Key points

  • Many non-invasive interventions exist to prepare and educate children for radiological procedures.

  • These non-invasive interventions differ in their aims, content, delivery and measures of outcomes.

  • These differences make it hard to judge which non-invasive interventions work best.

  • A core set of outcomes is needed to enable comparison between different interventions.

Background

Children frequently undergo a range of diagnostic radiological procedures including plain radiographs, ultrasound (US), magnetic resonance imaging (MRI) and computed tomography (CT). Simple radiological procedures such as plain radiographs are often the first encounter children have with health services with approximately 2 million plain radiographs being conducted on children under 14 years in 2019/2020 [1]. Children and young people undergo over 150,000 MRI scans and 50,000 CT scans each year [1]. Many of these radiological procedures are conducted within adult departments as opposed to dedicated children’s hospitals [2]. Children can often feel anxious, worried and uncertain when they attend hospital for a radiological procedure, due to the unfamiliar environment, noises, sounds and having to keep very still for a good quality image [3]. There is increasing evidence that children having radiological procedures have an improved experience during the procedure and better short- and long-term outcomes if they are prepared and informed about the procedure they are due to have [3,4,5] and are supported and distracted throughout [3]. Despite significant interest and investment in the development of different mediums and forms of preparatory and educational information, the use and provision of preparatory interventions can be ad hoc and there is a lack of evidence of which methods of delivery work best for children and have the best outcomes [6].

Studies developing and evaluating interventions to prepare, educate and familiarise patients before procedures and health interactions are frequently discussed within the frame of health literacy [7, 8]. Health literacy is gaining increasing traction as a lens through which to understand the individual as well as familial and contextual factors which can influence how a person accesses information, gains knowledge and applies that knowledge to influence their health and healthcare [7]. The concept of health literacy has been used to understand the education and decision-making of parents of children undergoing radiological procedures [9, 10] and of adult patients undergoing radiological scans [11] but has not been used as a framework to examine interventions to prepare, educate and familiarise children prior to undergoing radiological procedures.

Previous reviews have focussed on children being informed and prepared for surgery [12,13,14] or invasive procedures such as blood tests [15] and systematic reviews to examine methods to distract or support children during procedures [16, 17] but no review has focussed specifically on mapping the different types of interventions and outcomes used in studies examining children’s preparation and education prior to radiological procedures. Therefore, this scoping review aimed to examine the evidence of non-invasive interventions and methods to prepare, educate and familiarise children and young people for radiological procedures within a healthcare setting.

Method

A scoping review approach was chosen as our focus aligned with Arksey and O’Malley’s [18] review purpose to examine the scope, scale and nature of the current evidence base for preparing, educating and familiarising children and young people for radiological procedures. We used a scoping review methodological framework to guide the review process within the following five sections which will form the structure of the paper; identifying the research aim/question, identifying relevant studies, study selection, charting the data and collating, summarising, and reporting the results [18]. While we acknowledge that the quality appraisal of included papers is not a necessary part of a scoping review [18], the team felt that assessing the quality of the studies was important to inform the nature of the evidence. Ethics approval was not required for this scoping review.

Review aim

The aim of this scoping review was to examine the evidence of non-invasive interventions and methods to prepare, educate and familiarise children and young people for radiological procedures within a healthcare setting. The objectives were to: outline which interventions are being used, how these interventions are being used and evaluated, which radiological procedures and groups of children these interventions are being used with and the perceived impact of the interventions and methods.

Identifying relevant studies

Search strategy

The literature search to identify relevant studies was conducted in the databases MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Cochrane Library (CENTRAL), Web of Science (all databases) and PsycINFO. An experienced information specialist (M.M.) conducted the searches. We also scanned the references of the included studies. The search strategy was structured according to the Population, Concept and Context (PCC) approach [19]; the population of children and young people, the context of diagnostic planned radiological procedures and the concept of interventions to prepare, educate or familiarise children prior to their procedure. The search strategies were designed using a combination of both subject headings and free text terms and were limited to English language. Full search strategies can be found in Additional file 1: Appendixes A and B.

