Abstract
Background: Access to technology (and data) through mobile health (mHealth) can alleviate some of the challenges children experience in accessing healthcare services. However, the South African context is unique with children living in under-resourced and rural communities, with limited transport, long commute times to reach clinics, and poor access to technology. Therefore, even though mHealth tools can be beneficial, researchers need to determine the feasibility of such an application for the South African context.
Aim: The study focussed on determining the feasibility of the PicPecc application (app) (an mHealth tool) in South Africa for children requiring mental health support.
Setting: The study included 20 children between the age of 7 years and 18 years in different mainstream schools and a special school.
Methods: A qualitative research design was used to conduct structured interviews with children, either via an online meeting (e.g., Google Meet) or in a natural setting (in the child’s school or home context).
Results: The data were analysed and themes were identified according to five dimensions of access to healthcare and technology, namely acceptability, availability, accessibility, affordability, and accommodation.
Conclusion: This study found that the PicPecc app is promising for implementation in the South African clinical setting. Participants reported various advantages when utilising the app to self-report health symptoms and thus considered it feasible for implementation in the South African context.
Contribution: The study highlights important considerations for the implementation of mHealth technologies in the South African context.
Keywords: access to healthcare; children; eHealth; health technology; mobile health; paediatric.
Introduction
Access to healthcare in South Africa is largely influenced by socio-economic status. Often individuals with more financial resources tend to access healthcare services more efficiently than those with fewer resources (McLaren, Ardington & Leibbrandt 2014, Moeti et al. 2023). Mbarathi, Mthembu and Diga (2016) and Moeti et al. (2023) mention that many South African families are plagued by inequality, poverty and unemployment, and these barriers disproportionally affect the most vulnerable within a family, specifically children. Many children below the age of 15 years have difficulty accessing healthcare services, especially in rural communities, requiring transport and long commute to reach clinics (Adedini et al. 2020). Restricted access to healthcare can cause children to have reduced autonomy and self-care capacity, with limited opportunities to voice their needs (Moeti et al. 2023). However, with a high percentage of access to mobile phones for children in South Africa (Porter et al. 2015), access to mobile health (mHealth) support might be a viable option.
Providing access to technology (and data), creates better opportunities for mHealth applications to facilitate self-monitoring of health outcomes in children and may give children a voice in decision-making about their own healthcare (Fiordelli, Diviani & Schulz 2013). Furthermore, mHealth tools can support children’s communication of their symptoms to healthcare practitioners, to not only include physical ailments but also anxiety and other psychosocial support needs (Wiljén et al. 2022). Oja et al. (2018) conducted a review on mHealth tools and concluded that the implementation of such tools in South Africa is feasible, but a paucity of empirical evidence exists. Therefore, there is a need to improve the implementation of mHealth interventions aimed at providing comfort and support in conjunction with medical interventions in paediatric care and providing all children, regardless of their communication skills, the opportunity to make decisions about their care whenever possible (Nilsson et al. 2015). As such, a group of researchers from Sweden and South Africa developed the PicPecc application (app) to enable children with long-term illnesses to communicate their symptoms (Wiljén et al. 2022).
The development of the PicPecc app followed a user-centred design approach (Wiljén et al. 2022). Initially, the app development was guided by input from Swedish children with cancer, their parents, and healthcare practitioners (Wiljén et al. 2022). The study by Esplana, Olsson and Nilsson (2022) confirmed that the app is feasible to use in a specific healthcare setting in Sweden. This begged the question of whether such an app that was developed for a high-income country (e.g., Sweden) would also be feasible in a low middle-income country (e.g., South Africa). For this purpose the Gini Index – a statistical measure indicating the inequality of a country’s income distribution, which provides a score between 0 (perfect equality) and 1 (very high economic inequality) – was employed (Hasell & Roser 2023). The rationale of this study therefore was to determine whether the PicPecc app, which has proven to be effective in Sweden (a country with one of the lowest Gini coefficient of 0.29) (https://ourworldindata.org/grapher/economic-inequality-gini-index) will yield similar results in South Africa (a country with one of the highest Gini coefficients of 0.63). A comparison of the contextual factors for application of the PicPecc app in Sweden and South Africa follows. This was performed by specifically exploring the perspectives of South African children on the feasibility of the PicPecc app.
