A Phenomenological Research on the Lived Experience of Lipoabdominoplasty Clients

Background: Every year, a lot of cosmetic procedures are performed on female clients. Liposuction is one of the most common cosmetic surgeries conducted with abdominoplasty. With regard to the increasing number of lipoabdominoplasty clients and the probability of developing severe complications, the question of “what is the lived experience of people undergoing lipoabdominoplasty” comes to mind.

Objectives: This study was conducted to explore the females’ experiences of undergoing a lipoabdominoplasty surgery.

Patients and Methods: This study was a phenomenological qualitative research. Individual unstructured interviews were used for data collection. Participants were selected among female clients of lipoabdominoplasty. Van Manen method was used for data analysis.

Results: Seventeen female lipoabdominoplasty clients participated in the present study. Three main themes were emerged from the participants’ experiences, including “from good to bad”, “pain for freedom” and “interminable worries”. Findings showed that most of the participants faced a number of individual and social problems due to being “fat” and “ugly”. They tried different ways to gain beauty and physical fitness. They tended to cosmetic surgery to meet their goal fast and easily. They faced and accepted the surgery dangers and complications and underwent it. Finishing the recovery period and being relieved from surgery complications, they met their beauty goals and experienced a feeling of satisfaction to some extent; but, they faced worries and annoying mental involvements with how to maintain the surgery results.

Conclusions: Based on the participants’ experiences, undergoing lipoabdominoplasty is accompanied with risks, continuous worries and mental involvements. The participants advised the people who think of a liposuction or an abdominoplasty surgery to be careful and not to think about surgery as the first way to get rid of fatness and unfitness.

Body image is an important part of self-concept ( 1 ). An appropriate body image leads to developing a positive self-concept and consequently good function in role playing, self-esteem and identity aspects. Conversely, possessing an inappropriate body image leads to developing a negative self-concept and bad function in the aforementioned aspects ( 2 , 3 ). Dissatisfied with the body image and with negative self-concept, people tend to make changes in their appearance to obtain the ideal body image ( 4 ). Cosmetic surgery is a method to change the appearance which is increasing especially among females. American Society of Plastic Surgeons (ASPS) reported that 91% of all cosmetic surgeries in 2012 were performed on female clients ( 5 ). One of the most common cosmetic surgical procedures around the world is known as liposuction which is accounted among difficult and time-consuming surgeries and may be accompanied with complications such as septic shock, severe local pain, decreased level of consciousness, necrosis, ischemia and pulmonary emboli, especially when it is performed simultaneously with abdominoplasty ( 6 – 8 ). Several studies have reported dangerous complications and death following liposuction surgery ( 9 – 12 ). Some researchers paid attention to the persuading factors to undergo cosmetic surgeries. Didie and Sarwer, in a study aimed to assess the factors influencing the decision to undergo cosmetic surgery of breast augmentation, reported that these women were severely dissatisfied with their appearance ( 13 ). Mohammadpanah Ardakan and Yousefi found out that cosmetic surgery clients almost experience an inner humiliation and undergo surgery to obtain an ideal self-concept ( 14 ). Mousavizadeh et al. reported that the purpose of cosmetic surgery clients was to improve the appearance or function of an organ ( 15 ). With regards to the importance and impact of self-concept on peoples’ general health status, social relationships and quality of life ( 2 ), the increasing tendency for cosmetic surgeries especially among females seems to be a consequent of trying to improve social and familial relationships. Nevertheless, such a study has not been performed on lipoabdominoplasty clients yet. Therefore, questions such as what problems do these people have, how do they feel and live, why and how do they convince themselves to undergo the surgery, what do they know about the surgery, what is the purpose of these people to undergo the surgery, what happens to them before and after the surgery, what changes are made in their lives after the surgery, are they satisfied with the surgery results, what happens to them after the recovery period, what happens to their lives, and so many other questions remains unanswered. Such questions which are related to experiences of people about a certain event cannot be answered with quantitative research methods; they need to be assessed qualitatively. Considering the popularity of lipoabdominoplasty, and on the other hand, the complications and probable dangers in such surgeries, it seemed necessary to conduct a study on lipoabdominoplasty clients.

The present study aimed to explore the experiences of females undergoing lipoabdominoplasty surgery.

