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Introduction and Theoretical Background
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Depression in Older Adults
The world population is rapidly aging: Between 2015 and 2050, the percentage of people in the world over the age of 60 will nearly double, from 12% to 22% . Depression among older adults is one of the most serious public health problems facing modern societies . The appearance of depression is associated with serious consequences, including disability, functional decline, diminished quality of life, increased mortality, increased service utilization, and high levels of suicide in adults . In older adults, depression is connected with a marked reduction in cognitive abilities which, in turn, is commonly accompanied by a decrease in social and physical activities . Alongside coronary heart disease, cancer, and cardiovascular diseases, depression is a major public health problem that has become a common chronic disease in older adults .
Depression symptoms greatly influence both physical and cognitive functioning of older adults. Longitudinal studies have reported that depressive symptoms are connected to functional decline, as determined by both self-reported and objective measures of physical performance . They also contribute to limitation of basic activities of daily living in high functioning older adults initially free from disability . As depression deepens and more symptoms surface, the likelihood of becoming disabled increases. Moreover, depressive symptoms may accelerate the disablement process in older adults already exhibiting early signs of disability , and individuals with chronic depressive symptoms have greater declines in functioning compared to those who remained nondepressed .
Late-life depression is also associated with an increased risk of decline in cognitive functioning. Older adults with depression are more likely to have concomitant cognitive deficits, especially executive cognitive functioning deficits, or are subsequently more likely to develop dementia . Older adults with depression often develop cognitive impairment following onset of depression. Thus, depression might be a risk factor or an early symptom of dementia .
One of the risk indicators for depression is lack of social support and social networks. Many of depressed older adults are also lonely, and a correlation has been found between depression and loneliness. Depression with feelings of loneliness leads to more pronounced motivational depletion and serious consequences, including social isolation, reduced selfcare, decreased mobility, and poor diet . participants reported loneliness feelings in the week prior to the interview. The loneliest group was that of age 75+; women reported higher levels of loneliness than men, as did Arabs compared with Jews.
Today, loneliness is also perceived as a biological structure, similar to hunger, thirst, or pain, which are internal mechanisms activating behavior that prevents harm to the person. Hunger makes us seek food; loneliness prompts us to seek social relationships . Correlations have been reported between the feeling of loneliness and several physical health problems: cardiovascular diseases, chronic diseases, cancer, stroke, high blood pressure, and mental illness , low levels of emotional wellbeing, and a high level of suicidal thoughts . The problems caused by loneliness lead to decreased quality of life, increased mortality, poor recovery from illness, and high hospitalization rates among older adults .
Depression in older adults may result from a variety of reasons apart from loneliness feelings, including malnutrition. Some studies have reported a strong and independent association between nutritional deficit and depression, demonstrating that depression increased the risk of impaired nutritional status , whereas others have shown a modest association, or no association . Significantly, over 10% of adults with depression residing in the United States also suffer from malnutrition . Malnutrition impacts quality of life by undermining individual autonomy to perform necessary, instrumental, and social activities of daily living .
Malnutrition is defined as a state in which a deficiency, excess or imbalance of energy, protein, and other nutrients causes measurable adverse effects on tissue/body form , function, and clinical outcome . It is more prevalent and increases among older adults . Although malnutrition's etiology is multifactorial, adverse physiological, psychological, and social causes of malnutrition in older adults are consistently reported in the literature . Aging is accompanied by physiologic changes that can negatively impact nutritional status: Sensory impairment may result in reduced appetite and poor oral health and dental problems can lead to difficulty chewing, inflammation, and a monotonous diet that is poor in quality. The progressive loss of vision and hearing may also limit mobility and affect the elderly's ability to shop for food and prepare meals .
Along with physiologic changes, older adults may also experience profound psychosocial and social changes contributing to poor nutritional status. These include cognitive impairment, heavy use of medication, periods of lengthy hospitalization isolation, retirement from paid work, bereavement, increasing frailty, and loneliness and depression . These factors influence the ability of older adults to meet dietary needs or to digest, absorb, utilize or excrete nutrients that are ingested. The outcome is reduced energy intake and lean body mass, resulting in a reduced metabolic rate and a proportional decline in total energy expenditure that may lead to malnutrition .
Apart from the possible direct connection between loneliness feelings and depressive symptoms, loneliness feelings can have widespread implications for the mental and social lives of older adults, and these implications can explain some of the effects of loneliness feelings on depressive symptoms. Specifically, one mediator might be at play -malnutrition.
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The Current Study
The current study was conducted in Israel in 2020 during a Covid-19 pandemic quarantine, providing a unique opportunity to assess the effect of loneliness feelings on depressive symptoms, mediated by malnutrition, among older adults from different cultures during a particularly stressful period.
We posited three hypotheses: 1. Loneliness feelings due to the Covid-19 pandemic is associated with depressive symptoms. 2. Loneliness feelings due to the Covid-19 pandemic are indirectly associated with depressive symptoms through malnutrition; older adults feeling lonely will report higher levels of malnutrition, which will be associated with increased depressive symptoms. 3. Loneliness feelings, depressive symptoms, and malnutrition levels will differ between older adults from different cultures as a result of Covid-19 imposed quarantines.
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Method
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Study Design and Participants
The research employed a cross-sectional study of a convenience sample of 201 Jewish and Arab older adults, aged 65 and over, representing the two main ethnic groups living in Israel. Inclusion criteria were age 65 and over and the ability to speak and understand Hebrew or Arabic.
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Procedure
The study was approved by the Research Ethics Committee of the college at which the research took place. Recruitment of participants was random and the final sample comprised 100 Jews and 101 Arabs. Researchers explained the study objectives and procedure to the participants, including their right to withdraw freely at any time. Strict confidentiality was maintained. Data collection was performed by professional interviewers through telephone interviews, adhering to Covid-19 quarantine restrictions, using appropriate translated, validated, and structured questionnaires. Data collection took place from April to May 2020.
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Measures
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Independent variable
Loneliness. Loneliness was measured by a single direct question: «Do you sometimes feel lonely?» with four options: never, seldom, sometimes, often.
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Dependent variable
Depressive symptoms. Depressive symptoms were measured by the Geriatrics Depression Scale developed by Yesavage and Brink . The purpose of the questionnaire was to determine participants' depressive symptoms by using a simple and reliable tool that does not require the time and skills of a professional interviewer. The tool is composed of 15 items, in a yes / no response formats .
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Mediator
Malnutrition. Malnutrition was measured by the Determine Nutrition Screening Initiative developed jointly by the American Diabetes Association, the American Family Doctors Association, and the National Council of Old Age. The purpose of the questionnaire was to detect older adults at risk for malnutrition. The tool is composed of 10 items, in a yes / no response format.
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Covariates
The study controlled for socioeconomic variables. Background variables included gender, age, marital status, and years of education. Age and years of education were both defined as continuous measures. Gender was coded as dichotomous . Marital status was coded as "with partner" = 1; or "without a partner" = 0.
All instruments were translated into Hebrew and Arabic by bilingual translators. The complete questionnaire underwent a pilot test. The questionnaire took approximately 15 minutes to complete, the verbal instructions were comprehensible, and there was no need for further changes before administering the questionnaire.
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Data Analyses
Descriptive statistics were employed to calculate the means and standard deviations of the continuous variables and the percentage and frequency of the categorical variables. In the second stage, bivariate analyses were performed to examine the association between depressive symptoms and the independent variable, mediator variable, and socio-economic variable using an independent t-test, one-way ANOVA, Pearson or Spearman correlation tests.
Mediation analyses were then computed in which the selected mediator was entered to test the components of the mediation model using the bootstrapping method to assess the indirect effects of the mediation model . Thus, the meditation model was examined by directly testing the significance of the indirect effect of the independent variable on the dependent variable through the mediator , while controlling for background variables that were identified earlier as significant in the bivariate analyses. This method is based on regression analysis, calculating the direct effect , total effect and indirect effects of an independent variable on a dependent variable. The total and specific indirect effects were calculated through bootstrapping set at 5,000 samples. Confidence intervals were calculated using this method by sorting the lowest to highest of these 5,000 samples of the original dataset, yielding a 95-percentile confidence interval . All analyses were run using SPSS 25.0 with the PROCESS statistical program . All estimated effects reported by PROCESS are unstandardized regression coefficients.
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Results
Of the participants, 105 were women and 96 were men, ranging in age from 65 to 95 . Years of education ranged from 6 to 21 and 71.1% had a partner. The group had equal numbers of Arab and Jewish participants. There were significant differences based on ethnicity with regard to education, with Jewish participants reporting more years of education than Arab participants; the Cohen's effect size value was high. Arab participants reported a significantly higher level than Jewish participants of loneliness , malnutrition , and depressive symptoms . For most variables, the Cohen's effect size values were relatively high .
Table 2 presents the bivariate tests between the study variables with depressive symptoms as the dependent variable. Results revealed that all demographic variables, except for gender and marital status, were significantly related to depressive symptoms. Advanced age was positively correlated with depressive symptoms. Lower educational level was correlated with higher reported depressive symptoms. An ethnic difference in depressive symptoms was also found with Arab participants reporting higher depressive symptoms than Jewish participants. Both the independent and mediator variables were significantly related to the dependent variable-depressive symptoms. High malnutrition and high loneliness were positively associated with depressive symptoms.
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The Mediation Analyses
Using PROCESS model 4, we tested hypotheses two and three, whether malnutrition mediated the relationship between loneliness feelings and depressive symptoms controlling for covariates . The results indicated a significant total direct effect of loneliness feelings on depressive symptoms, a significant direct effect, and a significant indirect effect through malnutrition. The results also showed that loneliness feelings were associated with higher malnutrition scores and that malnutrition was positively associated with depressive symptoms. Finally, ethnicity was associated with depressive symptoms. However, no significant associations were found between depressive symptoms and the other covariates: gender, age, education, and marital status.
