104 Chapter 4 4 (medical)procedures and experience stress and anxiety, such as primary care practices, dentist practices and within vaccination programs (37-39). Limitations Both studies had some methodological challenges. First, we were restricted in our data collection methods due to COVID-19 measures. In the first study, we were unable to test the working prototype with children and caregivers at the outpatient clinic and set up a simulated hospital instead. Early testing in the outpatient clinic could have improved our understanding of the user experience earlier in the process (e.g. preferences during consultation). In the second study, we were unable to perform observations at the hospital and interviews were held online, a necessity many researchers reverted to to continue data collection during the pandemic. Although a review of online interviews and focus groups showed that the online setting does not compromise the quality of the data (40), it is unknown if this also goes for interviews with children. Nonetheless, we undertook multiple measures to ensure good quality data. We used an interview toolkit with photos and pictorial images to facilitate the conversation, had caregivers fill in an observation booklet during the appointment, which was used during the interview, and made use of screenshots of the app. Also, to minimize the burden on the healthcare professionals we decided not to collect their experiences in the evaluation. By evaluating the use of the Hospital Hero in practice we were however able to shed light on potential implementation issues (e.g. engagement of all healthcare providers, management of QR codes, reaching and activating caregivers to download the app) that need to be addressed in future research and implementation. Second, due to COVID-19 pandemic related postal capacity problems, not all participants received the invitation letter and did not download the app. Consequently, the onboarding process (being informed and activated to download the app) could not be properly evaluated. Interviews did give insight into how the onboarding process could be improved. Third, children and caregivers who participated in the study may have been more positive about the application overall. We tried to minimize this by setting out a broad recruitment strategy, approaching caregivers that showed no initial interest in the application in the face-to-face recruitment and emphasizing the importance of hearing all opinions during the interview. Future directions Real-world evaluation allowed us to identify important implementation issues that should be addressed in the future, like how to activate caregivers to download the app at home and how to engage all staff in the safari story. Hence, follow-up research should focus on how best to implement the Hospital Hero in practice, setting up an implementation strategy and evaluating the implementation efforts. Implementation and scaling efforts should be directed at being minimally disruptive to daily practice, creating stakeholder support and demonstrating impact for all stakeholders involved. Finally, we demonstrated that the app was evaluated positively by children and
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