Benefits Associated With The Prescription Of HRT
Methodology is described as the way to undertake and advance in the study. According to Sim and Wright (2000), methodology is the set of principles of research that guides the researcher to decide the type of research method which would be most appropriate considering the type of question the study is undertaken to answer, based on its core theoretical and philosophical hypothesis. The basic necessity of conducting a comprehensive, thorough and dependable research study is the researcher's intellectual knowledge and critical thinking (Guba, 1990). Hence it is vital for the researcher to have an in depth understanding of this research process and the philosophical aspects and assumptions which will shape this knowledge (Hart 1998). To conduct an inquiry or investigation for the research study a good and appropriate methodology is needed so as to ensure that the study is valid, dependable and more generalized (Booth, 2006). A methodology can also be addressed as an organization of rules and methods which assist the appropriate collection and synthesis of the relevant data (Hart, 1998). It is the format or structure of the ideology and identification of the topic selected. And method is the tools which are applied within the structure of the methodology to produce the results (Hart, 1998).
Theoretical Perspective behind the study-
It is advised to select the appropriate philosophical perspective during the process of the research question for choosing the appropriate methodology (Sim and Wright, 2000). The research methodology is carried out with a framework which directs the thoughts behind the studies to be selected and analyzed (Creswell, 2003). This process helps to submerge the ideas and the plan of the research in to the literature (Creswell, 2003).
The selection of the approach will depend on the three elements of philosophical assumption about the knowledge around the topic, plan of the inquiry and the well crafted process of data collection, analysis and writing (Creswell, 2003). In order to have an approach which will divulge the knowledge around the topic in many different ways the researcher should not select or favor any approach without comparing the existing approaches (Hart, 1998). This will build the critical thinking capacity which will assist in understanding the theoretical perspective behind the studies and critically review them within the paradigms they are constructed (Hart, 1998).
Paradigms are defined as the framework or the representation of the philosophical beliefs which will guide the researcher to undertake the disciplined enquiry and analyze the findings on the base of these assumptions (Guba, 1990). They are the group of theoretical beliefs which are meant to guide the researcher in the actions hence it is seen as a system or a theory which will be adopted (Stansfield, 2001)
A Paradigm presents a general perspective of the diversified view point of the real world with the help of the three philosophical questions which are defined by Guba, 18:1990 as
1) Ontological: what is the nature of the “knowable” or the nature of the “reality”?
2) Epistemological: What is the nature of the relationship between the knower (the inquirer) and the known (or knowable)?
3) Methodological: The process the inquirer will implement for finding the knowledge?
Selection of the right paradigms revolves around these three questions trying to answer the various aspects between the nature of knowledge and research (Pearson et al, 2007). Hence it can be seen as the opening point to determine the inquiry, the opinion behind the process, and finally the measures taken (Guba, 1990).
Paradigms Considered -
The positivist paradigm is scientific in nature with prediction and control being their eventual aim. With this scientific base it tries to uncover the “true” characteristics of the reality and how it works in the real world. And the epistemology is objective asking focused and direct questions and waiting patiently for it to revert while quietly observing its actions. The answers or response of the nature could be confounded by many factors. The methodology it proposes is manipulative with an attempt to control both the knowable and the researcher but the deciding factor lies with the characteristic of the knowable rather than the researcher. The positivist paradigm is quantitative in nature with aim being control (Pearson et al, 2007). The core theory here is deductive which means that the theory first is developed and then tried. Only after the trials is the fact accepted (Pearson et al, 2007).
But this study is based on the fact that reality exists and it is waiting to be uncovered, which are the benefits of HRT in menopausal women for which it is basically prescribed with foresaid risk of breast cancer.
As the name suggest the post-positivist paradigm is an extension of the positivist paradigm. It tries to rectify the limitations of positivism; hence prediction and control become the aim (Guba, 1990). The critical realist ontology of post-positivist approach is built on the belief that a real world or reality does exist but there are limitations to reach there. These limitations might confound the real picture making the findings less reliable, still the fact that the reality does exists remains (Guba, 1990). The post-positivist approach presents the opinion that there could be sizable limitations for a human researcher or inquirer to have an objective observation devoid of any human subjectivity. Methodologically post-positivist approach tries to address the imbalances by the modified experimental or manipulative approaches which emphasize innovation into the research process (Guba, 1990).
