Development of an Online, Interdisciplinary Intervention for Paediatric Chronic Pain Management
Conditions: Chronic Pain
Sponsor: University of Southampton

 
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HRA PROTOCOL COMPLIANCE DECLARATION 
This protocol has regard for the HRA guidance and order of content  

 
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STUDY TITLE 
FULL/LONG TITLE OF THE STUDY 
Development of an Online, Interdisciplinary Intervention for Paediatric Chronic Pain 
Management 
SHORT STUDY TITLE / ACRONYM 
Online Intervention for Paediatric Chronic Pain Management  
PROTOCOL VERSION NUMBER AND DATE 
Version 1.5 (12/06/2019) 

 
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RESEARCH REFERENCE NUMBERS 
IRAS Number: 
 
253044 
SPONSORS Number: 
45429 
 
FUNDERS Number: 
N/A 
 

 
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SIGNATURE PAGE 
The undersigned confirm that the following protocol has been agreed and accepted. The Chief 
Investigator agrees to conduct the study in compliance with the approved protocol. The Chief 
Investigator will adhere to the principles outlined in the Declaration of Helsinki, the Sponsor’s SOPs, 
and all other regulatory requirements. 
I agree to ensure that the confidential information contained in this document will not be used for any 
other purpose other than the evaluation or conduct of the investigation without the prior written 
consent of the Sponsor 
I also confirm that I will make the findings of the study publically available through publication or other 
dissemination tools without any unnecessary delay and that an honest accurate and transparent 
account of the study will be given; and that any discrepancies from the study as planned in this 
protocol will be explained. 
For and on behalf of the Study Sponsor: 
Signature:  
 
...................................................................................................... 
 
Date: 
Name (please print): 
...................................................................................................... 
 
 
Position: 
...................................................................................................... 
 
 
 
 
 
Chief Investigator: Professor Christina Liossi 
Signature:  
 
...................................................................................................... 
 
Date:  
Name: (please print): 
...................................................................................................... 
 
 
 

 
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LIST OF CONTENTS 
HRA PROTOCOL COMPLIANCE DECLARATION .......................................................... i 
STUDY TITLE .................................................................................................................. ii 
FULL/LONG TITLE OF THE STUDY ...............................................................................ii 
SHORT STUDY TITLE / ACRONYM ...............................................................................ii 
PROTOCOL VERSION NUMBER AND DATE ................................................................ii 
RESEARCH REFERENCE NUMBERS .......................................................................... iii 
SIGNATURE PAGE ........................................................................................................ iv 
LIST OF CONTENTS ...................................................................................................... v 
GENERAL INFORMATION ............................................................................................ vii 
KEY STUDY CONTACTS ............................................................................................. vii 
STUDY SUMMARY ....................................................................................................... vii 
FUNDING AND SUPPORT IN KIND ............................................................................ viii 
ROLE OF STUDY SPONSOR AND FUNDER ............................................................. viii 
ROLES AND RESPONSIBILITIES OF STUDY MANAGEMENT 
COMMITEES/GROUPS & INDIVIDUALS .................................................................... viii 
STUDY FLOW CHART ................................................................................................... x 
STUDY PROTOCOL ...................................................................................................... xii 
1 
BACKGROUND ............................................................................................................ xii 
2 
RATIONALE ................................................................................................................ xiv 
3 
THEORETICAL FRAMEWORK .................................................................................... xv 
4 
RESEARCH QUESTION/ AIM(S) ................................................................................ xvi 
4.1 
Objectives ........................................................................................................... xvi 
4.2 
Outcome ............................................................................................................ xvii 
5 
STUDY DESIGN AND METHODS ............................................................................. xvii 
5.1 
Analysis .............................................................................................................. xix 
6 
STUDY SETTING ......................................................................................................... xx 

 
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7 
SAMPLE AND RECRUITMENT ................................................................................... xx 
7.1 
Eligibility Criteria .................................................................................................. xx 
7.1.1 
Inclusion criteria ............................................................................................... xx 
7.1.2 
Exclusion criteria .............................................................................................. xx 
7.2 
Sampling ............................................................................................................. xxi 
7.2.1 
Size of sample ................................................................................................. xxi 
7.2.2 
Sampling technique ........................................................................................ xxii 
7.3 
Recruitment ....................................................................................................... xxii 
7.3.1 
Sample identification ...................................................................................... xxii 
7.3.2 
Consent ......................................................................................................... xxiii 
8 
ETHICAL AND REGULATORY CONSIDERATIONS ................................................ xxiii 
8.1 
Assessment and management of risk ............................................................... xxiii 
8.2 
Research Ethics Committee (REC) and other Regulatory review & reports ...... xxv 
8.3 
Peer review ....................................................................................................... xxvi 
8.4 
Patient & Public Involvement ............................................................................ xxvi 
8.5 
Protocol compliance ......................................................................................... xxvi 
8.6 
Data protection and patient confidentiality ....................................................... xxvii 
8.7 
Indemnity ......................................................................................................... xxvii 
8.8 
Access to the final study dataset .................................................................... xxviii 
9 
DISSEMINIATION POLICY ..................................................................................... xxviii 
9.1 
Dissemination policy ....................................................................................... xxviii 
9.2 
Authorship eligibility guidelines and any intended use of professional writers .. xxix 
10 REFERENCES ........................................................................................................... xxx 
11  APPENDICIES ......................................................................................................... xxxv 
11.1  Appendix 1- Required documentation ............................................................. xxxv 
11.2  Appendix 2- Amendment History .................................................................... xxxv 
 

 
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GENERAL INFORMATION 
KEY STUDY CONTACTS 
Chief Investigator 
Prof. Christina Liossi, phone: (023) 80594645, email: 
C.Liossi@soton.ac.uk 
Study Co-ordinator 
Miss Anna Hurley-Wallace, phone: (023) 80594719 email: 
A.Hurley-Wallace@soton.ac.uk 
Sponsor 
University of Southampton 
Joint-sponsor(s)/co-sponsor(s)  
N/A 
Funder(s) 
University of Southampton 
Key Protocol Contributors 
Miss Lauren Johnstone, phone: (023) 80593584, email: 
L.johnstone@soton.ac.uk 
Dr Daniel Schoth, email: D.E.Schoth@soton.ac.uk 
Dr Glyn Williams, phone: 020 7405 9200 ext. 6191, email: 
Glyn.Williams@gosh.nhs.uk  
Miss Suzanne Lilley, phone: 020 7405 9200 ext. 6191, email: 
Suzanne.Lilley@gosh.nhs.uk 
Dr Anna Karenia Anderson, phone: 020 8661 3625 (PA - 
Vicki Wilson, email: annakarenia.anderson@nhs.net 
Committees 
N/A 
STUDY SUMMARY 
Study Title 
Development of an Online, Interdisciplinary Intervention for 
Paediatric Chronic Pain Management  
Internal ref. no. (or short title) 
Online Intervention for Paediatric Chronic Pain 
Study Design 
Qualitative methods only. Semi-structured interviews. 
Study Participants 
The study aims to recruit adolescents (12 to 17 years) with 
either cancer-related or non-cancer chronic pain, from Great 
Ormond Street Hospital (GOSH) and Royal Marsden Hospital 
(RMH), with additional recruitment from patient organisations 
and charities, and via social media. Parents of adolescents 
with chronic pain of either type will also be recruited.  
Planned Size of Sample (if applicable) The study aims to recruit approximately 15 participants per 
group at GOSH: 
Children with chronic pain (n = 15) 
Parents of children with chronic pain (n = 15),  
Approximately 10 participants per group will be recruited from 
RMH: 

