Farzaneh Osati, MSc, PhD, ND

Boucher Institute of Naturopathic Medicine, Department of Research

200-435 Columbia Street
New Westminster, BC V3L 5N8 Canada
Phone: 604-777-9981 Fax: 604-777-9982

Email: fosati@binm.org

Brenda Leung, ND, MSc, (Corresponding Author)

Boucher Institute of Naturopathic Medicine, Department of Research
200-435 Columbia Street
New Westminster, BC V3L 5N8 Canada
Phone: 604-777-9981 Fax: 604-777-9982
Email: bleung@binm.org

Patricia Wolfe, ND

Boucher Institute of Naturopathic Medicine

200 – 435 Columbia Street,

New Westminster, B.C. V3L 5N8

Phone: 604-777-9981 ext.235| Fax: 604-777-9982

Email: pwolfe@binm.org

Sarah Beasleigh, ND

Boucher Institute of Naturopathic Medicine
200 – 435 Columbia Street,
New Westminster, B.C. V3L 5N8
Phone: 604-777-9981 ext.242 Fax: 604-777-9982
Email: sbeasleigh@binm.org

Karrin Fairman-Young, ND

Boucher Institute of Naturopathic Medicine

Phone: 604-777-9981 Ext. 241 Fax: 604-540-2879

Email: kfairmanyoung@binm.org

Chris Hergesheimer, BA, MA

Boucher Institute of Naturopathic Medicine, Department of Research
200-435 Columbia Street
New Westminster, BC V3L 5N8 Canada
Phone: 604-777-9981 Fax: 604-777-9982
Email: chergesheimer@binm.org

Number of Tables and Figures:  4

Abstract Word Count: 323

Word Count (without cover page, abstract, tables/figures): 4040

Abstract

Background:  Patient satisfaction has been considered an identifier of the quality of health care services in health settings. The more satisfied patients are with the care they are receiving, the more likely they return for follow up and the higher the retention rate.

Objectives: The purpose of this study was to evaluate the level of patient satisfaction in a teaching naturopathic clinic in Western Canada, and to determine factors affecting patient retention.

Methods: This was a cross-sectional study that assessed patient satisfaction using a modified version of the Patient Satisfaction Questionnaire with one group of patients, while patient retention was evaluated with a second group of patients who had not returned to the clinic in the last 6 months or more, via telephone interview using a standard set of questions.

Results: Of 122 questionnaires distributed, 98 questionnaires were completed and returned, giving a response rate of 80%. Of 36 eligible patients who agreed to be interviewed, 31 completed the interview, a response rate of 86%.  Patient satisfaction was high (>92%), mainly attributed to interpersonal manner (88%), communication with care provider (88%), and the technical quality of practitioners (80%). Cost of supplements (71%) and the technical quality of front desk staff (75%) were among the factors that received lower satisfaction ratings. While socio-demographic factors were not associated with patient satisfaction rate, there was a significant correlation (P<0.05) between patient satisfaction and health care quality. The results of the evaluation on patient retention found that ineffective treatments, distance, resolution of their health concern(s), lack of consistency in seeing the same clinician, and lack of extended health benefits were reasons patients cited for not returning to the clinic.

Conclusion: While our findings show a high level of patient satisfaction with the overall care received at the naturopathic teaching clinic, some aspects of the clinic services such as supplement cost, front desk staff training, and quality of treatment plans were associated with lower patient satisfaction and retention.


Introduction

Patient satisfaction has been seen as a validator of quality and efficiency of health care services 1-3. Whether in a conventional or alternative medicine setting, satisfied patients are important to a healthcare organization because they are more likely to continue with the services they received, comply with treatments, and as a result, achieve a more promising outcome, and recommend the healthcare service to others.

While the concept of patient satisfaction has not been as widely studied within alternative/ complementary medicine, it has gained more attention in recent years 4-7. A better understanding of patient’s satisfaction with the naturopathic services they receive is crucial for designing and adapting health services to the real needs of patient populations.  Among existing measurement tools to evaluate patient satisfaction, research surveys have been identified as valuable methods of gathering relevant information to assess quality of care as well as to ascertain ways to improve clinical practice 5,6.  While determination of which variables to include in an instrument that measures patient satisfaction is a difficult task, the most common items generated from the studies on patient satisfaction included:  respect for the patient 9,12; medical staff’s interactions with the patient, their knowledge, skills and availability, and their responsiveness 1,13-15 ; willingness of staff to help patients to make appropriate decision for their health issues 7; the clarity, adequacy and usefulness of the information provided by medical staff; and the relevance of information and services provided 6,10. These studies indicated that identifying approaches to improve services could help to achieve a higher quality of care, generate positive feedback from the clients, contribute to a better management of chronic conditions, and provide an increase in patient volume through returns and referrals.

