Understanding the Effectiveness and Design of Parent-Oriented Mobile Health Interventions: A Systematic Review and Narrative Synthesis

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Dyadic interventions have the potential to decrease this distress, however several barriers to access including time constraints have been reported. Mobile health (mHealth) interventions can address several of these barriers. Goal: The goal of this systematic review was to review and synthesize the literature examining the effects of parent-oriented mHealth interventions and their content and design. Methods: We searched PubMed/MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central databases from January 2013 to 2023. Included studies were randomized controlled trials assessing the effect of parent-oriented mHealth interventions on child and parent health. The Cochrane risk-of-bias tool was used to assess for bias in studies. Trial details and design and content features of interventions were extracted. Outcomes were organized using the Van Houtven’s Framework for Informal Caregiver Interventions. Results are presented narratively. Results: Fifty papers pertaining to 49 unique studies met our inclusion criteria. More than half of the studies scored high-risk for bias. Interventions targeted a wide range of pediatric conditions. Intervention type included texting (n=17) and investigator-developed mobile applications (n=16). Interventions significantly improved parent psychological health and child health outcomes. Key intervention features and design included the use/application of codesign and a theory-driven intervention. Conclusion: Parent-oriented mHealth interventions identified in this review significantly improved both parent and child health outcomes. Therefore, these interventions have the potential to support parents outside of a clinical setting. Parents Caregivers Mobile Health Interventions Acute and Chronic conditions Pediatrics Figures Figure 1 Figure 2 Figure 3 Background Parents of children with a physical or mental health condition or disability are often expected to take on several roles while caring for their child. Such roles include medical decision maker and care provider responsible for medication administration and assistance with activities of daily living. 1,2 These roles and parenting a child with an illness, particularly one life-limiting or life-altering, can cause parental distress and are associated with high levels of anxiety and depression, and low quality of life. 3-5 A parent’s psychological health has been shown to impact their child’s physical and psychological health including their child’s levels of anxiety. 1,6,7 Further, studies have shown a significantly positive association between children’s psychological health and overall family relationship. 8 This connection between parent and child health underpins why family-centered care models have become integral in pediatric medicine. 9 Parents have reported that having access to resources such as emotional support, and informational resources pertaining to clinical knowledge and skills are needed to support their caregiving ability. 10-13 Despite this known connection, parents of ill children have reported barriers in accessing supportive interventions. These barriers arise from a variety of issues including a lack of evidence-based interventions, 14-16 limited staff knowledge related to delivering psychosocial interventions, 17,18 and the inability to attend in-person support interventions related to child treatment and other family demands. 19 Mobile health interventions (mHealth) including digital applications, texting with clinicians or automated text-based prompts have the potential to address several of the known barriers to parent-oriented interventions. 20 Interest in these interventions has increased in part due to their potential to provide enhanced access to personalized support; allowing users to access personalized support and in-the moment and in all environments in response to changes in health status or behaviors. 20,21 The development and design of mHealth interventions is a complex process and without end-user involvement can limit intervention effectiveness, and integration into practice and sustainability. 22,23 Evidence indicates that the lack of end-users in intervention design and implementation is a key contributor to limited impact. 22-24 Co-design of mHealth interventions, where a diverse range of partners participate in the design and development process 22 is one method to address this pitfall. 25 Still, little is known regarding the extent to which co-design has been used to guide parent mHealth intervention development and the impact of doing so. Available reviews of the effectiveness of mHealth interventions have focused predominantly on adult patients and their family caregivers. 26-28 One review and meta-analysis focused on pediatric-oriented mHealth interventions found that parent involvement in mHealth interventions produced effect sizes larger than those without. 19 However, no review has explored the effect of parent-oriented mHealth interventions nor detailed the design, content, and features of these tool. 19,27,28 Our overarching goal was to synthesize the literature examining the effects of parent-oriented mHealth interventions and the content and design of such interventions. Our specific objectives were to describe: (1) the impact of parent-oriented mHealth interventions on parent health outcomes, when compared to a control group; (2) the impact of parent-oriented mHealth interventions on child health outcomes, when compared to a control group; (3) the design, content, and functionality of identified parent-oriented mHealth interventions. Materials and Methods Study Design, Literature Search and Study Selection A systematic review was undertaken. Our reporting is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Appendix A). 29 The review is registered on PROSPERO (ID# CRD42023404861). We searched the PubMed/MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central databases on January 26, 2023, with the assistance of a research librarian. A search strategy that was limited to 2013 to date of search was developed using synonyms for telemedicine and parents (Appendix B). Study inclusion criteria were randomized controlled trials (RCTs) of any size which compared parent-oriented mHealth interventions (either mobile application or texting) to a control group on parent and child psychological or physical health outcomes. Parents included any family members of children providing a significant proportion of childcare to support a child’s health and well-being. Children of these parent with a chronic or acute physical or mental health condition and neurodevelopmental and intellectual or developmental disabilities were included. Chronic conditions were conditions lasting > three months or occurred three times or more in one-year and requiring ongoing medical attention or limiting activities of daily living. 30 Acute conditions were conditions which onset was sudden, involved a short course of treatment (< three months) and a return to the patient’s baseline was likely (e.g. acute bronchitis). 31 Parent outcomes included any observer or self-reported outcome related to ability to care for their child and their own psychological or physical health. Child health outcomes included any observer or self-reported outcome related to the physical, psychosocial, or developmental health of the child. Control groups were usual care, no treatment, waitlist, or an active intervention. We excluded dissertations, abstracts, and published studies. Finally, studies were excluded if they were not published in English or if interventions were not accessible through a mobile electronic device including a smartphone or iPad with interactive cellular communication capability. 19,27 Perfect agreement on the application of eligibility criteria was reached through two pilot tests of 200 randomly selected abstracts assessed by two independent coders (A.K. and I.Z.). After duplicate removal, all title and abstracts and full text articles were screened in Covidence by two independent reviewers (A.K. and I.Z.). Any discrepancies were resolved by a third reviewer (P.P.). Data Extraction Procedures A code book was developed by two authors (A.K. and I.Z.) to guide the extraction of study, child, parent, and intervention information. Information extracted about the intervention was adapted from the Template for Intervention Description and Replication checklist. 32 Data from a random sample of 10% of identified studies were extracted in duplicate by two authors (A.K. and I.Z.) and 100% agreement was achieved. Data from the remaining studies were extracted by one author (A.K.) and checked for accuracy by a secondary author (I.Z.) Any identified disagreements were resolved through discussion until there was 100% agreement. Risk of Bias Using the Cochrane Risk-Of-Bias tool for randomized trials (ROB2) two reviewers (A.K. and E.M.) rated a random sample of 20% of studies in duplicate and achieved 80% agreement across all ROB2 domains. 33 The remaining studies were assessed singularly and if any questions related to bias assessment were arbitrated as a group. Images for ROB2 were made using the Risk-of-bias VISualization tool. 34 Outcomes and Data Synthesis A narrative synthesis, tabulation, and descriptive analysis of items extracted from the studies was conducted. To synthesize the cumulative impact of parent-oriented mHealth interventions, parent and child health outcomes were included in the narrative synthesis only if they were reported in two or more studies, with data on the remaining outcomes presented in tabular form. Significant impact of the intervention on outcomes was determined based on a reported statistical difference of p <0.05 between groups-over time, between groups, or a within a group from pre- to post-test. Data related to intervention content (type of intervention, frequency of use) and design features (co-design processes and theoretical frameworks utilized) were extracted and included in the narrative synthesis. Interventions and parent and child health outcomes were organized using the Van Houtven and colleagues (2011) organizing framework for informal caregiver interventions. 12 The framework, developed for primary caregivers of adult patients, demonstrates that most caregiver-oriented interventions aim to improve or decrease four major categories pertaining to caregiving: (1) clinical knowledge, (2) psychological skills (3) support seeking, and (4) quantity of caregiving (i.e. number of caregiving hours per week). 