JMIR Publications

ABSTRACT

Background:

Violence and abuse exert extensive health, social, and economic burdens on adolescents in low- and middle income countries. Digital parenting interventions hold promise for mitigating risks at scale. However, their potential for public health impact hinges on meaningful engagement with the digital platform.

Objective:

This study evaluated the impact of three intervention design and implementation factors aimed at increasing engagement with a non-commercialized, offline-first smartphone app for caregivers of adolescents in Tanzania, in partnership with UNICEF, WHO, and the Tanzanian National Government.

Methods:

Following Multiphase Optimization Strategy (MOST) principles, we conducted a 2x2x2 cluster randomized factorial trial involving caregivers of adolescents aged 10-17 years. Caregivers were recruited by community representatives from 16 urban and peri-urban communities (i.e., clusters) in the Mwanza region of Tanzania. Each cluster was randomized to one of two levels of each factor: guidance (self-guided/guided via facilitator-moderated WhatsApp groups), app design (structured/unstructured), and pre-program digital support (basic/enhanced). Primary outcomes were automatically tracked measures of engagement (app launches, modules completed, home practice activities reviewed), with secondary outcomes including time spent on app, modules started, and positive habits logged. Generalized linear mixed effects models assessed the impact of experimental factors on engagement.

Results:

Automatically tracked engagement data from 614 caregivers were analyzed, of which 33.4% were male. Compared to self-guided participants, receiving guidance alongside the app led to significantly more app launches (MR 2.93; 95% CI [1.84–4.68]), more modules completed (MR 1.29; 95% CI [1.05–1.58]), more time spent on the app (MR 1.45; 95% CI 1.39–1.51), more modules started (MR 1.20; 95% CI [1.02–1.42]), and more positive habits logged (MR 2.73; 95% CI [2.07–3.60]). Compared to the structured design, unstructured design use resulted in significantly more modules completed (MR 1.49; 95% CI [1.26–1.76]), more home practice activities reviewed (MR 7.49; 95% CI [5.19–10.82]), more time spent on the app (MR 1.84; 95% CI [1.70–1.99]), more modules started (MR 1.27; 95% CI [1.06–1.52]), and more positive habits logged (MR 55.68; 95% CI [16.48–188.14]). While analyses did not detect an effect of enhanced digital support on directly observed engagement, the combination of enhanced digital support and guidance positively influenced engagement across a range of outcomes.

Conclusions:

This study is the first to systematically optimize engagement with a digital parenting intervention in a low- and middle-income country. Findings offer important learnings for developing evidence-based, scalable digital services in resource-constrained settings. Clinical Trial: Pan-African Clinical Trial Registry PACTR202210657553944; https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=24051