Harnessing technology

Several tool developers noted the challenge of engaging with parents, whose time is often limited due to work and child-rearing responsibilities. To stand out amidst the many messages directed to parents, developers must offer a product that alleviates challenges that parents face and/or address an unmet need. Chian Gong, a venture capitalist with expertise in technology in early childhood at Reach Capital noted that “Parents are a very in-demand audience. It is important to cut through noise to offer something meaningful.” For example, SMS4Dads responds to the lack of targeted resources for fathers in Australia whereas the Winnie platform addresses challenges in identifying quality childcare in the U.S. by providing a comprehensive, inclusive, and searchable database of childcare providers, including home-based providers who have not typically been easily identifiable through standard web searches.

Given the breadth of offerings and freely available information on parenting topics, there is, according to those interviewed, a need to truly understand the user and figure out how to make the existing user experience better before launching something new. Carolina Casas, Vice President of Education, International Social Impact at Sesame Workshop noted, “True innovation is not about making something new, but about making something better.”

Beyond the scarcity of time that confronts parents, there are many other contextual factors that developers must consider. Ensuring accessibility and relevance of content is also important: many developers who target parents in disadvantaged communities highlighted the importance of written content which caters to low literacy environments. This is also corroborated by a review of mobile apps for child health and development in the U.S., which found that 96% of apps offering explanations of health topics used simple language to explain health terms (DeWitt et al., 2022). Similarly, a feasibility study of Afinidata found that users wanted simple wording and activities (Jaggi et al., 2023).

The tone and reliability of content is also critically important. In Brazil, the developers of the Pé de Infância WhatsApp Journey focused on delivering audio/video content in a calm-speaking manner to appeal to parents. A study of hybrid ECD programs noted that a program in Ecuador used images which reflected ethnic diversity to help families identify with the content that it presented (Rubio Codina & Lopez-Boo, 2022).

Many developers reflected on the importance of “bite-sized” content or micro-learning to simplify messaging. Additionally, developers frequently couple written information with various forms of media to increase uptake. For example, Paalan 1000 offers all content in both written and audio form, to ensure usage in rural settings where literacy levels remain low.

Developers must also consider the timing and frequency of outreach. Research on text messaging programs targeting parents in the U.S. highlight challenges related to frequency of outreach. A study of a program to improve parenting practices for parents of 4 year-olds found that one text per week was less effective than a set of three texts, but that five texts per week was not beneficial to children and contributed to program drop out (Cortes et al., 2018). In addition, a review of eight text messaging programs targeting parents to support school readiness in the U.S. also found that programs sending five texts per week had higher drop out rates compared to those sharing three messages per week, and those sending three texts per week had a higher dropout rate compared to those sending one per week (Fricke et al, 2018). ​​While these examples reflect some emerging evidence on this topic, there is a need for further research to better understand ideal timing and frequency of outreach across digital tools.

A number of developers also highlighted the importance of both conducting formative research and regularly collecting user feedback to ensure relevance of content and usability of tools. Performing early user testing was noted as a success factor, as was collecting feedback over the course of implementation. For example, an app in Jamii ni Afya which provides support to community health volunteers (CHVs) in Zanzibar, has been engaged in Plan-Do-Study-Act cycles to understand how best to increase community health volunteers’ ability to engage with fathers. Baby Buddy App, a UK-focused parenting app, utilizes a 300+ parent panel to collect insights on upcoming features through surveys, focus groups, and individual calls.

Rather than attempting to migrate parents and early childhood personnel to new platforms, evidence suggests that developers should instead leverage existing and proven technologies. For example, for parents who have only basic mobile phones with no internet access, text messaging may be an effective means of reaching them (Dinarte Diaz, 2023). For similar reasons, the Pé de Infância WhatsApp Journey, based in Brazil, decided to use WhatsApp because of the high rates of usage and familiarity with the platform. In another example, one developer noted the importance of using ‘low-tech’ (i.e. phone calls) options in a humanitarian context in Bangladesh, where other options may have been unfeasible. Providing a menu of options for using tools may also help to expand reach based on what is preferred and most accessible to users. For example, Digitaf, allows parents to view activities being offered either on the app, website, Facebook group, or through SMS notifications.

