“ATTITUDES AND PRACTICES OF WOMEN TOWARDS

SONOGRAPHY IN UPPER-MIDDLE TO LOWER-MIDDLE INCOME

COUNTRIES WITH SIMILAR CULTURES”

LITERATURE REVIEW
BY
FARZANA SIDDIQUI.

A DISSERTATION SUBMITTED IN PARTIAL FULFILMENT OF

THE REQUIREMENTS OF BOURNEMOUTH UNIVERSITY FOR
THE DEGREE OF MASTER OF SCIENCE
13th SEPTEMBER 2018.

FACULTY OF HEALTH AND SOCIAL SCIENCES

BOURNEMOUTH UNIVERSITY

WORD COUNT: 6553

 FACULTY OF HEALTH AND SOCIAL SCIENCES

MSC PUBLIC HEALTH, DISSERTATION PROJECT UNIT

STUDENT DECLARATION

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Signed:

Name: FARZANA SIDDIQUI

Date: 13-09-2018
Contents

ABSTRACT:...................................................................................................................................................4
1.INTRODUCTION AND BACKGROUND:.......................................................................................................5
3. METHODOLOGY AND METHODS:............................................................................................................8
3.1 INCLUSION /EXCLUSION CRITERIA:....................................................................................................8
3.2 KEYWORDS / SYNONYMS:..................................................................................................................9
3.3 SPELLINGS/ ABBREVIATIONS:.............................................................................................................9
3.4 BOOLEAN OPERATORS:......................................................................................................................9
3.5 DATABASES:........................................................................................................................................9
3.6 SEARCH ENGINES:............................................................................................................................10
3.7 CRITICAL APPRAISAL:.......................................................................................................................10
4. FINDINGS:..............................................................................................................................................11
4.1 AWARENESS REGARDING SCAN.......................................................................................................11
4.2 UNNECESSARY SCANS......................................................................................................................11
4.3 WILLINGNESS TO CONTINUE PREGNANCY DESPITE FETAL MALFORMATIONS.................................11
4.4 ANXIETY AND EMBARRASSMENT.....................................................................................................12
4.5 DISCLOSING FETAL GENDER.............................................................................................................12
4.6 POOR BEHAVIOUR OF THE STAFF.....................................................................................................12
4.7 ENVIRONMENTAL ISSUES.................................................................................................................13
4.8 SAFE AND AFFORDABLE TECHNOLOGY............................................................................................13
5. DISCUSSION:..........................................................................................................................................14
6. CONCLUSION:........................................................................................................................................16
7. RECOMMENDATIONS:............................................................................................................................16
8. REFERENCES:.........................................................................................................................................17
9. APPENDICES:……………………………………………………………………………………………………………………………………..22
ABSTRACT:
AIM: The aim of this study is to focus on the views of women about ultrasound procedures and to
understand their perceptions about invasive/non-invasive ultrasound scans when they undergo scanning
for gynecological/obstetrical reasons in upper-middle to lower-middle income countries with similar
cultures.

BACKGROUND: Ultrasound scanning is a useful technology and has great importance in

gynecology/obstetrics. The issue of women’s experiences about these procedures in upper-middle to
lower-middle income countries needs to be focused. In the past most of the studies on this topic had
been undertaken in Euro-American countries. Only negligible work has been undertaken in this context
in upper-middle to lower-middle income countries, out of which little has been explored regarding their
views. This leaves a gap in research knowledge about their experiences which needs to be filled.

METHODOLOGY & SEARCHING METHODS: A literature review approach has been chosen for this piece
of research which is a process of reviewing other authors’ studies in this field and use them as a basis of
data collection. Electronic databases and search engines were looked for relevant studies using
predefined search terms.

DATA SYNTHESIS: A narrative synthesis approach has been used to synthesize the findings from studies
having different aims and designs.

FINDINGS: 12 papers have been included in the synthesis of results which have identified eight themes
including anxiety, unnecessary scans, environmental issues and so on.

CONCLUSION: This study revealed that women are undergoing unnecessary scans, feel embarrassed,
facing environmental issues, disclosed some reasons for knowing fetal gender and having little
awareness about purposes of scans. Ultrasound scanning is an important part of prenatal care hence, it
is required to update these women and to set standard guidelines for their evidence-based information.

KEY WORDS: women, ultrasound, expectations

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1.INTRODUCTION AND BACKGROUND:
This study aims to focus on the experiences of women towards ultrasound scans and to understand their
perspectives about invasive and non-invasive ultrasound procedures when they undergo pelvic
examinations for gynecological/obstetrical reasons, in the upper-middle to lower-middle income
countries (ULMICs) with similar cultures.

Several studies have been undertaken in Europe and western countries about female’s views regarding
these procedures. It was found that there is little literature published on this topic of women’s thoughts
about ultrasound scans in ULMICs (upper-middle income countries having Gross National Income ranging
from $4,036-$12,475 while lower-middle income countries have $1,026-$4,035 per capita/year; The
World Bank Classification 2016) such as Nigeria, Pakistan, India and so on, having similar cultures. This
literature has addressed just superficial thoughts of women regarding ultrasound with fewer justification
of reasons behind their feelings thus, leaving a gap in knowledge about their experiences. It can be
suggested that the views of these women matter, so healthcare professionals can gain an insight into
what women really feel during ultrasound scans.

BACKGROUND OF SONOGRAPHY

The word sonography means ‘sound writing’, it is a medical skill used by a sonographer through
performing examination of patients using ultrasound devices (East Coast Polytechnic Institute University
2018). Ultrasound (U/S) is a breakthrough technology, according to Campbell (2013) it was first used for
clinical purposes by Ian Donald in 1958 in Glasgow almost 60 years ago. These are the scanning methods
which have useful applications in medicine (Norton 2016). It is safe and reliable as it does not use
ionizing radiations (Atlantic Medical Imaging 2018). It has strong links with obstetrics/gynecology as it
forms a cornerstone in the confirmation of conception, fetal age, growth, fetal lie in relation to maternal
bony pelvis, number of gestations, amount of liquor, adnexal masses, follicular size, fibroids and so on
(Abu Hamad et al. 2014). Doppler scans are meant to detect the direction and flow of blood in vessels
and are crucial in detecting placental blood flow insufficiency (Ovell 2013).

For transabdominal scans (TAS) women need to lay down on a couch and the examiner stands on her
right side (Ola-ajo 2005). In transvaginal scanning (TVS) a transducer is introduced, in lithotomy position,
into the vagina 2-3 inches distance to get a clearer view of the pelvic structures which sometimes result
in tenderness which is slightly more than that of TAS (Ovell 2013).

