Investigating a critical practice question through a literature review

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Complete Parts 1 and 2 of your Assignment:

  • Part 1: Literature Review: Be sure you have completed all required sections of the template (PDF) document.(attached below)
  • Part 2: Critical Assessment p aper: look at the rubric for instructions. keep in mind to also Apply feedback of value to you in completing your synthesis of evidence to inform a practice change initiative focusing on quality improvement

RUBRIC:- The Assignment: Part 1: Literature Review of at least 10 scholarly articles:• Using the Walden university Library as your source, search to select at least 10 scholarly articles that represent current literature (i.e., published within the previous 5 years) with evidence that addresses your critical question (I will send you the critical question) and could inform a practice change initiative for quality improvement. Using the Individual -Evidence Summary/Synthesis Tool template document, complete all sections for each article.

-The Assignment: Part 2: (example attached below) Critical Assessment In a p a per of at least 7 pages, plus cover page and references page, include the following:• Write a critical assessment of your search outcomes that synthesizes the evidence from your literature review.

-Demonstrate clear connections between the practice problem that informs your critical question, your appraisal of evidence that addresses the critical question, and resulting clarification on the need for a practice change initiative focusing on quality improvement. Be specific and provide examples.

-Written Expression and Formatting: Paragraph/Sentence StructureParagraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are clearly structured and carefully focused–neither long and rambling nor short and lacking substance.

-Written Expression and Formatting: The assignment contains parenthetical/in-text citations, and at least 10 evidence-based references are listed.

2

Week 10 Assignment: Part 2: Critical Assessment Paper: Investigating a Critical Practice Question Through a Literature Review

Name

Doctor of Nursing Practice (DNP), Walden University

NURS 8114: Theoretical and Scientific Foundations of Nursing

Dr. Camille McNicholas

Date

Synthesis Process and Recommendations

The purpose of the literature review was to critically assess the evidence on the effectiveness of community-based interventions (CBIs) for the prevention and management of childhood obesity. The proposed CBIs were physical activity (PA) and diet. The purpose of this assignment is to assess and synthesize consistencies in the findings, evaluate the meaning and relevance of the findings, integrate the findings to enhance knowledge, and highlight inconsistencies in the findings across the studies, to provide informed recommendations for effective childhood obesity prevention and management programs or interventions.    

Quality Appraisal of Individual Pieces of Evidence

Three databases were used to extract articles related to the clinical question developed. The three databases were PubMed, Science Direct, and CINAHL. The terms “childhood obesity”, “community-based interventions”, “physical activity”, “dietary behaviors”, and “community stakeholder engagement” were used as the primary search terms or keywords. Out of 44 studies that were identified, 10 met the inclusion criteria for review. 

The extracted articles were assessed for their level and quality of evidence using different factors. Some of the factors that were employed included the study design, sample size, and setting, observable measures, and limitations. Of the 10 articles included in the review, 4 articles were systematic reviews and meta-analyses, 3 studies were randomized controlled trial (RCT) studies, 1 was a critical review of original experimental controlled studies, 1 was a cross-sectional study, and 1 was a longitudinal cohort study.

The sampling and sample sizes significantly varied among the articles. Under reviews and meta-analyzes, Nally et al.’s (2021) study had the largest sample size of 48 articles, while Pamungkas and Chamroonsawasdi’s (2019) study had the smallest sample size of 22 articles. In the category of RCTs and observational studies, Puga et al. (2020) had the largest sample size of 27,686 children and adolescents, while Lek et al. (2021) had the smallest sample size of 178 overweight or obese children and adolescents. 

Data were collected from different implementing settings. Most of the studies were conducted in multiple community settings. A majority of studies were carried out in schools. Pamungkas and Chamroonsawasdi’s (2019) study was the only one conducted in the home setting. Schools emerged as one of the most feasible and effective settings for implementing CBIs.

The studies shared several limitations. One of them is that most studies excluded articles that were not published in English. A majority of studies did not also assess the long-term effects of CBIs. Some studies, including Narzisi and Simons’ (2021) used a small number of well-designed full RCTs. Despite these limitations, the overall strength of the evidence was strong. 

Assessment and Assimilation of Consistencies in Findings

Different themes, patterns, and trends emerged from this literature review. First, all ten studies reviewed agreed that childhood obesity is a growing epidemic in the U.S. and other developed countries. Furthermore, Puga et al. (2020) observed that children from low-income households are at an increasing risk of developing obesity. Several studies linked childhood obesity with different physical and psychological complications, such as metabolic disorders and poor academic performance (Wang et al., 2018; Pamungkas & Chamroonsawasdi, 2019; Dabravolskaj et al., 2020; Marsigliante et al., 2022) Generally, all the studies indicated that childhood obesity is a growing public health concern that must be addressed by applying evidence-based practice (EBP) interventions.

