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Scientific Section |
Eastman Dental Hospital, London, UK
Address for correspondence: Fiona Siobhan Ryan, Eastman Dental Hospital, London, UK., Email: fionaryan25{at}hotmail.com
Received 16 December 2008; accepted 26 January 2009
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Abstract |
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 Top Abstract IntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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Design: Prospective qualitative study.
Setting: UCLH Foundation Trust.
Subjects and methods: The study was divided into two parts. The first phase involved developing a patient-centred questionnaire by carrying out semi-structured interviews with 10 orthognathic patients and 10 clinicians involved in orthognathic treatment provision. The transcripts from these interviews were then analysed using the N6© software package for qualitative research and thematic content analysis was carried out. As key themes and theories of patients’ perceptions of referral to a mental health professional began to emerge from the data, this directed the source of further interviews, allowing exploration and validation of all theories. When new themes ceased to arise, it was assumed that data saturation was reached, and no further interviews were undertaken. A questionnaire was then developed using the key themes from the interviews and this was piloted.
Results: Analysis of the interviews revealed that patient views could be divided into two main themes: service provision and perceptions of mental health professionals. These themes were incorporated into a questionnaire.
Conclusions: A new measure of patients’ perceptions of referral to a mental health professional is presented.
Key words: Qualitative, questionnaire, orthognathic, mental health professional
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Introduction |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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–4 As most orthognathic procedures involve aesthetic changes, and thus can be termed in some part ‘cosmetic’, researchers have also investigated whether orthognathic patients exhibit the same psychological characteristics as cosmetic surgery patients.
A number of studies have been undertaken to establish the psychological profile of patients seeking orthognathic treatment on the basis that understanding the psychological make-up of patients may help to identify expectations, motives and thus affect potential outcomes. Most authors have found that patients who seek orthognathic treatment are well-adjusted psychologically and do not exhibit the same psychological disturbances attributed to other cosmetic surgery patients.5–11
It has been stated that the majority of patients seeking cosmetic-type surgery are unhappy with some aspect of their appearance.12 Indeed, the primary motivating factor for undergoing treatment is often aesthetic improvement, but can involve numerous psychosocial factors.8 Orthognathic treatment can produce marked aesthetic changes which may lead to an improvement in emotional well-being and it may, therefore, also be considered as a form of psychological intervention.12
Patient satisfaction rates following orthognathic treatment are generally high and a review of the literature suggested that 92–100% of orthognathic patients are satisfied with the results.10 However, Cunningham and colleagues discovered that patients frequently underestimated the impact of the treatment with respect to overall ‘life changes’, general appearance and performance at work or college.13 The importance of understanding patients’ motives and their psychological status before embarking on treatment should not be underestimated when considering post-operative satisfaction. Kiyak and colleagues found that the impact of orthognathic surgery continues long after the patient leaves hospital.14 Therefore, good patient preparation and counselling are important in improving satisfaction and outcome.13,15 A truly multidisciplinary team approach including orthodontist, surgeon, psychiatrist or psychologist, and general dental and medical practitioner before, during and after treatment is essential in providing the highest standards of care for all patients.
A recent national survey in the United Kingdom revealed that many orthodontists are reluctant to refer orthognathic patients for psychological assessment due to fears that patients will react badly to the suggestion of referral, leading to a breakdown in the professional relationship.16 An extensive review of the literature revealed no information regarding patients’ feelings about being referred to a mental health professional from any specialty to either support or refute these findings. Therefore, the aim of this study was to understand how patients perceive these referrals by developing a questionnaire which could be used on a wider population.
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Subjects and methods |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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illustrates the structure of the project.
