Development and Initial Validation of the Health-Related Quality of Life Pictorial Inventory for Children (HEALTH-PIC)

Development and Initial Validation of the Health-Related Quality of Life Pictorial Inventory for Children (HEALTH-PIC) | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Development and Initial Validation of the Health-Related Quality of Life Pictorial Inventory for Children (HEALTH-PIC) Tracy Chor Wai Tang, Mun Wong, Jianbin Li, Derwin King Chung Chan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4609586/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objective This 3-study paper aimed to develop and validate a self-reported health-related quality of life pictorial inventory for early childhood children. The scale was designed to overcome existing barriers of parent-proxy response styles and offers an alternative to age-suited literary questionnaires to assess self-reported health-related quality of life, including physical health, emotional health, social health and school health in early childhood. Methods Following an established protocol in the literature of pictorial scales, this 3-study paper leads to the development and validation of the Health-related Quality of Life Pictorial Inventory for Children (HEALTH-PIC). Study 1 involved item development/revision, which utilized a panel of 10 experts and 25 parents via the Delphi method to revise the scale and establish agreement. Study 2 invited a sample of 22 primary school students and 20 kindergarten students to establish face validity amongst primary respondents. Finally, Study 3 invited 342 parent and child dyads to complete the HEALTH-PIC and reference health-related quality of life (HRQoL) questionnaires to establish the questionnaire’s factorial, concurrent, discriminant and criterion validity in addition to internal consistency. Results In Study 1, scale items were developed alongside experts and parents with a strong theoretical and statistical support, ensuring that the items were clear, accurate and applicable for children (Aiken’s V p < .05). In Study 2, we ensured that primary respondents of different ages (kindergarten and primary school children) were able to accurately identify the pictorial images (Aiken’s V p .99; RMSEA and SRMR ≤ .08), concurrent validity ( p < .001), discriminant validity (AVE < shared variance), criterion validity ( p < .001) and an acceptable level of internal consistency (i.e., Cronbach’s α = .60 − .66). Conclusion Overall, the findings of the three studies provide preliminary evidence to support the content validity and construct validity of the HEALTH-PIC. This novel pictorial scale not only provides a reliable and valid assessment of the multidimensional aspects of health-related quality of life among children but can also overcome existing barriers of parent-proxy or age-suited questionnaires. Health-related quality of life Scale development Pictorial Scale Early Childhood Introduction There are many existing definitions of health-related quality of life (HRQoL), all of which have a consensus that it encompasses multidimensional constructs. The components of HRQoL can be defined in relation to the common constructs of physical health, emotional health, social health and school/daily health ( 1 – 4 ). HRQoL is important in the scientific literature because it has been used as an outcome variable to monitor health, track treatment effectiveness, and differentiate health status between sick and healthy individuals ( 1 , 5 – 9 ). Increased HRQoL in early childhood can even be further extended to long-term outcomes such as lower health care costs and family burden ( 10 , 11 ). The present study aimed to develop and preliminarily test a pictorial measure of HRQoL that overcomes previous barriers of traditional questionnaire measures. Measures of HRQoL for Children: Parent Proxy and Child Self-Report Assessing HRQoL in early childhood is especially important as children are experiencing a crucial period of growth and development, the outcomes of which may even have lasting effects in later life ( 7 , 12 – 15 ). Despite its importance and usage in research, clinical and educational fields, current measures of HRQoL for young children rely heavily on parent proxy questionnaires where parents respond on the child’s behalf due to language barriers and cognitive limitations. Research has investigated whether the scores of HRQoL by parent proxy reports are equivalent to children’s subjective HRQoL. In some cases, it has been reported that proxy reports may misrepresent child HRQoL, as there is a significant disparity when comparing both reporting methods ( 14 , 16 ). Qualitative investigations have considered the possibility of recall and observational bias, as parents tended to recall more instances of physical externalizations (rather than emotional internalizations) of child behaviors when they evaluated their child’s HRQoL ( 5 , 16 , 17 ). Alternative methods of quantifying child HRQoL include the use of age-suited questionnaires, where both appropriate language and vocabulary have been adapted, allowing children from age 8 onwards to self-report ( 18 ). Although this advancement resolves the disparity of parent proxy reports versus child self-reports, it remains questionable whether traditional questionnaires that involve literary items are suitable for children to complete, especially as the items are intended to measure complex or abstract concepts that require attentional focus to read and understand the questions and cognitive recollection of a specific situation or scenario ( 19 , 20 ). Other questionnaires that measure psychological constructs, such as the Big 5 personality, that encountered similar methodological challenges in obtaining first-person responses from young children have hence moved towards using pictorial questionnaires (e.g.,19, 21, 22) Pictorial Questionnaires Pictorial questionnaires make use of image-based elements to replace text-based literary items and/or the rating scale of traditional questionnaires. In particular, items in the pictorial questionnaires are presented as static pictures instead of words. Respondents then rate the extent to which the concepts are relatable to them or how often the scenarios have recently occurred to them. Young children, specifically, may then make direct interpretations of the items by looking at the pictures that incorporate daily life examples, ultimately lowering the necessary cognitive load on reading and recalling specific scenarios that match the description ( 19 ). It has also been suggested that children have more pleasure in completing pictorial questionnaires because the questions are more visually appealing. With the formatting like a children’s book, it may also allow children to engage more and hold their attention for longer, which can prevent young children from defaulting to mindless agreement, ultimately making them more susceptible to acquiescence bias ( 22 – 25 ). Despite the differences in the presentation of the items and the style of the responses, pictorial questionnaires have been statistically shown to be as accurate and reliable as traditional surveys ( 20 , 26 ). For example, a pictorial scale about children’s swimming competence has captured reliable responses that were significantly associated with an objective measure of swimming competence ( 26 ). The supportive evidence of pictorial scales has thus paved the way for extending their application in measuring other psychological or behavioural patterns of children. Sauer and colleagues ( 20 ) reviewed existing pictorial scales and identified 57 existing studies that were developed and provided examples of pictorial scales in research. It was noted that there was a wide variety of pictorial scales, and they were used even for complex concepts such as emotions, personality and family aggression ( 19 , 27 , 28 ). However, as far as we know, there has not been a pictorial scale developed for measuring young children’s general HRQoL even when presented with the theoretical and practical value of measuring this construct in early childhood. In addition, Sauer and colleagues ( 20 ) noted that there have been some inconsistencies in the way the pictorial scales were developed, and these inconsistencies might lead to measurement bias and generalizability problems. In combating this, the authors subsequently recommended a 3-phase structured protocol, directing future pictorial scales to be developed with a strong foundation. Therefore, the development and subsequent validation of a pictorial HRQoL scale that follows the 3-phase protocol recommended by Sauer and colleagues ( 20 ) is highly warranted. The Present Studies The measurement of HRQoL for children in early childhood has predominantly been measured by parent-proxy measures, where the responses could be subjected to observational bias, recall bias, and projection bias. Existing self-report questionnaires are all literary based and can only be completed by children older than 8 years; therefore, developing a pictorial HRQoL scale measuring overall health in the domains of physical health, emotional health, social health and school health for young children might resolve the limitations of existing measures and provide insight into early childhood children’s subjective wellbeing. Therefore, the aim of the present study was to develop and establish a Health-related Quality of Life Pictorial Inventory for Children (HEALTH-PIC) and to conduct a preliminary test of the validity of the scale by referring to Sauer and colleagues ( 20 ) 3-phase protocol. In particular, Phase 1 involves experts and parents in item generation, item revision and item visualization. Phase 2 is focused on establishing item validity via face validity with primary respondents, while Phase 3 is to investigate its construct validity. In addition to Sauer and colleagues ( 20 ) guidelines, we also followed existing recommendations in the literature on scale development ( 29 , 30 ) and incorporated the think-aloud technique ( 31 , 32 ) and Delphi method ( 33 , 34 ) to utilize the benefits of these methods and aid in the development of HEALTH-PIC. In this paper, we present three studies regarding the development of HEALTH-PIC. Study 1 followed Phase 1 of Sauer and colleagues ( 20 ) guidelines, which involved the development and revision of HEALTH-PIC items based on feedback from experts and parents. Study 2 was derived from Phase 2, which aimed to establish the face validity and preliminary test HEALTH-PIC in primary respondents of children in early childhood. Study 3 will follow Phase 3 to preliminarily test its psychometric properties, namely, the factorial, concurrent, discriminant, criterion validity and internal consistency of the scale. Study 1 Study 1 followed the scale development recommendations of Sauer and colleagues ( 20 ) and Boateng and colleagues ( 29 ), where the literature recommendations on early childhood development pertaining to our definition of HRQoL were examined. Experts and parents were then invited to develop/revise the item pool of the HEALTH-PIC. The ultimate purpose of Study 1 is to establish items of a pictorial HRQoL scale. Literature Research and Item Generation The literature was reviewed to identify developmental factors of our definition of HRQoL. In the initial item generation, we considered gross motor skills (i.e., Walking; 35), daily skills (i.e., Chores, putting toys away; 36), primary emotions (i.e., happiness, sadness; 37, 38), peer social interactions (i.e., bullying, teasing; 37, 38) and cognitive functioning (i.e., participation in class; 39), all of which are components that correspond to our definition of HRQoL: physical health, emotional health, social health and school health ( 4 , 18 ). During the initial development of the pictorial scale, we brainstormed the key items or components within the above literature that could be reflected in common situations that children encountered on a daily basis. Ultimately, a total of 23 items reflecting 4 factors (7 physical health, 6 primary emotions, 5 social health and 5 school health) were initially developed. A dichotomous Yes/No Smiley Face Likert Scale ( 40 ) in addition to an “I don’t know” option ( 19 ) was also adopted as a response scale for asking whether the displayed scenario had happened to children within the past month. To also account for gender differences in pictorial items and to make the scale more relatable, boy and girl versions were developed where the pictures differed only in hair length of the main character ( 21 , 41 – 43 ). Expert Consultation In addition to a literature search outlining the potential items, Sauer and colleagues ( 20 ) suggested for a group of experts in the field to gather ideas for items whilst being mindful of the target population (e.g., children or those who are sick). The experts in the current investigation, were recruited by following recommendations of Dunn, Bouffard ( 30 ), and were defined as those who had a publication record in research areas of children and HRQoL. The research protocol for the expert and parent consultation was approved by the Human Research Ethics Committee of the first author’s institution (Ref no. 2021-2022-0424). A total of 10 experts were invited to provide valuable feedback on the item, leading to the refinement and revision of the initial pool. The items were reviewed independently by the expert panel, and they were re-drawn until the expert panel felt that the items were the clearest and closest representation for children’s HRQoL. To further examine the face validity of the item pool, each expert was asked in each round to rate the pictorial item in terms of its clarity (i.e., Do you think this picture clearly conveys “walking” to children), accuracy (i.e., Do you think this picture is an accurate representation of “walking” for children) and applicability (Do you think the pictured scenario is realistic and applicable for children) for children (defined as 4–8 years old) on a scale of 1 (strongly disagree) to 5 (strongly agree) using an online platform. Additionally, to assess content relevance they were also asked to indicate which subscale the item most likely represented via a multiple-choice of: physical health, emotional health, social health or school health. Parent Consultation In addition to an expert panel, we also formed a parent panel group, as parents could evaluate the clarity, accuracy and applicability of the scale items from a child perspective. Specifically, the parent panel consisted of 25 eligible parents who were current fathers/mothers of at least one child who was between 4–8 years old. Similar to our expert group, each parent participant was asked to independently review the HEALTH-PIC via an online platform. For each item, they were able to suggest feedback to improve the pictorial representation and rated each item in terms of its clarity, accuracy and applicability for children (defined as younger than 8 years old) on a scale of 1 (strongly disagree) to 5 (strongly agree). Similarly, they were also asked to rate which subscale the item most likely represented: physical health, emotional health, social health or school health. Item Revision and Analysis Data from the expert and parent groups were analysed together as we wanted to reach a consensus across groups. The content relevance of the scale was coded as incorrect ( 1 )/correct ( 2 ) to the preconceived factor prior to calculating Aiken’s significance. The results were calculated via Aiken’s significance ( p < .05) using the Aiken ( 44 ) formula on item clarity, accuracy and applicability and content relevance. Items that did not reach significance were subsequently revised according to parents’ and experts’ comments. These revised versions were