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Literature Review

The preceding section entailed a critical review of the appropriate literature in existence concerning the uptake of smoking among the young people. This section starts by discussing the methodology of executing the research. It then continue to describe in depth and breadth the use of research methods which include criteria of review, development of how to obtain data and finally the techniques to examine the quality of research and data analysis.

This systematic review will borrow heavily from the educational intervention which according to Guise et al (2003), is described as individual instruction sessions or group classes, community outreach programs that contain structured content, including anatomy, physiology, and nutritional issues. These sessions often include practical skills training, such as positioning, latch-on techniques and questions and answers to address common fears, problems and myths. 

Systematic reviews

There are discrepancies over the differences in research consepts. These two concepts are interpretivist and positivists’ approaches. (Tilford and Delaney 1992). Positivist approach encompasses the use of quantitative methods of study which examines hypotheses and generates objective thoughts, which will finally give practical evidence (Tones and Tilford, 2001). In this method of research, standard questionnaires and structured interviews are used. Therefore it is classified as a deductive approach. The use of these techniques is is more reliable than inductive ones because the results can be represented in statistical manner and sequentially extrapolated to cover the whole population. On contrary to the positivist approach, there is interpretivist method which is rather a qualitative technique. The interpretivist method focuses more on exploring the social phenomenon than use of measurable parameters. The method attempts to unearth how the society perceives the day to day occurrences (Pope et al, 1995).

Therefore, systematic reviews can be taken to represent the best means of attaining evidence for practice. Systematic reviews have continued to gain fame in the field of public health aspects assessment. Nevertheless, the methods are not without the drawbacks. Sceptics criticize the method because it is widely seen as focusing more on individual health education interventions than looking at the wider scope of environmental aspects which brings about these interventions. (Jackson and Waters, 2005; The Cochrane Collaboration, 2005). Another drawback of these methods, is the facts that they are not so interesting in reading like single trials. Consequently they are unlikely to inform practice (Loke et al 2003). 

Petticrew (2003) adds by saying that systematic reviews have been criticised for their inability to provide specific guidance of effective or ineffective interventions. This has been noted in reviews of healthcare interventions, the electronic journals and more common in reviews of social and public health interventions (Petticrew 2003). Nonetheless, acknowledging that uncertainty will often remain, systematic reviews help researchers to map the areas of doubt. The strengths of systematic reviews lie in following steps which involve question formulation, searching for studies, and selection of studies, quality appraisal and data extraction, summary and synthesis of relevant studies and the determination of the applicability of results (Glasziou et al 2001).

According to Maggie McLure, giving more priority to systematic reviews as a way of attaining evidence depicts that the qualitative approach is not useful.  This school of thought can be taken as the firm foundation of dismissing systematic reviews to be demeaning the role of reviewer. This is because the actual research is not allowed to flourish. Consequently, there have been diverse views about the methodological criteria to be applied in a research. There have been issues of concern around the methodological criteria for inclusion of studies, assessment of quality of interventions and a deficiency in establishing the theoretical foundations of the interventions, mainly relying primary on RCT as the best evidence (Tilford, 2000).  Thus, qualitative research can provide depth and insight into people’s experiences and social contests if planned and executed with scientific rigour equal to that of quantitative methods (Nutbeam1998).


The use of evidence in formulation and implementation of public health policies is of paramount importance in a bid to make them worthwhile, efficient and effective. This encompasses the field of health promotion which requires effective examination and evidence (WHO Working Group 1999). The availability of scientifically obtained evidence from research studies should be used as a foundation of delivering high quality health care. This will therefore call for broad minded techniques of selecting the right evidence for the study (Peat 2001). The optimum evidence is only attainable using good methodology in the systematic review process. The selection of appropriate evidence will go a long way in eliminating systematic error in the synthesis of studies. A good systematic review must meet the requirements of the following three tenets: Undertaking Systematic of Research on Effectiveness from the centre of Reviews and Dissemination (2008), the recommendations of the International Union of Health Promotion and Education Effectiveness Project (Veen et al 1994) and the Guidelines for systematic Reviews of Heath Promotion and Public Health Interventions from the Cochrane Collaboration (2005).

