Children's Perceptions of Pictures Intended to Measure Anxiety During Hospitalization

Acceptability of a Serious Game About Proton Radiotherapy Designed for Children Aged 5 to 14 Years and Its Potential Impact on Perceived Anxiety: Feasibility and Randomized Controlled Pilot Trial

Background

Children who are going to undergo radiotherapy have displayed fear and anxiety. Therefore, a web-based serious game was developed as a psychological preparation to investigate if it could affect anxiety levels. In an earlier stage, children with experience of radiotherapy had been part of the developmental process.

Objective

The study aimed to investigate the feasibility in terms of reach, usability, and acceptability of a serious game about proton radiotherapy and to pilot that it did not increase anxiety levels in children aged 5 to 14 years undergoing radiotherapy.

Methods

The design was a randomized controlled pilot trial with predefined feasibility criteria. In total, 28 children were assessed for eligibility, and 23 met the inclusion criteria. They were consecutively randomized into 1 of 2 study arms. One child was excluded after randomization. If randomized into arm 1, the children received the intervention before treatment started. Children in arm 2 were treated as controls. Questionnaires with fixed answers were used to assess anxiety levels (an adapted version of the State-Trait Anxiety Inventory for Children) and experiences of gameplay (an adapted version of Player Experience of Need Satisfaction [PENS]). The children were asked to answer questionnaires at 5 different measurement occasions during their radiotherapy treatment.

Results

In arm 1, age ranged from 5 to 13 (mean 8.4, SD 2.4) years. In arm 2, age ranged from 5 to 11 (mean 7.6, SD 2.3) years. The sample consisted of 15 girls and 7 boys. The feasibility criterion that the children should play the game for 20 minutes or more was not met. Mean playtime for children in arm 1 was 32.1 (SD 23.8) minutes, where 18 children had played for at least 15 minutes. The criterion that 70% (n=16) or more of the participants should return all of the questionnaires was not met; however, more than 73% (n=16) returned the PENS questionnaires. The State-Trait Anxiety Inventory for Children was returned by 73% (n=16) on day 0, 77% (n=17) on day 1, 82% (n=18) on day 3, 82% (n=18) on day 6, and 86% (n=19) on day 15.

Conclusions

All feasibility criteria set for the study were not met, suggesting that adaptions need to be made if a future study is to be undertaken. Further, the analysis revealed that there was no indication that playing increased the children's self-reported anxiety. The PENS questionnaire adapted for children showed promising results regarding player satisfaction when using the serious game. When studying children with severe conditions and young age, 5 measurement occasions seemed to be too many. Measuring both player satisfaction or experience and knowledge transfer would be preferable in future studies.

Anxiety among children a year after the onset of the COVID-19 pandemic: a Brazilian cross-sectional online survey

Aim

This study seeks to build upon a prior investigation into the impact of the COVID-19 pandemic and to evaluate the prevalence of anxiety among Brazilian children, along with its associated factors, one year after the commencement of the pandemic.

Design

A cross-sectional study.

Methods

A survey was conducted from April–May 2021 in Brazil. Children aged 6–12 and their guardians from five Brazilian regions were included. The Children’s Anxiety Questionnaire (CAQ; scores 4–12) and Numerical Rating Scale (NRS; scores 0–10) were used to measure anxiety.

Results

Of the 906 children, 53.3% were girls (average age = 8.79 ± 2.05 years). Mothers responded for 87.1% of the children, and 70.9% were from the Southeast region. Based on a CAQ score of ≥9 and an NRS score of ≥8, the anxiety prevalence was 24.9 and 34.9%, respectively. Using logistic regression, a CAQ ≥9 score was associated with older children and children with chronic disease or disability. An NRS score of ≥8 was associated with reduced family income during the pandemic, the person caring for the children, and with children with chronic disease or disability.

Conclusion

These findings suggest the need to implement public health actions aimed at children with chronic diseases and disabilities and their parents to guide them regarding the warning signs and negative emotions. This study contributes to characterizing the evolution of the pandemic in Brazil and provides a basis for comparison with the literature from other countries.

