London Centre for Leadership in Learning

MA Leadership: Leading and Managing Change and Improvement

Introducing evaluation strategies of the teaching process

and students’ satisfaction

26 of January 2015
 Introduction

The purpose of this assignment is to outline a case study of change in a private

primary school in Athens, Greece. The change was implemented during two periods

of time and its aim to propose methods of initiating and sustaining educational change

at a level through the processes of policy development, implementation and review.

The above change was introduced for first time in the school and was conducted

through observations of the teaching process by the Leadership Team (LT) and

through questionnaires that were completed by the students. It is admitted that it was

well organized by the principal and the LT, and finally successful.

This essay, firstly, will represent some relevant theories of leading and

managing change and improvement, as well as some successful strategies which can

be implemented. Then, will be depicted the context of this effort of school change and

improvement, and the connection of this case study with the literature review.

Ultimately, after the analysis of the characteristics of this successful process, will be

provided a general overview and a conclusion.

 Literature Review

There has been a great controversy over the last years over change and reform as

inevitable notions in our world that constitute an integral part of schools ,yet Senge

(1990) underlines that the Greek word metanoia means “a fundamental shift of mind”.

This notion is fundamentally important for any educational change. Therefore, there

are important strategic key themes to developing leader’s responsibility to urge a

change, through the following phases as follows: initiation, implementation,

institutionalization and outcomes (Bubb & Earley, 2004).However, there is a deep

knowledge bond between school structure and culture in the process of implementing

a change .The review will focus on different approaches through the aforementioned

phases and their effect on change.

From the 1960s there were theories that were greatly developed about chaos and

complexity that capture the spirit of change, openness and unpredictability. According

to Gleick (1987, cited in Morrison, 1998) there are several principles in the chaos

theory, such as:

 Low-level changes in initial conditions that can produce massive and

unpredictable changes in outcome

 Very similar initial conditions that can produce very dissimilar outcomes

 If something works once, there is no guarantee that it will work in the same

way a second time

 Deterministic, linear and stable systems are replaced by ‘dynamical’,

changing, evolving systems and non-linear explanations of phenomena.

 Change is associated with risk-taking, fear, anxiety, and excitement. It is

“technically simple and socially complex” (Fullan, 2001a, p.69). Many theorists use

words such as: intricate, confusion, disruption and distress to describe the change

management. This illustrates the sense that any change is non-rational, non-linear and

complex (Miles et al, 1988 in Busher & Harris, 2000). As Bubb and Early (2004)

state” It is about changing the perceptions, of employers, parents, students,

the public and of teachers themselves.” (p 19)

Many schools have tried to introduce a reasonable model of school planning and

change either from within teacher faculty or from their management team that has led

into an over-demanding, ambiguous, unproven, poorly communicated dysfunctional

system. “The logical style is really forceful and attractive, proposing that the shift can

be designated and realized” (Morrison, 1998). Nonetheless, this proposition fails to

give a true notion of change, as human rationality is subjective, personal and most

times contradictory.

From the mid-1970s the characteristics of change have been identifies as:

 Structural, systematic and system-disturbing rather than superficial (Cuban,

1990)

 As a multidimensional phenomenon; embracing objectives and functions,

knowledge, values, roles, relationships, resources, assessment (Hopkins et al.,

1994)

 Depended on investment in each structures, institutions, people, technological

and psychological support (Morrison, 1998)

  Better to think big but start small (i.e. to identify ‘levers of change’), though

the areas of highest leverage often the least obvious (Senge, 1990:

63;Hargreaves, 1994:10)

The main lineament that connects these characteristics is that change concerns,

above all, the people. “Change changes people, but people change the change! The

best laid plans stand or fall, when the people are involved”(Hoyle, 1975; Dalin et al.,

1993). Therefore, some members of the teaching faculty within may welcome the

intention of a change, while the rest may be negative to any change. Furthermore,

some may demand more information about the plan of change, because they may be

anxious about how this change will affect them personally with any forthcoming

consequences. As Kotter (2005) indicates “usually 30 percent of the staff is convinced

that the vision has value, 30 percent is trying to understand the change, 20 percent is

very confused, 10 percent is mistrustful, but not rival and, finally 10 percent is totally

opponent with the change and they deem it irrational. (p.40).

