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The sound of 'silence': a framework for researching sensitive issues or marginalised perspectives in health Laura Serrant-Green Journal of Research in Nursing 2011 16: 347 originally published online 16 November 2010 DOI: 10.1177/1744987110387741 The online version of this article can be found at: http://jrn.sagepub.com/content/16/4/347

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Original Paper

The sound of ‘silence’: a framework for researching sensitive issues or marginalised perspectives in health

Journal of Research in Nursing 16(4) 347–360 ! The Author(s) 2010 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1744987110387741 jrn.sagepub.com

Laura Serrant-Green Professor of Community and Public Health Nursing, School of Health and Social Care, University of Lincoln, UK

Abstract This paper arises from the conceptual framework underpinning a research study focusing on black Caribbean men’s sexual decisions and health behaviour. In investigating these issues the notion of ‘screaming silences’ was developed to unite the theoretical and philosophical approaches that underpinned the research, the experiences of the researcher and participants involved. While ‘screaming silences’ was initially applied to a sexual health and ethnicity context it provides a useful basis for a theoretical framework for researching sensitive issues or the health care needs of marginalised populations. ‘Screaming silences’ (or ‘silences’) define areas of research and experience which are little researched, understood or silenced. ‘Silences’ reflect the unsaid or unshared aspects of how beliefs, values and experiences of (or about) some groups affect their health and life chances. They exposed issues which shape, influence and inform both individual and group understandings of health and health behaviour. This paper presents the notion of ‘screaming silences’ with reference to the original study and maps out a four-stage framework for its utilisation in ethnicities based and sensitive research. It is presented here for use by other researchers as a vehicle for exposing additional perspectives in studies involving sensitive subjects or marginalised populations. Keywords inequalities, marginalised perspectives, methods, sensitive research

Introduction There are many instances in which conducting research requires the researcher to address issues which are deemed sensitive by a particular society, or entail investigating the Corresponding author: Laura Serrant-Green, Professor of Community and Public Health Nursing, School of Health and Social Care, University of Lincoln, Bridge House, Brayford Pool Lincoln LN6 7TS, UK Email: [email protected]

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experiences of marginalised populations. Historically and pragmatically these subjects have been difficult to investigate as they bring with them a host of concerns for researcher, participants and communities around the ethical, moral and occasionally personal challenges embodied within them. As a result of these perceived difficulties research on ‘sensitive’ issues or marginalised perspectives may be avoided by researchers or conducted within the relative safety of a ‘sanitised’ survey. This was the case with the research study which initiated the development of the framework presented in this paper. The initial research study began in 2000 and focused on black Caribbean men, their sexual decision making and risk taking (Serrant-Green, 2004). This research study involved the investigation of issues pertaining to aspects of ethnicity and gender from an overtly black Caribbean female perspective. The research was therefore closely associated with a host of politically sensitive and personally problematic concerns related to issues of gender, ethnicity and sexual behaviour. Many of the general concerns relating to conducting such research have been well critiqued in the literature and were neither new or unique to the study (see Hooks, 1992; Hammersley, 1995). However, the study took place at a time when HIV/AIDS and other public consequences of private choices were becoming increasingly high on the political and health agendas. At the time, the resultant political and cultural discussions, arguments and strategies uniting health, sexual activity and ethnicity were inextricably linked with morality and social expectations around behaviour in society. To a large extent, research studies on these subjects relied on the use of surveys as the main form of enquiry into sexual health and ethnicity due to a range of factors including recognition of the difficulty in researching such sensitive subjects and the government’s reluctance to take political risks on this platform (Fenton et al. 1997; Lacey et al. 1997; Low et al. 1997). By confining research about sexual health and ethnicity into the more ‘objective’ scientific paradigm, many believed it would be possible to avoid public discussion or exposure of an embarrassing and politically sensitive issue. The traditional reliance on survey data, however, meant that the evidence base for understanding some of the cultural, ethnic or contextual nuances influencing the ‘statistics’ was scarce. In addition, the lack of review, critique or contribution of the minority ethnic perspective resulted in a consistently uni-dimensional presentation of research findings which linked ethnicity with ‘risky’ sexual behaviours and poor personal choices. This elicited for me a feeling of ‘unease’ about conducting my research wholly within a tradition where the interplay of these factors, from the perspective of the researcher and marginalised group themselves, remained relatively unexplored. In order to acknowledge and manage this ‘unease’ through and in my research, I formulated a conceptual viewpoint called ‘screaming silences’. The term ‘screaming silences’ (or ‘silences’) was used in my study to epitomise areas of research and experience which are at best under-researched and require more development, or are at worst historically and/or politically undervalued, absent or invisible (Serrant-Green, 2004). In simple terms, ‘silences’ reflect viewpoints and information that are not openly said, heard or evidenced in the available (mainstream or easily accessible) bodies of literature related to a specific subject. The paper will begin by briefly identifying the broader theoretical approaches underpinning the concept of ‘screaming silences’ with reference to aspects of the original study that gave rise to it. I will then present the framework for research arising out of the concept. This framework is presented here to encourage further scrutiny, comment and use by others.

