Is my mum going to hear this? Methodological and ethical challenges in qualitative health research with young people

Research Ethics of Involving Adolescents in Health Research Studies: Perspectives From Australia

PURPOSE

Adolescent participation in health research studies is critical yet complex given the lack of clarity around issues such as consent. This study aimed to understand how those conducting research in Australia navigate research ethics in health research involving adolescents, through qualitative interviews.

METHODS

Purposive sampling was used to recruit 23 researchers involved in adolescent health research using semi-structured in-depth interviews. Interviews were conducted via Zoom and audio-recorded after obtaining informed consent. Thematic analysis was used to construct themes and data were organised using NVivo.

RESULTS

Two contrasting positions emerged from the data: (1) framing of adolescents as inherently vulnerable, their participation in research understood in terms of risk and protection and (2) adolescent engagement in research is understood in terms of empowerment, emphasising their capacity to make decisions about research participation. We traced these positions through three key themes, particularly in relation to the role of ethics committees: (1) competing positions as a result of inferior or superior knowledge about adolescent lives, (2) competing positions resulting in a risk averse or an empowerment approach, and (3) reflections on processes of obtaining consent which involves gatekeeping and tokenism.

DISCUSSION

Our study highlights the contentious topic of navigating ethics committee requirements for the needs of adolescents. Majority of participants felt the current research ethics establishment is not favourable for researchers or adolescents themselves. While it is imperative that perceptions of ethics committees also be studied in the future, our study provides preliminary understanding of how experiences and perceptions shape how researchers interact with the research ethics establishment.

Recruiting hard-to-engage groups to online psychosocial interventions: Experiences from an RCT study targeting adolescents with a visible difference

Online interventions have the potential to reach individuals who are otherwise difficult to engage due to stigma and sensitive topics. However, these individuals also tend to be hard to recruit in clinical trials, a crucial step in order to provide evidence-based interventions. This highlights a need for more information about efficient recruitment strategies for difficult-to-engage groups. The present study aimed to share the systematised experiences of recruiting adolescents with a visible difference to an online psychosocial intervention RCT. With the intention to recruit 160 participants (age 12-17), recruitment efforts were nationwide and included multiple arenas (e.g., hospitals, schools, social media), and methods (e.g., in-consultation, targeted letters, posters). Ultimately, 102 participants were recruited, and results showed that recruitment involving patient organisations, hospital departments, and specialised resource centres were most successful in reaching participants. The most efficient recruitment strategy was targeted letters sent home to eligible patients/members, as 78% of the participants were recruited this way. Media and social media recruitment efforts yielded comparatively few participants. No participants were recruited through schools and educational health care services, primary health care services, or municipal and regional authorities. Our results are discussed in relation to barriers with recruiting difficult-to-engage groups to RCTs, providing useful recruitment tools to future similar studies. For instance, future studies are recommended to utilise targeted approaches over general population approaches. Also, results from recruitment efforts should routinely be reported, as this ultimately will provide more general strategies for effective recruitment and support studies in reaching recruitment goals.

Clinical research with adolescents: barriers and how to overcome them

PURPOSE OF REVIEW

This review aims to emphasize the importance of including adolescents in research, outline current standards and evaluate barriers that prevent adolescent research. We also hope to provide some guidance and call for much needed additional direction in the field.

RECENT FINDINGS

The absolute necessity for including adolescents in research has been an area of focus within the community of adolescent providers and care takers. Recent policy and support from major organizations has emphasized the importance of including this population in research but also pointed out many of the complexities.

SUMMARY

Adolescent research is imperative to guiding policy and promoting evidence-based care. Current standards provide both guidance and barriers, yet more research is needed to further guide conduct of ethical research in this population.

Accommodating interruptions: A grounded theory of young people with asthma

AIMS AND OBJECTIVES

The aim of this study was to develop an explanatory theory on the lives of young people with asthma, issues affecting them and the impact of asthma on their day-to-day lives.

BACKGROUND

Accommodating Interruptions is a theory that explains young people's concerns about living with asthma. Although national and international asthma management guidelines exist, it is accepted that the symptom control of asthma among the young people population is poor.

DESIGN

This study was undertaken using Classic Grounded Theory.

METHODS

Data were collected through in-depth interviews and clinic consultations with young people aged 11-16 years who had asthma for over 1 year. Data were also collected from participant diaries. Constant comparative analysis, theoretical coding and memo writing were used to develop the substantive theory.

