critical study research paper

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• v.12(2); Apr-Jun 2021

Critical appraisal of published research papers – A reinforcing tool for research methodology: Questionnaire-based study

Snehalata gajbhiye.

Department of Pharmacology and Therapeutics, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India

Raakhi Tripathi

Urwashi parmar, nishtha khatri, anirudha potey.

1 Department of Clinical Trials, Serum Institute of India, Pune, Maharashtra, India

Background and Objectives:

Critical appraisal of published research papers is routinely conducted as a journal club (JC) activity in pharmacology departments of various medical colleges across Maharashtra, and it forms an important part of their postgraduate curriculum. The objective of this study was to evaluate the perception of pharmacology postgraduate students and teachers toward use of critical appraisal as a reinforcing tool for research methodology. Evaluation of performance of the in-house pharmacology postgraduate students in the critical appraisal activity constituted secondary objective of the study.

Materials and Methods:

The study was conducted in two parts. In Part I, a cross-sectional questionnaire-based evaluation on perception toward critical appraisal activity was carried out among pharmacology postgraduate students and teachers. In Part II of the study, JC score sheets of 2 nd - and 3 rd -year pharmacology students over the past 4 years were evaluated.

One hundred and twenty-seven postgraduate students and 32 teachers participated in Part I of the study. About 118 (92.9%) students and 28 (87.5%) faculties considered the critical appraisal activity to be beneficial for the students. JC score sheet assessments suggested that there was a statistically significant improvement in overall scores obtained by postgraduate students ( n = 25) in their last JC as compared to the first JC.

Conclusion:

Journal article criticism is a crucial tool to develop a research attitude among postgraduate students. Participation in the JC activity led to the improvement in the skill of critical appraisal of published research articles, but this improvement was not educationally relevant.

INTRODUCTION

Critical appraisal of a research paper is defined as “The process of carefully and systematically examining research to judge its trustworthiness, value and relevance in a particular context.”[ 1 ] Since scientific literature is rapidly expanding with more than 12,000 articles being added to the MEDLINE database per week,[ 2 ] critical appraisal is very important to distinguish scientifically useful and well-written articles from imprecise articles.

Educational authorities like the Medical Council of India (MCI) and Maharashtra University of Health Sciences (MUHS) have stated in pharmacology postgraduate curriculum that students must critically appraise research papers. To impart training toward these skills, MCI and MUHS have emphasized on the introduction of journal club (JC) activity for postgraduate (PG) students, wherein students review a published original research paper and state the merits and demerits of the paper. Abiding by this, pharmacology departments across various medical colleges in Maharashtra organize JC at frequent intervals[ 3 , 4 ] and students discuss varied aspects of the article with teaching faculty of the department.[ 5 ] Moreover, this activity carries a significant weightage of marks in the pharmacology university examination. As postgraduate students attend this activity throughout their 3-year tenure, it was perceived by the authors that this activity of critical appraisal of research papers could emerge as a tool for reinforcing the knowledge of research methodology. Hence, a questionnaire-based study was designed to find out the perceptions from PG students and teachers.

There have been studies that have laid emphasis on the procedure of conducting critical appraisal of research papers and its application into clinical practice.[ 6 , 7 ] However, there are no studies that have evaluated how well students are able to critically appraise a research paper. The Department of Pharmacology and Therapeutics at Seth GS Medical College has developed an evaluation method to score the PG students on this skill and this tool has been implemented for the last 5 years. Since there are no research data available on the performance of PG Pharmacology students in JC, capturing the critical appraisal activity evaluation scores of in-house PG students was chosen as another objective of the study.

MATERIALS AND METHODS

Description of the journal club activity.

JC is conducted in the Department of Pharmacology and Therapeutics at Seth GS Medical College once in every 2 weeks. During the JC activity, postgraduate students critically appraise published original research articles on their completeness and aptness in terms of the following: study title, rationale, objectives, study design, methodology-study population, inclusion/exclusion criteria, duration, intervention and safety/efficacy variables, randomization, blinding, statistical analysis, results, discussion, conclusion, references, and abstract. All postgraduate students attend this activity, while one of them critically appraises the article (who has received the research paper given by one of the faculty members 5 days before the day of JC). Other faculties also attend these sessions and facilitate the discussions. As the student comments on various sections of the paper, the same predecided faculty who gave the article (single assessor) evaluates the student on a total score of 100 which is split per section as follows: Introduction –20 marks, Methodology –20 marks, Discussion – 20 marks, Results and Conclusion –20 marks, References –10 marks, and Title, Abstract, and Keywords – 10 marks. However, there are no standard operating procedures to assess the performance of students at JC.

Methodology

After seeking permission from the Institutional Ethics Committee, the study was conducted in two parts. Part I consisted of a cross-sectional questionnaire-based survey that was conducted from October 2016 to September 2017. A questionnaire to evaluate perception towards the activity of critical appraisal of published papers as research methodology reinforcing tool was developed by the study investigators. The questionnaire consisted of 20 questions: 14 questions [refer Figure 1 ] graded on a 3-point Likert scale (agree, neutral, and disagree), 1 multiple choice selection question, 2 dichotomous questions, 1 semi-open-ended questions, and 2 open-ended questions. Content validation for this questionnaire was carried out with the help of eight pharmacology teachers. The content validity ratio per item was calculated and each item in the questionnaire had a CVR ratio (CVR) of >0.75.[ 8 ] The perception questionnaire was either E-mailed or sent through WhatsApp to PG pharmacology students and teaching faculty in pharmacology departments at various medical colleges across Maharashtra. Informed consent was obtained on E-mail from all the participants.

Graphical representation of the percentage of students/teachers who agreed that critical appraisal of research helped them improve their knowledge on various aspects of research, perceived that faculty participation is important in this activity, and considered critical appraisal activity beneficial for students. The numbers adjacent to the bar diagrams indicate the raw number of students/faculty who agreed, while brackets indicate %

Part II of the study consisted of evaluating the performance of postgraduate students toward skills of critical appraisal of published papers. For this purpose, marks obtained by 2 nd - and 3 rd -year residents during JC sessions conducted over a period of 4 years from October 2013 to September 2017 were recorded and analyzed. No data on personal identifiers of the students were captured.

Statistical analysis

Marks obtained by postgraduate students in their first and last JC were compared using Wilcoxon signed-rank test, while marks obtained by 2 nd - and 3 rd -year postgraduate students were compared using Mann–Whitney test since the data were nonparametric. These statistical analyses were performed using GraphPad Prism statistical software, San Diego, Calfornia, USA, Version 7.0d. Data obtained from the perception questionnaire were entered in Microsoft Excel sheet and were expressed as frequencies (percentages) using descriptive statistics.

Participants who answered all items of the questionnaire were considered as complete responders and only completed questionnaires were analyzed. The questionnaire was sent through an E-mail to 100 students and through WhatsApp to 68 students. Out of the 100 students who received the questionnaire through E-mail, 79 responded completely and 8 were incomplete responders, while 13 students did not revert back. Out of the 68 students who received the questionnaire through WhatsApp, 48 responded completely, 6 gave an incomplete response, and 14 students did not revert back. Hence, of the 168 postgraduate students who received the questionnaire, 127 responded completely (student response rate for analysis = 75.6%). The questionnaire was E-mailed to 33 faculties and was sent through WhatsApp to 25 faculties. Out of the 33 faculties who received the questionnaire through E-mail, 19 responded completely, 5 responded incompletely, and 9 did not respond at all. Out of the 25 faculties who received the questionnaire through WhatsApp, 13 responded completely, 3 were incomplete responders, and 9 did not respond at all. Hence, of a total of 58 faculties who were contacted, 32 responded completely (faculty response rate for analysis = 55%). For Part I of the study, responses on the perception questionnaire from 127 postgraduate students and 32 postgraduate teachers were recorded and analyzed. None of the faculty who participated in the validation of the questionnaire participated in the survey. Number of responses obtained region wise (Mumbai region and rest of Maharashtra region) have been depicted in Table 1 .

Region-wise distribution of responses

Number of responses obtained from students/faculty belonging to Mumbai colleges and rest of Maharashtra colleges. Brackets indicate percentages

As per the data obtained on the Likert scale questions, 102 (80.3%) students and 29 (90.6%) teachers agreed that critical appraisal trains the students in doing a review of literature before selecting a particular research topic. Majority of the participants, i.e., 104 (81.9%) students and 29 (90.6%) teachers also believed that the activity increases student's knowledge regarding various experimental evaluation techniques. Moreover, 112 (88.2%) students and 27 (84.4%) faculty considered that critical appraisal activity results in improved skills of writing and understanding methodology section of research articles in terms of inclusion/exclusion criteria, endpoints, and safety/efficacy variables. About 103 (81.1%) students and 24 (75%) teachers perceived that this activity results in refinement of the student's research work. About 118 (92.9%) students and 28 (87.5%) faculty considered the critical appraisal activity to be beneficial for the students. Responses to 14 individual Likert scale items of the questionnaire have been depicted in Figure 1 .

With respect to the multiple choice selection question, 66 (52%) students and 16 (50%) teachers opined that faculty should select the paper, 53 (41.7%) students and 9 (28.1%) teachers stated that the papers should be selected by the presenting student himself/herself, while 8 (6.3%) students and 7 (21.9%) teachers expressed that some other student should select the paper to be presented at the JC.

The responses to dichotomous questions were as follows: majority of the students, that is, 109 (85.8%) and 23 (71.9%) teachers perceived that a standard checklist for article review should be given to the students before critical appraisal of journal article. Open-ended questions of the questionnaire invited suggestions from the participants regarding ways of getting trained on critical appraisal skills and of improving JC activity. Some of the suggestions given by faculty were as follows: increasing the frequency of JC activity, discussion of cited articles and new guidelines related to it, selecting all types of articles for criticism rather than only randomized controlled trials, and regular yearly exams on article criticism. Students stated that regular and frequent article criticism activity, practice of writing letter to the editor after criticism, active participation by peers and faculty, increasing weightage of marks for critical appraisal of papers in university examinations (at present marks are 50 out of 400), and a formal training for research criticism from 1 st year of postgraduation could improve critical appraisal program.

In Part II of this study, performance of the students on the skill of critical appraisal of papers was evaluated. Complete data of the first and last JC scores of a total of 25 students of the department were available, and when these scores were compared, it was seen that there was a statistically significant improvement in the overall scores ( P = 0.04), as well as in the scores obtained in methodology ( P = 0.03) and results section ( P = 0.02). This is depicted in Table 2 . Although statistically significant, the differences in scores in the methodology section, results section, and overall scores were 1.28/20, 1.28/20, and 4.36/100, respectively, amounting to 5.4%, 5.4%, and 4.36% higher scores in the last JC, which may not be considered educationally relevant (practically significant). The quantum of difference that would be considered practically significant was not decided a priori .

Comparison of marks obtained by pharmacology residents in their first and last journal club

Marks have been represented as mean±SD. The maximum marks that can be obtained in each section have been stated as maximum. *Indicates statistically significant ( P <0.05). IQR=Interquartile range, SD=Standard deviation

Scores of two groups, one group consisting of 2 nd -year postgraduate students ( n = 44) and second group consisting of 3 rd -year postgraduate students ( n = 32) were compared and revealed no statistically significant difference in overall score ( P = 0.84). This is depicted in Table 3 . Since the quantum of difference in the overall scores was meager 0.84/100 (0.84%), it cannot be considered practically significant.

