The Effectiveness Of Psychotherapeutic Interventions To Reduce Symptoms Of Trauma In Victims Of Rape/Sexual Assault: A Systematic Review
Contents
TOC o “1-3” h z u HYPERLINK l “_Toc380072240” Chapter 3: PAGEREF _Toc380072240 h 1
HYPERLINK l “_Toc380072241” 3.1. Search Strategy/ Methods PAGEREF _Toc380072241 h 1
HYPERLINK l “_Toc380072242” 3.2 Keywords Used PAGEREF _Toc380072242 h 1
HYPERLINK l “_Toc380072243” 3.3 Detailed Search Strategy PAGEREF _Toc380072243 h 2
HYPERLINK l “_Toc380072244” ELECTRONIC SEARCH STRATEGY PAGEREF _Toc380072244 h 2
HYPERLINK l “_Toc380072245” Hand search PAGEREF _Toc380072245 h 3
HYPERLINK l “_Toc380072246” 3.4 Grey literature PAGEREF _Toc380072246 h 3
HYPERLINK l “_Toc380072247” Chapter 4 PAGEREF _Toc380072247 h 5
HYPERLINK l “_Toc380072248” 4.1 Types of Studies Incorporated In the Systematic Review PAGEREF _Toc380072248 h 5
HYPERLINK l “_Toc380072249” 4. 3 Participants incorporated in the study PAGEREF _Toc380072249 h 5
HYPERLINK l “_Toc380072250” 4.3 Types of Controls/Interventions used in the Studies PAGEREF _Toc380072250 h 5
HYPERLINK l “_Toc380072251” 4.5. Types of Outcome Measures for the Studies PAGEREF _Toc380072251 h 6
HYPERLINK l “_Toc380072252” 4.6. Screening the Articles, Extraction of Data and Assessment of their Quality PAGEREF _Toc380072252 h 6
HYPERLINK l “_Toc380072253” 4.8. Inclusion and Exclusion Criteria PAGEREF _Toc380072253 h 8
HYPERLINK l “_Toc380072254” 4.8.1 General inclusion criteria PAGEREF _Toc380072254 h 8
HYPERLINK l “_Toc380072255” 4.8.2 General exclusion criteria PAGEREF _Toc380072255 h 11
HYPERLINK l “_Toc380072256” 4.8.3 Specific inclusion criteria at the Quantitative Stage PAGEREF _Toc380072256 h 12
HYPERLINK l “_Toc380072257” 4.8.5 Specific exclusion criteria at the Quantitative Stage PAGEREF _Toc380072257 h 12
HYPERLINK l “_Toc380072258” 4.9. Included and Excluded studies PAGEREF _Toc380072258 h 13
HYPERLINK l “_Toc380072259” JBI Critical Appraisal for Experimental Studies PAGEREF _Toc380072259 h 13
HYPERLINK l “_Toc380072260” JBI QARI Critical Appraisal Checklist for Interpretive, Critical Research and Systematic Reviews PAGEREF _Toc380072260 h 21
Chapter 3:3.1. Search Strategy/ Methods
Search engines were used as the primary source of relevant literature due to the ease of limiting the search and the expansiveness of the literature available. In this case, the search for relevant literature was limited to varied electronic databases over time period since their inception to December 2012. Databases included the Cochrane Central Register of Controlled Trials (CENTRAL), EMBASE, Cochrane Database of Systematic Reviews, Allied and Complementary Medicine Database (AMED), MEDLINE, PubMed and CINAHL. In addition, the search was extended to grey literature, where unpublished trials were searched through the Register of the Controlled Trials databases. On the same note, it was deemed necessary that constant communication with identified experts in relevant fields such as trauma and individuals interventions is maintained, not to mention that the search had to be extended to the departmental files. While entering keywords in the search engines may have seemed satisfactory considering the results, it was imperative that the included articles have their references examined so as to have other relevant articles that perhaps had not been picked using other techniques of searching.
3.2 Keywords UsedVaried key search terms were used so as to bring the most relevant articles into the picture. These words included PSTD or Posttraumatic Stress Disorder, post-traumatic, rape stress, sexual abuse stress disorder, sexual abuse trauma, sexual abuse trauma interventions, and stress disorders rape, rape stress disorder psychotherapeutic interventions, psychotherapeutic interventions for sexual abuse victims and stress disorder psychotherapeutic interventions. While search strategies had to be adjusted for every database that was examined, MeSH strategy proved effective as a powerful search strategy where applicable. On the same note, personal contact with the authors or researchers in particular journals or academic sources, especially in instances where clarity was sought on matters pertaining to the data used and the participants incorporated in the study.
