Youth & NCD Digital Health Interventions

A library of research on how digital health interventions can engage youth in low- and middle-income countries to minimize their risks of noncommunicable diseases.

AstraZeneca Young Health Programme

This site presents summaries of research projects from low- and middle-income countries (LMICs) on the effectiveness of digital health interventions, such as apps, websites, and online games, in curbing the following key risk behaviors for noncommunicable diseases (NCDs) among youth: tobacco and alcohol use, unhealthy diet, and physical inactivity.

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Why Focus on NCDs and Young People?

NCDs, such as cancer, diabetes, and cardiovascular disease, are the leading causes of death worldwide. Premature deaths from NCDs, defined by the World Health Organization as occurring between ages 30 and 70, take place disproportionately in LMICs and affect individuals at the height of their economic productivity.

NCDs pose a major threat to the health of populations, place an increasing burden on health systems, and threaten economic growth and development. Prevention is therefore a critical priority for addressing the growing NCD epidemic. In addition, the Sustainable Development Goals call for reducing premature mortality from major NCDs by one-third by 2030. Early intervention that focuses on young people is key to reducing premature NCD mortality.

Over 80% of premature deaths from NCDs are due to cardiovascular diseases, cancers, diabetes, and chronic respiratory diseases. These NCDs share four key behavioral risk factors—tobacco use, harmful use of alcohol, physical inactivity, and unhealthy diet—that are all modifiable and typically begin or become habits in adolescence and young adulthood.

Today, there is a unique window of opportunity to curb the NCD epidemic before young people develop unhealthy behaviors and while many LMICs still have relatively young populations. By encouraging young people to adopt positive behaviors and limit negative ones as they gain autonomy over their lives, we can reduce premature deaths from NCDs and set youth on healthier paths into adulthood.

Why Study Digital Health Interventions for Youth in LMICs?

The opportunity to implement digital health interventions in LMICs is increasing as access to the internet expands globally, particularly for young people who access the internet at a higher rate than older age groups. While many digital health interventions addressing the risk behaviors among young people have been tried and evaluated in high-income countries, such interventions have been much less common in LMICs. What’s more, only a few have been evaluated and information about their evaluation is scattered.

About the Studies

The research presented on this site covers a range of digital platforms, including phone apps, text messaging, websites, social media platforms, and online games. Only interventions that specifically targeted young people within the age range of 10 to 24, or those with a study sample predominantly composed of young people were considered for inclusion. Studies were further limited to those that had samples large enough to assess the effectiveness of the interventions, and most were published in 2015 or later.

Many of the studies suffered from limitations, including small sample sizes, high attrition rates, short trial periods, and reliance on self-reporting, and very few were grounded in theoretical behavior change. Nevertheless, our summaries highlight a variety of efforts to use digital platforms to address NCD risk behaviors in youth, some of which have shown promising results, and help build a knowledge base for anyone working to develop, revise, or better understand such interventions to improve health outcomes and to reduce the growing NCD epidemic.


Australian Fathers' Long Hours Affect Sons More Than Daughters

Boys and girls begin to show differences in behavioral problems as young as 5 years old, finds a recent study in Western Australia.1 Sixteen percent to 20 percent of Australian fathers worked 55 or more hours per week, and were more likely to have young sons with a higher level of aggressive behavior, compared with boys whose dads worked fewer hours, said the study.

Behavioral Problems Related to Gender

One possible explanation for these differences in child behavior could be that the absence of the same-gender parent (dad) due to long hours at work has a worse effect on a child (in this case, boy) than the absence of the opposite-gender parent (mom). To explore this possibility, the researchers examined child gender during a critical phase of development, middle childhood. This period before puberty is a time when children solidify their gender identity—when they see themselves as a “girl” or a “boy.”2

The study used data from the Western Australia Pregnancy Cohort (Raine) Study, with a sample of over 1,400 children in heterosexual two-parent families, mostly high income.3 The researchers analyzed the parent-reported (mostly mothers) Child Behavior Checklist, which measures changes in child behavior. They looked at children’s behavior at ages 5, 8, and 10, focusing on two types of behavior—externalizing (acting out, aggressiveness) and internalizing (withdrawing, anxiety).

Boys Act Out More When Their Fathers Work Longer Hours

Researchers looked at the breakdown of father-child interaction by gender: Boys whose fathers worked fewer than 55 hours a week acted out less, compared to boys whose fathers worked longer hours. No such significant difference was found for girls.

