The purpose of this essay is to critically analyse the article “Obstacles to adherence in living with type-2 diabetes: An international qualiatative study using meta-ethnography”. Firstly in order to begin a critique, a rationale for choosing the article must be confirmed. The rationale for choosing this study is that after working in the hospitals it has been noted that many people find it hard to adhere with the “rules” of living with diabetes. Critical evaluation allows an individual to assess the worth of a research article by looking carefully at all parts of the study (Walsh & Wigens 2003). The aim therefore, is to critique and evaluate the chosen article in terms of strengths and weaknesses, to demonstrate an understanding of the research process and to relate this to professional practice.
The article chosen is a qualitative research piece. Qualitative researchers argue that qualitative research gives you access to the nitty-gritty reality of everyday life viewed through a new analytic lens (Silverman 2005).
The research method used in the article is a meta-ethnography approach. In order to begin analysis on the method, we must first understand the meaning of meta-ethnography. Meta-ethnography is a method used to synthesise qualitative research findings. It involves induction and interpretation, and thus follows a similar approach to the methods of qualitative data analysis used in the studies being synthesised (Noyes 2006). In this particular article, meta-ethnography refers to the studies taking place in the different countries and cultures and comparing the results to achieve an overall conclusion about the obstacles surrounding diabetes.
In reading the article, it was found that the researchers encountered several problems with using the meta-ethnography approach. These problems included: six different languages, seven different cultures and translating languages into English may make the findings lose valuable content and context. However, Noblit and Hare (1988) adapted a technique that researchers should follow to be able to find similarities, differences and be able to reflect on the results of the research. The article states that many British researchers have used the Noblit and Hare (1988) technique and have done so successfully. This finding suggests the validity of the methodology technique used for this particular type of research.
Greenhalgh (1997) suggest that before changing your practice in the light of a published research paper, you should decide whether the methods used were valid.
For analysing the article, the Critical Appraisal Skills Programme (CASP) framework has been chosen. This framework has 10 questions which enables the critiquer to understand qualitative research and therefore allows them to continue to analyse their chosen article. These questions can be found in Appendix 1. The first two questions are screening questions which can be answered quickly with breif description.
1. Was there a clear statement of the aims of the research?
The aim of the research was clearly stated in the article introduction. The aim was to answer three different questions about adherence to diabetes. This was important to find the correct results and then be able to compare them with other results found in the EUROBSTACLE.
2. Is a qualitative methodology appropriate?
The methodology for the article used was the meta-ethnography approach and was found to be approprtiate for the articles purpose. Meta-ethnography enables the reviewer to understand and synthesise the findings of two or more qualitative studies concerning a similar research question or topic (Noyes 2006). In this articles case, it was comparing seven different lots of findings from seven different countries, cultures and healthcare settings, so this methodology was appropriate for the purspose of the article.
Appropriate research design
3. Was the research design appropriate to address the aims of the research?
The research design was to have focus groups which followed four different questions (Box 1: The questions or statements posed to the focus group participants). From looking at this table, we can only assume that the design used for the research was controlled and quasi-experimental. If random assignment is not used, then we have to ask a second question: Does the design use either multiple groups or multiple waves of measurement? If the answer is yes, we would label it a quasi-experimental design (Trochim 2006). Several focus groups were used, however, they were not put under an experiment, instead they were asked a series of questions which they answered and then the results of each question were cross referenced and analysed.
Sampling
4. Was the recruitment strategy appropriate to the aims of the research?
As we can see from the article, several different focus groups were chosen to perform the study on. People were recruited from seven different countries all with diabetes and of the average age of 63. Unfortunately, the researcher does not explain how the focus groups were chosen. From this we must assume that the focus groups were purposely chosen. In purposive sampling individuals are selected to participate in research based on their firsthand experience with a culture, social interaction, or phenomenon of interest (Streubert and Carpenter 1999). This could lead to problems in the rest of the article as we do not know if the article can be trusted. For example, the researcher could have selected only people who were know to be non-adherent to diabetes treatment or vice-versa. However, from the article we do get the information about the focus groups used and how many participants were in each focus group, male and female.
In looking at sampling techniques we must also be aware of bias. If a controlled group is being used, bias can be a major factor. Bias can be introduced if the sample is unrepresentative (Stewart & Parmar 1996) However, the sample used in this article is vast and can be argued that it is representative of the population. Samples from seven different countries were taken and 246 people took part in the study. Gaulter and Buchanan (2000) argue that most sampling methods are likely to produce biased samples.
