Written by Rachel Perowne, PhD Student (UCL Centre for Behaviour Change)

Children’s interaction with the online world is a hot topic – recently, The Economist magazine asked whether smartphones are to blame for recent increases in the rates of suicide among girls [1]. This week, the Children’s Commissioner for England published a report evidencing the effect of pornography on harmful sexual behaviour among children and suggesting a link between exposure to pornography and children being given their own phones at younger ages [2].

I was 21 when I got my first mobile phone and over 30 when I got my first smartphone, but today’s children and young people are growing up in the digital world where the concept of a ‘brick phone’ or landline is alien, and smartphones are the norm. As technology plays an ever-increasing role in our lives, it’s not surprising to learn that children are acquiring smartphones at a younger and younger age. To illustrate, in 2018, 35% of 8–11-year-olds owned a smartphone [3] and this had risen to 60% by 2022 [4].

So how do parents make the decision to give their child a smartphone?

This question fascinated me – both as a parent with a son approaching 11 years old and as a researcher interested in young people’s wellbeing in a digital world. I could hear many of my friends and peers with children of a similar age debating what to do and I took the opportunity, whilst waiting for my PhD to officially begin, to examine this, with the support of my supervisor Prof Leslie Gutman.

Our study, published this month, on parents’ perspectives of their children’s smartphone ownership [5], involved interviewing 11 mothers and fathers of 9- to 12-year-old children and using the COM-B model to identify which elements of Capability, Opportunity and Motivation were influencing their decision making.

Our analysis identified a number of influencing factors across all three COM-B domains:

• The external environment was a key enabling factor in parents deciding to give their child a smartphone; parents see smartphones as an inevitable aspect of the modern world that can only be resisted for so long because ‘technology is everywhere’.
• Added to this, the pressure of peers being given a smart phones – the social opportunity – creates a ‘domino effect’ which then affects parents’ motivation, making them want to prevent their children being left out and help them build their social relationships.
• They also see advantages in being able to track their child’s movements and ensure they are contactable once they start travelling independently to and from school. ‘When they… go to school by themselves, then obviously I need to give the smartphone’. Hence the transition from primary school is a key time for many children being given a smartphone.
• However, parents are conflicted. They also have worries about their children entering the world of smartphones and the unfettered access to the internet that this can bring. ‘Having his phone in his room at night is a big worry for me’.
• They worry about the impact of social media, about bullying, about overuse and addiction but are sometimes unsure of what the real benefits and risks are. ‘I think there are certain risks and I think there are certain benefits but it’s all kind of in my own head’.

This uncertainty is understandable. Evidence is mixed on the impact of smartphones on younger children, with many recognising that smartphones can support learning and increase digital skills which are important for life in a technological world. At the same time, whilst causal linkages are hard to demonstrate, correlations are apparent between smartphones and sleep disturbance, anxiety and academic performance. It seems clear that young people are also particularly prone to Problematic Smartphone Usage (where usage interferes with daily life and activities).

So where to go from here?

The parents we spoke to were grappling with their decision-making. They felt that there was a lack of guidance and support for them in planning how and when to give their child a smartphone. This challenge is heightened because their own digital technology skills and knowledge are often inferior to their child’s, meaning that their efforts to control usage and access can be undermined by a tech-savvy child. Our paper discussed potential intervention strategies (using the Behaviour Change Technique Taxonomy (v1) [6] including:

• Restrictions such as having a recommended minimum age for smartphone ownership
• Guidance and support for parents preparing and planning to give a child their first smartphone
• Education from credible sources on the benefits and risks of smartphones for children
• Training in setting up appropriate controls on a child’s smartphone

Whether there is a role for regulation and restriction (such as age limits) of smartphones is a debate that rages. In either case, it seems clear that expecting parents to navigate this significant decision on their own is too much. Given the potentially lasting impacts of owning a smartphone for children, better guidance and support from authoritative, trusted sources are required.

