Smartphone app to support goal setting in pediatric rehabilitation: app development, usability and acceptability study

Abstract

Objectives

Setting treatment goals is the core of the pediatric rehabilitation process. The participation of the children and their families is foundational to this approach. Goal setting would benefit from being standardized using formal procedures and guidelines. This study aimed to develop a smartphone app to guide rehabilitation professionals through the whole collaborative goal-setting process with children who have physical health related disabilities and their families and to explore its usability and acceptability.

Methods

There were 3 phases of app development. In phase 1, we analyzed the literature to establish key app components. Then, we worked with a development company to build a prototype. In phase 2, 7 rehabilitation professionals evaluated the usability of each function, and we made improvements according to their feedback. In phase 3, 14 rehabilitation professionals tested the app in clinical practice with 53 children. The usability and acceptability of the app were evaluated using standardized questionnaires (System Usability Scale (SUS), Technology Acceptance Model (TAM)) and through semi-structured interviews.

Results

According to the literature, effective goal setting in pediatric rehabilitation involves understanding the child’s preferences and needs, employing validated methodologies such as the SMART model to formulate goals, engaging children and families as collaborators, and fostering inter-professional communication. The “Kid’EM-app” was built on these principles. It comprises two interfaces: “Kid’EM-appVPro,” designed for professionals to guide them in this practice, and “Kid’EM-appVFam,” intended for families to collaborate after professional invitation. The phase 2 results showed that all the functions were used except chat/file sharing. The phase 3 results showed that the app was usable in clinical practice (mean SUS = 70.9/100, SD = 10.9; mean TAM ease of use = 71.4/100, SD = 15.1). The application aligned with the values of the professionals who seek to involve children more in their care.

Discussion

The “Kid’EM-app” is an all-in-one acceptable and usable solution designed to guide rehabilitation professionals through each aspect of goal setting. Consideration of both feedback from the field and scientific evidence enabled to us to identify content requirements and implementation barriers that must be overcome to facilitate use of the “Kid’EM-app” in clinical practice and accelerate knowledge translation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-025-01713-w.

Introduction

Children with physical health-related disabilities often undergo long rehabilitation periods with multidisciplinary teams in rehabilitation centers, outpatient clinics, or through health and social services [1]. The aim is to optimize the child’s autonomy and prepare their future by reducing impairment, activity limitations and participation restrictions [2, 3]. Rehabilitation is based on goals that define the activities that the individual wishes to perform and participate in [4]. Goal setting is the formal process whereby a rehabilitation professional or team negotiates goals with the individual and their family [4]. Collaboration with the individual in this process is a major motivational factor [5] and helps to reinforce their sense of self-efficacy [6].

In pediatric rehabilitation, guidelines strongly recommend delineating and using functional goals to improve the child’s daily life [7, 8]. Goal setting is considered an important aspect of care by children and their families [9]. However, in France, for example, a recent study showed that rehabilitation goals were of sufficient quality in less than 30% of cases, highlighting the need for goal-setting practices to be improved [10–12]. Goal setting is a complex, multi-phase process guided by the rehabilitation professional who facilitates child and family-driven goal setting. Placing the child at the center of this approach ensures that their opinions and desires are considered, along with those of their parents [13]. For example, ‘the bigger picture’, encompassing participation and activities of daily living is particularly important to children, whereas parents often focus on the efficiency of performing activities of daily living [14, 15]. In addition, holistic rather than discipline-specific goals should be preferred. However, this poses specific challenges regarding child-centered collaboration between professionals and families [16]. Goal setting would benefit from being standardized through formal procedures and structured guidelines, which would help rehabilitation professionals facilitate the involvement of all stakeholders [17–20]. Logistic challenges, like lack of time, must be considered because they are real barriers to improving this complex practice [14]. To our knowledge, no simple, easily available tool for rehabilitation professionals currently supports the whole collaborative goal-setting process in pediatric care.

eHealth is the use of information and communication technologies to support health [21]. Mobile Health (mHealth) is a subcategory of eHealth that refers to the use of mobile devices, for medicine and public health practice [22]. By the end of 2023, almost 70% of the world’s population were smartphone users [23]. The widespread use of mobile phones and the rapid growth of eHealth applications offer new opportunities to improve clinical practice [24]. mHealth appears particularly interesting for goal setting because it can provide an interactive, accessible and easy-to-use means of supporting and guiding rehabilitation professionals through this complex task, as well as facilitating interprofessional and professional-family coordination and communication [25].

Usability is an important concept in designing successful technologies; it refers to the ease with which a product can be used effectively and efficiently to achieve its intended purpose [26]. Acceptability is a multifaceted construct that reflects the extent to which people delivering or receiving a health care intervention consider it appropriate [27]. Changes in clinical practice may require multiple strategies that consider professionals’ behaviors, attitudes and skills [28, 29]. Smartphone apps are more likely to be acceptable to rehabilitation professionals if they are developed with them using the principles of human-centered design (HCD). HCD is a multi-stage process involving iterations of a design to ensure it meets the user’s needs. Gathering feedback from rehabilitation professionals during the development of an mhealth tool is essential to ensure it meets their needs [30] and to facilitate its adoption and use with children in current clinical practice [31].

