Pragmatism as a paradigm for patient‐oriented research

Abstract Background Mixed methods research studies continue to pervade the field of health care, where pragmatism as a research paradigm and patient‐oriented research (POR) as an engagement strategy are combined to strengthen the process and outcomes of the research. Pragmatists use the most appropriate research methods to address issues at hand, where complex social problems need multipronged approaches. As an emerging healthcare research strategy, POR actively engages individuals with lived experience across all stages of the research process. While POR continues to garner attention within mixed‐methods research designs, there is a paucity of literature that considers POR in relation to pragmatism. Objective As POR grows in popularity within the field of health care, there is a need to explore the theoretical and epistemological alignment with pragmatism and the implications to research. Methods To address this need, we provide a critical review of the literature to examine the synergies between POR and pragmatism, and argue for the adoption of pragmatism as a paradigm for conducting POR. Main Results This article begins with a discussion of the philosophical underpinnings informing the pragmatic paradigm. It then identifies key alignments between POR and pragmatism across three intersecting concepts: democratic values, collaborative approaches to problem‐solving and the pursuit of social justice. Discussion and Conclusions Reflecting on our experiences engaging with patient partners in a mixed‐methods POR study titled READY2Exit, we illustrate the relevance of pragmatism to POR by applying these concepts to practice. Implications and considerations for conducting POR within the pragmatic paradigm are also described. Patient or Public Contribution This paper provides a critical review of the literature and did not directly involve patients or the public. The authors reflected on their experiences collaborating with five young adult patient partners in the READY2Exit study (case exemplar described in this article) to demonstrate the relevance of the pragmatic paradigm to POR. We acknowledge and thank the young adult patient partners for their contributions to the research, for encouraging us to think critically about patient engagement in research, and for sharing their experiences.


| INTRODUCTION
A research paradigm is a theoretical framework comprised of a set of beliefs and values, which guides how research is conducted and knowledge conceptualized within scientific communities. [1][2][3] Pragmatism as a paradigm is based upon the premise of utilizing the best methods to investigate real-world problems, allowing for the use of multiple sources of data and knowledge to answer research questions. 4,5 This lends to its appropriateness for mixed methods research, whereby quantitative and qualitative data are collected and integrated within a single study, and multimethod research, which uses multiple forms of quantitative or qualitative data. [4][5][6][7][8] Key tenets underlying the pragmatic paradigm include the utilisation of the scientific method of inquiry, whereby solutions are tested and either accepted or rejected, and alignment with democratic values. 9 Pragmatists use the most appropriate research methods to address issues at hand, where complex social problems are in need of multipronged approaches. The adoption of the scientific method of inquiry, combined with values of democracy and social justice makes pragmatism a fitting paradigm for patient-oriented researchers.
In this article, we describe the innate connection between patient-oriented research (POR) and pragmatism drawing on the core concepts of democratic values, collaborative approaches to problemsolving and the pursuit and maintenance of social justice. Indeed, as POR continues to grow in popularity within the field of health care, the theoretical and epistemological alignment with pragmatism further supports its adoption as the guiding paradigm when conducting POR.
This article begins with an overview of pragmatism and its theoretical roots. It proceeds with describing connections to POR while also drawing on a mixed-methods case study exemplar to support this claim. The core concepts of democratic values, collaboration and social justice are further examined in connection to POR and pragmatism in the context of the healthcare field.  Table 1 to provide a succinct overview of how these are situated in terms of ontology, epistemology, axiology and quality criteria. While individuals with lived experience are central to research, their level of involvement varies depending upon the paradigm and methods used. Much has been written about the roles of individuals with lived experience in transformative and participatory paradigms; 10,11 however, less is known about synergies between the pragmatic paradigm and participatory methods like POR.

| RESEARCH PARADIGMS
This article contributes to the literature by illustrating how pragmatism can be adopted to underpin POR studies.

