Abstract
An estimated 43% of children under age 5 in low- and middle-income countries (LMICs) experience
compromised development due to poverty, poor nutrition, and inadequate psychosocial stimulation. Numerous
early childhood development (ECD) parenting interventions have been shown to be effective at improving ECD
outcomes, at least in the short-term, but they are a) still too expensive to implement at scale in low-resource
and rural settings, and b) their early impacts tend to fade over time in the absence of continued support. New
ways to deliver effective ECD parenting interventions are sorely needed that are both low-cost to be potentially
scalable, while also able to sustain impacts long-term.
The rapid growth and low cost of mobile communications in LMIC settings presents a potentially promising
solution to the competing problems of scalability and sustainability. Yet there is no rigorous research on
mobile-health (mHealth) interventions for ECD outcomes in LMIC settings. We recently showed that an 8-
month ECD parenting intervention featuring fortnightly group meetings delivered by Community Health
Workers (CHWs) from Kenya's rural health care system significantly improved child cognitive, language, and
socioemotional development as well as parenting practices, and our group-based delivery model was more
cost-effective than previous ECD interventions. Yet it is still too expensive for scaling in a rural LMIC setting
such as ours, particularly if we need interventions that can be extended for longer periods of time to increase
their ability to sustain impacts. Our proposed study experimentally tests a traditional in-person delivery model
for an ECD parenting intervention against two mHealth-based delivery models that partially or almost fully
substitute remote delivery for in-person meetings. Kenya is an ideal setting for testing mHealth programs given
its high penetration of mobile phones (94%). We will assess the relative effectiveness and costs of these
mHealth delivery models against a purely in-person model, and extend the interventions over two years to
increase their ability to sustain changes in child outcomes longer term. Our evaluation design is a non-
inferiority clustered Randomized Control Trial across 60 CHWs and 1200 households in which we will use an
adaptive trial design to allow for midcourse review and feedback on the remote delivery models. By testing
three interventions that vary in how much in-person delivery is substituted by remote-delivery, we can assess
the degree of substitutability or complementarity to inform the design of more scalable and sustainable
interventions. Our goal is to determine the best model to maximize the intervention's reach and sustained
impacts to improve child outcomes. By integrating delivery into the ongoing operations of local CHWs within
Kenya's rural health care system, utilizing new low-cost technology, and involving local ECD policymakers and
stakeholders as key collaborators from the project's inception, our project has the potential to make important
contributions towards discovering potentially scalable, sustainable solutions for resource-limited settings.