12 Interventions were categorized using this as a guide. Further, as per the framework, parent and child health outcomes were classified as: (1) psychological health, (2) physical health, (3) healthcare utilization, and (4) economic status (i.e. change in costs of health care services delivered). 12 Parent psychological outcomes were further delineated as non-social, social and caregiving related, and child psychological outcomes further delineated as self-management related and non-social outcomes. 12 Results Our search identified 10,035 titles and abstracts. After excluding 2850 duplicates, 7185 titles and abstracts were screened, and 108 full articles assessed for eligibility. Following screening, 50 articles pertaining to 49 unique studies were included (PRISMA diagram in Fig 1). Characteristics and Participant Traits Table 1 presents the study characteristics. Studies were published between 2014 and 2023 in 13 different countries, most often in 2017 (n=10/49; 20%), 2018 (n=9/49;18%) or 2020 (n=8/49;16%) (Figure 2) and in the United States (n=26/49; 53%) and China (n=6/49; 12%). Nineteen studies (39%) were pilot or feasibility RCTs and thirty (61%) were reported as full RCTs. Control groups were usual care (n=22/49; 45%), non-mHealth education interventions (21/49; 43%), and in-person interventions (n=6/49; 12%). Sample sizes ranged from 16-1677 M=155; SD=266). Type 1 diabetes was the most common child health condition (n=8/49; 16%), followed by autism spectrum disorder (ASD) (n=6/49; 12%), cancer (n=4/49; 8%), asthma (n=4/49; 8%), obesity (n=4/49; 8%), and heart disease (n=4/49; 8%). Six of the studies (12%) focused on an acute condition including post-operative management or post-acute stays in hospital. Characteristics of Parent-Oriented Interventions and their Development Table 2 presents detailed intervention characteristics, outcomes assessed and associated measurement tools used. The primary goal of interventions included improving or managing child health (n=34/49; 69%); improving or managing parent health (n=9/49; 18%) and improving or managing both child and parent health (n=6/49; 12%). Sixteen studies (32%) evaluated novel apps developed specifically for the purpose of health management, 17 (35%) used text-messaging, 13 (26%) used a previously developed app such as WhatsApp or WeChat and three (6%) used a combination of approaches. Participants used the intervention daily (n=16/49; 33%), weekly (n=10/49; 20%), 2-3 times a week (n=7/49; 14%) or as needed (n=6/49; 12%). Twelve articles (24%) presented a theoretical framework or model which underpinned intervention content or structure; these included Bandura’s self-efficacy theory (n=2/12; 17%), psychological models of stress and coping (n=1/12;12%) and resilience-based frameworks (n=1/12;12%). Nineteen studies reported interventions were co-designed with parents (n=4/19; 21%), parents and their children (n=3/19; 16%), healthcare professionals (n=2/19; 11%), and community-members (2/19;11%). The most common co-design approaches used were the creation of an advisory board with patient, parent, or community-partners (n=4/19; 21%), focus groups with end-users to develop a the content of a prototype (n=3/19; 16%), prototype usability-testing (n=2/19; 11%), and survey-based parent and child needs assessments (n=1/19; 5%). Interventional Target Thirty (61%) studies aimed to improve the parent’s clinical skills and knowledge, with 22 (45%) specifically focusing on improving parent skills or competence managing the condition, and eight (16%) focused on improving the parent’s knowledge of disease or expected clinical course. Seventeen (35%) studies aimed to enhance the parent’s psychological skills, specifically self-efficacy to perform tasks for their child (six studies) and coping (11 studies) with the role of caring for a child with a health condition. Three studies (6%) aimed to provide social support to the parent, however these were all secondary to a primary goal of either improving clinical or psychological skill. No interventions aimed at decreasing the quantity of caregiving including number of tasks or hours providing care. 12 Parent Health Outcomes Parent health outcomes identified pertained to their psychological health only, with no studies examining physical health, economic, or healthcare utilization outcomes were identified (Table 3). Parent Psychological Health Non-social Psychological Outcomes Depression scores were significantly improved in four of the seven (57%) studies which measured the outcome ,52,62,82 using a variety of validated tools. mHealth interventions significantly improved stress compared to the control group in three of the six studies which measured it (50%). 47,57,56 In a single study (17%), the control group, an in-person version of the intervention, reported a significantly greater decrease in stress compared to the intervention group. 77 Parent anxiety score was measured in six studies and significant intervention-related improvements were observed four times (67%). 52,81,86 Resilience was significantly improved in two of the three (67%) studies which measured the construct 62,68 and quality of Life (QoL), which was assessed in seven studies, with scores significantly improved three (43%) of the times it was measured. 51,52,82 Social Psychological Outcomes A parent’s relationship quality with their family, or their ill child, was measured in three studies. Two of the studies (67%) reported a significant improvement in the intervention group. 49,58 Caregiving Related Psychological Outcomes Parent ability to manage their child’s condition was measured six times across four studies. There was a significant improvement from baseline two of six times measurements (33%). Specifically, these improvements were seen in parent confidence in managing their child's arthritis symptoms 68 and reported ability to manage their child’s chronic kidney disease. 66 Seventeen studies examined the parent’s satisfaction with the intervention, including by qualitative interviews (n=2), the Client Satisfaction Questionnaire (n=3), 121 and investigator-developed surveys (n=10). All studies reported a high satisfaction with the mHealth intervention except in one case where only 37% of parents reporting the application to be somewhat useful compared to 70% endorsing the utility of the control treatment. 60 One additional study reported no difference in satisfaction of care between the mHealth and control group. 67 Child Health Outcomes Child health outcomes pertained to physical health related to diabetes, cardiovascular, asthma, and neurodevelopment disorders, healthcare utilization, psychological health, and disease management (Table 4). Child Physical and Neurodevelopmental Health Diabetes Diabetes related health was assessed in seven studies as glycemic control measured as Hemoglobin A1C (HgbA1C) levels. Two studies (29%) demonstrated a significant improvement in glycemic control in the mHealth group 51,52 ; in a third study (14%) the significant improvement favoured the control group. 37 Cardiovascular Health The most frequently assessed cardiovascular health outcomes were body mass index (BMI) (n=4 studies) and weight (n=2 studies). A between-group significant improvement in BMI, favouring mHealth intervention use, was observed in one of the four (25%) studies. 55 Asthma Asthma control was assessed in three studies using either spirometry or the child asthma control test 176 and was significantly improved in a single study (33%). 42 Neurodevelopmental Disorders The neurodevelopmental disorders identified in the studies were ASD (n=3), attention deficit hyperactivity disorder (ADHD) (n=1) and more than one neurodevelopmental disorder (n=1). Behaviors of children with these disorders were measured seven times in four studies including their behavioral and emotional problems, 49 pro-social behaviors, 49,53 and adaptive behaviors. 79 Of the seven times across the four studies, there was a significant improvement from baseline in child behaviors in five (71%). 47,53,79 Impact of mHealth interventions on severity of ASD 47 and ADHD 78 symptoms were measured each by one study and a significantly positive improvement was observed in both. Healthcare Resources Healthcare resource usage was measured, specifically as hospitalizations (n=4 studies) and visits to the emergency department (n=5 studies). Hospitalizations were significantly lower in the intervention group in one (25%) of the studies where it was evaluated. 52 In a second study (25%), significantly fewer infants in the control group were readmitted to hospital compared to the intervention group. 40 Child Psychological Self-Management Related Psychological Outcomes Child ability or confidence to manage their health condition was assessed as 17 outcomes across 9 studies related to management behaviors (n=7 outcomes), self-efficacy (n=4 outcomes), self-management (n=4 outcomes) and perceived burden of disease related problems (n=2 outcomes). Across these assessments, there was a significant difference in self-management activities and health knowledge that favored the interventional group three times across two studies (19%). 51,59 Adherence to treatment was measured in 21 instances across 14 studies and was significantly better in the intervention group in three (14%). 50,61,64 In one additional study, there was no significant difference observed; however, when the research team analyzed intervention engagement data, they determined that the participants who engaged the most with the intervention did have a significant improvement to medication adherence overall. 82 Non-social Psychological Outcomes Pediatric QoL was assessed twelve times in eleven studies as either disease specific QoL or generic health related QoL. Of these measurements, QoL significantly improved from baseline in the intervention group twice (17%). 