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Questionnaire development |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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Initially, the research team considered the main topics of interest to the research question. Two pilot interviews were then conducted to ensure the selected topics would yield constructive data. Following this process, semi-structured, open-ended, interviews were carried out with 10 orthognathic patients and 10 clinicians involved in orthognathic treatment provision. Interviews were conducted by one trained interviewer (FSR) in a non-clinical setting with no time constraints, using the list of topics from the topic guide developed by the research team. Topics were probed as necessary to ascertain all themes of interest regarding perceptions of referral to a mental health professional. All interviews were tape recorded and fully transcribed immediately afterwards.
Inclusion criteria for patients were that they were 16 years of age or older, non-syndromic, and could be either pre-treatment, or in active orthognathic treatment. Patients who had completed treatment and were in retention were excluded as, even though their viewpoint would have been interesting, it was considered that they may introduce recall bias. Purposive sampling was used to select potential participants on the basis that they had been offered orthognathic treatment. The sample was heterogenous in that it included some patients who had seen a mental health professional and others who had not. After six patients had been interviewed, no new data emerged and it was assumed that saturation had been reached and no important viewpoints were missed. However, despite the fact that no new data emerged, there is no guarantee that data saturation had been reached, thus a further four participants were interviewed. Of the 10 patients interviewed; four participants had not commenced active treatment, four were in the pre-surgical orthodontic stage, and two were in the post-surgical orthodontic stage.
Even though the current study was interested in patients’ perceptions of referrals, 10 clinicians were also interviewed at this stage of the research. The reason for this was that a previous study had revealed that clinicians involved in the provision of orthognathic treatment felt that patients view such referrals in a negative manner.16 It was, therefore, believed to be important to include clinicians’ viewpoints so that the patients completing the questionnaire could either agree or disagree. It would have been useful to analyse the clinicians and patient interviews separately and then compare them, however, this was outside the scope of the present study.
The clinicians who were interviewed were all actively involved in orthognathic treatment provision and included orthodontists, psychiatrists, and maxillofacial surgeons recruited from different hospitals in order to reduce selection bias.
Analysis of the interview data
The interviews were transcribed immediately after they were conducted and the data were examined, coded, and compared as they were collected and again once data collection was completed. This allowed additional concepts to be raised in future interviews.17 The interview transcripts were entered into the N6© software program for qualitative data analysis. The information from the interviews was also analysed by hand on a large flow diagram to ensure that all elements of the interviews had been fully explored. The data were considered on the basis of the main questions asked from the topic guide and then together under thematic headings as these emerged. Each question or theme was explored further to ascertain the key responses of both the clinicians and patients. When analysing the data, themes were explored by reading the relevant section from each interview together, for example, ‘the benefits of seeing a psychiatrist’, and getting a ‘feel’ for the opinions. It was not the aim of qualitative research to numerically establish exactly how many people shared a particular thought, but rather to identify a range of ideas. The data were analysed using a form of content analysis, where the broad themes expected to arise from the interviews were identified initially, and these were investigated with each interviewee.
Questionnaire development
Based on the information derived from analysis of the interviews (Table 1), a questionnaire was developed to include the most salient features (Appendix 1). Thirteen questions were developed, similar to those used in the interviews and based on the topic guide, but this time, a comprehensive list of possible answers was also included. Close-ended multichotomous questions were posed, the answers of which, for some, were mutually exclusive and required one answer from the list provided, and other questions allowed several responses. Colourful logos were incorporated on the front page to attract attention and instructions on how to complete the questions were in bold print or italics throughout the questionnaire. Once the first draft of the questionnaire was developed, a coding method for the questions and answers was devised and an SPSS© (statistics package, version 14, for Windows, SPSS Inc., Chicago, IL, USA, 1989–2006) spreadsheet was constructed to input and analyse the data generated.
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Assessing quality
Assessing rigour in qualitative research is just as important as in quantitative research, especially given the common criticism that qualitative results are anecdotal. The concepts of reliability and validity apply to qualitative research but should be assessed in different ways.18 The reliability of qualitative research may be enhanced by demonstrating a transparent pathway of data collection, analysis, and theory generation. This was achieved by minimising the possibility that the sample was biased, and by including actual quotes from the interviews so that it was apparent how the theories arose.