Comparison of marks obtained by 2 nd - and 3 rd -year pharmacology residents in the activity of critical appraisal of research articles

Marks have been represented as mean±SD. The maximum marks that can be obtained in each section have been stated as maximum. P <0.05 was considered to be statistically significant. IQR=Interquartile range, SD=Standard deviation

The present study gauged the perception of the pharmacology postgraduate students and teachers toward the use of critical appraisal activity as a reinforcing tool for research methodology. Both students and faculties (>50%) believed that critical appraisal activity increases student's knowledge on principles of ethics, experimental evaluation techniques, CONSORT guidelines, statistical analysis, concept of conflict of interest, current trends and recent advances in Pharmacology and trains on doing a review of literature, and improves skills on protocol writing and referencing. In the study conducted by Crank-Patton et al ., a survey on 278 general surgery program directors was carried out and more than 50% indicated that JC was important to their training program.[ 9 ]

The grading template used in Part II of the study was based on the IMRaD structure. Hence, equal weightage was given to the Introduction, Methodology, Results, and Discussion sections and lesser weightage was given to the references and title, abstract, and keywords sections.[ 10 ] While evaluating the scores obtained by 25 students in their first and last JC, it was seen that there was a statistically significant improvement in the overall scores of the students in their last JC. However, the meager improvement in scores cannot be considered educationally relevant, as the authors expected the students to score >90% for the upgrade to be considered educationally impactful. The above findings suggest that even though participation in the JC activity led to a steady increase in student's performance (~4%), the increment was not as expected. In addition, the students did not portray an excellent performance (>90%), with average scores being around 72% even in the last JC. This can be probably explained by the fact that students perform this activity in a routine setting and not in an examination setting. Unlike the scenario in an examination, students were aware that even if they performed at a mediocre level, there would be no repercussions.

A separate comparison of scores obtained by 44 students in their 2 nd year and 32 students in their 3 rd year of postgraduation students was also done. The number of student evaluation sheets reviewed for this analysis was greater than the number of student evaluation sheets reviewed to compare first and last JC scores. This can be spelled out by the fact that many students were still in 2 nd year when this analysis was done and the score data for their last JC, which would take place in 3 rd year, was not available. In addition, few students were asked to present at JC multiple times during the 2 nd /3 rd year of their postgraduation.

While evaluating the critical appraisal scores obtained by 2 nd - and 3 rd -year postgraduate students, it was found that although the 3 rd -year students had a mean overall score greater than the 2 nd -year students, this difference was not statistically significant. During the 1 st year of MD Pharmacology course, students at the study center attend JC once in every 2 weeks. Even though the 1 st -year students do not themselves present in JC, they listen and observe the criticism points stated by senior peers presenting at the JC, and thereby, incur substantial amount of knowledge required to critically appraise papers. By the time, they become 2 nd -year students, they are already well versed with the program and this could have led to similar overall mean scores between the 2 nd -year students (71.50 ± 10.71) and 3 rd -year students (72.34 ± 10.85). This finding suggests that attentive listening is as important as active participation in the JC. Moreover, although students are well acquainted with the process of criticism when they are in their 3 rd year, there is certainly a scope for improvement in terms of the mean overall scores.

Similar results were obtained in a study conducted by Stern et al ., in which 62 students in the internal medicine program at the New England Medical Center were asked to respond to a questionnaire, evaluate a sample article, and complete a self-assessment of competence in evaluation of research. Twenty-eight residents returned the questionnaire and the composite score for the resident's objective assessment was not significantly correlated with the postgraduate year or self-assessed critical appraisal skill.[ 11 ]

Article criticism activity provides the students with practical experience of techniques taught in research methodology workshop. However, this should be supplemented with activities that assess the improvement of designing and presenting studies, such as protocol and paper writing. Thus, critical appraisal plays a significant role in reinforcing good research practices among the new generation of physicians. Moreover, critical appraisal is an integral part of PG assessment, and although the current format of conducting JCs did not portray a clinically meaningful improvement, the authors believe that it is important to continue this activity with certain modifications suggested by students who participated in this study. Students suggested that an increase in the frequency of critical appraisal activity accompanied by the display of active participation by peers and faculty could help in the betterment of this activity. This should be brought to attention of the faculty, as students seem to be interested to learn. Critical appraisal should be a two-way teaching–learning process between the students and faculty and not a dire need for satisfying the students' eligibility criteria for postgraduate university examinations. This activity is not only for the trainee doctors but also a part of the overall faculty development program.[ 12 ]

In the present era, JCs have been used as a tool to not only teach critical appraisal skills but also to teach other necessary aspects such as research design, medical statistics, clinical epidemiology, and clinical decision-making.[ 13 , 14 ] A study conducted by Khan in 2013 suggested that success of JC program can be ensured if institutes develop a defined JC objective for the development of learning capability of students and also if they cultivate more skilled faculties.[ 15 ] A good JC is believed to facilitate relevant, meaningful scientific discussion, and evaluation of the research updates that will eventually benefit the patient care.[ 12 ]

Although there is a lot of literature emphasizing the importance of JC, there is a lack of studies that have evaluated the outcome of such activity. One such study conducted by Ibrahim et al . assessed the importance of critical appraisal as an activity in surgical trainees in Nigeria. They reported that 92.42% trainees considered the activity to be important or very important and 48% trainees stated that the activity helped in improving literature search.[ 16 ]

This study is unique since it is the first of its kind to evaluate how well students are able to critically appraise a research paper. Moreover, the study has taken into consideration the due opinions of the students as well as faculties, unlike the previous literature which has laid emphasis on only student's perception. A limitation of this study is that sample size for faculties was smaller than the students, as it was not possible to convince the distant faculty in other cities to fill the survey. Besides, there may be a variation in the manner of conduct of the critical appraisal activity in pharmacology departments across the various medical colleges in the country. Another limitation of this study was that a single assessor graded a single student during one particular JC. Nevertheless, each student presented at multiple JC and thereby came across multiple assessors. Since the articles addressed at different JC were disparate, interobserver variability was not taken into account in this study. Furthermore, the authors did not make an a priori decision on the quantum of increase in scores that would be considered educationally meaningful.

Pharmacology students and teachers acknowledge the role of critical appraisal in improving the ability to understand the crucial concepts of research methodology and research conduct. In our institute, participation in the JC activity led to an improvement in the skill of critical appraisal of published research articles among the pharmacology postgraduate students. However, this improvement was not educationally relevant. The scores obtained by final-year postgraduate students in this activity were nearly 72% indicating that there is still scope of betterment in this skill.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Acknowledgments

We would like to acknowledge the support rendered by the entire Department of Pharmacology and Therapeutics at Seth GS Medical College.

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What do you critically analyse?

In a critical analysis you do not express your own opinion or views on the topic. You need to develop your thesis, position or stance on the topic from the views and research of others . In academic writing you critically analyse other researchers’:

• concepts, terms
• viewpoints, arguments, positions
• methodologies, approaches
• research results and conclusions

This means weighing up the strength of the arguments or research support on the topic, and deciding who or what has the more or stronger weight of evidence or support.

Therefore, your thesis argues, with evidence, why a particular theory, concept, viewpoint, methodology, or research result(s) is/are stronger, more sound, or more advantageous than others.

What does ‘analysis’ mean?

A critical analysis means analysing or breaking down the parts of the literature and grouping these into themes, patterns or trends.

In an analysis you need to:

1. Identify and separate out the parts of the topic by grouping the various key theories, main concepts, the main arguments or ideas, and the key research results and conclusions on the topic into themes, patterns or trends of agreement , dispute and omission .

2. Discuss each of these parts by explaining:

i. the areas of agreement/consensus, or similarity

ii. the issues or controversies: in dispute or debate, areas of difference

ii. the omissions, gaps, or areas that are under-researched

3. Discuss the relationship between these parts

4. Examine how each contributes to the whole topic

5. Make conclusions about their significance or importance in the topic

What does ‘critical’ mean?

A critical analysis does not mean writing angry, rude or disrespectful comments, or  expressing your views in judgmental terms of black and white, good and bad, or right and wrong.

To be critical, or to critique, means to evaluate . Therefore, to write critically in an academic analysis means to:

• judge the quality, significance or worth of the theories, concepts, viewpoints, methodologies, and research results
• evaluate in a fair and balanced manner
• avoid extreme or emotional language

• strengths, advantages, benefits, gains, or improvements
• disadvantages, weaknesses, shortcomings, limitations, or drawbacks

How to critically analyse a theory, model or framework

The evaluative words used most often to refer to theory, model or framework are a sound theory or a strong theory.

The table below summarizes the criteria for judging the strengths and weaknesses of a theory:

• comprehensive
• empirically supported
• parsimonious

Evaluating a Theory, Model or Framework

The table below lists the criteria for the strengths and their corresponding weaknesses that are usually considered in a theory.

Critical analysis examples of theories

The following sentences are examples of the phrases used to explain strengths and weaknesses.

Smith’s (2005) theory appears up to date, practical and applicable across many divergent settings.

Brown’s (2010) theory, although parsimonious and logical, lacks a sufficient body of evidence to support its propositions and predictions

Little scientific evidence has been presented to support the premises of this theory.

One of the limitations with this theory is that it does not explain why…

A significant strength of this model is that it takes into account …

The propositions of this model appear unambiguous and logical.

A key problem with this framework is the conceptual inconsistency between ….

How to critically analyse a concept

The table below summarizes the criteria for judging the strengths and weaknesses of a concept:

• key variables identified
• clear and well-defined

Evaluating Concepts

Critical analysis examples of concepts

Many researchers have used the concept of control in different ways.

There is little consensus about what constitutes automaticity.

Putting forth a very general definition of motivation means that it is possible that any behaviour could be included.

The concept of global education lacks clarity, is imprecisely defined and is overly complex.

Some have questioned the usefulness of resilience as a concept because it has been used so often and in so many contexts.

Research suggests that the concept of preoperative fasting is an outdated clinical approach.

How to critically analyse arguments, viewpoints or ideas

The table below summarizes the criteria for judging the strengths and weaknesses of an argument, viewpoint or idea:

• reasons support the argument
• argument is substantiated by evidence
• evidence for the argument is relevant
• evidence for the argument is unbiased, sufficient and important
• evidence is reputable

Evaluating Arguments, Views or Ideas

Critical analysis examples of arguments, viewpoints or ideas

The validity of this argument is questionable as there is insufficient evidence to support it.

Many writers have challenged Jones’ claim on the grounds that …….

This argument fails to draw on the evidence of others in the field.

This explanation is incomplete because it does not explain why…

The key problem with this explanation is that ……


The existing accounts fail to resolve the contradiction between …

However, there is an inconsistency with this argument. The inconsistency lies in…

Although this argument has been proposed by some, it lacks justification.

However, the body of evidence showing that… contradicts this argument.

How to critically analyse a methodology

The table below provides the criteria for judging the strengths and weaknesses of methodology.

An evaluation of a methodology usually involves a critical analysis of its main sections:

design; sampling (participants); measurement tools and materials; procedure

• design tests the hypotheses or research questions
• method valid and reliable
• potential bias or measurement error, and confounding variables addressed
• method allows results to be generalized
• representative sampling of cohort and phenomena; sufficient response rate
• valid and reliable measurement tools
• valid and reliable procedure
• method clear and detailed to allow replication

Evaluating a Methodology

Critical analysis examples of a methodology

The unrepresentativeness of the sample makes these results misleading.