The wide range of the Gini coefficient between these two countries implies certain differences. For example, although the structure of the healthcare system is similar in Sweden and in South Africa with both countries having public and private hospitals, the healthcare system is free of charge for all children (birth to 18 years) in Sweden (Laugesen et al. 2021). In contrast, although the South African public healthcare services are free of charge for children younger than 6 years (Moeti et al. 2023), this is not true for children between 7 years and 18 years who are the population for this study. No private healthcare in South Africa is free. Another difference relates to language. In Sweden, there is only one official language (Swedish) despite reports of Sweden also becoming more multilingual (Bohman et al. 2021), whereas South Africa has 12 official languages including sign language – verifying the multilingual diversity of South Africa. English however, is the lingua franca [common language] in healthcare (Van der Walt & Evans 2017).
Sieck et al. (2021a) suggest that challenges in accessing healthcare cut across five dimensions specifically relating to the technology implementation such as telehealth. These dimensions include: acceptability (the relationship between the healthcare organisation’s telehealth tools and workflows, and the patient’s attitude toward and comfort with these tools and workflows); availability (the relationship between existing telehealth services and resources and the patient’s needs and abilities); accessibility (the relationship between the patient’s digital skills and literacy and the supports available to use them); affordability (the relationship between the costs of internet services and devices, and the patient’s ability to pay for them), and accommodability (the relationship between requirements of digital platforms and the patient’s ability to navigate them). Table 2 provides the revised and adapted definitions of the five dimensions conceptualised from Sieck et al.’s (2021a) study (acceptability, availability, accessibility, affordability, and accommodation) that should be considered when implementing an mHealth tool such as the PicPecc app. These five dimensions are used to conceptualise the findings of this study.
This study aimed to determine the feasibility of the PicPecc app (an mHealth tool) as perceived by South African children by utilising the five dimensions for the implementation of mHealth.
Research methods and design
Design and setting
The study followed a qualitative research design (Hissong, Lape & Bailey 2015) to describe and explore the feasibility of the PicPecc app as perceived by South African children. Data were collected through semistructured interviews and children were given a choice to participate either online (e.g., Google Meet) or in a natural setting (in the child’s school or home context).
Description of PicPecc app
The PicPecc app is an mHealth tool that was developed to allow children to communicate for symptom relief and improved well-being during hospitalisation (Wiljén et al. 2022). The app is based on the principles of universal design, meaning that all content is explained and implemented with support functions such as text, images, and sound (Thunberg et al. 2022). Children have the right to actively take part in decisions regarding their health. However, they require support to communicate their symptoms and also to function in their everyday life. Such communication support largely relies on information, a variety of communication methods, and technology.
Participants and sampling
Purposive convenience sampling was used, based on the following selection criteria: age (7–18 years); language (English or Afrikaans proficiency). Ethics approval was obtained after which data collection procedures commenced once parental consent and child assent were obtained. Table 1 provides detailed biographical information of the 20 participants. The different first languages (Afrikaans [n = 10], English [n = 4]; Zulu [n = 4]; Sepedi [n = 1] and Sesotho [n = 1]), of the 20 participants in this study represented diverse languages and cultural backgrounds. The biographical information was obtained from a questionnaire completed by the parents.
| TABLE 1: Demographic information of participants (N = 20). |
Nineteen participants lived in the provinces of Gauteng and the Western Cape. Eight participants did not own a smartphone, but they had frequent access to either their mother’s (n = 7) or their father’s phone (n = 1). All participants used their smartphones for leisure activities while only four indicated that they also used it for schoolwork. Their devices ranged from lower to higher price ranges (phone costs range between R500.00 to R30 000.00). The phones on the lower end of the price range included Ag (n = 1), Kika (n = 1), and Hisense (n = 1), with mid-range devices included Motorola (n = 1) and Nokia (n = 1). Phones in the higher price range included Samsung (n = 6), iPhone (n = 2), and Huawei (n = 2). Four participants were unsure of the brand names of the phones their parents used. A mean time of 2 h per day was spent on the devices during the week with a range of 1 h – 8 h. On the weekend, participants spent an average of 5 h per day on the phone with a range of 1 h – 10 h per day. Fifteen participants reported that they have Wi-Fi access at home with five who did not have any Internet access.
