Caregiver Experiences of of Public Services Following Child Trauma | Research Analysis

Critical Appraisal of Qualitative Research

Evidence-Based Social Intervention and Policy Evaluation

Introduction

Critically appraising qualitative research is essential for understanding the strengths, weaknesses, and implications of qualitative evidence. Understanding that there are no “perfect” studies, critical appraisal allows researchers to assess if and how flaws in a piece of research impact the validity of the conclusions (Mays and Pope, 2000). In this paper, I critically appraise a piece of qualitative research by Williamson et al. entitled “Caregiver experiences of public services following child trauma explore: a qualitative study” (2018). To conduct this appraisal, I use the Joanna Briggs Institute’s Critical Appraisal Checklist for Qualitative Research as a guide. I use this checklist because a thorough analysis of qualitative appraisal instruments finds this checklist to be the most coherent tool given its focus on congruity between research philosophy, design, and methods (Hannes et al., 2012).  I use the checklist to report the strengths, areas of concerns, and weaknesses in Williamson et al.’s study and discuss their implications. I conclude that the study has strong theoretical validity; the concepts and phenomena discussed in the research can act as building blocks for understanding the experiences and context of the participants in relation to the research question (Huberman and Miles, 2002, p. 51). While the philosophical and methodological underpinnings of the research are scantly discussed, and the impact of the researchers on the results is not thoroughly considered, these flaws are not fatal and they do not interfere with the researchers’ objectives. The authors indicate possible limitations of their research and do not draw faulty or unsubstantiated conclusions. As a result, the shortcomings of this article should only be used to contextualize where and how the research findings can be used. Ultimately, the findings provide an initial understanding to a previously underexplored area of research: how caregivers of child trauma victims in low and middle income countries (LMICs) experience interactions with public services.

Summary of the study’s aims and methods

Williamson et al.’s qualitative study aims to explore how the caregivers of child trauma victims in LMICs experience accessing and interacting with public services after their children have been exposed to trauma (2018). To undergo this exploration the authors conduct semi-structured interviews with 20 female caregivers of children who have experienced trauma, from Khayelitsha, a high-risk settlement in Cape Town, South Africa (pg. 2). Participants were recruited using opportunity sampling and snowball sampling methods (pg. 2). Interview questions focused primarily on caregiver experiences following child trauma exposure but there were also questions on caregivers’ perceptions of the formal support available from public services as well as their views on the need for and barriers to formal support (pg.3). The authors’ use thematic analysis to identify key themes relating to caregivers’ experiences and interactions with public services following child trauma exposure (pg. 3).

Weaknesses in the study

In qualitative studies, the researcher plays an active role in both developing data and constructing meaning; they are not solely a “pipeline for transmitting knowledge” (Holstein and Gubrium, 1997, pg 113). Knowledge is constructed through the collaboration between the interviewee and researcher therefore it is essential that a researcher describe their positionality to contextualize their findings and be reflexive in their research process to hypothesize their impact on the research and research subjects.

Positionality

The first main area of weakness in the study is that the authors do not state their philosophical perspective as a way of explaining their research approach or methodology.  Further they do not explicitly state their theoretical background.  While this weakness could be considered a reporting issue (this information could have been omitted because of word limitations), the complete omittance of positionality could be an indication that the researchers did not consider these aspects at all and in turn could impact the validity of the results. Knowing an author’s positionality is crucial for understanding why and how they made methodological decisions in the research and for contextualizing the results (Bourke, 2014). In Williamson et al.’s article, assumptions regarding the authors ‘position’ are not made explicit, and the reader is left to use the information that is presented to infer the theoretical, philosophical, and methodological underpinnings that guided the approach the researchers took.

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Given that the authors state that their aim is to “explore” suggests that they need to understand more about a phenomenon rather than measure it (Williamson et al., 2018, pg. 2). Therefore, it is inferred that the authors underlying theory for engaging in this type of research is interpretivism (Green and Thorogood, 2018). In this view, it is assumed that people are, for the most part, “rational and sensible in their choices and in understanding the constraints they are under, what their priorities are, and what they are trying to achieve” (Green and Thorogood, 2018, pg. 19). Through relying on semi structured interviews Williamson et al. ask questions about peoples’ interpretations of the reality of the world rather than trying to discover the reality itself. The authors are exploring a phenomenology and justify this approach through claiming that little is known about how families of victims interact with services in high risk LMIC contexts, and that their study will have implications for the improvements of clinical practice and policing practices (Williamson et al., 2018).