The presence of unmeasured variables in this study limits the interpretation of the results.

Other, unmeasured confounding variables may be influencing this association.

The interpretation of the data requires caution because the effect of confounding variables was not taken into account.

The insufficient control of several response biases in this study means the results are likely to be unreliable.

Although this correlational study shows association between the variables, it does not establish a causal relationship.

Taken together, the methodological shortcomings of this study suggest the need for serious caution in the meaningful interpretation of the study’s results.

How to critically analyse research results and conclusions

The table below provides the criteria for judging the strengths and weaknesses of research results and conclusions:

• appropriate choice and use of statistics
• correct interpretation of results
• all results explained
• alternative explanations considered
• significance of all results discussed
• consistency of results with previous research discussed
• results add to existing understanding or knowledge
• limitations discussed
• results clearly explained
• conclusions consistent with results

Evaluating the Results and Conclusions

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Write a Critical Review of a Scientific Journal Article

1. identify how and why the research was carried out, 2. establish the research context, 3. evaluate the research, 4. establish the significance of the research.

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Read the article(s) carefully and use the questions below to help you identify how and why the research was carried out. Look at the following sections: 

Introduction

• What was the objective of the study?
• What methods were used to accomplish this purpose (e.g., systematic recording of observations, analysis and evaluation of published research, assessment of theory, etc.)?
• What techniques were used and how was each technique performed?
• What kind of data can be obtained using each technique?
• How are such data interpreted?
• What kind of information is produced by using the technique?
• What objective evidence was obtained from the authors’ efforts (observations, measurements, etc.)?
• What were the results of the study? 
• How was each technique used to obtain each result?
• What statistical tests were used to evaluate the significance of the conclusions based on numeric or graphic data?
• How did each result contribute to answering the question or testing the hypothesis raised in the introduction?
• How were the results interpreted? How were they related to the original problem (authors’ view of evidence rather than objective findings)? 
• Were the authors able to answer the question (test the hypothesis) raised?
• Did the research provide new factual information, a new understanding of a phenomenon in the field, or a new research technique?
• How was the significance of the work described?
• Do the authors relate the findings of the study to literature in the field?
• Did the reported observations or interpretations support or refute observations or interpretations made by other researchers?

These questions were adapted from the following sources:  Kuyper, B.J. (1991). Bringing up scientists in the art of critiquing research. Bioscience 41(4), 248-250. Wood, J.M. (2003). Research Lab Guide. MICR*3260 Microbial Adaptation and Development Web Site . Retrieved July 31, 2006.

Once you are familiar with the article, you can establish the research context by asking the following questions:

• Who conducted the research? What were/are their interests?
• When and where was the research conducted?
• Why did the authors do this research?
• Was this research pertinent only within the authors’ geographic locale, or did it have broader (even global) relevance?
• Were many other laboratories pursuing related research when the reported work was done? If so, why?
• For experimental research, what funding sources met the costs of the research?
• On what prior observations was the research based? What was and was not known at the time?
• How important was the research question posed by the researchers?

These questions were adapted from the following sources: Kuyper, B.J. (1991). Bringing up scientists in the art of critiquing research. Bioscience 41(4), 248-250. Wood, J.M. (2003). Research Lab Guide. MICR*3260 Microbial Adaptation and Development Web Site . Retrieved July 31, 2006.

Remember that simply disagreeing with the material is not considered to be a critical assessment of the material.  For example, stating that the sample size is insufficient is not a critical assessment.  Describing why the sample size is insufficient for the claims being made in the study would be a critical assessment.

Use the questions below to help you evaluate the quality of the authors’ research:

• Does the title precisely state the subject of the paper?
• Read the statement of purpose in the abstract. Does it match the one in the introduction?

Acknowledgments

• Could the source of the research funding have influenced the research topic or conclusions?
• Check the sequence of statements in the introduction. Does all the information lead coherently to the purpose of the study?
• Review all methods in relation to the objective(s) of the study. Are the methods valid for studying the problem?
• Check the methods for essential information. Could the study be duplicated from the methods and information given?
• Check the methods for flaws. Is the sample selection adequate? Is the experimental design sound?
• Check the sequence of statements in the methods. Does all the information belong there? Is the sequence of methods clear and pertinent?
• Was there mention of ethics? Which research ethics board approved the study?
• Carefully examine the data presented in the tables and diagrams. Does the title or legend accurately describe the content? 
• Are column headings and labels accurate? 
• Are the data organized for ready comparison and interpretation? (A table should be self-explanatory, with a title that accurately and concisely describes content and column headings that accurately describe information in the cells.)
• Review the results as presented in the text while referring to the data in the tables and diagrams. Does the text complement, and not simply repeat data? Are there discrepancies between the results in the text and those in the tables?
• Check all calculations and presentation of data.
• Review the results in light of the stated objectives. Does the study reveal what the researchers intended?
• Does the discussion clearly address the objectives and hypotheses?
• Check the interpretation against the results. Does the discussion merely repeat the results? 
• Does the interpretation arise logically from the data or is it too far-fetched? 
• Have the faults, flaws, or shortcomings of the research been addressed?
• Is the interpretation supported by other research cited in the study?
• Does the study consider key studies in the field?
• What is the significance of the research? Do the authors mention wider implications of the findings?
• Is there a section on recommendations for future research? Are there other research possibilities or directions suggested? 

Consider the article as a whole

• Reread the abstract. Does it accurately summarize the article?
• Check the structure of the article (first headings and then paragraphing). Is all the material organized under the appropriate headings? Are sections divided logically into subsections or paragraphs?
• Are stylistic concerns, logic, clarity, and economy of expression addressed?

These questions were adapted from the following sources:  Kuyper, B.J. (1991). Bringing up scientists in the art of critiquing research. Bioscience 41(4), 248-250. Wood, J.M. (2003). Research Lab Guide. MICR*3260 Microbial Adaptation and Development Web Site. Retrieved July 31, 2006.

After you have evaluated the research, consider whether the research has been successful. Has it led to new questions being asked, or new ways of using existing knowledge? Are other researchers citing this paper?

You should consider the following questions:

• How did other researchers view the significance of the research reported by your authors?
• Did the research reported in your article result in the formulation of new questions or hypotheses (by the authors or by other researchers)?
• Have other researchers subsequently supported or refuted the observations or interpretations of these authors?
• Did the research make a significant contribution to human knowledge?
• Did the research produce any practical applications?
• What are the social, political, technological, medical implications of this research?
• How do you evaluate the significance of the research?

To answer these questions, look at review articles to find out how reviewers view this piece of research. Look at research articles and databases like Web of Science to see how other people have used this work. What range of journals have cited this article?

These questions were adapted from the following sources:

Kuyper, B.J. (1991). Bringing up scientists in the art of critiquing research. Bioscience 41(4), 248-250. Wood, J.M. (2003). Research Lab Guide. MICR*3260 Microbial Adaptation and Development Web Site . Retrieved July 31, 2006.

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Critical appraisal of a clinical research paper

What one needs to know.

Manjali, Jifmi Jose; Gupta, Tejpal

Department of Radiation Oncology, Tata Memorial Centre, Homi Bhabha National Institute, Mumbai, Maharashtra, India

Address for correspondence: Dr. Tejpal Gupta, ACTREC, Tata Memorial Centre, Homi Bhabha National Institute, Kharghar, Navi Mumbai - 410 210, Maharashtra, India. E-mail: [email protected]

Received May 25, 2020

Received in revised form June 11, 2020

Accepted June 19, 2020

This is an open access journal, and articles are distributed under the terms of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 License, which allows others to remix, tweak, and build upon the work non-commercially, as long as appropriate credit is given and the new creations are licensed under the identical terms.

In the present era of evidence-based medicine (EBM), integrating best research evidence into the clinical practice necessitates developing skills to critically evaluate and analyze the scientific literature. Critical appraisal is the process of systematically examining research evidence to assess its validity, results, and relevance to inform clinical decision-making. All components of a clinical research article need to be appraised as per the study design and conduct. As research bias can be introduced at every step in the flow of a study leading to erroneous conclusions, it is essential that suitable measures are adopted to mitigate bias. Several tools have been developed for the critical appraisal of scientific literature, including grading of evidence to help clinicians in the pursuit of EBM in a systematic manner. In this review, we discuss the broad framework for the critical appraisal of a clinical research paper, along with some of the relevant guidelines and recommendations.

INTRODUCTION

Medical research information is ever growing and branching day by day. Despite the vastness of medical literature, it is necessary that as clinicians we offer the best treatment to our patients as per the current knowledge. Integrating best research evidence with clinical expertise and patient values has led to the concept of evidence-based medicine (EBM).[ 1 ] Although this philosophy originated in the middle of the 19 th century,[ 2 ] it first appeared in its current form in the modern medical literature in 1991.[ 3 ] EBM is defined as the conscientious, explicit, and judicious use of the current best evidence in making decisions about the care of an individual patient.[ 1 ] The essentials of EBM include generating a clinical question, tracking the best available evidence, critically evaluating the evidence for validity and clinical usefulness, further applying the results to clinical practice, and evaluating its performance. Appropriate application of EBM can result in cost-effectiveness and improve health-care efficiency.[ 4 ] Without continual accumulation of new knowledge, existing dogmas and paradigms quickly become outdated and may prove detrimental to the patients. The current growth of medical literature with 1.8 million scientific articles published in the year 2012,[ 5 ] often makes it difficult for the clinicians to keep pace with the vast amount of scientific data, thus making foraging (alerts to new information) and hunting (finding answers to clinical questions) essential skills to help navigate the so-called “jungle” of information.[ 6 ] Therefore, it is essential that health-care professionals read medical literature selectively to effectively utilize their limited time and assiduously imbibe new knowledge to improve decision-making for their patients. To practice EBM in its true sense, a clinician not only needs to devote time to develop the skill of effectively searching the literature, but also needs to learn to evaluate the significance, methodology, outcomes, and transparency of the study.[ 4 ] Along with the evaluation and interpretation of a study, a thorough understanding of its methodology is necessary. It is common knowledge that studies with positive results are relatively easy to publish.[ 7 8 ] However, it is the critical appraisal of any research study (even those with negative results) that helps us to understand the science better and ask relevant questions in future using an appropriate study design and endpoints. Therefore, this review is focused on the framework for the critical appraisal of a clinical research paper. In addition, we have also discussed some of the relevant guidelines and recommendations for the critical appraisal of clinical research papers.

CRITICAL APPRAISAL

Critical appraisal is the process of systematically examining the research evidence to assess its validity, results, and relevance before using it to inform a decision.[ 9 ] It entails the following:

• Balanced assessment of the benefits/strengths and flaws/weaknesses of a study
• Assessment of the research process and results
• Consideration of quantitative and qualitative aspects.

Critical appraisal is performed to assess the following

aspects of a study:

• Validity – Is the methodology robust?
• Reliability – Are the results credible?
• Applicability– Do the results have the potential to change the current practice?

Contrary to the common belief, a critical appraisal is not the negative dismissal of any piece of research or an assessment of the results alone; it is neither solely based on a statistical analysis nor a process undertaken by the experts only. When performing a critical appraisal of a scientific article, it is essential that we know its basic composition and assess every section meticulously.