Here, we present a 3-phase approach to the creation and preliminary testing of a new tool supporting the whole goal-setting process in pediatric rehabilitation, based on scientific evidence as well as on-field requirements. We wish to share our experience and learning from this iterative and collaborative experience.

Our objectives were:

• To develop a smartphone app that provides guidance and support to the rehabilitation professional during the whole process of collaborative goal setting with children who have physical health related disabilities and their families.

• To determine whether rehabilitation professionals considered the smartphone app usable and acceptable for use with children who have physical health related disabilities within their clinical practice.

By reporting our approach, we aimed to provide some avenues regarding the more general question of digitalizing the goal-setting process in pediatric rehabilitation.

Methods

Our approach was structured in 3 phases: (1) creation of the “Kid’EM-app” prototype using recommendations in the literature and experience from an existing tool (“Kid’EM tool-paper version”, described below), (2) testing the usability of the prototype application functions and modification of the prototype based on findings, and (3) evaluation of usability and acceptability of the finalized app in clinical practice.

A multidisciplinary steering committee made up of different peditatric rehabilitation professionals (3 physical therapists [RB, LG and ALG], 2 occupational therapists [EF, DJ], 3 physical and rehabilitation medicine (PRM) physicians [SB, CP and VV], and an engineer [ED]) was involved during the project.

The study was submitted to the Brest University Hospital Ethics Committee and approved (B2021CE.56).

All information stored by the application was anonymized and complied with General Data Protection Regulation (GDPR) rules.

Phase 1: development of the application

In 2018, 2 physiotherapists, a psychologist and a PRM physician in our team developed and evaluated the usability of the “Kid’EM tool-paper” ( Supplementary Materials (SM I) with 13 therapists and 50 children [12]. This tool was found to be useful for pediatric rehabilitation, but the paper format did not allow collaboration around goals between the various stakeholders (parents and other rehabilitation professionals), and the presentation needed to be more attractive to maintain the child’s motivation [32]. The users suggested a digital version of the tool could solve these issues, therefore we sought funding (sponsorship) to create an app.

We searched the literature for current scientific evidence concerning goal setting and to identify elements that would encourage the use of the future application in pediatric rehabilitation.

A mind map of the application based on the key elements identified in the literature review and their experience of the “Kid’EM tool-paper version” was then created.

The steering committee then worked with a development company to create the “Kid’EM-app” prototype. The company was selected because of its willingness to work with the steering committee in designing the application, including collaborating on defining the application’s specifications and following an iterative development approach.

To familiarize the development team with clinical realities and our needs, we filmed a physical therapist from the steering committee co-determining goals with a child. We then simulated a session by imagining a scenario with a child, detailing how the app could be used at each step to establish a workflow. Based on these inputs and our discussions, the development team created a graphical prototype. This was followed by three development sprints, with testing by the research team after the second sprint to identify bugs and necessary minor adjustments.

Phase 2: testing the application prototype - usability of the app functions

This second phase aimed to test the usability of all the functions of the “Kid’EM-app” prototype. Rehabilitation professionals (physiotherapists and occupational therapists) providing health services to children with physical disabilities in any setting (outpatient clinic, rehabilitation center or health and social services) and willing to test and give feedback on the app were recruited between November and December 2020. Purposeful sampling was used. Variation criteria were working facility, profession and age. We took particular care to recruit professionals working in outpatient clinics, for whom time constraints can be important, making it difficult to set goals. First, participants were selected through FRISBEE (https://frisbee.bzh/) based on the above criteria. FRISBEE is a network that coordinates research, care and teaching in pediatric rehabilitation in France. After the first interviews, snowball sampling was used to recruit the subsequent participants. Potential participants were contacted by email, then the study was explained during a telephone call. Each rehabilitation professional received an information form and, after agreeing to participate, were asked to test the “Kid’EM-app” in their usual workplace for 2 weeks. They were required to test it with at least 2 children with physical health-related disabilities and their families. The children had to be aged 5 years or older and require at least one rehabilitation session per week for more than three months. The professionals explained the study to the children and parents with whom they planned to test the application and gathered their verbal consent. For this phase, professionals were asked to specifically focus on each app function to identify areas of improvement. No recommendations or guidelines on how to use “Kid’EM-app” were provided.

Two investigators (ALG or LG) conducted semi-structured focus groups and individual interviews by videoconference (Zoom pro) in French, asking the professionals about each app function, how the functions could be improved, and their overall perception of the “Kid’EM-app” (SM II). At the beginning of the interviews, the investigator presented herself and contextualized the interview and its purpose. The interview followed the guidelines and questions developed to ascertain the usability of each function (see Supplementary Materials II- Phase 2 Interview Guide).

