Child obesity is a modern global epidemic. A multitude of factors that shape the obesogenic environment make children susceptible to obesity; parental misperception may be one of them (Doolen, Alpert & MIller, 2008). Its prevention and treatment with particular focus on overweight and obesity affecting toddler and pre-school age children are urgent priority concerns for public health specialists (Bambra et al, 2012). In Scotland about 25% of children aged 24-30 months are already overweight (BMI â‰¥85th centile) and about 5% are clinically obese (â‰¥ 98th centile) (Bromley et al, 2010). Weight status at 24-30 months is important because rapid weight gain in this age group is associated with future obesity particularly if there is coexisting parental obesity (Daniels, 2006).
Parental misperception about their child’s weight is common (Rietmeijerâ€Mentink et al, 2012) and likely to occur more often if the child is overweight or obese regardless of the age (Parry et al, 2008). Parents of infants and toddlers show preference for their child to grow at higher percentiles and higher weights are perceived as healthier (Laraway et al, 2010). Further, parents express greater satisfaction with body sizes of overweight than healthy weight children (Hager et al, 2012). Higher inaccuracy rates are associated with higher parental weights, lower socio-economic status, lower maternal education, male gender and for children who are younger (Hudson et al, 2009; Baughcum et al, 2000).
Examination of parental perceptions of their toddler’s weight is vital because they strongly influence how they feed their child (Lewinsohn et al., 2005); further, parental awareness of the condition makes it more likely that intervention programs aimed at them to achieve and maintain healthy child weight will be successful (Wald et al, 2007; Doolen, Alpert & Miller, 2008). Research suggests that parents with accurate perceptions of child’s weight are more prepared to make weight related behavioural changes and are more effective in making them (Towns & D’Auria, 2009; Grimmet et al, 2008; Rhee et al, 2005). On the other hand, parental non-recognition of their child being overweight or obese and associated health risks makes it more likely that intervention programs directed at them will be unsuccessful (Maynard et al, 2003).Therefore, targeting parental perception and universal surveillance of children’s nutrition, physical activity and growth at 24-30 month are important (Perrin, 2012).
The Scottish Government (2011) has recommended adding a universal review for children aged 24-30 months to the Child Health Programme to promote early child development and healthy weight. The lead responsibility to deliver the review will be the Public Health Nurse/ Health visitor (PHN-HV).
Most studies have focussed on perceptions of parents of school age and adolescent children. Evidence related to parental perception of toddler’s weight is sparse (Garrett-Wright, 2011); the author has not identified any UK based study. One purpose of the universal review is to support parents provide the best health outcomes for their children. An understanding of parental perceptions and factors influencing those perceptions will enable PHN-HVs to provide promotive and preventive health guidance and information in a tailored and culturally sensitive manner (Towns and D’Auria, 2009; Redsell et al, 2010).
Research question: What is parent’s perception of his/her 24-30 month child (toddler)’s weight whose BMI is â‰¥ 85th centile.
For this study, perception is a person’s subjective experience that influences his/her interpretation of a phenomenon (Fortinash & Worret, 2007).
To identify obesity, the UK National BMI classification system reference curves (Cole, Freeman & Preece, 2000) will be used. Children will be classified as overweight or obese using the 85th and 95th percentiles respectively as cut points.
Ontology, epistemology and methodologies.
Popularised by Mertens (1998) and Lincoln and Guba (2000) and variously referred to as ‘research methodologies’ and as ‘worldview’ (Creswell, 2009), a research paradigm is a belief system defined by specific philosophical values (axiology), ontological (nature of reality) and epistemological (how we know what we know) beliefs and methodology (research practice and process) (Hanson et al, 2005; Morgan, 2007).
The researcher’s ontological approach establishes the epistemological stance and subsequently the methodology (Guba and Lincoln, 2005). For example, to answer questions relevant to the physical world that we live in, the ontology will be the ‘real’ world (and not the world of aesthetics and morals). Consequently, the researcher’s epistemology position will need to be objective (value-free) and methodologies will require controlling of all variable factors. Essentially, the choice of paradigm influences the questions that researchers will pose and the methods they employ to answer them (Morgan, 2007).
Several theoretical paradigms have been described, each with its ontological and epistemological beliefs and associated methodologies (Cresswell, 2009). According to Weaver and Olson (2006), no paradigm is ‘superior’; each paradigm has its applicability to a specific area of research.