Materials and equipment
The following materials and equipment were utilised for data collection: mobile device with data or Wi-Fi (mobile phone or tablet with either iOS or Android), PicPecc app, interview script, and procedural checklist. The interview schedule was developed based on the five dimensions of mHealth implementation proposed by Sieck et al. (2021a). Table 2 provides an overview of the development of the interview script based on the five dimensions to consider when implementing an mHealth tool. (Refer to Appendix 1 for the complete interview schedule.)
| TABLE 2: Development of an interview script based on the five dimensions that should be considered when implementing an mHealth tool. |
Data collection procedures
Participants were recruited from healthcare practitioners who were invited to refer potential participants. These healthcare practitioners consulted the parents of children from their private practices and asked parents to provide contact details if they consented that their children could participate in the study. The potential pool of participants was increased by also extending the invitation to colleagues and friends with children who met the selection criteria.
Parents were then contacted electronically and provided with an information letter stating the aim of the study and what would be expected of them and their children when downloading and using the PicPecc app. Parents were further asked to complete the informed consent letter and upon receiving this written parental consent, all children were approached and given written assent before data collection commenced. Thereafter, the children were provided with a username and a pin to login into the PicPecc app and were requested to use the app for at least 5 days. Finally, they were asked to indicate their preference regarding an online or an in-person interview at their preferred location.
The last author conducted all the interviews with participants and made field notes to increase personal reflexivity. A procedural checklist was used to prepare the interview and an interview script was used to guide the interviews. This ensured that the same procedure was followed with all participants thereby increasing the trustworthiness of results. The interviews lasted approximately 60 min – 80 min and were audio recorded.
Data analysis
The audio recordings of the interviews were transcribed verbatim by the last author. To ensure the trustworthiness of the transcriptions, the first author reviewed all the transcripts to check for correctness. All transcriptions were imported into ATLAS.ti – an electronic software programme for qualitative analysis (Friese 2019). Inductive thematic analysis was used to analyse qualitative content obtained in the interviews and to aid in holistically understanding the data through pattern recognition of the separate parts (Nowell et al. 2017).
During data analysis, an analytic process was followed to ensure the trustworthiness of the findings (Clarke & Braun 2013). The five phases of thematic analysis that were used include: (1) reviewing and rereading transcripts to increase familiarisation with data and obtain a deep understanding of the content; (2) searching for themes; (3) generating initial themes independently and reviewing the generated themes; (4) organising a meeting to compare and review themes and compile a codebook to increase consistency of coding; and finally (5) defining themes and linking these themes to the theoretical framework in a collaborative manner (Clarke & Braun 2013; Nowell et al. 2017; Roberts, Dowell & Nie 2019). A mutual agreement between the two coders (the first and the last author) was required for all steps of thematic analysis.
Trustworthiness
In this study, four components of trustworthiness were targeted, specifically credibility, transferability, conformability, and researcher bias. Credibility refers to data that truthfully represents the population of this study (Roberts et al. 2019). Credibility was increased through reviewing transcripts multiple times and by multiple authors and although collective data analysis to ensure that the findings were accurate and reflective of the participant’s experiences (Harper & Cole 2012). Transferability refers to the applicability of information representative of a larger population (Roberts et al. 2019). Thick and rich descriptions were provided in different settings. This assisted in increasing transferability, as the different settings may be more representative of a larger population. Conformability refers to the clarity of data collection procedures and documentation (Harper & Cole 2012). To maintain conformability in this study the authors made field notes and conducted a within-group discussion. The aim of these steps were to reduce researcher bias and possible assumptions that could influence the findings.
Ethical considerations
Ethical approval to conduct this study was obtained from the Research Committee of the Faculty of Humanities, University of Pretoria and the University of South Africa (UNISA) College of Education (No. HUM003/0219; 2023/03/08/90438574/02/AM).
Results
The questions of the interview schedule were based on the five dimensions of the implementation of mHealth as proposed by Sieck et al. (2021a). The findings are thus presented accordingly.
Table 3 provides comprehensive information on participants’ quotes as linked to the relevant themes.
Theme 1: Acceptability
All the participants mentioned that they liked the app, adding comments such as the ‘app is cool’ (P6; P7; P10; P13) or the ‘app is fun’ (P9; P11; P16; P18), ‘it is cute’ (P7; P8), ‘it is a good app’ (P1) and ‘I like everything’ (P13; P18). The participants further indicated that they enjoy the app features, particularly the avatar. Some participants mentioned that the avatar could have been created based on their personal preferences (P1; P2; P4; P13; P16) or ‘… I can choose their preferred facial expression and hairstyle’ (P4; P17). The participants specifically favoured the icons of pets and the adaptability of the pets (e.g., changing the pets’ names; P15, P16), which encouraged their frequent use of the app (P1; P4; P8; P20). In contrast, some children did not find the app appealing and engaging because of performing the same activity repetitively (‘commenting on how you feel over and over again’ [P5]; ‘little boring because it doesn’t have games to play’ [P11]). Despite these comments, the participants mentioned that this will not hinder their use of the app when they are sick.
