Parenting app to support socio-emotional and cognitive development in early childhood: iterative codesign learnings from nine low-income and middle-income countries

Abstract

Objective

Many children in low-income and middle-income countries are disadvantaged in achieving early developmental potential in childhood as they lack the necessary support from their surroundings, including from parents and caregivers. Digital technologies, such as smartphone apps, coupled with iterative codesign to engage end-users in the technology-delivered content development stages, can help overcome gaps in early child development (ECD). We describe the iterative codesign and quality improvement process that informs the development of content for the Thrive by Five International Program, localised for nine countries in Asia and Africa.

Design

Between 2021 and 2022, an average of six codesign workshops in each country were conducted in Afghanistan, Indonesia, Kyrgyzstan, Uzbekistan, Cameroon, the Democratic Republic of the Congo, Ethiopia, Kenya and Namibia.

Participants

A total of 174 parents and caregivers and 58 in-country subject matter experts participated and provided feedback to refine and inform the cultural appropriateness of the Thrive by Five app and its content. Detailed notes from the workshops and written feedback were coded and analysed using established thematic techniques.

Results

Four themes emerged from the codesign workshops: local realities, barriers to positive parenting, child development and lessons learnt about the cultural context. These themes, as well as various subthemes, informed content development and refinement. For example, childrearing activities were requested and developed to promote inclusion of families from diverse backgrounds, encourage best parenting practices, increase engagement of fathers in ECD, address parents’ mental well-being, educate children about cultural values and help bereaved children with grief and loss. Also, content that did not align with the laws or culture of any country were removed.

Conclusions

The iterative codesign process informed the development of a culturally relevant app for parents and caregivers of children in the early years. Further evaluation is required to assess user experience and impact in real world settings.

Correspondence to Dr Mafruha Alam; [email protected]

Strengths and limitations of this study

• This study used an iterative codesign process to inform the development of culturally relevant and appropriate content for an early child development app in selected low-income and middle-income countries in Asia and Africa.

• Purposive sampling through in-country partner organisations was practical for generating data from end-users.

• Inclusion of translators during data collection empowered participants to communicate in their own language.

• Internet lag during Zoom-supported workshops caused disruption in data collection.

• Recruitment bias including poor representation of participants from rural communities and low socioeconomic background, and male caregivers may have limited the generalisability of the findings.

Introduction

The first 5 years of a child’s life are a crucial window for promoting and protecting development, as adversities during this time may persistently undermine later developmental milestones.¹ However, more than one-third of 3-year-old and 4-year-old children in low/middle-income countries (LMICs) do not attain the basic cognitive and socio-emotional skills.¹ This led to the United Nations (UN) Sustainable Development Goal (SDG) 4.2, aiming to improve the proportion of under-5 children that are on track for health, learning and psychosocial well-being by 2030.²

Nurturing care is defined as a safe home environment supported by parents, caregivers and extended family members to respond to children’s health and nutritional needs as well as support their early learning and engagement that is responsive, emotionally supportive and developmentally stimulating.^{1 2} Child development is a fundamentally maturational, iterative process that requires an enabling environment and nurturing care to help children reach their developmental potential for academic, behavioural, socio-emotional and economic success.¹ In the early years, nurturing care interventions can reduce the negative impact of disadvantages associated with low socio-economic status on brain development and significantly improve early child and later adult outcomes.^{1 2}

The core components of nurturing care include behaviours, attitudes, and knowledge regarding caregiving (eg, hygiene, feeding), stimulation (eg, talking, singing, playing), responsiveness (eg, early bonding, secure attachment, trust and sensitive communication) and safety (eg, routines, protection from harm).^{1 2} Although low-cost home activities such as storytelling, singing, and playing with household objects can benefit children’s learning, there are significant disparities in engagement in such activities by country and wealth quintile.^{1 3} This suggests a need for global interventions to improve awareness among parents and caregivers about the importance of early child development (ECD).^{1 3} To that end, parenting programmes can provide caregivers with the information they need to create an engaging environment as well as to manage child behaviour, support socio-emotional development, and reduce child abuse and neglect.^{1 4 5}

Digital technologies are an effective way to educate parents and caregivers, including those in LMICs, about the importance of ECD. Increasingly, digital tools are being deployed in remote settings to improve parents’ access to health information and behaviour change interventions.^6–11 According to the International Telecommunication Union, in 2021 about 95% of the world population was within range of a mobile broadband network (3G or above) and 63% used the internet.¹² Mobile phone subscriptions have boomed due to affordability and improvements in infrastructure and network connectivity. Indeed in 2021, there were 67% unique mobile phone users worldwide with 53% accessing mobile internet (of which 58% access a 4G connection).¹³ Acknowledging the power of connectivity, the Global Observatory for eHealth of the WHO emphasised the use of mobile phones for health purposes (ie, mHealth), especially in LMICs where there is a health workforce shortage.¹⁴ Furthermore, the UN General Assembly highlighted the use of Information and Communications Technology in the 2020 SDG agenda to accelerate human welfare worldwide.¹⁵ Moreover, the COVID-19 pandemic highlighted the importance of digitising health systems and support services to address health challenges remotely.¹⁶

For better adoption and knowledge transfer, mHealth supported ECD programmes in LMICs must include culturally relevant content, address linguistic diversity, offer alternative modes of content delivery, and cater to the needs and skills of the target parents and caregivers.^17–21 To that end, the codesign process improves usability and adoption by engaging the end-users (eg, parents, caregivers) as active partners in the development process, including idea generation, prototyping and iterative feedback.^22–24

Thrive by Five

Minderoo Foundation’s Thrive by Five International Program aims to empower parents and caregivers with the knowledge they need to support the healthy development of children in the first 5 years. In particular, it seeks to ensure universal access to culturally appropriate and relevant parenting information regardless of region, socio-economic status, literacy, gender or other barriers through strong partnerships with in-country organisations.^{24 25} The Thrive by Five app and its content are free of charge to parents and caregivers of participating countries. The app functionality and content are developed, refined and finalised based on iterative feedback from stakeholders (ie, parents, caregivers and local subject matter experts) through a participatory codesign approach.

