1.Research / statement question What is the main question / statement you wish to answer/ explore? Have you included a specific Public Health or Social Care Management Policy issue, target population and context (location) in your research question / statement? 2.Introduction What are the key areas which will be addressed in this research proposal? 3.Background and Rationale for the study Have you read around your research topic? Have you provided background information of important historical & contextual events and research which informs the reader why and how the Public Health or Social Care Management Policy issue you are interested in exists as a problem? What other studies have been conducted and what is their relevance to your chosen topic issue? Where relevant, have you evidenced the Public Health or Social Care Management Policy issue with appropriate comparative statistical evidence supported by relevant literature, including the most current sources? Where relevant have you evidenced the Public Health or Social Care Management Policy issue with appropriate qualitative evidence supported by relevant literature, including the most current sources? Have you explicitly explained why your chosen research topic issue is important to your field of practice? Have you presented a Thesis/ Justification Statement? i.e. objectively justifying why, you are interested in the chosen research topic? 4.Aim and Objectives What is the aim of the study – what do you want to achieve? (Identify one overall aim) Does the aim of the study resonate with your research question/ statement? What are the objectives of the study? (identify at least 4 – 5 objectives) Have you considered whether the aim and objectives actually describe what your proposed study intends to do, whether it’s realistic and reflects the requirements for analytical rigour expected at Masters Level? 5.Methodology You have a choice of conducting either Primary Research OR Secondary Research. If considering conducting Secondary Research you are required to address the following: Have you explained your selected methodological approach- e.g. secondary research versus primary research? Have you critically discussed the strengths and weaknesses of your chosen methodological approach while supporting this with relevant literature? Have you justified it? What is your Literature Search Strategy? i.e. How will you conduct your literature search? *What search engines will be used to search for the literature? *What academic & professional data bases will be accessed? *What Key words & Boolean operators will be used in the literature search? *What is your literature search exclusion and inclusion criteria and have you justified it? *What tools will you use to critically appraise the identified literature? If considering conducting Primary Research, you required to address the following: Have you explained your chosen methodological approach-i.e. Primary versus secondary research? Have you critically discussed the strengths and weaknesses of your chosen approach while supporting this with relevant literature? Have you justified it? Have you discussed and justified your: a) Data collection methods b) Study participants & Sampling technique/s) c) Data analysis method What is your Literature Search Strategy? i.e. How will you conduct your literature search? *What search engines will be used to search for the literature? *What academic & professional data bases will be accessed? *What key words & Boolean operators will be used in the literature search? *What is your literature search exclusion and inclusion criteria and have you justified it? *What tools will you use to critically appraise the identified literature? 6.Ethical Considerations How will you address this? Whether you are considering conducting Secondary Research or Primary Research, you must avoid plagiarism (which is a punishable academic offence), citing all literature sources appropriately etc. In addition, if considering conducting primary research, you are required to seek ethical approval from the Ethics Review Committee. Issues pertaining to data protection, confidentiality, voluntary participation, participant anonymization inter alia must be addressed – see next pages for further guidance). 7.Indicative Research Time table When will you start, and finish the dissertation? Have you fully considered all relevant stages in the research process by identifying specific targets/ actions for completion within specific time frames? (e.g. a table with two columns – one with a list your targets/ actions and another timeframe, i.e. specific dates) 8.References Have you provided a comprehensive reference list of all cited literature sources? Ethical considerations This is a very important part of a Primary Research based Dissertation and further information can be obtained from the University Research Ethics Policy web site http://www.londonmet.ac.uk/research/graduate-school/policy-and-strategy/research-ethics-policy.cfm. All students are encouraged to visit this site prior to commencing their dissertation.SH7008
Research Methods for Health & Social Care
Semester 2, 2019/2020
What are the key sociodemographic and socioeconomic factors influencing adherence to endocrine therapy among women with estrogen positive breast cancer in the United states?
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Introduction Breast cancer (BC) is “a disease in which cells in the breast grow out of control” (Centers for Disease Control and Prevention, n.d, p. 1). In the United States (US), breast cancer in women is a highly prevalent cancer (except for skin cancer) with more than 245, 000 women diagnosed each year (Centers for Disease Control and Prevention, 2019). Although both men and women can get BC, the lifetime risk of being diagnosed with BC among US men is rare with 1 in 1000 compared to 1 in 8 women (National Breast Cancer Foundation, 2019). BC is most commonly diagnosed among women over the age of 50 however, it can also affect younger women with 10% of new BC cases in the US being diagnosed in women younger than 45 years old (Centers for Disease Control and Prevention, n.d). Breast cancer accounts for an average of 15.2% of all new cancer cases and 40,000 death each year (National Breast Cancer Foundation, 2019; Centers for Disease Control and Prevention, 2019).
