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Despite their growing popularity, there are very few mobile health (mHealth) interventions for Aboriginal and Torres Strait Islander people that are culturally safe and evidence based. A co-design approach is considered a suitable methodology for developing health interventions with Aboriginal and Torres Strait Islander people.
The aim of this study was to co-design an mHealth intervention to improve health knowledge, health behaviors, and access to health services for women caring for young Aboriginal and Torres Strait Islander children.
Aboriginal researchers led engagement and recruitment with health services and participants in 3 Aboriginal and Torres Strait Islander communities in New South Wales, Australia. Focus groups and interviews were facilitated by researchers and an app developer to gather information on 3 predetermined themes: design characteristics, content modules, and features and functions. Findings from the co-design led to the development of an intervention prototype. Theories of health behavior change were used to underpin intervention components. Existing publicly available evidence-based information was used to develop content. Governance was provided by an Aboriginal advisory group.
In total, 31 mothers and 11 health professionals participated in 8 co-design focus groups and 12 interviews from June 2019 to September 2019. The 6 design characteristics identified as important were credibility, Aboriginal and Torres Strait Islander designs and cultural safety, family centeredness, supportive, simple to use, and confidential. The content includes 6 modules for women’s health: Smoke-free families, Safe drinking, Feeling good, Women’s business, Eating, and Exercising. The content also includes 6 modules for children’s health: Breathing well; Sleeping; Milestones; Feeding and eating; Vaccinations and medicines; and Ears, eyes, and teeth. In addition, 6 technology features and functions were identified: content feed, social connection, reminders, rewards, communication with health professionals, and use of videos.
An mHealth intervention that included app, Facebook page, and SMS text messaging modalities was developed based on the co-design findings. The intervention incorporates health behavior change theory, evidence-based information, and the preferences of Aboriginal and Torres Strait Islander women and health professionals. A pilot study is now needed to assess the acceptability and feasibility of the intervention.
The health and well-being of Aboriginal and Torres Strait Islander people have been significantly affected by dispossession, interruption of culture, and intergenerational trauma since the colonization of Australia [
Aboriginal and Torres Strait Islander people make up 3.3% (798,400/24,193,939) of the Australian population [
mHealth is the use of mobile technology to improve health. Functions include SMS text messaging, multimedia messaging service, voice, internet access, and software apps, which range in complexity. mHealth is used for a variety of purposes, including health education, health behavior change, sensors and point-of-care diagnostics, registries and vital-event tracking, and data collection [
Studies focused on Aboriginal and Torres Strait Islander people using SMS text messaging to improve health show high acceptability of the modality [
Health apps continue to be popular, although the evidence suggests that apps have limited effectiveness on changing health behaviors [
Social media is a form of mHealth, with potential to support health. The Aboriginal and Torres Strait Islander health sector was an early adopter of social media networks to promote health [
In response to the limited mHealth interventions available for Aboriginal and Torres Strait Islander women and children, we aimed to co-design a prototype focused on the needs and ideas of Aboriginal and Torres Strait Islander mothers. Co-design is a partnership approach where end users are actively involved from conception to dissemination [
In total, 8 focus groups and 12 interviews were conducted from June 2019 to September 2019. Surveys were used to collect demographics at the start of focus groups and interviews. An Aboriginal advisory group that included Aboriginal team members who were also members of the participating communities met quarterly to oversee design, implementation, analysis, and reporting. An expert mHealth research group was consulted for opinion on research and intervention design.
Human research ethics approval was received from the Aboriginal Health and Medical Research Council (1485/19) and the University of Newcastle (H-2019-00760).
A co-design framework for an mHealth intervention with Māori and Pacific communities in New Zealand [
Focus groups and interviews were held at 3 regional NSW locations: Newcastle, Coffs Harbour, and Inverell. In total, 5 Aboriginal organizations (including 3 Aboriginal health services, an Aboriginal preschool, and an Aboriginal corporation) and 3 NSW Health sites participated. Venues for focus groups and interviews were decided in consultation with participants.
Women aged ≥16 years who were either mothers or primary carers of an Aboriginal or Torres Strait Islander child aged 0 to 5 years or were pregnant (≥30 weeks gestation), owned or regularly used a smartphone, and had accessed a participating service (Aboriginal health service or NSW Health service) were eligible to participate. Health professionals at participating services who worked with women or children were eligible.