The purpose of this study was to evaluate patient satisfaction and patient retention at a naturopathic teaching clinic to determine: 1) patients’ satisfaction level, as well as what patients like and dislike about their experience at the clinic, 2) reasons that might prevent patients coming back to the clinic.

Methodology

This was a cross-sectional study conducted at a naturopathic teaching clinic in New Westminster, British Columbia, Canada. This project consisted of two parts: 1) assessment of patient satisfaction using a self-administered questionnaire; 2) assessment of patients’ reasons for not returning to the clinic using telephone interviews.

Part 1: Patient Satisfaction

A: Questionnaire Development

The questionnaire included two sections. The first section was developed based on a standardized patient satisfaction questionnaire (RAND PSQ-50)16. The RAND questionnaire on patient satisfaction is one of the earliest developed validated questionnaires and includes taxonomies that define the major characteristics of health care providers and services that influence patient satisfaction. Questions from the original RAND questionnaire were modified to meet the objectives of this study and to reflect the nature of a teaching and naturopathic clinic.  This resulted in a 30-item questionnaire, and is referred to as the Modified PSQ-30 throughout this article. The items in this part included positively-worded and negatively-worded statements to control for acquiescent responding17. Responses to each item were given on a 5-point Likert Scale18, ranging from strongly agree to strongly disagree.

The second section of the questionnaire consisted of 13 socio-demographic questions and three open ended questions which asked patients for their input with regards to what they found positive and/ or negative about their experience, as well as their suggestions to improve services.

The questionnaire was pilot tested with 30 patients to test for the content and face validity. Patients’ feedback was incorporated into the final version of the questionnaire. The data from the pilot study was not incorporated into the final data analysis.

B: Participants

Using convenience sampling with consecutive eligible patients, those attending the teaching clinic were asked to complete the questionnaire if they were ≥ 19 years of age, willing to complete the survey, and had visited the clinic at least three times. Patients were excluded if they were students at the school or under age 19 years.

C: Data Collection

Data was collected during clinic hours from mid-November to mid-December 2011 and throughout January 2012. Eligible patients were given an information sheet explaining the purpose of the study and their rights to participate or refuse to take part in the study.  If the patients agreed to participate, they were provided with the questionnaire to complete any time before, during or after their clinic visit, and were asked to drop the completed questionnaire into a collection box at the reception desk. Surveys were treated as confidential documents and were kept in a locked cabinet.

D: Data Analysis

Completed questionnaires were coded and data was entered into an Excel spreadsheet. Descriptive statistics and bivariate analysis were conducted using the SPSS (version 16th) statistical program. Internal consistency was assessed by Cronbach’s alpha and correlations by Pearson correlation coefficient.

Questions in the first part of the patient satisfaction questionnaire (Modified PSQ-30) were categorized and scored based on the method as described by RAND 16. Briefly, these questions were grouped into one of eight dimensions of satisfaction with medical care, including:  general satisfaction, technical quality of health care practitioners (HCP), technical quality of front desk staff (FDS), interpersonal manner, communication, financial aspects, wait time, and convenience. Items were then grouped into seven categories related to satisfaction, including, General Satisfaction, Technical Quality of Health Care Providers, Technical Quality of Front Desk Staff, Interpersonal Manner, Communication, Financial Aspects, Wait time, and Convenience. Some of the Modified PSQ-30 items were worded so that agreement reflects satisfaction with medical care, whereas other questions were worded so that agreement reflects dissatisfaction with medical care. Following the RAND recommendation, questions left blank by respondents (missing data) were ignored when calculating category scores 16. In other words, each category score represents the average for all items in that category that were answered. The scores were then transformed linearly to a 0-100 possible range (percentages) to express level of satisfaction.

Part 2: Patient Retention

A: Methods

Patients were asked three main open-ended questions during a telephone interview that lasted 5 to 10 minutes. Patients were asked about their experience with the clinic, their personal reasons for not returning to the teaching clinic, and asked to provide suggestions for improvement of services at the clinic. Respondents were also asked whether they would recommend the clinic to a friend or family member and whether they would return to the teaching clinic. Prompt questions were used where answers were too broad or nonspecific.