A framework analysis was used, in which the questions about the different features provided a natural structure for the subsequent coding [33]. Data collection ceased when the research team perceived no new issues were emerging [34].

The results were shared and discussed with the steering committee. The prototype was then modified according to the feedback received.

Phase 3: usability and acceptability testing in clinical practice

This phase aimed to determine the acceptability and usability of the app in clinical practice with rehabilitation professionals. A mixed-method approach using a concurrent design, involving questionnaires and interviews was used.

Regarding the recruitment and testing of the “Kid’EM app”, the procedure was the same as in phase II, with two exceptions. First, psychomotor therapists were invited to participate following the suggestion of one of the testers. Second, in this phase, professionals were specifically asked to focus on using the app within their usual practice.

Evaluation of the application

In the first part, acceptance was assessed using a questionnaire based on the Technology Acceptance Model (TAM) [35], which states that perceived usefulness and perceived ease of use determine the behavioral intention to use a system. Perceived usefulness and perceived ease of use were evaluated with 12 questions (7-point Likert scale = totally disagree –– totally agree). The second part evaluated usability with the System Usability Scale (SUS) [36] which consists of 10 questions about satisfaction with the use of the application. A score below 50 indicates a lack of usability [37]. They were then asked to rate their overall satisfaction with the application out of 10. Overall satisfaction of the tester was evaluated using a scale from 0 to 10 (0 “not at all satisfied” to 10 “completely satisfied”). (SM V)

One investigator (VV) conducted semi-structured interviews in French with the professionals about the use and acceptability of the “Kid’EM-app” via videoconference (SM III). The procedure was the same as in phase 2.

Analysis

For the TAM questionnaire, the mean score and standard deviations were calculated for each of the 2 parts, subtracted from 1, and then multiplied by the factor 16.67 to obtain a score out of 100 [38]. Higher scores indicate more perceived usefulness and perceived ease of use of the application.

For the SUS questionnaire, the mean score and standard deviations were calculated. Odd-numbered questions were rated on a Likert scale from 0 to 4 and were scored positively, whereas even-numbered questions were rated on a Likert scale from 4 to 0 and were scored negatively, following the direction of reading. The sum of each item was then multiplied by 2.5. The result was a score between 0 and 100 [29]. A score above 68 was considered a good level of usability [39].

The interviews were transcribed verbatim by the first author (VV). The transcripts were coded using a thematic analysis, and an inductive analysis at an explicit level was carried out. Analysis was made using an Excel spreadsheet, following the six steps described by Braun and Clarke (2006) [40]. First, initial codes were generated by the first author (VV) and discussed with the last author (CP). Once agreement was reached on the list of codes, the interviews were individually coded (VV) and discussed with CP to assess whether data saturation had been reached. VV identified themes with the help of CP. Data collection ceased when VV and CP perceived no new themes were emerging [34]. The results were shared with the steering committee, who discussed necessary improvements.

Results

Phase 1: application development

This phase aimed to create a prototype that considered current scientific evidence.

Literature review

The literature review highlighted the following key elements of the goal-setting process, which were used to inform the development of the “Kid’EM-app”. It is essential for the professional to get to know the child by asking them about the things they enjoy and their needs so that their everyday difficulties emerge [41]. Children are able to express their views and priorities from the developmental age of 5 years [42]. Families can act as active collaborators to guide the choice of goals that the child needs to achieve in their daily life [43]. However, a scoping review published 2018 highlighted that the role of the parents - and even more so, children - are poorly articulated [14]. Goal formulation can be facilitated by using a validated methodology [44] that considers the child’s wishes [45]. The SMART model (Specific, Measurable, Attractive, Realistic and Time-bound) [46] is a simple model that guides the drafting of goals.

Inter-professional collaboration centered on the child is crucial within each aspect of goal setting to ensure consistency in the actions taken to achieve the goals [11]. Information sharing between the professionals involved in the child’s care is essential for maintaining continuity of care, which is highly valued by patients and their families [47]. Likewise, rehabilitation professionals must facilitate the generation of child and family-driven goals; thus, communication with the patients and their families is essential [48].

In adult rehabilitation, using a clear process facilitates the engagement of individuals in the goal-setting process [49].

Several articles reported the use of mHealth apps for adolescents, focusing on disease self-management and incorporating self-directed goal setting as a strategy to facilitate the adoption of healthy behaviors [50] or pain coping [51]. However, none involved goal setting in rehabilitation.

Two studies proposed mhealth apps for pediatric rehabilitation professionals to guide at least one part of the goal-setting process, focusing on improving the child’s daily life. The “GOALed app” was developed for pediatric physical therapists to simplify creating, recording, storing, scoring, and interpreting GAS goals. It provides an interface to enter the goal and GAS scores. It enables the visualization of GAS score changes and might facilitate promote greater GAS interpretation. The “Aid for Decision-making in Occupation Choice for School (ADOC-S)” is intended for occupational therapists and aims to assist with conducting collaborative occupation-based goal setting in school. It places particular emphasis on needs identification and prioritization. It provides illustrations of occupations that can be selected by the different stakeholders (child, parent, teacher and occupational therapist) and then prioritized during a discussion facilitated by the occupational therapist.

