Implementing transition readiness screening by nurses in pediatric oncology long-term follow-up care during the COVID-19 pandemic: Barriers and facilitators

Abstract

This study aimed to 1) describe adolescent cancer survivors’ transition readiness and self-reported goals in a limited clinical sample; and 2) investigate healthcare providers’ (HCPs’) perspectives about a nurse-led clinical utilization of the Transition Readiness Assessment Questionnaire (TRAQ) and its subsequent discontinuation in a long-term follow-up (LTFU) pediatric oncology clinic. Data were collected from adolescent survivors (n = 7) at a tertiary pediatric hospital, while in-depth interviews were conducted with HCPs (n = 3) from the LTFU oncology clinic. Qualitative data revealed barriers, facilitators, and strategies for TRAQ implementation, relating to the tool, HCPs, adolescents, and the clinical context. The understanding of the barriers and facilitators to TRAQ use will support a structured implementation plan for TRAQ use in future clinical practice. Analysis revealed varying levels of readiness for transition to adult care services among patients and identified themes in their self-set goals, supporting the need for transition readiness supports in this population.

INTRODUCTION

An estimated 400,000 individuals 20 years of age or less receive a cancer diagnosis annually (World Health Organization, 2021). Although the majority of childhood cancer survivors now live into adulthood, they are at risk of developing late effects of cancer and its treatment (Canadian Cancer Society, 2021; Gebauer et al., 2019). It is, therefore, recommended that childhood cancer survivors engage in long-term follow-up (LTFU) care designed to screen, monitor, and help alleviate long-term effects (Gebauer et al., 2019; Signorelli et al., 2017). Ideally, by the time of transfer to adult care facilities, childhood cancer survivors are able to manage their healthcare needs independently, which requires communication, decision-making, and self-management skills (Mulder et al., 2016).

Evidence-based guidelines on transitional care in pediatrics recommend the use of tools with reliable outcomes to formally evaluate and monitor transition processes (Society of Adolescent Health and Medicine, 2020). The Transition Readiness Assessment Questionnaire (TRAQ) has been identified as an optimal tool to this end (Parfeniuk et al., 2020; Sawicki et al., 2011; Zhang et al., 2014). It is used internationally, being translated and validated into several languages, including Spanish, Portuguese, and French (TRAQ-FR) (Anelli et al., 2019; Chapados et al., 2021; De Cunto et al., 2017; González et al., 2017). The TRAQ was designed to help monitor transition readiness progress, as well as goal setting tailored to patient specific needs.

Transition planning and goal setting are key to the development of transition readiness skills (Schmidt et al., 2020). Goal and action setting are among the various strategies used by childhood cancer survivors to manage their health and well-being (Brown et al., 2021; Larsen et al., 2022). These strategies are considered active ingredients of behaviour change and self-management interventions, leading to increased self-efficacy and autonomy (Got Transition/Center for Health Care Transition Improvement, 2014; Larsen et al., 2022; Michie et al., 2013; Sawicki et al., 2011). Goal setting as a self-management strategy may improve coping with the challenges of cancer survivorship and enhance well-being (Brown et al., 2021). Therefore, survivors’ self-set goals may be key to their transition readiness.

In May 2022, the LTFU program of a tertiary pediatric hospital set out to use the TRAQ and an accompanying goal-setting prompt in the routine clinical care of pediatric oncology survivors, led by the LTFU clinic nurse. At the time, initially, a research objective was established to explore potential associations between adolescent transition readiness and personal goals. However, the planned one-year recruitment process ended after three months due to several clinical challenges in implementing the TRAQ and goal prompt approach. To document and address the challenges encountered in the use of an assessment tool in routine adolescent cancer survivor care, we adjusted our aim to now identify the barriers and facilitators of this experience, which we saw as critical to future structured implementation planning. In implementation science, determinant frameworks suggest guiding implementation practice by initially documenting potential barriers and facilitators (Nilsen, 2015). The current paper therefore has two objectives: 1) to document the barriers and facilitators to the clinical use of the TRAQ for subsequent implementation planning in a pediatric oncology LTFU care clinic, and 2) to describe clinical examples of adolescent cancer survivor’s transition readiness and personal goals in those screened.

