Weaving Structural Violence into Trauma-Informed Qualitative Health Research with Populations Considered Vulnerable

Abstract

Trauma-informed approaches (TIA) are widely used in sensitive research to prevent re-traumatization and support the well-being of participants, often labelled as hard-to-reach or hidden populations. These labels reflect an individual-level framing, implying that certain groups have made themselves difficult to engage rather than acknowledging the structural barriers that limit their access to services and research participation. Trauma is deeply interconnected with social exclusion and systemic inequities. To address these limitations, researchers can further enhance trauma-informed research through a trauma- and violence-informed care (TVIC) approach, which emphasizes the structural and interpersonal violence experienced by populations considered vulnerable. A TVIC lens challenges deficit-based narratives by shifting focus away from individual responsibility and toward the structural violence that creates these conditions. This paper reflects on a qualitative study exploring burn injuries among underserved communities, particularly Indigenous Peoples and individuals experiencing homelessness or unstable housing. Burn injuries and fire-related incidents are often attributed to individual behaviour, obscuring the structural conditions that contribute to these outcomes. The paper uses researcher experiences to inform understanding of the need for trauma- and violence-informed qualitative research. Data collection involved document analysis, qualitative interviews, participant observations, and informal conversations, with the researcher using lessons learned to highlight the importance of applying a TVIC approach with populations considered vulnerable across all research stages—from researcher preparation and interview methodologies to sustained participant engagement. The lessons learned during the research underscore the need to move beyond individual-level framings of trauma to recognize structural determinants shaping lived and living experiences. A TVIC approach enhances equity-oriented research methodologies, equipping researchers to critically engage with systemic forces influencing participants’ realities. A structural perspective can help researchers develop methods, practices, and analyses that drive transformative and structurally oriented solutions.

In research, terms such as hard-to-reach, hidden population, and vulnerable population are frequently used to describe groups experiencing disadvantage. These groups often face intersecting forms of stigma, discrimination, and social marginalization within broader societal structures and healthcare settings (Varcoe et al., 2022). Thus, conducting qualitative research with individuals identified as vulnerable requires a nuanced understanding of the harms of structural inequities, processes of othering, and barriers to research participation and engagement.

Structural violence—embedded in social systems that privilege certain groups while disadvantaging others—produces profound harm and inequities (Lee, 2019). Many barriers to research participation are directly linked to structural violence, which is further compounded by interpersonal violence, shame, and stigma. For example, inequitable access to healthcare, as a manifestation of structural violence, often translates into interpersonal discrimination, such as biased treatment by healthcare providers (Varcoe et al., 2022).

Bamidele et al. (2018) argue that while researchers often categorize disadvantaged populations as ‘hard to reach,’ these individuals are not inherently ‘out of reach.’ Instead, researchers are responsible for developing more inclusive and contextually responsive engagement strategies. Health sciences research, particularly those relying on quantitative methodologies, often assesses outcomes and impacts in ways disconnected from individuals’ lived and living realities. Consequently, these approaches may fail to examine critical structural factors that shape health and social inequities (Jiao et al., 2022). As a result, populations affected by structural violence are frequently excluded or underrepresented in research due to ineffective sampling methods, recruitment challenges, individual-level barriers, population-specific risks, resource limitations, and methodological constraints (Ellard-Gray et al., 2015; Flanagan & Hancock, 2010; Hossain et al., 2021).

Thus, researchers play a critical role in ensuring meaningful participant engagement and producing findings that accurately reflect the experiences of diverse social groups. This commitment requires a deep understanding of violence shaped by sociopolitical, historical, economic, and cultural contexts and how these factors, in turn, shape people’s lives—insights essential for advancing health and social equity. Acknowledging power dynamics and diverse worldviews enhances research inclusivity and strengthens the impact of policies and programs addressing inequities (Bonevski et al., 2014; Nallala et al., 2023).

While trauma-informed approaches (TIA) in research emphasize fostering safety, trust, and empowerment for individuals who have experienced trauma, researchers can further strengthen TIA approaches by integrating a deeper understanding of the structural conditions that perpetuate trauma and marginalization. Recognizing how systemic factors shape lived (and living) experiences is essential for supporting individuals claiming agency over their lives. In qualitative health research—particularly when engaging with populations considered vulnerable—meaningful participation requires acknowledging both interpersonal and structural violence. Moreover, researchers can play a critical role in advancing trauma-informed research by continuously documenting practical strategies and challenges (Gonzalez et al., 2021).

Therefore, this paper provides insights into conducting qualitative research with individuals considered vulnerable through a trauma- and violence-informed care (TVIC) approach. A TVIC lens builds on trauma-informed approaches by explicitly addressing the impact of structural inequities on the social determinants of health and healthcare access while tackling the intersecting effects of racism, discrimination, and stigma (Varcoe et al., 2022; Wathen & Varcoe, 2023a). Drawing on a study involving individuals who have experienced burn injuries and structural marginalization, the first author drew on four principles of TVIC, as articulated by Wathen and Varcoe (2023b), to guide her research and reflections on the lessons learned during the study. These principles emphasize (1). understanding trauma and violence, (2). creating emotionally and physically safe environments, (3). fostering opportunities for choice, collaboration, and connection, and (4). demonstrating a strengths-based and capacity-building approach (Wathen & Varcoe, 2023a). This paper contributes to the growing discourse on equity-oriented research methodologies by reflecting on the methodological challenges, data collection insights, researcher-participant interactions, ethical dilemmas, and power dynamics.