Regardless of the type of technology selected, users may need additional technical support. A feasibility study of Afinidata found that mothers in remote areas benefit from assistance with installation and initial exploration, along with a physical booklet with instructions after the initial period (Jaggi et al., 2023). For similar reasons, once a new user is recruited to MomConnect, a WhatsApp-based chatbot in South Africa, they are provided with an onboarding over WhatsApp, with detailed information on how to navigate the platform. A study of ParentApp for Teens, a digital parenting program for parents of teens across several African countries found that users faced challenges with downloading and opening the app which contributed to high drop-out rates (Awah et al., 2022). Thus, unsurprisingly, developers spoke about the importance of a user-friendly interface; one developer noted “when there are multiple steps, you will lose the user.”

Connectivity challenges are widespread and can dampen usage for many of these tools. User testing of ParentApp for Teens found that participants anticipated barriers to use due to data costs for downloading the app, as well as the lack of android smartphones, and limited technological knowledge (Awah et al., 2022). These challenges tend to be more acute in rural settings, with one developer noting that in such areas, users tend to download content received every few weeks and review it offline, whereas in urban areas there is more frequent usage of material online. One tool developer acknowledged that their app cannot be used in low-bandwidth environments because it requires regular software updates. To address such needs, some apps, like Thrive by Five, once downloaded, can be fully accessed offline. The developers have also successfully tested and proven the app to work on older devices which do not require the latest software.

Access to devices may also pose a challenge. For example, developers noted that in some households, there may only be one device used by a male head of household making it difficult for others to use it regularly. Accordingly, there is some research which suggests that women’s mobile phone ownership is important for delivering digital health programs (LeFevre et.al., 2020). With the Jamii ni Afya digital platform, the program provides smartphones and a connection package to all community health volunteers so that they may access an app that helps them to carry out their home visits with families.

In addition, some users may not have sufficient data storage on their device. To address this challenge in particular, the Paalan 1000 parenting app in India provides external links to videos instead of embedding them within the app itself. ParentText further mitigates this issue by allowing parents to choose their preferred level of data use – basic, medium, or high – which determines if they will receive only text-based messages or both text-based and multimedia messages (e.g., images, GIFs, videos).

Maintaining interest in use of digital tools can be challenging, as there are often high attrition rates (Jaggi et al., 2023). Sheetal Singh, a digital technology expert at Start Early, commented that “with any digital solution, there is a cognitive burnout…You may be interested earlier on, and then at some point, you lose interest. Keeping users engaged is really hard.” A common strategy developers use for engaging users is to customize content, whether by user and/or age, gender, and stage of development of a child. For example, Kinedu, a parenting app, utilizes an AI-powered child milestone tracker to feed into personalized plans with play activity and video recommendations. The Baby Buddy app also offers differentiated pathways based on the profile of a parent/caregiver. Users can select a pathway – mothers, fathers, and healthcare professionals (further updates to the app will include pathways for LGBTQ+, adoptive parents, and surrogates) – which customize content.

Nudges and reminders are also commonly utilized to promote sustained use. For example, an app supporting community health volunteers (CHV) under the Jamii ni Afya digital platform in Zanzibar reminds CHVs when to make follow-up visits to families based on identified needs. Thrive by Five sends users simple nudges and reminders to try activities from the app. These messages can also boost engagement. The Parent Education Program sent push messages to nudge users to complete weekly modules; however, when this functionality was paused due to restrictions in the technology platform, they observed a 20% decrease in the number of users who completed the modules.