METHODS

The Standards for Reporting Qualitative Research were followed to meet rigorous standards for reporting qualitative research (O’Brien et al., 2014). The qualitative aspects were rooted in a post-positivist epistemology (Fox, 2008; Nilsen, 2015).

Participants

Adolescent inclusion criteria were to be 1) between 14–18 years old, 2) survivors of childhood cancer, 3) followed annually at the LTFU oncology clinic of a tertiary pediatric hospital, and 4) able to speak and read in French or English. Patients are typically transferred to adult services at 18, but there may be adjustments in individual situations. Clinicians of the LTFU oncology team were also contacted to document their experience using the TRAQ and a goal-setting prompt. The LTFU clinic consisted of 1 nurse practitioner, 1 pediatric physician, and 1 clinical-administrative nurse manager.

Setting and data collection procedures

The study protocol was approved by the hospital research ethics committee (#2022-3592 with specific amendments for this paper). A convenience patient sample was recruited from May 2022 to July 2022. Eligible patients were identified by the nurse practitioner in the LTFU Clinic and consent was obtained by trained research assistants. Aligned with the expressed preference of healthcare providers (HCPs) in the clinic, the research assistant then provided adolescents who consented with the TRAQ to complete individually. Subsequently, a personal goals prompt was answered during an interaction with the nurse practitioner. The nurse practitioner privately reviewed the responses on the TRAQ and then held a conversation concerning the responses and any self-set goals with survivors and their accompanying caregivers. The original hard copies of the TRAQ and goal-setting document were then scanned and included in the electronic health record after the appointment.

Following clinical difficulties implementing the TRAQ, the healthcare team was contacted to document barriers and facilitators to TRAQ clinical use. A significant clinical difficulty included the absence for several months of one of the two key nurses supporting the long-term follow-up clinic, and the impact of the more limited clinical resource time on implementation of a new clinical practice. Recruitment of the LTFU oncology team for qualitative interviews took place in January and February 2023. All agreed to participate (n = 3) and gave permission to their perspectives to be shared in an article.

An interview script was developed for the purposes of the study in which HCPs were asked to share their perceived barriers and facilitators to use of the TRAQ through semi-structured interviews. Interviews with HCPs were theory-informed and developed iteratively based on eight of the most commonly cited frameworks in implementation science, including the Consolidated Framework for Implementation Research (CFIR) (Damschroder et al., 2022; Nilsen, 2015). These determinant frameworks account for five types of characteristics: the implementation object, object users, end users, context, and strategies or means of facilitating implementation (Nilsen, 2015). Interviews were conducted individually by the first author (PC) in February and March 2023, in person or virtually, and lasted on average 65 minutes (range: 26–135 minutes). Interviews were audio-recorded and transcribed.

Measures

Participant characteristics

Patients’ sociodemographic (age, sex) and medical information (cancer diagnosis, age at diagnosis, cancer treatment[s]), TRAQ scores, and personal goals were collected from their electronic health record. Clinicians’ sociodemographic (age, sex) and occupational characteristics (professional title, years of experience in pediatric care, years of experience at the LTFU oncology clinic) were collected via questionnaire.

TRAQ

The TRAQ is a non-condition-specific questionnaire measuring transition readiness (Chapados et al., 2021; Sawicki et al., 2011; Wood et al., 2014). Each item is rated on a five-point Likert scale, ranging from “No, I do not know how” to “Yes, I always do this when I need to,” with higher scores indicating better transition readiness. Only the French version was administered in the study as per participant preference. The TRAQ-FR resembles the TRAQ, except for one item with low relevance within the Canadian context (health insurance). This version includes 5 subscales: Managing Medications (4 items), Appointment Keeping (6 items), Tracking Health Issues (4 items), Talking with Providers (2 items), and Managing Daily Activities (3 items) (Chapados et al., 2021).

Personal goal setting

A prompt was added, at the conclusion of the TRAQ, to be answered by patients in the consultation period with the nurse practitioner during their visit: “By your next appointment, what goals would you like to have achieved?” Survivors were thus invited to set their personal goals. The nurse practitioner transcribed patients’ self-set goals in an allotted space on the reverse side of the TRAQ.