3.3 Detailed Search StrategyELECTRONIC SEARCH STRATEGYThe Cochrane Medline optimal Randomized Controlled Trials search strategy was blended with keywords “rape”, “trauma”, “traumatic stress”, posttraumatic Stress” “PSTD” and PSTD in rape victims.
Embase Cochrane optimal RCT search strategy was combined with psychotherapeutic interventions, psychotherapy, PTSD psychotherapy, and interventions.
A search was done on Cochrane Central trials register with keywords PSTD or Posttraumatic Stress Disorder, post-traumatic, rape stress, sexual abuse stress disorder, sexual abuse trauma, sexual abuse trauma interventions, and stress disorders rape, rape stress disorder psychotherapeutic interventions, psychotherapeutic interventions for sexual abuse victims and stress disorder psychotherapeutic interventions
Hand search
The search for journal studies covering the topic was limited to journals dated 2007- to date. These journals included the following.
Journal of traumatic stress
Journal of Human Stress
Journal of the Emergency Medical Services
Mass Emergencies and Disasters (all years)
Transcultural psychiatry
3.4 Grey literatureWith the help of the other reviewers, I took it upon myself to look for the relevant literature in the varied libraries. All in all, I came across 17 controlled trials that had been published after 2007. A search in Medline database yielded 8 publications, a number that increased to 12 after checking the references incorporated in the literature, as well as references of those references. However, dissertations and congress reports proved to be more fruitful in the case of psychotherapeutic interventions.
Flow chart
314325073660Additional records identified through other sources (n = 17 )
Additional records identified through other sources (n = 17 )
57150073660Literature identified through database searching (n = 27)
Literature identified through database searching (n = 27)
1585595-215900Literature or articles after duplicates eliminated (n = 27)
Literature or articles after duplicates eliminated (n = 27)
4457700335280Records excluded (n = 10)
Records excluded (n = 10)
1498600335280Records that were screened (n = 27)
Records that were screened (n = 27)
4457700294640Full-text articles excluded (n = 5)
Full-text articles excluded (n = 5)
1828800294640Full-text articles assessed for eligibility (n = 17)
Full-text articles assessed for eligibility (n = 17)
211455017145Studies included in qualitative synthesis (n = 8)
Studies included in qualitative synthesis (n = 8)
1924050290830Studies included in quantitative synthesis (meta-analysis)(n = 4)
Studies included in quantitative synthesis (meta-analysis)(n = 4)
Chapter 44.1 Types of Studies Incorporated In the Systematic ReviewThere existed no restrictions as to the scope of the study especially with regard to the study design. However, it is required that the studies incorporated in the systematic review be prospective clinical trials. This systematic review incorporated randomised controlled trials, as well as nonrandomised controlled trials that examined the results of varied psychotherapeutic interventions on the symptoms of trauma in rape victims. In addition, the research question was given a more solid foundation through the inclusion of uncontrolled clinical trials (UCTs) pertaining to the varied psychotherapeutic interventions for post traumatic stress disorder. This also would come in handy in making recommendations to readers and researchers on areas that could be explored or other aspects that could be incorporated in future research.
However, any randomised controlled trials and others would be separately analysed, with more being interpreted on RCTs due to the quality of research as a result of the validity of the evidence. On the same note, it is noteworthy that the studies were not restricted with regard to the year of publication, languages, or even blinding.
4. 3 Participants incorporated in the studyAll studies were selected including those that had participants with posttraumatic stress disorder that had been diagnosed using any set or criteria ICD-10 and DSM-IV, irrespective of gender, nationality, age, inpatient therapy, as well as outpatient therapy.
4.3 Types of Controls/Interventions used in the StudiesTrials that included psychotherapeutic interventions either in isolation or as a set or comparison group were included in the study. In addition, trials that used control that had no treatment, conventional treatments for posttraumatic stress disorder patients were included.
