1.3 Research Paradigms and Philosophical Assumptions

Research involves answering questions, and the approach utilised is based on paradigms, philosophical assumptions, and distinct methods or procedures. Researchers’ approaches are influenced by their worldviews which comprise their beliefs and philosophical assumptions about the nature of the world and how it can be understood.⁹ These ways of thinking about the world are known as research paradigms, and they inform the design and conduct of research projects.^10,11 A paradigm constitutes a set of theories, assumptions, and ideas that contribute to one’s worldview and approach to engaging with other people or things. It is the lens through which a researcher views the world and examines the methodological components of their research to make a decision on the methods to use for data collection and analysis.¹² Research paradigms consist of four philosophical elements: axiology, ontology, epistemology, and methodology.¹⁰ These four elements inform the design and conduct of research projects (Figure 1.1), and a researcher would have to consider the paradigms within which they would situate their work before designing the research.

Ontology

Ontology is defined as how reality is viewed (nature of reality) – accurately captured as an entity or entities. It is the study of being and describes how the researcher perceives reality and the nature of human engagement in the world.^13,14 It is focused on the assumptions researchers make to accept something as true. These assumptions aid in orientating a researcher’s thinking about the research topic, its importance and the possible approach to answering the question.¹² It makes the researcher ask questions such as:

• What is real in the natural or social world?
• How do I know what I know?
• How do I understand or conceptualise things?

In healthcare, researchers’ ontological stance shapes their beliefs about the nature of health, illness, and healthcare practices. Here are a few examples of ontological stances that are commonly adopted by researchers in healthcare:

• Biomedical ontological stance: This ontological stance assumes that biological mechanisms can explain health and illness and that the body is a machine that can be studied and fixed when it malfunctions.¹¹ Researchers who take a biomedical ontological stance tend to focus on medical interventions such as drugs, surgeries, and medical devices.
• Social constructivist ontological stance: This ontological stance assumes that health and illness are social constructs that are shaped by cultural and social factors.¹³ Researchers who take a social constructivist ontological stance tend to focus on understanding the social and cultural context of health and illness, including issues such as health disparities, patient-provider communication, and the role of social determinants of health.
• Critical realist ontological stance: This ontological stance assumes that there is a reality that exists independently of our perceptions but that our understanding of that reality is always partial and mediated by our social context.^11,14 Researchers who take a critical realist ontological stance tend to focus on understanding the complex interactions between social and biological factors in health and illness.

Epistemology

Epistemology is the branch of philosophy that deals with the study of knowledge and belief. It describes the ways knowledge about reality is acquired, understood, and utilised.¹⁵ This paradigm highlights the relationship between the inquirer and the known –what is recognised as knowledge. Epistemology is important because it helps to increase the researcher’s level of confidence in their data. It influences how researchers approach identifying and finding answers while conducting research.¹² In considering the epistemology of research, the researcher may ask any of the following questions:

•       What is Knowledge?
•       How do we acquire knowledge and what are its limits?
•       Is it trustworthy? Do we need to investigate it further?
•       What is acceptable knowledge in our discipline?

The epistemological stance of healthcare researchers refers to their fundamental beliefs about knowledge and how it can be acquired. There are several epistemological stances that researchers may take, including positivism, interpretivism, critical theory, and pragmatism.

• Positivism: This epistemological stance is grounded in the idea that knowledge can be gained through objective observation and measurement.¹¹ Researchers who adopt a positivist stance aim to create objective, measurable, and replicable research that can be used to predict and control phenomena. For example, a researcher studying the effectiveness of a medication might conduct a randomized controlled trial to measure its impact on patient outcomes.
• Interpretivism: This epistemological stance is based on the belief that knowledge is constructed through human interpretation and social interactions. It emphasizes the subjective and interpretive nature of human experience.^{13, 14} Researchers who adopt an interpretivist stance seek to understand the subjective experiences of individuals and the meanings they attach to their experiences. For example, a researcher studying the experience of chronic pain might use qualitative methods to explore patients’ narratives and perspectives on living with pain.
• Critical theory: This epistemological stance is grounded in the belief that knowledge is shaped by power dynamics and social structures.¹⁴ Researchers who adopt a critical theory stance seek to uncover and challenge power imbalances and injustices in society. For example, a researcher studying healthcare disparities might use critical theory to explore the ways in which social and economic factors contribute to inequities in access to healthcare.
• Pragmatism: This epistemological stance is focused on the practical application of knowledge. Researchers who adopt a pragmatic stance aim to create research that is both theoretically sound and applicable to real-world settings.¹³  For example, a researcher studying the implementation of a new healthcare intervention might use mixed methods to gather both qualitative and quantitative data to understand how the intervention is working in practice.