Although many participants (P1, P2, P9; P10; P13, P15; P20) did not provide any recommendations to improve the app, some had innovative suggestions for app development. For example, participants suggested changing the background to include different scenes, such as at the beach (P11; P18); at home (P12), jungle (P18), a field with dogs (P11) or a friend’s house (P12) ‘to help the sick child to feel better’ (P4). Apart from adjusting the background to visual scenes, some participants suggested changing the background colour to their preference. Currently, the background is green in colour, but other colours were mentioned such as ‘yellow or lime green’ (P20); ‘pink’ (P7; P2; P19); ‘purple’ (P2; P19), blue (P2; P9; P18). These colour adaptations were also suggested for the hair colours of the avatar (at the time of data collection this option was limited to different shades of brown, black, reddish brown, pink and white or the option of no hair).
Generally, the participants enjoyed the app features, but recommended making the app more interactive especially referring to the avatars and pets (e.g., feeding, playing or dressing the avatar or pet [P4, P6, P8; P12; P14; P16, P17, P18, P19]). Furthermore, participants suggested adapting the app to allow them to access their favoured games (P5, P14, 17) and watch YouTube videos for entertainment (P11).
Theme 2: Availability
During the time of data collection, there were challenges with the downloading of the app, which resulted in technical glitches. Some participants complained that it was time-consuming to request a pin code to log into the app or that they had limited access to data and/or Wi-Fi (‘I do not have my own phone or access to data’ [P2]).
Theme 3: Accessibility
Participants had older model phones or phones in the lower price range, which affected the amount of storage available for downloading the PicPecc app as well as the compatibility of the device with the app (‘My device wasn’t compatible and I couldn’t download it from Play Store’ [P4]). Some participants could not download the app because of outdated software or found the spelling of the word ‘PicPecc’ difficult to remember. Adult assistance was required as mentioned by one participant who stated, ‘my mother had to help me’ (P2) when installing the app, although some mentioned that it was easy to install the app – ‘press install button’ (P7, P11). Even though downloading the app was generally considered to be easy, participants commented that the consistent loadshedding (the interruption of electricity supply during specific times of a day) and weak and/or slow Wi-Fi connection negatively impacted their use of the app (P8, P3).
Some participants commented that the fact that they needed a pin code to access the app made it slightly difficult to login: ‘It was hard due to the login details and the registration of your account and pin code’ (P18); ‘It [download] was easy, but the login was difficult because you needed the password and pin code’ (P17). Comments on the navigation of the app ranged from ‘First bit difficult – get used to it, easier’ (P1; P13); ‘learning how to use it’ (P15) to ‘easy’ (P2 – P9; P11; P17 – P19).
Participants mentioned that they would have loved it if the app could be used as a communication aid to communicate with somebody else in the hospital as a:
‘[K]ind of social networking to support each other – like WhatsApp but on the app regarding how you are feeling today and sharing it with somebody that is going through the same experience.’ (P15)
Participant P9 commented that one can ‘show the pictures to someone else to tell them that you are sick when you cannot talk’, and Participant P13 mentioned ‘It helps you when you not feel well I can just give it to my mom or brother’. Participant P12 also noticed, ‘This app can help me communicate and talk. If I am not in the mood to talk, I can just show the picture in the app’.
Theme 4: Affordability
The participants’ socio-economic status impacted the use of the app, with comments such as ‘data’ or ‘Wi-Fi’ when asked about challenges or stating their phone’s incompatibility with the app (P2, P6, P8, P12 – P16, P19). Participants utilised the app for different reasons, for example, to report anxiety (P15) or to report when the child was feeling sick at home, at the hospital or at school (P14).
Theme 5: Accommodability
Participants shared ideas on how the app could be adapted for various contexts and different users. They particularly enjoyed the idea that symptoms such as emotions, pain and nausea could be expressed with a link to a diary, and how the use of statistics could reveal how their current feelings compared to their previous ones, for example, ‘You can see that you feel today better than yesterday, e.g., my headache is better – it decreased from an 8 to a 2’ (P1).
The participants agreed that the app can be used by sick children at home; in the hospital; and in school and that ‘they [children in hospital] can share their stories over and over’ (P3) or that they can share the app with others ‘I can show the app to tell my mom how I am feeling’ (P2, P4, P9; P13, P14).