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Discussion
The general purpose of this study was to examine the extent to which loneliness feelings are connected with depressive symptoms of older adults from different cultures during isolation by conducting research during a Covid-19 pandemic quarantine in Israel. We measured whether older adults who suffered from higher degrees of loneliness feelings due to the Covid-19 quarantine had higher levels of depressive symptoms and what potentially accounted for this association. The findings confirmed the first hypothesis that older adults suffering from a high degree of loneliness feelings suffer from higher levels of depressive symptoms. These results are consistent with other studies executed before and during the Covid-19 pandemic, reporting that loneliness feelings are associated with mental wellbeing .
The mediation model confirmed the second hypothesis that the connection between loneliness feelings and depressive symptoms is accounted for by level of malnutrition. The association between loneliness feelings, depressive symptoms, and level of malnutrition can be explained by two different aspects: dietary behavior and the influence nutrition has on depressive symptoms. With regard to dietary behavior, loneliness feelings may affect appetite and nutrient intake through a decline in mood, physical functioning, or cognition . These various declines combine with the difficulty people have eating alone. Appetite can be further inhibited by changes in social status, particularly when older adults experience loneliness and/or bereavement due to loss of a spouse or friends of the same age-group . Eating in the company of others can help prevent malnutrition. It increases caloric intake and is related to healthier food habits , and maintains the motivation of older adults to eat and cook, providing them with opportunities for social interaction and connectedness .
The current study took place during a Covid-19 quarantine when older adults, as a high-risk group, were counseled to stay at home with their permanent partners only and to avoid, as much as possible, from going shopping and to depend on home deliveries. Hence, it is likely that older adults were forced not only to eat alone, but to be alone most of the time, resulting in insufficient food intake and, consequently, malnutrition.
The second aspect concerns the connection between depression and the diet of older adults. Recent studies have suggested that depressive symptoms are more prevalent in individuals with impaired nutritional status than in other older patients. It has been observed that individuals with specific nutritional deficiencies such as lack of folic acid and vitamin B12 as well as antioxidant vitamins had more depressive symptoms than those with normal nutritional status . The mechanism that might be at work here is that older adults who suffer from loneliness feelings tend to eat less and lack a healthy appetite and, for that reason, they will not consume all the nutrients they need and will suffer from malnutrition or depressive symptoms. This mechanism accelerates during a quarantine, when even older adults who do not suffer from loneliness ordinarily suffer from isolation. The third study hypothesis was that research variable levels will differ between cultures, particularly due to the extremity of the Covid-19 quarantine. Indeed, Arab older adults reported greater loneliness feelings, higher level depressive symptoms, and greater malnutrition compared to the Jewish older adults. The results with regard to depressive symptoms are consistent with studies reporting that being a member of an ethnic or racial minority is a risk factor for depression. Specifically, Arab respondents have reported higher depressive symptoms than Jewish respondents ; however, there are also contradictory results .
Concerning the higher levels of loneliness and malnutrition, the Covid-19 quarantine may have posed new challenges to the Arab study participants that explain the study findings. Arab society in Israel is known for family consolidation and solidarity. The extended family maintains a multi-generational structure, with grown children obligated to filial piety responsibilities . The Covid-19 quarantine forced new ways of communication upon family members, exposing the absence of digital literacy among Arab older adults: for Arab older adults, Internet use does not protect against loneliness . Moreover, the extended family often lives together, with the daughters and daughters-in-law cooking and serving the older adults . The quarantine isolated the Arab older adults from their extended family, resulting in reduced help with cooking and serving meals. Moreover, the strong connection between feeling loneliness and malnutrition cited above amplified the problem.
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Conclusion and Implications
The present study was executed during a Covid-19 pandemic quarantine. The results indicate that there is a connection between loneliness feelings, depressive symptoms, and malnutrition. The primary conclusion is that loneliness feelings are a serious problem facing all older adults since they negatively affect both depressive symptoms and malnutrition. In order to overcome these feelings, it is important to connect older adults to social network technologies and teach them how to use these technologies. Families can also receive guidance for meeting while maintaining social distancing. Another option is to encourage neighbors in the same building to talk to each other and find ways for mutual support.
Research indicates that members of the Arab society in Israel are a high-risk group and much more vulnerable to loneliness feelings, depressive symptoms, and malnutrition in times of crisis such as the Covid-19 pandemic. The lives of many Arab older adults changed from being surrounded and supported by their extended family to being alone during the quarantine and to suffering from malnutrition. In order to fight these two related outcomes, one possible solution is to provide psychological-nutrition intervention by telephone. This would provide by missing human contact and nutrition guidelines and encouragement to cook and eat healthier foods. We should point out three main limitations of the current study. One is the cross-sectional study design, which does not allow for prediction of a causal relationship between the variables. A future study should use longitudinal data to examine the relationship between loneliness feelings and depressive symptoms. A further limitation might be the use of only one question concerning loneliness feelings. However, previous studies have also used one question in order to describe loneliness feelings . Third, a generalization of the findings is limited because the sample and the sampling procedure do not guarantee the representativeness of Jewish and Arab older adults. The sample was conducted by telephone and included only older adults who answered the telephone at that moment. Those who did not answer or did not have a telephone are not represented in this study. These various factors may have biased the results.
Despite these limitations, the present study provides initial insights into the mechanisms of the association between loneliness feelings, malnutrition, and depressive symptoms during periods of quarantine imposed isolation.
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Conflict of Interest Statement: The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Ethical standards:
The number of the approval from Tel Hai College is 3/2020-5. | Research on loneliness conducted in different countries has demonstrated that it is a common, universal phenomenon, although its prevalence varies between societies and cultures (11). In the United States, more than 19% of older adults aged 65 and older reported loneliness feelings (12); in Australia, the comparable figure was 40% (13). In a study of loneliness in Israel ( 14), it was found that nearly half (47. | 0 | introduction and theoretical background depression in older adults the world population is rapidly aging between 2015 and 2050 the percentage of people in the world over the age of 60 will nearly double from 12 to 22 depression among older adults is one of the most serious public health problems facing modern societies the appearance of depression is associated with serious consequences including disability functional decline diminished quality of life increased mortality increased service utilization and high levels of suicide in adults in older adults depression is connected with a marked reduction in cognitive abilities which in turn is commonly accompanied by a decrease in social and physical activities alongside coronary heart disease cancer and cardiovascular diseases depression is a major public health problem that has become a common chronic disease in older adults depression symptoms greatly influence both physical and cognitive functioning of older adults longitudinal studies have reported that depressive symptoms are connected to functional decline as determined by both selfreported and objective measures of physical performance they also contribute to limitation of basic activities of daily living in high functioning older adults initially free from disability as depression deepens and more symptoms surface the likelihood of becoming disabled increases moreover depressive symptoms may accelerate the disablement process in older adults already exhibiting early signs of disability and individuals with chronic depressive symptoms have greater declines in functioning compared to those who remained nondepressed latelife depression is also associated with an increased risk of decline in cognitive functioning older adults with depression are more likely to have concomitant cognitive deficits especially executive cognitive functioning deficits or are subsequently more likely to develop dementia older adults with depression often develop cognitive impairment following onset of depression thus depression might be a risk factor or an early symptom of dementia one of the risk indicators for depression is lack of social support and social networks many of depressed older adults are also lonely and a correlation has been found between depression and loneliness depression with feelings of loneliness leads to more pronounced motivational depletion and serious consequences including social isolation reduced selfcare decreased mobility and poor diet participants reported loneliness feelings in the week prior to the interview the loneliest group was that of age 75 women reported higher levels of loneliness than men as did arabs compared with jews today loneliness is also perceived as a biological structure similar to hunger thirst or pain which are internal mechanisms activating behavior that prevents harm to the person hunger makes us seek food loneliness prompts us to seek social relationships correlations have been reported between the feeling of loneliness and several physical health problems cardiovascular diseases chronic diseases cancer stroke high blood pressure and mental illness low levels of emotional wellbeing and a high level of suicidal thoughts the problems caused by loneliness lead to decreased quality of life increased mortality poor recovery from illness and high hospitalization rates among older adults depression in older adults may result from a variety of reasons apart from loneliness feelings including malnutrition some studies have reported a strong and independent association between nutritional deficit and depression demonstrating that depression increased the risk of impaired nutritional status whereas others have shown a modest association or no association significantly over 10 of adults with depression residing in the united states also suffer from malnutrition malnutrition impacts quality of life by undermining individual autonomy to perform necessary instrumental and social activities of daily living malnutrition is defined as a state in which a deficiency excess or imbalance of energy protein and other nutrients causes measurable adverse effects on tissuebody form function and clinical outcome it is more prevalent and increases among older adults although malnutritions etiology is multifactorial adverse physiological psychological and social causes of malnutrition in older adults are consistently reported in the literature aging is accompanied by physiologic changes that can negatively impact nutritional status sensory impairment may result in reduced appetite and poor oral health and dental problems can lead to difficulty chewing inflammation and a monotonous diet that is poor in quality the progressive loss of vision and hearing may also limit mobility and affect the elderlys ability to shop for food and prepare meals along with physiologic changes older adults may also experience profound psychosocial and social changes contributing to poor nutritional status these include cognitive impairment heavy use of medication periods of lengthy hospitalization isolation retirement from paid work bereavement increasing frailty and loneliness and depression these factors influence the ability of older adults to meet dietary needs or to digest absorb utilize or excrete nutrients that are ingested the outcome is reduced energy intake and lean body mass resulting in a reduced metabolic rate and a proportional decline in total energy expenditure that may lead to malnutrition apart from the possible direct connection between loneliness feelings and depressive symptoms loneliness feelings can have widespread implications for the mental and social lives of older adults and these implications can explain some of the effects of loneliness feelings on depressive symptoms specifically one mediator might be at play malnutrition the current study the current study was conducted in israel in 2020 during a covid19 pandemic quarantine providing a unique opportunity to assess the effect of loneliness feelings on depressive symptoms mediated by malnutrition among older adults from different cultures during a particularly stressful period we posited three hypotheses 1 loneliness feelings due to the covid19 pandemic is associated with depressive symptoms 2 loneliness feelings due to the covid19 pandemic are indirectly associated with depressive symptoms through malnutrition older adults feeling lonely will report higher levels of malnutrition which will be associated with increased depressive symptoms 3 loneliness feelings depressive symptoms and malnutrition levels will differ between older adults from different cultures as a result of covid19 imposed quarantines method study design and participants the research employed a crosssectional study of a convenience sample of 201 jewish and arab older adults aged 65 and over representing the two main ethnic groups living in israel inclusion criteria were age 65 and over and the ability to speak and understand hebrew or arabic procedure the study was approved by the research ethics committee of the college at which the research took place recruitment of participants was random and the final sample comprised 100 jews and 101 arabs researchers explained