89 Development of a patient engagement tool; All Voices Count Some barriers to engagement in this study included logistic difficulties related to travelling to the hospital, time constraints and difficulties in scheduling a meeting with a group of adolescents. These barriers have been mentioned by both adolescents and adults in other fields [7,18,40]. Developing an online version of the game could potentially reduce these barriers, according to the adolescents in our study. Adolescent indicated that the advantages of an online game are that they do not have to visit the hospital, that it takes less time and that they can fit it more flexibly into their time schedule. For this reason, we would like to develop an online version of All Voices Count in the future. Conclusion In conclusion, we developed a patient engagement game called All Voices Count, working together with all stakeholders. This game lowers the barrier to include the voice of adolescents in decision-making about hospital care, research, and policy. Acknowledgements We would like to thank all participating adolescents for codesigning All Voices Count. Additionally, we thank all members of the project group and our colleagues Florrie Walraven en Merel Velu for thinking along. The data collection and development of All Voices Count were supported by FNO and Stichting Steun Emma. Ethics statement All procedures performed in this study were in accordance with the ethical standards of the international and/or national research committee (Medical Ethics Committee of the Amsterdam UMC – W17_068#17.086) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in this study. Conflict of interest The authors declare that they have no competing interests. Data availability statement The data generated and analyzed during this study are available from the corresponding author on reasonable request. Keywords Adolescent, codevelopment, patient engagement, patient participation, paediatrics, shared decision-making, user-centred design 3
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