Enhancing Trauma-Informed Approaches (TIA) in Qualitative Health Research Through Trauma - and Violence- Informed Care (TVIC)

Trauma-informed practices have been integrated into qualitative research for some time, particularly in studies involving individuals who have experienced sexual violence (Anderson et al., 2023; Campbell et al., 2019), social work practice and research (Levenson, 2017; Voith et al., 2020), populations facing disadvantages (Bonevski et al., 2014; Edelman, 2023), and research on mental health (Isobel, 2021). Various approaches aim to enhance inclusion and improve participant experiences in qualitative research. In settler-colonial nations such as Canada, Australia, New Zealand, and the United States, trauma-informed approaches increasingly acknowledge the historical trauma of colonization of Indigenous Peoples and their lands, recognizing it as an enduring structure of domination (Paradies, 2016).

Some trauma-informed approaches advocate for co-design processes to address structural inequities in researcher-participant dynamics, particularly when engaging with “communities disempowered by trauma” (Isobel, 2021, p. 1458). Similarly, trauma-informed research within a social justice framework prioritizes healing-centered interactions (Voith et al., 2020). Scholars have also proposed integrating trauma-informed intersectional analysis into patient engagement strategies across health research, training, practice, and evaluation (Shimmin et al., 2017). Additionally, trauma-informed approaches emphasize research team training that fosters awareness of researchers’ social locations and biases (Winfield, 2022).

While trauma-informed approaches have evolved to support individuals, they primarily focus on trauma at the individual level, particularly concerning substance use and mental health challenges (BC Mental Health & Substance Use Services [BCMHSUS], 2013). These approaches rarely direct attention beyond personal experiences, reinforcing an implicit assumption that a lack of agency stems from individual deficits rather than systemic conditions constraining empowerment. Although healing-centered engagements emphasize strengths and resilience, they tend to prioritize individual experiences over the structural barriers that impede healing at a systemic level. While these approaches acknowledge various forms of trauma and oppression, they may overlook the role of structural violence in perpetuating harm and disadvantage. Furthermore, researcher preparation must move beyond self-reflection to foster meaningful engagement with communities, deepen understanding of systemic inequities, and critically analyze these factors to support structural change.

Notably, foundational principles such as resilience, empowerment, strengths-based approaches, capacity building, and amplifying voices are central to trauma-informed practice (Karmakar & Duggal, 2024; Levenson, 2017). However, an overemphasis on individual vulnerabilities and resilience—without addressing the broader structural factors that perpetuate harm—constrains the potential of qualitative research to adopt methodologies that drive transformative systemic change. Expanding the focus beyond individual vulnerabilities and trauma to include the social structures that create and sustain inequities enables a more comprehensive analysis of the upstream determinants of social and health inequities.

From Individual Trauma to Structural Violence: Reframing Vulnerability

Structural violence refers to the social, political, and economic systems that systematically disadvantage individuals or populations, increasing their exposure to harm and perpetuating inequities (Farmer et al., 2006). To fully understand and cultivate empathy for individual’s lived and living experiences within their unique contexts, it is essential to situate vulnerability within the framework of structural violence. Vulnerability does not arise solely from individual circumstances. Instead, it is a consequence of systemic inequities and social conditions that expose individuals to harm and reinforce both structural and interpersonal violence, such as racism, poverty, and gender inequality (Fourie & Moore-Berg, 2022; Varcoe & Browne, 2023). Explicitly naming and analyzing these forms of violence enables a deeper understanding of their intersections with vulnerability, generating actionable knowledge to inform policies that address foundational inequities.

Structural violence is continuous because it is embedded within the organization of society (Winter & Leighton, 2001). Johan Galtung, who introduced the term in the 1960s, characterized structural violence as a form of harm that “kills slowly” due to its indirect yet deeply entrenched nature within societal structures (Farmer et al., 2006; Lee, 2019). Unlike physical violence, which is often visible and episodic, structural violence operates persistently, marginalizing individuals and groups by creating inequities that constrain their ability to achieve physical and mental well-being (Lee, 2019). Historical forces and cumulative processes subtly and often imperceptibly constrain individual agency, limiting access to the benefits of social progress for populations considered vulnerable (Browne et al., 2024). Moreover, structural violence often exacerbates interpersonal violence, including emotional and psychological abuse, interpersonal racism, verbal abuse, gender-based violence, social exclusion, and physical harm inflicted by individuals upon one another (Macpherson & Wathen, 2023).

Individuals affected by structural violence frequently experience interpersonal or everyday violence as well, illustrating how these two forms of violence are interconnected and reinforce cycles of harm within society (Bungay et al., 2010). For example, women who experience structural violence—such as restricted access to affordable housing, limited employment opportunities, and inadequate healthcare—are often placed in circumstances where interpersonal violence is more likely to occur (Montesanti & Thurston, 2015). These gendered experiences of violence are shaped by the structural conditions that govern women’s lives, further entrenching vulnerability and limiting access to safety and resources (Montesanti & Thurston, 2015).

Examples of structural violence include poverty, inadequate access to affordable housing, systemic stigma, racism, and other forms of discrimination rooted in social, political, and economic inequities (Varcoe et al., 2022). Often rendered invisible, structural violence becomes normalized in everyday life due to its persistent and repetitive nature (Winter & Leighton, 2001). However, it is neither natural nor inevitable; instead, it is a product of institutional structures and policies that can be changed, prevented, or dismantled through deliberate action (Winter & Leighton, 2001). A TVIC lens in qualitative health research, grounded in a social justice and equity agenda, is essential for uncovering how systemic and structural violence perpetuates harm and deepens vulnerability. A TVIC approach underscores the importance of addressing both individual and structural factors, encouraging health researchers to adopt methodologies and research questions that prioritize equity-centred actions and analyses aimed at structural solutions.

