# Lesson 1: The Research Process

*Companion-podcast transcript, Sarah and Kiffer*

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**Sarah:** Welcome back to Office Hours. I'm Sarah.

**Kiffer:** And I'm Kiffer. This is the first episode for Health Sciences two-oh-seven, Research Methods in Health Sciences, so we are starting at the very beginning.

**Sarah:** Most students listening have just finished Health Sciences one-thirty. What changes for them in this course?

**Kiffer:** In one-thirty they met the people, institutions and landmark studies of public health, mostly through what those studies found. This course is about how studies like that get done. Students learn the practical steps: writing a research question, drawing a diagram of what might cause what, filling in ethics forms, building a survey, running an interview, coding a transcript, making a table and writing up results. One fictional study runs through every one of those steps.

**Sarah:** And the later courses build on it.

**Kiffer:** They do. Health Sciences two-thirty takes study design further, three-forty-one takes sampling and questionnaire writing further, four-ten does the statistical analysis, eight-forty-one does qualitative analysis at graduate level, and two-forty-one covers systematic searching. This course gives students a working version of every step.

**Sarah:** Every lesson uses the same example study. Tell me about it.

**Kiffer:** It's called the Cedar Valley Social Connection Study, and it is fictional. A small team at a British Columbia university, led by a fictional faculty member named Dr. Maya Hart, works with the fictional Cedar Valley Health Authority. The region is mostly rural, with about two hundred and ten thousand residents, about forty-six thousand of them aged sixty-five and older. It has a mid-sized city called Cedar City, smaller communities such as Riverside, North Bench and Kestrel Lake, twenty-four primary care clinics, and a First Nations health partner.

**Sarah:** And what does the team want to know?

**Kiffer:** It starts with a concern that staff, clinicians and community groups keep raising: older adults in Cedar Valley seem lonely. The team wants to understand loneliness and social isolation among adults aged sixty-five and older, and how they relate to health and to the use of health services.

**Sarah:** Are loneliness and social isolation the same thing?

**Kiffer:** They are different, and the difference matters when the team decides what to measure. Loneliness is the distressing feeling that your relationships are fewer or less satisfying than you would like. Social isolation is an objective state, having few contacts. Someone can live alone without feeling lonely, and someone can feel lonely in a full house.

**Sarah:** Section one starts with a definition of research, which sounds almost too basic.

**Kiffer:** It turns out to be useful. Canada's three federal research agencies share an ethics policy called the Tri-Council Policy Statement, and it defines research as an undertaking intended to extend knowledge through disciplined inquiry or systematic investigation. Research aims at knowledge that is useful beyond the immediate situation, and it is systematic, so you decide in advance what to observe and record those decisions.

**Sarah:** Why does a second-year student need that?

**Kiffer:** Because a lot of activity in health care uses research methods for other purposes. A clinic that audits its own wait times to fix its scheduling is collecting data for internal improvement. The policy says that quality improvement, program evaluation and performance reviews used only for assessment, management or improvement do not need research ethics board review. Lesson five returns to that boundary, which can be hard to draw.

**Sarah:** Then the research cycle. Walk me around it.

**Kiffer:** Our version has eight stages. A team identifies a topic and a problem, reviews what is known, writes the research question, chooses an approach and a design, plans the ethics, sampling and measurement, collects the data, analyzes it, and then interprets, writes and shares the findings. Those findings raise new questions, and the cycle starts again.

**Sarah:** Why draw it as a circle? Most diagrams I remember from school were straight lines.

**Kiffer:** Two reasons. Research is cumulative, so one study usually leads to the next. And the stages connect in both directions. A pilot survey shows that people misread a question, so the team goes back to planning. Or the data it wanted are unavailable, so it narrows the question. Researchers expect those loops and write down what changed and why.

**Sarah:** And the course follows the same circle.

**Kiffer:** Lessons one and two cover the problem and the question, Lesson three adds causal diagrams, Lesson four covers the people with an interest in the study, whom we call interest holders, and Lesson five is ethics. Six is design and project management, seven is sampling and measurement, eight to ten are data collection, eleven is analysis, and twelve is writing up.

**Sarah:** Now the part I suspect students find hardest, going from a topic to a question.

**Kiffer:** It's the step people most often skip. So we separate three terms. A topic is a broad area of interest, like loneliness among older adults. A research problem adds a situation with consequences for health and a gap in what is known. A research question is one sentence saying what a study will find out, about whom and where, in terms that data can answer.