| ROOTS OF CLASSICAL PRAGMATISM
The pragmatic paradigm arose out of the desire to focus efforts on solving practical problems in the real world through inquiry. 15,16 It relies heavily on the tenets of modern science, including the experimental method as a model for human problem-solving. 15 Pragmatism argues that experience is needed to ascribe meaning to an event. 17 The goal, then, of pragmatic research is to utilize human experience as the primary means for building knowledge and understanding the world, as opposed to relying on absolute truths. 18 Pragmatism provides an action-oriented framework for research, wherein the researcher seeks to address practical issues arising directly from communities using the most appropriate methods for answering the research question. 19,20 John Dewey, one of the founding leaders of pragmatism, accepted a democratic and pluralistic way of life where social relations are characterized by cooperation, discussion, consultation and participation. 9,18 In pragmatism, it is argued that social problems are best defined by the individuals experiencing them, leading to the development of actionable research questions. 21,22 The inherent focus on social justice and joint problem-solving in pragmatic research provide a strong rationale for the involvement of individuals with lived experience in the design and execution of research, one of the key pillars of POR. Congruence between the theoretical underpinnings of pragmatism and POR and implications for researchers will be explored in this article. category of knowledge; 15 more specifically on the consequences and meanings ascribed to actions. 17 Dewey would argue that knowledge is constructed by interactions between humans and their environments, a concept he labels transactional realism. 15 In pragmatism, inquiry using the scientific method allows for thoughtful decisionmaking processes and choices aimed at reaching our intended outcomes. 24,25 Primary objectives of POR include conducting research that aligns with patient-identified priorities and generating study findings that can be used to improve health systems. 26  According to the pragmatist, knowledge is explicitly linked with experience. 18 Pragmatism recognizes the importance of the physical, psychological and social worlds, including culture, language, institutions and subjective thoughts. 20 Knowledge is 'both constructed and based on the reality of the world we experience and live in', 20  Our experiences and actions take place within particular historical, social and cultural contexts, therefore, there may be limits on our ability to use previous experiences to predict the outcomes of future actions. 24 Inquiry is needed because we cannot always rely on our past experiences, given our assumptions are viewed as fallible. 24 The process of inquiry involves careful, conscious and reflective decisionmaking before action using the scientific method. 27,28 We develop warranted assumptions by taking certain actions and experiencing the resulting outcomes. 27 The outcomes gleaned from the process of scientific inquiry then guide our future behaviours and actions. In the field of POR, results are often applied directly in clinical practice or policy development 26 given the collaborative nature of the research process, explicating another connection between pragmatism and POR.
Pragmatism does not privilege one type of knowledge or research method over another. Instead, it calls on researchers to critically analyse 'which interests are served in a particular situation by the application of a particular kind of knowledge'. 29 This pluralist approach allows for the acceptance and recognition of validity amongst different perspectives, interests and forms of knowledge. 29 Because pragmatism is accepting of different ways of knowing, it does not attempt to position particular forms of evidence in a hierarchical structure. 19 This allows for careful consideration of what type of knowledge would best serve the interests of a community within a given context, including the value of experiential knowledge contributed by individuals with lived experience.
Pragmatism asserts that the paradigm wars, concerning false dichotomies between quantitative and qualitative methods, are over, as this polarisation does not promote the advancement of the health science field. 30 Thus, this paradigm supports the adoption of different methods of inquiry to address problems in the most appropriate way, recognizing that methodologies are tools used to aid in understanding the world. 30 Indeed, pragmatism allows for the use and mixing of different data sources based on the premise that their consequences are developed in the processes of the ongoing inquiry. 22,28 It, therefore, serves as a paradigm accepting of mixed and multimethod research. While multiple paradigms may be used when conducting mixed methods research, 31-37 this paper argues that pragmatism's roots in social justice and democracy, combined with the resolve to produce tangible outcomes make it a fitting worldview to adopt when conducting mixed or multimethod studies in the healthcare field.
There are clear connections between the principles of pragmatism and POR, which will be explored in the next section.

| THE RELEVANCE OF PRAGMATISM IN POR
POR involves actively engaging with individuals from the population of interest in various aspects of health research from conceptualisation and design to governance, execution and dissemination of findings into clinical practice. 26,38 It finds its roots in wellestablished collaborative research approaches including participatory action research and patient/public involvement in research. 39 priority-setting activity), being involved (e.g., patients sit on standing advisory council), being collaborators (e.g., patients involved as research partners) and to leading research (e.g., community-based research projects where patients are lead investigators), with patients playing more prominent roles the further along the continuum the study is positioned. 14 These six patients' roles 14 are used in Table 1 to highlight how the responsibilities of patients vary based on the paradigm informing the research.
Leveraging the complementary strengths of researchers and patient partners produces powerful research teams, which are well-positioned to address real world, pressing issues in health care. 44  The study is a doctoral research project, which aims to expand our understanding of the needs and experiences of young adults with both physical and mental health issues as they transition from paediatric to adult services. It is well known that the paediatric-adult transition for adolescents with chronic health conditions is a high-risk period 48 and that assessing transition readiness is a core component of best practice transition planning. 49 'Transition readiness' refers to the extent of an adolescent's health-related knowledge (e.g., ability to describe condition) and self-management skills (e.g., filling prescriptions independently, making appointments) before transfer. 50 Though a large proportion (up to 57%) of individuals with chronic health conditions also experience mental health issues (e.g., depression, anxiety), 51,52 transition readiness for adolescents with co-occurring health and mental health issues has not been adequately explored.
The objectives of READY2Exit are to (1) describe the association between transition readiness and mental health comorbidities in adolescents with chronic health conditions, and (2) to better understand the experiences of this group as they prepare to exit paediatric services. 47 These goals are being addressed using a patient-oriented, mixed-methods approach. READY2Exit is currently in the data collection and analysis stage. Presently, we are collecting and analyzing quantitative data corresponding to objective #1, and are codesigning the qualitative interview guide and recruitment materials to address objective #2. Qualitative interviews are scheduled to take place within the next 3-4 months.