4.5. Types of Outcome Measures for the StudiesAs much as this study was supposed to look into the effectiveness of the psychotherapeutic Interventions in the reduction of symptoms of trauma in rape victims, it was imperative that recent guidelines pertaining to the key outcomes of interventions of PTSD were examined and used. Key outcomes included a reduction in the severity of the posttraumatic stress disorder symptoms, adherence of the patient to the treatment plan, reduction and prevention of trauma-related comorbid conditions, social, interpersonal, adaptive and occupational functioning, rate of collapse, quality of life, and response to treatment.
For this study, the key outcome measures included any relevant posttraumatic stress disorder scales such as depression scale, anxiety scale and even clinically-administered posttraumatic stress disorder scales (CAPS). In addition, predefined protocol was followed by the extraction of other scales that were related to proportion of patients that had recovered, as well as impairment.
4.6. Screening the Articles, Extraction of Data and Assessment of their QualityAfter carefully review and examination of the abstracts and titles that the search had brought up, all search results or articles that did not match the exclusion/inclusion criteria in line with the predefined eligibility criteria were excluded. This left me with expected or potential inclusions, which I carefully read in full text, after which I made a decision on the final inclusion using the matching technique. In cases where the studies were composed in languages that I could not comprehend, the colleagues would undertake a careful and comprehensive translation so as to determine their eligibility. These would then be categorised in line with the eligibility criteria. In cases where it was necessary to undertake a review of the full text, this would be assessed after translation. I extracted data independently on the basis of predefined characteristics so as to describe every study. In instances where I could not be sure about the quality and eligibility of any studies or articles, I would consult other individuals who are qualified to undertake reviews. A third party may be called in to give his opinion in instances where there is no agreement on the same. Of course, it was not given that I would agree with the opinions of the third party or even the second reviewer, in which case the final opinion or choice was at my discretion. The conduction of quality assessment and extraction of data by a single researcher is bound to introduce some bias, which can only be prevented by the inclusion of another researcher and even a third party in case of disagreements or discrepancies (Vickerman & Margolin, 2009, pp. 440). This would be further reduced by a process of quality control cross-check.
The CONSORT 2010 checklist for evaluation and reporting the quality of Randomised Controlled Trials and the Cochrane risk of bias for evaluating the quality of the same were used in assessing the methodological quality of the publications included in the study. It is worth noting that all reviewers that participated in the study had undergone full and comprehensive training on data extraction techniques and the assessment of the quality of data.
Every stage of the process involves recording of standardized data including details pertaining to methodology and design, the demographics and characteristics of the participants, year of study, country, where the articles were published, the adverse events, as well as findings and comments.
The quality appraisal pertaining to the reviewed quantitative studies depend on the type of study involved. In cases of cohort studies or case control, corresponding critical appraisal checklists and Critical Appraisal Skills Program (CASP) would be used. Incidence and prevalence studies are to be appraised by the use of methodological scoring systems.
Before the data is extracted, all articles that are included in the study would be coded so as to allow for the classification of the type of clinical presentation within which it falls. Coding defines the key clinical presentation with regard to any of the symptoms of trauma in victims of sexual abuse and rape. On the same note, in case it is required, articles that examine specific interventions may have the authors further coming up with a definition of the sub-classification process on the basis of the type of intervention. Such a priori classification would eliminate the possibility of any unintentional misclassification of data upon the conclusion of data analysis process and identification of interim results.
4.8. Inclusion and Exclusion Criteria4.8.1 General inclusion criteriaFor articles and academic works to be included in the review, it was imperative that they meet varied conditions or inclusion criteria.
First, all reports and articles had to include individuals who had undergone had traumatic experiences not less than 2 years prior to the study.
In addition, the participants have to be civilians. In instances where the participants were in the military, it is imperative that they are no longer in active serve. Alternatively, they could be territorial personnel or reservists that have undergone deployment but are now in civilian life.
