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Bailey C, Madden A, Alfes K, et al. Evaluating the evidence on employee engagement and its potential benefits to NHS staff: a narrative synthesis of the literature. Southampton (UK): NIHR Journals Library; 2015 Jun. (Health Services and Delivery Research, No. 3.26.)

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Evaluating the evidence on employee engagement and its potential benefits to NHS staff: a narrative synthesis of the literature.

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Chapter 3What is engagement?

Introduction

In this chapter, we address the first research question, namely:

How has employee engagement been defined, modelled and operationalised within the academic literature?

This overarching question can be broken down into the following three subquestions:

  1. How is employee engagement defined within the academic literature?
  2. How has engagement been measured and modelled within the academic literature?
  3. What theories have been used to underpin models of engagement within the academic literature?

In order to address these, we undertook the following analysis:

  1. Extraction of information relating to the definition, measurement and theorisation of engagement from all the studies included in the evidence synthesis for research questions 2 and 3 (see Chapter 2): a total of 172 papers.
  2. Review of relevant information from a number of literature reviews and conceptual papers focused on defining engagement that were identified in the second stage of the data extraction process but that either did not contain empirical data or contained empirical data that did not meet the quality threshold and so were excluded from the data extraction for research questions 2 and 3: a total of 38 papers.
  3. Consultation of three recent academic books focusing on engagement.16,59,60 The research team identified these as being the only academic books with an exclusive focus on engagement.
  4. Consultation of further conceptual articles focusing on defining engagement that were known among the research team or that were identified through a snowballing approach.
  5. Consultation of a number of conceptual articles or literature reviews that critiqued or questioned the engagement construct.

The chapter is organised as follows. First, we present an overview of the broad history and development of engagement, and outline the definitions and measures of engagement used within the literature. Next, the findings relating to question 1, the extraction of definitions and measures used in the empirical papers that formed the substance of our data extraction, are presented. This delineates the principal approaches that have been used within the empirical literature. Next, we outline the theoretical frameworks that have been used to explain the processes of engagement, before presenting an analysis of the critiques that have been proposed of the engagement construct. We conclude by highlighting the principal areas of agreement and disagreement with regard to engagement at a theoretical level, a topic that is explored further in Chapter 7, in the light of the evidence presented in Chapters 46.

The origins and definitions of employee engagement

Interest in engagement first arose as part of the wider development of the positive psychology movement that has burgeoned in recent decades as a counterbalance to the predominant focus on negative psychological states. As Youssef-Morgan and Bockorny61 note (p. 36), the earlier emphasis on factors such as stress, burnout and poor performance offered limited opportunity to understand strengths, optimal functioning and fulfilment at work.

William Kahn is widely acknowledged as being the first academic to research and write about engagement, which he referred to as ‘personal engagement’. In his seminal article,21 Kahn claimed that personal engagement or disengagement arises when ‘people bring in or leave out their personal selves during work-role performances’ (p. 702). Thus, personally engaged workers are those who express themselves authentically at work in three ways: cognitively, emotionally and physically. This authentic expression of self-in-role is contrasted with disengagement, whereby the individual ‘uncouples’ his or her true self from his or her work role, and suppresses his or her involvement. Since Kahn’s original research, interest in engagement has mushroomed, leading to the publication of significant numbers of publications, especially since 2005.62

Kahn’s original notion that engagement is the investment of the self into work roles has been developed further into the concept of ‘work engagement’, or the ‘relationship of the employee with his or her work’ (p. 15).62

However, along with this burgeoning interest has been considerable confusion and uncertainty about what engagement means, leading Christian et al.27 to conclude: ‘engagement research has been plagued by inconsistent construct definitions and operationalizations’ (pp. 89–90). A range of different terms has been used, including ‘work engagement’, ‘job engagement’, ‘role engagement’, ‘organisational engagement’ and ‘self-engagement’, with associated variations in the measures and theoretical underpinnings used.63 Some have gone so far as to argue that engagement may be no more than old wine in new bottles.18,19,64,65