then presented to the same panel again for another round of ratings/comments until satisfactory (indicated by Aiken’s significance of p < .05). To ensure an eventual consensus, the Delphi method was employed, where the panel was given the previous pictorial item, average ratings and sample comments of the previous round as a reference, allowing them insight into others’ opinions before their second round of ratings/comments on the revised pictorial item ( 33 , 34 ). Results Results of Study 1. There was a total of 2 rounds of expert/parent revisions before all the items reached significance. In the first round, a total of 7 items satisfied all the criteria of significant agreement of clarity (V = .80 to .94; p < .05), accuracy (V = .76 to .94; p < .05), applicability (V = .73 to .91; p < .05) and content relevance (V = .77 to .97; p .05) on all the requirements, we reconstructed these items according to the experts’ and parents’ comments and asked the parents/experts to re-evaluate these items. Examples of these initial comments include “maybe sweeping the floor is better than mopping the floor, both are chores” (item 6); “the box can be empty, you can draw more toys in the box to make it look heavier” (item 4); and “the other classmates can seem more relaxed when doing the test” (item 19). In the second round of panel review, 10 experts and 15 parents agreed to rate the revised version, and all 16 items met the required criteria for content relevance, clarity (V = .64 to .89; p < .05), accuracy (V = .64 to .86; p < .05), applicability (V = .63 to .91; p < .05) and its content relevance (V = .69 to 1.0; p < .05). The specific V values for each item are displayed in Table 1, and the final pictorial items can be found in Appendix A. [INSERT TABLE 1 AROUND HERE] Conclusions of Study 1 Following protocols for scale development, literature research and expert/parent consultation, Study 1 developed 23 items of the HEALTH-PIC. Evidence from expert and parent panel reviews provided initial support for face validity in terms of clarity, accuracy, applicability and content relevance on the HEALTH-PIC. Study 2 The purpose of Study 2 is to establish the face validity of the HEALTH-PIC in primary respondents of early childhood children. Specifically, according to Sauer and colleagues ( 20 ) and Boateng and colleagues ( 29 ), we tested whether children could accurately identify what the pictorial items portrayed in addition to their ability to complete the questionnaire. To also account for differing levels of cognitive development based on age and school year in early childhood, we invited primary and kindergarten students respectively to complete this study. Method Participants We recruited 22 primary school students (mean age = 6.18; S.D. = .39; age range = 6–8) and 20 kindergarten students (mean age = 4.55; S.D. = .50; age range = 4–6) as the participants of Study 2 by sending school invitations. The participants were all between 4 and 8 years old (n Total = 42, 50% female) and are currently residing in Hong Kong. Procedure The research protocol for this study was approved by the Human Research Ethics Committee of the first author’s institution (Ref no. 2021-2022-0424). Item Identification. After providing consent, each child was interviewed in person by a trained researcher. Initially, a researcher read a script outlining the instructions for questionnaire completion. After they understood the instructions, each child was then presented with a single item from the HEALTH-PIC, followed by the question “Can you tell me what is happening in the picture?”. Here, the child was encouraged that there was no right or wrong answer and that they could verbalize their thought process using the think-aloud technique. After the child responded, the researcher marked the answer verbatim. Questionnaire Completion . After identifying the item, the researcher then revealed the second part of the question, where the child participants were then asked whether they had experienced similar situation(s) within the past month and were presented with a smiley face Likert scale with the labels of “yes”, “no”, and “I don’t know”. After the children responded, the researcher encouraged them to circle their answers by themselves. This process was repeated with all 23 items of the HEALTH-PIC, and the whole process was audio recorded. At the very end, the child was also asked by the researcher whether they found the questionnaire too long or too difficult (yes/no). Analysis The data from kindergarten children and primary school children were analysed separately to account for differing cognitive development in different age ranges and school grades in early childhood. Item Identification Participants’ verbal responses were coded into numerical values that indicated correct/incorrect responses that corresponded to the questionnaire item/intended pictorial depiction. These responses had to be equivalent to the preconceived item description in Study 1; any other description was otherwise marked as wrong. Aiken’s validity coefficient and significance (44; p < .05) were used to reveal whether both kindergarten children and primary school children were able to correctly identify the picture to the corresponding item question (for evidence of face validity). Questionnaire Completion To observe whether children could complete the questionnaire by following the instructions of the scripted directions, we investigated whether there were missing or “I don’t know” values for at least 11 items (approx. 50% of the questionnaire). Additionally, to determine the statistical significance and agreement of Aiken’s validity coefficient (44; p < .05), the subsequent yes( 1 )/no( 2 ) responses on whether the questionnaire was too long or too difficult were numerically coded. Results of Study 2 Item Identification In terms of item identification, Aiken’s validity was computed similarly to Study 1. All 23 items satisfied the criteria of Aiken’s significance (kindergarten children V = .75–1.0; primary school children V = .73–1.0; p < .05; see Table 2), indicating that both kindergarten and primary school children were able to accurately identify all the pictorial items. Questionnaire Completion All child participants (n = 42) were able to follow the scripted directions to complete the questionnaire. In terms of length and difficulty, Aiken’s validity also revealed that the current questionnaire was considered suitable in terms of length (showing agreement that kindergarten and primary school children did not find it too long; kindergarten children V = .80; p < .05; primary school children V = .86; p < .05) and difficulty (showing agreement that kindergarten and primary school children did not find it too difficult; kindergarten children V = .85; p < .05; primary school children V = .90; p < .05) for the current sample of children. [INSERT TABLE 2 AROUND HERE] Conclusions of Study 2 Through Study 2, we investigated children’s perspectives of the HEALTH-PIC items and determined that children in kindergarten/primary school were able to accurately identify the pictorial depictions. Our investigation also revealed that children were able to follow the scripted directions to complete the questionnaire and that the length and difficulty of the pictorial items of the HEALTH-PIC appeared to be appropriate for children in early childhood. Study 3 The purpose of Study 3 is to examine the HEALTH-PIC in terms of its factorial, concurrent, discriminant, and criterion validity in addition to its internal consistency in a sample of children in early childhood. Additionally, we aimed to recruit participants from the United Kingdom to provide initial support for the generalizability of the scale across countries. We hypothesize that the validity indices stated above are as follows: (H1) Factorial validity: Consistent with our development, the items in the factors of physical health, emotional health, social health and school health, would load on their respective factors, and the four-factor model would yield an acceptable goodness-of-fit indices. (H2) Concurrent Validity: The overall score of the HEALTH-PIC would be positively associated with parent proxy HRQoL and Child HRQoL overall score. Moreover, the subscales of the HEALTH-PIC would also be positively associated with the subscales of parent proxy HRQoL and Child HRQoL in terms of physical health, emotional health, social health and school health respectively. (H3) Discriminant Validity: The average variance extracted from the HEALTH-PIC would be greater than its shared variance with a mental health questionnaire. (H4) Criterion Validity: The overall score of the HEALTH-PIC would significantly and negatively correlate with child illness. Moreover, the physical subscale would be positively associated with daily functioning, the emotional health subscale will be negatively associated with mood disturbances, the social subscale would be positively associated with social life and school health would be positively associated with academic status. (H5) Internal Consistency: The Cronbach’s alpha of the overall and subscales of the HEALTH-PIC would be acceptable. Method Participants An online survey platform was used to recruit parents who currently reside in the United Kingdom and who have healthy children aged between 4 and 8 years. Parents and their children were recruited to participate in the current questionnaire study and were given compensation for their time. We recruited 342 healthy parent‒child dyads participated in the current study. Two participants were excluded from the analysis for an apparent pattern of missing data (i.e., > 50% missing data/“I don’t know” responses in the HEALTH-PIC). Therefore, our final sample included 340 pairs of parent‒child dyads. The parent participants were mostly aged between 35 and 44 years (63.2%), and most of the mothers completed the questionnaire (65.3%). The participants were all aged between 4 and 8 years (M(SD) = 6.30(1.31)), with a balanced female/male percentage (52.1% female). Materials The online questionnaire for Study 3 was split into two parts: a parent questionnaire and a child questionnaire. Parents were invited to complete a series of self-reported measures on demographic information, child illness, parent proxy HRQoL, mental health and daily functioning in regards to their children. Children were invited to complete a series of self-reported measures measuring HRQoL (pictorial/literary), mood disturbances, academic status and social life. Demographic Information. Characteristics describing the participating parent and child was collected. Examples of which include, parent/child age, parent/child gender, current child’s grade level. Child Illness. A total of 8 questions were designed to capture observational aspects of particular situations indicative of a child’s health, specifically whether they were ill within the past month. They were presented as statements (e.g., days absent from class, days visited hospital), where parent participants indicated whether the situations happened to their children in the past month (yes/no). If the parent participant indicated “yes”, they were asked to indicate how many times/days it had happened. Example questions include “Gone to the hospital to receive treatment” and “Felt sick/unwell in school and had to go home early”. The number of time/days was then added together to indicate a child’s recent overall health status, where a higher number indicated poorer health. Parent Proxy HRQoL. The parent proxy PedsQL assesses the health-related quality of life of the child from the parents’ perspective (3, 18; α = .86). There are a total of 23 items where parents report how much of a problem the child had in the past month with physical functioning, emotional functioning, social functioning and school functioning. Response styles were based on a 5-point Likert scale ranging from 0 (“Never A Problem”) to 4 (“Almost Always A Problem”). Ultimately, after reverse scoring was applied, a higher average score indicated better HRQoL. Mental Health. The Patient Health Questionnaire (PHQ-4) is a brief 4-item questionnaire designed to detect symptoms of anxiety and depression (45, 46; α = .81). Parents were asked to answer based on their child’s emotions in the past month on a 4-point Likert scale ranging from 0 (Not At All) to 3 (Nearly Everyday). Higher summed scores indicated greater symptom severity. Daily Functioning . Only the 3 items that refer to daily movements from the EQ-5D-3L scale were measured (47, 48; α = .72). Parents were asked to rate whether their child had problems with mobility, self-care and conducting usual activities on a three-point Likert scale of “No Problems”, “Some problems” and “Unable to Perform”. After reverse scoring, the scores were summed so that a higher score indicated better daily functioning health. Pictorial HRQoL/HEALTH-PIC. The Health-PIC is a novel pictorial questionnaire developed (in Study 1 and Study 2) to assess self-reported HRQoL in children in the past month. There were a total of 23 items across multiple dimensions of HRQoL (i.e., physical health, emotional health, social health and school health), and a smiley face response Likert scale was used. A higher average score indicated better HRQoL. Parent participants were permitted to assist child participants in completing the items by reading aloud the scripted directions whilst allowing their child to select their answers. Child HRQoL. The 23-item Child PedsQL measures health-related quality of life in children (18; α = .88), where children are presented with common problems that they may face. Example items are “Is it hard for you to play sports or exercise; do you have hurts or aches?”