PREVIOUS WORK ON SONOGRAPHY AND IMPACT ON WOMEN IN WESTERN COUNTRIES: Many studies
have been conducted in Euro-American countries about the experiences of women regarding ultrasound

5
procedures which have suggested that acknowledging women’s expectations is essential for caregivers to
limit negative consequences associated with them. These studies showed that women’s responses in the
western countries are realistic and positive to the information provided by the healthcare professionals
(Georgsson and Waldenstorm 2008).

LACK OF RESEARCH EVIDENCE IN ULMICs AND RATIONALE OF THE STUDY:

The studies undertaken in western countries about U/S cannot be adapted to ULMICs due to socio-
demographic discrepancies, but they have provided new ideas which has helped the caregivers to
convey information to women about them in a more accessible and understandable way (Nykanen et al.
2017).

Women in the western countries had several expectations with U/S scans which were highlighted by the
studies conducted there. Similarly, women have several expectations with these scans in ULMICs as well,
and their awareness about them is essential as it might affect their psyche. Therefore, it is warranted to
investigate their attitudes and perspectives while undergoing scans in ULMICs.

BACKGROUND LITERATURE:

Women’s thoughts and experiences about ultrasound procedures are considered differently in various
articles (Hatamleh et al. 2012; Munim et al.2003) such as fear, lack of awareness, anger and their
hesitation to speak to staff. Unfortunately, there appears to be a limited number of papers which have
focused on this issue in ULMICs. Past studies (Dasan et al. 2011; Munim et al. 2003) have explored this
topic with improper evaluation of evidence, leaving a gap in knowledge. This section focuses on the
evidence from a number of these countries:

AN INDIAN STUDY:

Despite the discomfort associated with TVS, for in-vivo fertilization (IVF) treatment, several women
showed their willingness for future scans. Singhal et al (2017) conducted a study in which transvaginal
oocytes were retrieved from the ovaries by ultrasound guided techniques with conscious sedation rather
than laparoscopically, which needs general anesthesia. Here, the researchers used a visual analog scale
(VAS) for scoring pain. It was a good quality study having clear purpose along with ethical principles
(Beauchamp and Childress 2013).

IRANIAN AND UGANDAN STUDIES:

In Iran, some women were found themselves in dilemmas because they perceived U/S scans harmful for
their fetuses (Keikhaie et al. 2017). The same was evident in a Ugandan study where women assumed

6
that it might cause cancer (Gonzaga et al. 2009). Their limited knowledge about U/S was associated with
their level of education. In this study, participants were recruited by convenient sampling which is not
good as it leads to under-representation or over-estimation of a population (Polit and Beck 2018) but
data saturation was fulfilled which has boosted its quality (Parahoo 2014). However, they excluded those
women who had complicated pregnancies, thus missed some rich data which has reduced its quality.

VIETNAMIAN AND SYRIAN STUDIES:

Women were irritated by the behavior of obstetricians of repeating scans and were blaming them of
promoting a money-making business. Edvardson et al (2015) noticed this finding in Vietnam and
enquired about women’s experiences indirectly from the obstetricians.

In Syria, women felt marital security when they looked at their fetuses on the monitor (Bashour et al.
2005). They were particularly interested to know the fetal gender. If the sonographers refused this
request then, they changed to another physician and were even happy to pay for them in private
hospitals. Women felt embarrassed while visiting public settings, being ill-treated there and argued that
if the free services are offered in public sectors then they seemed to be of poor quality. In this study, the
interviews showed prolonged engagement of the researchers and the participants which has boosted its
quality (Ryan et al. 2007). However, the researchers did not mention about patients with hearing
disabilities despite them having an equal right to participate.

Due to reduced resonance of women’s experiences regarding U/S scans in ULMICs, it is unclear whether
current knowledge meets the expectations associated with them. Therefore, this study aims to fill this
gap in knowledge by describing their views to answer the question.

RESEARCH QUESTION: What are the attitudes and practices of women towards sonography in upper-
middle to lower-middle income countries with similar cultures?

AIM: To evaluate perception of women regarding the use of ultrasound technology while undergoing
scanning.

OBJECTIVES: To explore and understand women’s views about ultrasound procedures when they
undergo scans for gynecological/obstetrical reasons in ULMICs with similar cultures.

7
3. METHODOLOGY AND METHODS:
Literature review approach has been chosen for this study rather than primary research as it provides
assessment of current knowledge including substantive findings on an issue using less resources, while
primary research is costly, time-consuming and needs more funding (Cronin et al. 2008). A Literature
review offers conceptual foundations for a research and will determine the theoretical contribution to
this issue of women’s perspectives regarding U/S scans in ULMICs which remained unclear previously. It
will assist to critically evaluate the answer of research question by converging the literature about
women’s views about U/S and will fill the gaps in knowledge. In addition, it will illuminate the potential
areas for further research (Hewitt-Taylor 2017).

METHODS:

A systematic literature search was developed based on a preliminary scoping search of studies
surrounding women’s experiences of ultrasound procedures and was restricted to ULMICs with similar
cultures. It is useful to develop a strategy which contains a variety of the search terms, balances the
sensitivity of the search and adds search filters to narrow the results to identify the relevant topics
(University of Michigan 2018). Analysis of papers began by thorough reading and computer search was
supplemented by a manual search which initially identified 28 papers, 8 were excluded due to irrelevant
titles following a detailed review of their abstracts. Full text review of 20 papers resulted in exclusion of
further 5 papers which failed to meet the inclusion criteria.

3.1 INCLUSION/EXCLUSION CRITERIA:

To make this study rigorous within the limited time-frame certain criteria have been followed. In this
study, all relevant papers about women’s views regarding U/S scans in ULMICs with similar cultures have
been included which are peer-reviewed and written by scholars to ensure their credibility (Ryan et al.
2007). The dates should not be older than 5 years (Kamienski et al. 2013) but it includes papers
published from 2009-2018 as not more research has been undertaken previously on this topic in ULMICs.

Usually, in well-funded reviews there are no language limitations as translators are available there
(Hewitt-Taylor 2017) but in this study only those papers have been included which are published in
English language. This aspect would reduce the quality of this study as some rich data available in other
languages would be missed. Qualitative as well as quantitative papers are selected to evaluate the rich
and natural information regarding women’s views about U/S which is the hallmark of these types of
studies (Wahabi et al. 2014).

8
Exclusion criteria for this study are all articles published in languages other than English, grey literature,
studies undertaken in countries other than ULMICs, papers published before 2009 and non-peer
reviewed studies. In addition, editorial papers have also been excluded as it takes time to understand
their stance (Madrigal and McClain 2012).

3.2 KEYWORDS/SYNONYMS:
Keywords are the commonest and an ideal method to search a topic if entered correctly (Poojary and
Bagadia 2014). Electronic media has made searching easier these days than they were in the past (Elly
and Scott 2007). For this study the words women, experiences, ultrasound, gynecology/obstetrics and
upper-middle/lower-middle income countries and cultures have been used.

