformed [and] quantitatively
enriched by fundamental novelties of either fact or theory.”
Often, a paradigm doesn’t readily provide answers to research questions,
but it tells researchers where to look for answers and provides them with
concepts that are the building blocks of theories. For example, many theories
have been suggested to account for the fact that females in the United States
and in other modern industrialized societies have higher rates of morbidity than
males but live longer than males. One biomedical explanation for this posits
a fundamental physiological difference that causes women to experience more
morbidity than men but to live longer for reasons not yet clearly understood.
A sociological suggestion is that the different roles men and women play in so-
ciety expose them to different sources of illness or disability. A psychological
explanation is that perhaps men and women do not differ in their underlying
rates of morbidity. Rather, they have differential perceptions of and tolerance
for morbidity, as well as different ways of expressing their feelings about that
morbidity. Our social systems might have processed them differently so that it
appears, when we count up hospital visits and the like, that women have greater
morbidity rates.
Since it is possible to have several theories that explain a given empirical regu-
larity and that make similar predictions, the confirmation of a prediction does
not confirm that only one theory is correct (Hempel, 1967). Scientific inquiry is
directed toward testing and choosing from alternative theories. One theory is
generally judged to be superior to other competing theories if it: (1) involves the
fewest number of statements and assumptions, (2) explains the broadest range of
phenomena, and (3) predicts with the greatest level of accuracy (Singleton and
Straits, 2005). In short, scientific theories should be efficient, comprehensive,
and accurate.
There is an intimate connection between theory and research. Theory pro-
vides guidance for research. Research, in turn, verifies, modifies, or reconstructs
theory. This interactive process between theory and research contributes to the
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6 CHAPTER 1
Empiricism
The most critical characteristic of scientific inquiry is that it is based on empiri-
cism. As Thomas Kuhn (as cited in Neurath, Carnap, and Morris, 1970) stated,
science is a cognitive empirical investigation of nature. Empirical evidence is the
only means by which scientists can corroborate, modify, or construct theories.
Whether a question can be studied scientifically depends on whether it can be
subjected to verifiable observations (Singleton and Straits, 2005). That is, it must
be possible for the scientist to make observations that can answer the question.
The empirical requirement of scientific inquiry has several ramifications. First,
it means that nonempirical ways of acquiring knowledge cannot produce scien-
tific evidence. Examples of nonempirical approaches include appeals to author-
ity, tradition, common sense or intuition, and so on.
In general, scientists do not generalize about the world based on what an
authority or expert says. An authority or expert may be knowledgeable about
the subject matter, but his opinion alone cannot serve as scientific evidence
to prove or refute a hypothesis. However, this does not mean experts cannot
be studied in research. A representative sample of experts can be surveyed
regarding their perceptions of issues of research interest, as in the Delphi
method.
Tradition refers to inherited culture that is made up of fi rmly accepted knowl-
edge about the workings of the world (Babbie, 2004). These are the things that
“everyone knows.” An example is to consult a doctor when one is sick. The ad-
vantage of tradition is that one is spared the task of starting from scratch in
searching for understanding. The disadvantage is that tradition keeps us from
seeking a fresh and different understanding of something that everyone already
knows. Tradition is not always correct. Maybe better diet and exercise are more
important to one’s health than relying on medical treatment.
Common sense cannot be regarded as scientific evidence. Common sense
tends to be unconditional, uncomplicated, and nonsituational, and it does not
require systematic testing. It limits people’s reliance to the familiar and implies
that seeing is believing, although the reverse is often true. When one believes in
something, one is more likely to see (notice) it.
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Scientific Foundations of Health Services Research 7
Objectivity
Scientists, like most people, have their own values and often make value judg-
ments. This fact in and of itself is not problematic. But, in terms of research,
individual values may affect the validity of the inquiry and make the fi ndings
biased. The problem with value judgments in research is that not only are
they essentially untestable but they may make a researcher prejudiced in under-
taking research. Although it can be difficult, researchers should strive to sup-
press values and conduct value-free research in order to minimize bias in their
findings. They are perfectly free to hold and express their values in a nonresearch
environment.
Even though researchers may hold back their personal values while conduct-
ing research, they are likely to be influenced by their scientific disciplines or
paradigms. Different paradigms tend to espouse different values. They affect
the types and scope of problems to be studied, the methods adopted, and the
ways to interpret the findings. Biases may enter into the selection of problems
for study and the preference for certain research strategies. Often, where and
how one investigates largely determines the answers one will fi nd. Since it is very
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8 CHAPTER 1
hard to think beyond one’s established paradigm and difficult to suppress one’s
professional values, it is important that researchers state their professional values
(i.e., the research paradigm) explicitly so that readers may judge for themselves
the limitations of the research when considering other relevant paradigms.
