An Interactive Smartphone App, Nenne Navi, for Improving Children's Sleep: Pilot Usability Study

Evaluating a Mobile App Supporting Evidence-Based Parenting Skills: Thematic Analysis of Parent Experience

Background

Disruptive behavior disorders are among the most common disorders of childhood, and evidence-based parenting programs are the first-line treatment. Digital microinterventions have been proposed as one possible means of supporting parenting style change by giving parents in-the-moment advice about how to respond to challenging behavior. Until now, no digital microintervention supporting evidence-based parenting skills programs has been evaluated.

Objective

The aim of this study is to evaluate the subjective experience of parents using a digital microintervention to support evidence-based parenting skills, with particular attention to acceptability, usability, family relationships, and parents' values.

Methods

We conducted serial interviews with 11 parents of 33 children before and after spending 3 weeks using an app including 3 digital microinterventions. Parents were recruited via local authorities in the Midlands region of the United Kingdom. Previous participation in a parenting program was an inclusion criterion. Interviews explored family composition; child behavior problems; and experience of using the mobile app, including barriers to use. Thematic analysis was conducted from a user-centered design perspective, and illustrative case vignettes were produced.

Results

Many parents used the app in ways that helped them rather than strictly following the instructions they were given. Parents described a range of barriers to using the app including practical problems and failure to change child behavior. Parents and children responded in a variety of ways to the use of the phone, with many wholeheartedly embracing the convenience of technology. Case vignettes illustrate the uniqueness of each family's experience.

Conclusions

Parents' use of a mobile app supporting evidence-based parenting skills is difficult to predict due to the unique challenges each family encounters. Many parents found it an acceptable and helpful addition to family life, but increased personalization is likely to be key to supporting parents. Future digital microintervention developers should keep in mind that parents are likely to use the app pragmatically rather than following instructions, may struggle to use a complex app under pressure, and are likely to hold complex feelings about parenting with an app.

Identifying and developing strategies for implementation of a guided internet- and mobile-based infant sleep intervention in well-baby and community mental health clinics using group concept mapping

BACKGROUND

This study aimed to identify strategies for the implementation of a guided internet- and mobile-based intervention (IMI) for infant sleep problems ("Sleep Well, Little Sweetheart") in well-baby and community mental health clinics.

STUDY DESIGN

We used group concept mapping, a two-phased mixed methods approach, conducted as a two-day workshop in each clinic. We recruited 20 participants from four clinics and collected sorting and rating data for implementation strategies based on the Expert Recommendations for Implementing Change taxonomy and brainstorming sessions. Data were analyzed using descriptive statistics, multidimensional scaling, and hierarchical cluster analysis to create cluster maps, laddergrams, and Go-Zone graphs. Participants were presented with the results and discussed and interpreted the findings at each of the clinics in spring 2022.

RESULTS

Participants identified 10 clusters of strategies, of which Training, Embedding and Coherence, User Involvement and Participation, and Clinician Support and Implementation Counseling were rated as most important and feasible. Economy and Funding and Interactive and Interdisciplinary Collaboration were rated significantly lower on importance and feasibility compared to many of the clusters (all ps < 0.05). There was a correlation between the importance and feasibility ratings (r =.62, p =.004).

CONCLUSIONS

The use of group concept mapping made it possible to efficiently examine well-baby and community clinics' perspectives on complex issues, and to acquire specific knowledge to allow for the planning and prioritization of strategies for implementation. These results suggest areas of priority for the implementation of IMIs related to infant sleep problems.

TRIAL REGISTRATION

The study was pre-registered at Open Science Framework ( www.osf.io/emct8 ).

"I Just Wanted a Dentist in My Phone"-Designing Evidence-Based mHealth Prototype to Improve Preschool Children's Oral and Dental Health: Multimethod Study of the Codevelopment of an App for Children's Teeth

BACKGROUND

Dental caries in preschool children is a global health concern. With increased access to technology and the disruption of health care during the pandemic, mobile health apps have been of interest as potential vehicles for individuals' health maintenance. However, little is known about caring for their child's teeth and what their preferences would be regarding the content or design of an oral health app.

OBJECTIVE

This study aims to co-design the prototype of an app named App for Children's Teeth with parents, providing a source of information for them about caring for their children's teeth and promoting positive dental habits.

