3.3 Data collection
3.3.1 Survey questionnaires
3.3.1.1 Questionnaire design and development
There are a number of general considerations in the development of a satisfactory questionnaire (Bowling, 2005). The whole process of questionnaire design and construction in this study covered several important steps to ensure the validity and reliability of the research instrument. They included: identifying the conceptual domains, questions, and scales; developing the draft questionnaires; validating the questionnaires; and refining the questionnaires.
3.3.1.1.1 Domains for questionnaire
The first step in developing questionnaires is to identify the information needed to support research questions and the hypothesis. A continual reading, review of the relevant topics of the study, research questions and hypothesis, will keep the questionnaire focused and avoid unnecessary questions. In this study, the key domains were constructed from the literature review and the research framework. The table below is a summary of these domains, variables, definitions and
Table 3-1: Domains of questionnaire, their variables and definitions
Domains Variables Definitions
Frequency of nail biting Current, past, number of nail biting a day.
The number of actions of putting the finger nails or toe nails in the mouth
Proposed causes of nail biting
Anxiety, mineral imbalances, psychological disorders, poor diet, others.
Different views of the main factors that cause nail biting.
Complications associated with nail biting
Dental problems, poor diet, infections, skin damages, muscle pain, eyes twitching.
Dental problems: gum infection, gum bleeding, toothache, worn teeth, crack tooth enamel, teeth falling out, nail embedded between teeth. Infections: cold & flu, fungal
infections, cold sores, skin infections and skin infections.
Muscle pain: neck pain and stiffness, legs pain and cramps.
Poor diet: fussy eating, inconsistent diet, and lack of variety in diet.
Treatments for nail biting
Bitter nail polish, hypnosis, punishment, psycho- therapy, mineral supplements & medications.
Bitter nail polish- a very bitter taste inert chemical.
Hypnosis- a trance-like state, in which the person’s thoughts and actions can be influenced by a hypnotherapist.
Milk intake Amount of milk consume a day
Milk is a rich source of calcium that is required for growing in children.
Fussy eating Red meat (beef, lamb), chicken, cheese, nuts, pork, vegetables, fruits.
Things that the person does not like to eat and tend not to eat.
Social issues Bullying, anti-social behaviours, isolation, etc.
Health issues associated with nail biting person
ADHD, bed wetting, anxiety, Tourette syndrome, depression, jaw joint pain,
psychiatric disorder and oppositional defiant disorder.
ADHD: Attention deficit hyperactivity disorder.
3.3.1.1.2 Questions and scales
A search for published articles, books and websites related to nail biting was conducted in order to identify appropriate questions and scales to fit the relevant domains. The keywords used to search relevant questionnaires and scales were:
Nail biting
Onychophagia
Nail biting in children
Mineral deficiency and nail biting
Psychological disorders and nail biting
Children and fussy eating
Nail biting and treatments
Mineral therapy
Mineral status analysis
Children and nutrition deficiency
Common mineral deficiency in children
Magnesium and children
The search was conducted via Medline, PubMed, online Wiley Library, Scholar Google search and Primary search.
3.3.1.1.3 Development of questionnaire
3.3.1.1.3.1 Formulating questions and scales
Two basic types of questions were employed in the questionnaire: closed ended and open-ended questions. The former type is structured while the latter one is
unstructured. Both types have advantages and limitations, and thus were combined to complement each other in the study’s questionnaires.
Open-ended questions are pre-coded questions that are prompted by a full range of possible alternative answers. Participants could select one or more of the pre-coded answers provided. Two main concerns in developing the open-ended questions were the number of alternatives/options and the order bias. The alternative
answers were developed collectively exhaustive and mutually exclusive. In addition to the suggested alternatives, an “other” (please specify) category was included in all the multiple-choice questions. Instructions were also included to ensure survey respondents were clear about what to do, such as whether to select only one answer or choose all that apply. If the alternative choices are too long, respondents might find the questions more difficult to answer, hence might be discouraged from completing the survey. Therefore, the researchers broke down the questions to more than one to simplify the workload for respondents. Order bias is the
respondents’ natural inclination to select an alternative simply because the answer choice appears at a certain position in a list. Alternatives that stand at the beginning and at the end of a list are often selected the most compared to the answers in the middle in a list. To prevent this order bias, several versions of the questionnaire were prepared with different orders of the answer choices.
The closed-ended questions are generally easy for respondents to complete. They are also easier to analyse, tabulate and compare information than open-ended questions. In general, respondents are inclined to cooperate and complete the survey if the questions are structured with closed-ended questions. However, it is more challenging to develop a list of exhaustive alternatives in the answer for this type of questions. Moreover, the list of alternatives itself can be biased. To
overcome this shortcoming, open-ended questions were employed.
