Systematic Evaluation of the Psychometric Properties of Pain Assessment Scales for Use in Chinese Children: Where Are We?

Purpose: Many children experience moderate to severe pain during hospitalization. Systematic pain assessment using reliable and valid pain scales is the foundation for adequate pain management in children. The psychometric properties of pain measures used with children in China are still largely unknown relative to their properties when used in children in Western countries. The purpose of this study was to systematically evaluate the psychometric properties of pain assessment scales used in Chinese children.

Methods: We searched Chinese-language databases (e.g., CNKI, Wanfang, VIP and SinoMed) and English-language databases (e.g., PubMed, CINAHL, Health and Psychosocial Instruments and PsycINFO) from its inception to December 2013. Studies were eligible for inclusion if the psychometric properties of pain measures were examined in Chinese children (aged 0-18 years). Two independent bilingual reviewers screened search results based on title, abstract and full article for eligibility. Both reviewers used an 11-item coding system developed by Zwakhalen et al. (2006) to evaluate the psychometric properties of pain scales in the eligible studies. Total scores (range 0-20) of this coding system were categorized into four levels: very good (15-20), good (12-14.9), acceptable (10-11.9), and unacceptable (< 10).

Results: Our initial literature search identified 352 and 434 potential articles from Chinese-language and English-language databases. According to the inclusion criteria, a total of six studies were identified in this review. Six pain scales were evaluated: the Face, Legs, Activity, Cry, and Consolability (FLACC) Scale, COMFORT-Behavior Scale, Asian Oucher Scale, Pain Observation Scale for Young Children, Neonatal Facial Coding System and Pain Assessment Scale for Preterm Infants. Four of these scales were adapted from Western countries and two were developed in Taiwan. These identified scales were mostly examined in children undergoing invasive painful procedures pain after surgery. Results showed that the FLACC, COMFORT-Behavior Scale, and Pain Assessment Scale for Preterm Infants had very good psychometric qualities when administered in Chinese children, with a total score of 18.2, 16.4, and 17.3, respectively. The Asian Oucher Scale and Pain Observation Scale for Young Children showed acceptable to good psychometric qualities, with a total score of 14.6 and 11.8. The Neonatal Facial Coding System had unacceptable psychometric qualities, with a total score of 7.3.

Conclusion: Pain measures whose psychometric properties were examined had acceptable to good psychometric properties for pain assessment in Chinese children, even though few had been validated in Chinese children. The development and validation of pain assessment scales for Chinese children is still far behind the Western countries (Bai 2013; Sun et al., 2013a, 2013b), indicating that there is still a big gap of pain assessment in Chinese children compared with the international standards. Future studies should validate these measures and self-report pain scales in particular among Chinese children of various age groups and in different pain situations.