Discussion
As the future implementation of the PicPecc app in a clinical setting in South Africa is being considered, South African children’s perceptions of the PicPecc app are necessary. Children’s voices are essential to understand their concerns related to healthcare (Nilsson et al. 2021; Schiariti 2022; Thunberg et al. 2022). Schiariti (2022) also confirms the importance of purposefully including children’s voices in research, especially when they are involved in activities that will affect them, such as using the PicPecc app to report their symptoms to obtain treatment. As such, this study aimed to determine the feasibility of the PicPecc app by South African children by utilising the five dimensions of implementation of mHealth as adapted from Sieck (2021a) through children’s voices.
Interactivity and gamification
Acceptability refers to participants’ perceptions of the app’s features, which affect motivation to use the app. Although most participants believed that the ‘app is cool’, this study highlighted the importance of interactive and gamification features in apps to maintain and increase children’s engagement with the app (e.g., children suggested features to dress the avatar or links to access games in the app). Gamification builds on a person’s instinct to play (Treiblmaier et al. 2018a, 2018b). The aim of gamification is, therefore, to use game-design elements in non-game contexts (such as healthcare) to boost a person’s extrinsic and intrinsic motivation by helping them to analyse information to achieve better goals, and/or to change their attitude and subsequent behaviour (Treiblmaier et al. 2018a). Gamification should introduce a novelty component and avoid unnecessary repetition to appeal to this age group. The children preferred features such as interactive avatars and pets, for example, feeding, playing or dressing the avatar or pet. Additional comments addressed interactivity by allowing children to access their favoured games and YouTube videos for entertainment. Children utilise YouTube to watch videos on topics such as humour, nursery rhymes, television shows, and animal videos (Neumann & Herodotou 2020b). Neumann and Herodotou (2020a) also evaluated the content of YouTube videos of interest to children and found that learning increased when educational videos included interactive elements. This interactivity element was confirmed by the work of Linder et al. (2021) who found that interactivity can help children improve their creativity, specifically when they are sick and are required to report their symptoms. Although the children in this study highlighted the importance of interactivity, they stated that regardless of this feature, they would still utilise the app to report their symptoms when they are sick. Previous research shows the need to design a meaningful experience to increase the value of gamification. The quality of gamification is more important than quantification (Auf et al. 2021).
Colour and background
Participants suggested that they preferred changes to the colour of the background, which is currently a shade of green. A variety of other colours such as yellow, lime green, pink, purple, and blue, were suggested. This may be related to the fact that colours have specific affective meanings. For example, Jonauskaite et al. (2019a) found that a lighter shade of yellow was associated with joy, yellow-green with relaxation, and that a darker yellow was perceived as a less pleasant colour. Although pink and blue have traditionally been linked to gender – blue for boys and pink for girls (Jonauskaite et al. 2019b) these authors found that both pink and blue are linked to positive emotions. Therefore, this may be the reason why participants in this study opted for these colours.
Participants also suggested that the background should be changed to specific visual scenes ‘to help the child to feel better’. Since the participants believed specific happy scenes that are unrelated to the medical event might help the children to feel better, it may also be related to the fact that these types of scenes are often linked to specific colours. For example, Jonauskaite et al. (2019a) found that imaginary scenes, such as the beach scene may be linked to the colour blue and a sunset to red.
Social determinants of health
Non-medical factors that influence health (social determinants of health) (Richardson et al. 2022) related to the availability and accessibility dimensions were mentioned in this study. The World Health Organization (https://www.who.int/health-topics/social-determinants-of-health#tab=tab_1) defined social determinants of health as the environmental conditions (i.e., the circumstances within the surroundings where individuals are born, reside, acquire knowledge, engage in employment, participate in recreational activities, practice religion, and grow older) that impact various aspects of children’s health, abilities, and overall well-being, as well as the likelihood of encountering risks. Social determinants of health are also responsible for health disparities as they are influenced by the dispensation of money, power, and resources (Richardson et al. 2022). For example, in this study, these disparities were observed as some participants had to borrow a phone from a parent while some owned their own, some had older phones that were incompatible with the PicPecc app, while some had the latest high-end phones. Some had limited data or experienced poor or no Wi-Fi access while some had access to uncapped, unshaped Wi-Fi. Another challenge was that nationally scheduled power cuts (loadshedding) negatively influenced participants’ Wi-Fi access resulting in long download times. Challenges because of loadshedding have also been reported by various authors who confirmed that the continuous loadshedding in South Africa has a huge impact on healthcare, including the use of mHealth tools (Githaiga et al. 2023; Malange 2023; Romski et al. 2023).
