Otros estudios no centrados en la formación

In addition to the main data coding and analyses, data were also checked for reliability. Two methods were utilised in this study to check reliability and dependability of study findings, these being inter-rater reliability checks and also keeping a reflective diary of experiences whilst collecting data and coding and analysing it. These were based upon recommendations in the literature and surpassed levels of methodological rigour employed in previous child toothbrushing interview studies (Amin and Harrison, 2009; Huebner and Riedy, 2010). The reflective diary can

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be found in Appendix F and the outcomes from the inter-rater reliability analyses are now reported.

i) Inter-rater reliability

Once all data had been coded and themes and sub-themes identified, reliability of coding was check by a second, impartial researcher who had not been directly associated with the research. In accordance with the recommendations in the instructions to authors of the journal ‘Social Science and Medicine’, the codings assigned to 20% (n=3) of data transcripts were checked for reliability. Although there is some disagreement in the literature as to the appropriateness of reliability checks in qualitative research, the decision was made to conduct a reliability check as this would demonstrate methodological rigor, provide greater confidence in study findings and improve the chances of publication of study findings. It was not possible for the second researcher to be completely blind to the aims of the study, as they had to know what the identified themes were in order for them to use the themes to check the reliability of the themes. However, they were blind to the locations within the transcribed interviews where the themes were identified during the main data analysis procedures.

Following inter-rater reliability analyses with a second researcher (TK) unaffiliated with the study, an Intra-Class Coefficient (ICC) was generated using Cohen’s kappa (κ) statistics to derive level of agreement of sub-themes assigned to data collected by the first researcher (SE) from 20% of the sample of participating mothers. This is in accordance with best practice guidelines in the literature regarding the use of ICC

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when ascertaining inter-rater reliability (Streiner, 2003). Before conducting inter-rater reliability analyses, the second researcher also checked accuracy of transcription of these data, by comparing audio data to transcripts. All transcripts were found to be accurate representations of audio data.

The initial ICC coefficient generated for all sub-theme codings was .76 (p < .0001), indicating overall substantial reliability across all sub-themes included in the analyses. Additionally, reliability co-efficients were generated for each of the main themes which contained a number of sub-themes. Reliability coefficients of the separate sub- themes were as follows;

- Maternal Cognitions: κ = .33 (p = .22)

- Maternal Behaviours: κ = .69 (p = .01)

- Infant Behaviours: κ = .66 (p = .07)

- Support and Advice: κ = .89 (p = .02)

As ‘Family History’ was comprised of only one theme, it was not possible to conduct a statistical analysis of inter-rater reliability of this. However, closer inspection of the data revealed perfect agreement between the first and second researcher on codings for this variable.

Reliability for each of the individual themes was found to be excellent for ‘Support and Advice’ and moderate for ‘Maternal Behaviours’ and ‘Infant Behaviours’. However, the initial ICC for ‘Maternal Cognitions’ was found to be low. Further investigation discovered that discrepancies between first and second researcher codings for the

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sub-theme of ‘outcome expectancies’ had occurred. Discussion between the two researchers revealed that the definition provided by the first researcher for this sub- theme had not been clear enough for the second researcher to be able to code the sub-theme accurately. The definition provided was as follows;

‘Perceived expectancies of establishing toothbrushing routines: this was related to any statements made by mothers about their expectations of the outcomes of their attempts to establish toothbrushing routines with their infant.’

When coding transcripts for ‘outcome expectancies’, the second researcher had only coded sections for this sub-theme when statements in the transcript related to whether mothers thought they would be successful at establishing toothbrushing as a dyadic process with their infant. However, the second researcher had intended the definition for the ‘outcome expectancies’ sub-theme to have been broader and more in keeping with the classic definition of ‘outcome expectancies’, which is that they relate to a person's estimation that a given behavior will lead to certain outcomes (Bandura, 1977b). These outcomes need not necessarily be simply an individual’s estimation of their level of success. Rather, ‘outcome expectancies’ may also relate to

an individual’s estimation of the consequences of enacting (or failing to enact) certain

behaviours. Therefore, the first researcher coded the following statement by Participant 2 as being related to ‘outcome expectancies’ as she outlines her beliefs about what would happen to her infant’s teeth if she did not successfully establish dyadic toothbrushing with her son;

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“…I’ve heard a lot of horror stories about kids having to have their teeth pulled out and things like that. There’s absolutely no way at all I want to have that for (child)… ”

Participant 2

Whereas the second researcher did not code the above statement as reflecting ‘outcome expectancies’ due to the lack of clarity in the definition for this sub-theme. However, upon improving the definition for ‘outcome expectancies’ the second researcher agreed that she would actually code this statement from Participant 2 as reflecting ‘outcome expectancies’. The definition for the ‘outcome expectancies’ sub- theme was revised as follows;

‘Perceived outcome expectancies of establishing toothbrushing routines: this was related to any statements made by mothers about their expectations of how successful their attempts at establish toothbrushing routines with their infant would be. It was also related to their expectations of what would happen to their infant’s dental health if they were successful or unsuccessful at establishing toothbrushing routines.’

Refining the definition in this way meant that the reliability for the ‘Maternal Cognitions’ theme improved significantly from ICC = .33 to ICC = .60 (p = .10), indicating moderate reliability for this theme. This also improved the overall reliability across all five themes included in the analyses to ICC = .77 (p < .0001), which can be considered to reflect substantial reliability.

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- Other Areas of Discrepancy:

More detailed qualitative reliability analyses were then conducted to uncover other possible areas of discrepancy between the two researcher’s coding of the data for the ‘Maternal Behaviours’, ‘Infant Behaviours’ and ‘Support and Advice’ themes. This revealed that in some cases sections of text could potentially be coded as either one of two different sub-themes. As it is considered to be better practice to code a section of text as describing only one sub-theme, this kind of discrepancy is difficult to avoid in qualitative research, especially when the section of text cannot be disaggregated into smaller sections. So, for example, the following statement was coded by the first researcher as ‘modeling mother’ and by the second researcher as ‘allowing child to have a go’.

“…he loves you know, doing anything adults do, so he loves brushing his teeth”.

Participant 2

Another example of this kind of discrepancy was found. Whereas the first researcher coded the following statement as ‘brushing early’, the second researcher coded it as ‘professional advice’;

“Well, you get like a brush and thingy at the 8 month check with the health visitor. He got his first tooth when he was about 6 months…”

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Further, the following statement was coded as ‘perseverance’ by the first researcher and ‘routinisation’ by the second researcher;

“That is the main thing and I think she got used to brushing her teeth cos I stuck to it every day. It’s just persistence really. Like make sure you do it every day so they get used to it. So that they know what’s going to happen.”

Participant 10

Finally, the following statement was coded by the first researcher as ‘restraining infant’ and by the second researcher as ‘support from co-caregiver’.

“…he [husband] has to like hold her in a head lock and she just screams, it’s awful!”

Participant 14

Although such discrepancies were identified, the two researchers agreed that the sub- themes identified were all represented throughout the interview transcripts. Additionally, the researcher unaffiliated with the study did not identify any sub- themes that they disagreed could be relevant to mothers engaging in dyadic toothbrushing with their infant that aligned with dental expert guidelines. The unaffiliated researcher also did not identify any potential additional themes from the text that the first researcher may have failed to identify in the analyses. This would indicate that the thematic analyses conducted successfully identified all potential

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influences associated with mothers engaging in dyadic toothbrushing with their infant that aligned with dental expert guidelines.

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