Second, the studies proposed and assessed the effectiveness of different non-pharmacological or behavioral interventions for addressing childhood obesity. The interventions that appeared in most studies were PA and dietary behaviors. Specifically, some studies established that a combination of PA and diet was the most effective intervention for preventing or managing childhood obesity (Lambrinou et al., 2020; Narzisi & Simons, 2021). Some studies also suggested the need to limit sedentary time. Sedentary time refers to the time used for watching television and playing video games, among other related activities (Pamungkas & Chamroonsawasdi, 2019). PA is linked with increased energy expenditure, which helps children maintain healthy body weight and improve healthy sleep patterns.

Third, most of the studies reviewed found that childhood obesity could be better addressed by implementing CBIs. Implementing PA and dietary behaviors at community levels resulted in better health outcomes for children and adolescents. The most recommended level was a school (Dabravolskaj et al., 2020; Marsigliante et al., 2022). Additional recommended implementing settings included sporting clubs, child care centers, and healthcare settings. Narzisi and Simons (2021) and Pamungkas and Chamroonsawasdi (2019) also demonstrated that the home setting could be a suitable implementing site. Given these recommendations, the studies suggested the need for a meaningful stakeholder engagement. Stakeholders such as parents, teachers, primary care providers, and child psychologists could play important roles in implementing and sustaining community-based obesity prevention programs.

Evaluation of the Meaning and Relevance of the Findings

The synthesized evidence has implications for both practice and policy. Healthcare stakeholders must recognize that childhood obesity is a serious health concern with far-reaching physical and psychological effects for children and adolescents. Additionally, the stakeholders must understand that obese children and adolescents are likely to be obese in their adulthood (Lambrinou et al., 2020). Adulthood obesity is linked with additional serious complications such as diabetes, stroke, and obstructive sleep apnea. Healthcare stakeholders must also recognize that preventing or managing obesity in the early years of a child or in childhood could go a long way in preventing the development of associated health complications and reducing healthcare costs.

The findings also suggest that CBIs are effective interventions and they should be supported both in practice and legislation. Nurse practitioners are strategically positioned to promote the implementation of CBIs. They could achieve this by raising awareness of different community-based settings where parents could enroll their children. Nurse practitioners and other healthcare professionals could also train community stakeholders on how to implement the programs or interventions with children. For example, teachers and parents should be educated about appropriate PA exercises based on the age, weight status, and overall health status of a child. Nurse practitioners could also lead other team members such as dieticians in recommending diet plans for children or their families while considering cultural factors such as financial background and cultural beliefs and practices. Generally, the findings from this review have significant implications for nursing practice.

The findings also have policy implications. Healthcare policies that promote CBIs should be enacted. For example, it should be mandatory for all schools to adopt and implement PA programs. Teachers should be trained on appropriate and relevant exercises with children based on their age and health status. Furthermore, schools should promote and adopt recommended dietary plans by supporting healthy dietary behaviors among children and their parents. Legislation should also ban the sale of sugary foods, unhealthy snacks, and sugary drinks within the school precincts or nearby schools. The policy could also help address cultural and financial hindrances to the successful implementation of CBIs. Some studies demonstrated that children from low-income families or households, for instance, were less likely to benefit from CBIs (Puga et al., 2020). This could be attributed to transportation difficulties or a lack of access to quality food. These issues might be addressed by passing legislation that provides free or subsidized transportation for children to CBI-implementing settings or recommended foodstuffs to families living in low socioeconomic position (SEP) communities. 

Merging Findings to Either Enhance the Team’s Knowledge or Generate New Insights, Perspectives, and Understandings

As mentioned earlier, the studies reviewed agreed on several factors. Their findings contribute to a growing body of evidence that demonstrates that CBIs are valuable strategies for obesity prevention and management. However, healthcare teams must understand that different factors can influence the effectiveness of CBIs. These factors must be considered when implementing CBIs with children and other stakeholders in communities.

One of the factors is that a combination of interventions is the most effective approach for addressing childhood obesity. In particular, a combination of PA and diet interventions has proved more effective in preventing childhood obesity (Lambrinou et al., 2020; Narzisi and Simons, 2021). In other words, healthcare stakeholders should not focus on a stand-alone intervention if desirable outcomes are to be realized. Combining both interventions ensures that issues of energy intake and expenditures are adequately addressed. It could also enhance health-related quality of life (HRQOL) for children.

