Jimma University

Institute Of Health
Faculity Of Public Health

CRITICAL APPRAISAL ON CASE-CONTROL

STUDY

BY GROUP TWO MPH STUDENTS

Critical Appraisal By Group MPH

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GROUP MEMBERS

Zufan Tessema Epidemiology

TsegayeAtrese Epidemiology
Tamerat Anbessa GMPH
Lemma Tefera GMPH
Shifera Tolesa Epidemilogy
Dereje Tadese Epidemiology

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OUTLINE
• Overview of critical appraisal
• Article Review components:
• Title
• Abstract
• Introduction
• Methods
• Results
• Discussion
• Conclusion Critical Appraisal By Group MPH
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OBJECTIVES

– To exercise critical judgment

– To be familier with the ways to assess a

research process and results

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 WHAT IS CRITICAL APPRAISAL?
• Critical appraisal is the process of carefully and
systematically assessing the outcome of scientific research to

judge its relevance, validity and results in a particular

context.

• Assessment of strengths and weaknesses of research

against its flaws
• It looks at the way a study is conducted and examines factors
such as internal validity, generalizability and relevance.
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 CONT...

• It is not the assessment of results alone

• Not to be undertaken by expert researchers/

statisticians only or

• All health proffessionals can undertake the

process

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WHY CRITICAL APPRAISAL IS IMPORTANT?

• Published research is not always relevant and

reliable
• Different studies reported in the literature also
have different strengths and weaknesses
• It is sometimes difficult to find the specific
information you are looking for and interpret it
accurately.
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 CONT...

• Distinguish evidence from

opinion ,assumptions, misreporting, and belief
• Assess the validity of the study

• Assess the usefulness and clinical applicability

of the study

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THE KEY POINTS

 When we are going through with a critical

appraisal piece of research, we should consider the
following points:
– The results of the paper
– The validity of the result

– The importance of the result for our specific

objective .
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ARTICLE REVIEW
CASE-CONTROL DOCUMENT

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 TITLE

Determinants of stunting among children aged 6-59

months at Kindo Didaye woreda, Wolaita Zone,

Southern Ethiopia: Unmatched case control study

By: Bancha Batiro 1,Tsegaye Demissie 2 , Yoseph

Halala 2, Antehun Alemayehu Anjulo 3 *

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 ABSTRACT
Background
• Stunting is a well-established risk marker of poor child
development.
• Globally in 2017, 155 million children under 5 were estimated
to be stunted.
• Therefore, identifying determinants of stunting among
children aged 6–59 would help to set priorities for action and
to the design of stunting reduction plan at a grassroots level.

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 CONT...
Methods
• The unmatched case-control study conducted in randomly selected

8 rural kebeles of Kindo Didaye woreda, Ethiopia from February

to April, 2016

• From which 155 cases and 310 controls chosen using

anthropometric measurement based on the median of WHO 2006

reference population among children of age 6–59 months

• The anthropometric data were analyzed by WHO Anthrop 2010

software to generate Z-score values

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 CONT...
 Results
• Drinking water from unsafe source (AOR = 7.06, 95% CI; 4.40–20.42)

• occasionally eating animal source food (AOR = 0.51, 95% CI; 0.02–
0.68)

• ARI in the past two weeks (AOR =3.04, (95% CI; 1.04–13.35),

• late initiation of breastfeeding after one hours after birth (AOR =5.16,
95% CI; 2.24–15.90) and

• lack of vaccination (AOR = 6.38, 95% CI; 2.54–17.10)were

significantly associated with stunting

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 CONT...
Conclusions
• Factors like exposure to diarrhea disease, acute respiratory

infection , late initiation of breast milk after child birth

• Squeeze out 1st breast milk, lack of vaccination, animal

source of food, and unsafe source of water for drinking

could be used to set priorities for action and

• Expansion of vaccination program to enhance herd

immunity at the community level is important

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 INTRODUCTION
• Globally in 2017, 155 million children under 5
were estimated to be stunted.
• Childhood stunting is an outcome of maternal
under nutrition and inadequate Infant and Young
Child Feeding (IYCF), and would result in
impaired neurocognitive development, and a risk
factors for non-communicable diseases and reduced
productivity in later life .
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 CONT...
• A community-based survey conducted in Shinille
Woreda showed that the prevalence of stunting was
33.4% among children aged 6–59 months .
• The other study carried out in East Belesa District,
North West Ethiopia indicated that 57.7% of children
were stunted .
• The study conducted in Meskane Mareko District,
Ethiopia showed that prevalence of stunting in the
district was 43.7% among children aged 0–59 months