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Underpinning theoretical approaches ‘Screaming silences’ is derived from anti-essentialist viewpoints which accept that reality is neither objective, nor fixed, rather the social world is constructed and determined by human beings in a particular society at a particular point in time (Williams and May, 1996). ‘Screaming silences’, therefore, values individual or group interpretations of events and human experiences as a key part of what people believe to be ‘truth’. An important point arising out of this is that ultimately ‘screaming silences’ are situated in the subjective experiences of individuals or groups (known as ‘the listener’) and the social and personal contexts in which their experiences occur. The name ‘screaming silences’ reflects how an issue, as experienced by the listener, ‘screams’ out to them in relation to their health, because of its relationship or impact in their reality. Conversely, the same issue may be relatively ‘silent’ in the consciousness or experience of the greater majority in society, or absent from the available evidence base where it fails to have wider impact on shared aspects of health. The listener is therefore the person who identifies, prioritises or responds to a particular ‘silence’. Variations in experiences occurring between individuals or groups in different contexts elicit variations in terms of which ‘screaming silences’ are ‘heard’, the importance placed on the ‘silence’ and the impact it is perceived to have (how loud the scream is). The approach to research encourages recognition that researchers are no different to anyone else in being influenced by their experiences of being socialised into particular beliefs about the world and individuals in it (Stanfield and Dennis, 1993; Hammersley and Gomm, 1997). The ‘silences’ identified in my original research were initially located by me as researcher and lead to the choice of ethnicity and sexual health as a subject of study. Further ‘silences’ were revealed as the study progressed through other participants in the study. ‘Screaming silences’, like many aspects of any society are a product of the time spaces they occupy and the way in which the effects of power and inequality are experienced by an individual in a particular timeframe. ‘Screaming silences’ may be derived from, or illustrate, the ways in which power is used to determine an arbitrary norm at a particular historical and political point in a society. This perspective has been explored in detail through the work of Foucault, particularly in relation to sexuality and sexual expression and acted as the catalyst to the author’s thoughts around linking political or moral acceptability in a society to the validation (or otherwise) of personal experiences (see Foucault, 1998, 2002). The historical and political domination of research from the dominant perspective in this society, therefore, influences not only the interpretation of research but also the type of research projects conducted and funded in the public arena (Millen, 1997; Pilcher, 2001). This results in a situation where ‘gaps’ exist in the terms of the range of approaches, experiences and viewpoints presented through research and in the type of studies conducted (Hammersley, 1995; Mason, 2002). ‘Screaming silences’ are located in these gaps and closely associated with some of the issues arising out of these wider debates.