Developing and validating a 2D digital version of the Brazilian Children's anxiety questionnaire

PURPOSE

This study aims to transpose the printed Brazilian Children's Anxiety Questionnaire (CAQ BR) into a 2D digital format, validate it with nurses and hospitalized children, and analyze the association between the printed and 2D digital format versions.

DESIGN AND METHOD

This is a descriptive and multicentric study, conducted from 2021 to 2022 on working in pediatric care at two hospitals in Brazil. The nurses analyzed the printed and digital instruments and subsequently applied them to a child and proposed suggestions. A cutoff score of 0.80 on the content validity index was used; items that scored an average lower than the CVI in the study were adequate. Eighty children responded to the questionnaires sequentially according to the randomization table. A 90% agreement rate was used.

RESULTS

The digital instrument was validated in content by 51 experts, with a CVI of 0.95. Face validation data for 80 children (mean age = 7.9 years) shows a 90% agreement rate. The intraclass correlation index for the general score was 0.87 and 95% CI (0.79-0.91), which shows good stability of the children's responses in both questionnaires. In addition, 59% (n = 47) of the children reported a preference for the digital questionnaire.

CONCLUSIONS

The digital CAQ BR can be used as an audiovisual instrument by nurses when implementing the systematization of nursing care in pediatrics.

PRACTICAL IMPLICATIONS

The digital 2D version was successfully applied and can be used in hospitals to measure children's self-reported anxiety.

Virtual reality's impact on children with type 1 diabetes: a proof-of-concept randomized cross-over trial on anxiety, pain, adherence, and glycemic control

AIMS

 Assess the effectiveness of virtual reality (VR) technology, in reducing pain and anxiety, and improving adherence and glycemic control among children with type 1 diabetes (T1D).

METHODS

Children with T1D, managed with continuous glucose monitoring and insulin pumps, were recruited for a randomized cross-over trial. Children were randomized to one of two interventions for diabetes management: group 1 used VR glasses first and group 2 listened to vocal-guided affective imagery first (audio). After 1 month, the interventions were crossed over. The outcome measures included pain and anxiety assessment, adherence, glycemic control, and patient-reported outcome measures (PROMs) of VR satisfaction and effectiveness.

RESULTS

 Forty children, mean age 11.4 ± 1.8 years, were participated. During the VR part, the monthly mean pain score compared to the baseline improved in both groups by 30% (p = 0.03). A 14% reduction in the state anxiety score was observed from baseline to 1 month in both groups (p = 0.009). Glycemic control measures including time in range, time above range, and glucose management indicator improved in both groups during VR part (p < 0.004 for all), compared to audio part. After one month, the patient-reported outcome measure (PROM) of satisfaction and effectiveness was sixfold higher after 1 month in group 1 compared to group 2 (p = 0.002). Adherence improved for both groups.

CONCLUSIONS

VR was shown to be effective in reducing pain and anxiety, improving adherence, PROM, and glycemic control among children with T1D. We suggest incorporating VR technology in pediatric diabetes clinics to facilitate and improve coping and management of diabetes.

TRIAL REGISTRATION

Trial registration number and date of registration for prospectively registered trials:ClinicalTrials.gov Identifier: NCT05883267, May 10th, 2023.

Educational intervention through a comic book for preoperative anxiety in children, adolescents, and their parents: A randomized clinical trial

BACKGROUND

Reducing preoperative anxiety can help optimize surgical care.

AIM

To analyze the effectiveness of verbal guidance by nurses versus verbal guidance combined with a comic book on preoperative anxiety in children and their parents.

METHODS

We conducted a randomized parallel, two-group controlled clinical trial in the pediatric ward and a blinded anxiety assessment in the operating room of a Brazilian hospital. Individuals aged 6-14 years undergoing surgical procedures of up to 4 h for the first time were included in the study. Parents who were adults, literate, and able to communicate verbally were included. The primary outcome was the children's anxiety, measured by the Children Anxiety Questionnaire (CAQ), Visual Analog Scale (VAS), and the modified Yale Preoperative Anxiety Scale (mYPAS); the secondary outcome was the parents' anxiety, assessed by the Hamilton Anxiety Rating Scale. Participants were divided into the intervention (IG; n = 60) and control (CG; n = 60) groups.