In addition to keywords, synonyms are required for search phrases such as females, physicians,
sonographers, imaging, scanning and expectations. Some help has been taken from a medical dictionary
and google search for synonyms and an appropriate amount of time has been spent on identifying them
(Hewitt-Taylor 2017) to maximize the success of the employed search strategies (Wong et al. 2004).

3.3 SPELLINGS/ABBREVIATIONS:
Spelling of American databases are different from British databases for instance,
gynecology/gynaecology, tumor/tumour and transculture/multiculture. To solve this issue wildcard
characters have been used for example, if the search is for gynecology, gy*necology was used. The
asterisk facilitated searching any letter in that space (Waltho et al. 2015). However, whether American or
British spelling, it is advised to stay consistent throughout a paper as it is not a deciding factor for
accepting or rejecting an article (Stack Exchange 2018). Some abbreviations have been used in this study
these are U/S, TVS and IVF to capture the full range of ways that authors might have expressed
themselves (Hewitt-Taylor 2017).

3.4 BOOLEAN OPERATORS:

Additional search methods can identify more literature (Mattioli et al. 2012). Using Boolean operators
time and efforts have been saved by eliminating inappropriate terms. The common Boolean operators
are ‘AND, OR and NOT’ (Kamienski et al. 2013). AND find those papers which includes all the identified
key terms, while OR used for any of the key terms, NOT excludes that has this key term (Aveyard 2014).
In this study women OR females AND sonography OR ultrasound have been used.

3.5 DATABASES:
Databases enables a reviewer to obtain broad knowledge of relevance about a given topic (Levy and Ellis
2006). The databases used in this study were CINAHL, MEDLINE, EMBASE, AMED, ScienceDirect,

9
PsycINFO, Academic Research Complete and Complementary Index as these are reliable with credible
articles written by scholars having great experience (Siddiqi 2011).

3.6 SEARCH ENGINES:

These are useful in searching pages on every website (Zwaaf 2013) but not definitely provide the
relevant information and might be avoided (Hewitt-Taylor 2017). However, some are used here such as,
Cochrane and The National Institute of Health and Care Excellence (NICE) as they provide knowledge,
cover healthcare in a broader sense, prioritize review topics that have not yet been answered and assist
review process by making it accessible (Cochrane Groups 2009).

3.7 CRITICAL APPRAISAL:

Critical appraisal helps a reader to decide how trustworthy a piece of research is and weigh up how
useful the research will be as it consists of rigorous evaluation of each paper (Quick and Hall 2015). For
qualitative papers CASP tools will be used here to detect the strengths and weaknesses in the literature
(Ryan et al. 2007) and to assess the results, quality and weightage of the published researches. They
improve the quality of articles by its evaluation and are accepted by Public Health England as well
(Hewitt-Taylor 2017). However, they have some disadvantages as they are more time consuming (Katrak
et al. 2004). Quantitative part of the literature will be assessed by general principles of critiquing.
Detailed critical evaluation of each paper has been presented in appendices (see appendix 4 to appendix
15).

Literature search revealed that most of the papers were quantitative which shows that views of the
women about U/S scans would not been explored in depth and there is more room for qualitative
studies in this area.

Narrative synthesis approach will be used here which refers to synthesis of findings from multiple studies
with different aims and designs (Aveyard 2014). Due to its flexibility, it is an appropriate option for
literature review and provides a comprehensive narration of synthesized results (Ryan 2013). Narrative
inquiry is unique and inextricably linked to the interpretation of an issue to make the invisible, visible
(Holloway and Freshwater 2007). It gives meaning and insight of complex areas to the narrator which can
assist the practitioners to develop their interpersonal skills (Webster and Mertova 2007).

Data synthesis of this study has been conducted by seeking concepts across the studies and then
identifying the conflicts and similarities in the findings (Aveyard 2014) and care has been taken to
synthesize the themes rigorously (Rocker 2012).

10
4. FINDINGS:
20 papers were identified, a total of 15 relevant abstracts were reviewed. 12 of them fulfilled the
inclusion criteria. These were retrieved to become part of the study consisting of 2 qualitative, 1 mixed
method and 9 quantitative articles. Reporting studies were conducted in 10 countries, but the majority
were undertaken in Nigeria due to its diverse culture and potential to nurture co-operative work in
various fields (Juma 2015). A table of identified themes has been presented in appendix 3. A summary of
the characteristics of the final 12 papers taken forward by synthesis is presented in appendix 2. The
following eight themes have been emerged from the literature which represents the data:

4.1 AWARENESS REGARDING SCAN

Ugwa et al (2009) identified that lack of appropriate information about U/S procedures is common even
in those women who were previously exposed to these procedures. Kasap et al (2016) agreed with this
finding and reported that insufficient knowledge about scans was found among pregnant women. When
papers were reviewed for quality it was found that Ugwa et al (2009) recruited participants by
convenient sampling from three different hospitals of the same state which shows its weakness as
convenient sampling has inherent bias and the sample is unlikely to represent a population (Polit and
Beck 2018).

4.2 UNNECESSARY SCANS

Ranji and Dykes (2012) have highlighted an important issue that the mean number of scans per woman
during pregnancy were 5.9. This finding was close to Mensah et al (2014) study, which revealed this a
slightly reduced number of 5.2 scans per woman. None of the papers have justified about the exact
number of scans during pregnancy and there is lack of information in this area. Ranji and Dykes (2012)
selected appropriate sample and methodology but did not follow the ethical principles (Beauchamp and
Childress 2013) as none of the respondents gave informed consent, which has created bias whether their
results were valid.

4.3 WILLINGNESS TO CONTINUE PREGNANCY DESPITE FETAL

MALFORMATIONS
Kadagad et al (2011) explored that termination of pregnancy after diagnosis of fetal abnormalities have
been taken differently across the globe and depends on the religious and cultural beliefs. Women agreed
to continue their pregnancies despite orofacial clefts due to eastern familial values and ability to face
adversities. Firth et al (2011) reported that few women were worried about fetal defects but their
acceptance for malformed fetuses was not mentioned. The Kadagad et al (2011) study was undertaken in
rural settings hence its results are not transferable, thus decreasing its quality (Lincoln and Guba 1985).

11
4.4 ANXIETY AND EMBARRASSMENT
Mubuuke (2014) reported that stress and embarrassment was intensified by specific procedures such as
TVS and women described escalating agitation during scanning. During the procedure some elderly
women were worried as they felt guilty in front of young physicians and could not maintain eye contact.
Rijken et al (2012) agreed with these results as not only aged women but younger women had similar
views about them and this is supposed to be one of the barriers for its acceptance. Another reason for
this anxiety could be improper privacy as one of the patients said that she felt ashamed during the scan
showing her belly in front of others and another patient was waiting for her turn in the same room. In
Rijken et al (2012) study, interviews were recorded and transcribed by an interpreter (Hewitt-Taylor
2011) but a local staff assisted the participants during interviews, due to illiteracy among sample, which
has enhanced possibility of bias.