Through their objectives and methodology, the author’s theoretical perspective on the role of knowledge, how it is acquired from research activities, and what ‘counts’ as valid knowledge about the world can be inferred. As a result, while the study does not explicitly state a philosophical or theoretical background, this weakness is not fatal to the validity of the authors’ research (Green and Thorogood, 2018).

Reflexivity

Relatedly, the second main area of weakness in this study is that authors give little indication of how they influence the research and the research participants. While philosophical and theoretical positioning can be inferred, estimating the impact that the author has on the results is more difficult to understand. The authors describe a number of steps taken to ensure the credibility and reliability of their analysis however there are flaws in some of the decisions the authors make. First, the researchers indicate that data collectors undergo a process of “peer debriefing”  (Williamson et al., 2018). “Peer debriefing” helps to maintain descriptive and interpretive validity and ensure that the codes and themes they applied accurately reflected the sociocultural context of participants (Huberman and Miles, 2002). While this process could be construed as an attempt by the researchers to show that they are aware that cultural differences influences data collection and interpretation, the authors do not provide information on the cultural background, diversity, or positionality of the data collectors themselves. A better way of incorporating the sociocultural context would be to work with local partners and experts in this debriefing. Further, while peer debriefing is important to ensure the credibility and trustworthiness of the findings, this process does not consider the ways in which the research process could impact the research subjects and the findings.

Second, the author’s state that they engaged in reflective and reflexive practices throughout the research process; they sought feedback regarding interpretation of the data, completed reflective memos throughout data analysis, and the lead author kept a reflexive journal throughout the process (Williamson et al., 2018, pg. 3). Reflexivity involves researchers explaining how and why they focused on their research question, why it is important to them, what they hope to accomplish, and how the answers to these questions could affect the data produced and the interpretations made (Green and Thorogood, 2018). While the authors thoroughly engage in reflexivity and reflection in the data analysis stage, they do not consider if and how this reflective process shaped or could shape their research at any stage from the development of objectives to interpreting the findings.

This weakness is not fatal to the reliability of the research. The researchers take other steps to consider the impact of their research. They provide training to data collectors and analysts on the nature, function, and conduct of qualitative research methods, the potential impact of traumatic events on individuals, and the objective of each interview question. They also facilitate mock interviews and  generate feedback from the broader research team (Williamson et al., 2018, pg. 2).

Areas of concern

Williamson et al. draw conclusions in their research based on the transcribed interviews (2018). The text that is generated through the interview process serves as the evidence from which the authors pull their key themes and sub themes. The authors ensure that participants’ voices are represented in the report by providing illustrations from the data. For each of their seven sub themes, the authors provide one or two anonymized excerpts from their data. In all instances, the evidence provided clearly supports the conclusions the authors have drawn regarding the sub theme. For example, the authors describe that caregivers perceived the police to be unable to offer support as they were overwhelmed by the problem and able to offer only limited protection (pg. 4). This sentiment aligns with the quote that the authors provide as evidence  for this claim. In the quote a mother discusses that she is losing hope that the police are able to stand up to “the gangsters” perpetrating crimes (pg. 4). Ultimately, the quotes provided in the analysis are congruent with the interpretations made by the authors. However, the authors do not explicitly indicate the criteria for determining a theme or subtheme. Why were some aspects of participants answers included and others omitted? How many times did sentiments have to appear for the authors to code them as a subtheme? Without answers to these questions there is a lack of transparency on the completeness of the results. Further, while the authors do take the important steps to ensure confidentiality, they do not acknowledge which if any of the excerpts are coming from the same participant.

Ultimately there are some concerns over how the authors deem certain sentiments relevant and worthy of a theme and there is little clarity of the prevalence of these themes across participants. However, these concerns do not act as a fatal flaw and could instead be a weakness in reporting.

Strengths of the study

The strengths of this qualitative study outweigh its weaknesses and areas of concern. The researchers secured appropriate ethics criteria to undergo a methodological research process that is congruent with: (1) the research objectives (2) the representation and analysis of data and (3) the interpretation of the results.

