Improving hand hygiene of young children with a digital intervention: a cluster-randomised controlled field trial.

Contagious diseases that affect young children place a great burden on them and their families. Proper hand hygiene is an important measure to reduce the disease burden, however, its implementation in day care centres is challenging. This paper introduces a digital intervention to support independent and good handwashing among young children. The intervention leverages animated instructions triggered by water and soap use, together with a symbolic reward shown to children on a screen during and immediately after handwashing. We tested the intervention in a pre-registered, cluster-randomised controlled field trial in 4 day care centres in Finland and Germany with 162 children over 42 days. The intervention increased soaping time, used as a proxy for handwashing quality, by 5.30 s (+ 62%, p < 0.001). The effect occurs immediately at the onset of the intervention and is maintained throughout the intervention phase.

Hand hygiene of kindergarten children-Understanding the effect of live feedback on handwashing behaviour, self-efficacy, and motivation of young children: Protocol for a multi-arm cluster randomized controlled trial.

Early implementation of interventions at a young age fosters behaviour changes and helps to adopt behaviours that promote health. Digital technologies may help to promote the hand hygiene behaviour of children. However, there is a lack of digital feedback interventions focusing on the hand hygiene behaviour of preschool children in childhood education and care settings. This study protocol aims to describe a study that evaluates the effectiveness of a gamified live feedback intervention and explores underlying behavioural theories in achieving better hand hygiene behaviour of preschool children in early childhood education and care settings. This study will be a four-arm cluster randomized controlled trial with three phases and a twelve-month follow-up by country stratification. The sample size is 106 children of which one cluster will have a minimum number of 40 children. During the baseline phase, all groups will have automated monitoring systems installed. In the intervention phase, the control group will have no screen activity. The intervention groups will have feedback displays during the handwashing activity. Intervention A will receive instructions, and intervention B and C groups will receive instructions and a reward. In the post-intervention phase, all the groups will have no screen activity except intervention C which will receive instructions from the screen but no reward. The outcome measures will be hand hygiene behaviour, self-efficacy, and intrinsic motivation. Outcome measures will be collected at baseline, intervention, and post-intervention phases and a 12-month follow-up. The data will be analysed with quantitative and qualitative methods. The findings of the planned study will provide whether this gamified live feedback intervention can be recommended to be used in educational settings to improve the hand hygiene behaviour of preschool children to promote health. The trial is registered with ClinicalTrials.gov (registration number NCT05395988 https://clinicaltrials.gov/ct2/show/NCT05395988?term=NCT05395988&draw=2&rank=1).

Instruments assessing nurse educator's competence: A scoping review.

AIM: The aim of this review was to synthesize the instruments that assess nurse educators' competence. DESIGN: A scoping review was conducted with the five-stage process informed by Arksey and O'Malley. REVIEW METHODS: The predetermined search strategy was used including an additional hand search. The studies were selected according to inclusion and exclusion criteria to answer the research questions followed: (1) "What instruments are used to assess nurse educators' competence?", (2) "How are the psychometric properties of nurse educators' competence instruments reported in the literature?". The thematic synthesis was used. DATA SOURCES: The literature search was conducted in January 2021 using the CINAHL, MEDLINE and ERIC databases from January 2000 to December 2020. RESULTS: Of the 1,567 articles searched through, 25 met the inclusion criteria. A total of 19 instruments with 10 areas of competence were identified. Typical competence areas were pedagogical and nursing competence. In addition, leadership in managerial competence was included in several instruments. However, the theoretical backgrounds of the instruments varied and the psychometric properties were reported in varied ways in reviewed studies. IMPLICATIONS FOR THE PROFESSION: This study provides evidence about the valid and comprehensive assessment of nurse educators' competence, as competent nurse educators promote excellence in nursing education. To assess a nurse educators' competence comprehensively, a variety of theoretical backgrounds of this competence and more than one instrument for the measurement need to be considered. The selection of the instruments to assess nurse educators' competence should be based on the selected theoretical background and use of valid measurements. REPORTING METHOD: This study was reported by following the reporting recommendations of the PRISMA extension for Scoping Reviews (PRISMA-ScR). PATIENT OR PUBLIC CONTRIBUTION: No Patient or Public Contribution was applied, since research design was a scoping review.

Supporting LGBTQ+ Students: A Focus Group Study with Junior High School Nurses.