Study Overview: Burn Injuries in Underserved Communities

Our critical ethnographic (CE) study was conducted on the unceded traditional territories of the x^wməθk^wəyəm (Musqueam), Sḵwxwú7mesh (Squamish), səlilwətaɬ (Tsleil-Waututh) Nations, and S'ólh Téméxw (Fraser Valley). The study is grounded in critical theoretical perspectives emphasizing the need to understand individual experiences—such as fire risks, burn injuries, and burns care—within broader sociopolitical and historical contexts. This study examines the factors contributing to inequities in fire-related injuries and burns care among two key populations: Indigenous Peoples who survived burns and individuals with burns who also experience precarious living conditions due to homelessness. Both populations have historically faced and continue to endure various forms of structural and interpersonal violence.

This study examined the overarching question: ‘What shapes inequities in burn care?’ Specifically, it explored how systemic inequities and social determinants contribute to fire-related injuries and disparities in burn care access among populations considered vulnerable. It also investigated how historical and ongoing colonial violence shapes the experiences of Indigenous individuals, particularly concerning burn injuries and the intersecting challenges faced by individuals experiencing homelessness. Participants were recruited using purposive and snowball sampling (Polit & Beck, 2021). Recruitment posters were placed in shelters, Single-Room Occupancy (SRO) accommodations, rehabilitation centers, nonprofit organizations, and hospitals. Research participants with burns, community partners and service providers also facilitated participant connections through word-of-mouth referrals.

Ethics approval was granted by the University of British Columbia’s Behavioural Research Ethics Board and the First Nations Health Authority (FNHA) (Approval No: H22-03219). FNHA approval was required due to the study’s engagement with First Nations communities and Peoples. Additional approval was obtained from the Office of the Fire Chief, Vancouver Fire Rescue Services (VFRS), and leaders of various First Nations involved in the study. Informed consent was obtained at multiple stages, ensuring that participants fully understood the research objectives, potential risks, and their right to withdraw at any time.

To further contextualize fire risks contributing to burns among underserved populations—particularly individuals experiencing homelessness or living in precarious housing (e.g., SROs, homeless encampments, and shelters)—the first author conducted 80 hours of participant observation alongside the VFRS team as they provided services. During participant observation, individuals were briefed on research goals and confidentiality measures. For those who expressed apprehension about potential repercussions for sharing their experiences, additional anonymity protections were applied, and verbatim data recording was avoided. No personally identifiable information was collected.

Additionally, qualitative interviews were conducted with ten participants with burn injuries who self-identified as Indigenous and/or experienced homelessness, as well as seven community leaders in fire safety, housing, and healthcare. Informal conversations with 59 individuals living and working in Vancouver’s Downtown East Side (DTES) across 50 sites—including SROs, nonprofit organizations, municipal agencies, community clinics, faith-based organizations, shelters, homeless encampments, and modular housing—further enriched the study’s insights. Participant observation is currently underway in a First Nations community. The first author also analyzed documents, including municipal housing and fire safety policies, publicly available reports, and emergency response protocols to strengthen the analysis. Additional details on participant observations and informal conversations in the DTES have been published elsewhere (Liao et al., 2024).

Structural Violence and Vulnerability: Contextualising the Community

Vancouver’s Downtown East Side (DTES), the participant observation site in this study, is one of Canada’s oldest urban neighbourhoods. It has been shaped by historical and structural inequities and is characterized by high rates of poverty, homelessness, mental illness, substance use, communicable diseases, and crime (Linden et al., 2012). Indigenous Peoples are disproportionately represented in the DTES, comprising 39% of the unhoused population and being 18 times more likely to experience homelessness than non-Indigenous individuals (City of Vancouver, 2023). These disparities reflect the profound and ongoing impacts of structural violence rooted in Canada’s history of colonialism and systemic inequities.

Vancouver’s DTES, often referred to as Canada’s “poorest postal code,” has a population of approximately 19,960 (Statistics Canada, 2016) and is home to populations considered vulnerable and transient. This is partly due to the prevalence of low-income SRO accommodations, which remain among the few affordable housing options for individuals on social assistance (Linden et al., 2012). SRO units, typically 70 to 200 square feet with shared bathrooms and limited cooking facilities (Mifflin & Wilton, 2005), are often poorly managed and associated with hazardous living conditions, violence, and crime (Masuda, 2023). While the DTES has long been characterized by poverty, ongoing gentrification is increasingly displacing low-income residents (Burnett, 2014).

Burn injuries correlate strongly with socioeconomic deprivation and neighbourhoods ranking highly on the Area Deprivation Index (Purcell et al., 2021). Structurally, Indigenous Peoples in Canada have endured and continue to suffer the ongoing harms of colonialism, manifested in jurisdictional neglect, intergenerational trauma, Indigenous-specific racism, and significant health and social inequities (Ontario Chief Coroner, 2021). Consequently, Indigenous Peoples in Canada are more than five times more likely to die in a fire and have significantly higher hospitalization rates for burns compared to the non-Indigenous population (Statistics Canada, 2021). Situationally, a disproportionate percentage of individuals who survived burns, including Indigenous Peoples, live in precarious housing, where structural violence exacerbates their risk of homelessness due to a lack of affordable housing and limited access to financial, health and social support (Bingham et al., 2018).