The papers to be included in the review must only include mental health problems that emanate from a traumatic event rather than any that had emerged prior to the event. The articles and reports may be examining one symptom or many of them and making a comparison between the varied psychotherapeutic interventions. The symptoms of posttraumatic stress disorder for rape victims may include intense helplessness, fear, horror, distressing and repeated recollections of the traumatising event including thoughts, perceptions and images where the individual would be unable to differentiate between reality and past events (also called flashbacks). In addition, the victims may avoid anything that triggers thoughts on that episode including failing to talk about the episode itself, denial, inability to remember anything pertaining to the attack or even pretending that the act never occurred to them. In most cases, the victims are bound to undergo feelings of isolation and depression, deficiency in concentration, modify their sleep patterns, irritability, low confidence and self esteem, intense embarrassment, morbid hatred for or bitterness with the perpetrator and intense preoccupation on how they can humiliate or harm them (Nishith et al, 2003, pp. 248). As much as there seems to be a similarity between the response of individuals that have undergone a wide range of traumatic events including disasters, life-threatening accidents and rape, there exists a significant difference between the consequences associated with rape and those from other categories of trauma. This is especially with regard to the strong aspect of stigma, societal blame, self blame, and revictimisation in the system of criminal justice among others. Indeed, scholars have noted that such factors result in an increased risk of suicide and a higher incidence of concurrent depression (Nishith et al, 2003, pp. 248). Research comparing the incidence or occurrence of post traumatic stress disorder between victims of rape or sexual abuse and individuals who have undergone other forms of traumatic events showed that rape had the highest incidence of posttraumatic stress disorder at 49% as compared to other forms of sexual assaults at 23%, natural disaster at 3.8%, serious car accident at 2.3%, other forms of serious accident at 16.8%, or even being stabbed or shot which stood at 15% (Nishith et al, 2003, pp. 248).
The review is to be concentrated on psychotherapeutic interventions that are classified into seven groups. These include the following.
Interpersonal psychotherapy- this is a highly structured but short therapy that makes use of a manual to concentrate on the interpersonal issues pertaining to depression emanating from trauma.
Behavioral activation- this intervention aims at enhancing the awareness of the client to the pleasant things that may be happening around him or her in an effort to enhance positive interaction between him or her and the environment.
Problem solving therapy: this intervention seeks to come up with a definition of the problems that the patient is facing and proposing varied solutions for every problem before selecting, implementing and assessing the effectiveness of the problem.
Cognitive behavioral therapy: This therapy involves a close look at the current negative beliefs that the client may be having emanating from the incidence and causing emotional turmoil and depression. An evaluation would them be carried on the negative belief’s effects on future and current behavior after which there would be efforts to restructure the negative beliefs, as well as modify the patient’s outlook.
Social skills therapy: involves teaching patients skills that allow them to build, as well as maintain healthy relationships that are based on respect and honesty.
Psychodynamic therapy: mainly focuses on any unresolved relationships and conflicts in the past, as well as their impact on the current situation of the patient.
Supportive counseling: comes as a considerably general therapy that mainly aims at getting patients to talk about their emotions and experiences, as well as offer empathy without teaching new skills or making any suggestions on solutions.
In instances where the article was published prior to the publication of the International Classification of Diseases, Tenth Revision (ICD-10), then it will be imperative that the authors match the clinical presentation that is outlined in one of the contemporary classifications. In this case, symptoms such as anxiety reaction, psychoneurosis, and hysteria may be matched up with ICD-10 F40-48 classification, while reactive depression and manic depression would be matched up with ICD-10 F30-39 classification.
4.8.2 General exclusion criteriaWhile this paper would take a wholesome approach in the inclusion of articles and academic works, there are varied conditions that would result in the exclusion of a particular article as a reference. This would include the following.
Reports and articles that are entirely descriptive in instances where there exists no evidence pertaining to either quantitative or qualitative structured inquiry.
Reports and articles that mainly concentrate on the physical health consequences of rape or sexual abuse.
4.8.3 Specific inclusion criteria at the Quantitative StageStudies that outline the incidence and/or the prevalence of rape victims that have experience posttraumatic stress disorder and mental health problems.
Studies and articles that report on the varied psychotherapeutic interventions and their applications in individuals with posttraumatic stress disorder.
Articles that compare the applications of psychotherapeutic interventions with other forms of interventions.
Empirical cohort studies and case-control reports that compare victims of sexual abuse who have or have no posttraumatic stress disorder or mental health issues, who have or may not have undergone any psychotherapeutic interventions.
4.8.5 Specific exclusion criteria at the Quantitative StageStudies that outline issues pertaining to mental health symptoms and trauma prior to undergoing the sexual abuse or rape, in instances where there exists no empirical case control.
Case control studies that have obtained data on mental health in instances where no previous sexual abuse or rape has been meted on the individual.
Studies where there has not been any clinical confirmation as to the existence of posttraumatic stress disorder or mental health problems.