. The respondents were then asked to identify on a 3-point Likert scale whether they had experienced such problems in the past month. After reverse scoring was applied, a higher average score indicated better HRQoL. Mood Disturbances. The 13-item Mood & Feelings Questionnaire (49; α = .88, 50, 51) had a three-point Likert scale response style of “Not True”, “Sometimes” and “True” to assess children’s recent feelings. Scores were calculated via summation, and higher scores indicated greater emotional functioning problems. Example items include “I felt miserable or unhappy; I hated myself”. Academic Status. Only the subscale of intellectual and school status of the 2nd Edition Piers-Harris Children Self-Concept Scale was used in the current study (52, 53; α = .77). This subscale has a total of 11 true-false statements where children participants respond based on their past month academic status ( 53 ). Example items include “I am smart; I am good in my schoolwork”. After reverse scoring for some items was applied, a higher summed score indicated greater self-concept of academic status/intellect. Social Life. Parents were told to ask their children “Do you have any friends? Can you tell me their names” as an indicator of their social relationships and immediate social circles ( 54 , 55 ). Parents were also strictly told not to remind their child of any friends and subsequently counted the number of friends they named. Procedure The research protocol for this study was approved by the Human Research Ethics Committee of the first author’s institution (Ref no. 2021-2022-0424). Participants were invited via an online questionnaire platform and were eligible if they had a healthy child who was between the ages of 4 and 8 years, was currently residing in the United Kingdom, had a normal vision and understood English. Eligible parents first completed the first section of the questionnaire on their own (parent section) and assisted their child in “team completion” of the latter child questionnaire. Each parent and child dyad were given a small amount of compensation via the online platform for their time. Analysis (H1) Factorial validity Exploratory structural equation modelling (ESEM) was employed using Mplus 8 ( 56 ) to assess the factor structure of the HEALTH-PIC. Considering that the HEALTH-PIC has dichotomous categorical responses, we used the weighted least square estimator (WLSMV) because it does not assume normality and provides modelling for categorical data ( 57 , 58 ). Multiple indicators were used to assess the goodness-of-fit of the current proposed model using traditional fit indices of CFI and TLI values exceeding .90 and RMSEA and SRMR values below .08 ( 59 ). (H2) Concurrent validity Concurrent validity is established when there is a significant relationship between the overall and subscale scores of the HEALTH-PIC and the PedsQL respectively. A significant correlation coefficient of .30 or higher indicates an acceptable level of concurrent validity ( 60 ). (H3) Discriminant Validity To determine discriminant validity, we estimated the average shared variance (AVE) and the shared variance between the factors in the HEALTH-PIC and a measure of mental health. Specifically, the AVE is calculated by summing the squared factor loadings and dividing it by the number of items. With this, discriminant validity can be established when the AVE is greater than the shared variance between the constructs (HEALTH-PIC and PHQ-4; 59, 60). (H4) Criterion Validity To establish criterion validity, the calculated overall score of the HEALTH-PIC should be significantly and negatively associated with child illness. Moreover, the subscales of physical health, emotional health, social health and school health of the HEALTH-PIC should be significantly correlated with daily functioning, mood disturbances, social life, and academic status as we hypothesized. (H5) Internal Consistency Cronbach’s α coefficient of the HEALTH-PIC was calculated to determine the internal consistency of the scale. A value greater than .60 was used as a criterion for acceptable internal consistency ( 61 , 62 ). Results (H1) Factorial Validity ESEM analysis revealed that one item from the physical subscale and one item from the emotional subscale (items 7 and 8) had cross-loading indifferences where they loaded highly on two different factors. They were hence eliminated due to the inability to disentangle specific factors ( 56 ). Moreover, we investigated the inter-item correlations and items within the same subscale, and one item (item 3) from the physical subscale was eliminated because it formed negative correlations with the other items of the same subscale (item 3; 56). After these three items were eliminated, the 4-factor model showed an acceptable fit of (x² = 121.55 (df = 116), CFI = .99, TLI = .99, RMSEA = .01, 90%CI [.00,.03], SRMR = .08, establishing factorial validity. The factor loading range of each subscale can be found in Table 3. The final model had 5 items for each dimension of physical health, emotional health, social health and school health (see Appendix B). (H2) Concurrent Validity The current HEALTH-PIC overall score demonstrated significant correlations with the overall score of child PedsQL ( r = .74, p < .001) and of parents PedsQL ( r = .50, p < .001). The subscales of the HEALTH-PIC also correlated with the subscales of parent proxy HRQoL, namely, physical ( r = .18, p < .001), emotional ( r = .57, p < .001), social ( r = .33, p < .001) and school ( r = .49, p < .001) health, in addition to the subscales of child HRQoL; physical ( r = .43, p < .001), emotional ( r = .66, p < .001), social ( r = .52, p < .001) and school ( r = .69, p < .001) health. Discriminant Validity (H3) Discriminant validity can be established when the HEALTH-PIC is not significantly correlated with other theoretically different measures. In the case of HEALTH-PIC, the average variance extracted (AVE) was calculated by summing the squared factor loadings and dividing it by the number of items (AVE range = .34 − .60). Additionally, the shared variance between the factors of the HEALTH-PIC and mental health (measured via the PHQ-4) was also calculated (shared variance range = .01 − .11) and compared. Ultimately, discriminant validity was established as the AVE is greater than the shared variance between the constructs ( 59 ). Specific subscale’s AVE and shard variance can be found in Table 3. (H4) Criterion Validity In terms of criterion validity, the current HEALTH-PIC overall score demonstrated a significant negative correlation with parent-observed child illness ( r = − .34, p < .001). Looking at the subscales, the physical health subscale of the HEALTH-PIC correlated significantly with daily functioning ( r = .18, p = .003); and the emotional health subscale of the HEALTH-PIC correlated significantly with mood disturbances ( r = − .51, p < .001). The social health subscale of the HEALTH-PIC, however, did not correlate with children’s social life ( r = .07, p = .181), but the school health subscale of the HEALTH-PIC also significantly correlated with academic status ( r = .38, p < .001). All correlations for the criterion validity can be found in Table 3. (H5) Internal Consistency The Cronbach’s α coefficient of the HEALTH-PIC was also calculated to determine the internal consistency of the scale. The current scale shows acceptable reliability of α = .76 across all 20 items and α = .60 − .66 for each factor (61, 62; see Table 3). [INSERT TABLE 3 AROUND HERE] Conclusions of Study 3 The current findings largely supported HEALTH-PIC's factorial, concurrent, discriminant, criterion validity and internal consistency in a large-scale population, showing promise in the utilization of the HEALTH-PIC in further research. General Discussion The current three-study paper aimed to develop and preliminarily test the HEALTH-PIC, a pictorial measure of early childhood self-reported health-related quality of life. In the first study, we were able to follow the recommendations of Boateng and colleagues ( 29 ) and Sauer and colleagues ( 20 ) and utilize both parent and expert groups to develop and revise the items, making it clear, relatable and accurate for children. Our actual child population in Study 2 was able to show that both kindergarten and primary school children were able to correctly interpret the items in the picture and complete the questionnaire via scripted directions and that the overall questionnaire was not too long or difficult. In our last study, we were able to successfully determine the scale’s statistical properties, namely, factorial, concurrent, discriminant, criterion validity and internal consistency. Therefore, as supported by our studies, the HEALTH-PIC generally demonstrated its value as a newly developed comprehensive pictorial questionnaire for assessing self-reported early childhood HRQoL. Despite its general statistical agreement, there was no significant association between the social subscale of the HEALTH-PIC and children’s social life. However, because there were significant correlations between the HEALTH-PIC and parent-proxy HRQoL and child HRQoL, the lack of the aforementioned association might not necessarily indicate the inability of the HEALTH-PIC to assess social health. Instead, this could be because our measure of social life did not account for the quality of children’s friendships and did not quantify the volume of playtime they had with their friends ( 63 , 64 ). Future investigations could therefore aim to incorporate detailed assessments that consider friendship quality or closeness to evaluate a child’s social life. Overall, the HEALTH-PIC serves as a great addition to the existing literature as most measures of child HRQoL are completed via parent-proxy. As these parent proxy questionnaires are subjected to bias, it may not accurately reflect the underlying child HRQoL ( 14 , 16 ). This pattern can also be observed in Study 3, where the correlations between the parent proxy-reported overall HRQoL and its subscales showed lower strength in correlation than when comparing the child self-reported form. Other than parent proxy reports, most age-suited self-report questionnaires for children in the literature are often for children who are 8 years old or older, as they involve literary items (i.e., KIDSCREEN; 65); however, the newly developed HEALTH-PIC has demonstrated that even children as young as 4 years of age can understand and complete a self-report questionnaire with assistance from others in reading the instructions. In addition to overcoming these existing limitations, the nature of pictorial questionnaires can serve as a tool that allows child respondents to better understand and represent the items in the questionnaire when it is supported by relatable pictures ( 19 – 21 , 42 ). These findings therefore suggest that the HEALTH-PIC can be a more suitable measurement method for our current population of early childhood participants. Limitations & Further Direction With the strengths and novelty of the HEALTH-PIC, we have to acknowledge a few study limitations. Firstly, in the test of the psychometric properties of the HEALTH-PIC, the adoption of a cross-sectional design in Study 3 limited the level of evidence in our validation study. In particular, the criterion validity of the HEALTH-PIC that we demonstrated in Study 3 was only at a cross-sectional level, which meant that we could not determine whether the HEALTH-PIC was predictive of future health outcomes ( 66 ). Similarly, in the examination of its reliability, we were unable to examine the temporal stability of HEALTH-PIC. Future studies could investigate predictive power and test-retest reliability by adopting longitudinal designs ( 67 ). Secondly, our Studies 2 and 3 involved only healthy participants, as we aimed to investigate whether children could successfully complete the questionnaire and validate it without the need to account for confounding variables such as treatment effects or symptom severity. As such, we could not investigate the scale’s sensitivity to changes across diverse health statuses. Future studies could investigate its applicability and sensitivity across different illnesses and symptoms ( 68 , 69 ). Thirdly, while developing and testing the HEALTH-PIC, we did not examine if the reliability and validity of the scale were generalizable across countries and across cultures. Although the samples of our studies involved parent‒child dyads from Hong Kong and the United Kingdom, we did not collect sufficient cross-cultural data for comparison, which could allow us to examine any measurement invariances between cultural contexts ( 70 ). Future studies could compare the properties of HEALTH-PIC by conducting cross-country/cross-cultural studies ( 71 ). Conclusion The present study aimed to develop the HEALTH-PIC, a pictorial questionnaire for measuring HRQoL in early childhood children aged 4–8. We investigated the face validity and examined the psychometric properties (factorial validity, concurrent validity, discriminant validity, criterion validity, and internal consistency) of the HELATH-PIC through 3 studies. Our findings preliminarily revealed that children, even in early childhood, were able to complete the developed HEALTH-PIC with the assistance of their parents in reading the instructions. More importantly, the HEALTH-PIC was able to capture new boundaries of young children’s self-reported HRQoL and could therefore be a tool to supplement existing measures of HRQoL in early childhood research. Declarations Ethical Approval and Consent to Participate This research was approved by the Human Research Ethics Committee of the first author’s institution (Ref no. 2021-2022-0424). Informed consent was obtained from all individual participants included in the study. Data Availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing Interests The authors declare that they have no competing interests. Funding This work was supported by the Early Childhood Education Departmental Research Grant (DRG) of the first author’s institution. Authors’ contributions All authors contributed to study conceptualization, reviewing and editing. xxxx and xxxx analysed the data. 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Item No. Clarity Accuracy Applicability Content Relevance Item 1 .79** .75** .88** .84** Item 2 .80** .76** .91** .97** Item 3 .89* .86** .91** .96** Item 4 .78* .75** .63* .75** Item 5 .81** .76* .86** .91** Item 6 .85** .84** .82** .76** Item 7 .81* .79* .82* .77** Item 8 .76** .70* .81** 1.0** Item 9 .89** .82** .73* .97** Item 10 .94* .94* .91** 1.0** Item 11 .91** .91** .90** 1.0** Item 12 .77* .78** .75** .84** Item 13 .82** .80** .85* .76** Item 14 .82** .77** .88** 1.0 Item 15 .79** .80** .81** .92** Item 16 .86** .84** .77** .89** Item 17 .74** .74** .77** .69** Item 18 .66** .65** .75** .72** Item 19 .66** .64** .69** .96** Item 20 .72** .71** .74** .74** Item 21 .68** .67** .71** .69** Item 22 .71** .71** .79** .88** Item 23 .64* .64* .73* .80** *p < .05 **p < .001 Table 2 Study 2 Aiken’s V coefficient on coded children’s response on item identification of the HEALTH-PIC Item No. Kindergarten Students (Aged 4–6) Primary School Students (Aged 6–8) Item 1 .85** 1.0** Item 2 .95** .95** Item 3 .95** 1.0** Item 4 1.0** .82** Item 5 1.0** 1.0** Item 6 1.0** 1.0** Item 7 .80** .91** Item8 .90** .91** Item 9 .95** .81** Item 10 1.0** 1.0** Item 11 1.0** 1.0** Item 12 .75* .81** Item 13 .80** .73* Item 14 .90** 1.0** Item 15 .85** .95** Item 16 .85** .95** Item 17 .80** .73* Item 18 .80** .81** Item 19 .90** 1.0** Item 20 .80** .77** Item 21 .85** .81** Item 22 .80** .73* Item 23 .75* .91** Not Too Long .80** .86** Not Too Difficult .85** .91** *p < .05 **p < .001 Table 3 Study 3 Correlation matrix, factor loadings, validity indices of the HEALTH-PIC HEALTH-PIC- Physical Health HEALTH-PIC- Emotional Health HEALTH-PIC- Social Health HEALTH-PIC- School Health HEALTH-PIC- Total PedsQL – Child PedsQL – Parent Proxy Child Illness EQ-5D-3L PHQ-4 MFQ Social Life PHCSCS HEALTH-PIC - Physical Health - HEALTH-PIC- Emotional Health .15** - HEALTH-PIC- Social Health .10 .36** - HEALTH-PIC - School Health .20** .34** .21** - Health-PIC Total .41** .79** .65** .67** - PedsQL-Child .37** .61** .37** .53** .74** - PedsQL-Parent Proxy .23** .44** .27** .34** .50** .48** - Child Illness − .15** − .33** − .01 − .35** − .34** − .27** − .36** - EQ-5D-3L .18** .09 .14** .12* .19** .28** .25** − .10 - PHQ-4 − .07 − .33** − .12* − .22** − .30** − .37** − .52** .33** − .26** - MFQ − .27** − .51** − .21** − .34** − .54** − .65** − .40** .22** − .17** .34** - Social Life .12* − .01 .07 .05 .07 .08 .04 .05 − .02 − .02 .01 - PHCSCS .18** .23** .22** .38** .39** .46** .28** − .07 .14* − .19** − .35** .13* - Range of Item Loadings to Target Factors .61–1.13 .36–1.21 .52 − .96 .44 − .66 N/A N/A N/A N/A N/A N/A N/A N/A N/A Range of Mean (SD) 94.41 (13.69) 57.34 (32.51) 83.94 (22.82) 77.55 (25.44) 78.52 (15.92) 84.82 (11.80) 90.85 (8.61) 1.55 (2.63) 8.90 (.400) 4.62 (1.09) 1.89 (2.67) 8.14 (5.00) 7.75 (1.38) Cronbach’s α Coefficient .60 .66 .63 .60 .76 .85 .87 N/A .61 .69 .81 N/A .60 AVE .60 .46 .47 .34 N/A N/A N/A N/A N/A N/A N/A N/A N/A Shared Variance (R) 2 .04 .11 .01 .05 N/A N/A N/A N/A N/A N/A N/A N/A N/A HEALTH-PIC = Health-Related Quality of Life Pictorial Inventory for Children; PedsQL = Pediatric Quality of Life Inventory; EQ-5D-3L = subscales of mobility, mobility, self-care and usual activities only. PHQ-4 = Patient Health Questionnaire; MFQ= Mood and Feelings Questionnaire; PHCSCS= Piers-Harris Children Self-Concept Scale 2 nd edition; AVE= Average Variance Extracted. * p < .05 **p < .001 Additional Declarations No competing interests reported. Supplementary Files Appendix.