According to the Centres for Disease Control and Prevention (2019) in the United States each year between 1999-2016 the number of new BC cases had been rising due to the ageing population and population growth. Between 2012-2016, there was a 0.3% increase in the incidence rate of female BC (DeSantis et al., 2019). In contrast, from 1989 to 2017, 375,900 BC death has been avoided, which is a 40% decline in BC mortality rate (DeSantis et al., 2019). Nonetheless, it is the second leading cause of cancer mortality among US women (DeSantis et al., 2019). One of the main reasons for the decline in female BC mortality rate might be due to the improvement in anti-hormone treatment such as endocrine therapy (Centers for Disease Control and Prevention, 2019; DeSantis et al., 2019; Awan and Esfahani, 2018).
This research proposal will commence with a background of the most common form of BC, estrogen positive breast cancer and the importance of endocrine therapy in increasing disease-free survival rate in BC patients including the rationale for the study. Then the aim of the proposed study and four objectives will be provided. This will be followed by the methodology section which will include the study design, literature search strategy, study appraisal tool and data analysis method as well as
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ethical issues that will be considered. Finally, a time table outlining the time for the proposed project will be provided.
Background
Two out of three (75%) of breast cancers are estrogen positive hormone receptive (ER+) (Shah et al., 2020). Thus, women whose BC is ER+ are prescribed one of the two main types of endocrine therapy- tamoxifen, an oestrogen receptor modulator which is prescribed primarily to premenopausal women and aromatase inhibitors (AIs) such as Exemestane, Letrozole and Anastrozole for postmenopausal women which significantly reduces plasma oestrogen levels (Bender et al., 2014). Adjuvant endocrine therapy (ET) also known as hormone treatment (HT) is prescribed for up to ten years to reduce the risk of breast cancer recurrence and improve patients’ chance of survival (Shah et al., 2020). ET has been proven to reduce the risk of recurrence in breast cancer survivors by up to 50% (Lambert et al., 2018). Also, BC mortality reduces by 33% in the ten years after initial treatment if tamoxifen is taken for five years while the risk of mortality reduces by approximately 50% if tamoxifen is maintained for additional ten years (Early Breast Cancer Trialists’ Collaborative Group, 2011; Zhijun, Wei and Bradley, 2018). Besides, ET effectively reduces the risk of metastatic BC growth and progression in women whose tumours are hormone-sensitive (Salkeni and Hall, 2017).
Hence, adherence to adjuvant hormone therapy has become increasingly vital for improved recurrence and disease-free survival outcome (Lambert et al., 2018). Moreover, the implication of nonadherence to ET could result in an increased number of visits to a physician, compromised treatment efficacy, higher hospitalisation rates and reduced disease-free and overall survival rate (Moon et al., 2017; Bender et al., 2014).
Notwithstanding the proven clinical efficacy of ET, adherence among women in the US is suboptimal with 31-73% of women with ER+ BC failing to stay on recommended regimen or stop treatment (Shah et al., 2020; Lambert et al., 2018). Evidence also suggests that nonadherence to ET varies between tamoxifen (59%)
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and AIs (50%) (Murphy et al., 2012). According to the National Institute for Health and Care Excellence (NICE) (2009, p.2), the notion of adherence is defined as “ the extent to which a patient’s action matches the agreed recommendations” while non- adherence to long term therapy can be classified as unintentional or intentional. Unintentional nonadherence to long term therapy occurs due to barriers such as not remembering, not understanding therapy instruction or their inability to pay for therapy despite the will to follow the recommended therapy (NICE, 2009). Conversely, intentional nonadherence occurs due to the individual’s perception and beliefs about the treatment and decides to stop treatment (NICE, 2009).
The Necessity-Concerns Framework (NCF) can be utilised to understand a patient’s decision to adhere / not adhere to long term ET (Horne et al., 2013). Thus, adherence to therapy depends on the individual’s belief about the necessity of the treatment and their belief about the adverse outcome associated with taking the treatment (Horne et al., 2013). Furthermore, both quantitative and qualitative studies have found that factors such as severe side effects, lower quality of life and poor patient-provider communication are associated with nonadherence to ET (Bluethmann et al., 2017; Chlebowski, Kim and Haque, 2014; Chalela et al., 2018; Pan et al., 2018). What is more, adherence is greater in clinical trials compared to clinical practice due to the increased clinical contacts which indicates that regular follow-up and support with management of side effects increases adherence to endocrine therapy (Chlebowski, Kim and Haque, 2014). Thus, highlights the importance of access to regular follow-up care and effective patient-physician communication.
Sociodemographic and socioeconomic factors have also been reported to independently predict nonadherence to ET among women in the US (Bender et al., 2014). Evidence suggests that there is a strong association between sociodemographic factors such as age and ethnicity and non-adherence to ET among women in the US (Spencer, 2020). What is more, minority population who are also on a low income are less likely to integrate into the health care system thus, have poor access to health care providers resulting in suboptimal ET use (Roberts, Wheeler and Reeder-Hayes, 2015). Additionally, a retrospective cohort study of women under the age of 65 and Medicare insured, conducted by Farias and Du
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(2017) found that the cost of therapy was significantly associated with nonadherence to ET. Similarly, in a recent quantitative study conducted by Spencer et al. (2020) lack of resources and being public insured were identified as barriers to adherence to endocrine therapy. Thus, privately insured women were less likely to report trade-off and resource barriers compared to Medicare insured women (Spencer et al., 2020).
