Journal of Research in Nursing

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Research in Nursing
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
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Original Paper
Journal of Research in Nursing
16(4) 347–360
The sound of ‘silence’: ! The Author(s) 2010
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DOI: 10.1177/1744987110387741
sensitive issues or marginalised jrn.sagepub.com
perspectives in health
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: lserrant-green@lincoln.ac.uk
348 Journal of Research in Nursing 16(4)
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.
Serrant-Green 349
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
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
Serrant-Green 351
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 1: Working in ‘silences’

. Stage 2: Hearing ‘silences’
. Stage 3: Voicing ‘silences’
. Stage 4: 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: Stage 2:
Working in ‘silences’ Hearing ‘silences’
(Contextualisation) (Location)
(impact of completed research?) (impact of time on current research?)
Stage 4:
Stage 3:
Working with ‘silences’
Voicing ‘silences’
(Discussion)
(Verbalisation)
Figure 1. The ‘silences’ framework for research
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
Serrant-Green 353
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
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’.
Serrant-Green 355
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
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
Analysis phase 2:
1: Participant
Researcher review
review
Analysis phase Analysis phase

4: 3:
Researcher User voices
reflection
Figure 2. Phases of analysis in ‘silences’ framework
Serrant-Green 357
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.
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.
Serrant-Green 359
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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experiences of marginalised populations. Historically and pragmatically these subjects have

Underpinning theoretical approaches

‘Experience is at once always already an interpretation and in need of interpretation’

‘Silences’ framework: a four-stage framework for research

. Stage 1: Working in ‘silences’

A diagrammatic representation of the core ‘silences’ framework is shown in Figure 1.

(impact of completed research?) (impact of time on current research?)

Figure 1. The ‘silences’ framework for research

. Stage 5: Planning for ‘silences’

Stage 1: Working in ‘silences’

Stage 2: Hearing ‘silences’

Stage 3: Voicing ‘silences’

Participants. The inclusion of marginalised voices and personal experience in ‘silences’

Analysis phase Analysis phase

Figure 2. Phases of analysis in ‘silences’ framework

Stage 4: Working with ‘silences’

Laura Serrant-Green (PhD BA MA RGN PGCE) is currently Professor of Community and

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