40,61 Outcome Effects of mHealth Intervention Features and Design Table 5 shows outcome results per mHealth intervention features and design modality. In the 19 studies which reported co-designing interventions, 58 parent and child health outcomes were assessed, and there was a statistically significant improvement in 20 (34%). Thirty-seven child and parent health outcomes were measured in the 12 studies which reported a theory-driven intervention; 18 (49%) of which were significantly improved in the parent-oriented mHealth group. In studies where participants were required to engage with the intervention daily, 18 out of 40 assessed outcomes (45%) showed significant improvement. Similarly, in studies requiring at least weekly interaction with the intervention, 19 out of 49 outcomes (39%) demonstrated significant improvement. Text-messaging and novel mobile applications which had been developed by the research teams for the purpose of health management significantly improved 30% (11/37) and 32% (12/37) of the outcomes assessed across 17 and 16 studies respectively. Previously developed applications, adapted for health management, significantly improved 76% (28/37) of parent and child outcomes in 13 studies. Risk of Bias Assessment Twenty-six (53%) studies were high risk of bias per the Cochrane ROB2 tool, 16 (33%) presented as some concerns and 7 (14%) presented as low concerns (Figure 3a). The bias domains with the highest and lowest risks across studies were deviations from the intended interventions (16/49; 33%) and the randomization process respectively (41/49; 84%) (Figure 3b). Discussion We synthesized the literature examining the effectiveness of parent-oriented mHealth interventions on parent and child health outcomes and identified key content and design features which may have contributed to effectiveness. We identified 49 studies published most frequently in developed countries including the United States and more than half scored high-risk for bias. Overall, identified interventions were found to be highly acceptable to parents and improved parent psychological health, with the largest impact observed in non-social psychological outcomes including depression, anxiety, and resilience. Early evidence also suggests the utility of these interventions in improving child health outcomes, with the most predominant impacts related to neurodevelopmental health outcomes. Interventions frequently connected with participants used texting or novel applications daily or weekly but were infrequently underpinned by theoretical health behaviour frameworks or developed through end-user co-designed. Evaluated interventions that involved engaging with participants daily or weekly, used co-design development techniques, were theory-driven, and were mobile applications showed strong effectiveness in improving both parent and child health outcomes. Our finding that parent-oriented mHealth interventions are more common and beneficial in the context of chronic compared to acute childhood conditions may reflect the prolonged and complex care required of parents in the chronic condition circumstance. 189 Interventions applied in the context of neurodevelopmental disorders including ASD, cardiovascular disease and cancer had the largest impact on both parent and child health outcomes. Parents of children with these conditions are known to incur a significant subjective burden, characterized by feelings of intense physical, emotional, social, and financial stress, and linked to the extensive hours and demanding care tasks these conditions require. 190-192 Interventions aimed at enhancing caregiving capacity and support may be particularly effective in for these parents. 190-192 Demographics of the parents, with the exception of sex, were overall inconsistently reported making it challenging to determine who these interventions may be most suitable for. However, most parents identified as females and specifically mothers. The lack of engagement of fathers in parent-oriented interventions has been previously established and is linked to beliefs about gender roles regarding caregiving, lack of relevant interventions, and lack of intervention awareness. 193 Less than 20 percent of the interventions identified aimed to enhance parental psychological skills despite results showing positive impacts on parental psychological health, including reported anxiety and depression. This lack of interventional focus on the well-being of parents has been reported previously and should represent a research direction in the field. 194-196 Our review demonstrates that when mHealth applications do consider parent psychological health in their design, they positively impact caregiver and child outcomes. Such interventions are aligned with the family-centered care model integral to pediatrics and meet an expressed need by parent caregivers of children with chronic conditions. 190,197 Although some evaluated interventions resulted in significant positive child health outcomes, this result was not ubiquitous across studies. Challenges related to collecting health-related subjective ratings from younger children may, in part, explain this finding. 198 Many identified studies used parent proxy-reported outcomes, which may not accurately reflect the child health status, particularly in the case of child psychological health outcomes. 199 Further, longer interventional periods may be needed to improve many of child objective and functional health outcomes such as HgbA1C or blood pressure and to improve parental caregiving self-efficacy and thus child health. 200 Interventions that incorporate co-design methodologies in their development, are theory-driven, and include more frequent interaction with users appear most effective. The utility of co-design practices in developing better utilized digital interventions has been demonstrated and our results extend these findings to highlight the impact of using these design practices with young patients and their parent. 201,202 Although inconsistently done, the need to ground intervention features and function in behavioral change frameworks or models to bolster impact has also been shown and is reflected in our findings. 203 Given the complex and multi-component nature of mHealth interventions, comparisons between those which include these elements and those that did not are challenging. 204 Future research should focus on identifying features which work most effectively in different patient settings and age groups; a goal which could be completed through co-design work alongside parents, pediatric patients, and clinicians. Questions remain around methods to successfully implement parent-child mHealth interventions into clinical practice. In particular, the lack of digital inclusion which encompasses access and relevance of digital technologies to individuals or groups limits the capacity of many populations to engage with and potentially benefit from these care models. 205 Ensuring that digital health interventions are designed equitably is critical to minimizing the digital healthcare divide. Frameworks such as the eHealth Literacy Framework may inform the design and implementation of digital interventions to improve applicability across target populations. 206 Particular considerations, including those related to literacy and user experience norms, are needed in the situation of interventions targeting pediatric patients and their parents. Developing applications that include specific profiles for parent and child users may be one option to address this issue. Other concerns include how data from these interventions can be effectively integrated into child electronic health records; particularly if outcomes are parent-proxy reported when the child self-report is not possible due to age or illness or when data are related to parental health status, and not that of the child. 207 In addition, given family and treatment related demands, engaging parents of children with chronic conditions in consistent and longitudinal intervention usage is a barrier to implementation. 208 Engagement strategies such as gamifying interventions and push notifications have been suggested to improve retention in mHealth studies. 209 Limitations The studies identified in this review are not without limitations. Several studies scored high for risk-of-bias due to a lack of participant blinding. Although challenging to blind participants without an active control group, future studies could blind outcome assessors and analysts. Finally, most studies were published in high income countries. Given the pressing need to increase access to high quality child healthcare in lower income countries, future work should focus on evaluating mHealth interventions in these areas. ' This review also has limitations. Due to the large variety in health conditions and types of interventions, a meta-analysis was not possible. Further, we only included RCTs and therefore cannot comment on results of mHealth evaluations using different designs. In addition, to understand the full extent of mHealth interventions in the literature, pilot, or feasibility studies, not powered for statistical significance, were included. Finally, studies not published in English were excluded, potentially limiting understanding of these interventions in other cultural contexts. Conclusions Overall, parent-oriented mHealth interventions appear to improve parent psychological health and may positively affect child health as well. Given these encouraging findings and the accessibility of mobile digital devices, mHealth interventions may prove advantageous in advancing the quality of improving family-centered children’s healthcare. Intervention functionalities and design features including co-design and the use of health behaviour theoretical frameworks may prove valuable is amplifying any impacts of developed mHealth applications, with further research required to elucidate when and how to apply these technologies most usefully within pediatric care. Taken together, parent-oriented mHealth interventions are a promising tool to improve the outcomes for parents and their children to enable family-centered care. Abbreviations ADHD: Attention Deficit Hyperactivity Disorder ASD: Autism Spectrum Disorder HgbA1C: Hemoglobin A1C mHealth: Mobile Health PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses QoL: Quality of Life RCT: Randomized Controlled Trial ROB2: Risk-Of-Bias Tool for Randomized Trials Declarations Ethics approval and consent to participate: Not applicable Consent for publication: Not applicable Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests Funding: Not applicable Acknowledgements: Not applicable References Koch K, Jones B. Supporting Parent Caregivers of Children with Life-Limiting Illness. Children. 2018 Jun 26;5(7):85. Caicedo C. Families With Special Needs Children: Family Health, Functioning, and Care Burden. J Am Psychiatr Nurses Assoc. 2014 Nov;20(6):398–407. 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Int J Geriat Psychiatry. 2005 Jul;20(7):629–34. Bamber MD, Solatikia F, Gaillard P, Spratling R. Caregiver burden and inflammation in parents of children with special healthcare needs. Discov Psychol. 2023 Oct 9;3(1):29. Salvador Á, Crespo C, Barros L. The Benefits of Family-Centered Care for Parental Self-Efficacy and Psychological Well-being in Parents of Children with Cancer. J Child Fam Stud. 2019 Jul;28(7):1926–36. Fekete C, Tough H, Siegrist J, Brinkhof MW. Health impact of objective burden, subjective burden and positive aspects of caregiving: an observational study among caregivers in Switzerland. BMJ Open. 2017 Dec;7(12):e017369. Pelentsov LJ, Laws TA, Esterman AJ. The supportive care needs of parents caring for a child with a rare disease: A scoping review. Disability and Health Journal. 