Physicians' Roles in Learning Childbearing Women to Intake Folate Supplementations in Saudi Arabia - Research Proposal Example

Table of Contents Table of Contents 1 Research Methods for Social Epidemiology 2 Part I: 2 Part II: 4 Research Methods for Social Epidemiology Part I: Systematic search, systematic review, and critical review In order to do a literature search which is well-founded, reliable and critical, different types of searches are carried out. The basic goal of any research is to search the topic under consideration, analyse it critically and then synthesise the salient features of findings to reach a consensus. Systematic search, in this context, is the literature search carried out in the most thorough, rigorous and orderly manner with search exclusion and inclusion criteria clearly defined. The search is normally carried out to locate evidence from studies done previously, then review the evidence and finally synthesise the same using the desired scientific method. The most reliable search databases are used to carry out such a search. In Australian context, as most of the research carried out here is not indexed in major databases, certain organisational databases are used to fill the gap. Some of these are Australian Centre for Complementary Medicine, Education & Research (ACCMER), Australian Centre for Evidence-Based Aged Care (ACEBAC), Australian Centre for Evidence Based Nutrition & Dietetics (ACEBAND), Australasian Cochrane Centre, Center for Allied Health Evidence (CAHE), Center for Clinical Effectiveness (CCE), National Institute of Clinical Studies, Department of Health and Aging (Australian Government), etc. Besides this there are Australian full text resources, registries and databases like Australian Drug Information Network (ADIN), Australian Institute of Health & Welfare (AIHW), Australian Clinical Trials Registry, and AusHealth (Monashhealth.org, 2008). Of the best few medical databases which are considered as the most reliable in case of medical search, Cochrane Reviews, for example, come at the top. These are high-quality reviews on primary research on health policy and human health and have an international repute for adhering to the highest standards in reporting evidence-based debates on health care. Cochrane Reviews are highly investigative in nature and cover anything from treatment to rehabilitation to interventions, preventions, and diagnostics on individual or group patient settings (Cochrane.org, nd). Systematic search is the cornerstone for an evidence-based systematic review. Systematic reviews, on their own, are supposed to address questions that are clearly formulated; for example: Do physicians play any role in learning childbearing women to intake folate supplementations in Saudi Arabia? The questions itself would act as a guide towards an inclusion and an exclusion criteria. The question talks about physicians and childbearing women in Saudi Arabia; so these two terms become part of inclusion criteria, and any other terms outside the same exclusion criteria. When search results from the primary inclusion criteria is retrieved and then collated, it is categorised into different themes since this search is a set of mixed results. To narrow down the results further, the criteria are further refined. Saks & Allsop (2007) have provided comprehensive guidelines on how to conduct research; both from qualitative and quantitative perspectives. The researchers have even suggested methods to disseminate the health research, contemporary ethical issues and background to health research. After the search is done and research is collated, the writer re-interprets or interprets the findings in his or her own point of view. The review thus formed is a critical review. Critical review, thus, is the findings from the search integrated and synthesised, evaluated and assessed, discussed in context of relevant theories, hinting at the knowledge gap and establishing a research question or a hypothesis. A critical review, for example, of that of a journal article can be an evaluation of its validity, weaknesses and strengths (Coutts, nd). Similarly, critical review on a specific topic drawn from database searches using more than one database can be an evaluation of all the information put together and analysed. Part II: Topic: Physicians’ roles in learning childbearing women to intake folate supplementations in Saudi Arabia Research Protocol Following the development of research question, research protocol was developed for this systematic review. The methods used for searching literature, screening it, then data extraction, and finally analysis was documented prior to conducting the search and subsequent steps. This was done so that the pre-search bias could be minimised. Inclusion and exclusion criteria were strictly determined. Experimental design formed the focus of this step because the research question seemed to influence experimental designs. Some of these, for example, were randomized controlled trials, trials without randomization, control group observational studies (both case-control and cohort) and without control group (both case series and cross-sectional) observational studies. This is considered as an important method, even though it was known that quality of the studies appraised would determine the quality of the systematic review (Khan et al, 2003). The most important protocol was to include studies providing high-level evidence, notably Level I and Level II, particularly of randomized controlled nature, as studies providing low-level evidence have not found to be