Another commonly used approach to motivate tool usage is to incorporate elements of gaming (or gamification), which can take different forms. For example, in the mobile app Paalan 1000, completion of certain milestones prompts a celebration with confetti, whereas with the Thinking Healthy app, mothers can set a health-related goal (e.g., diet, relaxation exercises) and track its progress through a ‘progress tree’ that flowers when a goal is achieved. Other approaches include interactive quizzes and progress trackers, both of which are leveraged in ParentText (see Case Study on user engagement).

Network sharing, encouraging users to share specific content from a tool with others or to invite family/friends to share in a particular tool experience, can generate interest from users. Pregnancy+ and Baby+, pregnancy and parenting support apps, offer options for users to invite friends and family to download the apps and link to their account to follow stage- based updates. The Bebbo app allows users to save and share their favorite content with others.

Other programs have made creative use of incentives. For example, Mobile Academy, which provides training to ASHA workers in India, offers a formal certificate from the NHM and Government of India with a logo, which motivates users to use the tool and complete the training. Tools may also mix fun and entertaining content to increase user engagement. One program mentioned that interactive features such as uploading baby pictures helps its parenting app to retain users.

While a number of approaches are in use, further research on the effectiveness of different user engagement and behavioral change strategies is needed (see below).

Common user engagement strategies

• Customized messages: Sharing resources and content based on user needs (e.g., race/ethnicity, gender, age of child). This also includes sharing personalized content based on short user assessments (e.g., activities shared based on child development assessments).
• Flexible tool experience: Providing flexibility and choice for users to determine their use of the tool (e.g., frequency of messages, content, sequence)
• Gamification: Using common gaming design elements (e.g., points, badges, trophies, leaderboard)
• Interactive quizzes: Short questions (usually multiple choice) or polls provided to users after completing an activity or module to check their understanding
• Nudges and reminders: Sharing messages to encourage users to take particular actions (e.g., appointment reminders, nudge to complete an activity)
• Goal setting: Allowing users to choose their goals for a particular theme, usually from a list of pre-populated goals
• User progress tracking: Tracking user’s progression across tool features (e.g., number of activities completed, progress towards goals)
• Network sharing: Encouraging use of the tool simultaneously with a partner/alternate caregiver to create a shared experience or sharing tool resources and content with others through messages or social media

Recent research on hybrid programs (combining in-person and virtual elements) found that a minimum level of in-person interaction increases families’ buy-in and commitment (Rubio-Codina & Lopez-Boo, 2022). Similarly, an evaluation of a text message-based parenting intervention in Uruguay found that while messages alone had minimal impact on parenting knowledge or behaviors, child-rearing environments or family wellbeing, when paired with in-person interaction their impact increased (Balsa et al., 2022b).

Consistent with this evidence, a number of tools feature elements of in-person support, which they view to be critical for establishing relationships with families, facilitating trust, and increasing uptake. Interviewees frequently noted that community connections and trusted providers helped tools to reach their target audience. For example, MomConnect utilizes focal points in each province where it operates to ensure clinics know about the service. Similarly, Paalan 1000, a mobile parenting app in India, leverages frontline workers for recruitment and promotion since they already have touch points with target families. The CDC Milestone Tracker app is promoted by ‘Act Early Ambassadors’ who work with their respective states to expand the reach of CDC’s ‘Learn the Signs. Act Early’ program.

Where in-person support is not fully available, some form of human interaction (even virtual) may mitigate this challenge. One developer noted how, by facilitating Whatsapp groups, they have expanded user engagement.

While not the main focus of this review, adding remote support to ongoing in-person services may also be beneficial. A study in Jamaica of a home visiting program which pivoted during COVID-19 found that addition of remote support made caregivers feel that facilitators were interested in their children’s outcomes (Rubio-Codina & Lopez-Boo, 2022).

Our research highlighted the range of potential benefits of partnerships. Partners bring in expertise to help generate tool content, support development and maintenance of tool technology, and contribute to research and evaluation support (Early Learning Lab, 2017).

