Download part a: quantitative critical appraisal

1
DX4002 2015: Assignment 1
Critical Appraisal Exercise
2
PART A: QUANTITATIVE CRITICAL APPRAISAL
Feldens CA, Vıtolo MR, Drachler ML. A randomized trial of the effectiveness of home visits in
preventing early childhood caries. Community Dent Oral Epidemiol 2007; 35: 215–223.
1. Randomization (10%)
Question: Participants were randomly allocated into two groups. Critically discuss what
further information you may want to have seen reported in this paper about the
randomisation in order to assess potential risk of bias.
Randomization has the possibility of bias hence affecting the integrity of a research. The
researcher needs to provide additional information to assess the potential risk of bias. The
researcher has to provide information on how the randomization was concealed to ensure the
investigators, involved health care providers and subjects are not aware of the upcoming
assignment. To assess the potential risk bias, the reader needs to evaluate the measures taken to
ensure that the participants are completely unaware of the groups they are in and the intervention
they will receive until the end of the study. Lack of this concealment could lead to selection bias.
The researcher also needs to provide information on masking or blinding measures taken to
prevent ascertainment bias.
2. Balance of participant characteristics (15%)
Question: What information is presented in this paper about the balance of participant
characteristics across the two groups?
What further information do you think could have been presented and why?
The author has discussed information about the balance of participant characteristics across the
two groups. The two groups included both mothers who had agreed to participate and those who
had not agreed. The baseline variables used to for comparability between the two groups were
family income, mother’s education, and mother’s age at child’s birth. The author justifies the
choice of these variables from previous studies, which have shown that these factors have a high
correlation with each other and high impact on child health and child care. The author does not
3
however explain how the balance of participants based on these variables was adhered to when
doing randomization. This information should have been presented since it enhances the
completeness of the results. One major characteristic of the participants, which should also have
been presented, is the number of previous children that the mother has had. Previous studies
indicate that number of children is a big indicator of the likely health care that a parent is likely
to subject their children to.
3. Loss to follow up (20%)
Question: Critically discuss the implications of the rate of loss to follow up in this study on
the interpretation of the study findings.
The follow up in this study was done based on a 12-month assessment. The rate of follow up was
above average as oral examinations were conducted in 79% of the intervention group and 73% of
the control group. There were similar proportions for loss of follow up which includes address
not found, refusal, and family relocation to another city, child death, and severe illness of
mother. This rate of follow up has implications on the study and findings. According to Fleming
(2011), loss of follow up in randomized controlled trials could lead to bias results if the data is
not associated with the likelihood of outcome events. Therefore, in this study, because the
frequency of loss of follow up for the two groups differs, the prognostic balance created by
randomization will likely be disturbed. The analysis and interpretation of data obtained is
therefore subject to bias arising out of loss of follow up. The author should have addressed this
potential bias by discussing the strategies for handling data or by restricting their analysis and
interpretation to participants with full outcome information. Loss of follow up therefore leads to
bias in interpretation unless complete case analysis is used.
4. Outcome measures (10%)
Question: Critically discuss the relevance of the outcome measures to clinical practice.
4
The outcome measures used in this study are caries which include white spots and cavitated
lesions. Caries, which include white spots, are relevant to clinical practice because bone
formation for children is associated with health of mother and the healthcare given to children. A
number of factors including sweets, soft drinks, honey, and biscuits clinically causes teeth
deformations in children. Mothers who attended follow up were advised to ensure that their
children avoided these foods because the glucose and fructose from fruit juices and honey are the
major sugars associated with early childhood caries. The outcome measures therefore are highly
relevant to clinical practice.
5. Findings (20%)
Question: Describe and interpret the main findings of this study.
The study did not establish any difference in the distribution of dental surfaces between the
intervention and control groups. One child from the intervention group was predentulous same
for one child from the control group. These were excluded from the study. The study found out
that the maxillary incisors have been reported as the most affected in young children with 98.5%
of all caries in the whole sample. This is because of the maxillary teeth are the first to erupt and
are therefore highly exposed. The study found out that the proportion of children with dental
caries was 10.2% among the intervention group and 18.3% among the control group. The study
concluded that the risk of caries is lower to families who received home-visit dietary
intervention. This therefore implies that home-visits are effective in reducing caries in early
childhood. A percentage (10%) of children in the intervention group was also found to
experience dental caries. These findings therefore put the effectiveness of home-visit
interventions are question and raise need for improvement. The study also established that the
home-visits promoted exclusive breastfeeding in the first four months of life but was not
effective in avoiding common practices of using breast feeding and bottle feeding used by
mothers to calm children or put them to sleep.