As described in detail in Crouse et al, the Youth Mental Health and Technology Team from the University of Sydney’s Brain and Mind Centre is responsible for the development of the programme content.²⁶ The content is underpinned by a scientific framework highlighting key neurobiological systems (ie, stress-response, oxytocin, learning, fear-arousal-memory and circadian systems) that support a child’s socio-emotional and cognitive development and are organised under five domains, namely Cognitive Brain or ‘Play’, Social Brain or ‘Connect’, Language and Communication or ‘Talk’, Identity and Culture or ‘Community’, and Physical Health or ‘Healthy Home’ (figure 1). The primary content, referred to as collective action (CA), comprises two components: (1) ‘The Why’, which provides scientific information about key aspects of ECD (figure 2); and (2) childrearing activities that parents, extended family and the broader community can engage in to support the child’s development at different ages.

Figure 1. Collective actions library in the Thrive by Five app, featuring five domains. Source: Minderoo.

Figure 2. Example of a new collective action ‘Showing gratitude’ with ‘The Why’ and childrearing activities that emerged during the codesign workshops in Namibia. Source: Minderoo.

Identified through a comprehensive literature review and in consultation with local subject matter experts, the childrearing activities include examples of local children’s games, stories and authors, dances, songs, foods, festivals, and national or cultural holidays to help the content feel approachable and familiar to parents. Further, the content is translated into the major languages of each country where it is implemented. Importantly, once downloaded, the app works offline, ensuring that parents can continue to access the content without internet connectivity. Additionally, all content is audio recorded to allow parents to listen to the content if they have low levels of literacy or prefer not to read the text.

Aim

In this paper, we aimed to provide an overview of the codesign process and adaptation of the app content to the cultural context in nine selected countries: Afghanistan, Indonesia, Kyrgyzstan, Uzbekistan, Cameroon, the Democratic Republic of the Congo (DRC), Ethiopia, Kenya and Namibia.

Methods

Codesign workshops

The codesign process for the Thrive by Five app followed an iterative Research and Development (R&D) cycle in alignment with the Medical Research Council’s Framework for complex interventions.^{24 27} The R&D cycle explicitly positions end-users as empowered participants in all stages from design and development through to implementation and evaluation.²⁴ The full R&D cycle is described in the protocol published elsewhere.²⁴

Between 2021 and 2022, a series of 2-hour codesign workshops were held over 4 weeks consecutively in each of the nine countries. On average, this included 3-4 workshops with parents and caregivers and 2 workshops with in-country subject matter experts. The proof-of-concept app and content were tested in Afghanistan and Indonesia where the participants engaged with a beta version of Thrive by Five naturalistically (ie, in a manner of their choosing) for a minimum of 1 week. Subsequent to those countries, an initial test version of the app was developed for each country; however, unlike Afghanistan and Indonesia, participants and experts were not able to test the app prior to the workshops.

Minderoo Foundation as the lead organisation for this work and the funder of this research both selects target countries and identifies in-country partner organisations to provide support, guidance and expertise for the duration of the project. Using purposive sampling, the in-country partners recruited all the participants in nine countries through word-of-mouth, government and non-government organisations, kindergartens and professional networks. It was anticipated that 4–6 participants at each workshop would generate adequate data.²⁴

Typically, each workshop consisted of two sections. The first half focused on the technical aspects of Thrive by Five, including a walkthrough of the app, user testing (only when Minderoo Foundation staff were facilitating on the ground), and feedback on the look, feel and functionality of the app. The second half provided parents, caregivers and subject matter experts with the opportunity to critique the initial content as well as to reflect on their culture and values, parenting practices, expectations and parenting challenges. The workshops were cofacilitated by representatives from the University of Sydney, Minderoo Foundation and BBE (the technology provider building the app) in collaboration with representatives from the in-country partner in each country. The workshops were conducted via Zoom, with on-the-ground facilitation provided by Minderoo Foundation in Kyrgyzstan, Uzbekistan, Namibia, Ethiopia and Kenya.²⁸ Wherever required, verbatim translation services were provided to allow participants to communicate in their preferred languages. Apart from the codesign workshops, in-country subject matter experts were also able to review the content script of the app and provide written feedback.

Prompted discussion questions

A sample of open-ended, prompted discussion questions is provided in box 1. Typically, the questions inquired about cultural norms and values around childrearing and parenting; parenting challenges and information sought; parenting roles, strategies and practices, including how these may differ based on gender, socio-economic status and region; the role of other caregivers and community in childrearing; local examples of children’s activities and traditional games; parents’ concerns about children’s development; parents’ work schedules and engagement with children; socioeconomic challenges that influence ECD; and parent and child mental well-being.

Box 1

Sample discussion questions asked during the codesign workshops

• What values and morals do you teach your children?

• How do children learn about their culture and traditions?

• What behaviours are expected of young children?

• How do under-5 children socialise?

• What skills should children learn by the age of 5?

• How do you manage your children’s emotions and behaviour?

• Could you talk about activities that children do before they go to bed?

• What does a typical day look like for parents (weekdays and weekends)?

• What does a typical day look like for under-5 children (weekdays and weekends)?

• Who looks after children during the day and before they go to bed (multigenerational vs nuclear family, rural vs urban family)?

• What are your children’s favourite games and activities?

• Are there any community events/celebration you attend with your children and family?

• How are children raised in urban and rural areas?

• What are the traditional ways of parenting?

• Anything that you (contemporary parents) are doing differently from your parents?

• What information do new parents look for?

• Are there any gaps in parental knowledge, myths or false information about parenting and child development?

• Do you have any concerns or challenges (relevant to child development or parenting) that we should address through this app?

• Is there any specific support or content parents would want from this app?

• Are there any issues that would prevent parents/caregivers from using the app?

Data analysis

The workshops were recorded via Zoom and detailed notes were taken by two scribes from the University of Sydney research team, including select verbatim transcription of dialogue of particular relevance to the codesign. Interpretation of the qualitative data from the workshops followed established thematic techniques (ie, inductive reasoning).²⁹ All raw data were reviewed and checked across all participants by the research team to develop a coding framework outlining all key concepts. Initial codes were reviewed, discussed, revised, consolidated and further specified to develop the project codebook over an iterative process of coding conducted by four researchers (MA, AP, VL, ME) and supported by workshop debriefing discussions with the broader research team (MA, AP, HML, ME, VL, AY, CW, GC, GH, MS-N, JC). Subsequently, the majority of the data was coded in NVivo12 software (QSR International) using this framework by two researchers (MA, AP) with additional contributions from ME and VL.³⁰ The coding followed an established iterative process of reading, coding and exploring the pattern and content of coded data, followed by reflection and discussion to reach consensus. Further, MA, AP and HML reviewed data from the nine countries for similarities and combined findings under themes and subthemes.