 
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Children with cancer-related chronic pain (n = 10) 
Parents of children with cancer-related chronic pain (n = 10), 
Community:  
Children with chronic pain (any type) (n = 5)  
Parents of children with chronic pain (n = 5) 
The overall sample size projected is a group of 60 
stakeholders.  
Analysis will be ongoing and recruitment will continue up until 
the point of saturation (Guest, Bunce & Johnson, 2016). 
Follow up duration (if applicable) 
N/A 
Planned Study Period 
June 2019 – March 2021 
Research Question/Aim(s) 
 
The current study aims to gain an overall insight as to what 
adolescents and their parents want to be included in an 
intervention for paediatric chronic pain. 
The primary research question is: 
What content and features do young people with chronic 
pain, and their parents, want to see in an online pain 
management intervention? 
FUNDING AND SUPPORT IN KIND 
FUNDER(S) 
(Names and contact details of ALL organisations 
providing funding and/or support in kind for this 
study) 
FINANCIAL AND NON FINANCIALSUPPORT 
GIVEN 
University of Southampton 
AHW is funded by a University of Southampton 
Jubilee PhD scholarship. 
Great Ormond Street Hospital for Children 
NHS Foundation Trust 
Participating clinicians from GOSH will identify 
potential participants to the core research team. 
The Royal Marsden NHS Foundation Trust  
Participating clinicians from RMH will identify 
potential participants to the core research team. 
ROLE OF STUDY SPONSOR AND FUNDER 
The University of Southampton is sponsor and funder of this research as part of a PhD Jubilee +3 
research studentship for Miss A. Hurley-Wallace.  
ROLES AND RESPONSIBILITIES OF STUDY MANAGEMENT COMMITEES/GROUPS & 
INDIVIDUALS 
N/A 
PROTOCOL CONTRIBUTORS 

 
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Miss Anna Hurley-Wallace has developed this protocol under the guidance of Prof. Christina Liossi 
and Dr Daniel Schoth.  Miss Lauren Johnstone, Dr Daniel Schoth, Dr Glyn Williams, Miss Suzanne 
Lilley, and Dr Anna Karenia Anderson have also contributed to this protocol. 
KEY WORDS: 
Paediatric Chronic Pain, Paediatric Pain Management, Online Intervention, Interdisciplinary, Cognitive 
Behavioural Therapy, Qualitative Research 

 
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STUDY FLOW CHART 
 
Mar 2019 
Apr 2019 
May 2019 
Jun 2019 
Jul 2019 
Aug 2019 
Sep 2019 
Oct 2019 
Nov 2019 
Dec 2019 
Jan 2020 
Feb 2020 
Mar 2020 
Apr 2020 
May 2020 
Jun 2020 
Jul 2020 
Aug 2020 
Sep 2020 
Oct 2020 
Nov 2020 
Dec 2020  
Jan 2021 
Feb 2021 
University 
Research 
Governance 
(RGO) review 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
NHS REC 
ethical review 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
GOSH and 
RMH ethics 
(site-specific 
ethical review) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Intervention 
content 
development 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Participant 
recruitment 
from the 
community  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Participant 
recruitment 
from GOSH & 
RMH 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Semi-
structured 
interviews 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Transcription 
and data 
coding 
(thematic 
analysis)  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Write-up (initial 
interviews) for 
PhD thesis/ 
publication 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Re-recruit for 
think-aloud 
study 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Think-aloud 
interviews  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Transcription 
and data 
coding (think-
aloud study) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Final write-up 
for PhD thesis/ 
publication 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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STUDY PROTOCOL 
1 
BACKGROUND 
Chronic pain is most commonly defined as pain that lasts for a period of longer than three 
months, (Steingrimsdottir, Landmark, Macfarlane & Nielsen, 2017; Treede et al., 2015). Prevalence 
rates for children and adolescents suggest that chronic pain is experienced by up to 15-30% of the 
population, with an estimate of up to 1-3% of the paediatric population experiencing severe and 
disabling chronic pain (Eccleston, Bruce & Carter, 2006). Prevalence rates for different chronic pain 
conditions vary across the literature, where chronic headache appears to be the most common 
paediatric chronic pain condition; reported prevalence ranges from 8% to 83% (King et al., 2011). 
Across paediatric populations, females are more prone to chronic pain than males (King et al., 2011). 
Chronic pain in paediatric cancer survivors, often described as ‘cancer-related pain’, is usually 
conceptualised differently compared to chronic pain of other aetiologies, as reflected in the  recent 
ICD-11 classification guidelines (Treede et al., 2015). A systematic review of pain in adolescents with 
leukaemia or brain tumour found that chronic cancer-related pain may be procedure-related, 
treatment-related, or associated with the cancer itself, and is likely to persist chronically after treatment 
completion(Olson & Amari, 2015). A recent systematic review of chronic pain prevalence in childhood 
cancer survivors has estimated prevalence in paediatric populations between 3% and 50%, dependent 
on the type of cancer, and treatments received (Hurley-Wallace, Schoth, et al., 2018). The review 
noted that very few studies have investigated chronic cancer pain specifically in paediatric and 
adolescent samples. A theoretical model of chronic cancer pain has recently been developed by 
Heathcote and Eccleston (2017), which focuses on differentiating factors between chronic cancer and 
non-cancer pain, such as fear of recurrence, in cancer survivors.  
Chronic pain conditions can severely affect the lives of young people and their families. Children 
and adolescents with chronic pain report substantially worse quality of life than their healthy peers in 
domains of physical and psychosocial functioning, poorer performance in school and relationships with 
peers (Dick & Riddell, 2010; Forgeron et al., 2010; Logan, Simons, Stein & Chastain, 2008; Varni, 
Limbers & Burwinkle, 2007). The effects of paediatric chronic pain affect both the family unit and 
individual family members. Children with chronic pain and their families report worse behaviour 
control, family disturbances, family cohesion and conflict, and organisational structure than families 
without children with chronic pain (Lewandowski, Palermo, Stinson, Handley & Chambers, 2010). 
Parents of children with chronic pain also report suffering higher levels of anxiety and depression than 
parents of healthy children, as well as feelings of helplessness and a lack of control (Palermo & 
Eccleston, 2009). 
 Currently, treatment for paediatric chronic pain typically occurs in outpatient settings, and is 
usually focused on providing multimodal treatment, which can include physiotherapy, medication and 
cognitive behavioural therapy (Miro, McGrath, Finley & Walco, 2017). The use of interdisciplinary 
interventions for the treatment of paediatric chronic pain is supported by a recent review of treatments 
for paediatric musculoskeletal pain, which highlighted the lack of evidence supporting the use of 
pharmacologic treatment alone. The review also affirmed the strong evidence base for psychological 
treatment, and the promising yet limited support for the role of physiotherapy (Caes, Fisher, Clinch & 

