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Please read the “Interventions that increase use of Pap tests among ethnic minority women: a meta-analysis” Provide evidence from the article to support your response to the questions:

1.Did the article clearly state the research problem and/or research questions?

2.Is the scope of the project appropriate?

3.Is the topic of the review important for nursing?

4.Were concepts, variables, or phenomena adequately defined?

5.Was the integration approach adequately described, and was the approach appropriate?

Critique of the Paper Using Questions

The paper deals with the critique of the article, “Interventions that increase use of Pap tests among ethnic minority women: a meta-analysis” by Han et al. (2011). The critique is based on certain aspects of the systematic review article. It includes the “problem, search strategy, the sample, quality appraisal, data extraction and data analysis general, data analysis quantitative, and the conclusion” part of the chosen article.

The problem

Han et al. (2011), has clearly stated the research problem to be the lack of sufficient literature in the area of the ethnic minority women in US having barriers to early redetection of cervical cancer as well as interventions. Therefore the research focuses on the interventions methods to promote the screening among the target population in US. However, there is no clearly formulated research question in the meta-analysis as recommend by the Zeng et al. (2015). The research question can be understood by the research objectives and is considered a drawback.

The scope of the project is appropriate and can be considered the strength of the study as per Schmidt & Hunter (2014). It is well described in the abstract of the paper as well as in the introduction contextualising readers about the contents of the research process.  The scope of the project is appropriate as per clearly mentioned research objectives, succinct information about methodology, as well as results and primary outcome.  

The topic of the review is important for nursing as it may help the nurses to decrease the barriers to detection of cervical cancer among the US ethnic minority women. The nurses can use the intervention approaches described in the study to improve the screening behaviour of the ethnic minority women (Han et al., 2011).

The author has well stated that the patients or group of people concerned the strategies of interventions to be identified, comparison groups, efficacy of the interventions as comparison and the outcomes (quality of interventions). According to Khambalia et al. (2012) the four components in any metaanalysis is considered to reduce the bias. However, the main drawback is the lack of succinct information on the dependent and independent variable. It adds to confusion and makes the validity doubted.

The integration approach is discussed as the series of studies (clinical trials) to be reviewed that address the same question and analysed of its quality by different researchers independently. It is consistent with the most commonly evident approach of the metaanalysis study. This approach may be considered a gold standard as per the merits it offers over analysing set of different data. It ensures the validity of the data quality and conduct statistical analysis Sena et al. (2014). However, it would have been more convenient if the reader had defined the phenomena more comprehensively.

The Problem

Search strategy

The search strategy was appropriate and was consistent as per the method described by Zeng et al. (2015). However, there are no clearly defined criteria for selecting the primary studies. It is very confusing for the readers as the details related to search are not mentioned comprehensively.  The author had discussed using four electronic databases that are “MEDLINE, CINAHL, PsycINFO, and Science Citation Index-Expanded” (Han et al., 2011). It is not very comprehensive. The author had identified keywords that are not so exhaustive. The selection criteria were precisely summarized as initial screening of title, abstracts, and references of prior systematic reviews. It aligns with the method described by Haidich, (2010) as it states that working from references eliminates bias.   

The databases are considered to be appropriate as they contain rich literature both updated and outdated. However, there are drawbacks related to the databases search which appeared to be quick search. According to Schmidt & Hunter (2014), a sound review would occur only if all of the databases are searched. However, author had reviewed only few of them. It would have been effective to use “The Cochrane Controlled Trials Registry” as it is considered to be the complete database of clinical trials. In the MEDLINE database the author had not specified if the publication type was chosen as “clinical trial” (Han et al., 2011). According to members of the Cochrane Collaboration, MEDLINE database have incorrectly classified many trials (Schaumberg et al., 2018). It decreases the reliability. The drawbacks are balanced as the author had provided proper justification for not considering the databases like EMBASE. Overall criteria were reasonable as also found in other meta-analysis by Shazly et al. (2015). The limited database search can be justified considering the focus to improve screening of cervical cancer among US women of ethnic minority.

There were two independent reviewers who assessed the relevancy of the studies and if it meets inclusion criteria. The details of the adequate supplementary efforts to identify the relevant studies are not highlighted in the study. It may be considered a drawback in terms of the reliability and validity of the study (Han et al., 2011).  As recommend by Moher et al. (2015) PRISMA flow chart was included for the literature and the selection process.

