Including Young Children in the Development and Testing of Patient Reported Outcome (PRO) Instruments: A Scoping Review of Children's Involvement and Qualitative Methods.

Background: Qualitative research during the development/testing of Patient Reported Outcome Measures (PROMs) is recommended to support content validity. However, it is unclear if and how young children (≤ 7 years) can be involved in this research because of their unique cognitive needs.

Objectives: Here we investigate the involvement of children (≤ 7 years) in qualitative research for PROM development/testing. This review aimed to identify (1) which stages of qualitative PROM development children ≤ 7 years had been involved in, (2) which subjective health concepts had been explored within qualitative PROM development with this age group, and (3) which qualitative methods had been reported and how these compared with existing methodological recommendations.

Methods: This scoping review systematically searched three electronic databases (searches re-run prior to final analysis on 29 June 2022) with no date restrictions. Included studies had samples of at least 75% aged ≤ 7 years or reported distinct qualitative methods for children ≤ 7 years in primary qualitative research to support concept elicitation or PROM development/testing. Articles not in English and PROMs that did not enable children ≤ 7 years to self-report were excluded. Data on study type, subjective health and qualitative methods were extracted and synthesised descriptively. Methods were compared with recommendations from guidance.

Results: Of 19 included studies, 15 reported concept elicitation research and 4 reported cognitive interviewing. Most explored quality of life (QoL)/health-related quality of life (HRQoL). Some concept elicitation studies reported that creative/participatory activities had supported children's engagement, but results and reporting detail varied considerably across studies. Cognitive interviewing studies reported less methodological detail and fewer methods adapted for young children compared with concept elicitation studies. They were limited in scope regarding assessments of content validity, mostly focussing on clarity while relevance and comprehensiveness were explored less.

Discussion: Creative/participatory activities may be beneficial in concept elicitation research with children ≤ 7 years, but future research needs to explore what contributes to the success of young children's involvement and how researchers can adopt flexible methods. Cognitive interviews with young children are limited in frequency, scope and reported methodological detail, potentially impacting PROM content validity for this age group. Without detailed reporting, it is not possible to determine the feasibility and usefulness of children's (≤ 7 years) involvement in qualitative research to support PROM development and assessment.