 
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Eccleston, 2018). Interventions for paediatric chronic pain that combine two or more disciplines have 
been found to be effective in improving pain, disability, and emotional functioning; however, systematic 
reviews have also emphasised the substantial heterogeneity in the literature evaluating such 
interventions (Hechler et al., 2015; Liossi, Johnstone, Lilley, Williams & Schoth, 2018). Interdisciplinary 
interventions are considered the “gold standard” treatment for paediatric chronic pain.  
Despite the apparent success of interdisciplinary interventions, there are several barriers to 
successful interdisciplinary care in paediatrics, including time taken out of school to travel to clinics, 
and associated financial concerns (Bender, Radhakrishnan, Diorio, Englesakis & Jadad, 2011; Caes 
et al., 2018), and poor accessibility in rural areas (Elgar & McGrath, 2003). A possible solution would 
be remote delivery over the internet. 
Psychology-based interventions have been indicated to be effective when delivered remotely. A 
systematic review by Fisher, Law, Palermo, and Eccleston (2015) investigated studies that tested the 
efficacy of remotely delivered psychological interventions for children and adolescents with chronic 
pain. This review included eight studies utilising the internet, CD-ROMs and audio tapes to deliver 
Cognitive Behavioural Therapy (CBT) interventions to children. Five studies investigated patients with 
chronic headache, two studies investigated mixed pain conditions (headache and other chronic pain 
presentations), and one investigated juvenile idiopathic arthritis. The authors split the papers into 
headache related pain conditions and “mixed pain conditions”. Results of the review illustrate that 
remotely delivered therapies can effectively reduce headache severity post-treatment, and can reduce 
pain intensity post-treatment for mixed pain conditions in children. The review also notes a lack of 
research in the area. Another meta-analytic review of randomised controlled trials assessed the 
effects of psychological interventions on child and adolescent chronic pain, and found that 
interventions delivered via computer-based applications were as effective in reducing chronic pain and 
disability as face-to-face treatment (Palermo, Eccleston, Lewandowski, Williams & Morley, 2010). 
However, this evaluation is based on only two trials of computer-based applications for paediatric 
chronic pain management; hence, further research trials are needed to support the efficacy of online 
interventions. 
A key CBT-based intervention that has been developed and tested for the online management of 
paediatric pain is Web-MAP2 for adolescents aged 11 to 17 years (Palermo et al., 2016). The 
intervention is travel-themed, and includes modules on pain education, recognising stress and 
negative emotions, deep breathing and relaxation, implementing coping skills at school, cognitive 
skills, sleep hygiene and lifestyle, staying active, and relapse prevention. The parents of the 
participants complete modules relating to pain education, recognising stress and negative emotions, 
operant strategies, modelling, sleep hygiene and lifestyle, communication, and relapse prevention. 
The intervention also includes a symptom e-diary.  
Research has also evaluated mindfulness and acceptance therapy as part of the internet-
delivered “Teens taking charge: Managing arthritis online” intervention (Stinson et al., 2010). The 
intervention included components such as managing symptoms, distraction techniques, and 
information on exercise and nutrition. Taken together, outcomes from the WebMAP2 and “Teens 
taking charge” interventions support the efficacy of internet delivered self-management programs for 
significantly reducing pain intensity post-treatment (Palermo et al., 2016; Stinson et al., 2010). 

 
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There is currently a lack of literature investigating internet-delivered interventions for paediatric 
chronic cancer-related pain. However, one evidence-based mobile application (‘app’), which targets 
treatment-related acute cancer pain in children and adolescents, have been developed and evaluated; 
Pain Buddy (Fortier, Chung, Martinez, Gago-Masague & Sender, 2016).  
Pain Buddy (Fortier et al., 2016) focuses on self-management techniques and was developed 
with a multidisciplinary task force of psychologists and healthcare professionals. It uses social learning 
principles to encourage practice of self-management techniques at home. The app includes an e-
diary, guided interventions such as breathing techniques, and a reward system in which patients can 
“buy” new avatars. A pilot test of the app suggests that children considered it useful, and were 
encouraged to use non-pharmacological pain management techniques, such as social support, 
instead of analgesics. While preliminary, these results suggest that online interdisciplinary 
interventions may encourage effective cancer pain management in children. 
A key critique of the aforementioned interventions is that they do not consider adolescent or 
parent views in the intervention development process, which may be key to understanding patient 
perspectives, and producing improved tools (Higgins et al., 2018). Involvement of stakeholders in the 
design and development process also forms part of the Person-Based approach to intervention 
development, which outlines the importance of qualitative insights in health-related behaviour change 
interventions for improving health-related outcomes (Yardley, Morrison, Bradbury & Muller, 2015). 
There is no evidence to indicate that a Person-Based or user-centred approach was used to inform 
the development of Web-MAP2 or Teens taking charge. To date, only one study by Stinson et al. 
(2014) has considered adolescent views in the development of an intervention for paediatric chronic 
pain (iCanCope with pain). Twenty-three adolescents (aged 14 to 18 years) were recruited from two 
pediatric chronic pain clinics in Ontario. The study used focus groups with adolescents and healthcare 
professionals working in chronic pain, which were then analysed thematically to inform initial content 
and design (iCanCope is yet to be trialled). 
Whilst preliminary evidence suggests that psychology-based online pain management 
interventions in paediatrics can be successful in managing a variety of types of chronic pain, (Fisher et 
al., 2015; Palermo et al., 2010) the interventions that have been developed do not mirror the 
multimodal treatment that is delivered in practice, and have not considered stakeholder views in their 
development. These systematic reviews of interventions, as well as a recent review of researcher-led 
eHealth tools for pain assessment and management (Higgins et al., 2018) all note that more research 
is needed into online pain management in paediatrics. Particularly new interventions could consider 
including elements of physiotherapy (Caes et al., 2018), and whilst psychological elements may be 
successfully delivered online (e.g. Fisher et al., 2015), a balance between the disciplines may be 
essential to the success of a new online intervention for paediatric chronic pain. 
2 
RATIONALE  
Adolescents are spending increasingly more time online; 12-15 year olds may spend on average 
21 hours a week online (Ofcom, 2017); hence, it is unsurprising that recent review notes some 
preferences for e-health in paediatrics (Higgins et al., 2018). Additionally, whilst findings are 