the study objectives and procedure to the participants including their right to withdraw freely at any time strict confidentiality was maintained data collection was performed by professional interviewers through telephone interviews adhering to covid19 quarantine restrictions using appropriate translated validated and structured questionnaires data collection took place from april to may 2020 measures independent variable loneliness loneliness was measured by a single direct question «do you sometimes feel lonely» with four options never seldom sometimes often dependent variable depressive symptoms depressive symptoms were measured by the geriatrics depression scale developed by yesavage and brink the purpose of the questionnaire was to determine participants depressive symptoms by using a simple and reliable tool that does not require the time and skills of a professional interviewer the tool is composed of 15 items in a yes no response formats mediator malnutrition malnutrition was measured by the determine nutrition screening initiative developed jointly by the american diabetes association the american family doctors association and the national council of old age the purpose of the questionnaire was to detect older adults at risk for malnutrition the tool is composed of 10 items in a yes no response format covariates the study controlled for socioeconomic variables background variables included gender age marital status and years of education age and years of education were both defined as continuous measures gender was coded as dichotomous marital status was coded as with partner 1 or without a partner 0 all instruments were translated into hebrew and arabic by bilingual translators the complete questionnaire underwent a pilot test the questionnaire took approximately 15 minutes to complete the verbal instructions were comprehensible and there was no need for further changes before administering the questionnaire data analyses descriptive statistics were employed to calculate the means and standard deviations of the continuous variables and the percentage and frequency of the categorical variables in the second stage bivariate analyses were performed to examine the association between depressive symptoms and the independent variable mediator variable and socioeconomic variable using an independent ttest oneway anova pearson or spearman correlation tests mediation analyses were then computed in which the selected mediator was entered to test the components of the mediation model using the bootstrapping method to assess the indirect effects of the mediation model thus the meditation model was examined by directly testing the significance of the indirect effect of the independent variable on the dependent variable through the mediator while controlling for background variables that were identified earlier as significant in the bivariate analyses this method is based on regression analysis calculating the direct effect total effect and indirect effects of an independent variable on a dependent variable the total and specific indirect effects were calculated through bootstrapping set at 5000 samples confidence intervals were calculated using this method by sorting the lowest to highest of these 5000 samples of the original dataset yielding a 95percentile confidence interval all analyses were run using spss 250 with the process statistical program all estimated effects reported by process are unstandardized regression coefficients results of the participants 105 were women and 96 were men ranging in age from 65 to 95 years of education ranged from 6 to 21 and 711 had a partner the group had equal numbers of arab and jewish participants there were significant differences based on ethnicity with regard to education with jewish participants reporting more years of education than arab participants the cohens effect size value was high arab participants reported a significantly higher level than jewish participants of loneliness malnutrition and depressive symptoms for most variables the cohens effect size values were relatively high table 2 presents the bivariate tests between the study variables with depressive symptoms as the dependent variable results revealed that all demographic variables except for gender and marital status were significantly related to depressive symptoms advanced age was positively correlated with depressive symptoms lower educational level was correlated with higher reported depressive symptoms an ethnic difference in depressive symptoms was also found with arab participants reporting higher depressive symptoms than jewish participants both the independent and mediator variables were significantly related to the dependent variabledepressive symptoms high malnutrition and high loneliness were positively associated with depressive symptoms the mediation analyses using process model 4 we tested hypotheses two and three whether malnutrition mediated the relationship between loneliness feelings and depressive symptoms controlling for covariates the results indicated a significant total direct effect of loneliness feelings on depressive symptoms a significant direct effect and a significant indirect effect through malnutrition the results also showed that loneliness feelings were associated with higher malnutrition scores and that malnutrition was positively associated with depressive symptoms finally ethnicity was associated with depressive symptoms however no significant associations were found between depressive symptoms and the other covariates gender age education and marital status discussion the general purpose of this study was to examine the extent to which loneliness feelings are connected with depressive symptoms of older adults from different cultures during isolation by conducting research during a covid19 pandemic quarantine in israel we measured whether older adults who suffered from higher degrees of loneliness feelings due to the covid19 quarantine had higher levels of depressive symptoms and what potentially accounted for this association the findings confirmed the first hypothesis that older adults suffering from a high degree of loneliness feelings suffer from higher levels of depressive symptoms these results are consistent with other studies executed before and during the covid19 pandemic reporting that loneliness feelings are associated with mental wellbeing the mediation model confirmed the second hypothesis that the connection between loneliness feelings and depressive symptoms is accounted for by level of malnutrition the association between loneliness feelings depressive symptoms and level of malnutrition can be explained by two different aspects dietary behavior and the influence nutrition has on depressive symptoms with regard to dietary behavior loneliness feelings may affect appetite and nutrient intake through a decline in mood physical functioning or cognition these various declines combine with the difficulty people have eating alone appetite can be further inhibited by changes in social status particularly when older adults experience loneliness andor bereavement due to loss of a spouse or friends of the same agegroup eating in the company of others can help prevent malnutrition it increases caloric intake and is related to healthier food habits and maintains the motivation of older adults to eat and cook providing them with opportunities for social interaction and connectedness the current study took place during a covid19 quarantine when older adults as a highrisk group were counseled to stay at home with their permanent partners only and to avoid as much as possible from going shopping and to depend on home deliveries hence it is likely that older adults were forced not only to eat alone but to be alone most of the time resulting in insufficient food intake and consequently malnutrition the second aspect concerns the connection between depression and the diet of older adults recent studies have suggested that depressive symptoms are more prevalent in individuals with impaired nutritional status than in other older patients it has been observed that individuals with specific nutritional deficiencies such as lack of folic acid and vitamin b12 as well as antioxidant vitamins had more depressive symptoms than those with normal nutritional status the mechanism that might be at work here is that older adults who suffer from loneliness feelings tend to eat less and lack a healthy appetite and for that reason they will not consume all the nutrients they need and will suffer from malnutrition or depressive symptoms this mechanism accelerates during a quarantine when even older adults who do not suffer from loneliness ordinarily suffer from isolation the third study hypothesis was that research variable levels will differ between cultures particularly due to the extremity of the covid19 quarantine indeed arab older adults reported greater loneliness feelings higher level depressive symptoms and greater malnutrition compared to the jewish older adults the results with regard to depressive symptoms are consistent with studies reporting that being a member of an ethnic or racial minority is a risk factor for depression specifically arab respondents have reported higher depressive symptoms than jewish respondents however there are also contradictory results concerning the higher levels of loneliness and malnutrition the covid19 quarantine may have posed new challenges to the arab study participants that explain the study findings arab society in israel is known for family consolidation and solidarity the extended family maintains a multigenerational structure with grown children obligated to filial piety responsibilities the covid19 quarantine forced new ways of communication upon family members exposing the absence of digital literacy among arab older adults for arab older adults internet use does not protect against loneliness moreover the extended family often lives together with the daughters and daughtersinlaw cooking and serving the older adults the quarantine isolated the arab older adults from their extended family resulting in reduced help with cooking and serving meals moreover the strong connection between feeling loneliness and malnutrition cited above amplified the problem conclusion and implications the present study was executed during a covid19 pandemic quarantine the results indicate that there is a connection between loneliness feelings depressive symptoms and malnutrition the primary conclusion is that loneliness feelings are a serious problem facing all older adults since they negatively affect both depressive symptoms and malnutrition in order to overcome these feelings it is important to connect older adults to social network technologies and teach them how to use these technologies families can also receive guidance for meeting while maintaining social distancing another option is to encourage neighbors in the same building to talk to each other and find ways for mutual support research indicates that members of the arab society in israel are a highrisk group and much more vulnerable to loneliness feelings depressive symptoms and malnutrition in times of crisis such as the covid19 pandemic the lives of many arab older adults changed from being surrounded and supported by their extended family to being alone during the quarantine and to suffering from malnutrition in order to fight these two related outcomes one possible solution is to provide psychologicalnutrition intervention by telephone this would provide by missing human contact and nutrition guidelines and encouragement to cook and eat healthier foods we should point out three main limitations of the current study one is the crosssectional study design which does not allow for prediction of a causal relationship between the variables a future study should use longitudinal data to examine the relationship between loneliness feelings and depressive symptoms a further limitation might be the use of only one question concerning loneliness feelings however previous studies have also used one question in order to describe loneliness feelings third a generalization of the findings is limited because the sample and the sampling procedure do not guarantee the representativeness of jewish and arab older adults the sample was conducted by telephone and included only older adults who answered the telephone at that moment those who did not answer or did not have a telephone are not represented in this study these various factors may have biased the results despite these limitations the present study provides initial insights into the mechanisms of the association between loneliness feelings malnutrition and depressive symptoms during periods of quarantine imposed isolation conflict of interest statement the author declared no potential conflicts of interest with respect to the research authorship andor publication of this article ethical standards the number of the approval from tel hai college is 320205 | research on loneliness conducted in different countries has demonstrated that it is a common universal phenomenon although its prevalence varies between societies and cultures 11 in the united states more than 19 of older adults aged 65 and older reported loneliness feelings 12 in australia the comparable figure was 40 13 in a study of loneliness in israel 14 it was found that nearly half 47 |
Introduction
There are disagreements about, and contradictory indications of, the state of qualitative inquiry as a global endeavour. Denzin , for example, argues that qualitative inquiry faces a global onslaught from conservative and neo-liberal critics, especially in the field of educational research, and especially in the United States following the writing into legislation of the requirement for federal educational research funding to be allocated to so-called 'scientific' research . 'Scientific' research has been extensively defined in US legislation, and includes reference to "measurements or observational methods that provide reliable and valid data across evaluators and observers… evaluated using experimental or quasi experimental designs…with a preference for random assignment experiments…" ). The argument of critics is that qualitative research is not scientific, or not scientific enough, and cannot produce definitive evidence about 'what works' in social policy interventions. Qualitative research produces too many disconnected, non-cumulative studies that do not provide convincing evidence for central education, health, business and so forth . A key point that Atklinson and Delamont make is that qualitative research is still widely funded in countries such as the UK paper for the UK Department of Education, the terms of the debate may be changing in the UK). Delamont and Atkinson also note the development of a number of successful interdisciplinary journals in the field along with increases in the numbers of issues per year of these journals and thus the numbers of papers published. They also note the continuously expanding market for qualitative research methods texts and sourcebooks such as Sage Handbooks and Major Works, not least Denzin and Lincoln's Handbook of Qualitative Research, now in its fourth edition .
