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With the growing popularity of mobile health technology, app-based interventions delivered by smartphone have become an increasingly important strategy toward injury prevention.
This study aimed to develop a framework supporting the design of an app-based intervention to prevent unintentional injury, targeted for caregivers of Chinese children aged 0 to 6 years.
A theory-based mixed-method study, including focus groups and Web-based quantitative survey, was performed. Adult caregivers who care for children aged 0 to 6 years and own a smartphone were recruited into 2 sequential stages of research. First, focus groups were conducted among the caregivers at community health care centers and preschools from December 2015 to March 2016. Focus groups (8-10 participants per group) explored awareness, experiences, and opinions of caregivers toward using an app to prevent unintentional injury among children. Second, based on the focus groups findings, a Web-based quantitative survey was designed and distributed to caregivers in November 2016; it collected information on specific needs for the app-based intervention. Thematic analysis and quantitative descriptive analyses were performed.
In total, 12 focus groups were completed, involving 108 caregivers. Most participants expressed a strong desire to learn knowledge and skills about unintentional child injury prevention and held positive attitudes toward app-based interventions. Participants expressed multiple preferences concerning the app-based intervention, including their contents, functions, interactive styles, installation and registration logistics, and privacy protection and information security. Following the focus groups, 1505 caregivers completed a WeChat-based quantitative survey, which generated roughly similar results to those of focus groups and added numerical metrics concerning participants’ preferences on what to learn, when to learn it, and how to learn it. A detailed framework was established involving 5 components: (1) content design, (2) functional design, (3) interactive style, (4) installation and registration logistics, and (5) privacy protection and information security, and 15 specific requirements.
We developed a framework that can be used as a guide to design app-based interventions for parents and caregivers, specifically for unintentional injury prevention of children aged 0 to 6 years.
Unintentional injury is a serious public health problem among children aged 0 to 6 years in China. In 2017, over 20,000 Chinese children younger than 5 years died of unintentional injury, and nearly 2.4 million children required emergency or outpatient care because of unintentional injury [
Parenting interventions can substantially reduce child unintentional injury risk by improving caregivers’ safety knowledge and perceptions about the risk for injury to their children and through adoption of safety equipment and practices [
Encouragingly, the mobile health (mHealth) movement to deliver health interventions through technology has potential to overcome this barrier to parent education for child injury prevention. The number of smartphone users in China has grown quickly over the past decade, with recent estimates suggesting that about 403 million adults aged 20 to 39 years (95% of the Chinese population in that age group) accessed the internet through mobile phones in December 2017 [
Recently, app-based interventions have been developed to prevent or reduce unintentional injury risk in specific injury domains, including sports injuries [
Multiple health behavior change theories can be used in the development of an app to reduce injuries. The Theory of Planned Behavior (TPB) offers a social psychological theory that fits nicely, as it is used to interpret and predict why individuals perform specific behaviors [
Computer science theories are also critical to the development of an app-based intervention. The Framework for the Rational Analysis of Mobile Education (FRAME) model offers a theoretical grounding in computer science to guide the development of mHealth learning programs. The FRAME model considers 3 aspects of mobile learning: usability of the device and app, capacities of the learners, and social interaction between users. Regarded as a comprehensive model to develop and implement mobile learning, attention to the components of the FRAME model allows app development to proceed with attention to all relevant components of user learning [
We, therefore, conducted a mixed-method study to establish a theory- and need-based framework that would support and lead to the design of an app-based intervention for child injury prevention to be used by Chinese caregivers of children aged 0 to 6 years. All assessment protocols were grounded in TPB and the FRAME model and were designed to gather information that would be valuable for the design of app-based health interventions focused on improving parenting among Chinese caregivers to reduce child injury risk.
Grounded in TPB and the FRAME model [
To gather qualitative data first, focus groups were conducted to explore the experiences and preferences of adult caregivers on using an app-based intervention to prevent unintentional injury among children younger than 7 years. Next, focus group findings were used to guide development and implementation of a Web-based survey to quantify key needs for the app-based interventions (eg, frequency and length of content, variety and types of forms of learning, and duration of app-based learning).