Marginalised discourses In occupying these research ‘gaps’ ‘screaming silences’ can be associated with what some have identified as marginal discourses (Foucault, 1972; Ifekwunigwe, 1997; Afshar and Maynard, 2000). Marginal discourses are related to mainstream discourses in that they fulfil the same basic function in identifying bodies of knowledge, beliefs or assumptions about the world we inhabit and ourselves as human beings (Sawicki, 1991). However, the

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marginal nature of these discourses is exemplified by the fact that they are the positional ‘other’ to an arbitrary norm. As ‘other’ they are often positioned low down in the official hierarchies of a society where power is located and may even be presented as being far removed from the lived experiences of people within a given society (Hooks, 1992; Hammersley, 1995). As such research focusing or arising out of these less valued views of society may be taken less seriously or deemed inadequate. In my research marginal discourses were located though the central role played by experiences of racisms and ethnicities on the sexual health decisions of black Caribbean men. ‘Screaming silences’ enabled active recognition of the marginal nature of these viewpoints in my research and provided the basis for a framework in which they could be valued, explored and critiqued. Research based on ‘screaming silences’ is thus aligned with philosophical approaches that recognise all aspects of life, even scientific discoveries, as being influenced by a range of factors including human beliefs, social change and politics (Hollis, 1994). At the core of research embodying this philosophy such as feminist, ethnicities and criticalist based approaches lies a belief that any interpretation of the world, whether presented in the guise of formal, written scientific research or in verbal reports of lived experience, is always subjective and carried out from a particular political and social viewpoint. Maintaining personal experiences is a central and valuable component of ‘silences’ based research. ‘Screaming silences’ therefore draws on feminist, ethnicities based and criticalist viewpoints where personal experiences are critical strategies in freeing research from rigid adherence to traditional or dominant discourses (Solorzano, 1998; Seibold, 2000). In centralising personal experience in their discussions, these approaches highlight diverse experiences in society and relate them to the effects of living in an inequitable society rather than presenting them simply as matters of personal choice. The influence of critical perspectives on society and experience inherent in these approaches suggests that research that simply describes experiences provides insufficient information for it to be fully judged (Scott, 1991). These perspectives therefore encourage any examination of issues related to human experience to occur within theoretical, political or action focused frameworks while appreciating the variety and diversity of human experience. Proceeding beyond disclosure is therefore an important aspect of research conducted utilising the concept of ‘screaming silences’. The general beliefs underlying these approaches are summed up by Scott (1991) who said: ‘Experience is at once always already an interpretation and in need of interpretation’ (Scott 1991: 779)

Positioning experiences which are personal, and to a degree subjective, at the centre of the concept of ‘screaming silences’ does not imply that agreement on the nature of some ‘silences’ does not exist. Common experiences and the effects of inequality on particular groups may produce situations in which members of a social group are aware of the same ‘silences’ even though they may have differing experiences of their effect. For example, the issue of ethnic homogeneity, a key aspect of my study, was at the time evidenced in more than just discussions of race and ethnicity. There is a history of evidence available in literature discussing similarities and differences in political and historical experiences in a range of spheres including women’s lives, heterosexism and racism (Christian, 1989; Brah, 1996; Ribbens and Edwards, 1998; Balsa and McGuire, 2002; Gill and Maclean, 2002). In each of these cases, while the individual nature of the experiences and ‘silences’ encapsulated by society’s homogeneous approach to people’s lives varied, a common experience of living

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with inequality lay at the core. Women, members of minority ethnic communities and gay/ lesbian researchers in particular have worked to redress the balance; however, research focusing on these marginal experiences remains in the minority. The concept of ‘silences’ was used as a central reference point in my study, to seek out the unknown and unspoken in the health and life experiences of the participants. These were then presented for the reader so that they could assess and reflect on my findings in the ‘light of the silences’ rather than despite them. In the years since the completion of the project I have worked to develop this concept into a theoretical framework which may be used by other researchers to guide completion of studies incorporating sensitive issues or marginalised perspectives in their work. The framework presented below has been devised to support the completion of such research studies with the aim of revealing and working with the ‘silences’ inherent in participant experiences in health.

