Scaling and Sustaining Early Childhood Intervention Impacts through a Mobile Health Intervention: A Kenyan RCT

• In Event: Scaling up Effective and Cost-effective Early Childhood Interventions in LMICs: Evidence from 7 country contexts

Abstract

An estimated 250 million children under age 5 in low- and middle-income countries (LMICs) will not reach their full developmental potential due to poverty, stunting, or inadequate psychosocial stimulation (Black et al., 2017). Early childhood development (ECD) interventions that promote parental responsive stimulation and nutrition education can effectively improve ECD outcomes in LMICs, at least in the short-term (i.e. immediately after intervention completion) (Britto et al., 2017). However, early impacts of ECD parenting programs tend to fade over time, and the few that have shown longer-term impacts offered continued support over a period of years, not months (Jeong et al., 2021). Moreover, very few programs have been scaled to the regional or national level in LMICs. Two key remaining questions are how to sustain, and how to scale, promising ECD programs in LMICs.

We recently showed that Msingi Bora, an 8-month group-based ECD parenting intervention delivered by Community Health Workers (CHWs) from Kenya’s rural health care system significantly improved short-term ECD outcomes and parenting behaviors and was highly cost-effective. However, impacts two years later were still positive but smaller in magnitude, suggesting that our program may still not be scalable in a rural, resource-poor setting, particularly if we need interventions to offer continued support for years to sustain early impacts.

The increasingly widespread use and low costs of mobile phones have spurred development of many mobile health (mHealth) interventions, which are a potentially promising solution to the competing problems of scalability and sustainability of ECD interventions. While some mHealth interventions have improved parental engagement, all previous studies are from high-income countries and focus on parental literacy activities, ignoring other important nurturing care behaviors. They have also only featured passive one-way text messages, despite multiple reviews recommending the use of more continuous two-way interactions for sustaining behavior changes.

Our proposed study experimentally tests the short- and medium-term effectiveness and cost-effectiveness of three different delivery models for an ECD parenting intervention: a traditional in-person group-based delivery, a hybrid intervention that combines in-person meetings with remote (mHealth) delivery, and an intervention delivered almost entirely remotely. This design allows us to test the degree of substitutability or complementarity between in-person and remote delivery. Kenya is an ideal setting for testing mHealth programs given its high penetration of mobile phones (94%). Interventions will be based on the Msingi Bora curriculum, but adapted to a mobile format, and extended over two years to maximize potential to sustain impacts. Back-of-the-envelope cost estimates based on the Msingi Bora in-person intervention suggest potentially high cost savings from remote delivery of up to 78%. Our evaluation design is a non-inferiority clustered Randomized Control Trial across 60 CHWs and 1200 households using an adaptive trial design to allow for midcourse review and feedback on the mHealth delivery modes. By integrating delivery into the regular operations of local CHWs, utilizing new low-cost technology and involving local ECD policymakers from the project’s inception, our study has the potential to make important contributions to find potentially scalable, sustainable solutions for resource-limited settings.

Authors

• Jill E Luoto, University of Southern California

• Frances E Aboud, Centre universitaire de santé McGill

• Lia C.H. Fernald, University of California - Berkeley

• Teresa Mwoma, ECD Network for Kenya

• Italo Lopez Garcia, University of Southern California
  Presenting Author