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 METHODS
Study area, design and period
• A Community based unmatched case control study design
was carried out
• There are three agro-ecological zones in the woreda in a
range of 1200-to-2800 meter altitude above sea level
• The majority of Woreda (59%) classified as midland
(“woyndega”), 17.4% as high land and 23.6% as low land.
• The amount of average rainfall is about 1400mm-to-
2800mm per year.
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 CONT...
• Economically the area is much dependant on
agriculture and mostly kocho made from false
banana (Enset ventricosum), kita (mainly maize) by
cabbage and cassavas are common foods in the woreda.
• Cereals and roots are also common foods in the area.

• There were 25 health posts, 04 health centers and 01

district hospital providing health services for the
community
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 CONT...
Source and study population
• Source population were all children aged 6–59 months
and their mothers /care giver‘s resided in the woreda.
• Study population were all randomly selected children
aged 6–59 months and their mothers/caregiver‘s in
selected kebele

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 CONT...
Sample size calculation
• The sample size was computed using STATCALC
application of EPI- INFO version 7 software
• The required sample size was 465 (155 for cases and 310 for
controls)
• with 8% contingency for non-response rate
and design effect of 2
• The exposure variable was children who were sick every
month
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 CONT...
Sampling procedures

• A house to house census was made to enumerate 6–59

months of age children lived in 8 randomly selected kebele

• A child who had chronic malnutrition with z-scores -2

SD were taken as a cases and

• A child who had normal anthropometric reading between -

2SD and +2SD without bilateral pitting edema were taken
as controls
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 CONT...
 Data collection procedures and instruments

• Quantitative data were collected by qualified health care

professional using pretested interviewer administered structured

questionnaire from all eligible children mothers/caregivers.

• A UNICEF recommended measuring instruments of wooden

board inserted with a tape calibrated was used to collect the

anthropometric data from all children aged 6–59 months and

their mothers/care givers who lived for more than six months in

the study area

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 CONT...
Data quality control
• Training was given to the data collector and supervisors for
two days prior to data collection in line with the objectives
• The questionnaire was pre-tested and validated in 5% of
mothers/care givers (not included in sample) selected from
different kebele and some modifications were made based on
response categories

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 CONT...
Data processing and analysis
• Data were checked for completeness and entered into Epi Data Version
3.1 software.
• The entered data were then imported into SPSS version 20.0 for analysis.
• Hosmer–Lemeshow goodness-of-fit was used to test for the model fitness

• In bivariate analysis, the variables that showed an association with the

outcome variable with P- value <0.05 were entered into the multivariate
model after checking multicollinearity to control for all possible potential
confounders.

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 CONT...
Ethical consideration
• College of Health Sciences and Medicine Ethical committee at
Wolaita Sodo University approved this study and provided
ethical clearance letter

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 RESULT
• The mean age ± standard deviation for the mothers
of the cases was 30.25 (±4.97) years while it was
28.22 (±4.55) years for the mothers of the controls
and which were between the ages of 28–37 years.
• The mean age ± standard deviation for cases and
controls were 29.4±15.5 and 30.3±15.2 months
respectively

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 CONT...
• While their mean weight ± standard deviation for cases and
controls were 10.43±2.48 and 12.88 ±2.45 kg respectively and
• Also their mean height ± standard deviation for cases and
controls were 84.38±11.76and 91.69±11.12cm respectively
• From all mothers grouped under cases 66 (42.6%) and