**Sarah:** What is the research problem in Cedar Valley?

**Kiffer:** The health authority is planning services for lonely older adults without knowing how common loneliness is, who is most affected, or whether it relates to how people use health services. Money and staff time will be spent either way, and the evidence to guide that spending is missing.

**Sarah:** Where do problems like that come from?

**Kiffer:** Usually several places at once. Clinicians notice patterns, like physicians who think some older patients book appointments partly for the company. The people affected notice things, like advisory group members describing friends who stopped going out after giving up their driver's licence. Routine data, published studies and planning decisions all raise problems too.

**Sarah:** Isn't a planning decision a research question? Should the health authority expand its program, for example?

**Kiffer:** That decision belongs to the health authority. Research can inform it by answering questions such as how many people might benefit and where they live, and the decision itself also involves values and trade-offs.

**Sarah:** The section gives a template for a problem statement.

**Kiffer:** It has four parts. Who and what, meaning the population and the issue. Why it matters, meaning the consequences for health, services or equity. What is known, in a sentence or two. And what is missing, meaning the gap, who needs it filled, and for what decision. It is usually one hundred to two hundred words.

**Sarah:** And Dr. Hart drafts one.

**Kiffer:** Her first draft is about one hundred and forty words. It names older adults in a mostly rural region, notes that loneliness has been linked to poorer health and more health service use elsewhere, and then states a gap with three unknowns: how common loneliness is in rural communities, whether it relates to emergency department use in this region, and how older adults who move to smaller towns experience connection. It ends by saying the health authority cannot decide where to place new programs without that information.

**Sarah:** Three unknowns, three possible questions. What makes a question workable?

**Kiffer:** It names a population and a setting. It refers to something you can observe or measure, or an experience people can describe. You can realistically get the data. It is narrow enough for one study and broad enough to matter. And its answer is unknown in advance.

**Sarah:** Give me a weak one.

**Kiffer:** What causes loneliness in older adults? It names no setting, it would take a whole field of research to answer, and it gives the team no idea whom to recruit or what to measure.

**Sarah:** And a workable one?

**Kiffer:** What proportion of adults aged sixty-five and older in the Cedar Valley region are lonely, as measured by the three-item University of California, Los Angeles Loneliness Scale, usually called the UCLA scale? It names the population, the setting and the measure, a regional survey can answer it, and the answer is a number planners can use.

**Sarah:** Let me summarize Section one. Research is systematic work meant to extend knowledge. It moves around an eight-stage cycle with plenty of loops. And the hard early step is going from a topic to a problem, which needs a consequence and a gap, and then to a workable question.

**Kiffer:** That covers it. First drafts of questions are rarely final, so students should record each revision and the reason for it.

**Sarah:** Section two covers four kinds of research question. Why does the kind matter so much?

**Kiffer:** The kind of question decides the kind of answer you can get, the data you need and the approach that suits it. A team that is unclear about its question tends to collect the wrong data or claim too much. Our four kinds are descriptive, explanatory, predictive and exploratory. The first three follow a classification by Miguel Hernán and colleagues into description, prediction and causal inference, and we add exploratory questions for when we don't yet know what to measure.

**Sarah:** Start with descriptive.

**Kiffer:** A descriptive question asks what is happening, to whom, where and when. How many people have a condition, how something is distributed across places, how it has changed over time. The Cedar Valley version is the one we just built, asking what proportion of older adults score six or higher on the UCLA scale.

**Sarah:** Remind me how that scale works.

**Kiffer:** Three items ask how often you lack companionship, feel left out and feel isolated from others. Each is scored from one, hardly ever, to three, often, so totals run from three to nine. The team counts six or higher as lonely.

**Sarah:** What does the answer look like?

**Kiffer:** A proportion. The lesson jumps ahead to the team's regional survey to show it. Sixteen hundred older adults completed it, and three hundred and ninety-two scored six or higher. That is twenty-four point five percent, about one respondent in four. Lesson eleven returns to that figure and shows how to choose and report its denominator.

**Sarah:** So one in four older adults in Cedar Valley is lonely?

**Kiffer:** One in four of the people who answered. Whether that describes all forty-six thousand depends on how respondents were chosen and who chose to respond. If the loneliest people were less likely to fill in a survey, the true figure could be higher. Lesson seven takes that up.