METHODS

This multimethod study conducted user involvement research with a purposive sample of parents or carers of children aged ≤6 years to (1) understand their use of the internet through the eHealth Literacy Scale and interviews, (2) determine their opinions about content related to children's oral health, and (3) collect feedback about the app's acceptability using the Theoretical Framework of Acceptability. There were three stages: (1) interviews with parents to understand their needs, preferences, and abilities; (2) prototype design with app developers; and (3) parent feedback interviews using the think aloud method for data collection. Data were deductively analyzed using a codebook strategy, whereas data from the think aloud sessions were analyzed inductively using reflexive thematic analysis.

RESULTS

The prototype design stage involved 10 parents who reported using the internet for health information but found it to be scattered and contradictory. Parents generally welcomed the App for Children's Teeth but expressed concerns about screen time and practicality. They suggested guidance regarding oral hygiene practices, teething symptoms, and pain relief. Parents appreciated features such as clear fonts, categorization according to their child's age, and "In a Nutshell" bullet points. Topics that resonated with parents included information about teething, finding a dentist, and breastfeeding. They believed that the app aligned with their goals and offered suggestions for future developments, such as outlining the process of finding a dentist and incorporating a forum for parents to communicate and exchange ideas.

CONCLUSIONS

The coproduction design approach highlighted parents' need for solutions such as mobile health apps to access reliable information about oral health. Parents identified key design concepts for the app, including a simple and uncluttered interface, content categorization according to their child's age, and practical guidance supported by visual aids. Despite potential challenges related to screen time restrictions, parents provided insights into how such an app could fit seamlessly into their lives.

TRIAL REGISTRATION

Open Science Framework; https://osf.io/uj9az.

Improving the design of patient-generated health data visualizations: design considerations from a Fitbit sleep study

Interactive data visualization can be a viable way to discover patterns in patient-generated health data and enable health behavior changes. However, very few studies have investigated the design and usability of such data visualization. The present study aimed to (1) explore user experiences with sleep data visualizations in the Fitbit app, and (2) focus on end users' perspectives to identify areas of improvement and potential solutions. The study recruited eighteen pre-medicine college students, who wore Fitbit watches for a two-week sleep data collection period and participated in an exit semi-structured interview to share their experience. A focus group was conducted subsequently to ideate potential solutions. The qualitative analysis identified six pain points (PPs) from the interview data using affinity mapping. Four design solutions were proposed by the focus group to address these PPs and illustrated by a set of mock-ups. The study findings informed four design considerations: (1) usability, (2) transparency and explainability, (3) understandability and actionability, and (4) individualized benchmarking. Further research is needed to examine the design guidelines and best practices of sleep data visualization, to create well-designed visualizations for the general population that enables health behavior changes.

What daily factors affect the sleep habits of Japanese toddlers?

STUDY OBJECTIVES

Good sleep, especially during early childhood, is important for development. In Japan, the mean nocturnal sleep duration of toddlers is < 10 hours, and even if toddlers slept for > 11 hours/day, as recommended by the National Sleep Foundation, some of them showed late bedtime and late wake-up time or took long naps. Therefore, we provisionally assumed the minimal sleep conditions for Japanese toddlers, named Nenne-criteria, such as bedtime before 10:00 pm, nocturnal sleep duration of ≥ 9 hours, and < 1 average time of awakening after sleep onset, and investigated the important factors for good sleep.

METHODS

We analyzed cross-sectional data from online surveys describing the sleep-related behaviors of 2,124 toddlers and their caregivers. We compared the daily schedules that affect sleep between the Nenne-criteria-meet group and the not-meet group.

RESULTS

The Nenne-criteria-meet group showed better daytime behaviors than the not-meet group. Structural equation modeling on daily schedules revealed that, to increase sleep pressure at the appropriate time, it is important to restrict media viewing, play outdoors in the morning, have an early nap ending time, avoid hyperarousal-inducing behaviors before bedtime, maintain daily schedules regularly, and decrease social jetlag.

CONCLUSIONS

The Nenne-criteria are useful for screening Japanese toddlers who require intervention for sleep hygiene. To improve toddlers' sleep, it is important not only to guide the ideal bedtime but also to provide tips for improving daily schedules and to avoid suboptimal sleep-related behaviors.

CITATION

Murata E, Yoshizaki A, Fujisawa TX, Tachibana M, Taniike M, Mohri I. What daily factors affect the sleep habits of Japanese toddlers? J Clin Sleep Med. 2023;19(6):1089-1101.