Economic and insurance issues have been identified as barriers to access to health care among cancer survivors in the National Action Plan for Cancer Survivorship (NAPCS) (2004) Advancing Public Health Strategies. The Action Plan recommends that survivorship advocates should educate decision-makers about the financial barriers that cancer patients face to access quality follow-up care (NAPCS, 2004). A descriptive assessment of the implementation of NAPCS’s and its applicability at five national organisations conducted by Smith et al. (2013) found that insurance issues such as ineligibility to public health programmes and advocacy regarding insurance issues were being addressed by educating policymakers through a variety of methods such as briefing materials and white papers.
Furthermore, the National Comprehensive Cancer Network (2019) first published in 2013, recommends that cancer specialist and primary care providers should work together to support women who are on long term endocrine therapy. The guideline recommends that patients should be provided with a personalised survivorship treatment plan which includes a personalised summary of long term toxicity of the treatment as well as follow-up recommendations (NCCN, 2019). The guideline also states that patient engagement in their treatment is vital in improving adherence to endocrine therapy thus, requires frequent follow- up encouragement (NCCN, 2019).
Rationale
In the context provided above, considering the association between adherence and improved recurrence and disease- free survival outcome, adherence to adjuvant hormone therapy is becoming increasingly vital. Hence, it is crucial to identify the key sociodemographic and socioeconomic factors that influence adherence to adjuvant endocrine therapy among breast cancer patients as well as the extent to which those
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factors influence adherence. Hence, assist in the development and implementation of effective adherence-enhancing interventions. It is also vital to identify the key sociodemographic and socioeconomic factors influencing adherence to optimize allocation of resources and to inform evidence-based policies and strategies to increase endocrine therapy adherence among women with ER+ breast cancer. Aim: To explore the key sociodemographic and socioeconomic factors influencing adherence to adjuvant endocrine therapy among women with estrogen positive (ER+) breast cancer in the United states. Objectives: 1. To examine the prevalence of adherence to adjuvant endocrine therapy among women with ER+ breast cancer the United states.
2. To explore the key sociodemographic factors influencing adherence to adjuvant endocrine therapy among women with ER+ breast cancer the United states.
3. To explore the key socioeconomic factors influencing adherence to adjuvant endocrine therapy among women with ER+ breast cancer the United states.
4. To assess the effectiveness of national guidelines and strategies in promoting adherence to adjuvant endocrine therapy among women with ER+ breast cancer in the United states.
Methodology
This section will provide an overview of the methodologies that will be used to carry out the proposed health project. It will commence with an overview of the study design and literature search strategy. Followed by an overview of the study appraisal tool that will be used to critically evaluate each study and data analysis framework including the steps that will be followed. Finally, ethical considerations will be discussed.
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Study design
The proposed study will be carried out using secondary research method in the form of a narrative review of the literature. A secondary research method is a research technique that involves the process of collecting and analysing data from already existing studies such as peer-reviewed original studies (Bryman, 2016; Hox and Boeije, 2005). On the contrary, a primary research method is a research method that involves the process of collecting original data (Bryman, 2016). Although conducting primary research would answer the specific question at hand, it is nonetheless a much more time-consuming process (Hox and Boeije, 2005). Although in secondary analysis location and accessibility of data might be an issue, it is less time consuming compared to primary research method as the data has already been collected by other researchers (Miller and Brewer, 2011; Stewart and Kamins, 1993). What is more, one can also answer the question at hand by combining different findings and conclusions from various studies using secondary research method (Stewart and Kamins, 1993).
Another advantage of using a secondary research method is that secondary collection and analysis of data is a less- costly process (Bryman, 2016). Also, adherence to endocrine therapy is a well-researched topic in the US hence, it is more practical to utilize existing data than collect new data which might also result in BC patients being over-researched. Moreover, a narrative review of the literature might not cover all the literature and present difficulties in replicating as it is not comprehensive (Smith and Noble, 2016). Nevertheless, it is a useful method to identify gaps or omission all within summation to inform policy and/ or future research through a critical interpretation and a reasonably comprehensive assessment of existing data (Grant and Booth, 2009; Smith and Noble, 2016).
Literature search strategy
A literature search strategy will be followed to retrieve relevant articles. A literature search strategy is an organised structure of keywords, phrases and concepts used to search and retrieve relevant and accurate results from databases (Bryman, 2016). The use of literature search strategy is vital as it will eliminate errors in terms of retrieving irrelevant studies and biased information which might result in an
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incomplete and biased evidence base (Bryman, 2016). Additionally, it increases the replicability of the study as it gives a clear guide on how literature was retrieved (Bryman, 2016).
PICO (Population, Intervention, Comparison and Outcome)
The research question can be broken down using PICO to assist with the literature search strategy.
Population
Intervention
Comparison
Outcome
• Women with ER+ BC
• Sociodemographic factors
• Socioeconomic factors
Endocrine therapy
None
Adherence
Search engines and databases
Search engines such as google scholar, Academic Info, and Microsoft Academic will be utilised to access databases. London Metropolitan University library catalogue will also be used to accesses databases. The databases that will be used to retrieve literature are PubMed and Wiley online library.
Key Words
Synonyms
Sociodemographic factors
Sociodemographic characteristics
Socioeconomic factors