Other methods, more specific to qualitative data, are also available.19 The techniques of, reflexivity and fair dealing were used in this study. Reflexivity involves the researcher being aware of the way in which they may have influenced or shaped the results. During the interviews, the interviewer posed open non-leading questions and this technique was learned and practiced before conducting the interviews.
The technique of fair dealing was employed in this study where possible. Fair dealing is a term coined by Dingwall and involves a ‘commitment to even handedness’ by the researchers.20 This was achieved by including patients at different stages of treatment and also those who had exposure to a psychologist or psychiatrist in the past as well as those who had not. In addition, clinicians from different units around the UK, with different training backgrounds, and different access to a mental health professional within their unit were interviewed.
With regards to questionnaire development, validity assesses whether a tool measures what it purports to measure.21 Content and face validity were tested by both a panel of experts and the patients involved in the pilot study. Criterion validity could not be assessed, as there exists no ‘gold-standard’ measure to assess patients’ attitudes towards referrals to a mental health professional.
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Results |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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). On the following pages are examples of direct quotations from the interviews and following each quote are a letter and a number to identify each coded participant. ‘C’ indicates a clinician and ‘P’ indicates a patient.
Service provision
Who should make the referral?
The majority of clinicians and patients thought the referral should be made by someone on the orthognathic team, and most suggested that it should come from the orthodontist, as they tend to know the patient best and have most contact with them.
‘Probably the person they have had most contact with, usually the orthodontist.’(C3)
‘I think the referrals come for the team rather than an individual because orthognathic surgery is a team process between surgeons and orthodontists.’(C10)
Where patients would like to see the psychiatrist? The majority of clinicians and patients said they would prefer to be seen in the same place that they are seen for their orthodontic treatment or orthognathic clinics as it is familiar. A minority suggested being seen closer to home would be more convenient.
‘Here because you know the environment and you’re used to it.’(P9)
‘Better if it was somewhere more local, it might be a bit handier.’ (P3)
Would patients prefer to be seen alone with the psychiatrist or in a group with other patients? The majority of clinicians and patients felt it was more appropriate to be seen individually with the psychiatrist/psychologist, although most people also thought that there was a place for group sessions further along in treatment.
‘One on one, I’d like to speak to him by myself - it’s more private really.’(P2)
‘In a group so that you can get an idea of what they are going through.’ (P7)
Would patients object if referral was compulsory? All of the patients said they would agree to see the psychiatrist/psychologist if it was compulsory and it would not put them off having treatment.
‘Oh no, I’d just go with the flow.’(P2)
Perceptions of a mental health professional
What is a psychiatrist/psychologist?
The patients thought of a psychiatrist/psychologist as someone who is there to help, and a number of interviewees (including clinicians and patients) mentioned the word ‘help’ at some point in the interview. Other concepts that arose were that a psychiatrist/psychologist is someone to talk to, and someone who understands you. Interestingly, the definitions given by people were surprisingly similar. No negative comments were made with respect to defining what a psychiatrist/psychologist does, or is.
‘A psychiatrist is somebody you talk to.’ (P1)
‘Someone who helps you and answers your questions and helps with your problems.’ (P4)
‘...arranges different disorders. A psychologist is someone who studies the mind.’ (P10)
Benefits of seeing a mental health professional? This question was posed to both patients and clinicians. The majority of the benefits were patient-centred; the clinicians also felt that the outcome of treatment may be more successful if patients had seen a psychiatrist or psychologist. Both groups felt that seeing a psychiatrist or psychologist would help prepare patients psychologically for the treatment.