Constructivism paradigm has a different theory; it firstly believes that the positivist and the post-positivist paradigm is a group of mistakes and should be replaced (Guba, 1990). Within this paradigm a lot of importance is given to the mental framework. The ontology is that varied mental creations like social be it precise or specific are responsible or affect the reality. The epistemology is subjective contrary to objective the striking feature of positivist and post-positivist. This affects the outcome which means that the findings would be fairly dependent on the interaction between the knowable and the knower. Hence the methodology is pursued in two ways. First the hermeneutic methodology which aims to identify and understand the construction as best as possible and the dialectic approach is more accommodating which compares the different mental constructions and brings about a synchronization between them. The basic aim of both these methodological approaches is to open communication and make improvement an ongoing process (Guba, 1990).
Paradigm selected -
This study is trying to highlight the benefits which drive the prescription of HRT despite the risk of breast cancer. While contemplating the choice of the right paradigm the constructivist approach wouldn't be the right one due to its epistemology which has the space for mental creations but for this study the reality that is HRT prescriptions is there and it is waiting to be discovered; further its subjectivity and its methodological approach which are influenced by many mental creations leaves less room for the facts that arise from the inquiry.
While differentiating between the two similar paradigms of positivism and post-positivism; the post-positivism paradigm would be best justified as it would help answer the question better. Its philosophy would bring out the various aspects surrounding the question bringing more clarity to the subject and will make the research process more generalized and reliable.
Given the research question and the varied aspects attached to it, a step back approach would be needed to review one study in the perspective of the other hence the objectivist epistemological approach would assist this with its “regulatory ideal” (Guba, 1990).
The wide-ranging data and the message it would deliver could bring forth some discrepancies which the post-positivist approach with its modified experimental methodology would help address the imbalances and hence the study possibly would be more generalized (Guba, 1990). So to sum it up the aspects the three questions will address are explained as underneath:
1) Ontological: what is the nature of the “knowable” or the nature of the “reality”?
The natures of the knowable in this study are the reasons of prescribing HRT despite the risk of breast cancer. The reasons could be the benefits the women feel which could be physical, psychological or perhaps they just take it with a presumption it is needed and do so though it may not be needed.
2) Epistemological: What is the nature of the relationship between the knower (the inquirer) and the known (or knowable)?
The relationship between the researcher and the knowable is objective as the researcher will be reviewing secondary data from the existing studies selected by a comprehensive search of various databases. While this means that the researcher will not be contacting participants directly and it can be argued that interpretations of the available data can be subjective, the fact remains that objectivity can only be approximated and will do the best to remain objective in the research endeavor.
3) Methodological: Which process will the inquirer implement for finding the knowledge?
Data will be gathered by conducting a comprehensive search of published primary research studies. As medical practitioners make a choice based on specific contexts, there are measurable data pertaining to general parameters that have come out in numerous studies undertaken so far. After reviewing, selecting and collecting the data, the researcher will analyze it and summarize the findings so as to answer the research question (Punch, 2006).
Using the above mentioned arms of the post-positivism paradigm this dissertation intends to highlight the benefits menopausal women have with the treatment of HRT in presence of the foresaid side-effect of Breast cancer.
This dissertation as mentioned earlier is to explore the reasons of prescribing HRT despite the established link of use of HRT to breast cancer so as to help menopausal women know what benefits they could expect and what makes millions of menopausal women undergo the treatment in the presence of the foresaid risk (Million Women Study Collaborators, 2003).
A primary research could have been conducted within a clinic or a hospital setting to undertake this dissertation but it was not possible to conduct it in the given time period. Also enrolling the patients in the study and interviewing them to collect the relevant information would need the approval of the ethics committee which would be difficult to achieve given the time limitation of completing this research study. Whereas the literature review methodology doesn't need any ethical approval as there is no direct involvement between the researcher and the participant (Aveyard, 2007).
The other reason is that there are many relevant research studies which are readily available from different parts of the world. Since these studies already exist the researcher decided to use literature review as the appropriate methodology to undertake this dissertation.
Literature Review as a research methodology –
According to Aveyard (2007) a literature review with a well defined question which is carried out with a systematic approach is a research methodology in its own right. As mentioned earlier the preliminary research brought forth many studies that were linking or trying to evaluate the link between HRT and Breast cancer. Hence it become clear that by using the methodology of literature review many relevant studies from an extensive time span bringing in the opinion of the medical fraternity from different parts of the would could be generated which would help develop a better overview of the topic and the results would hence be more generalized and reliable.