This qualitative research was conducted through phenomenology method. The participants were selected purposefully from lipoabdominoplasty clients and then were interviewed individually. For the beginning of the study, the researchers took approvals from Kashan University of Medical Sciences (KAUMS) and then referred to the medical records units of relevant hospitals in Kashan and Isfahan cities, Iran, to take a list of lipoabdominoplasty clients who had undergone this surgery in those hospitals. After inviting the clients to participate in the study through telephone calls and taking their agreements, interview appointments were arranged. The interviews were performed in places proposed by participants. The main method of data gathering was in-depth unstructured interview. The interviews were performed in a peaceful setting for the participants such as their homes, workplaces or a quiet corner in public parks. In the interview meeting, after giving the information about the study by the interviewer, the participants signed written informed consent forms. The interview questions were open-ended to provide the participants with the opportunity to fully explain their experiences and perceptions. The main questions included: “please tell the real story of your life from the time you made your decision to undergo surgery till now”, “please compare a usual day of your life before and after the surgery” and “please give real examples of your experiences about this event”. Regarding every participant’s experiences, other follow up open-ended questions were asked to understand the participant’s experiences, such as “how did you feel about yourself after the surgery?” and “what changes were made in your life after the surgery?”. The interviews were recorded by an MP3 recorder. Every interview meeting lasted from 30 to 90 minutes. At the end of the interviews, participants were asked to introduce any other lipoabdominoplasty client they knew. The interviews were continued till data saturation, so we interviewed 17 female participants.

Van Manen method was used for data analysis, which includes six research activities: turning to a phenomenon which seriously interests us and commits us to the world, investigating experience as we live it rather than as we conceptualize it, reflecting on the essential themes that characterize the phenomenon, describing the phenomenon through the art of writing and rewriting, manipulating a strong and oriented relation to the phenomenon, and balancing the research context by considering parts and whole.

Van Manen believes that this is not a step-by-step linear research procedure to follow and one can work on various activities intermittently or simultaneously ( 16 ).

In the first activity of the present study, the research question was formulated based on the unanswered questions in the researchers’ minds regarding lipoabdominoplasty surgery. The research question was “what is the lived experience of people from lipoabdominoplasty surgery?”

In the second activity, searching to find the source of phenomenon, women who had undergone lipoabdominoplasty were selected purposefully and interviewed. The inclusion criteria included: undergoing lipoabdominoplasty, passing at least three months from the surgery, being able to communicate in an understandable dialect for the researcher, being accessible (address and telephone number), being completely conscious, and willing to participate in the study. The exclusion criteria were: catching a physical or mental illness through which participation would not be possible and not being accessible before member checking of the codes.

In the third activity, the recorded interviews were written as transcript verbatim. Each interview was read and reread carefully several times to emerge the essential structure of the participants’ experiences. Van Manen suggested three processes for isolating thematic statements which were used in the present study: the holistic or sententious approach, the selective or highlighting approach, and the detailed or line-by-line approach ( 16 ). After listing the patterns, the researchers classified the patterns, combined related patterns and formed themes to comprehensively describe the phenomenon of having a lipoabdominoplasty surgery.

In the fourth activity, the phenomenological text including research findings was written using the main themes and related subthemes, researchers’ perceptions from the participants’ experiences and samples of each participant’s stories.

In the fifth activity which in fact existed through all the activities, the researchers tried to keep the study question in mind the whole time and write brief notes about everything related to the subject to help better understanding of the lipoabdominoplasty phenomenon. In addition, the researchers tried not to enter their own viewpoints in the findings and described the phenomenon simply based on the participants’ experiences.

In the sixth and last activity, the researchers wrote and revised the phenomenological text several times based on the importance of each part, so that the text described the findings and the phenomenon appropriately.

To ensure the study rigor, the criteria described by Guba and Lincoln were used. These researchers introduced four criteria for judging the rigor of a qualitative research, including credibility, dependability, confirmability, and transferability ( 17 ). For credibility and dependability, prolonged engagement with the research subject, member checks and collaborative analysis were used. For member checks, the interview transcripts and the reports were given to and discussed with the participants to confirm or revise codes. For collaborative analysis, the transcripts and extracted codes were given to some qualitative researchers to verify the findings. For confirm ability, the researchers tried to provide an audit trail and document all the data, methods and decisions about the research. For transferability, the researcher presented the findings to some female clients eligible with the inclusion criteria, but not participated in the interviews, to determine if the findings represented their own experiences. In the present study, the researchers tried to enroll people with situations of extreme variety. For bracketing, the researchers wrote down the personal assumptions before data gathering and referred to them frequently during data analysis to make sure that the personal assumptions did not influence the data and all the results were the real experiences of participants.