There are some disagreements in the field then, in some respects representing different interpretations of the prospects for qualitative inquiry in the USA and the UK. However, what I want to argue in this paper is that these disagreements rather miss the point. The issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding and policy attention in diverse countries around the world, but rather to what purposes are qualitative methods being put? What research agendas are being pursued, and who sets them? It is clear that qualitative methods are indeed being taken up widely across regions and disciplines, with the scale and scope of the annual International Congress of Qualitative Inquiry from which this special issue derives being part of the positive evidence. It is also undeniable that, internationally, social research in general, qualitative approaches to social and educational research in particular, have been under very specific attack for fifteen year or more . Criticism is manifested in different ways, and with different levels of severity, in different countries and different disciplines. The pressure derives from concerns about the quality and the utility of social and educational research more generally, not just concerns about qualitative approaches . It also derives from an increased government focus on value-for-money in research, and how social research might better serve social policy .
Qualitative methods of inquiry can be seen to play to this policy and utility agenda as much as to a social justice agenda, or indeed a disinterested scientific agenda. Qualitative methods can be deployed in policy-driven research as well as in more open-ended inquiry, and thus may survive and even prosper, but not necessarily in ways that all qualitative researchers will welcome. Researchers and evaluators in many applied research fields including health care and education have noted the reduced timescales now associated with qualitative work, and the narrowness of many research agendas being pursued . This is also the case in what we might term the more traditional disciplines of anthropology and sociology. Mills and Radcliffe report on the increasingly truncated timescales for anthropological fieldwork and the use of a more limited range of ethnographic methods among 'freelance development consultants ' and in development agencies such as the World Bank. Thus while it can be argued that qualitative research remains widely supported, the form that such research takes might be said to be somewhat limited, and even of poor quality, given arguments for exploratory and extensive field immersion that are apparent in many ethnographic textbooks.
Such an orientation towards the use of qualitative methods is apparent in a range of policy development settings and intervention agencies. Thus for example, Valerie Caracelli , writing from the perspective of the US Government Accountability Office, argues for the inclusion of qualitative methods in evaluation studies "to assure contextual understanding" . She states that:
Recently, there has been an acknowledgement about how ethnographic studies can inform agency actions and how it can be used to study culture in organisations .
However whether truncated timescales and narrow policy agendas can be easily reconciled with the theory and practice of 'ethnographic studies' is a moot point. Moreover studying 'culture in organisations', in order to 'inform agency actions' seems to suggest the utilization of qualitative inquiry as as technology of government, rather than as an approach to understanding emergent issues that policy may not want to address.
A recent UK Cabinet Office report produced in the context of the move toward evidenceinformed policy and practice presented guidelines for judging the quality of qualitative approaches and methods. Interestingly, one of the key quotes in the report used to justify the use of qualitative methods comes not from the epistemological or methodological literature, but from a civil servant, a government department "research manager": I often commission qualitative research when it's about users or stakeholders and . . . It is in this context of the potential co-option of qualitative inquiry to the agendas of policy that I want to focus on a particular sub-issue of this wider debate: that of research selectivity and concentration in the UK and its implications for qualitative research methods.
Significant changes are being enacted in the UK, with regard to university finance, governance and the nature of scholarly activity, that carry potentially very severe implications for the practice of social research in general, and for qualitative approaches to research in particular. There is an argument that social research is increasingly being nationalised and corporatized in the UK -seen by many social researchers as well as policymakers as an arm of government and more important to universities for its incomegenerating potential than for its contribution to knowledge and the public good. Thus arguments about whether or not qualitative approaches to research remain popular are rather irrelevant. What is at stake is the legitimacy and quality of the research which is being undertaken, and the purposes to which it is being put. As noted above, policymakers, and some social science scholars themselves, have argued that social and educational research, particularly qualitative research, is too often conceived and conducted as a small scale 'cottage industry', producing too many small scale, non-cumulative studies which do not provide firm evidence for decision-making. It is axiomatic to such criticisms that providing evidence for policymaking is indeed the proper role for social science.
Additionally, governments around the world are seeking better value for money from their investment in research and university teaching, and this has involved restricting and focusing resource allocation. Selectivity and concentration of research resources are particularly being pursued in the UK. The Conservative dominated coalition government is cutting public spending in the wake of the 2008 banking crisis and global recession; so there are fewer resources available for research than might otherwise have been the case, and selectivity and concentration have become even more severe in the UK over the last couple of years. Concentration of research is effected both through focused core allocations from the higher education funding agencies and through highly competitive bidding to research councils and foundations as described below. Success leads to further success and to relatively few universities securing the overwhelming majority of available funding. This in turn produces the issue of universities seeking research funding first and foremost for their own corporate survival, rather than for the public benefits that may accrue. It also leads to social research becoming part of a nationalized approach to managing national social problems, rather than being part of an international community pursuing better understanding of the nature of social problems and what produces them.
Funding agencies and individual universities are now concentrating resources on fewer research units and programs, and are taking decisions to develop a 'big science' model of social science. This is being pursued by funders supporting fewer, larger projects, with explicit policy encouragement for researchers to develop cross-institutional, mixed method approaches, to address the supposedly 'big issues' of our time: health and well being, an aging population, sustainable growth, and so forth. These issues are indeed important, and research evidence should be produced to interrogate and inform public debate. But such issues are being presented as part of a common-sense, taken-for-granted trade-off of government funding in exchange for social scientists serving policy. Critique, diversity of perspective, and the insight into complexity which detailed qualitative studies can provide are potentially being marginalized. Social science is being reconceptualised as a technical service to government rather than developed as a democratic intellectual resource for the community.
The remainder of the paper will provide some brief illustrative examples of policy initiatives and how this change is being accomplished.
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Funding universities
University policy and funding is located in the UK government department of Business, Innovation and Skills -evidence in itself of where government priorities lie.
Universities are not housed in the Department for Education . A recent BIS White Paper stated quite clearly that "we intend to maximize the impact of our research base on economic growth" . It went on:
To compete effectively the UK must harness its strengths in…research…and its expertise in areas such as design and behavioural science… .
In essence the White Paper argues that investment in research should be oriented to those areas that promise most economic return, with "behavioural science" being deployed to understand and change people's behaviour in relation to key threats to economic development such as poor health and global security. Moreover the White Paper goes on to assert that major social and economic challenges "can only be resolved through interdisciplinary collaboration" and thus government will "actively support strong collaborations" across disciplines and institutions. Research, including social research, will be marshaled and directed in the national economic interest.
Such policy discourse then sets the tone for the activities of intermediary agencies such as research funding councils and individual universities. While individual research councils can set their own agenda, their budgets derive from government are unlikely to stray too far from policy imperatives. Similarly universities, while independent, must compete for specific forms of funding under common national rules and thus common institutional structures of research prioritization, monitoring and compliance emerge across institutions. The research allocation which universities receive from the Higher Education Funding Council is based on quality ratings derived from an accountability exercise originally called the Research Assessment Exercise , and now known in its current iteration as the Research Excellence Framework . As a result of these exercises funding has become highly concentrated in historically elite institutions, with, for example, only four universities receiving 32% of all HEFC research funding in 2009-10, and 25 universities receiving 75% of funding . Of course it might be argued that not receiving such funding is not necessarily such a bad thing, since it leaves the majority of universities outside the mainstream funding agenda and thus outside this particular mechanism of government control. However the mainstream agenda remains dominant since university managers simply cannot ignore it. Some research success, however small, is regarded as better than none, especially with respect to the reputational gains associated with research activity and associated student fee income. For all practical purposes, when it comes to research funding in the UK, the REF is the only game in town.
Clearly, this level of selectivity begs serious issues for university finance, management and The pursuit and measurement of 'Impact' is likely to drive research activity further towards applied and policy-oriented research. Moreover the pursuit of specific research tenders and contracts is also likely to be increasingly emphasized by individual universities, as noted above, both to fill gaps in core funding left by increasing selectivity and concentration, and to maximize the metrics available for the 'Environment' element of the profile. So this element of core research funding, derived from the Higher Education Funding Council, which is intended to provide the underpinning platform for basic university research, is becoming increasingly selective and concentrated, and is now being significantly oriented towards applied rather than basic research. Thus while, technically, the agenda for this research activity remains under the control of individual scholars and research groups, increasingly they need to think about developing research programs which fit with government, university and departmental priorities, in order to maximize quality gradings and income. In turn universities and departments are developing strategies and programs to manage the REF accountability procedures, and research impact and environment issues more generally, such that research is becoming an increasingly planned, bureaucratized and managed activity. Ironically, given the current emphasis in some quarters on the 'gold standard' of scientific method, university research is ceasing to be scientific in the sense of the disinterested pursuit of knowledge and becoming a corporate, commercial activity undertaken on behalf of individual universities themselves and their financial survival. In turn, the social relations of research within universities and departments are changing.