‘Silences’ framework: a four-stage framework for research The ‘silences’ framework comprises four core stages pertinent to all research projects investigating sensitive issues or marginalised perspectives. The four core stages provide a framework to guide the research activity from conceptualisation of the research question through to helping structure the report. The four core stages are: . . . .

Stage Stage Stage Stage

1: 2: 3: 4:

Working in ‘silences’ Hearing ‘silences’ Voicing ‘silences’ Working with ‘silences’

A diagrammatic representation of the core ‘silences’ framework is shown in Figure 1. There also exists an additional fifth stage which is not applicable to all research but may be particularly useful where the research outputs required are more applied and/or for those

Stage 1: Working in ‘silences’

Stage 2: Hearing ‘silences’

(Contextualisation)

(Location)

(impact of completed research?)

(impact of time on current research?)

Stage 4: Working with ‘silences’ (Discussion)

Stage 3: Voicing ‘silences’ (Verbalisation)

Figure 1. The ‘silences’ framework for research

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utilising existing studies to produce an action plan for service delivery or community action. This fifth stage is: . Stage 5: Planning for ‘silences’ This paper will present the four core stages of the model in detail utilising examples from my own work in order to assist prospective users of the framework to conceptualise how it may be used in ‘real world’ research. A separate paper exploring the elements of stage 5 in depth and its possible use in specific action research or innovation research projects is currently under construction.

Stage 1: Working in ‘silences’ The purpose of research conducted from within an anti-essentialist approach to reality is to understand and describe events that occur but at all times seek to gain a clearer appreciation of the meanings ascribed to the event by the individual (Denzin and Lincoln, 1998). An appreciation of the inequality inherent in society and the impact this has on people’s experiences means that, in order to understand and make sense of the ‘silences’ that influence individual experiences and activities, it is important to consider the wider social as well as individual context in which decisions take place. The first stage of this framework begins with the researcher presenting a contextualised, situated exploration of the research subject which values personal experiences alongside the established theoretical debates. This first stage therefore sets the context for the research through a critical literature review. It begins by identifying the range and scope of existing knowledge relating to the research subject and the characteristics of the location in which the research takes place. It may include exploration of the cultural, clinical, psychosocial or moral arena in which the research will be conducted. In doing so it sets the proposed or planned research project within a particular timeframe in a specific society. The aim is to expose the ‘real’ world in which the research will take place. It begins from a position of acceptance that ‘silences’ exist and are inherent in the ‘imperfect’ world. In reviewing the literature (or what is known) the research also seeks out and presents for the reader the ‘silences’ heard within it. The aim is not to present an ideal picture of what should be, in isolation from ‘what is’ but to set out for the reader ‘how things are’ and ‘what is not evident or reported’ utilising the evidence and information sources easily accessed in the current public domain. The researcher’s exploration in this stage should conclude with an indication of the possible ‘gains’ for participant groups, health care practice and/or the available evidence base in optimising the health of individuals and groups involved as a result of the planned research. In essence, at conclusion of this stage, the researcher should aim to address for the reader the key question ‘why research this study at this particular time?’ based on exposure of ‘what we don’t know’ or ‘which stories are still to be told?’. For example, at the time of my research, quantitative studies demonstrated that in some areas of the UK the infection rates for STIs were up to 12 times higher in men from black Caribbean communities who in turn were less likely to present for STI treatment (Fenton et al., 1997; Lacey et al., 1997; Low et al., 1997). At that time there was very little published qualitative information on what factors were affecting the personal sexual health decisions of black Caribbean men and how this related to their use of sexual health services. The focus on ‘silences’ in the research

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provided a vehicle to through which the ‘risk data’ could be viewed alongside the political, social and personal context impacting on the sexual health decisions of black Caribbean men.