Firth et al (2011) have pointed out a unique finding that myths and superstitions are one of the causes of
anxiety. They added that stigmas are culturally embedded in some societies since long as one of the
patients said that U/S would suck her blood. A thought-provoking belief was highlighted by women that
super-natural forces would not let them deliver if they tell their expected date of delivery (EDD) to
someone. In this study, data was collected by note-taking as ethical approval was not available for audio-
recording which has reduced its quality (Coughlan et al. 2007). In addition, the local interpreter for
language translation was not constantly present during interviews which has enhanced bias (Parahoo
2014).

4.5 DISCLOSING FETAL GENDER

Shukar-ud-din et al (2013) illuminated gender determination by U/S and found that two reasons for
discovering gender were most common, first was male preferences as he support his parents in their old
age, another reason was to complete shopping for the baby in advance. Rijken et al (2012) agreed with
these results as several women asked for gender. Ugwa et al (2009) contradicted both these studies and
reported that gender detection was least considered. Shukar-ud-din et al (2013) have undertaken their
study in three different hospitals of the same city, hence their results are not transferable and reducing
its quality (Coughlan et al. 2007).

4.6 POOR BEHAVIOUR OF THE STAFF

Mensah et al (2014) reported that healthcare providers are perceived as a crucial source of support by
patients, but inadequate knowledge about scans given by them has resulted in dismissive attitudes and
insensitive comments. Zira (2017) contradicts this finding and noted that the staff showed empathy,
focused on women’s concerns and committed to a collaborative relationship with them. This was a good

12
study with appropriate methodology, but its questionnaires were not validated (Polit and Beck 2018)
which is one of its weaknesses.

4.7 ENVIRONMENTAL ISSUES

Kyei et al (2016) explored that as pregnancy is a sensitive period for women prolong waiting time for
scans irritated them and majority wanted to move elsewhere however, some of them were not anxious
during waiting. Zira (2017) not only disagreed with these results but added that majority of the women
were happy with the waiting atmosphere. Kyei et al (2016) excluded emergency cases and selected
subjects by convenient sampling which is unlikely to represent a population (Polit and Beck 2018) thus
created bias which has reduced its quality.

Okeji et al (2017) noticed that for the provision of peace and better conductive environment, selection of
female sonographers is better to decrease guilt felt by women during TVS as this behavior is self-
explanatory due to their customs. Rijken et al (2012) disagree this finding as male examiners were not
subjected to objection in their study however, due to illiteracy, local staff assisted the respondents in
their study which is its weakness.

4.8 SAFE AND AFFORDABLE TECHNOLOGY

Kasap et al (2016) identified majority of the women with positive responses about scanning. Ugwa et al
(2009) agreed with these results and perceived them as safe, reliable and suitable for settings with lean
resources. Rijken et al (2012) and Zira (2017) accepted their importance in safe child-birth. Kasap et al
(2016) selected appropriate sample but did not mention how questionnaires were sent to the
respondents, hence decreasing its quality regarding procedural rigor (Hewitt-Taylor 2011).

13
5. DISCUSSION:
A variety of attitudes and experiences of women have been discovered after reviewing the literature
when they undergo ultrasound scans in ULMICs. This section will consider them in the light of these
issues and events.

LACK OF PROPER GUIDELINES/COST ISSUES:

The World Health Organization (2016) recommends 1 scan before 24 weeks to estimate fetal well-being,
as by that period fetal organs are almost formed, but if it is missed it can be planned later in pregnancy.
In contrast to this, the findings showed that a large number of scans were performed unnecessarily
(Ranji and Dykes 2012). This strengthens the evidence that sonographers are taking advantage and
ignoring proper guidelines regarding scans and promoting their businesses. Women are already living in
hand to mouth circumstances, this extra stress of cost may lead to increase their anxiety. How much
knowledge these women may have in relation to the number of scans that would be offered.

For some women cost was not an issue, as their husbands were supporting them financially or some of
them were government employees (Ugwa et al. 2009). This situation appears to be ambiguous for
widows or unemployed women who might be under stress, as these scans are not free of cost in ULMICs
(Pell et al. 2013).

CULTURE AND IT’S IMPORTANCE:

Cultural norms and practices have an impact on women’s views as the trend of accepting malformed
fetuses due to feto-maternal bonding (Kadagad et al. 2011) is common in poor Hindu families where
children are trained to face adversities of life since childhood. Similar findings were reported by
Wyszynski et al (2003) in Argentina where only 6.4% of respondents, who were Catholics, were willing to
terminate pregnancy due of fetal malformations. In contrast to these studies, in Israel Blumenfed et al
(1999) explored that 93.3% of parents, who were Jewish, were willing to terminate pregnancy due to
fetal abnormalities. This concludes that culture and religion influence their decisions to abort malformed
fetuses rather than demographic factors. For this reason, there is a need to focus on the spiritual and
cultural understandings held by these women prior to and after they have attended a scan.

Embarrassment was felt by women while undergoing TVS (Mubuuke 2014) which results in anxiety. This
supports the idea that sonographers do not give importance to culture, beliefs and ethical issues which
can create serious consequences in conservative families (Rijken et al. 2012). In most cultures of these
countries women are not allowed to shake hands or even be touched by men except their husbands or
blood-relatives (Al-Munajjid 2018) that is why they are reluctant to be examined by male physicians.

14
LACK OF AWARENESS:

Inadequate knowledge of women about the purposes of U/S scans suggests that healthcare
professionals counsel them improperly. For example, Kasap et al (2016) reported that they are unable to
make informed decisions. This may in part be related to social issues as women feel shy when having to
speak to a male physician (Okeji et al. 2017) which is common in their culture. Another element in
relation to limited awareness of women might be illiteracy, which is common problem in these countries
(Firth et al. 2011). It is prudential query that who would arouse these women from deep slumber.
Although improving literacy rate is government’s responsibility, health authorities could arrange sessions
to provide further information and support concerning scans.

SIDE-EFFECTS OF SCANS:

The findings highlighted that side-effects of ultrasound were one major issue for the women as it might
cause damage to their fetuses (Firth et al. 2011). Confusion regarding harm was a result of unawareness
about scans (Kasap et al. 2016). Indeed, it is recognized that Doppler scans are contraindicated in the
first-half of pregnancy (Baby-Centre Medical Advisory Board 2018). However, scans after these dates are
to be recommended. Assisting women to understand this difference is a key element for this finding.

ENVIRONMENTAL FACTORS:

Prolong waiting for scans irritated women and many of them often decide not to wait for their
appointments (Kyei et al. 2016). This finding suggests that there are clear areas within the timings of the
services that need further consideration. Addressing this would possibly reduce anxiety of the women.
To avoid such situations, it is better to book the patients in advance (Zira 2017) as environmental issues
have negative impact on their health (Kyei et al. 2016) as most of which are already experiencing a
sensitive period of pregnancy.