• From all mothers grouped under controls 283(91.3%) started

breast feeding within the 1st one hour after birth

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 CONT...
• The exclusive breastfeeding rate for 6 months 32(20.6%) and
177(57.1%) for cases and controls respectively.
• Similarly, 123(79.4%) of cases and 133(42.9%) of controls were
initiated complementary feeding before 6 months
• Concerning immunization status 72(46.5%) of cases and
253(81.6%) of controls, not completed the vaccination
• Households used unsafe source of water for drinking accounts
82(52.9%) and 19 (6.1%) for both cases and controls
respectively
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 DISCUSSION
• This study pointed out that determinants of stunting were
– Exposure to diarrheal disease
– Exposure to acute respiratory infection

– Late initiation of breast milk after child birth

– Squeeze out of 1st breast milk
– Lack of vaccination

– Animal source of food, and

– Unsafe source of drinking water

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 CONT...
• The finding of this study was similar with the other studies
conducted in different parts of the world like Ethiopia,Nepal,
Vietnam and Afghanistan

• All the referenced studies confirmed that exposure to diarrhea

had association with under-nutrition

• All the referenced studies concluded that access to unsafe

water supply has been found as a risk factor for chronic under-
nutrition

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 CONCLUSIONS
• Factors like
– Exposure to diarrhea disease, exposure to acute respiratory
infection, late initiation of breast milk after child birth,
squeeze out of 1st breast milk, lack of vaccination, and
unsafe source of water for drinking could be used to set
priorities for action
– Therefore, Zonal health department and health office
should work aggressively to prevent and reduce stunting at
a grassroots level
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 CRITICAL APPRAISAL ON:
1. Title

2. Abstract
3. Introduction
4. Objective

5. Methods
6. Results

7. Discussion
8. Conclusion
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 TITLE
• Strength
– The title was written with the commonly used terms
– Study design was mentioned
– The study area specified

• Weakness
– The study period not mentioned

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 ABSTRACT
• Strength

– The background information was precisely mentioned

– Study area was mentioned

– Study design was mentioned

• Weakness

– Time sequence problem with the background data and the

study period

– The objectives of the study was not mentioned

– Study period eas notCritical

specified
Appraisal By with date
Group MPH
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 INTRODUCTION
• Strength

– Scientific background well explained

– Background information flow was from global to local

– Significance of the study was mentioned

– Magnitude of the problem was stated

• Weakness

– Time sequence was not coherent(background data 2017)

– Some area listed was not specified (where it is found)
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 OBJECTIVES
• Both general and specific objectives were not
set

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 METHODS
• Strength
– Ascertainment of cases and controls
• “WHO” Z score cut point was used to select cases and
controls to avoid mis classification
• Control to case ratio was apropriate to gain power (2:1)
• The source population was clearly mentioned

– Study design was clearly stated

– The study area was mentioned
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 Strength...
– Simple random sampling technique was used to select the
study subjects
– Data quality assurance well done
– Data were checked for completeness and entered into Epi
Data Version 3.1 software
– Statistical softwere was used to calculate the sample size

– Ethical approval was obtained and all the necessary

consent was taken before the data collection

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 Cont...
• Weakness
– The study design was not appropriate for the case

– The calculated sample size was not correct (465)

– Considering design effect while using simple random sampling

technique
– Only the rural kebeles were included in the study

– Inclussion and exclusion criteria not clearly stated

– Missing data management process not mentioned

– Performing multivariate analysis for variables with P value <0.05

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 RESULTS
• Strength
– Appropriate statistical softwares used to analyse the data

– Appropriate measure of association was used (OR)

– Response rate mentioned (100%)

– The result was stated in clear and sequencial way

• Weakness

– The standard devation was stated with ± which is inappropriate

– Different ways of data presentation not used other than tables.

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 DISCUSSION
• Strength
– The results were discussed
– Comparission with other similar studies were appropriately
done
• Weakness
– The results were not compared with the objective of the study

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CONCLUSION&RECOMMENDATIONS

• Strength

– Short and precise conclussion given

• Weakness
– Stake holders responsible for intervention were not
addressed (agriculture,water,education)
– Limitations of the study not clearly stated

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 REFERENCES
• Strength
– The references used are listed in appropriate order
with Vancouver style
• Weakness
– Few out dated references used (2006)

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THANK YOU!!!

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