Stage 2: Hearing ‘silences’ The theoretical approaches underpinning the concept of ‘screaming silences’ stress the importance of recognising that as individuals and groups we ‘hear’ different ‘silences’. The key point is that it is the listener who identifies, conceptualises and ultimately lives with the manifestation of a particular ‘silence’ in their lives. ‘Silences’ have been defined above as areas of research or experiences which are for a host of reasons ‘little researched, understood, undervalued and silenced’. This second stage of the ‘silences’ model sets out to identify the ‘silences’ at the centre of the planned research. This stage therefore begins with an identification of the ‘silences’ inherent in conducting this research study, by this researcher at this time. The researcher, research participants and subject of the study are seen as existing in a dynamic and interdependent relationship within the context of the research set out in Stage 1. Completing this second stage requires the researcher to expose and reflect on the ‘silences’ arising out of this relationship as an inherent part of conducting this study. There are three aspects of the ‘silences’ which the researcher must present to support the reader to ‘hear’ as key features in the study. These aspects underpin and will ultimately inform the overall study design, data collection and analysis as well as any subsequent recommendations arising out of the study findings. These relate to the possible ‘silences’ inherent in researcher identity, the research subject itself and the nature of the research participants.

a) Researcher identity The researcher must precede active engagement in any study utilising this framework by identifying themselves in the study. ‘What is their relationship to the study?, what led them to study these issues? What are the personal/professional drivers for their inquiry?’ This is a critical aspect in utilising this framework as it forms the central mechanism through which all other ‘silences’ are ‘heard’ and located within the context of the study. The researcher thus identifies themselves as the primary listener in the study. The study is therefore conducted in line with the criticalist and marginalised discourses embodied in the theories underpinning this approach to research. The reader is encouraged to step into the study from the perspective of the researcher and is assisted through this process to understand not only the experiences and thought processes underpinning the research study itself, but perhaps even the pragmatic or professional choices that heave led to the researcher setting out to complete this work. In my study, for example, interest was driven by my identity as a black female sexual health professional seeking to optimise sexual health in a perceived ‘high-risk’ community. Clarification of the researcher identity is essential in all studies utilising this framework. The inclusion of the next two aspects will be determined by the nature and focus of the study itself. Some studies may require inclusion of one or both of the aspects listed below. In essence, clarifying these two aspects, as relevant to a study, reflects for the reader

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what is missing or where the gaps are in the research evidence currently available in the public domain.

b) Research subject This aspect of ‘hearing silences’ is particularly pertinent where the focus of the study is on a subject that may be seen as a ‘sensitive’ or seldom evidenced issue in a given society at a particular point in time. The researcher should identify the specific aspects of the subject in the named society that renders it ‘sensitive’ or under-researched because of the nature of the subject itself or at the particular point in time. On occasion it may be that it is the exploration of a subject by the researcher themselves that make it either sensitive or allows the ‘silence’ to be heard. This may happen for example where a generally non-sensitive issue becomes so when it is investigated from a marginal perspective, could illicit a degree of political or community backlash, or is conducted utilising innovative methods. In the initial study ‘sensitivities’ existed in the subject (sexual health, ethnicity) as well as the issue of researching your own community (black Caribbean researcher and participants).

c) Research participants This final aspect of the ‘hearing silences’ stage also involves explicitly identifying missing evidence. The researcher identifies the ‘silences’ arising from the ‘missing voices’ or marginalised perspectives of those taking part in the study. Again, as for those ‘silences’ emerging from studying a particular research subject as outlined above, here it is in the nature of the research participants (in my example, black Caribbean men) and their experiences to be included in the proposed study that specific ‘silences’ are housed. In summary, Stage 2 of the framework (‘hearing silences’) must incorporate more than a descriptive identification of the ‘silences’ existing in a particular research project. Through detailed reflection on researcher identity, research subject and research participants the researcher also gives critical comment on: . why these ‘silences’ exist: related to the cultural, clinical, psychosocial or moral arena identified in Stage 1; . how they came to be identified by the researcher: Insight into the researcher motivations to conduct the study; and . the researcher biases which are inherent in the study. These critical comments are important as they will influence the decision on study design, final reflections on the study outcomes and research processes undertaken to complete the study. The key driver for this stage lies in remembering that the researcher is the primary vehicle through which ‘silences’ are heard, identified and prioritised as a focus any research study. It is imperative therefore that the thinking and decision pathways and scripts through which the ‘silences’ are located are made explicit. Without this, the reader can never hope to (as far as possible) hear the ‘silences’ from the position of the researcher. This is essential to enable appraisal of the research project to be derived ‘in the light of’ the ‘silences’, rather than ‘despite them’.