There has been uncertainty over whether engagement is a relatively stable personality trait or a state that is susceptible to fluctuation over time, as well as whether it is a one-, two- or three-dimensional construct. However, the emerging consensus is that engagement is a psychological state, as summarised by Christian et al.:27 engagement is ‘a relatively enduring state of mind referring to the simultaneous investment of personal energies in the experience or performance of work’ (p. 90). Parker and Griffin29 extend this by arguing that engagement is an active rather than a passive psychological state, and therefore is associated with energetic states of mind. There is, additionally, broad agreement that engagement is not a one-dimensional construct but rather comprises several facets.66

Below, we explore the most widely used definitions and conceptualisations of engagement found through our data extraction process. Drawing on and extending previous typologies such as that of Shuck63 and Simpson,36 we categorise the definitions and operationalisations of engagement within the literature under six headings, and review each in turn (Table 12):

TABLE 12

TABLE 12

Definitions and measures of engagement used in the selected studies

  • Personal role engagement, including the work of Kahn21 and researchers who have sought to operationalise his theoretical framework.
  • Work task or job engagement, including the work of the Utrecht Group,71 which has focused specifically on the notion of engagement with work tasks.
  • Multidimensional engagement, drawing on the work of Saks,72 who distinguishes between engagement with work and engagement with the organisation as a whole.
  • Engagement as a composite attitudinal and behavioural construct, drawing on the work of various consultancy firms and researchers who regard engagement as a broadly defined positive attitudinal state; this approach is what is commonly referred to as ‘employee engagement’.
  • Engagement as practice: scholars within the HRM field have recently begun to focus on engagement, and there is a small emergent literature on engagement as an employment relations practice.16,17
  • Self-engagement with performance: one measure has been developed that regards engagement as the extent to which high levels of performance are salient to the individual.

While some meta-analyses of engagement such as that of Christian et al.27 restrict themselves to a narrow view of engagement purely in terms of an individual’s engagement with his or her work tasks, we seek here to be inclusive in terms of encompassing the range of various definitions within the literature, while remaining rigorous in terms of the application of a quality threshold.

Several measures that have been published in peer-reviewed journals were excluded on grounds of quality. Most significantly, following Christian et al.27 we excluded several papers that drew on the Gallup Q12 engagement measure (e.g. Jones and Harter81). This was because of concerns that the Q12 is a composite, catch-all measure that lacks construct and discriminant validity.20,36,62 Little and Little in their critique of the measure82 note that ‘merely attaching a name to a collection of survey items does not make it a construct’ (p. 112), while Guest18 argues that the consultancy perspective on engagement is akin to a management fad.

We also excluded scales developed to capture engagement specifically within the context of health, such as that of Mark et al.83 This scale included nursing expertise, commitment to care and tenure, aggregated into one overarching engagement construct. Again, this measure lacked validity. The Shirom–Melamed vigour scale, which has also been used to measure engagement,84 was excluded on the grounds that the scale more accurately captures the single notion of ‘vigour’ rather than engagement.

The included measures are reviewed in the following paragraphs.

Personal role engagement

William Kahn21 stated that ‘people occupy roles at work; they are the occupants of the houses that roles provide’, and showed through an ethnographic study that individuals ‘constantly bring in and leave out various depths of their selves during the course of their work days’ (p. 692). Thus, Kahn viewed engagement as the individual’s cognitive, emotional and physical expression of the authentic and preferred self at work. In his ethnographic observational study, Kahn found that those who were engaged in their work were energetic, cognitively vigilant and empathically connected with others. In contrast, those who were disengaged withdrew and defended their preferred self, and their role performances were passive and incomplete (p. 701).21 Levels of personal engagement were found to vary across time and according to the strength of three conditions: experienced meaningfulness of work; psychological safety, or lack of fear of negative consequences of the employment of self; and psychological availability, or having the personal resources needed to personally engage. Kahn later wrote:

Engagement is both very delicate and fragile, and quite resilient . . . People have a desire to engage. They have an instinctive drive to express who they are, and who they wish to be, and given a chance at work, they will do so.

(p. 30)85

Kahn’s research was qualitative and so did not provide a quantitative scale by which engagement could be measured. Several researchers have since sought to operationalise engagement according to Kahn’s definition. May et al.22 developed a 13-item scale to capture cognitive, emotional and physical engagement (referred to as employees’ engagement in their paper; see Table 12). A total of four papers using this measure met the quality threshold.