‘I think it would give you an idea of what you’re going to face in the future with the changes.’ (P5)
‘In this day and age of ‘plastic fantastic’ people are aspiring to be more perfect and I think if people get that side of their head sorted, their expectations won’t be so high, because I think you can put too much emphasis on what the surgery will do for you. It won’t change your life. I’ll be honest; I did fall into that trap. I did think it was going to do other things and it suddenly was going to change and I was going to be really popular and none of those things happened, nothing changed, you’re still you on the inside.’ (P10)
Drawbacks of seeing a mental health professional? Many of the drawbacks listed by the clinicians were what they assumed that patients would perceive as drawbacks, such as being stigmatized or labelled. However, the majority of patients did not mention these and, if they did, they mentioned it as something other people may perceive, but that they themselves did not see as being an issue.
‘I suppose some people might worry about being labelled as "mad".’ (P2)
‘..there’s the expense of another visit to the hospital, because for some patients they live a long way away and there’s the time off work as well as the actual travelling expenses.’ (C13)
‘Can lead to problems with your relationship with the patient. If you are not able to help them yourself that might undermine their confidence in you.’ (C17)
Feelings about being referred? Most patients said they would not mind, or they would be happy, to be referred to a psychiatrist/psychologist. Two patients admitted that they were afraid that the psychiatrist might prevent them getting treatment or tell them they did not need it.
‘My honest reaction was ‘oh no, they’re going to find a reason why I can’t have it done, I’ve got to have this done, I’ve got to have this done.’ (P10)
‘The way that it was put forward to me was don’t be concerned by the term psychiatrist, you may have preconceived ideas, all it is a talk and if you have any concerns put them forward and he or she will be able to help you. I didn’t think oh my God a psychiatrist. I was happy to do it.’ (P7)
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Results of the pilot study |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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Participants
Six patients participated in the pilot study, all were female, and the mean age was 23.8 years (range 17–41 years), one patient was post-surgery, and the other five pre-surgery. One patient had seen a psychiatrist as part of their treatment.
Time to complete
The time taken to complete the questionnaire ranged between 4 minutes and 22 seconds and 8 minutes 46 seconds, the mean time was 6 minutes and 22 seconds.
Readability
Two patients queried what was meant by question 5 (What do you understand by the term psychiatrist/psychologist?) and wording changes were made following this. The response section for question 8 was also adjusted. The questionnaire was tested for readability using the Flesch software package available through Microsoft Word© software. The Flesch Reading Ease Score was 61.4 and the Flesch-Kincaid Grade Level was 6.5, which were both within the acceptable range.22,23 The Fog Index (FI) was also calculated for the questionnaire, as this is a measure more commonly used in the UK. The FI was 15, which indicates easy readability.
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Discussion |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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Importantly, a questionnaire can be also used again by other researchers to assess other populations. However, there are disadvantages to using self-report questionnaires to collect information, the most frequent being that they can be intrinsically manipulative.24 These criticisms are often based on a lack of knowledge of the process involved in constructing a questionnaire as there are ways of limiting these drawbacks in the early design stage. Qualitative methods can be used as the first stage in questionnaire development to reduce researcher bias, and to ensure that all points of view are included and that the measure is patient-centred.25 By using this approach in the current study, the validity of the questionnaire developed was improved by basing it on the opinions of the population to be studied. The interviews raised several interesting points. In response to question 1 (what do you understand by the term psychiatrist or psychologist?) patients thought of a psychiatrist/psychologist predominantly as someone who is there to help, and this word came up frequently. In fact, the majority of interviewees (clinicians and patients) mentioned the word ‘help’ at some point in the interview. No negative comments were made with respect to defining what a psychiatrist/psychologist does, or is.
In response to question 2, patients suggested that orthognathic treatment would lead to physical, emotional, and mental changes and they felt that patients were referred to see a psychiatrist/psychologist to explain these changes and to help the individual come to terms with them. While this is commonly recognized as being the case by clinicians involved in orthognathic care provision, the fact that patients seem to recognize this is encouraging.26 Regardless of whether or not they had seen a mental health professional as part of their treatment, patients seemed to have a good insight into the fact that orthognathic treatment may affect them psychologically as well as physically, and recognized the fact that they needed to be prepared for this.
