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Journal of Clinical Epidemiology 102 (2018) 129e133

COMMENTARY

Qualitative research is a fundamental scientific process

Joanna E.M. Salea,b,*, Stephen Thielkec,d aMusculoskeletal Health and Outcomes Research, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, 30 Bond Street, Toronto, Ontario M5B 1W8,

Canada bInstitute of Health Policy, Management & Evaluation, University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Toronto, Ontario M5T

3M6, Canada cGeriatric Research Education and Clinical Center, Puget Sound VA Medical Center, 1660 S. Columbian Way, Seattle, Washington 98108, USA

dPsychiatry and Behavioral Sciences, University of Washington, Seattle, 1959 NE Pacific Avenue, Seattle, Washington 98195, USA

Accepted 2 April 2018; Published online 21 May 2018

Abstract

By framing the investigation of scientific inquiry around Plato’s "arch of knowledge", we argue that qualitative inquiry is essential to the scientific process. We propose that because qualitative research applies a systematic and self-critical approach to induction and deduction, it should be considered a fundamental scientific enterprise. � 2018 Elsevier Inc. All rights reserved.

Keywords: Qualitative research; Science; Arch of knowledge; Induction; Deduction

1. Introduction

A recent debate about the status and utility of qualitative research [1] motivated us to consider how qualitative research is scientific. This requires a broad perspective on the systematic accumulation of knowledge. We characterize the scientific status of qualitative research by appealing to Plato’s ‘‘arch of knowledge’’. Within this arch, knowledge development proceeds from induction to deduction; partic- ulars (sensory perceptions) provide the basis for universals (concepts/models/theories), which in turn are supported by testable predictions and explanation. Although the ‘‘univer- sals’’ are often considered to constitute scientific knowl- edge in the abstract, the interactions among the points of the arch constitute the scientific method, and all of the com- ponents are legitimate providing they apply rigorous methods. Qualitative research generates meaning through a systematic approach to induction and deduction, and thus is essential to the scientific method in the pursuit of knowledge.

Conflicts of interest: J.E.M.S. has been trained in qualitative research at

the doctoral and postdoctoral level. She has 9 years of teaching experience

at the graduate level at the University of Toronto with a strong emphasis on

philosophical foundations, the role of theory, and theoretically informed

critical appraisal (she has published several papers related to critical

appraisal). S.T. has no conflicts of interest to declare.

* Corresponding author. Tel.: þ1-416-864-6060x77305. E-mail address: [email protected] (J.E.M. Sale).

https://doi.org/10.1016/j.jclinepi.2018.04.024

0895-4356/� 2018 Elsevier Inc. All rights reserved.

2. Recent debates about the status and utility of qualitative research

We define qualitative research as an inquiry process that focuses on interpretation and meaning and aims to explore social or human problems [2e4]. Furthermore, we consider qualitative research that is based on interpre- tivism [4e7] and constructivism [8]. The investigator and object of study are interactively linked, and findings are mutually created within the context of the situation that shapes the inquiry [8,9]. Several recent publications [1,10,11] have re-examined the status and utility of qual- itative research. Denzin [11] suggested ‘‘critical qualita- tive research is under assault’’, but that an ethically responsible research agenda depends on qualitative per- spectives. Torrance [10] questioned the definition of sci- ence as being primarily identified with randomized controlled trials and asked for ‘‘reasserting a wider defini- tion of scientific method grounded in curiosity, observa- tion, interpretation, and judgment’’. Greenhalgh et al.[1] expressed concern about The British Medical Journal’s apparent de facto policy of rejecting qualitative research because such studies were seen as low priority and un- likely to be cited and proposed that the journal allocate space to qualitative research. The British Medical Journal subsequently defended their position by stating they did not prioritize qualitative research because qualitative studies do not provide generalizable answers [12].

Theories/concepts/ models

(“Universals”)

130 J.E.M. Sale, S. Thielke / Journal of Clinical Epidemiology 102 (2018) 129e133

What is new?

Key findings � In this article, we argue that qualitative inquiry is an

essential part of scientific knowledge by appealing to Plato’s ‘‘arch of knowledge’’.

What this adds to what was known? � The arch of knowledge demonstrates how induc-

tion and deduction are essential processes in the scientific method.

� Qualitative research systematically generates knowl- edge through the process of induction and deduction and thus, solidifies the arch of knowledge.

What is the implication and what should change now? � Qualitative research is therefore a fundamental part

of the scientific process.