**Sarah:** Some people treat description as the less interesting kind of research.

**Kiffer:** I'd disagree. Planners cannot place services until they know where need is concentrated, a program cannot show change without a baseline, and differences between groups often reveal inequities that later studies try to explain.

**Sarah:** Explanatory questions next.

**Kiffer:** An explanatory question asks why something happens, or whether one factor affects another. In quantitative health research these are usually causal. They ask whether changing one factor, the exposure, would change another, the outcome. In Cedar Valley, the question is whether loneliness is associated with the number of emergency department visits in the following twelve months.

**Sarah:** You said associated, yet you called it causal.

**Kiffer:** The wording is associational, and the team's underlying interest is causal. Planners want to know whether reducing loneliness would reduce emergency visits. Lesson two shows how to structure that question with the PECO framework, which stands for population, exposure, comparison and outcome.

**Sarah:** So what separates an association from a cause?

**Kiffer:** Two factors are associated when they occur together more or less often than chance would produce. One causes the other when changing the first would change the second. Loneliness might lead to emergency visits, for instance if lonely people delay care until a crisis. Poor physical health might also make it hard to get out and see people, raising loneliness, while raising emergency visits on its own. Then loneliness and visits are associated even if loneliness has no effect.

**Sarah:** And that is confounding.

**Kiffer:** Yes, with poor health as the confounder, a factor that causes both the exposure and the outcome. There is also reverse causation, where a hospital stay cuts someone off and makes them lonelier, and there is chance and bias. Answering an explanatory question needs a comparison and a plan for those alternatives. Lesson three starts drawing them as diagrams.

**Sarah:** Can qualitative research explain things too?

**Kiffer:** In its own way. Interviews might show how giving up driving led one woman in North Bench to stop going to church and then to feel cut off. That describes a process from the inside, which a survey can only infer from patterns in numbers.

**Sarah:** Then predictive questions.

**Kiffer:** A predictive question asks who is likely to experience an outcome, using information available now. The team could ask whether information from a routine clinic visit, such as age, living alone, bereavement, hearing loss and a loneliness score, can identify who will visit an emergency department next year. The answer is a forecast, judged by its accuracy.

**Sarah:** That sounds a lot like the explanatory question.

**Kiffer:** Both involve factors and an outcome, and the difference is what the answer is for. A predictor only has to be informative. Last year's emergency visits probably predict next year's well, and no intervention can change last year's count. The more common mistake runs the other way. If hearing loss predicts visits, that alone does not show that hearing aids would reduce them, because hearing loss may simply mark people who are older or sicker. Galit Shmueli wrote an influential paper on this difference between explaining and predicting.

**Sarah:** And the fourth kind, exploratory.

**Kiffer:** An exploratory question asks what an experience or process is like when too little is known to say what to measure. In Cedar Valley it asks how older adults who live alone experience social connection after moving to a smaller town such as Riverside or Kestrel Lake. It could be transport, churches, neighbours, volunteering or video calls that matter most, and the team doesn't know which. An exploratory study can find out, and its findings might later shape a survey.

**Sarah:** I can hear students mixing up exploratory and explanatory.

**Kiffer:** Every year. An exploratory question opens up a topic that is poorly understood. An explanatory question tests or accounts for a relationship between factors already identified.

**Sarah:** The section ends with wording that doesn't match the plan. What's the usual problem?

**Kiffer:** Causal words in a descriptive study. Someone writes, what is the impact of rural living on loneliness, when they only plan to compare the proportion lonely in Cedar City with the smaller communities. Impact implies a cause. The better version asks how the proportion who are lonely differs between Cedar City and the smaller communities, which is a perfectly good descriptive question.

**Sarah:** To summarize Section two: descriptive questions produce numbers, explanatory questions need a comparison and a plan for alternative explanations, predictive questions are judged by accuracy, and exploratory questions produce themes. And the wording should match the plan.

**Kiffer:** Yes, and the test is what the team intends to find out, because signal words alone can mislead.

**Sarah:** Section three is about approaches. What is an approach?

**Kiffer:** The broad strategy a study uses, defined mainly by whether it works with numbers, with words and observations, or with both. So the approaches are quantitative, qualitative and mixed methods. Four terms get blurred. A paradigm is a set of assumptions about knowledge. An approach is the broad strategy. A design is the plan for who is studied, when and with what comparison. A method is a technique, such as a questionnaire or a focus group.