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4609586","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":325663236,"identity":"b38bad48-a466-458f-8cfb-5083d660f900","order_by":0,"name":"Tracy Chor Wai Tang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYDACZsbmBx8qauT4QRwehgMGDBJsBLSwM7cZzjhzzFiygWgt/OwN0rwtzIkbDhCrRb6ZscFwZgMb4+bzBxgfvG27Y8wg3ZaAV4vBYcaGBx93yDCb3UhgNpzb9syMQebYAfxamEG2nGFjM7vBwCbN23bYhkEivYGgw4AqmXmM+w+w/yZKC8NhiBYJA4YENmagFjMGiTQCDjvMCA5kA4kbic2Sc84dNmaTSEvA77D+449BUVnf33/44Ic3ZYcN+yXSDPA7DAEYIV4gFJGjYBSMglEwCogAAGaPSUWzPXKCAAAAAElFTkSuQmCC","orcid":"","institution":"Education University of Hong Kong","correspondingAuthor":true,"prefix":"","firstName":"Tracy","middleName":"Chor Wai","lastName":"Tang","suffix":""},{"id":325663237,"identity":"7eb68926-fab6-4fb2-a799-e7e0ca8467c8","order_by":1,"name":"Mun Wong","email":"","orcid":"","institution":"Education University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Mun","middleName":"","lastName":"Wong","suffix":""},{"id":325663240,"identity":"dd59e8c1-86aa-4de9-ba4f-43c627c4cd5e","order_by":2,"name":"Jianbin Li","email":"","orcid":"","institution":"Education University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Jianbin","middleName":"","lastName":"Li","suffix":""},{"id":325663241,"identity":"7a0c1227-f576-4d0b-ab67-ac7fedebc81d","order_by":3,"name":"Derwin King Chung Chan","email":"","orcid":"","institution":"Education University of Hong Kong","correspondingAuthor":false,"prefix":"","firstName":"Derwin","middleName":"King Chung","lastName":"Chan","suffix":""}],"badges":[],"createdAt":"2024-06-20 06:32:25","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4609586/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4609586/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":62288478,"identity":"f1f7824c-cbeb-41c5-ab5d-fd958db87c44","added_by":"auto","created_at":"2024-08-12 14:05:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1014875,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4609586/v1/c8e024ea-a864-463b-9887-8225446c1bdd.pdf"},{"id":60153566,"identity":"a1f4af3f-a406-4761-a365-30106d1340fa","added_by":"auto","created_at":"2024-07-12 11:28:16","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":8166086,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix.docx","url":"https://assets-eu.researchsquare.com/files/rs-4609586/v1/0035a59e5562afa7635a1d71.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development and Initial Validation of the Health-Related Quality of Life Pictorial Inventory for Children (HEALTH-PIC)","fulltext":[{"header":"Introduction","content":"\u003cp\u003eThere are many existing definitions of health-related quality of life (HRQoL), all of which have a consensus that it encompasses multidimensional constructs. The components of HRQoL can be defined in relation to the common constructs of physical health, emotional health, social health and school/daily health (\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). HRQoL is important in the scientific literature because it has been used as an outcome variable to monitor health, track treatment effectiveness, and differentiate health status between sick and healthy individuals (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan additionalcitationids=\"CR6 CR7 CR8\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Increased HRQoL in early childhood can even be further extended to long-term outcomes such as lower health care costs and family burden (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). The present study aimed to develop and preliminarily test a pictorial measure of HRQoL that overcomes previous barriers of traditional questionnaire measures.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eMeasures of HRQoL for Children: Parent Proxy and Child Self-Report\u003c/h2\u003e \u003cp\u003eAssessing HRQoL in early childhood is especially important as children are experiencing a crucial period of growth and development, the outcomes of which may even have lasting effects in later life (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan additionalcitationids=\"CR13 CR14\" citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Despite its importance and usage in research, clinical and educational fields, current measures of HRQoL for young children rely heavily on parent proxy questionnaires where parents respond on the child\u0026rsquo;s behalf due to language barriers and cognitive limitations.\u003c/p\u003e \u003cp\u003eResearch has investigated whether the scores of HRQoL by parent proxy reports are equivalent to children\u0026rsquo;s subjective HRQoL. In some cases, it has been reported that proxy reports may misrepresent child HRQoL, as there is a significant disparity when comparing both reporting methods (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Qualitative investigations have considered the possibility of recall and observational bias, as parents tended to recall more instances of physical externalizations (rather than emotional internalizations) of child behaviors when they evaluated their child\u0026rsquo;s HRQoL (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlternative methods of quantifying child HRQoL include the use of age-suited questionnaires, where both appropriate language and vocabulary have been adapted, allowing children from age 8 onwards to self-report (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Although this advancement resolves the disparity of parent proxy reports versus child self-reports, it remains questionable whether traditional questionnaires that involve literary items are suitable for children to complete, especially as the items are intended to measure complex or abstract concepts that require attentional focus to read and understand the questions and cognitive recollection of a specific situation or scenario (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Other questionnaires that measure psychological constructs, such as the Big 5 personality, that encountered similar methodological challenges in obtaining first-person responses from young children have hence moved towards using pictorial questionnaires (e.g.,19, 21, 22)\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePictorial Questionnaires\u003c/h2\u003e \u003cp\u003ePictorial questionnaires make use of image-based elements to replace text-based literary items and/or the rating scale of traditional questionnaires. In particular, items in the pictorial questionnaires are presented as static pictures instead of words. Respondents then rate the extent to which the concepts are relatable to them or how often the scenarios have recently occurred to them. Young children, specifically, may then make direct interpretations of the items by looking at the pictures that incorporate daily life examples, ultimately lowering the necessary cognitive load on reading and recalling specific scenarios that match the description (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). It has also been suggested that children have more pleasure in completing pictorial questionnaires because the questions are more visually appealing. With the formatting like a children\u0026rsquo;s book, it may also allow children to engage more and hold their attention for longer, which can prevent young children from defaulting to mindless agreement, ultimately making them more susceptible to acquiescence bias (\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDespite the differences in the presentation of the items and the style of the responses, pictorial questionnaires have been statistically shown to be as accurate and reliable as traditional surveys (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). For example, a pictorial scale about children\u0026rsquo;s swimming competence has captured reliable responses that were significantly associated with an objective measure of swimming competence (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). The supportive evidence of pictorial scales has thus paved the way for extending their application in measuring other psychological or behavioural patterns of children.\u003c/p\u003e \u003cp\u003eSauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) reviewed existing pictorial scales and identified 57 existing studies that were developed and provided examples of pictorial scales in research. It was noted that there was a wide variety of pictorial scales, and they were used even for complex concepts such as emotions, personality and family aggression (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). However, as far as we know, there has not been a pictorial scale developed for measuring young children\u0026rsquo;s general HRQoL even when presented with the theoretical and practical value of measuring this construct in early childhood. In addition, Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) noted that there have been some inconsistencies in the way the pictorial scales were developed, and these inconsistencies might lead to measurement bias and generalizability problems. In combating this, the authors subsequently recommended a 3-phase structured protocol, directing future pictorial scales to be developed with a strong foundation. Therefore, the development and subsequent validation of a pictorial HRQoL scale that follows the 3-phase protocol recommended by Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) is highly warranted.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eThe Present Studies\u003c/h3\u003e\n\u003cp\u003eThe measurement of HRQoL for children in early childhood has predominantly been measured by parent-proxy measures, where the responses could be subjected to observational bias, recall bias, and projection bias. Existing self-report questionnaires are all literary based and can only be completed by children older than 8 years; therefore, developing a pictorial HRQoL scale measuring overall health in the domains of physical health, emotional health, social health and school health for young children might resolve the limitations of existing measures and provide insight into early childhood children\u0026rsquo;s subjective wellbeing. Therefore, the aim of the present study was to develop and establish a Health-related Quality of Life Pictorial Inventory for Children (HEALTH-PIC) and to conduct a preliminary test of the validity of the scale by referring to Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) 3-phase protocol. In particular, Phase 1 involves experts and parents in item generation, item revision and item visualization. Phase 2 is focused on establishing item validity via face validity with primary respondents, while Phase 3 is to investigate its construct validity. In addition to Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) guidelines, we also followed existing recommendations in the literature on scale development (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e) and incorporated the think-aloud technique (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e) and Delphi method (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) to utilize the benefits of these methods and aid in the development of HEALTH-PIC. In this paper, we present three studies regarding the development of HEALTH-PIC. Study 1 followed Phase 1 of Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) guidelines, which involved the development and revision of HEALTH-PIC items based on feedback from experts and parents. Study 2 was derived from Phase 2, which aimed to establish the face validity and preliminary test HEALTH-PIC in primary respondents of children in early childhood. Study 3 will follow Phase 3 to preliminarily test its psychometric properties, namely, the factorial, concurrent, discriminant, criterion validity and internal consistency of the scale.\u003c/p\u003e"},{"header":"Study 1","content":"\u003cp\u003eStudy 1 followed the scale development recommendations of Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and Boateng and colleagues (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), where the literature recommendations on early childhood development pertaining to our definition of HRQoL were examined. Experts and parents were then invited to develop/revise the item pool of the HEALTH-PIC. The ultimate purpose of Study 1 is to establish items of a pictorial HRQoL scale.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eLiterature Research and Item Generation\u003c/h2\u003e \u003cp\u003eThe literature was reviewed to identify developmental factors of our definition of HRQoL. In the initial item generation, we considered gross motor skills (i.e., Walking; 35), daily skills (i.e., Chores, putting toys away; 36), primary emotions (i.e., happiness, sadness; 37, 38), peer social interactions (i.e., bullying, teasing; 37, 38) and cognitive functioning (i.e., participation in class; 39), all of which are components that correspond to our definition of HRQoL: physical health, emotional health, social health and school health (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eDuring the initial development of the pictorial scale, we brainstormed the key items or components within the above literature that could be reflected in common situations that children encountered on a daily basis. Ultimately, a total of 23 items reflecting 4 factors (7 physical health, 6 primary emotions, 5 social health and 5 school health) were initially developed.\u003c/p\u003e \u003cp\u003eA dichotomous Yes/No Smiley Face Likert Scale (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) in addition to an \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo; option (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) was also adopted as a response scale for asking whether the displayed scenario had happened to children within the past month. To also account for gender differences in pictorial items and to make the scale more relatable, boy and girl versions were developed where the pictures differed only in hair length of the main character (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan additionalcitationids=\"CR42\" citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eExpert Consultation\u003c/h2\u003e \u003cp\u003eIn addition to a literature search outlining the potential items, Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) suggested for a group of experts in the field to gather ideas for items whilst being mindful of the target population (e.g., children or those who are sick). The experts in the current investigation, were recruited by following recommendations of Dunn, Bouffard (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e), and were defined as those who had a publication record in research areas of children and HRQoL. The research protocol for the expert and parent consultation was approved by the Human Research Ethics Committee of the first author\u0026rsquo;s institution (Ref no. 2021-2022-0424).\u003c/p\u003e \u003cp\u003eA total of 10 experts were invited to provide valuable feedback on the item, leading to the refinement and revision of the initial pool. The items were reviewed independently by the expert panel, and they were re-drawn until the expert panel felt that the items were the clearest and closest representation for children\u0026rsquo;s HRQoL.