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Address for correspondence: Laura L. Bellows, PhD, MPH, RDN, Division of Nutritional Sciences, Cornell University, 3107 Martha Van Rensselaer Hall, Ithaca, NY 14853
Division of Nutritional Sciences, Cornell University, Ithaca, NYDepartment of Food Science and Human Nutrition, Colorado State University, Fort Collins, CO
The ubiquity of mobile devices and their use in daily life create new paths for health promotion interventions, such as promoting healthy behaviors among families.
The preschool years are an important stage of development when children begin displaying independence while still requiring guidance to help them develop healthy eating and physical activity (PA) behaviors.
The increase in the use of technology can pose both challenges and opportunities, particularly for parents who must define time limits and the type of media children access (ie, educational vs entertainment) while also balancing screentime with other activities, such as developing literacy skills (both reading and numeracy), engaging in play (active, dramatic, social, etc), and developing social-emotional skills, all of which are essential for healthy growth and development. Mobile applications (apps) can serve as tools that help parents positively engage with their children and assist them in developing skills needed for optimal development, including eating and movement skills.
Digital strategies, such as mobile apps, can substitute some of the time spent engaging in entertainment with education about foods and eating while also potentially replacing some sedentary screentime with active screentime, thus, moving children closer to respective recommendations.
The effectiveness of digital strategies for nutrition and PA-related behaviors focused on children is emerging, with 2 recent systematic reviews offering evidence for their potential. First, a review by Zarnowieki et al,
suggests that digital efforts promoting nutrition behaviors to parents can achieve small to moderate changes in fruit and vegetable intake and nutrient-poor foods and drinks in children. Secondly, a review examining PA apps designed specifically for preschool-aged children revealed that of the interventions with a significant effect on PA, child-centered activities were used, and those that used parent-directed digital interventions alone were ineffective for improving PA.
HEROs: design of a mixed-methods formative research phase for an ecocultural intervention to promote healthy eating and activity behaviors in rural families with preschoolers.
The intervention was implemented with 33 mother-child dyads in 2 cohorts during 2019–2020. Participants were mothers of a child aged 3–5 years who was enrolled in 2 rural Head Start/preschool centers, serving families with limited resources, and were able to communicate in English. This study was reviewed as an expedited protocol and approved by the Institutional Review Board at Colorado State University. Baseline data revealed that preschoolers exceeded screentime recommendations of < 60 min/d (97.8 ± 95.8), were below daily PA recommendations of 60 minutes (13.3 ± 7.6), and less than half (45%) were willing to try new foods when given the opportunity (A. Lieb, unpublished data, 2021). As part of the HEROs intervention, 4 custom mobile apps were developed to enhance behavioral capability (Social Cognitive Theory) of trying new foods and movement skills. During in-person workshops, the apps were introduced to preschoolers on case-protected iPads (Apple, Inc, Cupertino, CA). At the start of the study, each dyad was provided with their study-issued iPad, including the HEROs apps. Parents brought these iPads to each workshop while preschoolers played on other iPads used only in child workshops. This aspect of the HEROs study aimed to assess parents’ subjective quality and perceived behavioral benefits of 4 mobile apps developed to engage preschoolers in trying new foods and PA in the home environment.
HEROS INTERVENTION MOBILE APPS
The 4 HEROs apps—Tasting Party Express, Jungle Gym 1, Jungle Gym 2, and Spin-n-Move (Figure)—aimed to build food- and movement-based vocabulary, encourage new foods, support the progression of movement skills, and offered opportunities for PA. The apps included 2 animated preschool-aged characters who introduced 10 other characters of 6 colorful monster creatures, intended to be neutral in observable characteristics such as gender and ethnicity/race and 4 preschool-aged characters with diverse characteristics. Although preschoolers were the primary target, parents were also an important audience to support positive parent-child interactions. Pretesting was conducted with preschoolers and parents to assist designers in the number of activities within the apps, duration of app activities, character preferences, visual cues (eg, scenery, colors), and overall acceptability of the apps.
Bellows LL. Mobile device use among rural, low-income families and the feasibility of an app to encourage preschoolers’ physical activity: qualitative study.