 
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preliminary and long-term efficacy is unclear, online psychological interventions for paediatric chronic 
pain can be effective in improving pain-related outcomes (Fisher et al., 2015; Palermo et al., 2010).  
Current clinical practice utilises interdisciplinary methods to manage paediatric pain (Miro et al., 
2017), and future online interventions should reflect this. There is also no current online 
interdisciplinary pain management intervention, which includes a module specifically targeting cancer-
related chronic pain. Additionally, of the interventions that have been developed, the vast majority do 
not consider the views of adolescents and parents as part of the development process. Engagement 
of stakeholders from the earliest stage of the development process can help researchers better 
understand patient priorities and perspectives, and therefore develop improved tools (Higgins et al., 
2018). 
Stinson et al. (2014) considered adolescent views in the development of an intervention for 
paediatric chronic pain, in-line with the Person-Based Approach to intervention development (Yardley 
et al., 2015). However, this approach has not been undertaken to develop an online intervention for 
paediatric chronic pain management in the UK. Research has noted the importance of grounding 
health interventions in the context of the cultural system that relates to the patients who will be using 
the intervention. This may help to achieve sustainable change resulting in positive health outcomes 
(Airhihenbuwa, Ford & Iwelunmor, 2014). The NHS is a key part of health care system in the UK; 
hence, it is important that the intervention being developed is grounded in this context, and matches 
the standards of care and mode of delivery that patients would receive in NHS clinics.  
The current study aims to gather adolescent and parental views about what interdisciplinary 
content should be included in an online intervention for chronic pain management, what this should 
look like, and gain an overall insight as to what adolescents and their parents want from an 
intervention for paediatric chronic pain management. 
The wider programme of research, that this study is a part of, aims to develop, implement and 
evaluate the efficacy of an online intervention for paediatric pain management. The ultimate ambition 
of this intervention, if evaluated as efficacious, is to make it freely available via the NHS, such that it 
will be easily accessible to paediatric pain patients. The collaborating NHS clinicians contributing to 
this research will help to ensure that the intervention will mirror the multimodal treatment for paediatric 
chronic pain that is used in practice. This collaboration, alongside the user-centred approach to 
intervention development, may optimise intervention design and adoption by stakeholders (Higgins et 
al., 2018). 
3 
THEORETICAL FRAMEWORK 
This study is the first step in the development process for an online intervention for paediatric 
chronic pain management. The Person-Based approach will inform the overall development of the 
intervention. The first stage of this approach highlights the importance of developing online 
intervention content with insights from stakeholders in order for interventions to be effective (Yardley 
et al., 2015); hence the current study investigates the views of children and adolescents, as they are 
key stakeholders for this intervention. Recent review of e-health tools for pain assessment and 
management clarifies that these insights are important to understand stakeholder priorities and 

 
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perspectives, and thereby develop a more effective intervention (Higgins et al., 2018). However, in the 
process of co-design, whilst stakeholder views are important, there is recognition that the expertise of 
professionals is essential to the development process (Blandford et al., 2018); hence, some elements 
of the intervention will be non-dependent on stakeholder views. For example, the addition of 
physiotherapy videos has been indicated by recent research in paediatric chronic pain (Caes et al., 
2018). 
Person-Based development is an iterative approach, where qualitative insights are integrated to 
inform changes to the intervention from the planning stage of development, through to implementation 
and trialling. Qualitative feedback can be sought using a variety of methodologies, including (however, 
not limited to) semi-structured interviews, focus groups and think-aloud procedures. For the present 
study, semi-structured interviews will be used. 
The intervention content is based on The Biopsychosocial Approach to paediatric pain 
management (Liossi & Howard, 2016). This approach emphasises the importance of managing 
chronic pain using knowledge and techniques from a variety of disciplines, including medicine, 
nursing, physiotherapy, and psychology. Improving coping skills is a key focus of psychological 
treatment for paediatric chronic pain (Liossi & Howard, 2016), and is a skill that can be improved using 
CBT techniques. CBT can also address catastrophizing of pain symptoms in children and adolescents. 
The research team decided a-priori to include components from each discipline (medicine, nursing, 
physiotherapy, and psychology) in the intervention, in-line with the biopsychosocial approach.  
The intervention will require for the young people and their parents to change their behaviour. A 
useful theory to consider when addressing long-term changes in behaviour is The Behaviour Change 
Wheel (Michie, van Stralen & West, 2011). The central element to this framework is a behaviour 
system (COM-B, which highlights three essential conditions for behaviour change: capability, 
opportunity and motivation. These essential conditions can be fulfilled using nine outlined intervention 
functions; at least three of these functions (training, educating, and enabling) can be addressed using 
the interdisciplinary intervention the current study seeks to develop. Providing an accessible online 
intervention to adolescents with chronic pain can help to train, educate and enable young people to 
manage their pain more effectively. Overarching this, the implementation of this type of this 
intervention in the NHS represents a public service provision, and secures the intervention as an 
established support service that can facilitate positive behaviour change in the wider population of 
adolescents with chronic pain, rather than patients attending individual specialist services.  
4 
RESEARCH QUESTION/ AIM(S) 
4.1 Objectives 
The current study aims to gain an overall insight as to what adolescents and their parents want to be 
included in an intervention for paediatric chronic pain. 
The primary research question is:  
What content and features do young people with chronic pain, and their parents, want to see in an 
online pain management intervention? 

 
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4.2 Outcome 
This research aims to identify a set of themes and sub-themes regarding aspects of intervention 
content and usability using a thematic analytic approach (Braun & Clarke, 2006). Extracted themes will 
be used to inform the design and content of an online interdisciplinary intervention for paediatric pain 
management, which will then be re-evaluated in a follow-up study. 
5 
STUDY DESIGN AND METHODS  
5.1 Methodology 
Semi-structured interviews (one per participant) will be used to find out what content and 
features adolescents and parents believe should be included in an online interdisciplinary intervention. 
The interviewing researcher will agree a mutual time and location with parents.  
Informed consent, and assent for minors, will be sought upon recruitment by the research or 
clinician who recruited the participant, as well as immediately before study participation by interviewing 
researchers Miss A. Hurley-Wallace (AHW) and Dr D. Schoth (DS). 
Age-tailored study information sheets will be provided for adolescents and parents when they 
are invited to the study (if invited in-person at Great Ormond Street) or when they contact the research 
team to ask to enrol in the study (if recruited via advertising/ social media). Participant information 
sheets will be provided again in-person immediately prior to the interview. The parents or guardians of 
all participating adolescents will be provided with a consent form to sign to indicate that they agree to 
participate in the study, with the addition of an assent (indication of willingness to participate from a 
minor) from the adolescents. For the parent participant group, appropriate study information sheets 
will be provided, and participants will then be given a consent form to sign. 
A pre-piloted interview schedule has been developed to guide the conversation. The style of the 
interview is semi-structured; hence, questions may be asked in any order, and appropriate prompts 
may be used. All questions in the interview schedule are open-ended e.g. 'what do you think about 
adding videos to the intervention?' and are worded appropriately for respective ages of participants. 
The researcher may provide some diagrams of content from other online interventions to prompt the 
participant. The research may also use generic prompts such as 'Can you tell me a bit more about 
that?' Interviews are not expected to last longer than one hour. At the end of the interview participants 
will be debriefed verbally and provided with a debrief form for their records.  
One of the researchers (AHW or DS) will be conducting the interviews, face-to-face where 
possible, which will be audio-recorded for later write-up (transcription) and analysis. Parents may be 
present during adolescent interviews if they wish, however adolescents aged 12 to 15 may 
alternatively request a chaperone, which can be provided as long as the interview is not taking place 
at the participant’s home. A researcher may also conduct some interviews with parents, and 
adolescents aged 16 years + over the telephone. 
At the end of the semi-structured interview, participants will also be presented with a ‘consent to 
contact form’ and study information for a follow-up study, which will be in the format of a think-aloud 
interview. Providing consent to contact for the think-aloud study is not compulsory. 

