Acceptability and feasibility of an app to prepare children for a blood test: An exploratory cohort study

Abstract

Objective:

Children report needle procedures as one of their most feared and painful experiences. Negative blood test experiences can lead to lifelong implications. Xploro is an online health information platform (app) that uses age-appropriate self-directed augmented reality (AR) techniques. This study evaluated the acceptability, feasibility and self-reported impact of Xploro on children undergoing a planned blood test.

Method:

Children aged 6–14 years accessed Xploro at home before attending hospital for a planned blood test. Paper data collection booklets were completed by children, their parents and health professionals. We explored participants’ views of using Xploro and the perceived impact on a child’s ability to undergo the blood test. Data were analysed using descriptive statistics and content analysis procedures.

Results:

Notably, 24 children, 24 parents and 6 health professionals participated. Children (96%; n = 23/24) reported that Xploro was ‘fun’ and ‘easy to use’ and helped them have their blood test (94%, n = 17/18), as they ‘knew what to expect’ and what would help them. Parents reported that the app helped ‘open up a dialogue about the blood test’ with their child and helped their child ‘know what would happen during the blood test’ and how to ‘stay calm’. Health professionals (n = 6) reported that Xploro helped children access information ‘at their leisure at home’.

Conclusion:

Xploro was reported as being a useful and engaging self-directed child-friendly information app for children having a planned blood test which helped children know what was going to happen and improved their experiences of having a blood test.

Keywords

Blood test children information preparation Xploro digital intervention

Introduction

Needle procedures, although prevalent across the lifespan, are especially common in childhood (Kolk et al., 2000). Generally, a child’s first experience with a needle is during a routine immunisation. However, children with chronic conditions may undergo numerous needle procedures including repeated blood sampling. Needle procedures have been reported to be one of the most feared and painful experiences children face while in hospital (Kortesluoma and Nikkonen, 2004) and nearly 45% of children aged 4–6 years having a blood test have been observed showing signs of either serious distress, severe distress or panic (Jacobson et al., 2001). Distress during a needle procedure can go unnoticed if children do not appear to be in pain (Taddio et al., 2009) or if children do express distress or resist, they may be held against their will for the test to be completed (Bray et al., 2016).

A poor experience with needles during childhood, can have a lasting impact, with 1 in 10 people developing needle phobia (Taddio et al., 2009) or a fear of injections and transfusions (International Classification of Diseases, F40.231; World Health Organisation [WHO], 2004), leading people to actively avoid needle procedures (Cook, 2016). In the longer term, a fear of needles can lead to increased perceived needle pain (McMurtry et al., 2015), avoidance behaviour (Orenius et al., 2018), the refusal of medical procedures and a negative impact on health (McMurtry et al., 2015).

Preparing children for needle-related procedures and supporting them before, during and after has been shown to have clear benefits (Dalley and McMurtry, 2016; Uman et al., 2008). Children have better experiences and outcomes if they are prepared for an upcoming procedure, are cared for in an environment that is comfortable, receive pain management and distraction techniques and are coached through the procedure by a calm adult (Bray et al., 2023; Taddio et al., 2009). By providing meaningful information and supporting children to develop positive coping mechanisms and self-regulation, children experience less anxiety and less pain and have shorter appointment times (Orenius et al., 2018). Various interventions have been developed to try and help children when they undergo needle-related procedures, with evidence showing that combined cognitive-behavioural interventions, distraction, breathing techniques and hypnosis help to lower children’s level of distress and pain (Birnie et al., 2018).

However, evidence commonly focuses on the use of interventions during a needle procedure to help children cope with their fear and pain, and there is less robust evidence on the effectiveness of preparation and information interventions on reducing children’s anticipatory anxiety, procedural distress and pain. The evidence that is available shows variability in the impact of information and preparation on children’s experiences and outcomes of needle procedures. Preparation photo/picture storybooks (Harrison et al., 2013; Tsao et al., 2017; Zieger et al., 2013), interactive preparation of handheld electronic devices (Miller et al., 2016), immersive virtual reality cannulation experiences (Whu et al., 2023), humanoid robots (MEDi®) to teach children cognitive-behavioural strategies and deep breathing (Lee, 2019) and play-based preparation programmes (Kyriakidis et al., 2021) have been shown to have a positive effect on children’s pain and distress during needle procedures, while other interventions show a variable effect, with an educational game to prepare children for a blood test helping half of the children who played the game feel better about the blood test (Oulton et al., 2018), and a learning event where children played doctor for the day has been reported as reducing some children’s fear of needles (Kajikawa et al., 2014). However, these interventions generally require facilitation.