Initial assessment

This involves taking a generalized look at the details of the article. The journal it was published in holds special value – a peer reviewed, indexed journal with a good impact factor adds robustness to the paper. The setting, timeline, and year of publication of the study also need to be noted, as they provide a better understanding of the evolution of thoughts in that particular subject. Declaration of the conflicts of interest by the authors, the role of the funding source if any, and any potential commercial bias should also be noted.[ 10 ]

COMPONENTS OF A CLINICAL RESEARCH PAPER

The components of any scientific article or clinical research paper remain largely the same. An article begins with a title, abstract, and keywords, which are followed by the main text, which includes the IMRAD – introduction, methods, results and discussion, and ends with the conclusion and references.

It is a brief summary of the research article which helps the readers understand the purpose, methods, and results of the study. Although an abstract may provide a brief overview of the study, the full text of the article needs to be read and evaluated for a thorough understanding. There are two types of abstracts, namely structured and unstructured. A structured abstract comprises different sections typically labelled as background/purpose, methods, results, and conclusion, whereas an unstructured abstract is not divided into these sections.

Introduction

The introduction of a research paper familiarizes the reader with the topic. It refers to the current evidence in the particular subject and the possible lacunae which necessitate the present study. In other words, the introduction puts the study in perspective. The findings of other related studies have to be quoted and referenced, especially their central statements. The introduction also needs to justify the appropriateness of the chosen study.[ 11 ]

This section highlights the procedure followed while conducting the study. It provides all the data necessary for the study's appraisal and lays out the study design which is paramount. For clinical research articles, this section should describe the participant or patient/population/problem (P), intervention (I), comparison (C), outcome (O), and study design (S) PICO(S), generally referred to as the PICO(S) framework [ Table 1 ].

Study designs and levels of evidence

Study designs are broadly divided into descriptive and interventional studies,[ 12 ] which can be further subdivided as shown in Figure 1 . Each study design has its own characteristics and should be used in the appropriate setting. The various study designs form the building blocks of evidence. This in turn justifies the need for a hierarchical classification of evidence, referred to as “Levels of Evidence,” as it forms the cornerstone of EBM [ Table 2 ]. Most medical journals now mandate that the submitted manuscript conform to and comply with the clinical research reporting statements and guidelines as applicable to the study design [ Table 3 ] to maintain clarity, transparency, and reproducibility and ensure comparability across different studies asking the same research question. As per the study design, the appropriate descriptive and inferential statistical analyses should be specified in the statistical plan. For prospective studies, a clear mention of sample size calculation (depending on the type of study, power, alpha error, meaningful difference, and variance) is mandatory, so as to identify whether the study was adequately powered.[ 13 ] The endpoints (primary, secondary, and exploratory, if any) should be mentioned clearly along with the exact methods used for the measurement of the variables.

Statistical testing

The statistical framework of any research study is commonly based on testing the null hypothesis, wherein the results are deemed significant by comparing P values obtained from an experimental dataset to a predefined significance level (0.05 being the most popular choice). By definition, P value is the probability under the specified statistical model to obtain a statistical summary equal to or more extreme than the one computed from the data and can range from 0 to 1. P < 0.05 indicates that results are unlikely to be due to chance alone. Unfortunately, P value does not indicate the magnitude of the observed difference, which may also be desirable. An alternative and complementary approach is the use of confidence intervals (CI), which is a range of values calculated from the observed data, that is likely to contain the true value at a specified probability. The probability is chosen by the investigator, and it is set customarily at 95% (1– alpha error of 0.05). CI provides information that may be used to test hypotheses; additionally, they provide information related to the precision, power, sample size, and effect size.

This section contains the findings of the study, presented clearly and objectively. The results obtained using the descriptive and inferential statistical analyses (as mentioned in the methods section) should be described. The use of tables and figures, including graphical representation [ Table 4 ], is encouraged to improve the clarity;[ 14 ] however, the duplication of these data in the text should be avoided.

The discussion section presents the authors' interpretations of the obtained results. This section includes:

• A comparison of the study results with what is currently known, drawing similarities and differences
• Novel findings of the study that have added to the existing body of knowledge
• Caveats and limitations.

It is imperative that the key relevant references are cited in any research paper in the appropriate format which allows the readers to access the original source of the specified statement or evidence. A brief look at the reference list gives an overview of how well the indexed medical literature was searched for the purpose of writing the manuscript.

Overall assessment

After a careful assessment of the various sections of a research article, it is necessary to assess the relevance of the study findings to the present scenario and weigh the potential benefits and drawbacks of its application to the population. In this context, it is necessary that the integrity of the intervention be noted. This can be verified by assessing the factors such as adherence to the specified program, the exposure needed, quality of delivery, participant responsiveness, and potential contamination. This relates to the feasibility of applying the intervention to the community.

BIAS IN CLINICAL RESEARCH

Research articles are the media through which science is communicated, and it is necessary that we adhere to the basic principles of transparency and accuracy when communicating our findings. Any such trend or deviation from the truth in data collection, analysis, interpretation, or publication is called bias.[ 15 ] This may lead to erroneous conclusions, and hence, all scientists and clinicians must be aware of the bias and employ all possible measures to mitigate it.

The extent to which a study is free from bias defines its internal validity. Internal validity is different from the external validity and precision. The external validity of a study is about its generalizability or applicability (depends on the purpose of the study), while precision is the extent to which a study is free from random errors (depends on the number of participants). A study is irrelevant without internal validity even if it is applicable and precise.[ 16 ] A bias can be introduced at every step in the flow of a study [ Figure 2 ].

The various types of biases in clinical research include:

• Selection bias: This happens while recruiting patients. This may lead to the differences in the way patients are accepted or rejected for a trial and the way in which interventions are assigned to the individuals. We need to assess whether the study population is a true representative of the target population. Furthermore, when there is no or an inadequate sequence generation, it can result in the over-estimation of treatment effects compared to randomized trials.[ 14 ] This can be mitigated by using a process called randomization. Randomization is the process of assigning clinical trial participants to treatment groups, such that each participant has an equal chance of being assigned to a particular group. This process should be completely random (e.g., tossing a coin, using a computer program, and throwing dice). When the process is not exactly random (e.g., randomization by date of birth, odd-even numbers, alternation, registration date, etc.), there is a significant potential for a selection bias
• Allocation bias: This is a bias that sets in when the person responsible for the study also allocates the treatment. It is known that inadequate or unclear concealment of allocation can lead to an overestimation of the treatment effects.[ 17 ] Adequate allocation concealment helps in mitigating this bias. This can be done by sequentially numbering identical drug containers or through central allocation by a person not involved in study enrollment
• Confounding bias: Having an effect on the dependent and independent variables through a spurious association, confounding factors can introduce a significant bias. Hence, the baseline characteristics need to be similar in the groups being compared. Known confounders can be managed during the selection process by stratified randomization (in randomized trials) and matching (in observational studies) or during analysis by meta-regression.[ 18 ] However, the unknown confounders can be minimized only through randomization
• Performance bias: This is a bias that is introduced because of the knowledge about the intervention allocation in the patient, investigator, or outcome assessor. This results in ascertainment or recall bias (patient), reporting bias (investigator), and detection bias (outcome assessor), all of which can lead to an overestimation of the treatment effects.[ 17 ] This can be mitigated by blinding – a process in which the treatment allocation is hidden from the patient, investigator, and/or outcome assessor. However, it has to be noted that blinding may not be practical or possible in all kinds of clinical trials
• Method bias: In clinical trials, it is necessary that the outcomes be assessed and recorded using valid and reliable tools, the lack of which can introduce a method bias[ 19 ]
• Attrition bias: This is a bias that is introduced because of the systematic differences between the groups in the loss of participants from the study. It is necessary to describe the completeness of the outcomes including the exclusions (along with the reasons), loss to follow-up, and drop-outs from the analysis
• Other bias: This includes any important concerns about biases not covered in the other domains.

Trial registration

In the recent times, it has become an ethical as well as a regulatory requirement in most countries to register the clinical trials prospectively before the enrollment of the first subject. Registration of a clinical trial is defined as the publication of an internationally agreed upon set of information about the design, conduct, and administration of any clinical trial on a publicly accessible website managed by a registry conforming to international standards. Apart from improving the awareness and visibility of the study, registration ensures transparency in the conduct and reduces publication bias and selective reporting. Some of the common sites are the ClinicalTrials. gov run by the National Library of Medicine of the National Institutes of Health (), Clinical Trials Registry-India () run by the Indian Council of Medical Research, and the International Clinical Trials Registry Platform () run by the World Health Organization.

Tools for critical appraisal

Several tools have been developed to assess the transparency of the scientific research papers and the degree of congruence of the research question with the study in the context of the various sections listed above [ Table 5 ].

Ethical considerations

Bad ethics cannot produce good science. Therefore, all scientific research must follow the ethical principles laid out in the declaration of Helsinki. For clinical research, it is mandatory that team members be trained in good clinical practice, familiarize themselves with clinical research methodology, and follow standard operating procedures as prescribed. Although the regulatory framework and landscape may vary to a certain extent depending upon the country where the research work is conducted, it is the responsibility of the Institutional Review Boards/Institutional Ethics Committees to provide study oversight such that the safety, well-being, and rights of the participants are adequately protected.

CONCLUSIONS

Critical appraisal is the systematic examination of the research evidence reported in the scientific articles to assess their validity, reliability, and applicability before using their findings to inform decision-making. It should be considered as the first step to grade the quality of evidence.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

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Introduction

Critical analysis may or may not be a component of this particular course's evaluation, but it is an important component of any research process. 

Inquiry-based learning

Critical thinking is at the heart of scientific inquiry. A good scientist is one who never stops asking why things happen, or how things happen. Science makes progress when we find data that contradicts our current scientific ideas.

Scientific inquiry includes three key areas:

         1.  Identifying a problem and asking questions about that problem          2.  Selecting information to respond to the problem and evaluating it          3.  Drawing conclusions from the evidence

Hart, T. (2018, 18 October) Teaching critical thinking in science - the key to students' future success.  Brighter Thinking Blog . https://www.cambridge.org/us/education/blog/2018/10/18/teaching-critical-thinking-science-key-students-future-success/

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Critical thinking refers to deliberately scrutinizing and evaluating theories, concepts, or ideas using reasoned reflection and analysis. The act of thinking critically involves moving beyond simply understanding information, but going further by questioning its source, its production, and its presentation in order to expose potential bias or researcher subjectivity [i.e., evidence of being influenced by personal opinions and feelings rather than by external determinants ] . Applying critical thinking to investigating a research problem involves actively challenging basic assumptions and questioning the choices and potential motives underpinning how a study was designed and executed and how the author arrived at particular conclusions or recommended courses of action. Applying critical thinking to writing involves effectively synthesizing information and generating compelling arguments.

Hanscomb, Stuart. Critical Thinking: The Basics . 2nd edition. London: Routledge, 2023; Mintz, Steven. "How the Word "Critical" Came to Signify the Leading Edge of Cultural Analysis." Higher Ed Gamma Blog , Inside Higher Ed, February 13, 2024; Van Merriënboer, Jeroen JG and Paul A. Kirschner. Ten Steps to Complex Learning: A Systematic Approach to Four-component Instructional Design . New York: Routledge, 2017.

