Uploaded by Pól Mac Aoidh

Systematic Review

Systematic review
Patient education has a positive effect in patients with a
stoma: a systematic review
A. K. Danielsen, J. Burcharth and J. Rosenberg
Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev, Denmark
Received 6 September 2012; accepted 23 November 2012; Accepted Article online 7 March 2013
Aim A systematic review was performed to assess
whether education of patients having stoma formation
improves quality of life and whether it is cost effective.
Method A literature search was performed to identify
studies on the structured education of ostomates and
outcome using the following databases: MEDLINE,
Cinahl, Embase, Cochrane and PsycInfo. Inclusion criteria were: clinical studies reporting effects of educational interventions in relation to patients with a stoma.
Commentaries or studies not testing an intervention
were excluded.
Results Seven articles met the inclusion criteria of having rigorously evaluated an educational programme
related to living with a stoma. The programmes were
organized in different ways and had explored various
interventions. The results showed an increase in healthrelated quality of life, as measured using a stoma quality
of life instrument (P = 0.00001) and with the Short
Form 36 (SF-36) (P = 0.000–0.006), an increase in
proficiency in management of the stoma (P = 0.0005),
Stoma creation has an impact on everyday life, often
with several physical, mental and social impairments
[1,2]. The patient may feel overwhelmed by having a
serious disease and may find it difficult to understand
the implications of a stoma [3]. It is known that
health-related quality of life (HRQoL) is negatively
affected by a stoma [4], and that positive adjustment is
related to its acceptance [5]. Most articles on stomas
describe the technique and other technical factors from
the surgical point of view, but there is little published
Correspondence to: Anne Kjærgaard Danielsen Ph.d., RN, MA(ed), MClN,
Department of Surgery, Herlev Hospital, University of Copenhagen, Herlev
Ringvej 75, DK-2730 Herlev, Denmark.
E-mail: anne.k.danielsen@gmail.com
two studies pointed to a reduction in postoperative hospital stay (8 days vs 10 days, P = 0.029; and 8 days vs
14 days, P = 0.17), a significant reduction in cost in
the intervention group ($US 8570.54) compared with
the control group ($US 7396.90) as well as higher
effectiveness scores in the intervention group (166.89)
compared with the control group (110.98), a significant
rise in stoma-related knowledge (P = 0.0000) and an
increase in psychosocial adjustment (P = 0.000).
Conclusion Structured patient education aimed at
patients’ psychosocial needs seems to have a positive
effect on quality of life as well as on cost. The interventions may be performed before, during or after hospital
stay. However, the available data come from few studies
with differences in interventions and in study design,
and further studies are therefore needed before a final
conclusion can be drawn.
Keywords Systematic review, patient education, stoma
creation, patient-reported outcome, cost efficiency
evidence on the value of preoperative or postoperative
patient education [6–9].
It has been suggested that patient education might
reduce the length of hospital stay, the frequency of postoperative complications and the frequency of hospital
readmissions [5,10]. A qualitative analysis of patient
interviews pointed to common themes indicating that
patients found both individual and group-based discussions to be helpful [11]. Much professional effort has
been put into patient education and training [12–14]. A
review focusing on preoperative patient education and
stoma site marking found insufficient evidence to conclude that preoperative education improves postoperative
outcome [15]. However, this considered the literature
only up to 2006.
Despite the accumulating evidence for the positive
effect of patient education, little is known about best
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283
A. K. Danielsen et al.
practice in the education of patients with a stoma. For
this reason we performed a systematic review of the
literature regarding education in patients having a stoma
Positive effects of education in patients with stoma
discharge [23,24]; time until proficiency in managing
the stoma [23]; readmissions [24]; and scores related to
symptoms of depression, knowledge about the stoma,
self-efficacy and psychosocial adjustment [25,26]
(Table 1).
Statistical analysis
Study design
A systematic review including both qualitative and quantitative studies was performed. We applied a method of
joint synthesis based on narrative summaries of all
included studies on a study level [16]. The literature was
searched from 1950 to July 2012 using MEDLINE, Cinahl, Embase, Cochrane and PsycInfo databases, with the
following MESH search terms: patient education and ostomy. Related search terms in all fields were: ileostomy, ileostomies, colostomy, colostomies, stoma*, ostomy,
effect, efficiency, impact. Search terms were combined
with the Boolean operators AND and OR to identify relevant studies. We applied a filter to include studies in English, German and Danish, and only retrieved papers that
were accessible as full-text. Furthermore, we searched the
references to supply the systematic search [17].