associated with meaningful conclusions. Medical evidence hierarchy of i) Meta-analysis, ii) Systematic Review, iii) Randomized Clinical Trials, iv) Clinical Trials, v) Cohort, vi) Case-control, vii) Case Series, viii) Case Reports, and ix) Expert Opinion was kept in consideration while fixing the protocol (Wright et al, 2007). Literature Search Since a Quick Google scholar and PubMed search indicated a likelihood of dearth of documented research studies directly linked to the research question, an attempt was made to include as many databases as possible in the literature search. These databases included Cochrane Central Register of Controlled Trials, Database of Abstracts of Reviews of Effects (DARE), Cochrane Database of Systematic Reviews, Cochrane Library, CINAHL, Scopus, PsycINFO, Medline and Embase, Journals, Raw data from published trials, Conference proceedings, Bibliographies and references listed in primary sources Foreign language literature (so as not to limit searches to English), and PubMed Clinical Queries . However, Embase and Medline bibliographic databases were preferred over other on account of their straightforward use (Egger et al, 2001; Glasziou et al, 2001; Khan et al, 2003; Torgerson, 2003). Medline provides journal references and links to articles since 1966 and has grown to more than 10 million references. Embase contains a little over 8 million journal article references and has been indexing since 1974. But this systematic review had to drop Embase because it required paid access, whereas Medline didn't. Some more were dropped that required paid access. Data Extraction Standardised paper forms were used for data extraction with these items that are considered as standards for the same: references, objectives, study design, population, intervention, control, outcome and comments. References included journal, title, author, volume in page numbers, objectives included as stated by the authors, design specified the type of trial, population signified demographics of the study population, intervention was the approach used, and control, outcome and comments meant as the names suggest. After the data extraction final inclusions and exclusions were made. For example, many studies revolving around the one being searched in Saudi Arabia context led the search to other countries which did not have the same demographics as this one, so they were excluded in the subsequent search or simply deleted from the data extracted. Quality Appraisal Quality appraisal is considered as one of the key steps in the development of a systematic review and for this a number of checklists and scales have been developed (Atkins et al, 2004; Emerson et al, 1990; Huwiler-Muntener, 2002; Oxman, 1994; Schunemann, 2003). However, keeping in mind that it is still very difficult to see the weakness or strengths of a study in an adequate manner, the nearest possible scales were tallied. Data Analysis and Results Nutrition-related diseases, in both childbearing women and new born, have been of concern. But as the economic and social situation in the nation has changed over the last three decades, remarkable changes have as well been felt in this picture which was grim earlier. Women have been victims of two types of nutritional deficiencies; the first type is inadequate nutrition intake during childbearing periods and second one is the lifestyle-related nutritional disorders. These factors vary from one place to another and are often determined by the socioeconomic condition of the region. In all there are some basic factors like poor sanitation, unsound dietary habits, lack of access to safe health services and water, and poverty and ignorance which form the epicenter of poor nutritional status of these women. What compounds the problem is that there is absolute lack of nutritional surveillance and epidemiological studies pertaining to Saudi women. Information on nutrition is scare too and women often do not have access to this information, of which whatever little is available. Folate deficiencies in childbearing women can be attributed as a cause for undernutrition in school-going children and the single most prevalent cause of child mortality in some regions which have middle or low income populations. According to WHO estimates nearly one-third of the children population is so malnourished that they suffer from severe micronutrient deficiencies. Even if this was not related to the search which was made or this systematic review, it was startling to come across an article that gave bits and pieces of some important revelation. One of them was that most of the Saudi women are not even as educated as to know their rights. With regard to childbearing they have too little options with them. Practically they are neither emotionally nor mentally or physically prepared for this. Quote often they are not informed of the risk, precautions or care they should take during childbearing times. A statistics reveals that nearly 23 percent of women looking for pain relief during pregnancy do not even find cocaine being therapeutically effective on them. Saudi culture has been long equated with culture of men dominance and it also seems to be working up with situations as this, which takes uneasy dimensions when doctors seem to take control of childbearing bodies (Hajjar, 2011). Even as physicians in Saudi Arabia have been doing an active role regarding folate supplementation to childbearing women, but the impediments are felt when taking into consideration that care and pregnancy among Saudi Arabian women are characterised on a composition based