Researcher Characteristics and Reflexivity

The first author is a doctoral student and identifies as a woman of colour. She is of Asian descent (Chinese and Tibetan ancestry), was born in India, has lived in the United Kingdom, and is now a settler in Canada. Having navigated life as a racialized minority in all three countries, she has firsthand experience of othering and is acutely aware of the stigma associated with poverty and class. She is a registered nurse with over twenty years of experience in clinical practice, education, and healthcare leadership. For the past 13 years, she has also served as the director of a registered charity dedicated to strengthening health systems for burn care in low-resource settings in West Africa. Her work recognizes the strong correlation between burn injuries and socioeconomic status. It is further informed by an awareness of the gendered dimensions of burn injuries, including those resulting from gender-based violence—a reality she witnessed growing up in India.

To ensure reflexivity, the first author engaged in a continuous process of critical self-examination, interrogating how her positionality, subjectivity, and lived experiences influenced the research process. As a woman of colour with personal experiences of othering, racism, class stigma, and gendered violence, she remained attentive to how these perspectives shaped her interactions with participants and the interpretation of findings. The first author was acutely aware of the privilege afforded to her as an able-bodied, cis-gender individual, as well as the advantages gained through her educational attainment and professional status.

The first author maintained analytic memos throughout the study to systematically document observations, interpret responses, and critically question her assumptions during participant observation and qualitative interviews. This critical self-reflexivity was essential due to her dual role as a practicing registered nurse and researcher. These memos served as a tool for reflecting on power dynamics, potential biases, and how her personal experiences and professional background in nursing and global health/development might influence participants’ engagement.

The first author approached the research with a critical awareness of structural violence, intergenerational trauma, and intersecting oppressions that influence participants’ experiences and responses. Additionally, ongoing debriefing and consultation with her supervisor and committee members provided an external lens to interrogate assumptions, refine interpretations, and reinforce ethical commitments to cultural safety and equity. Although this article does not present research findings, the shared reflections include selected participant quotes to illustrate interconnections of structural and interpersonal violence in populations considered vulnerable.

Expanding Researcher Preparation: Insights From the “Burn Injuries in Underserved Communities” Study

Researchers must move beyond foundational preparation and procedural practices to ensure meaningful inclusion of underrepresented populations in health research. The literature on sensitive research highlights the ethical and responsible preparation of researchers, ensuring they can manage participant expectations and responsibilities that may exceed the initial scope of the study (UK Research and Innovation, n.d.). This preparation includes adherence to ethical standards and developing competence in trauma-informed approaches to address the effects of trauma during participant interactions (BCMHSUS, 2013; Edelman, 2023; Karmakar & Duggal, 2024).

While efforts to prevent re-traumatization and continuous self-examination to enhance researcher reflexivity are essential, researchers must also understand the structural and interpersonal forces shaping participants’ experiences and responses. Fully implementing trauma-informed approaches requires researchers to move beyond understanding trauma and toward generating knowledge that addresses ongoing structural and interpersonal violence shaped by historical, cultural, political, and disciplinary power dynamics (Varcoe et al., 2022). This more profound preparation enhances trauma-informed approaches by integrating attention to the structural forces influencing participants’ lives, enabling researchers to address the broader contexts in which trauma and vulnerability are engendered. Additionally, when researchers undergo training to develop an informed understanding of populations, cultures, and the study before engagement, it reduces the burden on the communities to educate researchers.

One of the training programs undertaken by the first author was the San’yas Indigenous Cultural Safety program (https://sanyas.ca/), which focuses on cultural safety, the history and impacts of colonization in Canada, and the systemic racism, discrimination, and stereotyping affecting Indigenous Peoples. Designed to catalyze system-level responses to systemic racism, the program promotes pathways to health equity for Indigenous Peoples in Canada (Browne et al., 2021). It also explores strategies to enhance Indigenous cultural safety ¹ in relationships, practices, and services. The first author engaged in self-reflection and critical reflexivity throughout the training, shifting from a focus on cultural competence, sensitivity, and awareness to cultural safety (Curtis et al., 2019) and cultural humility (First Nation Health Authority [FNHA], n.d.). Cultural safety is an ongoing process of learning and unlearning that prioritizes respectful engagement, challenges power imbalances, and fosters an environment free from racism and discrimination (FNHA, n.d.). Similarly, cultural humility requires recognizing oneself as a lifelong learner committed to understanding and respecting others’ lived experiences (FNHA, n.d.). Through this process, the first author learned that cultural safety and humility are dynamic, evolving concepts shaped by diverse perspectives—one can never be fully culturally competent, only continually striving toward deeper learning, critical reflection, and meaningful engagement.

The first author also completed a 12-month course titled Xwelítem Siyáya: Allyship and Reconciliation Building (https://www.ufv.ca/peace-and-reconciliation/allyship-building-program/), offered by a local university in partnership with First Nation leaders. This program deepened her understanding of allyship, continuous learning and unlearning, relationship building, and transformative action(s). The curriculum covered topics such as land and resources, settler colonialism, governance, assimilation, residential schools, Indigenous culture and spirituality. By learning the historical and current contexts of the land and Indigenous communities, the first author was better equipped to build trust and rapport with participants and First Nation leaders, fostering meaningful relationships throughout the research process.