Study selection criteria
The searches were carried out by the first author, and
the first and second authors then discussed them. To
identify the most fitting inclusion and exclusion criteria,
we used the pico-question for quantitative studies [18]:
P(opulation): patients, admitted for stoma creation; I
(ntervention): teaching sessions; C(omparison): before/
after stoma creation; and O(utcome).
Following removal of duplicate reports, we excluded
papers based on title and abstract (Fig. 1). Then, eligible articles were reviewed independently by two reviewers, and consensus was obtained through discussion.
Only studies that evaluated patient educational activities
incorporating stoma creation were included. Descriptive
reports were excluded.
The studies were analysed separately, and as they did
not have comparable outcomes or interventions it was
not possible for us to carry out any statistical synthesis
of the effects [27]. The results were presented as narrative summaries of the outcomes of the included studies.
However, we present all the statistical results that were
reported in the individual studies.
Forty-five papers were identified, of which 38 were
excluded (Fig. 1) (14 were duplicates, four were not
retrievable, eight did not focus on the correct theme
and 12 were rejected because they were descriptive
papers or commentaries). Seven studies (Table 1) met
the inclusion criteria of having rigorously evaluated an
educational programme related to stoma creation
(Table 2). Only quantitative studies were included in
the review, as the literature search did not retrieve any
articles reporting studies with a qualitative design.
Health-related quality of life
HRQoL was assessed in two single-group interventional
studies [20,21]. The first study included 50 patients,
who participated in six sessions with a total of 16 h of
teaching over a time period of 6 weeks [21]. Patients
were assessed three times, and the results showed a
positive and statistically significant difference between
the first and the third assessments (P = 0.0001).
The second study included 72 patients who participated
in all-day education sessions performed every
4–6 months. The results revealed a statistically significant
improvement in HRQol in those having education.
Data extraction
Data extraction from relevant studies was performed by
two reviewers, and data quality was scored by both
reviewers according to PRISMA guidelines [19].
PRISMA stands for Preferred Reporting Items for
Systematic Reviews and Meta-Analyses. It is an
evidence-based minimum set of items for reporting in
systematic reviews and meta-analyses. The outcomes
were presented as health-related quality of life (HRQoL)
[20,21]; cost effectiveness [22]; days until postoperative
Assessment of self-care knowledge, self-care attitude,
self-care behaviour, self-efficacy, self-management and
psychosocial adjustment
Self-care knowledge was explored in two studies
[25,26]. The first study, a randomized controlled trial
(RCT), assessed self-care knowledge, self-care attitude
and self-care behaviour relating to life after stoma
creation and included 102 participants (46 in the experimental group and 56 in the control group) enrolled
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283
A. K. Danielsen et al.
Positive effects of education in patients with stoma
Records identified through
database searching
(n = 44)
Additional records identified
through other sources
(n = 1)
Records after duplicates removed
(n = 31)
Records screened
(n = 31)
Records excluded : not the
right focus
(n = 8)
Records not retrievable
(n = 4)
Full-text articles assessed
for eligibility
(n = 19)
Full-text articles excluded:
no clinical intervention:
(n = 12)
Studies included in review
(n = 7)
Figure 1 Flow diagram of the study design [21].
shortly after stoma creation whilst still in hospital [25].
The assessment of knowledge was performed at baseline
and 1 week after discharge. The questionnaires were
based on Likert or binominal scales, and showed a significant difference between groups in scores related to
self-care knowledge (P < 0.001), self-care attitudes
(P < 0.001) and self-care behaviour (P < 0.001).
The second study, a single-group interventional
study, exploring the effect of patient education performed by expert patients (patients with a stoma who
were trained to become expert patient-teachers as part
of the study) assessed knowledge related to stoma care,
self-efficacy, self-management and psychosocial adjustment [26]. Ninety-two participants were included,
whereof 11 were trained as expert patients. The assessment of the stoma-related knowledge showed a significant increase in six domains of knowledge (P = 0.001),
and self-efficacy and self-management (P = 0.001).