Convenience sampling was used to recruit participants. Aboriginal researchers (BH, NS, and BL) who worked within the participating communities used their personal networks. In addition, participants were asked if they would like to recommend a friend or family member to the study. Potential participants were screened for eligibility when they contacted the researcher on the telephone. The researcher explained the study and gained informed consent over the telephone initially and again in person before the start of the focus group or interview. Participants were reimbursed with a shopping voucher worth Aus $30 (US $21.6) for attending focus groups and interviews and provided with refreshments. Health professionals were recruited using a snowball methodology through the participating services. Health professionals were not reimbursed.
Mothers and health professionals participated in separate focus groups and interviews. Focus groups and interviews were cofacilitated by a combination of Aboriginal researchers (NS and BH), a PhD student (SJP), and an app developer. Interviews and focus groups were 20 to 90 minutes in length. The number of participants in focus groups ranged from 2 to 6. Focus groups and interviews were recorded and transcribed, and field notes were taken.
Different surveys and discussion guides were used with mothers and health professionals. Discussions and activities were used to identify (1) design characteristics, (2) content modules, and (3) features and functions.
The survey comprised 16 items, including demographic, cultural, and socioeconomic items. The items were selected from a previous study [
In all focus groups and interviews with mothers, 3 main questions were asked. Follow-up questions were asked depending on responses. Additional questions about mobile phone use to inform features and functions were asked in focus groups cofacilitated by the app developer. The three main questions were as follows:
How would an mHealth intervention designed for healthy living for Aboriginal and Torres Strait Islander people differ from other mHealth interventions?
Are you more interested in mHealth for your own health or your child’s health? What topics and features interest you?
What do you think stops or prevents some women from accessing health information and services for themselves and their children?
Card-sorting activities were used to identify current mobile phone use (functions used, frequency of use, and reasons for use). Storyboarding activity was used to elicit creative descriptions of the mHealth intervention using drawings and words on what the intervention should include. Design activity was used to gain feedback on potential designs.
The survey comprised 5 items related to demographic and professional practice characteristics.
In all focus groups and interviews with health professionals, 3 main questions were asked. Additional follow-up questions were asked depending on the response. The three main discussion questions were as follows:
What do you think are the most important health and well-being topics to include for Aboriginal or Torres Strait Islander women, children, and family?
What are the barriers for Aboriginal or Torres Strait Islander families to having good health?
What types of mobile technology do you think could support Aboriginal or Torres Strait Islander women’s and children’s health?
A generalized thematic analysis was completed. An Aboriginal researcher (BH) and a PhD student (SJP) independently coded themes. NVivo software (version 12.0; QSR International) was used to complete independent coding and comparison by the 2 coders. In total, 3 predetermined codes were used based on a similar co-design study [
The findings from the co-design stage were subsequently used to develop a prototype intervention incorporating an app, SMS text messaging, social media, and videos. The intervention development was an iterative process, with meetings held among the team members to decide the final features and functionalities. Not all ideas could be adopted because of various reasons, such as time, funding, and technology constraints. We used a combination of building new functions (app) and using existing functions (Facebook page and SMS text messaging).
The intervention was grounded in behavior change theory. The Health Belief Model was used to underpin the app portion of the intervention. The Health Belief Model is considered to be well suited to mHealth interventions with use of the
Key messages were developed on health topics identified from the focus groups and interviews. Content was formulated from publicly available evidence-based health resources. Key messages were adapted to SMS text messages, small pieces of written information for the app, and Facebook posts.
The prototype intervention included an app, videos, Facebook page, and SMS text messaging (
A web-based prototype app was developed. Rapid iterative cycles between the app developer and research team were used to refine the design. An Aboriginal graphic designer developed graphics for each module and logo.
A total of 12 short videos were captured on a Canon camera. All presenters were health professionals from participating sites or contacts of the research team. Short scripts were provided to health professionals based on key messages. Staff were encouraged to use their own knowledge and expertise on each topic. Videos were filmed by a videographer and professionally edited. Captions were completed by Rev, and voiceovers were completed by 2 Aboriginal researchers (BH and NS). The videos ranged from 112 to 300 seconds in length. Vimeo was used as the platform to host the videos.
A Facebook group was developed and administrated by 2 Aboriginal researchers (BH and NS). Both researchers were regular Facebook users and had significant networks and knowledge of Aboriginal and Torres Strait Islander organizations, events, and health services. Key messages were predeveloped in text and video format. Other content shared was decided by the administrators, including sharing posts from their personal accounts if they were suited to the broad aim of the intervention.