\u003c/p\u003e \u003cp\u003eTo further examine the face validity of the item pool, each expert was asked in each round to rate the pictorial item in terms of its clarity (i.e., Do you think this picture clearly conveys \u0026ldquo;walking\u0026rdquo; to children), accuracy (i.e., Do you think this picture is an accurate representation of \u0026ldquo;walking\u0026rdquo; for children) and applicability (Do you think the pictured scenario is realistic and applicable for children) for children (defined as 4\u0026ndash;8 years old) on a scale of 1 (strongly disagree) to 5 (strongly agree) using an online platform. Additionally, to assess content relevance they were also asked to indicate which subscale the item most likely represented via a multiple-choice of: physical health, emotional health, social health or school health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eParent Consultation\u003c/h2\u003e \u003cp\u003eIn addition to an expert panel, we also formed a parent panel group, as parents could evaluate the clarity, accuracy and applicability of the scale items from a child perspective. Specifically, the parent panel consisted of 25 eligible parents who were current fathers/mothers of at least one child who was between 4\u0026ndash;8 years old. Similar to our expert group, each parent participant was asked to independently review the HEALTH-PIC via an online platform. For each item, they were able to suggest feedback to improve the pictorial representation and rated each item in terms of its clarity, accuracy and applicability for children (defined as younger than 8 years old) on a scale of 1 (strongly disagree) to 5 (strongly agree). Similarly, they were also asked to rate which subscale the item most likely represented: physical health, emotional health, social health or school health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eItem Revision and Analysis\u003c/h2\u003e \u003cp\u003eData from the expert and parent groups were analysed together as we wanted to reach a consensus across groups. The content relevance of the scale was coded as incorrect (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)/correct (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) to the preconceived factor prior to calculating Aiken\u0026rsquo;s significance. The results were calculated via Aiken\u0026rsquo;s significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) using the Aiken (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e) formula on item clarity, accuracy and applicability and content relevance. Items that did not reach significance were subsequently revised according to parents\u0026rsquo; and experts\u0026rsquo; comments. These revised versions were then presented to the same panel again for another round of ratings/comments until satisfactory (indicated by Aiken\u0026rsquo;s significance of \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). To ensure an eventual consensus, the Delphi method was employed, where the panel was given the previous pictorial item, average ratings and sample comments of the previous round as a reference, allowing them insight into others\u0026rsquo; opinions before their second round of ratings/comments on the revised pictorial item (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003e \u003cb\u003eResults of Study 1.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere was a total of 2 rounds of expert/parent revisions before all the items reached significance. In the first round, a total of 7 items satisfied all the criteria of significant agreement of clarity (V\u0026thinsp;=\u0026thinsp;.80 to .94; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), accuracy (V\u0026thinsp;=\u0026thinsp;.76 to .94; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), applicability (V\u0026thinsp;=\u0026thinsp;.73 to .91; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) and content relevance (V\u0026thinsp;=\u0026thinsp;.77 to .97; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). As 16 items did not reach significance (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;.05) on all the requirements, we reconstructed these items according to the experts\u0026rsquo; and parents\u0026rsquo; comments and asked the parents/experts to re-evaluate these items.\u003c/p\u003e \u003cp\u003eExamples of these initial comments include \u0026ldquo;maybe sweeping the floor is better than mopping the floor, both are chores\u0026rdquo; (item 6); \u0026ldquo;the box can be empty, you can draw more toys in the box to make it look heavier\u0026rdquo; (item 4); and \u0026ldquo;the other classmates can seem more relaxed when doing the test\u0026rdquo; (item 19).\u003c/p\u003e \u003cp\u003eIn the second round of panel review, 10 experts and 15 parents agreed to rate the revised version, and all 16 items met the required criteria for content relevance, clarity (V\u0026thinsp;=\u0026thinsp;.64 to .89; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), accuracy (V\u0026thinsp;=\u0026thinsp;.64 to .86; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05), applicability (V\u0026thinsp;=\u0026thinsp;.63 to .91; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) and its content relevance (V\u0026thinsp;=\u0026thinsp;.69 to 1.0; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). The specific V values for each item are displayed in Table\u0026nbsp;1, and the final pictorial items can be found in Appendix A.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003cp\u003e[INSERT TABLE 1 AROUND HERE]\u003c/p\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eConclusions of Study 1\u003c/h2\u003e \u003cp\u003eFollowing protocols for scale development, literature research and expert/parent consultation, Study 1 developed 23 items of the HEALTH-PIC. Evidence from expert and parent panel reviews provided initial support for face validity in terms of clarity, accuracy, applicability and content relevance on the HEALTH-PIC.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Study 2","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003cp\u003eThe purpose of Study 2 is to establish the face validity of the HEALTH-PIC in primary respondents of early childhood children. Specifically, according to Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and Boateng and colleagues (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e), we tested whether children could accurately identify what the pictorial items portrayed in addition to their ability to complete the questionnaire. To also account for differing levels of cognitive development based on age and school year in early childhood, we invited primary and kindergarten students respectively to complete this study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eMethod\u003c/h2\u003e \u003cdiv id=\"Sec15\" class=\"Section3\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eWe recruited 22 primary school students (mean age\u0026thinsp;=\u0026thinsp;6.18; S.D. = .39; age range\u0026thinsp;=\u0026thinsp;6\u0026ndash;8) and 20 kindergarten students (mean age\u0026thinsp;=\u0026thinsp;4.55; S.D. = .50; age range\u0026thinsp;=\u0026thinsp;4\u0026ndash;6) as the participants of Study 2 by sending school invitations. The participants were all between 4 and 8 years old (n\u003csub\u003eTotal\u003c/sub\u003e = 42, 50% female) and are currently residing in Hong Kong.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eThe research protocol for this study was approved by the Human Research Ethics Committee of the first author\u0026rsquo;s institution (Ref no. 2021-2022-0424).\u003c/p\u003e \u003cp\u003e\u003cb\u003eItem Identification.\u003c/b\u003e After providing consent, each child was interviewed in person by a trained researcher. Initially, a researcher read a script outlining the instructions for questionnaire completion. After they understood the instructions, each child was then presented with a single item from the HEALTH-PIC, followed by the question \u0026ldquo;Can you tell me what is happening in the picture?\u0026rdquo;. Here, the child was encouraged that there was no right or wrong answer and that they could verbalize their thought process using the think-aloud technique. After the child responded, the researcher marked the answer verbatim.\u003c/p\u003e \u003cp\u003e \u003cb\u003eQuestionnaire Completion\u003c/b\u003e. After identifying the item, the researcher then revealed the second part of the question, where the child participants were then asked whether they had experienced similar situation(s) within the past month and were presented with a smiley face Likert scale with the labels of \u0026ldquo;yes\u0026rdquo;, \u0026ldquo;no\u0026rdquo;, and \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo;. After the children responded, the researcher encouraged them to circle their answers by themselves.\u003c/p\u003e \u003cp\u003eThis process was repeated with all 23 items of the HEALTH-PIC, and the whole process was audio recorded. At the very end, the child was also asked by the researcher whether they found the questionnaire too long or too difficult (yes/no).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eAnalysis\u003c/h2\u003e \u003cp\u003eThe data from kindergarten children and primary school children were analysed separately to account for differing cognitive development in different age ranges and school grades in early childhood.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eItem Identification\u003c/h2\u003e \u003cp\u003e Participants\u0026rsquo; verbal responses were coded into numerical values that indicated correct/incorrect responses that corresponded to the questionnaire item/intended pictorial depiction. These responses had to be equivalent to the preconceived item description in Study 1; any other description was otherwise marked as wrong. Aiken\u0026rsquo;s validity coefficient and significance (44; p\u0026thinsp;\u0026lt;\u0026thinsp;.05) were used to reveal whether both kindergarten children and primary school children were able to correctly identify the picture to the corresponding item question (for evidence of face validity).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire Completion\u003c/h2\u003e \u003cp\u003eTo observe whether children could complete the questionnaire by following the instructions of the scripted directions, we investigated whether there were missing or \u0026ldquo;I don\u0026rsquo;t know\u0026rdquo; values for at least 11 items (approx. 50% of the questionnaire). Additionally, to determine the statistical significance and agreement of Aiken\u0026rsquo;s validity coefficient (44; p\u0026thinsp;\u0026lt;\u0026thinsp;.05), the subsequent yes(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)/no(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) responses on whether the questionnaire was too long or too difficult were numerically coded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eResults of Study 2\u003c/h2\u003e \u003cdiv id=\"Sec21\" class=\"Section3\"\u003e \u003ch2\u003eItem Identification\u003c/h2\u003e \u003cp\u003eIn terms of item identification, Aiken\u0026rsquo;s validity was computed similarly to Study 1. All 23 items satisfied the criteria of Aiken\u0026rsquo;s significance (kindergarten children V\u0026thinsp;=\u0026thinsp;.75\u0026ndash;1.0; primary school children V\u0026thinsp;=\u0026thinsp;.73\u0026ndash;1.0; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05; see Table\u0026nbsp;2), indicating that both kindergarten and primary school children were able to accurately identify all the pictorial items.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire Completion\u003c/h2\u003e \u003cp\u003e All child participants (n\u0026thinsp;=\u0026thinsp;42) were able to follow the scripted directions to complete the questionnaire. In terms of length and difficulty, Aiken\u0026rsquo;s validity also revealed that the current questionnaire was considered suitable in terms of length (showing agreement that kindergarten and primary school children did not find it too long; kindergarten children V\u0026thinsp;=\u0026thinsp;.80; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05; primary school children V\u0026thinsp;=\u0026thinsp;.86; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) and difficulty (showing agreement that kindergarten and primary school children did not find it too difficult; kindergarten children V\u0026thinsp;=\u0026thinsp;.85; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05; primary school children V\u0026thinsp;=\u0026thinsp;.90; \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) for the current sample of children.\u003c/p\u003e \u003cdiv id=\"Sec23\" class=\"Section3\"\u003e \u003ch2\u003e[INSERT TABLE 2 AROUND HERE]\u003c/h2\u003e \u003cdiv id=\"Sec24\" class=\"Section4\"\u003e \u003ch2\u003eConclusions of Study 2\u003c/h2\u003e \u003cp\u003eThrough Study 2, we investigated children\u0026rsquo;s perspectives of the HEALTH-PIC items and determined that children in kindergarten/primary school were able to accurately identify the pictorial depictions. Our investigation also revealed that children were able to follow the scripted directions to complete the questionnaire and that the length and difficulty of the pictorial items of the HEALTH-PIC appeared to be appropriate for children in early childhood.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e "},{"header":"Study 3","content":"\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e \u003cp\u003eThe purpose of Study 3 is to examine the HEALTH-PIC in terms of its factorial, concurrent, discriminant, and criterion validity in addition to its internal consistency in a sample of children in early childhood. Additionally, we aimed to recruit participants from the United Kingdom to provide initial support for the generalizability of the scale across countries. We hypothesize that the validity indices stated above are as follows:\u003c/p\u003e \u003cp\u003e(H1) Factorial validity: Consistent with our development, the items in the factors of physical health, emotional health, social health and school health, would load on their respective factors, and the four-factor model would yield an acceptable goodness-of-fit indices.\u003c/p\u003e \u003cp\u003e(H2) Concurrent Validity: The overall score of the HEALTH-PIC would be positively associated with parent proxy HRQoL and Child HRQoL overall score. Moreover, the subscales of the HEALTH-PIC would also be positively associated with the subscales of parent proxy HRQoL and Child HRQoL in terms of physical health, emotional health, social health and school health respectively.\u003c/p\u003e \u003cp\u003e(H3) Discriminant Validity: The average variance extracted from the HEALTH-PIC would be greater than its shared variance with a mental health questionnaire.\u003c/p\u003e \u003cp\u003e(H4) Criterion Validity: The overall score of the HEALTH-PIC would significantly and negatively correlate with child illness. Moreover, the physical subscale would be positively associated with daily functioning, the emotional health subscale will be negatively associated with mood disturbances, the social subscale would be positively associated with social life and school health would be positively associated with academic status.\u003c/p\u003e \u003cp\u003e(H5) Internal Consistency: The Cronbach\u0026rsquo;s alpha of the overall and subscales of the HEALTH-PIC would be acceptable.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec26\" class=\"Section3\"\u003e \u003ch2\u003eMethod\u003c/h2\u003e \u003cdiv id=\"Sec27\" class=\"Section4\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003eAn online survey platform was used to recruit parents who currently reside in the United Kingdom and who have healthy children aged between 4 and 8 years. Parents and their children were recruited to participate in the current questionnaire study and were given compensation for their time.\u003c/p\u003e \u003cp\u003eWe recruited 342 healthy parent‒child dyads participated in the current study. Two participants were excluded from the analysis for an apparent pattern of missing data (i.e., \u0026gt;\u0026thinsp;50% missing data/\u0026ldquo;I don\u0026rsquo;t know\u0026rdquo; responses in the HEALTH-PIC). Therefore, our final sample included 340 pairs of parent‒child dyads. The parent participants were mostly aged between 35 and 44 years (63.2%), and most of the mothers completed the questionnaire (65.3%). The participants were all aged between 4 and 8 years (M(SD)\u0026thinsp;=\u0026thinsp;6.30(1.31)), with a balanced female/male percentage (52.1% female).