Walking the Walk and Talking
the Talk: An Appraisal Guide
for Qualitative Evidence
Qualitative Description
Sword, W., Busser, D., Ganann, R., McMillan, T., & Swinton, M. (2008). Women's
care-seeking experiences after referral for postpartum depression. Qualitative Health
Research, 18, 1161-1173.
Question: What were women's experiences of seeking care after referral from public health
nurse for probable postpartum depression, including responses to being referred, specific factors
that hindered or facilitated care seeking, experiences seeking care, and responses to interventions
offered?
Design: Qualitative description... the method of choice when straight descriptions of phe-
nomena are desired... The description in qualitative descriptive studies entails the presentation
of the facts of the case in everyday language... [lt] is less interpretive than phenomenological,
theoretical, ethnographic, or narrative descriptions... [but) more interpretive than quantitative
description, which typically entails surveys or other prestructured means to obtain a common
dataset on preselected variables..." (Sandelowski, 2000, pp. 336, 339).
Sample: New mothers (N = 18) recruited from an early prevention and intervention initiative
(Healthy Babies, Healthy Children) who accepted, as part of the program, the offer of a home
visit by a public health nurse
Procedures: In-depth, semistructured telephone interviews conducted approximately 4 weeks
after screening for postpartum depression were thought to be less burdensome on new mothers
than asking for face-to-face interviews in their homes or another location. Two trained research
assistants used an interview guide containing broad, open-ended questions about women's feel-
ings about being referred for probable postpartum depression and their subsequent care-seeking
experiences. The conversational interview style included probes and reflective statements to
obtain clarification and to encourage more detailed description. The interviews, averaging
40-50 minutes in length, were audiotaped and transcribed verbatim. In addition, participants'
demographic data were obtained from the women's completion of a structured questionnaire.
Data entry and management in NVivo qualitative data software supported conventional
content analysis as described by Hsieh and Shannon (2005). Preliminary codes were assigned to
meaningful units of data (sentences or phrases). Further data reduction occurred over the course
494
the
analysis,
as related codes were subsumed under broader emergent categories. Focusing
Appendix c
w the research questions led to development of a rich description of women's care seeking after
waferral for postpartum depression.
waisal:
appendix C
495
Are the results valid/trustworthy and credible? Yes. (Sample selection): English-speaking
women in the public health program, Healthy Babies, Healthy Children with an Edinburgh
Postnatal Depression Scale (EPDS) score of 12 or higher, indicative of probable depres-
sion (Cox & Holden, 2003), were eligible to participate in the study. "The EPDS is a
well-validated and widely used instrument to assess the presence of depressive symptoms
(p.1163)" (Accuracy and Completeness): Accuracy (credibility) was assured through
analysis of each interview by multiple independent coders followed by research team
review and the arrival at initial and final coding schemes through a process of discus-
sion and consensus. Transcripts were reviewed to ensure that the final coding scheme had
been consistently applied to all the data. Completeness of data (credibility) was assured
by a search for negative cases (outliers/exceptions to identified informational categories
and concepts). Goodness of fit between analysis and data from which it was generated
(contirmability) was demonstrated by the use of quotes and examples. Reliability (depend-
ability) was assured by careful documentation of the research process (the audit trail).
including a record of evolving and finalized coding decisions and data analysis procedures.
[Plausibility/Believability]: Quotes that give voice to study participants and illustrate
different aspects of the phenomenon are well chosen and appropriately introduced. These
representations of the women's thoughts and feelings illuminate and draw the reader into
their experience.
What were the results of the study? (Approach/Purpose/Phenomenon): Qualitative descrip-
tion accomplishes the intended purpose to produce a detailed and straightforward report
of women's experiences related to seeking care following referral for probable postpartum
depression. "A socioecological framework of health services utilization was used as an orient-
ing framework for data collection (p. 1163)." [Reported Results]: Specific barriers and facilita-
tors of care seeking were identified at individual, social network, and health system levels of
influence. At the individual level, women's normalizing of symptoms, limited understanding,
waiting for symptoms to improve, discomfort discussing mental health concerns, and fears
deterred care seeking. Symptom awareness and not feeling like oneself prompted women to
seek care. At the social network level, normalizing of symptoms and limited understanding of
postpartum depression on the part of family and friends posed barriers; while expressions of
worry or concern and encouragement to seek care facilitated women's care seeking Health
system level barriers included normalizing of symptoms, offering unacceptable interventions,
and disconnected care pathways (communication and timing disruptions). Care seeking was
facilitated by having established and supportive relationships, legitimization of postpartum
depression, outreach and follow-up, and timeliness of care.
Will the results help me in caring for my patients? [Relevance): Promotion of knowledge
and awareness of postpartum depression is needed among both the general public and health
care professionals, since normalizing symptoms and limited understanding were found to be
barriers to care seeking at all three levels of influence. The research reflects patient values
(preferences, concerns, and expectations) and circumstances (clinical state). (Application):
All care providers coming in contact with new mothers should be alert for symptoms; and
consistent use of screening instruments should be considered. Findings also highlight the
importance of interpersonal skills in establishing trust and supportive relationships that
include acknowledgement of women's fears about discussing mental health concerns,
assistance to making informed decisions, and efforts to learn about various treatment
ppendices
modalities that may be used to more effectively match interventions with women's individual
needs and preferences. Analysis further suggests that improved coordination of care would
broaden opportunities for appropriate assessment and treatment of women with postpartum
depression
Ethnography
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