The sample

The inclusion and exclusion criteria were clearly articulated. The eligibility criteria was chosen as studies that aimed to  increase use of Pap tests either exclusively or among other health behaviors among the asymptomatic women. Studies were chosen that concerns Black, Hispanic woman or Asian American and it was considered if represented 440% of the total sample. The criterion was taking studies that were based on outcomes as women adherence to Pap tests. Further studies with quasi experimental design were considered. The exclusion criteria was eliminating article that focuses on health professionals oriented interventions. It can be concluded that the criteria was reasonable as it helped the author meet the research objectives by obtaining article pertaining to the “interventions that can increase the use of Pap tests among ethnic minority women”. The articles only published in English language and between 1984 and April 2009 were included.  It can be considered the strength of the study as the inclusion and exclusion criteria was defensible (Han et al., 2011). The criteria were sufficient to meet the research objectives (Zeng et al., 2015).  

Scope of the Project

The search strategy should be designed in a manner that it yields comprehensive sample of studies as per Shazly et al. (2015). In the chosen research article wide range of studies were included. However, no international databases were used as the focus was on US population.  

The studies lacking key information were excluded as per the inclusion criteria and the exclusion criteria. Therefore, overall only 18 articles were considered. The reviewers did not attempt to contact the original researchers.

However, the author had provided adequate justification for eliminating some studies as mentioned by researcher of meta-analysis in medical research Haidich (2010). For instance, the author had mentioned that, “Interventions exclusively aimed at health professionals were not included,” It was justified as the same was highlighted by previous reviews. The justifications are also supported with relevant literature in the same area. 

Quality appraisal

The study used the meta-analysis technique to calculate the affect size (dependent variables) of the interventions. For multiple studies the authors compared two or more treatment groups with one comparison group. Using the evidenced based framework, “Research and Quality Scoring Method, the Jadad scale, and the items published by Cho and Bero”, the quality of the studies was rated (Han et al., 2011). The author considered the interventions with more than one component.  It may be drawback as considering multiple components may be misleading. Scores between 0 to 9 were considered ad the studies with quality score of 6–9 were considered to be high.

The variables coded independently by the reviewers. With detailed discussion among the team members the discrepancies were eliminated. This set of criteria as per Sena et al. (2014) is beneficial as it would reduce the risk of bias.

The two raters did come up with coding agreement and calculated the Cohen’s k, average k was 0.812, using SPSS version 15. The quality scores were documented and illustrated as tabular charts.  However, this method has less power to detect the heterogeneity of review (Hughes-Morgan et al. 2018.. The study also documented the estimated affect size with 95% CIs. The drawback arises from lack of presentation of the quality assessment protocol as highlighted by Zeng et al. (2015). The inter-rater agreement report was not presented.

For both the analysis of the results and selection of study the appraisal information was used in a well-defined and defensible manner. At each stage, the information was supported with relevant literature and evidences from meta-analysis used by other authors. 

Importance of the Topic for Nursing

Date extraction

The reviewers identified the methodological and the administrative aspects of the study.  It is evident from the extracted information section that highlights the coding of the following information-

  • First author, year, study design;
  • sample (% ethnic minority women)
  • types of intervention and duration
  • time to outcome measure
  • method of outcome
  • proportion of Pap tests for the treatment and comparison groups;
  • comparison group (no intervention, minimal intervention/usual care, or other non-cervical cancer intervention);
  • cultural strategies used
  • study quality

Sample characteristics extracted were adequate as recommended by Shazly et al. (2015). It takes the research process one step close to the intervention strategies required for detecting the cervical cancer among the concerned population.

Sufficient information was extracted about the study findings and is detailed in tabular form for the readers. It is convenient and easy to interpret. The administrative aspects were not clearly highlighted. Instead the author had adopted the typology. The same was used in previous reviews of cancer screening interventions. It was convenient to find the different categories of the cultural strategies identified by the authors. The author had defined the different components of interventions. It can be constituted as the drawback of the study (Han et al., 2011).  

The data set integrity can be considered to have been enhanced as the review process used more than two members for data analysis. It is sufficient enough to eliminate the discrepancies in the reviewed data. According to Haidich (2010) several steps should be considered in the investigation of the interventions. Although random models may seem appropriate, it is recommended to examine the data and make use of common sense in decision making (Wulff et al. 2018). It will help determine the influence of the dependent and independent variable.  