2015 Oct;8(4):475–91. Sicouri G, Tully L, Collins D, Burn M, Sargeant K, Frick P, et al. Toward Father‐friendly Parenting Interventions: A Qualitative Study. ANZ J of Family Therapy. 2018 Jun;39(2):218–31. Park JYE, Tracy CS, Gray CS. Mobile phone apps for family caregivers: A scoping review and qualitative content analysis. DIGITAL HEALTH. 2022 Jan;8:205520762210766. El-Dassouki N, Pfisterer K, Benmessaoud C, Young K, Ge K, Lohani R, et al. The Value of Technology to Support Dyadic Caregiving for Individuals Living With Heart Failure: Qualitative Descriptive Study. J Med Internet Res. 2022 Sep 7;24(9):e40108. Benmessaoud C, Pfisterer KJ, De Leon A, Saragadam A, El-Dassouki N, Young KGM, et al. Design of a Dyadic Digital Health Module for Chronic Disease Shared Care: Development Study. JMIR Hum Factors. 2023 Dec 25;10:e45035. Jibb LA, Chartrand J, Masama T, Johnston DL. Home-Based Pediatric Cancer Care: Perspectives and Improvement Suggestions From Children, Family Caregivers, and Clinicians. JCO Oncology Practice. 2021 Jun;17(6):e827–39. Ozsivadjian A, Hibberd C, Hollocks MJ. Brief Report: The Use of Self-Report Measures in Young People with Autism Spectrum Disorder to Access Symptoms of Anxiety, Depression and Negative Thoughts. J Autism Dev Disord. 2014 Apr;44(4):969–74. Baca CB, Vickrey BG, Hays RD, Vassar SD, Berg AT. Differences in Child versus Parent Reports of the Child’s Health-Related Quality of Life in Children with Epilepsy and Healthy Siblings. Value in Health. 2010 Sep;13(6):778–86. Grzadzinski R, Janvier D, Kim SH. Recent Developments in Treatment Outcome Measures for Young Children With Autism Spectrum Disorder (ASD). Seminars in Pediatric Neurology. 2020 Jul;34:100806. Nimmanterdwong Z, Boonviriya S, Tangkijvanich P. Human-Centered Design of Mobile Health Apps for Older Adults: Systematic Review and Narrative Synthesis. JMIR Mhealth Uhealth. 2022 Jan 14;10(1):e29512. Bevan Jones R, Stallard P, Agha SS, Rice S, Werner‐Seidler A, Stasiak K, et al. Practitioner review: Co‐design of digital mental health technologies with children and young people. J Child Psychol Psychiatr. 2020 Aug;61(8):928–40. Atkins L, Francis J, Islam R, O’Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Sci. 2017 Dec;12(1):77. Dawson RM, Felder TM, Donevant SB, McDonnell KK, Card EB, King CC, et al. What makes a good health ‘app’? Identifying the strengths and limitations of existing mobile application evaluation tools. Nursing Inquiry. 2020 Apr;27(2):e12333. Kemp E, Trigg J, Beatty L, Christensen C, Dhillon HM, Maeder A, et al. Health literacy, digital health literacy and the implementation of digital health technologies in cancer care: the need for a strategic approach. Elmer S, editor. Health Prom J of Aust. 2021 Feb;32(S1):104–14. Norgaard O, Furstrand D, Klokker L, Karnoe A, Batterham R, Kayser L, Osborne RH. The e-health literacy framework: a conceptual framework for characterizing e-health users and their interaction with e-health systems. Knowledge Management & E-Learning. 2015;7(4):522. Omoloja A, Vundavalli S. Patient generated health data: Benefits and challenges. Current Problems in Pediatric and Adolescent Health Care. 2021 Nov;51(11):101103. Amagai S, Pila S, Kaat AJ, Nowinski CJ, Gershon RC. Challenges in participant engagement and retention using mobile health apps: literature review. Journal of medical Internet research. 2022 Apr 26;24(4):e35120 Dawson RM, Felder TM, Donevant SB, McDonnell KK, Card EB, King CC, et al. What makes a good health ‘app’? Identifying the strengths and limitations of existing mobile application evaluation tools. Nursing Inquiry. 2020 Apr;27(2):e12333. Tables Tables 1 to 4 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files ParentmHealthAllTablesFinalBMC.docx AppendixAParentmHealth.docx AppendixBPediatrics.docx Cite Share Download PDF Status: Published Journal Publication published 10 May, 2025 Read the published version in BMC Pediatrics → Version 1 posted Editorial decision: Revision requested 28 Oct, 2024 Reviews received at journal 18 Sep, 2024 Reviews received at journal 16 Sep, 2024 Reviewers agreed at journal 06 Sep, 2024 Reviewers agreed at journal 06 Sep, 2024 Reviewers agreed at journal 02 Sep, 2024 Reviews received at journal 30 Aug, 2024 Reviewers agreed at journal 28 Aug, 2024 Reviewers agreed at journal 25 Aug, 2024 Reviewers agreed at journal 23 Aug, 2024 Reviewers invited by journal 11 Jun, 2024 Editor invited by journal 06 Jun, 2024 Submission checks completed at journal 01 Jun, 2024 Editor assigned by journal 01 Jun, 2024 First submitted to journal 16 May, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Fifty research articles (49 studies) were included in this analysis.\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4432616/v1/1855baf9c67261d0995644e7.jpg"},{"id":58595865,"identity":"96569360-33b2-4d48-9587-0f4ed416fa54","added_by":"auto","created_at":"2024-06-18 16:41:54","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45118,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eNumber of studies and intervention type per year: \u003c/strong\u003e\u003c/u\u003eThis bar graph shows the number of studies (y-axis) published per year (x-axis). Each bar is broken down and colour coded according to intervention type.\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4432616/v1/3e7fe6360dafb75231df7c61.jpg"},{"id":58595867,"identity":"159fc235-2aac-4108-89ea-7a5f9fceb214","added_by":"auto","created_at":"2024-06-18 16:41:54","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":310077,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cu\u003e\u003cstrong\u003eRisk of bias assessment: \u003c/strong\u003e\u003c/u\u003eIndividual bias assessment (a) and (b) overall summary for included randomized controlled trials assessed using the Cochrane collaboration tool.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4432616/v1/e292957fc59ba55319ddb08a.jpg"},{"id":82537606,"identity":"6fadd2b5-c42b-4cf9-8450-e173bef04f4d","added_by":"auto","created_at":"2025-05-12 16:09:14","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1463449,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4432616/v1/2f38deb3-8e35-4377-aad2-8afc1e2ca2a5.pdf"},{"id":58596424,"identity":"748dbe9b-5a58-4d6d-9bb2-8adf4a835668","added_by":"auto","created_at":"2024-06-18 16:49:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":224528,"visible":true,"origin":"","legend":"","description":"","filename":"ParentmHealthAllTablesFinalBMC.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432616/v1/fdaf5e0aa32f8c973851c17e.docx"},{"id":58596425,"identity":"dc9fc384-1d6b-4e48-8f94-54a80499ff8f","added_by":"auto","created_at":"2024-06-18 16:49:54","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":32053,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixAParentmHealth.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432616/v1/2130b0e1fc321ed74f0a28e9.docx"},{"id":58596427,"identity":"0533f0ea-b6b3-4a5f-a409-2681ed4b6a12","added_by":"auto","created_at":"2024-06-18 16:49:54","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":16499,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixBPediatrics.docx","url":"https://assets-eu.researchsquare.com/files/rs-4432616/v1/6779e17cc405fdf7b72f61dd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding the Effectiveness and Design of Parent-Oriented Mobile Health Interventions: A Systematic Review and Narrative Synthesis","fulltext":[{"header":"Background","content":"\u003cp\u003eParents of children with a physical or mental health condition or disability are often expected to take on several roles while caring for their child. Such roles include medical decision maker and care provider responsible for medication administration and assistance with activities of daily living.\u003csup\u003e1,2\u0026nbsp;\u003c/sup\u003eThese roles and parenting a child with an illness, particularly one life-limiting or life-altering, can cause parental distress and are associated with high levels of anxiety and depression, and low quality of life.\u003csup\u003e3-5\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eA parent\u0026rsquo;s psychological health has been shown to impact their child\u0026rsquo;s physical and psychological health including their child\u0026rsquo;s levels of anxiety.\u003csup\u003e1,6,7\u003c/sup\u003e Further, studies have shown a significantly positive association between children\u0026rsquo;s psychological health and overall family relationship.\u003csup\u003e8\u0026nbsp;\u003c/sup\u003eThis connection between parent and child health underpins why family-centered care models have become integral in pediatric medicine.\u003csup\u003e9\u003c/sup\u003e Parents have reported that having access to resources such as emotional support, and informational resources pertaining to clinical knowledge and skills are needed to support their caregiving ability.\u003csup\u003e10-13\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eDespite this known connection, parents of ill children have reported barriers in accessing supportive interventions. These barriers arise from a variety of issues including a lack of evidence-based interventions,\u003csup\u003e14-16\u003c/sup\u003e limited staff knowledge related to delivering psychosocial interventions,\u003csup\u003e17,18\u003c/sup\u003e\u0026nbsp; and the inability to attend in-person support interventions related to child treatment and other family demands.\u003csup\u003e19\u003c/sup\u003e\u003cbr\u003eMobile health interventions (mHealth) including digital applications, texting with clinicians or automated text-based prompts have the potential to address several of the known barriers to parent-oriented interventions.\u003csup\u003e20\u0026nbsp;\u003c/sup\u003eInterest in these interventions has increased in part due to their potential to provide enhanced access to personalized support; allowing users to access personalized support and in-the moment and in all environments in response to changes in health status or behaviors.\u003csup\u003e20,21\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe development and design of mHealth interventions is a complex process and without end-user involvement can limit intervention effectiveness, and integration into practice and sustainability.\u003csup\u003e22,23\u003c/sup\u003e Evidence indicates that the lack of end-users in intervention design and implementation is a key contributor to limited impact.\u003csup\u003e22-24\u003c/sup\u003e Co-design of mHealth interventions, where a diverse range of partners participate in the design and development process\u003csup\u003e22\u0026nbsp;\u003c/sup\u003eis one method to address this pitfall.