It might of course be argued that 'twas ever thus' -universities have always had to fund their activities and individual scholars and research groups have always had to manage and mediate the relationship between funding opportunities and the research that they think is important to design and undertake. My argument is that this balance of calculation is under severe pressure in the UK at the present time -both with respect to the overall funding available and with respect to the position of qualitative research activity within this funding environment. It might be further argued that this balance should change, and that the pursuit of more applied policy-oriented research should be undertaken; a second paper could be written about the issues at stake and the arguments deployed. My point for moment however, is simply that such change does indeed seem to be occurring.
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Funding social science
Still, to reiterate, in principle the research agenda pursued with this funding regime remains under the control of faculty and research groups. However, another irony of the current situation in the UK is that, if anything, the funding strategy of the research council -the Economic and Social Research Council -further compounds the problem rather than providing any sort of counter weight. In principle the ESRC is an 'arms length' body, independent of government, allocating awards for excellent social science research in response to competitive bids refereed by peer review. It might be thought, therefore, that the ESRC's agenda would reflect the research agenda of the social scientific community as a whole. However all research council funding derives from government and as such is clearly influenced by government priorities; the ESRC is no exception. The ESRC shapes the content of the social science research agenda much more directly than government policy, but does so in large part, because its funds derive from government. Again, of course, there are many intermediary processes and activities, with ESRC officials seeking to maximize funding available in difficult times, in return for responding to government priorities. Likewise peers review proposals on merit but these proposals have already been produced in response to priority areas and specific funding calls.
The ESRC works within the context of an overarching cross-research council strategy. There are seven research councils in the UK, distributing funds across the natural and social sciences, humanities, and medicine. Each council has become progressively more managerial over recent years, not simply responding to bids from the scholarly community for funding, but actively shaping the agenda around which bids can be made -establishing priorities and issuing specific calls for proposals, as noted above. The assumptions embedded in this statement of strategy reflect the development of an institution which sees itself governing social science rather than supporting it -defining priorities, selecting "future leaders" and concentrating PhD training in a few selected centres so that those leaders are in any case selected from an increasingly narrow institutional and intellectual base. The use of the term "training" for the development of future scholars also seems indicative of a directive rather than a supportive role. The "Deliver Plan" goes on to address this specifically and states:
We will develop national capability through: …Broadening the skill of all social science PhD students by emphasizing transferable skills training…We will require institutions to provide training on core topics such as impact, public engagement and media training…to ensure the continuing pipeline of excellent researchers for the Nation .
The Strategic Plan and Delivery Plan also identify a need for the longer, larger projects to be interdisciplinary and involve cross-institutional collaborations which are defined as "essential in studying and resolving complex challenges" . In effect social science is being re-conceived and re-structured as the "behavioural science" arm of government, so that social science can 'influence behavior and inform interventions'.
It might be argued that because ESRC's budget and level of activity is very small when compared with overall funding for social science in the UK, its influence will be similarly small. The ESRC budget is c. £166M in 2014/15 . The total 'science' budget for UK higher education is £4.6B . Detailed breakdowns between different natural and social science allocations are difficult to identify but it is likely that ESRC does not fund more than 10% of overall social science teaching and research activity including that supported from student fees. Thus, again, there is a case for suggesting that most UK social science research is beyond the reach of ESRC and, in turn, government policy agendas. But, as with the REF, influence far exceeds scale of activity, as universities and research groups seek to bid for research council funding despite success rates dipping well below 20%, and develop postgraduate training activities to mirror ESRC provision so that they are not excluded from future funding possibilities. Nevertheless further concentration of funding might be construed as an opportunity as well as a challenge for qualitative social research, to reach out to community support and other forms of charitable, foundation and European Union funding. An interestingly critical issue for the current policy of selectivity concentration is at what point might the nationally state-supported funding base shrink so low that the research council's influence over the sector as a whole will disappear? Furthermore, there is a separate paper to be written about whether or not, and if so in what ways, social science should develop so that it can 'influence behavior and inform interventions' on behalf of government. Many would argue that social science should engage more directly with the public and help to inform democratic debate and decision-making, though such activity is not necessarily co-terminous with simply acting in response to and in support of government policy .
Likewise, with respect to the content of research 'training', some would point to statistics indicating that only around 20% of research council supported research students secure academic posts in universities and thus a wider training in 'employability' is important . Yet by the same token the statistics indicate that 80% go on to work in researchrelated and more general administrative, teaching and managerial roles in other public sector, charitable and commercial organisations. If these figures are accurate then not only is such a problem not the responsibility of ESRC to solve, it is not actually a problem at all, since PhD graduates are already securing employment outside academia and the influence of social science training could be said to be extending well beyond university departments. In fact students often value these broader elements of their doctoral programs as academic employment opportunities are so limited. Nevertheless time spent on 'public engagement' and 'media training' is time not spent on fieldwork and data analysis -the core of any qualitative research training. These matters are not necessarily clear-cut, but my point for the moment is simply that these developments are shaping social science in general in the UK at the present time, qualitative educational and social research in particular.
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Short term consequences and implications
The first and most obvious consequence is that relatively small scale funding to undertake specific qualitative and case study-type work is no longer available from ESRC. Hitherto ESRC ran a specific 'small grant' scheme which was able to accommodate small scale exploratory investigations, pilot projects and post-doc projects from early career researchers. It was particularly suitable for supporting individual scholars to undertake detailed case study work over the period of a year or eighteen months, by 'buying their time' to concentrate on research for short periods; and of course because the grants were small, more could be funded. In the absence of knowing in advance which project would show most theoretical and empirical advance, funding more small scale projects seems sensible. This support is no longer available. The smallest 'open call' grant now available is £200K -still modest by international standards -but substantial enough to indicate that a larger scale mixed methods approach would be more likely to win funding when evaluated against 'value-for-money' criteria. Additionally ESRC used to support a 'first grant' scheme, which was similarly oriented, as the name implies, towards early career researchers who, again, often applied for small scale funding for qualitative work. This Thus qualitative work must now be conceived and proposed either in terms of much larger scale longitudinal ethnographic investigations , or as part of a large scale, cross disciplinary and cross-institutional mixed methods research design. Again, involvement in such work is no bad thing, and no doubt will contribute to the continuing popularity which Delamont andAtkinson claim for qualitative methods in the UK, but it should not be the only qualitative research that secures support. Moreover, when such large scale investigations are only funded because government wants to 'influence behavior and inform interventions', be they mixed method or ethnographic, and perhaps especially when they are ethnographic, then they beg many questions about the legitimate role of social science in a democracy. As noted above, qualitative research 'is a wonderful vehicle if you want to understand the motives of people'.
The key issues here comprise both the scale of endeavour now expected, and the control of the research agenda. Social scientists are being positioned, by government and by some leading members of the social science community as experts in social policy whose function is to respond to social problems. Again, social science should indeed be prepared to respond to social issues, but not to the exclusion of critical social inquiry. Furthermore the 'expertise' of the community depends on what we might term a hinterland of basic social theory and social research. From this hinterland expertise can be drawn and framed in response to particular issues -the move from basic to applied research. But if social science can only now act in relation to prescribed issues, problems and large scale empirical research designs then, over time, it will lose the ability to construct its objects of study independent of the context of inquiry. It will in effect cease to be social science in any meaningful sense.
With respect to the social relations of research, opportunities for early and mid career social scientists to develop their own intellectual trajectories are likely to decrease as areas of strategic investment are defined by funding agencies. Moreover large scale grants are likely only to be awarded to senior researchers who have a track record of managing and 'delivering' on previously funded work. Thus early career researchers must now attend to bidding for research grants, especially in areas of applied research, and look to secure collaborative funding with more senior colleagues. This is now a core feature of any social science career. Developing scholars must also become able to design impact strategies and build networks, including with policymakers as well as other scholars, in order to become included in collaborative research designs. In effect involvement in social research is being reconstructed as a technical and professional career, and indeed a quasi-governmental career, rather than as a contribution to science, or as an independent and critical service to the community and the democratic process. The very nature of the purposes and practices of social research is being changed.
My argument is not that that these matters are entirely novel or uncontentious. Social science has had an uneasy relationship with government funding for many years . Similarly, outcomes are not easily determined.
There are many mediating interpretations, actions and institutional processes between grandiose policy documents, often written first and foremost to secure funding rather than control it, and the activities of individual researchers and research groups. Yet the material and discursive context of interpretation and mediation means the direction of travel becomes ever more difficult to resist. Nor is my argument that none of these things should be happening; to reiterate, universities, research groups and individual scholars have always had to fund their work and certainly should be responsive to the needs of social policy development. However, responsiveness to policy and to wider contexts of action should take their proper place in the overall career trajectories of social researchers and scholars more generally. Intellectual curiosity, about how society operates and with what effects and consequences for individuals and social groups, must remain the driving force of social science and scholarly activity. Otherwise it simply becomes a technology in service of government, rather than an independent and critical intellectual resource for democratic debate.