Some of the above interventions use digital technology, mirroring the growth of the use of digital technology in health care (WHO, 2019) which can have particular relevance when targeted towards young people (WHO, 2020). Studies including meta-analyses have shown that using digital technologies to distract children during a procedure leads to a reduction in pain and distress (Gates et al., 2020) and decreased pain and anxiety (Sajeev et al., 2021). Virtual reality used during a needle procedure has been shown to significantly decrease acute procedural pain and anxiety (Gold and Mahrer, 2018), child self-reported pain (Chan et al., 2019) and fear of pain (Dumoulin et al., 2019). Digital technologies have typically high intervention satisfaction and acceptability (Gold and Mahrer, 2018) and very few adverse effects as well as being associated with low cost, ease of use on mobile phones and appeal to a wide age range (Özalp Gerçeker et al., 2020). Even though evidence-based strategies exist to mitigate distress and pain during needle procedures, these interventions are not consistently implemented by health care providers (Harrison et al., 2013; McMurtry et al., 2015; Taddio, 2013; Taddio et al., 2009) and less is known about the acceptability and feasibility of using digital technology interventions to prepare and educate children before a needle procedure.

Xploro is a health information platform that has been designed to prepare children for the hospital environment and procedures they may face using age-appropriate augmented reality (AR) techniques (https://youtu.be/gexV9IzJddU). Models of real-world environments (such as the blood clinic) and the interactive experience that explains blood tests can be viewed in AR through the user’s own device and without the need for additional hardware such as headsets. Engagement with the platform is self-directed and paced by children. For example, children use their avatar to find out what will happen to them for a particular procedure, alongside what they may hear, smell and feel. The intervention is underpinned by the theoretical concept of health literacy which refers to a person’s ability to access and gain information, understand this information and use it to positively shape their experiences and interactions within the health care system (Peerson and Saunders, 2009).

Xploro provides information to children to help them understand what will happen when they have their procedure and learn skills to support their interactions and experiences. It has been demonstrated that Xploro reduces children’s procedural anxiety, improves children’s knowledge of what will happen to them when they undergo a wide variety of procedures, increases children’s participation in the procedure and improves children’s happiness with the procedure (Bray et al., 2020). Xploro has recently developed a new element to the platform focussed on supporting children to have a blood test or cannulation. The blood test module shows a child what will happen when they come to the hospital for a blood test, including exactly what the hospital department will look like (Figure 1), who will be there in the room, that they will feel a scratch, that they need to try and sit really still, that the blood goes in a tube and then to the lab to be tested and it also includes a part to show and help children practise how to control their breathing by inflating a virtual balloon to aid relaxation and self-regulation (Figure 2).

Figure 1.

Virtual outpatient clinic.

Figure 2.

Balloon to facilitate breathing technique.

This study aimed to explore the perceptions of children and their parents of the acceptability and value of Xploro on their experiences of undergoing a blood test. The study also gained health professionals’ opinions of the value of Xploro within the blood test clinic and the feasibility of evaluating the app within this context. The work aligned with the framework developed by the Medical Research Council (MRC) and National Institute of Health Research (NIHR) in the United Kingdom for developing and evaluating complex interventions which highlight the importance of ‘strong and early engagement with patients and practitioners to judge whether an intervention will be acceptable’ (Skivington et al., 2021). This project focussed on assessing the feasibility and acceptability of an intervention (Xploro) within a new context (the blood clinic). The study was not registered on a clinical trial register. The study set out to answer the following research questions (RQs):

RQ1. What are children’s and their parents’ perceptions of using Xploro to prepare them and support them, before and during their planned blood test?

RQ2. What are health professionals’ views and opinions of the value of Xploro to children attending the blood test clinic and any barriers to its use?

RQ3. How feasible is it to recruit and collect data from children and parents when evaluating procedural information and preparation prior to blood tests?