Eligibility criteria

The inclusion and exclusion criteria are outlined in Table 1. This scoping review focussed on the preparation, education or familiarisation of children and young people aged between 5 and 16 years for planned radiological procedures. The rationale for the chosen age range was related to being school-aged children, this aimed to help boundary the search to children who were likely to have reached a level of understanding and cognitive ability. Only peer-reviewed articles, written in English, were included. The search included all sources of evidence from inception to February 2021.

Table 1 Inclusion and Exclusion criteria
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Study selection

The screening and review process was facilitated by using Covidence [20] throughout. The first two steps of the selection process were the title and abstract screening and subsequent full text screening. Two reviewers (L.Br., H.S.) independently screened the studies during both stages of the screening process. Any disagreements were flagged within the Covidence platform and these were reviewed and discussed between the reviewers until consensus was reached.

Charting the data

Data extraction or charting was conducted and mapped onto a form structured to capture details of the empirical study (e.g. author, date, country, study design), characteristics of the intervention, delivery of the intervention/method and the outcomes of the study (Table 2, a more detailed chart is included as an Additional file 1). Five reviewers (L.Br., H.S., V.G., L.Bo., J.T.) conducted and checked the charting of data for each included paper.

Table 2 Data extraction of the included studies
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Quality assessment

Even though a scoping review methodological framework does not require quality appraisal, a critical appraisal of the selected papers was conducted using The Mixed Methods Appraisal Tool (MMAT) version 2018 [21]. This tool was chosen as it is validated and appropriate for appraising quantitative, qualitative and mixed methods research [22]. Two reviewers from the team (LBr, HS, VG, LBo & JT) were allocated to each paper to conduct quality appraisal and quality assessments were then cross-checked. The quality assessment of the included studies is detailed in Table 3. No studies were excluded as a result of the quality appraisal process.

Table 3 Mixed Method Appraisal Tool quality appraisal for the included studies
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Synthesis

Due to clinical and methodological heterogeneity across the included studies, it was not considered feasible to conduct a meta-analysis. Therefore, a narrative synthesis of the key findings was undertaken, this synthesis adopted a textual approach to ‘tell the story’ of the evidence from the included studies [23].

Results

Search results

A total of 34,934 articles were identified after the database search. Among those articles, 7559 duplicates were removed. The remaining 27,375 papers were screened independently by two reviewers (LBr, HS) according to their title and abstract. This resulted in 26,203 papers being removed and 1172 papers remaining within the review for full-text screening. Each full-text paper was reviewed independently by two reviewers (LBr, HS) within the review software. This resulted in 1135 papers being excluded (reasons for exclusion included not an intervention to prepare or familiarise children or young people, not empirical evidence, not a radiological procedure, duplicate, radiotherapy, age of children outside the review criteria, non-English language, not within a healthcare setting) and 36 papers being retained for data extraction and quality appraisal. The PRISMA procedure is detailed in Fig. 1.

Fig. 1
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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)

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Key characteristics of the included studies

There was huge variability in the radiological procedures included in the studies, the foci and delivery of the interventions and methods to prepare, educate or familiarise children and young people, the study designs and the outcomes assessed.

The research designs included in the studies

All of the 36 studies used a range of quantitative methods including; 10 randomised controlled trials [24,25,26,27,28,29,30,31,32,33], 11 cohort studies [34,35,36,37,38,39,40,41,42,43,44], 3 before and after studies [45, 47], 6 descriptive quantitative studies [48,49,50,51,52,53], 1 prospective audit [54] and 5 retrospective audits [55,56,57,58,59]. Four of the studies also had a nested qualitative element, to gather views and experiences either through short, structured interviews or open text responses on a questionnaire from children and young people [29, 47, 50] and parents [47].