 
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5.1.1 Follow-up study – approvals 
The Clinical Research Adoptions Committee (CRAC) (GOSH) strongly recommended that the 
participants in our study would be well placed to evaluate the final intervention. See section 8.3 for full 
statement of rationale for including think-aloud interviews as part of this application. NHS Research 
Ethics Committee (REC), Hampshire ‘B’, have requested that the online content to be used for the 
follow-up study must be submitted via IRAS, to the REC as a substantial amendment for review. 
Participants will not be approached to participate in the follow-up study until the content material has 
been reviewed and approved by the REC. 
5.1.2 Follow-up study - procedure 
Think-aloud interviews are a qualitative methodology, within which participants are presented 
with the draft intervention content and asked to say aloud their thoughts about the content (as well as 
other aspects they wish to comment on) as they navigate through the intervention. Think-aloud 
techniques have been cited as a useful method for conducting usability studies in children (Donker & 
Markopoulos, 2002). The procedure used in this study will be similar to that described by Boren and 
Ramey (2000), which is recommended for usability and feasibility type studies (Krahmer & Ummelen, 
2004). This approach allows for flexible prompts, unlike traditional approaches to the think-aloud 
method, which advise to only use “keep on talking” (Ericsson & Simon, 1993). Using the approach by 
Boren and Ramey (2000) researchers can provide acknowledging utterances throughout the process, 
using prompts such as “And now…” which are thought to be less likely to interrupt free-thinking and 
illicit apologies from the participants. 
Each participant will undergo one think-aloud interview, hence all participants have the 
opportunity to participate in a maximum of two interviews (the semi-structured interview and the think-
aloud). The intervention content to be presented to participants will be in a modular format on a 
computer. Participants will be asked to say aloud their thoughts whilst they are working through the 
content. All utterances will be audio-recorded. A practice task will also be conducted, to help 
participants get used to talking aloud. The procedure should not take more than 1 hour. At the end of 
the task, participants will be debriefed verbally and provided with a debrief form for their records. 
The content will include modules that present multi-modal chronic pain management techniques. 
All content will be informed by healthcare professional input, as well as by the Royal College of 
Paediatrics in Child Health (RCPCH) e-learning Pain Management course, which was developed as a 
pain education tool for professionals using a biopsychosocial, interdisciplinary perspective (Hurley-
Wallace, Wood, Franck, Howard & Liossi, 2018). Adolescent and parental insights gathered from the 
first set of interviews will be integrated into the content and design of the intervention where possible; 
however, the basic modules that are to be included will cover the following areas in line with clinical 
practice in the UK:  
• Pain education; 
• Medications; 
• SMART goals/ goal-setting; 

 
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• Physiotherapy; 
• Non-pharmacological physical therapies e.g. using a TENS machine (NHS, 2019); 
• Multi-component CBT e.g. relaxation, breathing, mindfulness; 
• Sleep hygiene; 
• School support and daily activities;  
• Transitional care.  
Pain education will be the first module presented to all participants, and transitional care will be 
the last module presented to all participants. The final order of the other modules is not yet defined, 
and is likely to be a flexible order.  
The draft content that will be shown to participants will be uploaded to the IRAS checklist for this 
study, for review by the REC, before any participants are recruited for the follow up study.  
5.2 Analysis  
All data from semi-structured and think-aloud interviews will be analysed thematically (two 
separate analyses). The current study intends to abide by the six phases of thematic analysis, as 
outlined by Braun and Clarke (2006). The first stage phase includes familiarizing yourself with the 
data: transcribing audio data, reading, and re-reading. The second phase is code generation, which 
involves systematically coding interesting features of the data that are noticed across the data set. The 
third phase is searching for themes. To do this, codes are grouped together to form potential themes; 
Braun and Clarke (2006) describe a theme as follows: “A theme captures something important about 
the data in relation to the research question, and represents some level of patterned response or 
meaning within the data set.”  
The fourth phase involves reviewing themes and checking if they fit the initial coded extracts, as 
well as whether they fit the entire data set. At this stage, a thematic map of the analysis can be 
created – this is similar to a spider diagram or mind map. In the fifth phase, the aim is to define the 
specifics and finalise the names of extracted themes. The sixth and final phase is the production of the 
report. A selection of compelling quotes from the data can be included in the report to provide an 
example of each theme. Selected extracts from the data may be analysed further for the purpose of 
the report, and the analysis will be related back to the research question and wider literature.  
All utterances made by participants during the interview procedure will be transcribed and coded 
individually by AHW using NVivo qualitative analytic software. Coded data will be organised into a 
variety of themes and sub-themes representative of participant views on intervention content and 
features; this will be done by AHW. Sections of the transcripts will be sent to Prof. C. Liossi or DS to 
be coded using the developed themes/ sub-themes (back-coded), and inter-rater reliability will be 
assessed using the Kappa statistic. Any disagreements regarding themes will be resolved through 
discussion with the research team. Finalised themes and insights will then be used to inform changes 
to the intervention; this will be an iterative process, where the semi-structured interviews will inform the 

 
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first round of changes to the intervention, and the think-aloud interviews will inform a second round of 
changes. 
The analysis for this study will use a constructivist epistemological approach; a naturalistic 
enquiry method, which considers that the surrounding environment and context has an impact on how 
individual’s attribute meaning, such that each individual forms their own version of reality (Lincoln & 
Guba, 1985). This study will also adhere to the 15-point checklist of criteria outlined for good thematic 
analysis (Braun & Clarke, 2006), which covers the transcription, coding, analysis, overall quality, and 
final report.  
6 
STUDY SETTING 
The current study is a multicentre study. Participants will be identified by collaborating clinicians 
at GOSH and RMH; clinicians will then advise AHW of which patients are happy to be approached, 
and AHW will invite potential participants with the study information sheet and contact details should 
they wish to participate. This will be done in person at the site in question as much as possible. At 
GOSH, some participants may also be recruited by letter or email by clinicians Prof. C. Liossi (CL) and 
Miss S. Lilley (SL). Participants may also be recruited in this way at RMH by Dr AK Anderson. 
Additional participants will be recruited from social media, the wider community and charities, or 
patient organisations (see section 7.3.1). 
Interviews will be conducted in private rooms at either one of the specified hospital sites or at the 
Pain Research Laboratory at the University of Southampton, Psychology building where possible. This 
setting will allow the researchers to control for excess noise or distractions. Participants also have the 
opportunity to request home interviews if they wish. In these instances, the researcher attending the 
participant’s home will abide by the University of Southampton Lone Working Policy (March 2017).  
Researcher AHW has attended University of Southampton Training in Personal Safety for Lone 
Working. This policy is included as a supplement to this protocol.  
7 
SAMPLE AND RECRUITMENT 
7.1 Eligibility Criteria 
7.1.1 Inclusion criteria  
Eligible adolescent participants will be a) aged 12 to 17 years, b) been experiencing chronic pain 
(cancer or non-cancer related) that has lasted for at least three months (Treede et al., 2015), and c) 
patients in the cancer related pain group must not have received treatment to eradicate cancer in the 
last three months; biological and pharmacological maintenance therapies are acceptable. 
Eligible parent participants will be a) parents or legal guardians of adolescents (aged 12 to 17 
years, experiencing chronic pain of any type). 
7.1.2 Exclusion criteria  