Methodology

Participants

Children aged 6–14 years old who were due to attend a regional non-specialist hospital for a planned blood test and their parents/carers were recruited to take part in the study between March and June 2023. We excluded children who were identified by the clinical team as having moderate to severe cognitive impairment or those who were non-English speaking. Health professionals (including play specialists, nurse phlebotomists, nurses and doctors) working within the blood clinic were also recruited to share their views.

Design

This mixed-method exploratory study gathered quantitative and qualitative data concurrently from children, their parents and health professionals. This study aimed to gain insight into the views and reported experiences of all those involved in a child’s blood test. This study design drew on elements (data collection tools and recruitment materials) of a previous study which was informed by extensive consultation with children and young people (Bray et al., 2020).

Procedure

Ethics approval was granted by the authors’ institution (Edge Hill University Ref ETH2122-0126) and the Health Research Authority (22/NW/0182).

Families, on the set clinic days the research team was available to attend, were contacted by the clinic staff 1–2 weeks before their appointment, to ask if they would be interested in taking part in a study to evaluate the Xploro app to prepare their child for their upcoming blood test. Those who agreed to hear more about the study were contacted by a member of the team (LB and JK) and provided with information about the study and given directions to download the Xploro app. Children were asked to access Xploro before attending the hospital for their planned blood test and were met by the research team on arrival at the blood clinic. We gained written consent from parents and written assent from children when they arrived at the clinic on the day of their blood test.

Children were asked to complete a short paper survey/booklet that included both open and closed questions, and space to write or draw their responses. This gave children the opportunity to respond to the questions in accordance with their preferences, strengths and abilities. The booklet collected information on a child’s perceptions of Xploro, the procedural information accessed on Xploro or elsewhere, their feelings prior to the blood test, the perceived impact of Xploro on their blood test experiences, as well as what went well and what could have been better during their procedure. The paper booklet was designed to be quick to complete, with some information being collected while families were waiting and then some further information being completed after the blood test. Data collection was designed so as not to add too much delay to the child and family being able to leave the department after the blood test had been completed. Each child’s accompanying parent was also given a paper data collection booklet to complete which mirrored the questions in the children’s booklet. Parents could take part in the study independently of their child. The booklet completion was facilitated by a member of the research team. We also collected key characteristics of what happened during the child’s procedure, for example length of time from entering the clinical room to leaving the room, whether the blood test was completed and if the child needed to be re-referred for completion of the procedure on another day. Health professionals were asked to complete a short, anonymous paper booklet near to the end of the study period to seek their views about whether Xploro was a useful intervention to prepare and support children for their blood test and whether any alterations were needed to enhance the content.

Data analysis

The quantitative data were analysed using descriptive statistics. The open-text qualitative data were analysed using content analysis techniques (Hsieh and Shannon, 2005) as the text was short and structured in nature. Two members of the team (LB and JK) independently examined and categorised the qualitative data. Formal analysis was not conducted on the content of any images drawn by the children; we analysed the words they used to accompany or describe their drawings to prevent any misinterpretation.

Results

A total of 24 children, 24 parents and 6 health professionals shared their views on the acceptability and perceived impact of Xploro on children having planned blood tests.

We contacted 47 families who agreed to have their details shared with the research team. From these, 6 parents declined to take part as they did not want to tell their child they were due to have a blood test as they thought it would make them anxious, 3 declined as the child did not want to take part, 8 were uncontactable prior to the blood clinic and 6 did not take part due to cancelled appointments. Furthermore, the clinic staff told us that on initially screening the families to ask if they were willing to receive information about the study, many families declined to take part as the parents did not want to tell their child that they were due to have a blood test.

Notably, 24 children (10 boys and 14 girls, aged 6–14 years, mean 9 years) took part in the study. Four of these children only completed the first part of data collection and did not want to complete the part of the booklet after the blood test due to being upset.

The children who took part had a range of experiences from previous blood tests. For most children (50%; n = 12), this was their first blood test, 9 (38%) had experience of between 1 and 4 previous blood tests, and 3 children had 5 or more previous blood tests. Many of the children (n = 13, 54%) reported having looked at the information within Xploro with their parents. One-third of the children (n = 8, 35%) reported accessing preparation information via leaflets and the Internet in addition to Xploro.