Thinking Critically

Applying Critical Thinking to Research and Writing

Professors like to use the term critical thinking; in fact, the idea of being a critical thinker permeates much of higher education writ large. In the classroom, the idea of thinking critically is often mentioned by professors when students ask how they should approach writing a research paper [other approaches your professor might mention include interdisciplinarity, compare and contrast, gendered perspective, global, etc.]. However, critical thinking is more than just an approach to research and writing. It is an acquired skill associated with becoming a complex learner capable of discerning important relationships among the elements of, as well as integrating multiple ways of understanding applied to, the research problem. Critical thinking is a lens through which you holistically interrogate a topic.

Given this, critical thinking encompasses a variety of inter-related connotations applied to writing a college-level research paper:

• Integrated and Multi-Dimensional . Critical thinking is not focused on any one element of research, but instead, is applied holistically throughout the process of identifying the research problem, reviewing the literature, applying methods of analysis, describing the results, discussing their implications, and, if appropriate, offering recommendations for further research. It permeates the entire research endeavor from contemplating what to write about to proofreading the final product.
• Humanizes the Research . Thinking critically can help humanize what is being studied by extending the scope of your analysis beyond the traditional boundaries of prior research. The scope of prior research, for example, could have involved only sampling homogeneous populations, only considered certain factors related to the investigation of a phenomenon, or was limited by the way the study was framed or contextualized. Critical thinking supports opportunities to think about incorporating the experiences of traditionally marginalized groups into the research, leading to a more inclusive and representative examination of the topic.
• Non-Linear . This refers to analyzing a research problem in ways that do not rely on sequential decision-making or rational forms of reasoning. Creative thinking relies on intuitive judgement, flexibility, and unconventional approaches to investigating complex phenomena in order to discover new insights, connections, and potential solutions . Thinking critically involves going back and modifying your thinking as new evidence emerges , perhaps multiple times throughout the research process, and then drawing conclusions from multiple perspectives as a result of questioning initial impressions about the topic.
• Normative . This refers to the idea that critical thinking can be used to challenge prior assumptions in ways that advocate for social justice, equity, and resilience, leading to research having a more transformative and expansive impact. In this respect, critical thinking can be viewed as a method for breaking away from dominant culture norms so as to produce research outcomes that illuminate previously hidden aspects of exploitation and injustice.
• Power Dynamics . Research in the social sciences often includes examining aspects of power and influence, focusing on how it operates, how it can be acquired, and how it can be maintained, thereby shaping social relations, organizations, institutions, and the production and maintenance of knowledge. Thinking critically can reveal how societal structures and forces perpetuate power in ways that marginalizes and oppresses specific groups or communities within the contexts of history , politics, economics, culture, and other factors.
• Reflection . A key component of critical thinking is practicing reflexivity; the act of turning ideas and concepts back onto yourself in order to reveal and clarify your own beliefs, assumptions, and perspectives. Being critically reflexive is important because it can reveal hidden biases you may have that could unintentionally influence how you interpret and validate information. The more reflexive you are, the better able and more comfortable you are in opening yourself up to new modes of understanding.
• Rigorous Questioning . Thinking critically is guided by asking questions that lead to addressing complex principles, theories, concepts, or problems more effectively, and in so doing, help distinguish what is known from from what is not known [or that may be hidden]. Critical thinking involves deliberately framing inquiries not only as hypotheses or axioms, but as a way to apply systematic, disciplined,  in-depth forms of questioning about the research problem and in relation to your positionality as a researcher.
• Social Change . An overarching goal of critical thinking applied to research and writing is to seek to identify and challenge forces of inequality, exploitation, oppression, and marinalization that contribute to maintaining the status quo within institutions of society. This can include, for example, schools, court system, businesses, government agencies, or religious organizations that have been created and maintained through certain ways of thinking within the dominant culture. Thinking critically fosters a sense of awareness and empathy about where social change is needed within the overall research process.

Critical thinking permeates the entire research and writing process. However, it applies in particular to the literature review and discussion sections of your paper. These two sections of a research paper most clearly reflect the external/internal duality of thinking critically.

In reviewing the literature, it is important to reflect upon specific aspects of a study, such as, 1) determining if the research design effectively establishes cause and effect relationships or provides insight into explaining why certain phenomena do or do not occur; 2) assessing whether the method of gathering data or information supports the objectives of your study; and, 3) evaluating if the assumptions used t o arrive at a specific conclusion are evidence-based and relevant to addressing the topic. Critically thinking applies to these elements of reviewing prior research by assessing how each source might perpetuate inequalities or hide the voices of others, thereby, limiting its applicability for understanding the scope of the problem and its impact throughout society.

Critical thinking applies to the discussion section of your paper because this is where you contemplate the results of your study and explain its significance in relation to addressing the research problem. Discussion involves more than just summarizing findings and describing outcomes. It includes deliberately considering the importance of the findings and providing reasoned explanations why your paper helps to fill a gap in the literature or expand knowledge and understanding in ways that inform practice. Critical thinking uses reflection to examine your own beliefs concerning the significance of the results in ways that avoid using biased judgment and decision making.

Using Questions to Enable Critical Thinking

At its most fundamental level, critical thinking is thinking about thinking in ways that improve the effectiveness of your ability to reason, analyze, synthesize, evaluate, and report information and, as a result, it advances deeper explorations of the topic*. From a practical standpoint, critical thinking is an act of introspective self-examination that involves formulating open-ended questions that inspire higher levels of reasoning about a research problem. The purpose of asking questions during the research process is to apply a framework of inquiry that challenges conventional assumptions, scrutinizes the evidence presented, determines how effectively arguments have been supported by that evidence, discerns patterns or trends in the findings, and helps imagine alternative outcomes if new or different factors were introduced.

Below are examples of questions that can stimulate critical thinking:

• Why is this a problem?
• Why does this research problem matter?
• Does the problem matter to everyone or just certain groups?
• How might your perspective change if you were on the other side of the argument?
• What patterns or connections can you see in the results?
• What key factors could have altered the outcomes described in the results?
• What evidence would be needed to support any alternative outcomes?
• Should there be any additional or alternative interpretations of the research outcomes?
• What is the explanation for the cause of an event or phenomenon?
• Why has a particular situation or condition arisen?
• Who will be impacted by the recommendations posed by the author?
• Who might be excluded from the author’s recommendations?
• When and how will you know that the recommendations have worked?
• In what ways can you apply knowledge from this study to new situations?
• What is another way to look at how the study was designed?
• How does the study contradict or confirm your understanding of the research problem?
• Do the outcomes of the study inform your own lived experiences?
• What do you think is the significance of this study and why?
• What are the overall strengths and weakness of this study?

NOTE: Being a critical thinker doesn't just happen. Casting a critical eye on how effectively others have studied a research problem requires developing self-confidence in your own abilities to actively engage with information, to consistently ask how and why questions about the research, and to deliberately analyze arguments and recommendations set forth by the author. Examining critically your own beliefs and feeling about your writing involves a willingness to be comfortable questioning yourself in a way that promotes a strong sense of self-awareness and introspection. Together, these outward and inward looking habits can help improve your critical thinking skills and inform how to effectively research and write a college-level research paper.

* Kharbach, Med. “Examples of Critical Thinking Questions for Students.” Educational Technology and Mobile Learning blog , Last Update: November 10, 2023.

Behar-Horenstein, Linda S., and Lian Niu. “Teaching Critical Thinking Skills in Higher Education: A Review of the Literature.” Journal of College Teaching and Learning 8 (February 2011): 25-41; Bayou, Yemeserach and Tamene Kitila. "Exploring Instructors’ Beliefs about and Practices in Promoting Students’ Critical Thinking Skills in Writing Classes." GIST–Education and Learning Research Journal 26 (2023): 123-154; “Bloom's Taxonomy.” Centre for Teaching Excellence. University of Waterloo; “Higher Order Thinking: Bloom’s Taxonomy.” The Learning Center. University of North Carolina; Butcher, Charity. "Using In-class Writing to Promote Critical Thinking and Application of Course Concepts." Journal of Political Science Education 18 (2022): 3-21; Krathwohl, David R. “A Revision of Bloom's Taxonomy: An Overview.” Theory into Practice 41 (Autumn 2002): 212-218; Loseke, Donileen R. Methodological Thinking: Basic Principles of Social Research Design. Thousand Oaks, CA: Sage, 2012; Mintz, Steven. "How the Word "Critical" Came to Signify the Leading Edge of Cultural Analysis." Higher Ed Gamma Blog , Inside Higher Ed, February 13, 2024; Hart, Claire et al. “Exploring Higher Education Students’ Critical Thinking Skills through Content Analysis.” Thinking Skills and Creativity 41 (September 2021): 100877; Lewis, Arthur and David Smith. "Defining Higher Order Thinking." Theory into Practice 32 (Summer 1993): 131-137; Sabrina, R., Emilda Sulasmi, and Mandra Saragih. "Student Critical Thinking Skills and Student Writing Ability: The Role of Teachers' Intellectual Skills and Student Learning." Cypriot Journal of Educational Sciences 17 (2022): 2493-2510. Suter, W. Newton. Introduction to Educational Research: A Critical Thinking Approach. 2nd edition. Thousand Oaks, CA: SAGE Publications, 2012; Van Merriënboer, Jeroen JG and Paul A. Kirschner. Ten Steps to Complex Learning: A Systematic Approach to Four-component Instructional Design. New York: Routledge, 2017; Vance, Charles M., et al. "Understanding and Measuring Linear–Nonlinear Thinking Style for Enhanced Management Education and Professional Practice." Academy of Management Learning and Education 6 (2007): 167-185; Yeh, Hui-Chin, Shih-hsien Yang, Jo Shan Fu, and Yen-Chen Shih. "Developing College Students’ Critical Thinking through Reflective Writing." Higher Education Research & Development 42 (2023): 244-259.

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What is Critical Research? | Definition, Examples & Methods

Introduction

What does critical research mean, what is an example of critical qualitative research, approaches to critical theory.

Critical research was created out of a need to examine power , inequities, and the resulting societal implications on the status quo in society. It is a necessary departure from traditional scientific research in that it looks beyond what is directly observable to analyze the social world and develop social theory from novel perspectives to address previous injustices. In this article, we'll look at what critical theory entails for qualitative research , as well as the different strands that make up critical research.

In specific terms, critical research examines the nature of power dynamics influencing the social world. More broadly, this has implications for understanding inequality and disparity across cleavages of race, gender, ethnicity, sexual orientation, and economic class, among other differences in identity.

