Using an interactive communication tool in healthcare situations: Patterns in young children’s use of participation cues

Abstract

This study forms part of a larger project about developing and using interactive technology to facilitate young children’s participation in healthcare situations. Children’s participation in these situations improves their motivation and situated understanding. Likewise, their participation helps professionals to more fully understand the child’s perspective. In the project, an interactive communication tool, that is, an application suitable for tablet use, was developed with children, aged three to five, in two clinical settings. When tested, the children’s participation cues, identified from video recordings of healthcare situations, were understood as having curious, thoughtful or affirmative meanings. This study aimed to investigate the similarities and differences in the young children’s use of participation cues when using an interactive communication tool in healthcare situations. A secondary analysis of the identified cues was performed focusing on age, setting and examination or procedure. In total, 2167 cues were identified representing either curious, thoughtful or affirmative cues. The curious cues were mainly used (66%), followed by thoughtful (28%) and affirmative (6%) cues. Differences in cue usage were seen in relation to the children’s age and setting. Knowing how children may react to common healthcare procedures may help increase healthcare professionals’ awareness of the need to support children in an individual and situational way.

Keywords

Children cues examinations healthcare situations health technology participation

Introduction

This study aimed to investigate similarities and differences in young children’s use of participation cues when using an interactive communication tool in healthcare situations. Young children are frequent visitors, as patients, in healthcare settings. Participation in these situations can strengthen the children’s understanding (Hallström and Elander, 2004), increase their motivation and engagement (Söderbäck, 2012) and facilitate adults’ attention to their perspectives, perceptions and experiences (Shier, 2001). Children’s preferred level of participation may vary due to individual and situational aspects (Harder et al., 2013; Hemingway and Redsell, 2011). This fluctuated level of engagement, combined with children’s preferences for non-verbal expressions, reinforces the need for adults to pay close attention to children’s expressions in a sensitive and responsive way (Söderbäck, 2012). Child participation in healthcare situations is also a right for children as stated in both conventions and laws (SFS, 2014:821; United Nations, 1989).

Within children’s healthcare, interactive technology solutions are increasingly used to facilitate children’s participation in healthcare situations through communication (Ruland et al., 2008) and preparation (Fernandes et al., 2015; Tseng et al., 2011; Williams and Greene, 2015). The last decade has seen an exponential growth of applications, suitable for tablet and/or smartphone use, developed for children, to be used either for fun or for education purposes. The touchscreen technology, which is easy to use, has enabled even young children to become skilful users of applications in different devices (Beschorner and Hutchison, 2013; Plowman et al., 2012; Swedish Media Council, 2017). Despite the rapid growth of applications in general and within the pediatric context specifically, the development of age-appropriate applications that actively promote young children’s participation remains largely under developed.

The present study formed part of a larger project, in which an application, called Inter-Active Communication Tool Activities (IACTAs), was developed with the aim to facilitate children’s, aged three to five years, participation in healthcare situations. Children within the target age participated as co-designers throughout the development process of the application (Stålberg et al., 2015; Stålberg et al., 2016). The children’s active involvement has been essential to ensure that IACTA emanated from the child’s perspective, a perspective that influences how the situation is understood, perceived and experienced by the individual child (Sommer et al., 2010). The application is intended for a situated joint use between a child and a healthcare professional. IACTA provides a step-by-step visual information about specific healthcare situations. Throughout the storyboard, an avatar created by the child and a virtual accompanying person are present. Interactive circles appear onto the body of the avatar indicating sites for examinations or procedures relevant for the child’s health visit ‘in real life’, see Figure 1, for example, scenes. The child selects a circle and performs the examination step-by-step, when needed by guidance from the healthcare professional. The purpose of the application is to facilitate the child, by being more familiar with the virtual examinations, to find an adequate level of participation in the real-life examinations.

Figure 1.

(a) to (c) Screenshots from the storyboard of IACTA. IACTA: Inter-Active Communication Tool Activities.