Participants were recruited for focus groups using purposive sampling. Eligible participants included primary caregivers of 1 or more children younger than 7 years and who used a smartphone regularly. No exclusion criteria applied beyond the age of children that caregivers looked after.
Caregivers of children aged 0 to 3 years were recruited primarily from community health centers. Caregivers of children aged 4 to 6 years were recruited from preschools. To maximize sampling variation, we sampled from a range of preschool types (including both public and private) and geographic locations (including varied socioeconomic status and living areas). Focus group members represented both sexes and a range of household incomes, ages, and levels of education.
Focus groups were completed between December 2015 and March 2016 in Changsha, China. A semistructured discussion guide was developed and refined through pilot testing first among the research group and then with an independent focus group of caregivers of children aged 0 to 3 years (
Broadly, discussions were organized to concentrate on perceptions and opinions about unintentional child injury prevention and app-based injury interventions as well as on issues of designing app-based intervention (eg, content, function, interfaces, and data security). To support discussion about intervention interfaces, the facilitators prepared a series of slides that illustrated different styles of interface designs.
When each focus group discussion concluded, participants completed short paper-based questionnaires that collected information on sociodemographic characteristics for both caregivers and their children and unintentional injury history for their children.
Following scholarly recommendations to organize focus groups [
Focus group audiotapes were transcribed verbatim and checked for accuracy. All participant names were removed to permit anonymized analysis. The transcripts were then analyzed using thematic analysis strategies [
Study participants for the Web-based survey component of the study were recruited through snowball sampling. Inclusion criterion matched those of the focus groups: caregivers of children younger than 7 years who owned a smartphone. No exclusion criteria applied beyond the age of children that caregivers looked after.
To maximize reach to the target population, we used WeChat, the most popular social media communication platform in China, with an average of 889 million active users each month [
The Web-based survey was completed in November 2016. It was developed based on the results of the focus groups, grounded in TPB and especially the FRAME model, and finalized through pilot testing with 20 caregivers. The survey included items assessing demographic characteristics, history of child unintentional injury, prior learning experiences about child unintentional injury prevention, and preferred learning contents (
The collected questionnaires were screened to exclude those completed by caregivers who did not meet the inclusion criteria. Proportions were then calculated to describe preferred contents of the app-based intervention, forms of app-based learning, preferred learning time, and frequency and duration for using app-based learning. Chi-square test examined group differences across groups. Data analysis was performed using the Statistical Product and Service Solutions (SPSS 18.0; IBM Corporation).
The protocol was approved by the ethics committee of the Institute of Clinical Pharmacology of Central South University. This study was conducted, analyzed, and reported according to the consolidated criteria for reporting qualitative research (COREQ) [
In total, 12 focus groups were organized; together they included 108 caregivers (90 parents, 6 grandparents, and 12 preschool teachers;
Most caregivers reported a strong desire to learn unintentional injury prevention strategies for children aged 0 to 6 years. Many participants mentioned that they felt unintentional injuries were largely preventable and that they had a strong intention to learn knowledge and skills that would help them prevent unintentional injuries to children under their care. A typical opinion was as follows:
We definitely want to learn it[knowledge about unintentional injury prevention for children ages 0-6 years]. From my point of view, it would be very useful and valuable for us [to learn that information].
Demographic characteristics of caregiver participants.