 
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The current study will exclude adolescents who a) cannot communicate in fluent, spoken 
English*, b) are aged 18 or over, and c) for the cancer pain group are continuing to undergo 
treatments to eradicate their primary cancer or have received these treatments in the last three 
months. 
The current study will exclude parents who a) do not speak fluent English* 
*The research team does not have any translators, and poor English skills may lead to language 
misinterpretation in the qualitative analysis to follow. 
7.2 Sampling 
7.2.1 Size of sample 
The overall sample size projected is a group of 60 stakeholders (teenagers and parents). 
The study aims to recruit approximately 15 participants per group at GOSH: 
• Children with chronic pain (n = 15) 
• Parents of children with chronic pain (n = 15),  
Approximately 10 participants per group will be recruited from RMH: 
• Children with cancer-related chronic pain (n = 10) 
• Parents of children with cancer-related chronic pain (n = 10), 
Approximately 5 participants per group will be recruited from the community:  
• Children with chronic pain (any type) (n = 5)  
• Parents of children with chronic pain (n = 5) 
Analysis will be ongoing and recruitment will continue up until the point of saturation (Guest et 
al., 2016). The research team anticipate that approximately 15 participants per group will be sufficient 
for saturation, as has been the case in similar intervention development studies conducted in the field 
of paediatric pain management (e.g. Stinson et al., 2014). We hence aim to recruit this baseline 
amount of 30 participants at GOSH (15 parents and 15 children), with the addition of insights from 
community volunteers, as well as children and parents from the Chronic Cancer Pain Clinic at RMH.  
7.2.2 Sample diversity 
As we are using an opportunistic sample the research team cannot guarantee complete 
representation across sexes, pain diagnoses, chronicities, or otherwise. If the sample is 
misrepresentative in any way, this will be accounted for in the qualitative analyses and discussed in 
the study write-up. Participants may be from either a clinical or a non-clinical population; there is no 
guarantee of whether a higher proportion of the sample will be recruited from Great Ormond Street 
Hospital verses the wider community. 

 
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A representative sample would include a mixture of ages ranging from 12 to 17 years, and a 
representative split between the sexes (chronic pain is more common in teenage girls compared to 
boys). A fully representative sample would also include a mixture of adolescents from varying socio-
economic backgrounds. Adolescents are likely to have a variation of pain diagnoses and chronicities, 
however if this is not the case then this will be discussed in the study write-up.  
 Similarly, for the parent feedback groups, a representative sample would include parents of 
children with a mixture of chronic pain diagnoses, a mixed sample of mothers and fathers, and parents 
from a variety of socio-economic backgrounds.   
7.2.3 Sampling technique 
Adolescent participants and their parents will be primarily sampled from GOSH Pain Control 
Service. If recruitment is successful, the secondary hospital collaboration will be implemented, and 
participants will additionally be sampled from RMH Chronic Cancer Pain Clinic. Where possible, 
opportunity sampling will be used to find additional adolescent and parent participants from the 
community, voluntary services, social media, and patient organisations.  
A local newspaper advertisement will be circulated (online and paper format) to advertise the 
study. Participants will also be sought using poster advertisements (online and paper format). This 
includes advertising the study using posters at the specified NHS sites where possible. Approval from 
a collaborating clinician at each site will be sought prior to advertisement at the site in question. 
Copies of the study poster advertisement and newspaper advertisement are available as a 
supplement to this protocol. This variety of sampling techniques widens participation and provides the 
opportunity for any paediatric chronic pain patients or parents to contribute to the study if they would 
like to. 
The research team will be recruiting participants from GOSH and RMH for up to one year, 
however recruitment from the community will continue for an additional 8 months, hence the total 
study duration is 1 year 8 months. 
7.3 Recruitment 
7.3.1 Sample identification 
Participants recruited from NHS hospitals will primarily be identified by co-applicants who are 
part of the patient’s clinical care team at the site in question. Participants will be identified by 
collaborating clinicians or the PI; clinicians will then advise AHW of which patients are happy to be 
approached. AHW will then invite potential participants to the study in-person at the pain clinic, by 
providing the participant information sheet and researcher contact details should they wish to 
participate. Participants will then be given time to think about whether they would like to join the study 
and may contact the central research team to enrol formally at a later date. Recruitment will be 
conducted in this way as much as possible. At GOSH, some participants may also be recruited by 
letter or email by clinicians CL and SL. Participants may also be recruited in this way at RMH by Dr AK 
Anderson.  

 
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AHW will additionally identify other potential adolescent and parent participants by searching 
social media for groups that meet eligibility criteria, for example a forum for parents of children with 
chronic pain. Voluntary services in London and Southampton will be investigated to see if any groups 
may match the eligibility criteria. If so, the admin or the lead of the group will be approached to ask if 
they can advertise the study, or alternatively to ask permission for the research team to advertise the 
study within the group or organisation. Study advertisement materials (poster and newspaper 
advertisements) provide the contact details of the research team, so that potential participants can 
contact AHW or CL if they would like to take part. 
All participants will be offered travel expenses. These funds will be taken from the research 
expenses that are part of University of Southampton funded studentship for AHW. For adolescents, all 
and any reimbursements will be made to the consenting parents or guardians. 
Participants that take part in the semi-structured interviews will be given the option for the 
research team to retain their contact details, so that we may contact them about taking part in the 
think-aloud study. Hence, some participants may be re-recruited following approval of the content for 
the follow-up study. In addition, the same community recruitment strategy will be used as described for 
the semi-structured interviews, however new advertisements will be uploaded for approval by the REC 
as part of the substantial amendment required for the think-aloud study.   
7.3.2 Consent 
Consent is an ongoing process. AHW will initially invite potential participants to the study in-
person at the pain clinic, by providing the participant information sheet and researcher contact details 
should they wish to participate. Participants will have time to think about whether they would like to 
participate and will be formally enrolled to the study at a later date. Informed consent, and assent for 
minors, will additionally be sought immediately before study participation by interviewing researchers 
AHW and DS.  
Prior to the start of the interview, all participants and/or their legal representative will be 
presented with an information sheet detailing the procedure of the study, their right to withdraw 
consent at any time, and the dissemination of results. Separate information sheets, which are age 
appropriate for adolescents, will be provided. This information will be reiterated by AHW or DS. 
Participants will be given the opportunity to ask any questions they may have, before being presented 
with a consent/ assent form. The forms are worded in an age-appropriate manner for all participants. 
No activities designed for this study will begin before informed consent is received.  
Any participants under the age of 16 years will be asked to assent with the addition of informed 
consent sought from the parent or guardian. Informed consent from the parent or guardian is 
compulsory for minors, hence adolescents will not be allowed to participate without parental/ guardian 
consent. Consent without assent will also not be accepted, and as such, the adolescent in question 
would not be allowed to participate.  
8 
ETHICAL AND REGULATORY CONSIDERATIONS 
8.1 Assessment and management of risk 