In a previous stage of the project (Stålberg et al., 2018), IACTA was jointly used by children and professionals in healthcare situations. These situations, consisting of physical examinations and needle procedures, were video-observed. In these observations, the children’s demonstrated cues of participation were identified and analysed hermeneutically to enable an understanding of what meaning the use of IACTA represented for the children (Ödman, 2007). Participation was defined as involvement in the (healthcare) situation (World Health Organization, 2013) where the degree of engagement may vary due to the needs of the individual child (Söderbäck, 2012). This definition includes all aspects of interaction and communication. A cue was understood as a verbal or non-verbal signal or hint made by the child in the situation (Oxford Dictionaries, 2016; Zimmermann et al., 2011). The cues were identified in a detailed way as to ensure that also non-verbal cues of participation were described. The cues were interpreted as having a curious, thoughtful and affirmative meaning. Curious cues were expressed in situations where the children wanted more knowledge of the situation presented on the screen or when they wanted to interact with IACTA. Examples of curious cues are turns towards, watches carefully/in a focused way and/or points at IACTA, initiates the use of IACTA, gets hold of it and pulls it closer and makes non-verbal sounds of joy or anticipation (when IACTA is used in the situation). Cues of thoughtful participation were demonstrated when the children needed additional time or support to be able to proceed with the task(s), for instance, looks for clues through eye contact with professionals, leans towards or seeks support from the parent and prolongs the interaction with a single task. Affirmative cues were shown when the children felt satisfied with a virtual achievement, such as smiles and/or laughs as a result of a good performance, demonstrates satisfaction and pride through eye contact with professionals and pulls the body to an upright position and shrugs the shoulders in a happy and relaxed way (Stålberg et al., 2018).

Within the project, children were viewed as competent social actors of their own who participate and co-construct situations with other people present (Alanen, 1988; Prout and James, 1997; Sommer, 2005). Although age remains a key factor involved in child development, it is not the sole determining criterion as many other factors are involved (Sommer et al., 2010). According to Bronfenbrenner’s ecological systems theory (Bronfenbrenner, 1979), children’s development is viewed as reciprocal interactive processes between the child and its immediate and more remote environments. Depending on which situations the children encounter, they obtain varied experiences resulting in divergent developmental trajectories. Thus, the research question was what patterns, in relation to age, setting and examination or procedure, can be identified in the distribution of the children’s participation cues?

Method

A quantitative descriptive design was used involving a secondary analysis (Carter and Lubinsky, 2016) of the participation cues demonstrated by children in video-recorded healthcare situations.

Sample and settings

The inclusion criteria were children aged three to five years visiting either a paediatric outpatient unit (POU) or a primary healthcare clinic (PHCC). Both children and parents had to understand and speak Swedish, however, not excluding children with other ethnic origin than Swedish. In the PHCC, 15 children participated, 11 boys and 4 girls, and in the POU, 5 children, 2 boys and 3 girls were included. In total, these 20 children made up 21 video recordings consisting of 13 physical examinations and 8 needle procedures, as one child met the doctor and underwent a needle procedure, too. In the following text, the PHCC represents the physical examinations. Although three needle procedures per se were carried out in the PHCC setting, the POU will represent these procedures, see Table 1 for a detailed description.

Table 1.

Descriptive statistics of the child participants in each setting.

	PHCC + POU	PHCC (physical examinations)	POU (needle procedures)
Boys/girls	13/7	9^a/4	5^a/3
Age range (months)	40–70	40–70	45–68
Mean age (months)	55	54	57
SD age (months)	9.5	10.4	7.8

POU: pediatric outpatient unit; PHCC: primary healthcare clinic.

^a One boy was scheduled for a visit to the doctor (= physical examinations) but went through a needle procedure as well.

IACTA was tested in both settings. In the POU, needle procedures were the focus, carried out by children’s nurses. The POU provides a specialized paediatric care to children suffering from more complex health problems, such as cancer or chronic illnesses. In the PHCC, the tests focused on physical examinations (ear and chest), provided by a paediatrician. In this setting, a ‘first-line’ care is provided. Children suffering from minor health problems, such as coughs, colds, sore throat and minor allergy symptoms are treated there.

