Enhancing equitable engagement for digital health promotion: Lessons from evaluating a childrearing app in Indonesia.

Part of the appeal of digital health interventions, including mHealth, is the potential for greater reach in places where conventional health promotion is hampered by geographical, financial or social barriers. Yet, 'engagement' - typically understood as user experience and interactions with technology - remains a persistent challenge, particularly in places where technology access or familiarity with technology is limited. We undertook an evaluation of a childrearing app to promote socioemotional and cognitive development in early childhood across the world. In this article, we present findings from qualitative research on app rollout in Indonesia, the first of numerous low- and middle-income countries targeted by the app. We draw on systems theory and complexity thinking to broaden the lens of 'engagement' beyond individual users to encompass collective systems (families and communities), exploring how the intervention was harnessed to meet local contextual needs. The qualitative research involved semi-structured interviews, workshops and audio diaries with 57 diverse stakeholders, including Indonesian parents, caregivers, and collaborators involved in funding, development, and dissemination of the app. We observed the importance of social connection, sense-making, and interactive learning for enhancing engagement with the app and its messages. Enthusiastic users, strongly linked across community networks (e.g. kindergarten teachers), improvised dissemination strategies to facilitate uptake. Interactive learning that tapped into familiar social structures (e.g. intergenerational hierarchies) was crucial for engagement. Understanding ways the app failed to tap into structures of social connection served to highlight the need to embed strategies to support collective engagement.

Developing Culturally Appropriate Content for a Child-Rearing App to Support Young Children's Socioemotional and Cognitive Development in Afghanistan: Co-Design Study.

BACKGROUND: Optimal child-rearing practices can help mitigate the consequences of detrimental social determinants of health in early childhood. Given the ubiquity of personal digital technologies worldwide, the direct delivery of evidence-based information about early childhood development holds great promise. However, to make the content of these novel systems effective, it is crucial to incorporate place-based cultural beliefs, traditions, circumstances, and value systems of end users. OBJECTIVE: This paper describes the iterative approach used to develop the Thrive by Five child-rearing app in collaboration with Afghan parents, caregivers (eg, grandparents, aunts, and nannies), and subject matter experts (SMEs). We outline how co-design methodologies informed the development and cultural contextualization of content to meet the specific needs of Afghan parents and the content was tested and refined in collaboration with key Afghan stakeholders. METHODS: The preliminary content was developed based on a comprehensive literature review of the historical and sociocultural contexts in Afghanistan, including factors that influence child-rearing practices and early childhood development. After an initial review and refinement based on feedback from SMEs, this content was populated into a beta app for testing. Overall, 8 co-design workshops were conducted in July and August 2021 and February 2022 with 39 Afghan parents and caregivers and 6 SMEs to collect their feedback on the app and its content. The workshops were audio recorded and transcribed; detailed field notes were taken by 2 scribes. A theoretical thematic analysis using semantic codes was conducted to inform the refinement of existing content and development of new content to fulfill the needs identified by participants. RESULTS: The following 4 primary themes were identified: child-rearing in the Afghan sociocultural context, safety concerns, emotion and behavior management, and physical health and nutrition. Overall, participants agreed that the app had the potential to deliver valuable information to Afghan parents; however, owing to the volatility in the country, participants recommended including more activities that could be safely done indoors, as mothers and children are required to spend most of their time at home. Additionally, restrictions on public engagement in music required the removal of activities referencing singing that might be performed outside the home. Further, activities to help parents reduce their children's screen time, promote empathy, manage emotions, regulate behavior, and improve physical health and nutrition were requested. CONCLUSIONS: Direct engagement with Afghan parents, caregivers, and SMEs through co-design workshops enabled the development and refinement of evidence-based, localized, and contextually relevant child-rearing activities promoting healthy social, emotional, and cognitive development during the first 5 years of children's lives. Importantly, the content was adapted for the ongoing conflict in Afghanistan with the aim of empowering Afghan parents and caregivers to support their children's developmental potential despite the security concerns and situational stressors.

Parenting app to support socio-emotional and cognitive development in early childhood: iterative codesign learnings from nine low-income and middle-income countries.