\u003csup\u003e25\u0026nbsp;\u003c/sup\u003eStill, little is known regarding the extent to which co-design has been used to guide parent mHealth intervention development and the impact of doing so.\u003c/p\u003e\n\u003cp\u003eAvailable reviews of the effectiveness of mHealth interventions have focused predominantly on adult patients and their family caregivers.\u003csup\u003e26-28\u0026nbsp;\u003c/sup\u003eOne review and meta-analysis focused on pediatric-oriented mHealth interventions found that parent involvement in mHealth interventions produced effect sizes larger than those without.\u003csup\u003e19\u0026nbsp;\u003c/sup\u003eHowever, no review has explored the effect of parent-oriented mHealth interventions nor detailed the design, content, and features of these tool.\u003csup\u003e19,27,28\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eOur overarching goal was to synthesize the literature examining the effects of parent-oriented mHealth interventions and the content and design of such interventions. Our specific objectives were to describe: (1) the impact of parent-oriented mHealth interventions on parent health outcomes, when compared to a control group; (2) the impact of parent-oriented mHealth interventions on child health outcomes, when compared to a control group; (3) the design, content, and functionality of identified parent-oriented mHealth interventions.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Design, Literature Search and Study Selection\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA systematic review was undertaken. Our reporting is in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Appendix A).\u003csup\u003e29\u0026nbsp;\u003c/sup\u003eThe review is registered on PROSPERO (ID# CRD42023404861). We searched the PubMed/MEDLINE, Embase, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Central databases on January 26, 2023, with the assistance of a research librarian. A search strategy that was limited to 2013 to date of search was developed using synonyms for telemedicine and parents (Appendix B).\u003c/p\u003e\n\u003cp\u003eStudy inclusion criteria were randomized controlled trials (RCTs) of any size which compared parent-oriented mHealth interventions (either mobile application or texting) to a control group on parent and child psychological or physical health outcomes. Parents included any family members of children providing a significant proportion of childcare to support a child\u0026rsquo;s health and well-being. Children of these parent with a chronic or acute physical or mental health condition and neurodevelopmental and intellectual or developmental disabilities were included. Chronic conditions were conditions lasting \u0026gt; three months or occurred three times or more in one-year and requiring ongoing medical attention or limiting activities of daily living.\u003csup\u003e30\u003c/sup\u003e Acute conditions were conditions which onset was sudden, involved a short course of treatment (\u0026lt; three months) and a return to the patient\u0026rsquo;s baseline was likely (e.g. acute bronchitis).\u003csup\u003e31\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eParent outcomes included any observer or self-reported outcome related to ability to care for their child and their own psychological or physical health. Child health outcomes included any observer or self-reported outcome related to the physical, psychosocial, or developmental health of the child. Control groups were usual care, no treatment, waitlist, or an active intervention. We excluded dissertations, abstracts, and published studies. Finally, studies were excluded if they were not published in English or if interventions were not accessible through a mobile electronic device including a smartphone or iPad with interactive cellular communication capability.\u003csup\u003e19,27\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ePerfect agreement on the application of eligibility criteria was reached through two pilot tests of 200 randomly selected abstracts assessed by two independent coders (A.K. and I.Z.). \u0026nbsp;After duplicate removal, all title and abstracts and full text articles were screened in Covidence by two independent reviewers (A.K. and I.Z.). Any discrepancies were resolved by a third reviewer (P.P.).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Extraction Procedures\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA code book was developed by two authors (A.K. and I.Z.) to guide the extraction of study, child, parent, and intervention information. Information extracted about the intervention was adapted from the Template for Intervention Description and Replication checklist.\u003csup\u003e32\u003c/sup\u003e Data from a random sample of 10% of identified studies were extracted in duplicate by two authors (A.K. and I.Z.) and 100% agreement was achieved. Data from the remaining studies were extracted by one author (A.K.) and checked for accuracy by a secondary author (I.Z.) Any identified disagreements were resolved through discussion until there was 100% agreement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRisk of Bias\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eUsing the Cochrane Risk-Of-Bias tool for randomized trials (ROB2)\u003csup\u003e\u0026nbsp;\u003c/sup\u003etwo reviewers (A.K. and E.M.)\u0026nbsp;rated a random sample of 20% of studies in duplicate and achieved 80% agreement across all ROB2 domains.\u003csup\u003e33\u003c/sup\u003e The remaining studies were assessed singularly and if any questions related to bias assessment were arbitrated as a group. Images for ROB2 were made using the Risk-of-bias VISualization tool.\u003csup\u003e34\u003c/sup\u003e\u003cbr\u003e\u003cstrong\u003e\u003cem\u003eOutcomes and Data Synthesis\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA narrative synthesis, tabulation, and descriptive analysis of items extracted from the studies was conducted. To synthesize the cumulative impact of parent-oriented mHealth interventions, parent and child health outcomes were included in the narrative synthesis only if they were reported in two or more studies, with data on the remaining outcomes presented in tabular form.\u003c/p\u003e\n\u003cp\u003eSignificant impact of the intervention on outcomes was determined based on a reported statistical difference of \u003cem\u003ep\u003c/em\u003e\u0026lt;0.05 between groups-over time, between groups, or a within a group from pre- to post-test. Data related to intervention content (type of intervention, frequency of use) and design features (co-design processes and theoretical frameworks utilized) were extracted and included in the narrative synthesis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInterventions and parent and child health outcomes were organized using the Van Houtven and colleagues (2011) organizing framework for informal caregiver interventions.\u003csup\u003e12\u003c/sup\u003e The framework, developed for primary caregivers of adult patients, demonstrates that most caregiver-oriented interventions aim to improve or decrease four major categories pertaining to caregiving: (1) clinical knowledge, (2) psychological skills (3) support seeking, and (4) quantity of caregiving (i.e. number of caregiving hours per week).\u003csup\u003e12 \u0026nbsp;\u0026nbsp;\u003c/sup\u003eInterventions were categorized using this as a guide. Further, as per the framework, parent and child health outcomes were classified as: (1) psychological health, (2) physical health, (3) healthcare utilization, and (4) economic status (i.e. change in costs of health care services delivered).\u003csup\u003e12\u0026nbsp;\u003c/sup\u003eParent psychological outcomes were further delineated as non-social, social and caregiving related, and child psychological outcomes further delineated as self-management related and non-social outcomes.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eOur search identified 10,035 titles and abstracts. After excluding 2850 duplicates, 7185 titles and abstracts were screened, and 108 full articles assessed for eligibility. Following screening, 50 articles pertaining to 49 unique studies were included (PRISMA diagram in Fig 1).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCharacteristics and Participant Traits\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 1 presents the study characteristics. Studies were published between 2014 and 2023 in 13 different countries, most often in 2017 (n=10/49; 20%), 2018 (n=9/49;18%) or 2020 (n=8/49;16%) (Figure 2) and in the United States (n=26/49; 53%) and China (n=6/49; 12%). Nineteen studies (39%) were pilot or feasibility RCTs and thirty (61%) were reported as full RCTs. Control groups were usual care (n=22/49; 45%), non-mHealth education interventions (21/49; 43%), and in-person interventions (n=6/49; 12%). \u0026nbsp;Sample sizes ranged from 16-1677 M=155; SD=266). Type 1 diabetes was the most common child health condition (n=8/49; 16%), followed by autism spectrum disorder (ASD) (n=6/49; 12%), cancer (n=4/49; 8%), asthma (n=4/49; 8%), obesity (n=4/49; 8%), and heart disease (n=4/49; 8%). Six of the studies (12%) focused on an acute condition including post-operative management or post-acute stays in hospital.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCharacteristics of Parent-Oriented Interventions and their Development\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 2 presents detailed intervention characteristics, outcomes assessed and associated measurement tools used.\u0026nbsp;The primary goal of interventions included improving or managing child health (n=34/49; 69%); improving or managing parent health (n=9/49; 18%) and improving or managing both child and parent health (n=6/49; 12%). Sixteen studies (32%) evaluated novel apps developed specifically for the purpose of health management, 17 (35%) used text-messaging, 13 (26%) used a previously developed app such as WhatsApp or WeChat and three (6%) used a combination of approaches. Participants used the intervention daily (n=16/49; 33%), weekly (n=10/49; 20%), 2-3 times a week (n=7/49; 14%) or as needed (n=6/49; 12%).\u003c/p\u003e\n\u003cp\u003eTwelve articles (24%) presented a theoretical framework or model which underpinned intervention content or structure; these included Bandura\u0026rsquo;s self-efficacy theory (n=2/12; 17%), psychological models of stress and coping (n=1/12;12%) and resilience-based frameworks (n=1/12;12%). Nineteen studies reported interventions were co-designed with parents (n=4/19; 21%), parents and their children (n=3/19; 16%), healthcare professionals (n=2/19; 11%), and community-members (2/19;11%). The most common co-design approaches used were the creation of an advisory board with patient, parent, or community-partners (n=4/19; 21%), focus groups with end-users to develop a the content of a prototype (n=3/19; 16%), prototype usability-testing (n=2/19; 11%), and survey-based parent and child needs assessments (n=1/19; 5%).