Critical Appraisal of “Women's understanding of abnormal cervical smear test results: a qualitative interview study (BMJ)"

 Introduction:-

The qualitative study that I have selected for discussion regarding its contribution to public health is by Anne M. Kavanagh and Dorothy H. Broom, 1997 with the title “Women's understanding of abnormal cervical smear test results: a qualitative interview study”, published in British Medical Journal in the year 1997; 314 doi: http://dx.doi.org/10.1136/bmj.314.7091.1388 (Published 10 May 1997) Cite this as: BMJ 1997;314:1388.

The aspect of social health and people’s experiences:-

The author has adopted an interpretivist (Avis, 2005) approach in his research. The women attending the clinic had difficulty understanding the technical/medical terms describing their condition. It was partly because they had no idea of the anatomy of cervix. So, this lack of understanding resulted in confusion and dissatisfaction in the women and they had no idea how to go about its treatment. The gynecologists counseled the women in technical language, which was of little help. The key message was that the lack of understanding of their medical condition was resulting in confusion and incomplete treatment.

Relevance to public health:-                                                                                                                                                     

Public health is all about preventing diseases via screening. In colposcopy, precancerous cervix is diagnosed, which can be treated and cervical cancer can be prevented. Hence it is relevant to public health. If women are given awareness regarding the importance of annual gynecological examination, the incidence of preventable gynecological diseases can be minimized.

What knowledge this study gives that quantitative research cannot give:-

Quantitative research can only ‘collect’ data regarding the number of women having precancerous cervix, their age, their sexual activity, number of partners, sexual transmitted diseases etc. but qualitative research on the contrary ‘generate’ data regarding how they understand their disease, their social standing, the role of the service provider, as a result of which better and group counseling techniques can be introduced for women to understand their disease better and then follow the treatment plan effectively.

Professional point of interest:-                                        

 I myself am a practicing physician in reproductive health. It is quite interesting to prevent a disease such as cervical cancer by simple screening. Although we do not have the facility to perform such screening at our service centre, but still if during the insertion of Intra Uterine Contraceptive Device, there is something suspicious regarding the look of the cervix, I refer it to the gynecologist for screening and biopsy.

Personal point of interest:-

Personally I am fond of good counseling techniques. If one makes the patient understand, more than half of the problem is solved. In this study, it is concluded that as it is difficult for the physician to counsel each and every patient individually due to time constraints, so patients having similar condition must be counseled in groups.

Critical Appraisal of the study (CASP Checklist, 2013):-

1. Was there a clear statement of the aims of the research?

 

The research topic was clearly stated, with an aim to understand women’s perspective of an abnormal cervical smear test as a result of their interaction with the service provider. It is important because without understanding one’s condition, it is difficult to follow the proper treatment plan, and to avoid unnecessary stress. It is relevant to those women who are about to develop cervical cancer, if not treated within time.

2. Is a Qualitative methodology appropriate?

The qualitative methodology is the right choice for the research topic as this study aims to interpret the subjective experiences of the research participants. It aims to understand the short comings of counseling and how do the women understand their condition.

3. Was the research design appropriate to address the aims of the research?

The researcher has justified the use of the qualitative research design by saying that this study involves ‘women’s feelings and perceptions’ (Kavanagh, 1997) regarding cervix and abnormal smear.

4. Was the recruitment strategy appropriate to the aims of the research?

The researcher has explained that the 29 participants were recruited from three private Gynecology Clinics in Australia (as the services are not available in public sector in Canberra) and a women’s health centre from late 1990 to mid 1992. The participants had an abnormal cervical cytology and were being diagnosed and treated. Women with invasive cervical disease were not included in the study. The former were appropriate for the study, as they could better answer the study question regarding their understanding of disease which was not cervical cancer, but had complex understanding and non conventional treatment (Kavanagh, 1997). On the contrary, there is no discussion why some of the participants did not take part in the interview, or that all the women with mentioned criteria took part.

5. Was the data collected in a way that addressed the research question?

 Semi structured interviews was the tool for data collection. “There was a topic guide to conduct the interviews and all the interviews were tape recorded and transcribed. Text from the interviews was entered into the computer program NUDIST (Non-numerical Unstructured Data Indexing, Searching and Theorising) (Kvanagh, 1997). A coding framework was constructed based on the aims of the research, the interview schedule, and recurring themes (Kavanagh, 1997). Because the analysis is based on small numbers, the research findings are not presented numerically, instead, terms such as most or many (more than half), several, and a few (usually two to five women) are used to provide an indication of the frequency of a particular interpretation or theme” (Kavanagh, 1997). So the saturation of the data is discussed but there is no indication about the modification of the methods during the study.