RESULTS

The theory explains how young people resolve their main concern of being restricted by Accommodating Interruptions in their lives. They do this by assimilating behaviours in balance finding, moderating influence, fitting in and assuming control minimising the effects of asthma on their everyday lives.

CONCLUSION

The theory of Accommodating Interruptions explains young people's asthma management behaviours in a new way. It allows us to understand how and why young people behave the way they do because they want to participate and be included in everyday activities, events and relationships. The theory adds to the body of knowledge on how young people with asthma live their day-to-day lives and it challenges some existing viewpoints in the literature regarding their behaviours.

RELEVANCE TO CLINICAL PRACTICE

The findings have implications for developing services to support young people in a more meaningful way as they accommodate the interruptions associated with asthma in their lives.

Intentional strengths interviewing in occupational justice research

BACKGROUND

Occupational justice research can generate knowledge about societal conditions that support participation in meaningful occupations. This is useful because occupational therapy's human rights goal is to create societal conditions that are conducive to occupational engagement. Participants in this research field are likely to be vulnerable and need special ethical considerations. However, no model exists to support ethical considerations for vulnerable participants in occupational justice research.

AIM

This study aimed to develop a model for additional ethical considerations for occupational justice research with vulnerable participants.

MATERIALS AND METHODS

A secondary analysis was carried out on data from a previous study with asylum seekers. Data included semi-structured interview transcripts with seven asylum seekers, researcher memos, and text from the researcher's written report. Template analysis was employed.

RESULTS

The Intentional Strengths Interviewing model was developed. It has three component strategies: strengths-informed interview processes, strengths questioning, and strengths responding.

CONCLUSION AND SIGNIFICANCE

This model might be considered in the design of future occupational justice research involving vulnerable participants in order to best support their inclusion. This model might support future occupational justice research and might be evaluated in other contexts.

Client and parent feedback on a Youth Mental Health Service: The importance of family inclusive practice and working with client preferences

In mental health settings, feedback from clients and carers is central to service evaluation, development and delivery. Increasingly, client and carer feedback is considered an integral part of service planning, and recognized as a critical element of the provision of recovery oriented service. This paper outlines the findings of a qualitative evaluation of a Youth Mental Health (YMH) service from the perspective of discharged clients and their parents. The service researcher conducted telephone interviews with 39 parents of discharged clients, and 17 young people themselves. Participants reported positive or mixed experiences with the service. In addition to more generic positive statements about the service, analysis identified two key themes: the importance of 'family inclusive practice' and the importance of 'working with client preferences'. Young people and their parents want to be actively engaged in treatment and have their treatment preferences considered in treatment planning. Participants expressed the importance of "a good fit" between the client and the worker in terms of the clinician's gender, personality and treatment style/modality. While for some participants these themes were raised in the context of service strengths, others identified them as limitations or opportunities for service improvement. The extent to which clients and their parents felt engaged and heard by their allocated clinician is critical to their satisfaction or dissatisfaction with the service, depending on their unique experience. As an outcome of this evaluation, a range of service improvement strategies have been recommended.

How Not to Let Secrets Out When Conducting Qualitative Research With Dyads

Confidentiality is one of the cornerstones of research involving human participants. Researchers are the frontline gatekeepers of their participants' right to confidentiality, and situations can arise that challenge this responsibility. This is the case when individuals who have shared a common experience (i.e., dyads) are interviewed separately, but interview results are disseminated within the context of dyads. Based on our experience of conducting research with dyads and given how little literature is available to serve as guide, we set out to write this article to share the knowledge we acquired and the solutions we found. We will describe both the ethical challenges and the methodological decisions involved in conducting qualitative research with dyads. The article also describes different modalities of dyadic analysis, their benefits and drawbacks. This endeavor seems especially relevant as research with dyads is emerging in several domains involving couples, families, caregivers and health.