The radiological procedures included in the studies

The majority of the studies focussed exclusively on MRI scans (n = 29) [24, 28, 29, 31, 32, 34,35,36, 38,39,40,41,42, 45, 47,48,49,50,51,52,53,54,55,56, 58, 59]. The other studies focussed on interventions linked to children undergoing intravenous pyelograms (n = 2) [25, 26] voiding cystourethrograms (VCUG) (n = 2) [26], dimercaptosuccinic acid (DMSA) scans (n = 1), chest radiography (n = 1) [27] or interventions linked to multiple radiological procedures, CT, MRI, nuclear medicine and fluoroscopy (n = 3) [30, 44, 46].

The interventions to prepare, educate or familiarise children included in the studies

The non-invasive interventions in the studies focussed on different methods of delivery of preparation, education or familiarisation. Some papers included detailed descriptions of how and when a specific intervention was delivered and some only included minimal information of the intervention delivery. The non-invasive interventions included access to technology, facilitated play, the provision of information and opportunities to practice a radiological procedure. The interventions using technology included smartphone applications (n = 4) [30, 34, 44, 49], interactive videos (n = 2) [31, 33], animations (n = 3) [33, 41, 50] and one study focussed on virtual reality information [27]. The most frequent non-invasive intervention described was the opportunity to practice undergoing a procedure, to model what would happen and experience the sensory elements involved in undergoing an MRI scan; these included mock scanners (n = 9) (both toy-sized or pretend full-sized scanners) [24, 35, 37, 47, 48, 51, 53, 55, 57], one study using simulated practice [32] and studies with a focus on play-based learning and preparation (n = 7) [38, 39, 45, 54, 56, 58, 59].

The non-invasive interventions which focussed on the provision of information or education included the use of; educational videos (n = 5) [29, 31, 32, 49, 52], a radiology colouring book (n = 2) [46, 59], a photo-diary/booklet (n = 2) [28, 43], a story-book (n = 2) [26, 54], individualised information provision (n = 2) [25, 57] or a visit to the department to meet staff and watch a child having an MRI scan [40]. Some studies evaluated interventions with multiple elements [32, 35, 36, 42, 58].

The delivery of the non-invasive interventions varied and included play specialists/child life specialists (n = 11) [34, 37,38,39, 44, 45, 51, 54, 56, 58, 59], parents (n = 6) [26, 28, 35, 46, 48, 49] radiology department staff (n = 2) [32, 35, 47].. Delivery in the other studies was by a paediatrician and medical social worker [24], medical staff [24, 37], volunteers within the department [36], paediatrician and child life specialist [37, 57], paediatric occupational therapist [55], research team member [30, 40, 43], behaviour analyst [48], staff trained in child neurology and behavioural paediatrics [53], nurse [25] or in seven studies, the non-invasive interventions were used by the children in a self-directed manner [27, 29, 41, 44, 46, 50, 52]. In two of the papers, it was not clear who had delivered the intervention [31, 42].

The outcomes measured in the studies

The outcomes measured and assessed within the included studies were varied; the outcomes measured within each study are given in Table 4. The most common outcomes were focussed on the completion of a good quality radiological image and these included; image quality (n = 11) [24, 36,37,38, 42, 52, 56, 58], and successful completion of the procedure (n = 7) [31, 33, 36, 39, 40, 48, 49]. The child orientated outcomes included; child anxiety (n = 8) [27, 28, 32, 44, 46, 47, 50, 51], child distress (n = 4) [25,26,27, 43], other studies included, child cooperation [25], child information seeking behaviours [25], a child’s need for parental presence [27], child stress [28, 30], child knowledge [29, 41, 50], child relaxation [29], child displaying challenging behaviour [30], child’s confidence in staying still [33] and child compliance [44]. The measurement and definition of what constituted ‘compliance’ or the ‘successful completion’ of a procedure was often not included within the papers. Some outcomes focussed on children’s engagement with the interventions these included a child’s ability to undergo the training session [37], helpfulness of information [34, 41], ease of use of the intervention [34] and enjoyability of the resource [34].

Table 4 The different outcomes measured within the evidence
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The parent-focussed outcomes included parental satisfaction [27], process difficulty score [27], parental anxiety [28, 43] and parental satisfaction [42].