CONSEQUENCES OF DISCLOSING GENDER:

Women were interested in finding out the gender of their baby (Rijken et al. 2012). However, this
knowledge could place further stress on those women who already have daughters and are hopeful for a
son in current pregnancy as in some cultures boys have greater value (Edvardson et al. 2015). Indeed,
female feticide is common in some of these countries (Shukar-ud-uddin et al. 2013). It is questionable
that is there need for restrictions on gender disclosure by scans.

15
LIMITATIONS/STRENGTHS OF THIS LITERATURE REVIEW:

All studies have some limitations (Hewitt-Taylor 2017) in relation to the methods. This study has only
considered the perspectives of women concerning U/S scanning in ULMICs, reviewed by a single author,
other useful information which was published in non-English languages may have been missed. In
addition, grey-literature was excluded. This study has included articles older than 5 years, which would
reduce its quality. However, the strength of this study is that little work has been done into women
experiences concerning U/S procedures in ULMICs.

6. CONCLUSION:
The findings of this work have revealed a number of women’s perspectives concerning their experiences
about ultrasound scans in ULMICs with similar cultures. Issues that are clearer within the remit of a
sonographer working within public health might include careful consideration related to gender
disclosure, environmental factors and cultural boundaries that lead to anxiety in women, which can be
problematic for their physical and mental health. In addition, it has illuminated some social issues, which
can be eliminated by certain strategies to enhance a peaceful and healthy environment similar as that of
western countries, so that they would have the potential to feel satisfied while visiting the medical units
for scanning.

7. RECOMMENDATIONS:
This review recommends:
 The development of standard guidelines for scans to avoid unjustified scans.
 The inclusion of educational programs (with input from sonographers) to improve women’s
experiences of ultrasound.
 The need of finances for training and for scans.
 Further research into non-medical purposes of ultrasound as the promotion of businesses using
ultrasound scans is becoming popular in ULMICs.
STRATEGIES FOR DISSEMINATION: It anticipated that this work might be considered for
publication to journal PLOS One and would be disseminated at the British Institute of Radiology
Annual Congress 2018, which will be held on 1 st and 2nd November in London.

16
8. REFERENCES:
1. Al-Munajjid, S., M., S., 2018. Ruling on shaking hands with opposite sex. Islam Question and Answer.
[online].

2. Aveyard, H., 2014. During a literature review in health and social sciences: a practical guide, 3rd
edition. Maidenhead: Open University Press.

3. Abuhamad, A., Chaoui, R., Jeanty, P. and Paladini, D., 2014. Ultrasound in obstetrics and gynecology: a
practiced approach. London: Paula and David Bloomer.

4. Atlantic Medical Imaging, 2018. About ultrasound scans. AMI [online]

5. BabyCentre Medical Advisory Board 2018. Are ultrasound scans safe? [online]

6. Beauchamp, T. and Childress, J., 2013. Principles of bio-medical ethics. 7th edition. London: Sage

7. Blumenfeld, Z., Blumenfeld, I and Bronchtein, M., 1999. The early prenatal diagnosis of cleft-lip and
decision-making process. Cleft palate craniofascial journal. 36, 105-107.

8. Bashour, S., Hafez, R. and Salam, A. A., 2005. Syrian women’s perceptions and experiences of
ultrasound screening in pregnancy: implications for antenatal policy. PubMed, 13(25), 147-154.

9. Coughlan, M., Cronin, P. and Ryan, F., 2007. Step-by-step guide to critiquing quantitative research. Part
1: quantitative research. British Journal of Nursing. 16(11), 658-663.

10. Cronin, P., Ryan, F. and Coughlan, M., 2008. Understanding a literature review: a step-by-step
approach. British Journal of Nursing, 17, 38-43.

11. Campbell, S. 2013. A short history of sonography in obstetrics and gynecology. Facts, views and
vision in ObsGy. NCBI. 5(3), 213-229.

12. Cochrane: consumer network 2009. Cochrane Groups. [online]

13. Dasan, T. A., Singh, S., Korategere, R. S., Raja, B. and Rangaswamy, N. B., 2016. Knowledge and
attitude of women towards routine antenatal ultrasound screening in pregnancy at a tertiary institute in
Bengaluru. International Journal of Anatomy, Radiology and Surgery. 5(4)

14. Edvardson, K., Graner, S., Thi, L. P., Ahman, A., Small, R., Lalos, A. and Mogrin, I., 2015. Women think
pregnancy management means obstetrical ultrasound: Vietnamese obstetricians views on the use of
ultrasound during pregnancy. Global Health Action, 8

17
15. East Coast Polytechnic Institute University 2018. [online]

16. Ely, C. and Scott, I., 2007. Study skills for nursing. London: Elsevier.

17. Firth, E. R., Malay, P., Walker, R. and Sill, P. R., 2011. Pregnant women’s beliefs expectations and
experiences of antenatal ultrasound in Northern Tanzania. African Journal of Reproductive Health. 15(2),
91-107.

18. Gonzaga, M. A., Kiguli-Malwadde, E. Francis, B. and Rosemary, B., 2009. Current knowledge, attitudes
and practices of expected women toward routine sonography in pregnancy at Naguru health center,
Uganda. The Pan African Medical Journal. 3(18), 97.

19. Georgsson, S. and Waldenstorm, U., 2008. Second trimester routine ultrasound screening:
expectations and experiences in a nationwide Swedish sample. Research Gate. 32, 15-22.

20. Hewitt-Taylor, J., 2011. Using research in practice: it sounds good, but will it work, Basingstoke:
Palgrave Macmillan.

21. Hewitt-Taylor, J., 2017. The essential guide to doing a health and social care literature review,
London: Routledge

22. Hatamleh, R., Sinclair, M. and Khader, Y., 2012. Jordanian pregnant women’s knowledge, expectations
and informed choice of the second trimester ultrasound. Evidence-based midwifery. The Royal College of
Midwives. 10(3), 87-93.

23. Holloway, I. and Freshwater, D., 2007. Narrative research in nursing. London: Blackwell

24. Juma, C., 2015. “Why Nigeria matters to the world”. Belfer Centre for Science and International
Affairs, Harvard Kennedy School.

25. Katrak, P., Bialocerkowski, A. E., Masst-Westropp, N., Kumar, V. S. S., Grimmer, K. A., 2004. A systemic
review of the content of critical appraisal tool. Research Methodology. BMC, 4(22).

26. Kadagad, P., Pinto, P. and Powar, R., 2011. Attitudes of pregnant women and mothers of children with
orofacial clefts toward prenatal diagnosis of non-syndromic orofacial clefts in a semi-urban setup in
India. Indian Journal of Plastic Surgery. 44(3), 489-493.