While there are many different strands to critical research, there are a number of common characteristics that are shared by scholars of critical theory:

• Contextualization : Traditional research assumes a singular, almost absolutist approach to knowledge. In contrast, critical theory challenges the positivist outlook on scientific research and assumes a more sociocultural outlook to the social world. In adopting a more contextualized approach to any particular social phenomenon, scholars look to making propositions specific to different contexts rather than defining grand, unifying theories that explain socially constructed concepts regardless of individual or cultural circumstances.
• Subjectivity : Unlike more positivist approaches to research, critical research presupposes a lack of an ability to directly observe physical reality. Moreover, a researcher's perception is often confounded by culturally-reinforced presumptions such as stereotypes and other biases that privilege those in power. The possibility that the social world can be subjectively construed directly challenges assumptions of a positivist understanding of social phenomena. Instead, critical research encourages scholars and laypeople alike to consider the world from different points of view in order to identify problems and inequities that are otherwise invisible within traditional worldviews.
• Social change : Critical research is seldom interested in generating insights purely out of intellectual curiosity. Critical scholars tend to adopt a philosophy of social justice where research is aimed at benefiting marginalized or oppressed populations who lack the same opportunities and benefits that are otherwise granted to those in mainstream society. In this respect, research and analysis within a critical paradigm are merely preliminary steps in a process that appeals to institutions, stakeholders, and social activists to draw on actionable insights from the research and make tangible proposals for enacting change.
• Transformation : Similar to the imperative of social change, transformation deals with fundamentally altering contemporary paradigms. However, this aspect to critical research is more concerned with problematizing traditional perspectives of the social world and the phenomena within it, both from a layperson's point of view and from the view of traditional academic institutions that perpetuate mainstream scientific inquiry. Rather than simply acknowledge the subjective nature of the social world, critical research calls for fundamentally transforming perceptions and attitudes in a manner that views marginalized populations more equitably.

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One of the more famous studies to produce a critical analysis is the doll test first devised by Mamie Clark, then conducted with husband Kenneth Clark starting in the 1940s and replicated in later years. In the doll test, children were asked how they felt about dolls that were put in front of them. The children preferred to play with the dolls that looked white rather than the dolls that looked black, and had more positive views about the white-looking dolls. Children who were black also tended to share the same perception of black-looking dolls, which suggested that their surrounding environment - particularly the school system but more broadly the culture around them - profoundly impacted them by reinforcing negative stereotypes about racial minorities.

Critical theorists argue that such stereotypes, especially when perpetuated by institutions like education and mass media, further contribute to economic and social disparities when children of color experience exposure to negative attitudes about race and ethnicity. This novel research provided fundamental insights that led to the following real-world changes:

• Desegregation of schools : This research took place in the era where public schools in the United States were separated by race. The findings from the doll test helped make the case that institutionalized discrimination had effects on the educational and emotional development of children of color, ultimately leading to judicial rulings that contributed to school desegregation.
• Educational reforms : Subsequent discussions of racial stereotypes have helped to further promote initiatives for racial equity and equality in public education. While still undoubtedly controversial to this day, efforts to promote diversity training for teachers, multicultural curriculum development, and other policies to address racial disparities can be partly attributed to the findings of the doll test.
• Anti-discrimination policies : The findings from the doll test form a scientific basis for anti-discrimination frameworks for public policy, workplace organization, and other formal institutions. Where racism and equality might otherwise be abstract, potentially vague concepts, a scientific framework regarding discriminatory attitudes provides a language for discussing practical implications addressing racism.

Here are some of the various forms of critical research. Keep in mind that these approaches are not exclusive to each other, though they have their own distinct focus to shed light on specific issues relevant to the social sciences, nor are they exhaustive of the entire array of critical theory.

• Critical discourse analysis : Researchers who critically analyze communication look at how people exercise power through speech to manipulate or control others. This analytical method connects theories from linguistics, sociology, and anthropology to look at the power of language in constructing social reality.
• Critical ethnography : Ethnography is an all-encompassing approach to research aimed at capturing relationships, practices, and behaviors within any given context. Beyond a comprehensive examination of cultures, critical ethnographers use the resulting findings to advocate for social change.
• Critical methodology : Critical scholars may also look at how methods are used to construct scholars' epistemology about scientific knowledge and question approaches to science that emphasize objectivity to a fault. Critical methodology advocates for reflexivity and participatory research as a departure from traditional research methods.
• Critical race theory : Scholars engaged in critical race theory look at longstanding racial disparities to examine how institutions and power structures perpetuate racism and how people of color can challenge those structures from legal and advocacy standpoints in order to foster equity and equality.
• Decolonizing research : Focusing on the critique that most established research comes from a Western-based perspective, research on decolonization seeks to deconstruct established philosophical paradigms that disadvantage perspectives of indigenous populations, cultures from the Global South, and other communities that have long been ignored by mainstream scholarship.

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Journal articles are the academic's stock in trade, t he basic means of communicating research findings to an audience of one’s peers. That holds true across the disciplinary spectrum, so no matter where you land as a concentrator, you can expect to rely on them heavily. 

Regardless of the discipline, moreover,  journal articles perform an important knowledge-updating function .

Textbooks and handbooks and manuals will have a secondary function for chemists and physicists and biologists, of course. But in the sciences, articles are the standard and  preferred publication form. 

In the social sciences and humanities , where knowledge develops a little less rapidly or is driven less by issues of time-sensitivity , journal articles and books are more often used together.

Not all important and influential ideas warrant book-length studies, and some inquiry is just better suited to the size and scope and concentrated discussion that the article format offers.

Journal articles sometimes just present the most  appropriate  solution for communicating findings or making a convincing argument.  A 20-page article may perfectly fit a researcher's needs.  Sustaining that argument for 200 pages might be unnecessary -- or impossible.

The quality of a research article and the legitimacy of its findings are verified by other scholars, prior to publication, through a rigorous evaluation method called peer-review . This seal of approval by other scholars doesn't mean that an article is the best, or truest, or last word on a topic. If that were the case, research on lots of things would cease. Peer review simply means other experts believe the methods, the evidence, the conclusions of an article have met important standards of legitimacy, reliability, and intellectual honesty.

Searching the journal literature is part of being a responsible researcher at any level: professor, grad student, concentrator, first-year. Knowing why academic articles matter will help you make good decisions about what you find -- and what you choose to rely on in your work.

Think of journal articles as the way you tap into the ongoing scholarly conversation , as a way of testing the currency of  a finding, analysis, or argumentative position, and a way of bolstering the authority (or plausibility) of explanations you'll offer in the papers and projects you'll complete at Harvard. 

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Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China : Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention

• 1 Chinese Center for Disease Control and Prevention, Beijing, China
• Viewpoint Coronavirus Infections—More Than Just the Common Cold Catharine I. Paules, MD; Hilary D. Marston, MD, MPH; Anthony S. Fauci, MD JAMA
• Viewpoint The 2019 Novel Coronavirus and Challenges for Global Health Governance Alexandra L. Phelan, SJD, LLM; Rebecca Katz, PhD, MPH; Lawrence O. Gostin, JD JAMA
• Original Investigation Clinical Characteristics of Patients With 2019 Novel Coronavirus (2019-nCoV)–Infected Pneumonia in Wuhan, China Dawei Wang, MD; Bo Hu, MD; Chang Hu, MD; Fangfang Zhu, MD; Xing Liu, MD; Jing Zhang, MD; Binbin Wang, MD; Hui Xiang, MD; Zhenshun Cheng, MD; Yong Xiong, MD; Yan Zhao, MD; Yirong Li, MD; Xinghuan Wang, MD; Zhiyong Peng, MD JAMA
• Research Letter Clinical Characteristics of Patients With Novel Coronavirus (2019-nCoV) Infection Hospitalized in Beijing, China De Chang, MD, PhD; Minggui Lin, MD; Lai Wei, MD; Lixin Xie, MD; Guangfa Zhu, MD; Charles S. Dela Cruz, MD, PhD; Lokesh Sharma, PhD JAMA
• Viewpoint 2019 Novel Coronavirus—Important Information for Clinicians Carlos del Rio, MD; Preeti N. Malani, MD, MSJ JAMA
• Viewpoint Preparation for Possible Sustained Transmission of 2019 Novel Coronavirus David L. Swerdlow, MD; Lyn Finelli, DrPH, MS JAMA
• Viewpoint US Emergency Legal Responses to Novel Coronavirus—Balancing Public Health and Civil Liberties Lawrence O. Gostin, JD; James G. Hodge Jr, JD, LLM JAMA
• Research Letter Novel Coronavirus Infection in Hospitalized Infants Under 1 Year of Age in China Min Wei, MD; Jingping Yuan, MD, PhD; Yu Liu, PhD; Tao Fu, PhD; Xue Yu, MS; Zhi-Jiang Zhang, MD, PhD JAMA
• Viewpoint Preparing for the Most Critically Ill Patients With COVID-19: The Potential Role of ECMO Graeme MacLaren, MSc; Dale Fisher, MBBS; Daniel Brodie, MD JAMA
• Viewpoint COVID-19 in Singapore—Experience and Critical Issues That Require Attention and Action John E. L. Wong, MBBS; Yee Sin Leo, MBBS, MPH; Chorh Chuan Tan, MBBS, PhD JAMA
• Viewpoint COVID-19—New Insights on a Rapidly Changing Epidemic Carlos del Rio, MD; Preeti N. Malani, MD, MSJ JAMA
• Viewpoint Response to COVID-19 in Taiwan: Big Data Analytics, New Technology, and Proactive Testing C. Jason Wang, MD, PhD; Chun Y. Ng, MBA, MPH; Robert H. Brook, MD, ScD JAMA
• Viewpoint Priorities for the US Health Community Responding to COVID-19 Amesh A. Adalja, MD; Eric Toner, MD; Thomas V. Inglesby, MD JAMA
• Original Investigation Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore Barnaby Edward Young, MB, BChir; Sean Wei Xiang Ong, MBBS; Shirin Kalimuddin, MPH; Jenny G. Low, MPH; Seow Yen Tan, MBBS; Jiashen Loh, MBBS; Oon-Tek Ng, MPH; Kalisvar Marimuthu, MBBS; Li Wei Ang, Msc; Tze Minn Mak, PhD; Sok Kiang Lau, PhD; Danielle E. Anderson, PhD; Kian Sing Chan, MBBS; Thean Yen Tan, MBBCh; Tong Yong Ng, MBBS; Lin Cui, PhD; Zubaidah Said, MSc; Lalitha Kurupatham, MPH; Mark I-Cheng Chen, PhD; Monica Chan, BMBS; Shawn Vasoo, MBBS; Lin-Fa Wang, PhD; Boon Huan Tan, PhD; Raymond Tzer Pin Lin, MBBS; Vernon Jian Ming Lee, PhD; Yee-Sin Leo, MPH; David Chien Lye, MBBS; for the Singapore 2019 Novel Coronavirus Outbreak Research Team JAMA
• Research Letter RT-PCR Test Results in Patients Recovered From COVID-19 Lan Lan, MD; Dan Xu, MD; Guangming Ye, MD; Chen Xia, MS; Shaokang Wang, MS; Yirong Li, MD, PhD; Haibo Xu, MD, PhD JAMA
• Viewpoint Diagnostic Testing for the Novel Coronavirus Joshua M. Sharfstein, MD; Scott J. Becker, MS; Michelle M. Mello, JD, PhD JAMA
• Viewpoint Supporting the Health Care Workforce During the COVID-19 Global Epidemic James G. Adams, MD; Ron M. Walls, MD JAMA
• Viewpoint From Containment to Mitigation of COVID-19 in the US Stephen M. Parodi, MD; Vincent X. Liu, MD, MSc JAMA
• JAMA Insights Care for Critically Ill Patients With COVID-19 Srinivas Murthy, MD, CM, MHSc; Charles D. Gomersall, MBBS; Robert A. Fowler, MD, CM, MSc JAMA
• Viewpoint Critical Care and the COVID-19 Outbreak in Italy: Early Experience and Forecast Giacomo Grasselli, MD; Antonio Pesenti, MD; Maurizio Cecconi, MD JAMA
• Viewpoint Managing COVID-19 in Low- and Middle-Income Countries Joost Hopman, MD, PhD, DTMH; Benedetta Allegranzi, MD, DTMH; Shaheen Mehtar, MBBS, MD (Lon) JAMA
• Research Letter Detection of SARS-CoV-2 in Different Types of Clinical Specimens Wenling Wang, PhD; Yanli Xu, MD; Ruqin Gao, MD; Roujian Lu, MPH; Kai Han, BS; Guizhen Wu, MD; Wenjie Tan, MD, PhD JAMA
• Research Letter Ethics Committee Reviews of Research Applications in China for COVID-19 Hui Zhang, MBBS; Fengmin Shao, MD, PhD; Jianqin Gu, MD, PhD; Li Li, MBBS; Yuming Wang, MD, PhD JAMA
• Original Investigation Public Health Interventions and Epidemiology of the COVID-19 Outbreak in Wuhan, China An Pan, PhD; Li Liu, MD, PhD; Chaolong Wang, PhD; Huan Guo, MD, PhD; Xingjie Hao, PhD; Qi Wang, MD, PhD; Jiao Huang, PhD; Na He, PhD; Hongjie Yu, PhD; Xihong Lin, PhD; Sheng Wei, MD, PhD; Tangchun Wu, MD, PhD JAMA
• JAMA Insights Determining How Public Health Measures Might Be Slowing COVID-19 Using the Reproduction Number ( R t ) Thomas V. Inglesby, MD JAMA
• The JAMA Forum Prescribing Paid Sick Leave—An Important Tool for Primary Care During the Pandemic Benjamin D. Sommers, MD, PhD; Brett E. Coburn, JD JAMA
• Research Letter Time Course of a Second Outbreak of COVID-19 in Beijing, China, June-July 2020 Zunyou Wu, MD, PhD; Quanyi Wang, MD; Jing Zhao, MS; Peng Yang, MD; Jennifer M. McGoogan, PhD; Zijian Feng, MD, MS; Chun Huang, MD JAMA
• In the News Coronavirus Outbreak—an Evolving Global Health Emergency Joan Stephenson, PhD JAMA Health Forum

