Bedtime Routines Intervention for Children (BRIC) using an automated text messaging system for behaviour change

Our work concerns the activities in the last hour before bed for young children born to first time parents; so called Bedtime Routines (BTR). These activities include among others tooth brushing, reading a book, having a bath and avoiding food and drinks before bed. Having a set bedtime at a suitable hour is also very important. Establishing good bedtime routines has been shown to be really important for a number of health, wellbeing, development and social outcomes. These include dental health, healthy weight, school readiness, prosocial behaviours and overall wellness. Our research is interested in how we can help first time parents to secure a good bedtime routine. Our earlier work found that those children with poorer bedtime routines suffered more dental decay (leading to pain, sleepless nights and costs to the NHS of over £60 million in preventable dental extractions) than those with good bedtime routines. Moreover, school readiness and performance at school is closely related to a good night's sleep and reading before bed is recommended by lots of national bodies concerned with child welfare. Bedtime routines therefore offer an opportunity to influence the health and wellbeing of young children (aged under 5) in many ways simultaneously, meeting important needs for their futures. Children with good routines at bedtime will be happier, healthier and more successful at school.

Most families start establishing their bedtime routines by the end of the 1st year of their child's life. Many parents manage to achieve good routines while others struggle, with first time parents being particularly vulnerable. At the moment, there is no available intervention to help parents, especially first-time parents who have no prior experience of getting their child to sleep. Our main aim is to develop, by talking to parents and professionals, a bedtime routine intervention for first time parents and their children using text messages sent to parents' mobile phones. We have already used this system with parents to monitor what happens in the lead up to children's bedtime. The parents told us that they enjoyed receiving the text messages and that they helped remind them about their routines. This made us think that text messages can potentially be a useful tool in changing routines to make them better. Text messages can be sent to every type of mobile phone with no need to own a smartphone. Also, our previous work has shown that almost every parent had a mobile phone, even those from poorer backgrounds. That finding is supported by existing statistics regarding access and use of mobile phones and text messages.

In this proposed study, we are going to do two pieces of work. The first will help us design the type and frequency of the messages we send to parents and the second will test this on a group of first-time parents to see how well it works. To do the first piece of work we will talk to first time parents to find out about their children's bedtimes and find out what problems they experience and how we might help them. For example, a message might be a simple reminder that it's time to start going to bed, or a recommendation on a good reading book for their child. We found that simple text messages sent in real time were a really useful tool in our earlier work. As well as parents we will speak with experts in reading, diet, sleep and general health to make sure that we use information from them to design the messages. We will also talk to people in local authorities whose responsibility it is to fund programmes like this to make sure that our plans can be afforded and will be used. Finally, we will combine the information about changing behaviours from parents and experts and build these in to the intervention. The second piece of work will be to test our new programme with a group of first-time parents to make sure that the system is working and is acceptable and practical. We will also consider cost and savings.

The aim of this early phase study is to develop an evidence-based, user and stakeholder informed bedtime routine intervention for first time parents using automated text messages for behaviour change. The early phase study will include 2 work packages (WP) building on existing work from this research team using text-surveys for bedtime routines in families with young children. WP 1 will develop and refine the intervention through 1:1 interviews using the Theoretical Domains Framework (TDF) (n=20) with first time parents to explore barriers and facilitators in establishing and maintaining good bedtime routines. Interviews will be open to first-time parents from diverse socio-demographic backgrounds to allow for a better exploration and inclusion of differences between levels of deprivation and ethnicities. Findings from the interviews will be use to select appropriate theory based Behaviour Change Techniques (BCTs) (i.e. to prompt, educate, motivate parents etc.) that will then be incorporated into the automated text message system. The text messaging system will utilise secure software with UK-based servers. An expert workshop with key stakeholders (NHS, academic, local authorities, research, educational representatives etc.) will examine their views on such an intervention and explore possible avenues for future support-funding-implementation. WP 2 will include an uncontrolled quantitative and qualitative feasibility study with first time parents (n=50) from diverse socio-demographic backgrounds to assess the APEASE (acceptability, practicability, effectiveness, affordability, safety, equity) criteria through user feedback and focus groups from participating first time parents and insight information on uptake, retention, user engagement, problems encountered and cost per participant. Should the pilot intervention meet the APEASE criteria, a more comprehensive intervention will be explored in a more robust (RCT-longitudinal) study.

Due to the diverse range of outcomes associated with good bedtime routines, beneficiaries from this early phase study include: (a) first-time parents and parents with young children in general, (b) academics and researchers in public health, dental public health, psychology, behaviour change, digital health interventions, health policy, education and child wellbeing, (c) NHS and non-NHS practitioners especially GPs, dentists and the wider oral health team, nurses, health visitors, child health specialists, (d) charities, trusts, local-regional-national level organisations specialising in child development-wellbeing (e.g. Children's society), specific bedtime routines activities (e.g. Book Trust for book reading before bed) or the health of public in general (e.g. Public Health England) and (e) education bodies, schools and practitioners (e.g. Education Endowment Foundation).

The majority of listed individuals, groups and organisations will benefit from general awareness of the outcomes and the innovative methodology of this early phase study. First-time parents and parents in general can benefit from increased awareness of the importance of bedtime routines, the constituent parts of a good bedtime routine and the importance of establishing a good bedtime routine from an early age. This benefit can be immediate for participating first-time parents. Non-participating parents can be reached and will benefit either directly (through the communication plan) or indirectly through the overall increased awareness and sharing of information between the research team and the wider public. Academics, researchers, policy makers and organisations can benefit from this early phase study especially its novel and innovative methodology when tackling their own research projects focusing on either human behaviour or similar populations. Also, researchers and academics working with deprived and ethnically diverse samples can gain valuable information due to the inclusion of such populations in this early phase study. Should this early phase study show promising results then a larger and more comprehensive study may produce positive differences in bedtime routines in first-time parents with short and long-term benefits for their children, parents themselves as well as public finances and the health service. These benefits can emerge from possible lower incidents of dental problems in children (i.e. fewer dental caries, less need for treatment, fewer hospitalisations, fewer dental extractions etc.), better quality of sleep, higher school readiness and school attainment with fewer school drop-outs later in life etc. Finally, with regards to the research team, it is expected that the Co-I and RCo-I will gain invaluable experience in organising, managing and executing an innovative study with benefits translating to future opportunities and career development.