Quantitative research based on the paradigms of positivism and post-positivism (realism) and qualitative research based on the concepts of interpretivism and constructionism are the two primary methodologies (Creswell, 2009). The traditional view is that these two methodologies are not compatible because it is not possible to combine their ontological and epistemological stances (Leininger, 1992; Guba and Lincoln, 1988). This concept is increasingly challenged in nursing and health care research (Johnson and Onwuegbuzi, 2004).
Positivists assume that the world is ‘real’ (Young, 2008) and reality is determined by natural laws and mechanisms (Denzin and Lincoln, 1994). Yet, their epistemological stand of viewing the researcher and the participant as separate entities (dualism) can distort the objectivity of their ‘real’ world view (Gaventa and Cornwall, 2008). Although Guba and Lincoln (1994) argue that objectivity, scientific neutrality and a dualist approach enhances the credibility of research, Howe (1988) states that no research endeavour is truly free from value judgments. Further, according to Stevenson et al (2004), evidence produced by a detached researcher in a positivist inquiry is of limited relevance in the complex setting of healthcare. This approach has been largely replaced with post-positivism or realism (Yu, 2003; Phillips & Burbules, 2000) by quantitative researchers. Post-positivists remain objective but propose that knowledge is relative and researchers cannot separate themselves from what they know. They accept that researchers make discretionary judgements and therefore, causation of complex social phenomena cannot be determined with certainty. Schumacher and Gortner (1992) have suggested that this approach is relevant to nursing and healthcare research.
On the other hand, interpretivist-constructivist approaches, the theoretical frameworks for qualitative research methodologies, view the ‘real’ world as dynamic and changing – constructed and interpreted by people living in their natural environments (Bogdan & Biklen, 1982). Referred to as the naturalistic inquiry (Guba and Lincoln, 1985) since they apply to naturally evolving real-world situations, qualitative methodologies emerged in nursing and healthcare research to understand the human experience in a subjective manner (Schwandt, 2000) and have steadily gained importance (Weiner et al, 2011).
The interpretivist and constructionist paradigms share common ontological and epistemological beliefs. Interpretivists view ‘truth’ from multiple perspectives and accept multiple realities (Forde-Gilboe et al 1995). The aim is to understand phenomena and derive meaning from perspectives and experiences of people living in their natural situations by focussing on the internal ‘reality’ of participants that is created by their interaction with their environments (Weaver and Olson, 2006). However, constructivism emphasises on how participants construct reality (socially constructed reality) in their mind through their interactions with the world around them (Ponterotto, 2005).
Historically, in healthcare research, quantitative research strategy, characterised by objectivity has been the ‘gold standard’ to study the utilization, cost, and clinical effectiveness of health care processes. In contrast, qualitative research explores complex social phenomena by examining perceptions of participants to find meaning into beliefs, values, and motivations that underlie individual or social behaviour and produces data for comprehensive understanding of a problem (Welford, Murphy & Casey, 2011).
To measure objective reality and obtain knowledge deductively, quantitative researchers adopt an independent and value-free assessment approach to test carefully constructed hypotheses and examine causal relationships between variables. It is typically performed in randomized or nonrandomized experimental settings to produce and analyse numeric data through standardized processes and instruments. On the other hand, qualitative research is exploratory in nature and seeks to generate novel insights using inductive (starting with observations and developing hypotheses) rather than deductive (starting with extant hypotheses and testing them with observations) approaches (Lincoln & Guba, 2005; Weaver and Olson, 2006). While reliability and validity are terms to describe the construct (theory of how and why) and instrument in quantitative research, these are differently conceptualised by qualitative researchers who have used a range of terms to describe quality (Golafshani, 2003). In qualitative research, Lincoln and Guba (1985) have argued that validity and reliability depends on trustworthiness; further, reliability/dependability is assumed if validity can be demonstrated.
The diversity of frameworks and theories pose challenges to qualitative researchers (Devers, 2011) including developing validity standards (Whittemore et al, 2001). Furthermore, matching the correct qualitative methodology to the research question is a complex task (Starks and Trinidad, 2007). Rolfe (2004) questions the concept of a qualitative research paradigm and argues that the term ‘qualitative research’ is valid only for data collection methods; he contends that the field of ‘non-quantitative’ methodologies is too wide and diverse to be included within one (qualitative) research paradigm.