Patient and public involvement statement

The participants were involved with the programme throughout the content development and refinement process. They provided feedback on the initial content that was developed by the research team of the University of Sydney and helped localise the content to their cultural context. Study outcomes will be made available to participants via the in-country partners on request.

Results

Participants

A total of 174 parents and caregivers (109 mothers, 59 fathers, 5 grandmothers and 1 uncle) and 58 in-country subject matter experts participated in 54 workshops in nine selected countries between 2021 and 2022. Table 1 provides background information on the parent and caregiver participants. All participants came from LMICs; however, varying levels of diversity were noted within the country-specific groups. For example, parent and caregiver participants came from low-income, lower-middle-income and upper-middle-income households in Indonesia, DRC, Ethiopia, Kenya and Namibia. Additionally, there was diversity in literacy and digital skills of participants in these countries, whereas some were illiterate, and others completed high school or received tertiary education. However, there was less diversity among the participants in Afghanistan, Kyrgyzstan, Uzbekistan and Cameroon as they represented middle-income and upper-middle-income households and attained higher education. Participants’ occupations included paid employment in government and private companies, small and large businesses, while others noted they were unemployed and/or stay-at-home mothers. Parents’ and caregivers’ ages ranged between 20 and 55 years and the children they cared for ranged in age from 7 months to 21 years, with the majority being younger than 5 years old. One participant reported that she was pregnant and expecting her first child.

Table 1

Background information of participants (parents and caregivers) (N=174)

Country	Parents/caregivers (n)	Male:female ratio within each country	Average no. of children per family	Region(s)
Afghanistan	32	5:3	2.7	Kabul
Indonesia	20	1:4	2.2	North Sumatera, West Sumatera, East Java, East Nusa Tenggara and Daerah Istimewa Yogyakarta
Namibia	20	2:5	2.5	Oshana, Khomas
Kenya	21	2:1	3.4	Nairobi, Mombasa and Kisumu
Kyrgyzstan	22	1:10	1.8	Bishkek
Uzbekistan	15	1:4	2.0	Tashkent
Democratic Republic of the Congo	17	4:5	5.8	Kinshasha, Uvira
Cameroon	14	1:6	3.1	North, north-west, far north, centre, south, south-west, east and west
Ethiopia	13	1:12	1.0	Addis Ababa

The in-country subject matter experts had varied professional qualifications and occupations, including ECD specialist, clinical psychologist, teacher, medical doctor, nurse, dentist, disability policy specialist, social scientist, clinical biologist, social worker, media and communication expert as well as government employees of the representative countries.

Feedback and adaptation

This section presents the themes and subthemes that emerged primarily from the analysis of feedback given during the workshops with the parents, caregivers and experts and provided in the experts’ written feedback on the CA library. Table 2 demonstrates the changes made to the content based on the themes and subthemes identified.

Table 2

Examples of feedback on the content and changes made

Themes	Subtheme	Feedback	Implicated countries	Changes made to the content
Local realities	Understanding diversity	Experts requested to include activities that can be done by low-income families who lack resources	DRC, Namibia	Updated content on children’s activities and food to include resources available to them. Activities that could be done during ‘breakfast’ and ‘dinner’ were replaced with ‘morning’ and ‘night’ as some families cannot provide multiple meals per day
	Aligning with local policies	Experts requested to exclude activities that are prohibited according to the law of the country	Afghanistan	Seven CAs were removed that involved music and dancing
Barriers to positive parenting	Conflicting parenting approaches	Parents requested strategies to be reasonable with children when they get frustrated or do not behave appropriately	Ethiopia, Kenya, Namibia	A new CA titled ‘Positive behaviour management’ was developed and included in the library
		Parents noted that consistency among parents is a challenge (ie, one parent may undermine the decisions of another)	Cameroon	A new CA titled ‘Raising children as a team’ was developed addressing the benefits of parents being consistent in their parenting practices
		Parents requested content to address the conflict between traditional strict and contemporary permissive parenting strategies	Kyrgyzstan, Uzbekistan, Ethiopia	A new CA titled ‘Traditional and contemporary parenting’ was included
	Gender	Experts requested typically male-oriented activities (eg, learning to count, playing football, riding a tricycle and climbing a tree) within the first set of CAs to better engage male users with the app	Kenya	No content changes were made. The research team highlighted the importance to consider how this approach to presenting the content might further reinforce gender roles and stereotypes by assigning a gender to specific activities. Wherever possible instructions were changed from ‘you’ to ‘the whole family, parents, fathers, grandparents, older siblings, etc’
	Unmet parental well-being	Parents, especially new mothers expressed their struggles to cope with ‘baby blues’ and requested content	Kenya	A new CA titled ‘Coping after childbirth’ was developed to support young mothers and fathers to cope with their parenthood
	Role of multiple caregivers	Experts requested that the activities further consider supporting caregivers of abandoned or bereaved children	Cameroon, Kenya	A new CA (titled ‘Fostering a child’) supporting families who are fostering or caring for a non-biological child was added
		Parents requested content to involve older siblings for childrearing when parents are at work	DRC	No new CA was developed. It is important to note that the Thrive by Five app considers parents and adult caregivers as the primary target audience for the content and does not promote underage children to be the main user of the app
Child development	Skills and activities	Parents requested content to help children to be cooperative from an early age	Ethiopia	A new CA titled ‘Motivating children to cooperate’ was added to the library
		Experts suggested to include local activities (eg, solving riddles) that would develop children’s problem-solving skills	Ethiopia	A new CA titled ‘Riddles help children learn’ was developed where children are encouraged to solve riddles
		Experts suggested content to encourage parents to participate in children’s imaginative play and foster bonding between parents and children	Ethiopia	An additional activity was added in the CA ‘Imaginative free play’ indicating parents’ active participation
	Managing screen time	Parents and experts expressed concerns about children’s sleep as parents allow children to take gadgets to bed	Afghanistan, Indonesia	New CAs titled ‘Screen time’ and ‘Lights out’ were included informing parents about the negative impacts of excessive screen time on children’s psychosocial well-being and motor and cognitive development with suggestions of alternative activities (eg, reading from books)
	Building resilience	Experts requested information to support children who have lost parent(s) due to HIV/AIDS	Kenya	A new CA titled ‘Dealing with loss’ provides information to caregivers to support children with grief and loss
		Experts requested content to support children who were impacted by abuse, violence and neglect in conflict areas	DRC	A new CA titled ‘Building resilience’ was developed and incorporated into the app
		Parents requested content about helping older children adjust to the arrival of a new sibling	Afghanistan	A new CA titled ‘Welcoming a new sibling’ was included
	Disability	Experts requested for diagnosis of clinical symptoms or disability through the app and customised support to families as per their need	Almost all countries included in the study	The Thrive by Five app is not a diagnostic tool; a disclaimer about the scope of the app is planned. Although it is beyond the scope of Thrive by Five to provide customised content for children with disability, it is likely that parents could still make use of many of the activities in the app, noting that some adjustments or accommodations may be required
	Staying safe	Parents requested information to increase awareness about unsupervised children meeting fatalities (burning, road accidents) at home and outside due to a lack of safety measures	DRC	A new CA titled ‘Safety first’ was developed to help parents and adult family members including older siblings take safety measures at home and outside to prevent children from falling victim to accidents
Lessons learnt	Values and norms	Parents and experts requested content regarding children learning to respect diversity in their community (including disability)	Kenya	A new CA titled ‘Celebrating diversity’ was developed and included
		Parents highlighted the need for children to appreciate what they have and in turn to recognise that others around them may not be as fortunate	Namibia	A new CA titled ‘Showing gratitude’ was developed and included