6. Implications (25%)
Question: Critically discuss the implications of the findings for Brazilian and UK
populations, dental professionals and policymakers.
5
The study concluded that home-visit dietary interventions were effective in reducing caries in
early childhood. This has implications for the Brazilian and UK populations, dental professionals
and policy makers. First, policy makers should emphasize on recommendations by the WHO for
breastfeeding up to 2 years or more in order to avoid poor dietary tendencies. Mothers need to be
sensitized during prenatal and perinatal periods on desirable dietary patterns and follow ups
should be made to ensure that they adhere to these recommendations. A percentage of the
intervention group also experienced caries. This implies that improvement in intervention is
required since the interventions did not achieve desirable results. The Brazilian and UK
populations, dental professionals and policy makers need to put more efforts to prolong breast
feeding on demand after the eruption of teeth in order to reduce the risk factor of early childhood
caries. The study also recommends the implementation of the Family Health Programme of the
Department of Health through home health visits. The policy makers and the Department of
Health should evaluate the effectiveness of the Family Heath Programme in families of low
economic background. The study recommends that more frequent reinforcement visits are
needed for these families of low economic status in order to make the programme effective.
Finally, the study recommends that the department of Health and policy makers should evaluate
the cost effectiveness of the intervention and ensure that the benefits of the programme in the
first year are maintained up to school age.
PART B: QUALITATIVE CRITICAL APPRAISAL
6
Trulsson, U. et al (2002) ‘A qualitative study of teenagers’ decisions to undergo orthodontic
treatment with fixed appliance’ Journal of Orthodontics’, 29, 197-204.
1. Method (20%)
Question: The study uses a Grounded Theory approach. How do the researchers’ justify
this approach and do you agree?
The aim of this study was to describe and analyze the thoughts and values influencing the young
people’s decisions to undergo orthodontic treatment. The researcher used grounded theory
approach to achieve the objectives of the study. The justification for using grounded theory is
that the study is qualitative in nature and grounded theory is suitable for qualitative studies
especially when studying social processes or areas where the theories are rarely common. The
author therefore argues that grounded theory approach will generate concepts, models, or
theories describing the areas under this study. Qualitative analysis, theory generation, and
symbolic interactionism are therefore the justifications for use of grounded theory approach.
Although this justification is agreeable to, the author should have considered need for constant
comparison between data and theory as the major justification of the use of grounded theory.
According to Dey (1999), grounded theory approach is mainly considered when the researcher
needs to compare data with the existing theories so that the researcher can understand a research
situation and discover the theory that is implicit in the data. The justification by the researcher
for use of grounded theory is valid because they did not base the justification on hypothesis
testing, which is a common mistake made by most researchers.
2. Ethics (15%)
Question: What ethical issues are raised by this study and have these been adequately
discussed?
The researcher identifies the major ethical issues in the study to be consent and confidentiality.
7
These ethical issues were adequately addressed. The study design was approved by the Research
Ethical Committee at the University of Göteborg as required. This approval means that the
requirements concerning informed consent and confidentiality were fulfilled. The research
sought informed consent from the parents of all the subjects. Confidentiality is adhered to
throughout the research as the author does not mention the name of any subject. The research
however did not adequately cover the issues of confidentiality. The research should have
enumerated the steps taken to ensure that confidentiality is observed throughout the study. The
study also omits a major ethical consideration for social researchers. The research should have
covered measures taken to ensure that the subjects are not harmed in the course of the research
either physically or emotionally.
3. Sampling (20%)
Question: How was the sample of teenagers selected? Does this have any limitations?
This research uses theoretical sampling to select the sample teenagers. According to Strauss &
Corbin (1998), theoretical sampling is continued until the identified categories are saturated and
new information is does not emerge from new data. Through this sample frame was twenty-eight
patients were selected aged 13 and 19 years and who were on the waiting list for treatment at an
orthodontic clinic in the western part of Sweden. Out of the twenty-eight, eleven were boys and
17 were girls. The selection of the study group considered gender, age, place of residence, and
family situation. The study therefore only considered the teenagers in the waiting list for
accessing orthodontic treatment. This sample has limitations since it considers a sample of
teenagers who has not yet made a decision to access orthodontic treatment. The consideration of
teenagers who have not decided to access orthodontic treatment would have provided a balanced
approach to the study and therefore balanced research findings.
4. Data collection (25%)
Question: Data was collected through open, in-depth interviews. How well are these
described and what alternative methods might be applicable?