Success of a change depends on successful management, as well as on others

particular characteristics of the change respectively such as: complexity,

compatibility, clarity, nature, the amount of the change and the contribution to the

overall vision of the organization that the change will bear (Morrison, 1998).

Equation for effective change

A many great formula equations of driven approaches have been formulated and

proposed in order to guarantee a positive impact and strategic thinking and a clear
vision to promote a successful understanding change and avoid any unnecessary

inessential steps.

An interesting and clear formula equation is the following.

Figure 1.1 The Original Change Equation

Therefore we have C= (ABD)>X, where

C=change

A=dissatisfaction with the status quo

B= the desirability of the proposed change

D= the practicability of the proposed change

X=the cost of the change (Clarke, 1994)

Figure 1.2 Factors for meaningful organizational change

From the above, we can understand that there is a set of factors that can radically

influence change and determine realistic change. The cost of change is the most

significant variable, which has to be overwhelmed in order to have a goal oriented and

positive change. Clarke( 1994) views this formula as a strategic step of planning and

monitoring the practical cost of change , considering the pragmatic targets and

purposes , while others view it as purposeless and disorganized plan and express their

resistance to any change (Busher and Harris, 2000).

However, this lack of desirability is more or less depending on the approach that is

implemented, as the resistance is always an innate reply to the existence and the

demands of a shift procedure (ibid., p.19).

Bubb and Earley (2004) present different approaches to overwhelm the negative

mood of a change and the resistance with clear knowledge of the strategy of change,

its consequences, the consultation with neglected people, the supplement of the

appropriate education and coaching.

Garrett (2005) emphasizes another impediment that may reinforce the resistance to

change into three groups:

1. Personal barriers (intimate morals)

2. Psychological barriers (the innate resistance)

3. Organizational barriers (the rigid formation of change)

4. Power barriers (if the future allocation of power is not the desirable).

Consequently, both the individuals’ resistance and organizations structure to swift

have to be comprehensive, well –directed and time planned in order to have

development.

Managing Change

One more equation, (see Figure 1.3) significant to understand the management of a

change, is as follows:

R + V + P = C, where

R= a compelling reason for the change

V= a clear vision of the future

P= a coherent plan for getting there, and finally

C= the change
Figure 1.3 Change Equation of Reasoning

The above equation presupposes that a change can be accomplished with the existence

of purpose to change, a lucid insight for the future and of course, an intricate outline

planning of possible actions to be implemented and institutionalized. However, the

formulation and existence of the three terms above aforementioned is hard to find as

there must always be a preference, resistance, readiness and a reason for change

(Garrett, V (2005).

Steps for implementing change

Many a great theorists’ claim that a change is a steady and gradual process, even

if the nature of this change appears radical and transformative. A change is a

consecutive procedure which shows sequel with the past and current situations

(Johnson, 1993:58-64). When a leader manages an incremental change it entails:

caring for the needs, broadening comprehension and knowledge of the present
situation and necessities; controlling the disinterest, the impendence and the dangers

(Quinn, 1993: 65-6).

Strategies for effective change

There are important strategies that need to be examined before implementing and

structure change such as:

1) Directive strategies, which point to out leader’s power to enforce change to others.

The advantage of this approach is that the change can be realized rapidly.

2) Expert strategies, which face the change as a situation that requires solution by an

expert or a group of experts to introduce the change.

3) Negotiating strategies, which express the eagerness of managers to negotiate the

change with people affected by the change to make final decision.

4) Educative strategies, which comprises people with “winning hearts and minds”, in

order to evolve a set of morals that individuals are able and ready to support with a

combination of activities used, such as: cogency, tutoring and coaching.

5) Participative strategies, which give particular emphasis in the involvement of all of

those who are included in the changing plan. Another name for this strategy is

“distributativ"e.
Figure 1.4-Strategies for effective change

All mentioned strategies for change have to be examined for pros and cons .The

leadership team has to decide which method is better to choose, taking into

consideration that nature of the change, the culture, the background of the school and

personal characteristics of the people who will apply the change.

Furthermore, as Earley (2008) identifies there are ‘zones of acceptance’ that can

be recognized as more suitable approaches for each case, guaranteeing success for its

following implementation and institutionalization. Indeed, directive strategy is quick

to foster but confines the opinion of others people involved in the change. This

strategy can cause crucial barriers and obstacles in the process of transformation,

increased resistance and demand.