The first author also participated in an 8-week Vulnerable Research Workshop (pilot) designed to support researchers conducting field studies with populations considered vulnerable. The workshop emphasized trauma- and justice-informed ethnography. It introduced key competencies, including self-awareness, participant-centred approaches, recognition of social location, attention to trauma, professional limits, boundary-setting, and self-care (Winfield, 2022). It provided opportunities to engage with facilitators and peers on best practices for interviewing individuals at heightened risk of homelessness due to unaffordable housing and inequitable health and social policies. This training offered a framework for incorporating trauma and social justice perspectives into the research methodology tailored to specific populations.

Preparatory work gave the first author a deeper understanding of the communities in this study. For example, an Indigenous leader conducting fire safety inspections highlighted how hoarding among Elders ² increases fire risks. Discussions revealed that hoarding is linked to intergenerational trauma, the lasting impacts of residential schools, poverty, and past experiences of trauma. Similarly, a fire safety leader described plans to implement virtual reality (VR) technology to teach adolescents how to use fire extinguishers—an approach designed to eliminate the need for real extinguishers and prevent land, air, and water contamination in First Nations communities. This approach reflected a commitment to land stewardship and highlighted a connection between historical trauma and fire risks in Indigenous communities—a link previously unconsidered by the first author. Participation in the Xwelítem Siyáya: Allyship and Reconciliation Building program deepened the first author’s understanding of land stewardship as integral to community well-being and ecosystem protection, even in fire safety. Researchers can establish a foundation of respect by exploring the land, history, and community realities (Indigenous Research Support Initiative, n.d.).

The preparatory work also heightened the first author’s awareness of biases in existing literature. It reinforced the importance of using language that accurately reflects participants’ lived and living realities while minimizing harm. For instance, studies often associate burn injuries among Indigenous populations with substance use and alcohol (Callegari et al., 1989; Papp & Haythornthwaite, 2014) without acknowledging the structural and colonial violence they endure. Browne et al. (2024) demonstrate how such assumptions result in harmful practices, as Indigenous Peoples presenting to emergency departments with slurred speech or unsteady gait are often presumed to be intoxicated. The first author engaged in ongoing reflexivity and consultation to ensure terminology aligned with participants’ perspectives. For example, the first author learned from a participant to use the term “self-medicated” over “high” because individuals who use substances do so in response to unmanageable pain and trauma rather than for the sensation of being “high.” These conversations heightened the first author’s attentiveness to centering participants’ language choices and challenging dominant narratives that portray substance use as a personal failure rather than a response to systemic trauma.

Fostering Emotionally and Physically Safe Research Spaces: Lessons Learned

Trauma-informed research and practice have galvanized efforts to prioritize the well-being of survivors in all interactions, decisions, and program practices (Campbell et al., 2019). Trauma-informed approaches emphasize emotional and cultural competence, empowering participants, ensuring their agency, and fostering a sense of value throughout the research process (Isobel, 2021; SAMHSA, 2014). Additionally, promoting physically safe interview environments—with appropriate lighting and accessibility—while fostering respectful social interactions through considerate language and an awareness of power dynamics are key considerations (Levenson, 2017). Trauma-informed strategies include maintaining confidentiality, using inclusive language, offering breaks, monitoring for re-traumatization, providing resources, conducting member checks, and ensuring researcher well-being (Karmakar & Duggal, 2024; SAMHSA, 2014). Furthermore, Karmakar and Duggal (2024) recommend engaging participants through initial phone calls or in-person meetings to explain the study, clarify procedures, and discuss data collection methods. However, in this research, many participants often lacked direct phone access, relying instead on support workers or shelter staff to relay information. This dependency sometimes gave these intermediaries control over communication, influencing the flow and accessibility of information.

One key lesson the first author learned was the critical role of interview locations, which reflect the intersection of social and spatial relations and broader power dynamics within the research setting (Elwood & Martin, 2000). Initially, the first author was concerned about her safety while conducting interviews in unfamiliar settings, including a homeless encampment, a safe injection site, and public seating areas on the street. When she suggested meeting at a café, a participant reminded her they were not welcome in such spaces. Recognizing this as an opportunity to examine structural violence in this context, the first author explored, through the interview, how stigma shapes participants’ everyday experiences. This exchange illuminated how interpersonal stigma reinforces structural stigma through policies, laws, and cultural norms (Link & Phelan, 2001), ultimately constraining individuals who are stigmatized to have the ability to exercise their agency and feel included. For example, the participant reported experiencing diarrhea and sustaining burn injuries after accidentally igniting themselves with a butane torch in an alleyway at night. This incident occurred as they attempted to relieve themselves, having been denied access to restroom facilities at a coffee shop for not making a purchase. The participant expressed gratitude for receiving a coffee card as compensation, enabling them to access the washroom by demonstrating proof of purchase.

Following this interview, the first author became more intentional about interview settings, taking guidance from participants on the location and their preference to have a friend, family member, Elder, or pet present for support. Nearly all participants chose to bring companions, such as a ‘buddy’ or their pet dog. Companions often contributed to the conversation, raising dilemmas about consent and whether their presence undermined the participant’s agency. The literature offers limited guidance on this issue. When companions dominated discussions, the first author tactfully redirected the focus to the participant and provided companions with the option of a separate interview. Companions were compensated for their time. In future interviews, the first author plans to clarify roles at the outset, acknowledging companions’ potential contributions while ensuring the focus remains on the participant.