Tasting Party Express invited children to offer animated characters foods via a drag-and-drop action to build familiarity with food-based vocabulary and encourage trying new foods. The app paired characters’ reactions to the foods with vocabulary that described food tastes (eg, sour), textures (eg, crunchy), and characters’ reactions (eg, mmm) to the foods. The app began with a mix of 2 characters in a randomly selected setting, illustrating a birthday party, a farm, a kitchen, a picnic, or a submarine. In each setting, 3 food items were presented separately at 1 time. After the child drags and drops (ie, offers) a presented food item to a character several times, the food item disappears, and a new food item is presented. When the last food item is offered and disappears after multiple taste offerings, the child is taken to a new setting (eg, from a picnic to a submarine).
Jungle Gym 1 and Jungle Gym 2 consisted of outdoor-like activities encouraging children to perform movement skills. In the beginning, the 2 lead characters invite the preschooler to join them in moving their bodies on a virtual jungle tour to find the lead characters’ friends. Once the preschooler selects the ‘go’ button, the preschooler is taken to a randomly selected activity focused on movement-based learning. These activities offer a skill (eg, run, gallop, hop) combined with concepts of direction (eg, forward, sideways), level (eg, high, low), and speed (eg, fast, slow) using an imitative approach (eg, gallop like a horse, hop like a frog). Jungle Gym 1 and Jungle Gym 2 differ in the progression of the movements; Jungle Gym 1 introduces the movements individually, and Jungle Gym 2 begins forming movement patterns. Activities range in duration, with none exceeding 3 minutes.
Spin-n-Move involved a spinning wheel in which children are invited to perform movement skills on which the spinner randomly lands. The app starts with a monster character greeting the preschooler, then asks them to choose 1 of 4 themed spinning wheels. The themed spinning wheels are Moving like Food, Moving like Animals, Playing at the Park, and Going on a Picnic. Once a wheel is spun, an activity is illuminated on a new screen, and the movement skill identified can include direction, level, speed, and/or imitation, which are demonstrated by the characters. For example, 1 activity invites the child to march around the park progressively, indicating to march forward, sideways, and zigzag.
Participant Engagement With the Apps
Each app was introduced to children and parents weekly via parallel program workshops to promote the usage of the apps. In the children's workshops,
led by a researcher, each app was introduced individually in weeks 1–4 by projecting the app on a wall (Jungle Gym 1 and 2 and Spin-n-Go) or giving children individual time to play on the iPad (Tasting Party Express app). In weeks 1–4, researchers went through the app with the children, whereas in weeks 5 and 6, children played the apps of their choosing for 15 minutes. To promote app usage at home, all apps were preloaded on iPads provided to parent-child participants at the start of the study. After each weekly parent workshop (weeks 1–4), participants were provided with a description of the app children were introduced to that week, shown the app's location on their study-issued iPad, and given guidance on how to use the apps to help their children engage with the apps in the home environment. In weeks 5 and 6, parents were encouraged to continue to co-play the apps with their children, and connections between the apps and behavioral objectives presented in the parent workshops were reiterated. Although the apps were designed to be used by low-technology users (ie, preschoolers), it was important to dually introduce the apps to parents and children to ensure understanding of the platform used in the study (ie, Apple iPads). For parents, demonstrating the apps’ features and purpose provided an awareness of the apps and their contents, whereas for children, the introduction engaged children in fun, silly activities to harness pester power for continued use of the apps at home.
EVALUATION
Parents’ subjective quality and perceived behavioral benefits of the 4 mobile apps to engage preschoolers in trying new foods and PA was assessed postintervention using an 8-item questionnaire with 5-point (7 items) and 3-point (1 item) Likert response options. Items were adapted from the Mobile Application Rating Scale, a reliable tool for assessing the quality of mobile health apps, including 4 items from the app subjective quality section (4 items) and a behavior change question (repeated 4 times for each app) from the app-specific section.
Specifically, the questionnaire, administered postintervention (in-person for cohort 1; electronically for cohort 2), inquired about the perceived behavioral benefits of each of the 4 apps in helping children with target behaviors (1, strongly disagree; 5, strongly agree; 4 items), frequency of continued use in the next 12 months (none, 0 times; rare, 1–2 times, low, 3–10 times; moderate, 10–50 times; high, > 50 times), likelihood to recommend (1, very unlikely; 5, very likely), rating of each app (1–5 stars) and would you pay for this app (no, maybe, yes).