How can we better serve adolescent key populations? Strategies to encourage and inform future data collection, analysis, and use

Young key populations (ages 10-24) (YKPs) are uniquely vulnerable to HIV infection. Yet they are often underserved, due in part to a limited understanding of their needs. Many successful approaches to understanding YKPs exist but are not widely used. To identify the most useful approaches and encourage their uptake, we reviewed strategic information on YKPs and experiences collecting, analysing, and utilising it from countries in Africa, Asia, and Central and Eastern Europe. As a result, we recommend one central guiding principle - any effort to understand and serve YKPs should include a specific focus on adolescent key populations (AKPs) (ages 10-19) - and three strategies to inform data collection, analysis, and use: tailor recruitment practices to ensure young people's representation, select indicators and research methods based on their ability to inform responsive programming for and give a voice to YKPs, and thoroughly disaggregate data. We demonstrate the utility of each strategy in YKP research and programmes, and in doing so note the particular importance for AKPs. We hope that this paper encourages additional research on YKPs and helps bridge the gap between research and effective programmes to serve the youngest and most vulnerable members of key populations.

Be my guest! Challenges and practical solutions of undertaking interviews with children in the home setting

This article aims to share critical debate on undertaking interviews with children in the home setting and draws on the authors' extensive research fieldwork. The article focuses on three key processes: planning entry to the child's home, conducting the interviews and exiting the field. In planning entry, we include children's engagement and issues of researcher gender. In conducting the interviews, we consider issues such as the balance of power, the importance of building a rapport, the voluntary nature of consent and the need for a flexible interview structure. Finally, we address exiting from the child's home with sensitivity at the end of the interview and/or research study. Undertaking research in the child's home provides a known and familiar territory for the child, but it means that the researcher faces a number of challenges that require solutions whilst they are a guest in a child's home.

Thank you for your lovely card: ethical considerations in responding to bereaved parents invited in error to participate in childhood cancer survivorship research

Research exploring the needs of families of childhood cancer survivors is critical to improving the experiences of future families faced by this disease. However, there are numerous challenges in conducting research with this unique population, including a relatively high mortality rate. In recognition that research with cancer survivors is a relational activity, this article presents a series of cases of parents bereaved by childhood cancer who unintentionally received invitations to participate in survivorship research. We explore six ethical considerations, and compare our experiences with that described previously. Our considerations include the sharing of confidential information with external parties to confirm past patients' vital status and appropriate researcher responses to bereaved parents. The management of researchers' emotional safety when working with illness populations and the fact that study invitations can elicit grief responses in non-bereaved families are discussed. To conclude, we argue for the benefits of inviting bereaved parents whose children died after treatment completion in survivorship research. Such parents' early survivorship experiences will otherwise be systemically neglected. We argue that discussing complex cases can assist researchers to protect participants' and researchers' emotional well-being. We hope to contribute to the dearth of discussion about research operating procedures to address these issues.

Confidentiality, privacy, and respect: experiences of female sex workers participating in HIV research in Andhra Pradesh, India

Female sex workers (FSWs) from Andhra Pradesh, India, who had participated in HIV research were interviewed to examine participant perspectives on research ethics. Content analysis indicated that aspects of the consent process, staff gender and demeanor, study environment, survey content, time requirements for study participation, and perceived FSW community support for research were key factors influencing whether FSWs perceived their confidentiality and privacy had been maintained, and whether they felt the study was conducted respectfully. Findings suggest that partnership with community-based organizations and investigation of participant's experiences in HIV prevention research can provide critical information to best inform research ethics protocols, a particular priority among research studies with highly stigmatized populations, such as FSWs.

Developing biographies: the experiences of children, young people and their parents of living with a long-term condition

This article reports on data from a qualitative interview study that sought to understand the experiences, choices and actions of children and young people undergoing surgery for a long-term condition and that of their parents. Using the concept of biography the article examines how the biographies of children, young people and their parents can be influenced by surgery and the ongoing management of a long-term continence condition. This article challenges previous work that characterises the presence of a condition from birth as a continuous and normal part of the illness experiences of these patients. Although this may be the case in some instances, children, young people and their parents can experience diverse and changing experiences associated with ongoing condition management as well as surgery. Biographical continuity, enrichment and disruption are all relevant concepts for such patients living with a long-term continence condition. These can be influenced by their previous experiences of their condition, their expectations, and dynamics with parents, including changes associated with development and the increasing independence of young people.

The ‘other participant’ in the room: The effect of significant adults in research with children

This article discusses the practical implications and ethical dilemmas of ‘other’ adults being present in a research setting where the participant is a child. The article focuses on three key issues in relation to this theme. First, the range of ways that ‘other’ adults (for example, parents or guardians, teachers or youth workers) may become involved in the process of research is discussed. Second, the article considers how the presence of ‘other’ adults may raise ethical challenges, impact on the research process, and ultimately affect the data collected. Finally, suggestions are offered for the range of strategies open to researchers in negotiating the involvement of ‘other’ adults within a research context.