Data analysis

Objective 1: Document the barriers and facilitators to the clinical implementation of the TRAQ in an oncology LTFU clinic

Each semi-structured healthcare interview transcript represented a single unit of analysis and was analyzed individually by PC and AM. A deductive-inductive hybrid thematic analysis approach was used, guided by the determinant frameworks and using the 6-step reflexive process by Braun & Clarke (2012) (Nilsen, 2015; Proudfoot, 2023). After analyzing each transcript, PC and AM reviewed the coding structure to identify emerging themes. Consensus discussion was used to refine theme development, and decisions were recorded in reflexive logs to create an auditable trail. Final implementation barriers, facilitators, and strategies were identified by PC and AM, and subsequently reviewed by SS and LD.

Objective 2: Describe clinical examples of adolescent cancer survivors transition readiness and goal setting

Descriptive statistics are reported for TRAQ-FR items. To describe patients’ self-set goals, each patient response represented a unit of analysis, and inductive thematic analysis was used following the procedure reported in Braun and Clarke (2012). Coding and theme development were conducted by authors PC and AM. Adolescents’ personal goals were analyzed separately by PC and AM, and disagreements were resolved by consensus. Final themes were approved by SS and LD.

RESULTS

Participant characteristics

All clinicians (n = 3) were female. The nurse practitioner had between 15 and 20 years of experience in pediatric care and between 5–10 years at the LTFU oncology clinic. The clinical-administrative manager had between 5–10 years of experience in pediatric care and 1–5 years at the clinic. The pediatric physician had between 15–20 years of experience in pediatric care and the clinic.

With regards to patients, from May 2022 to July 2022, 26 eligible adolescent cancer survivors were initially eligible and eight agreed to participate in the study (30.8%; Figure S1). The large discrepancy between those who met criteria and those who agreed to participate was due to no-shows, cancelled or rescheduled appointments, and unavailability of HCPs. The data of one patient who consented was ultimately unavailable, due to difficulties in comprehending TRAQ items either English or French. Survivors’ sociodemographic and medical information is presented in Table 1.

Table 1.

Adolescent CCS Sociodemographic and Medical Information (n = 7)

Identification	Sex	Age	Age at diagnosis	Cancer diagnosis(es)	Cancer treatment(s)
1	Male	14	4	Wilm’s tumor	Chemotherapy, Surgery
2	Female	14	1	Pilocytic astrocytoma Optic chiasmatic-hypothalamic glioma	NA
3	Male	14	2	Rhabdomyosarcoma	Surgery, Transplant
4	Male	14	2	Neuroblastoma	Surgery
5	Female	14	5	Acute lymphoblastic leukemia	Chemotherapy
6	Female	16	5	Osteosarcoma	Chemotherapy, Surgery
7	Female	14	5	Wilm’s tumor	Chemotherapy, Surgery

Note. CCS = childhood cancer survivors; n = number of respondents.

Objective 1: Document the barriers and facilitators to the clinical implementation of the TRAQ in an oncology LTFU clinic

Based on the analysis of the semi-structured interviews, implementation barriers, facilitators, and strategies for improvement were identified as guided by the determinant. Every participant (n = 3) reported barriers and facilitators related to 1) the implementation object (TRAQ), 2) object users and developers (HCPs), 3) end users (adolescent cancer survivors), and 4) the context (tertiary pediatric hospital and COVID-19). Each participant also reported potential implementation means and strategies.

Barriers to TRAQ implementation

Characteristics of the TRAQ

First, difficulties related to the tool itself were noted, such as non-intuitive response options and a language barrier for non-native speakers. HCPs suggested going through a sample item verbally with patients who have greater difficulty understanding the tool could facilitate its implementation. Second, completing and reviewing the TRAQ required additional time in a busy schedule, hindering its clinical use. For instance, one HCP explained, “Time is a barrier, you know? Because you tell yourself: ‘I have to do this in addition to what I already have to do.”.

Characteristics of HCPs

Only one barrier was identified at the level of clinicians more broadly throughout oncology care, namely concerns about TRAQ administration by others. In particular, a lack of training with the TRAQ and with its administration to adolescents specifically were highlighted as a concern by a HCP: “Not all nurses in oncology feel comfortable administering a questionnaire such as this one to teenagers”.