Data Collection
5. Were the data collected in a way that addressed the research issue?
The focus groups were asked a series of questions and were asked to describe their experiences living with diabetes. This unstructured interview method is used primarily in descriptive and qualitative studies (Burns & Grove 2001). The unstructured interview provides the opportunity for the participants to fully explain their experiences and provides a greater depth in the answers provided (Streubert & Carpenter 1999).
Turnstone (2005) suggests that in-depth interviews last for about an hour and are ideal for exploring detailed processes, individual cases, and confidential or sensitive topics. However, this article does not explain how much time was spent on each interview. This in turn makes it difficult to evaluate this part of the data collection. Even if the sample size was sufficient the study must continue long enough to achieve high-quality results for analysis.
Eventhough the researcher doesn’t mention how much time was spend with the focus groups, it does however, mention the saturation of the data. Saturation refers to the repetition of discovered information and confirmation of previously collected data (Morse 1994). The article states that the researchers who took part in the study used a process of returning repeatedly to the original data from each country to either verify, contradict or enrich findings.
Data Analysis
8. Was the data analysis sufficiently rigorous?
The article is sufficient with its data analysis as it states that it coded and re-coded the findings; “This process required returning repeatedly to the original data from each country to either verify, contradict, or enrich interpretations” (Vermeire 2005). This shows that the researcher rigorously checked the data collected and goes on to state that the process of rigor ensured that the data was correct and that no meaning was lost during interpretation of different languages. First, second and third order interpretations were used in the article to ensure once again that meanings and context was not lost during translation.
In conjunction with coding and re-coding, thematic analysis was also used. Table 2 in the research article shows key themes that were perceived by patients and their condition. However, the article does not state how it went through the thematic analysis process. The first step is to collect the data. Audiotapes should be collected to study the talk of a session or of an enthnographic interview (Spradley, 1979). From the transcribed conversations, patterns of experiences can be listed. This can come from direct quotes or paraphrasing common ideas. The article uses direct quotes from patients interviewed and this leads us to the conclusion that audiotapes were used during the interviewing process. The researcher however, fails to discuss their role in analysing the data. This can lead to untrue results and data analysis as the researcher could have chosen only a small amount of the data collected to analyse in order to achieve their research aim.
Results
9. Is there a clear statement of findings?
The article clearly states where the results are so it is easy for the reader to find the results when needed. They are set out clearly and systematically in sub-headings with quotations from patients who took part in the study. Although direct quotations are used for the patients, it could be argued that the meanings of them could be misinterpreted by the researcher and therefore true and trustworthy results haven’t been founded. Overall the article uses around 8 verbatim quotes for each of the sub-heading areas, this seems an inadequate amount to give an overview of a population of 246 participants. However, it would be impractical to use 246 verbatim quotes. It was also noted that some of the quotes used in the findings were neither valid nor applied to the research question. This however, is stated in the article itself “There were many examples of incomplete, conflicting or misunderstood information.”
The findings were then discussed in relation to the research question and it was found that the results, according to the researcher, answered the research question and that the results were synthesised successfully to provide the answers. The article has also discussed the credibility of the results using triangulation to double and triple check the results found.
Value of the Research
10. How valuable is the research?
The studies conclusion summarised the main points which contributed to answering the question. It identifies the obstacles to adherence and assitainted that these are common amoungst a variety of different countries and cultures. The researcher states further research should be conducted as to how the results found on this topic affects the outcome of patient care. The research on this particular topic has been backed by several other studies relating to the same sort of issues, however, these are mostly quantitative studies. These studies have recently been found to be invalid as they do not look at the beliefs of the patients and the patient participation in taking the correct medication. All of these issues must be taken into account when researching the question. This article does this and therefore can be classed as being valuable as it also takes other quantitative studies into account.
The article was easy to find. By accessing the internet and going to www.sciencedirect.com and typing in a topic I found interesting, I found this article.
Interpreting and understanding research is a fundamental part of the process involved in working towards evidence-based nursing. It is essential that nurses are able to make judgements about the value of research, before altering their practice. Critiquing allows the assessment and identification of valid research, highlighting both its strengths and weaknesses. It can tempting to take published statements at face value, however the reader should remember that authors may misrepresent what they actually did, and can overestimate its originality and potential importance.
The results found that the major factors in non-adherence were the course of diabetes, the information given to the patient was insufficient, and also body awareness and relationship with the healthcare provider was poor. This shows that more attention is needed in practice focusing on these main areas that patients found they had a problem with.
On reflection, in doing the critique I have found that patients need to be educated in their conditions in order to adhere to treatment. As a student nurse I understand that education is a major factor in patients refusing treatment. Patients need to be aware of what will happen if they do not adhere to treatment and this will hopefully make patients become more adherent.