Addressing methodological and ethical challenges of qualitative health research on persons with schizophrenia and bipolar disorder

Qualitative studies of persons with schizophrenia and bipolar disorder may affect clinical practice and social policy. However, methodological and ethical challenges may present during studies of persons with these specific mental illnesses. The purpose of this paper is to increase transparency about how researchers addressed these challenges during a recent grounded theory study about engagement in primary care. As the researchers addressed the challenges, they increased understanding about persons with schizophrenia and bipolar disorder. They also gained insight about the challenges of studying persons with these specific mental illnesses and about the rigor and credibility of qualitative methods.

Ethical issues in health-care inquiry: a discussion paper

This paper is a discussion of the possible ethical dilemmas that may arise in both qualitative and quantitative research despite stringent methodological protocols. Three categories of ethical issues will be elaborated on, namely, researcher-participant relations, informed consent and confidentiality and privacy. These are of note because ethical dilemmas most often arise in these areas. Both qualitative and quantitative research types may thus present with problems associated with any, or a combination, of these categories. Methodological rigour will also be discussed as a vital component of any research study. Critics of the qualitative approach have often suggested that the innate lack of methodological rigour has resulted in the preponderance of ethical issues in qualitative studies. Qualitative studies, similar to quantitative studies, have mechanisms that guarantee rigour, quality and trustworthiness. These checks are at par with those of quantitative research but based on different criteria. Both types of research, then, can be considered equal in terms of methodological rigour, regardless of the nature. As no research approach can be perfectly free from threats of ethical issues, it is the researcher's responsibility to address these in ways that will be less harmful to the participants, bearing in mind ethical problems can arise at any time during the research endeavour.

Informative privacy and confidentiality for adolescents: the attitude of the Flemish paediatrician anno 2010

Confidentiality is a major issue in adolescent healthcare, and its perceived absence may be the main barrier for an adolescent to seek medical care. Little is known about the right on informative privacy and confidentiality for adolescents in Belgium, although these rights are unambiguously foreseen in the law on patients' rights since 2002. There are no data available regarding the introduction of a private moment with the physician during a consultation, about the nature and the quantity of information made available to parents by the paediatricians regarding the health situation of adolescents and about the existence of procedures with regard to these matters. The purpose of this study is to map out the current interpretation and the attitude of the paediatrician with regard to the right to confidentiality and informative privacy. The answers of 117 Flemish paediatricians to an anonymous questionnaire were analyzed. An unaccompanied medical visit is not frequent in Belgium (only 1%). Only 35.1% of the paediatricians systematically offer the possibility to have a private conversation with an adolescent. Almost 80% of the paediatricians render, as a rule, all information to the parents. Parents are informed about sensible information regarding psychosocial aspects, including data concerning sexual behaviour, in not less than 83.2% of the consultations by adolescents. Only in 2.9% no information is given to the parents. The paediatricians employ only for 13% the procedures regarding confidentiality for minors. This study reveals that Flemish paediatricians have a paternalistic attitude concerning the right on confidentiality and informative privacy, which is not in line with the Belgian legislation. Paediatricians offer only seldom the possibility for a private conversation to the adolescent. The small incidence of unaccompanied medical consultations contributes to this. Proper application of the legal context, the handling of the watertight procedures and the necessary communication in this respect is indispensable for the confidence and will lower the barrier for adolescents to use the healthcare system.

Visual storytelling: a beneficial but challenging method for health research with young people

Visual storytelling is a new research approach drawing on established methods of photovoice and photo elicitation. It appears well suited to research with young people. We explored the feasibility of this approach, reflecting on benefits and challenges encountered while using it during a study of chronic disease self-management in adolescents. During in-depth interviews, 68 participants were questioned about the value of visual storytelling. Thematic analysis was applied. Visual storytelling was valued for (a) being a draw card during recruitment and increasing positive feelings about the research; (b) being fun; (c) promoting self-understanding; and (d) promoting expression, communication, and focus during interviews. Deciding what to photograph was difficult. More time and effort was required by researchers than for a standard qualitative interview study. The technique facilitated rich interviews, drawing into focus details of young peoples' lives that otherwise might not have been discussed.