The outcomes which were focussed on procedural time, costs and the need for additional procedural support also varied across the studies; eight studies included the need for sedation [24, 32, 38, 42, 43, 45, 51, 56], nine studies measured the need for a general anaesthetic [31, 33, 42, 45, 52, 55,56,57, 59], other outcomes measured included additional time taken to be ready for imaging [44], procedure time [27, 30, 49, 58], cost savings [39, 42, 58] and additional attempts to complete a successful scan [27, 35].

Reported impact and value of the interventions and methods to prepare, educate or familiarise children for radiological procedures

The evidence shows that the introduction of additional preparation, education or familiarisation interventions have a positive reported impact on children’s anxiety and distress levels and increase the number of radiological procedures, particularly MRI, which are completed without sedation or anaesthesia. However, due to the variability in outcomes, measures and research designs we are unable to report and conclude on the overall effectiveness of interventions. The reported impact and value of the interventions will be discussed according to the following outcomes: children’s use and perceptions of the interventions, children’s and parents’ knowledge and understanding of the radiological procedure, completion of the radiological procedure, quality of the scan/image obtained, children’s anxiety and distress levels and children’s and parents’ satisfaction (see Table 4).

Children’s use and perceptions of the interventions and methods to prepare, educate or familiarise them before their radiological procedure

Several of the studies examined children’s and parents’ views of their child using the intervention [34, 41, 46, 50]. In one study, 96% (n = 22) of children reported that they liked the MRI animation they saw and 100% (n = 23) liked the way the animation looked and sounded [50]. While most feedback about watching the MRI animation before the procedure was positive, some children in McGlashan et al.’s (2017) study wanted more realistic and louder noises within the animated video. Parent proxy reports showed that their children found using a preparation smartphone application enjoyable (median 8.5), useful (median 8) and easy to use (median 10) [34] and 92% (n = 155) of parents reported that their child was ‘pleased’ to have had access to a colouring book to help prepare them [46]. One study asked health professionals for their views about children using a smartphone application to prepare them for an MRI and all reported that the intervention was useful for children to access and use prior to their procedure [34].

Impact and value of the preparation, education or familiarisation interventions on children’s and parents’ knowledge and understanding of the radiological procedure

Children undergoing an MRI have been shown to have an improved understanding of their procedure after watching an instructional video compared to controls [29] and after watching an educational animation [41, 50].

Parents have also reported an improved understanding of their child’s radiological procedure after their child used a colouring book to help prepare them [46] and after their child interacted with a smartphone application and booklet before their MRI scan [34].

Impact and value of the preparation, education or familiarisation interventions on radiological scan quality

All the studies (n = 6) which measured the impact of an intervention on the quality of the scan/image obtained showed a positive impact, with the majority of these focussing on the use of mock scanners, 92% (n = 204) of children had usable MRI scans after accessing a mock scanner [35], 90% (n = 81) of MRI scans were of diagnostic quality after children accessed a mock scanner [37], 100% (n = 891) of brain MRI images were of a sufficient quality after children accessed a toy ‘kitten’ scanner [38], 96% (n = 218) of scans were of a diagnostic quality on children who practised their scan [54], 100% (n = 17) of scans (T1-weighted images) met quality assurance for acceptable motion artefact and 94% (n = 16) of children achieved a high-quality diffusion-weighted image after using a mock scanner [48]. After play-based sessions, 97% (n = 121) of children who accessed a medical play session including a mock scanner and information achieved a good quality MRI image [58] and 92% (n = 61) of children achieved clinical diagnostic MRI scans after play-based simulation [36].

Impact and value of the preparation, education or familiarisation interventions on radiological scan completion

The studies report a mainly positive impact of the intervention on radiological scan completion along with a reduced need for additional procedural support. The reported impacts include: increased first-time scan completion (n = 3) [27, 31, 35], successful scan completion (n = 2) [49, 53], reduced time of scan completion (n = 2) [44, 58], reduced preparation time (n = 1) [44], reduced use of sedation (n = 9) [24, 32, 38, 42, 43, 45, 51, 52, 56], reduced need for a general anaesthetic (n = 9) [32, 34, 42, 45, 54,55,56,57, 59] and improved compliance during scan procedures (n = 2) [40, 44]. Some studies showed no effect of an intervention on scan completion, particularly in regard to the need for a general anaesthetic [31, 33].