Characteristics of adolescent cancer survivors

According to HCPs, survivors sometimes doubt the relevance of LTFU care after their remission or want to avoid remembering their cancer experience, especially younger patients (14-year-olds). For example, a HCP answered, “For patients, I’d say magical thinking […]. Thinking that it’s all over, wondering why we ask these questions. They don’t always understand the issues at stake”. Furthermore, survivors’ comprehension of the TRAQ may be affected by cognitive sequelae related to their cancer diagnosis and treatment, or by general difficulties with language. One HCP was surprised by “How weak [patients’ language] skills were,” affecting their reading, understanding, and answering of the TRAQ.

Characteristics of the context

The context refers to both the specific tertiary pediatric hospital and the COVID-19 pandemic. Related to the hospital, 2 barriers were identified: 1) the lack of a distinct LTFU oncology clinic time, and 2) limited resources. According to a HCP, the absence of a distinct clinic entails “That we don’t have a specific time allocated for the LTFU [care of survivors only]” and that the clinical populations followed up were heterogeneous (malignant versus benign tumors; survivors in active versus post-treatment). Therefore, it may be challenging to differentiate between patients to whom the TRAQ can be administered versus not.

Resource-wise, insufficient staffing and offices increased the workload of the HCPs and limited appointment spaces for survivors. As mentioned by a HCP: “There really is a staffing issue. […] At one point, what happens is work overload. When we only have one person [while they] should already be two”. Related to COVID-19, three barriers were found: 1) government and institutional measures, 2) being in a “survival mode”, and 3) a general increase in distress level. At the government and institutional level, after receiving a positive COVID-19 test, clinicians were unable to attend work for some time: “In fact, everyone had COVID in turn, with varying periods of isolation. […] Now, we’re down to 5 days, then we’re working”. Furthermore, since survivors were considered at high risk for COVID-19, their LTFU appointments were often either cancelled or adapted to tele-practice, limiting in-person TRAQ administration during the study period. The pandemic also brought changes to the daily work lives of the HCPs, including regular mandatory COVID-19 meetings and frequent task reorganization: “The goal was to survive what was happening, because there was so much reorganization of tasks for everyone”.

Finally, providers observed a general increase in distress among patients, including COVID-19-related fears and an increase in mental health symptoms. Consequently, distress assessment “Was part of every follow-up appointment” according to a HCP, taking priority over TRAQ administration.

Facilitators to TRAQ implementation

Characteristics of the TRAQ

First, a number of features specific to the tool were highlighted as facilitating its implementation, such as its psychometric properties, self-administration, and annual completion. One HCP noted that the TRAQ items represented concrete examples of transition readiness skills, which was also appreciated: “What is an autonomous teenager? […] That’s someone who is able to book their appointments; when they have a prescription, they feel comfortable filling it, and so on”. Second, the TRAQ supported clinicians at follow-up appointments, providing a measure of transition readiness and facilitating conversations about transfer to adult care. For instance, a HCP said, “You know, it helps to know where you’re starting from with the patient. […] Then, to see where it’s more worthwhile to invest time in that particular appointment.”

Characteristics of HCPs

HCPs displayed personal qualities that appeared to facilitate TRAQ clinical use, including being passionate, experienced, and able to create a bond of trust with patients. Another facilitator to TRAQ implementation is a general positive attitude towards the TRAQ, such as believing that it would bring added value to LTFU care and understanding the relevance of its systematic administration. For instance, a HCP stated: “Personally, I like this questionnaire. […] If I use it with some [patients], then I’ll use it with everyone, because I’ve seen that there’s added value in it” and “I want to give myself, like, 3, 4 minutes to look over [the TRAQ] before I begin the appointment. You know, so that I already have some content before I start.”

Characteristics of adolescent cancer survivors

Perceived patient-related facilitators to TRAQ implementation included survivors’ commitment level to preparing for transition and parental involvement in CCS transition readiness. Patients’ understanding of the issues at stake and desire to develop transition readiness skills appeared to promote the completion of the TRAQ, particularly in older survivors: “Usually, the older teenagers get, the more they understand what’s at stake, […] especially when we talk about the last appointment [in pediatric settings]. Then, they start to realize that things are about to change”. Additionally, using the TRAQ also enabled parents to know which tasks their children should be able to perform on their own before transfer and to offer them autonomy support during the transition process. A HCP stated that “Parents showed interest. […] They were also able to get into it, to self-assess […], to evaluate themselves too.”

Characteristics of the context

HCPs noted that useful technology was readily available, such as a list of eligible patients for TRAQ administration, facilitating its clinical use: “In terms of equipment, here, it’s not really a problem, because I think there was money for that.”

