Prakriti-based research: Good reporting practices.

The recent advances in the fields of genomics, personalized medicine, and Ayurveda have motivated many researchers to look at the relationship between Prakriti (phenotype-based Ayurveda constitution) and various objective biological parameters. As a result, a number of studies reporting such a relationship have made their way into mainstream scholarly journals. However, when it comes to the protocols that these workers follow to identify one's Prakriti, there are several issues that are yet to be resolved. In this communication, we propose a few reporting practices that such workers are required to be encouraged to follow, while submitting their work on Prakriti to scholarly journals. We have arranged this proposal under the following domains that may serve as a preliminary checklist in this context: The textual references, validation process, assessment of characters, scoring pattern, weightage assignment, criterion for expressing the final Prakriti type, and a need to publish the complete Prakriti-determination tool. We advocate that only if the workers in the field adhere to these good reporting practices, one will be able to draw meaningful, generalizable, and applicable interpretations out of such studies. We also suggest that the editors of relevant scholarly journals may recommend these reporting practices while considering such reports for publication.

Introduction

Current advances in the fields of Ayurveda, genomics, and personalized medicine have motivated several workers to explore a possible association between the Prakriti (Ayurveda constitution) and different objective parameters encircling the fields of hematology, biochemistry, physiology, psychology, and genomics [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]. Although the trend is a welcome step in validating and evaluating the applicability of the Ayurvedic conceptual framework, there are certain issues that are required to be addressed by the scientific community and academia so as to render the results reported by these studies into generalizable, reproducible, and applicable inferences.

To be specific, the problems in the determination of one's Prakriti are the ones that have not yet been completely overcome. This is, especially true when it comes to the fulfillment of the research requirements, where a reliable, validated, and reproducible method becomes essential. Although there have been several attempts at designing the reliable tools and protocols for this purpose, each of these suffers from its own limitations [12], [13], [14], [15], [16], [17], [18], [19], [20]. The common problems that are encountered in these protocols can be listed as follows: (a) Discrepancies related to the adherence to the textbooks, (b) ambiguities in assessing the characters, (c) inadequate attention given to inter-rater variability, (d) inadequate attention paid at the scoring pattern and weightage assignment, (e) ambiguities in assigning the criteria followed to express the final “Prakriti” type, (f) nondisclosure of the complete protocol used to identify Prakriti, etc.

Therefore, there is a need to develop a universally acceptable standard tool/protocol with a consensus of the entire scientific community working in this field. However, since this may take a few years of time to materialize, we advocate that the workers in the field must adhere to certain good reporting practices while submitting their Prakriti-based research work to scholarly journals. In the following paragraphs, we summarize our proposal, which is of course, open for debate and further corrections.

Textual references

There are variations and at times contradictions in the description of characters or assessment methods among different classical textbooks of Ayurveda [21], [22], [23]. For instance, in the case of body frame, Alpa Sharira, Hrasva Sharira (small body frame, short stature) has been indicated as a feature of Vata Prakriti in Caraka Samhita, whereas, Dirgha Sharira (height more than average) has been suggested as a feature by Vagbhata in Ashtanga Hridaya. Similarly, according to Sushruta, a person belonging to Vata Prakriti tends to have an inclination for stealth, which possibly translates into some form of deviation from normalcy with reference to psycho-social health. On the other hand, the individual belonging to Vata Prakriti has been described to be of normal psycho-social health in Caraka Samhita.

Further, Caraka has laid down the least emphasis on the physical features of an individual while explaining Prakriti, whereas, Vagbhata has emphasized much on this domain. For instance, the physical description of hair, forehead, skin, eyes, eye lashes, nails, teeth etc., are either not described at all, or have been described just as a passing reference in Caraka Samhita, whereas they have been described at length with extensive details in Ashtanga Hridaya.

A researcher is, therefore, expected to clearly state as to which textbook was taken as reference for determining Prakriti of the individuals (volunteers/patients) in the study and therefore, we propose that the terms such as “Carakokta Prakriti” (Prakriti as described by Caraka) or “Sushrutokta Prakriti” (Prakriti as described by Sushruta) be used while reporting Prakriti-based work. If at all the workers still wish to use a mixed tool, incorporating references from all the texts, they must clearly mention as to how they circumvented these contradictions.

Validation details

It is advisable and preferable to administer any questionnaire/tool only after it is validated. There are different methods to validate the tools ranging from simple one, such as “face validity” to complex ones, such as “concurrent validity.” The validation of questionnaire/tool may itself prove to be an extensive exercise and therefore, needs to be carried out systematically. We, therefore, propose that the validation methods have to be reported adequately.

Although the objective behind developing questionnaire/tool is to bring objectivity, many aspects of Prakriti assessment fall in the realm of subjectivity. To overcome the issue of subjective interpretation of questions and the prejudice while answering certain questions, majority of the existing tools make it necessary for a researcher to take a detailed interview of each participant, examine the participant physically, and fill in the details. However, there are a few tools which are “self-reporting” in nature, where the individual participant has to fill in the details. The limitation with the self-reporting tools is that the participants may not be able to report certain traits in an objective manner because of several biases. On the other hand, the positive aspect of the self-reporting tools is that the participants feel no inhibition while responding to some personal questions. Ideally, for the purposes of research, it is advisable to determine Prakriti in two different methods and to include (wherever feasible) only those volunteers/subjects whose Prakriti determined by two methods match. Alternatively, two physicians can determine Prakriti of all the participants separately and only those volunteers/subjects may be included in the study whose Prakriti matches. This takes care of inter-rater variability. What is important, however, is to report clearly as to how Prakriti was determined.

