The ‘new normal’ in parenting support?

As a researcher I have worked on a number of trials evaluating the effectiveness of parenting programmes (PPs) when delivered to the most vulnerable parents in the community. Every trial typically has its own challenges, not least the very basics of conducting a research study i.e. recruitment, retention and engagement. However, the arrival of Covid-19 has thrown even the simplest study and the most basic support services into turmoil.

Like other researchers working in the social sciences, many of my projects have had to pause during this time. For the majority of my projects, the decision to pause will have little impact on the study or the findings themselves. However, for one project, an Randomised Controlled Trial (RCT) of a home visiting parenting programme delivered to families of young children considered 'in need', the decision to pause has generated a series of crisis talks, and significant discussion of potential future scenarios that may thwart the trial and affect all families involved. 

Whilst COVID-19 might be an inconvenience to the evaluation, my colleagues and I are very aware of the real human impact that the pandemic is having on the families involved in the trial. Because of this, and the ethical implications of removing an intervention from families in need, the decision was made to pause face-to-face delivery of the intervention but continue to support our families in varying capacities. Subsequently, the delivery team have worked quickly to adapt their working practices to accommodate the social distancing measures and provide continuity to the families in their care. Remote contact with parents is being documented, including the method of contact (text, email, phonecall), and the type of support they are providing i.e. learning support in accordance with the intervention, or personal support in relation to the parents primary concerns during this time.

Whilst this experience is very personal, we recognise that our trial is not unique. Indeed a recent report by the EIF (2020) has indicated that our adopted changes to usual delivery appear to be replicated by many other service providers across the country. Whilst this is reassuring, we have to acknowledge that in the wake of COVID-19, these services will continue to face new challenges, and a reconceptualisation of existing service delivery might be needed to avoid families falling between the gaps in the future (Holmes et al., 2020). 

As we look to the future, it is inevitable that technology assisted programmes and the creation of virtual spaces for practitioners and families in their care, will become an essential requirement in order for the 'services as usual' infrastructure to continue. The last few months has, however, highlighted two areas of concern, specifically within the area of parenting support. Firstly, the current infrastructure of technology assisted PPs is not ready for population level roll out, due to limited knowledge of their effectiveness. Secondly, a shift to online or remote delivery has greater potential to 'lose' the hardest to reach in society; specifically, those who have English as a second language, and those who may not have access to technology, or may have limited digital literacy skills. At this point we have to revisit the literature, and fully acknowledge the gaps in our understanding in order to devise an effective plan for dealing with any future lockdowns.  

Despite significant technological advancements, and a proliferation in the development of manualised online PPs over the last 20 years, we still lack knowledge regarding their utility, adaptability, and impact in comparison to traditional models (Corralejo & Rodríguez, 2018). Outside rigorous trials, online PPs are known to have issues regarding retention, completion rates, and general levels of acceptability amongst users. Although research appears to suggest that web-based delivery of PPs is the most prefered method by users (Hansen et al., 2019), researchers have reported that online programme completion rates generally fall between 41.7 and 99.2%, with programmes composed of more sessions reporting lower completion rates (Breitenstein et al., 2014). Kelders et al. (2012) suggest that differences in modes of delivery, and expected levels of interaction with practitioners or peers, predict adherence to the programme. Given that social support is regarded as an important factor in behaviour change it therefore comes as no surprise that provision of social support as part of delivery is observed to reduce dropout by 30 to 40% (Richards & Richardson, 2012). Despite this, anecdotal evidence suggests that, regardless of the benefits provided by social support networks, it does not always lead to increased engagement with the material (Hall & Bierman, 2015). Subsequently, there is a need to better understand the facilitators and barriers behind engagement with online PPs for target groups.

Our knowledge of programme acceptability is also limited to evidence drawn from trials where there is a sampling bias towards white, middle class mothers (Hanson et al., 2019). Specifically, we have little knowledge of the acceptability of programmes for more diverse populations such as; 1) ethnic minority groups, where programme adaptations may be required in order to meet cultural expectations, or where content requires translation; 2) fathers, who are often absent from traditional face to face PPs and often feel excluded from parenting support programmes, and; 3) parents from lower socio-economic groups, who are reported to be less receptive to web-based delivery (Hall & Bierman, 2015). Further engagement with these populations is needed to better understand the specific parental characteristics that predict engagement with online interventions, but also to identify what level of adaptation is required for population level roll out. Moreover, we need to consider how we can support and engage families living in the poorest communities where access to technology is problematic, or digital literacy skills are limited. 

Extensive investigation of the impact and cost-benefit of utilising online PPs is also needed through rigorous evaluation methods. Few studies to date have considered medium or longer-term follow ups via randomised controlled trials (Hanson et al., 2019), and with the prospect of exponential growth in population mental health issues following the pandemic, this a particularly salient issue for exploration. In addition, researchers need to better understand the cost-benefits of implementing online PPs compared to their more traditional counterparts. Whilst published trials indicate some promise of online PPs to match outcomes achieved through traditional methods of delivery, without direct comparisons we must be cautious about implementing service delivery changes based on assumptions alone (Breitenstein et al., 2014).

Based on the current evidence, of biggest concern to colleagues working across the field of parenting support is that we all get carried away with the concept of the 'new normal'. There appears to be a rhetoric that post Covid-19 we will all be living in a digital utopia. However, the shift to virtual spaces for community health support is very likely to leave the hardest to reach families behind. Consequently, there is a real need for researchers, practitioners and policy-makers to work collaboratively, share models of best practice, and begin to re-envision what really works in early intervention.  

- Dr Nicole Gridley, Senior Lecturer in Developmental Psychology, Leeds Beckett University

References

Breitenstein, S. M., Gross, D., & Christophersen, R. (2014). Digital delivery methods of parenting training interventions: a systematic review. Worldviews on Evidence‐Based Nursing, 11(3), 168-176.

Corralejo, S. M., & Rodríguez, M. M. D. (2018). Technology in parenting programs: A systematic review of existing interventions. Journal of Child and Family Studies, 27(9), 2717-2731.

EIF (2020). Covid-19 and early intervention: Evidence and challenges relating to the virtual and digital delivery of services. 

Hall, C. M., & Bierman, K. L. (2015). Technology-assisted interventions for parents of young children: Emerging practices, current research, and future directions. Early childhood research quarterly, 33, 21-32.

Hansen, A., Broomfield, G., & Yap, M. B. (2019). A systematic review of technology‐assisted parenting programs for mental health problems in youth aged 0–18 years: Applicability to underserved Australian communities. Australian Journal of Psychology, 71(4), 433-462.

Holmes EA, O'Connor RC, Perry VH, et al. Multidisciplinary research priorities for the COVID-19 pandemic: a call for action for mental health science. Lancet Psychiatry 2020; published online April 15, 2020. https://doi.org/10.1016/S2215-0366(20)30168-1 

Kelders, S. M., Kok, R. N., Ossebaard, H. C., & Van Gemert-Pijnen, J. E. (2012). Persuasive system design does matter: a systematic review of adherence to web-based interventions. Journal of medical Internet research, 14(6), e152.

Richards, D., & Richardson, T. (2012). Computer-based psychological treatments for depression: a systematic review and meta-analysis. Clinical psychology review, 32(4), 329-342.