The children reported feeling nervous (n = 12, 50%) and scared (n = 5, 21%) before their procedure, although some children reported feeling happy to be having the blood test and getting it over and done with. For example, children told us that they felt: ‘scared, stressed, a bit happy and nervous’ (C22), ‘scared, nervous, happy to get it over and done with’ (C39), ‘nervous, scared, kind of glad so I can find out what’s wrong’ (C29) and ‘nervous . . . a little worried and a little happy because I want to get better’ (C27). Some children chose to draw how they were feeling (Figure 3). Of the 24 children who took part, 23 (96%) reported that they enjoyed using Xploro, commenting that they found it ‘good’ (n = 9), ‘fun’ (n = 8) and helped them ‘understand’ (n = 2). Two children reported that the app had made them feel nervous about the blood test.

Figure 3.

Children’s responses to how they felt about coming for their blood test.

Children were asked in an open text ‘bubble’ what they thought of Xploro, comments included ‘it helped me as I knew I could look away’ (C1), ‘A little calming because the boy didn’t cry’ (C27), ‘I love Xploro it is so fun and exciting to play with’ (P38), ‘It was good but hard for me to use’ (C47) and one 11-year-old stated that they thought ‘that the app is clever and fun how you can ask questions with an easier answer. But I think it’s better for younger ones’ (C29). After the blood test, 17 (85%) children reported that the app had helped them have their blood test. Children (n = 5, 25%) commented that ‘the app helped them know what was going to happen’ (C3) and ‘it helped me a lot’ (C19). One child, as noted above, reported that it ‘made me feel nervous’ (C14). Most of the children (n = 17,85%) felt like they had had enough information about their blood test.

The children were asked to report more widely what had worked well during their procedure; there were a range of responses including that ‘the nurse made it fun’ (C42), ‘the cold numbing spray’ (C1), ‘the numbing cream’ (C5) and that specific parts of Xploro helped ‘bendy bones helped me be occupied’ (C26) and ‘stopped me from worrying’ (C29). In contrast, children were asked what had not worked well while they were having their blood test, and many (n = 6, 30%) reported that nothing could have been improved or that it could have hurt less (n = 2, 10%).

Parent’s perceptions of their child using Xploro to prepare and support them, before and during their planned blood test

The majority of parents/carers who completed the data collection booklet reported that they had had enough information about their child’s procedure (n = 21, 91%) and some had used Xploro with their child (n = 10, 42%). The parents reported that Xploro had been ‘easy to use’ (n = 2, 8%), included ‘interesting facts’ (P13), was ‘child-friendly’ (P39), it was ‘great to see visually what happens when a child needs a blood test’ (P20), that their child ‘liked making the avatar’ (P25) and ‘the app answered any questions’ their child had (P5). One of the parents felt that the information could be improved by the text being ‘read aloud for children with special needs’ (P1) or by it highlighting the need to ‘drink lots in the run up to the appointment’ (P17). Two parents stated that the app had made their child, who was already worried about having a blood test, a little more worried.

Of the 23 parent/carers who answered the question, 20 (87%) stated that the app had helped their child have their blood test completed successfully. Parents (n = 7, 30%) stated that it had helped their child understand what was going to happen when they had their blood test, reporting ‘she knew what to expect, and who she would be seeing’ (P22), ‘she liked to see what happens once they’ve taken the sample’ (P18) and ‘it showed him it wouldn’t hurt’ (P27). One parent stated that it had helped them ‘know some of the words nurses may use’ (P14). Parents reported that the games were fun and engaging and ‘the breathing exercises have helped to calm him’ (P27) and it made them ‘less nervous’ (P19) as there were ‘no surprises’ (P3).

Parents were asked what had worked well during their child’s blood test, and they commented that the app had helped their child learn about what would happen (n = 3, 13%), by answering their child’s questions (n = 2, 9%) and helping them ‘know what to expect’ (P1), ‘take away the fear of the unknown’ (P4) and ‘The app reminded us that we could bring a comforting item from home’ (P25) and this had ‘helped their child experience less stress’ (P18). Many parents also reported that the nurses had been ‘friendly and professional’ (P6) and provided ‘much needed distraction’ (P20), other aspects such as numbing cream (P22) and distraction techniques (P14) were identified as helping.

