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Critique of a Research Paper –  ‘The Pap smear screening as an occasion for smoking cessation and physical activity counselling: effectiveness of the SPRINT randomized controlled trial’.

Students are required to select a research paper from a peer reviewed academic journal (qualitative in nature) journal, this is to be formally critiqued.

Critique of a Research paper

The article of choice that has been selected for critique is one that has been published in the British Medical Council, Public Health Journal; titled ‘The Pap smear screening as an occasion for smoking cessation and physical activity counselling: effectiveness of the SPRINT randomized controlled trial’. This paper has been peer reviewed and has received many citations amongst other researchers. 

This research study was implemented by Gorini et al., (2012), and this research sought to investigate how the Cervical Cancer Screening Programme (CCSP) in Italy, could be used in a manner, that would present an opportunity for health care workers to deliver information and counselling regarding smoking cessation (SC) to women who were attending the clinical for a Pap test examination.  The research was based on many different aspects  include the current evidence that was available in regards to smoking cessation; which displayed that the effectiveness for the promotion of physical activity (PA) by use of such interventions such as smoking cessation counselling were not very prevalent. Thus the objective of this research trial, SPRINT was to assess and analyse how effective the implementation of standard SC counselling interventions, which were being delivered by trained midwives in CCSP could present themselves to be. The underlying objectives entailed evaluating how the conjunction of PA counselling to SC counselling could contribute to the increased quit rates amongst those women attending the clinical for Pap examinations. The hypothesis and the aims for this study were explained clearly throughout the article and referred to accordingly throughout; it was also validated appropriately as to why this study should take place.

Gorini et al., present an extensive literature review encompassing the justifications for the implementation of this research trial. They demonstrate how the prevalence of smoking and its conjunction to be a leading cause of death and diseases is an issue that must be tackled, by adopting new methods that shall increase the awareness of the dangers associated with smoking.  The Framework Convention on Tobacco Control, have suggested that there should be control strategies in place that accommodate for both genders accordingly;  however the development of these approaches still remains poorly understood and definitely requires attention.. So the method adopted in this study for targeting women attending for a Pap-smear examination, is one that could be very beneficial and productive for future initiatives related to smoking cessation. As this allows many factors to addressed, and could prove to be not only economical but also time efficient for both the patients, the healthcare workers and on the healthcare system, presenting an opportunity for healthy lifestyle promotions. The methods employed by the SPRINT trial present a platform for principal prevention activity to be incorporated quite easily with continuing routine subordinate prevention measures. In addition to this, a crucial aspect is the link between smoking as a co-factor in the development of cervical cancer, with the human papilloma-virus, being one of the principal factors associated with this.

The intervention strategy for delivering the counselling for SC during the Pap-smear examination, was a non-invasive method and it was one that would benefit the patient even if they choose not to participate; it would still provide them with vital information regarding how they could make lifestyle changes which may help to contribute to the prevention of any future health problems they may experience. The method employed to deliver this research involved undertaking a randomized controlled trial that involved 1,100 women undergoing the Pap examination. This was carried out in three study centres Florence, Turin, and Mantua, in which the women were randomly allotted to the different arms of the study. 363 women were randomly assigned to the SC counselling arm and 366 were consigned to the SC + PA counselling arm, the remaining and 371 were accordingly assigned to the to the control group. The adopted approach involved a standard brief SC counselling combined with a short counselling session on increasing PA, and was based in accordance with the Di Clemente-Prochaska motivational stages of change. The primary outcomes that were evaluated were the quit rates, changes related to the motivational stages of change for SC, and how their daily cigarette consumption was reduced.

The stages involved in the smoking cessation counselling and how it worked were explained thoroughly to the patients. It corresponded to two main phases which involved brief interventions for smoking cessation. Depending on the phase that the participants were in e.g. the precontemplation stage of change for smoking cessation, the midwives goal was to help these individuals reach the next phase which would be the contemplation stage of change. If they were in the preparation stage of counselling the midwives aim was to help them quit accordingly, and to keep them motivated throughout this period. The six month follow up period allowed the individuals and the health care workers to work together to set targets and goals to help them in this process of SC. The general consensus demonstrated that this method of approach was user friendly, easy to implement and reaped benefits amongst the participants. The overall purpose of this approach of counselling was centred on the purpose to treat the individuals. The use of a stage – specific method of counselling in this study proved to be favourable as it allowed individuals who were at differing stages of SC to receive the appropriate level of care and counselling. This methodology used is also easily replicable, thus allowing the strategies to be adopted by other centres undertaking pap-smear examinations.