SMS text messages were developed based on the processes described by Abroms et al [
A total of 42 participants were recruited to the study: 31 mothers and 11 health professionals. Demographics and cultural characteristics of mothers are presented in
Demographic and cultural characteristics of mothers (N=31).
Characteristics | Values | ||||
Age (years), mean (SD; range) | 31.17 (7.69; 19-50) | ||||
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Aboriginal | 21 (68) | |||
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Torres Strait Islander | 2 (7) | |||
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Nonidentified | 7 (23) | |||
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Did not answer | 1 (3) | |||
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Yes | 25 (81) | |||
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No | 1 (3) | |||
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Unknown | 4 (13) | |||
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Did not answer | 1 (3) | |||
Maintain cultural connections at home, yes, n (%) | 25 (81) | ||||
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Music or dance | 19 (61) | |||
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Storytelling | 19 (61) | |||
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Indigenous television | 18 (58) | |||
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Art | 15 (48) | |||
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Food | 14 (45) | |||
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Indigenous internet sites | 10 (32) | |||
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Indigenous newspapers | 7 (23) | |||
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Traditional medicine | 6 (19) | |||
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Indigenous radio | 5 (16) | |||
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Other | 1 (3) | |||
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Yes | 6 (19) | |||
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No | 12 (39) | |||
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Unknown | 13 (42) | |||
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Did not finish high school | 6 (19) | |||
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High school | 6 (19) | |||
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Certificate | 10 (32) | |||
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Diploma | 2 (7) | |||
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Bachelor’s degree | 4 (13) | |||
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Postgraduate degree | 1 (3) | |||
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Did not answer | 2 (7) | |||
Currently pregnant, yes, n (%) | 1 (3) | ||||
Partner, yes, n (%) | 16 (52) | ||||
Number of people living in household, mean (SD; range) | 4 (1.31; 2-7) | ||||
Number of children (aged <18 years) living in household, mean (SD; range) | 2.39 (1.41; 1-5) | ||||
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Nonsmoker | 21 (68) | |||
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Yes, daily | 5 (16) | |||
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Yes, at least once a week | 2 (7) | |||
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Yes, less often than once a week | 1 (3) | |||
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Did not answer | 2 (7) | |||
Number of cigarettes smoked per day (on the days smoking), mean (SD; range) | 8.5 (3.21; 4-12) | ||||
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0 | 14 (45) | |||
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1 | 10 (32) | |||
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2 to 3 | 4 (13) | |||
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>3 | 1 (3) | |||
Child exposure to indoor tobacco smoke, yes, n (%) | 1 (3) | ||||
Child exposure to outdoor tobacco smoke, yes, n (%) | 15 (48) | ||||
Child exposure to tobacco smoke in the car, yes, n (%) | 0 (0) |
aThe Stolen Generations refers to a period in Australia’s history when Aboriginal children were removed from their families through government policies. This happened during the period from the mid-1800s to the 1970s [
Demographics of health professionals (N=11).
Characteristics | Values | |
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Aboriginal medical service | 6 (55) |
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NSWa Health service | 5 (45) |
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Sex: female | 11 (100) |
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Aboriginal | 4 (36) |
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Torres Strait Islander | 0 (0) |
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Nonidentified | 7 (64) |
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Registered nurse | 7 (64) |
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Aboriginal health worker | 3 (27) |
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Senior family health practitioner | 1 (9) |
Number of years at service, mean (SD; range) | 12 (8.7; 3-32) |
aNSW: New South Wales.
We identified six main design characteristics: (1) credibility, (2) Aboriginal and Torres Strait Islander designs and cultural safety, (3) family centeredness, (4) supportive, (5) simple to use, and (6) confidential.
Mothers talked about the difficulty of finding information on the web that was evidence based. Most of the mothers said that they used Google to find real-time health information for themselves and for their children: “Literally, I Google everything.” Many of the mothers said that it can be difficult to know which websites are most up to date and accurate and that it is difficult to find information: “The biggest thing I find on Google, you get everything. You don’t get the ones that are reputable.” Another mother said, “I'm finding you’re having to like scroll, scroll, and scroll to try and find that information.” Mothers said that they want current health information from reputable health professionals and organizations, including “useful websites links.” Health professionals talked about the importance of credible health information to improve health literacy: “I think lack of knowledge that they are so sick. Recognizing the signs of illness that can lead to them being really, really [sick].” This highlighted why it is important that all content included in the prototype intervention be sourced from credible evidence-based health resources and broken down into palatable small chunks with links to further information.