LBGTQ+ students often miss the support and information they need in the school nursing, but little is known about junior high school (JHS) nurses' work with LGBTQ+ students. 15 JHS nurses were interviewed in focus groups about their perceptions of supporting LGBTQ+ students. Four interconnected themes were identified with inductive thematic analysis: (1) JHS nurses' professional identity and practice; (2) Recognition of sexual and gender diversity in school; (3) Family acceptance process; and (4) LGBTQ+ students as school nursing clients. JHS nurses self-identified as accepting professionals, but having limited skills, knowledge, and education needed in supporting LGBTQ+ students. Supporting LGBTQ+ students is a complex phenomenon, and to enhance JHS nurses' competence in providing care for these students, sexual and gender diversity needs to be included in evidence-based nursing information sources, covered in nursing education, and the school needs to be secured as LGBTQ+ safe place.

Promoting the health and wellbeing of children: A feasibility study of a digital tool among professionals.

The foundations of children's health and wellbeing are laid in early childhood. A gamified app (EmpowerKids tool) was designed to support professionals to have discussions with 6- to 12-year-olds from low-income families about their health and wellbeing. The aim of this feasibility study was to evaluate the usability and acceptability of the tool from the perspective of professionals in social, health and education settings. The study was conducted using a one-group post-test-only design. The usability data were collected using System Usability Scale and the acceptability data were collected using an open-ended questionnaire distributed to professionals (n = 24) in Estonia, Finland and Latvia. The data were collected during two phases. The tool was modified further on the basis of the results. The total usability scores were 82/100 (first testing) and 84/100 (second testing), indicating excellent usability. The answers related to acceptability were divided into four categories: suitability for the context; satisfaction and quality; attractiveness; modification needs. The professionals perceived that the tool helped them to build an overall picture of a child's health and wellbeing, and to gain information about the child's individual needs. The requirements for modification detected during the first testing were mostly related to difficulties with textual expressions and graphics. No major modification requirements were expressed during the second testing. The tool is considered feasible and may be used by professionals from different settings to support children's health and wellbeing. Further studies are needed to evaluate the effectiveness of the tool from the perspective of child outcomes.

Developing a Health Game to Prepare Preschool Children for Anesthesia: Formative Study Using a Child-Centered Approach.

BACKGROUND: Every year, millions of children undergo medical procedures that require anesthesia. Fear and anxiety are common among young children undergoing such procedures and can interfere with the child's recovery and well-being. Relaxation, distraction, and education are methods that can be used to prepare children and help them cope with fear and anxiety, and serious games may be a suitable medium for these purposes. User-centered design emphasizes the involvement of end users during the development and testing of products, but involving young, preschool children may be challenging. OBJECTIVE: One objective of this study was to describe the development and usability of a computer-based educational health game intended for preschool children to prepare them for upcoming anesthesia. A further objective was to describe the lessons learned from using a child-centered approach with the young target group. METHODS: A formative mixed methods child (user)-centered study design was used to develop and test the usability of the game. Preschool children (4-6 years old) informed the game design through playful workshops (n=26), and usability testing was conducted through game-playing and interviews (n=16). Data were collected in Iceland and Finland with video-recorded direct observation and interviews, as well as children's drawings, and analyzed with content analysis and descriptive statistics. RESULTS: The children shared their knowledge and ideas about hospitals, different emotions, and their preferences concerning game elements. Testing revealed the high usability of the game and provided important information that was used to modify the game before publishing and that will be used in its further development. CONCLUSIONS: Preschool children can inform game design through playful workshops about health-related subjects that they are not necessarily familiar with but that are relevant for them. The game's usability was improved with the participation of the target group, and the game is now ready for clinical testing.

LGBTQ+ Students' Experiences of Junior High School Nursing in Finland: A Qualitative Study.

Previous research shows that lesbian, gay, bisexual, transgender, queer/questioning, and other (LGBTQ+) students can experience substantial emotional- and health-related issues at school, but research into LGBTQ+ students' experiences of school nursing is limited. This qualitative study describes the experiences of Finnish LGBTQ+ students engaging with junior high school nurses. Data were collected from 35 LGBTQ+ students using an online survey tool comprising of a set of open-ended questions. Two interconnecting themes were identified following thematic analysis: (1) junior high school nurse engagement: a mixed or unsatisfactory experience and (2) LGBTQ+ students' needs for diversity-affirming junior high school nursing. Findings show that LGBQT+ students felt junior high school nurse engagement was often unsupportive with issues around their sexuality and gender identity. LGBTQ+ students expressed the need for diversity-affirming information and support in school settings. Further research from school nurses' perspective is needed to increase understanding of this topic.

The Association between the Preference for Active Play and Neurological Development in Toddlers: A Register-Based Study.