Qualitative and quantitative approaches alone cannot fully study all phenomena, particularly in the context of nursing research (Weaver and Olson, 2006). Some researchers consider these two approaches as opposite ends of a continuum, with positivists at one end and constructionists on the other with mixed methods in between (Welford, Murphy and Casey, 2011; Doyle, Brady, & Byrne, 2009).
There are opposing arguments about integrating quantitative and qualitative methodologies within mixed methods research (Sale, Lohfeld and Brazil, 2002; Foss and Ellefsen, 2002). Yet, qualitative and quantitative methods are often combined in a single study in health care research (Yanchar and Williams, 2006; Morgan, 2007) through data triangulation processes to enhance the completeness and confirmation of research findings (Bryman, 2006; Thurmond, 2001). For example, addition of quantitative data by using standardised self-completed questionnaires to a qualitative research design (in-depth interviews) within a single study is commonly practiced (Adamson, 2005). Such practice is, however, simply mixing data collection techniques and not methodologies (Morris and Burkett, 2011).
Strategies for triangulation of data and methodologies can also be used within qualitative research (Guion, Diehl & McDonald, 2011). Although there are concerns about ‘method slurring’ (Baker, Wuest & Stern, 1992), Johnson, Long & White (2000) have proposed advantages of blending distinct qualitative methods. Similarly, Annells (2006) suggests that grounded theory and hermeneutic phenomenology can be used together; however, integrity of underpinning philosophical assumptions is essential.
Methodologies that have studied this research question
Both quantitative and qualitative research methodologies have explored parental perceptions of their child’s weight (Towns and D’Auria, 2009; Parry et al, 2008; Pocock et al, 2009).
Quantitative studies used the descriptive approach to observe and identify attributes of the phenomenon in its current state. To explore association between variables influencing the phenomenon, correlation techniques and cross-sectional designs methods were employed; data was collected using surveys and/or questionnaires (LoBiondo-Wood, 2002).
Qualitative researchers used phenomenology methodology as they wanted to collect rich descriptive narrative data related to parents’ perceptions of child body weight. These studies employed focus groups and semi-structured interviews (Pocock et al, 2009). Significantly, one common theme that emerged across qualitative studies is that parents often perceived functional ability and emotional well-being as measures of obesity and not a numerical figure (Jones et al, 2011).
A diverse range of methods have developed in phenomenology-led research around two distinct approaches (King et al, 2008). The descriptive (eidetic) approach based on Husserl’s philosophy focuses on understanding essential, general meanings of a phenomenon from rich, descriptive narratives of participants in their real-life world. It assumes that a person’s motivational behaviour is not influenced primarily by culture, society and politics (Giorgi, 1997). In contrast, interpretive (hermeneutics) phenomenology inspired by Heidegger, Gadamer, and Ricoeur postulates that people are submerged in their life-world and their behaviours and subjective experiences are closely linked with social, cultural and political contexts (Lopez and Willis, 2004; van-Manen, 1997). This approach aims to offer multiple perspectives from multiple contexts of participants’ lived experiences and how they impact on their behaviours. Some researchers view phenomenology as a continuum of methods, of which some are more interpretive than others (Finlay, 2009; Langdridge, 2009).
There is debate about whether the focus in a given study should be on shared meanings or individual meanings of the phenomenon. According to Giorgi (2008a), analysis of individual (idiographic) experience may be a part of the analysis, but the objective is to accurately identify the most shared meanings of participants’ experiences. However, others (Ashworth, 2006; King et al, 2008) explicitly seek out idiographic meanings to try to understand the individual experience. Halling (2008) suggests a conciliatory middle approach and proposes different levels of analysis.
Phenomenology as research method
To transform the essential principles of Husserl’s philosophy into scientific research applications, the researcher is asked to use descriptions of experiences from others and not just from reflection of self- experiences (Giorgi, 2000).
Descriptive/ exploratory phenomenology is the commonest approach in nursing research (Ansell, 2006). But the practice is immersed in debate. Key issues are embedding philosophical principles in research (Dahlberg, 2006), comparison of different approaches within phenomenology (Wojnar and Swanson, 2007) and establishing validity checks to ensure methodological rigour within various approaches (De Witt & Ploeg, 2006). Morse et al (2002) have proposed a set of verification strategies built within the research process which the researcher must use to ensure rigour. However, Rolfe (2004) challenges the notion of a universal framework of validity criteria for qualitative research and suggests that each study should be judged individually.