Data collection and analysis

This study used data collected in a previous study (Stålberg et al., 2018). The data consisted of video-observations of the joint use of IACTA between children and professionals in healthcare situations. The total recorded time was 391 minutes, 285 minutes recorded in the PHCC, and 106 minutes in the POU. However, the episodes of interest, that is, in which IACTA was used, lasted altogether approximately 80 minutes; 57 minutes recorded in the PHCC and 23 minutes in the POU. In the PHCC, the mean time for IACTA use/healthcare situation was 4.38 minutes (SD = .79) and 2.92 minutes/healthcare situation (SD = .70) in the POU. Each selected episode was transcribed into text and used for identification of participation cues demonstrated by the children. In total, 53 specific participation cues were identified: 17 curious (C), 25 thoughtful (T) and 11 affirmative (A) cues. The re-analysis of the data for this study began with all identified cues being decontextualized and gathered together in a separate document. Information regarding age, setting and examination or procedure was added to each cue. In total, the 53 specific participation cues were identified 2167 times altogether. Depending on the high number of cues in each meaning of participation (C = n 17, T = n 25, A = n 11) and to clarify the children’s cue usage, the aggregated usage of curious, thoughtful and affirmative cues per age group, setting and examination or procedure was used for analysis. As the data initially were collected for a previous study with another aim, uneven groups of participants were formed regarding age. These uneven group sizes influenced the total number of cue usage in each separate group. An adaptation of the cue usage was performed as to reduce this influence and to get comparable numbers between the groups. This adaptation process was made in two steps. In the first step, the total cue usage per age group and meaning of participation were divided with the number of situations in which the cues had been demonstrated. The cue usage according to setting was gathered from more virtual sequences compared to the specific situations where the cue usage focused solely on them expressed during examinations or procedures. This approach explains why the aggregated cue use in the columns PHCC and POU does not equal the numbers presented in the columns chest, ear and needle. In the second step, comparable numbers of the cue usage of each age group were calculated as to identify similarities and differences. These numbers were the result of the division of cue usage between two age groups and were presented in percentages. A number above or below 100 (%) indicated a higher or lower cue usage in the age group being compared. A number close to, or equalling, 100% indicated a similar or even cue use between the compared groups. The higher or lower the results (in %), the stronger or weaker the tendency to use those cues, indicating differences in the children’s cue usage.

Validity and reliability

The cues were identified by the first author from the written transcripts as they were expressed by the children, verbally or non-verbally. To ensure a valid identification of participation cues (Bryman, 2016), there was a need for a detailed and accurate definition of these concepts. The definitions used in this study are described in the Introduction of this article. To further strengthen the validity of the identified cues, a repeated review process was conducted involving all authors who then verified the accuracy of the cues. The reliability relied on an inter-rater reliability test. A research assistant, independent of the research group, organized the identified cues into meanings of participation, that is, either as having a curious, thoughtful or affirmative meaning. The agreement of the cue organization was 76%.

Ethical considerations

Ethical approval was granted by the Swedish regional vetting board. The children and their parents were invited to participate through written information sent to their home or provided at the clinical setting. Verbal study information was provided by the first author and all participants were encouraged to ask questions. Information was provided of participants’ rights to withdraw from the study at any stage or to deny recordings of some situations during the visit. The children and parents were informed that the video observations would focus on the interaction between the child and professional when IACTA was used (Heath et al., 2010). Both parents and children were asked to provide signed consent. Ability and competence to give informed consent is not associated with age (Alderson, 2007), but it is a combination of the personal and social skills a child needs to be able to understand and act in a specific situation (Sommer, 2005). As the professionals appeared overtly in the video recordings, they were also asked to consent their participation.

Results

In this study, the similarities and differences in the children’s usage of participation cues were examined in relation to age, setting and examination or procedure. In the total sample of demonstrated cues (n 2167), the curious cues were mostly used and comprised approximately two-third (66%) of the total cue use. The thoughtful and affirmative cues were used to a lesser extent, 28% and 6%, respectively. A similar distribution of cue usage was seen when separating the total cue use into age groups. However, minor variations in the internal distribution of cues between the age groups were noted when each meaning of participation was specifically focused on, see Figure 2.

Figure 2.

The overall cue usage divided into meanings of participation and presented by age groups.

When separating the total cue use into settings and examinations or procedures, the pattern of a high use of curious cues and a more restricted use of thoughtful and affirmative cues remained. Regardless of setting or situation, the three-year olds showed the overall highest comparable cue usage compared to the four- or five-year-old children. However, the internal cue distribution regarding age showed a slightly different pattern, a difference most evident for the needle procedures (see Table 2).

Table 2.

The cue usage regarding age, setting, examination and procedure.

	PHCC			POU			Chest			Ear			Needle
Age (years)	3	4	5	3	4	5	3	4	5	3	4	5	3	4	5
Children (n)/age group	4	3	6	1	2	5	4	3	6	4	3	6	1	2	5
Curious cues	89	83	75	49	58	42	21	16	9	24	8	14	27	29	21
Thoughtful cues	29	24	38	23	29	22	10	8	11	8	3	7	10	18	11
Affirmative cues	10	8	7	23	2	1	4	2	3	1	-	2	18	2	1
Cues_tot	128	115	120	95	89	65	35	26	23	33	11	23	55	49	33

POU: pediatric outpatient unit; PHCC: primary healthcare clinic.

When comparing the total cue usage in each setting, the children who underwent physical examinations appeared to have a higher cue usage in total for all meanings of participation and age groups. When instead focusing on the visit to either the PHCC or POU-settings, the three- and-four-year olds used curious and affirmative cues more frequently. The use of thoughtful cues showed a more divergent pattern between both age groups and settings.