Clinicians felt that there were many benefits in patients seeing a mental health specialist; they felt that the psychiatry/psychology service could act as both a screening service to identify patients who require additional support during treatment, and a means of educating and preparing patients as to what to expect. Patients saw the psychiatrist less as someone to screen patients and more as someone who is there to explain the treatment and the outcomes in more depth. They also felt that it would be good to talk to someone ‘neutral’ and objective who was not directly involved in their care.
Where drawbacks were discussed, a number of the clinicians were concerned that patients would be worried about being stigmatized or labelled. However, importantly, most patients did not mention these issues and, if they did, they mentioned them as something other people may perceive, but did not concern them directly. Almost all of the clinicians were worried about suggesting referral to a psychiatrist or psychologist as they thought this might lead to a breakdown in trust and in their relationship with the patient. Interestingly, of the clinicians who had access to psychological services, few actually had experience of a patient refusing to see a psychiatrist/psychologist or reacting badly to the suggestion.
The limitations of this study should be borne in mind when considering the results or applying these to other study populations. Selection bias may have been introduced as patients who were interviewed had already decided to proceed with treatment this may limit generalizability. The results may also have been influenced by the method of data collection as patients may be slightly intimidated by the one-to-one contact with the researcher, and it is possible they may give answers they think are expected of them. While every effort was made to remain neutral and objective using open and non-leading questions, it is accepted that an interviewer may influence participants during the interview process. Interestingly, some schools of thought consider the relationship between the interviewer and interviewee an essential part of qualitative research.27 In addition, using patients at different stages of treatment may introduce confounding variables but it was felt importantly to include patients at different time points and not just at the start of treatment. Ideally, these subgroups could be analysed separately, but the small numbers involved precluded this at this stage. Also, including patients who had seen a psychiatrist in the past means that their responses may well be influenced by this experience. However, this study attempts to mimic real-life situations and their view-points were thought to be important to include.
From the detailed analysis of the information yielded from interviews with this cohort of patients, it would seem that clinicians may underestimate patients’ knowledge of the scope of orthognathic treatment, and erroneously assume patients will not accept the psychological aspect of their care. Of course, there will be patients who do object to seeing a mental health professional but such patients appear to be in the minority and are potentially the very ones who would benefit from psychological intervention. A blanket approach of denying all patients the service because of the reactions of some should not be adopted, and indeed goes against current national guidelines proposed by the Royal College of Psychiatrists, in collaboration with The Royal College of Surgeons of England (1997).28 A questionnaire survey of a larger cohort of patients is presented in article 2 of this series.
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Conclusions |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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Contributors |
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TopAbstractIntroductionSubjects and methodsQuestionnaire developmentResultsResults of the pilot...DiscussionConclusionsContributorsReferences |
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Acknowledgments |
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References |
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2 Jacobson WE, Edgerton MT, Meyer E, Canter A, Slaughter R. Psychiatric evaluation of male patients seeking cosmetic surgery. Plast Reconstr Surg 1960; 20: 356–72.
3 Reich J. The surgery of appearance: psychological and related aspects. Med J Aust 1969; 2: 5–13.[Medline]
4 Wictorin L, Hillerstrom K, Sorensen S. Biological and psychosocial factors in patients with malformations of the jaws: twelve months after maxillofacial surgery. Scand J Plast Reconstr Surg 1969; 3: 138–43.[CrossRef][Medline]
5 Cunningham SJ, Gilthorpe MS, Hunt NP. Are orthognathic patients different? Eur J Orthod 2000; 22: 195–202.
6 Kiyak HA, Hohl T, Sherrick P, West RA, McNeill RW, Butcher F. Sex differences in motives for, and outcomes of, orthognathic surgery. J Oral Surg 1981; 39: 757–64.[Medline]
7 Kiyak HA, McNeill RW, West RA, Hohl T, Butcher F, Sherrick P. Predicting psychologic responses to orthognathic surgery. J Oral Surg 1982; 40: 150–55.