 
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8.1.1 Safeguarding of children and teenagers 
The research team is responsible for the safeguarding of children and teenagers taking part in 
this study. If a member of the research team has reason to suspect physical, emotional or sexual 
abuse, or neglect, normal escalation procedures will be followed and the most appropriate person will 
be informed.  This preceding statement is included on all version of the participant information sheet. 
The research team are aware that safeguarding issues could arise during any form of patient 
contact. For participants recruited from participating hospital sites, if abuse or neglect is suspected the 
safeguarding officer for that hospital will be contacted, such that the safeguarding process can be 
carried out in-line with hospital standards. For participants recruited from the community, social 
services will be informed. In the case of suspected immediate danger to a child or teenager, the police 
will be contacted via emergency services; a member of the research team will remain with the young 
person whilst the police are contacted. Any safeguarding issues that arise will be prioritised and dealt 
with efficiently, without causing alarm to the young person in question as much as possible.  
8.1.2 Protection of participants from psychological harm 
The research team do not anticipate there to be any distress or disadvantages due to taking part 
in this study. It is possible that some interview questions, or some content that we display to the 
participants, could provoke stressful thoughts about the adolescents’ chronic pain condition. As 
researchers, we are aware of this and would stop the interview or task to check that the adolescent or 
parent participant is happy to continue with the study if they appeared to be becoming distressed. We 
will stop the study if the participant becomes noticeably upset or emotionally/ psychologically 
distressed. 
In the case of any emotional or psychological distress, trained clinicians will be on hand to help 
deal with this immediately. This includes clinical nurse specialists at GOSH and Psychologist CL at the 
University of Southampton. If the interview is taking place at a participant’s home – AHW will contact 
CL for assistance.  
We do not expect anticipate any long-term distress will be caused by participating in the study. 
Any cases of long-term distress will be advised to contact the research team, so that we may refer 
them to the most appropriate person/ team. 
8.1.3 Chaperones 
Parents/ guardians may be present with adolescents under 16 years during the study if they 
wish, however, the adolescent must agree for them to be present. If there is any disagreement 
between the two parties, the adolescent and parent in question will be advised that they can no longer 
take part in the study.  
Adolescents may not wish for their parent/ guardian to be present and may ask for someone 
else to accompany him or her instead. We can provide a chaperone to accompany them if they wish, 
however this cannot be done for home interviews. Researchers must consider safeguarding 
implications with regard to chaperone requests.  

 
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8.2 Research Ethics Committee (REC) and other Regulatory review & reports 
Before the start of the study, approval will be sought from the UK Health Departments Research 
Ethics Service (NHS REC), with the addition of a governance review from the University of 
Southampton for the study protocol, study information sheets, consent forms and other relevant 
documents.  
Substantial amendments that require review by NHS REC will not be implemented until that 
review is in place and other mechanisms are in place to implement changes at the site. All 
correspondence with the REC will be retained by the research team. 
The Chief Investigator will produce the annual reports as required by the REC and will notify the 
REC of the end of the study. An annual progress report (APR) will be submitted to the REC within 30 
days of the anniversary date on which the favourable opinion was given, and annually until the study is 
declared ended. Within one year after the end of the study, the Chief Investigator CL will submit a final 
report with the results, including any publications or abstracts, to the REC. 
In the instance that the study is ended prematurely, the Chief Investigator will notify the REC, 
and provide reasons for the premature termination. 
Regulatory Review & Compliance  
 
Before GOSH or RMH enrols patients into the study, the Chief Investigator or designee will ensure 
that appropriate approvals from participating organisations are in place. Approvals from participating 
organisations (GOSH and RMH) will be in place prior to the start of the research. This project will be 
registered with GOSH using the guidance as advised for unfunded projects, which is available at: 
https://www.gosh.nhs.uk/research-and-innovation/information-researchers/joint-rd-office/registering-
project-or-funding-application#Unfunded  
For any amendment to the study, the Chief Investigator or designee, in agreement with the 
sponsor will submit information to the appropriate body in order for them to issue approval for the 
amendment. The Chief Investigator or designee will work with sites (R&D at GOSH and RMH sites, as 
well as the study delivery team) so necessary arrangements can be put in place to implement the 
amendment(s) and confirm their support for the study amendment(s). 
Amendments  
If the sponsor wishes to make a substantial amendment to the REC application or the supporting 
documents, the sponsor must submit a valid notice of amendment to the REC for consideration. The REC 
will provide a response regarding the amendment within 35 days of receipt of the notice. It is the 
sponsor’s responsibility to decide whether an amendment is substantial or non-substantial for the 
purposes of submission to the REC. 
Amendments also need to be notified to the national coordinating function of the UK country 
where the lead NHS R&D office is based and communicated to the participating organisations (R&D 
office and local research team) departments of participating sites to assess whether the amendment 
affects the NHS permission for that site. Some amendments that may be considered to be non-
substantial for the purposes of REC still need to be notified to NHS R&D (e.g. a change to the funding 
arrangements).  

 
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The Chief Investigator is responsible for the decision to amend the protocol and for deciding 
whether an amendment is substantial or non-substantial. Substantial amendments must be completed 
via IRAS and validated by the REC that approved the original application. Any non-substantial 
amendments can be emailed to hra.amendments@nhs.net, using the template available at 
https://www.hra.nhs.uk/approvals-amendments/amending-approval/.    
Guidance on the categorisation of amendments for studies involving the NHS can be found on 
the HRA website. http://www.hra.nhs.uk/resources/after-you-apply/amendments/. Any amendment 
made to the research protocol will be documented by updating the version number.  
8.3 Peer review 
The research team has reviewed this research protocol.  
This protocol has been reviewed and accepted by the Clinical Research Adoptions Committee 
(CRAC) at Great Ormond Street Hospital.  
The CRAC strongly recommended that the participants in our study would be well placed to 
evaluate the final intervention. As informed by patient representatives within the CRAC, the research 
team have developed a single application for this project based on recruitment, development and 
testing of the online resource, which presents minimal risk to the patients or participants. This protocol, 
and the IRAS Ethics application, hence include consent to contact participants for the second part of 
the study, which will be a think-aloud study (described in section 5.1). This follow-up study will not start 
recruiting participants until the content that we are showing participants has been submitted to the 
REC, and approved as a substantial amendment. 
8.4 Patient & Public Involvement 
Patients and carers will be participating in the research. The study will involve interviewing a 
mixture of patients, and parents or guardians of patients recruited from GOSH, RMH and the wider 
community. Insights from the qualitative study will inform alterations to the online intervention as part 
of an iterative process.  
We will also ask participants over the age of 16 years if they would like to join the design team. 
Patients, carers, and members of the public will not be involved in the management or design of 
the research, the analysis of results or dissemination of findings. These aspects will be managed by 
the research team and collaborating clinicians. 
8.5 Protocol compliance  
In the instance that the research protocol is deviated from, changes or errors will be reported to 
the Chief Investigator. Any changes will be documented on a new version of the protocol and 
published accordingly.  
Frequent deviations from protocol are unacceptable and may require immediate action. The 
Chief Investigator will determine how to proceed in this case. 

 
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8.6 Data protection and patient confidentiality  
All investigators and study site staff must comply with the requirements of the General Data 
Protection Regulation (GDPR) and the Data Protection Act 2018 concerning the collection, storage, 
processing and disclosure of personal information and will uphold the Act’s core principles.  
Participants will be allocated a pseudonym that does not contain any personal information. For 
example, participant ‘Joan Smith’ may be given a pseudonym data label such as ‘Starling1’. 
Participants from the same family will be grouped by pseudonym such as ‘Robin1’ and ‘Robin2’. 
Pseudonyms will be kept in a password protected data key file that only the central research team will 
have access to (AHW, LJ, DS and CL). Each participant’s data will be labelled with their pseudonym, 
so that data remains anonymous, however, if they later wish to withdraw their data, this may be done 
using the data key file.  
For the purposes of patient note keeping, consent forms will remain to have participant names 
and signatures on them. Paper copies of consent forms will be stored in a securely locked file within 
offices in the University of Southampton Psychology Department building. 
Participants will not be able to withdraw their data once their interview has been transcribed. 
This will be made clear in the study information sheet. The study information sheet for participating 
parents and consenting parents will also include the University of Southampton Data Protection 
Privacy Notice. 
All data stored electronically will be subject to a process of direct de-identification through 
pseudonymisation to ensure confidentiality; only the researchers listed on this protocol will have 
access to the final study dataset (see section 8.8), and all files will be password protected. All 
identifying information obtained during interviews will be removed and replaced with an appropriate 
pseudonym, for example, the name of a school may be taken out and replaced with a fictional name.  
Paper copies of consent forms, and any other personal or sensitive data will be stored securely 
in a locked file in offices within the University of Southampton Psychology Department building. 
Following study completion and publication, all sensitive or personal data will be destroyed. The data 
custodian for this project is the principal investigator, Professor C. Liossi.  
8.7 Indemnity 
1. Regarding legal liability of the sponsor for harm to participants arising from the management or 
design of the research:  
The University of Southampton (sponsor) has insurance in place for Errors and Omissions to 
indemnify the insured in respect of claims first made against the insured during the period of the 
policy arising out of negligent acts, errors or omissions. 
2. Regarding the legal liability of investigators or collaborators (GOSH and RMH clinicians) arising 
from harm to participants in the conduct of the research:  
NHS indemnity scheme or professional indemnity will apply (participants NHS sites only). 
University of Southampton insurance may also apply where the cause of the harm was not due to 
clinical negligence as covered by CNST. 