Variable | Focus group participants, n (%) | Web-based survey participants, n (%) | |||
Total | 108 (100.0) | 1505 (100.00) | |||
Male | 12 (11.1) | 687 (45.65) | |||
Female | 96 (88.9) | 818 (54.35) | |||
≤19 | 2 (1.9) | 33 (2.19) | |||
20-29 | 48 (44.4) | 805 (53.49) | |||
30-39 | 46 (42.6) | 604 (40.13) | |||
40-49 | 8 (7.4) | 62 (4.12) | |||
≥50 | 4 (3.7) | 1 (0.07) | |||
Parent | 90 (83.3) | —a | |||
Grandparent | 6 (5.6) | —a | |||
Preschool teacher | 12 (11.1) | —a | |||
Male | 49 (51) | 859 (57.08) | |||
Female | 47 (49) | 646 (42.92) | |||
≤1 | 34 (35) | 205 (13.62) | |||
2-3 | 27 (28) | 602 (40.00) | |||
4-6 | 35 (37) | 698 (46.38) |
aInformation was not collected.
bChildren of the participant supervisors (90 parents and 6 grandparents) in the focus groups, excluding participants who were preschool teachers.
Beyond wanting to learn knowledge about child injury prevention, the majority of focus group participants expressed the opinion that they could use a smartphone app to learn that knowledge. The participants believed that an app developed by a professional team to address child injury prevention would be credible and could be created to include sufficient content for their learning. They also expressed the opinion that an app may be a more convenient educational method than alternatives, such as written brochures or social networks like WeChat, to search for injury prevention content when they wanted it:
Compared to other options, an app-based intervention developed by a professional team would provide rich content. Thus, it will be convenient to search for the knowledge we need. For example, knowledge we can obtain in WeChat is hard to retrieve when we need it again.
A few participants expressed some concerns about the utility of a child injury prevention app. They worried about the possible difficulty in the installation and registration process and the possibility that it would use too much memory space on their smartphones, but they said they would accept the app if these problems were addressed.
Participants mentioned with some frequency 10 major causes of child unintentional injury that would be worth including in the app: exposure to animate mechanical forces (including animal bites and being trampled or bumped by other people); exposure to inanimate mechanical forces (including being pinched between 2 surfaces, such as in the doors of elevators, or cut or punctured by sharp objects); falls; contact with heat and hot substances; exposure to smoke, fire, and flames; transport crashes; unintentional threats to breathing that create suffocation risk; unintentional poisoning by and exposure to noxious substances; unintentional drowning and submersion; and exposure to electrical currents. Example statements appear below:
I really worry about injury from falls because children always like jumping from high places to lower places, which highly increases the risk of getting injured. In addition, road crashes are another important injury that I want to learn about, because many children run across or play in the street even when they see a car nearby.
Falls and burns are common types of unintentional injury for children ages 0-6 years at home. Relatively speaking, their harm to children is not as great as other types, such as electricalcurrents, which is one of the most dangerous injury causes for children.
Participants also recommended 3 facets of content design that could potentially increase the use of app-based intervention by caregivers: (1) providing professional and believable content to gain the trust of app users, (2) using plain language to make the contents easy to learn, and (3) providing easy-to-implement interventions to improve the practicability of applying lessons from the app-based intervention.
Several forms of learning from an app were proposed by the participants. Most frequently mentioned were short written alarms or warnings with pictures, cartoon vignettes, video testimonials, and interactive games. The participants believed these 4 forms would make learning easier and more engaging. Participants also mentioned the desire to learn the knowledge interactively with their children, a strategy they felt might maximize the effectiveness of the injury prevention program:
Pictures and video are easy to understand for both adults and children and might be the best way to disseminate the prevention knowledge. I also think both caregivers and children need to learn unintentional injury prevention. The easier the learning form, the better the learning outcome. In addition, it is better to include short warning words in the pictures to more effectively stop the children from adopting dangerous behaviors.
There was some variation across caregivers, but the general consensus was that they preferred the opportunity to use the app twice a week, for between 2 to 5 min at each session. As an example, a participant made the following statement:
The duration of the app-based learning should not be too long. I think “no more than 5 minutes” is fine for me because over five minutes learning would make me dizzy.
Participants also recommended evening as the best time of the day to interact with the app:
For me, it is particularly suitable to learn injury prevention knowledge at 8 or 9 o'clock in the evening. At that time, I have finished housework and my child hasfallen asleep.
Some participants felt the length of time they used the app would depend greatly on how much they enjoyed using it and that tangible cases and visual attraction would improve the authority and authenticity of the training, increasing their desire to use the app.