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Longer term trends and prospects
A more general issue is whether or not the social science community is right to accept that proximity to government will necessarily ensure its sustainability. Part of the backcloth to the current debate is the uncertain status and legitimacy of both science and government at the present time. Government, and the process of mainstream electoral politics, is itself generally unpopular and under pressure 'to deliver', especially with respect to economic competence and with regard to the provision of public services. Can we always assume the benign intent and impact of government? What reasons are there for state intervention in the lives of ordinary citizens? How appropriate is it for social research to attempt to 'influence behaviour and inform interventions'? It is at least arguable that government intervention can dis-empower communities, and it certainly locates agency in government and professional bureaucracies, including those of social science, rather than local communities. A different approach would involve social research helping to build communities' capacities to develop themselves, rather than simply providing evidence for central policymaking and the development and evaluation of government intervention programs. In this respect it may be the case that deriving legitimacy for social research from proximity to government is self-defeating. Such a strategy links social research to an inherently unpopular institution and at one and the same compromises the basic claim for the legitimacy of science -that of disinterested inquiry. Of course many qualitative researchers also want to pursue a social justice agenda, not just a social scientific agenda. But here too, collaborating with local organisations, institutions and communities, rather than government, would seem to hold much more promise with respect to both the quality of the research and its potential 'impact' on social and economic life.
A second element of an alternative approach to the further development of qualitative research must be to maintain involvement in international networks and debates, and resist attempts to render qualitative research into a parochial set of research techniques to be pursued in the national interest. The use of qualitative research methods has a long and distinguished history in education and the social sciences. Discussions of qualitative methodology have been at the forefront of many decades of debate over whether, and if so in what ways, we can conduct enquiry and build knowledge in the social sciences. It might even be argued that it is qualitative methods, or perhaps, more generally, a qualitative sensibility and approach, that constantly questions the development of social research as a technology.
The strengths of qualitative research are at their most manifest when used to address both the substantive topic under investigation and the way in which that topic is constituted and realised in action by the social processes at play. The phenomenon under study is not simply taken as given.
Thus local activity and development can draw intellectual sustenance from global debates. A key strength of a qualitative approaches to social research is face-to-face engagement with participants. This must be maintained as both an ethical and political strength, as well as an epistemological strength. Many recent international discussions of quality in qualitative research revolve around issues of engagement, deliberation, ethical process and responsiveness to participant agendas, along with the need to maintain a critical perspective on both the topic at hand and the power of particular forms of knowledge . It is these strengths of a qualitative approach that should be privileged in any discussion of their inclusion larger scale social research activities, not in order to 'influence behaviour' but in order to maximise the possibilities for the democratic development of research procedures. If research is to serve the periphery as much as the centre, in political debate and decisionmaking, then engagement of research participants in both setting the research agenda and evaluating the outcomes of the process must be developed as central to the future development of social research methodology. | There are disagreements about, and contradictory indications of, the state of qualitative inquiry as a global endeavour. The paper argues that these disagreements rather miss the point. The issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding, but rather to what purposes are qualitative methods being put? What research agendas are being pursued, and who sets them? The paper illustrates these issues with respect to the effects of research selectivity and concentration in the UK and argues that qualitative research should continue to develop as an iuntellectual resource for the community rather than as a technical service to government. policy-making. What is required is the 'gold standard' of randomised controlled trials (RCTs) for establishing cause and effect in social programs. Such criticism is not confined to the USA. In a speech to the UK's Economic and Social Research Council in 2000, titled "Influence or Irrelevance" the then Secretary of State for Education, David Blunkett (2000), asserted that Many feel that too much social science research is inward-looking, too piecemeal, rather than helping to build knowledge in a cumulative way, and fails to focus on the key issues of concern to policy-makers, practitioners and the public (p.1). More recently, similar arguments have arisen once again in a paper from the UK Department for Education. In language paralleling the US debate, the paper asserts that randomized assignment of treatment to samples is the most appropriate way to conduct research in general, educational research in particular, and that more experimental research should be undertaken in education, specifically via RCTs (Goldacre 2013). Such criticisms combine critique of methods employed, with critique of purposes pursued, arguing that social research in general, qualitative approaches to social and educational research in particular, are not responsive enough to the needs of government. So significant challenges to qualitative inquiry are apparent, but others are more cautious in their assessment of these challenges. Fielding (2010) for example shares Denzin's concerns with respect to 'the dirigisme and anti-intellectualism of the gold standards lobby' (p.127) but notes that circumstances vary internationally and that threats to qualitative research should not simply be read from a North American perspective. Others still, argue that qualitative inquiry is healthy, diverse and growing, both geographically in terms of its global reach, and in terms of its diffusion across disciplines and across applied research fields such as | 1 | introduction there are disagreements about and contradictory indications of the state of qualitative inquiry as a global endeavour denzin for example argues that qualitative inquiry faces a global onslaught from conservative and neoliberal critics especially in the field of educational research and especially in the united states following the writing into legislation of the requirement for federal educational research funding to be allocated to socalled scientific research scientific research has been extensively defined in us legislation and includes reference to measurements or observational methods that provide reliable and valid data across evaluators and observers… evaluated using experimental or quasi experimental designs…with a preference for random assignment experiments… the argument of critics is that qualitative research is not scientific or not scientific enough and cannot produce definitive evidence about what works in social policy interventions qualitative research produces too many disconnected noncumulative studies that do not provide convincing evidence for central education health business and so forth a key point that atklinson and delamont make is that qualitative research is still widely funded in countries such as the uk paper for the uk department of education the terms of the debate may be changing in the uk delamont and atkinson also note the development of a number of successful interdisciplinary journals in the field along with increases in the numbers of issues per year of these journals and thus the numbers of papers published they also note the continuously expanding market for qualitative research methods texts and sourcebooks such as sage handbooks and major works not least denzin and lincolns handbook of qualitative research now in its fourth edition there are some disagreements in the field then in some respects representing different interpretations of the prospects for qualitative inquiry in the usa and the uk however what i want to argue in this paper is that these disagreements rather miss the point the issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding and policy attention in diverse countries around the world but rather to what purposes are qualitative methods being put what research agendas are being pursued and who sets them it is clear that qualitative methods are indeed being taken up widely across regions and disciplines with the scale and scope of the annual international congress of qualitative inquiry from which this special issue derives being part of the positive evidence it is also undeniable that internationally social research in general qualitative approaches to social and educational research in particular have been under very specific attack for fifteen year or more criticism is manifested in different ways and with different levels of severity in different countries and different disciplines the pressure derives from concerns about the quality and the utility of social and educational research more generally not just concerns about qualitative approaches it also derives from an increased government focus on valueformoney in research and how social research might better serve social policy qualitative methods of inquiry can be seen to play to this policy and utility agenda as much as to a social justice agenda or indeed a disinterested scientific agenda qualitative methods can be deployed in policydriven research as well as in more openended inquiry and thus may survive and even prosper but not necessarily in ways that all qualitative researchers will welcome researchers and evaluators in many applied research fields including health care and education have noted the reduced timescales now associated with qualitative work and the narrowness of many research agendas being pursued this is also the case in what we might term the more traditional disciplines of anthropology and sociology mills and radcliffe report on the increasingly truncated timescales for anthropological fieldwork and the use of a more limited range of ethnographic methods among freelance development consultants and in development agencies such as the world bank thus while it can be argued that qualitative research remains widely supported the form that such research takes might be said to be somewhat limited and even of poor quality given arguments for exploratory and extensive field immersion that are apparent in many ethnographic textbooks such an orientation towards the use of qualitative methods is apparent in a range of policy development settings and intervention agencies thus for example valerie caracelli writing from the perspective of the us government accountability office argues for the inclusion of qualitative methods in evaluation studies to assure contextual understanding she states that recently there has been an acknowledgement about how ethnographic studies can inform agency actions and how it can be used to study culture in organisations however whether truncated timescales and narrow policy agendas can be easily reconciled with the theory and practice of ethnographic studies is a moot point moreover studying culture in organisations in order to inform agency actions seems to suggest the utilization of qualitative inquiry as as technology of government rather than as an approach to understanding emergent issues that policy may not want to address a recent uk cabinet office report produced in the context of the move toward evidenceinformed policy and practice presented guidelines for judging the quality of qualitative approaches and methods interestingly one of the key quotes in the report used to justify the use of qualitative methods comes not from the epistemological or methodological literature but from a civil servant a government department research manager i often commission qualitative research when its about users or stakeholders and it is in this context of the potential cooption of qualitative inquiry to the agendas of policy that i want to focus on a particular subissue of this wider debate that of research selectivity and concentration in the uk and its implications for qualitative research methods significant changes are being enacted in the uk with regard to university finance governance and the nature of scholarly activity that carry potentially very severe implications for the practice of social research in general and for qualitative approaches to research in particular there is an argument that social research is increasingly being nationalised and corporatized in the uk seen by many social researchers as well as policymakers as an arm of government and more important to universities for its incomegenerating potential than for its contribution to knowledge and the public good thus arguments about whether or not qualitative approaches to research remain popular are rather irrelevant what is at stake is the legitimacy and quality of the research which is being undertaken and the purposes to which it is being put as noted above policymakers and some social science scholars themselves have argued that social and educational research particularly qualitative research is too often conceived and conducted as a small scale cottage industry producing too many small scale noncumulative studies which do not provide firm evidence for decisionmaking it is axiomatic to such criticisms that providing evidence for policymaking is indeed the proper role for social science additionally governments around the world are seeking better value for money from their investment in research and university teaching and this has involved restricting and focusing resource allocation selectivity and concentration of research resources are particularly being pursued in the uk the conservative dominated coalition government is cutting public spending in the wake of the 2008 banking crisis and global recession so there are fewer resources available for research than might otherwise have been the case and selectivity and concentration have become even more severe in the uk over the last couple of years concentration of research is effected both through focused core allocations from the higher education funding agencies