Systematic literature reviews of public health interventions

There has been a continuous rise in the use of systematic literature reviews in public health interventions studies Jackson and Waters, 2005; The Cochrane Collaboration, 2005). Despite being a popular method, a good number of researchers in the public health field have voiced their concerns about the criteria of using studies, assessment of quality of interventions and a deficiency in establishing the theoretical foundations of the interventions (Tilford, 2000). Application of systematic reviews in public health interventions has been further criticized for failing to address the complexities of the environment at large (Tilford, 2000). Consequently, the researchers in the field of public health have designed the guidelines to guide in conducting systematic reviews of public health interventions (The Cochrane Collaboration, 2005). Although there are these gains have been realized there are cases where the requirements o good quality systematic review are not met bet by primary studies. In such cases, the researcher may not be in a position of drawing out all the data required to the objectives of the study a stipulated in the stated guidelines (Jarlais et al, 2004).

It is worth noting that the public health interventions have a wide range of methodological pluralism (Nutbeam, 1999). The techniques utilized include Randomised Controlled Trials (RCTs), which are controlled before and after studies. It also includes Interrupted Time Series (ITS) designs and qualitative techniques. Nevertheless, the selection of the most appropriate method of study design to be employed in systematic review study must depend on intervention under review but not the other way round (Nutbeam, 1999).

RCTs are preferred by most researchers because of its ability to minimize bias occurrences. Therefore it is the best alternative method of findings reliability enhancement (Jackson and Waters, 2005; Oliver et al, 2005; The Cochrane Collaboration, 2006). However if Randomized Controlled Trials are not possible to be utilized, then other study design may be utilized (CRD, 2001).

According to the CRD Report 4, there are several ways through which reviews effectiveness can be enhanced by use of qualitative studies. To start with, the use of qualitative research is the best method of evaluating the actual needs of consumers. Therefore, the research questions could be formulated with close reference to the needs identified in the qualitative research. In the long run, the method will ensure that consumer needs are satisfied. Secondly, it is possible to pin-point the factors which enhance or curtail implementation of the proposed intervention. Thirdly, the method is one of the best tools for identification of the exact feelings and perceptions of the research population where intervention is being carried. Further, it is advisable to include qualitative studies in systematic reviews because they give a broad spectrum identification of human experiences and useful in the development of new and effective methods of intervention.

It is also important in suggestion of possible strategies to be used in improving the current ways of intervention (The Cochrane Collaboration, 2006). In an attempt to reap from the benefits of both quantitative and qualitative methods, there have been efforts geared at integrating the two methods. It is a new frontier in research field which offering a great challenge to researchers (Woods and Fitzpatrick, 2001). When the two methods have been merged successfully, it would be possible to address complex issues like interventions to promote healthy eating among children (Thomas et al, 2004).

Systematic review methodology must entail the following chronological order of stages. The stages are arranged in a logical sequence which allow for adequate arrangement of thoughts (CRD, 2008). These steps are:

  1. Formulation of review question
  2. Identification of existing volume of literature on the chosen topic
  3. Identification of inclusion and exclusion criteria
  4. Development of Data extraction form
  5. Development of tools for quality assessment
  6. Search strategy  and search terms
  7. Selection of studies and reading of  abstracts
  8. Data synthesis and analysis

The chronological sequences outlined above are best utilized in the identification of the best intervention program for preventing juvenile smoking. The following sections will now focus on each of the steps outlaid above. However, in practice there may be no clear cut between subsequent stages because their details are overlapping and thus calling for parallel study.

Assessment of the existing volume of relevant literature

It is highly recommended that the primary search of already existing literature on the subject topic should be done (CRD 2009). To ascertain that the subject topic has been studied earlier, a search was done in the Cochrane database. The search yielded one systematic review titled ‘School based interventions to prevent the uptake of smoking among children and young people: effectiveness Uthman et al (2009)’. The systematic review employed in this search was able to assess the evidence concerning the interventions which have been put in place to prevent juvenile smoking and evaluation of interventions. However the survey did not limit its scope to any particular intervention. The current systematic review examined the interventions in smoking prevention in the peer-led program.