Rich et al.4 used modified versions of three pre-existing scales to measure personal engagement (referred to as ‘job engagement’ in their article): Brown and Leigh’s86 ‘work intensity’ measure to capture physical engagement; Russell and Barrett’s87 ‘core affect’ scale to measure emotional engagement; and Rothbard’s88 engagement measure capturing attention and absorption for cognitive engagement. Their study showed that the scale had discriminant validity. Three papers using this scale were included in the data extraction.

Soane et al.’s70 intellectual, social and affective (ISA) scale operationalised Kahn’s engagement through measures of intellectual, social and affective aspects of engagement (referred to as ‘work engagement’ in their article). The ISA scale was shown to have internal reliability and construct validity. A further three papers using this measure were included. Finally, Reio and Sanders-Reio68 used Shuck’s67,89 16-item workplace scale, which in turn is a modified version of May et al.’s22 scale.

Work task or job engagement

The second, and dominant, stream of research within the engagement literature refers to ‘work engagement’ rather than ‘personal engagement’. According to this line of reasoning, engagement is viewed as a positive state of mind directed towards work tasks. Whereas the ‘personal role engagement’ state reviewed in the previous subsection refers to the expression of the authentic self, here engagement is viewed as a positive, activated state of mind achieved in relation to the job.

This strand of research was originally founded in the notion that engagement was the opposite of burnout (the ‘burnout-antithesis’ approach).63 Burnout has been described as ‘a (negative) psychological syndrome in response to chronic interpersonal stressors on the job’ (p. 399)90 that comprises exhaustion, cynicism and reduced professional self-efficacy. Engagement, on the other hand, was defined as ‘intense involvement and satisfaction (with work)’ (p. 65)91 and was measured by reverse scoring burnout questionnaire scales, such as the Maslach Burnout Inventory (MBI). In a meta-analysis comparing the Utrecht Work Engagement Scale (UWES) with the MBI, Cole et al.92 conclude that engagement as measured by the UWES and burnout as measured by the MBI are strongly reverse-correlated. However, their analysis also shows that engagement accounts for a small to moderate amount of variance in job satisfaction and organisational commitment over and above that accounted for by burnout. Other research has suggested that engagement, rather than being at the opposite end of a continuum from burnout, is in fact a distinct construct in its own right and has cast doubt on the possibility of measuring engagement by reverse-scoring burnout scales.71,93,94 Given the level of uncertainty about this issue, we have excluded from our evidence synthesis studies that measure engagement by reverse-scoring the MBI.

Building on this, a group of scholars based at the University of Utrecht suggested that, although engagement was generally negatively related to burnout, it was in fact a distinct construct that should be defined and measured separately. Thus, Schaufeli et al.71 defined engagement as ‘a positive, fulfilling, work-related state of mind’ (p. 74) and proposed that an engaged employee has a strong sense of vigour towards, dedication to and absorption in work activities. This refined conceptualisation has similarities to Kahn’s21 in that engagement is concerned with a psychological experience, while at work, that is highly positive and self-fulfilling. Moreover Schaufeli et al.71 also support Kahn’s21 view that engagement is a psychological state that leads to positive personal and organisational behaviours.

The UWES71 has become the most widely used measure of engagement in the academic world. It has been proposed as both a longer 17-item scale and a short 9-item version,95 and has been validated in other versions for use in several languages. It has also been validated for use in measuring fluctuating levels of engagement through the working day,96 and for use either as a higher-order, one-factor model or as three separate factors.97 Seppälä et al.’s95 analysis suggests that the 9-item Finnish version of the scale has better construct validity and stability than the 17-item version.

A total of 148 papers using various versions of the UWES were included in the data extraction, plus one qualitative paper;98 42 of these used the full 17-item scale and 90 used the 9-item version. The remainder used between five and 16 items; some of these were validated versions of the scale in other languages, while others were shortened versions of the scales that had acceptable psychometric properties. A number of papers that used just one or two of the three scales were excluded from our analysis on the grounds that the measure of engagement used did not correspond with the underpinning theorisation of the construct (see Table 8).