and through highly competitive bidding to research councils and foundations as described below success leads to further success and to relatively few universities securing the overwhelming majority of available funding this in turn produces the issue of universities seeking research funding first and foremost for their own corporate survival rather than for the public benefits that may accrue it also leads to social research becoming part of a nationalized approach to managing national social problems rather than being part of an international community pursuing better understanding of the nature of social problems and what produces them funding agencies and individual universities are now concentrating resources on fewer research units and programs and are taking decisions to develop a big science model of social science this is being pursued by funders supporting fewer larger projects with explicit policy encouragement for researchers to develop crossinstitutional mixed method approaches to address the supposedly big issues of our time health and well being an aging population sustainable growth and so forth these issues are indeed important and research evidence should be produced to interrogate and inform public debate but such issues are being presented as part of a commonsense takenforgranted tradeoff of government funding in exchange for social scientists serving policy critique diversity of perspective and the insight into complexity which detailed qualitative studies can provide are potentially being marginalized social science is being reconceptualised as a technical service to government rather than developed as a democratic intellectual resource for the community the remainder of the paper will provide some brief illustrative examples of policy initiatives and how this change is being accomplished funding universities university policy and funding is located in the uk government department of business innovation and skills evidence in itself of where government priorities lie universities are not housed in the department for education a recent bis white paper stated quite clearly that we intend to maximize the impact of our research base on economic growth it went on to compete effectively the uk must harness its strengths in…research…and its expertise in areas such as design and behavioural science… in essence the white paper argues that investment in research should be oriented to those areas that promise most economic return with behavioural science being deployed to understand and change peoples behaviour in relation to key threats to economic development such as poor health and global security moreover the white paper goes on to assert that major social and economic challenges can only be resolved through interdisciplinary collaboration and thus government will actively support strong collaborations across disciplines and institutions research including social research will be marshaled and directed in the national economic interest such policy discourse then sets the tone for the activities of intermediary agencies such as research funding councils and individual universities while individual research councils can set their own agenda their budgets derive from government are unlikely to stray too far from policy imperatives similarly universities while independent must compete for specific forms of funding under common national rules and thus common institutional structures of research prioritization monitoring and compliance emerge across institutions the research allocation which universities receive from the higher education funding council is based on quality ratings derived from an accountability exercise originally called the research assessment exercise and now known in its current iteration as the research excellence framework as a result of these exercises funding has become highly concentrated in historically elite institutions with for example only four universities receiving 32 of all hefc research funding in 200910 and 25 universities receiving 75 of funding of course it might be argued that not receiving such funding is not necessarily such a bad thing since it leaves the majority of universities outside the mainstream funding agenda and thus outside this particular mechanism of government control however the mainstream agenda remains dominant since university managers simply cannot ignore it some research success however small is regarded as better than none especially with respect to the reputational gains associated with research activity and associated student fee income for all practical purposes when it comes to research funding in the uk the ref is the only game in town clearly this level of selectivity begs serious issues for university finance management and the pursuit and measurement of impact is likely to drive research activity further towards applied and policyoriented research moreover the pursuit of specific research tenders and contracts is also likely to be increasingly emphasized by individual universities as noted above both to fill gaps in core funding left by increasing selectivity and concentration and to maximize the metrics available for the environment element of the profile so this element of core research funding derived from the higher education funding council which is intended to provide the underpinning platform for basic university research is becoming increasingly selective and concentrated and is now being significantly oriented towards applied rather than basic research thus while technically the agenda for this research activity remains under the control of individual scholars and research groups increasingly they need to think about developing research programs which fit with government university and departmental priorities in order to maximize quality gradings and income in turn universities and departments are developing strategies and programs to manage the ref accountability procedures and research impact and environment issues more generally such that research is becoming an increasingly planned bureaucratized and managed activity ironically given the current emphasis in some quarters on the gold standard of scientific method university research is ceasing to be scientific in the sense of the disinterested pursuit of knowledge and becoming a corporate commercial activity undertaken on behalf of individual universities themselves and their financial survival in turn the social relations of research within universities and departments are changing it might of course be argued that twas ever thus universities have always had to fund their activities and individual scholars and research groups have always had to manage and mediate the relationship between funding opportunities and the research that they think is important to design and undertake my argument is that this balance of calculation is under severe pressure in the uk at the present time both with respect to the overall funding available and with respect to the position of qualitative research activity within this funding environment it might be further argued that this balance should change and that the pursuit of more applied policyoriented research should be undertaken a second paper could be written about the issues at stake and the arguments deployed my point for moment however is simply that such change does indeed seem to be occurring funding social science still to reiterate in principle the research agenda pursued with this funding regime remains under the control of faculty and research groups however another irony of the current situation in the uk is that if anything the funding strategy of the research council the economic and social research council further compounds the problem rather than providing any sort of counter weight in principle the esrc is an arms length body independent of government allocating awards for excellent social science research in response to competitive bids refereed by peer review it might be thought therefore that the esrcs agenda would reflect the research agenda of the social scientific community as a whole however all research council funding derives from government and as such is clearly influenced by government priorities the esrc is no exception the esrc shapes the content of the social science research agenda much more directly than government policy but does so in large part because its funds derive from government again of course there are many intermediary processes and activities with esrc officials seeking to maximize funding available in difficult times in return for responding to government priorities likewise peers review proposals on merit but these proposals have already been produced in response to priority areas and specific funding calls the esrc works within the context of an overarching crossresearch council strategy there are seven research councils in the uk distributing funds across the natural and social sciences humanities and medicine each council has become progressively more managerial over recent years not simply responding to bids from the scholarly community for funding but actively shaping the agenda around which bids can be made establishing priorities and issuing specific calls for proposals as noted above the assumptions embedded in this statement of strategy reflect the development of an institution which sees itself governing social science rather than supporting it defining priorities selecting future leaders and concentrating phd training in a few selected centres so that those leaders are in any case selected from an increasingly narrow institutional and intellectual base the use of the term training for the development of future scholars also seems indicative of a directive rather than a supportive role the deliver plan goes on to address this specifically and states we will develop national capability through …broadening the skill of all social science phd students by emphasizing transferable skills training…we will require institutions to provide training on core topics such as impact public engagement and media training…to ensure the continuing pipeline of excellent researchers for the nation the strategic plan and delivery plan also identify a need for the longer larger projects to be interdisciplinary and involve crossinstitutional collaborations which are defined as essential in studying and resolving complex challenges in effect social science is being reconceived and restructured as the behavioural science arm of government so that social science can influence behavior and inform interventions it might be argued that because esrcs budget and level of activity is very small when compared with overall funding for social science in the uk its influence will be similarly small the esrc budget is c £166m in 201415 the total science budget for uk higher education is £46b detailed breakdowns between different natural and social science allocations are difficult to identify but it is likely that esrc does not fund more than 10 of overall social science teaching and research activity including that supported from student fees thus again there is a case for suggesting that most uk social science research is beyond the reach of esrc and in turn government policy agendas but as with the ref influence far exceeds scale of activity as universities and research groups seek to bid for research council funding despite success rates dipping well below 20 and develop postgraduate training activities to mirror esrc provision so that they are not excluded from future funding possibilities nevertheless further concentration of funding might be construed as an opportunity as well as a challenge for qualitative social research to reach out to community support and other forms of charitable foundation and european union funding an interestingly critical issue for the current policy of selectivity concentration is at what point might the nationally statesupported funding base shrink so low that the research councils influence over the sector as a whole will disappear furthermore there is a separate paper to be written about whether or not and if so in what ways social science should develop so that it can influence behavior and inform interventions on behalf of government many would argue that social science should engage more directly with the public and help to inform democratic debate and decisionmaking though such activity is not necessarily coterminous with simply acting in response to and in support of government policy likewise with respect to the content of research training some would point to statistics indicating that only around 20 of research council supported research students secure academic posts in universities and thus a wider training in employability is important yet by the same token the statistics indicate that 80 go on to work in researchrelated and more general administrative teaching and managerial roles in other public sector charitable and commercial organisations if these figures are accurate then not only is such a problem not the responsibility of esrc to solve it is not actually a problem at all since phd graduates are already securing employment outside academia and the influence of social science training could be said to be extending well beyond university departments in fact students often value these broader elements of their doctoral programs as academic employment opportunities are so limited nevertheless time spent on public engagement and media training is time not spent on fieldwork and data analysis the core of any qualitative research training these matters are not necessarily clearcut but my point for the moment is simply that these developments are shaping social science in general in the uk at the present time qualitative educational and social research in particular short term consequences and implications the first and most obvious consequence is that relatively small scale funding to undertake specific qualitative and case studytype work is no longer available from esrc hitherto esrc ran a specific small grant scheme which was able to accommodate small scale exploratory investigations pilot projects and postdoc projects from early career researchers it was particularly suitable for supporting individual scholars to undertake detailed case study work over the period of a year or eighteen months by buying their time to concentrate on research for short periods and of course because the grants were small more could be funded in the absence of knowing in advance which project would show most theoretical and empirical advance funding more small scale projects seems sensible this support is no longer available the smallest open call grant now available is £200k still modest by international standards but substantial enough to indicate that a larger scale mixed methods approach would be more likely to win funding when evaluated against valueformoney criteria additionally esrc used to support a first grant scheme which was similarly oriented as the name implies towards early career researchers who again often applied for small