In total, 17 females, 25-55 years old, who had experienced lipoabdominoplasty (at least once) participated in this study. Their personal characteristics are shown in Table 1 .

In total, 500 primary codes were emerged from participants’ experiences, which were organized in three main themes and six subthemes ( Table 2 ). The main themes included “from good to bad”, “pain for freedom” and “interminable worries”. These main themes had close relationships with each other and all of them were in line with the main goal of the present study, exploring the lived experience of lipoabdominoplasty surgery. These main themes and subthemes are presented here with parts of the exact speech of the participants, each one by a number to ensure anonymity of the participants.

4.1. From Good to Bad

According to participants’ experiences, the changes provoking them to undergo cosmetic surgery, were classified in the “from good to bad” main theme. The participants said they used to be beautiful and physically fit long ago, in their bachelorhood or pre-pregnancy period; but that attitude changed due to different reasons. Most of the participants were married and some others were divorced; so, they had experienced pregnancy and delivery at least once in their lives. They mentioned pregnancy and delivery as the main reasons for this undesirable change. Dealing with the unfamiliar feelings following the change, these women decided to make themselves beautiful and physically fit again. They tried different ways, but did not meet their goals. Getting to know about cosmetic surgery of the abdomen, the participants accepted the probable complications and dangers and underwent lipoabdominoplasty surgery.

With regards to the unpleasant changes in these women’s lives, and since we wanted to present these changes, we named this main theme as “from good to bad” which was organized into two subthemes: “good: the beauty” and “bad: the ugliness”.

Most of the participants said they were physically fit, beautiful and satisfied with their appearances before developing the undesirable changes which persuaded them to think about cosmetic surgery. In addition, they had good relationships with their families, friends, coworkers and other relatives. The participants’ experiences in this regard were classified in “good: the beauty” subtheme. Participant 1 said “I was a sportswoman, I used to do aerobic and bodybuilding, I cared about exercising, I love to exercise, I love to go to gym, I have participated in sport matches in other cities and even other countries”.

However, this beauty and satisfaction with the appearance was not permanent. All of the participants had lost their beauty and physical fitness for a reason, felt undesirable and unpleasant and experienced some problems in their individual and social lives. The participants’ experiences in this regard were classified in “bad: the ugliness” subtheme. Most of the participants were married and had experienced pregnancy and delivery (often caesarian) for several times. Participant 5 said “I had a lot of operations; three caesarians, one ovarian cyst surgery and once for hysterectomy; my abdomen got so big, so I also had abdominal hernia”. Participant 7 also said “when I got pregnant, my abdomen portended a lot; after my deliveries, my abdomen fell; like a balloon you fill with water, when you empty the balloon, it will never return to the first position”.

Following the ugliness, the participants’ lives changed. They complained about undesirable changes in their relationships with coworkers, friends, relatives, husbands, and children. Participant 5 said that she felt embarrassed in front of her coworkers because of her big abdomen. Participant 8 also said that she quit her job because of this embarrassing feeling. Most of the participants told stories about the negative effects of ugliness on their relationships with family members, especially their husbands and children. Participant 3 said that her husband and three children blamed her constantly and told her she was fat and ugly.

The participants tried different weight loss plans to get rid of the unpleasant feelings, embarrassment and torture. They experienced long and difficult diets, exhausting exercises, weight loss drugs and topical lipotropic agents. Not getting the ideal outcome, the participants were tempted to undergo abdominal cosmetic surgery to regain the beauty fast and easily.

4.2. Pain for Freedom

The participants sustained some difficulties and problems to undergo abdominal cosmetic surgery. They tolerated the discomforts prospecting to meet what they knew as the ideal outcome or the valuable goal after the recovery period. The difficulties and problems were over after a while and the participants’ goals of beauty and physical fitness were achieved to some extent. They experienced self-approbation, happiness and freedom.

To present the participants’ difficulties, problems, costs, complications, etc. in a way to be more pleasant, we named this main theme as “pain for freedom” which was organized into two subthemes: “surgery costs” and “satisfaction and freedom”.