Complete assessment of the available relevant literature was done using electronic database search. CINAHL and Medline were used in this process. The general search was aided by the use of initial key words within the topic. These key words included: young people, public health, prevention, tobacco use, intervention, smoking, prevention, peer, evaluation and prevalence.

Identification of inclusion and exclusion criteria

There are a number of aspects which were considered in the identification of which study should be included or excluded in this systematic literature review. The first feature which must be considered in the selection criteria is the scope of the study. The study must be broad enough to ensure that the entire range of peer interventions geared towards the reduction of smoking are captured. Secondly, the criteria of selection should bear in mind how the system is able to discriminate against studies which do not cover the interventions and its evaluation.  The criteria for inclusion of a study in this systematic review were considerably ambitious. Thus, both quantitative and qualitative studies included.

Nevertheless, the initial search revealed that the chosen criteria could have led to inclusion of irrelevant studies. The identified studies could have taken too much time because they need to be scrutinized. To amicably solve this looming challenge, Randomized Control Trials is the best way out since they control studies for unknown cofounders (Cochrane Collaboration, 2006). However, this method could not be used because all epidemiologic associations based on health-related behaviours cannot be randomly assigned. The methods could have been a prime source of inadequate control errors (Green and Tones 1999).       

Qualitative research is ideal for situations where it is important to shed important insights into the manner in which interventions are delivered and the factors which affect their effectiveness. Qualitative methods like Focus Group Discussions (FGD), interviews and observations are very critical in providing information regarding the perception and experience of the population (Dixon-Woods and Fitzpatrick, 2001). The methods are very useful in generation of detailed understanding of the intervention features as perceived by both providers and receivers of the intervention. It is broad spectrum and useful in determination of the impact of intervention on either the participants or community at large. It is more precise than the conventional qualitative methods. The recent trends reveal that most public health interventions are finding qualitative research to be the best way of obtaining detailed information (Dixon-Woods and Fitzpatrick, 2001). In conclusion, fro a study to be included in the systematic review it must have met the following requirements:

  • The study completely or partly related to, peer-led interventions aimed at reducing the smoking initiation in young people;
  • The study conducted in a school based setting;
  • The study conducted from 2005 - 2010 (within the last 5 years);
  • The study was available in English language;
  • Studies that recorded some form of outcome measures with or without process evaluation.
  • The study design was Randomised (Controlled/Uncontrolled) Trial/survey containing qualitative data.

 Development of the data extraction form

The development of the data extraction form was based on the guidelines given by the

Centre for Reviews and Dissemination (CRD report, 2001), International Union of Health Promotion and Education (IUHPE) questionnaire (Veen et al, 1994), and the Review Guidelines on Data Collection from the EPI-Centre (1996). In the light of these guidelines,

A data mining form was designed. It was designed into the following 11 categories:

  1. Bibliographic identification and source of the study
  2. Study characteristics (verification of study eligibility)
  3. Study population characteristics
  4. Intervention characteristics
  5. Methods of evaluation
  6. Methodological quality of study
  7. Analysis     
  8. Results
  9. Conclusions
  10. Recommendations by the author(s)
  11. Reviewer’s comments                                         

The data mining form was based on two various analyses and some minimal alteration were performed. Its ultimate edition that comprised of 67 questions is provided in (Annotation1).  

Identification of search sources

In essence, both digital and physical explorations are to be carried for a methodical analysis (CRD, 2001). The first review procedure revealed that this will be carried. However, it was comprehended that a physical search will not be achievable. In addition, the accessible resources to perform the physical search were extremely insufficient to produce satisfactory outcomes. Grey literature was analysed for any work not published and was not effective. It was concluded that the literature analysis may be performed by using accessible electronic database only. The search expressions were experimented on the accessible digital storage structures. The databases that realised to be applicable included: CINAHL, Psycho Info, Medline, EMBASE, Academic Search Premier and Web of Knowledge. These were analysed methodically for applicable studies.   