B: Participants

Patients 19 years or older who had paid a fee for services, have had at least three visits in the past, and have not returned to the teaching clinic in the past six months or more were eligible for the interview.

C: Data Collection

A list of potential patients was generated by the front office staff. To ensure confidentiality,  prior to research staff contacting potential subjects, third year student assistants and fourth year student clinicians were asked to call patients on the list to get permission for an interview by the research coordinator using a standard script. Each patient who agreed to be interviewed was assigned a time and date at that patient’s convenience. Patients were contacted a maximum of ten times before they were considered “not reachable”.  At each interview, patients were provided with a brief summary of the purpose of the call using a standard script, and then each question was read clearly to the patient and responses were recorded in writing. Handwritten notes were transcribed verbatim into Microsoft Word (MS Word).  The telephone interviews started in mid-January 2012 and were completed by end of March 2012.

D: Data Analysis

The content of the patient telephone interviews was entered into MS Word. The responses were reviewed and common themes were extracted from patients’ responses.

Ethics Review

Advice on applying for ethics approval was sought, and was deemed not necessary as it was a survey of patients (past and present), but no intervention was given. Patients were provided with a detailed information sheet, and given the option to complete a questionnaire anonymously or partake in a short telephone interview, and consent was obtained prior to the patient taking part in either task.

Results

Part 1: Patient Satisfaction

A: Modified PSQ-30:

Of the 122 questionnaires distributed, 98 questionnaires were completed and returned, a response rate of 80%. Overall, the satisfaction ratings were high. Figure 1 shows the level of satisfaction in each of the eight multi-item categories. General satisfaction scored the highest (92%), followed by Interpersonal manner and Communication, both at 88%.  Financial aspects scored the lowest level of satisfaction (71.2%), following the technical quality of front desk staff (75%).

Figure 1:

When patients’ satisfaction scores in each category (middle line) were compared with the highest (diamond) and the lowest (triangle) possible satisfaction scores, respondents generally scored toward the higher end of the continuum (Figure 2).

Figure 2:

Cronbach’s alpha  test for internal consistency of responses found alpha coefficient = 0.84, indicating the high reliability of responses (data not shown). Furthermore, to assess the correlation between overall patient satisfaction and the items within Modified PSQ-30, the Pearson correlation coefficient (r) was calculated.  As shown in Figure 3 patient satisfaction was positively and in most cases were statistically significantly (*) (p<0.05) correlated across the Modified PSQ-30 categories.

Figure 3:


B: Demographic/ Descriptive Questions

Socio-demographic characteristics of the respondents are summarized in Table 1.  The response rate for each question ranged from 89% to 97%. In item one of patients’ overall satisfaction with care, the respondents stated they are either very satisfied (63%) or satisfied (34%), making up 97% of the patients.  More than one third of the participants (38%) were in the “free service” category; almost two thirds (64%) were < 50 years of age; more than 80% had postsecondary education or more; and almost 50% made >$30,000 a year. The findings also show that more than 50% of respondents were employed; 55% had extended health benefits; 53% utilized massage therapy as another alternative care; close to 50% were referred to the clinic by their family/friends, and the majority (55%) have been patients of the teaching clinic for more than six months.

When asked whether they would be back to the clinic for further care, 94.6% responded positively, and on the question whether they would recommend the clinic to family/friends, 94.6% responded “yes”. No statistically significant association was found between the demographic characteristics and levels of satisfaction.