CA, collective action; DRC, Democratic Republic of the Congo.

Theme 1: local realities

Understanding diversity

Rich feedback emerged in the workshops to make the content inclusive and adoptable by all, irrespective of their socioeconomic status. Requests were made to include activities that can be done by members of low-income households with limited resources. For example, CAs in Namibia were updated to remove references to food or vegetables that are not available in local markets or out of reach of low-income households. In countries comprised of multiple significantly distinct ethnic communities and religions (eg, Cameroon, Namibia), it was recommended that examples of festivals or activities specific to certain communities be removed from the content so as not to exclude those who did not engage in such celebrations. Further, it was suggested that a CA about breast feeding benefits acknowledge the challenges of working mothers who cannot exclusively breast feed. Participants stressed that the CA should be encouraging rather than generating concerns among young mothers about their inability to perform the best practices.

Aligning with local policies

The in-country experts noted that working together with the government was critical to ensure that the content aligned with the local ECD framework and policies of the country. As such, involving representatives from authorised agencies in the codesign process was essential to shaping the content. For example, the workshops in Namibia were enriched by representatives from relevant government ministries (eg, Ministry of Gender, Ministry of Education) and partnering organisations involved with the implementation and monitoring of national ECD frameworks.^{31 32} It is also critical to determine if the laws of a country forbid any of the recommended activities; for example, CAs that included public engagement in music and dancing were removed for the Afghan context.

Feasibility of the activities

Understanding the local day-to-day activities of parents and how they will use the CA is crucial. Participants and in-country experts suggested to keep the information simple, concise and attention-grabbing. Specific feedback included keeping the app ‘lightweight’ and providing examples of activities that can be done in conjunction with regular caregiver responsibilities without much effort or scheduling.

Theme 2: barriers to positive parenting

Conflicting parenting approaches

The importance of conscious and positive parenting strategies was voiced across all workshops; a ‘friendly’ relationship was deemed helpful to raise self-assured children rather than a strict approach. However, parents opined that permissive parenting may not be favoured by elderly family members in multigenerational households who also take part in childrearing. Indeed, additional content was added in response to parents expressing difficulties resolving tensions between traditional and contemporary parenting approaches. For the most part, although contemporary parents respected traditional parenting practices, they rejected harsh punishments and looked for new ways to manage children’s behaviour. To that end, the scientific information (ie, ‘The Why’) was received favourably for behaviour management. Further, parents highlighted that it is difficult to discipline children when one parent overrides another’s decision. Hence, a new CA was developed to inform parents about the ‘united front’ parenting approach.

Unmet parental well-being

Parental stress, stress management and related social support were discussed frequently during the workshops as parents and in-country experts acknowledged that parents may transfer stress to their children and act quickly with harsh punishments as a result.^{33 34} Reported major contributors to stress were poverty, single motherhood, challenges associated with living in slums, informal settlements, conflict areas, and crowded places, lack of resources, and the impact of the COVID-19 pandemic on employment and lifestyle in general. Although mothers were indicated to be the primary caregivers of young children, few supports were available to them. New CAs were developed to inform parents about the importance of their mental well-being and resources to find support (eg, doctors).

Gender

Throughout all the workshops, parenting was considered to be a woman’s role and, thus women were expected to be the primary users of the app. Whereas women were described as being the ones to handle minor childrearing issues and to be more understanding of misbehaviour and mistakes, men typically managed more serious misconduct or disobedience and dispersed stern discipline with less thoughtfulness. Father’s involvement was considered essential for teaching stereotypically masculine skills to boys, while mothers taught girls skills commonly perceived as feminine. Despite well-established gender roles, participants requested information to better involve fathers in childrearing practices from an early age and reduce the childcare burden on mothers. To that end, the CAs were revised to further emphasise the involvement of all family members including fathers.

Role of multiple caregivers

Participants noted that childcare was often shared with extended family members (ie, grandparents, aunties) in multigenerational households as well as with nannies, maids (ie, resident nannies) and day-care centres, particularly in urban areas. Often, when urban parents migrated for work, children were sent to live with their extended family members in rural areas. Parents felt that it was important to be able to prescribe how they wanted their children to be raised, disciplined and rewarded by another caregiver in their absence. Further, childrearing information was requested for caregivers in African countries where foster care is a common practice.^{35 36} To that end, a new CA was added to support parents fostering children. Also, there were requests to include a CA for sibling care as it is common for older siblings to look after young children when parents are at work. However, Thrive by Five app does not consider children to be the main user of the app, hence, no content was developed specifically for older siblings.

Theme 3: child development

Skills and activities

The workshops enabled parents’ interests in fostering strong vocabulary and multilingual, interpersonal and motor skills in young children. Specifically, parents perceived ‘multilingual children’ as more adaptive and suggested that they learn languages faster when individual caregivers communicate with them in unique languages consistently (eg, one speaks English and another speaks Amharic). This feedback was incorporated into the library of CAs.