3.3.1.1.3.2 Open-ended questions
Unlike close-ended questions, open-ended ones are unstructured and allow respondents to freely express their views, attitudes and opinions without bias associated with predefined alternatives. Therefore, they are helpful in investigating
underlying causes, motivations, beliefs and attitudes in exploratory studies. They also help researchers understand the multiple choices questions more clearly and form an essential component to their exploratory study. The current nail biting study employed the open-ended questions mainly in the interviews and a few of them in the survey questionnaires.
3.3.1.1.3.3 Structuring questionnaires
It is important to take into consideration the characteristics of the respondents, the language used and the context of the questions as respondents may have different educational levels, experiences, and backgrounds. For example, the language and context used for health practitioners may not be appropriate for the parents of nail biting children. If technical terms or medical terms are used in the questionnaire for the parent respondents, there might be a high incidence of uncertainty or no opinion responses. Therefore, for parents of nail biting children, simple words and plain language were used in the questionnaires.
Another issue to consider was the order of the questions, which could affect the results of the survey. It is suggested by survey experts that whenever possible, early questions in a questionnaire should be easy and pleasant to answer to encourage respondents to continue and complete the survey. Therefore, in the two
questionnaires of the survey, the more difficult closed-ended questions and open- ended ones were placed towards the end of the survey.
The order of the choices on a scale is also believed to make questions more pleasant or odd, easier or more difficult to answer. According to the survey guidelines, the more logical or natural order for the choices is to present “True” followed by “False” or “Agree” to “Disagree”. For the same logic, positive to negative and excellent to poor rating scales should be presented in those natural orders. All of these guidelines were observed and followed in the building of the two questionnaires in this present study.
3.3.1.1.3.4 Questionnaire design checklist
1. Validate that all the information gathered fully addresses the overall components of the research problems.
2. Understand the key aspects of the target population. 3. Is the question relevant?
4. Avoid using questions that have two different aspects to the subject. 5. Have the respondent been informed?
6. Is the question too long?
7. Does it require great effort to answer? 8. Is it sensitive?
9. Is it easy to understand?
10. Do the multiple-choice questions include all the response alternatives? 11. Is the question order bias?
12. Does it have many ambiguous words (such as usually, normally, frequently, often, regularly, occasionally, sometimes)?
3.3.1.1.4 Expert review
After the completion of questionnaire design, it is important to have experts to examine the questionnaire for potential problems. Experts can be survey methodologists or survey researchers with extensive experience in writing and administering questionnaires, who could identify problems and may recommend possible solutions such as rewording, reordering questions, examining scales and questions to ensure sufficient coverage of the domain areas of the research. In this study, three experts with extensive experience in research and relevant field of research were invited to review the two questionnaires. All three experts
willingly accepted the invitation to review the questionnaires. A review package was sent to them, including the following documents:
A summary of the background and the goals of the study;
Literature review chapter;
A draft questionnaire; and
Questionnaire design checklist.
All of the returned comments and suggestions, such as removal of technical terms or medical jargons in the questionnaire (e.g., compulsive disorders, misguided perfection instinct etc.); rephrase the questions to make them easier for the participants to answer “Why do you think children bite their nails?” to “What is your understanding of the most common causes of nail biting?”; corrections of typographical errors, etc. by the three experts were carefully noted and the two draft questionnaires were revised accordingly.
3.3.1.1.5 Questionnaire pre-test
Another important step in questionnaire formulation is to conduct a trial of the questionnaire with a group of sample respondents before the main survey
administration. The main purpose of a trial or pilot study is to detect and improve weaknesses in the questionnaire design that can have an influence on the findings and hance the achievement of the research objectives. Questionnaire pre-testing or piloting is highly advocated by researchers to validate the research procedures during the phase of data collection, and consequently enhancing the validity and reliability of the main research (Glesne & Peshkin, 1992; Wolf, 1997); particular, this step of pre-testing questionnaires is reported to greatly assist the investigator to identify any unanticipated issues such as wording, instructions, level of difficulties in answering the questions, and length of the questions. In this study, questionnaire pre-testing was conducted with two different groups of target respondents, including nail biters/parents of nail biters and health professionals. They were invited to join the trial run of the questionnaire and responded to a checklist
(Appendix 8) about various aspects of the questionnaire, including format, content, wording, and completion time.