Baby Buddy App’s partnership approach highlights how collaborators can augment their impact. For instance, UK’s National Health Service accredits messages shared through the app, lending credibility to the tool. Baby Buddy App also utilizes a panel of experts drawing from Royal Colleges of Medicine to validate the content. Similarly, Descobrir Brincando, the developer of JOPI, has judiciously cultivated partnerships, including with a local university (Faculdade Getulio Vargas, São Paulo) to conduct a randomized control trial to assess the impact of the tool-provided training on supervisors’ behaviors.

Partners may also help promote uptake of tools, as partnerships with local grassroots and non-profit organizations, health centers, preschools, and frontline workers have been leveraged to reach and recruit users. For example, SMS4Dads partners with National Rural Health Alliance and Indigenous HealthInfoNet to expand their support to fathers in rural and remote areas, as well as Aboriginal and Torres Strait Islander men. It also collaborates with health centers where providers are briefed about the tool and given informative pamphlets to support recruitment of fathers. Ready Rosie, a web-based platform that connects schools and families with children ages 0-9 in the U.S., relies on partnerships with public schools and NGOs to deliver parenting curriculum in the form of videos and workshops to caregivers, facilitate communications between families and teachers, and provides online and/or live professional learning to teachers.

Establishing partnerships can also help new initiatives build on existing efforts rather than starting from scratch, thereby saving time and resources and avoiding duplication. This was a particularly common practice in developing tool content. For example, the Parent Education Program partnered with the East London Research School to adapt their “What to expect in the Early Years Foundation Stage: a guide for parents” curriculum. They also translated messages from Vroom, a well-known parenting app developed by the Bezos Family Foundation, to create short videos in Arabic to share with parents. Vroom messages have also been adapted for use in other tools like Paalan 1000 and Bright Tomorrows.

In addition to providing technical expertise, government partners are also critical to support scaling and sustainability efforts. Developers have commonly leveraged existing government infrastructure (e.g., public health clinics, network of frontline workers) to spread awareness and reach more users. For example, all frontline workers receive immediate access to Mobile Academy in India, a phone-based refresher training, once they register on the Government’s Reproductive and Child Health portal. Government agencies can also support funding and implementation efforts. The Ministry of Health worked closely with D-Tree to test different versions of the Jamii ni Afya app and supported adaptations, where necessary, to better meet the needs of families (see Case Study on partnerships).

While government partnership can provide a range of benefits, they are not without risk. Of note, changing government leadership can disrupt established relationships with outside organizations. To mitigate this risk, MomConnect has a dedicated person responsible for the tool in the National Department of Health, which has helped sustain it for nearly 10 years.

Developers emphasized the importance of considering and reflecting users’ cultural contexts, especially when implementing a tool in a new country. Recognizing that “one size does not fit all”, developers used processes like human- centered design and anthropological research to adapt their tools to different contexts. This included ensuring that tool content is reflective of local culture, values, and practices; illustrations, photos, and videos are representative of users; and content is translated to local languages. For example, Pregnancy+ does not include content on buying clothes for babies before birth across all countries since this is not appropriate in some cultures. Thinking Healthy, a maternal depression support intervention in Pakistan, has an illustrated ‘avatar therapist’ in the app which resembles features and clothing of women in the country. Paalan 1000 adapted Vroom messages by including contextualized examples such as “luka-chuppi” (hide-and-seek) instead of “peek-a-boo” and “local bazaar” (market) instead of supermarket.

The adaptation process usually involves a range of stakeholders, including local subject matter experts, parents and caregivers, curriculum specialists, and in-country partners such as grassroot non-profits and government agencies who help identify and incorporate local needs, practices, and examples and test the tool content. For example, the Thrive by Five program’s adaptation process involves a series of workshops with local stakeholders to ensure that local parenting practices are reflected in the content. User testing of Vroom, a parenting app first developed for the U.S., in Syrian refugee contexts, found that parents responded better to messages which were framed as supporting brain development rather than those that were intended to be fun (Wilton et al., 20187) (see Case Study on adaptation).