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eInterventional Target\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThirty (61%) studies aimed to improve the parent\u0026rsquo;s clinical skills and knowledge, with 22 (45%) specifically focusing on improving parent skills or competence managing the condition, and eight (16%) focused on improving the parent\u0026rsquo;s knowledge of disease or expected clinical course. Seventeen (35%) studies aimed to enhance the parent\u0026rsquo;s psychological skills, specifically self-efficacy to perform tasks for their child (six studies) and coping (11 studies) with the role of caring for a child with a health condition. Three studies (6%) aimed to provide social support to the parent, however these were all secondary to a primary goal of either improving clinical or psychological skill. No interventions aimed at decreasing the quantity of caregiving including number of tasks or hours providing care.\u003csup\u003e12\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eParent Health Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParent health outcomes identified pertained to their psychological health only, with no studies examining physical health, economic, or healthcare utilization outcomes were identified (Table 3).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eParent Psychological Health\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNon-social Psychological Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDepression scores were significantly improved in four of the seven (57%) studies which measured the outcome\u003csup\u003e,52,62,82\u003c/sup\u003e using a variety of validated tools. mHealth interventions significantly improved stress compared to the control group in three of the six studies which measured it (50%).\u003csup\u003e47,57,56\u003c/sup\u003e In a single study (17%), the control group, an in-person version of the intervention, reported a significantly greater decrease in stress compared to the intervention group.\u003csup\u003e77\u003c/sup\u003e Parent anxiety score was measured in six studies and significant intervention-related improvements were observed four times\u003csup\u003e\u0026nbsp;\u003c/sup\u003e(67%).\u003csup\u003e52,81,86\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResilience was significantly improved in two of the three (67%) studies which measured the construct\u003csup\u003e62,68\u0026nbsp;\u003c/sup\u003eand quality of Life (QoL), which was assessed in seven studies, with scores significantly improved three (43%) of the times it was measured.\u003csup\u003e51,52,82\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSocial Psychological Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA parent\u0026rsquo;s relationship quality with their family, or their ill child, was measured in three studies. Two of the studies (67%) reported a significant improvement in the intervention group.\u003csup\u003e49,58\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCaregiving Related\u003c/em\u003e \u003cem\u003ePsychological Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParent ability to manage their child\u0026rsquo;s condition was measured six times across four studies. There was a significant improvement from baseline two of six times measurements (33%). Specifically, these improvements were seen in parent confidence in managing their child\u0026apos;s arthritis symptoms\u003csup\u003e68\u003c/sup\u003e and reported ability to manage their child\u0026rsquo;s chronic kidney disease.\u003csup\u003e66\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSeventeen studies examined the parent\u0026rsquo;s satisfaction with the intervention, including by qualitative interviews (n=2), the Client Satisfaction Questionnaire (n=3),\u003csup\u003e121\u003c/sup\u003e and investigator-developed surveys (n=10). All studies reported a high satisfaction with the mHealth intervention except in one case where only 37% of parents reporting the application to be somewhat useful compared to 70% endorsing the utility of the control treatment.\u003csup\u003e60\u003c/sup\u003e One additional study reported no difference in satisfaction of care between the mHealth and control group.\u003csup\u003e67\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eChild Health Outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChild health outcomes pertained to physical health related to diabetes, cardiovascular, asthma, and neurodevelopment disorders, healthcare utilization, psychological health, and disease management (Table 4).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eChild Physical and Neurodevelopmental Health\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eDiabetes\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDiabetes related health was assessed in seven studies as glycemic control measured as Hemoglobin A1C (HgbA1C) levels. Two studies (29%) demonstrated a significant improvement in glycemic control in the mHealth group\u003csup\u003e51,52\u003c/sup\u003e; in a third study (14%) the significant improvement favoured the control group.\u003csup\u003e37\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCardiovascular Health\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe most frequently assessed cardiovascular health outcomes were body mass index (BMI) (n=4 studies) and weight (n=2 studies). A between-group significant improvement in BMI, favouring mHealth intervention use, was observed in one of the four (25%) studies.\u003csup\u003e55\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAsthma\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Asthma control was assessed in three studies using either spirometry or the child asthma control test\u003csup\u003e176\u003c/sup\u003e and was significantly improved in a single study (33%).\u003csup\u003e42\u003c/sup\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNeurodevelopmental Disorders\u003c/em\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe neurodevelopmental disorders identified in the studies were ASD (n=3), attention deficit hyperactivity disorder (ADHD) (n=1) and more than one neurodevelopmental disorder (n=1). Behaviors of children with these disorders were measured seven times in four studies including their behavioral and emotional problems,\u003csup\u003e49\u0026nbsp;\u003c/sup\u003epro-social behaviors,\u003csup\u003e49,53\u003c/sup\u003e and adaptive behaviors.\u003csup\u003e79\u003c/sup\u003e Of the seven times across the four studies, there was a significant improvement from baseline in child behaviors in five (71%).\u003csup\u003e47,53,79\u0026nbsp;\u003c/sup\u003e Impact of mHealth interventions on severity of ASD\u003csup\u003e47\u003c/sup\u003e and ADHD\u003csup\u003e78\u003c/sup\u003e symptoms were measured each by one study and a significantly positive improvement was observed in both.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;Healthcare Resources\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHealthcare resource usage was measured, specifically as hospitalizations (n=4 studies) and visits to the emergency department (n=5 studies). Hospitalizations were significantly lower in the intervention group in one (25%) of the studies where it was evaluated.\u003csup\u003e52\u0026nbsp;\u003c/sup\u003eIn a second study (25%), significantly fewer infants in the control group were readmitted to hospital compared to the intervention group.\u003csup\u003e40\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eChild Psychological\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSelf-Management Related Psychological Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eChild ability or confidence to manage their health condition was assessed as 17 outcomes across 9 studies related to management behaviors (n=7 outcomes), self-efficacy (n=4 outcomes), self-management (n=4 outcomes) and perceived burden of disease related problems (n=2 outcomes). Across these assessments, there was a significant difference in self-management activities and health knowledge that favored the interventional group three times across two studies (19%).\u003csup\u003e51,59\u003c/sup\u003e\u003cbr\u003e Adherence to treatment was measured in 21 instances across 14 studies and was significantly better in the intervention group in three (14%).\u003csup\u003e50,61,64\u0026nbsp;\u003c/sup\u003eIn one additional study, there was no significant difference observed; however, when the research team analyzed intervention engagement data, they determined that the participants who engaged the most with the intervention did have a significant improvement to medication adherence overall.\u003csup\u003e82\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eNon-social Psychological Outcomes\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePediatric QoL was assessed twelve times in eleven studies as either disease specific QoL or generic health related QoL. Of these measurements, QoL significantly improved from baseline in the intervention group twice (17%).\u003csup\u003e40,61\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eOutcome Effects of mHealth Intervention Features and Design\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTable 5 shows outcome results per mHealth intervention features and design modality. In the 19 studies which reported co-designing interventions, 58 parent and child health outcomes were assessed, and there was a statistically significant improvement in 20 (34%). Thirty-seven child and parent health outcomes were measured in the 12 studies which reported a theory-driven intervention; 18 (49%) of which were significantly improved in the parent-oriented mHealth group.\u0026nbsp;In studies where participants were required to engage with the intervention daily, 18 out of 40 assessed outcomes (45%) showed significant improvement. Similarly, in studies requiring at least weekly interaction with the intervention, 19 out of 49 outcomes (39%) demonstrated significant improvement.