\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec28\" class=\"Section2\"\u003e \u003ch2\u003eMaterials\u003c/h2\u003e \u003cp\u003eThe online questionnaire for Study 3 was split into two parts: a parent questionnaire and a child questionnaire.\u003c/p\u003e \u003cp\u003e Parents were invited to complete a series of self-reported measures on demographic information, child illness, parent proxy HRQoL, mental health and daily functioning in regards to their children.\u003c/p\u003e \u003cp\u003eChildren were invited to complete a series of self-reported measures measuring HRQoL (pictorial/literary), mood disturbances, academic status and social life.\u003c/p\u003e \u003cp\u003e \u003cb\u003eDemographic Information.\u003c/b\u003e Characteristics describing the participating parent and child was collected. Examples of which include, parent/child age, parent/child gender, current child\u0026rsquo;s grade level.\u003c/p\u003e \u003cp\u003e \u003cb\u003eChild Illness.\u003c/b\u003e A total of 8 questions were designed to capture observational aspects of particular situations indicative of a child\u0026rsquo;s health, specifically whether they were ill within the past month. They were presented as statements (e.g., days absent from class, days visited hospital), where parent participants indicated whether the situations happened to their children in the past month (yes/no). If the parent participant indicated \u0026ldquo;yes\u0026rdquo;, they were asked to indicate how many times/days it had happened. Example questions include \u0026ldquo;Gone to the hospital to receive treatment\u0026rdquo; and \u0026ldquo;Felt sick/unwell in school and had to go home early\u0026rdquo;. The number of time/days was then added together to indicate a child\u0026rsquo;s recent overall health status, where a higher number indicated poorer health.\u003c/p\u003e \u003cp\u003e\u003cb\u003eParent Proxy HRQoL.\u003c/b\u003e The parent proxy PedsQL assesses the health-related quality of life of the child from the parents\u0026rsquo; perspective (3, 18; α\u0026thinsp;=\u0026thinsp;.86). There are a total of 23 items where parents report how much of a problem the child had in the past month with physical functioning, emotional functioning, social functioning and school functioning. Response styles were based on a 5-point Likert scale ranging from 0 (\u0026ldquo;Never A Problem\u0026rdquo;) to 4 (\u0026ldquo;Almost Always A Problem\u0026rdquo;). Ultimately, after reverse scoring was applied, a higher average score indicated better HRQoL.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMental Health.\u003c/b\u003e The Patient Health Questionnaire (PHQ-4) is a brief 4-item questionnaire designed to detect symptoms of anxiety and depression (45, 46; α\u0026thinsp;=\u0026thinsp;.81). Parents were asked to answer based on their child\u0026rsquo;s emotions in the past month on a 4-point Likert scale ranging from 0 (Not At All) to 3 (Nearly Everyday). Higher summed scores indicated greater symptom severity.\u003c/p\u003e \u003cp\u003e\u003cb\u003eDaily Functioning\u003c/b\u003e. Only the 3 items that refer to daily movements from the EQ-5D-3L scale were measured (47, 48; α\u0026thinsp;=\u0026thinsp;.72). Parents were asked to rate whether their child had problems with mobility, self-care and conducting usual activities on a three-point Likert scale of \u0026ldquo;No Problems\u0026rdquo;, \u0026ldquo;Some problems\u0026rdquo; and \u0026ldquo;Unable to Perform\u0026rdquo;. After reverse scoring, the scores were summed so that a higher score indicated better daily functioning health.\u003c/p\u003e \u003cp\u003e \u003cb\u003ePictorial HRQoL/HEALTH-PIC.\u003c/b\u003e The Health-PIC is a novel pictorial questionnaire developed (in Study 1 and Study 2) to assess self-reported HRQoL in children in the past month. There were a total of 23 items across multiple dimensions of HRQoL (i.e., physical health, emotional health, social health and school health), and a smiley face response Likert scale was used. A higher average score indicated better HRQoL. Parent participants were permitted to assist child participants in completing the items by reading aloud the scripted directions whilst allowing their child to select their answers.\u003c/p\u003e \u003cp\u003e \u003cb\u003eChild HRQoL.\u003c/b\u003e The 23-item Child PedsQL measures health-related quality of life in children (18; α\u0026thinsp;=\u0026thinsp;.88), where children are presented with common problems that they may face. Example items are \u0026ldquo;Is it hard for you to play sports or exercise; do you have hurts or aches?\u0026rdquo;. The respondents were then asked to identify on a 3-point Likert scale whether they had experienced such problems in the past month. After reverse scoring was applied, a higher average score indicated better HRQoL.\u003c/p\u003e \u003cp\u003e \u003cb\u003eMood Disturbances.\u003c/b\u003e The 13-item Mood \u0026amp; Feelings Questionnaire (49; α\u0026thinsp;=\u0026thinsp;.88, 50, 51) had a three-point Likert scale response style of \u0026ldquo;Not True\u0026rdquo;, \u0026ldquo;Sometimes\u0026rdquo; and \u0026ldquo;True\u0026rdquo; to assess children\u0026rsquo;s recent feelings. Scores were calculated via summation, and higher scores indicated greater emotional functioning problems. Example items include \u0026ldquo;I felt miserable or unhappy; I hated myself\u0026rdquo;.\u003c/p\u003e \u003cp\u003e \u003cb\u003eAcademic Status.\u003c/b\u003e Only the subscale of intellectual and school status of the 2nd Edition Piers-Harris Children Self-Concept Scale was used in the current study (52, 53; α\u0026thinsp;=\u0026thinsp;.77). This subscale has a total of 11 true-false statements where children participants respond based on their past month academic status (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Example items include \u0026ldquo;I am smart; I am good in my schoolwork\u0026rdquo;. After reverse scoring for some items was applied, a higher summed score indicated greater self-concept of academic status/intellect.\u003c/p\u003e \u003cp\u003e\u003cb\u003eSocial Life.\u003c/b\u003e Parents were told to ask their children \u0026ldquo;Do you have any friends? Can you tell me their names\u0026rdquo; as an indicator of their social relationships and immediate social circles (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Parents were also strictly told not to remind their child of any friends and subsequently counted the number of friends they named.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec29\" class=\"Section2\"\u003e \u003ch2\u003eProcedure\u003c/h2\u003e \u003cp\u003eThe research protocol for this study was approved by the Human Research Ethics Committee of the first author\u0026rsquo;s institution (Ref no. 2021-2022-0424). Participants were invited via an online questionnaire platform and were eligible if they had a healthy child who was between the ages of 4 and 8 years, was currently residing in the United Kingdom, had a normal vision and understood English.\u003c/p\u003e \u003cp\u003e Eligible parents first completed the first section of the questionnaire on their own (parent section) and assisted their child in \u0026ldquo;team completion\u0026rdquo; of the latter child questionnaire. Each parent and child dyad were given a small amount of compensation via the online platform for their time.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalysis\u003c/h3\u003e\n\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e \u003ch2\u003e(H1) Factorial validity\u003c/h2\u003e \u003cp\u003eExploratory structural equation modelling (ESEM) was employed using Mplus 8 (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e) to assess the factor structure of the HEALTH-PIC. Considering that the HEALTH-PIC has dichotomous categorical responses, we used the weighted least square estimator (WLSMV) because it does not assume normality and provides modelling for categorical data (\u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e57\u003c/span\u003e, \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e58\u003c/span\u003e). Multiple indicators were used to assess the goodness-of-fit of the current proposed model using traditional fit indices of CFI and TLI values exceeding .90 and RMSEA and SRMR values below .08 (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec32\" class=\"Section2\"\u003e \u003ch2\u003e(H2) Concurrent validity\u003c/h2\u003e \u003cp\u003eConcurrent validity is established when there is a significant relationship between the overall and subscale scores of the HEALTH-PIC and the PedsQL respectively. A significant correlation coefficient of .30 or higher indicates an acceptable level of concurrent validity (\u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e60\u003c/span\u003e).\u003c/p\u003e \u003cdiv id=\"Sec33\" class=\"Section3\"\u003e \u003ch2\u003e(H3) Discriminant Validity\u003c/h2\u003e \u003cp\u003eTo determine discriminant validity, we estimated the average shared variance (AVE) and the shared variance between the factors in the HEALTH-PIC and a measure of mental health. Specifically, the AVE is calculated by summing the squared factor loadings and dividing it by the number of items. With this, discriminant validity can be established when the AVE is greater than the shared variance between the constructs (HEALTH-PIC and PHQ-4; 59, 60).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec34\" class=\"Section3\"\u003e \u003ch2\u003e(H4) Criterion Validity\u003c/h2\u003e \u003cp\u003eTo establish criterion validity, the calculated overall score of the HEALTH-PIC should be significantly and negatively associated with child illness. Moreover, the subscales of physical health, emotional health, social health and school health of the HEALTH-PIC should be significantly correlated with daily functioning, mood disturbances, social life, and academic status as we hypothesized.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003e(H5) Internal Consistency\u003c/h3\u003e\n\u003cp\u003eCronbach\u0026rsquo;s α coefficient of the HEALTH-PIC was calculated to determine the internal consistency of the scale. A value greater than .60 was used as a criterion for acceptable internal consistency (\u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e61\u003c/span\u003e, \u003cspan citationid=\"CR62\" class=\"CitationRef\"\u003e62\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e \u003ch2\u003e(H1) Factorial Validity\u003c/h2\u003e \u003cp\u003eESEM analysis revealed that one item from the physical subscale and one item from the emotional subscale (items 7 and 8) had cross-loading indifferences where they loaded highly on two different factors. They were hence eliminated due to the inability to disentangle specific factors (\u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Moreover, we investigated the inter-item correlations and items within the same subscale, and one item (item 3) from the physical subscale was eliminated because it formed negative correlations with the other items of the same subscale (item 3; 56).\u003c/p\u003e \u003cp\u003eAfter these three items were eliminated, the 4-factor model showed an acceptable fit of (x\u0026sup2; = 121.55 (df\u0026thinsp;=\u0026thinsp;116), CFI\u0026thinsp;=\u0026thinsp;.99, TLI\u0026thinsp;=\u0026thinsp;.99, RMSEA\u0026thinsp;=\u0026thinsp;.01, 90%CI [.00,.03], SRMR\u0026thinsp;=\u0026thinsp;.08, establishing factorial validity. The factor loading range of each subscale can be found in Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003eThe final model had 5 items for each dimension of physical health, emotional health, social health and school health (see Appendix B).\u003c/p\u003e \u003cdiv id=\"Sec38\" class=\"Section3\"\u003e \u003ch2\u003e(H2) Concurrent Validity\u003c/h2\u003e \u003cp\u003eThe current HEALTH-PIC overall score demonstrated significant correlations with the overall score of child PedsQL (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.74, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and of parents PedsQL (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.50, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001).\u003c/p\u003e \u003cp\u003eThe subscales of the HEALTH-PIC also correlated with the subscales of parent proxy HRQoL, namely, physical (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), emotional (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.57, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), social (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.33, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and school (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.49, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) health, in addition to the subscales of child HRQoL; physical (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.43, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), emotional (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.66, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), social (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.52, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and school (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.69, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) health.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec39\" class=\"Section2\"\u003e \u003ch2\u003eDiscriminant Validity (H3)\u003c/h2\u003e \u003cp\u003eDiscriminant validity can be established when the HEALTH-PIC is not significantly correlated with other theoretically different measures. In the case of HEALTH-PIC, the average variance extracted (AVE) was calculated by summing the squared factor loadings and dividing it by the number of items (AVE range\u0026thinsp;=\u0026thinsp;.34 \u0026minus;\u0026thinsp;.60). Additionally, the shared variance between the factors of the HEALTH-PIC and mental health (measured via the PHQ-4) was also calculated (shared variance range\u0026thinsp;=\u0026thinsp;.01 \u0026minus;\u0026thinsp;.11) and compared. Ultimately, discriminant validity was established as the AVE is greater than the shared variance between the constructs (\u003cspan citationid=\"CR59\" class=\"CitationRef\"\u003e59\u003c/span\u003e). Specific subscale\u0026rsquo;s AVE and shard variance can be found in Table\u0026nbsp;3.\u003c/p\u003e \u003cdiv id=\"Sec40\" class=\"Section3\"\u003e \u003ch2\u003e(H4) Criterion Validity\u003c/h2\u003e \u003cp\u003eIn terms of criterion validity, the current HEALTH-PIC overall score demonstrated a significant negative correlation with parent-observed child illness (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.34, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). Looking at the subscales, the physical health subscale of the HEALTH-PIC correlated significantly with daily functioning (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.18, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.003); and the emotional health subscale of the HEALTH-PIC correlated significantly with mood disturbances (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;\u0026minus;\u0026thinsp;.51, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). The social health subscale of the HEALTH-PIC, however, did not correlate with children\u0026rsquo;s social life (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.07, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.181), but the school health subscale of the HEALTH-PIC also significantly correlated with academic status (\u003cem\u003er\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.38, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001). All correlations for the criterion validity can be found in Table\u0026nbsp;3.