FINDINGS

The two groups were homogeneous. The median age of the children was 8 years. No significant differences were observed in the CAQ and VAS scores between the two assessment time points or in the mYPAS scores between the IG and CG. However, parents' anxiety significantly decreased in both groups.

APPLICATION TO PRACTICE

Preoperative guidance by nurses, either verbal only or verbal information with a comic book proved beneficial in reducing parental anxiety. However, both interventions, performed on the day of surgery, failed to reduce preoperative anxiety in children and adolescents upon admission to the operating room. We recommended the process of preparing the child should begin after scheduling the surgery.

Association of Pre-procedural Anxiety with Procedure-related Pain During Outpatient Pediatric Burn Care: A Pilot Study

The relationship between preprocedural anxiety and pain is not clear but has the potential to change the way pediatric patients need to be cared for prior to burn procedures. Using results from our recent randomized clinical trial among outpatient burn patients (n=90) age 6-17 years, the objective of this subsequent analysis was to assess whether preprocedural anxiety was associated with self-reported and researcher observed pain scores. Anxiety before the dressing change was assessed using an abbreviated State-Trait Anxiety Inventory for Children (range 6-21) and reported with 95% confidence intervals (CI). Self-reported pain was reported using a Visual Analog Scale (range 0-100) and observed pain was assessed using the Face, Legs, Activity, Cry, and Consolability-revised scale. Over half of patients (58.9%) reported mild anxiety (score <12) and about 5% of patients reported severe anxiety (score >16). Younger children (6-8 years) reported higher anxiety scores than older children (15-17 years), but the difference did not achieve statistical significance (mean=12.7, 95% CI: 11.5-13.9, p=0.09). Nonparametric spearman correlation indicated that anxiety score was significantly correlated with observed pain (p=0.01) and self-reported overall pain neared statistical significance (p=0.06). In the final logistic regression of reporting moderate-to-severe pain (pain score >30), the association between anxiety scores and self-reported overall moderate-to-severe pain was statistically significant (p=0.03) when adjusting for race, healing degree, and pain medication use within 6 hours prior to burn dressing care. This pilot study provides preliminary data showing that anxiety before outpatient pediatric burn dressing changes is significantly associated with self-reported overall moderate-to-severe pain.

The Development of an mHealth Tool for Children With Long-term Illness to Enable Person-Centered Communication: User-Centered Design Approach

BACKGROUND

Children with long-term illnesses frequently experience symptoms that could negatively affect their daily lives. These symptoms are often underreported in health care. Despite a large number of mobile health (mHealth) tools, few are based on a theoretical framework or supported by scientific knowledge. Incorporating universal design when developing a product can promote accessibility and facilitate person-centered communication.

OBJECTIVE

The aim of this study is to identify the symptom-reporting needs of children with cancer and congenital heart defects that could be satisfied by using a mobile app. Another aim is to evaluate how the child might interact with the app by considering universal design principles and to identify parents' views and health care professionals' expectations and requirements for an mHealth tool.

METHODS

User-centered design is an iterative process that focuses on an understanding of the users. The adapted user-centered design process includes 2 phases with 4 stages. Phase 1 involved interviews with 7 children with long-term illnesses, 8 parents, and 19 health care professionals to determine their needs and wishes for support; a workshop with 19 researchers to deepen our understanding of the needs; and a workshop with developers to establish a preliminary tool to further investigate needs and behaviors. Phase 2 involved interviews with 10 children with long-term illnesses, 9 parents, and 21 health care professionals to evaluate the mock-up (prototype) of the mHealth tool. Data were synthesized using the interpretive description technique.

RESULTS

A total of 4 aspects of needs emerged from the synthesis of the data, as follows: different perspectives on provided and perceived support; the need for an easy-to-use, non-clinic-based tool to self-report symptoms and to facilitate communication; the need for safety by being in control and reaching the child's voice; and a way of mapping the illness journey to facilitate recall and improve diagnostics. The children with long-term illnesses expressed a need to not only communicate about pain but also communicate about anxiety, fatigue, fear, and nausea.

