83 Development of a patient engagement tool; All Voices Count addition of keywords about the situations to the playing cards, but we decided not to because it can reduce the possibility of free association. Furthermore, adolescents indicated that a map with an overview of the themes would be helpful. In addition, a few adolescents made some suggestions to improve the design of the game, for example changing the rules of the game or create an online version. These suggestions were discussed with the research team, the design agency and the representative of the youth panel. We decided to change the images, the lay-out of the playing cards, the rules of the game and the game explanation, and we added an personal overview card of the themes and associated subthemes. This card clarifies to adolescents what kind of subthemes are related to the specific themes (Table 3). Finally, we discussed the naming of the themes within the project group, as we noticed that the naming did not always match the perception of adolescents. We decided to rename the themes to make them more appealing and understandable for adolescents: my hospital, I can (not) do this, my disease & treatment, me & others, I feel this, the people in my hospital, I am okay, I do (not do) it myself, talk about it and just like me (Table 2). Step 3: Testing usability in clinical practice The pilot version (Figure 2) of the game was tested for usability by four patients (mean age: 14.5 years, range 13-16 years, 50% female, Table 1) in clinical practice. During this pilot workshop, the adolescents gave their opinion about a question of the educational facility, and a report on this workshop has been presented to the education facility to help them improve their daily clinical care. At the end of the workshop, the adolescents gave their opinion about the engagement game. All adolescents were enthusiastic about the game and enjoyed giving their opinion. Although it was difficult for some adolescents to give an opinion on all themes, the cards helped adolescents to come up with ideas about topics to talk about. The adolescents mentioned that not all themes were applicable for the educational facility. Therefore, we added some instructions to the game manual for professionals about the selection of themes and the minimum number of themes to be included in the game (Table 3). Furthermore, adolescents suggested the addition of keywords about the situations to the playing cards. In consultation with the research team, we decided to add the theme name to all playing cards. Adolescents evaluated the overview card of the themes (as developed and added after step 2) positively; however, we noticed that these personal maps were distracting and reduced the group feeling. By introducing the themes on a game board (Table 3), the focus of all players is on the game, and they are invited to help each other as not all words are visible from every corner. 3
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