Ease of use and design are key to facilitating end-user engagement [52] Gamification, a process by which the desirable features of games are used in non-game contexts to leverage a person’s interest in competition might be helpful to promote greater engagement with the technology [52, 53].

Mind map

Specific attention was paid to specifying the roles of each stakeholder (rehabilitation professional, child, parents) in the “Kid’EM-app” with the aim of offering a structured approach to facilitate collaboration. The components of the “Kid’EM tool-paper version” (getting to know the child, identifying and prioritizing needs for goal setting, guidance for formulating goals) were adapted and distributed to the users. In line with the literature review, a collaborative review was held on how to leverage the opportunities offered by digitalization to better involve the child in the process (enhancing their engagement, facilitating collaboration), enable communication with the family and maintain a direct connection with their daily life, and ensure coherent care coordination with other professionals (SM IV).

Development of the application

The “Kid’EM-app” prototype has a simple, colorful design, is adapted to children, and is designed to guide and support rehabilitation professionals through the goal-setting process as well as enable them to involve the child and family. We aimed to provide a quick and easy to use tool (requiring only a short time during the session).

To facilitate intra-professional and family communication, the “Kid’EM-app” frontend includes 2 versions: “Kid’EM-appVPro” for rehabilitation professionals to use during sessions with the child, and “Kid’EM-appVFam” for the child’s parents, accessible by invitation from the rehabilitation professional, with a digital space to facilitate exchanges between parents and professionals. The “Kid’EM-app” back office, a user interface built on the back-end to configure the application (e.g., facilitate user management and database modification) without the need for coding, is managed by the research team and allows them to monitor the app.

The “Kid’EM-appVPro” is designed to be used by professionals who share their smartphone screen with the child to place the child at the center of the process. However, the child is never left alone with the tool. It includes the following functions: creating a patient file, identifying what they enjoy, defining and prioritizing needs according to their difficulties, formulating goals, goal monitoring, file sharing, and chat. In the first part, the professional creates a profile for the child, who can choose an avatar. Together, they identify the child’s needs based on what they enjoy, and their difficulties and priorities. In the second part, the professional is guided to formulate SMART goals related to motor rehabilitation. An explanation is provided for each criterion (Specific, Measurable, Attainable, Realistic and Time-bound), and examples of functional objectives are available. The professional completes a free-text box for the first 4 criteria and checks boxes to set the goal over time. This process creates an editable patient file in which progress toward goal achievement can be tracked by the professional and the child with a 4-star system. There is a notes space where the professional can specify barriers and facilitators for the child’s follow-up (e.g., personal and environmental factors). The application also has a chat system for communication between the parents and professionals and between the professionals caring for the child, as well as a feature for sharing the child’s file. (Fig. 1)

Fig. 1.

Model of the application functions

The professional can invite colleagues to use the “Kid’EM-appVPro” and parents to use the “Kid’EM-appVFam”. The “Kid’EM-appVFam” enables parents to view the child’s file and access the chat feature allowing the exchange of photos so that the therapist can observe the situations in which the child encounters difficulties in their daily life.

After the second sprint, the research team and the steering committee tested the prototype frontend and backend in preproduction. Front-end testing was carried out using download links sent individually by the company to the testers’ email addresses to identify bugs, display issues and text that needed to be changed. Backoffice testing was carried out via a URL provided by the company to the testers to ensure that the parts of the application that allowed customization were working correctly and to check that data were being stored and retrieved correctly from the database.

Phase 2: testing the application prototype

The application prototype was tested by 7 professionals (5 physiotherapists and 2 occupational therapists) (Table 1).

Table 1.

Characteristics of the rehabilitation professionals who participated in phases 2 and 3. Data are % (n)

		Phase 2 (N = 7)	Phase 3 (N = 14)
Gender	Woman	71% (5)	93% (13)
	Man	28% (2)	7% (1)
Age	20–30 years	14% (1)	43% (6)
	30–40 years	85% (6)	29% (4)
	40–50 years	0% (0)	29% (4)
Practice setting	Outpatient clinic	57% (4)	21% (3)
	Rehabilitation center	29% (2)	64% (9)
	Mixed (Health and social services and outpatient clinic)	14% (1)	14% (2)
Discipline	Pediatrics	71% (5)	79% (11)
	Mixed	29% (2)	21% (3)
Profession	Physical therapist	71% (5)	50% (7)
	Occupational therapist	29% (2)	36% (5)
	Psychomotor therapist	0% (0)	14% (2)

Several testers described the application as “intuitive,” “fun,” and “attractive to the child.” Two of them found it “complicated” to use the “Kid’EM-app” because of bugs.