6. Has the relationship between researcher and participants been adequately considered?

The researcher has not discussed her role and relationship with the participants, the sources of potential bias while formulating research questions or the recruitment of participants and location. The researcher has also not considered any implications to change the study design as a result of the challenges faced while conducting the study.

7. Have ethical issues been taken into consideration?

The study did not mention how the ethical issues were taken into account. It is not mentioned whether informed consent was taken from the women recruited in the study or how the effect of the study has been handled during and after the interviews from the participant. The approval from the ethics committee has also not been mentioned.

8. Was the data analysis sufficiently rigorous?        

The data analysis is mentioned quite briefly. A coding framework has been developed keeping in view the aim of the research, the interview schedule, recurring themes, the socio demographic profile and the clinical diagnosis and treatment (Kavanagh, 1997). The researcher has explained how the data presented was selected from the original sample. Sufficient data has been presented to support the findings. Contradictory data was also taken into account to some extent. The researcher’s own role during the data analysis and potential bias has not been discussed.

9. Is there a clear statement of findings?

The research findings are clear. The discussion of results is in favor of the research argument. The arguments against the research question are not taken into account. The credibility of the research findings in relation to triangulation and respondent validation has not been discussed. The findings have been discussed in relation to the original research question and are generalized to Silverman’s (1987) work on pre admission counseling.

10. How valuable is the research?

The researcher has mentioned that the previous studies on women with abnormal cervical smear were its relation to their fears about cancer, reproductive function, diagnosis and treatment (Kavanagh, 1997). But this study has contributed a new angle by discussing that how the interaction of women with healthcare providers contributes to the psychosocial difficulties they experience. So in this way the researcher has identified new area of research. The research findings are applicable to other areas such as the paeds clinic mentioned previously.

THE RIGOR FRAMEWORK FOR THE RESEARCH (Green and Thorogood, 2008):-

-Validity:-

The researcher has used excerpts from the data to support the research findings. Its validity has also been confirmed by feeding back the data to the women and also talking to their gynecologist (Kavanagh, 1997).

-Reliability:-

The concepts that developed during data analysis were discussed in relation to the data.

-Comparing participants’ accounts:-

The author has compared the accounts of the women who had seen their cervix during colposcopy via a monitor and those who have not. The former had a better understanding about their condition and were mentally relaxed. The later were confused and distressed.

-Choosing appropriate data generation for the research question (Morse et al 2002):-

 

The researcher has chosen appropriate data generation to answer the research question.

 

-Sampling:-

 

The sampling was appropriate for the research purpose, but I suggest including further participants from other clinics as well.

 

-Drawing on theory (Morse et al, 2002):-

 

The researcher has drawn on the theory of the work done by Silverman (1987), who instituted preadmission clinics for parents of children attending paediatric cardiology clinics. Hence the researcher also advises such pre colposcopy clinics for women with abnormal cervical cytology, to save time and burden on the physician and answer all the questions of the women in focus groups.

 

References:-                                                                                                                                                  

Anne M. Kavanagh and Dorothy H. Broom (1997), “Women's understanding of abnormal cervical smear test results: a qualitative interview study”. British Medical Journal; 314 doi: (Published 10 May 1997) Cite this as: BMJ 1997;314:1388.http://dx.doi.org/10.1136/bmj.314.7091.1388

Avis, M. (2005), “Is there an Epistemology for Qualitative Research?” .In Holloway, I (ed).Qualitative Research in Health Care. Maidenhead: Open University Press

http://discovered.ed.ac.uk/44UOE_VU1:default_scope:44UOE_ALMA51137413870002466

 

Critical Appraisal Skills Programme (2013), Qualitative Research Checklist. CASP, Oxford http://media.wix.com/ugd/dded87_29c5b002d99342f788c6ac670e49f274.pdf   

 

Green, J. and Thorogood, N. (2014), “Qualitative Methods for Health Research”. 3rd edition. London: SAGE.

 

Morse, J, Barrett, M, Mayan, M, Olson, K, Spiers, J. (2002), “Verification strategies for

establishing reliability and validity in qualitative research”. International Journal of

Qualitative Methods. 1 (2)

Silverman D. (1987), “Communication and medical practice: social relations and the clinic”. Bristol: Sage Publications, 1987.