Active play is regarded as physical activity during early childhood. Physical activity has many benefits for children's physical and psychosocial health and wellbeing, as well as for their cognitive development. The aim of this study was to investigate associations between the preference for active play and neurological development in toddlers. The study was conducted as a register-based study, and the data were collected from a public-health clinic's electronic health records. The register data about active play used in this study were originally assessed by parents at home and by early years teachers at nurseries. Neurological development was assessed by the public health nurses in public child-health clinics. The data eligible for this study were available from 717 toddlers aged 2.5-3.0 years old (mean: 2.5 years ± 2 months). The majority of toddlers (85%) showed a preference for active play, both at home and at the nursery. The prevalence of delays in the neurological development of toddlers varied in different developmental areas (by 1-15%). Delays in gross motor competence, auditory perception, and self-help skills were associated with a lower preference for active play in nursery settings, but none of the neurodevelopmental items were found to be associated with toddlers' preference for active play at home. Nurseries need to encourage children to actively play and support their gross motor competence and self-help skills.

Encountering sexual and gender minority youth in healthcare: an integrative review.

AIM: To describe the encounters with sexual and gender minority (SGM) youth in healthcare based on the existing research. BACKGROUND: The development of sexual orientation and gender identity can create challenges in an SGM youth's life, and they may need support from health professionals. Heteronormativity has been recognised as a barrier to the identification of diversity in sexuality and gender, and no previous literature review has studied heteronormativity thoroughly. METHODS: An integrative review following Whittemore and Knafl was conducted. A literature search was systematically undertaken in six databases (PubMed/MEDLINE, CINAHL, Cochrane Library, PsycINFO, Eric, and Academic Search Premier). Finally, 18 research articles were included. Data were analysed deductively with the theoretical framework from Stevi Jackson's (2006) article to understand the role of heteronormativity in the healthcare of SGM youth. FINDINGS: The encounters with SGM youth consisted of two simultaneous themes. Heteronormative care included three elements: (1) the effect of heteronormativity on health professionals' competence to work with SGM youth, (2) false assumptions about SGM youth, and (3) the influence of heteronormativity on encounters with SGM youth. Diversity-affirming care included two elements: (4) the considerateness of health professionals towards SGM youth and (5) inclusive care of SGM youth. CONCLUSION: This review summarised how SGM youth were encountered in healthcare and how heteronormativity was affecting their healthcare. Furthermore, this review identified elements that supported diversity-affirming care. With diversity-affirming care, SGM youth may access the information and support they need from healthcare. Further research is needed about how diversity-affirming care can be applied to the healthcare of SGM youth and how elements of heteronormative care are occurring globally in the healthcare of SGM youth. The perceptions of transgender and other gender minority youth were under-represented in the studies and research needs to focus more on how they are encountered in healthcare.

Feasibility of mobile health game "Fume" in supporting tobacco-related health literacy among early adolescents: A three-armed cluster randomized design.

OBJECTIVE: New interventions supporting health literacy and a tobacco-free lifestyle in adolescence are needed to narrow the widening gap in existing health inequalities. Health games offer potential and could be utilized for example in school healthcare, but more research is needed to increase the understanding of the effects of game elements in health interventions. The aim of this feasibility study is to determine the short-term effectiveness of the tobacco-related mobile health game Fume and a non-gamified website in comparison with a no-intervention control group, regarding tobacco-related health literacy among 10-13-year-old early adolescents. In addition, we compare the demand for and acceptability of Fume to that of the website. METHODS: In total, 151 early adolescents participated in this single-blinded, three-armed cluster randomized trial. The participants from three municipalities in southwest Finland were randomly allocated between a group with access to the health game Fume (n = 61), a group with access to the website (n = 47), and a group with no intervention (n = 43). The intervention groups first participated in a 20-min training session with Fume/the website, and then had two weeks to use Fume/the website based on their own interest. Short-term effectiveness was measured by primary (anti-smoking self-efficacy) and secondary (smoking outcome expectations, attitudes towards tobacco use, tobacco-use motives, motivation to decline tobacco use in the future, and knowledge about tobacco) outcomes derived from the theory-based determinants of tobacco-related health literacy and evaluated with self-assessment questionnaires at baseline and post-intervention (after a two-week follow-up). For evaluating the demand, the actual use of Fume/the website was tracked during the two-week period. Regarding acceptability, the raised interest towards Fume/the website and opinions about the interventions were evaluated post-intervention. Differences were tested with the McNemar, Fisher exact, and non-parametric tests. RESULTS: Statistically significant favorable changes during the study period were found for positive (P = 0.002) and negative (P = 0.02) smoking outcome expectations and attitudes towards cigarette smoking (P = 0.01) within the group using Fume. No statistically significant changes were detected within the website or control groups. Statistically significant differences were not found for the change in outcome variables among the three groups. The number of visits (P < 0.001), number of separate visit days (P < 0.001) and total duration of use (P < 0.001) were larger for the group using Fume than for that using the website. Fume sparked more interest in early adolescents than the website did (P <  0.001). There were no statistically significant differences in opinions about Fume and those regarding the website. CONCLUSIONS: The intervention with embedded game elements, the health game Fume, was found to be more feasible as a tobacco-related health education intervention than the non-gamified website among early adolescents in light of demand and acceptability (raised interest). Even though no change in anti-smoking self-efficacy was found, the results of this feasibility study demonstrated favorable short-term changes with Fume in some other theory-based determinants of tobacco-related health literacy.