Perhaps the worst approach is to deny that one has a value position that has in
fact influenced the research. Such a lack of openness will make it difficult for the
reader to assess the validity of the research.
Sponsorship and funding can be another source of bias. Large-scale studies
are typically beyond the means of researchers and require outside funding sup-
port as well as sponsorship. If the study has relevance to the interests of the
sponsor or funder and an adverse fi nding might negatively affect those interests,
researchers may be hesitant in being forthright about their conclusions for fear of
endangering current or future support and sponsorship.
Sometimes, particularly in social sciences, maintaining objectivity is difficult
through no fault of the researchers. If subjects know that they are being observed,
they often will feel self-conscious and may alter their behavior, either consciously
or unconsciously. This reactivity problem exists because social interaction
with subjects is often part of the social science research process.
The reactive effect of research on the social phenomena being studied is known
as the Hawthorne effect, derived from the study of workers assembling tele-
phone relays in the Hawthorne plant of the Western Electric Company in Chicago
(Roethlisberger and Dickson, 1939). In studying the impact of varying working
conditions on work performance among employees, researchers were surprised
to note that productivity increased even when rest periods were eliminated. They
later realized that it was a reactive effect. The researchers’ presence altered the
very behavior (worker productivity) they wished to study. The Hawthorne effect
is also common in health studies, especially when interventions are introduced.
This is called the placebo effect, in which the belief in the presence of a promis-
ing treatment (even though it is in fact an inert substance) creates a real result
(e.g., recovery from disease).
Fortunately, scientists adopt numerous measures to enhance objectivity. Dur-
ing the research process, scientists use procedures to control for, minimize, or
eliminate, as far as possible, sources of bias that may mislead their fi ndings.
Research findings are often open to a variety of interpretations. The concept of
control involves the use of procedures (either by design or by statistical mod-
eling) to exclude alternative explanations. For example, in medical research, a
double-blind procedure is often used to assign patients to experimental or con-
trol groups. Patients in the control group use a placebo; neither the patients nor
the doctors know which group patients belong to. This procedure is designed
to rule out the possibility of doctors’ and patients’ expectations contributing to
the effectiveness of a treatment. The Hawthorne effect may be reduced through
an improved design (for example, by using more control groups including those
whose subjects are not aware of the research, or by extending the study period
since the reactive effect tends to be relatively short-lived). The use of control pro-
cedures to reduce biases is a common method for enhancing objectivity.
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Scientific Foundations of Health Services Research 9
Ethical Standards
Ethical standards, or the proper conduct of research with full consideration of
the subjects’ interests, became paramount in the wake of one marker event. The
Nuremberg war crimes trials following World War II brought to public view the
ways German scientists had used captive human beings as subjects in oftentimes
gruesome experiments. These revelations prompted worldwide development and
refinement of ethical standards and principles (see Chapter 15 for discussion of
ethics in research) that ensure that potential human subjects are protected from
being used as “guinea pigs” in scientific research.
When developing research plans, scientists should consider all relevant ethical
issues to assure the safety and rights of study participants. An Institutional
Review Board (IRB), a panel of persons that reviews research plans with
respect to ethical implications, makes sure this is done properly and decides
whether additional actions need to be taken. Also, IRBs help protect both the
organization and the researcher against potential legal implications of important
ethical negligence.
In designing the study, researchers should not put participants in a situa-
tion where they might be at risk of harm, whether physical or psychological. No
one should be coerced into participating in research. Voluntary participa-
tion is especially important among “captive audiences” (e.g., those in prisons,
universities, and workplaces). All prospective study participants must provide
informed consent. This means they must be made fully aware of the proce-
dures and risks involved in the research.
During the study, researchers have to respect a person’s right to service.
When an experimental treatment or program may have beneficial effects, per-
sons assigned to the no-treatment control should be provided equal access to the
benefits.
Both during and after the study, the privacy of the subjects should be pro-
tected through either anonymity (which means that the participant will remain
anonymous throughout the study, even to the researchers) or confidentiality
(which means that identifying information will not be made available to anyone
not directly involved in the study).