� The scientific status of qualitative research has im- plications for its inclusion in evidence-based medicine.

3. How is qualitative research scientific?

These articles reflect a contemporary conflict about what types of research deserve primacy and support, yet they only indirectly address a more fundamental question: how is qual- itative research science? We acknowledge that not all quali- tative researchers concern themselves with whether they are considered scientists. For instance, they may downplay or deny the special status accorded to scientific knowledge on the grounds that establishing its credentials involves the in- terests of scientists and groups of scientists, financial or so- cial status, and professional interests [13]. However, although others have argued that scientific knowledge can be derived from qualitative inquiry (e.g., see Malterud 1993 [14]), we take this claim one step further by arguing that qualitative inquiry is an essential part of the ‘‘arch of knowl- edge’’ that science builds, and that such inquiry is thus funda- mental to any validated scientific enterprise.

Interviews, observa�ons, textual data

(“Par�culars”)

Interpreta�on, meaning

(“Predic�ons and

Explana�on”)

Fig. 1. The arch of knowledge applied to qualitative research. Adapted from Figure 1 in Chalmers A.G. What is this thing called science? Queensland, Australia: University of Queensland Press; 1982.

4. The arch of knowledge

The term ‘‘arch of knowledge’’ was used by Plato to describe the process of knowledge acquisition [15]. Aristotle refined this paradigm, detailing the process of ascending and descending the arch [15]. Induction is themeans of ascending from ‘‘particulars’’ to ‘‘universals’’. Particulars are sensory perceptions that have been equated with observable facts or experimental results [13] and could be analogous to qualita- tive data in the form of interviews, observation, and text.

Universals constitute general statements, scientific laws, principles, or theories [13]. Although not using the term ‘‘generalizable’’, qualitative researchers describe findings that apply across various contexts as ‘‘transferable’’ [16]. Furthermore, qualitative researchers often describe their re- sults as concepts and relationships and may refer to their work as being theoretically generalizable because it produces theoretical explanations about phenomena or contributes to a theory [17]. Thus, the term ‘‘universals’’ is analogous to con- cepts, models, or theories in qualitative research. Insofar as science focuses on general knowledge rather than facts about specific objects, times, or places, the universal findings at the apex of the arch constitute what we consider to be scientific knowledge in the abstract [13].

The descent of the ‘‘arch’’ involves deduction, a logical process that allows for predictions and explanations from the universals or generalizations [15]. These predictions and explanations can then be tested systematically, and re- sults used to refine the general findings, a cyclical process back through the arch. Predictions and explanations are anal- ogous to interpretation and meaning in qualitative research (see Fig. 1). Science is not simply the set of universals at the apex of the arch but rather the arch itself. Most of the arch is not composed of isolated facts, but rather of processes, the ‘‘scientific method’’, by which propositions are examined by means of systematic investigation.

5. Induction

Most of the inductive and deductive processes in the arch cannot be subjected to quantitative investigation. First, induction assumes that observed premises or particulars are true, but it cannot independently establish their validity, as by experiment [13]. Second, the inductive logic that ex- tends from some to all can never be fully tested or proven because this logic goes beyond what is contained in the pre- mises [13]. Third, observations are dependent on the act of observation that involves a specific observer working in a specific place and time. What we see depends on what

131J.E.M. Sale, S. Thielke / Journal of Clinical Epidemiology 102 (2018) 129e133

we expect to see [13]. For these reasons, the inductive pro- cess that leads up to and supports the examination of phe- nomena, which in turn supports general scientific knowledge, can only be examined by approaches that ac- count for subjectivity. Qualitative research provides a means for critically examining the inductive process.

6. Deduction

At the other end of the arch, the deductive process gen- erates conclusions from the universals or generalizations. This process depends on appreciating the context of the universals to identify in what settings they might or might not apply. Deduction requires appreciating the meaning of the generalizations. Facts, no matter their nature, do not tell us anything about a right course of action or what the desired objective is [18]. Meaning is constructed rather than absolute [19]. Thus, to interpret universals into useful state- ments, it might be essential to consider the values and pref- erences of the affected individuals and to address unintended consequences. Qualitative investigations can rigorously examine how universals (concepts, models, the- ories) might apply in specific situations.