The availability and accessibility dimensions also highlighted the importance of acknowledging the participants’ digital literacy. Some participants also complained that they misspelled the name of the app when searching for it on Google Play Store or had to ask someone to help them search and download the app. They also believed it was time-consuming to request the pin code to log into the app. Therefore, Sieck et al. (2021b) mentioned that healthcare practitioners should be aware that some participants may need support on the use of digital tools, for example, how to create an email account or log into an app. These recommendations should be followed when the PicPecc app (or any other app) is introduced to patients in a clinical setting.
There was a difference in the frequency with which the five dimensions to consider regarding the implementation of mHealth were reported in the findings. For example, the ‘affordability’ dimension was mentioned the least. Previous research reported that the affordability dimension was more difficult to interpret than the other four dimensions (Adolfsson, Johnson & Nilsson 2017).
Limitations
A possible limitation of this study is that the participants’ exposure to the app was relatively short, which might have influenced their perceptions of the feasibility of the app. Research has shown that the longer a person uses an app, the interest in the app decreases as the novelty wears off (Romski et al. 2023). Another limitation could include the socioeconomic inequality in South Africa as many South African children may not have access to smartphones. However, as found in this study, most children use their parents’ or relatives’ phones if they do not own one. Therefore, the findings may impact generalisation to the larger representation of South African children.
Suggestions for future research include replicating this study with parents and healthcare practitioners as they are often enablers for children to access mHealth. Furthermore, the PicPecc app could also be utilised as a reflective journal to express children’s emotions related to medical procedures.
Conclusion
According to participants’ perspectives, the PicPecc app is feasible for implementation in the South African context. When conceptualising the features of the app according to the five dimensions mentioned by Sieck et al. (2021a), namely accessibility, acceptability, affordability, availability and accommodability, the findings indicate advantages when utilising this app for the reporting of health symptoms. Participants stated that they thought that the app was promising in the South African context. However, when implementing mobile health technologies, a variety of important considerations should be considered to ensure that such a solution does not defeat the intended purpose by increasing health disparities (Sieck et al. 2021b). Therefore, future recommendations should systematically assess individual patients’ access and digital literacies when implementing mHealth tools in clinical settings.
Acknowledgements
Competing interests
The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.
Authors’ contributions
E.J. and S.N. conceptualised the study, obtained funding, and planned the methodology. A.K. refined the methodology, did data collection and together with E.J. analysed the data. All five authors (E.J., K.M., S.N., J.B. and A.K.) were involved in the writing and revision of the manuscript drafts.
Funding information
The financial support of the South African National Research Foundation (NRF) is hereby acknowledged (STNT220213660170; SRUG2204285248).
Data availability
Data supporting the findings of this study are available from the corresponding author, E.J.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency, or that of the publisher. The authors are responsible for this article’s results, findings, and content.
References
Adedini, S.A., Sello, M., Thaele, D. & Madhi, S.A., 2020, ‘Patterns of healthcare utilisation and barriers affecting access to child healthcare services in low-income urban South African settings’, South African Journal of Child Health 14(1), 34–39. https://doi.org/10.1080/16549716.2021.1874138
Adolfsson, M., Johnson, E. & Nilsson, S., 2017, ‘Pain management for children with cerebral palsy in school settings in two cultures: Action and reaction approaches’, Disability and Rehabilitation 40(18), 2152–2162. https://doi.org/10.1080/09638288.2017.1327987
Auf, H., Dagman, J., Renström, S. & Chaplin, J., 2021, ‘Gamification and nudging techniques for improving user engagement in mental health and well-being apps’, Proceedings of the Design Society 1, 1647–1656. https://doi.org/10.1017/pds.2021.426
Bohman, H., Ryan, J., Stjernborg, V. & Nilsson, D., 2021, ‘A study of changes in everyday mobility during the COVID-19 pandemic: As perceived by people living in Malmö, Sweden’, Transport Policy 106, 109–119. https://doi.org/10.1016/j.tranpol.2021.03.013
Clarke, V. & Braun, V., 2013, ‘Teaching thematic analysis: Overcoming challenges and developing strategies for effective learning’, The psychologist 26(2), 120–123.