Within the physical examinations the children’s cue usage deviated partly. The chest examination rendered a high usage of both curious and thoughtful cues, with a considerably lower use of affirmative cues, a pattern evident for all age groups. In the ear examination, the three- and-five-year-old children showed a similar pattern of cue use. However, during that examination, the four-year-old children’s cue usage showed a deviating pattern, demonstrating a low level of cues about all meanings of participation. In the POU, with focus on needle procedures, all age groups appeared to use a rather high number of curious and thoughtful cues, especially among the four-year olds. However, these children used a low number of affirmative cues, a pattern that was similar among the five-year olds. The three-year-old children diverged from the pattern of the older children regarding their use of affirmative cues which were demonstrated to a high extent during and after the needle procedures (see Table 2).

When comparing the cue usage between age groups, the two settings revealed different patterns. In the PHCC, the overall difference (in %) in cue usage was largest between three- and four-year-old-children (see Table 3), a difference that remained also when the cue usage in the ear examinations was focused on. However, in the chest examinations, the largest difference in cue usage was instead shown between the three-and-five-year olds (see Table 4). In the POU/needle procedures, the largest difference was identified between the three- and-five-year olds (see Tables 3 and 4).

Table 3.

Relations in cue usage between age groups (in %) regarding setting.

	PHCC			POU
	3- to 4-year olds	3- to 5-year olds	4- to 5-year olds	3- to 4-year olds	3- to 5-year olds	4- to 5-year olds
Curious cues	107	119	111	84	117	138
Thoughtful cues	121	76	63	79	105	132
Affirmative cues	125	143	114	1150	2300	200
Total	111	107	96	107	146	137

POU: pediatric outpatient unit; PHCC: primary healthcare clinic.

Table 4.

Relations in cue usage between age groups (in %) regarding examination and procedure.

	Chest			Ear			Needle
	3- to 4-year olds	3- to 5-year olds	4- to 5-year olds	3- to 4-year olds	3- to 5-year olds	4- to 5-year olds	3- to 4-year olds	3- to 5-year olds	4- to 5-year olds
Curious cues	131	233	178	300	171	57	93	129	138
Thoughtful cues	125	91	73	267	114	43	56	91	164
Affirmative cues	200	133	67	—	50	—	900	1800	200
Total	135	152	113	300	143	48	112	167	148

Discussion

In this study, patterns of young children’s participation cues when using an interactive communication tool in healthcare situations were investigated. The results indicated that curious cues were predominantly used. Children’s curiosity to use IACTA could be explained by the introduction of a new, appealing, and age-appropriate element, which the children had not used in similar situations before but felt that it facilitated them both a situated understanding and participation. The curiosity could also be explained by children’s generally positive attitude towards interactive technology (Swedish Media Council, 2017). Even young children, aged three to five years, are skilled users of devices such as tablets and smartphones (Ahearne et al., 2016; Beschorner and Hutchison, 2013; Plowman et al., 2012). Thoughtful cues were used when the children felt a need to postpone the continuation of a situation or needed support. Affirmative cues were used while doing a task or after it was successfully performed. Although these cues also were understood as being of importance for the children, they were not demonstrated as often as the curious cues.

A cue was understood as a verbal or nonverbal hint. Most cues, regardless of meaning of participation, were expressed nonverbally. The younger the children, the higher the degree of nonverbal communication added to the conversation (Bjar and Liberg, 2010; Iversen and Goldin-Meadow, 2005) which is consistent with the three-year olds demonstrating the highest cue usage. IACTA is intended as a communication tool, by which both verbal and nonverbal messages and information can be disclosed. Another reason for the youngest children’s more intense way of interacting with IACTA could be due to their (potential) less experience of being in healthcare situations. Likewise, when comparing the cue usage between the settings, the children in the PHCC, who in general were unfamiliar with healthcare situations, seemed to use IACTA more intensively. Therefore, their more accentuated commitment to use IACTA may be due to limited health literacy (Berkman et al., 2010; Borzekowski, 2009) and that IACTA provided visual guidance which enabled the children to try out the examinations and procedures virtually.