These women experienced some discomforts after the surgery (in the recovery period), prospecting to meet their ideal goal (ie, beauty and physical fitness). In fact, they had to pay a value (beyond money) to meet their goal. The participants’ experiences in this regard were classified under the “surgery costs” subtheme. The participants encountered with some complications after revival, the most important of which were severe local pain in abdominal area, bleeding, and respiratory complications. These painful experiences were accompanied with hope for meeting their goals. Participant 1 mentioned pain, irritation, tension, and other discomforts she sustained in the recovery period, describing them “sweet” and said: “it was very painful; the pain was associated with irritation, because the abdomen skin was pulled; this caused an unpleasant feeling and a specific type of pain; however, I do not say this surgery was a mistake because it was my own willing and it was sweet for me”. In a similar experience, participant 8 said: “I had pain, but I tolerated it; those pains and discomforts were such a convenient thing for me because I was waiting to get rid of that big abdomen”.

More pleasant experiences had been started for the participants after the complications subsided. They met their goals and reached what they wanted, but to some extent. These women obtained positive outcomes due to surgery. As the most important result, they mentioned the feeling of getting rid of a disaster, feeling to be pleasant, to care for oneself, happiness from seeing their flat and small abdomens, and self-approbation. However, there were more important things beyond the aforementioned outcomes, such as being loved and respected, being satisfied with their sexual relationships, being able to participate in groups, playing roles in group activities, self-expression, high self-esteem, getting rid of blames, and getting rid of loneliness. The participants’ experiences in this regard were classified under the “satisfaction and freedom” subtheme.

Participant 1 was a sportswoman and thought that being a sportswoman and not being physically fit were in conflict. She felt that she had removed an important lesion from her body. She said: “that fatty lesion is not in my body anymore; it is what I wished for”. Participant 5 also said: “as soon as I revived, I stroked my abdomen. I enjoyed a lot. I acquired the natural status I desired for; the torture I tolerated was resolved; the status after the surgery was so pleasant for me; I can put on my desired dress; I feel lightness and ease”. She added: “I am satisfied with my appearance; my appearance is as I wished for; I am more comfort in my daily activities; I do not want to go back to that previous status”.

Others’ reactions had a great impact on these women’s feelings about themselves and satisfaction with the surgery. Participant 5 mentioned her easier attendance in groups, especially in occupational environment and said: “I have a better appearance among people; all say lucky you! my clients say wow! What did you do? You have improved a lot!”. Participant 7 who was a health instructor in a guidance school mentioned the positive feedbacks she received from her family and coworkers. She said: “after the surgery, my children said mom, how better you are! Where did that abdomen go? My coworkers said you seem so much younger; their relationships with me have become much better”.

4.3. Interminable Worries

Satisfaction with abdominal cosmetic surgery was a feeling, which in the participants’ experiences did not last so long. The feeling of concern supplanted it after a while. Participants were sensitized to health- and beauty-related topics such as watching weight, going on diet, and doing exercise. They tried to keep themselves away from factors causing the presurgery conditions to get back. They felt they should do their best to keep the surgery results. They had undergone the cosmetic surgery to be free from ugliness and become beautiful fast and easily, but keeping this beauty was another matter that was not easy and needed a lot of effort. On the other hand, friends and relatives of these women advised and monitored them to avoid overeating and to do regular exercise. To present the new issues that these women were faced to after the surgery, we named this main theme as “interminable worries” which was organized into two subthemes: “individual worries” and “living under control”.

Participants frequently mentioned the mental engagement they experienced with health-related topics, keeping physical fitness and the ideal weight after the surgery. They wanted to maintain the surgery results as much as possible. The participants’ experiences in this regard were classified under the “individual worries” subtheme.

Participant 8 mentioned that before the surgery, she tried to lose weight in different ways several times, but she did not succeed. After the surgery, she felt that she got close to her goal and she must maintain the surgery result. This subject came to her mind continuously. She said: “I try to maintain my current weight. I try not to overeat. I have a scale, I weigh myself frequently”. In a similar experience, participant 5 said: “It will be so good for me to skip dinner or to eat less rice; if I do so, it (presurgery conditions) will not come back for sure; so I try to skip dinner or to eat less rice”.