\u003c/p\u003e\n\u003cp\u003eText-messaging and novel mobile applications which had been developed by the research teams for the purpose of health management significantly improved 30% (11/37) and 32% (12/37) of the outcomes assessed across 17 and 16 studies respectively. Previously developed applications, adapted for health management, significantly improved 76% (28/37) of parent and child outcomes in 13 studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eRisk of Bias Assessment\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTwenty-six (53%) studies were high risk of bias per the Cochrane ROB2 tool, 16 (33%) presented as some concerns and 7 (14%) presented as low concerns (Figure 3a). The bias domains with the highest and lowest risks across studies were deviations from the intended interventions (16/49; 33%) and the randomization process respectively (41/49; 84%) (Figure 3b).\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWe synthesized the literature examining the effectiveness of parent-oriented mHealth interventions on parent and child health outcomes and identified key content and design features which may have contributed to effectiveness. We identified 49 studies published most frequently in developed countries including the United States and more than half scored high-risk for bias. Overall, identified interventions were found to be highly acceptable to parents and improved parent psychological health, with the largest impact observed in non-social psychological outcomes including depression, anxiety, and resilience. Early evidence also suggests the utility of these interventions in improving child health outcomes, with the most predominant impacts related to neurodevelopmental health outcomes. Interventions frequently connected with participants used texting or novel applications daily or weekly but were infrequently underpinned by theoretical health behaviour frameworks or developed through end-user co-designed. Evaluated interventions that involved engaging with participants daily or weekly, used co-design development techniques, were theory-driven, and were mobile applications showed strong effectiveness in improving both parent and child health outcomes.\u003c/p\u003e\n\u003cp\u003eOur finding that parent-oriented mHealth interventions are more common and beneficial in the context of chronic compared to acute childhood conditions may reflect the prolonged and complex care required of parents in the chronic condition circumstance.\u003csup\u003e189\u0026nbsp;\u003c/sup\u003eInterventions applied in the context of neurodevelopmental disorders including ASD, cardiovascular disease and cancer had the largest impact on both parent and child health outcomes.\u0026nbsp;Parents of children with these conditions are known to incur a significant subjective burden, characterized by feelings of intense physical, emotional, social, and financial stress, and linked to the extensive hours and demanding care tasks these conditions require.\u003csup\u003e190-192\u003c/sup\u003e Interventions aimed at enhancing caregiving capacity and support may be particularly effective in for these parents.\u003csup\u003e190-192\u003c/sup\u003e\u003csup\u003e\u0026nbsp;\u003c/sup\u003eDemographics of the parents, with the exception of sex, were overall inconsistently reported making it challenging to determine who these interventions may be most suitable for. However,\u0026nbsp;most parents identified as females and specifically mothers. The lack of engagement of fathers in parent-oriented interventions has been previously established and is linked to beliefs about gender roles regarding caregiving, lack of relevant interventions, and lack of intervention awareness.\u003csup\u003e193\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eLess than 20 percent of the interventions identified aimed to enhance parental psychological skills despite results showing positive impacts on parental psychological health, including reported anxiety and depression. This lack of interventional focus on the well-being of parents has been reported previously and should represent a research direction in the field.\u003csup\u003e194-196\u0026nbsp;\u003c/sup\u003eOur review demonstrates that when mHealth applications do consider parent psychological health in their design, they positively impact caregiver and child outcomes. Such interventions are aligned with the family-centered care model integral to pediatrics and meet an expressed need by parent caregivers of children with chronic conditions.\u003csup\u003e190,197\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAlthough some evaluated interventions resulted in significant positive child health outcomes, this result was not ubiquitous across studies. Challenges related to collecting health-related subjective ratings from younger children may, in part, explain this finding.\u003csup\u003e198\u003c/sup\u003e Many identified studies used parent proxy-reported outcomes, which may not accurately reflect the child health status, particularly in the case of child psychological health outcomes.\u003csup\u003e199\u0026nbsp;\u003c/sup\u003eFurther, longer interventional periods may be needed to improve many of child objective and functional health outcomes such as HgbA1C or blood pressure and to improve parental caregiving self-efficacy and thus child health.\u003csup\u003e200\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Interventions that incorporate co-design methodologies in their development, are theory-driven, and include more frequent interaction with users appear most effective. The utility of co-design practices in developing better utilized digital interventions has been demonstrated and our results extend these findings to highlight the impact of using these design practices with young patients and their parent.\u003csup\u003e201,202\u0026nbsp;\u003c/sup\u003eAlthough inconsistently done, the need to ground intervention features and function in behavioral change frameworks or models to bolster impact has also been shown and is reflected in our findings.\u003csup\u003e203\u0026nbsp;\u003c/sup\u003eGiven the complex and multi-component nature of mHealth interventions, comparisons between those which include these elements and those that did not are challenging. \u003csup\u003e204\u0026nbsp;\u003c/sup\u003eFuture research should focus on identifying features which work most effectively in different patient settings and age groups; a goal which could be completed through co-design work alongside parents, pediatric patients, and clinicians.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQuestions remain around methods to successfully implement parent-child mHealth interventions into clinical practice. In particular, the lack of digital inclusion which encompasses access and relevance of digital technologies to individuals or groups limits the capacity of many populations to engage with and potentially benefit from these care models.\u003csup\u003e205\u0026nbsp;\u003c/sup\u003eEnsuring that digital health interventions are designed equitably is critical to minimizing the digital healthcare divide. Frameworks such as the eHealth Literacy Framework may inform the design and implementation of digital interventions to improve applicability across target populations.\u003csup\u003e206\u0026nbsp;\u003c/sup\u003eParticular considerations, including those related to literacy and user experience norms, are needed in the situation of interventions targeting pediatric patients and their parents. Developing applications that include specific profiles for parent and child users may be one option to address this issue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOther concerns include how data from these interventions can be effectively integrated into child electronic health records; particularly if outcomes are parent-proxy reported when the child self-report is not possible due to age or illness or when data are related to parental health status, and not that of the child.\u003csup\u003e207\u003c/sup\u003e In addition, given family and treatment related demands, engaging parents of children with chronic conditions in consistent and longitudinal intervention usage is a barrier to implementation.\u003csup\u003e208\u0026nbsp;\u003c/sup\u003eEngagement strategies such as gamifying interventions and push notifications have been suggested to improve retention in mHealth studies.\u003csup\u003e209\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe studies identified in this review are not without limitations. Several studies scored high for risk-of-bias due to a lack of participant blinding. Although challenging to blind participants without an active control group, future studies could blind outcome assessors and analysts. Finally, most studies were published in high income countries. Given the pressing need to increase access to high quality child healthcare in lower income countries, future work should focus on evaluating mHealth interventions in these areas. \u0026apos;\u003c/p\u003e\n\u003cp\u003eThis review also has limitations. Due to the large variety in health conditions and types of interventions, a meta-analysis was not possible. Further, we only included RCTs and therefore cannot comment on results of mHealth evaluations using different designs. In addition, to understand the full extent of mHealth interventions in the literature, pilot, or feasibility studies, not powered for statistical significance, were included. Finally, studies not published in English were excluded, potentially limiting understanding of these interventions in other cultural contexts.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOverall, parent-oriented mHealth interventions appear to improve parent psychological health and may positively affect child health as well. Given these encouraging findings and the accessibility of mobile digital devices, mHealth interventions may prove advantageous in advancing the quality of improving family-centered children\u0026rsquo;s healthcare. Intervention functionalities and design features including co-design and the use of health behaviour theoretical frameworks may prove valuable is amplifying any impacts of developed mHealth applications, with further research required to elucidate when and how to apply these technologies most usefully within pediatric care. Taken together, parent-oriented mHealth interventions are a promising tool to improve the outcomes for parents and their children to enable family-centered care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADHD: Attention Deficit Hyperactivity Disorder\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eASD: Autism Spectrum Disorder\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eHgbA1C: Hemoglobin A1C\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003emHealth: Mobile Health\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eQoL: Quality of Life\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRCT: Randomized Controlled Trial\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eROB2: Risk-Of-Bias Tool for Randomized Trials \u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials: \u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eNot applicable\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eKoch K, Jones B. 