The functions for creating a patient file, identifying what the child enjoys, defining and prioritizing needs according to their difficulties, formulating goals, and goal monitoring were used by all testers. Two testers asked for help from the research team when using the application for the first time. The sharing the file with family, professionals and chat functions were not used, mainly because it was difficult to access them at this stage of the development. The theoretical use of these functions was underlined by several testers.

The testers reported that the process of identifying what the child enjoys, and defining and prioritizing needs according to their difficulties created a time for exchange with the child and helped establish a relationship. They reported that the guidance provided by the app for the formulation and monitoring of goals helped to systematize child-centered care. The monitoring-goals function provided a simple method to assess the child’s clinical progress. Most felt that there were too few suggestions for identifying what the child enjoys. Some stated that the wording of certain questions was clumsy or too evasive. The testers suggested new functionalities, such as specific versions for different age groups and/or cognitive levels and being able to share summary elements with non-rehabilitation professionals.

The developer resolved bugs when the application was serviced. Existing functionalities were modified according to the feedback from the testers. Items were more positively worded, and the function for identification of what the child enjoys was enriched from the back office. More items with their graphical representation (superheroes, sports activities, creative leisure activities, ….) have been entered in the back office so that they are available to users in the front office. The application was published on download platforms after these changes.

Phase 3: implementation

We recruited 14 professionals to test the application in clinical practice: 7 physiotherapists, 5 occupational therapists and 2 psychomotor therapists, all with a variety of practice modalities (Table 1). They each reported having tested the application with 2 to 10 children, for a total of 53 children. The children who participated had all verbal communication. Their age range was wide (between 7 and 16 years). 52.8% of the children had cerebral palsy, 15.1% orthopaedic diseases, 11.3% neuromuscular diseases, 11.3% neurodevelopmental disorders. Most of the objectives were set in outpatient clinic or rehabilitation centers (Table 2). Most professionals reported having used the “Kid’EM-app” twice for each child during the test (creation of the form and 1 reassessment).

Table 2.

Characteristics of the children who participated in phases 3

Age (years)
Mean (SD)	9.7 (2,4)
Range	7–16
Sex
Female	25 (47.2%)
Male	28 (52.8%)
Pathologies
Cerebral palsy	28 (52.8%)
Neuromuscular diseases (Duchenne muscular dystrophy, …)	6 (11.3%)
Orthopaedic diseases (arthrogryposis, amputation, scoliosis, …)	8 (15.1%)
Neurodevelopmental disorders (learning disabilities, attention-deficit/ hyperactivity disorder)	6 (11.3%)
Other and unknown	5 (9.4%)
Children with a verbal communication	53 (100%)
Places where objectives were set
School, home	8 (15.1%)
Clinics (oupatient clinic, rehabilitation center)	45 (84.9%)

The mean total TAM score was 64.8/100 (SD = 14.6) for all the professions combined (Table 3). The physiotherapists assigned the same score to perceived usefulness and ease of use, whereas the occupational and psychomotor therapists rated perceived ease of use higher than usefulness.

Table 3.

Quantitative analysis of the implementation phase: satisfaction and usability according to the SUS and TAM scores. Data are mean (SD)

	Physiotherapists	Occupational therapists	Psychomotor therapists	Total
Number	7	5	2	14
Satisfaction (/10)	6.6 (1.4)	5.8 (1.9)	3.5 (4.9)	5.9 (2.2)
Total TAM Score(/100)	68.6 (9.6)	62.1 (14.5)	57 (30.4)	64.8 (14.6)
TAM Perceived Utility	68 (9.06)	50 (19.6)	42 (58.9)	58 (23.3)
TAM Ease of use	69.1 (19.2)	73.7 (12.9)	73.6 (1.9)	71.4 (15.1)
SUS Score (/100)	70 (11.3)	72 (13.1)	71.3 (8.8)	70.9 (10.9)

The mean SUS score was 70.9/100 (SD = 10.7), indicating that the testers found the application usable.

In the qualitative analysis, all the testers reported that the “Kid’EM-app” was easy to use and intuitive. Using the app did not substantially increase their workload. They reported a time of 30 to 45 min for the first goal setting - compatible with the use of the tool during a regular rehabilitation session regardless of the practice setting.

The mean satisfaction rating was 5.9/10 (SD = 2.2), with wide variations by profession (mean satisfaction was 6.6 for physiotherapists, 3.5 for psychomotor therapists and 5.8 for occupational therapists) (Table 3).

The qualitative analysis showed that all the testers considered the “Kid’EM-app” to be in line with their practices and values, and it met the need to focus on the child, communicate and exchange with them, and give meaning to their care to keep them motivated. Almost all the testers recommended the app, even though it did not necessarily meet a need they had identified before participating in the study.