Multidimensional engagement

Saks72 defined engagement as ‘a distinct and unique construct consisting of cognitive, emotional and behavioural components that are associated with individual role performance’ (p. 602), distinguishing between job engagement on the one hand and organisational engagement on the other. Shuck63 refers to this as the multidimensional approach to engagement. This introduces the notion that engagement can be directed towards a range of different loci, not just towards the job itself. A total of six papers using this measure were included in the data extraction; three used both job and organisation engagement scales, two used the job scale only and one used the organisation scale only.

Selmer et al.73 argued that engagement could be examined at the work group level and proposed a measure of work group engagement. One paper was included that used this measure.

Engagement as a composite attitudinal and behavioural construct

The fourth approach views engagement as a composite attitudinal and behavioural construct, combining a range of perspectives into one measure. We included one measure under this heading, although, as discussed above, we excluded a number of measures for quality reasons. Swanberg et al.76 adopted the Utrecht definition of engagement but operationalised this through measures of cognitive and emotional engagement as well as behavioural engagement (see Table 12), thereby extending the notion of engagement beyond the strict boundaries of the construct proposed by the Utrecht Group. This measure demonstrated appropriate psychometric properties and therefore two papers using the measure were included.

Engagement as employment relations practice

Recently, scholars within the HRM field have begun to consider engagement as a management practice. Here, engagement is viewed in the sense of ‘doing engagement’ rather than ‘being engaged’.16 This is a small and emergent field of research that has to date comprised case study-based approaches. For instance, Jenkins and Delbridge78 argue that engagement approaches, or strategies for managing employee engagement, can take ‘soft’, developmental, or ‘hard’, performance-focused, approaches. Arrowsmith and Parker77 highlight the tensions and ambiguities apparent within a longitudinal case study on engagement initiatives within one firm, and show the variety of ‘engagement schemas’ held by organisational actors, arguing that engagement is not a static value-free construct. Contributions within this stream address longstanding debates within the HRM field concerning unitarist and pluralist perspectives on the employment relationship or theories of organisational communication.79 A total of three studies adopting this perspective met the quality threshold and were included in the data extraction.

Self-engagement with performance

Finally, one measure was included that was based on the notion of ‘self-engagement’, defined as the individual’s sense of responsibility for and commitment towards performance.80 One study using this measure met the quality threshold.

The discriminant validity of engagement

A fundamental question is whether engagement can be considered a distinct construct in its own right or the overlaps between engagement and other, similar, constructs are so great that it adds little or nothing.19 The notion that engagement might be little more than an assemblage of other constructs has been referred to as the ‘jangle fallacy’ (p. 97).27 Several studies have addressed this point, but the findings generally suggest that at least some of the conceptualisations of engagement can be classed as a distinct construct.

Christian et al.27 examined whether or not engagement as defined by the Utrecht Group demonstrates discriminant validity as compared with more established constructs such as job satisfaction, job involvement and organisational commitment. They found evidence to support the notion that engagement is different from these other constructs and showed that engagement has incremental validity over other job attitudes in predicting performance. However, they also concluded that there is sufficient overlap, of around r = 0.50, between engagement and these other constructs to conclude that they share ‘conceptual space’ (p. 120). Hallberg and Schaufeli99 similarly found that engagement measured by the UWES has discriminant validity compared with job involvement and organisational commitment.

However, although Viljevac et al.100 found that both the UWES and the scale proposed by May et al.22 showed discriminant validity compared with affective commitment, and that the UWES showed some evidence of differentiation compared with job involvement and intent to stay, they also found that neither measure showed discriminant validity compared with job satisfaction. Partial convergent relationships were found between the UWES and the May et al.22 scale, suggesting that they are similar but not overlapping constructs. Viljevac et al.100 conclude: ‘our results suggest that neither measure should be considered an adequate measure of work engagement’ (p. 3706). Wefald et al.101 could not confirm the three-factor structure of the UWES, and found, further, that the measure was not able to predict a range of outcomes when satisfaction and affective commitment were controlled for.

With regard to the UWES and the Britt102 scale, Wefald et al.101 conclude: ‘these findings potentially suggest that the way engagement is typically measured may be inherently flawed, and that engagement, as measured by both Schaufeli and Britt, may be redundant with the more established constructs of job satisfaction and affective organisational commitment’ (p. 87). These findings suggest that some degree of caution should be exercised in interpreting the findings of quantitative engagement studies. More research is needed that explores the construct, discriminant and predictive validity of the engagement scales currently in use.