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Development of six PROMIS pediatrics proxy-report item banks. Health Qual Life Outcomes. 2012;10(1):22.\u003c/li\u003e\n\u003cli\u003eLiu AH, Zeiger R, Sorkness C, Mahr T, Ostrom N, Burgess S, et al. Development and cross-sectional validation of the Childhood Asthma Control Test. Journal of Allergy and Clinical Immunology. 2007 Apr;119(4):817\u0026ndash;25.\u003c/li\u003e\n\u003cli\u003eKemp R, Kirov G, Everitt B, Hayward P, David A. Randomised controlled trial of compliance therapy: 18-month follow-up. The British Journal of Psychiatry. 1998 May;172(5):413-9.\u003c/li\u003e\n\u003cli\u003ePappas D. ADHD Rating Scale-IV: Checklists, Norms, and Clinical Interpretation. Journal of Psychoeducational Assessment. 2006 Jun;24(2):172\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eMolinas S. U.S. Department of Health, Education, and Welfare Public Health Service. Clinical Toxicology. 1970 Jan;3(2):307\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eRimland B, Edelson SM. 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Family caregivers of older adults: Improving helping skills. The Gerontologist. 1983 Dec 1;23(6):637-42.\u003c/li\u003e\n\u003cli\u003eHulst JM, Zwart H, Hop WC, Joosten KF. Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clinical Nutrition. 2010 Feb 1;29(1):106-11\u003c/li\u003e\n\u003cli\u003eKvaal K, Ulstein I, Nordhus IH, Engedal K. The Spielberger State-Trait Anxiety Inventory (STAI): the state scale in detecting mental disorders in geriatric patients. Int J Geriat Psychiatry. 2005 Jul;20(7):629\u0026ndash;34.\u003c/li\u003e\n\u003cli\u003eBamber MD, Solatikia F, Gaillard P, Spratling R. Caregiver burden and inflammation in parents of children with special healthcare needs. Discov Psychol. 2023 Oct 9;3(1):29.\u003c/li\u003e\n\u003cli\u003eSalvador \u0026Aacute;, Crespo C, Barros L. The Benefits of Family-Centered Care for Parental Self-Efficacy and Psychological Well-being in Parents of Children with Cancer. J Child Fam Stud. 2019 Jul;28(7):1926\u0026ndash;36.\u003c/li\u003e\n\u003cli\u003eFekete C, Tough H, Siegrist J, Brinkhof MW. Health impact of objective burden, subjective burden and positive aspects of caregiving: an observational study among caregivers in Switzerland. BMJ Open. 2017 Dec;7(12):e017369.\u003c/li\u003e\n\u003cli\u003ePelentsov LJ, Laws TA, Esterman AJ. The supportive care needs of parents caring for a child with a rare disease: A scoping review. Disability and Health Journal. 2015 Oct;8(4):475\u0026ndash;91.\u003c/li\u003e\n\u003cli\u003eSicouri G, Tully L, Collins D, Burn M, Sargeant K, Frick P, et al. Toward Father‐friendly Parenting Interventions: A Qualitative Study. ANZ J of Family Therapy. 2018 Jun;39(2):218\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003ePark JYE, Tracy CS, Gray CS. Mobile phone apps for family caregivers: A scoping review and qualitative content analysis. DIGITAL HEALTH. 2022 Jan;8:205520762210766.\u003c/li\u003e\n\u003cli\u003eEl-Dassouki N, Pfisterer K, Benmessaoud C, Young K, Ge K, Lohani R, et al. The Value of Technology to Support Dyadic Caregiving for Individuals Living With Heart Failure: Qualitative Descriptive Study. J Med Internet Res. 2022 Sep 7;24(9):e40108.\u003c/li\u003e\n\u003cli\u003eBenmessaoud C, Pfisterer KJ, De Leon A, Saragadam A, El-Dassouki N, Young KGM, et al. Design of a Dyadic Digital Health Module for Chronic Disease Shared Care: Development Study. JMIR Hum Factors. 2023 Dec 25;10:e45035.\u003c/li\u003e\n\u003cli\u003eJibb LA, Chartrand J, Masama T, Johnston DL. Home-Based Pediatric Cancer Care: Perspectives and Improvement Suggestions From Children, Family Caregivers, and Clinicians. JCO Oncology Practice. 2021 Jun;17(6):e827\u0026ndash;39.\u003c/li\u003e\n\u003cli\u003eOzsivadjian A, Hibberd C, Hollocks MJ. 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JMIR Mhealth Uhealth. 2022 Jan 14;10(1):e29512.\u003c/li\u003e\n\u003cli\u003eBevan Jones R, Stallard P, Agha SS, Rice S, Werner‐Seidler A, Stasiak K, et al. Practitioner review: Co‐design of digital mental health technologies with children and young people. J Child Psychol Psychiatr. 2020 Aug;61(8):928\u0026ndash;40.\u003c/li\u003e\n\u003cli\u003eAtkins L, Francis J, Islam R, O\u0026rsquo;Connor D, Patey A, Ivers N, et al. A guide to using the Theoretical Domains Framework of behaviour change to investigate implementation problems. Implementation Sci. 2017 Dec;12(1):77.\u003c/li\u003e\n\u003cli\u003eDawson RM, Felder TM, Donevant SB, McDonnell KK, Card EB, King CC, et al. What makes a good health \u0026lsquo;app\u0026rsquo;? Identifying the strengths and limitations of existing mobile application evaluation tools. Nursing Inquiry. 2020 Apr;27(2):e12333.\u003c/li\u003e\n\u003cli\u003eKemp E, Trigg J, Beatty L, Christensen C, Dhillon HM, Maeder A, et al. Health literacy, digital health literacy and the implementation of digital health technologies in cancer care: the need for a strategic approach. Elmer S, editor. Health Prom J of Aust. 2021 Feb;32(S1):104\u0026ndash;14.\u003c/li\u003e\n\u003cli\u003eNorgaard O, Furstrand D, Klokker L, Karnoe A, Batterham R, Kayser L, Osborne RH. The e-health literacy framework: a conceptual framework for characterizing e-health users and their interaction with e-health systems. Knowledge Management \u0026amp; E-Learning. 2015;7(4):522.\u003c/li\u003e\n\u003cli\u003eOmoloja A, Vundavalli S. Patient generated health data: Benefits and challenges. Current Problems in Pediatric and Adolescent Health Care. 2021 Nov;51(11):101103.\u003c/li\u003e\n\u003cli\u003eAmagai S, Pila S, Kaat AJ, Nowinski CJ, Gershon RC. Challenges in participant engagement and retention using mobile health apps: literature review. 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Nursing Inquiry. 2020 Apr;27(2):e12333.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Parents, Caregivers, Mobile Health, Interventions, Acute and Chronic conditions, Pediatrics","lastPublishedDoi":"10.21203/rs.3.rs-4432616/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4432616/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eParents of children with a health condition experience high levels of distress which can have long-term impact on the child and parent. Dyadic interventions have the potential to decrease this distress, however several barriers to access including time constraints have been reported. Mobile health (mHealth) interventions can address several of these barriers.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGoal:\u003c/strong\u003e The goal of this systematic review was to review and synthesize the literature examining the effects of parent-oriented mHealth interventions and their content and design.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e We searched\u003cstrong\u003e \u003c/strong\u003ePubMed/MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central databases from January 2013 to 2023. Included studies were randomized controlled trials assessing the effect of parent-oriented mHealth interventions on child and parent health. The Cochrane risk-of-bias tool was used to assess for bias in studies. Trial details and design and content features of interventions were extracted. Outcomes were organized using the Van Houtven’s Framework for Informal Caregiver Interventions. Results are presented narratively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eFifty papers pertaining to 49 unique studies met our inclusion criteria. More than half of the studies scored high-risk for bias. Interventions targeted a wide range of pediatric conditions. Intervention type included texting (n=17) and investigator-developed mobile applications (n=16). Interventions significantly improved parent psychological health and child health outcomes. Key intervention features and design included the use/application of codesign and a theory-driven intervention.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eParent-oriented mHealth interventions identified in this review significantly improved both parent and child health outcomes. Therefore, these interventions have the potential to support parents outside of a clinical setting.\u003c/p\u003e","manuscriptTitle":"Understanding the Effectiveness and Design of Parent-Oriented Mobile Health Interventions: A Systematic Review and Narrative Synthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-18 16:41:49","doi":"10.21203/rs.3.rs-4432616/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-10-28T06:23:36+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-18T18:17:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-09-17T01:22:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"261064872887046536599420432558345180045","date":"2024-09-06T14:53:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233621328571680949727486286632517116547","date":"2024-09-06T12:44:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"148454377838413070382577069315792209854","date":"2024-09-02T09:48:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-08-30T20:03:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152666334291247168513116581447897939158","date":"2024-08-28T04:41:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"306109423249783441165765217771257317143","date":"2024-08-26T03:01:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"298952201078285858343936063478682299965","date":"2024-08-23T08:51:07+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-12T02:25:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-06T12:26:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-01T04:38:50+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-01T04:38:50+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2024-05-16T17:36:58+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c3219351-1430-489a-9154-d8c402c5c7fa","owner":[],"postedDate":"June 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-12T16:05:42+00:00","versionOfRecord":{"articleIdentity":"rs-4432616","link":"https://doi.org/10.1186/s12887-025-05656-y","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2025-05-10 15:57:30","publishedOnDateReadable":"May 10th, 2025"},"versionCreatedAt":"2024-06-18 16:41:49","video":"","vorDoi":"10.1186/s12887-025-05656-y","vorDoiUrl":"https://doi.org/10.1186/s12887-025-05656-y","workflowStages":[]},"version":"v1","identity":"rs-4432616","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4432616","identity":"rs-4432616","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}