Interviews with participants did not always proceed as planned. The first author would arrive at the agreed-upon location, only for the participant to either decline to participate that day or request a reschedule. On several occasions, participants cancelled or postponed the interviews at the last minute, and at times, the first author felt frustrated, as she lived approximately 90 kilometres from the interview site. Seeking guidance from her supervisor and existing literature on power dynamics and social positioning (Jacobson & Mustafa, 2019), she adapted her approach to foster a more participant-led process, remain flexible, and honour participants’ relationships with time. When participants rescheduled, they felt a sense of control over the process, with one noting the first author’s patience. Another participant insisted on reading aloud a seven-page letter instead of engaging in the standard semi-structured interview. As illustrated in Figure 1, this letter recounted their experiences and injuries in their own words. While this diverged from the planned interview format, the first author recognized the importance of honouring participants’ preferred modes of storytelling. This experience underscored the value of flexibility, attentive listening, and allowing participants to guide the conversation, prioritizing significant aspects rather than focusing solely on their injuries. For subsequent interviews, the first author adjusted the opening question to: ‘Where would you like to start?’ This shift empowered participants to determine if, when, and how they wished to discuss their burn injuries, reinforcing their autonomy in the storytelling process.

Figure 1.

This Letter, Written by a Participant to the First Author, was Read Aloud During the Interview as Their Preferred Way to Share Their Experiences. Note. The First Author Took the Photograph of the Letter With the Participant’s Consent. The Participant Agreed to Its Inclusion in This Publication, December 2023.

Depending on how participants initiated their narratives, the first author guided the conversation toward systemic issues by asking questions such as, ‘Did you face other challenges when you got burned?’ Many participants readily shared details about their housing situations rather than their burn injuries, prompting the first author to adapt the interview guide. One participant, for instance, expressed frustration with repeated instructions from healthcare providers to “keep it [the burn wound] clean and dry,” explaining how their living conditions [living in a homeless encampment] made it nearly impossible to meet these expectations for proper wound care. Framing interview questions to highlight broader social conditions signals the researcher’s awareness of structural factors and helps mitigate concerns about personal blame.

Initially, the first author felt uneasy with prolonged silences, interpreting them as communication breakdowns or signs of participant discomfort. This unease intensified when participants did not respond as expected to questions about their burn mechanisms, prompting the author to prematurely reframe questions or fill gaps with unnecessary dialogue to maintain conversation. However, over time, it became clear that silence often provided participants the space to process their thoughts, leading to deeper and more reflective discussions. Through critical reflexivity, the first author grew to recognize silence not as an obstacle to engagement but as an essential tool for fostering meaningful dialogue. This experience underscored the importance of embracing silence to create space for participants to share their narratives on their terms.

The Dilemmas of Incentives: Fostering Choice and Agency in this Research

The Government of Canada (2018) states that incentives often encourage participation in research projects and can take monetary and non-monetary forms. However, the guidelines emphasize that incentives should not be so significant or enticing that they cause participants to overlook potential risks or create undue influence (Canadian Institute of Health Research [CIHR], n.d). Despite this caution, there is limited guidance on the appropriate use of incentives, particularly when engaging with populations considered vulnerable. Assumptions about these groups often suggest that incentives might compromise participants’ ability to assess risks or lead to unjust inducements, raising ethical concerns about their influence on decision-making (Bungay et al., 2022; Halpern et al., 2021). Additionally, the perspectives guiding Institutional Review Boards (IRBs) are often viewed as paternalistic, rooted in the assumption that participants are inherently vulnerable (Bungay et al., 2022). These perspectives create tension between protecting participants and respecting their right to self-determination (Bungay et al., 2022). However, research by Halpern and colleagues (2021) found that incentives did not function as an unjust inducement for underserved individuals, challenging the notion that participants should be viewed as inherently vulnerable. An important consideration is that researchers must reflect on how decisions regarding research ethics and incentivization are made, paying close attention to the socio-structural contexts in which research occurs and the influences of the various forces involved (Bungay et al., 2022).

Reflecting on this study, the first author recognized that her cultural upbringing emphasized gift-giving as a means of celebration, relationship-building, maintaining connections, and showing respect, appreciation, and gratitude. As a result, the first author was socialized to view gift-giving as an act of respect and did not initially question the practice of offering incentives to participants to honour their time and contributions. Consequently, she did not immediately consider the potential power dynamics associated with gift-giving. However, through engagement with the literature, reflective practice, and discussions with her supervisor, the first author became more attuned to power dynamics and began questioning the ethical implications of participants requesting alternative participation incentives.

One example that prompted a shift away from using only coffee gift cards as an incentive was a participant living in a homeless encampment who requested vegetable seeds instead. This request led to an ethical dilemma as it deviated from the approved incentivization method. Initially, the first author questioned the practicality of this request, reflecting personal biases, but later learned that the participant and their partner maintained a small vegetable garden, finding joy and sustenance in “gardening.” The discussion about vegetable seeds illuminated everyday experiences of discrimination and underscored broader food insecurity issues. The participant showed the first author their portable butane stove, which they used for cooking, sharing that this stove was involved in an incident that caused severe burns to their scalp. The participant recounted how emergency department healthcare providers assumed the injuries were “due to substance use,” reflecting the pervasive stigma against unhoused individuals. The conversation about vegetable seeds revealed further experiences of discrimination, such as how the stigma around homelessness limited their access to garden stores.