“I would expect to see similar results in lower SES [socioeconomic status] families,” said Jianghong Li of the Social Science Research Center in Berlin, one of the study authors. “Possibly, the link between fathers’ long work hours and sons’ behaviors might be even stronger because children from lower SES families may be doubly disadvantaged by a lack of adequate parental time when parents work long hours, [at] low income, and [with the] stress associated with low quality jobs.”

Another possible reason for behavioral problems in boys whose fathers work longer hours: The play time typical in father-son relationships that helps release boys’ high energy levels or aggressive behaviors is missing, suggested Li and her co-authors.

They found no association between mothers’ work hours and child behavior during middle childhood—consistent with prior work of others, including a literature review of work and family research by Suzanne Bianchi of the University of California, Los Angeles, and co-author, Melissa Milkie of the University of Maryland.4


Equal Opportunities for Mothers and Fathers

Li believes that the negative effect of fathers’ long work hours could be even stronger for American fathers. “I would expect similar results for American families,” said Li. She thinks that family and social support networks are weaker in the United States than in Australia. Combined with the greater share of U.S. mothers with young children who work outside the home, U.S. fathers’ very long work hours may have even a stronger negative impact on children, in Li’s opinion.

Bianchi and Milkie recommended that contributors to the work-family policy literature look more at the balance between work and family life.5 “The 24-7 economy may be adding to the challenges faced by parents in managing their work and parenting commitments, when jobs require them to work unsociable hours,” Australian researchers said in a press release.6 This study provides further evidence to support equal opportunities for both parents to share parenting and work responsibilities.


  1. Sarah Johnson et al., “Mothers’ and Fathers’ Work Hours, Child Gender, and Behavior in Middle Childhood,” Journal of Marriage and Family 75, no. 1 (2013): 56-74.
  2. Johnson et al., “Mothers’ and Fathers’ Work Hours, Child Gender, and Behavior in Middle Childhood.”
  3. “High-income” in the Johnson et al., study refers to families of higher socioeconomic status (a gross annual income of at least $36,000).
  4. Johnson et al., “Mothers’ and Fathers’ Work Hours, Child Gender, and Behavior in Middle Childhood”; and Suzanna Bianchi and Melissa Milkie, “Work and Family Research in the First Decade of the 21stCentury,” Journal of Marriage and Family 72, no. 3 (2010): 705-25.
  5. Bianchi and Milkie, “Work and Family Research in the First Decade of the 21st Century.”
  6. Jianghong Li et al., “Parents’ Work Hours in Evenings, Nights, and Weekends to Children’s Disadvantage,” press release (Dec. 12, 2013).

International Migration Transforms Australia

(June 2001) Immigration since World War II has transformed Australian society and population. Many residents of Australia are immigrants or are the children of immigrants. More than one-fifth of Australians were born overseas (23 percent), compared with 10 percent in the United States and 17 percent in Canada. In addition, 19 percent of those born in Australia have at least one parent who was born overseas. Between 1945 and 2000, most of Australia’s population increase (59 percent of the increase from 7.4 million to 19.1 million) has come from immigration. Australia is likely to become increasingly diverse, with immigrants continuing to influence Australia’s society, economy, and settlement patterns.

Asia Surpasses Europe as the Largest Source of Immigrants to Australia

The post-World War II period stands out as an exceptional era in Australia’s immigration history because of a major influx of immigrants from outside the United Kingdom and Ireland. For much of the post-World War II period, the UK and Ireland have been the major source of immigrants even while there was a series of successive waves of immigrants from various non-English speaking regions. The immediate post-war period saw the arrival of substantial numbers of displaced persons from Eastern Europe. This was followed by waves from the Netherlands, Germany, Italy, Greece, and the Middle East. In the late 1970s, substantial flows from Asia commenced and still continue. Since the late 1980s, Asia has been a more important origin of migrants than Europe. In the 1990s, the United Kingdom lost its place as the largest single source of immigrants.

These patterns reflect some significant shifts in immigration policy over the last half-century. In the aftermath of World War II, significant labor shortages arose in the newly expanding manufacturing sector as well as in traditional areas like agriculture. When this demand for labor could not be met from traditional sources, the government assisted more than 300,000 displaced persons from Eastern Europe to settle in Australia and fill vacant jobs. This policy broke the previous almost exclusive reliance on immigrants from the UK-Ireland. The success of the displaced-persons policy led to an extension of the immigration program to other parts of Europe.