Scholars recommend that researchers must identify the precise phenomenological approach underpinning the study to ensure quality and rigour of the study (Ansell, 2007). Yet, this is not common practice (Nordyk and Harder, 2008). Further, selection of the correct approach can be complex (Wojnar and Swanson, 2007). According to Finlay (2009), the appropriate approach is determined by the type of phenomenon under study and the nature of knowledge that the researcher seeks.
This author’s position
This author aims to engage with parents of toddlers (group of people) to understand the meanings (perceptions) of their lived experiences (life-world) of their child’s weight (phenomenon) and describe this ‘intentional relationship’ between the parent and the meanings of their experiences. The epistemology of descriptive phenomenology assumes that a person’s experience with a phenomenon is a relationship, described as intentionality (Moustakas, 1994a) and aspects of that relationship can be expressed in language and meaningfully described (Giorgi, 1997). Interpretive phenomenologists scholars disagree; according to them, meanings cannot be described but can only be interpreted (Todres, 2005). According to Lopez and Willis (2004), the descriptive method is appropriate to describe universal meanings of phenomena that are as yet incompletely understood by prior research and the interpretive approach to explore a phenomenon’s characteristics in more depth, in different contextual settings.
Guided by theory (Starks and Trinidad, 2007) to match the research question and purpose, methods and objectives, the author has identified descriptive phenomenology as the appropriate approach for this inquiry.
Descriptive phenomenology concepts underpin the discovery interviews that NHS Modernising Agency employ to gather perceptions of service users, with the aim to improve holistic care (Wilcock et al. 2003) and of life-world led healthcare approach to humanise and reshape patient-led care (Todres, Galvin and Dahlberg, 2009).
Researcher – participant relationship
An open, empathic attitude and researcher subjectivity are accepted as essential features in phenomenological research (Giorgi, 1994). The process of reduction (bracketing) enables the researcher to understand the participant’s described experience of the phenomenon in its own inherent meaning. It requires the researcher to block (bracket) existing knowledge and presuppositions including transcendental (not experienced but knowable) and eidetic (memory recall) knowledge. While the descriptive approach endorses bracketing to increase scientific validity (LeVasseur 2003), the interpretive approach considers researcher’s existing knowledge as useful and necessary (Geanellos 2000).
Wertz (2005) and Finlay (2009) have described the researcher “phenomenological attitude” which involves bracketing pre-existing knowledge but also inertly using that knowledge. Referred to as researcher reflexivity, this approach helps the researcher to eliminate previously held biases by continually reflecting upon interpretations of both personal experiences and the phenomenon being studied. It is argued that this inter-subjective relationship (relational approach) with the participant allows data extraction from the conversations (dialogal method) (Halling, Leifer & Rowe, 2006). Nevertheless, Giorgi (2008b) criticizes this approach because of the risk of the phenomenon moving onto the relationship.
Challenges/limitations of phenomenological approach
In phenomenology, it is argued that the concept of validity is less precise and less prescriptive. Inherent characteristics of this methodology challenge conventional concepts of research validity and reliability with implications on trustworthiness and rigour (De Witt & Ploeg, 2006). These include non-randomness of sample, smaller number of participants, absence of control groups, absence of hypotheses and prediction, lack of generalisability and replicability of results, accuracy of participants’ narratives, and researcher’s own subjectiveness (Hycner, 1985).
Methods alone cannot ensure rigour or achieve the goals in phenomenological research (Finlay, 2009). As the research instrument (Barrett, 2007), the researcher plays the central role to ensure rigor in all key processes of data collection, analysis and description which requires assuming the phenomenological attitude (Finlay, 2008; Colaizzi, 1973).The main judge of validity in descriptive phenomenology is the researcher (Maggs-Rapport, 2001) as he/she needs to demonstrate responsiveness to verification strategies that are built in the research process to ensure rigour (Morse et al, 2002).
