August 23rd 2023
Reaching and Supporting All Children with Digital Parenting Interventions
Millions of children in low-income settings are at risk of missing their developmental potential in early life. One type of preventive measure is a home visiting programme, in which facilitators support parents with skills and knowledge related to early child development. Now, a collaborative study led by researchers of the Swiss Tropical and Public Health Institute, University of Basel, ETH Zurich, Universidad Peruana Cayetano Heredia (UPCH) and Harvard Graduate School of Education has examined whether families, instead of being visited physically, could also be reached digitally via an app. The study was conducted in remote areas in Peru – with promising results.
What if each parent, irrespective of income or location, had their own virtual tutor to help them take care of their little ones? A tutor that makes suggestions on how to stimulate the development of a young child with age-tailored activities? That’s the idea behind the start-up founded by Andreana Castellanos, Afinidata, a platform that uses artificial intelligence to support parents with care practices and knowledge about child development.
Afinidata uses channels like WhatsApp, Facebook Messenger and a mobile App to interact with parents of children aged 0-6 years. “Similar to facilitators that make home visits to parents, the virtual Afinidata tutor asks parents about the child’s well-being through messages and push notifications, and it suggests development-promoting activities that parents can do with their children,” explains Dr Lena Jäggi, a developmental psychologist of the Swiss Tropical and Public Health Institute (Swiss TPH) at the University of Basel and a researcher deeply involved in the pilot study. According to UNICEF there is “a large gap for effective, easy-to-access educational tools that are inclusive with lower-income families.” Digital tools such as Afinidata have the potential to close that gap. However: “There has been limited evidence on how feasible digital parenting interventions are in practice,” says Lena Jäggi, “especially in rural settings in low- and middle-income countries.”
That’s where the study* published by the journal Archives of Disease in Childhood and first-authored by Lena Jäggi steps in. Lena Jäggi: “We wanted to find out whether Afinidata would work in a very remote area in Latin America, and if changes had to be made to adapt the platform to the local context.” The “local context” was the Cajamarca region in the north of Peru, in three provinces located in the Andes where the Swiss – Peruvian Health Research Platform of Swiss TPH and UPCH maintains a research station.
Milagros Alvarado Ilatance is also a developmental psychologist and one of the two study coordinators in Peru who together co-lead the training of local research team members and the collection of the field data. She explains how Afinidata had to be adapted to the context of Andean Peru: “For example, in order to facilitate ease and understandability for the parents, we had to rephrase some of the questions or change the vocabulary of the chatbot to a certain extent since we were working with a version that was originally intended for families in Guatemala.”
In this mountainous region, stretching from 1900 to 3900 metres above sea level, the research team recruited families for their study. “The communities are small and thus representative of many rural settings in Andean South America, with a large share of low-income and remote households engaged in farming,” says Lena Jäggi.
Even so, almost 90 % of these households have access to at least one cell phone and the internet. For the pilot study, the research team enrolled 180 mothers with children aged between 2 and 24 months who either owned or had regular access to a smartphone. The field work was done by the Peruvian part of project team, consisting of the two study coordinators, Milagros Alvarado Ilatance and Maria Luisa Huaylinos Bustamante, from the Universidad Peruana Cayetano Heredia and about a dozen local facilitators who visited the mothers at their homes from February to July 2021.
Study coordinator Maria Luisa Huaylinos Bustamante discusses the digital parental intervention and the study with a mother and her children. Credit: Swiss-Peruvian Health Research Platform/Digital Support Systems to Improve Child Health and Development
During their first visit, the research team introduced the mothers to Afinidata, installed it on their smartphone and showed them how to navigate the app. After two months, the facilitators visited them again, interviewing and collecting detailed feedback. During their final visit five months from the start, the mothers were asked about their overall experience, satisfaction and use of the platform.
A mother participating in the study said that with the app, she was “jugar con mi niña, cantar…,a traves de la aplicación tenemos la actividad y nos dedicacabamos a ellos un momento, a veces hasta hacerla dormir” "playing with my daughter, singing..., through the application we have the activity and we dedicate ourselves to them for a moment, sometimes until it puts her to sleep." From Jäggi et al. 2023, Supplemental Data 2 .