Most of the mothers said that Aboriginal designs, language, and representation were important for engagement. A mother said, “I think if it had Aboriginal designs that would be really good because if I download an app and it doesn’t have the look, like being culturally aware [I don’t use it].” Another mother said, “Don’t make it black and white, it’s got to be like colorful.” A mother spoke about the intervention needing Aboriginal representation in images and videos: “If it’s going to be an Aboriginal app, I think you have to have Aboriginal people.” Another mother discussed using an app for quitting smoking that was not representative of Aboriginal people: “It was easy to use, but I couldn’t relate to it...didn’t seem like it was aimed at Blackfellas even though we thought it was.”
It was evident from the mothers’ experiences of racism that the intervention needed to be centered in culturally safety. Some mothers talked about feeling fearful and judged when seeking health care. A mother said, “Being an Aboriginal mum especially, I was just worried about DoCS [Department of Child Services]. Like whether they could see if I was handling having two children on top of my own family breakdown. Like my mum’s kids are in DoCS. So that’s what my biggest fear was.” Other mothers expressed feeling judged about certain health behaviors and topics, and a mother said, “The biggest thing is why people do hide it [smoking], because they don’t want to be judged. They don’t want to hear all that stuff.”
To center cultural safety in the intervention, all aspects of the intervention were codeveloped by Aboriginal people: the research was governed by an Aboriginal advisory board and coled by an Aboriginal academic (KH); 4 of the 8 members of the research team are Aboriginal; an Aboriginal graphic designer designed the module icons and logo; Aboriginal researchers were administrators of the Facebook page and shared cultural links, events, activities, affirmations, and images; an Aboriginal videographer filmed all the videos; Aboriginal health professionals presented in the videos; an acknowledgment of Country and a
It was decided unanimously that the intervention should include content for both mother and child. A mother said, “Is this just for children’s health? Because I feel like it should incorporate the mother’s health too.” The mothers asked for information on “things to do with our kids,” and “stuff for us women too. Pap smears and stuff like that.” Many of the mothers and health professionals suggested that the intervention needed to encompass the entire family, including the extended family. A health professional said, “Put the main focus on the child and then how their [family] health affects the baby’s health,” and a mother said, “I think a family app would be really good. Like, I know my husband, he’s never been around babies.” Some participants talked about how other family members help bring up children: “It’s nothing to see an aunt bringing up a child, or a grandparent or a sister” [health professional]. Family centeredness in the intervention was therefore conveyed through messaging that families are the most important role models for jarjums (an Aboriginal word meaning children) across modules and functions. Links to websites, events, and health information for partners and other family members were included.
Most of the mothers and health professionals indicated that it was important that the intervention promoted positive self-esteem and well-being of mothers. A health professional said that the intervention should give new mothers “understanding [of] how tired you are going to be, and it’s okay, ask for help, everyone feels like that but you’re not failing or not doing something wrong.” A mother suggested that we include “some sanity sayings or something like that, or some little sage advice from mums that have been there, done that before, that’d be really helpful,” and another mother said that the intervention could be “like a reassurance type thing.” Mothers and health professionals recognized that motherhood can be “totally exhausting” [health professional] and challenging at times. A mother described the initial period after coming home from hospital: “I didn't know what to do with him. What do I do with this kid? I was lost.” To create an intervention that was supportive of motherhood and of Aboriginal and Torres Strait Islander women, positive and affirming messages were posted on Facebook, sent through SMS text messages, and included in the app. Links on where to seek help for mental health concerns were included.