The 1970s saw several major shifts in the immigration policy. First, Australia began to experience substantial levels of unemployment with structural change in the economy, the movement of manufacturing jobs away from Australia, and the entry of the baby-boom cohorts into the labor force. Immigration policy shifted from an emphasis on the recruitment of semi-skilled and skilled foreign workers for manufacturing to a more complex program with four main components:

  • Economic migration. Attraction of people with skills in demand in Australia.
  • Family migration. Relatives of Australian residents. The specific regulations of this part of the program have changed over the subsequent years.
  • Refugee and humanitarian migration.
  • Special categories. The largest is New Zealanders who can move more or less freely across the Tasman Sea.

The government introduced a points system to assess applicants for economic migration. In the 1980s a system was introduced whereby each year the government sets the numbers of immigrants to be allowed into the country. Over the years, the numbers and balance of the four categories has shifted with changes in government policy, the economy, and the global situation.

The second major policy change in the 1970s was the removal of the final vestiges of the “White Australia policy” which was one of the first initiatives of Australia’s first national government in 1901. This policy prevented non-Europeans from immigrating to Australia. With its removal, Asians began to compete equally for places in the immigration program. The entry of refugees from Indo-China was the first wave of a continuing influx from the region.

Trends Point to Increasing Diversity in Australia’s Population

Growing diversity among immigrants has made Australia increasingly multicultural. In 1947, 98 percent of the Australian population were born either in Australia or in another English speaking nation. By 1996, this figure had dropped to 86 percent.

C.A. Price has estimated the “ethnic strength” of the main groups in the Australian population. (Ethnic strength is derived by adding fractions of ancestry for generations.) A distinctive feature of post-World War II immigration to Australia is that it has not been dominated by a single birthplace or ethno-linguistic group. The result is a highly diverse population. According to the 1996 census, there were 53 birthplace groups with 10,000 or more residents in Australia, and 111 groups with 1,000 or more residents. Table 1 shows the largest 15 birthplace groups in Australia in 1947, 1971, and 1996. This indicates the increased importance of continental European groups in the first half of the post-World War II period and of Asian groups in the second.

Table 1
Australia’s 15 Largest Birthplace Groups, 1947, 1971, and 1996

1947 1971 1996
Birthplace Number Birthplace Number Birthplace Number
Australia 6,835,17 Australia 10,176,320 Australia 13,227,776
UK and Ireland 541,267 UK and Ireland 1,088,210 United Kingdom 1,124,031
New Zealand 43,610 Italy 289,476 New Zealand 291,388
Italy 33,632 Greece 160,200 Italy 238,426
Germany 14,567 Yugoslavia 129,816 Viet Nam 151,053
Greece 12,291 Germany 110,811 Greece 126,520
India 8,160 Netherlands 99,295 China 111,009
Poland 6,573 New Zealand 80,466 Germany 110,331
China 6,404 Poland 59,700 Philippines 92,949
USA 6,232 Malta 53,618 Netherlands 87,898
South Africa 5,866 USA 30,035 India 77,551
Yugoslavia 5,866 India 29,211 Malaysia 76,255
Ukraine 4,976 Hungary 29,160 Lebanon 70,224
Austria 4,219 Egypt 28,226 Hong Kong 68,430
Canada 4,061 Lebanon 24,218 Poland 65,113

Source: Australian censuses of 1947, 1971, and 1996.

Australian policies toward the settlement of immigrants have also undergone a substantial change since World War II. In the early post-war decades the official policy regarding settlement of immigrants was assimilation. In the 1970s, however, a new policy of multiculturalism emerged. This policy encouraged immigrants to retain their distinctive cultures while becoming part of broader Australian society. A number of mechanisms were put in place to ensure cultural maintenance such as the introduction of multicultural television and radio networks funded by the federal government.

Growth in Both Short and Long-Term Movement To and From Australia

For almost the entire post-World War II period there has been bipartisan agreement in Australia that permanent settlement of a significant number of overseas immigrants is desirable. Accordingly, each post-war government has had an active immigration program while strongly opposing non-permanent labor migration encouraged by some other Organisation for Economic Cooperation and Development (OECD) nations during the 1950s and 1960s. The policy focus has changed. In response to major changes in the Australian economy — including internationalization of labor markets and globalization forces — there has been an increase in the entry of persons with the right to work in Australia on a nonpermanent basis. Over recent decades, there has been substantial growth of both short and long-term movement to and from Australia while permanent movement has remained stable.