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10 CHAPTER 1
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Scientific Foundations of Health Services Research 11
ample, will the research and theories apply to people of the world or only to
Americans, or more specifically, to young Americans? Will the study be relevant
to all racial/ethnic groups or to people with different immigration status? Are
the findings generalizable only to the insured or would they be applicable to the
uninsured as well? Will the study results be generalizable to all hospitals or only
to urban community hospitals? Research or theories are more useful the greater
the range of phenomena they cover, although broader theories are more difficult
to construct. For one thing, data have to be collected from a wider spectrum of
the population. Many of the clinical practice guidelines are based on best prac-
tices rendered to well-insured patients and are considered inadequate for many
of the uninsured, who are often more vulnerable with greater comorbidities and
psychological needs.
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12 CHAPTER 1
have the opportunity to earn better income. The question is, which comes first:
good health status or adequate income? Perhaps each influences the other. The
treatment of these variables will be discussed in the next step when we consider
causal relationships.
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Scientific Foundations of Health Services Research 13
an empirical level. For example, we can define poor as those with income below
the poverty line, adequacy as the U.S. average, and health care as number of
visits to the doctor. We can then state, “Compared with the U.S. average, those
with income below the poverty line experience fewer visits to the doctor.” This
becomes a testable hypothesis.
Hypotheses may be generated from a number of sources. They may be deduced
from a formal theory that summarizes the present state of knowledge about the
research problem. This is the standard deductive process. Or they may be in-
spired by past research, by commonly held beliefs, or by current evidence, as in
many HSR studies. Or they may be generated through direct analysis of data.
The latter two approaches are used typically when there is an absence of relevant
theories related to the topic of research, often common in HSR. Regardless of
how hypotheses are expressed, they should indicate at least the form of the re-
lationship between variables. A hypothesis is an expected but yet unconfirmed
relationship between two or more variables. An adequate hypothesis statement
about two variables indicates which variable predicts or causes the other or how
changes in one variable are related to changes in the other.
The properties of the relationship (Bailey, 1994; Miller and Salkind, 2002;
Singleton and Straits, 2005) between two variables involve the strength of the
relationship and the designation of each variable as either independent or depen-
dent (as in a causal relationship). Other properties include whether the relation-
ship is positive or negative, symmetrical or asymmetrical, linear or curvilinear,
and is spurious or involves an intervening or suppressor variable.
Strength of Relationships
The strength of the relationship reflects how much the variables are re-
lated. When two variables are unrelated, knowing the value of one does not
tell us the value of the other. The more two variables are related, the more ac-
curately we can predict the value of one variable based on the value of the other.
Statistics (see Chapter 14) can be used to measure the strength of a bivariate
relationship.
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14 CHAPTER 1
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Scientific Foundations of Health Services Research 15
Antecedent
variable
In other words, younger age tends to elevate health status but lower access level,
whereas older age raises access level but reduces health status. The combined ef-
fect is likely to cancel out the relationship between access and health status. If ac-
cess and health status are studied for each age group separately, the relationship
between them will reappear.
Existing theories play a significant role in the identification of independent,
dependent, spurious, and intervening variables. Theories also help researchers
understand the complex relationships among variables and indicate the process
that connects events. Research findings can then be used to validate, modify, or
reconstruct existing theories.
Causal Relationships
When we say that two variables are related, we mean simply that they vary to-
gether, so that a change in one is accompanied by a change in the other, and vice
versa. Such variation is often referred to as concomitant variation, or correlation.
The discovery that there is a correlation between two variables does not ensure
that the relationship is a causal one, that change in one variable causes change in
the other variable.
There are three basic requisites to a causal relationship: statistical asso-
ciation, sequence of influence, and nonspuriousness. For one variable to be a
cause of the other, the two variables must have a statistically significant relation-
ship, or correlation. However, a perfect association between variables is not re-
quired of a causal relationship, because a perfect association may be expected only
under the theoretical condition that all other things are held constant. In health
services research, a phenomenon is typically caused by multiple factors, not all of
which may be identified. Causal relationships may also be affected by relatively
imprecise measurements. Commonly, statistics are used to judge whether an as-
sociation is strong enough to imply a meaningful causal relationship.
