Development of a survey tool to measure pediatric experience of care: Cognitive testing and validation in the Laos

Despite increased availability of child health services, poor quality of care remains a major barrier to improved health outcomes in low-resource settings. Few validated tools exist to measure pediatric experience of care (PEC). Building on prior work in respectful maternity care, this study developed a caregiver-reported PEC survey based on a new conceptual framework and assessed the clarity, relevance, and cultural appropriateness of survey items through cognitive testing in Laos. Qualitative cognitive testing was conducted in May 2023 with 34 caregivers of children under five in Vientiane and Oudomxay provinces. Five rounds of interviews were completed. Lao-speaking researchers used structured probes and open-ended questions to assess comprehension, cultural fit, and interpretation of items. Daily debriefings informed iterative revisions. Interview notes were analyzed using three types of potential response error: unclear or ambiguous question wording; translation and linguistic challenges; and cultural relevance. Respondents had difficulty interpreting abstract or subjective concepts, such as "respect," "trust," or perceptions of privacy or wait time. Items using such constructs were revised to reference concrete, observable experiences (e.g., quantifying wait times; describing "kindness" instead of "respect"). Translation challenges also shaped understanding; respondents preferred common terms such as "health worker" and cognitively oriented language ("think") rather than emotional wording ("feel"). Several concepts, such as "building trust," had limited cultural resonance; revised items emphasized behavioral indicators (e.g., whether the child was helped to feel calm). These adaptations improved clarity, cultural alignment, and response validity. Cognitive testing demonstrated that valid measurement of PEC requires more than accurate translation; it demands cultural and linguistic adaptation reflecting local norms and communication practices. The study confirms the feasibility and necessity of contextually grounded PEC measurement in low-resource settings and reinforces the importance of iterative, culturally responsive instrument development to ensure meaningful, actionable data for improving child health services.