Socioeconomic characteristics
Influencing
Associated with
Adherence
Endocrine therapy
Hormone treatment, hormone therapy
Women
Female
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Estrogen-positive (ER+) Breast cancer
ER+ Breast cancer, hormone-receptor-positive breast cancer, estrogen-dependent
United States
North America, America
Search strategy (using Boolean operators)
Boolean operators will be utilised to enhance the search by combining the keywords and synonyms. Boolean operators that will be used for the search are OR and AND. OR will be used to find studies that mention either of the keywords and AND will be used to find studies that mention both search terms.
1. (Sociodemographic factors OR sociodemographic characteristics) AND (influencing OR associated with) AND (adherence) AND (endocrine therapy OR hormone treatment OR hormone therapy) AND (women OR Female) AND (oestrogen positive (ER+) OR ER+ breast cancer OR hormone-receptor-positive breast cancer) AND (United States OR North America OR America).
2. (Socioeconomic factors OR Socioeconomic characteristics) AND (influencing OR associated with) AND (adherence) AND (endocrine therapy OR hormone treatment OR hormone therapy) AND (women OR Female) AND (oestrogen positive (ER+) OR ER+ breast cancer OR hormone-receptor-positive breast cancer) AND (United States OR North America OR America).
Inclusion and exclusion criteria
To be considered for the proposed narrative review articles have to be peer-reviewed and conducted using primary research method. Also, as the focus of the study is the US, articles that are published in the US will be included and articles published outside the US will be excluded. See below table for further inclusion and exclusion criteria.
Inclusion
Exclusion
Women
Men
ER+ BC
Other types of BC
Endocrine therapy
None endocrine therapy
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Endocrine therapy for post-treatment
ET as chemoprevention or palliative therapy of metastatic disease
English
Other languages
Primary studies
Secondary studies such as literature and systematic reviews
Published scholarly or Peer-reviewed articles
Non-scholarly or nonpeer-reviewed articles, Preliminary findings/ unpublished
Studies published between 2013 – 2020
Studies published before 2013
Appraisal of the Literature
In conducting a literature review, it is important to critically appraise each study to identify potential bias and reduce data overload and this will allow for high- quality and relevant evidence to be used (Cronin, Ryan and Coughlan, 2007). The literature identified through the literature search strategy will be systematically and carefully assessed to ensure the quality of the studies in terms of their validity, reliability and acceptability. In doing so, critical appraisal skills program (CASP) (2018) a tool that includes structured checklists will be used to critically evaluate the literature. Critical appraisal tools are useful to evaluate the methodological quality of research literature to inform and implement evidence-based practices (Wendt and Miller, 2012). Firstly, studies will be read for familiarisation and to decide on the study designs each study used. Then a CASP tool relevant and appropriate for the study will be chosen and the appraisal of the literature will begin with screening, a process which will assist in determining if the study should be included. Then more detailed questions will be used to further evaluate the studies.
Data analysis
Data will be analysed following Braun and Clarke’s (2006) six-phase thematic analysis framework. Thematic analysis is a method in which repeated patterns or themes within qualitative literature or data collected can be identified and analysed (Braun and Clarke, 2006). One of the advantages of using thematic analysis compared to other qualitative data analysis methodologies is its flexibility as it is not
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tied to theoretical or epistemological perspectives (Maguire and Delahunt, 2017). Core themes that can be distinguished both within and between literature will be extracted by examining the data and coding each literature (Bryman, 2016). This will assist in the summary of the most relevant and important aspects of literature by synthesising past and current studies related to key sociodemographic and socioeconomic factors influencing adherence to endocrine therapy among women in the US. It will also assist in the reduction of large data (Bryman, 2016). Following the six-phase thematic analysis framework (Braun and Clarke’s, 2006)- the process of data analysis will begin with a thorough reading of the literature for familiarization with a specific focus on repeated patterns that might occur. Then initial codes will be generated through labelling of relevant phrases, words and/ or sentences which will then be combined into overarching initial themes for further analysis. This will be followed by reviewing the initial themes by checking the coded data against the initial themes and then define core themes. Finally, the results will be written.
Public health ethics
Ethical considerations are a crucial part of a research and public health practice (Coughlin, 2006). Researchers have to anticipate and identify ethical issues and effectively address before carrying out research (Coughlin, 2006). As stated in the Stewardship model, a framework for public health ethics, research and public health practises involving humans should prevent potential harm to individuals and should aim to reduce unfair health inequalities (Nuffield on Bioethics, 2007). For example, if studies are not carefully assessed for their accuracy, misinterpreted or falsified, they cannot be considered in public health policy to prevent harm to the publics’ health (Nuffield on Bioethics, 2007). Therefore, evidence for public health policy or interventions should not be based on preliminary findings or unpublished studies but from peer-reviewed studies (Nuffield on Bioethics, 2007). It is also important for researchers to provide an adequate presentation of the evidence without discrimination by avoiding selective use of evidence and provide an adequate citation of all the literature used (Nuffield on Bioethics, 2007). Hence, one should not ignore or exclude evidence based on one’s perspective as well as assessing other researchers findings for bias in terms of their funders or political views (Nuffield on Bioethics, 2007).
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Ethics concerning the literature