Problems in the Development of the Sleep-Wake Rhythm Influence Neurodevelopmental Disorders in Children

Development of the sleep-wake rhythm has a significant effect on the physical and mental development of children. The sleep-wake rhythm is controlled by aminergic neurons in the brainstem's ascending reticular activating system, which is associated with synaptogenesis and the promotion of brain development. The sleep-wake rhythm develops rapidly within the first year after birth. At 3-4 months of age, the framework of the circadian rhythm is established. The objective of the present review is to assess a hypothesis concerning problems in the development of the sleep-wake rhythm and their effect on neurodevelopmental disorders. Autism spectrum disorder is characterised by a delay in the development of sleep rhythms at 3-4 months of age and also insomnia and night-time awakenings, as supported by several reports. Melatonin may shorten the sleep latency in ASD. Rett syndrome sufferers kept awake during the daytime were analysed by the Sleep-wake Rhythm Investigation Support System (SWRISS) (IAC, Inc., (Tokyo, Japan)), and the cause was found to be the dysfunction of aminergic neurons. Children and adolescents with attention deficit hyperactivity disorder show sleep problems such as resistance to bedtime, difficulty falling asleep, sleep apnoea, and restless legs syndrome. Sleep deprivation syndrome in schoolchildren is deeply influenced by Internet use, games, and smartphones, and this syndrome affects emotion, learning, concentration, and executive functioning. Sleep disorders in adults are strongly considered to affect not only the physiological/autonomic nervous system but also neurocognitive/psychiatric symptoms. Even adults cannot avoid serious problems, much less children, and the impact of sleep problems is considerably greater in adults. Paediatricians and nurses should be aware of the significance, from birth, of sleep development and sleep hygiene education for carers and parents. This research was reviewed and approved by the ethical committee of the Segawa Memorial Neurological Clinic for Children (No. SMNCC23-02).

Questionnaire survey on sleep habits of 3-year-old children in Asahikawa City: Comparison between 2005 and 2020

BACKGROUND

Good sleep is essential for children's healthy growth. In 2005, we conducted a questionnaire survey on children's sleep habits and their background, targeting parents who attended health checkups for their 3-year-old children in Asahikawa City, Hokkaido. In 2020, we performed a secondary survey, including additional questions regarding media usage. We analyzed changes in children's sleep environment by comparing the results of both surveys.

METHODS

Children from 500 families (n = 420; 219 males, 201 females; mean age, 3.6 years) who underwent 3.5-year-old health checkups (per the changed schedule in 2015) in Asahikawa City from July 2020 to November 2020 and their parents who had completely answered the questionnaire were included.

RESULTS

The proportion of children who used childcare support system such as nursery schools or kindergarten increased from 30% in the previous survey to 95% in the present survey. The mean nocturnal sleep duration of children was 9.33 h in the present survey, 0.77 h shorter than that in the previous survey; similar to the previous survey results, it was significantly short (8.71 h) in children who went to bed after 10 PM. Moreover, it was significantly short in children who watched television for more than two hours or used media within two hours before going to bed or if parents used smartphones or watched motion pictures for >30 min/day. The rate of consulting pediatricians regarding sleep problems decreased from 3% to 2.4%.

CONCLUSION

Parents' lifestyles greatly influenced children's sleep habits in 2020. Pediatricians should actively participate in managing children's sleep problems.

Improving Children's Sleep Habits Using an Interactive Smartphone App: Community-Based Intervention Study

BACKGROUND

Sleep problems are quite common among young children and are often a challenge for parents and a hinderance to children's development. Although behavioral therapy has proven effective in reducing sleep problems in children, a lack of access to professionals who can provide effective support is a major barrier for many caregivers. Therefore, pediatric sleep experts have begun developing apps and web-based services for caregivers. Despite the substantial influence of cultural and familial factors on children's sleep, little effort has gone into developing cultural or family-tailored interventions.

OBJECTIVE

This study aimed to examine the effectiveness of the interactive smartphone app "Nenne Navi," which provides culturally and family-tailored suggestions for improving sleep habits in young Japanese children through community-based long-term trials. The study also aimed to investigate the association between app-driven improvements in sleep and mental development in children.