‘Findings’ in descriptive phenomenology research are meaningful perceptions drawn from lived experiences. This methodology does not claim that its ‘findings’ are the final and best way to understand perceptions; nor are they quantifiable (Finlay, 2008). However, its strength lies in its ability to facilitate better or deeper understanding of the phenomenon for readers. Additionally, Todres (2005) argues that findings may be transferable to understand other lived experiences of the same or even a different phenomenon through a reflective and critical approach.
The research process
Various validity ‘checking’ measures embedded within the research process to ensure rigour will be referred to in texts.
Sample and data collection methods
To meet the purpose of this research and gather ‘thick and rich’ descriptions, the author has identified the criterion sampling technique, a purposive sampling strategy, to select participants who have experienced the phenomenon of interest (Collingridge and Gantt, 2008). Some scholars (Sandelowski, 1995) have suggested variation sampling to seek as much as possible, participants from range of demographic characteristics who may have varying experiences of the phenomenon. Such variation makes it possible for the researcher to distinguish essential (invariant) meanings from other meanings across participants’ perceptions (Todres, 2005).
The target population for this research are parent(s) of a toddler who has BMI â‰¥ 85 percentile. Biological, adoptive, or foster parents who are willing to participate will be included. Participants will be excluded if they are unable to consent for themselves, if their child has a chronic illness or if they decline to participate. Parents of children with chronic health conditions may have perceptions about their child’s weight that are influenced by the nature of the condition (Krulik, 1980). Non-English speaking parents will be included if they speak any of the languages that this author speaks.
Although Webb (2003) argues that focus groups are incompatible with the philosophy of phenomenology, Bradbury-Jones, Sambrook & Irvine (2009) contend that interviewing participants in groups may enhance the quality of phenomenological research. However, concerns about numbers, composition of the group, interview content and lack of standards remain (Lafferty, 2004). Other issues are dominance by member(s) (Krueger, 1995) and non-attendance. Sample size recommendation for a focus group varies from 4 to 20 (McLafferty, 2004). Smaller groups may be easier to manage (Morgan, 1996) and generate more discussions (Carey, 1994); yet, others recommend larger numbers (Fern, 1982). The moderator of a focus group has a key role (Basch, 1987); but, opinions differ about whether the researcher is best suited to be the moderator (Millward, 1995; Carey, 1994).
Data can also be collected through concrete written descriptions (Langdridge, 2007) or recording of oral (talking aloud) (Aanstoos, 1985) account of the participant’s experience through semi-structured interviews (Priest, 2002). These remain traditional methods in phenomenology (Wimpenny and Gass, 2001). According to Todres (2005), data gathered from diverse sources can supplement each other.
The emphasis here is sample quality and not size. Data from only a few participants who are able to describe their experiences in depth may be sufficient. Although Bertaux (1981) suggested 15 as the smallest number of participants for a qualitative study, Creswell (2009) recommends a range between 5 and 25 interviews whereas Morse (1994) recommends minimum of six. The author intends to carry out semi-structured interview with maximum of 10 participants, on an individual basis. Interviews are not ‘perfect’ tools and there are several methodological concerns (Fontana and Frey, 1994); comprehensive guidelines exist for student researchers, in particular (Englander, 2012).
This research can proceed only after ethical review and approval. Measures designed to address specific ethical issues relevant to the proposed inquiry are discussed next.
Ethical issues and governance
Ethical approval from the appropriate NHS Research Ethics Committee (REC) is required for student research proposal in health and social care services (NHS HRA). The functions of RECs are governed by a harmonised Department of Health policy and coordinated through CSO in Scotland (D.H, 2011). Student research projects for which the chief investigator is the student’s academic supervisor may qualify for the fast-tracked proportionate review service (NRES, 2010). It is argued that REC processes need to be reviewed to streamline the bureaucracy of the process and address the culture of fear and distrust particularly towards social researchers (Reed, 2007).
Essential principles, key areas of concerns and rules of professional ethics have been described by Beauchamp and Childress (2001). In addition to adhering to mandated ethical codes, the researcher is expected to show professional integrity and responsible behaviour. Any deviation from this is considered unethical because the researcher is responsible to protect the dignity, rights, safety and well-being of participants (Iphofen, 2005). In the context of the methodology of this research, the REC project filter will be ‘qualitative only’ (IRAS, 2011). The author has identified potential risks for participants which include anxiety and distress, perceived power imbalance, misrepresentation of participants’ views, loss of anonymity, and inconvenience and costs(time and travel) (Allmark et al, 2009; Richards & Schwartz, 2002).