Although the proposed study does not involve the collection of original data from participants, there are fundamental ethical issues that need to be considered before carrying out a secondary analysis of existing data (Tripathy, 2013). Nevertheless, one has to consider to what extent the original researchers have considered and effectively addressed ethical and bias issues (Coughlin, 2006). Also, whether they have obtained ethical approval from the appropriate and relevant ethics board before conducting the research and that it is clearly stated in the study will be assessed. It is also the responsibility of the literature reviewer to ensure informed consent has been obtained from participants in the original studies and data has been anonymised to avoid identifying information of participants to protect them from potential harm. Hence, ethical considerations in studies will be examined through the CASP study appraisal tool. However, for studies such as clinical trials where the study appraisal tool cannot be used to assess ethical considerations specifically, ethical considerations will be examined thoroughly.
Ethics concerning the literature reviewer
As discussed above the reviewer will follow best practise by documenting the process of obtaining data through the literature strategy and the process of critical appraisal of studies as well as reflect on the process and choices for selecting and deselecting of studies. Also, any potential limitation that might arise and the process of categorising and summarising of the data will be explained in detail. The reviewer will also be mindful of the limitations of professional competence in terms of not being able to review all the existing literature concerning the area of study. Additionally, the reviewer will avoid misinterpretation of other researchers findings and fabrication and falsification of data. Also, report carefully by accurate citation and referencing to give credit to the original writer and avoid plagiarism.
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Timeframe
Approval of proposal
15 June – 18 June 2020
Meet supervisor for feedback, on proposal, edit and amend Introduction
19 June – 21 June 2020
Literature search and obtaining sources
22 June – 26 June 2020
Reading
27 June – 03 July 2020
Study Appraisal/ Critical evaluation of the literatures
04 July – 09 July 2020
Consider ethical issues
10 July – 12 July 2020
Meet supervisor discuss progress and for feedback, edit amend
13 July – 17 July 2020
Organise project and write objectives
17 July – 19 July 2020
Data analysis
20 July – 06 August 2020
Meet supervisor for feedback, edit amend
7 August – 10 August 2020
Write Methodology
11 August – 16 August 2020
Meet supervisor for feedback, edit amend
17 August – 20 August 2020
Write results
20 August – 27 August 2020
Meet supervisor for feedback, edit amend
28 – 31 August 2020
Write discussion
1 September – 4 September 2020
Meet supervisor for feedback, edit amend
5 September – 7 September 2020
Write reflective account
08 September – 13 September 2020
Proof reading
12 September – 14 September 2020
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10. Chleboski, R. T., Kim, J. and Haque, R. (2014) Adherence to endocrine therapy in breast cancer adjuvant and prevention setting. Cancer Prevention Resaerch, 7(4), pp. 378-387.
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21. Maguire, M. and Delahunt, B. (2017) Doing a thematic analysis: A practical, step-by-step guide for learning and teaching scholars. Aishe Journal, 3. 22. Milata, J. L., Otte, J. L., & Carpenter, J. S. (2018) Oral Endocrine Therapy Nonadherence, Adverse Effects, Decisional Support, and Decisional Needs in Women With Breast Cancer. Cancer nursing, 41(1), pp. 9–18. 23. Moon, Z., Moss-Morris, R., Hunter, M. S., Carlisle, S. and Hughes, L. D. (2017) Barriers and facilitators of adjuvant hormone therapy adherence and persistence in women with breast cancer: a systematic review. Patient Prefer Adherence, 11, pp. 305-322. 24. Murphy, C. C., Bartholomew, L. K., Carpentier, M. Y., Bluethmann, S. M. and Vernon, S. W. (2013) Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: A systematic review. Breast Cancer Research and Treatment, 134(2), pp. 459-478.
25. NAPCS (2004) A National Action Plan for Cancer Survivorship: Advancing Public Health Strategies. Available at: https://www.livestrong.org/sites/default/files/what-we-do/reports/National-Action-Plan-Full-Report-2004.pdf (Accessed: 05 May 2020).
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prospective study. Breast cancer research and treatment, 168(3), pp. 667–677.
31. Roberts, M. C., Wheeler, S. B. and Reeder-Hayes, K. (2015) Racial/ Ethnic and socioeconomic disparities in endocrine therapy adherence in breast cancer: A systematic review. American Journal of Public Health, 105(3), pp. 4- 15.
32. Salkeni, M. A., and Hall, S. J. (2017) Metastatic breast cancer: Endocrine therapy landscape reshaped. Avicenna Journal Medicine, 7(4), pp. 144- 152.
33. Shah, C. H., Balkrishnan, R., Diaby, V., Xiao, H. (2020) Examining factors associated with adherence to hormonal therapy in breast cancer patients. Social adm Pharmacy, 16(4), pp. 574-582.
34. Smith, J. and Noble, H. (2016) Reviewing the literature. Evidence Based Nursing Journal, 19(1).
35. Smith, J. L., Pollack, L. A., Rodriguez, J. L., Hawkins, N. A., Smith, T., Rechis, R., Miller, A., Willis, A., Hall, I. J., Fairley, T. L. and Stone- Wiggins, B. (2013) Assessment of the status of A National Action Plan for Cancer Survivorship in the USA. Journal of Cancer Survivors, 7(3), pp. 425- 438.
36. Spencer, J. C., Reeve, B. B., Troester, M. A. and Wheeler, S. B. (2020) Factors associated with endocrine therapy non- adherence in Breast Cancer survivors. Psychology, 29(4), pp. 647-654. 37. Stewart, D. W., & Kamins, M. A. (1993).Applied Social Research Methods: Secondary research. Thousand Oaks, CA: SAGE Publications. 38. Tripathy, J. P. (2013) Secondary Data Analysis: Ethical issues and challenges. Iran Journal of Public Health, 42(12), pp. 1478-1479.
39. Wendt, O. and Miller, B. (2012) Quality Appraisal of Single-Subject Experimental Designs: An Overview and Comparison of Different Appraisal Tools. Education and treatment of children, 35(2).
40. Zhijun, Y., Wei, X. and Bradley, M. A. (2018) Talking about my care: Detecting mentions of hormonal therapy adherence behaviour in an online community. AMIA Annual Symposium, 2017, pp. 1868-1877.
SH7008 Research Methods for Health and Social care 17000554
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Table of Contents