The Chinese Center for Disease Control and Prevention recently published the largest case series to date of coronavirus disease 2019 (COVID-19) in mainland China (72 314 cases, updated through February 11, 2020). 1 This Viewpoint summarizes key findings from this report and discusses emerging understanding of and lessons from the COVID-19 epidemic.

Epidemiologic Characteristics of the COVID-19 Outbreak

Among a total of 72 314 case records ( Box ), 44 672 were classified as confirmed cases of COVID-19 (62%; diagnosis based on positive viral nucleic acid test result on throat swab samples), 16 186 as suspected cases (22%; diagnosis based on symptoms and exposures only, no test was performed because testing capacity is insufficient to meet current needs), 10 567 as clinically diagnosed cases (15%; this designation is being used in Hubei Province only; in these cases, no test was performed but diagnosis was made based on symptoms, exposures, and presence of lung imaging features consistent with coronavirus pneumonia), and 889 as asymptomatic cases (1%; diagnosis by positive viral nucleic acid test result but lacking typical symptoms including fever, dry cough, and fatigue). 1

Key Findings From the Chinese Center for Disease Control and Prevention Report

72 314 Cases (as of February 11, 2020)

Confirmed cases: 44 672 (62%)

Suspected cases: 16 186 (22%)

Diagnosed cases: 10 567 (15%)

Asymptomatic cases: 889 (1%)

Age distribution (N = 44 672)

≥80 years: 3% (1408 cases)

30-79 years: 87% (38 680 cases)

20-29 years: 8% (3619 cases)

10-19 years: 1% (549 cases)

<10 years: 1% (416 cases)

Spectrum of disease (N = 44 415)

Mild: 81% (36 160 cases)

Severe: 14% (6168 cases)

Critical: 5% (2087 cases)

Case-fatality rate

2.3% (1023 of 44 672 confirmed cases)

14.8% in patients aged ≥80 years (208 of 1408)

8.0% in patients aged 70-79 years (312 of 3918)

49.0% in critical cases (1023 of 2087)

Health care personnel infected

3.8% (1716 of 44 672)

63% in Wuhan (1080 of 1716)

14.8% cases classified as severe or critical (247 of 1668)

Most case patients were 30 to 79 years of age (87%), 1% were aged 9 years or younger, 1% were aged 10 to 19 years, and 3% were age 80 years or older. Most cases were diagnosed in Hubei Province (75%) and most reported Wuhan-related exposures (86%; ie, Wuhan resident or visitor or close contact with Wuhan resident or visitor). Most cases were classified as mild (81%; ie, nonpneumonia and mild pneumonia). However, 14% were severe (ie, dyspnea, respiratory frequency ≥30/min, blood oxygen saturation ≤93%, partial pressure of arterial oxygen to fraction of inspired oxygen ratio <300, and/or lung infiltrates >50% within 24 to 48 hours), and 5% were critical (ie, respiratory failure, septic shock, and/or multiple organ dysfunction or failure) ( Box ). 1

The overall case-fatality rate (CFR) was 2.3% (1023 deaths among 44 672 confirmed cases). No deaths occurred in the group aged 9 years and younger, but cases in those aged 70 to 79 years had an 8.0% CFR and cases in those aged 80 years and older had a 14.8% CFR. No deaths were reported among mild and severe cases. The CFR was 49.0% among critical cases. CFR was elevated among those with preexisting comorbid conditions—10.5% for cardiovascular disease, 7.3% for diabetes, 6.3% for chronic respiratory disease, 6.0% for hypertension, and 5.6% for cancer. Among the 44 672 cases, a total of 1716 were health workers (3.8%), 1080 of whom were in Wuhan (63%). Overall, 14.8% of confirmed cases among health workers were classified as severe or critical and 5 deaths were observed. 1

COVID-19 rapidly spread from a single city to the entire country in just 30 days. The sheer speed of both the geographical expansion and the sudden increase in numbers of cases surprised and quickly overwhelmed health and public health services in China, particularly in Wuhan City and Hubei Province. Epidemic curves reflect what may be a mixed outbreak pattern, with early cases suggestive of a continuous common source, potentially zoonotic spillover at Huanan Seafood Wholesale Market, and later cases suggestive of a propagated source as the virus began to be transmitted from person to person ( Figure 1 ). 1

Daily numbers of confirmed cases are plotted by date of onset of symptoms (blue) and by date of diagnosis (orange). Because, on retrospective investigation, so few cases experienced illness in December, these cases are shown in the inset. The difference between the cases by date of symptom onset curve (blue) and the cases by date of diagnosis curve (orange) illustrates lag time between the start of illness and diagnosis of COVID-19 by viral nucleic acid testing. The graph's x-axis (dates from December 8, 2019, to February 11, 2020) is also used as a timeline of major milestones in the epidemic response. The first few cases of pneumonia of unknown etiology are shown in blue boxes on December 26 (n = 4) and 28-29 (n = 3). Most other cases that experienced onset of symptoms in December were only discovered when retrospectively investigated. Major epidemic response actions taken by the Chinese government are shown in brown boxes. The normally scheduled Lunar New Year national holiday is shown in light yellow, whereas the extended holiday during which attendance at school and work was prohibited (except for critical personnel such as health workers and police) is shown in dark yellow. This figure was adapted with permission. 1 CDC indicates Chinese Center for Disease Control and Prevention; HICWM, Hubei Integrated Chinese and Western Medicine; 2019-nCoV, 2019 novel coronavirus; WHO, World Health Organization.

Comparison of COVID-19 With SARS and MERS

The current COVID-19 outbreak is both similar and different to the prior severe acute respiratory syndrome (SARS; 2002-2003) and Middle East respiratory syndrome (MERS; 2012-ongoing) outbreaks. SARS was initiated by zoonotic transmission of a novel coronavirus (likely from bats via palm civets) in markets in Guangdong Province, China. MERS was also traced to zoonotic transmission of a novel coronavirus (likely from bats via dromedary camels) in Saudi Arabia. All 3 viral infections commonly present with fever and cough, which frequently lead to lower respiratory tract disease with poor clinical outcomes associated with older age and underlying health conditions. Confirmation of infection requires nucleic acid testing of respiratory tract samples (eg, throat swabs), but clinical diagnosis may be made based on symptoms, exposures, and chest imaging. Supportive care for patients is typically the standard protocol because no specific effective antiviral therapies have been identified.

The World Health Organization (WHO) declared the SARS outbreak contained on July 5, 2003. A total of 8096 SARS cases and 774 deaths across 29 countries were reported for an overall CFR of 9.6%. MERS is still not contained and is thus far responsible for 2494 confirmed cases and 858 deaths across 27 countries for a CFR of 34.4%. Despite much higher CFRs for SARS and MERS, COVID-19 has led to more total deaths due to the large number of cases. As of the end of February 18, 2020, China has reported 72 528 confirmed cases (98.9% of the global total) and 1870 deaths (99.8% of the global total). This translates to a current crude CFR of 2.6%. However, the total number of COVID-19 cases is likely higher due to inherent difficulties in identifying and counting mild and asymptomatic cases. Furthermore, the still-insufficient testing capacity for COVID-19 in China means that many suspected and clinically diagnosed cases are not yet counted in the denominator. 2 This uncertainty in the CFR may be reflected by the important difference between the CFR in Hubei (2.9%) compared with outside Hubei (0.4%). 1 , 2 Nevertheless, all CFRs still need to be interpreted with caution and more research is required.

Most secondary transmission of SARS and MERS occurred in the hospital setting. Transmission of COVID-19 is occurring in this context as well—3019 cases have been observed among health workers as of February 11, 2020 (of whom there have been 1716 confirmed cases and 5 deaths). 1 However, this is not a major means of COVID-19 spread. Rather, it appears that considerable transmission is occurring among close contacts. To date, 20 provinces outside of Hubei have reported 1183 case clusters, 88% of which contained 2 to 4 confirmed cases. Of note, 64% of clusters documented thus far have been within familial households (Chinese Center for Disease Control and Prevention presentation made to the WHO Assessment Team on February 16, 2020). Thus, although COVID-19 seems to be more transmissible than SARS and MERS, and many estimates of the COVID-19 reproductive number (R 0 ) have already been published, it is still too soon to develop an accurate R 0 estimate or to assess the dynamics of transmission. More research is needed in this area as well.

Response to the COVID-19 Epidemic

Since 2003, the Chinese government has improved its epidemic response capacity. Some of these efforts are evident in the response to COVID-19 ( Figure 2 ). For example, in the 2002-2003 SARS outbreak, 300 cases and 5 deaths already had occurred by the time China reported the outbreak to the WHO, whereas in the COVID-19 outbreak, only 27 cases and zero deaths had occurred when the WHO was notified (January 3, 2020) ( Figure 2 ). From the time of WHO notification, 2 months elapsed before SARS-CoV was identified compared with only 1 week from the time of WHO notification until 2019-nCoV was identified.

The timeline of events for the SARS outbreak (left) from first case to final worldwide containment. The timeline of events for the COVID-19 outbreak (right) from the onset of symptoms for the first case on December 8, 2019, to status on February 20, 2020. Over the course of the first 2 months, more than 70 000 cases have been confirmed and many more are suspected. WHO indicates World Health Organization.

a Identified later retrospectively.