Definition of search terms

The method used to identify search expressions was first to categorize key words from research resources on school-based effort to minimize smoking up rise and then to experiment these. The list of search expressions is presented in annotation2. As recommended by the CRD procedures (2001), the search terms were grouped as follows:     

  • population/ target group
  • intervention
  • problem area
  • prevention topic
  • type of article

Literature search

The first pace of the literature search was to guide the search expressions and schemes on the databases found applicable to the central literature search. The databases were realised to be quite diverse in features such as sensitivity consequently an method employed by Cattan et al (2005) was used and the search expressions were categorised into two:

  • The core terms used for searches on all databases; and
  • The peripheral terms used to add possible value to the searches.

The literature search was performed by merging search expressions from the five groups. The searches were not the same. It was realised that the methodical merging of core expressions was a triumphant scheme to classify applicable research articles. Peripheral expressions did aid in classifying applicable research articles, but to a minimal extent.   

Obtaining and reading abstracts and articles

For the ultimate addition of the studies, a gradual approach was adopted. First, various studies were omitted on the grounds that either title or their nonfigurative recognized these as immaterial. Second, the rest of the articles were attained from the department of Health library. These articles were analysed in order to establish whether or not they should be incorporated in the methodical review on the grounds inclusion and exclusion conditions. Third, the rest studies were significantly appraised and expressive studies without any estimation were also omitted. Lastly, the studies left after these scrutiny steps were incorporated in the review and data was mined from them.           

Data extraction and synthesis

Data was mined by way of the standard mining form. The practical quality of the survey, the usefulness of the involvement and the validity of findings were exhaustively scrutinized.

It is significant that public health practitioners and program planners can use proof to take on proof based involvements and incorporate them with proof on the population and setting features, theory, and knowledge into locally acceptable programs (Russell, 2004).    

‘Applicability’ defined as the extent to which an intervention process could be implemented in another setting; and ‘transferability’ as the extent to which the measured effectiveness of an applicable intervention could be achieved in another setting (Wang et al 2005).

The handbook of Systematic Reviews of Health Promotion and Public Health Promotion Interventions declares: 

“Applicability is a key part of the process of summarizing evidence, since the goal of systematic reviews is to recommend interventions that are likely to be effective in different settings. Reviewers should use the RE-AIM model for conceptualising the potential for translation and the public health impact of an intervention. The user can then compare their situation to the RE-AIM profile of the included studies or the body of evidence.” (The Cochrane Collaboration, 2005; pp. 85-86) The RE-AIM replica (Glasgow, Vogt and Boles, 1999) has five major considerations to moderate the usefulness of an intercession: (a) Reach; (b) Effectiveness; (c) Adoption; (d) Implementation; and (e) Maintenance of an intercession. In this observation, the Reach relates to the absolute number and representative-ness of the study stakeholders while Effectiveness means the influence of an intercession on significant results. Adoption comprise of:

The decision about the ‘effectiveness’ of the intercession was made on the grounds of the following criteria:

  • proof of a decline in smoking uptake; and
  • The reported results by the author(s), taking into consideration the study objectives, study design, procedural worth and suitability for intercession.

Regarding the grounds of these criteria, the study was subdivided into the following:

  • Inconclusive, when the study was taken as practically poor;
  • Effective, where the study methods were considered to be sound and there was a major decline in smoking introduction;
  • Partially effective, if the study procedures were sound but the decline smoking uptake were not commendable; and
  • Ineffective, where there was no adjustment in smoking introduction.

The practical superiority of the surveys moderated on the grounds of the study plan, means, and also the superiority of the reporting by the investigators (CRD, 2001). The procedures that were employed are charted below:   

  • Was the research plan suitable?
  • Was the research design guarded or unguarded?
  • Was the allotment of study subjects random or non-random?
  • Was the eligibility criteria specified?
  • Were the same measurements employed before and after the intercession?
  • Is it likely for the reader to duplicate the study on the grounds of the article?

The mechanical superiority of the studies was assessed by using the crucial evaluation checklist suggested by Crombie (1996).

Although each of the decisive factors, both for the trials and studies, was regarded separately, the ultimate conclusion about the superiority of the survey was reached on the grounds of the quality of the reporting and feasibility of the survey design and methods. Therefore, the surveys were categorised into three:  

  • High quality studies
  • Moderate quality studies
  • Low quality studies

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