The results demonstrated that the participants that were randomised in both intervention arms and thus were placed in the preparatory stage of change for SC, doubled their chances of quitting within a six month follow up study with a 95% confidence interval being obtained ; this was in comparison to those individuals that were assigned to the control group. Furthermore,  those participants in the intervention arms that were in the contemplation stage were  found to be more likely to reduce their daily cigarette consumption after the intervention had been completed, these results presented a confidence interval of 95% and with an odds ratio of 1.8. However, the study did not demonstrate that physical activity counselling had much of a contribution to the various outcomes. The data analysis that took place provided information in regards to the three main outcomes which consisted of quitting smoking, improving the motivational stage of change for smoking cessation, and reducing the number of cigarettes per day, further analysis regarding physical activity outcomes was also analysed. All in all the approach and the analysis of the data was carried out thoroughly and to the extent such that estimates for 6 month follow up study were also obtained.

The findings of the study demonstrated that smoking cessation counselling delivered by the midwives during the Pap-smear examination visits was effective. It increased the 6-month quit rates in women in the preparation motivational stage of change for smoking cessation and thus supported the initial hypothesis that the delivery of smoking cessation counselling would be beneficial to the women attending the examinations. It was also effective in demonstrating the amount of women that reduced their daily cigarette consumption post SC counselling, despite these findings supporting the initial objectives of the study no difference was demonstrated in the individuals by the additional introduction of physical activity counselling, in both the SC and physical activity aspects of the study.

The authors of this study present an unbiased approach to the analysis of their data and their findings and clearly stated the limitations that arose. Nonetheless the findings were beneficial and it would be appropriate to suggest that the use of this method of counselling in helping SC and various other centres is an approach that must be adopted. Not only is this method cost effective but it also allows the healthcare workers to build a long term ongoing relationship with the patient, which shall prove to be of great significance in helping the patient deal with the social, psychological, emotional and health issues that shall arise throughout their treatment.

One must remain aware that although the number of women that are more likely to become long term quitters may remain small ~8.9%, the effect no doubt could be important, given the number of women that could be reached via this method. The data obtained in this study corroborated and supported the findings of previous research that had been carried out in regards to smoking cessation, and this was clearly demonstrated in this article. The authors were very clear about the benefits of this research which were evidentially supported by the findings, and even the limitations that they experienced and the unexpected results that were demonstrated in regards to the physical activity aspect of the study still reaped some positive benefits. Even though these benefits were not significant enough to be mentioned they still instigated small life changes in the individuals who participated such as increases in number of minutes walked among inactive individuals contemplating changes in their PA levels. This data corroborates with the findings that were displayed in the Cochrane review of 13 randomised controlled trials; in which physical activity programmes were examined as a support for individuals attempting smoking cessation, the evidence displayed was limited, showing that PA did not make much difference in the outcomes.

Limitations faced in this study included factors such as sample size, time constraints, staff shortage, and there were a few concerns in regards to one aspect of the methodology which required a self-report six months post the study period. Although the method of self- reporting was beneficial in the economical aspect one could question the reliability and accuracy of such information from the patient. Also, although the intended sample was meant to be 430 participants per arm only 370 women were recruited per arm, which was still a sufficient number. The reason this occurred was one the study centres that had initial enrolled in the study decided to opt out, nonetheless the study was still conducted with a reliable sample size.

Thus in conclusion, from these findings one can proclaim that smoking cessation counselling delivered by midwives to smokers who are in the preparation and contemplation stages of change; during a Pap smear screening was effective and should be recommended and given high priority , especially since the number of women attending cervical cancer screening programmes in Italy, is high. In addition,  it was observed that the number of women attending the Pap-smear examination should be slightly lowered in order to maximise the benefits of the counselling offered,  thus allowing the midwives to spend a sufficient amount of time delivering SC counselling to smokers allowing them to answer and queries accordingly.

In the overall analysis of this article, one can say that it was well presented and thoroughly explained; and the background reasoning’s for the implementation of the study and the choice of methodology were justified clearly. The literature review provided an insight into previous research that had been carried out and how the data obtained from this corroborated and disputed previous findings. The data analysis was thorough and the findings presented were beneficial. The advantages of replicating this study were presented accordingly as were the limitations and future improvements. The concepts regarding the choice of counselling and the method in which it should be delivered to reap most benefits were also presented well. All in all this article was very helpful in providing an insight into possible approaches that can be adopted by health care workers, thus allowing them to maximise the use of the available resources, with the primary focus on the  patient and long term benefits that can be obtained. The methodology could also be adopted at other centres for investigations into other disease that are linked to smoking and not only in women, but this approach can also be used for men attending examinations for prostate cancer. This article is worth recommending and presents a platform for future initiatives to be addressed.

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