There was limited information within the papers to accompany what exactly constituted ‘compliance’ [44] and ‘successful completion’ [36, 39, 48]. Many of the studies which note a statistically significant reduction of the use of sedation and anaesthesia have small sample sizes [24].

Impact and value of the preparation, education or familiarisation interventions on children’s and parents’ anxiety and distress

The evidence indicates that interventions and methods used before a radiological procedure can help reduce children’s anxiety before and also during a radiological procedure. However, there are difficulties in drawing together the evidence as the studies use different terms and approaches to measuring anxiety and distress with many using locally developed unvalidated scales and many studies only involving small sample sizes or no comparison/ control group.

The majority of the studies focussed on children undergoing MRI scans and showed that watching an educational animated video helped children feel less ‘nervous’ before their MRI scan [41, 50] and ‘more confident’ and ‘less frightened’ during their scan [50]. Children exposed to a teddy-bear-sized mock MRI scanner had lower anxiety levels before their MRI examination [47] and training with a mock scanner alongside coping strategies such as deep breathing or guided imagery was shown to reduce children’s procedural anxiety [51]. Interestingly, this study found that those children who had higher baseline levels of procedural anxiety did not benefit from the training [51]. Other studies have shown decreased distress and higher ‘tolerance’ prior to undergoing an VCUG for children who viewed a storybook [26] and decreased distress as rated on the Observation Scale of Behavioural Distress (OSBD) for children undergoing a chest radiograph who had used VR [27]. A further study showed that a photo booklet depicting a child having a DMSA scan and an information guide for parents decreased children’s distress levels before their scan [43]. A smartphone application developed to educate a cohort of children prior to having a range of medical imaging procedures was shown to reduce children’s anxiety levels [44]. Two studies reported null findings, showing that children’s procedural 93anxiety was not reduced after using a photo book to familiarise and prepare them prior to an MRI scan [28] or after using a colouring book to prepare them prior to a CT, fluoroscopy, ultrasound or nuclear medicine procedure [30]. While no statistical significance was seen between the control and intervention group, parents (57%, n = 95) reported that they felt the colouring book had made their child ‘less worried’ about the procedure [30]. One study demonstrated that a smartphone application helped to reduce children with Autism Spectrum Conditions (ASC) anxiety by measuring physiological parameters (blood pressure, pulse) and assessing rates of ‘challenging behaviours’ to judge that a smartphone application helped prior to undergoing MRI, CT scan, plain radiograph and nuclear medicine [30].

Some studies evaluating interventions linked to MRI scans focussed on parental anxiety as an outcome, showing a reduction in parental anxiety after their child had accessed a smartphone application pre-scan [34] or a significant reduction in parental anxiety after access to a multi-element intervention (instructional booklet, video and simulation practice) prior to an MRI scan [32].

Impact of the preparation, education or familiarisation interventions on children’s and parents’ satisfaction of undergoing radiological procedures

The studies (n = 4) which measured the impact of an intervention on parents’ satisfaction related to a radiological procedure, show mixed results. Studies showed significantly higher parent-reported procedural satisfaction in a cohort of children who accessed a photo booklet before a DMSA scan [43], in parents whose child accessed virtual reality prior to a chest radiograph [27] and a nonsignificant trend for greater satisfaction in parents whose child accessed a photo diary before an MRI scan [28]. One study showed no significant difference in parents’ reported satisfaction after their child accessed a multi-element preparation program before an MRI compared to controls [42].