The Department of Immigration and Multicultural Affairs categorizes arrivals to Australia into three separate categories as it does departures from Australia:

  • Permanent residents: Persons migrating to Australia and residents departing permanently.
  • Long-Term Movement: Visitors arriving and residents departing temporarily with the intention to stay in Australia or abroad for 12 months or more, and the departure of visitors and the return of residents who stayed in Australia or abroad for 12 months or more.
  • Short-Term Movement: Travelers whose intended or actual stay in Australia or abroad is less than 12 months.

While Australia is an immigration country, it also has a significant and increasing population outflow. There has long been an outflow of immigrants: an estimated one-fifth of persons settling in Australia as immigrants eventually leave the country — most returning to their home country. In recent years, however, there has been an increase in the outflow of the Australia-born and naturalized citizens. These emigrants tend to have a higher-level occupational profile than the corresponding inflow immigrants — which has led to increasing “brain drain” concerns.

Immigrants Tend to Opt for Urban Areas

Australian immigrants tend to settle in different places than the nonimmigrant population. They are more concentrated in urban areas where 80 percent of them lived in 1996, compared with 58 percent of the Australia-born. Moreover, they are especially concentrated in Sydney, which has 18 percent of the Australia-born but 32 percent of the overseas-born and 38 percent of those who had been in Australia for less than five years. They are also more concentrated in some states (New South Wales, Victoria, Western Australia) than others.

There is considerable variation between different birthplace groups in their propensity to cluster together. For example, in the early post-war migrations, Italians and Greeks tended to cluster, especially in inner suburban areas of major cities. More recently, Indo-Chinese groups have shown a strong tendency to cluster while other Asian groups like Filipinos are relatively dispersed. There is considerable debate about this issue with some maintaining that such clustering assists newly arrived immigrants to adjust to the Australian society and economy since earlier migrants can assist them to get work and housing and otherwise adjust to the new environment. Others argue that such concentration hinders adjustment to Australia and fosters the development of separateness.

Undocumented Immigrants

Australia’s status as an island continent has protected it somewhat from large influxes of undocumented immigrants. However, the numbers arriving by boat — especially on Australia’s northern shores — have accelerated in recent years.

Between 1989 and 1994, the annual number of people on boats arriving secretly in Australia and detected by authorities ranged from 78 to 224. Between 1995 and 2000, this range was from 157 to 4,174 arrivals per year. In the past decade, the largest annual number of undocumented immigrants arriving by boat was documented in the fiscal year 1999-2000. These groups tend to be placed in detention centers until their claims for refugee status are processed.

Other types of undocumented migrants in Australia include those who have entered Australia legally and overstayed the period of their visas. In recent years, their numbers have been relatively stable at around 50,000. Additionally, there are those who arrive in Australian airports without documentation who are returned to their origin unless they can make a substantial claim for asylum.

Graeme Hugo is professor of geography and director of the National Key Centre for Social Applications of GIS, University of Adelaide, Australia.


Australian Bureau of Statistics, Migration Australia, various issues, Catalogue no. 3412.0.

Australian Bureau of Statistics, Overseas Arrivals and Departures, Australia, various issues, Catalogue no. 3402.0.

Bureau of Immigration and Population Research, Immigration Update, June Quarter 1992 (1993).

Department of Immigration and Multicultural Affairs, Australian Immigration Consolidated Statistics, various issues.

Department of Immigration and Multicultural Affairs, Immigration Update, various issues.

Department of Immigration and Multicultural Affairs, Immigration Update, June Quarter 2000 (2000a).

Department of Immigration and Multicultural Affairs, Locating Overstayers in Australia, DIMA Fact Sheet 80 (2000b).

Department of Immigration and Multicultural Affairs, Unauthorised Arrivals by Sea and Air, DIMA Fact Sheet 81 (2000c).

G.J. Hugo, Australia’s Changing Population: Trends and Implications (Melbourne: Oxford University Press 1986).

G.J. Hugo, “A New Paradigm of International Migration in Australia,” New Zealand Population Review 25, nos. 1-2 (1999).

R. Kippen and P. McDonald, “Australia’s population in 2000: the way we are and the ways we might have been,” People and Place (2000).

C.A. Price, Australian Immigration: A Bibliography and Digest, No. 4 (Department of Demography, Australian National University, Canberra, 1979).

C.A. Price, Ethnic Groups in Australia (Australian Immigration Research Centre, Canberra, 1989).