Data analysis- general

According to Khambalia et al. (2012) the most effective method of examining the pattern of the summary-effect size is the cumulative metaanalysis. It helps identify the impact of a specific study on the overall conclusion. In the given study the author did not comprehensively explain the pooling of the results. The pooling is evident from the affect size at (95%) confidence interval that signified the efficacy of the interventions to increase the Pap test among US women of ethnic minority.  The results also demonstrated the intervention that is access enhancement to have largest effect size. Next to it was community education and individual counseling. The statistical significance of the data was also given. The result section were well described the studies in the meta –analysis as also recommended by Murad et al. (2014). It detailed the types of interventions in different studies, followed by the effects of interventions on the use of Pap tests at follow up. The author ensured that it met certain criteria.  

Definition of Concepts, Variables, or Phenomena

It can be concluded from the results presented in the paper that the data is credible and addressed the research objective. The researchers were affective in summarising the findings using tables and figures.  

Data analysis-quantitative

Narrative review is the summary of all the primary studies collected that is modified with the reviewer’s perspective and practical knowledge. It gives broader picture of the problem and is considered useful to develop a conceptual framework. However, there are several drawbacks as it is based on the personal beliefs of the reviewer. Therefore, it is considered lowest evidence type. On the other hand the meta-analysis is the superior technique. It is most effective when compared to narrative review in integrating literature. With literature review it would not have been possible to collect the affect size or correct studies. Also it would not have been possible to collect quantitative synthesis (Pae, 2015). Therefore, it was justified to conduct metaanalysis. There is no adequate justification for using the narrative review it would not have been possible to collect different interventions with efficacy for cervical cancer.

Procedures for computing effect size estimates for all relevant outcomes were highlighted and appropriate. It includes interventions at different settings, intervention types, and cultural strategies, ethnic groups, and intervention of different quality. Using the evidenced based framework, “Research and Quality Scoring Method, the Jadad scale, and the items published by Cho and Bero”, the quality of the studies was rated. Thus, each affect size was calculated using the meta-analyses techniques. For data analyses, STATA software was used and raw-score metric was opted to define the effect size. It was used to calculate the overall mean weighted effect size for the selected studies. It is considered beneficial as per Miles & Crisp (2014) for its ease in interpretation and usefulness in clinical purposes. For studies with odd ratios post-intervention Pap test rates were calculated. 

DerSimonian and Laird Q-statistic was used to test heterogeneity. If significant results were observed then the random effects model was use to poll affect sizes. The author conducted sensitivity analysis for influence from studies, and fail-safe analysis for publication bias. Further, the author used leave-one-out approach to remove potentially influential studies. The author also used Rosenthal’s fail-safe N to rule out of potential bias. However, it was not adequately addressed. Excluding the unpublished data may lead to inaccurate estimation of effect sizes and cause bias. These models can be considered sound as per similar approach used in study by Schuch et al. (2016). The author used pooled proportions for ethnic subgroup analysis and is justified considering the research objective and target population.

Integration Approach

Conclusion of review

The author has drawn clear conclusions from the review process. Readers have detailed understanding about the consistency of the evidence. It is evident from the discussion well supported with the relevant literature, that the ethnic minority women are highly likely to use Pap test if access-enhanced strategies were combined. The results were found to be consistent with the research objectives and purpose of the research appeared to be fulfilled. The conclusion related to single and multiple cultural strategies of interventions targeting ethnic minority women and those related to social network satisfied the curiosity of the readers. In regards to the quality of the results, the author clearly stated that there was insignificant number of studies signifying increase in Pap test through cultural strategy involving members of target community. At the same time highlighted social network interventions were of high quality. The conclusion indicates need of robust studies.  

The limitations of the review were noted. According to Haidich (2010), the researcher must highlight the limitations of the paper succinctly to ensure the reliability of the results and must be well justified. The researcher in the meta-analysis has comprehensively discussed the heterogeneity found. The author also highlighted about the publication bias and lack of generalisability of the results to other countries having ethnic minority women.  The provision of appropriate justification to the limitations can be considered the strength of the study.