scale funding for qualitative work this thus qualitative work must now be conceived and proposed either in terms of much larger scale longitudinal ethnographic investigations or as part of a large scale cross disciplinary and crossinstitutional mixed methods research design again involvement in such work is no bad thing and no doubt will contribute to the continuing popularity which delamont andatkinson claim for qualitative methods in the uk but it should not be the only qualitative research that secures support moreover when such large scale investigations are only funded because government wants to influence behavior and inform interventions be they mixed method or ethnographic and perhaps especially when they are ethnographic then they beg many questions about the legitimate role of social science in a democracy as noted above qualitative research is a wonderful vehicle if you want to understand the motives of people the key issues here comprise both the scale of endeavour now expected and the control of the research agenda social scientists are being positioned by government and by some leading members of the social science community as experts in social policy whose function is to respond to social problems again social science should indeed be prepared to respond to social issues but not to the exclusion of critical social inquiry furthermore the expertise of the community depends on what we might term a hinterland of basic social theory and social research from this hinterland expertise can be drawn and framed in response to particular issues the move from basic to applied research but if social science can only now act in relation to prescribed issues problems and large scale empirical research designs then over time it will lose the ability to construct its objects of study independent of the context of inquiry it will in effect cease to be social science in any meaningful sense with respect to the social relations of research opportunities for early and mid career social scientists to develop their own intellectual trajectories are likely to decrease as areas of strategic investment are defined by funding agencies moreover large scale grants are likely only to be awarded to senior researchers who have a track record of managing and delivering on previously funded work thus early career researchers must now attend to bidding for research grants especially in areas of applied research and look to secure collaborative funding with more senior colleagues this is now a core feature of any social science career developing scholars must also become able to design impact strategies and build networks including with policymakers as well as other scholars in order to become included in collaborative research designs in effect involvement in social research is being reconstructed as a technical and professional career and indeed a quasigovernmental career rather than as a contribution to science or as an independent and critical service to the community and the democratic process the very nature of the purposes and practices of social research is being changed my argument is not that that these matters are entirely novel or uncontentious social science has had an uneasy relationship with government funding for many years similarly outcomes are not easily determined there are many mediating interpretations actions and institutional processes between grandiose policy documents often written first and foremost to secure funding rather than control it and the activities of individual researchers and research groups yet the material and discursive context of interpretation and mediation means the direction of travel becomes ever more difficult to resist nor is my argument that none of these things should be happening to reiterate universities research groups and individual scholars have always had to fund their work and certainly should be responsive to the needs of social policy development however responsiveness to policy and to wider contexts of action should take their proper place in the overall career trajectories of social researchers and scholars more generally intellectual curiosity about how society operates and with what effects and consequences for individuals and social groups must remain the driving force of social science and scholarly activity otherwise it simply becomes a technology in service of government rather than an independent and critical intellectual resource for democratic debate longer term trends and prospects a more general issue is whether or not the social science community is right to accept that proximity to government will necessarily ensure its sustainability part of the backcloth to the current debate is the uncertain status and legitimacy of both science and government at the present time government and the process of mainstream electoral politics is itself generally unpopular and under pressure to deliver especially with respect to economic competence and with regard to the provision of public services can we always assume the benign intent and impact of government what reasons are there for state intervention in the lives of ordinary citizens how appropriate is it for social research to attempt to influence behaviour and inform interventions it is at least arguable that government intervention can disempower communities and it certainly locates agency in government and professional bureaucracies including those of social science rather than local communities a different approach would involve social research helping to build communities capacities to develop themselves rather than simply providing evidence for central policymaking and the development and evaluation of government intervention programs in this respect it may be the case that deriving legitimacy for social research from proximity to government is selfdefeating such a strategy links social research to an inherently unpopular institution and at one and the same compromises the basic claim for the legitimacy of science that of disinterested inquiry of course many qualitative researchers also want to pursue a social justice agenda not just a social scientific agenda but here too collaborating with local organisations institutions and communities rather than government would seem to hold much more promise with respect to both the quality of the research and its potential impact on social and economic life a second element of an alternative approach to the further development of qualitative research must be to maintain involvement in international networks and debates and resist attempts to render qualitative research into a parochial set of research techniques to be pursued in the national interest the use of qualitative research methods has a long and distinguished history in education and the social sciences discussions of qualitative methodology have been at the forefront of many decades of debate over whether and if so in what ways we can conduct enquiry and build knowledge in the social sciences it might even be argued that it is qualitative methods or perhaps more generally a qualitative sensibility and approach that constantly questions the development of social research as a technology the strengths of qualitative research are at their most manifest when used to address both the substantive topic under investigation and the way in which that topic is constituted and realised in action by the social processes at play the phenomenon under study is not simply taken as given thus local activity and development can draw intellectual sustenance from global debates a key strength of a qualitative approaches to social research is facetoface engagement with participants this must be maintained as both an ethical and political strength as well as an epistemological strength many recent international discussions of quality in qualitative research revolve around issues of engagement deliberation ethical process and responsiveness to participant agendas along with the need to maintain a critical perspective on both the topic at hand and the power of particular forms of knowledge it is these strengths of a qualitative approach that should be privileged in any discussion of their inclusion larger scale social research activities not in order to influence behaviour but in order to maximise the possibilities for the democratic development of research procedures if research is to serve the periphery as much as the centre in political debate and decisionmaking then engagement of research participants in both setting the research agenda and evaluating the outcomes of the process must be developed as central to the future development of social research methodology | there are disagreements about and contradictory indications of the state of qualitative inquiry as a global endeavour the paper argues that these disagreements rather miss the point the issue is not whether or not qualitative approaches to social research are developing across disciplines and continuing to receive funding but rather to what purposes are qualitative methods being put what research agendas are being pursued and who sets them the paper illustrates these issues with respect to the effects of research selectivity and concentration in the uk and argues that qualitative research should continue to develop as an iuntellectual resource for the community rather than as a technical service to government policymaking what is required is the gold standard of randomised controlled trials rcts for establishing cause and effect in social programs such criticism is not confined to the usa in a speech to the uks economic and social research council in 2000 titled influence or irrelevance the then secretary of state for education david blunkett 2000 asserted that many feel that too much social science research is inwardlooking too piecemeal rather than helping to build knowledge in a cumulative way and fails to focus on the key issues of concern to policymakers practitioners and the public p1 more recently similar arguments have arisen once again in a paper from the uk department for education in language paralleling the us debate the paper asserts that randomized assignment of treatment to samples is the most appropriate way to conduct research in general educational research in particular and that more experimental research should be undertaken in education specifically via rcts goldacre 2013 such criticisms combine critique of methods employed with critique of purposes pursued arguing that social research in general qualitative approaches to social and educational research in particular are not responsive enough to the needs of government so significant challenges to qualitative inquiry are apparent but others are more cautious in their assessment of these challenges fielding 2010 for example shares denzins concerns with respect to the dirigisme and antiintellectualism of the gold standards lobby p127 but notes that circumstances vary internationally and that threats to qualitative research should not simply be read from a north american perspective others still argue that qualitative inquiry is healthy diverse and growing both geographically in terms of its global reach and in terms of its diffusion across disciplines and across applied research fields such as |
"Introduction\n\nNumerous studies have demonstrated that social networks have a positive effect on f(...TRUNCATED) | "With the advancement of social network research over time, a research consensus has been reached th(...TRUNCATED) | 2 | "introduction numerous studies have demonstrated that social networks have a positive effect on find(...TRUNCATED) | "with the advancement of social network research over time a research consensus has been reached tha(...TRUNCATED) |
"IntrOduCtIOn\n\nDue to the rapidly ageing population and increasing longevity, in addition to incre(...TRUNCATED) | "Objective In general, published studies analyse healthcare utilisation, rather than foregone care, (...TRUNCATED) | 3 | "introduction due to the rapidly ageing population and increasing longevity in addition to increasin(...TRUNCATED) | "objective in general published studies analyse healthcare utilisation rather than foregone care amo(...TRUNCATED) |
"Introduction\n\nBackground. Explanations for monogamous marriage have centered around the prevalenc(...TRUNCATED) | "Explanations for the emergence of monogamous marriage have focused on the cross-cultural distributi(...TRUNCATED) | 4 | "introduction background explanations for monogamous marriage have centered around the prevalence of(...TRUNCATED) | "explanations for the emergence of monogamous marriage have focused on the crosscultural distributio(...TRUNCATED) |
"Introduction\n\nEndometriosis is a chronic, multisystemic disease of inflammation affecting approxi(...TRUNCATED) | "Endometriosis is a chronic, multisystemic disease often presenting with significant phenotypic vari(...TRUNCATED) | 5 | "introduction endometriosis is a chronic multisystemic disease of inflammation affecting approximate(...TRUNCATED) | "endometriosis is a chronic multisystemic disease often presenting with significant phenotypic varia(...TRUNCATED) |
"Introduction\n\nFamily is a very important social institution of the society. It is one of the basi(...TRUNCATED) | "Given that social institutions are the basis of any society, they must ideally operate in unison wi(...TRUNCATED) | 6 | "introduction family is a very important social institution of the society it is one of the basic in(...TRUNCATED) | "given that social institutions are the basis of any society they must ideally operate in unison wit(...TRUNCATED) |
"HOW ARE OLDER PEOPLE FARING POST-PANDEMIC? EVIDENCE FROM THE ENGLISH LONGITUDINAL STUDY OF AGING\n\(...TRUNCATED) | "questions were included to explore caregivers' feelings of preparedness and family support. Of all (...TRUNCATED) | 7 | "how are older people faring postpandemic evidence from the english longitudinal study of aging chai(...TRUNCATED) | "questions were included to explore caregivers feelings of preparedness and family support of all pa(...TRUNCATED) |
"Introduction\n\nPhysical inactivity can be a fundamental cause of various public health problems, e(...TRUNCATED) | "Neighborhood built environment may influence residents' physical activity, but evidence of non-majo(...TRUNCATED) | 8 | "introduction physical inactivity can be a fundamental cause of various public health problems espec(...TRUNCATED) | "neighborhood built environment may influence residents physical activity but evidence of nonmajor c(...TRUNCATED) |
"Background\n\nProviding cost-effective care for the increasing numbers of complex elderly and/or co(...TRUNCATED) | "Background: Patients with chronic conditions and multiple comorbidities represent a growing challen(...TRUNCATED) | 9 | "background providing costeffective care for the increasing numbers of complex elderly andor comorbi(...TRUNCATED) | "background patients with chronic conditions and multiple comorbidities represent a growing challeng(...TRUNCATED) |
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