8 Heldt L, Haffke EA, Davis LF. The psychological and social aspects of orthognathic treatment. Am J Orthod 1982; 82 : 318–28.[CrossRef][Medline]
9 Auerbach SM, Meredith J, Alexander JM, Mercuri LG, Brophy C. Psychological factors in adjustment to orthognathic surgery. J Oral Maxillofac Surg 1984; 42: 435–40.[CrossRef][Medline]
10 Flanary CM, Barnwell GM, van Sickels JE, Littlefield JH, Rugh AL. Impact of orthognathic surgery on normal and abnormal personality dimensions: a two-year follow up study of 61 patients. Am J Orthod Dentofac Orthop 1990; 98 : 313–22.[Medline]
11 Stirling J, Latchford G, Morris DO, Kindelan J, Spencer RJ, Bekker HL. Elective orthognathic treatment decision making: a survey of patient reasons and experiences. J Orthod 2007; 34: 113–27.
12 Sarwer DB, Pertschuk MJ, Wadden TA, Whitaker LA. Psychological investigations of cosmetic surgery patients: a look back and a look ahead. Plast Reconstr Surg 1998; 101: 1136–42.[Medline]
13 Cunningham SJ, Crean SJ, Hunt NP, Harris M. Preparation, perceptions, and problems: A long-term follow-up study of orthognathic surgery. Int J Adult Orthod Orthognath Surg 1996; 11: 41–47.
14 Kiyak, HA, McNeill, West RA. The emotional impact of orthognathic surgery and conventional orthodontics. Am J Orthod 1985; 88: 225–34.
15 Peterson LJ, Topazian RG. The preoperative interview and psychological evaluation of the orthognathic surgery patient. J Oral Surg 1974; 32: 583–88.[Medline]
16 Juggins KJ, Feinmann C, Shute J, Cunningham SJ. Psychological support for orthognathic patients- what do orthodontists want? J Orthod 2006; 33: 107–15.
17 Glaser B, Strauss A. The discovery of grounded theory: Strategies for qualitative research. London: Wiedenfield and Nicolson, 1967.
18 Ritchie J, Lewis J. Qualitative Research Practice: A Guide for Social Science Students and Researchers, 3rd Edn. London: SAGE Publications Ltd, 2003.
19 Mays N, Pope C. Assessing quality in qualitative research. Br Med J 2000; 320: 50–52.
20 Murphy E, Dingwall R. Qualitative Methods and Health Policy Research, 2nd Edn. New York: Aldine Transaction, 2003.
21 Streiner DL, Norman GR. Health Measurement Scales: A Practical Guide to Their Development and Use, 2nd Edn. Oxford: Oxford University Press, 1995.
22 Flesch R. A new readability yardstick. J Appl Psychol 1948; 32 : 221–33.[CrossRef][Medline]
23 Kincaid, JP, Fishburne RP Jr, Rogers RL, Chissom BS. Derivation of new readability formulas (Automated Readability Index, Fog Count and Flesch Reading Ease Formula) for Navy enlisted personnel. Research Branch Report p8-7S5. Millington, TN: Naval Technical Training, US Naval Air Station, 1975.
24 de Vaus DA. Surveys in Social Research, 4th Edn. London: UCL Press Limited, University College London, 1996.
25 Williams A. How to...Write and analyse a questionnaire. J Orthod 2003; 30: 245–52.
26 Pruzinsky T, Edgerton MT. Body image change in cosmetic plastic surgery. In Cash TF, Pruzinsky T (eds.) Body images: development, deviance, and change. New York: Guilford Press, 1990, 217–36.
27 Douglass B, Moustakas C. ‘Heuristic inquiry: the internal search to know’. J Humanist Psychol 1985; 25: 39–55.
28 Report of the working party on the psychological care of surgical patients. Council report 55. London: Royal College of Surgeons of England and Royal College of Psychiatrists, 1997.
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