For a critical appraisal of the literature, it is important that the different kinds of research in terms of study design are considered (Shea et al., 2017). First, the articles are screened for titles, then abstract are screened and then the full text is taken for further appraisal. One of the principles that are required and used is to make sure that the PICO required is matched with the evidence selected. Next, the study design is explored and the study participants who have been taken in the study are evaluated (Downes et al., 2016). Next, the methodology is appraised if it is right for the mentioned aim and objectives followed by if the results have provided the answer to the research question. Lastly, it is required that the strengths and limitations of the published literature are evaluated well (Downes et al., 2016).These principles are explained in the following examples.
For example, a study was conducted by Mehrifar et al. (2019) which was aimed to determine the toxic effect of the toxic gases that are produced during welding process, on the respiratory symptoms and pulmonary function. The study conducted was a cross-sectional study in a single setting and 60 welders were selected as an exposed group and compared to 45 staff from the administrative unit. The analysis for respiratory symptoms was done as per the methods suggested by the National Institute of Occupational Safety and Health and assessment of pulmonary function of each participant was done. The key findings of the study reflected that respiratory symptoms were significantly higher in welders compared to control group.The study participants can be considered as the strength of the study and the main limitation was that it was conducted in a single sitting as it affects the external validity of the results.
Rahul et al. in 2020 conducted a literature review where they aimed to explore the health hazards that are faced by welders.The study design was a literature review which is appropriate for the research questions. One of the main health hazards that is seen in welders is respiratory issues and in the review, a total of four articles were included that supported this. The main strength of the study was the study design but the articles selected were heterogeneous and not of the same study design which is a major limitation of the study.
Another review was conducted by Bakri et al. (2019) which was aimed to explore the toxicity caused by the fumes produced in welding in the respiratory systems. In this review, the authors reviewed extensive literature from a wide range of databases. The articles included were of different study designs. The key finding of the study was that the fumes consist of trace elements which interact with the system causing the respiratory system. The main strength of the study is the large amount of literature that is included in the review and the main limitation is that the articles selected were heterogeneous and not of the same study design.
The research question that is formulated for the present study: “is there an association between the exposure to the fumes which are produced during welding of stainless steel and the symptoms seen in the respiratory system?” The aim of the present study is to see whether there is an association between exposure to fumes and respiratory symptoms. The objective of the study is to establish the association between respiratory symptoms and exposure to fumes of stainless steel welding. The study design that will be taken for the present study is a cross-sectional study design. A descriptive study design is the best study design that can be employed for the present research question (Fusch et al., 2017). Cross-sectional study design can help in the formation of a causal association between the dependent and independent variables that are selected for the research question (Blackwell & Glynn, 2018). For the present research question, the independent variable is the exposure to the fumes produced during welding of stainless steel irrespective of industry and the dependent variable is the toxic effect on the respiratory system causing the symptoms.
For the research question that has been formulated, the result that will be obtained will be pertaining to the point prevalence of the dependent variable. The research data that is obtained in the cross-sectional study design is that there is no place for assumptions. In the background, there is always an assumption to the causation of a particular disease and if the researchers assume that exposure to fumes might be related to the health hazard, the cross-sectional study can help in proving or refuting the assumption. The main advantage that can be seen in the cross-sectional study design for the present research question is that it can help in proving or refuting of the assumption (Patten & Newhart, 2017).It is costly as well as time-efficient and it shows the prevalence of an event or in this case, disease in a particular point of time.
Multiple variables are in play in this study design and the result that is obtained paves the way to other study designs which can explore other aspects of the study (Patten & Newhart, 2017).There are few disadvantages that can be seen with cross-sectional study design: it cannot be used to see an event or in this case disease over a period of time (Johnson & Christensen, 2019). Cause and time for the event cannot be determined and as the event is measured at a particular time, it cannot be the representative of the entire population. This study design has the maximum chance of getting the data which is skewed and the source of funding can cause a conflict of interest. Lastly, there are various variables which can affect the actual result of the study (Johnson & Christensen, 2019). For the present research question, using this study design cannot have external validity.