Table 1: Demographic/Descriptive Distribution of Respondents

Visit Payment Categories Percent (n)* Naturopathic Coverage Percent (n)
Fee for Service 33 (31) Yes 40 (36)
Free Service 38.4 (36) No 48.9 (44)
Discounted Rate 28.6 (27) Not Sure 11 (10)
Age Range Percent (n) Means of Referral Percent (n)
19-49 64.2 (61) Family/Friends 48.4 (44)
50-69 32.6 (31) My doctor 2.2 (2)
70-89 3.2 (3) Internet 8.8 (8)
>90 0 Passing by 17.6 (16)
Level of Education Percent (n) Other 28.6 (26)
Grade School 0 Length of Being a Patient Percent (n)
High school/GED 16.8 (16) <1mnt 4.3 (4)
College/University 66.3 (63) 1-3mnts 23.6 (22)
Postgraduate 16.8 (16) 4-6mnts 17.2 (16)
Annual Income (CAD) Percent (n) 7-12mnts 8.6 (8)
< 30,000 52.9 (46) >1year 46.2 (43)
30,001-49,000 20.7 (18) Seeking other Alternative Care Percent (n)
50,000+ 26.4 (23) Chiropractic 34.9 (29)
Employment Status Percent (n) Physical Therapy 12 (10)
Employed 67.7 (63) TCM/Acupuncture 28.9 (24)
Un-employed 10.8 (10) Massage Therapy 53 (44)
Retired 12.9 (12) Homeopathy 9.6 (8)
Student 19.4 (18) Other 6 (5)
Insurance Status Percent (n) None 20.5 (17)
MSP only 86.8 (79) Possibility of Return to the Clinic Percent (n)
MSP+ Extended Health 57 (52) Yes 94.6 (87)
None 12.1 (11) Possibility of Recommending to others Percent (n)
Other 2.2 (2) Yes 94.6 (88)

* n= Frequency

 

C: Open Ended Questions

Eighty five percent of respondents answered question one, while 64% responded to question 2, and 39% answered question 3.  In response to the first question regarding the aspects of the clinic experience that patients liked the most, the dominant, interconnected themes revolved around 1) the creation of a therapeutic environment, and 2) the integral role of student-clinician attributes in fostering this environment. A number of identifying characteristics from the data informed the conceptual creation of these themes. The following quotes are some examples:

“How thorough the clinicians are. I really feel like I am being treated as a person not just another patient- It is a great benefit to me to receive the services I do….”

“Patience of the clinicians when dealing with my long term conditions… willingness to explore different treatments”

“Friendly atmosphere and always welcoming”

Responses to the second question, which asked patients what they didn’t like about the clinic, included a variable combination of “internal factors”, those beyond clinician attributes. The dominant themes in this case were related to high cost of supplements, compared to other clinics and health/food stores, long waiting times during the supervisory review, and quality of front desk staff.

The third question asked the respondents for suggestions for improvement. Suggestions included improvement in professionalism and efficiency of front desk staff, as well as more affordable supplements similar to those noted as responses to question two.

Part 2: Patient Retention (Telephone Interview)

An initial list of 150 patients fulfilling the above criteria was generated for contact. Of the 36 patients who agreed to be interviewed, 31 patients completed the interviews, a response rate of 86%. In response to the first question, which inquired about patient’s overall experience with the teaching clinic, the majority of interviewed patients expressed that they had “a great experience with the clinic”. Most of the interviewees referred to the clinicians as friendly, knowledgeable, and thorough, characteristics similar to those which fall under the theme of “clinician attributes” identified in question one of the survey above (patient satisfaction). One respondent commented:

“Very good- impressed with the students’ manner, thoroughness and professionalism. They were very friendly, respectful and helpful”. Another respondent expressed a similar sentiment saying: “Really good, great experience-I liked the clinician, very thorough, knowledgeable-Front desk staff was helpful too. Overall it was a good and fun experience.”

Another participant echoed similar sentiments:

“I am impressed with the quality of care by my current clinician. She is compassionate, sensitive and interested in my wellness. She is a good listener and often goes beyond the call of duty to find/research ways to deal with my health issues. I never feel rushed like I do when I go to my G.P…”

A few patients however, reported an unfavourable experience in the clinic, mostly with poor time management with regards to their appointment booking and supervisor consultation as well as commented on the lack of student clinician’s skill set and/or experience. The remainder of responses to the first question was mixed. These patients commented on a good experience overall despite some aspects of the clinic that displeased them, including supervisory and front desk staff concerns.

Responses to the second question, when asked reason (s) why they discontinued their visit to the clinic, included in order of importance: ineffective treatments, service cost, in particular the cost of supplements, distance to travel to the clinic, resolution of their health concern(s), lack of continuity and consistency in having the same clinician or supervisor, lack of extended health coverage, and rejection of patients with vehicle insurance claims.  Furthermore, one patient mentioned a lack of follow up by his/her clinician, and another perceived a lack of privacy and confidentiality to patient information as reasons for not returning to the clinic.

The last question queried the patients for their suggestions on how the clinic could improve their services. The most common responses included: more affordable supplements, having the same student clinician during their course of treatment, shorter waiting time in the treatment rooms, more advertisements and public appearance in community events. Additional suggestions such as better hours of operation, providing parking facilities, better supervision of FDS and their training especially on familiarity with insurance policies in naturopathic care coverage, were also captured in the interviews.  About one third of respondents did not provide a suggestion to the last question.