Time until discharge and proficiency in stoma
A single-group study explored the influence of preoperative patient education on time to discharge after stoma
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283
A. K. Danielsen et al.
Positive effects of education in patients with stoma
Table 1 Outcome of included studies.
Olsen, 2011 [21]
Descriptive study. Examining effect of
patient education within 2 years after
stoma creation. Patients with a stoma
as a result of benign disease were primarily
included. Median age 59 years
HRQoL measured at baseline, and after
module 5 and module 6. A significant
difference was found between
measurements (P < 0.0001)
Chaudhri et al., 2005 [23]
RCT studying the effects of intensive
community-based preoperative stoma
education compared with current
practice of postoperative stoma
education and an economic assessment.
Forty-two patients (21 in each group)
underwent stoma creation. Median
age = 64 (range, 36–82) years
Proficiency in management of the stoma
was obtained after 5.5 (range, 2–10)
days in the study group compared with
9 (range, 4–10) days in the control
group (P = 0.0005). Postoperative
hospital stay was 8 days for the study
group compared with 10 days for the
control group (P = 0.029). Fewer
unplanned visits post discharge was
seen in the intervention group
Lo et al., 2011 [25]
Single-blinded RCT to test the
effectiveness of a multimedia education
programme. One hundred and two
patients with a stoma were
randomized, with 46 people placed in
the intervention group and 56 in the
control group
The self-care knowledge scale, the self-care
attitudes scale and the self-care behaviour
scale revealed statistically significant
differences in the experimental group
as well as in the control group
Lo et al., 2010 [22]
RCT evaluating whether multimedia
learning programmes were more or less
cost effective than conventional education
service programmes. The participants
were 54 patients after stoma creation
(27 subjects in each group)
The cost-effectiveness analysis was measured
including stoma care knowledge, attitudes
and behaviours, and found a reduction in
costs between the intervention group ($US
7396.90) and the control group
($US 8570.54)
Cheng et al., 2012 [26]
Precourse postcourse single-group
comparison to study the short-term
effects of an EPP. Ninety-two eligible
patients with stomas (up to 3 years
after stoma creation) volunteered to
participate, whereof 11 were trained to
be expert patients and the remaining
81 participated in the 3-week EPP
The total level of stoma-related
knowledge increased significantly in
the 66 tested domains. The total score
for stoma care self-efficacy increased
significantly, but the domain of social
life and other items did not improve.
The total score for stoma self-management
increased. All three domains of psychosocial
adjustment increased
Younis et al., 2011 [24]
Comparison of retrospective data before
introduction of the ERP compared
with prospective data from patients
enrolled in the ERP. The aim of the
study was to explore the length of
hospital stay. One hundred and twenty
patients undergoing elective anterior
resection were compared with 120
patients adhering to an ERP
Baseline data did not differ. Average
length of hospital stay was 14 (range,
7–25) days before introduction of the
ERP. This was reduced to 8 (range,
3–17) days in the patients following
the ERP (P = 0.17). Hospital
discharge was postponed in 21 patients
because of a delay in independent
stoma management via the ERP,
compared with only one patient
experiencing such a delay after the
introduction of the ERP
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283
A. K. Danielsen et al.
Positive effects of education in patients with stoma
Table 1 (Continued).
Altuntas et al., 2012 [20]
Precourse postcourse single-group
intervention study to evaluate the
effects of patient education on
HRQoL. Seventy-two patients were
enrolled after creation of ileostomy,
colostomy or urostomy. The median
period between surgery and education
was 7 (range, 1–75) months
There was a statistically significant
improvement in all eight profile scores
except for the vitality score
EPP, expert patient programme; ERP, enhanced recovery programme; HRQoL, health-related quality of life; RCT, randomized
clinical trial.
creation [24]. The results pointed at a significant reduction in the average length of hospital stay after introduction of the enhanced recovery programme. The
readmission rates for the control and the experimental
groups were 2.5% and 0%, respectively, and no patient
was readmitted for stoma-related issues.