Moreover, Bubb and Earley (2004) stress that” the formation of a collaborative

way of thinking, deciding and acting is probably the most important element of an

accomplished change”. (p.420) Therefore, any participation approach enhances

teachers’ incentives, promotes communication between colleagues and raises the

feeling of belonging (Chapman, 1990). On the contrary, the rest styles of change have

been criticized that underestimate human sentiments and perspectives, and as a result

are linked with the shortage of eagerness on the personnel.

Therefore, Kanter et al. (1992) identifies the necessary elements for the

implementation of a change:

 the detailed knowledge of the society and the recognition of the requirement

for change

 the formation of a common insight

 the need to escape from the past and look forward

 the demand to transmit a feeling of emergency for shift

 the need for a dynamic and encouraging leader

 the requirement to evolve and apply political subsidy

 the attentive formation of the procedure for implementation

 the demand for extensive understanding, morality and trustworthiness

 the requirement to strengthen change with the purpose to end up as

institutionalized.

Therefore, the implementation of the change is a multidimensional procedure and

it is not necessarily required to endeavor and impose one particular style for each kind

of change as each one has its own distinctive and personal style.
 The next step is for the leader to determine the change, and identify the obstacles

that may exist, because in this way they can be eliminated or restrained. There are

many implements that can help leaders to point out what barriers may they have to

come up with, such as power ties examination, SWOT analyses, devotion outline in

three different steps frame.(Figure 1.5 )

Figure 1.5 The three stage SWOT of a contingency plan of change

Last but not least of the change procedure is the institutionalization. It is when the

leader embodies the innovation into the school and into the learning process.

Therefore, the novelty turns out to a component of the school function. Constant

coaching and assessment should be directed to assure that there is success at all levels.
The outcomes will show the degree of effectiveness of the effort that was made

(Busher & Harris, 2000). It is leader’s duty to consider and review if the outcome is

successful or fruitless and to suggest another planning for the future.

It has been remarkable that the parts of change are strongly reliant on each other.

As James & Connolly (2000) have stated “attentive examination, organization and

consultation are vital for its evolution, since change is not simple and is associated

with the feelings “(pg. 221). Researchers claim that teachers want to incorporate the

change, but they don’t have enough time and vigor to implement it. Hence, the

innovations that they apply are not big and probably are not transmitted to their

colleagues (Fullan, 2001).

Lastly, it is necessary to mention a table with four frames of a change, which are:

1) The policy, when there in a change on the strategies. In every policy

development situation of education change, we can witness a

diversification of different views by all leaders and nominated

representatives supporting their group form opinion or their viewpoints.

2) The theory, which means change of a sum of ideas. Indeed sometimes we

need to make our institutional theory more dynamic to achieve maximum

benefits to our academic institutions .We need to change and evolve new

ideas sometimes a change process with Information and Communication

Technology (ICT) field may be useful, even if that will mean compelling

changes in current higher education management processes.

 3) The practitioner, in other words change in the people who are engaged

with a case, as they can contribute and justify a clear sense of purpose

and input and focus on improving system performance .

4) The research, when the change affects the investigation process as this

will contribute to the key points for a successful change to flourish filling

up and completing all appropriate recourses and spaces as that grants for

an expertise presence ,participation and evaluation, making change more

progressive and reasonable.

The frame of method used in my case study is that of policy development

change as there it proposes a different strategy that aims at changing and

managing institutional practices through policies. Based on the principles

of the qualitative classic grounded theory and trying to secure an effective

way to adopt educational change (Glaser and Strauss, 1999; Glaser, 2010)

; data sources as well as literature finding , experiences and views of

different scholars and academic practitioners.

Change Management Process

According to Krüger (1996) some of the most important obvious and hidden

barriers to change in an institution, are such as: price, fundamental time and expected

level of achievement. However, many managers tend to concentrate only to the

obvious barriers, neglecting strong points as conceptions and politics. Another aspect

is that people involved in change can dramatically lead to believe others with their

positive or negative altitude.

 Nevertheless, there are three types of management applied to overcome the

barriers of change such as:

a) Issue Management,

b) Management of Perceptions and Beliefs,

c) Power and Politics Management.