Another challenge was the availability of material for the parent-child activities. “Sometimes the mothers didn’t have the craft material at hand which the chatbot suggested,” adds fellow study coordinator Maria Luisa Huaylinos Bustamante. “With no supermarket nearby where they could have bought these things, the mothers would simply switch to alternatives they had in their house or created the toys themselves. They were amazingly flexible and creative,” says Huaylinos Bustamante.
The biggest challenge though was familiarizing the mothers with Afinidata so that they would feel confident and motivated to engage with the platform on a regular basis. “That’s one point we had clearly underestimated in the beginning,” says Milagros Alvarado Llatance. Through this pilot study, they found that the initial orientation to Afinidata during the first visit was not sufficient. “So to meet this need, we had to adapt. We created for them a physical, laminated booklet which detailed the app step by step that we will use in the main trial.”
This point was one of the principal learnings of the pilot study for Lena Jäggi as well: “Just because people have access to a smartphone and the internet doesn’t mean they are automatically proficient in using digital health tools,” she says. The booklet, which will be implemented when the main trial begins, also includes general information on child development, sample activities and detailed instructions on how to self-enroll in case a phone got lost. “So we learned also to be flexible and creative and that this additional effort is important because ultimately, our goal is for the mothers to get the full benefit of the intervention,” says Lena Jäggi.
Even before adding this booklet, the results of the pilot study are very promising. After five months, 42 % of mothers were still active on the platform. One might argue that an adherence of less than half of the original participants is not very successful, but those 42 % have to be viewed within the larger frame, says Lena Jäggi: “Compliance is a big challenge in any kind of parental intervention, i.e. in home-visiting programmes too,” she says. “And as far as digital programmes resembling Afinidata are concerned, other studies have reported completion rates as low as 15 and 7 %.” Meaning that compared to similar interventions, a 42 % engagement with Afinidata at five months post-introduction was relatively high, “but more data on continued use over longer periods are needed.”
Digital health tools like Afinidata stand not only to broaden the accessibility of interventions to families in remote regions but also to mitigate the consequences of sudden upheavals in the public healthcare system. This case in point: the field testing fell squarely in the COVID-19 pandemic, which hit Peru quite severely. In non-pandemic times, the Peruvian government offers families in areas of poverty and with children under 36 months a national visiting programme (Programa Nacional Cuna Más; PNCM) for early childhood and parental support. The PNCM, although only able to support the most vulnerable, is one of the largest of its kind in the world. During the COVID-19 pandemic, however, those services were shut down completely. So, digital parenting interventions actually filled a gap that was unforeseen.
These pilot study results are promising, but what the pilot study hasn’t assessed is the impact of the intervention on the mother’s or child’s outcome. Nor has cost-effectiveness been studied. These are follow-up research steps yet to be taken: A randomized-control study is already underway to address these aspects. Milagros Alvarado Ilatance: “I think this is a very important opportunity for the families in Cajamarca to have access to new strategies to improve their children’s development.”
Dr Lena Jäggi, Milagros Alvarado Llatance and Maria-Luisa Huaylinos Bustamante are researchers in a BRCCH research project "Digital Support Systems to Improve Child Health and Development in Low-Income Settings" and one of the activities of the Swiss – Peruvian Health Research Platform of Swiss TPH and UPCH. The research project is one of BRCCH’s cornerstone projects, within the overarching Multi-Investigator Programme.
Interview article: Irène Dietschi
JÄGGI L, AGUILAR L, LLANTANCE ALVARADO M, CASTELLANOS A, FINK G, HINCKLEY K, BUSTAMANTE HUAYLINOS M-L, MCCOY DC, VERASTEGUI H, MÄUSEZAHL D & HARTINGER PENA SM. 2023. “Digital Tools to Improve Parenting Behaviour in Low-Income Settings: A Mixed-Methods Feasibility Study.” Archives of Disease in Childhood. https://doi.org/10.1136/ARCHDISCHILD-2022-324964