Almost all focus group participants mentioned interactive features as an indispensable function of the app-based intervention. They explained that interactive portions would maintain the attention of app users and increase the effectiveness of the intervention. Web-based chats, forums, and message boards were suggested as ways to implement interactive processes:
Web-based chatting is the best way to solve the problems that we encounter in our lives.
As we know, our kids may encounter various unintentional injuries in daily life. If the app intervention can set up a module listing possible ways to prevent common injury causes, it would be great. In addition, it would be attractive to me if the app had a forum in which I could discuss these topics with other caregivers who confront the same questions.
In addition, a customer service agent who was accessible through Web-based chatting and a frequently asked questions module was suggested by the caregivers participating in the focus groups.
Beyond interactive portions of the app, most caregivers in the focus groups felt that a survey with feedback would be an important function of the app-based intervention. Such a component would allow app users to be aware of children’s unintentional injury risk in their homes and to obtain tailored professional recommendations to prevent injuries to their children. Both Web-based and printed questionnaire surveys were recommended as appropriate approaches to obtain feedback from professionals.
In addition, some participants suggested surveys and feedback should be scheduled to be brief (eg, 5 min to complete each survey) and to be repeated regularly (eg, 3-4 times per year). Parents felt their responses might change as children develop new skills with older age, and therefore, tailored information that coincides with their children’s development would be valuable. Participants recommended that questionnaires be based on items with categorical response options (eg, true or false) that could be responded to quickly. A few caregivers suggested providing survey participants with small gifts or bonuses to maintain their adherence to the intervention. Furthermore, to increase compliance in completing Web-based surveys, participants suggested the use of short message service text message reminders:
I’d like to use Web-based questionnaires to send feedback. I think survey questions with single options are much better than open-ended survey questions because I really do not know what should be filled in in many cases.
Both Web-based and printed questionnaire surveys are acceptable for me, but a Web-based questionnaire survey is preferred since it is more convenient and takes less time than a printed questionnaire survey. I probably would agree to complete a paper questionnaire survey if I received small gifts after I completed it.
Some caregivers extended the survey idea further, suggesting that it would be valuable to have the app customized to their preferences and priorities in terms of content, form, frequency, and interface of the app. As an example, preventive content concerning riding a bicycle may not be of interest or relevant to caregivers whose children are younger than 3 years, as most Chinese children do not learn to ride bicycles until they are at least 4 years old. Thus, parents suggested the app be tailored so that such segments would be omitted in their version of the program.
Participants stated that they would like to choose the app interface (eg, color and style) based on their preferences. During the group discussion, the moderator demonstrated various interfaces, including the layout of 3 existing apps, to obtain participants’ opinions on the app design. Of the 3 options offered by the research team, most caregivers chose a cartoon style. A few caregivers preferred a simple interface with 3 replaceable pages, and fewer still selected a simple interface with only 1 page.
Caregivers strongly suggested the app should take up only a small amount of memory space on their smartphone and that it should require a simple registration procedure. They believed a user manual or help module might assist them with app use, and they requested an informational module that described the purpose, details, and benefits of the project before starting to use the app-based intervention.
Many caregivers expressed privacy and security concerns about using the app, especially if they were requested to provide sensitive information about their children (eg, home address and activities and locations where children engage in those activities). They did state that they would trust apps downloaded from officially certified app shops or promoted by official agencies such as preschools.