 
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3. Payment of compensation, by the sponsor, in the event of harm to the participants where no 
legal liability arises is not applicable; the study is qualitative using semi-structured interviews 
only.  
4. No equipment is provided to the sites for the purpose of the study; hence, no arrangements for 
insurance or indemnity in relation to the equipment (e.g. loss, damage, or harm to participants 
or site staff) are applicable.  
8.8 Access to the final study dataset 
Study information sheets will outline how study data will be used in the context of the wider research 
project (online intervention development). This will be worded in an age-appropriate manner for 
adolescents.  
Only members of the research team conducting interviews and conducting or overseeing analyses 
(central research team) will have access to the full data set: 
• Miss Anna Hurley-Wallace, 
• Miss Lauren Johnstone,  
• Prof. Christina Liossi,  
• Dr Daniel Schoth 
Personal data will only be used by the research team to arrange face-to-face interviews, and to 
conduct interviews by telephone. Personal details of participants may also be used to identify 
anonymised data in the case that a participant wishes to withdraw their data from the study. 
Dr Glyn Williams, Miss Suzanne Lilley and Dr Anna Karenia Anderson will only have access to data 
relating to their own patients. 
9 
DISSEMINIATION POLICY 
9.1 Dissemination policy 
The University of Southampton owns the data arising from this study. On completion of the 
study, the data will be analysed and tabulated and a Final Study Report prepared. This research will 
be presented at the participating centres GOSH and RMH (monthly meetings of clinicians), and will be 
written up for publication in a peer-reviewed journal. Study methodology and results will be reported in 
in AHW’s PhD thesis.  
 GOSH and RMH collaborators will be acknowledged in any publications resulting from this 
study.  
All adult participants and parents/ guardians of participating children will be asked if they would 
like to be notified about the outcomes of the study at the end of the interview. If they would like to be 
notified, this would take place after the Final Study Report has been compiled - they will be sent the 
report with a cover letter lay summary. Participants may also request results from the Chief 
Investigator or AHW after the Final Study Report had been compiled. Details of who to contact for 

 
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further information about the study are provided in the study information sheet and debrief form (adult 
and parent/ guardian versions). 
The study protocol and full study report will not be made publically available. 
9.2 Authorship eligibility guidelines and any intended use of professional writers 
 The research team will all be eligible authors for any publications resulting from this work:  
• Miss Anna Hurley-Wallace, 
• Miss Lauren Johnstone,  
• Prof. Christina Liossi,  
• Dr Daniel Schoth 
• Dr Glyn Williams,  
• Miss Suzanne Lilley,  
• Dr Anna Karenia Anderson 

 
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10 
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doi:10.1177/1090198113487199 
Bender, J. L., Radhakrishnan, A., Diorio, C., Englesakis, M., & Jadad, A. R. (2011). Can pain be 
managed through the Internet? A systematic review of randomized controlled trials. PAIN, 
152(8), 1740-1750. doi:10.1016/j.pain.2011.02.012 
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11  
APPENDICIES 
11.1  Appendix 1- Required documentation  
The following documentation is required prior to initiating research at GOSH and RMH sites: 
• Qualitative research protocol (current form) (HRA headed paper) 
• Participant Information Sheets – Adolescents* 
• Assent forms – Adolescents* 
• Participant Information Sheets – Consenting Parent/ Guardian* 
• Consent forms – Consenting Parent/ Guardian* 
• Participant Information Sheets – Parents and adults aged 16+* 
• Consent forms – Parents and adults aged 16+ * 
• Debriefs for Adolescents (Under 16’s)*  
• Debriefs for Adults* 
• Consent-to-contact consent form – Consenting Parent/ Guardian* 
• Consent-to-contact consent form – Participating Parents* 
• Interview Schedule (optimised for adolescents and parents) 
• Study poster advertisement 
• Study advertisement for local newspaper 
• Statement of activities  
• Schedule of events 
• Clinical Research Adoptions Committee (CRAC) approval documentation 
• University of Southampton Lone Working Policy 
*participant information sheets, consent and debrief forms, and advertisement should be on 
University of Southampton headed paper. 
11.2  Appendix 2- Amendment History 
Amendment 
No. 
Protocol 
version no. 
Date issued 
Author(s) of 
changes 
Details of changes made 
1 
1.1 
04/01/2019 
Anna Hurley-
Wallace 
Protocol number and dates adjusted to 
match within document and headers/ 
footers. 
Addition to section 7.3.1. “Approval 
from a collaborating clinician at each 
site will be sought prior to 

 
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advertisement at the site in question.” 
Required documentation – statement of 
activities and schedule of events 
added. 
2 
1.2 
29/01/2019 
Anna Hurley-
Wallace 
Researcher Dr Daniel Schoth added as 
interviewing researcher additional to 
Miss A. Hurley-Wallace.  
Several small changes made to GOSH 
processes in-line with changes made to 
the CRAC application form. 
3 
1.3 
05/02/2019 
Anna Hurley-
Wallace 
Edits to pseudonymisation process with 
advice from University of Southampton 
research governance – section 8.6.  
Edits to dissemination policy 9.1 from 
participants will not be notified of 
outcomes to “All adult participants and 
parents/ guardians of participating 
children will be asked if they would like 
to be notified about the outcomes of the 
study at the end of the interview.” 
 
4 
1.4 
24/03/2019 
Anna Hurley-
Wallace 
Suggested amendments added in-line 
with CRAC review (GOSH): 
- Sample age range adjusted to 12 
to 17 years. See section 7. 
Sample diversity clarified in 
section 7.2.2. 
- Added consent to contact for 
second (follow-up) study, and 
methodology details of follow up 
study (think-aloud). See section 
5.1.1. Reasoning for this added 
to peer review statement, 
section 8.3.  
- Necessary adjustments to Gantt 
chart to incorporate changes. 
See study flow chart 
5 
1.5 
12/06/2019 
Anna Hurley-
Wallace 
Amendments added to comply with 
requests from REC Hampshire B: 
- Children with statement of special 
needs to be included in the 
study – eligibility section 7.1 
- Sample diversity statement altered 
- Social media recruitment clarified 

 
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(7.3.1.) 
- Updated information on 
safeguarding and chaperones 
added to section 8. 
- Removed all mentions of letter to 
GP