7. How is qualitative research inductive and deductive?

Qualitative research is often described as being both inductive and deductive. For example, as fieldwork begins, the inquirer may analyze data such as text, observations, or interviews about experiences without making prior assump- tions or specifying hypotheses, an approach that is largely inductive [20]. We say ‘‘largely’’ because data collection and analysis do not happen in a vacuum; they are theoreti- cally informed or theoretically dependent, a concept consis- tent with the theory-dependence of observation in the philosophy of science [13]. Then, as patterns and major di- mensions of interest are developed, the investigator may focus on confirming and elucidating the exploratory find- ings, using a deductive approach. For example, qualitative work is purported to be more deductive when theory directs and drives the inquiry process [21].

Most importantly, qualitative research is not just ‘‘com- mon sense’’ induction or deduction. It uses structured and theory-based procedures and reflects on the nature of the knowledge it produces. It is self-aware and self-critical in its application of the scientific process. By engaging in reflexivity, qualitative researchers acknowledge how they influence the selection, collection, and interpretation of data [22]. The process of reflexivity is important for the evaluation of the quality of the scientific knowledge pro- duced [23]. Thus, when applied rigorously, qualitative research provides a strong support for inductive and deduc- tive conclusions. At the same time, scrutinizing the

inductive and deductive processes, and challenging both the premises (particulars and universals) and the assump- tions on which these are based, promotes rigor in qualita- tive research. Although quantitative research can use ‘‘common sense’’ to ascend from observations to general- izations and to descend from generalizations to specific cases, failing to scrutinize the logical and empirical basis of the connections and the assumptions underlying those connections produce a less structurally sound arch.

8. An example using risk factors for suicide

As an example, consider an investigation of risk factors for suicide based on a large data set and suppose that one factor, a certain environmental exposure, is a strong predic- tor. This would seem to be a purely quantitative result with obvious consequences for human health. But stepping back to see the whole arch of knowledge exposes the many induc- tive steps needed to formulate the quantitative question and the many deductive steps needed to interpret the results meaningfully. There are many inductive steps leading up to a quantitative evaluation. How did the people who coded the data identify and categorize suicide? What processes were involved in surveillance? In what settings did the envi- ronmental exposure occur, and what did this exposure mean for those who experienced it? After results are obtained, the interpretation and meaning requires deduction. How might other lifestyle factors have influenced the environmental exposure? How could one go about changing the exposure? What would the unintended consequences be of modifying the exposure? Without the ability to conduct a controlled experiment (which would likely fail on ethical grounds), the only meaningful way to address such questions would be to subject them to qualitative inquiry to make transparent assumptions around this investigation. To give two exam- ples: a qualitative study exploring how medical examiners or coroners choose to use codes for cause of death would provide the necessary background for accepting or rejecting the outcomes about suicide; and a qualitative study about the environmental exposure would clarify what ‘‘exposure’’ means, would identify unintended consequences, and would generate ideas for modifying it. Without such qualitative steps conducted in a systematic manner, the scientific finding in isolation would lack meaning and utility.

9. An example using the effectiveness of pain medication

Consider the question about whether drug A is effective at reducing postfracture pain. This would appear to be a question that ideally would be addressed with a randomized controlled trial where the outcome is measured by a number of indices, such as a visual analogue scale. The arch of knowledge illustrates the inductive and deductive steps in

132 J.E.M. Sale, S. Thielke / Journal of Clinical Epidemiology 102 (2018) 129e133

formulating this question and in interpreting the results of the trial. First, why are we interested in this question and what assumptions are implicit in asking it? If we observe that a sample of older adults report long-term pain after a fragility fracture, is the pain experienced the same for all individuals or are certain characteristics such as cultural at- titudes, one’s history of pain, or one’s personality important in how these individuals describe or attend to that pain? Given that drug A has been shown to reduce pain by 50%, how will individuals respond to recommendations to take the pain medication as prescribed? The concept of adherence is complex and medication use is not predict- able. The real-world use of medication depends on patient perspectives which would not easily be captured through quantitative research. A qualitative study exploring the ex- periences of postfracture pain would ascertain whether old- er adults actually recognize postfracture discomfort and limitations as ‘‘pain’’ in the first place. A qualitative study exploring attitudes and beliefs toward this pain and toward pain medication in general would inform how, and under what circumstances, individuals might take this medication. If the scientific goal is to develop effective approaches to help older adults in pain, then effectiveness trials fail to identify almost all of the important factors, whereas quali- tative research provides a mechanism to ascertain and inter- pret the meaning of pain and pain treatments. Thus, the effectiveness of pain medication as determined by clinical trials is only one part of the scientific understanding.