Advantages of Literature Review -
One of the advantages of using literature review is that through the preliminary search the research ability of the topic can be ensured even before the dissertation or the study commences (Hart, 1998). At the initial stage a researcher is mostly enthusiastic of a topic of interest which might make them select a topic too broad perhaps out of feasible limitations, but literature review helps overcome this by narrowing it down and giving a practical aspect to it (Hart, 1998). This process also develops the critical thinking and analyzing skills of the researcher which are so vital for conducting a research (Guba, 1990). Due to these aspects Hart (13: 1998) defines Literature review as “integral to the success of academic research”.
The critical reading and critical thinking aspects of the literature review methodology helps gather knowledge of a topic and make a decision (Aveyard and Sharp, 2009). It helps differentiate between what is not known and needs to be known from what is known. By developing understanding of a topic it helps discover important determinants of the topic. Combining these determinants and synthesizing them would help bring out a new outlook to the study. This synthesis is carried out with the epistemological practice of analyzing existing studies and drawing new interpretations (Hart, 1998).
This process helps identify the relationship between ideas and practice, establish the context of the study and rationalize the significance of the dilemma. This is done by an extensive reading and understanding of the subject in depth which developed the subject terminology (Aveyard and Sharp, 2009). It also helps to understand the structure of the subject and apply the theory into practice. And most importantly the process of literature review will bring forth a historical aspect to the study and generalize it to the systematic expansion of research around this topic over the span of time (Hart, 1998).
And there is less purpose of applying literature review as a methodology if it doesn't develop this subject further and aid the medical fraternity and women know more than what is already known (Burns and Groove 2005; Hart, 1998). To sum it up the thorough appraisal of the secondary data would help uncover new perspectives.
Information in health and social care sector is increasing everyday and literature review would help explore published and un-published primary and secondary research studies to give a comprehensive view pertaining to the necessities and hindrances doctors may consider while prescribing HRT (Aveyard, 2007).
A comprehensive and apt explanation of the literature review methodology by Hart (1998:13) is “The selection of available documents (both published and unpublished) on the topic which contains information, ideas, data and evidence written from a particular standpoint to fulfill certain aims or express certain views on the nature of the topic and how it is to be investigated and the effective evaluation of these documents in relation to the research being proposed” (Hart 1998 pg13).
These aspects of the literature review can help construct a comprehensive study and analysis of the relevant literature which enables to view a particular research study within the perspective of the other. This will assist the identification and help summarize the literature available with extensive overview of the subject (Aveyard, 2007). The researcher will then analyze the studies, synthesis the findings and interpret them so as to answer the question and facilitate further interpretations for future research studies (Sim and Wright 2000, Aveyard, 2007).
This dissertation is aiming to explore the benefits associated with the treatment of HRT though there is a risk of breast cancer associated with its use. There are various types of studies available like Randomized Controlled Trials, Cohort, Case-control, meta-analysis, systematic reviews and case-series.
The cause and effect relationship of HRT its benefits and prevalent risk of breast cancer would be explored using prospective studies like randomized control trails and cohort, as they are the most accurate method. Case control studies too as they are the cost-effective and time-efficient method for research studies and Meta-analysis of previously conducted studies would also be a helpful resource to have a comprehensive study (Smith and Ryan 2008).
Further the extracted data would be synthesized to understand the benefits and any other aspects of the continued prescription of HRT (Aveyard, 2010). As menopause itself is a different experience for every woman so would be the benefits and effects of the treatment of HRT.
Limitations of Literature Review
Researcher bias and vast literature available could perhaps be the limitation of this methodology but the researcher will maintain transparency of the method of data selection and analysis and a comprehensive search strategy would help overcome them. With the fore mentioned striking features literature review has been chosen to give a detailed summary of the research question (Aveyard, 2007).
Critical Appraisal of literature –
Another important step towards conducting a good literature review is for the researcher to understand the concept of critical appraisal (Aveyard, 2007). Aveyard (2010) explains critical appraisal as a well thought-out method to examine a piece of research so as to evaluate their strengths and limitations. Critical appraisal is an essential tool for evidence based medicine which can be used by researchers to ensure that the studies are reliable and resourceful (Bandolier site, 2009). It is the process of minute and organized examination of appropriate studies identified to evaluate their validity, importance and quality in context to the research question. It is vital for the researcher to develop this skill and use it appropriately (Bandolier site, 2009).
Different designs form different studies and all studies are subject to bias which can distort the results (Bandolier site, 2009). Hence critically appraising the selected studies to evaluate their strengths and weaknesses and focusing on the synthesis of these studies will be a step to minimize bias and ensure that they are valid and reliable (Bandolier site, 2009, Burns and Grove, 2005).