On a second visit, the first author helped the participant move belongings as the encampment was set to be demolished. Walking alongside them through the streets and assisting with a cart provided a relational perspective on place and space (Carpiano, 2009), offering a deeper understanding of how the participant navigated health and well-being amidst burn injuries-related challenges. The participant remarked, “Now you are walking with us,” further deepening the connection between researcher and participant.

French sociologist and anthropologist Marcel Mauss’s perspective on gift exchange, as cited in Heins et al. (2018), underscores that gift-giving and incentivization are deeply embedded in social processes and cannot be reduced to mere economic transactions. Heins et al. (2018) further argue that European colonial powers historically manipulated the concept of “gift giving” to obscure exploitation, rationalize colonial rule, and legitimize power imbalances—an influence that persists today, as reflected in development assistance, foreign aid, and humanitarian interventions. Similarly, Gosovic (2019) underscores how gift-giving in research mirrors colonial structures of asymmetrical exchange. Gosovic (2019) further contends that researchers are never entirely independent or neutral but are invariably embedded within systems of value, exchange, and obligation—a notion that postcolonial scholars have long challenged. Thus, these complexities necessitate a reflexive approach, emphasizing relational accountability, humility, and acknowledging participants’ agency in shaping knowledge production (Gosovic, 2019).

Bungay et al. (2022) also emphasizes the importance of continuous reflection on the complexities of research incentives and encourages researchers to consider their methods and methodologies to ensure sustained, meaningful engagement with participants and their communities. This approach includes embracing collaborative decision-making grounded in participants’ everyday needs and lived realities (Bungay et al., 2022) while remaining attuned to participants’ social and physical environment, which are shaped by interpersonal and structural violence, as illustrated in this research. Acknowledging these dynamics, the first author engaged in continuous reflexivity, recognizing that gift-giving inherently establishes a power dynamic in which the giver influences the recipient, reinforcing an unequal relationship (Gosovic, 2019). The first author ensured participants exercised their agency in selecting incentives while adhering to ethical guidelines. She also informed participants that incentives were funded through grants, a detail explicitly documented in the ethics consent form to enhance transparency.

Navigating Ethical Engagement, Authenticity, and Reciprocity: The Dilemmas

Shearer et al. (2020) proposed the concept of “ engaged consent,” in which researchers maintain ongoing relationships with participants for research purposes, such as in longitudinal data collection. In health research, particularly in clinical trials, researcher-participant relationships are often framed around building trust to ensure continued engagement in ongoing studies (Wong et al., 2021). However, many of these interactions appear transactional, prioritizing research objectives by increasing participation rather than fostering capacity-building for participants themselves. Additionally, although a fundamental aspect of social interaction and exchange, reciprocity is often overlooked in health sciences research (Maiter et al., 2008). While reciprocity and mutual benefit are commonly discussed within community-based participatory research (CBPR), limited literature addresses reciprocity and mutual benefits for research participants considered vulnerable.

In this research, nearly all participants expressed a desire for ongoing engagement with the first author that extended beyond disseminating research findings. They perceived the first author not solely as a researcher but as part of their collective social fabric, often referring to her as a “friend.” This relational dynamic created an ethical and methodological dilemma regarding navigating these evolving expectations while maintaining professional research boundaries. Within the context of this study, participants’ expectations of continued engagement reflect how research relationships can blur the lines between professional roles and social obligations, raising critical ethical considerations about the responsibilities of researchers in fostering authentic engagement and reciprocity. Maiter et al. (2008) conceptualize reciprocity as a profoundly relational process wherein exchanges occur within established social bonds and carry an implicit expectation of return. These reciprocal exchanges reinforce existing relationships and contribute to their evolution over time (Maiter et al., 2008).

For instance, one participant shared that they had been “kicked out of rehab” for not participating in a required activity, explaining that they were “having one of those days,” referring to a period of low mood. With no stable housing, they returned to the hospital, as they had nowhere else to go. After sustaining severe burns and losing several digits, the participant spent an extended hospital stay after being barred from their SRO following the fire that caused their injuries. They recalled being “made to sign papers” from the housing association while in the hospital without understanding their purpose. Despite these challenges, they adapted to using their remaining fingers and rediscovered their drawing ability (Figure 2).

Figure 2.

A Picture “Thunderbird” Drawn by a Participant and Gifted to the First Author. Note. Picture Taken by the First Author and Shared With Participant’s Permission, January 2024.

Recognizing the role of reciprocity in the participant’s healing process, the first author facilitated their involvement as an advisor for an Indigenous art project at the local Burns Unit. She engaged in critical self-reflection to ensure her actions were not driven by personal gain but by a commitment to fostering a strengths-based, capacity-building approach—an essential principle of trauma- and violence-informed care (TVIC). She collaborated with the participant’s Most Responsible Physician (MRP), patient care coordinator (PCC), and nursing staff to support this opportunity by securing a day pass. She then transported the participant to the Burns Unit, where they worked alongside Squamish Nation Indigenous artist Austin Aan’yas Harry (https://www.indigitaldesign.ca/about) on a mural project. The participant described the experience as profoundly fulfilling, expressing how empowering it was to be recognized for their artistic contributions rather than being solely identified as a “burn survivor.”

Four months later, the first author accompanied the participant to the unveiling ceremony of the art project in the Burns Unit, where the participant saw their visions of healing reflected in the murals. Their contributions to the Indigenous art project are illustrated in Figures 3–5, while Figure 6 depicts the artist’s interpretation of their shared healing visions. The participant was formally acknowledged and compensated for their advisory role, marking their first paid opportunity to be compensated for their expertise and share their story on their terms. Following this experience, they expressed a strong desire to contribute to ongoing initiatives and support individuals with burn injuries in the future, underscoring the transformative potential of authentic research engagement and the personal empowerment fostered through meaningful collaboration. Embedding the ethics of reciprocity in health and social research can enhance research relationships and improve health outcomes (Maiter et al., 2008).