Effectiveness of Strategies to Curb Obesity Frequency among the United Kingdom’s Adolescents. 4

1.0:  Research Question. 4

2.0: Introduction. 4

3.0: Background and Rationale for the Study. 6

3.1: Social Determinants of Health. 6

3.1.1: The life-course model 8

3.1.2: The Total Environment Assessment Model: Early Childhood Development (TEAM: ECD) 9

3.2: Rationale for Study. 10

4.0: Aims and Objectives. 10

4.1: Research Aim.. 10

4.2: Research Objectives. 11

5.0: Methodology. 11

5.1: Secondary Research. 11

5.2: Literature Search Strategy. 13

5.2.1: Databases. 13

5.2.2: Exclusion/Inclusion Criteria. 13

5.2.3: Key Words and Boolean Operators. 14

5.2.3: Analysis Tools. 15

6.0: Ethical Considerations. 15

7.0: Indicative Research Timetable. 16

 

1.0:  Research Question

1. How effective are strategies to improve access to healthy food in reducing the prevalence of obesity in adolescents in the UK?

2.0: Introduction

Obesity is a global issue, and a significant public health issue in the United Kingdom (UK) as obesity rates are increasing even among younger people. Children, particularly adolescents, the power/autonomy to control what they consume as urbanization means more parents are away from home while internet technologies provide virtual parent/child interaction. As such, dietary habits become more established at adolescence and thus the rising obesity rates that predispose young people to grave long-term illnesses. According to Her Majesty’s Government (2016), more children between two and fifteen years are obese or overweight, and children are becoming more at risk for longer as obese children are more likely to die prematurely and contract Type 2 diabetes. Type two diabetes increases chances for a reduced quality of life due to blindness or limb amputation.  Not only does obesity influence conditions such as heart disease, but it also increases the risks of depression. In a briefing paper by the House of Commons, the costs of obesity rise to £8.3 billion in 2025 (Baker, 2019).  With increased rates of obesity in the UK (England, 15%; Northern Ireland, 9%; Scotland, 10%; Wales, 15 %), Baker suggested that the economic costs will increase immensely by 2025. If these trends increase the disease burden will also become much more intensive as obesity places adolescents at risk of severe illnesses.

Modern strategies that attempt to reduce or lessen obesity in the UK are numerous, but the rising trends depict a deteriorating health outcome. Procedures take both the upstream and downstream approach with the focus on tackling the low consumption of a balanced meal per day (5-a-day) to increase the intake of necessary minerals, to prevent irregular or more proportions (irregular intake) and most importantly to reduce the overreliance of fast foods. As well, strategies to augment health aimed at engaging schools, communities, and families. While the United Kingdom respects citizens’ consumer choices, economic realities, and the need to consume, the government takes various steps in developing tactics that enable healthy diets. One of the strategies used includes introducing levies to the soft drinks industry in a bid to limit the sugar content in the carbonated drinks. According to Brooks et al. (2015), teens are the most significant consumers for sugary beverages in Europe. Too much sugar leads to an augmented intake of too many calories and teeth decay. One can of soft drink contains up to 35gm sugar in a 330ml bottle. Public Health England, in conjunction with all industries, has been collaborated to reduce the sugar content in all foods and beverages to reduce the sugar intake by 20% (Zilberter and Zilberter, 2013). Besides sugar reduction, there are other tactics (policy) and individuals that the government has used to mitigate obesity.

Another strategy commonly used includes supporting innovation so that businesses can make healthier products. There is no doubt that innovation enhances leadership in aspects of health and nutrition. As well, there have been efforts to update the current nutrient model to encompass a more efficient model that assigns a score on food items to assess whether the ingredients contained are healthy. Another vital area in which policy has targeted includes making healthy foods available in public amenities such as schools as that impact on children. Also, poles that want to mitigate the central role of inactivity and obesity. There is a strong correlation between physical activity and exercise with reduced obesity rates. Current policies aimed at physical activity recommend children to have at least 60 minutes of play to enhance blood flow, reduce obesity, and augment creativity (Street, Wells, and Hills, 2015).  Most importantly, the government gives support to families of underprivileged households to encourage healthy diets. The significance of support to disadvantaged families supports the notion that social determinants of health affect families and hence adolescent obesity.

3.0: Background and Rationale for the Study

3.1: Social Determinants of Health

How people live to grow determines the extent of their quality of life. Almost all social determinants of health associated with the scope to which a person is affected by obesity. As relates adolescents, for instance, early childhood development is critical in progress because a child that receives opportunities for a stable development is likely to have long-term health and development. Some studies that have shown the significance of the early development stage is crucial for child development. According to Hurley, Yousafzai, and Lopez-Boo:

The provision of optimal infant and young children’s feeding practices depends upon the caregiver’s knowledge and capacity to provide age-appropriate feeding responsivity and nutritional sufficiency, quality, and diversity. The quality of care provided to young children by their caregivers, typically parents, is the most proximal factor that influences children’s survival, health, growth, and development. Early nutrition and development interventions depend on the knowledge, skills, and capacity— both emotional and financial—of caregivers to provide their young child with optimal care for development and nutrition (2016, Pg. 358).

Hence Hurley et al. illustrate that early childhood development is a critical factor for child development as it dictates a child’s future. Besides,  a child determined by other factors such as skill and nutritional sufficiency. According to Rai et al. (2015), poor nutrition begins at the womb and amplifies risk children getting retardation and limited capacity to handle the disease. Women with a low diet give birth to small nutrition-body babies who fall ill repeatedly. As shown in figure one, the health of a child s affected due to the proposed causal links that affect lifecycles. Thus, the lack of enough nutrients for a mother may have a significant impact on a child, but lack of social amenities, urbanization that leads to access to foods also interlay with early childhood development.   Social status, level of education, and type of employment in most parts of the world determine access to adequate foods. For minority groups and in particular, immigrants accessing healthy eating is a challenge, and hence children are at risk of getting poor diets that are more affordable. However, the causal links are vital in understanding how a child may have augmented health or derailed life.

 

Figure One: Lifecycle’s proposed causal links that may impact child development adapted from Kofi Annan’s Life Cycle Approach (2000).

3.1.1: The life-course model

The life course model asserts that underlying obesity pathways commence early in life and continue through the life course. For instance, a child’s fat cells are established based on how the body is composed n thus impact on the biological processes that control appetite, diet inclination, metabolism, fat deposition as well as insulin emission (Daniels, 2019). Accordingly, these epigenetic procedures change by altering gene purposes without modifying hereditary genetic factors. These insights then inform on why early childhood d may be critical in augmenting obesity in children. The life course model is vital as it sets a background for why improving diets among mothers would deter childhood obesity and also how adopting healthy foods may prevent adolescents from perpetuated obesity.