Validity is termed as recording or measuring data which it is meant to measure. Reliability means consistency and is concerned with the repetition of same result in future (Aveyard and Sharp, 2009). Replication is of prime concern for quantitative research since if a study couldn't be replicated its validity would be questioned (Bryman, 2004). The selected methodology of literature review uses the process of the skimming, comprehending, analyzing and synthesizing the studies to eventually critique them to deduce and summarize the relevant studies (Burns and Groves, 2005). This step in turn will increase the creditability and reliability of the study and a better literature review can be expected (Burns and Grove, 2005).
Quantitative research is often attributed with strong emphasis on scientific rigor whereas qualitative research is often presented as a compilation of anecdote and personal impressions (Creswell, 2009). In quantitative research rigor is linked to excellence with discipline and consistent approach to detail with accuracy (Burns and Grove, 2005). It is also an appropriate method where pre-existing knowledge is present and hence standardized collection methods could be expected (Bowling, 2002).
Critical Appraisal tools –
This dissertation intends to adapt a structured method of appraisal for quantitative literature which has varied tools to critically evaluate the different types of studies which are going to be selected (Aveyard and Sharp, 2009). The studies selected will be Randomized control Trials, cohort and case-control studies (Polit and Beck, 2004, Aveyard, 2010).
It is suggested to critically appraise the selected studies with specific tools according to their specific design in order to help evaluate their usefulness and relevance to the study (Aveyard and Sharp, 2009). The critical appraisal tool by Center for Evidence Based Medicine (CEBM) wouldn't be the right choice as it has tools only for Randomized Controlled Trials though it was developed with the aim to promote evidence based health care. The critical review appraisal form developed by McMaster University Occupational Therapy Evidence-Based Practice Research Group has a single form with the design section having specific design types hence the appraisal isn't optimal with limited analysis of studies (Law et.al, 1998). However the Critical appraisal skills program (CASP) by the Solutions of Public Health (SPH) has developed specific tools for specific studies (SPH, 2010).
This dissertation will hence use the methodology of literature review and the CASP tools to critically appraise the studies. These tools take into consideration the three broad issues that are important for reviewing quantitative research SPH (2010):
1) Are the results valid: Are the methodology and the research method applied appropriate to answer the research question without bias and confounding?
2) Are the results reliable: Is there a role of chance to play in the result?
3) Applicability: Can the study be generalized?
By the help of 10 detailed questions these tools will enhance the validity of the studies
and reliability of the findings which are important for the study to be generalized (Bowling, 2002).
While comparing quantitative research against qualitative research it can be argued that it is more systematic, objective and prescribed to use numerical data to deduce the needed information. Quantitative research is predominantly used in medical research based on the philosophy of post-positivist, providing sounder base for applying results into practice (Burns and Grove, 2005) by its involvement of rigor, validity, objectivity and control. The selection of the right tool plays an important role in extracting the data relevant for the review.
Reductionist is the perspective of quantitative research and this involves breaking the whole into parts to have a better examination (Burns and Grove, 2005).
This dissertation will hence look at each selected study individually by appraising them to review the quantitative research terms of validity, reliability and applicability (SPH, 2010).
DATA TO BE EXTRACTED
For synthesis of the findings so as to deduce information in totality Averyard (2007) suggest the assigning of codes and themes, comparing them and close scrutiny of them. These will be addresses as Issues in this dissertation.
The aim of this study is to evaluate the benefits associated with the prescription of HRT despite the risk of breast cancer. With this background the theme developed befitting to extract the right information from the study are:
ISSUE-1 Breast cancer risk associated with the use of HRT. The incidence of breast cancer
will be recorded in context to relative risk or attributable risk or number of breast
cancer cases. Duration of HRT will be looked for.
ISSUE-2 Benefits associated with the treatment of HRT- Every well conducted study reports
about the general outlook and acceptance of the treatment. Any information about
the benefits will be recorded.
A specific table will be used to present the studies with detailed characteristics. This will assist to summarize the contents, compare the studies and deduce the results and also aid to evaluate the magnitude of the studies. These issues will be also shown in a table which will assist to divulge the information and the synthesis of the result with this systematic approach would clarify the process of analysis and interpretation (Hart, 1998; Aveyard, 2007).
This dissertation is conducted within the post-positivist paradigm using literature review methodology and quantitative research by critically appraising the studies to synthesis the results into relevant and reliable data. The researcher is hopeful to deliver a good review which will link the past research to the present and assimilate the knowledge derived so as to learn from the past and instill new ideas for the future (Neuman, 2006).