Relatives’ opinions and criticisms was another factor which forced these women to pay more attention to their physical condition and appearance. The participants felt they were being supervised by family members and friends. The participants’ experiences in this regard were classified under the “living under control” subtheme. Participant 1 mentioned her husband’s behavior after the surgery and said that he watched out for her eating and activities and warned her about avoiding the probable behaviors leading to go back to presurgery conditions. She said: “for all the difficulties I experienced, he encouraged me to try not to go back; but I almost felt, especially in the meal time, when we wanted to start eating, he told me ‘be careful, you are indulging, you should not go back to that condition, that is for yourself, because you put yourself in danger; you were stressed a lot; not only you, but also the family, me and our daughter; you should try to maintain your physical status”. Participant 9 also mentioned her friends applauded her within three to four months after the surgery for losing weight. She was so glad for this, but after about one year or more she gained some weight again. She said: “the ones who told me ‘how better you look’ the ones who told me ‘bravo’ this time they told me ‘why are you gaining weight again? What are you doing? Why don’t you watch yourself?’ They meant the diet and the exercise; they do not know how difficult it is”.

The experiences of participants from lipoabdominoplasty surgery were organized in three main themes including “from good to bad”, “pain for freedom” and “interminable worries”.

“From good to bad” was one of the main themes emerged from data including two subthemes: “good: the beauty” and “bad: the ugliness”. In searching to find studies related to the first subtheme, no similar studies were found and “good: the beauty” in this meaning is being represented for the first time in the present study. However, related to the second subtheme, “bad: the ugliness”, the results of the present study were congruent with some studies performed on other cosmetic surgeries. Researchers reported that the clients of other cosmetic surgeries sustained dissatisfaction with their appearance and consequently mood disorders, anxiety, depression, low emotional health, low quality of life, dissatisfaction with body image, low self-esteem, obesity stigma and losing social support. These clients underwent cosmetic surgery to get rid of these problems ( 18 – 22 ).

“Pain for freedom” was another main theme emerged from data. It included two subthemes: “surgery costs” and “satisfaction and freedom”.

Related to the first subtheme, “surgery costs”, the results of the present study were congruent with some studies. Koehler et al. assessed liposuction procedures on a sample of 116 people in two groups, cosmetic and noncosmetic seeking clients ( 10 ). They reported that patients came back to their jobs 14 and four days after the surgery, respectively. Both groups experienced complications such as seruma, bleeding, infection, local and chronic pain, edema, hematoma and deformity, but the rate of these complications was higher in the first group. In addition, satisfaction and self-esteem of the clients increased, especially in the second group ( 10 ). The results of this study showed that these people experienced complications of great importance, but after the surgery their satisfaction levels with their own appearance and their self-esteem increased. Menderes et al. in Turkey, assessing morbid obese patients who underwent bariatric surgery, reported that these people experienced some complications such as the problems with the incision, seruma, infection and hematoma postoperatively, but despite these problems, insight of these people toward themselves improved ( 23 ). Considering the findings of the present study and other aforementioned studies, it seems that dangers and complications of surgery can not hinder people from doing it. Beauty-seeking people accept them and select surgery to reach their goals, despite the probable dangers and complications.

Related to the second subtheme, “satisfaction and freedom”, the results of the present study were congruent with Didie and Sarwar’s study on mammoplasty clients. In a study aiming to assess motivational factors for undergoing mammoplasty, these researchers reported that these women were severely dissatisfied with their appearance preoperatively, while this dissatisfaction disappeared after the surgery and their sexual functions improved. Nevertheless, despite getting important positive outcomes, these women were more pleased with their inner feelings toward their appearance than outer factors such as romantic relationships or the socio-cultural aspects of beauty ( 13 ). Kinnunen, in a study on clients of facial cosmetic surgeries in Finland, reported that patients over the age of 55 looked at cosmetic surgery as a way to compensate the life’s tough experiences leading to early aging. They wanted to combat with the negative attitude toward old people and get rid of the factors causing them to seem older, sadder and swarthier than what they wished to be ( 24 ). Darisi et al. in a qualitative research on the people who wished to do cosmetic surgery reported that improving physical health led to earning emotional and social advantages from the viewpoint of the participants. These people had not undergone surgery, but they were deciding to do it; they thought that they could reach their desired emotional and social advantages following improving their physical health ( 25 ).