27. Kamienski, M., Carman, M. J., Wolf, L. A., Henderson, D. and Manton, A., 2013. Searching the
literature: what is known and not known about your topic? Journal of emergency nursing, 39(4), 395-
397.

28. Kasap, B., Yeniceri, E. N., Kucuk, M., Akin, M. N., Turhan, N. O., Akbaba, E. and Saglam, A., 2016.
Ultrasound in pregnancy: a cross-sectional study of knowledge and expectations among pregnant
women in South-west Turkey. Medbol Haseki. 54, 224-231.

29. Kyei, K. A., Bamfo-Quaicoe, K., Antwi, W. K., Vanderpuye, V., Banson, R. and Atuwo-Ampoh, D. V.,
2016. Anxiety level among pregnant women awaiting ultrasound examination in Ghana. OMICS Journal
of Radiology. 5, 244.

30. Keikhaie, K. R., Behzadmehr, R. and Pour, N. S., 2017. Investigating the attitude of pregnant women
on the efficacy of ultrasound in diagnosing pregnancy based on level of education and number of
pregnancies in Zabol. International Journal of Pharmacology LifeScience. 8(7&8).

18
31. Levy, Y. and Ellis, T. J., 2006. A systemic approach to conduct an effective literature review in support
of information system research. Informing Science Journal, 9181-9212.

32. Mubuuke, A. G., 2014. A phenomenological study to explore the experiences of Ugandan women
that have undergone transvaginal ultrasound. Journal of medical radiation sciences, 61(2), 78-84.

33. Madrigal, D. and McClain, B., 2012. Strengths and weaknesses of quantitative and qualitative
research: insight for research. UX matters.

34. Munim, S., Khuwaja-Akhun, N. and Qureshi, R., 2003. Knowledge and perspective of women about
ultrasound screening and prenatal diagnosis during pregnancy. Ultrasound in Obstetrics and Gynecology.
22, 71-175.

35. Mensah, Y. B., Nkyekyer, K. and Mensah, K., 2014. The Ghanaian women’s experience and perception
of ultrasound use in antenatal care. Ghanaian Medical Journal. 48(1)

36. Mattioli, S., Farioli, A., Cooke, R. M., Baldasseroni, A., Ruotsalainen, J., Placidi, D., 2012. Hidden
effectiveness? Results of hand-searching Itaian Language journals for occupational health interventions.
Occupational and Environmental Medicine. 69(7), 522-524.

37. Nykanen, M., Vehvilainen-Julkunen, K. and Klemetti, R., 2017. The expectation of antenatal screening
and experiences of first trimester screening scan. PubMed. 47, 15-21.

38. Norton, M. E., 2016. Callen’s ultrasonography in obstetrics and gynecology. 6th edition. California:
Elsevier.

39. Ola-ojo, O. W., 2005. Obstetrics and gynecology ultrasound: a self-assessment guide. London:
Elsevier.

40. Ovel, S., 2013. Sonographic examination review: physics, abdomen, obstetrics and gynecology, 2 nd
edition. CA: Elsevier.

41. Okeji, M. C., Agwuna, K. K., Ihudiebube-Splendor, C. N., Izge, I. Y., Ekuma, K. K. and Emeter, J. O.,
2017. Transvaginal sonography: perception and attitude of Nigerian women. BMC Women’s Health. 17,
54.

42. Parahoo, K., 2014. Nursing research: principles, process and issues. 3rd edition. Basingstoke: Palgrave
Macmillon

43. Polit, D. F. and Beck, C. T., 2018. Study guide for essentials of nursing research: appraising evidence
for nursing. 9th edition. London: Wolters Kluwer

44. Pell, C., Menaca, A., Were, F., Afrah, N. A., Chatio, S., Manda-Taylor, L., Hamel, M. J., Hodgson, A.,
Taqbor, H., Kalilani, L., Ouma, P. and Pool, R., 2013. Factors affecting antenatal care attendance: results
from qualitative studies in Ghana, Kenya and Malawi. PLOS one, 8.

43. Poojary, S, A. and Bagadu., 2014. Receiving literature for research doing at the right way. Indian
journal of sexually transmitted diseases and AIDS, 35(2), 85-91.

44. Quick, J. and Hall, S., 2015. Part one: an introduction to the research process. Journal of
perioperative practice, 25(4), 78-82.

45. Readex Research-Advantages of Self-adimistered Surveys 2018. [online]

19
46. Ranji, A. and Dykes, A. K., 2012. Ultrasound screening during pregnancy in Iran: women expectations,
experiences and number of scans. PubMed, 28, 24-29.

47. Ryan, F., Coughlan, N. and Cronin, P., 2007. Step by step guide to critiquing research part 2:
qualitative research. British Journal of Nursing, 16(12), 738-744.

48. Ryan, F., 2013. Cochrane consumers and communication review group: data synthesis and analysis.
[online]

49. Rocker, C., 2012. Hierarchy of evidence awareness saves time. Journal of American Chiropractic
association.

50. Rijken, M. J., Gilder, M. E., Thwin, M. M., Kajeechewa, H. M. L., Wiladphaingern, J., Lwin, L. M., Jones,
C., Nosten, F. and McGready, R., 2012. Refugee and migrant women’s views of antenatal ultrasound on
the Thai-Burmese border: a mixed methods study. PLOS One. 7(4)

51. Stack Exchange, 2018. How to approach an American English vs British English spelling in a paper
[online]

52. Singhal, H., Premkumar, P. S., Chandy, A., Kunjummen, A. T. and Kamath, M., 2017. Patients sedation
with conscious sedation as a method of pain relief for transvaginal oocyte retriever: a cross sectional
study. Journal of human reproductive sciences, 10(2), 119-123.

53. Siddiqi, N., 2011. Publication bias to epidemiological studies. Central European journal of public
health, 19(2), 118-120.

54. Shukar-ud-din, S., Ubaid, F., Shahani, E. and Saleh, F., 2013. Reasons for disclosure of gender to
pregnant women during prenatal ultrasonography. International Journal of Women’s Health. 5, 781-785.

55. The World Bank 2016. New country classification by income level: 2016-2017. [online].

56. Ugwa, A. C., Osungbade, E. O. and Erondu, F. O., 2009. Maternal perspectives of prenatal sonogram
in a North-eastern population in Nigeria. LJM [online]

57. University of Michigan, 2018. Systemic reviews in health sciences. Research Guides [online]

58. World Health Organization 2016. Recommendations on antenatal care for a positive pregnancy
experience: Ultrasound examination. Maternal and child survival program [online].