OBJECTIVE: Many children in low-income and middle-income countries are disadvantaged in achieving early developmental potential in childhood as they lack the necessary support from their surroundings, including from parents and caregivers. Digital technologies, such as smartphone apps, coupled with iterative codesign to engage end-users in the technology-delivered content development stages, can help overcome gaps in early child development (ECD). We describe the iterative codesign and quality improvement process that informs the development of content for the Thrive by Five International Program, localised for nine countries in Asia and Africa. DESIGN: Between 2021 and 2022, an average of six codesign workshops in each country were conducted in Afghanistan, Indonesia, Kyrgyzstan, Uzbekistan, Cameroon, the Democratic Republic of the Congo, Ethiopia, Kenya and Namibia.ParticipantsA total of 174 parents and caregivers and 58 in-country subject matter experts participated and provided feedback to refine and inform the cultural appropriateness of the Thrive by Five app and its content. Detailed notes from the workshops and written feedback were coded and analysed using established thematic techniques. RESULTS: Four themes emerged from the codesign workshops: local realities, barriers to positive parenting, child development and lessons learnt about the cultural context. These themes, as well as various subthemes, informed content development and refinement. For example, childrearing activities were requested and developed to promote inclusion of families from diverse backgrounds, encourage best parenting practices, increase engagement of fathers in ECD, address parents' mental well-being, educate children about cultural values and help bereaved children with grief and loss. Also, content that did not align with the laws or culture of any country were removed. CONCLUSIONS: The iterative codesign process informed the development of a culturally relevant app for parents and caregivers of children in the early years. Further evaluation is required to assess user experience and impact in real world settings.

The Relationship between Mindfulness and Readiness to Change in Alcohol Drinkers.

Mindfulness is a multi-faceted construct that involves paying attention to thoughts and emotions without automatically reacting and being critical of them. Recent research has suggested that mindfulness might play an important role in reducing problematic alcohol use. Further, Readiness to Change (RTC) is related to motivation to change drinking behaviours. The RTC scale identifies motivation to change drinking behaviours including Precontemplation, Contemplation, and Action stages. The current study investigated, for the first time, the relationship between mindfulness (and its facets) and RTC in relation to drinking behaviours. Undergraduate students from Western Sydney University (N = 279) were screened for drinking levels using the Alcohol Use Disorder Identification Test (AUDIT) and then completed the Readiness to Change Questionnaire (RCT) and the Five Facets Mindfulness Questionnaire (FFMQ), which includes the following facets: Acting with Awareness, Non-Judging of Inner Experience, Non-Reactivity to Inner Experience, Describing, and Observing. Results show that overall, mindfulness and its facets negatively correlated with RTC. Multiple regression analysis further showed that Awareness and Non-Judgement facets negatively predicted RTC. These findings provide insight into how the facets of mindfulness interact with the drinking motives of individuals and their intentions to change drinking behaviours. Based on these findings, we recommend the incorporation of mindfulness techniques in interventions targeting problematic drinking.

Developing a Parenting App to Support Young Children's Socioemotional and Cognitive Development in Culturally Diverse Low- and Middle-Income Countries: Protocol for a Co-design Study.

BACKGROUND: Digital technologies are widely recognized for their equalizing effect, improving access to affordable health care regardless of gender, ethnicity, socioeconomic status, or geographic region. The Thrive by Five app is designed to promote positive interactions between children and their parents, extended family, and trusted members of the community to support socioemotional and cognitive development in the first 5 years of life and to strengthen connections to culture and community. OBJECTIVE: This paper aims to describe the iterative co-design process that underpins the development and refinement of Thrive by Five's features, functions, and content. Minderoo Foundation commissioned this work as a quality improvement activity to support an engaging user experience and inform the development of culturally appropriate and relevant content for parents and caregivers in each country where the app is implemented. METHODS: The app content, referred to as Collective Actions, comprises "The Why," that presents scientific principles that underpin socioemotional and cognitive development in early childhood. The scientific information is coupled with childrearing activities for parents, extended family, and members of the community to engage in with the children to support their healthy development and to promote positive connections between parents, families, and communities and these young children. Importantly, the initial content is designed and iteratively refined in collaboration with a subject matter expert group from each country (ie, alpha testing). This content is then configured into the app (either a beta version or localized version) for testing (ie, beta testing) by local parents and caregivers as well as experts who are invited to provide their feedback and suggestions for improvements in app content, features, and functions via a brief web-based survey and a series of co-design workshops. The quantitative survey data will be analyzed using descriptive statistics, whereas the analysis of qualitative data from the workshops will follow established thematic techniques. RESULTS: To date, the co-design protocol has been completed with subject matter experts, parents, and caregivers from 9 countries, with the first results expected to be published by early 2023. The protocol will be implemented serially in the remaining 21 countries. CONCLUSIONS: Mobile technologies are the primary means of internet connection in many countries worldwide, which underscores the potential for mobile health programs to improve access to valuable, evidence-based, and previously unavailable parenting information. However, for maximum impact, it is critically important to ensure that mobile health programs are designed in collaboration with the target audience to support the alignment of content with parents' cultural values and traditions and its relevance to their needs and circumstances. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/39225.