Mothers and health professionals recommended that the intervention be intuitive, use simple language, and have few technical barriers. Some of the mothers talked about trying to use other health apps; however, they were unable to do so because of technological challenges. For example, a mother said, “It was just too hard to log in and get started so I gave up or just called someone.” Many of the mothers and health professionals emphasized that the language used in the intervention needed to be nonjargon. A mother said, “Don’t put it in a textbook. Because I’m telling you, if my family member downloaded that and it was a textbook way, they would be like—No.” Another mother said that the content should be “just little pieces of information...then links to the bigger pieces.” We aimed for simple, intuitive app design and used other mobile functions commonly used by mothers (Facebook and SMS text messaging). To ensure that the intervention was simple and easy to use, health information was presented in short key messages with links to websites for further information. All key messages were written to be at an 8th grade reading level using the Flesch-Kincaid Grade Level Test as recommended by Abroms et al [
Mothers and health professionals talked about the importance of confidentiality. Health professionals focused on confidentiality in the health care setting and the complexities for some staff regarding knowing patient health details. A health professional said, “There are big things surrounding our health services confidentiality. People don’t know or want to know what other people’s business is.” Some of the mothers spoke about confidentiality; regarding being anonymous when communicating with other mothers or health professionals in a hypothetical mHealth intervention, a mother said, “Oh God, yeah. I’d ask an anonymous person on a phone. Rather than ask the doctor face to face.” Other mothers were happy to not be anonymous: “It wouldn’t bother me having my name because it would just be, this is my experience, and it is what it is. But I would understand if some women didn’t.” To ensure that women can choose to remain anonymous and keep their information confidential, the intervention design meant that no personal data were collected in any part of the intervention, other than a mobile number for the SMS text messaging component. Joining the Facebook group is an optional part of the intervention.
Most of the mothers and health professionals suggested that the intervention needed to cover a wide range of health topics for both the mother and child. Health topics identified in the data included
We identified eight features and functions: (1) content feed, (2) social connection, (3) diary and storage of health information, (4) local context, (5) reminders, (6) rewards, (7) talk with health professionals, and (8) use of videos.
A content feed was chosen to be a feature of the intervention based on the mothers’ current mobile phone use. During the card-sorting activity, most of the mothers reported scrolling the content feed on Facebook numerous times per day. Of the 13 women who were asked how many hours per day they used Facebook, 12 (92%) reported using it >4 hours per day. When asked what kept them going back to Facebook, a mother responded, “The content keeps changing.” Mothers frequently talked about watching photo and video stories that were uplifting, funny, or motivating on Facebook. They talked about using Instagram and Snapchat, too, although less frequently. The intervention was therefore designed to include a Facebook page with daily posts covering a variety of health content.
Mothers talked about the social connection and learning from other women when becoming a mother, including from their “mum,” “mother-in-law,” and “girlfriends.” The importance of positive relationships when first becoming a mother was well recognized by health professionals as well as mothers. It was acknowledged by many of the mothers that some new mothers “don’t have a big support network.
A feature that enabled users to store specific information about a child’s health received mixed responses. Some of the mothers thought that having their child’s health information on hand would be of practical benefit when attending medical appointments: “Like a diary section...I found, when [my child] was sick I started recording when I gave the medication, those sorts of things. That’d be good to have an app when you go into the hospital, you go, this is his recordings.” Another mother said, “So they [health professionals] could just add in medication, add in reports...it’d be good because like [the health service] is only open during the week. Usually, like on the weekend, I’d have to go up to the hospital...So it would be good if there was information like after the visit. Because you don’t always take everything in. It goes right over your head.” Other mothers and health professionals thought there would be confidentiality concerns. Because of the confidentiality concerns raised in the co-design process, a diary feature was not included, although it may be considered as an optional feature in future iterations.
Many of the mothers and health professionals spoke about the uniqueness of their community and said that the intervention needed to be relevant to each community, including language and environment (eg, coastal and desert), as well as health services and other resources. A mother suggested, “You could put in your postcode, location, or area or something and then it could be localized,” and a health professional said, “The contact numbers, if they can’t get into emergency, the [local] health line numbers where they can get a bit of advice would be handy on there as well.” The intervention included phone numbers of local health services for each community in the app, and Facebook posts were designed promoting local health services, events, organizations, and languages.
Many of the mothers talked about the usefulness of SMS text messaging reminders from their health services for appointments, and they said that reminders for other areas of health care would be useful too. A mother said, “I would probably like all of them [milestone reminders]. I’d like the whole lot, make sure I’m not missing anything.” Another mother said, “If someone notified me on this app that I’m due for a [pap smear] or something like that, I would like being reminded of things like that.” Most of the mothers said that they would prefer reminders through SMS text messages rather than a push notification from an app because they could go back to the message and reread it. For the intervention, SMS text messages were developed covering a range of reminders, including vaccinations, developmental milestones, check-ups, smoking quit date, exercise, and eating well. Reminders about local health initiatives and events were also created for posting on the Facebook page.