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Stage 3: Voicing ‘silences’ This stage encompasses the active data collection phase of the research. The purpose of Stage 3 is to explore the identified ‘silences’ in context from the perspectives of key players in the research. As such it aims to collect data to expose the situated views and experiences of those involved.

Methods The methods incorporated in a study utilising the ‘silences’ framework are driven by the research design which is most appropriate for addressing the aims and objectives of the propose study. This means that studies may incorporate primary or secondary approaches to data collection utilising qualitative or mixed method approaches. Irrespective of the method used, however, the influence or impact of ‘silences’ acknowledged in Stage 2 on the choice of methods and data collection phase must be evidenced alongside the data collected. This may be incorporated through the keeping of ancillary notes, a research diary, face to face debriefing or reflective exercises conducted throughout the period of data collection. The researcher may utilise any one or a combination of these approaches as appropriate to their study. For example in my study, conducting a qualitative study on sexual health and ethnicity by a researcher from the same community required careful planning of community liaison and participant recruitment to allow for the ‘cultural norms’ of professional working in private spaces. This stage provides reference points at this critical phase in the research journey, where ‘new evidence’ is being generated to expose previous ‘silences’. These reference points in turn will be used to inform the data analysis and discussions at a later stage.

Participants. The inclusion of marginalised voices and personal experience in ‘silences’ research is paramount. At the heart of this framework is the drive to locate and hear the ‘Silent Voices’ embedded in a particular issue. It is often in the recounting of human experience and insight into research studies that ‘silences’ research makes a unique and original contribution to the evidence base. The exact nature of the participants will be dependant on the study but this could include service users, community groups, individuals and professionals as research subjects. These participants provide sources of evidence from their own direct experience of or perspectives on an issue. Studies may also include the perspectives of those belonging to the social networks of research subjects to collate indirect evidence from those not directly affected by an issue but whose clinical, political or cultural viewpoints and roles impact on the experience of the participants. For example my work involved black women, sexual health professionals and partners of black Caribbean men as identified influences from their ‘sexual social’ networks. The ‘silences’ framework seeks to acknowledge and redress the balance of power relating to ‘what and whose experiences count’ in a research study. Even where research is conducted from an insider perspective with the researcher as a member of the same social group as participants (such as my own study), the subtle influences of power still exist (professional versus service user) and may potentially impact on the study. Researchers are encouraged to address this issue and increase the validity of their study by convening a user or members of the public group to support the study from research question formulation through to analysis and decisions about dissemination, where possible. This is particularly pertinent where the data collection methods utilised in the study do not directly include service users

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or those experiencing a particular issue in their lives, for example in research which seeks to use secondary data sets, review policy or other documentary evidence.

Analysis. The method of analysis in the ‘silences’ framework, just as for conducting data collection, is driven to a great extent by the need to address the research aims and objectives. However, there are some underpinning aspects which, irrespective of the method used, must be included in the approach to analysis, when using the ‘silences’ framework. This introduction to the analysis stage starts by restating and acknowledging, through a brief summary, the researcher identity and inherent biases which existed at the data collection phase and which will continue to shape the outcomes from the analysis. These are presented at the outset in framing the limitations of the study. The process of analysis in the ‘silences’ framework has four phases and is cyclical. A diagrammatic representation of the phases of analysis is shown in Figure 2. Phase 1 begins with analysis of the data collected by the researcher with reference to the research question and in the light of any acknowledged limitations or constraints identified in the introduction to the analysis. It may also include identification of the limitations and challenges to completing the analysis faced by the researcher as a result of the ‘silences’ identified earlier in Stage 1 (Working in ‘silences’) and Stage 2 (‘hearing silences’). This serves to reconceptualise the ‘real world’ in which the research takes place and locate the outputs to be presented within it. At the end of this phase the initial findings from the analysis are generated for further scrutiny.