One parent commented that while the app was useful, ‘It might have been a different outcome if he hadn’t had a blood test before, he had a previous bad experience and was completely traumatised’ (P27), no amount of information was seen to help in this situation ‘The app might work better for children who are having their first blood test’ (P27).

Health care professionals’ views and opinions of the value of Xploro to children attending the blood test clinic and any barriers to its use

Health care professionals expressed positive views of Xploro, reporting that ‘Xploro is a great interactive tool to help children learn about the clinic environment and what to expect during a blood test. The characters are brilliant, and the layout of the clinic is realistic’ (HCP5). Most professionals (n = 5) reported that children did not receive any other preparation or information before coming to the blood clinic apart from Xploro and the blood clinic appointment letter from the hospital. All the health professionals (n = 6) reported that Xploro was useful for children having a blood test, mainly because it helped to ‘prepare’ (n = 3) children in terms of ‘the clinic setting and the actual procedure’ (HP4) and helped them know ‘what to expect’ (n = 2) by allowing ‘them to see what will happen and who might be involved’ (HP5).

Professionals recognised the importance of preparing children because ‘It is always best to be honest with children and this gives parents the tools to help explain’ (HP5), with another professional adding ‘some parents choose not to tell the child about the blood test as they think it will make them more anxious. This option is a great way to prepare the child and stop the anxiety’ (HP6). A couple of professionals reported that Xploro ‘Helps open a dialogue about what might happen on the day’ (HP2), reporting that ‘we hear some parents using terms from the app when talking through the test in the clinic room’ (HP5). However, some professionals reported that Xploro may not be as attractive to older children: ‘A lot of the older children wasn’t interested in Xploro’ (HCP4) and that ‘I did think there was a lot of text–if some children are not as advanced with reading an audio option would be good’ (HCP6).

When asked what worked well about using Xploro and what could be better, many professionals commented that Xploro worked well as it was accessed before coming to the clinic, ‘it was good that the children could watch it at home’ (HP2), ‘at their own leisure’ (HCP4). Several of the professionals noted that ‘unfortunately some parents refused using Xploro and as they didn’t think it would help their child’ (HP5). This led professionals to comment that it would be better if Xploro was ‘part of clinic letter’ (HP3) as it ‘would be nice to be able to send it to everyone without having to ask permission so all children get chance to look if parents decide’ (HCP5).

Health professionals were asked what it was like having the study running within the department. Despite one professional stating that it had been ‘hard to get hold of parents’ (HCP4) to ask if they wanted to take part, all the professionals made positive comments stating that it was ‘great’ or ‘nice’ (HP5) with one professional stating that it was ‘Interesting to challenge something new in clinic’ (HP6).

Discussion

This study aimed to examine the acceptability and reported impact of Xploro as an intervention to provide preparatory information to children prior to a planned blood test. Xploro was reported by most children, parents and professionals as fun, informative and having a positive impact on children’s experiences of having a blood test by helping children understand what was going to happen, what would be expected of them and what they could do to improve their experience. The study showed that important elements of a health literacy intervention were met; Xploro was reported as providing accessible and engaging information that children reported they could understand and use to shape their procedural experiences and interactions. The data show the intervention also addressed the key elements of information needed to prepare children of this age group prior to hospital procedures, as it includes procedural, sensory and self-regulation information (Bray et al., 2019; Jaaniste et al., 2007). The study adds to the evidence that preparing children for needle-related procedures has value in that it can help them know what will happen and how they will experience the procedure and also helps them rehearse how they will self-regulate or remain calm for the procedure. Many self-directed preparatory resources focus on providing children with procedural information and do not provide children with skills to help self-regulation (Jaaniste et al., 2007). Two children reported that having information about the blood test made them feel more anxious and worried before the test; however, both children reported a good procedural experience, stating that ‘nothing’ could have been better about their blood test. This finding aligns with evidence that being informed about what will happen during a procedure can increase children’s anticipatory anxiety (Margolis et al., 1998), but children who are better informed have better outcomes (Jaaniste et al., 2007).