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16 CHAPTER 1
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DANCE ON STILTS AT THE GIRLS’ UNYAGO, NIUCHI
I see increasing reason to believe that the view formed some time
back as to the origin of the Makonde bush is the correct one. I have
no doubt that it is not a natural product, but the result of human
occupation. Those parts of the high country where man—as a very
slight amount of practice enables the eye to perceive at once—has not
yet penetrated with axe and hoe, are still occupied by a splendid
timber forest quite able to sustain a comparison with our mixed
forests in Germany. But wherever man has once built his hut or tilled
his field, this horrible bush springs up. Every phase of this process
may be seen in the course of a couple of hours’ walk along the main
road. From the bush to right or left, one hears the sound of the axe—
not from one spot only, but from several directions at once. A few
steps further on, we can see what is taking place. The brush has been
cut down and piled up in heaps to the height of a yard or more,
between which the trunks of the large trees stand up like the last
pillars of a magnificent ruined building. These, too, present a
melancholy spectacle: the destructive Makonde have ringed them—
cut a broad strip of bark all round to ensure their dying off—and also
piled up pyramids of brush round them. Father and son, mother and
son-in-law, are chopping away perseveringly in the background—too
busy, almost, to look round at the white stranger, who usually excites
so much interest. If you pass by the same place a week later, the piles
of brushwood have disappeared and a thick layer of ashes has taken
the place of the green forest. The large trees stretch their
smouldering trunks and branches in dumb accusation to heaven—if
they have not already fallen and been more or less reduced to ashes,
perhaps only showing as a white stripe on the dark ground.
This work of destruction is carried out by the Makonde alike on the
virgin forest and on the bush which has sprung up on sites already
cultivated and deserted. In the second case they are saved the trouble
of burning the large trees, these being entirely absent in the
secondary bush.
After burning this piece of forest ground and loosening it with the
hoe, the native sows his corn and plants his vegetables. All over the
country, he goes in for bed-culture, which requires, and, in fact,
receives, the most careful attention. Weeds are nowhere tolerated in
the south of German East Africa. The crops may fail on the plains,
where droughts are frequent, but never on the plateau with its
abundant rains and heavy dews. Its fortunate inhabitants even have
the satisfaction of seeing the proud Wayao and Wamakua working
for them as labourers, driven by hunger to serve where they were
accustomed to rule.
But the light, sandy soil is soon exhausted, and would yield no
harvest the second year if cultivated twice running. This fact has
been familiar to the native for ages; consequently he provides in
time, and, while his crop is growing, prepares the next plot with axe
and firebrand. Next year he plants this with his various crops and
lets the first piece lie fallow. For a short time it remains waste and
desolate; then nature steps in to repair the destruction wrought by
man; a thousand new growths spring out of the exhausted soil, and
even the old stumps put forth fresh shoots. Next year the new growth
is up to one’s knees, and in a few years more it is that terrible,
impenetrable bush, which maintains its position till the black
occupier of the land has made the round of all the available sites and
come back to his starting point.
The Makonde are, body and soul, so to speak, one with this bush.
According to my Yao informants, indeed, their name means nothing
else but “bush people.” Their own tradition says that they have been
settled up here for a very long time, but to my surprise they laid great
stress on an original immigration. Their old homes were in the
south-east, near Mikindani and the mouth of the Rovuma, whence
their peaceful forefathers were driven by the continual raids of the
Sakalavas from Madagascar and the warlike Shirazis[47] of the coast,
to take refuge on the almost inaccessible plateau. I have studied
African ethnology for twenty years, but the fact that changes of
population in this apparently quiet and peaceable corner of the earth
could have been occasioned by outside enterprises taking place on
the high seas, was completely new to me. It is, no doubt, however,
correct.
The charming tribal legend of the Makonde—besides informing us
of other interesting matters—explains why they have to live in the
thickest of the bush and a long way from the edge of the plateau,
instead of making their permanent homes beside the purling brooks
and springs of the low country.
“The place where the tribe originated is Mahuta, on the southern
side of the plateau towards the Rovuma, where of old time there was
nothing but thick bush. Out of this bush came a man who never
washed himself or shaved his head, and who ate and drank but little.
He went out and made a human figure from the wood of a tree
growing in the open country, which he took home to his abode in the
bush and there set it upright. In the night this image came to life and
was a woman. The man and woman went down together to the
Rovuma to wash themselves. Here the woman gave birth to a still-
born child. They left that place and passed over the high land into the
valley of the Mbemkuru, where the woman had another child, which
was also born dead. Then they returned to the high bush country of
Mahuta, where the third child was born, which lived and grew up. In
course of time, the couple had many more children, and called
themselves Wamatanda. These were the ancestral stock of the
Makonde, also called Wamakonde,[48] i.e., aborigines. Their
forefather, the man from the bush, gave his children the command to
bury their dead upright, in memory of the mother of their race who
was cut out of wood and awoke to life when standing upright. He also
warned them against settling in the valleys and near large streams,
for sickness and death dwelt there. They were to make it a rule to
have their huts at least an hour’s walk from the nearest watering-
place; then their children would thrive and escape illness.”