Nearly two-thirds of the testers already set rehabilitation goals with children and their families but reported difficulties generating meaningful goals. They found that the SMART approach to goal formulation guided by the application simplified the process. They stated that the “Kid’EM-app” provided a different approach to discussing the reasons for their treatment with the child and to involve the child more effectively in the rehabilitation process. They also found that the app helped to boost communication and motivation during a long-term rehabilitation process. The testers said the children liked the design and were enthusiastic about the medium. However, some testers reported that the graphics seemed too childish for children over the age of 12.

They found that the “Kid’EM-app” needed to provide more guidance on the emergence of needs. Only one tester used the chat function with families. Social (language barriers, etc.) and organizational difficulties frequently complicated communication with families.

The testers questioned the need for an additional communication device when many others exist (email, SMS). A limiting factor in using the “Kid’EM-app” was that it required a smartphone, which was not always allowed in the establishments where the rehabilitation professionals worked. Furthermore, the managers were not always in favor of introducing a new tool.

The professionals suggested several improvements: allowing video-type content to be added, providing assistance with needs identification, enabling hierarchical organization of needs, and widening the range of professionals who could access the application (e.g., special educators and psychologists). (Table 4, SM VI)

Table 4.

Main results of the phase 3 qualitative analysis

Citation	Axial code
Routine practice: challenges and issues for goal setting
“it’s a job in itself to help families to come up with goals (OT3)”	An expertise practice?
“Sometimes the parents don’t have any realistic objectives that can be agreed on. (PT2)”
“You mustn’t set goals that you want to work because that’s what’s most relevant from the outside but it isn’t what the child wants. (OT1)”	Children’ motivation and involvement
“It’s important to give meaning to the treatment, otherwise it won’t be continued at home (PT1)”
“It’s important [for children] to get feedback, so they don’t get discouraged. I take videos or photos, so they can actually see their progress (PT7)”.
“It’s quite systemic to have the position of knowledge as doctors and paramedics, which creates a barrier (PT5)”.	Establishing a partnership with the family?
“We don’t meet enough with the families, which is difficult (OT2)”.
“Follow-up of objectives is done on computer, it’s long, tedious and boring (PT7)”.	Methods for measuring goals achievement
Application acceptability
“A young person who wasn’t comfortable with his body really liked the medium. Since using it, he’s been able to talk about his body in a different way. (PT7)”	Using Kid EM helps motivation and involvement of the child
“It was nice to be able to ask the child if they knew why they were here. For us, it’s obvious and we don’t necessarily take the time to go over it with the child (PT2)”
“I thought it was a good idea to set objectives with the child, it really gets them involved (PT3)”
“I thought it was great because they actually realized what they were capable of (PT4)”
“It enabled me to set clear, precise goals (PT4)”.	Interest of the application throughout the follow-up
“I was more focused on the goal (PT3)”
“I discussed it again with the child and they could see their progress (PT4)”
“With the improvements we talked about, I’d definitely recommend it (PT7)”	Intention to use by professionals
“The department psychologist thought it was great and that we should do it for all children (PT2)”.
“The application is very attractive.Everyone liked it (OT3)”	The children’s view
“It wasn’t the most fun part of the session (OT3)”.
Application usability
“The application is quite clear, it’s true that everything is noted (PT4)”	Handling and design
“There were no problems in terms of design and appearance (OT1)”
“Is easy to integrate in a session, it doesn’t create extra work (OT5)”
“I tried sending the form by e-mail, but it didn’t work, and sharing the form with another professional, but when you share the form with someone else, you lose the form on your account. (PT2)”	Obstacles to the use of Kid’EM
“A certain level of cognitive ability is required (PT7)”.
“The limit is taking out the mobile phone, especially with little ones (PT1)”.
“Some parents find it complicated to download a new application (OT1)”
“Lack of equipment to use the app, there need to be enough tablets and equipment in the department (OT1)”
“The main obstacles are institutional because as soon as there is the slightest change, you have to push (PM2)”.
“I said to myself that it adds yet another communication tool when we already have e-mail (PT3)”
Suggestion for improvement
When we got to the end, I was a little disappointed, because it wasn’t the application in itself that helped identify the goals (PT7)”	Enhancing existing functionalities
“The pathologies are not listed and some of the children said “so my thing doesn’t exist?” (PT6)”
“The “likes/dislikes” targeted really small children, even for some 11-year-olds, the centres of interest were not really suitable (PT2)”.
“Perhaps there should be a ‘completed by the child’ or ‘completed by the adult’ tab (PT7)”	Addition of new functions
“I would have liked it to be accessible to more people to see the psychologist’s view, the educator’s view etc (OT5)”.
“Be able to add steps to each objective (OT1)” “Wouldn’t it be possible to have a global or priority objective, for example? (PT4)”
“Maybe a tutorial would be interesting for the objectives (OT1)”

Discussion

The “Kid’EM-app” was built to guide rehabilitation professionals through each aspect of goal co-determination (identification of needs based on what the child enjoys and both the child’s and family’s priorities, goal formulation, goal monitoring) with specific attention paid to providing a tool that facilitates child-parent-professional collaboration. This study showed that the “Kid’EM-app” aligned with the values of rehabilitation professionals who seek to increase children’s involvement in their care. Its usability was rated as satisfactory. Further improvements are needed to consider the rehabilitation professionals’ feedback while remaining consistent with scientific evidence so that this app can become a fully-fledged rehabilitation tool for setting high-quality goals in pediatric rehabilitation.

