Universal Digital Programs for Promoting Mental and Relational Health for Parents of Young Children: A Systematic Review and Meta‐Analysis

Despite the potential advantages of such online parenting programs, the e-mental health literature has highlighted existing program shortcomings. These include low adherence/high drop-out rates, as well as access program barriers for some populations due to low digital literacy (e.g., program navigation, troubleshooting), minimal technology accessibility (computer and/or internet connection), high internet data usage costs, and technology reliability concerns (Day et al., 2021; Ramos et al., 2022; Ros-DeMarize et al., 2021). Suitability for and impact on different population groups is important, however, the benefit of these programs at the sub-group level is currently under-researched. Similarly, the efficacy of these programs at a broad public health level is un-established. Preventative evidence is also lacking for early de-escalation of parent mental health concerns, and sequalae for parents and children.

Considering the limitations and advantages of universal online parenting programs, their rapid growth warrants systematic examination alongside evidence that has long supported the utility and efficacy of traditional in-person parenting programs (Barlow et al., 2002; Mingebach et al., 2018). Prior meta-analytic evidence demonstrates the efficacy of online parenting programs for enhancing parent, child, and, to a lesser extent, systemic relational outcomes. However, these reviews have been largely limited to selective and/or indicated prevention samples (Baumel et al., 2016; Cai et al., 2022; Florean et al., 2020; Li et al., 2021), or pooled populations with aggregated evidence across selected, indicated, and/or universally targeted interventions (Flujas-Contreras et al., 2019; MacKinnon et al., 2022; Nieuwboer et al., 2013; Thongseiratch et al., 2020). For children, these reviews have demonstrated small-to-moderate reductions in behavioural problems (Florean et al., 2020; Thongseiratch et al., 2020), psychological issues, anxiety (Spencer et al., 2020), and increased positive behaviours (Baumel et al., 2016; Spencer et al., 2020), adjustment (Cai et al., 2022), and emotional problems (Thongseiratch et al., 2020). For parents, they have shown moderate-to-large positive increases in parenting behaviour (Baumel et al., 2016; Florean et al., 2020; Spencer et al., 2020), confidence (Baumel et al., 2016), self-efficacy (Florean et al., 2020; Flujas-Contereras et al., 2019), and decreases in parent stress (Florean et al., 2020; MacKinnnon et al., 2022), depression (MacKinnon et al., 2022) and anxiety (MacKinnon et al., 2022). While prior meta-analyses and primary studies have assessed child-specific and parent-specific outcomes for target groups, there exists a dearth of literature examining relational outcomes. To date, only two digital parenting program meta-analyses have examined relational impacts, and these were for selective and indicated prevention samples (Li et al., 2021; Spencer et al., 2020). Each study identified significant relational effects for both parent–child and parent-parent level outcomes (Li et al., 2021; Spencer et al., 2020).

While these results appear promising, there is room now for meta-analytic evidence assessing the efficacy of universally targeted online parenting programs. To date, only one meta-analysis (Spencer et al., 2020) has been conducted, and only included a small number of studies (k = 3–6). The authors reported significant increases in parent confidence (d = 0.30) and decreases in stress (d = 0.31) for universal online programs and observed no significant effect for child problem behaviours or parent depression. This study reported significant declines in parent depression. Due to limited relevant studies, relational outcomes (i.e., parent–child and parent-parent) were not examined in Spencer et al. (2020) for universally targeted programs. Only a small number of universal studies has been previously identified in meta-analyses that pool indicated, selected, and universal target populations (Spencer et al., 2020 [k = 9]; MacKinnon et al. (2022) [k = 6]; Li et al., 2021 [k = 0]; Flujas-Contereras et al., 2019 [k = 6]). Taken together, there is a clear lack of literature evaluating the efficacy of socioemotional outcomes for online, universal parenting programs.

An additional limitation across prior meta-analyses is the aggregation of heterogenous data such as different socioemotional outcomes, guided and self-guided programs (Baumel et al., 2016; Flujas-Contreras et al., 2019; Li et al., 2021; Thongseiratch et al., 2020), broad child age ranges (Flujas-Contreras et al., 2019; Li et al., 2021; Nieuwboer et al., 2013; Spencer et al., 2020; Thongseiratch et al., 2020), and studies with varying methodological designs (randomized control trial [RCT] and pre-post; MacKinnon et al., 2022). In the case of study design, results observed in within-group study designs, which lack a control group, may be due to normative changes in outcomes from pre-to-post-intervention, rather than the intervention itself. This makes it challenging to draw causal conclusions regarding the effectiveness of interventions and raises questions about what the effect size meaningfully reflects. These concerns are reflected in these studies’ moderate-to-high rates of statistical heterogeneity, which lowers confidence that the parenting programs under examination have consistent effects across populations.

In this light, the current study aimed to meta-analytically evaluate all self-directed, universal, online, or smart phone-based parenting program studies and identify the impacts of such programs on parent, child, and relational socioemotional outcomes. The research question can be summarized as: “Do online universal parenting programs have a positive impact on socioemotional outcomes when compared to care as usual control groups?”.