To enhance scientific rigour of the study and increase compliance with ethical guidelines, the researcher will seek mentorship throughout the research process from the research supervisor (NRES, 2010).
To minimise risk of compulsion, participants will be given sufficient time to consider consent and ask questions; further, they will be informed about the non-therapeutic nature of the inquiry and that refusal or withdrawal from the process has no association with access to care. In the context of the proposed study, the power balance is more equal because potential participants are not ‘patients’ or require special protection and this researcher is not a healthcare provider. Additionally, the interview location will be participant’s own choice. Appropriate timing of the interview is important (Cowles, 1988); if participant(s) have recently experienced a traumatic or emotional incident, the interview will be postponed or cancelled.
The right of self determination, the right to refuse participation or withdraw at anytime will be clarified prior to the key process of informed consent. Here, the principle of veracity (truth telling) is linked implicitly to respect of participants’ autonomy, gaining informed consent and information sharing (Iphofen, 2005). However, because of the dynamic, flexible and serendipitous nature of the interview process, wherein information is gradually revealed, consent obtained at the beginning of the interview cannot always be fully ‘informed’. Hence, the concept of consent as a process rather than a one-off event will be presented (RCN, 2011).
Interviews can provoke distressing memories and strong emotions in the participant and sometimes in the researcher (Butler, 2003); they may even be construed as a therapeutic encounter (Allmark et al, 2009). This researcher will employ skills and attributes gained through other work experiences to conduct interviews in a professional manner whilst adopting a sustained reduction posture and maintaining professional boundaries. If participants’ perceived or expressed need for support and information are identified, liaison with PHN-HV will be made.
To minimise risk of misinterpretation and misrepresentation, researcher will rely on self-awareness (reflexivity) about personal and professional characteristics, including biases so that participants’ experiences are clearly separated from those of the researcher’s (Colaizzi, 1973). Other processes to minimise these risks include validation of data by participants (member checking) and scrutiny of data by the research supervisor/ team. They will be referred to, along with arguments, in subsequent texts.
This research will involve few participants who are expected to provide thick descriptions; additionally, modern information technology enables prolonged storage, sharing and fusion of data (Parry & Mauthner, 2004). Therefore, anonymity and confidentiality is a concern even if no medical information will be collected or retrieved for this study (Richards & Schwartz, 2002). To protect identities, the author will use a coding system to identify transcripts, tapes and records. Data will be securely stored and shared only with the research supervisor; however, communication data are not always privileged and both researcher and data can be summoned for scrutiny (Cowles, 1988).
Participant access and recruitment:
The delivery plan of the universal 24-30 month child health review includes measures to achieve maximal uptake by families and children (S.G., 2011). A core task of the review is height and weight assessment of the child by the PHN-HV following guidelines established for this objective. To approach and recruit participants who fulfil the study criteria and are willing, the author intends to work with the PHN-HV. An explicit process of invitation, information about the study and nature of the interview process and informed consent will follow (NRES). Proposed formats of these documents are described in Appendices 5âˆ’7.
Data collection and analysis, reporting
To ensure ethical principles, method rigour and validity of the interview process, the researcher is expected to follow recommended guidelines (Kvale, 1996). These are detailed in Appendix 4.
The selected venue of the interview will be participants’ choice, either at the family home or if preferred, at the local baby and toddler group centre. The aim is to select a location that allows privacy, comfort and is familiar to the participant(s).
The researcher is expected to facilitate the open-ended interview in a sensitive, non-directive and informal manner, with open questions whilst keeping the focus on the phenomenon of interest and adopting the posture of phenomenological reduction (Moustakas, 1994b). This requires the researcher to consciously and with effort, suspend (bracket) all personal meanings and interpretations of the phenomenon (Lopez and Willis, 2004). However, complete reduction to achieve ‘pure objectivity’ is impossible (Hycner, 1985). To aid the process, the author intends to list all known personal presuppositions about the phenomenon and dialogue with the research supervisor to reveal additional (unidentified) presuppositions.
A recorder with a lapel or remote microphone is recommended (Balls, 2009). At this stage, the researcher is responsible to the participant for ascertaining that the interviews accounts are precise and reliable.
Data analysis in descriptive phenomenology is a multi-step disciplined process (C