CONCLUSIONS

The findings of this study indicated that the PicPecc (Pictorial Support in Person-Centered Care for Children) app is a potential solution for providing communicative support to children with long-term illnesses dealing with multiple symptoms and conditions. The interview data also highlighted symptoms that are at risk of being overlooked if they are not included in the mobile app. Further studies are needed to include usability testing and evaluation in hospitals and home care settings.

Evaluating pictorial support in person-centred care for children (PicPecc): a protocol for a crossover design study

INTRODUCTION

This study protocol outlines the evaluation of the pictorial support in person-centred care for children (PicPecc). PicPecc is a digital tool used by children aged 5-17 years to self-report symptoms of acute lymphoblastic leukaemia, who undergo high-dose methotrexate treatments. The design of the digital platform follows the principles of universal design using pictorial support to provide accessibility for all children regardless of communication or language challenges and thus facilitating international comparison.

METHODS AND ANALYSIS

Both effect and process evaluations will be conducted. A crossover design will be used to measure the effect/outcome, and a mixed-methods design will be used to measure the process/implementation. The primary outcome in the effect evaluation will be self-reported distress. Secondary outcomes will be stress levels monitored via neuropeptides, neurosteroids and peripheral steroids indicated in plasma blood samples; frequency of in-app estimation of high levels of distress by the children; children's use of analgesic medicine and person centeredness evaluated via the questionnaire Visual CARE Measure. For the process evaluation, qualitative interviews will be carried out with children with cancer, their legal guardians and case-related healthcare professionals. These interviews will address experiences with PicPecc in terms of feasibility and frequency of use from the child's perspective and value to the caseworker. Interview transcripts will be analysed using an interpretive description methodology.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the Swedish Ethical Review Authority (reference 2019-02392; 2020-02601; 2020-06226). Children, legal guardians, healthcare professionals, policymaking and research stakeholders will be involved in all stages of the research process according to Medical Research Council's guidelines. Research findings will be presented at international cancer and paediatric conferences and published in scientific journals.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT04433650.

Transcultural adaptation of the children's anxiety questionnaire in Brazil

Aim

To describe the transcultural adaptation process of the Children's Anxiety Questionnaire (CAQ) for the Brazilian culture.

Design

This is a methodological study of cross‐cultural adaptation.

Methods

Study conducted in Brazil and Sweden involved the following steps: preparation, translation, synthesis of translations, back‐translation and review, and harmonization of the translations by a committee of 13 healthcare professionals using the content validity index (CVI). Cognitive debriefing, using children between 4–10 years old, was completed by 15 children to determine if the images corresponded with their meanings and 17 children to determine if they could understand the Global CAQ after listening.

Results

Convergences and discrepancies between the original instrument in Swedish, the English version and the Brazilian translation were compared. The process of culturally adapting the CAQ to Brazilian Portuguese was validated, as demonstrated by a satisfactory S‐CVI (0.94) among professionals and an agreement of 95% and above by children.

Children's Anxiety and Factors Related to the COVID-19 Pandemic: An Exploratory Study Using the Children's Anxiety Questionnaire and the Numerical Rating Scale

The repercussions of the COVID-19 pandemic on children's lives deserve attention. This study aimed to assess the prevalence of anxiety among Brazilian children and its associated factors during social distancing during COVID-19. We used a cross-sectional design with an online survey from April to May 2020 in Brazil. We included children aged 6-12 years and their guardians. The Children's Anxiety Questionnaire (CAQ; scores 4-12) and the Numerical Rating Scale (NRS; scores 0-10) were used to measure anxiety. We enrolled 157 girls and 132 boys, with a mean age of 8.84 (±2.05) years; 88.9% of respondents were mothers. Based on CAQ ≥ 9, the prevalence of anxiety was 19.4% (n = 56), and higher among children with parents with essential jobs and those who were social distancing without parents. In logistic regression, the following variables were associated with higher CAQ scores: social distancing without parents; more persons living together in home; and education level of guardians. Based on NRS > 7, the prevalence of anxiety was 21.8% (n = 63); however, no associations with NRS scores were found with the investigated variables. These findings suggest the necessity of implementing public health actions targeting these parents and their children at the population level.