The first thing that needs to be defined is the population that needs to be studied. The population that is to be studied for the present research question is welders who work specifically with stainless steel. Keeping the power of the study to be 80% and the level of significance is taken to be 95% which is required to get the sample size calculation. The welders will be selected from different workplaces and the selection criteria for the study participants are that they have to be working with stainless steel. Secondly, they should be working for a period of at least two years in the same industry. Study participants are excluded if they have underlying respiratory illness and if they do not consent to be a part of the study.Prior to the commencement of the study, approval is obtained from the institutional review board. Sampling design for selecting the study participants are convenient sampling, the workplace will be selected based on the convenience and all the participants who consented for the study will be recruited.
The study participants will be given complete information about the study regarding the aim and objectives. Initially, a self-administered questionnaire will be given to the participants which will collect the information regarding the descriptive statistics and their self-perception of respiratory illness (Mehrifar et al., 2019).For the demographic details age, sex, duration of work in the current workplace and duration of work in the field of welding is recorded (Mehrifar et al., 2019). Another aspect that will be asked is if they feel they are not able to breathe properly or is it reduced compared to earlier.For the measurement of outcome, two aspects of respiratory symptoms first, exhaled air from the welders will be examined and next the lung function tests will be measured (Mehrifar et al., 2019). The lung function test will be compared with the normal ranges for the age and sex of the welders. The data collected will be entered into a Microsoft excel sheet which will be imported to SPSS and descriptive and analytic statistics.
The total number of participants that were included in the study was 90 welders. The exposure level to the fumes from welding was again categorized into low exposure, medium exposure and high exposure. In each category, the welders were again categorized into the ones having respiratory symptoms and symptom-free. The low level of exposure was taken as the reference category and the instantaneous respiratory rate for the medium and high category was compared against the category of low level. From the number of people affected in each category, it is seen that number of people who did not have respiratory symptom in the low category was 5 and 16 of them were symptom-free. In the medium category, 12 participants had respiratory symptoms while 10 were symptoms free and in the high category, it was seen that 26 of the participants had respiratory symptoms while only 18 were symptom-free.
It can be seen that as the level of exposure increases so does the proportion of a number of people who are affected and show respiratory symptoms. The relative numbers of people who are symptom-free are less which means as the exposure increases effect is more on the respiratory symptoms. In the first model, there is no adjustment done for the confounders that are present and IRR is 2.62 for medium category compared to 2.84 in the higher one. When the potential confounders are adjusted for it, it can be seen that IRR is 2.42 for the medium category and that for higher one it is 2.79.From the result, it can be seen that exposure to fumes of welding of stainless steel is causative of respiratory symptoms. This causation could have been a result of other factors as well, that is, it could have been due to confounding. After the adjustment for the potential confounding factors, it can be seen that IRR is still high for the group with higher exposure to fumes from welding and also for the medium group it is more. This reflects that high IRR is not due to chance and it is due to the exposure itself.
There can be few biases that can be seen in a cross-sectional study. The first bias that can be seen in the current study is selection bias. The sampling technique that is taken for the current study is convenience sampling which is non-probability sampling. Ideally, simple random sampling should be used which is a probability sampling and in this, all the individuals of the whole population have the chance of getting selected in the study (Rahi,2017). Next bias which can be seen in this study is ascertainment bias which can affect the measurement of exposure as well as the outcome. In this case, presence of allergic reaction to other factors or having a common cold can affect self-perceived respiratory symptoms as there might be difficulty in breathing if there is upper respiratory tract infection or allergic rhinitis (Wolkoff, 2018). Another bias which can be seen in the present study is bias due to confounding factors (Haneuse, 2016). The common confounders can be age, gender, other environmental factors at places other than workplace and underlying respiratory pathology which is not explored earlier. In future studies, these potential biases can be mitigated or avoided by a stringent selection process to reduce the selection bias and employment of the random sampling method.
Next, the sources of potential biases should be identified and proper adjustment should be done for the same.The self-perceived aspect can be removed and professional assessment by use of spirometer can be done for the reduction of ascertainment bias.The main weakness of the present study is that it measures point prevalence of the health outcome and only association can be established not the causal relationship. There are a few limitations that can be seen in the present study. Firstly, the dose-response relationship cannot be established. Secondly, it is a cross-sectional study and there is a requirement of further study to assure a causal relationship and dose-response relationship (Johnson & Christensen, 2019). Lastly, the external validity or generalizability of the results that will be obtained is questionable and it is because of the study design. To address the shortcoming the study design that is required to be carried in the future is a prospective cohort study where the same set of welders are followed over a period of time till they show signs of respiratory symptoms.
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