Data was collected using open in depth interviews lasting about one hour. An interview guide
was used covering various themes such as school situation, family situation, body image, factors
8
influencing decision to seek orthodontic treatment, attitudes, expectations and reactions from
other people. The researcher used questions based on these themes and made follow up where
necessary. The interviewees were also allowed to ask questions. The use of personal interviews
was the most suitable method since it provided the researcher with an opportunity of asking
follow up questions and interacting with the subjects. The researcher described the use of open
taped interviews for the research. The advantages and rationale for selection of this method is
however not well covered. The researcher should have enumerated advantages of open personal
interviews such as opportunity for follow up questions and relative ease of administration. The
researcher should also have described how the possible limitations of open individual interviews
are avoided in the study. The major limitation is that only a limited number of respondents can
be reached with this method. The choice of the open in-depth individual interviews is therefore
good but it is not well justified. There are other alternative methods of data collection for
qualitative studies. These includes own observation, action research and focus groups. These
alternative methods are not applicable for this research since the variables under study are not
observable and are personal considerations. The researchers should also have enumerated these
alternative data collection methods and justify why they were not considered for the study as a
justification for the selected method.
5. Analysis (25%)
Question: How effectively do you feel the data analysis process has been described and
discussed? Is it clear how the main analytical themes were derived from the data? How
might this be strengthened?
The researcher explains that the interviews were transcribed verbatim and analyzed by open,
axial and selective coding processes. Open coding was used to ensure the substance of data was
identified from the recorded interviews and allocated to codes, which are specifically labeled.
The main labeling used for the open coding was the interviewees own words. The open coding
was then clustered into higher order categories of similar content. Axial coding further developed
axial coding into subcategories and relationships between the subcategories were identified and
9
combined. The selective coding process entailed saturation of the generated categories with
information from new interviews or from earlier assessed data. The researcher also emphasizes
that during the entire process of analysis, ideas, preliminary assumptions, and theoretical
reflections were written down in memos. The research analysis is well and effectively described
and discussed. However, it is not clear how the main analytical themes were derived from the
data. This area should have been strengthened. This could have been strengthening by explaining
the variables of the respondents and describing the outcome variables. According to Patton
(2002), the characteristics of the respondents and characteristics of the outcome variables are the
most important aspects for deriving analytical themes. The researcher could have strengthened
the area of derivation of the analytical themes by providing a profile of the characteristics of the
respondents and also the characteristics of outcome variables.
6. Implications -15%
Question: Critically discuss the implications of the study’s findings for dental and/or
aesthetic professionals and policy makers?
The findings of this research showed that the decision to seek orthodontic treatment was based
on massive influence from external sources. This therefore means the findings are not in
accordance with the theory of Montgomery, which claims that a decision is made from a
subjective point of view. The study presents the power of social processes in influencing the
decision to seek orthodontic treatment although there was no evidence of self-awareness of the
external influences by the respondents. This therefore implies that dental and aesthetic
professionals and policy makers need to change the method of communication they make in
order to encourage teenagers to undergo orthodontic treatment. Since the media was the major
influencing factor of the opinion of the teenagers studies, policy makers, dental and aesthetic
professional need to focus on the use of media to appeal to the teenagers to seek orthodontic
treatment. This study however emphasizes that improving critical thinking and self-esteem in
children at an early age is of utmost important and helps the children to resist external influences
such as the media. The study therefore seems to suggest a balance between media appeal and
critical thinking and self esteem in children as the determinants of teenagers seeking orthodontic
treatment.
10
REFERENCES
Berkowitz, R.J., (2003). Causes, treatment and prevention of early childhood caries: a
microbiologic perspective. J Can Dent Assoc 2003;69:304–7.
Dey, I., (1999) Grounding grounded theory: guidelines for qualitative inquiry. San Diego:
Academic Press.
Feldens, C.A., Vıtolo, M.R., Drachler, M.L., (2007). A randomized trial of the effectiveness of
home visits in preventing early childhood caries. Community Dent Oral Epidemiol 2007;
35: 215–223.
Fleming, T.R., (2011). Addressing missing data in clinical trials. Ann Intern Med 2011;154:1137.
Legard, R., Keegan. J., Ward, K.. (2003) In-depth interviews. In Ritchie J, Lewis J (eds)
Qualitative research practice: a guide for social science students and researchers. pp 139–
169. London: Sage Publications, 2003.
Patton, M. (2002). Qualitative evaluation and research methods. Newbury Park: Sage.
Strauss, A. & Corbin, J. (1998). Basics of qualitative research: Techniques and procedures for
developing grounded theory. Thousand Oaks: Sage.
Trulsson, U. et al (2002) ‘A qualitative study of teenagers’ decisions to undergo orthodontic
treatment with fixed appliance’ Journal of Orthodontics’, 29, 197-204