59. Webster, L. and Mertova, P., 2007. Using narrative inquiry as a research method: an introduction to
using critical event narrative analysis in research on learning and teaching. London: Taylor & Francis

60. Wyszynski, D. F., Perandones, C. and Bennun, R. D., 2003. Attitudes toward prenatal diagnosis,
termination of pregnancy and reproduction by parents of children with non-syndromic oral-clefts in
Argentina. Prenatal Daignosis. 23, 722-727.

61. Wong, S. S., Wilczynski, N. L., Haynes, R. B. and the Hedges team, 2004. Developing optimal search
strategies for detecting clinically relevant qualitative studies in MEDLINE. Medinfo: studies in health
technology and information. 107(1), 311-316.

62. Wahabi, H.A., Channa, N.A., Fayed, A., Esmaeil, S. A., Masha, A. O., Al-Sheikh, G. K. and Abdul-Karim,
A. A., 2014. Knowledge, expectations and source of information of pregnant Saudi women undergoing
second trimester ultrasound examination. Gynecology and obstetrics, OMICS international.

20
63. Waltho, D., Kaur, M. N., Haynes, R. B., Farrokhyar, F. and Thoma, A., 2015. User’s guide to surgical
literature: how to perform a high-quality literature search. Canadian Journal of Surgery, 58(5), 349-358.

64. Zwaaf, E., 2013. 8 reasons I accepted your article: journal editors reveal the top reasons a manuscript
gets published. Elsevier.

65. Zira, J. D., 2017. Patient’s satisfaction and perception of care during obstetrics ultrasound scan.
Pakistan Journal of Radiology. 27(3), 195-199.

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9. APPENDICES:

INCLUSION CRITERIA EXCLUSION CRITERIA

Peer-reviewed articles Non-peer Reviewed articles

Published from 2009-2018 Grey Literature

Articles in English Language Papers other than English Language

Qualitative articles Papers older than 2009

Quantitative articles Editorials

Studies undertaken in upper- Studies undertaken in countries

middle to lower-middle income other than upper-middle to lower-
countries with similar cultures. middle income countries.

APPENDIX 1 (Inclusion/Exclusion Criteria of this Literature Review)

22
AUTHOR SETTING/ AIM OF STUDY TYPE OF STUDY MAIN FINDINGS/ STRENGTH/
/ DATE COUNTRY CONCLUSION LIMITATIONS
Ugwa et To explore views of survey/ Affordable Questionnaires
al (2009) Nigeria pregnant women & their Convenience technology, Fetal validated previously/
level of awareness Sampling gender least sample chosen from
regarding U/S considered single state
Firth et al To assess views & beliefs Qualitative/ Fear and myths Inductive
(2011) Tanzania of women concerning thematic regarding U/S approach/Convenience
U/S scans analysis. scanning sampling
Kadagad India Views of pregnant Prospectively Women agreed to Study piloted before/
et al women & mothers with hypothesized continue included only rural
(2011) orofacial deformities pregnancy despite areas
abnormalities
Ranji & Iran To explore views of Descriptive Unnecessary Authorized
Dykes postpartum women & study scans taken during researchers/lack of
(2012) no. of scans in pregnancy pregnancy consent
Rijken et Thai- To assess experiences of Mixed method U/S helps in safe Transcripts were
al (2012) Burmese female immigrants about approach child-birth confirmed by sample/
border U/S procedures local staff assisted
interviewers
Shukar- To find proportion of Descriptive, 31% willing to Consent taken/ results
ud-din et Pakistan women willing for gender cross-sectional know gender for not transferable.
al (2013) disclosure & its reasons familial support
Mensah Ghana To explore postpartum Cross-sectional Women were Randomly selected
et al women's perceptions unhappy with sample/included
(2014) regarding U/S staff females with live-births
only
Mubuuke Uganda To identify lived Negative Interview questions
(2014) experiences of women Phenomenolog experiences about were piloted/ lack of
undergoing TVS y TVS consent
Kasap et To evaluate knowledge & Cross-sectional Women had questionnaires
al (2016) Turkey expectations of women insufficient validated previously/
regarding U/S knowledge about how qusetionnaires
scans posted, created bias
Kyei et al Ghana To assess level of anxiety Non- Prolong waiting Confidentiality
(2016) & waiting time for U/S probability/ irritated women restored/researchers
convenience helped subjects during
sampling data collection
Okeji et Nigeria To determine views of Cross-sectional Positive views Sample selected
al (2017) patients about TVS survey with demand for purposively/neglected
female physician environmental factors
in pain scoring
Zira Nigeria To assess pregnant Cross-sectional Majority were Sample randomly
(2017) women's satisfaction study satisfied with staff selected/
during & after the scans & services questionnaires not
validated

APPENDIX 2 (SUMMARY OF PAPERS IN RELATION TO THIS LITERATURE REVIEW)

23
THEME 1 THEME 2 THEME 3 THEME 4
AWARENESS UNNECESSARY CONTINUE ANXIETY AND
REGARDING SCANS SCANS PREGNANCY EMBARRASSMENT
DESPITE FETAL
MALFORMATIONS
Ugwa et al (2009) Ranji & Dykes Kadagad et al (2011) Rijken et al (2012)
(2012)
Kasap et al (2016) Mensah et al (2014) Mubuuke (2014)
Firth et al (2011). Okeji et al (2017)
Firth et al (2011)
THEME 5 THEME 6 THEME 7 THEME 8
DISCLOSING FETAL POOR BEHAVIOR OF ENVIRONMENTAL SAFE &
GENDER STAFF ISSUES AFFORDABLE
TECHNOLOGY
Rijken et al (2012) Ranji & Dykes Firth et al (2011) Kasap et al (2016)
(2012)
Shukaruddin et al Mensah et al (2014) Kyei et al (2016) Zira (2017)
(2013)
Mensah et al (2014) Mubuuke (2014) Okeji et al (2017) Rijken et al (2012)
Zira (2017) Ugwa et al (2009)
Kasap et al (2016)
APPENDIX 3 (THEMES FROM PAPERS INCLUDED IN THIS LITERATURE REVIEW)

24
APPENDICES (4-15) PERTAINING CRITICAL ANALYSIS & CLARITY
OF THE PAPERS INCLUDED IN THIS REVIEW.
APPENDIX 4.

PAPER 1. Ugwa et al (2009)

 This study has clear aims and objectives.

 Methodology and methods of data collection were appropriate.
 Convenient sampling was done from three hospitals of single state so, the findings could not be
transfer to other settings as it is less rigorous than random selection of participants.
 How researchers identified the sample, whether subjects were recruited from the same or
different cities, is not mentioned or whether they were treated in the same way (Polit and Beck
2018).
 Study had enough participants to minimize chances of bias.
 All the participants who entered accounted for at its conclusion.
 Results were precise and presented in frequencies and percentages.
 Questionnaires were validated in previous study.

25
APPENDIX 5.

PAPER 2. Ranji and Dykes (2012)

 Study addressed clear and focused question.