In total, 1505 valid questionnaires were collected through the Web-based survey, including 687 from men (45.65%) and 818 from women (54.35%). The respondents supervised 807 children aged 0 to 3 years (53.62%) and 698 children aged 4 to 6 years (45.97%). The proportion of male to female children supervised was 1.33 (
Of the 1505 participants who completed the Web-based survey, 1313 (87.24%) expected the app would teach them relevant knowledge concerning unintentional injury prevention for children aged 0 to 6 years. Participants felt it would be valuable to learn knowledge about preventing the 10 major causes of child unintentional injury at different rates: contact with heat and hot substances (534/1313, 40.67% felt it would be valuable to learn); inanimate mechanical forces (including being pinched between 2 surfaces, such as in the doors of elevators, or cut or punctured by sharp objects; 520/1313, 39.60%); falls (449/1313, 34.20%); transport crashes (362/1313, 27.57%); unintentional threats to breathing (361/1313, 27.49%); exposure to animate mechanical forces (317/1313, 24.14%);exposure to smoke, fire, and flames (210/1313, 15.99%); unintentional poisoning by and exposure to noxious substances (146/1313, 11.12%); unintentional drowning and submersion (113/1313, 8.61%); and exposure to electrical currents (108/1313, 8.23%). The differences were statistically significant (χ29=989.7;
Number of participants who expressed a desire to learn knowledge about preventing major types of child unintentional injury causes.
Cause of injury | n (%) |
Contact with heat and hot substances | 534 (40.67) |
Exposure to inanimate mechanical forces | 520 (39.60) |
Falls | 449 (34.20) |
Transport crashes | 362 (27.57) |
Unintentional threats to breathing | 361 (27.49) |
Exposure to animate mechanical forces | 317 (24.14) |
Exposure to smoke, fire, and flames | 210 (15.99) |
Unintentional poisoning by and exposure to noxious substances | 146 (11.12) |
Unintentional drowning and submersion | 113 (8.61) |
Exposure to electrical currents | 108 (8.23) |
The 5 most frequent learning forms that participants stated they would like to use were as follows: (1) short written alarms or warnings with pictures, (2) video testimonials, (3) cartoon vignettes, (4) pictures, and (5) interactive games, which were, respectively, preferred by 62.30% (818/1313), 54.53% (716/1313), 40.67% (534/1313), 38.31% (503/1313), and 28.03% (368/1313) of respondents (note that respondents were permitted to select multiple preferred learning forms). Differences were significant (
Caregivers varied in their preferred frequency for using an app to learn about unintentional child injury prevention. Just over half the sample (705/1313, 53.69%) preferred to use the app twice a week, followed by once a week (337/1313, 25.67%) and once a day (215/1313, 16.37%). Differences were significant (
On the basis of responses from the focus groups and the Web-based survey, as well as the 3 principles of TPB (attitudes toward the behavior, subjective norms, and perceived behavioral control) and the 3 aspects of the FRAME model (learner, devices, and social aspects), we developed a framework to guide design of an app to teach caregivers knowledge about preventing child unintentional injury. The design included 5 primary components: (1) content design, (2) functional design, (3) interface design, (4) installation and registration, and (5) privacy and data security, plus 15 subcomponents. Details, including the theoretical basis for each recommendation of the participants, appear in
Framework for developing an app to teach knowledge about preventing child unintentional injury to Chinese caregivers of children aged 0 to 6 years.