The workshops captured descriptions of the typical social activities of children in each country that, in turn, informed the CAs. For example, a new CA was created to encourage children to engage in household and communal activities with others. Updated CAs emphasised the importance of children’s play for motor skill development and bonding with parents and peers. While school readiness is not the primary focus of the app content, some CAs promote reading, storytelling habits and numerical skills of children. Further, requests to develop problem-solving skills in children resulted in the integration of local logical games (eg, child-friendly riddles in Ethiopia) in the CA library. Examples of local songs, games and activities were collected throughout the workshops to localise the content to each country.

Physical wellness

Children’s physical fitness and development were consistently one of the major concerns of parents. Requests for information relating to children’s physical wellness are reflected in the existing CAs addressing nutrition, complementary feeding practices and strategies to make mealtime enjoyable for children. However, there were some out-of-scope requests for information to track child vaccinations and developmental milestones which are better suited to longer-form articles outside of the app.

Building resilience

Participants noted that children experienced anxiety when there was a change in their physical environment, such as the arrival of a new sibling, or more marked trauma when faced with economic hardship or the death of a household member. In some instances, orphaned children required special support from caregivers to overcome trauma.^{37 38} Further, parents felt that children need to be trained on standing up for themselves when they are bullied. To that end, new CAs were included to support children in overcoming grief and loss and present strategies for parents and caregivers to comfort children when they are afraid, feeling out of place or experiencing ‘big’ emotions.

Disability

Participants discussed the needs of children with disability at length. Children with disability were often excluded from mainstream education and parents navigated through the existing systems to support their needs. Requests were made to customise the activities based on individual needs of children. However, providing person-centric solutions is beyond the scope of the app and hence no changes were made to the CAs.

Staying safe

Risks to child safety and the potential for fatalities were discussed in the workshops. For example, working parents in the DRC reported that unsupervised children often gathered along the main road due to a lack of safe common places for them to play and in turn encountered road accidents. Additionally, children hurt themselves with electricity, fire or sharp objects when trying to prepare food. Further, children fell victim to unsafe adults in cases of abuse and abduction. As such, participants noted a need to educate parents and caregivers about safety strategies as well as train young children about unsafe behaviour. New CAs were developed in response to these needs.

Managing screen time

Participants were concerned about children’s increasing usage of digital gadgets as parents lacked strategies and resources to engage them in creative activities such as playing, reading and storytelling. Excessive screen time can have a negative impact on children’s sleep-wake cycle (when used at night), parent–child interaction and behaviour management.^39–42 As such, new CAs inform parents about the potential negative impacts of excessive screen time for young children and provide strategies to engage children in alternative activities.

Theme 4: lessons learned about the cultural context

Values and norms

During the workshops, the CAs were appreciated as a gateway to promote good behaviour, values and norms among young children. Universally, parents wanted to instil some behavioural traits among children including kindness, humility, empathy, the ability to share and respect for others. Being grateful and helping others were some other qualities that parents valued. Importantly, children were expected to acknowledge and respect cultural identity and diversity. To that end, new CAs were included to help impart gratitude, respect, and appreciation of diversity in children.

Community involvement

In many participating countries (eg, Uzbekistan, Ethiopia, Kenya, Namibia), the popular adage ‘It takes a village to raise a child’ emerged as salient. Relatives and neighbours played a significant role in childcare when parents were busy and provided young parents with parenting advice. Further, children socialised with peers and neighbours around communal events such as birthdays, funerals, weddings, new year celebrations, religious festivals and prayers. However, participants noted that children from urban areas were losing touch with the neighbourhood kinship and were less likely to develop a sense of cultural belongingness compared with their rural counterparts. As such, the CAs were revised to emphasise the importance of encouraging children to participate in shared rituals and traditions in their community and to learn about the history of their place and people.

Discussion

This study exemplified the iterative codesign, development and refinement of culturally appropriate content for a childrearing app designed to support healthy ECD with local stakeholders in LMICs. Codesign workshops with parents, caregivers and in-country subject matter experts captured valuable information about the cultural norms and values that underpin childrearing and parenting practices in the selected countries.

The findings suggest that the development and customisation of an app supporting ECD rely on four main themes: local realities, barriers to positive parenting, child development and lessons learnt about the cultural context. That is, the content needs to be (1) responsive to local realities to ensure that the information is inclusive and adoptable by the mass population and consistent with national policies and frameworks; (2) mindful of parenting challenges with regards to parenting practices, mental health and wellness, gender and caregivers roles; (3) suited to local child development needs such as to develop preferred skills, support children to overcome extraneous barriers and thrive, nurture health and reduce screen time; and (4) culturally relevant and appropriate by incorporating local values, norms and community practices.

Previous studies suggest that the involvement of end-users in family-centred research leads to positive health outcomes and increased satisfaction.^{43 44} Further, empowering end-users by involving them in the decision-making process from the initial design stage helps researchers identify the needs of the target population and address them iteratively.⁴⁵ In this study, open discussions during the workshops helped end-users and researchers engage in conversation to understand the cultural norms and practices around childrearing in individual countries. This novel study advances research by describing a mHealth-based parenting and ECD programme that included international end-users in an iterative codesign process, resulting in the endorsement, refinement and inclusion of more than 100 localised CAs in the library that parents and caregivers can access through the Thrive by Five app.

The codesign process resulted in numerous great ideas and suggestions; however, as is common in mHealth research, not all were suitable for implementation.⁴⁶ For example, researchers were conscious that older siblings cannot be addressed as primary users of the app for ethical reasons although they may play a significant role in childrearing when adults are not at home. Additionally, Thrive by Five has integrated lessons learnt from other mHealth services (eg, ‘Mobile Alliance for Maternal Action’ in Bangladesh, South Africa, Nigeria and India) and involved government partners and lead organisations in the codesign process to provide necessary support and linkages to support scalability.⁴⁷

In addition, emerging themes provided a snapshot of the current parenting challenges and ECD practices in LMICs. First, despite a lack of proper implementation of ECD policies in many countries, parents are keen to support the socio-emotional and cognitive development of their children. Indeed, parents’ positive attitudes towards supporting healthy ECD was effective for facilitating children’s engagement in early childhood education in India.⁴⁸

Second, childrearing is stereotypically considered a woman’s job. Often mothers are the sole caregivers of young children which can be both physically and emotionally challenging. In a cluster randomised trial in rural western Kenya, father’s interpersonal support to mothers and shared household decision-making were positively associated with children’s development,⁴⁹ highlighting the benefits of distributing childrearing among multiple caregivers.