\u003c/p\u003e \u003cp\u003e \u003cb\u003e(H5) Internal Consistency\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe Cronbach\u0026rsquo;s α coefficient of the HEALTH-PIC was also calculated to determine the internal consistency of the scale. The current scale shows acceptable reliability of α\u0026thinsp;=\u0026thinsp;.76 across all 20 items and α\u0026thinsp;=\u0026thinsp;.60 \u0026minus;\u0026thinsp;.66 for each factor (61, 62; see Table\u0026nbsp;3).\u003c/p\u003e \u003cp\u003e[INSERT TABLE 3 AROUND HERE]\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eConclusions of Study 3\u003c/h3\u003e\n\u003cp\u003eThe current findings largely supported HEALTH-PIC's factorial, concurrent, discriminant, criterion validity and internal consistency in a large-scale population, showing promise in the utilization of the HEALTH-PIC in further research.\u003c/p\u003e"},{"header":"General Discussion","content":"\u003cp\u003eThe current three-study paper aimed to develop and preliminarily test the HEALTH-PIC, a pictorial measure of early childhood self-reported health-related quality of life. In the first study, we were able to follow the recommendations of Boateng and colleagues (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) and Sauer and colleagues (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e) and utilize both parent and expert groups to develop and revise the items, making it clear, relatable and accurate for children. Our actual child population in Study 2 was able to show that both kindergarten and primary school children were able to correctly interpret the items in the picture and complete the questionnaire via scripted directions and that the overall questionnaire was not too long or difficult.\u003c/p\u003e \u003cp\u003eIn our last study, we were able to successfully determine the scale\u0026rsquo;s statistical properties, namely, factorial, concurrent, discriminant, criterion validity and internal consistency. Therefore, as supported by our studies, the HEALTH-PIC generally demonstrated its value as a newly developed comprehensive pictorial questionnaire for assessing self-reported early childhood HRQoL.\u003c/p\u003e \u003cp\u003eDespite its general statistical agreement, there was no significant association between the social subscale of the HEALTH-PIC and children\u0026rsquo;s social life. However, because there were significant correlations between the HEALTH-PIC and parent-proxy HRQoL and child HRQoL, the lack of the aforementioned association might not necessarily indicate the inability of the HEALTH-PIC to assess social health. Instead, this could be because our measure of social life did not account for the quality of children\u0026rsquo;s friendships and did not quantify the volume of playtime they had with their friends (\u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e63\u003c/span\u003e, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e64\u003c/span\u003e). Future investigations could therefore aim to incorporate detailed assessments that consider friendship quality or closeness to evaluate a child\u0026rsquo;s social life.\u003c/p\u003e \u003cp\u003eOverall, the HEALTH-PIC serves as a great addition to the existing literature as most measures of child HRQoL are completed via parent-proxy. As these parent proxy questionnaires are subjected to bias, it may not accurately reflect the underlying child HRQoL (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). This pattern can also be observed in Study 3, where the correlations between the parent proxy-reported overall HRQoL and its subscales showed lower strength in correlation than when comparing the child self-reported form.\u003c/p\u003e \u003cp\u003eOther than parent proxy reports, most age-suited self-report questionnaires for children in the literature are often for children who are 8 years old or older, as they involve literary items (i.e., KIDSCREEN; 65); however, the newly developed HEALTH-PIC has demonstrated that even children as young as 4 years of age can understand and complete a self-report questionnaire with assistance from others in reading the instructions.\u003c/p\u003e \u003cp\u003eIn addition to overcoming these existing limitations, the nature of pictorial questionnaires can serve as a tool that allows child respondents to better understand and represent the items in the questionnaire when it is supported by relatable pictures (\u003cspan additionalcitationids=\"CR20\" citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). These findings therefore suggest that the HEALTH-PIC can be a more suitable measurement method for our current population of early childhood participants.\u003c/p\u003e\n\u003ch3\u003eLimitations \u0026 Further Direction\u003c/h3\u003e\n\u003cp\u003eWith the strengths and novelty of the HEALTH-PIC, we have to acknowledge a few study limitations. Firstly, in the test of the psychometric properties of the HEALTH-PIC, the adoption of a cross-sectional design in Study 3 limited the level of evidence in our validation study. In particular, the criterion validity of the HEALTH-PIC that we demonstrated in Study 3 was only at a cross-sectional level, which meant that we could not determine whether the HEALTH-PIC was predictive of future health outcomes (\u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e66\u003c/span\u003e). Similarly, in the examination of its reliability, we were unable to examine the temporal stability of HEALTH-PIC. Future studies could investigate predictive power and test-retest reliability by adopting longitudinal designs (\u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e67\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSecondly, our Studies 2 and 3 involved only healthy participants, as we aimed to investigate whether children could successfully complete the questionnaire and validate it without the need to account for confounding variables such as treatment effects or symptom severity. As such, we could not investigate the scale\u0026rsquo;s sensitivity to changes across diverse health statuses. Future studies could investigate its applicability and sensitivity across different illnesses and symptoms (\u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e68\u003c/span\u003e, \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e69\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThirdly, while developing and testing the HEALTH-PIC, we did not examine if the reliability and validity of the scale were generalizable across countries and across cultures. Although the samples of our studies involved parent‒child dyads from Hong Kong and the United Kingdom, we did not collect sufficient cross-cultural data for comparison, which could allow us to examine any measurement invariances between cultural contexts (\u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e70\u003c/span\u003e). Future studies could compare the properties of HEALTH-PIC by conducting cross-country/cross-cultural studies (\u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e71\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study aimed to develop the HEALTH-PIC, a pictorial questionnaire for measuring HRQoL in early childhood children aged 4\u0026ndash;8. We investigated the face validity and examined the psychometric properties (factorial validity, concurrent validity, discriminant validity, criterion validity, and internal consistency) of the HELATH-PIC through 3 studies. Our findings preliminarily revealed that children, even in early childhood, were able to complete the developed HEALTH-PIC with the assistance of their parents in reading the instructions. More importantly, the HEALTH-PIC was able to capture new boundaries of young children\u0026rsquo;s self-reported HRQoL and could therefore be a tool to supplement existing measures of HRQoL in early childhood research.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthical Approval and Consent to Participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was approved by the Human Research Ethics Committee of the first author\u0026rsquo;s institution (Ref no. 2021-2022-0424). Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Availability\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Early Childhood Education Departmental Research Grant (DRG) of the first author\u0026rsquo;s institution.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors\u0026rsquo; contributions\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to study conceptualization, reviewing and editing. xxxx and xxxx analysed the data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank xxx,xxxx,xxxx,xxxx for their help in data collection.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eLe HND, Petersen S, Mensah F, Gold L, Wake M, Reilly S. 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Cross-cultural adaptation and validation of psychological instruments: Some considerations. Paid\u0026eacute;ia (Ribeir\u0026atilde;o Preto). 2012;22:423\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv class=\"gridtable\"\u003e\n \u003ctable id=\"Tab1\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAiken\u0026rsquo;s V coefficient for Study 1 expert\u0026rsquo;s and parent\u0026rsquo;s ratings of HEALTH-PIC items\u0026rsquo; clarity, accuracy, applicability and content relevance.\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem No.\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eClarity\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv 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7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.79*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.82*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.77**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.76**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.70*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.89**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.82**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.73*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.97**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 10\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.94*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.94*\u003c/div\u003e\n 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align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.77*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.78**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.75**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.84**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 13\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.82**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.85*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.76**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 14\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.82**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.77**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.88**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 15\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.79**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.92**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 16\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.86**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.84**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.77**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.89**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 17\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.74**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.74**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.77**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.69**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 18\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.66**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.65**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.75**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.72**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 19\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.66**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.64**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.69**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.96**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 20\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.72**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.71**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.74**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.74**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 21\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.68**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.67**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.71**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.69**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 22\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.71**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.71**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.79**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.88**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 23\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.64*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.64*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.73*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e*p \u0026lt; .05\u003c/p\u003e\n\u003cp\u003e**p \u0026lt; .001\u003c/p\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eStudy 2 Aiken\u0026rsquo;s V coefficient on coded children\u0026rsquo;s response on item identification of the HEALTH-PIC\u003c/div\u003e\n \u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem No.