**Sarah:** Start with quantitative research.

**Kiffer:** It collects numbers and analyzes them statistically. Concepts are defined in advance and measured the same way for everyone, often with a standardized instrument like the UCLA scale. Samples are often large and chosen to represent a population. It gives precise estimates that can be compared and combined. Its limit is that a survey only measures what its designers thought to ask, and a number can say how often something happens without saying what it means.

**Sarah:** And in Cedar Valley?

**Kiffer:** Three parts. The regional survey with sixteen hundred responses. With consent, those responses are linked to administrative records of physician visits, hospital discharges and emergency visits through Population Data B C, which supports research access to linked administrative data in British Columbia. And a review of three hundred medical record charts at six partner clinics.

**Sarah:** Now qualitative research.

**Kiffer:** It collects words, images and observations and interprets their meaning. Questions are open and data collection is flexible, so an interviewer follows up on what someone says. Samples are small and chosen through purposive, or judgement, sampling, which means picking people because they can speak to the experience being studied. Analysis means coding passages and grouping codes into themes. Because the researcher interprets, qualitative researchers practise reflexivity, examining how their own background shapes what they notice.

**Sarah:** The Cedar Valley qualitative strand has twenty-four interviews. A skeptic would say that twenty-four people can't represent forty-six thousand.

**Kiffer:** That criticism applies a standard meant for surveys. The interviews aim to understand an experience in depth, so people are chosen for what they can describe. Qualitative studies are judged mainly by credibility and transferability, which asks whether readers have enough detail to decide if the findings apply in their own setting. The study also runs four focus groups: two with older adults, one with family caregivers, and one with clinic staff and community connectors.

**Sarah:** The section also introduces paradigms.

**Kiffer:** Lightly, because Health Sciences two-thirty Lesson one goes deeper. Thomas Kuhn used the word paradigm for the shared assumptions of a scientific community, and Egon Guba and Yvonna Lincoln applied it to the worldviews behind research approaches. Post-positivism assumes a reality that can be measured imperfectly and goes with quantitative research. Constructivism assumes people construct the meanings of their experiences and goes with qualitative research. Pragmatism judges methods by whether they answer the question and goes with mixed methods. Critical, or transformative, stances hold that research should address inequity, with communities as partners.

**Sarah:** Where does the Cedar Valley team sit?

**Kiffer:** It is pragmatic, choosing the approach for each question by the answer that question needs. Its advisory group of older adults and its First Nations partnership also reflect a participatory commitment. For this course, the approach should fit the question, and the team should be able to explain why.

**Sarah:** So how do students match questions to approaches?

**Kiffer:** Ask what form the answer should take. A number, an estimate or a forecast, which covers most descriptive, explanatory and predictive questions, usually calls for a quantitative approach. An understanding of experiences, meanings or processes, which covers exploratory questions, usually calls for a qualitative approach. Lesson six builds this into a fuller decision map.

**Sarah:** And mixed methods?

**Kiffer:** Mixed-methods research collects both kinds of data and deliberately integrates them. Integration is where the strands meet, for example when survey results decide whom you interview, or when interviews explain a survey result. A study that collects both kinds of data and reports them in separate boxes gains little from having both.

**Sarah:** Is an open-ended question on a survey enough to make a study mixed methods?

**Kiffer:** Most mixed-methods researchers would say it falls short. Mixed methods usually means a qualitative strand with its own data collection and analysis, and a plan for integration. John Creswell and Vicki Plano Clark describe three core designs, convergent, explanatory sequential and exploratory sequential, and Lesson six teaches them.

**Sarah:** Why does Cedar Valley need both strands?

**Kiffer:** Because its questions need different kinds of answer. How common loneliness is, and whether it is associated with emergency visits, need numbers from a large sample. How people experience connection after a move needs open conversation. And the strands help each other. Survey results can guide whom the team interviews, and interviews can help explain why loneliness is higher in one community than another.

**Sarah:** So, Section three. An approach sits below a paradigm and above design and method. Quantitative research measures and estimates, qualitative research interprets meaning, the form of the answer points to the approach, and mixed methods means integration.