 Study design and instrument were appropriate (polit and Beck 2018).
 They selected appropriate sample size consisting of women in post-partum period.
 They did not mention patient’s mode of delivery either they delivered vaginally or by cesarean-
section which would create bias due to difference in their responses depending on differences in
recovery time. This shows that all participants were not treated in the same way (Hewitt-Taylor
2011).
 The researchers did not mention about those women who had still-births and none of the
respondents taken informed consent which are its limitations.
 Results were clear and precise and were presented in percentages.
 Results are not transferable to other settings as study was conducted in one hospital only.

26
APPENDIX 6.

PAPER 3. Kadagad et al (2011)

 Study has clear aims and objectives.

 Study is focused at a clear issue.
 Participants recruitment strategies were appropriate according to study aims.
 Sample was selected purposively from obstetrical and craniofascial departments.
 Study was piloted earlier which is its strength.
 Results were clear and precise.
 Findings are valuable to the existing knowledge.
 Results cannot be applied to other settings as only rural areas were included in this study.

27
APPENDIX 7.

PAPER 4. Firth et al (2011)

 Study has clear aims and objectives.

 Study has addressed a focused question.
 Methodology was appropriate.
 Informed consents were not taken which has reduced its quality.
 Data was collected by note-taking as ethical approval for audio-recording was not available,
which has reduced its quality.
 Sample was collected from the same hospital which is its limitation.
 Data analysed thematically which was fine.
 Interpretater did not give consistently verbatim translations during interviews, which has
increased chances of bias.
 Participants expressed their views to please the researchers hence, created bias.
 Inductive approach was adopted for themes along with data saturation which are its strengths.
 Findings are valuable to share.

APPENDIX 8.

PAPER 5. Rijken et al (2012)

 Study is focused on an issue with clear aims and objectives.

 Methodology and methods were appropriate.

28
 Sample size was appropriate but sample recruiting strategies were not mentioned.
 All the participants were treated in the same manner.
 Data collected has addressed the research question.
 Proper engagement of the researcher and the respondents was fulfilled.
 Data analysis was rigorous and confirmed by interpreter for qualitative part of the study and
quantitative part was categorized and compared using percentages and appropriate statistical
tests.
 Results were precise and significant.
 Transferability is questionable as it was undertaken among refugees at Thai-Burmese border.

29
APPENDIX 9.

PAPER 6. Shukar-ud-din et al (2013)

 The study has clear aims and objectives.

 Study asked a clear focused question.
 Sample recruiting by convenient sampling which is not likely to represent a population (Polit and
Beck 2018).
 All the participants who entered the study accounted for its conclusion.
 Study has enough participants to avoid chances of bias and all were treated in the same way.
 Data collected addressed the research question.
 Ethical principles were followed as informed consent were taken.
 The results were precise and presented using frequencies and percentages.
 Results cannot be transferred to other settings as study was conducted in different hospitals of
the same city.
 Results were clear and contributing to the existing knowledge.

30
APPENDIX 10.

Paper 7. Mensah et al (2014)

 Study has clear aims and objectives.

 Study has asked clear focused question.
 Sample selected randomly from different hospitals which has improved its quality.
 Sampling method is appropriate to the study design with enough sample size to avoid biases.
 Informed consents were taken.
 Interviewer/self-administered questionnaires were used which are good for literate population
but not for poorly educated sample (Readex Research 2018) hence created bias.
 All the participants who entered the study accounted for its conclusion and were treated in the
same way.
 Data saturation was mentioned which has boosted its quality.
 Results were clear and precise and presented using percentages.
 Findings are transferable as sample was recruited randomly from three different hospitals.

31
APPENDIX 11

PAPER 8. Mubuuke (2014)

 The study has clear aims and objectives.

 Exploratory phenomenology was appropriate methodology selected.
 Sample recruited by the nursing staff rather than the researcher which is its weakness.
 Data collected has addressed the research issue.
 Ethical issues were not followed as verbal consent were taken (Beauchamp and Childress 2013)
which is its weakness.
 Duration of interviews was not mentioned, which has reduced its quality.
 Data saturation was mentioned with validation of questionnaires contributing to the strength of
this study.
 Findings are clear and concise and contributing knowledge is valuable.
 Findings cannot be applied to other situations as the study was conducted in only one setting.

APPENDIX 12

PAPER 9. Kyei et al (2016)

 Study has clear aims and objectives.

32
 Study asked a clear focused question.
 Non-probability convenient sampling was done which is non-random and could give biased
findings.
 Sampling method was appropriate but subjects were allocated either from single or different
hospitals was not mentioned.
 Study had enough participants to minimize chances of bias.
 Whole sample was treated in the same way.
 Ethical principles were followed and consents were signed anonymously.
 All the participants entered this study accounted for its conclusion.
 Questionnaires were self-administered which are quicker and cheaper but the response rate is
low and the researcher does not interfere the participants (Readex Research 2018) which has
improved its quality.
 Results were precise and presented using percentages.
 Findings cannot be inferred to the whole population as it was not mentioned from where
subjects were recruited.

33
APPENDIX 13

PAPER 10. Kasap et al (2016)

 Study has clear aims and objectives.

 Study asked a clear focused question.
 How the researchers selected the sample was not mentioned.
 Participants allocated were appropriate to the study design.
 Sample size was appropriate to avoid the chances of bias.
 How questionnaires were sent to the participants was not mentioned.
 All the participants entered the study accounted for its conclusion.
 Results were precise and presented using simple descriptive statistics (categorical were
compared using chi-square and p value <0.05 was considered statistically significant).
 Findings were precise and contributed knowledge.
 Findings cannot be transferred to other settings as the study was conducted in one clinic of a
city.

34
APPENDIX 14

PAPER 11. Okeji et al (2017)

 Study has clear aims and objectives.

 Study has a focused question.
 The methodology was appropriate as cross-sectional survey can estimate the prevalence of a
condition.
 Sampling method and sample size was appropriate to avoid chances of bias.
 Sample recruited purposively.
 Method of data collection (Visual analogue scale) for pain expression was properly categorized
into 4 levels on a scale of 100.
 Results were statistically significant.
 Findings were precise using percentages.
 Findings are informative, contributing to the existing knowledge.
 Study was conducted in three different hospitals hence results can be applied to other settings.

35
APPENDIX 15

PAPER 12. Zira (2017)

 Study addressed a clear focused question.

 Aims and objectives were clear.
 Sample recruited randomly from the radiology department with appropriate sample size to avoid
chances of bias.
 All participants who entered the study accounted for its conclusion.
 Questionnaires were not validated which is one of its weaknesses.
 Results were precise and presented using percentages.
 Results were statistically significant.
 Findings cannot be applied to other settings as the study was conducted in one city which has
reduced its quality.

_____________________________________________________________________________________

36