Overall, researchers’ epistemological stances have important implications for the questions they ask, the methods they use, and the interpretations they make. Understanding researchers’ epistemological stances can help healthcare professionals and policymakers to critically evaluate research findings and to consider the broader social, cultural, and political contexts that shape health and healthcare.

Axiology

Axiology refers to the researcher’s understanding of values and their role in research. It examines values, deals with issues of right and wrong and measures the level of development and types of perceptual biases.⁹ Axiology explains the role and importance of the research process, considers the values researchers assign to their research, and guides their pursuit of knowledge.¹⁰ It makes the researcher consider the following questions:

• What should be done to uphold and respect the rights of each participant?
• What ethical principles will you follow during your research?
• What are the cultural and intercultural issues to be considered in the research?
• How can I conduct the research ins a respectful manner?
• How can we minimise or reduce risk during the research?

Researchers’ axiological stance in healthcare refers to their values, beliefs, and ethical positions that guide their research practices and interpretations of findings. Here are some examples of axiological stances that researchers may take in healthcare:

• Patient-centeredness: This value emphasizes the importance of incorporating patients’ perspectives, values, and preferences in healthcare decision-making.⁹ For example, a researcher may prioritize qualitative research methods to explore patients’ experiences and needs in a specific healthcare setting.
• Evidence-based practice: This value emphasizes the use of the best available evidence to guide clinical decision-making.¹⁴ For example, a researcher may conduct a randomized controlled trial to evaluate the effectiveness of a new medication or intervention.
• Health equity: This value emphasizes the importance of addressing health disparities and promoting fairness and justice in healthcare.⁹ For example, a researcher may use a community-based participatory research approach to engage with marginalized or underrepresented populations and identify solutions to health inequities.
• Cultural humility: This value emphasizes the importance of acknowledging and respecting cultural differences and avoiding assumptions and stereotypes in healthcare interactions.¹⁰ For example, a researcher may use qualitative research methods to explore the perspectives and experiences of patients from diverse cultural backgrounds.

These axiological stances are not mutually exclusive and can be combined in various ways depending on the research question and context.

Methodology

Methodology is the strategy or action plan that informs the choice and use of particular methods within the context of a particular research paradigm.^11,16 The term methodology refers to the study design, methods, and procedures employed in a well-planned investigation to find answers. Examples include data collection, survey instruments, participants, and data analysis. In considering the methodology, researchers would ask the questions:

• How do I find out more about this reality?¹⁷
• What approaches or methodology shall I use to obtain the data that will enable me to answer my research question?¹²

The main types of methodology include quantitative and qualitative research. In some cases, mixed methods research, i.e., a combination of quantitative and qualitative research, may also be used. Researchers’ methodological stance in healthcare refers to their underlying beliefs and approach to conducting research in this field. Here are three examples of methodological approaches in healthcare research:

• Quantitative: This approach emphasizes objective and empirical measurement and relates to positivism. Quantitative researchers assume that there is a single objective reality and that the purpose of research is to discover the truth.¹¹ For example, a researcher using a quantitative, positivist approach might conduct a randomized controlled trial to determine the efficacy of a new medication for treating a specific condition.
• Qualitative: This approach emphasizes the importance of understanding multiple perspectives and the subjective experiences of individuals.^{14, 18} Qualitative researchers believe that reality is socially constructed and that the purpose of research is to generate new insights and understandings. For example, a researcher using a constructivist approach might conduct a qualitative study to explore how patients experience a particular health condition and how it affects their daily lives.
• Mixed methods: This approach emphasizes the use of multiple methods and the importance of adapting research to specific contexts and goals.^{13, 19} Researchers who use this approach are pragmatists and they believe that research should be practical and useful for addressing real-world problems. For example, a researcher using a pragmatic approach might conduct a mixed-methods study to evaluate a new healthcare intervention, using both quantitative measures of effectiveness and qualitative data to understand patient experiences and preferences.