An RCT [23] explored the effect of preoperative
training in the homes of the patients, which was aimed
at reducing postoperative hospital stay. Forty-two
patients (21 in each group) were included, all undergoing elective colorectal resection with formation of a
temporary or a permanent stoma. Postoperative assessment of stoma proficiency was performed by the ward
nursing staff using a specific checklist. The median duration of hospital stay was 8 (range, 5–15) days for the
study group and 10 (range, 4–16) days for the control
group (P = 0.029). Following discharge there were
fewer unplanned readmissions in the study group than
in the control group, although this was not statistically
significant. Furthermore, the time until proficiency in
the management of the stoma was 5.5 (range, 2–10)
days in the study group compared with 9 (range, 4–10)
days in the control group (P = 0.005).
Cost-effectiveness analysis
An RCT assessed the cost effectiveness of patient education when using a multimedia educational programme
compared with a conventional education service
programme [22]. Fifty-four patients admitted to the
surgical ward for any kind of stoma formation, were
included and randomized. The cost-effectiveness analysis was based on measurements of self-care knowledge,
self-care attitude and self-care behaviour that were
related to calculation of the direct costs tied to the provision of healthcare. The cost-effectiveness calculation
showed that patients in the intervention group received
a more effective and less costly intervention, pointing at
a reduction in costs in the experimental group ($US
7396.90) compared with the control group ($US
Although few studies are available, this review supports that patient education may have a positive effect
on HRQoL, on length of stay after stoma creation,
on level of knowledge and self-efficacy, and on cost
effectiveness. In two of the included studies, participants admitted for patient education had had a stoma
for a median of 5.5 months [21] and 7 months [20],
respectively. These are relatively long periods of time,
and in both studies some of the participants had had
their stoma for 2 years or longer. Therefore, it should
be considered that an increase in HRQoL may simply
occur with time following stoma creation [4]. However, in this study it was not possible to identify the
unique scores of patients with a stoma of the gastrointestinal tract.
The curriculum of the different patient-education
programmes focused on issues that are generally recognized to be important to patients after stoma creation,
such as handling the stoma, different kinds of appliance,
nutrition and sexuality [5,28–30]. In addition, the
educational activities were organized in groups, which
enabled participants to share their experiences and to
learn from each other. This may be central as stoma
creation can lead to feelings of stigma [31] and
self-imposed isolation [32]. Organizing teaching sessions with lay teachers is not common. When introducing lay teachers to people with chronic disease, a
significant improvement regarding self-efficacy and
health status was shown [33]. However, to date, the
issue of introducing lay teachers or peer teachers in
patient education aimed at patients with a recently created stoma has not been fully explored.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283
Youinisk et al., 2011 [26]
Altunas et al., 2012 [22]
Chaudhri et al. 2005 [25]
Olsen, 2011 [23]
CN, colorectal specialist nurse. Lay teacher: teachers who have a stoma themselves.
Lo et al., 2011 [27]
Lo et al., 2010 [24]
Cheng et al., 2012 [28]
of stoma bag
and drink
by the researcher
stoma care
as teachers
stoma model
including emptying
about stoma care,
for patients with
social impact,
daily activities, food
answers’ session
Hand out of
by CN teaching
life, work-life,
‘Questions and
including: family
care, stoma-related
Formal education
including: stoma
Positive effects of education in patients with stoma
Handbook about
Table 2 Interventions applied in the included studies.
Formal education
Home visits
A. K. Danielsen et al.
The cost-effectiveness results from the included
study [22] demonstrated a positive outcome in relation
to cost effectiveness. Nevertheless, it should be questioned whether the measurement instrument was sufficiently sensitive to detect real differences between the
baseline assessment and a second assessment only
1 week later. Moreover, a cost-efficiency ratio should
preferably be assessed after a long study period, as
there is some evidence that the beneficial effects may
last for only a short period of time [34]. More studies
on the cost effectiveness of patient education are obviously needed.
The length of hospital stay was explored in two studies [23,24]. In the first, description of the assessment of
proficiency in stoma management was stated and was
closely related to the time of discharge [23]. Furthermore, interventions applied before admission to hospital
were reported, and the results indicated a shorter time
to discharge. The second study [24], exploring the
effect of patient education, did not specify how patients’
competence was assessed. Moreover, the risk of
selection bias should be discussed as the patients in the
control group had open surgery, whereas those in the
intervention group had laparoscopic surgery. Self-care
knowledge, self-care-attitude, self-care behaviour,
self-efficacy, self-management and psychosocial adjustment [22,25,26] were separately assessed in three studies. Although these reported several interesting
outcomes, it might not be justified to assume that such
a gain in knowledge would automatically imply a
change in behaviour and the ability to use the knowledge [35]. Nevertheless, the published data are favourable for patients participating in educational activities.