Research methodology and research objectives

Although the authors’ do not provide a name or give philosophical/theoretical context for their methodological decisions, their objective to “explore and understand” the experiences of caregivers who have a child that has experienced trauma is consistent with the methodological actions used. The authors’ decision to conduct semi-structured interviews is consistent with the desire to begin to understand a particular issue. Semi-structured interviews allow researchers to explore certain phenomena while also not adhering to prespecified themes. In semi-structured interviews the researcher sets the agenda and guides the conversation allowing participants torespond in different ways (Green and Thorogood, 2018). In Williamson et al.’s study the researchers set the agenda in terms of the topics covered, but allow the interviewees’ responses to determine the kinds of information produced about the topics (ie. the themes and subthemes generated) (Green and Thorogood, 2018). Further, the sampling method (opportunity and snowball sampling) used is sufficient given that they are undertaking an exploratory study (Williamson et al., 2018, pg. 2). More systematic purposive sampling strategies would only be needed for studies wanting to generate more representative data (Green and Thorogood, 2018).

Congruity between the research methodology and the representation and analysis of data

The semi-structured interview component of the research methodology focused on how caregivers of child trauma victims perceive formal support available from public services as well as the support and barriers to formal support. The types of interview questions asked lend themselves well to the thematic analysis approach used by the researchers. Thematic analysis aims to discover the central aspects of a set of accounts and to establish patterns of meaning within the data collected (Green and Thorogood, 2018).  Thematic analysis allows the researchers to examine all of the data and identify, code and report on, relevant or recurring themes. Using this method, the researchers categorize experiences to summarise findings and then assess the variation or irregularities in the data (Green and Thorogood, 2018). Williamson et al.’s decision to use thematic analysis to analyse the data is consistent with the ways in which the researchers structured their data collection. Williamson et al. provide a clear and concise summary of the topics covered across the data set  (pg. 3-6).

Congruity between the research methodology and the interpretation of results.  

The research method is aligned with the types of interpretations the authors draw from their evidence. The researchers discuss the limitations of the study and argue that they expand on the extremely limited research of the experience and challenges faced by caregivers in accessing formal support from public services following child trauma exposure in an high-risk context. This claim is not ambitious and it appears to hold true. The study does not make any firm policy recommendations, attempt to generate a checklist or framework, or make any generalizations beyond the context in which the interviews were conducted. The purpose of this study was to explore and understand families’ experiences of accessing formal support and interacting with public services following child trauma in low and middle income contexts. The authors clearly establish the prevalence of child trauma in South Africa. They also provide good justification for why it is important to look at caregivers in South Africa: Parents of children exposed to trauma in Khayelitsha have been found to “report significant anxiety for their child’s physical safety and feel helpless to prevent future trauma” and little is known about families’ experiences of interacting with services post-trauma in high- risk, LMIC contexts (pg. 2).

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The results of the study are theoretically valid (Huberman & Miles, 2002). The results section highlights cases where there appears to be a limited attempt by public services to deliver support and treatment to families and the author’s do not inappropriately extend their findings; they add that additional research is needed to investigate “feasible improvements” to public services in LMIC (pg. 7).

Conclusion

Williamson et al.’s study is not “perfect.” The author’s do not articulate their positionality or philosophical background and they do not explain their influence or impact on the research process, methods, data analysis, or interpretations. This is a concern in qualitative research. When sample sizes are small and evidence collection relies heavily on interpersonal interaction, it is essential that the authors explain their positionality and their impact on the research (Green and Thorogood, 2018). Even though this insight is not provided in Williamson et al,’s study, the findings still have validity. The researchers give importance to the rigour and sensitivity needed to conduct qualitative analysis. Further, there is strong congruency between the objectives of the research, the research methods, and the ways the authors analysed and interpreted the data.

References

• Bourke, B. (2014). Positionality: Reflecting on the research process. The qualitative report, 19(33), 1-9.
• Green, J., & Thorogood, N. (2018). Qualitative methods for health research. Sage.
• Hannes, K., Lockwood, C., & Pearson, A. (2010). A comparative analysis of three online appraisal instruments’ ability to assess validity in qualitative research. Qualitative health research, 20(12), 1736-1743.
• Huberman, M., & Miles, M. B. (2002). The qualitative researcher’s companion. Sage.
• Mays, N., & Pope, C. (2000). Assessing quality in qualitative research. Bmj, 320(7226), 50-52.
• The Joanna Briggs Institute. Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews Checklist for Qualitative Research. 2017. http://joannabriggs.org/assets/docs/critical-appraisal-tools/JBI_Critical_Appraisal-Checklist_for_Qualitative_Research2017.pdf
• Williamson, V., Halligan, S. L., Coetzee, B., Butler, I., Tomlinson, M., Skeen, S., & Stewart, J. (2018). Caregiver experiences of public services following child trauma exposure: a qualitative study. International Journal of Mental Health Systems, 12(1), 15.