Analysis phase 1: Researcher review

Analysis phase 4: Researcher reflection

Analysis phase 2: Participant review

Analysis phase 3: User voices

Figure 2. Phases of analysis in ‘silences’ framework

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Analysis then moves on in Phase 2 to review of the initial findings by the study participants. The requirements in this phase of analysis in the ‘silences’ framework are aimed at ensuring active incorporation of user/public perspectives in the process and outputs of the research, and to reflect the desire of the researcher utilising this framework not to further ‘silence’ the voices of marginalise groups or restrict discussion of sensitive subjects through their own research activities. The inclusion of user and public perspectives at this stage is essential for providing an additional check point and opportunity to engage in a dialogue with ‘silenced’ participants about the researchers situated view of the findings. The ‘silence dialogue’ generated in Phase 2 may ratify, refute, challenge or further contextualise the findings from the study so far, thus providing valuable insight into the impact, importance and potential realities for participants arising out of the research. The methods, processes and strategies used to incorporate this in a particular study will depend on the overall study design and should be planned in advance. In my study, for example, the ‘silence dialogue’ arose from secondary feedback sessions with black male participants to check out my initial analysis with them. Following the ‘silence dialogue’ the researcher revisits the initial analysis to incorporate more detailed second level analysis, utilising any feedback or comments from the ‘silence dialogue’ around the initial findings. At the end of this second level analysis, draft 1 findings are produced as outputs and taken forward to the next phase of analysis. In Phase 3 the inclusion of ‘user’ voices is expanded to include the social networks of participants or others whose cultural, social or professional situation may impact on the research question. This may include individuals with a similar profile (cultural, social or experiential) to the research participants but also any steering group and other critical friends who mirror the social networks of participants. Ideally the group would include representation from groups/individuals identified as part of the context in which the ‘silences’ exist presented in Stage 1 of the ‘silences’ framework (Working in ‘silences’). The aim here is to hear from ‘collective voices’ to analyse the scope or diversity of the evidence collated through the experiences of the research participants. This may give some indication (dependant on the study questions) as to the potential generalisability of the research findings. An additional aspect of the exploration of the findings here could include reflection by this group as to the ‘silences’ they consider still exist or remain unchanged as a result of the study. These reflections will serve to provide additional insights to inform the fourth stage of the overall ‘silences’ framework (Working with ‘silences’). The discussion around these issues by the ‘collective voices’ of the social networks alongside the consideration of the ‘silence dialogue’ from Phase 2 are the draft 2 findings from the study. Finally in Phase 4 of the analysis the researcher critically reflects on the findings from the preceding phases of analysis and presents these as the final study outputs. The action of continuously revisiting and reviewing the developing and emerging research findings while integrating user and public perspectives are an essential component of the framework. This process of analysis enables the data analysis in the ‘Voicing silences’ stage to retain its close alliance with the broader theoretical and philosophical approaches underpinning the notion of ‘screaming silences’ which lie at the heart of the framework. While one cycle of analysis within the framework is described here, the number of times a cycle is completed is not prescriptive. The researcher may repeat the cycle as many times as needed following reflection on the completeness of the data during Phase 4 or where no new information pertinent to the research question is revealed.