Goal setting is widely used in mHealth applications to promote user engagement, including in pediatric populations. It is a common feature of behavior change intervention [54]. Pediatric rehabilitation, with its focus on functional goals and daily life, offers valuable insights that can be extended to broader applications for children. However, the field also faces significant challenges, particularly in facilitating effective collaboration within the triadic relationship between the child, family and therapist that the therapist must establish. Two applications aiming to facilitate the goal-setting process were found, the first intended for physiotherapists and the second for occupational therapists [55, 56]. They highlight the potential of mHealth to track and visualize progress towards a goal [56] and facilitate collaboration for needs assessment [55] using easily understandable images to reach a wide range of children and involve them. In developing the “Kid’EM-app,” made possible thanks to sponsorship donations, we aimed to guide rehabilitation professionals through the entire goal-setting process while enabling them to engage children and families meaningfully in the different steps of the process. This responds to the need to create multi-phase tools to streamline the goal setting and evaluation process recently highlighted by Ryan et al. in their scoping review [13]. Specific attention was paid to promote the active involvement of children [13]: the app encourages therapists to share their screen with the child during sessions, placing the child at the center of the process. Various gamification elements were integrated to foster the child’s engagement, including graphical representations of information [55], the selection of a personalized avatar, and feedback mechanisms such as performance progress tracking. For parents, a shared digital space is provided where they can contribute their ideas and opinions, identify their child’s needs, and share images and videos to provide real-life insights into their child’s challenges. Given that in France, children are often supported by multiple rehabilitation professionals across diverse settings, we prioritized the development of a simple tool to facilitate the integration of goal-setting practices in a variety of contexts and clinical routines. This decision reflects a deliberate choice not to rely on more complex methodologies such as the Canadian Occupational Performance Measure (COPM) for needs identification or Goal Attainment Scaling (GAS) for goal tracking, which require specific training and can be time consuming as they require the same time for a part of the goal setting process as the time required for the whole process on the “Kid’EM-app” and are best left to experts.

The prototype testing phase highlighted some changes to improve the “Kid’EM-app”. The SUS was rated at 70.9, equivalent to digital health applications. More specifically, it was equivalent or slightly lower than, other clinical decision-making mHealth applications [57, 58]. A didactic tutorial could improve usability while providing a global vision of the goal-setting process, thus playing an educational role [59].

The testers proposed expanding the “Kid’EM-app” to include non-rehabilitation professionals involved in pediatric disability care. This aligns with the need to enhance care coordination and collaborative goal achievement [4] within integrated care frameworks [60]. Consequently, the “Kid’EM-app” should incorporate interoperability and broad mobile compatibility. This was not realized in phase 2 due to significant operational bugs. Nonetheless, the divergent feedback from various rehabilitation professionals underscores the complexity of developing a universal tool for diverse practitioners [61]. Physiotherapists exhibited a stronger interest in the tool than their counterparts. The creation of the “Kid’EM tool-paper version” and the “Kid’EM-app” was influenced by the nature of physiotherapy in France, as i/ physiotherapists are often unfamiliar with goal-setting for daily activities and participation [11], ii/ unlike occupational therapists, physiotherapists in France lack specific tools for this aim, and iii/ they typically have limited time for this practice, particularly in outpatient clinics where many children receive care. Occupational therapists found the app’s guidance for needs identification and goal setting inadequate and suggested enhancements for better usability. In response to the recommendation to broaden the app’s use to additional rehabilitation professionals, attempts were made to involve psychomotor therapists in the 3rd phase; however, most declined participation, possibly because their current practice is not focused on objectives related to activities of daily living and participation [62].

The testers also suggested developing versions adapted to different age groups and cognitive levels, corresponding to the diversity of situations encountered in pediatric rehabilitation. Digitalization allows the creation of adapted and personalized versions of the same tool to democratize and personalize [63] the practice of goal setting for all children [13]. This is necessary for proposing person-centered rehabilitation [2].

The file sharing and chat functions were underutilized despite their design to enhance information sharing between rehabilitation professionals and parents, a key aspect of goal setting in rehabilitation [11]. The limited use of these features could be attributed to (i) their lack of visibility and the absence of a tutorial [59], and (ii) the need to change professional practices, a more complex challenge [64]. Some issues regarding implementation were also raised during the tests. For several professionals, the digitalization of treatment processes and exposure to screens were sensitive issues that limited their desire to participate in the study. The WHO supports eHealth [65], but specific guidelines for children with chronic conditions are lacking, requiring further efforts to ensure their protection [66, 67]. In the case of the “Kid’EM-app”, the child’s use of the application was supervised by the rehabilitation professional and corresponded to a dedicated time within the rehabilitation follow-up.