Figure 3.

A Mural Titled “Calm,” Created by Artist Austin Aan’yas Harry, Reflects Creative Input From a Participant in This Study. Note. Photograph Taken by the First Author With Permission From the Artist, the Participant, and the Staff Involved in the Mural Project in the Burn Unit, November 2024.

Figure 4.

A Mural Titled “Soar,” Created by Artist Austin Aan’yas Harry, Reflects Creative Input From a Participant in This Study. Note. Photograph Taken by the First Author With Permission From the Artist, the Participant, and the Staff Involved in the Mural Project in the Burn Unit, November 2024.

Figure 5.

A Mural Titled “Care,” Created by Artist Austin Aan’yas Harry, Reflects Creative Input From a Participant in This Study. Note. Photograph Taken by the First Author With Permission From the Artist, the Participant, and the Staff Involved in the Mural Project in the Burn Unit, November 2024.

Figure 6.

The Artist’s (Austin Aan’yas Harry) Statement About the Three Murals “Soar, Care, and Calm,” Captured in a Photograph by a Staff Member, Incorporates Descriptions Shared by a Participant in This Research. Note. Image provided With Permission to Use by the Project Team and the Artist, November 2024.

Expanding the View: From Individual Level Descriptions to Structural Level Perspectives Through a Trauma-and Violence-Informed Care Approach

While trauma-informed research has laid a necessary foundation, incorporating a trauma- and violence-informed care (TVIC) approach ensures that qualitative health research moves beyond individual-level factors to a structural perspective in addressing the widespread prevalence and impacts of trauma and violence (Wathen & Varcoe, 2023a). Research and services aimed at populations impacted by violence and trauma – whether interpersonal, structural, historical, or ongoing – are fundamentally grounded in a commitment to minimizing the risk of re-traumatization during the engagement (Alessi & Kahn, 2023; BCMHSUS, 2013; Elliot et al., 2005). However, this approach often assumes that the trauma is solely in the past, overlooking the persistence of ongoing trauma and the importance of addressing its current manifestations.

Furthermore, despite the foundational principle of aiming to prevent and mitigate re-traumatization, trauma-informed frameworks often underemphasize structural violence as a root cause of trauma. This oversight is reflected in the continued use of labels such as hidden, hard-to-reach, or vulnerable, which implies a fixed state of being and obscures the systemic structures contributing to exclusion and disadvantage. Addressing both structural and interpersonal violence shifts the focus from using individual-level descriptors such as hard-to-reach, vulnerable, or homeless. It centers attention on the structural violence that creates barriers, perpetuates trauma, and marginalizes these populations. By reframing language that defines these groups as excluded, considered vulnerable, or structurally disadvantaged, researchers can redirect focus from individual deficits to systemic causes of inequities.

A TVIC approach can strengthen trauma-informed research by explicitly addressing structural violence as a core determinant of health and well-being. A TVIC approach is particularly critical when working with populations considered vulnerable due to structural and social determinants of health. By applying a TVIC approach, qualitative health researchers can shift from an individual-centered understanding of vulnerability to critically examine the systemic forces perpetuating vulnerabilities. Explicitly integrating both structural and interpersonal violence into trauma-informed qualitative research strengthens a commitment to social justice, cultural safety, and antiracism while encouraging researchers to pursue structurally oriented solutions.

Limitation

Despite the first author’s efforts to prepare herself, experiencing vicarious trauma as a researcher presented challenges (Isobel, 2021). One of the most difficult tensions she grappled with was the realization that, as a researcher, she could walk away after conducting interviews or fieldwork. In contrast, participants remained in the same social and physical environments that continued to expose them to violence and hardship. This dissonance—between the researcher’s ability to disengage and the participants’ ongoing lived realities—was a source of emotional distress. The first author conducted this study as part of a doctoral research project with limited funding to support community-participatory action research design. As a result, meaningful community engagement with those who would most benefit from participation was not fully integrated. Furthermore, a critical component of addressing structural violence is ensuring community involvement across all stages of research. Despite these limitations, the first author remains committed to advancing an equity-oriented research agenda, aiming to foster meaningful partnerships with populations considered vulnerable in future projects.

Conclusion

Qualitative health researchers working with populations considered vulnerable have widely adopted trauma-informed approaches. However, trauma extends beyond individual experiences; it is deeply rooted in systemic and structural inequities that sustain both structural and interpersonal violence. While trauma-informed approaches emphasize preventing re-traumatization and understanding the physiological and psychological impacts of trauma, they can be further strengthened by integrating a trauma- and violence-informed care (TVIC) lens. A TVIC approach enables qualitative researchers to explicitly recognize and address the structural and interpersonal violence that shapes the lived and living experiences of populations considered vulnerable. This paper highlights the need for embedding a TVIC approach in research by drawing on lessons learned from this study. By fostering ongoing dialogue, critical reflection, and intentional action, researchers can advance equity-oriented methodologies and practices that not only enhance engagement with populations considered vulnerable but also promote authentic researcher-participant relationships, apply a structural perspective in analysis, challenge power imbalances in research, influence policy, and contribute to systemic changes that foster social justice.