on religious, if not experimental, elements. The religious elements come in the way of properly educating Saudi Arabian women about the advantages of folate supplementation. This is followed by women's expression of symptoms like dizziness, fatigue and tiredness but, all of which they unfortunately, attribute to the will of God. God's will has a consequence for almost everything else. In times of disease these women do not attribute it to God's will but to a notion that God wants to test them for their endurance. Even though Saudi Arabian women give great importance to pregnancy, childbearing and delivery, the practices and beliefs are greatly influenced by the religious and cultural norms (Baldo et al, 1995). But that childbearing is important, the health care services think it morally binding to lay special emphasis on the same. But the fact that Saudi women stress to be seen mostly by female doctors proves to be a barrier because presence of a female physician cannot be guaranteed at all times. In the absence of a female doctor, they urge to be accompanied by a female nurse. Furthermore the conditions at the health care facilities are not generally favoured by the Saudi women so any further attempt at providing out of way counseling, for example, on folate supplementation even if desirable often go in vain. If, per chance, the counseling is provided, but the availability of the supplement products is not always guaranteed by the health centers. Saudi culture has a propensity to separate women from men which makes it difficult for physicians well-versed in disseminating information on folate supplementation As a result of this they prefer midwives over physicians in providing them delivery or antenatal care. The problem is that midwives are not knowledgeable about supplementation facts. Other factors that limit the role of physicians in making childbearing women learn about folate supplementation is minimal number of visits childbearing women pay to the physicians or health centers. Saudi women hold certain strong notions about these visits. Some think one visit in the first trimester is enough, while a few think 2 or 3 are fine. This limits the scope of physicians in interacting with these women. It has been suggested that there is a lot of room for improvement in the information that is provided by either physicians or even nurse, which means at the moment enough of information dissemination does not take place. Reports have indicated that there have been instances when information, which was supposed to be passed on by physicians, was actually handed over by nurses (Gustavo et al, 2003). Interpretation of Results One important finding of this systematic search was a study by Murad Al-Holy (2013) which revealed that health care providers (it did not specify physicians) were the main educators on folate supplementation to childbearing women. The study emphasised the need to educate more and more women about the benefits of taking folate supplementation during childbearing period. The study also called on media to be a partner in such programs. The study was conducted in Hail region of Saudi Arabia and evaluated for a number of parameters like timing of folate supplementation, awareness of the same and identification of the sources of knowledge (Al-Holy, 2013). The study, which was conducted between October 2011 and January 2012, involved 300 married women, all of whom were of childbearing age between the years 19-45. A set of questions was posed to all participants who included those on level of education, age monthly income, occupation, gravidity and adequate number of questions regarding folate, knowledge on the same, supplementation practices and folate intake before conception. They were also asked what defects would result in case there was folate deficiency during or other than childbearing period (Molloy, 2005) . Eighty one percent of these women revealed that they know the negative effects of folate deficiency and importance of its intake during pregnancy; 91 percent said they were aware of information related to folate and a mere 10 percent said that they were aware that iot should be taken after or during pregnancy. While they agreed health care providers provided information of folate supplementation, it was their university education that had actually apprised them of its importance (Al-Mendalawi and Kari, nd). Women with planned pregnancies and those with lower gravidity reported folate supplementation which was significantly higher (Mansour and Hassan, 1994). This study is a recently published one and was a breather for this systematic review since comprehensive searches elsewhere could not fetch up-to-date and abundant data. Research done elsewhere has revealed that primary care physicians in Saudi Arabia needed to update their knowledge on nutrition. This research, which was conducted in Department of Food Sciences and Nutrition, King Saud University, in 2004, urged integration of nutrition subjects in medical school curriculum. It should, suggested the research, be also be integrated as a major part in CMEs or continuing medical education for doctors (Al-Numair, 2004). In this research, folate, incidentally, figured in relation to its relationship with neural tube defects, but not in relation to whether or not physicians were responsible in learning childbearing women to intake folate supplementations in the country. Research Question Do physicians play any role in learning childbearing women to intake folate supplementations in Saudi Arabia? 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