The mothers talked about rewards and incentives from health programs and services increasing their motivation. They talked about material rewards such as “shirts,” “caps,” and “supermarket vouchers,” as well as social rewards, including “comments” and “likes” on social media and “clapping” and “cheers” on health apps
Some of the mothers suggested that being able to communicate with health professionals using SMS text messages or a live chat function would be beneficial. Some of the mothers said that this function would be useful to confirm whether they required face-to-face health care and for reassurance. A mother said, “Sometimes you don’t know if you should go up there [health service] or not, so you could kind of message and say, ‘Hey, this is what’s happening...is it worth coming up or is it just a viral thing going around?’” Another mother said, “I know a lot of women are just like, ‘What do I do?’ So just having that reassurance I suppose online.” Another mother suggested that it would be helpful to be able to ask health questions anonymously:
Most of the mothers reported during the card-sorting activity that they frequently watched short videos on social media and YouTube. A number of mothers and health professionals advised us that videos and images may be more accessible and preferable for some mothers. A health professional said, “Videos, everyone can watch a video and understand.” Therefore, a video for each health module was developed for the intervention. Each video was stored in the app and added to the Facebook page. Additional health videos from external sources were also able to be shared on the Facebook page.
The final mHealth intervention, named Growin’ Up Healthy Jarjums, aimed to improve health knowledge and health behaviors, along with providing access to health services. The intervention comprises 3 delivery modalities: app, SMS text messaging, and Facebook page.
The app is a central place for users to access all content. The app is primarily for the user who wants in-depth information and has the necessary digital device, internet connection, and literacy skills to access it. It is designed to allow the user to navigate to the topic of interest; for example,
The app has four menu screens: (1) home screen, (2) women’s health, (3) children’s health, and (4) contacts (
Examples of Growin’ Up Healthy Jarjums app screens: (top, from left) home, women’s menu, and children’s menu; (above, from left) contacts, Breathing well, and Our health advice (accessed from Breathing well).
Alongside the app, the prototype included an SMS text messaging library comprising 112 SMS text messages (
Example SMS text messages developed for the Growin’ Up Healthy Jarjums modules.
Module | Example SMS text message | |
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Smoke-free families | Text4jarjum: Giving up the smokes is the best thing you can do for your health. Be a role model and be smoke free. Get support from Quitline 13 78 48 or a doctor and quit for good! |
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Safe drinking | Text4jarjum: While under the influence of alcohol, people can make less safe decisions about their jarjums. Check out 'Safe drinking' for tips to set limits. |
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Feeling good | Text4jarjum: You’re probably not getting much sleep right now. Try to make time for yourself, ask for support from family & friends, and nap when bub does. If you feel that you are not coping, talk to your doctor or midwife. There is help. |
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Women’s business | Text4jarjum: Be kind to yourself. Your body has gone through some big changes during and after birth. It will take time to bounce back. Whether you had a caesarean or vaginal birth, both may require rest & time for recovery. Here’s what to expect after birth. |
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Eating | Text4jarjum: The Australian Breastfeeding Association has some useful tips on nutritional needs for breastfeeding mums. |
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Exercising | Text4jarjum: Any amount of movement is good for you. Start by doing a little, and gradually build up. You could start with a walk around the block a few times a week and then gradually increase. |
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Breathing well | Text4jarjum: A cough is often caused by a cold. Usually, a cough gets better on its own and is not serious, but if your child has a cough that doesn’t go away after TWO weeks, or if you are concerned sooner – see your doctor or child health nurse. |
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Sleeping | Text4jarjum: A routine that includes relaxing time like bath, book, a gentle song before bed and a regular bedtime each night can help your child settle better. |
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Milestones | Text4jarjum: Playgroups, day care and pre-school are great places for jarjums to play and develop. Contact your AMS (Aboriginal Medical Service) or health nurse and find out what’s on. |
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Ears, eyes, and teeth | Text4jarjum: Ear infections are really common and can cause long term hearing loss if not treated. Often there are no signs. Ask your doctor to have quick look in [insert child name] ears each visit to make sure there is no infection. |
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Vaccinations and medicines | Text4jarjum: Immunising [insert child name] is a safe and easy way to keep jarjums healthy and prevent disease. To check that [insert child name] is up to date with immunisations click here. |
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Feeding and eating | Text4jarjum: It’s recommended you breastfeed exclusively until [insert child name] starts solid foods at around 6 months of age. Keep breastfeeding until at least 12 months and beyond. |
The final modality included in the prototype was the Facebook page. The purpose of the Facebook page was to create community and connection, allow 2-way communication, and use a platform that is highly popular among users. Daily content was designed to be added to the Facebook page, including (1) links to reliable health websites, (2) activities for families, (3) weekly competitions, (4) key messages (written and video), (5) events in the community, and (6) supportive affirmative posts. The page was administrated by 2 Aboriginal team members (NS and BH), who shared posts relevant to their community and region. The Facebook page was embedded into the main screen of the app; it could also be accessed through Facebook. Examples of posts are presented in
Examples of the content feed shared on the Growin’ Up Healthy Jarjums Facebook page.