With a classification of the people mentioned as:

 Supporters, who are positive about the change and anticipate to earn rewards

 Eventual Supporters, who have positive mood for the change, but they are not

completely sure of its benefits

 Concealed Rivals, who give the impression that they want the change, but

their inner feeling is opposite to it.

 Rivals, who have a clear negative opinion for the change and in order to

change their mind, management of perceptions and beliefs should be applied.

The change management process was through a qualitative research design to

have a choice for examination, in-depth interviews, focus groups, and document

review The policy frame in my case study has provided an excellent different vies and

strategies to approach into this investigation. The understanding of policy

development and implementation is most productively reinforced through careful

analysis and different views, diversification of perceptions, and prospects of a change

over time.
 The Case of Study

Context –

School evaluation process and case study performance in Greek School

My case study took place in a mixed primary private school in Athens two years

ago from November 2012 .Indeed, the change was introduced and implemented by the

Principal and the four members of the leadership team of the school (LT). The

introduced change was to inspect and evaluate the level of the teaching applied in

each classroom, by the faculty of teachers providing an analysis of the display of a

change and access the conditions of the approach in that faculty. In other words, the

idea was to assess the performance of the teaching staff, conducted through

observations of the teaching process by the Leadership Team (LT) and through

questionnaires that were completed by the students aiming to propose methods of

initiating and sustaining educational change at a level through the processes of policy

development, implementation and review.

Case study process and method -Initiatives steps

The change was introduced by the principal in a meeting with the LT and the

teaching staff, where everyone was informed prior about the change. The

implementation of the change took place in two periods of time; the first was in
November 2012 and the second one was in May 2013. In both cases, the assessment

was implemented by the Leadership Team (LT), with observations and evaluation of

the teaching process, as well as with questionnaires provided to the students, in order

to assess their teachers in teaching and learning in a systematic and coherent way. The

whole process each time lasted one week, with the LT evaluating the teaching staff,

with grades from 0 to 10, in a sum of categories, such as the transmissibility, the

organization of the teachers and the discipline of the students. Moreover, there were

two page-questionnaires distributed to the students in a form of (SEF) Self Evaluation

Form that gave the ability to students to grade their teachers from 0 to 10, discreetly

in a total of characteristics, such as assistance, extra academic material help, and

additional support that teachers offered to their students within academic hour lessons.

Case study results and grading.

In the first place students were very ambitious to fill all questionnaires as that would

reflect their own opinion towards teaching faculty .The results were later collected by

the LT, who conducted an introductory various final grade ranking for each teacher

such as Excellent, Competent, Poor, Very poor, Not observed , I don’t know .(see

Appendix 1.1)
The grades that the LT had evaluated through analyzing the questionnaires are the

results that have been gathered in association with the grade that reflected with the

opinion of the students. Indeed, the framework of questions was able to provide

significant findings as to assist in a developing a school improvement change policy

plan.(Figure 1.5).

Figure1.6 Case study plan steps

However, the purpose of the case study for a second period of time, when the

research was conducted twice as mentioned above, was mainly introduced and

implemented to investigate if any change in findings and evaluation had occurred that

would vary the previous results or standards of the learning process.

 It is worth mentioned that this kind of teacher evaluation was taken place for the

time and had never occurred again in the school. The main objectives of this case

study was for the principal and teaching faulty to have an overview of the teaching

process that was transacted within the school, as well as to be informed about the

perception that the students have about their teachers and how to sustain a successful

educational change at a level of policy development, implementation and application

in the Greek school.

Key Concerns and barriers reflections for Change

Nevertheless, during an emergency meeting that happened one week before the

research had originally started for the first time, many concerns and misconceptions

arose on behalf of the teachers. Their main anxieties were based on understanding

why this inquiry was carried out and how the final outcome with the results should

affect the whole case.. They were anxious about if their grades were going to be

announced to their colleagues, the parents, and so on. Of course, all of those concerns

vanished when the principal explained them that the results would be absolutely

confidential, and the teachers could be informed privately about their score, without

be announced in any case. None else except the principal and the four members of the

LT could have access to the findings and only the teachers could request to be

informed about their personal mark tete-a-tete.