\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eKindergarten Students (Aged 4\u0026ndash;6)\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePrimary School Students (Aged 6\u0026ndash;8)\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 1\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.85**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 2\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.95**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.95**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 3\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.95**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.82**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 5\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 6\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 7\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.91**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem8\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.90**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.91**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 9\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.95**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 10\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 12\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.75*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 13\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.73*\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 14\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.90**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 15\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.85**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.95**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 16\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.85**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.95**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 17\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.73*\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 18\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 19\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.90**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"char\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.0**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 20\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.77**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 21\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.85**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 22\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.73*\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eItem 23\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.75*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.91**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNot Too Long\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.80**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.86**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eNot Too Difficult\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.85**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.91**\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e*p \u0026lt; .05\u003c/p\u003e\n\u003cp\u003e**p \u0026lt; .001\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\n \u003ccaption language=\"En\"\u003e\n \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n \u003cdiv class=\"CaptionContent\"\u003eStudy 3 Correlation matrix, factor loadings, validity indices of the HEALTH-PIC\u003c/div\u003e\n \u003c/caption\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC- Physical Health\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC- Emotional Health\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC- Social Health\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC- School Health\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC- Total\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePedsQL \u0026ndash; Child\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePedsQL \u0026ndash; Parent Proxy\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChild Illness\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEQ-5D-3L\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePHQ-4\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMFQ\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSocial Life\u003c/div\u003e\n \u003c/th\u003e\n \u003cth align=\"left\" style=\"width: 7.2131%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePHCSCS\u003c/div\u003e\n \u003c/th\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC - Physical Health\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC- Emotional Health\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.15**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC- Social Health\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.10\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.36**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHEALTH-PIC - School Health\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.20**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.34**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.21**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eHealth-PIC Total\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.41**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.79**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.65**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.67**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePedsQL-Child\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.37**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.61**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.37**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.53**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.74**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePedsQL-Parent Proxy\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.23**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.44**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.27**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.34**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.50**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.48**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eChild Illness\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.15**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.33**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.01\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.35**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.34**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.27**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.36**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eEQ-5D-3L\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.18**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.09\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.14**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.12*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.19**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.28**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.25**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.10\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePHQ-4\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.07\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.33**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.12*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.22**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.30**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.37**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.52**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.33**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.26**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eMFQ\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.27**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.51**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.21**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.34**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.54**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.65**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.40**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.22**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.17**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.34**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eSocial Life\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.12*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.01\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.07\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.05\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.07\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.08\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.04\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.05\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.02\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.02\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.01\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\u0026nbsp;\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003ePHCSCS\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.18**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.23**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.22**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.38**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.39**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.46**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.28**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.07\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.14*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.19**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e\u0026minus;\u0026thinsp;.35**\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.13*\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e-\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRange of Item Loadings to Target Factors\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.61\u0026ndash;1.13\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.36\u0026ndash;1.21\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.52 \u0026minus;\u0026thinsp;.96\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.44 \u0026minus;\u0026thinsp;.66\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eRange of Mean (SD)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e94.41 (13.69)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e57.34 (32.51)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e83.94 (22.82)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e77.55 (25.44)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e78.52 (15.92)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e84.82 (11.80)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e90.85 (8.61)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.55 (2.63)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8.90 (.400)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e4.62 (1.09)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e1.89 (2.67)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e8.14 (5.00)\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e7.75 (1.38)\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eCronbach\u0026rsquo;s \u0026alpha; Coefficient\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.60\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.66\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.63\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.60\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.76\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.85\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.87\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.61\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.69\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.81\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.60\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eAVE\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.60\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.46\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.47\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.34\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eShared Variance (R)\u003csup\u003e2\u003c/sup\u003e\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.04\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.11\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.01\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003e.05\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 6.6667%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003ctd align=\"left\" style=\"width: 7.2131%;\"\u003e\n \u003cdiv class=\"SimplePara\"\u003eN/A\u003c/div\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eHEALTH-PIC = Health-Related Quality of Life Pictorial Inventory for Children; PedsQL = Pediatric Quality of Life Inventory; EQ-5D-3L = subscales of mobility, mobility, self-care and usual activities only. PHQ-4 = Patient Health Questionnaire; MFQ= Mood and Feelings Questionnaire; PHCSCS= Piers-Harris Children Self-Concept Scale 2\u003csup\u003end\u003c/sup\u003e edition; AVE= Average Variance Extracted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e* p \u0026lt; .05\u003c/p\u003e\n\u003cp\u003e**p \u0026lt; .001\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Health-related quality of life, Scale development, Pictorial Scale, Early Childhood","lastPublishedDoi":"10.21203/rs.3.rs-4609586/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4609586/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eObjective\u003c/h2\u003e \u003cp\u003eThis 3-study paper aimed to develop and validate a self-reported health-related quality of life pictorial inventory for early childhood children. The scale was designed to overcome existing barriers of parent-proxy response styles and offers an alternative to age-suited literary questionnaires to assess self-reported health-related quality of life, including physical health, emotional health, social health and school health in early childhood.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eFollowing an established protocol in the literature of pictorial scales, this 3-study paper leads to the development and validation of the Health-related Quality of Life Pictorial Inventory for Children (HEALTH-PIC). Study 1 involved item development/revision, which utilized a panel of 10 experts and 25 parents via the Delphi method to revise the scale and establish agreement. Study 2 invited a sample of 22 primary school students and 20 kindergarten students to establish face validity amongst primary respondents. Finally, Study 3 invited 342 parent and child dyads to complete the HEALTH-PIC and reference health-related quality of life (HRQoL) questionnaires to establish the questionnaire\u0026rsquo;s factorial, concurrent, discriminant and criterion validity in addition to internal consistency.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eIn Study 1, scale items were developed alongside experts and parents with a strong theoretical and statistical support, ensuring that the items were clear, accurate and applicable for children (Aiken\u0026rsquo;s V \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05). In Study 2, we ensured that primary respondents of different ages (kindergarten and primary school children) were able to accurately identify the pictorial images (Aiken\u0026rsquo;s V \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.05) and complete the questionnaire when the scripted instructions were read aloud. In Study 3, structural equation modelling of the HEALTH-PIC demonstrated a robust factor structure (CFI and TLI\u0026thinsp;\u0026gt;\u0026thinsp;.99; RMSEA and SRMR\u0026thinsp;\u0026le;\u0026thinsp;.08), concurrent validity (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001), discriminant validity (AVE\u0026thinsp;\u0026lt;\u0026thinsp;shared variance), criterion validity (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001) and an acceptable level of internal consistency (i.e., Cronbach\u0026rsquo;s α\u0026thinsp;=\u0026thinsp;.60 \u0026minus;\u0026thinsp;.66).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eOverall, the findings of the three studies provide preliminary evidence to support the content validity and construct validity of the HEALTH-PIC. This novel pictorial scale not only provides a reliable and valid assessment of the multidimensional aspects of health-related quality of life among children but can also overcome existing barriers of parent-proxy or age-suited questionnaires.\u003c/p\u003e","manuscriptTitle":"Development and Initial Validation of the Health-Related Quality of Life Pictorial Inventory for Children (HEALTH-PIC)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-12 11:28:11","doi":"10.21203/rs.3.rs-4609586/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"08e3aabf-cf7b-4fee-99ae-43aea11c82e1","owner":[],"postedDate":"July 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-08-12T13:57:27+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-12 11:28:11","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4609586","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4609586","identity":"rs-4609586","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}