The life course model is vital as it shows how obesogenic surroundings lead people to their current positions. The model presents various risk factors that may be critical in understanding how adolescents respond to diverse aspects and the extent to which a person may react to these issues to gain optimum wellbeing. (Mamun, Mannan, and Doi, 2014). Hence, the life course model is vital as it explains the problems that may be causing obesity among adolescents. Elements that are vital in the model include plasticity, flexibility, and resilience; however, mobility is highest during early development.

3.1.2: The Total Environment Assessment Model: Early Childhood Development (TEAM: ECD)

The World Health Organisation (WHO) created the (TEAM: ECD) to explain factors that may impact a child’s healthy childhood but also through the life course. The objective of using this model is, in particular, a reference to early childhood development, a social determinant of health. The total environment assessment model is crucial because it shows that various processes, including behavioral as well as broader environmental contextual issues, are vital for child development.  For example, the economic, ecological, policy, political, and social environments highly determine a child’s growth and, thus, consumption. Another fact is that the epigenetics of a child and the social context of a mother may evaluate a child’s inclination to obesity (Park, Skaar, Jirtle, and Hoyo, 2017). However, this model advances the model to even other social factors such as residential community, culture, as well as the social environment. Hence, WHO created this model to the interplay between civil society, institutions, family, and the individual for optimum health functioning. Thus, the reason why adolescents are more likely to be at risk of obesity is not only because of behavior but also the environmental risk factors such as epigenetics. It is for this reason that the trans-generational passage of peril proposes how “obesity begets obesity” or how “healthy living begets healthy living” because even exposure to the harmful environment is likely to transfer severe threats to a person (Klengel, Dias and Ressler, 2016; Shaw et al., 2017).

3.2: Rationale for the Study

Investigating this subject is vital because it emphasizes and evaluates whether strategies in place are working to mitigate the level of obesity in the world today. Upstream approaches while have been fundamental in creating positive dietary behaviors, there seems to be a severe gap in tackling the role of epigenetics in developing poor habits. Policies would need to reduce the unhealthy intake of unhealthy foods because they highly determine the infant’s food decisions from adolescence into adulthood. Hence, the significance of this study is that it will use a narrative analysis approach to uncover literature on how adolescents and mothers’ stories and experiences can inform on the best policy tactics to reduce obesity among adolescents. The purpose of understanding and investigating obesity about causal links and social determinants may help mitigate the pervasive rates of obesity and other diseases that impact future generations through epigenetics and, ultimately, the trans-generational passage of risk. The study will be useful for both academics in the social health discipline and practices because this study links both social factors and epigenetics in understanding the effectiveness of strategies that reduce obesity among adolescents. In practice, this study will be vital for policymakers and practitioners of public health because tactics may not only be linked to social factors but also to epigenetics, which profoundly impacts on a teenager’s eating habits.

4.0: Aims and Objectives

4.1: Research Aim

1. To investigate whether the current strategies to improve access to healthy food are useful in lessening the rates of obesity among UK adolescents through a narrative review.

4.2: Research Objectives

1. To assess literature data to find how and why adolescents create perceptions of strategies available to reduce obesity.
2. To research how the theory of social constructionism interacts with access to healthy food and the resulting obesity among adolescents.
3. To extract peoples’ experiences and how they represent their lives on issues such as policy and attaining healthy foods.
4. To synthesize literature on social determinants that impact on access to healthy food to adolescents.

5.0: Methodology

5.1: Secondary Research

Secondary research is the primary approach for this study. Databases that provide quality data for availing ease of access to peer-reviewed journals that would otherwise be hard to find through search engines. According to Johnston (2017), “Secondary data analysis is an analysis of data that was collected by someone else for another primary purpose. The utilization of this existing data provides a viable option for researchers who may have limited time and resources”. The advantages of using specific databases help to identify needed data for secondary research quickly.  While databases are also extensive and avail diverse permission requirements, they are less costly to acquire, especially for students because institutions ensure that students can access all valuable information through databases specific to disciplines.

Thus, it is much easier and appropriate to access academic resources from a database such as PubMed as opposed to a database such as Hein Online that is vital for legal research or PsycINFO that specifically assists Psychology research. The ease of access and inexpensive way of finding data for a narrative review analysis is thus one significant advantage of secondary data research (Dale, Arber and Procter, 1988). Not only is secondary research cost-effective and convenient, but it accelerates research because the data is available. Another advantage is that secondary research, exceptionally when large, offers greater validity and generalizable findings. Most importantly, conducting such an analysis is vital as it provides opportunities for further study through replication and re-evaluation. Through secondary analysis, we can test new ideas, theories, as well as new research design methods. However,  Another limitation is that it requires the researcher to purposively become engaged in the research as entrusting another person with the investigation could invalidate the study due to a misunderstanding question. Therefore, conducting secondary research requires complete immersion of the subject and, thus, the link between the research question and the data collected to avoid invalidity issues.

Research notes that like primary research, secondary research is viable as long as it follows a systematic process. Creswell (2009) suggests that a research method attempts to collect, analyze and interpret data, and thus, secondary research is a practical approach that follows procedures and specific tests to respond to the study’s research question. The secondary research process begins by collecting previously collected data on a topic as data that exists may adequately answer a question. The advantage of using previously stated data in research is that it may contain data that was not fully utilized by researchers and can be used in the study to provide insightful aspects about the research (Johnston, 2012). After identifying the data, the researchers move to evaluate the data when the initial data has fulfilled all the requirements discussed to enable an appropriate fit with the research topic. The researcher can find the fit of the research data with the research question by carefully determining:

1. The objective of the research
2. Finding the responsible parties in the data collection process.
3. The collected information from the study
4. Dates/timelines of data collection
5. How the data in a literature review was collected/ obtained
6. The consistency of the data collected from the source in comparison to other sources (Stewart & Kamins, 1993).