Furthermore, the principal explained the reason of this research, which was the

deep knowledge of the learning processes that took place inside the school and the
level that the students felt happy and convenient with their teachers inside the

classroom. The research had carried out important information about the grade that

teachers have engaged a learning environment that students are contributing and are

active members of their academia how much tied they feel with them. Therefore, the

objectives of this study were much informative about the standards of the teaching

approaches within the school and the sentiments of the students about their teachers

and the way of learning.

The above meeting never occurred for a second time, as teachers were fully

knowledgeable of the research process and convinced about its confidentiality. They

were convinced that the results are not going to provoke any changes in their position,

status or academic image and any information will be kept in discrete to anyone,

except of them. The grades from the observations and also from the questionnaires

were kept by the principal in a secret locked place, were absolutely no one else could

have access.

Analysis and Conclusion

As it was made clear in the literature review, it is the leader’s responsibility to

take action and provoke change. The first stage was to introduce the change, and the

principal achieved that through a meeting with the leadership members and the

teaching staff. It was a good choice to gather all faculty target board of teachers to

enable them to use all appropriate information involved in the change process,

because in this way everyone could have a clear focus on specific areas that need to

be targeted for improvement and developmental change directly from the principal

about its rights and its responsibilities, and simultaneously could create a personal
relationship with the others. Therefore, a good climate of mutual help and respect was

developed. It is necessary to remark the significant role of the urgent meeting that

took place, in order to affirm no existence of any misunderstanding of the change

process and its aims. The principal made it absolutely understandable that the results

are not going to be published and that they will not affect any of teaching staff

position. It is true, that especially in the beginning many teachers were anxious and

distressed about this process that would take place and the possible outcome and

effects of the achieved score on them. However, the objective of the assembly was

accomplished and after that everyone was more relieved.

The next stage of implementation had shown that the LT was really well

organized and disciplined. One week before the outset, the main observations were

announced with a plan in the classrooms that would have daily visits and this schedule

key plan was to be implemented periodically. There was a common opinion that LT

would not provoke any inconvenience and that both the teaching staff and the students

would face any trouble.

Furthermore, the LT had arranged a specific day and time to distribute the

questionnaires to the students after communication and agreement with the

responsible teacher of each class. The day that the students had to fill up the

questionnaires the LT explained them in detail what they should do and what for was

asked to fill in the questionnaires. The LT stated to the students that they are not

going to write their name, in order for the results to be anonymous. This was a very

good approach used as the students could complete the form with trueness, without

being afraid that their teachers will criticize and blame them afterwards. They felt free

to write what they believed and felt, with no fear or anxiety of any further
consequences. Afterwards, the LT collected the questionnaires and put them in a safe

place to analyze them and ascertain scores for each teacher.

Overall, there seemed to be a little resistance from some teaching members, which

was normal, particularly at the stage of the introduction of the idea, but finally

diminished and didn’t grow as to be an obstacle for the implementation of the change.

Few of the teaching faculty remained a little bit of conscious about the process of the

change, even after the emergency meeting, but they didn’t provoke any problem in the

whole process. Conceivably, it happened because everything was well-organized and

planned from the principal and the LT. Therefore, regards the barriers that Garrett

(2005) mentioned we can identify that the personal morals of the people involved

were not bothered, the innate resistance reduced to the minimum, the formation of the

change was enough flexible, as there was dialogue and communication with the

teaching staff and ultimately, the power barriers were absent since the results were

being kept in secrecy and wouldn’t affect any teachers’ position.

One of the applicable mentioned strategies used is that of negotiating approach for

an effective change, where the principal was willing to induce a change, taking into

account the sentiments of the people involved in the change and trying to diminish

any negative feelings or concern. This was the key theme for the success of this

change and its smooth realization. Everyone was meticulously informed about the

process and the LT followed the original plan, without swifts and misunderstandings.

Concerning the institutionalization of the change and the innovation that was

applied, both the principal and the LT were very enthusiastic about the change process

and tried to inspire the teaching staff. The second time that the assessment was

prompt , scores were a slight higher for the majority of the teachers, probably because
they were less stressed about the process and the outcomes, since they were aware

about the purpose of this change and its confidentiality.

In addition, this change is now institutionalized in the school, even if the LT is not

constituted exactly from the same members, and it is scheduled to take part twice per

year; usually, once before Christmas and once after Easter. This innovation became an

integral part of the school and its principal’s responsibility to keep on this novelty.