Esplana, L., Olsson, M. & Nilsson, S., 2022, ‘“Do you feel well or unwell?”A study on children’s experience of estimating their nausea using the digital tool PicPecc’, Journal of Child Health Care 27(4), 13674935221089746. https://doi.org/10.1177/13674935221089746
Fiordelli, M., Diviani, N. & Schulz, P.J., 2013, ‘Mapping mHealth research: A decade of evolution’, Journal of Medical Internet Research 15(5), e95. https://doi.org/10.2196/jmir.2430
Friese, S., 2019, Qualitative data analysis with ATLAS.ti, Sage, London.
Githaiga, J.N., Späth, C., Sicwebu, N., Perera, S., Tolla, T. & Leon, N., 2023, ‘Critical reflections on conducting qualitative health research during COVID-19: The lived experiences of a cohort of postgraduate students in a South African University’, International Journal of Qualitative Methods 22, 16094069221148406. https://doi.org/10.1177/16094069221148406
Harper, M. & Cole, P., 2012, ‘Member checking: Can benefits be gained similar to group therapy’, The Qualitative Report 17, 510–517, viewed n.d., from https://core.ac.uk/download/pdf/51086813.pdf
Hasell, J., 2023, Measuring inequality: What is the Gini coefficient? viewed n.d., from https://ourworldindata.org/whatis-the-gini-coefficient.
Hissong, A.N., Lape, J.E. & Bailey, D.M., 2015, Bailey’s research for the health professional, F.A. Davis Company, Philadelphia, PA.
Jonauskaite, D., Althaus, B., Dael, N., Dan-Glauser, E. & Mohr, C., 2019a, ‘What color do you feel? Color choices are driven by mood’, Color Research & Application 44(2), 272–284. https://doi.org/10.1002/col.22327
Jonauskaite, D., Dael, N., Chèvre, L., Althaus, B., Tremea, A., Charalambides, L. et al., 2019b, ‘Pink for girls, red for boys, and blue for both genders: Colour preferences in children and adults’, Sex Roles 80, 630–642. https://doi.org/10.1007/s11199-018-0955-z
Laugesen, K., Ludvigsson, J.F., Schmidt, M., Gissler, M., Valdimarsdottir, U.A., Lunde, A. et al., 2021, ‘Nordic health registry-based research: A review of health care systems and key registries’, Clinical Epidemiology 2021, 533–554. https://doi.org/10.2147/CLEP.S314959
Linder, L.A., Newman, A.R., Stegenga, K., Chiu, Y., Wawrzynski, S.E., Kramer, H. et al., 2021, ‘Feasibility and acceptability of a game-based symptom-reporting app for children with cancer: Perspectives of children and parents’, Supportive Care in Cancer 29, 301–310. https://doi.org/10.1007/s00520-020-05495-w
Malange, T.D., 2023, ‘Loadshedding and healthcare: Salt in the wound?’, South African Medical Journal 113, 52–52. https://doi.org/10.7196/SAMJ.2023.v113i2.431
Mbarathi, N., Mthembu, M.E. & Diga, K., 2016, Early childhood development and South Africa: A literature review, University of KwaZulu-Natal, Durban.
Mclaren, Z.M., Ardington, C. & Leibbrandt, M., 2014, ‘Distance decay and persistent health care disparities in South Africa’, BMC Health Services Research 14, 1–9. https://doi.org/10.1186/s12913-014-0541-1
Moeti, T., Mokhele, T., Weir-Smith, G., Dlamini, S. & Tesfamicheal, S., 2023, ‘Factors affecting access to public healthcare facilities in the City of Tshwane, South Africa’, International Journal of Environmental Research and Public Health 20(4), 3651. https://doi.org/10.3390/ijerph20043651
Neumann, M.M. & Herodotou, C., 2020a, ‘Evaluating YouTube videos for young children’, Education and Information Technologies 25, 4459–4475. https://doi.org/10.1007/s10639-020-10183-7
Neumann, M.M. & Herodotou, C., 2020b, Young children and YouTube: A global phenomenon’, Childhood Education 96(4), 72–77. https://doi.org/10.1080/00094056.2020.1796459
Nilsson, S., Björkman, B., Almqvist, A.L., Almqvist, L., Björk-Willen, P., Donohue, D. et al., 2015, ‘Children’s voices – Differentiating a child perspective from a child’s perspective’, Developmental Neurorehabilitation 18(3), 162–168. https://doi.org/10.3109/17518423.2013.801529