Objective 2: Describe clinical examples of adolescent cancer survivors transition readiness and goal setting

Transition Readiness

Adolescent cancer survivors reported highest transition readiness abilities on the subscales of Talking with Providers (M = 4.86; SD = .24) and Managing Daily Activities (M = 4.57; SD = .37). The lowest abilities were reported for the subscales of Managing Medications (M = 2.71; SD = .64), Tracking Health Issues (M = 2.21; SD = .96), and Appointment Keeping (M = 2.12; SD = .92).

Goal setting

In response to the goal-setting prompt, three themes emerged from survivors’ self-set goals: 1) goal type, 2) means of achieving goal, and 3) goal motivation.

Goal type

Although patients were not asked to set goals solely related to getting ready for transition, all respondents mentioned wanting to improve either broad or specific transition readiness skills related to the TRAQ. For instance, one patient (female, age 14) indicated that she “Would like to learn how to book appointments” as a personal goal, referring to the Appointment Keeping subscale of the TRAQ. Another patient (female, age 14) referred to a specific item on the TRAQ (item 17): “More involvement in daily tasks, such as meals.” Another component is related to the level of skill acquisition implied in the self-set goals, such as identifying skills that were either in need of development or emerging. For instance, a patient (male, age 14) reported wanting to “Start working to begin budgeting,” whereas another (female, age 14) identified “Continuing current learning: making non-medical appointments” as a personal goal, representing to-be-developed and emerging skills, respectively.

Means of achieving goal

When setting their personal goals, patients varied in the degree of practicality of the means they would use to achieve them. One patient (male, age 14) suggested the general means of “Sharing my desire to learn with my parents” to reach his goal, while another patient (female, age 16) provided more specific details to achieve hers with regards to making medical follow-up appointments: “Knowing the phone number, where, who to call.” A number of patients also indicated a specific timeframe to reach their goals (n=3), such as “Trying for the next year” (female, age 16).

Independence as goal motivation

Two patients set a personal goal related to completing tasks on their own (“by myself”) or being independent, referring to the motivation behind the achievement of their goals: “Going to the pharmacy by myself to get my medication” (male, age 14).

DISCUSSION

The initial research objective of this initiative was to explore associations between adolescent transition readiness and personal goals. However, difficulties with the introduction of the screening and goal setting application in the clinic shifted the focus to identifying barriers and facilitators of the nurse-led TRAQ implementation in a LTFU oncology clinic and describing clinical examples of readiness transition in adolescents.

Previous studies have identified barriers and facilitators to administering the TRAQ in pediatric healthcare settings (Clark et al., 2020; Faugno, 2016; Goetsch Weisman et al., 2020; Okumura et al., 2014; Pauley, 2022; Vainman et al., 2022; Velez, 2019; Whelan, 2020). However, none of the previous efforts involved implementation of the TRAQ with adolescent cancer survivors, nor followed determinant frameworks as a means to guide and document implementation barriers and facilitators (Nilsen, 2015). Nonetheless, several of our study findings are consistent with prior research with youths with chronic conditions, including HCPs’ lack of training with youth (Clark et al., 2020; Goetsch Weisman et al., 2020; Velez, 2019), survivors’ limited knowledge about transition (Okumura et al., 2014), and limited clinical staff (Pauley, 2022).

Amongst cancer survivors, a recent study identified several barriers with respect to LTFU care, including lack of time and low priority given to follow-up, supporting our study’s findings (Prasad & Goswami, 2021). The COVID-19 outbreak came with frequent cancellations of LTFU appointments and increased levels of distress, consistent with a recent finding that HCPs were worried for survivors’ risk of exposure, and faced restrictions for in-person clinic visits (van den Oever et al., 2022). In terms of facilitators, the properties of the TRAQ, experienced HCPs, and stakeholder support have also been noted (Clark et al., 2020; Faugno, 2016; Goetsch Weisman et al., 2020; Okumura et al., 2014; Pauley, 2022; Vainman et al., 2022; Velez, 2019; Whelan, 2020). The implementation strategies of formalizing a healthcare transition policy (Whelan, 2020) and improving HCPs’ training in transition readiness screening with youths have also been suggested previously (Velez, 2019).