The explanation of the name Makonde given by my informants is
somewhat different from that contained in the above legend, which I
extract from a little book (small, but packed with information), by
Pater Adams, entitled Lindi und sein Hinterland. Otherwise, my
results agree exactly with the statements of the legend. Washing?
Hapana—there is no such thing. Why should they do so? As it is, the
supply of water scarcely suffices for cooking and drinking; other
people do not wash, so why should the Makonde distinguish himself
by such needless eccentricity? As for shaving the head, the short,
woolly crop scarcely needs it,[49] so the second ancestral precept is
likewise easy enough to follow. Beyond this, however, there is
nothing ridiculous in the ancestor’s advice. I have obtained from
various local artists a fairly large number of figures carved in wood,
ranging from fifteen to twenty-three inches in height, and
representing women belonging to the great group of the Mavia,
Makonde, and Matambwe tribes. The carving is remarkably well
done and renders the female type with great accuracy, especially the
keloid ornamentation, to be described later on. As to the object and
meaning of their works the sculptors either could or (more probably)
would tell me nothing, and I was forced to content myself with the
scanty information vouchsafed by one man, who said that the figures
were merely intended to represent the nembo—the artificial
deformations of pelele, ear-discs, and keloids. The legend recorded
by Pater Adams places these figures in a new light. They must surely
be more than mere dolls; and we may even venture to assume that
they are—though the majority of present-day Makonde are probably
unaware of the fact—representations of the tribal ancestress.
The references in the legend to the descent from Mahuta to the
Rovuma, and to a journey across the highlands into the Mbekuru
valley, undoubtedly indicate the previous history of the tribe, the
travels of the ancestral pair typifying the migrations of their
descendants. The descent to the neighbouring Rovuma valley, with
its extraordinary fertility and great abundance of game, is intelligible
at a glance—but the crossing of the Lukuledi depression, the ascent
to the Rondo Plateau and the descent to the Mbemkuru, also lie
within the bounds of probability, for all these districts have exactly
the same character as the extreme south. Now, however, comes a
point of especial interest for our bacteriological age. The primitive
Makonde did not enjoy their lives in the marshy river-valleys.
Disease raged among them, and many died. It was only after they
had returned to their original home near Mahuta, that the health
conditions of these people improved. We are very apt to think of the
African as a stupid person whose ignorance of nature is only equalled
by his fear of it, and who looks on all mishaps as caused by evil
spirits and malignant natural powers. It is much more correct to
assume in this case that the people very early learnt to distinguish
districts infested with malaria from those where it is absent.
This knowledge is crystallized in the
ancestral warning against settling in the
valleys and near the great waters, the
dwelling-places of disease and death. At the
same time, for security against the hostile
Mavia south of the Rovuma, it was enacted
that every settlement must be not less than a
certain distance from the southern edge of the
plateau. Such in fact is their mode of life at the
present day. It is not such a bad one, and
certainly they are both safer and more
comfortable than the Makua, the recent
intruders from the south, who have made USUAL METHOD OF
good their footing on the western edge of the CLOSING HUT-DOOR
plateau, extending over a fairly wide belt of
country. Neither Makua nor Makonde show in their dwellings
anything of the size and comeliness of the Yao houses in the plain,
especially at Masasi, Chingulungulu and Zuza’s. Jumbe Chauro, a
Makonde hamlet not far from Newala, on the road to Mahuta, is the
most important settlement of the tribe I have yet seen, and has fairly
spacious huts. But how slovenly is their construction compared with
the palatial residences of the elephant-hunters living in the plain.
The roofs are still more untidy than in the general run of huts during
the dry season, the walls show here and there the scanty beginnings
or the lamentable remains of the mud plastering, and the interior is a
veritable dog-kennel; dirt, dust and disorder everywhere. A few huts
only show any attempt at division into rooms, and this consists
merely of very roughly-made bamboo partitions. In one point alone
have I noticed any indication of progress—in the method of fastening
the door. Houses all over the south are secured in a simple but
ingenious manner. The door consists of a set of stout pieces of wood
or bamboo, tied with bark-string to two cross-pieces, and moving in
two grooves round one of the door-posts, so as to open inwards. If
the owner wishes to leave home, he takes two logs as thick as a man’s
upper arm and about a yard long. One of these is placed obliquely
against the middle of the door from the inside, so as to form an angle
of from 60° to 75° with the ground. He then places the second piece
horizontally across the first, pressing it downward with all his might.
It is kept in place by two strong posts planted in the ground a few
inches inside the door. This fastening is absolutely safe, but of course
cannot be applied to both doors at once, otherwise how could the
owner leave or enter his house? I have not yet succeeded in finding
out how the back door is fastened.