Castle et al. reviewed 36 studies about psychosocial consequences of cosmetic surgeries and reported that most of these people were satisfied with surgery outcomes and had found a better feeling toward them. Furthermore, self-respect, self-confidence, anxiety, shyness and quality of life improved in them ( 26 ). Other studies reported that the satisfaction with surgery outcomes depended on different factors such as the reason to do the surgery. One study on liposuction clients after surgery reported that the clients who underwent surgery not for cosmetic reasons had better results both physically and emotionally, and thus, were more satisfied with the surgery ( 10 ). Castle et al. introduced this as the patients’ expectations of surgery outcomes, and also the quality and the dose of change due to surgery as a predicting factor for the result of the surgery and its following satisfaction or dissatisfaction ( 26 ).

“Interminable worries” was the last theme emerged from data including two subthemes: “individual worries” and “living under control”.

Related to the first subtheme, “individual worries”, the results of the present study were congruent with some study results. Menderes et al. studied patients with mortal obesity who had undergone vertical banded gastroplasty (VBG) and cosmetic surgery and reported that weight and body mass index (BMI) greatly decreased in these patients and consequently their body image and social acceptability increased significantly. Although, they were engaged with cosmetic and fitness issues and felt that they were still unattractive and should lose more weight ( 23 ).

Other studies paid attention to the necessity of developing a healthy life style after the surgery; they reported that liposuction can decrease the fat aggregated in some specific areas of body, but it does not prevent gaining weight in future. In general, the positive outcomes of this type of surgery will be consistent until the clients maintain a healthy life style ( 20 , 21 ).

Lack of a healthy diet, physical activity and exercise and consequently gaining weight again, may lead the clients to a second cosmetic surgery. The results of some studies have shown that liposuction clients have gained the fat that was decreased by the surgery, not only in the surgery area but also in different parts of their body. Therefore, a lot of them decided to undergo surgery again to get rid of the excess fat ( 22 , 27 ). Related to the second subtheme, “living under control”, no similar findings were found in other studies and it was introduced for the first time in this study.

The three main themes including “from good to bad”, “pain for freedom” and “interminable worries”, extracted from the participants’ experiences, showed that they faced unfitness and ugliness and they tended to cosmetic surgery to get rid of the negative personal and social consequences. They faced post-operative problems and complications; but after finishing those problems, they met their goals in beauty to some extent and felt pleasant. This satisfaction persuaded these women to endeavor to keep the condition they acquired through surgery. Therefore, most of them faced mental engagements and permanent worries about fitness and beauty after the surgery, which was annoying for them. It seemed like they got rid of a series of problems, difficulties and mental engagements and met new problems and worries. Based on the experiments of the participants in this study, it is advised to people who are thinking about undergoing a liposuction or abdominoplasty to make careful decisions. In addition, the experiences of these people may be used as a guide to provide better care by healthcare teams.

5.1. Study Limitations

In the present study, the participants’ experiences were categorized in three main themes and six subthemes; although, regarding the nature of qualitative research, repetition of this research by other researchers may lead to different categories. Researchers of the present study tried to involve the participants of extreme varieties; although, other people who did not participate in the present study may have different experiences. Therefore, repetition of this research on participants with different conditions may lead to other data and results besides the results of the present study. Another limitation of the present study was that in this research only lipoabdominoplasty was considered, while other cosmetic surgeries such as rhinoplasty are common in the country. Therefore, experiences of people who had undergone other cosmetic surgeries remained unknown to the researchers.

5.2. Study Implications

Promotion of less expensive methods than surgery with less complication to reach physical fitness via public media is recommended. In addition, it is recommended to consider this subject and related issues in educational programs for nurses who work in operating rooms, cosmetic surgery operating rooms, post-anesthesia care units and surgery wards and even for nursing students who will be working in such fields in future.

5.3. Suggestions for Further Investigations

It is recommended to carry out other researches with the same goal to fulfill the results of the present study in other cities. Furthermore, it is recommended to explore the experiences of people who have undergone other types of cosmetic surgeries.

This article was extracted from a M.Sc. thesis written by Maryam Houshmand, supervised by Dr. Mohsen Adib-Hajbaghery. The researchers gratefully acknowledge the support and generosity of Dr. Negin Masoudi Alavi, adviser and reviewer, and Dr. Mohammad Afshar, reviewer of the present thesis, without whose help the present study could not be completed. In addition, the researchers thank all the participants of this study and their families, who helped fulfilling this project.