Nilsson, S., Wiljén, A., Bergquist, J., Chaplin, J., Johnson, E., Karlsson, K. et al., 2021, ‘Evaluating pictorial support in person-centred care for children (PicPecc): A protocol for a crossover design study’, BMJ Open 11(5), e042726. https://doi.org/10.1136/bmjopen-2020-042726
Nowell, L.S., Norris, J.M., White, D.E. & Moules, N.J., 2017, ‘Thematic analysis: Striving to meet the trustworthiness criteria’, International Journal of Qualitative Methods 16(1), 1609406917733847. https://doi.org/10.1177/1609406917733847
Oja, P., Kelly, P., Murtagh, E.M., Murphy, M.H., Foster, C. & Titze, S., 2018, ‘Effects of frequency, intensity, duration and volume of walking interventions on CVD risk factors: A systematic review and meta-regression analysis of randomised controlled trials among inactive healthy adults’, British Journal of Sports Medicine 52(12), 769–775. https://doi.org/10.1136/bjsports-2017-098558
Porter, G., Hampshire, K., Abane, A., Munthali, A., Robson, E., Bango, A. et al., 2015, ‘Intergenerational relations and the power of the cell phone: Perspectives on young people’s phone usage in sub-Saharan Africa’, Geoforum 64, 37–46. https://doi.org/10.1016/j.geoforum.2015.06.002
Richardson, S., Lawrence, K., Schoenthaler, A.M. & Mann, D., 2022, ‘A framework for digital health equity’, NPJ Digital Medicine 5, 119. https://doi.org/10.1038/s41746-022-00663-0
Roberts, K., Dowell, A. & Nie, J., 2019, ‘Attempting rigour and replicability in thematic analysis of qualitative research data; a case study of codebook development’, BMC Medical Research Methodology 19, 1–8. https://doi.org/10.1186/s12874-019-0707-y
Romski, M.A., Sevcik, R.A., King, M., Deleo, G., Branum-Martin, L. & Bornman, J., 2023, ‘Using a self-guided app to provide communication strategies for caregivers of young children with developmental disorders: A pilot investigation’, Journal of Policy and Practice in Intellectual Disabilities 20(1), 73–88. https://doi.org/10.1111/jppi.12436
Schiariti, V., 2022, ‘Every child matters: Yesterday, today, and tomorrow’, The Lancet Child & Adolescent Health 6(5), 291–292. https://doi.org/10.1016/S2352-4642(22)00063-3
Sieck, C.J., Rastetter, M., Hefner, J.L., Glover, A.R., Magaña, C., Gray II, D.M. et al., 2021a, ‘The five A’s of access for TechQuity’, Journal of Health Care for the Poor and Underserved 32(2), 290–299. https://doi.org/10.1353/hpu.2021.0064
Sieck, C.J., Sheon, A., Ancker, J.S., Castek, J., Callahan, B. & Siefer, A., 2021b, ‘Digital inclusion as a social determinant of health’, NPJ Digital Medicine 4, 52. https://doi.org/10.1038/s41746-021-00413-8
Thunberg, G., Johnson, E., Bornman, J., Öhlén, J. & Nilsson, S., 2022, ‘Being heard–Supporting person-centred communication in paediatric care using augmentative and alternative communication as universal design: A position paper’, Nursing Inquiry 29(2), e12426. https://doi.org/10.1111/nin.12426
Treiblmaier, H., Lowry, P.B. & Putz, L.M., 2018a, ‘Research commentary: Setting a definition, context, and theory-based research agenda for gamifying non-gaming applications’, AIS Transactions on Human-Computer Interaction 10(3), 129–163. https://doi.org/10.17705/1thci.00107
Treiblmaier, H., Putz, L.-M. & Lowry, P.B., 2018b, Setting a definition, context, and theory-based research agenda for the gamification of non-gaming applications’, Association for Information Systems Transactions on Human-Computer Interaction (THCI) 10(3), 129–163. https://doi.org/10.17705/1thci.00107
Van der Walt, C. & Evans, R., 2017, ‘Is English the lingua franca of South Africa’, in J. Jenkins, W. Baker & M. Dewey (eds.), The Routledge handbook of English as Lingua Franca, pp. 186–198, Routledge. London.
Wiljén, A., Chaplin, J.E., Crine, V., Jobe, W., Johnson, E., Karlsson, K. et al., 2022, ‘The development of an mHealth tool for children with long-term illness to enable person-centered communication: User-centered design approach’, JMIR Pediatrics and Parenting 5(1), e30364. https://doi.org/10.2196/30364
Appendix 1
|
Hide
Show all
Email this article (Login required)