[1] https://www.economist.com/graphic-detail/2023/05/03/suicide-rates-for-girls-are-rising-are-smartphones-to-blame [2] https://assets.childrenscommissioner.gov.uk/wpuploads/2023/05/Evidence-on-pornographys-influence-on-harmful-sexual-behaviour-among-children.pdf

[3] https://www.ofcom.org.uk/__data/assets/pdf_file/0024/134907/children-and-parents-media-use-and-attitudes-2018.pdf

[4] https://www.ofcom.org.uk/__data/assets/pdf_file/0024/234609/childrens-media-use-and-attitudes-report-2022.pdf

[5] Perowne, R., & Gutman, L. M. (2023). Parents’ perspectives on smartphone acquisition amongst 9-to 12-year-old children in the UK–a behaviour change approach. Journal of Family Studies, 1-19. https://www.tandfonline.com/doi/full/10.1080/13229400.2023.2207563https://www.tandfonline.com/doi/full/10.1080/13229400.2023.2207563

[6] Michie, S., Richardson, M., Johnston, M., Abraham, C., Francis, J., Hardeman, W., Eccles, M., Cane, J, & Wood, C. (2013). The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: Building an international consensus for the reporting of behaviour change interventions. Annals of Behavioral Medicine, 46(1), 81–95.

Over the past years, thanks to the innovation in technology, we can assist to the widespread devices aimed at monitoring behavioural and physiological data in real time. The way in which such devices collect the data is becoming ever easier and more reliable. Among them, activity trackers are very widespread and accessible. They are mainly based on GPS, tri-axial accelerometer or heart rate monitors. Often such monitoring systems are connected to or directly built-in to people’s smartphones in order to provide the user with useful and meaningful information about their physical activity. (more…)

By: Dr Mark Cobain, co-founder and director, Younger Lives Group

We’ve been asked to consider the question of what makes digital data valuable. Is it visualisation? Insight generation? Personalisation, behaviour change etc.?

The short answer is all of the above but the ‘value’ of data can only be clear when you know what question you want to ask?

Visualisation to highlight awareness for a campaign

A year ago, we published a map of ‘heart ages’ (a more understandable measure of ‘cardiovascular risk’ aimed at the public) across US states using analyses in collaboration with the US Centers for Disease Control. We revealed differences in heart age across different states that were exacerbated by race and education. It was published in the (CDC) ‘Vital Signs’ journal and led to widespread coverage and usage across the US media outlets and supported by our campaign site americanheartage.com where we created a colour coded visualisation representation of the country. It was a good example of how metrics that are scientifically valid and predictive need to be impactful and visual o the public to raise awareness through all forms of media.

Insight Generation

The data from our own digital heart age tools reveal more fine-grained insights about a variety of different public health issues that we feel are of equal importance. For example if we want to use digital tools to personalise health risks, do they actually reach those they are claimed to be for? What is the impact of missing user information on subsequent outputs? Do the gaps in information render recommendations irrelevant?

Having access to millions of first time users of the heart age tool in multiple countries we could analyse our data to help shed light on these questions and published the results in the Journal of Medical Internet Research two years ago. It was a smaller impact publication and not as widely covered as our CDC research. However, these are vitally important questions for digital health to answer. It’s vitally important to share more information about the impact of your program/product/service on users. For example, we discovered that users of the heart age tool were not the ‘worried well’ and had adverse risk profiles (10% smoked, the average BMI was overweight and blood pressure and cholesterol profiles were in line with population averages). However, (in some user sub-groups) missing information in the tool led to a degree of CVD risk misclassification and more often than not this was due to missing biometric data.

From insight generation to behaviour change

Insights such as this need not be a threat. We could align our business with the desire to solve these problems. The last thing we want is ‘false optimism’ (we want to stimulate lifestyle change, not falsely reassure those who need to). It’s just the opposite of what our tool is intended to do and shown to do in clinical trials. We’ve since made changes to tailor messages for people with missing information to get tested for an accurate heart age and partnered with organisations who can provide that service to them. Not all users however need full cholesterol tests and so it’s about matching the need to the right messages (and tracking the consequences over time)

What are the consequences for those working in digital health?

Providers of digital tools with a high user base have a duty to address issues of public health importance or risk being seen as damaging to population health. The good news is that their data can be used to address highly important questions AND to help their business grow by adopting new solutions. Instead of a threat, they can be an opportunity to drive collaboration between public health and digital health and an education for both sets of stakeholders.