Twenty-seven parents completed the questionnaire (82% response rate). For perceived behavioral benefits related to food, 63% of parents agreed or strongly agreed (A/SA) that Tasting Party Express was likely to help children try new foods. For perceived behavioral benefits with target PA behaviors, nearly all parents (93%) A/SA that Jungle Gym 1 and 2 were likely to increase their children's PA. For Spin-n-Move, 77% of parents A/SA that the app was likely to increase PA. The frequency of continued use over the next 12 months of the apps combined varied, with 8% of parents indicating none and rare use, 33% low use, 24% moderate use, and 34% high use. More than 80% of parents reported that they were likely or very likely to recommend each of the apps to others who might benefit. Most parents rated the 4 apps for app rating: 4 stars (35% to 59%) or 5 stars (37% to 42%). A small proportion of parents indicated that they would pay for the apps (11% to 22%).
DISCUSSION AND IMPLICATIONS
Parents’ ratings of subjective quality and perceived behavioral benefits related to the 4 HEROs apps were high, particularly in the perceived behavioral benefits for children and the likelihood of continued use at home. These findings are consistent with existing evidence that parents are more accepting of children's technology use when its purpose is educational instead of exclusively for entertainment.
Bellows LL. Mobile device use among rural, low-income families and the feasibility of an app to encourage preschoolers’ physical activity: qualitative study.
Preschoolers are growing up in a rapidly digitizing world, which has implications for their digital literacy given early-life exposures to digital devices.
Mobile apps provide opportunities for young children to engage with technology, and considerations of parents’ and preschoolers’ roles and skills in the technology design are critical. Preschoolers need their parents’ assistance to understand the content and monitor the quality of the content to which they are digitally exposed, parents need digital literacy to optimize their children's learning opportunities, and technology needs to be sufficiently adapted to the specific needs of its audience to foster acceptance.
This interaction between parents and preschoolers is important to understand in developing and evaluating mobile apps. In the HEROs study, the apps were presented to both parent and child participants, with the child as the primary user and the parent as the evaluator. By capturing only parents’ perceptions of the apps, we may not fully understand the app's acceptability among the primary user (children). For instance, the simplicity of the HEROs apps’ behavioral focus was favorable for preschoolers (eg, repeatedly dragging and dropping foods onto a plate), but may have seemed boring to parents, and thus resulted in a lower perceived rating of the Tasting Party Express app by parents. Ideally, it would be advantageous if preschoolers’ cognitive abilities would allow them to give reliable responses about the app qualities; however, the cognitive abilities of children aged 3–5 years are limited.
The HEROs suite of 4 mobile apps was customized for preschoolers, but parents’ high subjective quality and perceived behavioral benefits of the apps were critical as they are primary gatekeepers in the home environment. These ratings could represent experiences through parent-child interactions or child-only play with the apps. The high ratings of these educational apps from parents support the possibility that mobile apps may help parents promote healthy behaviors that guide new skills and knowledge in fun and engaging ways for young children, which may also help displace sedentary screentime with active screentime.
NOTES
This study was approved by the Institutional Review Board at Colorado State University. This project is supported by Agriculture and Food Research Initiative (Grant no. 2015– 68001–23240) from the US Department of Agriculture National Institute of Food and Agriculture, Childhood Obesity Prevention: Integrated Research, Education, and Extension to Prevent Childhood Obesity—A2101. The apps are available for download on the iOS (Apple) Store and Google Store or at www.FoodsAndMoves.org. The authors would like to thank the families and staff at Iliff Head Start and ABC West Child Development Center for participating in the study.
HEROs: design of a mixed-methods formative research phase for an ecocultural intervention to promote healthy eating and activity behaviors in rural families with preschoolers.
Bellows LL. Mobile device use among rural, low-income families and the feasibility of an app to encourage preschoolers’ physical activity: qualitative study.
Conflict of Interest Disclosure: The second author of this article (S. L. Johnson) serves on the JNEB staff as Senior Associate Editor. Review of this article was handled, exclusively, by the Editor-in-Chief to minimize conflict of interest. The rest of the authors have not stated any conflicts of interest.
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