**Kiffer:** That's an accurate summary of the section.

**Sarah:** Section four turns to reading articles. Why is reading part of a methods course?

**Kiffer:** Every published study is the end of a series of decisions, and the article is the authors' account of them. Reading for those decisions is an efficient way to learn to make your own.

**Sarah:** Where are the decisions recorded?

**Kiffer:** Most empirical articles follow a structure called IMRaD, which stands for Introduction, Methods, Results and Discussion. The final paragraph of the introduction usually states the question. The methods section records most of the decisions. The results report what was found. The discussion is where the authors interpret their findings, so that is where you read most carefully.

**Sarah:** And students record the decisions in a decision log.

**Kiffer:** It's a twelve-row template, running from the problem and gap and the question and its kind, through the approach, design, setting, participants, measures, ethics and analysis, to the findings, the authors' interpretation and the limitations. I ask students to quote the article only for the research question and put everything else in their own words.

**Sarah:** And they read in passes.

**Kiffer:** Three passes. The first is a ten-minute overview of the title, abstract, last paragraph of the introduction, tables, figures and conclusion, recording the question, its kind and the approach. The second reads the methods and results in full and completes the log. The third is judgement: does the design fit the question, and do the conclusions follow from the results? Trisha Greenhalgh's writing on how to read a paper makes a similar point about identifying the question and the type of study first.

**Sarah:** The worked example uses a fictional abstract. What happens in it?

**Kiffer:** It's a practice abstract with illustrative numbers. Researchers in one city mailed a survey to five thousand older adults, and two thousand returned it, which is forty percent. With consent, they linked responses to a year of emergency records. Lonely participants made an average of zero point eight visits, compared with zero point five for everyone else, after adjusting for age, sex, chronic conditions and living alone. The conclusion says loneliness increases emergency department use and that health authorities should fund loneliness programs to reduce visits.

**Sarah:** And the findings don't fully support that.

**Kiffer:** They show an association. The word increases makes a causal claim, and adjustment for four factors may leave other explanations, such as severity of illness. The recommendation assumes that programs reduce loneliness and that less loneliness means fewer visits, and the study tested neither. A careful reader would also note that sixty percent did not respond, and that one city says little about rural or First Nations communities.

**Sarah:** Is the article still useful to the Cedar Valley team?

**Kiffer:** Yes. It supports the problem statement, it confirms the gap, and the low response pushes the team to plan how to reach older adults who rarely answer surveys.

**Sarah:** The section also has a qualitative abstract to log. What does that look like?

**Kiffer:** It's another practice abstract, about older adults who moved to a small town. Researchers interviewed eighteen adults aged sixty-eight to eighty-four who lived alone and had moved in the previous five years, and they analyzed the transcripts with reflexive thematic analysis. The question is exploratory, the approach is qualitative, and the design is an interview study. The findings are three themes: losing the map, meaning not knowing where people gather, the work of being new, and finding a role.

**Sarah:** And the interpretation?

**Kiffer:** The authors recommend that programs for newcomers help older adults find roles that are useful to others. That fits the themes, and it is still a proposal the study did not test. A careful reader would also note that recruiting through community centres and a newspaper notice may miss the most isolated newcomers, and that the abstract mentions neither ethics approval nor the researchers' position.

**Sarah:** Does the log work the same way for both kinds of article?

**Kiffer:** The rows are the same, and what you look for in them changes. In a qualitative article you look at how participants were chosen, how the analysis was done, and whether readers get enough detail about the setting to judge transferability. Here, a reader would need details of the three towns before deciding whether the findings apply in Cedar Valley.

**Sarah:** So what should students take from Section four?

**Kiffer:** Four things. Most articles follow IMRaD, and the methods section records most of the decisions. A decision log turns an article into a record of twelve decisions. Reading in three passes moves from an overview to the methods and results and then to a judgement. And a careful reader keeps the findings separate from the authors' interpretation, checking for causal words, conclusions that reach beyond the people studied, and recommendations the study never tested.

**Sarah:** And that leads into Lesson two.

**Kiffer:** It does. Lesson two turns candidate questions into structured questions with frameworks such as PECO and SPIDER and scores them against the FINER criteria, and Lesson three adds the causal web and the diagram.

**Sarah:** Thanks, Kiffer.

**Kiffer:** Thanks, Sarah. See everyone in Lesson two.