Studies that primarily concentrate on assessing the psychometric characteristics pertaining to the measuring tools for identifying or perceiving issues pertaining to mental health issues or posttraumatic stress disorder.
Specific inclusion criteria at the Qualitative Stage
Interview studies that and focus group reports that outline the opinions, experiences, as well as views of rape victims that have trauma or mental health problems regardless of the qualitative analysis model that is used.
Qualitative stage specific exclusion criteria
Qualitative study articles and reports would be excluded in instances where they are outlining-:
Single case studies
Studies that only examine the use of qualitative methodological issues.
4.9. Included and Excluded studiesJBI Critical Appraisal for Experimental Studies
RESICK, P. & SCHNICKE, M (1992). Cognitive processing therapy for sexual assault victims. Journal of Consulting and Clinical Psychology;60(5):748-756.
ReviewerDate: 20th September, 2013
Author: RESICK & SCHNICKE, Year1992Record Number
Yes No Unclear
Was the assignment to treatment groups random? Yes Were participants blinded to the allocation of treatment? Yes Was the allocator blinded to the allocation to treatment group? No Were the outcome assessors blinded to the allocation of treatment? Unclear
Were the outcomes of individuals that withdrew from the study included in the analysis and described? Yes Were the individuals that assessed the outcomes blind to the allocation of treatment? Yes Were the treatment and control groups comparable at entry? Yes Was the same measurement used for all groups? Unclear
Were the outcomes of the study measured in a reliable manner? Yes Was sufficient follow up indicated in the study (>80%) Yes Did the study use appropriate statistical analysis? Yes Overall appraisal: Include Yes
Comments
Brunet, A., Orr, S. O., Tremblay, J., Robertson, K., Nader, K., & Pitman, R. K (2008). Effect of post-retrieval propranolol on psychophysiologic responding during subsequent script-driven traumatic imagery in post-traumatic stress disorder. Journal of Psychiatric Research. Volume 42, Issue 6 , Pages 503-506
ReviewerDate: 20th September, 2013
Author: Brunet et al Year2008Record Number
Yes No Unclear
Was the assignment to treatment groups random? Yes Were participants blinded to the allocation of treatment? Yes Was the allocator blinded to the allocation to treatment group? Unclear
Were the outcome assessors blinded to the allocation of treatment? Unclear
Were the outcomes of individuals that withdrew from the study included in the analysis and described? Yes Were the individuals that assessed the outcomes blind to the allocation of treatment? Yes Were the treatment and control groups comparable at entry? Unclear
Was the same measurement used for all groups? Yes Were the outcomes of the study measured in a reliable manner? Yes Was sufficient follow up indicated in the study (>80%) Yes Did the study use appropriate statistical analysis? Yes Overall appraisal: EXCLUDE
Comments (for excluded studies only)
While the journal was sufficiently comprehensive and outlined studies on posttraumatic stress disorder, it had very little to offer on psychotherapeutic interventions and their effectiveness in treating the same.
Gros, D. F., Price, M., Strachan, M., Yuen, E. K., Milanak, M. E & Acierno, R (2012). Behavioral Activation and Therapeutic Exposure: An Investigation of Relative Symptom Changes in PTSD and Depression During the Course of Integrated Behavioral Activation, Situational Exposure, and Imaginal Exposure Techniques Behav Modification. 36:580-599
ReviewerDate: 20th September, 2013
Author: Gros et al Year2012Record Number
Yes No Unclear
Was the assignment to treatment groups random? Yes Were participants blinded to the allocation of treatment? Yes Was the allocator blinded to the allocation to treatment group? Yes Were the outcome assessors blinded to the allocation of treatment? Unclear
Were the outcomes of individuals that withdrew from the study included in the analysis and described? Yes Were the individuals that assessed the outcomes blind to the allocation of treatment? Yes Were the treatment and control groups comparable at entry? Unclear
Was the same measurement used for all groups? Unclear
Were the outcomes of the study measured in a reliable manner? Yes Was sufficient follow up indicated in the study (>80%) Yes Did the study use appropriate statistical analysis? Yes Overall appraisal: Include
Comments (for excluded studies only)
Litz, B.T., Engel, C.C., Bryant, R.A., & Papa, A (2008). A Randomized, Controlled Proof-of-Concept Trial of an Internet-Based, Therapist-Assisted Self-Management Treatment for Posttraumatic Stress Disorder Am J Psychiatry;164:1676-1684.