Assessment of characters

It is desirable that while reporting the Prakriti-based work, the researchers must specify as to how they recorded the different physical parameters. For example, if the shape of the eye was recorded as “round” or “elongated,” what parameters were chosen to arrive at such a conclusion, must be specified. Similarly, skin color has several determinant factors, including exposure to Sun and ethnicity. We advocate that while recording the skin color as “dark,” for instance, the workers must clearly spell out the basis on which it was recorded as dark and how did they exclude the external factors such as exposure to Sun.

In addition, if a classical textbook has not described any specific variation for a character in case of a particular Prakriti, it is necessary to report whether the specific character was analyzed in case of that Prakriti or not. For example, there is no description of the specific body frame in case of Pitta Prakriti, therefore, if it was considered as a “medium” or “moderate,” it needs to be mentioned along with the rationale.

We propose that the description of the assessment methods can be added as a supplement as it may not be directly relevant to the topic of research.

Scoring pattern

Many Prakriti-assessment tools use different scoring patterns for final determination of the result. These scoring patterns are mainly of two types: Absolute and Relative. Most of the tools calculate the percentage contribution of each Dosha on a “relative” basis. In such a “relative” kind of calculation, if the contribution of a particular Dosha is stated to be, say, 50%, it need not necessarily mean that the concerned Dosha expresses 50% of the total traits ascribed to it. This is because, the denominator used in this calculation is not the maximum “attainable” scores for that Dosha; rather, it is the sum of the total scores “attained” for all the three Doshas by that individual. This calculation ignores the maximum attainable scores for a Dosha [11].

In the tools that are based on “absolute” calculation, the results are derived in terms of absolute percentage values, where, the calculation of contribution of one Dosha does not depend on the contribution of the other. Such a tool assumes that each Dosha can express itself in a person to its fullest extent (100%) and then calculates the percentage expression of that Dosha on an “absolute” basis. Therefore, if such kind of a tool expresses the contribution of a particular Dosha to be 50%, it means that the concerned Dosha expresses 50% of the total traits ascribed to it [11].

Though it is a matter of debate as to which kind of a calculation is more suitable for the purpose of research, we propose that the specific kind of calculation that was used to determine the Prakriti must be clearly reported by the workers.

Weightage assignment

Since the focus of every researcher is different depending on the study, he/she may assign a different degree of importance to different characters being assessed while determining Prakriti. For instance, one researcher might consider certain physical features such as height and bone length, to be relatively more stable throughout one's life, and therefore, assign more weightage, while a second researcher may assign more weightage for the features that are likely to be easily identified/categorized, e.g., color of the iris, complexion of the skin, etc. It is possible that a third researcher might assign more weightage to “most specific” features of a particular Dosha, e.g., digestive capacity in case of Pitta, sleep duration and quality in case of Kapha, talkativeness in case of Vata, and so on. A fourth researcher, on the other hand, may assign different scores for different characters based on the “Guna” (attribute of a Dosha) that they represent [7].

It is, therefore, ideal to describe the weightage assigned to various characters along with the basis for the same.

Final expression of Prakriti type

Since the textbooks do not specify as to when an individual must be categorized as Ekadoshaja (due to the dominance of one Dosha) and when as Dvandvaja (due to the dominance of two Doshas), it becomes essential for the researchers to state clearly on what basis the individuals were assigned to a particular group of Prakriti type. This becomes important considering the fact that every individual would have scored some points for every Dosha. Therefore, “extreme Ekadoshaja” individuals are extremely rare [7]. This necessitates the workers to report it clearly as to what cutoff points were used to categorize the individuals into Ekadoshaja or Dvandvaja individuals. It is ideal to report the scores obtained for each Dosha by all the participants as supplementary files or tables.

The full Prakriti determination tool

Since the Prakriti-based research work is still in its infantile stage, the workers need to be open-minded to publish the full questionnaire/tool that they used to assess Prakriti along with the weightage they assigned to each item along with the publication. This may be done as a supplementary file if the topic of their study does not allow it to be incorporated in the main article. This would help other workers in the field to test their tools or to improvise the tool in question so that a standard protocol may eventually emerge.

Conclusion

In this communication, we have enlisted a few vital points that the workers engaged in the field of Prakriti-based research may consider as a “checklist” and adhere to while communicating their work to scholarly journals. Table 1 summarizes these points. This, we believe, would help in deciphering the outcomes of these studies in a more meaningful way and in eventually building a strong evidence-base. We further suggest that the editors of the relevant scholarly journals may recommend or ask their reviewers to verify these points while considering such reports for publication.

Table 1

Summary of the major points addressed in this proposal.

Points	What descriptions are expected in the report
Textual references	Was the protocol based on one textbook or multiple textbooks?
a. If based on one, mention the textbook
b. If based on multiple textbooks, describe how did you address the issues related to variations and contradictions
Validation details	Mention if the tool/protocol was validated or not
a. If validated, describe the process of validation
b. Mention if the issues related to inter-rater variability were addressed or not
c. If not validated, describe the reasons for not validating the same
Assessment of characters	Was the tool “self-assessment” in nature?
If not, describe the assessment methods followed while recording the different characters
Scoring pattern	Describe the scoring pattern followed (absolute/relative) along with the formulae that were used
Weightage assignment	Describe the weightage assignment procedure followed
Describe which characters received more weightage:
a. That are relatively more stable throughout one's life
b. That are likely to be easily identified/categorized
c. Most specific features of a particular Dosha
Mention if the weightage assignment was based on Guna algorithm or not
Final expression of Prakriti type	What cut-off points were used to categorize the individuals into Ekadoshaja or Dvandvaja groups?
Report the scores obtained for each Dosha by all the participants either in a table or as a supplementary file
The full Prakriti determination tool	Provide the full questionnaire/tool that was used to assess Prakriti along with the weightage assigned to each item

Source of support

Nil.

Conflicts of interest

None declared.