The Questions We Ask Shape the Answers We Find

This summer, I had two interns who both did exceptional work in research and public health in Karachi, Pakistan. They shared a genuine interest in health literacy and came from similar academic backgrounds; both were medical graduates. Curious to better understand how each of them was thinking, I asked a simple question: How do you understand health literacy?

Their answers could not have been more different.

One described health literacy as a measurable skill. For him, it was about whether people could read medicine labels, follow dosage instructions, and understand basic health information. Either someone could do these things, or they could not, considering the fact that around 90% of the population in Karachi has formal education PBS National Census 2023.

The other paused before answering. Health literacy, she said, looked very different depending on who you were and where you lived. A young woman in a semi-urban town may rely more heavily on family advice, WhatsApp forwards, local healers, and informal networks when navigating health information. Someone growing up in more urban settings may still draw on these sources, however, is often exposed to a wider range of formal health services, digital platforms, and institutional messaging, shaping different expectations about health and care.

Both interns were thoughtful. Both were convincing. And both, I realized, were right.

What they were unknowingly engaging with was a long-standing philosophical question that quietly shapes all research: What is real, and how can we know it?

Every time we design a research project, we make philosophical choices whether we acknowledge them or not. These choices revolve around two fundamental questions: Ontology asks: What is the nature of reality?; Epistemology asks: How can we know that reality?
Ontology is about what exists “out there” in the world. Epistemology is about how we come to know and understand it.

These are not abstract ideas meant only for philosophy texts; they influence the questions we ask, the methods we choose, and the kinds of answers we accept as valid in health research.

Consider the example of studying health literacy among young adults in Karachi, Pakistan. The way we conceptualize health literacy depends heavily on our philosophical lens.

From the measuring lens (realist ontology) perspective, health literacy is a concrete skill. Young people either understand blood test reports or they do not. Research takes the form of surveys, scores, and comparisons across populations. The outcome is clear and appealing to decision-makers: “43% of youth cannot correctly calculate medicine dosages.”

From the meaning-making lens (constructivist ontology) perspective, health literacy cannot be reduced to reading ability or test scores alone. It lives in how people interpret, negotiate, and act on health information within their everyday worlds. A young man in a rural town may not articulate health concepts in clinical language, yet he knows which clinics are reliable, when home remedies are sufficient, and when biomedical care becomes necessary. This form of knowledge is learned through experience, relationships, and local histories. Seen this way, health literacy is not something people simply possess, it is something they continuously practice within their social and cultural context.

The power lens (critical realist ontology) recognizes that while biological realities exist, access to knowledge is shaped by power. Why do English-medium students often appear more health literate than their Urdu-medium peers? How do class, language, and institutional trust influence which health information is available, credible, or actionable?

These philosophical positions shape research in very practical ways. They create a cascade:

Ontology → Epistemology → Methodology → Methods → Findings → Impact

So, what approach will help us understand and address this problem most effectively?

The risk is not choosing one approach over another, it is forgetting that these choices are being made at all. In complex urban settings like Karachi, this flexibility is not a weakness; it is a necessity.

Finding our philosophical footing, without getting stuck

Researchers do not need to adopt one philosophical position and defend it forever. Different questions demand different lenses.

Studying vaccine efficacy? A realist approach is appropriate.
Trying to understand why young people reject vaccines despite knowing they work? An interpretive or critical lens becomes essential.

What matters is awareness. When we treat our preferred approach as the only “scientific” one, we narrow our understanding. The two interns I worked with were not in disagreement; they were looking at the same issue through different windows.

What this example makes clear is that research is never neutral. Before a questionnaire is drafted or an interview guide is written, decisions have already been made about what counts as knowledge and whose understanding matters. Ontology and epistemology are not academic decorations; they are the quiet architecture of every study.

In a city like Karachi, treating health literacy as a single, measurable trait risks mistaking partial visibility for truth. Equally, focusing only on lived experience without acknowledging structural constraints risks overlooking why some forms of knowledge carry more authority than others. Both moves narrow our understanding in different ways.

The strength of a study lies not in loyalty to one philosophical camp, but in how well its choices align with the problem it seeks to understand.

The disagreement between my two interns was not a methodological conflict; it was a reminder that reality is layered. When researchers become conscious of the philosophical choices they are making, they stop arguing about which approach is “more scientific” and start asking a better question: What kind of knowledge is needed here, and what will it allow us to see or miss?

That shift is not abstract. It determines whether research merely produces results, or whether it produces understanding

Authors: Dr Wardah Ahmed is PhD Candidate  in Population and Public Health, Faculty of Health Sciences, Aga Khan University, Karachi, Pakistan. She is working on the nexus of health literacy, and health system research.

Ms Fatima Farishtay is the Research Assistant in Institute of Global Health Sciences (IGHD), Aga Khan University, Karachi, Pakistan. Her research focuses on how medical sciences and health knowledge shapes the path for better health and well-being

Competing interest: None

Handling Editor: Neha Faruqui