Another factor that emerged is the need to tailor interventions to meet the expectations and cultural factors of children and parents. Cultural factors that should be considered include SEP, cultural beliefs, and language barriers. For instance, some studies found significant differences in intervention outcomes according to SEP (Puga et al., 2020; Jacobs et al., 2021). Most of the interventions favored high-SEP communities. This could be attributed to a lack of cultural barriers, such as food accessibility, transportation costs, and access to social amenities like sports clubs and playing grounds. Therefore, when planning and developing interventions, CBI stakeholders must consider these factors and tailor them according to specific cultural factors for better outcomes.

The review also indicated the need to include the perspectives of parents and other community stakeholders in planning and implementing interventions. Planning and implementation of interventions may have a significant impact on the HRQOL of children and their parents. Some of the crucial HRQOL domains are physical, emotional, social, and school functioning. Although this is an important determining factor when evaluating the effectiveness of CBIs targeted at childhood obesity prevention and management, the two studies that focused on this factor did not comprehensively establish factors that led to the differences in the HRQOL (Jacobs et al., 2021; Lek et al., 2021). The present study will attempt to consider factors influencing the HRQOL of participants. 

These findings suggest that healthcare stakeholders should combine interventions to promote health outcomes for children. Additionally, community-based programs should be tailored to address potential cultural barriers to the successful implementation of obesity prevention interventions. Parents should also be actively involved in the planning and implementation of findings to promote HRQOL and health outcomes.

Highlighting Inconsistencies in Findings

The studies reviewed differed in methodological approaches among other issues. For example, some studies had a larger sample size, while others had a smaller sample size. Furthermore, some studies focused on schools, while others focused on other settings such as homes and community centers. Despite these differences, there were no major inconsistencies found in the findings of the studies.

Recommendations Based on the Synthesis Process

The synthesis process has resulted in key insights about the prevention and management of obesity. Controlling obesity in childhood is essential for reducing its prolonged effects in adulthood as well as comorbidities. PA and diet are two well-established obesity prevention measures. Healthcare stakeholders and policymakers should consider promoting collaborative community-based measures for preventing and managing obesity. In other words, key community stakeholders should be trained and actively involved from planning to evaluation of programs or interventions. Furthermore, intervention creators should consider cultural factors when designing CBIs. A specific approach may be more suitable for a given community. The proposed interventions could be better adopted and used if they are integrated into practice and policy. 

To adequately establish the long-term effects of the CBIs, future research should evaluate the long-term outcomes of these interventions. Most of the studies reviewed highlighted that they could not determine the long-term effects of the programs. This could be attributed to financial constraints and loss of follow-up. Therefore, future research should make adequate preparations for long-term projects to determine whether outcomes could be sustained for longer periods or not. The findings might further impact practice and policy.

Summary

The ten articles that were included in the review provided key insights into the prevention and management of childhood obesity. The synthesis process has further highlighted consistencies in the findings of the studies, contributing to a growing body of evidence that suggests that CBIs are effective approaches for addressing the childhood obesity epidemic. New insights included the need to embrace a collaborative community approach, tailor interventions to address potential cultural barriers and integrate CBIs into practice and policy for sustainable outcomes. 

References

Dabravolskaj, J., Montemurro, G., Ekwaru, J. P., Wu, X. Y., Storey, K., Campbell, S., Veugelers, P. J., & Ohinmaa, A. (2020). Effectiveness of school-based health promotion interventions prioritized by stakeholders from health and education sectors: A systematic review and meta-analysis. 
Preventive Medicine Reports
19, 101138.
https://doi.org/10.1016/j.pmedr.2020.101138

Jacobs, J., Strugnell, C., Allender, S., Orellana, L., Backholer, K., Bolton, K. A., Fraser, P., Le, H., Brown, A. D., & Nichols, M. (2021). The impact of a community-based intervention on weight, weight-related behaviors and health-related quality of life in primary school children in Victoria, Australia, according to socio-economic position. 
BMC Public Health
21(1), 2179.
https://doi.org/10.1186/s12889-021-12150-4

Lambrinou, C. P., Androutsos, O., Karaglani, E., Cardon, G., Huys, N., Wikström, K., Kivelä, J., Ko, W., Karuranga, E., Tsochev, K., Iotova, V., Dimova, R., De Miguel-Etayo, P., M González-Gil, E., Tamás, H., Jancsó, Z., Liatis, S., Makrilakis, K., Manios, Y., & Feel4Diabetes-study group (2020). Effective strategies for childhood obesity prevention via school-based, family-involved interventions: A critical review for the development of the Feel4Diabetes-study school-based component. 
BMC Endocrine Disorders
20(Suppl 2), 52.
https://doi.org/10.1186/s12902-020-0526-5