We need to motivate, inspire and stimulate the LT on its eagerness with fervor as to

be responsible and liable, avoid losing its reliability and trustworthiness and motivate

the teaching staff to continue to be positive and willing to cooperate to this

accomplishment change.

How has this study altered my views about the change process and about
leadership and about change?

    Having inventive ideas and motivation can never bring   the change process in the

same level. It is the role of the principal and academic leader that has to go far as to

secure the continual school improvement. I have discovered that we need to

concentrate and boost our sights for a school improvement and boost our insights
through a new sustainable revolutionized change as to meet the demands of our rapid

complex society. While the evidence of my case study showed little signs of

improvement  , we need significant efforts to stabilize the relationship between the

spectrum of teachers and students in a learning environment , I have come up to

support that we need strong leadership skills existing in schools in Greece to avoid

considerable difficult  circumstances in classes. Leadership is always the incentive for

any successful change and as the case study has shown the existing results in

troubling schools can hardly exist without a prompt change. In my case study that

took place in a school in Athens , Greece there was an urgency for a reform and the

change boost its targets to enhance teaching and learning as well as the relationship
between teachers and students .Although there were answers that indicated huge

differences , we have come to discover that some changes can improve the school ,

while at times can influence the overall approach to teaching and learning , by

focusing on innovative curricula and seek for implementation and cooperative

learning through change innovative approaches  hoping to change teachers’ practices

one teacher at a time. The results, therefore, have highlighted that there is a need and

urgency for changing for under performing schools as well as urgency to improve all

efforts or as part of school reconstitution change. However, I came upon to believe

that many of the teaching faculty development approaches are essential once they lead

to a successful autonomous change process and intelligible educations for students.

Finally, my suggestion is that a change .I have arrived at so far is that there is always

a good chance for reform and change as long as the teaching faculty and leaders agree

with its purposes and appreciate all required changes with equal respect and concern,

towards the goals and concerns for all students .

References

Bubb, S and Earley, P (2004) Why is managing change not easy? Chapter 3 in:

Managing Teacher Workload: Workload and Wellbeing, London: PCP/Sage.

Busher, H. & Harris, A. (2000) ‘Managing change within the subject area’, in Busher,

H & Harris, A with Wise, C. Subject Leadership and School Improvement, London:

Sage.
Chapman J, (ed) (1990) School based decision making and Management, Bristol:

Falmer Press

Clarke, L (1994) The Essence of Change, London: Prentice-Hall.

Cuban, L. (1990) A fundamental problem of school reform. In A. Lieberman (ed.),

op. cit.

Earley, P (2008) Leading and Managing Change and Improvement, Lecture Notes,

Institute of Education, November 2008.

Fullan, M (2001a) The New Meaning of Educational Change. London: Routledge

Falmer

Fullan, M (2001) Leading in a Culture of Change, London: Bassey/Wiley.

Garrett, V (2005) Leading and managing change, Chapter 6 in Davies, B, Ellison, L

and Bowring-Carr, C (eds) School Leadership in the 21st Century (2nd edition),

London: RoutledgeFalmer.

Hargreaves, A. (1994) Changing Times. London: Cassell

James, C. & Connolly, U. (2000) Effective Change in Schools, London: Sage.

Hopkins, D., Ainscow, M. and West, M. (1994) School Improvement in an Era og

Change. London: Cassell.

Hoyle, E. (1975) The creativity of the school in Britain. In A.Harris, M.Lawn and

M.Prescott (eds) Curriculum Innovation. London: Croom Helm and the Open

University Press.

Johnson,G. (1993) Processes of managing strategic change. In C.Mabey and B.

Mayon-White (eds.), op.cit.

Kanter, R.M., Stein, B.A. andJick, T.D. (1992) The Challenge of Organizational

Change. New York: Maxwell Macmillan International.

Kotter J., Rathgeber H. (2005) Our Iceberg Is Melting, London: Pan Macmillan Ltd

Morrison, K (1998) Management Theories for Educational Change, London: Paul

Chapman Publishing.

Quinn, J.B. (1993) Managing strategic change. In C.Mabey and B. Mayon-White

(eds), op.cit.

Senge, P. (1990) The fifth Discipline: The Art and Practice of the learning

Organization. New York: Doubleday.

Web-links:

http://www.data-group.com.au/change-management-iceberg

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC61464/
Appendix 1.1-Questionnaire