No research to date has examined the evidence emerging from the body of qualitative studies of engagement in the organisational sociology/industrial relations field, in which engagement is defined in a very different way from the psychology literature, as practice. This emergent field holds some promise as an antidote to what Godard103 has termed the ‘psychologisation of employment relations’ (p. 1).

Taken together, these findings suggest that further research is required to demonstrate engagement’s properties as a distinct psychological state that can explain more of the variance in other attitudes and behaviours than other states, and to explain and synthesise the wide range of definitions of engagement that have arisen.

Definitions and measures of engagement: conclusions

As Schaufeli62 notes, ‘probably the most important issue in defining engagement is “where to draw the line?” ’ (p. 19). As we have seen, the variety of ways in which engagement has been defined suggests that the construct has been subject to ‘fixing, shrinking, stretching and bending’ (p. 19),17 creating a bewildering array of definitions and meanings, and ways of measuring and evaluating levels of engagement. Although Macey and Schneider25 suggest that engagement is a synthesis of trait engagement (including personality traits such as conscientiousness), state engagement (including satisfaction and involvement) and behavioural engagement (including proactivity and role crafting), the emerging consensus appears to be that engagement should be considered as a relatively enduring psychological state experienced by an individual in relation to his or her work activities that is affected by various antecedent factors and leads to a range of outcomes. The most widely used definitions of engagement, those of the Utrecht Group71 and Kahn,21 share a number of commonalities, in that both regard engagement as multifaceted and as comprising three dimensions: an affective, a cognitive and an energetic dimension.

A number of studies have been conducted to examine the construct validity and discriminant validity of engagement in the wake of accusations that engagement has conceptual overlaps with constructs such as commitment, involvement and satisfaction. Evaluating these has not been a primary focus of this investigation; however, meta-analysis conducted by Christian et al.,27 as well as primary research,4,99 suggests the cautious conclusion that engagement is sufficiently different from these other attitudes to be considered as an attitude in its own right. However, more research is needed to address the concerns that have been raised and that examines the emerging view of engagement as employment relations practice.

Theoretical frameworks: introduction

Engagement scholars have used a wide range of theoretical frameworks to ‘explain’ engagement, either in the sense of explaining how engagement fits within wider positive psychological paradigms, or in order to explain the relationship between engagement, its antecedents and its outcomes. To identify what theories have been used to underpin models of engagement within the academic literature, we undertook an analysis of the principal theoretical frameworks used in empirical studies of engagement to ‘explain’ the engagement process. This involved reading the papers to extract the principal explicit or implicit theory/ies underpinning the analysis presented. The findings are presented in Table 13.

TABLE 13

TABLE 13

Theories of engagement used in the selected studies

However, these findings should be interpreted with some caution; in some cases, the theories were not made explicit in the paper. We have coded 21 papers as ‘unspecified’ where no theory was mentioned and it was not clear on reading the paper what the author’s intention was. In other cases where no theory was mentioned, we have inferred based on available information within the paper what the author’s intention was. In many instances, authors referred to a range of different theories; for most of these, we have reported on the main theoretical frameworks only, but in some cases it was not clear that there was one overriding theory, and so we have included several theories for one item. The results presented in Table 13 should therefore be regarded as indicative of general trends within the literature.

Theoretical frameworks: findings

As Table 13 indicates, 65 studies have used the JD-R framework. This is true of most of the papers that have used the UWES. The JD-R framework distinguishes between resources on the one hand, in the form of either job-related resources or personal resources, and demands on the other. According to this model, resources energise employees and foster engagement, which, in turn, yields positive outcomes such as high levels of performance (p. 26).62 Job demands, on the other hand, require employees to expend additional effort, which over time can cause exhaustion and lead to negative outcomes. Job resources comprise physical, social and organisational job features that can reduce job demands, help individuals achieve work goals or aid with personal growth. These are regarded as playing a motivational role, since they help fulfil human needs for autonomy, competence or relatedness. They also help foster the willingness to dedicate effort towards the accomplishment of work. Personal resources such as self-efficacy, self-esteem or optimism can also be relevant for high levels of engagement. Thus, the JD-R ‘explains’ engagement on the basis that, where employees have high levels of job-related and/or personal resources, they are more likely to be engaged with their work.