We codeveloped a prototype mHealth intervention focused on the knowledge of mothers of young Aboriginal and Torres Strait Islander children. The aim of the intervention was to improve health knowledge, health behaviors, and access to health services. The final prototype incorporates 3 modalities—app, SMS text messaging, and Facebook page—and includes a range of health topics. In addition, it is centered on being supportive of mothers and culturally safe.
The modality choices were based on a few factors: (1) early discussions with mothers and health services about the need for an app that is culturally relevant and safe, (2) evidence suggesting that SMS text messaging is the most effective mHealth function for health behavior change, and (3) findings from focus groups and interviews indicating that Aboriginal and Torres Strait Islander women were high users of Facebook and SMS text messaging. As suggested in a recent pilot study of a smartphone app with Aboriginal Australians, a
The first limitation of this research is that it was initiated by a research institution rather than by the community itself. True co-design should begin with completing a needs assessment with communities to see what the health priorities and potential solutions are for that community [
A key strength of this study is that Aboriginal researchers (BH, NS, and BL) led engagement with participants and community organizations. Understanding the importance of trusted and strong cultural relationships, we only engaged with communities that the Aboriginal researchers had a relationship with, which likely resulted in trust as well as interest in participating in this study. Another strength of this study is the thorough reporting of the co-design processes. Inadequate reporting of intervention development was identified as a weakness in a recent systematic review on mHealth development (33). An additional strength is the involvement of primary health services and professionals. A recent review on health promotion programs in Aboriginal communities highlighted that an important consideration is to partner with primary health care services because they are well placed with frequent patient contact, health expertise, and often intricate knowledge of the community [
Design characteristics identified in this study, including
The finding that Aboriginal and Torres Strait Islander women were high users of social media, in particular Facebook, was unsurprising. Aboriginal and Torres Strait Islander health organizations have capitalized on the popularity of Facebook among Aboriginal and Torres Strait Islander people and have been early and adept users of social media for health promotion [
As stated earlier, the methodologies used in this study were based on a co-design study for a health app with Māori and Pacific Islander people [
Culture was also identified as important in both studies, although cultural representation may have been a more nuanced finding in the New Zealand study. In our Australian-based study, participants expressed the importance of Aboriginal and Torres Strait Islander representation in terms of designs, colors, images, people, organizations, and safety. Participants in the New Zealand study [
An mHealth intervention that included app, SMS text messaging, and Facebook page modalities was developed based on co-design findings. The intervention incorporates health behavior change theory, evidence-based information, and the preferences of Aboriginal and Torres Strait Islander women and health professionals. The next step of this research is to assess the acceptability and feasibility of the intervention in a pilot study. The pilot study will be conducted with the Aboriginal Health Services and NSW Health sites that participated in this co-design study. Participating mothers will also be invited to participate in the pilot study. If the
Behavior change techniques in SMS text messages.
Aboriginal Medical Service
mobile health
New South Wales
The authors would like to acknowledge and pay their respects to the Aboriginal and Torres Strait Islander women who shared their views and knowledge in the study. The authors would also like to acknowledge the Aboriginal Community Controlled Health Services that participated in the study (Armajun Aboriginal Medical Service [AMS], Galambila AMS, Awabakal AMS, Kulai Aboriginal preschool, and Muloobinba Aboriginal Corporation) as well as the New South Wales Health sites that participated (Aboriginal Maternal and Infant Health Services located in Inverell, Coffs Harbour, and Newcastle). The authors wish to thank researchers from the National Institute for Health and Innovation, Auckland University, Auckland, New Zealand, for sharing expertise on mobile health and Sam McCrabb for coding behavior change techniques.
None declared.