Discussion

The evidence suggests that interventions to prepare, educate or familiarise children and young people prior to their radiological procedures have value in improving children’s knowledge, increasing the opportunity to gain good quality scans, reducing children’s anxiety and reducing the need for sedation and general anaesthetic. What is less clear is which elements and modes of delivery of an intervention are most valuable for improving the outcomes of children attending for radiological procedures. Many of the interventions included complex and interrelated components and there was huge disparity between studies relating to the resource and staff input required to deliver an intervention. The complexity and heterogeneity of the interventions and evaluation is exacerbated by the range of outcomes measured and reported. This results in challenges in drawing together a clear understanding of the value and impact of interventions to improve children’s experiences of undergoing a radiological procedure. This led us to consider the challenges and opportunities linked to amassing an evidence base to underpin the development of interventions to prepare, educate and familiarise children prior to radiological procedures.

In examining the findings from this review, we conclude that the use of a health literacy framework is useful to consider the focus, delivery and potential outcomes of such interventions. The need for child-centred interventions and approaches to improve children’s health literacy is well recognised [8, 60], with literature increasingly showing that while improving children’s ability to access, understand and evaluate health information and services is important, health literacy also has an important role in empowering children to become more engaged in shaping and making decisions and choices about their healthcare [61, 62]. We will consider the review findings within three elements of health literacy, accessing procedural information, gaining procedural understanding and knowledge and lastly the application of knowledge and understanding to shape a child’s behaviour and experiences during their radiological procedure (Fig. 2).

Fig. 2
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Mapping the outcomes of interventions alongside a health literacy framework

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This review highlights how children valued the focussed delivery of engaging interventions, enabling them to access useful information and gain knowledge. It is not clear in the papers we reviewed how involved children had been in the development of the interventions and not all studies asked children their opinions of using and accessing information within the various interventions.

The review highlights that the interventions improved children’s and parents’ reported knowledge and understanding of their radiological procedure. However, knowledge and understanding were only included as outcomes in a few studies.

The main focus of interventions and methods was on reducing children’s anxiety and improving their ability to sit or lie still to facilitate a good quality scan without the use of sedation or general anaesthetic. However, there are a lack of first-hand accounts from children within the evidence to help determine which specific elements of the interventions are most valuable to children and how the content and delivery translates to children being able to shape their procedural experiences by self-regulating their emotions and enacting their gained knowledge or practice into sitting still for their procedure. There is a need for evaluations to place greater emphasis on children’s self-reports and procedural experiences as an important outcome alongside scan quality and length of radiological procedure as metrics. There is currently a lack of child voice to shape the important outcomes and metrics of interventions to help inform, educate and prepare children prior to radiological procedures. The need to include children as equal voices in the development of core outcomes for interventional studies is gaining increased awareness to ensure measured outcomes are clinically meaningful [63].

The lack of consistency across the focus, delivery and outcomes of non-invasive interventions to prepare, educate and familiarise children before a radiological procedure has resulted in challenges for the speciality in drawing together a clear understanding of which interventions offer the best option for use within radiology departments. This paper has attempted to outline a framework of the core outcomes to be considered in the future development, evaluation and reporting of non-invasive interventions to prepare, educate and familiarise children before a radiological procedure. The authors conclude that integral to any further development, implementation and evaluation, radiology professionals and researchers carefully consider this framework to amass a core of evidence which would enable comparison between different interventions and inform evidence-based decision-making.

Limitations of the scoping review

There are several limitations to this work which should be considered when interpreting the findings. The scoping review findings are informed by English-language papers only and therefore evidence in papers written in other languages was excluded. The findings of the review are limited to non-invasive interventions to prepare, educate and familiarise children aged 5 years and above.

Conclusion

Interventions and methods to prepare, educate or familiarise children and young people prior to their radiological procedures have value in improving children’s knowledge and reducing their anxiety while increasing the opportunity to gain good quality scans without the need for sedation and general anaesthetic. However, there is insufficient consistency within the evidence to recommend implementation. Many of the interventions include complex and interrelated components, there was huge disparity between the resource and staff input involved in delivering an intervention and wide variability in the outcomes used to judge impact and value. There is a need for consistency of measures and outcomes across evaluation studies and for children to help shape the development of core outcomes for interventional studies.