This is the first study documenting TRAQ implementation barriers in pediatric oncology care, including characteristics related to the tool itself, language-based barriers, and frequent changes in HCPs’ work lives due to the pandemic. Additionally, facilitators to the implementation of the TRAQ were identified, including the tool’s perceived valuable contribution to providers’ clinical work, clinicians’ positive attitude toward the TRAQ, and useful material resources. Ideas to improve implementation have been identified, such as adapting HCPs’ working conditions and conducting a sample item with patients verbally. Understanding these barriers and facilitators may influence the systematic use and sustainability of TRAQ as an assessment and counseling tool in clinical practice (Whelan, 2020).

Although the patient sample size was small, the findings align with those of a larger study assessing transition readiness in youths with chronic conditions (Chapados et al., 2024). The patient participants reported having started Talking with providers and Managing daily activities, reflecting skills adolescents often have frequent opportunities to practice. In contrast, more complex transition readiness activities such as Managing Medications, Tracking Health Issues, and Appointment Keeping were on average not started, possibly because they are practiced less frequently and require greater effort to master. However, participants did indicate a desire to learn these skills.

With respect to survivors’ self-set goals, three themes emerged: 1) goal type, 2) means of achieving goals, and 3) goal motivation. Despite the nine broad categories for childhood cancer survivors’ self-identified goals outlined by Schwartz and Parisi (2013)’s model, adolescents in this study only set goals related to the health, interpersonal, and administrative categories and aligned with constructs referred to in the TRAQ (Wood et al., 2014). This result could be influenced by the priming effect of the TRAQ, implicitly encouraging patients to identify goals related to transition readiness (Segal & Cofer, 1960). Interestingly, the motivation of patients in this study differed from that of adolescent survivors in other research (Darabos et al., 2023; Schwartz & Parisi, 2013) with patients motivated by a desire for independence rather than a desire to fit in or feel in control. Together, these desires refer to the basic psychological needs for autonomy, competence, and relatedness, core aspects of the Self-Determination Theory (Ryan et al., 2019), and could inform intervention efforts in transition readiness.

LIMITATIONS

This research project has several limitations. The sample size of adolescents was small (n=7) and consisted mostly of 14-year-olds (n=6), limiting the generalizability of patients’ personal goals to older survivors. Furthermore, the research team assisted in administering the TRAQ to patients, as requested by the clinical staff to lighten their workload, supporting study findings that TRAQ use in the clinic was too burdensome. Finally, the study focused only on HCPs’ views of barriers and facilitators to TRAQ use and could be complemented with the insight of survivors and their parents.

IMPLICATIONS

The clinical application of transition readiness screening lacked a structured plan for implementing the TRAQ, limiting its administration to a small sample of survivors. To address this, a scientific approach to implementation planning is essential when integrating the TRAQ into a LTFU oncology clinic. Others have also found that implementation planning needs to align clinical workflow with integration of new care practices in pediatric oncology (Hamilton et al., 2024). Drawing on the barriers, facilitators, and strategies identified in this study, our research and clinical teams have collaboratively developed a new plan to ensure systematic TRAQ delivery in routine care, with input from clinicians, survivors, and parents guiding the process and informing solutions to emerging challenges. Future implementation efforts should consider adolescents’ developmental stages, as older adolescents tend to recognize the importance of transition preparation, while clinics must address time constraints by integrating the TRAQ into workflows and providing staff training. Additionally, actively involving parents to support youth autonomy and offering verbal guidance to overcome language barriers will improve engagement for patients with comprehension difficulties. Lessons from the COVID-19 pandemic further highlight the importance of virtual administration options and balancing transition planning with psychosocial assessments to meet both practical and emotional needs.

CONCLUSION

Overall, changing clinical practice to align with recommended standards of care is a complex endeavor that may face unanticipated barriers limiting application even when there is strong clinical desire to put new processes in place. Data collected from the small sample further supported the importance of screening for transition readiness in adolescent survivors of pediatric cancer. The rich qualitative data revealed barriers, facilitators, and strategies for TRAQ implementation, relating to the tool, HCPs, adolescents, and context. These results will support a structured and long-term implementation plan for TRAQ use in future clinical practice.

Supplementary Information

Figure S1

Patient Recruitment Flowchart from May 2022 to July 2022

Note. n = number of individuals; TRAQ-FR = Transition Readiness Assessment Questionnaire—French version.