Our business (Younger Lives Group) believes there is great value in developing health apps and sites founded on validated science (our background combines epidemiology, psychology and social marketing as well as digital), however it’s always a balance between the academic science, the user journey and analytics, in trying to avoid unintended consequences. Tracking use data is a requirement for that. We’ve learned a great deal on how to get it right as well as what to do when you get it wrong and if you want to learn more about how please visit us at youngerlivesgroup.com.

BIO: Dr Cobain has spent over 20 years working at the intersection of health psychology, epidemiology and digital health applications. He has worked across the foods and pharma industry as well as having been a research fellow in the Framingham Heart Study and is an honorary lecturer in preventive cardiology at Imperial College London. He also has a track record of publishing at this intersection in peer reviewed journals and acts as part of the editorial team for journals such as the American journal of health promotion. In 2008 he published the concept of ‘Heart Age’, which has now been adopted by the NHS and has collaborated with the CDC on its use in the United States to motivate lifestyle changes. He is also a director and co-founder of a health behaviour change company that specialises in the area of ‘healthy ageing’.

By: Dr Aileen McGloin, Communications Manager, Digital & Health, Marketing & Communications at safefood

On the island of Ireland we have a genetic make up that means we are more likely to have babies with neural tube defects. Predispositions like this are typical of any islanders. Another genetic nutritional issue for us is coeliac disease.

A couple of years ago, in contrast to decades of decreasing incidence, we saw the number of cases of Spina Bifida and other NTDs rising in both the Republic of Ireland and Northern Ireland. We now know that this is likely to be the result of changing food patterns over the course of our economic recession.

In an attempt to address this, public health bodies began reviewing our policies, including fortification and safefood, the government agency that addresses food safety and nutritional issues, was charged with developing a behaviour change campaign.

With limited time and resources, our job was to raise awareness of the issue and promote folic acid supplement consumption. We started by looking at all the key behavioural barriers:

• Relevancy – most women in the 18-45 year bracket are not planning pregnancies, those taking contraception think that it’s 100% reliable, women who had already had healthy pregnancy(ies) didn’t think they needed it and everyone enters pregnancy with an optimistic bias about the outcome for their baby.
• Confusion – that you can get enough naturally from food, or that food is already fortified.
• Cultural issues – taking folic acid is considered a ‘tell-tale’ sign (sexual activity and planning pregnancy)
• Practical issues – cost and inconvenience

In short, our job was to reach the unreachable and convince them of the inconvincible. We focused on increasing knowledge through education, changing attitude through persuasion and behaviour by enablement. We choose digital and social media as key channels for communicating with younger women. All the right nuts and bolts for a behaviour change campaign, right?

Not quite.

Successful digitally or socially led campaigns must create something fascinating and compelling that people want to share and talk about or use. We were rolling out the same health message that had been around for 20 years and we knew most women weren’t going to relate to it anyway. What I rarely hear spoken about at behaviour change conferences is creativity and how science must meet art if we are to be successful.

People love stories, they like to be entertained and they like to laugh. If we want to engage and influence behaviour via the channels that people use to do their daily business, talk to their friends or be entertained we have to be able to grab their attention first and see if they will engage with our message second.

That’s where our babies came in (video below). We used moving images of cute babies sharing wisdom that is usually the domain of the ‘Irish Mammy’. There was surprise and humour and charm.

So far we know that this meeting of art and science seems to be working. Over 95% of women know what folic acid is, what it does and who should take it. The proportion of those taking it has risen from 30% to 36% and over our first phase of the campaign, folic acid sales increased by 26%.

We have a long way to go yet though.

You can read more about it here:

http://adfx.ie/databank/reaching-the-unreachable-convincing-the-inconvincible.html

I’d really like to hear about other examples of behaviour change campaigns that have been rolled out via digital advertising and social media. What have you seen that you think works well?

BIO: Aileen McGloin is the Communications Manager, Digital & Health, at safefood. She’s a public health nutritionist with a particular interest in food-related behaviour. In the past she has worked in the food industry, academia and research. She has been with safefood for almost 8 years and now manages all aspects of safefood’s digital and social media communications. She lives in Co. Wicklow in Ireland and is married to a crime writer so thankfully loves books. Her daughter is 8 and wants to be a spy. She spins, walks and swims to stay healthy. Her vices are TV that is so bad it’s good and clothes.