title: Measuring children's distress during burns dressing changes: literature search for measures appropriate for indigenous children in South Africa.
abstract: BACKGROUND
  Virtual reality is consistently reported as effective in reducing pain and anxiety in children during burns dressing changes in recent Western studies. Pain scales are a commonly reported outcome measure. Virtual reality is persuasive for all children in distress during medical procedures, because it is a nonaddictive, novel, and inexpensive form of distraction which can be applied repeatedly with good effect. We intend to use virtual reality in South Africa for the many children hospitalized with severe burns from mechanisms rarely seen in the Western world (paraffin/kerosene stoves exploding, electrical fires, shack/township fires, boiling liquid spills). Many severely burnt children are indigenous South Africans who did not speak English, and whose illiteracy levels, cultures, family dynamics, and experiences of pain potentially invalidate the use of conventional pain scales as outcome measures. The purpose of this study was to identify objective measures with sound psychometric properties and strong clinical utility, to assess distress during burns dressing changes in hospitalized indigenous South African children. Choice of measures was constrained by the burns dressing change environment, the ethics of doing no harm whilst measuring distress in vulnerable children, and of capturing valid measures of distress over the entire burns dressing change procedure.
  
  
  METHODS
  We conducted two targeted systematic reviews of the literature. All major library databases were searched, and measures with strong psychometric properties and sound clinical utility were sought.
  
  
  RESULTS
  Seven potentially useful measures were identified, ie, child's and caregivers' heart rate, which was measured continuously throughout the procedure, observed physical manifestations of distress using different scales (FLACCs [Face, Legs, Activity, Cry, Consolability Scale] and/ or Pain Behavior Checklist), time taken, and number of staff required to complete the procedure, and staff perspectives on the ease of use of the procedure.
  
  
  CONCLUSIONS
  These psychometrically sound, clinically useful measures are alternatives to conventional pain scales, and should support valid research into the effectiveness of virtual reality for illiterate children with non-Western cultures and languages.
authors.affiliation: Department of Physiotherapy, Stellenbosch University, Cape Town, South Africa.
authors.forename: Quinette
authors.initials: Q
authors.lastname: Louw
authors.forename: Karen
authors.initials: K
authors.lastname: Grimmer-Somers
authors.forename: Angie
authors.initials: A
authors.lastname: Schrikk