Lek, D., Haveman-Nies, A., Bezem, J., Zainalabedin, S., Schetters-Mouwen, S., Saat, J., Gort, G., Roovers, L., & van Setten, P. (2021). Two-year effects of the community-based overweight and obesity intervention program Gezond Onderweg! (GO!) in children and adolescents living in a low socioeconomic status and multi-ethnic district on Body Mass Index-Standard Deviation Score and quality of life. 
EClinicalMedicine
42, 101217.
https://doi.org/10.1016/j.eclinm.2021.101217

Marsigliante, S., Ciardo, V., Di Maglie, A., My, G., & Muscella, A. (2022). Efficacy of school-based intervention programs in reducing overweight: A randomized trial.
Frontiers in Nutrition,
9, 1001934.
https://doi.org/10.3389/fnut.2022.1001934

Nally, S., Carlin, A., Blackburn, N. E., Baird, J. S., Salmon, J., Murphy, M. H., & Gallagher, A. M. (2021). The effectiveness of school-based interventions on obesity-related behaviors in primary school children: A systematic review and meta-analysis of randomized controlled trials. 
Children (Basel, Switzerland)
8(6), 489.
https://doi.org/10.3390/children8060489

Narzisi, K., & Simons, J. (2021). Interventions that prevent or reduce obesity in children from birth to five years of age: A systematic review. 
Journal of Child Health Care : For Professionals Working with Children in the Hospital and Community
25(2), 320–334.
https://doi.org/10.1177/1367493520917863

Pamungkas, R. A., & Chamroonsawasdi, K. (2019). Home-based interventions to treat and prevent childhood obesity: A systematic review and meta-analysis. 
Behavioral Sciences (Basel, Switzerland)
9(4), 38.
https://doi.org/10.3390/bs9040038

Puga, A. M., Carretero-Krug, A., Montero-Bravo, A. M., Varela-Moreiras, G., & Partearroyo, T. (2020). Effectiveness of community-based interventions programs in childhood obesity prevention in a Spanish population according to different socioeconomic school settings. 
Nutrients
12(9), 2680.
https://doi.org/10.3390/nu12092680

Wang, Z., Xu, F., Ye, Q., Tse, L. A., Xue, H., Tan, Z., Leslie, E., Owen, N., & Wang, Y. (2018). Childhood obesity prevention through a community-based cluster randomized controlled physical activity intervention among schools in China: The health legacy project of the 2nd World Summer Youth Olympic Games (YOG-Obesity study). 
International Journal of Obesity (2005)
42(4), 625–633.
https://doi.org/10.1038/ijo.2017.243

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Synthesis Process and Recommendations Tool

Key Points:

• Evidence synthesis is best done through group discussion. All team members share

their perspectives, and the team uses critical thinking to arrive at a judgment based

on consensus during the synthesis process. The synthesis process involves both

subjective and objective reasoning by the full EBP team. Through reasoning, the

team:

▪ Reviews the quality appraisal of the individual pieces of evidence

▪ Assesses and assimilates consistencies in findings

▪ Evaluates the meaning and relevance of the findings

▪ Merges findings that may either enhance the team’s knowledge or

generate new insights, perspectives, and understandings

▪ Highlights inconsistencies in findings

▪ Makes recommendations based on the synthesis process

• When evidence includes multiple studies of Level I and Level II evidence, there is

a similar population or setting of interest, and there is consistency across findings,

EBP teams can have greater confidence in recommending a practice change.

However, with a majority of Level II and Level III evidence, the team should

proceed cautiously in making practice changes. In this instance,

recommendation(s) typically include completing a pilot before deciding to

implement a full-scale change.

• Generally, practice changes are not made on Level IV or Level V evidence alone.

Nonetheless, teams have a variety of options for actions that include, but are not

limited to: creating awareness campaigns, conducting informational and educational

updates, monitoring evidence sources for new information, and designing research

studies.

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

• The quality rating (see Appendix D) is used to appraise both individual quality of

evidence and overall quality of evidence.