The limitations of this systematic review lie primarily
in the heterogeneity and scarcity of data published on
patient education and stoma creation. When reviewing
the literature, we initially intended to perform the
search for studies reporting different methodologies
[36,37]. Unfortunately, however, no studies using qualitative research methodology were found. Moreover,
some of the included studies lacked rigour and did not
clearly report the interventions and the outcome measurement scales. Therefore, it was not possible to perform any kind of statistical synthesis, as the studies
varied in design, method and outcome measures.
Despite these difficulties, the results indicated a positive impact of patient education on patients’ psychosocial needs, self-care knowledge, attitude and behaviour.
They also suggested that education may be cost
effective. Sessions by a specialist in the patient’s home
before surgery may reduce the length of hospital stay,
although, as this conclusion is based on only a few
studies with large differences in interventions and
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283
Positive effects of education in patients with stoma
design, the effect of patient education in patients with a
newly created stoma should be further evaluated.
Conflicts of interest
The authors report no conflicts of interest.
Author contributions
Study conception and design: AKD, JB, JR; acquisition
of data: AKD; analysis and interpretation of data: AKD,
JB; writing and reviewing manuscript: AKD, JB, JR.
The study was initiated by the authors and was not
externally funded.
1 Sprangers MA, Taal BG, Aaronson NK, te Velde A. Quality
of life in colorectal cancer. Stoma vs. nonstoma patients.
Dis Colon Rectum 1995; 38: 361–9.
2 Brown H, Randle J. Living with a stoma: a review of the
literature. J Clin Nurs 2005; 14: 74–81.
3 Carlsson E, Berndtsson I, Hallen A-M, Lindholm E, Persson
E. Concerns and quality of life before surgery and during the
recovery period in patients with rectal cancer and an ostomy.
J Wound Ostomy Continence Nurs 2010; 37: 654–61.
4 Hamashima C. Long-term quality of life of postoperative
rectal cancer patients. J Gastroenterol Hepatol 2002; 17:
5 Simmons KL, Smith JA, Bobb K-A, Liles LLM. Adjustment to colostomy: stoma acceptance, stoma care self-efficacy and interpersonal relationships. J Adv Nurs 2007; 60:
6 Jeter KF. Perioperative teaching and counseling. Cancer
1992; 70: 1346–9.
7 Erwin-Toth P. Ostomy pearls: a concise guide to stoma siting, pouching systems, patient education and more. Adv
Skin Wound Care 2003; 16: 146–52.
8 Turnbull GB, Erwin-Toth P. Ostomy care: foundation for
teaching and practice. Ostomy Wound Manage 1999; 45:
9 Metcalf C. Stoma care: empowering patients through
teaching practical skills. Br J Nurs 1999; 8: 593–603.
10 Beaver K, Latif S, Williamson S et al. An exploratory study
of the follow-up care needs of patients treated for colorectal cancer. J Clin Nurs 2010; 19: 3291–300.
11 Grant M, Ferrell B, Dean G, Uman G, Chu D, Krouse R.
Revision and psychometric testing of the City of Hope
Quality of Life-Ostomy Questionnaire. Qual Life Res
2004; 13: 1445–57.
12 Burch J. Providing information and advice on diet to stoma
patients. Br J Community Nurs 2011; 16: 479–84.
A. K. Danielsen et al.
13 O’Shea HS. Teaching the adult ostomy patient. J Wound
Ostomy Continence Nurs 2001; 28: 47–54.
14 Benjamin H. Teaching the stoma care routine to a patient
with a low vision. Br J Nurs 2002; 11: 1270–7.
15 Colwell JC, Gray M. Does preoperative teaching and stoma
site marking affect surgical outcomes in patients undergoing ostomy surgery? J Wound Ostomy Continence Nurs
2007; 34: 492–6.
16 Goldsmith MR, Bankhead CR, Austoker J. Synthesising
quantitative and qualitative research in evidence-based
patient information. J Epidemiol Community Health 2007;
61: 262–70.