5.2: Literature Search Strategy

5.2.1: Databases

One of the critical elements of this research is that it concerns a social public health problem. The primary databases utilized in answering the questions must then be relevant and appropriate for the study. As well, the databases must be comprehensive to cover crucial numerous journal articles that are (a) peer-reviewed, (b) be systematic reviews, or (c) empirical studies, among others. Thus, the central databases that are as vital for assessing whether strategies to curb obesity among adolescents are useful to include Google Scholar, PubMed, The Cochrane Library, and Social Sciences citation index.  These archives are all relevant for social sciences and provide insightful topics on obesity.

5.2.2: Exclusion/Inclusion Criteria

Firstly, it is essential to note that this study pertains to only adolescents and how strategies (policy or campaigns) are useful in curbing obesity. As such, the study will only concern adolescent topics. When conducting narrative analysis reviews, systematic reviews, or content analyses, researchers to use only recent peer-reviewed publications that can be as relevant and appropriate for obesity. The use of seminal works is highly discouraged because recent reviews contained updated perspectives on a study. Another criterion to follow is that the study will only use journal articles that are in the English language because the researcher may not have sufficient resources or the time for adequate translation.

5.2.3: Key Words and Boolean Operators

The leading Boolean operators used to search the databases are “AND” as well as “OR” because both operators can extend the research of journal articles. Perhaps it is best to consider that this research will not use “NOT” as it would risk eliminating necessary items in the study. As well, the analysis will identify various keywords and synonyms that can be used in the study as they would help narrow down a topic. The table below distinctively identifies synonyms for “OR” to broaden the search. The researcher will include “AND” to narrow the research to the UK. However, a more general search is crucial as it would identify the UK, EU, and the US.

Table One: Keywords used for the research for “OR” to broaden the research:

Name	Synonym
Obesity	Corpulence
Strategies	Policies
Effectiveness	Efficiency
Adolescents	Teenagers, Children Under 18
Healthy Food	Diets
Improve	Augment, Increase,

5.2.3: Analysis Tools

The importance of using narrative review analysis is that it uses existing literature to find answers to the question under investigation. Using Microsoft Word’s Excel, the researcher will manually document the essential findings and then summarise the data. Excel as it is a readily available and dynamic tool to document and categorize data.

6.0: Ethical Considerations

Research ethics concerns how to treat data after it has collected, and every discipline encompasses distinctive ethical guidelines. The realms of narrative analysis are very different from other approaches in that the researcher uses literature to comprehend experiences and stories. While privacy or informed consent may not apply in narrative analysis, plagiarism is a risk that may place whole research under threat. Avoiding peoples’ ideas, whether intentionally or accidentally or failing to give full credit to the work, is highly unprofessional and a severe academic and intellectual offense to consider. To mitigate paper retractions and loss of author credibility, it is thus vital for all researchers to have the highest ethical attitudes. In some academic traditions, authentication may not be as essential. Still, the global academic code of conduct not only insists on an academic code of conduct but ethical uprightness when conducting research. It appears that there are a few key issues that may affect narrative review analysis, including ownership and intellectual property rights, the honesty of life stories, misrepresentation for the communities or individuals studies, and Deconstructing assumptions of ’empowerment.’ As historical research is about obtaining and reflecting on a person’s or a community’s lived experiences, researchers thus must protect the dignity of the people studied.

According to Vanderstoep and Johnson, institutions of higher learning have Research Ethics committees (REC) that oversee research projects, and proposals must be approved before data collection begins (2009, Pg. 12). Thus, the researcher will submit a thorough plan for data collection. Because this study does not directly involve participants, there a copy of the informed consent sheet will not be required. However, the researcher will be required to provide a description of the sample as well as instruments that will as used to collect data. Since the burden of ethical conduct lies with the researcher, and then it is vital to maintain the highest standards of ethics throughout the research.

7.0: Indicative Research Timetable

The final submission for the study will be in September, and thus, the research schedule has divided into nine sections. The Gantt chart in Appendix A shows that the project will begin within February after the IRB approval. The search for the databases begins in February using keywords and Booleans before reading through abstracts and then finally skimming through content to find twenty most relevant peer-reviewed articles. By August, the researcher will have finished the literature review and began the narrative analysis. The last month before submission includes combining all parts of the literature review with the sequential analysis before the final presentation.

 

 

 

 

 

 

 

References

Annan, K., 2000. Global nutrition challenges: a lifecycle approach. Food Nutr Bull, 21, pp.18-34.

Baker, C., 2019. UK Obesity Statistics for the House of Commons. Available at https://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN03336, (Accessed: 26 December 2019).

Brooks, F., Magnusson, J., Klemera, E., Chester, K., Spencer, N., and Smeeton, N., 2015. HBSC England National Report: Health behavior in school-aged children (HBSC): World Health Organization collaborative cross-national study.

Creswell, J.W., and Creswell, J.D., 2017. Research design: Qualitative, quantitative, and mixed methods approach. Sage publications.

Dale, A., Arber, S., and Procter, M., 1988. Doing secondary analysis. Unwin Hyman.

Daniels, L.A., 2019. A Life-Course Model of Obesity: Primary and Secondary Interventions to Prevent Childhood Obesity. Multidisciplinary Digital Publishing Institute Proceedings, 8(1), p.59.

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integrated nutrition

and early child development intervention may have additive

or synergistic benefits for child development

 

 

Appendix A