Overall, when the patients were asked whether they would return to the clinic and or recommend the clinic to others, about two thirds responded that they would come back if they needed naturopathic care. Furthermore, the vast majority of patients claimed that they have either recommended or will recommend the teaching clinic to others.

 

Discussion

This study examined patient’s level of satisfaction with naturopathic services at a teaching clinic, as well as explored reasons for former patients not returning to the clinic. The results of the survey and the interviews showed overall satisfaction with the care received.  Our results are similar to other studies, indicating that in spite of some deficiencies, the patients’ general satisfaction was high 19,20.

Patient Satisfaction: Clinicians’ Attributes

Our results from both survey and interview data indicate that “clinician attributes” were the main reasons for high level of satisfaction, as indicated by around 80% of the responders. Examples of these attributes are included: interpersonal manner, communication, technical quality and level of knowledge of health care provider. In agreement with other researchers’ findings 22,27,28  the nature of naturopathic medicine (in conjunction with the attributes of the providers) was the main reason indicated by our patients that they visited the teaching clinic and continued with the care.  In a conventional health setting, a physician’s diagnostic and instructions about treatment regimens are usually done with minimum  patient involvement and as such, the physicians spend less time explaining the nature of the illness and how the patient can self-manage it 29,30. In naturopathic care however, adequate time spent by our clinicians to explain the underlying factors affecting patient’s illness and how to involve the patients in self-management of their health problem was mentioned by a number of participants in our study. Similar findings are reported in other CAM studies as well 22, 28-30.

Patient satisfaction, however, is not simply a sole product of the “clinicians’ attributes”. It is also affected by the system in which care is provided. One study found that while physician care was most influential to patients’ satisfaction, the compassion, willingness to help and promptness of non-medical staff were next in importance 31.  In another study, patients who had remained in a practice for more than 15 years attributed their loyalty to their physician first and to the “team concept” second 32.  In terms of system-related factors, our study results from both questionnaire and interview identified financial aspects (cost of the supplements) and the technical/professional quality of front desk staff as major reasons for patients’ low satisfactory ratings and criticism. In this study, the high cost of supplements was repeatedly brought up by the patients as a barrier to continue regular visits with the clinic and the reason to drop out. These findings warrant a closer examination of this issue. In terms of the technical quality of front desk staff, literature indicated that training of non-medical staff may improve patient satisfaction in this regard. Suggested training techniques could range from “understanding exactly what the patient is asking, and using sympathetic phrases when communicating with the patients and family members”, to “maintaining high morale and avoiding treating the patients poorly before seeing their caregiver” 33,34. The nature of a busy teaching clinic may prevent proper communication of the front desk staff with the visiting patients, though a well-trained staff can minimize such an obstacle. As the front desk staff are the “face of the clinic” and the first point of contact with patients, it is important to support their role in the system.

Patient Retention

The patient retention part of this study was a significant piece that added valuable information from an inactive patients’ point of view. The results for this section came from the perspective of patients who had discontinued coming to the clinic for a variety of reasons. The results of the interview found that what participants termed “ineffective treatments”, distance, resolution of their health concern, lack of consistency in seeing the same clinician, and lack of extended health benefits contributed the most to patients not returning to the clinic.

Ineffective treatment might be explained by a number of factors including: early discontinuation of patient’s visits, lack of adherence to the treatment regimen, high expectations of patients beyond the skills and knowledge of student clinicians, and/or misdiagnosis. The extensive first visit would be the best opportunity for student clinicians to provide information on the philosophy and nature of the naturopathic treatment, role of the clinician and patient in his/her healthcare, and the treatment approaches with the expected cost and length of treatment. Patients with this clear vision would have a better idea to what to expect with their naturopathic service. But issues such as distance would be beyond the clinic’s ability to address.

Study Limitations and Future recommendations

There are a number of limitations associated with this study. The self selection by participants may bias the results as patients who chose to participate may differ from those who refused to participate.  This may result in the high level of satisfaction, as patients who were likely to be satisfied were more likely to participate. In addition, as with other survey studies where non-probability sampling technique is used, the results presented here cannot be generalized to all naturopathic clinics.  In regards to demographics, studies have shown that gender and ethnicity/race are some key demographical factors affecting the patients’ decision to seek naturopathic services, as more than 75% of the service users are females and more than 80% are Caucasian patients 25,35-37. In our study, the patient’s gender and ethnicity were omitted in the interest of survey length. In addition, about a third of the participants were staff, faculty and family members of those in some way associated with school, and another third were sponsored or received reduced fees. As such, some responses may be biased.