ReviewerDate: 20th September, 2013
Author: Litz et al Year2008Record Number
Yes No Unclear
Was the assignment to treatment groups random? Yes Were participants blinded to the allocation of treatment? Yes Was the allocator blinded to the allocation to treatment group? Yes Were the outcome assessors blinded to the allocation of treatment? Unclear
Were the outcomes of individuals that withdrew from the study included in the analysis and described? Yes Were the individuals that assessed the outcomes blind to the allocation of treatment? Yes Were the treatment and control groups comparable at entry? No Was the same measurement used for all groups? Unclear
Were the outcomes of the study measured in a reliable manner? Yes Was sufficient follow up indicated in the study (>80%) Unclear
Did the study use appropriate statistical analysis? Yes Overall appraisal: Include
Comments (for excluded studies only)
Gross, A., A. Winslett, M. Roberts and C. Gohm (2006). An examination of sexual violence against college women, Violence Against Women; 12 (3): 288–300.
ReviewerDate: 20th September, 2013
Author: Gross, Winslett, and Gohm, Year2006Record Number
Yes No Unclear
Was the assignment to treatment groups random? Unclear
Were participants blinded to the allocation of treatment? Unclear
Was the allocator blinded to the allocation to treatment group? Unclear
Were the outcome assessors blinded to the allocation of treatment? Unclear
Were the outcomes of individuals that withdrew from the study included in the analysis and described? Yes Were the individuals that assessed the outcomes blind to the allocation of treatment? Unclear
Were the treatment and control groups comparable at entry? Yes Was the same measurement used for all groups? Yes Were the outcomes of the study measured in a reliable manner? Yes Was sufficient follow up indicated in the study (>80%) Unclear
Did the study use appropriate statistical analysis? Yes Overall appraisal: EXCLUDE
Comments
While the study dealt primarily with sexual violence against college women and examined the perpetrator characteristics, racial differences, and type of sexual violence, it does not examine anything pertaining to the effectiveness of any therapy on such victims. On the same note, there are numerous informational gaps in the study, in which case it is difficult to verify it.
JBI QARI Critical Appraisal Checklist for Interpretive, Critical Research and Systematic ReviewsTAYLOR, JOANNE E., AND SHANE T. HARVEY. (2009). “Effects of Psychotherapies With People Who Have Been Sexually Assaulted: A Meta-Analysis.” Aggression and Violent Behavior 14:273–85.
ReviewerDate: 20th September, 2013
Author: Taylor and ShaneYear: 2009Record Number
Yes No Unclear
Does congruity exist between the research methodology and philosophical perspective? Yes Does congruity exist between the research objectives or question and research methodology? Yes Does congruity exist between the method of research and the methods used in the collection of data? Unclear
Does congruity exist between the research methodology and data representation & analysis? Yes Does congruity exist between the research methodology and result interpretation? Yes Does the review include a statement that outlines the theoretical or cultural background of the researcher? No Does the paper address the author’s influence and vice-versa? No Is there adequate representation of the participants and their voices? Yes Do the conclusions made in the research report flowing from the interpretation and analysis of the data? Yes Overall appraisal; Include
Comments
Ozer, Emily J.; Best, Suzanne R.; Lipsey, Tami L.; Weiss, Daniel S. (2008). Predictors of posttraumatic stress disorder and symptoms in adults: A meta-analysis. Psychological Trauma: Theory, Research, Practice, and Policy. American Psychological Association, Vol S(1), , 3-36
ReviewerDate: 20th September, 2013
Author: Ozer et al Year: 2008Record Number
Yes No Unclear
Does congruity exist between the research methodology and philosophical perspective? Yes Does congruity exist between the research objectives or question and research methodology? Yes Does congruity exist between the method of research and the methods used in the collection of data? Unclear
Does congruity exist between the research methodology and data representation & analysis? Yes Does congruity exist between the research methodology and result interpretation? Yes Does the review include a statement that outlines the theoretical or cultural background of the researcher? No Does the paper address the author’s influence and vice-versa? No Is there adequate representation of the participants and their voices? Yes Do the conclusions made in the research report flowing from the interpretation and analysis of the data? Yes Overall appraisal; Include
Comments
McFarlane, C.A &