Protocol for digital intervention for effective health promotion of small children-A cluster randomized trial.

AIM: This article introduces the protocol of a study aiming to evaluate the effectiveness of digital WellWe intervention in supporting the participation of families with small children in the promotion of their health. BACKGROUND: Early childhood is a meaningful period for building a strong base for good health. Parents play a key role in affecting the health behaviour and psychosocial development of their children. A family-centred approach makes it possible to support families' individual health literacy needs and empower them to take actions towards promoting healthier behaviour. However, there are a lack of family-centred digital health interventions intended for parents and their small children. DESIGN: The study is designed as a two-arm cluster, randomized, controlled trial with a 4-month follow-up. METHODS: The data are being collected from 200 families with a 4-year-old child. Cluster randomization is being performed at the municipality level. Municipalities (N = 4) located in Southwest Finland, comprising child health clinics (N = 15) with their family clients, were randomly allocated to either an intervention (WellWe intervention) or a control group (usual care). The outcome measures include parental self-efficacy for healthy behaviours, mindfulness in parenting and the family-centred approach of the extensive health examination. Data collection is being performed at baseline, after the intervention and at a 4-month follow-up. DISCUSSION: The results from this study will make it possible to determine whether this new method can be recommended for implementation in child health clinic settings to support the participation of families with small children in promoting their health.

Designing a Health-Game Intervention Supporting Health Literacy and a Tobacco-Free Life in Early Adolescence.

OBJECTIVE: The purpose of this study was to explore the design of a health game that aims to both support tobacco-related health literacy and a tobacco-free life in early adolescence and to meet adolescents' expectations. MATERIALS AND METHODS: Data were collected from adolescents using an open-ended questionnaire (n = 83) and focus groups (n = 39) to obtain their view of a health game used for tobacco-related health education. The data were analyzed using thematic analysis. A group of experts combined the adolescents' views with theoretical information on health literacy and designed and produced the first version of the game. Adolescents (session 1, n = 16; session 3, n = 10; and session 4, n = 44) and health promotion professionals (session 2, n = 3) participated in testing the game. Feedback from testing sessions 3 and 4 was analyzed using descriptive statistics. RESULTS: Adolescents pointed out that the health game needs to approach the topic of tobacco delicately and focus on the adolescents' perspective and on the positive sides of a tobacco-free life rather than only on the negative consequences of tobacco. The adolescents expected the game to be of high quality, stimulating, and intellectually challenging and to offer possibilities for individualization. Elements from the adolescents' view and theoretical modelling were embedded into the design of a game called Fume. Feedback on the game was promising, but some points were highlighted for further development. CONCLUSION: Investing especially in high-quality design features, such as graphics and versatile content, using humoristic or otherwise stimulating elements, and maintaining sufficiently challenging gameplay would promote the acceptability of theory-based health games among adolescents.

Physical activity among children: objective measurements using Fitbit One® and ActiGraph.

BACKGROUND: Self-quantification of health parameters is becoming more popular; thus, the validity of the devices requires assessments. The aim of this study was to evaluate the validity of Fitbit One step counts (Fitbit Inc., San Francisco, CA, USA) against Actigraph wActisleep-BT step counts (ActiGraph, LLC, Pensacola, FL, USA) for measuring habitual physical activity among children. DESIGN: The study was implemented as a cross-sectional experimental design in which participants carried two waist-worn activity monitors for five consecutive days. METHODS: The participants were chosen with a purposive sampling from three fourth grade classes (9-10 year olds) in two comprehensive schools. Altogether, there were 34 participants in the study. From these, eight participants were excluded from the analysis due to erroneous data. Primary outcome measures for step counts were Fitbit One and Actigraph wActisleep-BT. The supporting outcome measures were based on activity diaries and initial information sheets. Classical Bland-Altman plots were used for reporting the results. RESULTS: The average per-participant daily difference between the step counts from the two devices was 1937. The range was [116, 5052]. Fitbit One gave higher step counts for all but the least active participant. According to a Bland-Altman plot, the hourly step counts had a relative large mean bias across participants (161 step counts). The differences were partially explained by activity intensity: higher intensity denoted higher differences, and light intensity denoted lower differences. CONCLUSIONS: Fitbit One step counts are comparable to Actigraph step counts in a sample of 9-10-year-old children engaged in habitual physical activity in sedentary and light physical activity intensities. However, in moderate-to-vigorous physical activity, Fitbit One gives higher step counts when compared to Actigraph.