In the PHCC, the children underwent chest and ear examinations during the same visit. Implicitly, several aspects were in common: the physical condition of the children, the context, the accompanying person(s) and the professional. Despite these common aspects, the children demonstrated a varied cue use regarding the different examinations. The cue usage in the chest examination resembled the pattern of the total cue distribution, a pattern not shown within the ear examination. The children who visited the POU setting were regular visitor. They underwent needle procedures. It is known that needle procedures and blood frequently evoke anxiety and fear in children (Karlsson et al., 2014; Meltzer et al., 2008; Salmela et al., 2010). Despite these adverse aspects of needle procedures, the children’s overall cue use showed a predominance of curious cues. During the needle procedures, the three-year olds intensified their use of affirmative cues and used less curious and thoughtful cues. This pattern could be explained by the fact that needle procedures were well-known to them; delaying actions, support or guidance were not needed; and, despite being used to needle procedures, the children showed happiness, through their use of affirmative cues, when the procedure was done, which is understandable. The older children used a slightly different distribution of cues, for instance, regarding their use of thoughtful cues which was comparably high.

According to Bronfenbrenner’s systems theory (1979), children’s increased competence is gained from relations with others and the situations they are part of. As children grow, they are involved in more complex relations which influence their competence and add to their resources of how to handle situations they encounter. Interactions in the immediate environment, that is, the micro systems, have a considerable impact on children’s development (Hwang and Nilsson, 2011). In these interactions, the children are active participants together with their parents (Paat, 2013). Accordingly, children’s expressions of participation cues are a combination of their understanding of the situation, related to earlier experiences of similar situations and their parents’ influence on them in both the present and previous situations (Bronfenbrenner, 1979). Although immediate relations have a strong impact, other relations and situations influence children’s evolving competencies and promote aspects of their developmental trajectory. Furthermore, when healthcare professionals are involved, they can influence the ways children express their cues of participation (Bronfenbrenner, 1979; Lave and Wenger, 1991). There was an individual pattern in the movement between which participation cues the children expressed, a pattern not influenced by the child’s previous, or not, experiences of similar situations. Children in the POU, that is, regular visitors in the healthcare context, also indicated a need for extra time, support and guidance, a pattern most evident among the five-year olds. This pattern suggests that experience is not always the best predictor of a certain way of how a child may behave in a situation. Instead, their specific cue use emphasizes the need for an individualized guided participation, formed by a mutual understanding between the children and professionals, based on the children’s present requirements, regardless of previous experiences (Rogoff, 1990).

The focus in this study—the pattern of children’s expressions of participation cues when using IACTA—could be viewed as representing a narrow scope of interest. However, the results could be understood in a wider sense. Many of the expressed cues were general, both the verbal and the nonverbal. Knowledge about children’s various ways of interacting with IACTA—curiously, thoughtfully and affirmatively may raise healthcare professionals awareness of other ways of seeking, understanding and including the child’s perspective in the healthcare situation (Sommer et al., 2010; Söderbäck et al., 2011). Child participation in health visits is purposeful as it facilitates the child’s understanding of the situation (Hallström and Elander, 2004). By paying close attention to a child’s verbal and non-verbal cues in a situation, professionals are provided with an understanding of the individual child. That situated understanding can be used to support the child’s participation according to their preferences, which is essential for promoting a child-centred and a child’s rights’ approach (Coyne et al., 2016; United Nations, 1989).

Limitations are that the study was conducted in only two clinical settings and comprised a small sample of situations. The small sample size was the result of using a dataset obtained for a previous study. The inter-rater reliability test revealed an agreement of cue organization of 76%. That score was considered as moderately high, although a stronger agreement would have been preferable. Separating the children’s cue use into age groups, settings and examinations or procedures resulted in an uneven division of situations in which the cues were expressed. No statistical significant results could be drawn from the data. However, this present study aimed to reveal patterns in the children’s demonstrated cue use as to enable a better understanding of their participation when engaging with IACTA.

Conclusion

It appears that younger children, aged three to five, are keen to use an application in specific healthcare situations. When introducing the interactive communication tool (IACTA), the children embraced this innovative element with curiosity, which was shown in their extensive use of curious cues of participation when IACTA was used. The participation of the youngest children seemed to be most facilitated. By their interaction with IACTA, they were provided, through expressions understood as participation cues, with additional ways to express questions, thoughts, worries and fears. The children with no, or limited, experiences of healthcare situations also seemed to participate more in the situation with the support of IACTA. These different ways of expressing a preferred way of participation in a situation may guide healthcare professionals to adopt an individualized child-centred care approach.

There is a need for further research on how this application may be used by even younger children (less than three years) or in other healthcare situations. The results only indicated patterns in the children’s cue usage. Further studies are required, using larger samples, to get a more extensive picture of children’s ways of engaging with and participating in situations when IACTA is used.

Footnotes

Authors’ note

The research was conducted at Mälardalen University, Västerås, Sweden.

Acknowledgement

The authors would like to thank Dr Larm, senior lecturer at Mälardalen University, Västerås, Sweden, for important contributions of how to analyse and present the result.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Imelda Coyne

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