Pilot Questionnaire Checklist
1. How long did it takes for you to complete the questionnaires?... minutes
2. Did you complete the questionnaire in one session or over two or more sessions?
3. How did you find the length of the survey? a. Fine
b. Too short
c. Long but bearable d. Too long
4. How did you find the wording of the questions? a. Fine
b. Easy to understand c. Too technical
d. Too difficult to understand
5. Did you find any of the questions offensive or too sensitive? a. No
b. Yes (please specify which question): ……….. 6. How did you find the size of the print?
b. Difficult to read
7. How did you find the instructions? a. Easy/understandable b. Hard to understand
8. Did you find the questions are repetitive? a. No
b. Yes (please specify the repetitive questions): ………. 9. Do you have any comments about the survey?
The suggestions and feedback (e.g., removal of many medical jargons and repetitive questions/options, shortening the questionnaires from 35 to 17 question items, increasing the font size for readability, corrections of typos, etc.) from the two groups of questionnaire trial participants were then utilised to make appropriate adjustments. Thanks to this process, the questionnaires were believed to be well suited to the target respondents.
3.3.1.1.6 Final versions of the two questionnaires
After the whole process of drafting, revising, and refining, the quantitative instruments of the present study consisted of a four-page A4 booklet of
“Questionnaire for nail biters or the parents of nail biting children” (Appendices 2 and 3) and a three-page A4 booklet of “Questionnaire for health professionals.” (Appendix 4)
The questionnaire for parents composed of 17 items divided into two main sections. Section A covered three items of general questions about the nail biting child or nail biter, such as age, body weight, body height, and whether the child / nail biter was a past or current nail biter. Section B included a range of questions related to the nail biting habit and health status of the nail biting child or nail biter. Specifically, they were related to the duration and frequency of the child’s / nail biter’s nail
biting habit; the perceived most common cause of nail biting; the nail biting related health problems suffered by the child or nail biter; the utilised treatment methods and their effectiveness; the child’s or nail biter’s diet preferences; current
medications or supplements taken by the child or nail biter; the child’s or nail biter’s co-occurring health issues diagnosed by doctors; and possible social issues
experienced by the nail biting child or nail biter. At the end of the questionnaire, an open-ended question was included to invite for parents’ or nail biters’ further comments and suggestions.
The questionnaire for health practitioners consisted of seven items that aimed to explore their views and experiences in dealing with nail biting among children. Specifically, the questions were related to their profession (medical doctor, pharmacist, naturopath, or others); their perceived most probable cause of nail biting; observed health issues and disorders of nail biters; and recommended treatment methods.
The questionnaires for parents of nail biting children / nail biters were presented in the following order:
1. General questions: participant’s / child’s age, body weight, height, nail biting status (current or past), duration of nail biting condition, and frequency of nail biting.
2. Common cause: covering anxiety, mineral, psychological and diet perspectives.
3. Health status: covering common associated health issues such as dental problems, infections, infestations and muscle pain.
4. Treatments: including common bitter nail polish, hypnotherapy, punishment, psychotherapy, mineral supplements and medications. 5. Diet: covering amount of milk daily intake and fussy eating of certain food.
6. Other medications/supplements: including Vitamins, Minerals, herbs, over the counter medications and prescribed medications.
7. Co-occurring health issues: covering common health issues that frequently associated with nail biters such as ADHD, bed wetting, oppositional defiant disorder, anxiety disorder, Tourette syndrome, depression, joint pain, psychiatric disorder and others.
8. Social issue: including only yes or no question.
The questionnaires for health practitioners were presented as follow:
1. Profession: includes medical doctors, pharmacist, naturopath and others 2. Possible causes: covering anxiety/nervousness/stress, mineral deficiency,
psychological disorders, genetic, poor diet
3. Health status of nail biting children: dental, infections and infestations 4. Co-occurring health disorders: ADHD, enuresis, anxiety, oppositional defiant
disorder, Tourette syndrome, depression, jaw joint pain and psychiatric disorder(s).
5. Treatments: bitter nail polish, hypnosis, punishment, psycho-therapy, mineral supplements, medications and others.
6. Experiences of treating nail biting: including yes or no option.
3.3.1.1.7 Questionnaire validity and reliability
The two survey questionnaires had undergone face and construct validation between July 2011 and March 2012. Face validity, an important aspect of an instrument’s validity, refers to whether the instrument or measure looks valid to the targeted users (Glesne & Peshkin, 1992). It normally involves judgment on the content, format and general usefulness of the instrument from a personal
perspective. In this study, face validity was assessed and established in terms of the presentation and relevance of the questionnaire by two supervisors, two academic
staff members from different professional backgrounds, and the questionnaire trial respondents. The questionnaires were revised at various stages, incorporating the feedback and comments from these experts and target participants.
Construct validity was also assessed, to ensure the questionnaires measured what they set out to measure. Construct validity seeks to establish the relationship
between the operational definition of a variable and the true theoretical meaning of a concept (Burns, 2000). In other words, it aims to ensure (Mark, 2003).