Recommendations

While the majority of the patients were satisfied with the services they received in the clinic under study, major concerns noted by the patients were the cost of the supplements and treatments. While not directly minimizing the actual cost of the supplements, one suggestion for transparency’s sake could be that the student clinicians provide an estimate of supplement cost beforehand. As indicated by a few patients, this estimate would potentially eliminate a patient’s sense of “moral responsibility” to purchase supplements which may be beyond their financial means. Another suggestion is that, if the patient is educated about the quality and the exclusivity of the prescribed supplements by their clinicians, the cost may be justified. In addition, the lack of the service coverage by national health programs, which could prevent follow up visits and continuity was noted on occasion.

In addition, the results of our study have provided the following suggestions to improve the patient satisfaction and retention rate at student naturopathic clinics both in Canada and farther afield.

1)    More structured and informative patient-clinician visits. A few patients mentioned that in their experience, being provided an itemized treatment plan for the upcoming visit gives them better insight and preparation for their follow up visits and results in more efficient therapy. Furthermore, to ensure patient compliance to the treatment protocol, i.e. taking their supplements and following other recommendations, clear communication is essential. Patients who adhere to their treatment plans are more likely to have better outcomes.  Clinician follow up with patients is essential to patient well-being and satisfaction. Providing the patients with information regarding their diagnosis, treatment options, what to expect from their treatment and what to do next is not only helpful for the patient but can also provide key details to their loved ones who are providing them with support at home.

2)    More training for front desk staff. As the front desk staff is the first (and last) line of contact for patients, their ability to communicate and connect with patients is integral to both satisfaction and potentially, patient retention. The front desk staff would benefit from set guidelines that instruct them how they could interact with patients prior to an appointment. For example, staff should make sure the patients know about the insurance policy specific to the clinic, understand their payment options (i.e.: credit card, debit, or cash), have directions to the clinic, complete any required forms that might be on the website prior to their visit or be directed to fill out the forms when in clinic, understand how long the visit is going to take including wait time in the reception area or exam room, and have clear information and directions when they leave the clinic. These guidelines would result in more organized and more efficient visits.

3)    Future evaluations of patient care. To ensure continual improvements to clinic services, continued assessment of patient satisfaction, the quality of care and services provided to patients, as well as monitoring patients who do not return, is recommended on a regular basis.

Conclusion

The results of this study show high levels of patient satisfaction with the naturopathic care they received, and continue to receive at the student teaching clinic. The findings indicate two main components that contribute to this satisfaction. These components were labelled “professionally competent clinicians” and “interpersonal relationship” with the staff (both clinical and administrative staff). Overall, the findings of this study highlighted patient satisfaction determinants that may be used as a measure of quality or effectiveness of the health care services in such settings. It might also assist to identify further research questions that remain to be answered in the area of patient satisfaction with naturopathic care, as well as, inform the students’ clinical experience and their clinical education requirements in dealing with patients and their health conditions.


Acknowledgment

The authors would like to thank the clinic staff for their cooperation during data collection, and third year students for their assistance in initial phone contact with clinic past patients. Special thanks to Maryam Ferdosian, third year naturopathic medical student, for her vital assistance in establishing a list of potential patients for patient retention interviews.  Sincere thanks to all the patients who took the time to complete the questionnaire and the interview process; the authors are grateful for their valuable input.

 

Funding sources

No external funding was obtained for this project.


Author Contributions

FO, BL, and PW provided substantial contributions to the conception and design of the project. SB and KF assisted with developing the methods for patient recruitment. FO and BL were responsible for developing the questionnaire and interview questions. FO was responsible for data collection, analysis and interpretation. FO and BL were involved in drafting the manuscript, and CH helped to review drafts of the manuscript. All authors have given final approval of the version to be published. All authors had full access to all of the data (including statistical reports and tables) in the study.


 

Conflict of Interest

The authors declare that there is no conflict of interest in terms of ownership of shares, consultancy, speaker’s honoraria or research grants from commercial companies or professional or governmental organizations with an interest in the topic of the paper.


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