| READY2Exit young adult engagement strategy
READY2Exit is being conducted in collaboration with a projectspecific Young Adult Advisory Council (YAAC). 47

| Democratic values
Underlying pragmatic research is Dewey's guiding principle of democracy, where the goal is to minimize imbalances of power by engaging communities with differing perspectives to obtain their input on priorities for inquiry. 18 The Motivations for health researchers to collaborate with patient partners in research vary. Goals for engaging patient partners in research may be transactional in nature, reflecting efforts to achieve certain outcomes like increased relevance of the research to key stakeholders or higher retention rates in clinical trials. 57 Other motivations may relate to the shift away from paternalism in health care and towards a more inclusive and accountable research agenda. 38,41,57 A moral stance to POR dictates an imperative to collaborate with patient partners in designing research that will inform the policies and programmes serving them. 58 collaborative approach to problem-solving, ensuring READY2Exit is exploring areas of concern for the YAAC.

| Pursuit of social justice
An important principle in pragmatic research is the commitment to producing a positive change in the world by addressing a problem through experimentation in context. Hall 22 asserts that any knowledge gained through pragmatic research should be shared with communities, clinicians and key stakeholders to improve society and address the conditions that prompted the research in the first place.
The pragmatic paradigm operates in pursuit of social justice using inquiry that is action-oriented and context-specific. 10 Pragmatism and POR are connected in that both aim to generate knowledge through inquiry that warrants action and stimulates change. where adjustments are made to enhance the real-world utility of the methods and results. 45 The integration of quantitative and qualitative data on transition readiness, while working in partnership with YAAC members to problem solve and adapt our study materials to best reach youth, demonstrates how a mixed-methods, POR project operates within the pragmatic paradigm.
By approaching POR with an intentional research paradigm guiding the work, researchers will be armed with the knowledge and tools to carry out studies that are internally coherent in terms of epistemology, axiology and ontology. As we have demonstrated, we advocate for the adoption of the pragmatic paradigm in the field of POR given the goals of addressing problems arising within communities and producing societal change that is meaningful to local stakeholders are common to both pragmatism and POR.

| CONCLUSION
Health researchers are required to consider the alignment of paradigm, epistemological stance, methodology and methods in designing coherent and meaningful studies. Throughout this paper, we have made the case that the pragmatic paradigm is well-suited for POR, given the alignment of their underlying principles. We identified parallels between the concepts of democratic values, collaborative approaches to problem-solving and the pursuit of social justice in pragmatism and POR, and used a case example to demonstrate their application in practice. This paper provides a critical contribution to the literature by examining the epistemological and theoretical underpinnings of pragmatism, and synergies with public participation in health research. It seeks to further develop the growing field of POR by arguing for thoughtful consideration of research design, reflection upon the core values of this study and its alignment with the pragmatic paradigm.
Pragmatism's focus on addressing real-world problems, as defined by the communities within which these occur, makes it a natural guiding approach for health researchers who value collaborations with patient partners. Using the READY2Exit case example, we have We have also argued that health researchers operating within the pragmatic paradigm are well-positioned to conduct POR, given its action-oriented, democratic approach to inquiry. A value-based approach to POR, where the inclusion of patient partners is viewed as a moral imperative, can allow researchers to conduct studies aligned with democratic values, while honouring the patient voice and advocating for change. Considering the epistemological and ontological assumptions of pragmatism and how these apply to the growing field of POR is a frontier that requires further exploration.