A Factorial Randomized Controlled Trial to Optimize User Engagement With a Chatbot-Led Parenting Intervention: Protocol for the ParentText Optimisation Trial.

BACKGROUND: Violence against children (VAC) is a serious public health concern with long-lasting adverse effects. Evidence-based parenting programs are one effective means to prevent VAC; however, these interventions are not scalable in their typical in-person group format, especially in low- and middle-income countries where the need is greatest. While digital delivery, including via chatbots, offers a scalable and cost-effective means to scale up parenting programs within these settings, it is crucial to understand the key pillars of user engagement to ensure their effective implementation. OBJECTIVE: This study aims to investigate the most effective and cost-effective combination of external components to optimize user engagement with ParentText, an open-source chatbot-led parenting intervention to prevent VAC in Mpumalanga, South Africa. METHODS: This study will use a mixed methods design incorporating a 2 × 2 factorial cluster-randomized controlled trial and qualitative interviews. Parents of adolescent girls (32 clusters, 120 participants [60 parents and 60 girls aged 10 to 17 years] per cluster; N=3840 total participants) will be recruited from the Ehlanzeni and Nkangala districts of Mpumalanga. Clusters will be randomly assigned to receive 1 of the 4 engagement packages that include ParentText alone or combined with in-person sessions and a facilitated WhatsApp support group. Quantitative data collected will include pretest-posttest parent- and adolescent-reported surveys, facilitator-reported implementation data, and digitally tracked engagement data. Qualitative data will be collected from parents and facilitators through in-person or over-the-phone individual semistructured interviews and used to expand the interpretation and understanding of the quantitative findings. RESULTS: Recruitment and data collection started in August 2023 and were finalized in November 2023. The total number of participants enrolled in the study is 1009, with 744 caregivers having completed onboarding to the chatbot-led intervention. Female participants represent 92.96% (938/1009) of the sample population, whereas male participants represent 7.03% (71/1009). The average participant age is 43 (SD 9) years. CONCLUSIONS: The ParentText Optimisation Trial is the first study to rigorously test engagement with a chatbot-led parenting intervention in a low- or middle-income country. The results of this study will inform the final selection of external delivery components to support engagement with ParentText in preparation for further evaluation in a randomized controlled trial in 2024. TRIAL REGISTRATION: Open Science Framework (OSF); https://doi.org/10.17605/OSF.IO/WFXNE. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/52145.

A Hybrid Digital Parenting Program Delivered Within the Malaysian Preschool System: Protocol for a Feasibility Study of a Small-Scale Factorial Cluster Randomized Trial.

BACKGROUND: The United Nations' Sustainable Development Goal 4, and particularly target 4.2, which seeks to ensure that, by 2030, all children have access to quality early childhood development, care, and preprimary education so that they are ready for primary education, is far from being achieved. The COVID-19 pandemic compromised progress by disrupting education, reducing access to well-being resources, and increasing family violence. Evidence from low- and middle-income countries suggests that in-person parenting interventions are effective at improving child learning and preventing family violence. However, scaling up these programs is challenging because of resource constraints. Integrating digital and human-delivered intervention components is a potential solution to these challenges. There is a need to understand the feasibility and effectiveness of such interventions in low-resource settings. OBJECTIVE: This study aims to determine the feasibility and effectiveness of a digital parenting program (called Naungan Kasih in Bahasa Melayu [Protection through Love]) delivered in Malaysia, with varying combinations of 2 components included to encourage engagement. The study is framed around the following objectives: (1) to determine the recruitment, retention, and engagement rates in each intervention condition; (2) to document implementation fidelity; (3) to explore program acceptability among key stakeholders; (4) to estimate intervention costs; and (5) to provide indications of the effectiveness of the 2 components. METHODS: This 10-week factorial cluster randomized trial compares ParentText, a chatbot that delivers parenting and family violence prevention content to caregivers of preschool-aged children in combination with 2 engagement components: (1) a WhatsApp support group and (2) either 1 or 2 in-person sessions. The trial aims to recruit 160 primary and 160 secondary caregivers of children aged 4-6 years from 8 schools split equally across 2 locations: Kuala Lumpur and Negeri Sembilan. The primary outcomes concern the feasibility and acceptability of the intervention and its components, including recruitment, retention, and engagement. The effectiveness outcomes include caregiver parenting practices, mental health and relationship quality, and child development. The evaluation involves mixed methods: quantitative caregiver surveys, digitally tracked engagement data of caregivers' use of the digital intervention components, direct assessments of children, and focus group discussions with caregivers and key stakeholders. RESULTS: Overall, 208 parents were recruited at baseline December 2023: 151 (72.6%) primary caregivers and 57 (27.4%) secondary caregivers. In January 2024, of these 208 parents, 168 (80.8%) enrolled in the program, which was completed in February. Postintervention data collection was completed in March 2024. Findings will be reported in the second half of 2024. CONCLUSIONS: This is the first factorial cluster randomized trial to assess the feasibility of a hybrid human-digital playful parenting program in Southeast Asia. The results will inform a large-scale optimization trial to establish the most effective, cost-effective, and scalable version of the intervention. TRIAL REGISTRATION: OSF Registries; https://osf.io/f32ky. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/55491.