The timing of the COVID-19 outbreak, prior to China’s annual Lunar New Year holiday, was an important factor as China considered how to respond to the outbreak. Culturally, this is the largest and most important holiday of the year. It is the expectation that people return to their family homes, which is the cause for the several billion person-trips made by residents and visitors during this time, mostly on crowded planes, trains, and buses. Knowing this meant each infected person could have numerous close contacts over a protracted time and across long distances, the government needed to quickly act. However, it was not only the speed of the government’s response, but also the magnitude of that response that were influenced by the impending holiday travel time. Knowing that specific treatment and prevention options, such as targeted antiviral drugs and vaccines, were not yet available for COVID-19, China focused on traditional public health outbreak response tactics—isolation, quarantine, social distancing, and community containment. 3 - 5

Identified case patients with COVID-19 were immediately isolated in designated wards in existing hospitals, and 2 new hospitals were rapidly built to isolate and care for the increasing numbers of cases in Wuhan and Hubei. People who had been in contact with COVID-19 cases were asked to quarantine themselves at home or were taken to special quarantine facilities, where they could be monitored for onset of symptoms. Enormous numbers of large gatherings were canceled, including all Lunar New Year celebrations, and traffic in Wuhan and in cities across Hubei was restricted and closely monitored. Virtually all transportation was subsequently restricted at a national level. All of these measures were instituted to achieve social distancing. In addition, an estimated 40 million to 60 million residents of Wuhan and 15 other surrounding cities within Hubei Province were subjected to community containment measures. Although these types of traditional outbreak response actions have been successfully used in the past, they have never been executed on such a large scale.

There have been some questions about whether these actions are reasonable and proportional responses to the outbreak. Some have argued that a number of these approaches may infringe on the civil liberties of citizens, and some of these measures have been referred to as “draconian.” However, it is not only individual rights that must be considered. The rights of those who are not infected, but at risk of infection, must be considered as well. Whether these approaches have been effective (eg, in terms of reduced infections and deaths averted), and whether these potential benefits have outweighed the costs (eg, economic losses), will be debated for years. 4 , 5

Importantly, another major goal of China’s current outbreak response activities is to help “buy time” for science to catch up before COVID-19 becomes too widespread. China must now focus on adjusting tactics and strategies as new evidence becomes available. 3 , 6 Much remains to be done and many questions remain unanswered. China is very grateful for the help it is receiving from the international scientific, health, and public health communities. The global society is more interconnected than ever, and emerging pathogens do not respect geopolitical boundaries. Proactive investment in public health infrastructure and capacity is crucial to effectively respond to epidemics like COVID-19, and it is critical to continue to improve international surveillance, cooperation, coordination, and communication about this major outbreak and to be even better prepared to respond to future new public health threats.

Corresponding Author: Zunyou Wu, MD, PhD, Chinese Center for Disease Control and Prevention, 155 Changbai Rd, Beijing 102206, China ( [email protected] ).

Published Online: February 24, 2020. doi:10.1001/jama.2020.2648

Conflict of Interest Disclosures: None reported.

Funding/Support: This work was supported by the National Health Commission of the People’s Republic of China (2018ZX10721102).

Role of the Funder/Sponsor: The funder had no role in the preparation, review, or approval of the manuscript, or the decision to submit the manuscript for publication.

Disclaimer: The opinions expressed herein reflect the collective views of the coauthors and do not necessarily represent the official position of the Chinese Center for Disease Control and Prevention.

Additional Contributions: We thank China CDC Weekly for its permission to re-create the epidemic curve with modifications.

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Wu Z , McGoogan JM. Characteristics of and Important Lessons From the Coronavirus Disease 2019 (COVID-19) Outbreak in China : Summary of a Report of 72 314 Cases From the Chinese Center for Disease Control and Prevention . JAMA. 2020;323(13):1239–1242. doi:10.1001/jama.2020.2648

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UAV Swarm Objectives: A Critical Analysis and Comprehensive Review

• Survey Article
• Published: 05 August 2024
• Volume 5 , article number  764 , ( 2024 )

Cite this article

• Preethika Ajay Kumar 1 ,
• Nandana Manoj 1 ,
• Neeraj Sudheer 1 ,
• Pranamya P. Bhat 1 ,
• Arti Arya 1 &
• Richa Sharma   ORCID: orcid.org/0000-0002-4539-7051 1  

Unmanned Aerial Vehicles (UAVs) are now used in multiple sectors for a vast array of purposes. These vehicles working in swarms can be used for reconnaissance, search and rescue, photography, and crop monitoring. In addition, the versatility of UAVs is highly utilized by several governments to play an integral role in the defense of a country. This survey paper provides a comprehensive study of the various advancements in the field of UAV swarms, such as Maximal Area Coverage, Path Planning, Intra-swarm collision avoidance, Obstacle avoidance, Formation of Swarms, Target tracking and Optimal resource allocation. An extensive study has been performed on each of these objectives, and an overview of the same has been consolidated from the year 2005–2024 in this survey. This study thoroughly examines the unique approaches used to accomplish the endeavors assigned to the UAV swarms. Moreover, the challenges and potential for future advancements in all the studies above have been highlighted. The research areas in the cutting-edge field of generative artificial intelligence have been clearly defined. This survey highlights significant advancements in UAV swarm technology over nearly two decades, focusing on key areas like coverage, path planning, and collision avoidance. It also outlines the challenges and future potential in integrating generative AI for further development.

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Preethika Ajay Kumar, Nandana Manoj, Neeraj Sudheer, Pranamya P. Bhat, Arti Arya & Richa Sharma

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Preethika Ajay Kumar: Conceptualization, Writing-Original Draft. Nandana Manoj: Conceptualization, Writing-Original Draft. Neeraj Sudheer: Conceptualization, Writing-Original Draft. Pranamya P Bhat: Conceptualization, Writing-Original Draft. Arti Arya: Writing-Reviewing and Editing, Supervision. Richa Sharma: Writing-Reviewing and Editing, Supervision.

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Kumar, P.A., Manoj, N., Sudheer, N. et al. UAV Swarm Objectives: A Critical Analysis and Comprehensive Review. SN COMPUT. SCI. 5 , 764 (2024). https://doi.org/10.1007/s42979-024-03156-x

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• Generative AI
• Maximal area coverage
• Path planning
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Understanding epistemic justice through inclusive research about intellectual disability and sexuality anonymized for peer review.

1. Introduction

2. epistemic agency and (in)justice.

Parliament really needs to pay attention to how people deal with disabilities, and remove the taboo from sexuality. They need to accept that not everyone just wants to share everything with their caregivers/healthcare professionals. Caregivers should live like us for a week. We need more agency. The ministry of health wants to know a lot about us, but we never see anything in return. Caregivers need to be trained better. The idea that sexuality doesn’t exist among us is ridiculous.

Tools [that are used for sex education] are often developed like ‘we did it together with people with an intellectual disability and now we’re done’, and then it turns out it doesn’t work (interviewee #2 in [anonymized source for peer review]).

3. Epistemic Justice and Relational Research

4. epistemic justice and future inclusive research, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Verbeek, L.; Koning, M.; Schippers, A. Understanding Epistemic Justice through Inclusive Research about Intellectual Disability and Sexuality Anonymized for Peer Review. Soc. Sci. 2024 , 13 , 408. https://doi.org/10.3390/socsci13080408

Verbeek L, Koning M, Schippers A. Understanding Epistemic Justice through Inclusive Research about Intellectual Disability and Sexuality Anonymized for Peer Review. Social Sciences . 2024; 13(8):408. https://doi.org/10.3390/socsci13080408

Verbeek, Lesley, Mark Koning, and Alice Schippers. 2024. "Understanding Epistemic Justice through Inclusive Research about Intellectual Disability and Sexuality Anonymized for Peer Review" Social Sciences 13, no. 8: 408. https://doi.org/10.3390/socsci13080408

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• DOI: 10.54097/5zdfbb51
• Corpus ID: 271471343

Evaluation Study of a New Insurance Model for Extreme Weather

• Haoqian Deng , Xiaoyang Huang
• Published in Highlights in Business… 22 July 2024
• Environmental Science
• Highlights in Business, Economics and Management

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NXT2 is the key player for nuclear RNA export in the human testis and critical for spermatogenesis

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In eukaryotes, the nucleocytoplasmic export of bulk poly(A) + -mRNAs through the nuclear pore complex is mediated by the ubiquitously expressed NXT1-NXF1 heterodimer. In humans, NXT1 has an X-chromosomal paralog, NXT2, which exhibits testis-enriched expression, suggesting a role in spermatogenesis. Here, we report the in vivo interaction of NXT2 with crucial components of the nuclear export machinery, including NXF1, the testis-specific NXF1 paralogs NXF2 and NXF3, and the nuclear pore complex proteins NUP93 and NUP214. Further, NXT2’s NTF2-like domain mediates binding to NXF2 and NXF3. By identifying infertile men with loss-of-function variants in NXT2 and NXF3 , we link the impaired NXT2-NXF activity to disturbed germ cell development. The predominant absence of germ cells in men with NXT2 deficiency indicates its critical function already during fetal or first steps of germ cell development. In contrast, loss of NXF3 affects later stages of spermatogenesis resulting in quantitatively and qualitatively impaired sperm production.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This work was carried out within the frame of the Deutsche Forschungsgemeinschaft (DFG, German Research Foundation) funded Clinical Research Unit Male Germ Cells (CRU326, project no. 329621271, grants to F.T. and N.N.).

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The Ethics Committees/Institutional Review Board of the University of Muenster (Ref. No. Muenster: 2012-555-f-S and 2010-578-f-S) gave ethical approval for this work. The Ethics Committee/Institutional Review Board of Nijmegen University gave ethical approval for this work (NL50495.091.14 version 5.0). The Ethics committee of Newcastle upon Tyne Hospitals NHS Foundation Trust (Newcastle, UK) gave ethical approval for this work (REC ref. 18/NE/0089).

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov . I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable.

Data Availability

Sequencing data of the MERGE study is available upon request to the corresponding author. Access to this data is limited for each case and specific consent of the respective samples. Sequencing data from the Nijmegen cohort have been deposited in the European Genome-phenome Archive(EGA) under the accession code EGAS00001005417 [ https://ega-archive.org/studies/EGAS00001005417 ] and will be made available upon reasonable request for academic use and within the limitations of the provided informed consent by the corresponding author upon acceptance. Every request will be reviewed by the Newcastle University Male Infertility Genomics Data Access Committee; the researcher will need to sign a data access agreement after approval. All other data supporting the findings of this study are available from the corresponding author upon reasonable request. AlphaFold2 structure accession code for NXT2 is AF-Q9NPJ8-F1 [ https://alphafold.ebi.ac.uk/entry/Q9NPJ8 ]. The mass spectrometry proteomics data have been deposited the ProteomeXchange Consortium via the PRIDE56 partner repository with the dataset identifier PXD052904 [ https://www.ebi.ac.uk/pride/ ] and will be released upon acceptance of the manuscript. Genetic variants identified in NXT2 and NXF3 were submitted to ClinVar (SCV005043065-SCV005043067; [ https://www.ncbi.nlm.nih.gov/clinvar/ ]). Source data are provided with this paper

https://www.ncbi.nlm.nih.gov/clinvar/

https://ega-archive.org/studies/EGAS00001005417

https://alphafold.ebi.ac.uk/entry/Q9NPJ8

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