Third, disintegration of multigenerational families has spiked a conflict between traditional and contemporary parenting in countries where childcare traditionally followed a collectivist approach.⁵⁰ Unlike their parents, contemporary parents are keen to adopt a permissive approach that encourages conversation and play activities with children, flexibility around their routines and rejection of punitive discipline. However, contemporary parents continue to face difficulties balancing ‘work and life’ as well as the contributions and advice provided by older generations (eg, grandparents).

Fourth, consistent with previous study findings the workshops highlighted a lack of services and information to support children with disabilities in the LMICs.⁵¹ Fifth, poverty, the COVID-19 pandemic and prolonged conflicts were reported as factors exacerbating parenting challenges, emphasising the need for a holistic approach.^52–54 That being said, an ECD app cannot be a ‘one-stop’ solution for all the factors that may hinder a child’s development. Acknowledging the scope of the Thrive by Five app and the aforementioned culturally relevant factors identified in this study, the app aims to only provide relevant and practical ideas that parents may try to implement and adapt at their discretion.

Limitations

The study has a few limitations. First, not all participants were able to test the app naturistically prior to the workshops. Hence, in some cases, the feedback on all the CAs was not based on critical user experience but rather a brief demonstration of the app during the workshops. Importantly, however, all content was thoroughly reviewed on paper by country-specific subject matter experts prior to the implementation of the app in each country.

Second, the participant recruitment strategy risks some bias in this study. Due to logistical issues, workshops in some countries were held in urban areas and, therefore, there was more representation of urban parents and caregivers compared with those from rural settings. Similarly, there was more representation of mothers and less representation of fathers and other caregivers (such as grandparents) in the workshops, though this was expected given that mothers are typically the primary caregivers worldwide.

Third, poor internet connectivity during the online workshops conducted via Zoom at times resulted in poor sound quality, impacting the accuracy and completeness of the field notes. Finally, the quality of the data was reliant on the translation services available during the workshops and often verbatim transcription was not possible. To that end, potential collaborations with local research organisations that work with rural populations can mitigate issues with data quality and ensure inclusion of a representative sample of rural participants in the future.

Conclusion

The workshops provided indispensable feedback on the content and helped integrate Thrive by Five in the local context before it is implemented. Discussion with parents and in-country experts helped improve the CAs with rich cultural context and parenting practices as a prerequisite for designing an app aiming to be culturally relevant and appropriate. Further, planned follow-up interviews with stakeholders, ongoing evaluation, iterative modification and testing of the app will ensure the app is updated and caters to the needs of local parents and caregivers. This study will inform the development of future apps for ECD and participatory research engaging end-users in resource-limited settings.

The authors would like to thank all in-country partners, including the Bayat Foundation (Afghanistan), The Indonesian Breastfeeding Mothers Association and The Indonesia Child Welfare Foundation (Indonesia), Roza Otunbayeva Initiative (Kyrgyzstan), The Innovation Centre (Uzbekistan), Kalkaba Development Initiative (Cameroon), Mission in Health Care and Development (DRC), Chapa project team (Ethiopia), Shining Hope for Communities (Kenya) and Development Workshop Namibia (Namibia), for recruiting parents, caregivers and subject matter experts to participate in the codesign process. Further, we would like to thank all the parents, caregivers and experts who contributed their valuable time and knowledge to support this project. In addition, the authors would like to thank the technology team at BBE for their ongoing efforts to develop, build and refine the Thrive by Five app. Finally, we are very appreciative of our partner, Minderoo Foundation, for their support of and contributions to this research. This research is being conducted by the University of Sydney’s Brain and Mind Centre pursuant to a 3-year agreement between the University of Sydney and Minderoo Foundation Limited (Minderoo). Minderoo Foundation’s Thrive by Five International Program targets parents and caregivers of children aged 0–5 years to support the cognitive and socio-emotional development and well-being of young children across diverse cultures. JC is supported by a National Health and Medical Research Council Emerging Leadership Fellowship (GNT2008197).

Data availability statement

No data are available. Not Applicable.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

This study involves human participants and was approved by the University of Sydney Human Research Ethics Committee (Protocol no: 2021/956). Participants gave informed consent to participate in the study before taking part.

Footnote

Contributors The University of Sydney’s Brain and Mind Centre is conducting the research pursuant to a 3-year agreement between the University and Minderoo. Minderoo’s Thrive by Five International Program aims to promote an increased understanding of and focus on the importance of early child development, with the Thrive by Five app serving as the flagship product of this program of work. This research was commissioned as a Quality Improvement activity to support a quality and engaging user experience and to inform the development of culturally appropriate and relevant content for parents and caregivers in each country in which the app is implemented. Prior to embarking on work in each country, Minderoo Foundation has governed the selection and collaboration of in-country partners to provide support for this project, including providing information about the local context, resourcing beta testers to test and review the app features, functions, and content, and setting up workshops. Importantly, the partners are a mix of governmental and non-governmental organisations; they are not research organisations nor are they formally affiliated academic institutions. All data for this study were collected through quality improvement and codesign workshops facilitated by the University of Sydney research team. These workshops were an important source of local cultural knowledge and were used to inform cultural aspects of the research for each country. As the in-country partners are not research organisations and as this is an ongoing global study involving numerous countries over more than 3 years, the overarching protocol design did not intend for local organisations to contribute to study conceptualisation and design, data collection, analysis, and interpretation, and manuscript preparation. However, the in-country partners are acknowledged for their support and partnership in the research activities. MA, HML, AP, ME, VL contributed to the design, conception, data collection, coding, analysis, interpretation and knowledge translation of data with subsequent contribution from JC, GH, YJCS, AY, GC, CW, MS-N. MA was the major contributor in writing the manuscript. AY, AP, GC, CW and MS-N contributed to notetaking and transcription of the workshops. Scientific oversight and guidance were provided by IBH and JT to ensure that all activities were conducted responsibly and in a culturally appropriate manner. All authors contributed to and approved the final manuscript. All authors are guarantors for this work.

Funding This study is supported by Minderoo Foundation’s Thrive by Five International Program (grant number: NA).

