Magister Psychologiae - MPsych / This study investigated the factor analytic structure of the Childhood Trauma Questionnaire(CTQ) in school-going adolescents in the greater Cape Town area. This questionnaire is a retrospective method, assessing childhood exposure to trauma in the form of emotional abuse,physical abuse, sexual abuse, emotional neglect and physical neglect (Bernstein & Fink,1998). The data used originated from a survey where several questionnaires including the Childhood Trauma Questionnaire were used to examine perceived stress and resilience in adolescence. The primary study found that there is extensive published research on trauma exposure in adolescents. However, the investigators found that there is a lack of research on actual perceived stress in the context of certain traumatic experiences. This study examined one of the questionnaires used in the primary study, the CTQ. The question of how the factors cluster in a sample of 631participants between the ages of 11 and 18 was answered by using exploratory factor analysis. Three factor analyses, using principal component analysis and Varimax rotation with Kaiser Normalisation were run. The three factor analyses are (i) the entire sample (adolescents, both trauma exposed and non trauma–exposed) (ii) the sample with moderate/severe childhood trauma and (iii) the sample with mild/no childhood trauma.The results of the current study revealed that for group one, five rotated factors were yielded that accounted for 59.22% of the variance among items, for group two, eight rotated factors was extracted that accounts for 62.47% of the variance among items and for group three, nine rotated factors which accounted for 65.38% of variance among the items was yielded.After conceptual analysis, it was found that only group two held to the five-factor stucture described in the CTQ's manual. This indicates that the severity of trauma exposure does affect the factor structure of the CTQ in this sample of school-going adolescents.

Introduction: Activity pacing is often advised as a coping strategy for managing chronic conditions (such as chronic low back pain, chronic widespread pain and chronic fatigue syndrome/myalgic encephalomyelitis). Despite anecdotal support for activity pacing, there is limited and conflicting research evidence regarding the efficacy of this strategy. Pacing has not been clearly operationalised, and existing descriptions are diverse and include strategies that encourage both increasing and decreasing activities. Moreover, there are few validated scales to measure activity pacing. Aim: To develop an activity pacing questionnaire (APQ) for adult patients with chronic pain and/or fatigue, and to determine its psychometric properties and acceptability. Methods: The study had a three stage mixed method design. Stage I, the Delphi technique involved a three-round consensus method to develop the initial items of the APQ using an expert panel of patients and clinicians. Stage II, the psychometric study, implemented a cross-sectional questionnaire design study, involving a large sample of patients with chronic conditions. This stage assessed the underlying pacing themes of the APQ using factor analysis, internal and test-retest reliability using Cronbach’s alpha and intraclass correlations (ICCs); and validity using correlations with validated measures of pain, fatigue, anxiety, depression, avoidance, and mental and physical function. Stage III, the acceptability study, explored patients’ opinions of the APQ, together with the concept of activity pacing via telephone interviews. The qualitative interview data were analysed using framework analysis. Results: Forty-two participants completed Stage I, the Delphi technique (4 patients, 3 nurses, 26 physiotherapists and 9 occupational therapists). The resulting APQ contained 38 questions involving a number of different facets, including breaking down tasks, gradually increasing activities and setting goals. Stage II, the psychometric study, was completed by 311 patients, of whom 69 were involved in a test-retest analysis. Following factor analysis, eight items were removed from the APQ. Five themes of pacing were identified in the 30-item APQ: Activity limitation, Activity planning, Activity progression, Activity consistency and Activity acceptance. These demonstrated satisfactory internal consistency, test-retest reliability, and construct validity against validated measures. Activity limitation, Activity planning, Activity progression and Activity acceptance correlated with worse symptoms, and Activity consistency correlated with improved symptoms. Sixteen patients participated in Stage III, the acceptability interviews. The APQ was found to be generally acceptable. Four activity behaviour typologies emerged through the interviews: Task avoidance, Task persistence, Task fluctuation (boom-bust) and Task modification (activity pacing).Conclusion: This is the first known study that has engaged both patients and clinicians in the development of an activity pacing questionnaire. Developed to be widely used across a heterogeneous group of patients with chronic pain and/or fatigue, the APQ is multifaceted, comprehensive and contains more themes of pacing than existing pacing subscales.

Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment seen within the outpatient orthopaedic clinic; therefore assessment and management of this common condition is of significant importance. Traditionally diagnosis has been made through detailed questioning; clinical examination and nerve conduction studies (NCS). There is however no true consensus as to the gold standard assessment of CTS and the use of NCS can confer additional costs and delay treatment. Previous studies have explored methods of predicting the presence of CTS including the clinician-administered Carpal Tunnel Questionnaire (CTQ) (Kamath and Stothard, 2003). The aim of the present studies is therefore to explore the versatility of the CTQ to see how a novel Patient-completed Version of the CTQ compares to the original Clinican-completed version. Psychometric properties of the questionnaire will be explored together the economic impact of integrating both versions within an orthopaedic care pathway. A further aim is to answer whether the CTQ more effective and cost-effective than NCS for patients referred to an orthopaedic clinic with suspected CTS. Method: 100 patients referred for further investigation of suspected CTS were assessed using parallel patient and clinician-completed versions of the CTQ and results were subsequently compared with those obtained from NCS. Item analysis explored each of the nine constructs of the questionnaire and the original scoring algorithm was validated using binary logistic regression and compared with alternative algorithms. Sensitivity and specificity of the questionnaire when compared to results of NCS was explored using Receiver Operating Characteristic (ROC) analyses. Inter-rater reliability was explored through Pearson’s correlation coefficient. Economic analysis and modelling was carried out to explore potential cost savings of use of the questionnaire rather than NCS for those with suspected CTS. Results demonstrated sensitivity of 92% and specificity of 54.67% (positive predictive value 95.35%) for the patient-completed questionnaire and 96% sensitivity with 70.67% specificity (98.15 positive predictive value) for the clinician-completed questionnaire when used to predict the outcome of NCS. Binary logistic regression confirmed the original scoring algorithm and a revised algorithm did not significantly improve sensitivity. Adoption of the clinician-completed CTQ would have screen out 54% of referrals for NCS, which in the case of the study site would have conferred cost savings of £73,305 per annum (base upon a referral rate of 750 per annum). The patient-completed CTQ in the current sample resulted in 43% of referrals with suspected CTS not requiring NCS to assist in diagnosis with a potential saving of £58,372.5 per annum. There are further considerations of the reduction in waiting times, which are explored further within the analysis. Conclusion: Economic evaluation is complex due to the variety of pathways adopted by different orthopaedic departments. While the results of the Patient-complete version of the CTQ may not be as convincing as the clinician completed the study does provide validation for its use and expands the versatility of this useful adjunct to the assessment of CTS. Both versions could potentially confer significant cost savings and reduce demands on investigative services, reducing waiting times and improving the patient journey in suspected CTS.

Self-report questionnaires are frequently used in health fields; however, subjective interpretation is often ignored. One way of assessing this is using techniques derived from cognitive interviewing. Of these, ‘think-aloud’, in which respondents speak their thoughts aloud as they complete a questionnaire, is the original paradigm. The thesis focusses on the use of ‘think-aloud’ methodology in the evaluation of questionnaires already in use in the health domain. The current thesis has been prepared in the format of scientific papers. Paper 1 is a systematic review (23 studies) of the appropriateness and usefulness of think-aloud techniques for evaluating health-related questionnaires. A descriptive account is provided of the aims of the studies reviewed; the justification for using think-aloud; populations studied; and methodology; an evaluative account depicts the usefulness of the think-aloud method in addressing researchers’ aims. Think-aloud was successfully used to address researchers’ aims and was effective at elucidating problems with questionnaires. Theoretical and clinical implications are discussed, and recommendations made for future research. Paper 2 is a cross-sectional observational study using think-aloud methods to examine the way in which people with End Stage Renal Disease (N=25) interpret and respond to the Emotion Regulation Questionnaire (ERQ). All questions were found to be problematic to some extent and reappraisal questions yielded the most problems. A tendency to deny or minimise negative emotions and present a positive self-image was also noted. Implications are discussed for use of the ERQ and replication with further samples suggested. Paper 3 is a critical appraisal of the above papers and provides personal reflections on the research process as a whole. The current thesis was a transition from a different study; amended due to time constraints. The journey is also outlined from this original study to the present thesis. Strengths and limitations are considered as well as areas for improvement and future research.

Patients undergoing surgery with unrecognized obstructive sleep apnea (OSA) are at greater risk of complications. Ninety percent of those affected in the United States remain undiagnosed. To improve identification, screening tools such as the STOP-Bang questionnaire (Chung et al. 2008), provide anesthesia providers a method of detecting undiagnosed OSA. The purpose of this study is to assess anesthesia providers' practice of preoperative screening for OSA. An email survey was conducted at a Level-III trauma center in Phoenix, Arizona. The survey consisted of a 13 question, 5-point Likert scale questionnaire. It was sent to 29 Certified Registered Nurse Anesthetists (CRNA). A total of 8 CRNA's responded. Respondents were either neutral or disagreed that current methods of OSA screening works well and generally agree that the STOP-Bang tool would provide an advantage over the current methods, accurately detect OSA, and inform their anesthetic plan over current methods. Respondents leaned towards strong agreement that improving the recognition of undiagnosed OSA is needed. However, they were generally neutral on agreement that the STOP-Bang is necessary at their facility. Respondents agreed that the STOP-Bang tool is easy to use and interpret. However, most agreed that integrating the tool would add complexity to the preanesthesia evaluation but they remained neutral on whether it would add significant time to this process. Respondents were neutral on their observations that the STOP-Bang tool would improve early detection of OSA or reduce perianesthesia complications. Just 25% of respondents reported being aware of the existence of the STOP-Bang tool and none reported having used it. In conclusion, this project demonstrates that some providers have not used the STOP-Bang screening tool to detect undiagnosed OSA, but agree this tool is preferred over their current method. Results from the survey brought insight to a potential quality improvement strategy related to improving the perianesthesia care of patients with undiagnosed OSA. Improving knowledge through dissemination of evidence illustrates the value of the STOP-Bang prior to piloting the tool. The rates of perioperative complications justify the implementation of perioperative strategies such as the STOP-Bang as a tool for anesthesia providers.