The second most widely used framework was social exchange theory (SET), used in 26 studies. According to SET, relationships between employees and employers are based on norms of reciprocity. Where employees feel that they are being treated well and valued by their employer, they are more likely to respond by exerting effort on behalf of the employer in the form of raised levels of engagement.104

Conservation of resources theory, used in 14 studies, is based on the premise that individuals seek to acquire and preserve valued resources, which can be personal, energetic, social or material resources. Resource-gain spirals occur when individuals are able to build on resources they already have, and resource-loss spirals arise for those without access to strong resource pools. According to this view, the provision of resources may be particularly salient in raising engagement levels among those who are experiencing high levels of demand.107

Broaden-and-build theory was used in eight studies. Fredrickson146 argued that engagement is more likely to occur when individuals experience positive rather than negative emotions, since these create the space for a broader range of thought–action repertoire. Activated positive affect is important for stimulating action.29 Hence, those drawing on broaden-and-build theory argue that individuals who experience positive emotions are able to draw on a wider range of behavioural responses and hence are more likely to be engaged.

Seven referred explicitly to Kahn’s21 engagement theory, also referred to as the ‘needs satisfying’ approach,63 which is based on the premise that engagement is influenced by three antecedent psychological conditions: experienced meaningfulness of work (or feeling that one experiences a return for the effort expended in working); experienced psychological safety (or feeling able to demonstrate engagement without fear of negative consequences); and experienced availability (or having sufficient personal resources to experience engagement). Kahn21 argues that these three conditions are influenced by the nature of the job, the social environment, and personal resources and energy. This perspective draws on job characteristics theory30 and shows that some aspects of work design such as autonomy, feedback and task significance will generate the psychological conditions necessary for engagement.

All the remaining theories or frameworks referred to in the studies were used in five papers or fewer.

Summary of theoretical frameworks

The predominant theoretical framework used in the engagement literature is the JD-R framework. It is important to note that, in line with the principal conceptualisation of engagement as a work-related state of mind, most of the theories used to explain the engagement process are derived from the psychology field. The instances of theories and models from work sociology or industrial relations such as critical HRM theory78 are very few. Consequently, most of the theorisation around engagement adopts a within-person perspective that does not take account of the broader social or organisational context,147 individual differences16 or the contested nature of engagement as a potential tool for managerial control.17

Engagement definitions, models and theories: synthesis

The roots of engagement within the academic literature can be traced back to the work of William Kahn.21 Although Kahn saw engagement as the expression of the preferred self in relation to work roles, and some subsequent researchers have sought to operationalise Kahn’s framework, the academic field has come to be dominated by the work of the Utrecht Group, which has argued that engagement is a positive, activated state of mind experienced by individuals in relation to their work, and has three facets: vigour, dedication and absorption. The UWES has been used as the means to evaluate engagement levels in 83% of the studies of engagement deemed to have met the quality threshold for inclusion. The JD-R framework was mentioned as a major theoretical framework in 39% of the empirical papers included. The majority of studies using the UWES are based on the JD-R framework.

Some other scales have been developed based on a conceptualisation of engagement as something that employees can experience in relation to their employer overall, or towards their work group; however, these studies are in the minority.

More recently, studies are starting to take place that consider engagement as a strategy for people management78 or form of communication.79 This perspective is more aligned with the practitioner perspective, whereby engagement tends to be viewed either as an employment relations strategy or as a composite attitudinal and behavioural construct.18,148 However, no quantitative measures that met the quality threshold were identified, so this body of work comprises qualitative studies.

The evidence from prior studies concerning the validity and reliability of the engagement construct has been equivocal, although there is some preliminary evidence that engagement has both construct and discriminant validity. This issue is explored further in subsequent chapters, particularly Chapter 7.

Summary

In this chapter, we have reviewed how engagement has been defined within the academic literature, discussed the main measures used to evaluate engagement and examined the main theories used to explain the engagement process. Our analysis showed the predominance of the UWES as the means of evaluating engagement levels, and the JD-R analytical framework. In the next chapter, we present the results of our data extraction in relation to the association between engagement and morale.

Copyright © Queen’s Printer and Controller of HMSO 2015. This work was produced by Bailey et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Included under terms of UK Non-commercial Government License.

Bookshelf ID: NBK299343

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