Adapting tools to different contexts was recognized as a key success factor to benefit parents (Early Learning Lab, 2017). As one developer noted, “the more you [the user] feel it is made for you, the more you enjoy the experience.” However, while beneficial, this process can also be time intensive and costly. One developer reported taking an entire year to translate and contextualize content including re-making videos in a different context. Another cited that while the translation process is easier, adaptation can be difficult as it requires carefully considering all of the content and ensuring appropriateness. To address the high cost of adapting a tool to a specific country, one expert recommended avoiding the use of words that are specific to a particular country and instead using common activities and examples, and providing neutral recommendations. This would ensure, for example, that an app in Spanish could be beneficial across different Spanish-speaking countries, where there are significant cultural variations.

The high cost of developing and maintaining the infrastructure for digital tools was noted by several developers as a barrier to sustainability. Ongoing investments are required not only to build tools but also to maintain (e.g., fix bugs), scale, and upgrade them (e.g., adding new features, new content). For instance, in response to updated guidance on developmental milestones from the Centers for Disease Control (CDC), the Kinedu app had to change its content, which required new work and costs. Costs may also change across the tool’s lifecycle. A program in Brazil, JOPI, which initially started on WhatsApp, transitioned to a LMS accessible by computer partly due to a change in WhatsApp policies which led to increased costs to the user.

Cristina Gutierrez de Piñeres, a pioneer and proponent of the use of digital technologies at United Way Colombia, highlighted a misconception that technology can “run itself” when in fact, there are ongoing, hidden costs associated with the training of users and facilitators, implementation itself, and monitoring and evaluation, which is indispensable for tracking the effects of digital tools. For example, Pashe Achhi, a telecommunication-based tool that provides psychosocial and parenting support, had to train facilitators on the script and communication skills to deliver the program content. As noted earlier, costs are also incurred in adapting tools to different contexts to support translation and development of contextualized resources and content.

Developers and experts also highlighted the need to be agile and responsive to changing landscapes. In addition to having to integrate user feedback and latest evidence in child development in the tool content to remain relevant, developers also need to be aware of and integrate rapidly changing technology features (e.g., new softwares, compatibility with new devices). Recognizing the need to “be thoughtful and deliberate in learning”, the developers of Sésamo Chatbot set up an internal working group with members working with technology (e.g., distance learning programs, integrating technology in programs) to discuss challenges, brainstorm solutions, and determine how to integrate their learnings in the tool.

While iterating tools is critical for their relevance and sustainability, developers expressed concerns in raising the funds to support these upgrades. Funders usually require a clear proposal and results to grant funding; however, this is difficult to provide until a tool has been rolled out and produced demonstrable results. One developer also highlighted the challenge of piecing together resources from different funders with varied interests under one overarching vision. Relying solely on external funding from private foundations and government agencies could also be a risk to sustainability when their funds dissipate. Similarly, if user fees are the only source of revenue for a for-profit developed tool, it competes with freely available resources and lower-income populations may be excluded. Examples of tools that are launched but eventually cease operations owing to lack of funding abound.

To overcome these challenges, developers and experts recommend generating buy-in and support from the government to champion the initiative, and cultivating collaborations and partnerships to reduce or share costs. Developers also suggest exploring creative pathways for lowering costs. For example, MomConnect started offering content over WhatsApp to circumvent the high telecommunication costs incurred through SMS. ParentText offers SMS as an option only in countries where they have partnerships with telecommunication companies, as universal provision of this feature is too costly. In the case of Jamii Ni Afya, D-Tree has developed a long-term transition plan for shifting technical and financial responsibility of running the platform to the government in support of sustainability (see Case Study on partnerships).