METHODS

This study adopted a community-based approach to recruit individuals from the Higashi-Osaka city (Japan) who met ≥1 of the following eligibility criteria for sleep problems: sleeping after 10 PM, getting <9 hours of nighttime sleep, and experiencing frequent nighttime awakenings. A total of 87 Japanese caregivers with young children (mean 19.50, SD 0.70 months) were recruited and assigned to the app use group (intervention group) or the video-only group (control group). Both groups received educational video content regarding sleep health literacy. The caregivers in the intervention group used the app, which provides family-tailored suggestions, once per month for 1 year.

RESULTS

A total of 92% (33/36) of the caregivers in the app use group completed 1 year of the intervention. The participants' overall evaluation of the app was positive. The wake-up time was advanced (base mean 8:06 AM; post mean 7:48 AM; F_1,65=6.769; P=.01 and sleep onset latency was decreased (base mean 34.45 minutes; post mean 20.05 minutes; F_1,65=23.219; P<.001) significantly in the app use group at the 13th month compared with the video-only group. Moreover, multiple regression analysis showed that decreased social jetlag (β=-0.302; P=.03) and increased sleep onset latency SD (β=.426; P=.02) in children predicted a significant enhancement in the development of social relationships with adults. At 6 months after the completion of the app use, all the caregivers reported continuation of the new lifestyle.

CONCLUSIONS

The present findings suggest that the app "Nenne Navi" has high continuity in community use and can improve sleep habits in young Japanese children and that interventions for sleep habits of young children may lead to the enhancement of children's social development. Future studies must focus on the effectiveness of the app in other regions with different regional characteristics and neuroscientific investigations on how changes in sleep impact brain development.

mHealth interventions targeting movement behaviors in Asia: A scoping review

mHealth interventions can promote healthy movement behaviors (physical activity, sedentary behavior, and sleep). However, recent reviews include few studies from Asia, despite it being home to over 60% of the world population. The aim is to map the current evidence for mHealth interventions targeting movement behaviors in Asia. Six databases were searched up until August 2021. Included studies described an mHealth intervention targeting one or more movement behaviors, delivered in a country/territory in Asia, to a general population. A total of 3986 unique records were screened for eligibility in duplicate. Eighty studies with 1,413,652 participants were included. Most were randomized (38.8%) or quasi-experimental (27.5%) trials. Studies were from 17 countries/territories (out of 55); majority were high- (65.0%) or upper middle-income (28.7%). Physical activity was targeted most often (93.8%), few targeted sedentary behavior (7.5%), or sleep (8.8%). Most targeted one movement behavior (90.0%), and none targeted all three together. Interventions typically incorporated a single mHealth component (70.0%; app, pedometer, text messages, wearable) and were delivered remotely (66.3%). The average intervention length was 121.8 (SD 127.6) days. mHealth interventions in Asia have primarily targeted physical activity in high- and upper middle-income countries. There are few interventions targeting sedentary behavior or sleep, and no interventions in low-income countries.

Sleep and the General Behavior of Infants and Parents during the Closure of Schools as a Result of the COVID-19 Pandemic: Comparison with 2019 Data

This study compared cross-sectional data from online surveys describing the sleep behavior of infants and caregivers in March 2020 (the school closure period during the early stages of the COVID-19 pandemic; n = 295, 23.8 ± 3.8 months old) and March 2019 (before the pandemic; n = 2017, 24.2 ± 3.8 months old). In comparing those two points in time, no significant differences were found in wake-up times (2019: 7:19 ± 0:46 am vs. 2020: 7:18 ± 0:47 am, p = 0.289), bedtimes (21:01 ± 0:48 pm vs. 21:04 ± 0:53 pm, p = 0.144), or nocturnal sleep times (593.7 ± 43.9 min vs. 588.1 ± 50.3 min, p = 0.613). Regarding the caregivers, in 2020, wake-up times (2019: 6:46 ± 0:50 am vs. 2020: 6:39 ± 0:50 am, p = 0.017) and bedtimes (22:53 ± 1:17 pm vs. 22:42 ± 1:04 pm, p = 0.016) became significantly earlier compared to 2019. Among infants staying at home, total sleep time and percentage of outdoor play decreased significantly, and media use increased significantly in 2020. Lower levels of exercise and more frequent media viewing may have caused prolonged sleep latency in these children. The percentage of caregivers responding with "negative childcare feelings" was significantly higher in the group with less than three nursery school attendance days. Caregivers and infants staying at home are a high-risk group during the pandemic.