Competing interests IBH is the codirector, Health and Policy at the Brain and Mind Centre at the University of Sydney. The Brain and Mind Centre operates an early intervention youth service at Camperdown under contract with headspace. He is the Chief Scientific Advisor to, and a 3.2% equity shareholder in, Innowell Pty Ltd. Innowell was formed by the University of Sydney (45% equity) and PwC (Australia; 45% equity) to deliver the A$30 million (US$21.63 million) Australian Government-funded Project Synergy (2017–2020; a 3-year programme for the transformation of mental health services) and to lead the transformation of mental health services internationally through the use of innovative technologies. Importantly, Innowell has no role in the development, production or distribution of the Thrive by Five app. VL is a board member for Matana Foundation, a philanthropic organisation that provides funding to programmes for disadvantaged young people in Australia. She does not receive any financial benefit for this role.

Patient and public involvement Patients and/or the public were involved in the design, or conduct, or reporting, or dissemination plans of this research. Refer to the Methods section for further details.

Provenance and peer review Not commissioned; externally peer reviewed.

References

¹ Black MM, Walker SP, Fernald LCH, et al. Early childhood development coming of age: science through the life course. Lancet 2017; 389: 77–90. doi:10.1016/S0140-6736(16)31389-7

² Britto PR, Lye SJ, Proulx K, et al. Nurturing care: promoting early childhood development. Lancet 2017; 389: 91–102. doi:10.1016/S0140-6736(16)31390-3

³ Barros AJ, Matijasevich A, Santos IS, et al. Child development in a birth cohort: effect of child stimulation is stronger in less educated mothers. Int J Epidemiol 2010; 39: 285–94. doi:10.1093/ije/dyp272

⁴ Engle PL, Black MM, Behrman JR, et al. Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. Lancet 2007; 369: 229–42. doi:10.1016/S0140-6736(07)60112-3

⁵ Engle PL, Fernald LCH, Alderman H, et al. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. Lancet 2011; 378: 1339–53. doi:10.1016/S0140-6736(11)60889-1

⁶ Alam M, Banwell C, Olsen A, et al. Patients’ and doctors’ perceptions of a mobile phone-based consultation service for maternal, neonatal, and infant health care in Bangladesh: a mixed-methods study. JMIR Mhealth Uhealth 2019; 7: e11842. doi:10.2196/11842

⁷ Alam M, D’Este C, Banwell C, et al. The impact of mobile phone based messages on maternal and child healthcare behaviour: a retrospective cross-sectional survey in Bangladesh. BMC Health Serv Res 2017; 17: 434. doi:10.1186/s12913-017-2361-6

⁸ Murthy N, Chandrasekharan S, Prakash MP, et al. Effects of an mHealth voice message service (mmitra) on maternal health knowledge and practices of low-income women in India: findings from a pseudo-randomized controlled trial. BMC Public Health 2020; 20: 820. doi:10.1186/s12889-020-08965-2

⁹ Downs SM, Sackey J, Kalaj J, et al. An mHealth voice messaging intervention to improve infant and young child feeding practices in Senegal. Matern Child Nutr 2019; 15: e12825. doi:10.1111/mcn.12825

¹⁰ Coleman J, Black V, Thorson AE, et al. Evaluating the effect of maternal mHealth text messages on uptake of maternal and child health care services in South Africa: a multicentre cohort intervention study. Reprod Health 2020; 17: 160. doi:10.1186/s12978-020-01017-3

¹¹ Saronga NJ, Burrows T, Collins CE, et al. Mhealth interventions targeting pregnancy intakes in low and lower-middle income countries: systematic review. Matern Child Nutr 2019; 15: e12777. doi:10.1111/mcn.12777

¹² ITU. Global connectivity report 2022; 2022.

¹³ GSMA. The mobile economy 2022; 2022.

¹⁴ World Health Organization. mHealth: new horizons for health through mobile technologies: second global survey on eHealth. Geneva, 2011.

¹⁵ United Nations General Assembly. Transforming our world: the 2030 agenda for sustainable development. United Nations, 2015.

¹⁶ Whitelaw S, Mamas MA, Topol E, et al. Applications of digital technology in COVID-19 pandemic planning and response. Lancet Digit Health 2020; 2: e435–40. doi:10.1016/S2589-7500(20)30142-4

¹⁷ Harkness S, Super CM. Culture and parenting. In: Bornstein MH, ed. Handbook of parenting. New Jersey: Lawrence Erlbaum Associates, 2002: 253–80.

¹⁸ Mingebach T, Kamp-Becker I, Christiansen H, et al. Meta-meta-analysis on the effectiveness of parent-based interventions for the treatment of child externalizing behavior problems. PLoS One 2018; 13: e0202855. doi:10.1371/journal.pone.0202855

¹⁹ Morelli G, Quinn N, Chaudhary N, et al. Ethical challenges of parenting interventions in low- to middle-income countries. J Cross Cult Psychol 2018; 49: 5–24. doi:10.1177/0022022117746241

²⁰ Lachman JM, Sherr LT, Cluver L, et al. Integrating evidence and context to develop a parenting program for low-income families in South Africa. J Child Fam Stud 2016; 25: 2337–52. doi:10.1007/s10826-016-0389-6

²¹ Hall GCN, Ibaraki AY, Huang ER, et al. A meta-analysis of cultural adaptations of psychological interventions. Behav Ther 2016; 47: 993–1014. doi:10.1016/j.beth.2016.09.005

²² Bjerkan J, Hedlund M, Hellesø R. Patients’ contribution to the development of a web-based plan for integrated care-a participatory design study. Inform Health Soc Care 2015; 40: 167–84. doi:10.3109/17538157.2014.907803

²³ Clemensen J, Larsen SB, Kyng M, et al. Participatory design in health sciences: using cooperative experimental methods in developing health services and computer technology. Qual Health Res 2007; 17: 122–30. doi:10.1177/1049732306293664

²⁴ LaMonica HM, Crouse JJ, Song YJC, et al. Developing a parenting app to support young children’s socioemotional and cognitive development in culturally diverse low- and middle-income countries: protocol for a co-design study. JMIR Res Protoc 2022; 11: e39225. doi:10.2196/39225

²⁵ Minderoo. Thrive by five international program. 2022. Available: https://www.minderoo.org/thrive-by-five-international-program/