Requirements | Description | Theoretical basis | ||
Content | Ten major unintentional injury causes: contact with heat and hot substances; inanimate mechanical forces; falls; transport crashes; unintentional threats to breathing; animate mechanical forces; exposure to smoke, fire, and flames; unintentional poisoning by and exposure to noxious substances; unintentional drowning and submersion; and exposure to electrical currents, with the suggested proportions for knowledge disseminations of these 10 injury causes at the suggested proportions of 5:5:4:4:4:3:2:1:1:1 | Learner aspect (FRAMEa model) | ||
Tied to theory-based goals to improve attitudes, alter subjective norms, and increased perceived control to perform child unintentional injury prevention behaviors | Attitudes, subjective norms, and perceived control (TPBb) | |||
Form | Short written alarms or warnings with pictures, cartoon vignettes, video testimonials, and interactive games, with the suggested proportions of 2:2:1:1 across the 4 forms | Learner aspects (FRAME model) | ||
Time | Preferred time to learn (evening, afternoon, or noon) | Learner aspects (FRAME model) | ||
Frequency | Twice a week | Learner aspects (FRAME model) | ||
Duration | No more than 5 min per time | Learner aspects (FRAME model) | ||
Other attributes | Professionally disseminated contents | Learner aspects (FRAME model) | ||
Using plain language | Learner aspects (FRAME model) | |||
Easy to implement | Learner aspects (FRAME model) | |||
Interactive style | Regular communication between users and experts through online chat, forums, and message boards; frequently asked questions module; and Web-based customer service agents and ask-and-answer service | Social aspects (FRAME model); attitude and subjective norms (TPB) | ||
Survey and feedback | Use Web-based and printed questionnaires and short message service text message reminders for surveys and to collect feedback, no more than once every 2 months | —c | ||
After each survey, motivate users through virtual rewards | — | |||
Personalized customization | Allow personalized customization of contents, forms, frequency, and interface of app intervention | Learner aspect (FRAME model) | ||
Interface design | Offer several choices of app interfaces: cartoon interface preferred for default | Device aspect (FRAME model) | ||
Registration | Simple app registration procedure | Device aspect (FRAME model) | ||
Memory space | Minimize the size of app so smartphone storage is not used excessively | Device aspect (FRAME model) | ||
Informed background | Provide informational background to users’ informed consent process, so they understand before downloading and using the app intervention | Device aspect (FRAME model) | ||
Manual and help module | Provide a user manual and help module | Device aspect (FRAME model) | ||
Personal privacy and data security | Do not collect sensitive individual or family information such as name, home address, or family income | Device aspect (FRAME model) | ||
Ensure safe sharing and storage of data, for example, by using an individualized password | Device aspect (FRAME model) |
aFRAME: Framework for the Rational Analysis of Mobile Education.
bTPB: Theory of Planned Behavior.
cNot applicable.
Using a mixed-method study, we explored the preferences of caregivers of Chinese children aged 0 to 6 years for an app offering knowledge about child unintentional injury prevention. Study results helped us establish a framework for the app that includes 5 primary components (content design, functional design, interface design, installation and registration, and privacy and security) and 15 subcomponents focused on educating Chinese caregivers on child unintentional injury prevention strategies. The framework in
In addition to replicating previous work underlying the urgency to implement unintentional injury prevention education strategies for caregivers of young children in China [
Our findings agree to a large extent with previous work in the design of app interventions, as we uncovered user preferences to emphasize a user-centered design [
This study has important implications. First, the research will lead to the development of an app designed to help caregivers learn how to reduce injury risk among their children. Although mobile device interventions are most effective when they are based upon theory [
Our study has 2 strengths. First, we adopted a mixed-method design with large sample sizes. We conducted a rigorous mixed-method study and analyzed data and reported results in accordance with COREQ [
Second, we implemented rigorous science to develop the focus group guides and the questionnaire for the Web-based survey. Methodological strategies included 2-round discussions within the research member group and pilot tests to improve the experimental stimuli and ensure they were grounded in theory and constructed to yield the information we desired.
Our results also extend fragmented recommendations from previous publications [
This study has several limitations. First, focus groups were conducted using standard procedures and moderated by skilled individuals, but like all focus groups, the conversation was susceptible to bias and to swaying of individual opinions by dominant participants [
A theory-driven and evidence-based framework was established to guide the design of an app-based unintentional injury intervention program for the caregivers of Chinese children aged 0 to 6 years.
Procedure and discussion guide for focus groups.
Web-based survey questionnaire.
Data reporting guidelines, checklist for reporting results of internet E-Surveys (CHERRIES).
checklist for reporting results of internet E-survey
consolidated criteria for reporting qualitative research
Framework for the Rational Analysis of Mobile Education
mobile health
Theory of Planned Behavior
This work was funded by the National Natural Science Foundation of China (No. 81573260). The funding body had no role in the design, collection, analysis, or interpretation of this study.
GH and PN contributed to the design of the study. PN performed the data analysis. PN, DG, and GH drafted the manuscript. All authors finalized and approved the final version of the manuscript.
None declared.