Association of Self-Perceived Physical Competence and Leisure-Time Physical Activity in Childhood-A Follow-Up Study.

BACKGROUND: The basis of self-perceived physical competence is built in childhood and school personnel have an important role in this developmental process. We investigated the association between initial self-perceived physical competence and reported leisure-time physical activity (LTPA) longitudinally in 10-, 12-, and 15-year-old children. METHODS: This longitudinal follow-up study comprises pupils from an elementary school cohort (N = 1346) in the city of Turku, Finland (175,000 inhabitants). The self-perceived physical competence (fitness and appearance) and LTPA data were collected with questionnaires. The full longitudinal data were available from 571 pupils based on repeated studies at the ages of 10, 12, and 15 years in 2004, 2006, and 2010. We analyzed the association of self-perceived physical competence and LTPA using regression models. RESULTS: Self-perceived physical competence was positively associated with LTPA at all ages (10 years p < .05, 12 years p < .0001, 15 years p < .0001). Increase in the self-perceived physical fitness scores was likely to associate with higher LTPA at each age point (10 years [odds ratio, OR] = 1.18, 95% confidence interval, CI: 1.09-1.27; 12 years [OR] = 1.27, 95% CI: 1.18-1.37; and 15 years [OR] = 1.28, 95% CI: 1.19-1.38). CONCLUSIONS: Self-perceived physical competence is associated with LTPA in children and adolescents, and the association is strengthened with age.

Health game interventions to enhance physical activity self-efficacy of children: a quantitative systematic review.

AIM: To describe and explore health game interventions that enhance the physical activity self-efficacy of children and to evaluate the effectiveness of these interventions. BACKGROUND: Physical inactivity among children has increased globally. Self-efficacy is one of the key determinants of physical activity engagement in children. There is a need to explore new and innovative interventions to enhance physical activity self-efficacy that are also acceptable for today's children. DESIGN: Quantitative systematic review. DATA SOURCES: MEDLINE (Ovid), CINAHL, PsychInfo, EMBASE and the Cochrane Library between 1996-2016. REVIEW METHODS: A review was conducted in accordance with the Cochrane Collaboration guidelines. A systematic search was done in June 2016 by two independent reviewers according to the eligibility criteria as follows: controlled trial, comparison of digital game intervention with no game intervention control condition, participants younger than 18 years of age and reported statistical analyses of a physical activity self-efficacy outcome measure. RESULTS: Altogether, five studies met the eligibility criteria. Four game interventions, employing three active games and one educational game, had positive effects on children's physical activity self-efficacy. An intervention, employing a game-themed mobile application, showed no intervention effects. The variation between intervention characteristics was significant and the quality of the studies was found to be at a medium level. CONCLUSION: Although health game interventions seemingly enhance the physical activity self-efficacy of children and have potential as a means of increasing physical activity, more rigorous research is needed to clarify how effective such interventions are in the longer run to contribute to the development of game-based interventions.

Promoting Children's Health with Digital Games: A Review of Reviews.

Effective, evidence-based, and interesting methods are needed for children's health promotion. Digital games can be such a method, but there is need for a summary of the evidence on the effectiveness of digital games in promoting children's health. The aim of this review of reviews was to evaluate the quality of systematic reviews, to summarize the evidence in systematic reviews and reviews related to the effectiveness of digital games in children's health promotion, and to identify gaps in knowledge. A systematic literature search was conducted in May-August 2013 from relevant databases, and 1178 references were found. In total, 15 systematic reviews and reviews met the inclusion criteria. Most of the systematic reviews were found to be medium quality on the AMSTAR checklist. Most commonly, systematic reviews and reviews evaluated active videogames. According to the results, evidence of the highest level and quality seems to support an increase in physical activity to light to moderate levels and energy expenditure, especially when playing active videogames that require both upper and lower body movements. In addition, sedentary games were shown to have potential in children's health education, especially in supporting changes in asthma- and diabetes-related behavior and in dietary habits. However, there are still several gaps in the knowledge. There is a need for further high-quality systematic reviews and research in the field of health games.