Finally, the professionals reported that their managers did not always favor integrating new technologies into current practice [68], demonstrating the importance of involving all stakeholders when proposing a new tool in rehabilitation practice to facilitate adoption in routine clinical situations.

Limitations

This study represents a preliminary step in the development and evaluation of the “Kid’EM-app”. Some limitations are inherent to its exploratory nature, providing a foundation for more comprehensive investigations which will inform the development of the new version of the “Kid’EM-app”.

In phases 2 and 3, purposeful sampling was used with only three variation criteria (working facility, profession and age). We chose to involve testers interested in improving goal-setting practices and receptive to innovation to receive constructive feedback. Therefore, the sample was not representative of the entire population of pediatric rehabilitation professionals. Notable differences were highlighted in the quantitative results for each profession category in phase 3, but the data reached saturation for the qualitative part of this phase. The feedback identified improvements to meet the needs of each professional category better. Therefore, we decided to stop the recruitment and work on the improvements needed for version 2. Only French rehabilitation professionals were involved because the “Kid’EM-app” was developed in response to the French situation. In the medium term, researchers and testers from other countries will be needed to adapt the “Kid’EM-app” to the specifies of other countries.

We focused on gathering feedback from rehabilitation professionals who enable and lead the goal-setting process. They gave us indirect feedback from children based on the tests they performed. Taking feedback from families and children into account is crucial. The functional abilities of the children with whom the “Kid’EM app” was tested were not systematically recorded. Obtaining this information to further characterize the population of interest and to better understand the profiles of those for whom the app would be useful will be necessary in the next steps. It will also be necessary to broaden the population of children with whom the.

application is used.

Engagement with the application and behavior change among users were not evaluated. Although the two-week testing period and immediate feedback offered valuable insights, future studies must assess these outcomes. To ensure long-term adoption of the next version, behavior change techniques should be integrated to enhance macro engagement. A Behavioral Design Thinking approach might also be incorporated to address user behavior better and promote sustained engagement [69].

Perspectives

New funding will be sought to incorporate the suggestions from testers in phases 2 and 3, as well as input from families and children, whose perspectives will be integrated into the iterative development process. To align with the needs of the “Kid’EM-app” end-users, we propose starting with improvements in the app’s guidance for needs identification and enhancing the visibility and usability of key features (e.g., file sharing and chat). In subsequent phases, we plan to broaden the range of target professionals and develop versions tailored to the diverse characteristics of children. Given the small size of the pediatric rehabilitation market, it will be necessary to extend this tool to adults, for whom it should also be useful. A modular app design will be used in the following steps to allow for broader use [64]. These steps, supported by additional funding, are expected to help the app evolve to meet its users’ needs more comprehensively while expanding its adoption and implementation and accelerating knowledge translation. An impact study is also planned to assess the impact of the “Kid’EM-app” on the quality of goal setting [70].

Conclusion

The “Kid’EM-app” is the first mHealth tool designed to guide rehabilitation professionals of all disciplines through the whole goal-setting process and to help them involve the children and their parents in the process. We have established that the app is acceptable and usable. Taking into account both feedback from the field and scientific evidence enabled us to identify content requirements and implementation barriers that must be overcome to enable the app to be used in clinical practice and accelerate knowledge translation. Digitalization holds promise for facilitating and personalizing goal setting by providing an easily accessible and common tool for all stakeholders, providing support for each aspect of this complex practice. Development strategies for such tools developed from research have to consider not only the scientific measurement of the impact but also the implementation perspectives from the beginning as well as sustainability models taking into account the specificity of pediatric rehabilitation field.

Supplementary Information

Below is the link to the electronic supplementary material.

Abbreviations

GDPR

General data protection regulation

HSD

Human-centered design

mHealth

Mobile health

PRM

Physical and rehabilitation medicine

SD

standard deviation

SM

Supplementary material

SMART

Specific, measurable, attainable, realistic and time-bound

SMS

Short message service

SUS

System usability scale

TAM

Technology acceptance model

Author contributions

CP and SB conceived the study and defined the original study protocol. CP, RB, EF and SB developed the protocol. LG, ALG and VV were responsible for the ethics applications and the ethical reporting of the study. LG, ALG and VV were responsible for recruitment, data collection and implementation of the study. CP was responsible for the study methodology. All authors participated to the discussions about the development and improvement of the application. All authors have read and approved the final manuscript. VV, CP, SB, RB, DJ drafted the final version of this manuscript.

Funding

“Kid’EM-app” was developed thanks to sponsorship donations with no commercial aim.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

The study was validated by the B2021CE.56 ethics committee. Each tester signed a consent form for participation. All information stored by the application was anonymized and complied with RGPD rules.

Competing interests

The authors declare no competing interests.