²⁶ Crouse JJ, LaMonica HM, Song YJC, et al. Designing an app for parents and caregivers to promote cognitive and socioemotional development and well-being among children aged 0 to 5 years in diverse cultural settings: scientific framework. JMIR Pediatr Parent 2023; 6: e38921. doi:10.2196/38921

²⁷ Skivington K, Matthews L, Simpson SA, et al. A new framework for developing and evaluating complex interventions: update of medical research council guidance. BMJ 2021; 374: n2061. doi:10.1136/bmj.n2061

²⁸ Zoom. Security guide. 2019. Available: https://d24cgw3uvb9a9h.cloudfront.net/static/81625/doc/Zoom-Security-White-Paper.pdf

²⁹ Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006; 3: 77–101. doi:10.1191/1478088706qp063oa

³⁰ QSInternational. NVivo12. n.d. Available: https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home

³¹ National integrated early childhood development policy. Namibia Ministry of Gender Equality and Child Welfare; 2007.

³² National early childhood development policy framework 2006. Kenya Ministry of Education; 2006.

³³ Brown SM, Doom JR, Lechuga-Peña S, et al. Stress and parenting during the global COVID-19 pandemic. Child Abuse Negl 2020; 110: 104699. doi:10.1016/j.chiabu.2020.104699

³⁴ McQuillan ME, Bates JE, Staples AD, et al. Maternal stress, sleep, and parenting. J Fam Psychol 2019; 33: 349–59. doi:10.1037/fam0000516

³⁵ Nsagha DS, Bissek A-CZ, Nsagha SM, et al. The burden of orphans and vulnerable children due to HIV/AIDS in Cameroon. Open AIDS J 2012; 6: 245–58. doi:10.2174/1874613601206010245

³⁶ Shiferaw G, Bacha L, Tsegaye D. Prevalence of depression and its associated factors among orphan children in orphanages in ilu abba Bor Zone, South West Ethiopia. Psychiatry J 2018; 2018: 6865085. doi:10.1155/2018/6865085

³⁷ Tanyi PL, Pelser A, Okeibunor J. HIV/AIDS and older adults in Cameroon: emerging issues and implications for caregiving and policy-making. SAHARA J 2018; 15: 7–19. doi:10.1080/17290376.2018.1433059

³⁸ Bergman AS, Axberg U, Hanson E. When a parent dies-a systematic review of the effects of support programs for parentally bereaved children and their caregivers. BMC Palliat Care 2017; 16: 39. doi:10.1186/s12904-017-0223-y

³⁹ Reyna-Vargas ME, Parmar A, Lefebvre DL, et al. Longitudinal associations between sleep habits, screen time and overweight, obesity in preschool children. Nat Sci Sleep 2022; 14: 1237–47. doi:10.2147/NSS.S363211

⁴⁰ Xie G, Deng Q, Cao J, et al. Digital screen time and its effect on preschoolers’ behavior in China: results from a cross-sectional study. Ital J Pediatr 2020; 46: 9. doi:10.1186/s13052-020-0776-x

⁴¹ Oflu A, Tezol O, Yalcin S, et al. Excessive screen time is associated with emotional lability in preschool children. Arch Argent Pediatr 2021; 119: 106–13. doi:10.5546/aap.2021.eng.106

⁴² Zhao J, Zhang Y, Jiang F, et al. Excessive screen time and psychosocial well-being: the mediating role of body mass index, sleep duration, and parent-child interaction. J Pediatr 2018; 202: 157–62. doi:10.1016/j.jpeds.2018.06.029

⁴³ Cypress BS. Family presence on rounds: a systematic review of literature. Dimens Crit Care Nurs 2012; 31: 53–64. doi:10.1097/DCC.0b013e31824246dd

⁴⁴ Aufegger L, Bùi KH, Bicknell C, et al. Designing a paediatric hospital information tool with children, parents, and healthcare staff: a UX study. BMC Pediatr 2020; 20: 469. doi:10.1186/s12887-020-02361-w

⁴⁵ Martin A, Caon M, Adorni F, et al. A mobile phone intervention to improve obesity-related health behaviors of adolescents across Europe: iterative co-design and feasibility study. JMIR Mhealth Uhealth 2020; 8: e14118. doi:10.2196/14118

⁴⁶ Thabrew H, Fleming T, Hetrick S, et al. Co-design of ehealth interventions with children and young people. Front Psychiatry 2018; 9: 481. doi:10.3389/fpsyt.2018.00481

⁴⁷ USAID. Lessons from country programs implementing the mobile alliance for maternal action programs in Bangladesh, South Africa, India and Nigeria, 2010–2016; 2018.

⁴⁸ Ghosh S, Steinberg H. Parents’ attitudes and unequal opportunities in early childhood development: evidence from eastern India. J Early Child Res 2022; 20: 413–30. doi:10.1177/1476718X221077170

⁴⁹ Garcia IL, Fernald LCH, Aboud FE, et al. Father involvement and early child development in a low-resource setting. Soc Sci Med 2022; 302: 114933. doi:10.1016/j.socscimed.2022.114933

⁵⁰ Chadda RK, Deb KS. Indian family systems, collectivistic Society and psychotherapy. Indian J Psychiatry 2013; 55: 299. doi:10.4103/0019-5545.105555

⁵¹ Smythe T, Zuurmond M, Tann CJ, et al. Early intervention for children with developmental disabilities in low and middle-income countries-the case for action. Int Health 2021; 13: 222–31. doi:10.1093/inthealth/ihaa044

⁵² Alonzo D, Popescu M, Zubaroglu Ioannides P. Mental health impact of the covid-19 pandemic on parents in high-risk, low income communities. Int J Soc Psychiatry 2022; 68: 575–81. doi:10.1177/0020764021991896

⁵³ Hamadani JD, Hasan MI, Baldi AJ, et al. Immediate impact of stay-at-home orders to control COVID-19 transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in Bangladeshi women and their families: an interrupted time series. Lancet Glob Health 2020; 8: e1380–9. doi:10.1016/S2214-109X(20)30366-1

⁵⁴ Bürgin D, Anagnostopoulos D, Vitiello B, et al. Impact of war and forced displacement on children’s mental health-multilevel, needs-oriented, and trauma-informed approaches. Eur Child Adolesc Psychiatry 2022; 31: 845–53. doi:10.1007/s00787-022-01974-z