More Than Ethnicity Behind Fiji's Unrest

(March 2001) Fiji is still reeling from a coup on May 19, 2000, in which armed indigenous Fijians took the nation’s first prime minister of Indian descent, Mahendra Chaudhry, and other parliamentarians hostage.

The nonelected interim government appointed after the release of the hostages has now been declared unconstitutional, the man who was declared the legitimate president has resigned, and the country waits while the courts determine whether to dissolve parliament and conduct new general elections. The interim government includes no officials from the deposed government, which seeks reinstatement. In fact, the interim government includes no members of the Indo-Fijian community, who make up over 40 percent of the country’s 800,000 citizens.

Press reports have chalked the situation in Fiji up to ‘ethnic resentments’ that suddenly boiled over. But a fuller understanding of the recent instability in Fiji requires analysis of its demographic, economic, and political complexities. The problem with many Pacific Islands states is not so much that they are prone to falling apart, but rather that they were never fully put together. The people of Fiji were never united prior to British rule, and the transplantation by the British of thousands of indentured workers from the Indian subcontinent to labor on the islands’ sugar plantations only complicated prospects for national cohesion.

Barriers of culture and religion separate indigenous Fijians and Fijians of Indian ancestry, and the two groups have extremely low rates of intermarriage. Although many Indo-Fijians remain humble cane farmers, others now dominate Fiji’s commercial sector. The indigenous, largely village-based Fijian ‘nation’ is also deeply divided into traditional confederacies and increasingly fractured by class and privilege. The 2000 coup was ostensibly conducted in the name of indigenous rights to counter Indo-Fijian political power represented by the one-year-old government of Prime Minister Chaudhry. Yet now-imprisoned coup leader George Speight pressed his demands in defiance of the commander of the overwhelmingly indigenous Fijian armed forces, as well as the Great Council of Chiefs (the supreme repository of traditional power). And many hostages were indigenous Fijian members of Chaudry’s government.

Changes in traditional land-tenure arrangements lie at the heart of many contemporary disputes in the islands. More than 80 percent of all land in Fiji is still held under traditional tenure by indigenous Fijian land-owning groups, and land-related legislation cannot be changed without the consent of the Great Council of Chiefs. A central element in the current unrest was Chaudhry’s insensitivity to indigenous Fijians’ suspicions as he sought to assist Indo-Fijian smallholder sugar cane farmers whose land leases were expiring. Indigenous Fijian landowners wanted either to farm the land themselves or to receive higher rents with shorter leases. Indo-Fijian farmers sought to renew leases for at least 50 years, gain greater certainty about landlord-tenant rights, and receive compensation for land improvements in cases when leases were not renewed.

A new approach to development has accentuated these tensions. International donors today are pushing restructuring, emphasizing economic growth and market forces. Pacific island governments are urged to drastically cut their bureaucracies, privatize public assets, and strip away protective tariffs to create attractive conditions for foreign investment — at almost any cost. The private sector has often been unable to compensate for the lost jobs and incomes associated with drastic cuts in government employment. Domestic tensions have risen as the gap between rich and poor has widened.

What’s needed is more engagement by the international community, which has a continuing interest in regional stability. Initiatives such as increasing peacekeeping capabilities and targeting aid to education, health, infrastructure, and jobs could help put Fiji back on its feet.

Gerard A. Finin is a research fellow at the East-West Center in the Pacific Islands Development Program. Terence A. Wesley-Smith is an associate professor in the Center for Pacific Islands Studies, University of Hawaii.

Fiji Facts and Figures

  • Population: 800,000
  • Land area 7,054 sq. miles on 300 islands
  • Births per 1,000 population: 22
  • Deaths per 1,000 population: 7
  • Natural increase: 1.5% per year
  • Total fertility rate: 3.3
  • GNP per capita, 1998: $US$2,210
  • Annual average emigration, 4,700 — 90% Indo-Fijian

Sources: PRB, 2000 World Population Data Sheet; and Secretariat of the Pacific Community, Fiji Islands Population Profile, 1999.

More Than Ethnicity Behind Fiji’s Unrest

For a more thorough discussion of the ideas presented in this article, see the following publication, on which it is based:

Gerard A. Finin and Terence A. Wesley-Smith, “Coups, Conflicts, and Crises: The New Pacific Way?” Working Paper 13, Pacific Island Development Series (Honolulu: East-West Center, June 2000).

The paper is available on the website of the Pacific Islands Development Program, East-West Center, Other reports and publications by the East-West Center can be viewed or searched for at


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