17 Greenhalgh T, Peacock R. Effectiveness and efficiency of
search methods in systematic reviews of complex evidence:
audit of primary sources. BMJ 2005; 331: 1064–5.
18 Moher D, Liberati A, Tetzlaff J, Altman DG. Preferred
reporting items for systematic reviews and meta-analyses:
the PRISMA statement. Int J Surg 2010; 8: 336–41.
19 Liberati A, Altman DG, Tetzlaff J et al. The PRISMA
statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions:
explanation and elaboration. J Clin Epidemiol 2009; 62:
20 Altuntas YE, Kement M, Gezen C et al. The role of group
education on quality of life in patients with a stoma. Eur J
Cancer Care 2012; 21: 776–81.
21 Olsen AG. Stoma education provides a new life [Stomiskole giver nyt liv]. Sygeplejersken 2011; 21: 78–81.
22 Lo S-F, Wang Y-T, Wu L-Y, Hsu M-Y, Chang S-C,
Hayter M. A cost-effectiveness analysis of a multimedia
learning education program for stoma patients. J Clin Nurs
2010; 19: 1844–54.
23 Chaudhri S, Brown L, Hassan I, Horgan AF. Preoperative
intensive, community-based vs. traditional stoma education:
a randomized, controlled trial. Dis Colon Rectum 2005;
48: 504–9.
24 Younis J, Salerno G, Fanto D, Hadjupavlou M, Chellar D,
Trickett JP. Focused preoperative patient stoma education,
prior to ileostomy formation after anterior resection, contributes to a reduction in delayed discharge within the
enhanced recovery programme. Int J Colorectal Dis 2012;
27: 43–47.
25 Lo S-F, Wang Y-T, Wu L-Y, Hsu M-Y, Chang S-C, Hayter
M. Multimedia education programme for patients with a
stoma: effectiveness evaluation. J Adv Nurs 2011; 67:
26 Cheng F, Xu Q, Dai XD, Yang LL. Evaluation of the
expert patient program in a Chinese population with permanent colostomy. Cancer Nurs 2012; 35: 27–33.
27 Higgins J, Green S. (2008) Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1. The Cochrane
Collaboration, 2011.
28 Haugen V, Bliss DZ, Savik K. Perioperative factors that
affect long-term adjustment to an incontinent ostomy.
J Wound Ostomy Continence Nurs 2006; 33: 525–35.
29 Herlufsen P, Olsen AG, Carlsen B, Nybaek H, Jemec
GBE, Karlsmark T. The causes of peristomal skin disorders.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283
A. K. Danielsen et al.
J Wound Ostomy Continence Nurs 2007; 34(Supplement):
Persson E, Gustavsson B, Hellstr€
om A-L, Lappas G,
Hulten L. Ostomy patients’ perceptions of quality of care.
J Adv Nurs 2005; 49: 51–8.
MacDonald LD, Anderson HR. Stigma in patients with
rectal cancer: a community study. J Epidemiol Community
Health 1984; 38: 284–90.
Danielsen AK, Burcharth K, Soerensen EE, Rosenberg J.
Learning to live with a permanent intestinal ostomy: impact
on everyday life and educational needs. J Wound Ostomy
Continence Nurs 2013; [in press].
Foster G, Taylor SJC, Eldridge SE, Ramsay J, Griffiths CJ.
Self-management education programmes by lay leaders for
Positive effects of education in patients with stoma
people with chronic conditions. Cochrane Database Syst
Rev 2007; CD005108.
Riemsma RP, Taal E, Kirwan JR, Rasker JJ. Patient education programmes for adults with rheumatoid arthritis. BMJ
2002; 325: 558–9.
Rankinen S, Salanter€a S, Heikkinen K et al. Expectations
and received knowledge by surgical patients. Int J Qual
Health Care 2007; 19: 1–13.
Dixon-Woods M, Agarwal S, Jones D, Young B, Sutton A.
Synthesising qualitative and quantitative evidence: a review of
possiblemethods. J Health Serv Res Policy 2005; 10: 45–53.
Greenhalgh T. Integrating qualitative research into evidence based practice. Endocrinol Metab Clin North Am
2002; 31: 583–601.
Colorectal Disease ª 2013 The Association of Coloproctology of Great Britain and Ireland. 15, e276–e283