This study showed that, as well as impacting positively on children’s experiences of having a blood test, Xploro also helped parents know what to say to their child and how to support them, learn what would happen and be familiar with some of the words used by health professionals during the procedure. In this way, the information directly improved children’s procedural health literacy (their access to information they can understand and apply) but also impacted parent’s health literacy (their knowledge, skills and ability to support their child). This is important as parents can lower as well as heighten the distress of their child during a blood test (Kolk et al., 2000; Frank et al., 1995). During recruitment, we encountered some reluctance from some parents to tell their child about the planned blood test as they were concerned it would cause their child to become upset and anxious prior to or during the procedure. The reluctance of some parents to inform their child of a forthcoming procedure has been noted in previous research, where parents have stated that they withheld or shaped the information they shared with their child to prevent upset (Bray et al, 2016). This study highlights the important gatekeeping role parents have in facilitating or blocking their child’s access to procedural information (Bray et al., 2022; Gordon et al., 2011). The concept of distributed health literacy helps highlight how parental knowledge and assumptions can influence their child’s access to procedural information (Edwards et al., 2015). We were not able to identify from this study if those parents who were happy for their child to take part differed in any way from those who declined participation.

The app delivers self-directed education using digital technology which can be accessed on multiple occasions by children at a time to suit them. Children are able to access the different elements of the intervention depending on their individual preferences and information needs. This individual tailoring of information has been cited of key importance when delivering preparatory information to children (Fortier and Kain, 2015) and interventions which can be accessed several days prior to a procedure and re-visited enable children to process information and build mastery in their use (Jaaniste et al., 2008, Fortier and Kain, 2015). The information ‘pull’ approach, where children access information at their own pace in response to their needs, recognises that children usually learn best when engaged in an active way, rather than as passive recipients (Bray et al., 2019). As the intervention is self-directed, it means that adult guidance or the input of health professionals is not needed in order for children to access the information. This means that this intervention has potential to run with lower operational costs than preparation requiring resources or staff time such as virtual reality headsets (Whu et al., 2023; Özalp Gerçeker et al., 2020), supported specialist play staff (Diener et al., 2019; Getchell et al., 2022) and dedicated learning events (Dalley and McMurtry, 2016; Kajikawa et al., 2014). Digital technology has a role to play in preparing children for procedures in an appealing and low-cost way. This study showed children found Xploro fun, engaging and easy to use, aligning with previous evidence that digital technologies have typically high intervention satisfaction and acceptability (Gold and Mahrer, 2018). Young people are now growing up in the digital world (Kardefelt Winther et al., 2019) and are accessing the Internet at a younger age than ever before (Keeley et al., 2017). However, as digital technology is increasingly used within health care, it is important to be mindful of digital poverty and how some children and young people may be excluded from accessing information and resources reliant on access to data and the Internet (Aisbitt et al., 2023). This acceptability study of the self-directed information platform (Xploro) has demonstrated that there is merit in conducting further research to test its efficacy in an interventional study. Further work needs to robustly assess the impact of Xploro on key outcomes of children undergoing blood tests (anxiety, pain and fear) compared with standard practice and other commonly used forms of preparatory resources.

Limitations

The main limitation of the study was that the families who took part were a small self-selecting sample from those due to attend the clinic for a planned blood test, meaning that the parents who were interested in taking part in the study may well have been those who could already see the benefit in preparing their child for a blood test. However, all eligible participants were asked if they would like to take part in the study. Data were not formally collected regarding the demographic characteristics of the families who declined to take part, limiting insights into the acceptability of the intervention for these children.

An additional limitation is that the data were self-reported by parents, children and health professionals and despite the team ensuring space and anonymity to complete the paper booklets, participants may have felt pressure to respond in a socially desirable manner. Furthermore, in order to access Xploro and take part in the study, families needed the use of an electronic device and Internet connection.

Conclusion

Xploro is a useful and engaging self-directed child-friendly information app for children having a planned blood test which helps children know what is going to happen and improves their reported experiences of having a blood test. The app was also reported as helping parents understand what would happen during the procedure and open up a conversation with their children about the planned blood test. Health professionals reported Xploro as useful and helpful as an intervention to prepare children for a blood test; its self-directed format meant that children could access it in their own time at home.

Footnotes

Acknowledgements

We thank the children, parents and health professionals for taking part and sharing their views as part of the study.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship and/or publication of this article: this project was funded by the European Regional Development Fund (ERDF) and delivered by the University of Central Lancashire.

ORCID iD

Lucy Bray

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