The drawback of the section arises from the lack of succinct implications of the data obtained in nursing practice (Rhodes & Anastasi, 2012). It only concerns the care provider and the patient’s outcomes. However, recommending further research on the tightly controlled studies for interventions pertaining to the cervical cancer screening adds to reader’s convenience.


The meta-analysis of the chosen paper is critically reviewed. The critical analysis has enlightened the knowledge of evidence based practice. It enhanced the awareness of way to collect the research evidence on a particular problem area. In future studies similar research can be conducted to address the problem in the nursing practice. 


Haidich, A. B. (2010). Meta-analysis in medical research. Hippokratia, 14(Suppl 1), 29. Retrieved from:

Han, H. R., Kim, J., Lee, J. E., Hedlin, H. K., Song, H., Song, Y., & Kim, M. T. (2011). Interventions that increase use of Pap tests among ethnic minority women: a meta?analysis. Psycho?oncology, 20(4), 341-351.

Hughes-Morgan, M., Kolev, K., & Mcnamara, G. (2018). A meta-analytic review of competitive aggressiveness research. Journal of Business Research, 85, 73-82.

Search Strategy

Khambalia, A. Z., Dickinson, S., Hardy, L. L., Gill, T. A., & Baur, L. A. (2012). A synthesis of existing systematic reviews and meta?analyses of school?based behavioural interventions for controlling and preventing obesity. Obesity Reviews, 13(3), 214-233.

Miles, E., & Crisp, R. J. (2014). A meta-analytic test of the imagined contact hypothesis. Group Processes & Intergroup Relations, 17(1), 3-26.

Moher, D., Shamseer, L., Clarke, M., Ghersi, D., Liberati, A., Petticrew, M., ... & Stewart, L. A. (2015). Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Systematic reviews, 4(1), 1.

Murad, M. H., Montori, V. M., Ioannidis, J. P., Jaeschke, R., Devereaux, P. J., Prasad, K., ... & Meade, M. O. (2014). How to read a systematic review and meta-analysis and apply the results to patient care: users’ guides to the medical literature. Jama, 312(2), 171-179.

Pae, C. U. (2015). Why Systematic review rather than narrative review?. Psychiatry investigation, 12(3), 417-419.

Phan, K., Tian, D. H., Cao, C., Black, D., & Yan, T. D. (2015). Systematic review and meta-analysis: techniques and a guide for the academic surgeon. Annals of cardiothoracic surgery, 4(2), 112.

Rhodes, M. G., & Anastasi, J. S. (2012). The own-age bias in face recognition: a meta-analytic and theoretical review. Psychological bulletin, 138(1), 146.

Schaumberg, D. A., McDonald, L., Shah, S., Stokes, M., Nordstrom, B. L., & Ramagopalan, S. V. (2018). Evaluation of comparative effectiveness research: a practical tool. Journal of comparative effectiveness research, (00).

Schmidt, F. L., & Hunter, J. E. (2014). Methods of meta-analysis: Correcting error and bias in research findings. Sage publications. Retrieved from:

Schuch, F. B., Vancampfort, D., Richards, J., Rosenbaum, S., Ward, P. B., & Stubbs, B. (2016). Exercise as a treatment for depression: a meta-analysis adjusting for publication bias. Journal of psychiatric research, 77, 42-51.

Sena, E. S., Currie, G. L., McCann, S. K., Macleod, M. R., & Howells, D. W. (2014). Systematic reviews and meta-analysis of preclinical studies: why perform them and how to appraise them critically. Journal of Cerebral Blood Flow & Metabolism, 34(5), 737-742.

Shazly, S. A., Murad, M. H., Dowdy, S. C., Gostout, B. S., & Famuyide, A. O. (2015). Robotic radical hysterectomy in early stage cervical cancer: a systematic review and meta-analysis. Gynecologic oncology, 138(2), 457-471.

Wulff, D. U., Mergenthaler-Canseco, M., & Hertwig, R. (2018). A meta-analytic review of two modes of learning and the description-experience gap. Psychological bulletin, 144(2), 140.

Zeng, X., Zhang, Y., Kwong, J. S., Zhang, C., Li, S., Sun, F., ... & Du, L. (2015). The methodological quality assessment tools for preclinical and clinical studies, systematic review and meta?analysis, and clinical practice guideline: a systematic review. Journal of evidence-based medicine, 8(1), 2-10.

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