10. Relevance to science

Why does it matter whether qualitative research is sci- ence? We believe that the status of qualitative research partially depends on it being recognized as a scientific enter- prise. Claiming that qualitative research is legitimate, that it deserves attention, and that it contributes to knowledge is not enough. Qualitative research answers different scientific questions than those of quantitative research. A qualitative study may not inform whether an intervention is effective us- ing measures of clinical and statistical significance but it could clarify how patients experienced the intervention and what outcomes they most valued [24]. It could also explore how the evidence generated by the intervention is turned into practice [25]. The ambiguous status of qualitative research as a scientific enterprise may explain its reception: qualitative research is not part of the evidence-based medicine hierar- chy; it is often considered the lowest level of evidence along- side expert opinion [26,27]; it continues to have a low presence in medical journals as noted by Shuval et al.[28]; it is rarely published in high impact medical and health ser- vices and policy research journals [29]; and its publication rates have been decreasing in health services and manage- ment journals [30].

These trends may not bode well for health care or at least for patients. As Shuval et al. observe, the low

proportion of qualitative research means that questions per- taining to patient-doctor communication, patients’ medica- tion compliance and treatment decisions, and dissemination of evidence into practice may be inhibited [28]. Although evidence-based medicine has traditionally favored quantita- tive evidence [31], qualitative research has always been fundamental to evidence-based medicine because patient values and preferences are its very foundation [32]. Unfor- tunately, patients’ values and preferences are often reduced to quantitative reports of benefits and harms (e.g., see Mc- Cormack & Loewen 2007 [33]). Ironically, there are also numerous criticisms of evidence-based medicine, including those concerning its scientific status. It has been criticized for not being driven by science [34], for failing to under- stand science as situated or contingent knowledge [31], and for not being scientific [35]. By dismissing induction, deduction, and the evidence between them, the health sci- ences will be left only with data-driven sophistry, or, as William Osler proposed in 1909, a ‘‘plausible pseudosci- ence’’ [36].

As we outlined, ‘‘common sense’’ may seem to accom- plish the same inductive and deductive outcomes as does qualitative research, but the lack of scrutiny in induction and deduction weakens the links in the arch of knowledge. We are optimistic about the movement for qualitative research to become part of what is claimed as ‘‘evidence’’; The Cochrane Collaboration now has a qualitative and im- plementation methods group and syntheses in qualitative research are becoming more common [37]. Nevertheless, the future of this movement is uncertain. The Cochrane Collaboration has been criticized as a threat to good medi- cal practice [35], and qualitative syntheses have been con- demned for yielding low quality works and discrediting the enterprise of qualitative research [37]. In light of these ca- veats and disputes, we propose that qualitative researchers can earnestly claim to be carrying out ‘‘real science’’ and can stop feeling compelled to prove the merit of their work. They can, we hope, get back to the business of conducting theoretically informed and rigorous qualitative research.

11. Qualitative research is a fundamental part of the scientific process

Qualitative approaches, through their systematic approach to induction and deduction, generate a broader form of meaning that is essential for applying the scientific method to human studies. An even broader question relates to the definition and use of the scientific method, and whether it has a universal and timeless definition that can accommodate the complex physical and historical condi- tions, which influence scientific change [13,38,39]. Chalm- ers [13] has observed that we can view the world only from our humanly generated perspectives and theories. Qualita- tive inquiry makes it possible for humans to produce and to understand science, in a manner that withstands logical

133J.E.M. Sale, S. Thielke / Journal of Clinical Epidemiology 102 (2018) 129e133

and empirical scrutiny. As such, it solidifies the arch of knowledge and is a fundamental part of the scientific process.

Acknowledgments

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for- profit sectors. J.E.M.S. holds a Canadian Institutes of Health Research New Investigator Salary Award (COB 136622).

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  • Qualitative research is a fundamental scientific process
    • 1. Introduction
    • 2. Recent debates about the status and utility of qualitative research
    • 3. How is qualitative research scientific?
    • 4. The arch of knowledge
    • 5. Induction
    • 6. Deduction
    • 7. How is qualitative research inductive and deductive?
    • 8. An example using risk factors for suicide
    • 9. An example using the effectiveness of pain medication
    • 10. Relevance to science
    • 11. Qualitative research is a fundamental part of the scientific process
    • Acknowledgments
    • References