Measuring behavioral and social drivers of COVID-19 vaccination in health workers in Eastern and Southern Africa.

BACKGROUND: In 2021, twenty out of twenty-one countries in the Eastern and Southern Africa (ESA) region introduced COVID-19 vaccines. With variable willingness to uptake vaccines across countries, the aim of the present study was to better understand factors that impact behavioral and social drivers of vaccination (BeSD). Using the theory-based "increasing vaccination model", the drivers Thinking & Feeling, Social Processes, Motivation, and Practical Issues were adapted to the COVID-19 context and utilized in a cross-country assessment. METHODS: Data was collected on 27.240 health workers in Kenya, Malawi, Mozambique, South Africa and South Sudan. This was done by administering a survey of seven target questions via the UNICEF Internet of Good Things (IoGT) online platform between February and August 2021. RESULTS: Findings showed a gap between perceived importance and trust in vaccines: Most health workers thought Covid-19 vaccination was very important for their health, while less than 30% trusted it very much. The pro-vaccination social and work norm was not well established since almost 66% of all respondents would take the vaccine if recommended to them, but only 49% thought most adults would, and only 48% thought their co-workers would. Access was highlighted as a crucial barrier, with less than a quarter reporting that accessing vaccination services for themselves would be very easy. Women exhibited slightly lower scores than men across the board. When testing the associations between drivers in Kenya and South Africa, it appears that when target interventions are developed for specific age groups, social norms become the main drivers of intention to get vaccinated. CONCLUSIONS: The present study revealed various key relations with demographic variables that would help immunization programmes and implementing partners to develop targeted interventions. First, there is a serious gap between perceived importance of COVID-19 vaccines and how much trust people in them. Second, problems with access are still rather serious and solving this would strongly benefit those who demand a vaccine, Third, the role of social norms is the most important predictor of willingness when considering age differences.

A disruptive cue improves handwashing in school children in Zambia.

Behavioral economics hold great promise in changing patterns of behavior that influence human health. Handwashing with soap is one such behavior that is important in reducing exposure to pathogens, and in school-age children, handwashing helps reduce absenteeism through the prevention of respiratory and diarrheal diseases. However, the gap between knowledge on the importance of handwashing and actual handwashing practice, especially with soap, persists. Many traditional behavior change communication approaches have failed in achieving and sustaining improved handwashing practices. Cognitive psychology research on habits as well as nudge theory, a component of behavioral economics predicated on the idea of making a behavior as easy as possible to do, suggests that introducing a disruptive cue into the environment may be able to interrupt current habitual neurological patterns to effect and then sustain behavior change. We used a participatory process to identify and introduce a locally appropriate disruptive cue to improve handwashing behavior in schools in Zambia. We then utilized a school-randomized controlled trial to test the soap-on-a-rope in 50 government schools in Namwala District of Southern Province. Two outcomes were considered among school children; washing hands with water and using soap while washing hands. Following the intervention, soap use was more likely in intervention schools than control schools [Odds ratio = 7.23, 95% confidence interval = (1.76-29.71)], though both intervention and control schools saw an increase in handwashing without soap. This low-cost intervention could be scaled throughout Zambia and may work well in other countries of similar circumstances.