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Stage 4: Working with ‘silences’ This phase incorporates the final ‘discussion’ aspects of the majority of studies. As with any robust discussion of outputs from research the primary purpose in this stage is to ensure there is clear consideration of the initial aims and objectives of the research. This stage also includes detailed reflection on the theoretical contribution and pragmatic gains arising out of the study outputs. The key question to be answered by the researcher is ‘what has changed as a result of this study?’ – this is the ‘so what?’ question that must be addressed by research utilising the ‘silences’ framework. In doing so, the researcher identifies and contextualises the options and opportunities for achieving or, at the very least, working towards some of the anticipated ‘gains’ as a consequence of addressing pre-existing ‘silences’ illustrated in Stage 1. The pragmatic and theoretical elements of the framework also require the researcher to acknowledge the potential and probable ‘risks’ that could arise from acting on the research in the light of the findings. These may reveal the limitations or cautionary notes for any follow-on study or any generalisability of the completed project. In accepting that ‘silences’ exist as an inherent part of all societies, the framework also acknowledges that, on completion, some ‘silences’ are changed, exposed or even newly created as a result of their research. This information may be derived directly through the contributions ‘silence dialogue’ and ‘collective voices’ as well as outputs from Phase 4. In determining the conclusions arising out of a study, the researcher needs to reflect on the possible impact of the findings on the current context as presented in Stage 1 and the ‘silences’ to be heard as a result. These conclusions act to set demarcation points of the ‘value added’ or ‘distance travelled’ through completing the research while recognising that, when finished, the research evidence itself cannot fail to shape the context in which further research in this area will occur by sitting as part of Stage 1 of subsequent similar studies using this framework.

Concluding comments In the 21st century it is apparent that many of the challenges to health and health care are situated in the personal experiences of people living inequitable societies. As we seek to expand our understanding of the broad range of factors impacting on health and life chances, research is increasingly called upon to explore issues which have a degree of sensitivity in particular communities at a point in time. In addition, exposing how health may be differently experienced may call on researchers to seek out the views of seldom heard or marginalised groups in a society. This requires researchers to be able to utilise an approach to conducting studies which centralises the sensitive or marginalised nature of the research in order to appraise health and health care ‘in the light of’ these hidden perspectives. This paper proposes a framework for conducting research on sensitive issues or marginalised perspectives in health and social care. It was developed out of a concept called ‘screaming silences’ which acknowledges and seeks to give voice to the experiences, subjects and issues which are often hidden, devalued or ‘silenced’ in research. The ‘silences’ framework is closely aligned with anti-essentialist viewpoints, acknowledging the importance of situated views and the existence of power and inequality as contextualising features in society, research and researchers who seek to explore it.

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The concept of ‘screaming silences’ and the ‘silences’ framework developed from it were derived from my own experiences of conducting research and delivering health care around sexual health and ethnicity. The framework is presented here with the invitation for further peer review, utilisation in other contexts and by different researchers in order to test out its usefulness and enable critique by a wider audience.

Key points . ‘Screaming silences’ (or ‘silences’) define areas of research and experience which are little researched, understood or silenced. . This paper presents the notion of ‘screaming silences’ with reference to the original study and maps out a 4 stage framework for its utilisation in ethnicities based and sensitive research. . It provides a useful basis for a theoretical framework for researching sensitive issues or the health care needs of marginalised populations. . It is presented here for use by other researchers as a vehicle for exposing additional perspectives in studies involving sensitive subjects or marginalised populations.

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Laura Serrant-Green (PhD BA MA RGN PGCE) is currently Professor of Community and Public Health Nursing at The University of Lincoln and visiting professor at The University of the West Indies. She was editor of Nurse Researcher Journal for 4 years and is currently a member of the Prime Minister’s commission for the review of Nursing and Midwifery. Laura has received various national research awards around sexual health and ethnicity including the 1998 Mary Seacole Nursing Leadership Award, the 2002 Smith and Nephew Nursing Research Fellowship and the 2004 Florence Nightingale Travel Fellowship. She has previously sat on Independent Advisory Group to the UK government on Black and minority ethnic issues relating to sexual health and HIV which informed the development of the national strategy for sexual health and HIV for England. She is a member of INVOLVE, a national organisation ensuring effective user involvement in research. She has worked closely with several health, education and care organisations around the needs of Black and Minority Ethnic communities. Laura continues to work as a community Mentor with Black and minority ethnic communities. Her family is from Dominica in the West Indies.

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