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Date:

EBP Question:

Article

Number

Author and Date

Evidence Type

Sample, Sample

Size, Setting

Findings That

Help Answer the
EBP Question

Observable
Measures

Limitations

Evidence Level,

Quality

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

EBP Question:

Category (Level Type)
Total Number of
Sources/Level

Overall Quality
Rating

Synthesis of Findings
Evidence That Answers the EBP Question

Level I

▪ Experimental study
▪ Randomized controlled trial (RCT)

▪ Systematic review of RCTs with or without
meta-analysis

▪ Explanatory mixed method design that
includes only a Level I quaNtitative study

Level II

▪ Quasi-experimental studies

▪ Systematic review of a combination of RCTs
and quasi-experimental studies, or quasi-
experimental studies only, with or without
meta-analysis

▪ Explanatory mixed method design that
includes only a Level II quaNtitative study

Level III

▪ Nonexperimental study
▪ Systematic review of a combination of RCTs,

quasi-experimental and nonexperimental
studies, or nonexperimental studies only,
with or without meta- analysis

▪ QuaLitative study or meta- synthesis

▪ Exploratory, convergent, or multiphasic
mixed-methods studies

▪ Explanatory mixed method design that
includes only a level III QuaNtitative study

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Category (Level Type)
Total Number of
Sources/Level

Overall Quality
Rating

Synthesis of Findings

Evidence That Answers the EBP Question

Level IV

▪ Opinions of respected authorities and/or
reports of nationally recognized expert
committees or consensus panels based on
scientific evidence

Level V

▪ Evidence obtained from literature or
integrative reviews, quality improvement,
program evaluation, financial evaluation, or
case reports

▪ Opinion of nationally recognized expert(s)
based on experiential evidence

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Based on your synthesis, which of the following four pathways to translation represents the
overall strength of the evidence?

❑Strong, compelling evidence, consistent results: Solid indication for a practice change is indicated.

❑Good and consistent evidence: Consider pilot of change or further investigation.

❑Good but conflicting evidence: No indication for practice change; consider further investigation for new
evidence or develop a research study.

❑Little or no evidence: No indication for practice change; consider further investigation for new evidence,
develop a research study, or discontinue project.

If you selected either the first option or the second option, continue. If not, STOP , translation is not indicated.

Recommendations based on evidence synthesis and selected translation pathway

Consider the following as you examine fit:

Are the recommendations:

▪ Compatible with the unit/departmental/organizational cultural values or norms?

▪ Consistent with unit/departmental/organizational assumptions, structures, attitudes, beliefs, and/or

practices?

▪ Consistent with the unit/departmental/organizational priorities?

Consider the following as you examine feasibility:

▪ Can we do what they did in our work environment?

▪ Are the following supports available?

• Resources

• Funding

• Approval from administration and clinical leaders

• Stakeholder support

• Is it likely that the recommendations can be implemented within the unit/department/organization?

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

Directions for Use of This Form

Purpose of form

Use this form to compile the results of the individual evidence appraisal to answer the EBP question. The

pertinent findings for each level of evidence are synthesized, and a quality rating is assigned to each level.

Total number of sources per level

Record the number of sources of evidence for each level.

Overall quality rating

Summarize the overall quality of evidence for each level. Use Appendix D to rate the quality of evidence.

Synthesis of findings: evidence that answers the EBP question

• Include only findings from evidence of A or B quality.

• Include only statements that directly answer the EBP question.

• Summarize findings within each level of evidence.

• Record article number(s) from individual evidence summary in parentheses next to each statement

so that the source of the finding is easy to identify.

Develop recommendations based on evidence synthesis and the selected translation
pathway

Review the synthesis of findings and determine which of the following four pathways to translation

represents the overall strength of the evidence:

• Strong, compelling evidence, consistent results: Solid indication for a practice change.

• Good and consistent evidence: Consider pilot of change or further investigation.

• Good but conflicting evidence: No indication for practice change; consider further investigation for

new evidence or develop a research study.

• Little or no evidence: No indication for practice change; consider further investigation for new

evidence, develop a research study, or discontinue the project.

Fit and feasibility

Even when evidence is strong and of high quality, it may not be appropriate to implement a change in

practice. It is crucial to examine feasibility that considers the resources available, the readiness for

change, and the balance between risk and benefit. Fit refers to the compatibility of the proposed change

with the organization’s mission, goals, objectives, and priorities. A change that does not fit within the

organizational priorities will be less likely to receive leadership and financial support, making success

difficult. Implementing processes with a low likelihood of success wastes valuable time and resources on

efforts that produce negligible benefits.

Johns Hopkins Nursing Evidence-Based Practice

Appendix H
Synthesis Process and Recommendations Tool

© 2017 The Johns Hopkins Hospital/ Johns Hopkins University School of Nursing

References

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