The search followed a PICOS framework for systematic reviews (Higgins et al., 2019). Studies were considered for inclusions if they met the following criteria reported in Table 1.

Identified studies were screened for eligibility via: (1) title, keyword, and abstract screening; and (2) full-text article screening. Due to the heterogenous array of potential socioemotional sequalae that could be examined after participating in parent online training, outcome terms were omitted from the search, but screened for in accordance with the inclusion and exclusion criteria.

A post hoc study amendment was made wherein universal only studies were examined, while selected studies were excluded from the review, a result of the large volume of references identified and minimal resources. This decision was made as we chose to examine this vast body of literature by commencing with programs that are most accessible to the widest population cohorts.

Four authors (JO, AV, FP, AB) extracted data, which included (1) study details (i.e., author name, year, country, design, sample size); (2) sample details and recruitment (i.e., parent age/sex, child age, recruitment); (3) intervention details (i.e., program name, delivery method, program goal, length, and duration, guidance provided); (4) socioemotional outcomes; and (5) results.

The Quality Assessment for Diverse Studies tool (QuADS; Harrison et al., 2021) was used to assess methodological quality and risk of bias of all included studies. QuADS is an appraisal tool for methodological and reporting quality in systematic reviews of mixed- or multi-method studies allowing for direct comparison of heterogenous study designs. QuADS comprises 13 criteria scored on a four-point scale. An additional item from the Jadad Scale for Reporting Randomized Control Trials (Jadad et al., 1996) was included to assess for study randomization where relevant. This resulted in four risk of bias levels for items 1–13 (i.e., small, small-moderate, moderate-high, high), and three levels of risk (i.e., small, moderate, high) for item 14. Per study, a maximum quality assessment score of 41 could be generated; when the Jadad item was excluded, a maximum quality score of 39 could be achieved. Quality assessment was independently conducted by two authors (AV, FP). A third independent author (JO), double reviewed 20% of all studies, yielding a weighted Cohen’s κ (Cohen, 1968) of 100%.

Analyses focused on socioemotional outcomes. Many programs also reported on additional non-socioemotional outcomes, such as program user experience outcomes; however, these were excluded to contain the review’s scope. Only between-groups design studies were included to ensure rigour and increase homogeneity. The review only included experimental and quasi-experimental designs, with a sensitivity analysis to explore whether any heterogeneity present was due to the design. Findings were analyzed quantitatively, via a meta-analysis. An a priori decision was made to limit analyses to outcomes with a minimum of five independent effect sizes to reduce the likelihood of identifying spurious associations between variables due to ‘overfitting’, as recommended by (Geissbühler et al., 2021).

The reported data (i.e., raw scores, effect sizes, etc.) from primary studies were converted to Cohen’s d using several different methods, depending on the available effects. When available, our preference was to calculate Cohen’s d directly from reported means, standard deviations, and sample sizes. If these were not available, reported Cohen’s d values were used. When other effect types were used, these were converted to Cohen’s d if possible. One study was excluded from analysis as no data could be extracted that facilitated calculating Cohen’s d (Barrera et al., 2015). For all studies that included a pre-intervention baseline assessment for control and intervention groups, we applied the method in Morris (2007) to make a baseline adjustment and include a bias term. For parent satisfaction, parent self-efficacy, social support, and parent–child interaction, an increase in d represents positive change. For depression, anxiety, and stress, a decrease in d represents positive change. For instance, a d value of − 0.5 for depression indicates a reduction in depression for participants after completing the program. Cohen’s d can represent a small (d = 0.2), medium (d = 0.5), or large (d = 0.8) effect size (Cohen, 1988).

Meta-analyses were categorized into parent and relational outcomes. Meta-analyses were possible for six parent socioemotional outcomes (i.e., parent anxiety, parent depression, parent stress, parent satisfaction, parent self-efficacy, and parent social support) and one dyadic socioemotional outcome (parent–child interaction). No child-specific sub-group analyses could be conducted as fewer than five independent effects were reported for these outcomes (Geissbühler et al., 2021). To assess if effects of the interventions were stronger for mother or fathers, a meta-regression was conducted for each outcome.

From the 11,663 references identified through database searching, grey literature searching, and hand searching reference lists, 22 published studies were included in the meta-analysis. Studies were published from 2003 to 2023. No unpublished references were included. See Fig. 1 for a PRISMA diagram of all included literature (Page et al., 2021) and Supplementary Material 3 for a PRISMA checklist (Page et al., 2021). See Supplementary Material 4 for a PRISMA diagram of the grey literature.

Table 2 present the characteristics of included studies. Sixteen studies were experimental (i.e., RCTs) and six were quasi-experimental study designs. Study samples size ranged from 32 to 1141 parents (M = 236.29), with a total of 5671 parents included in the meta-analysis.

Studies came from 13 countries, with most studies conducted in the USA (n = 5), Singapore (n = 4), Australia (n = 2), China (n = 2) and South Korea (n = 2). All participants were recruited from community settings and fell on the universal risk continuum, with no participant experiencing an acute psychiatric illness. Fifteen studies included only mothers, one study included only fathers, and six studies included both mothers and fathers. Eighteen studies reported on parents’ age, with a mean age of 30.47 years (range: 18–53). Six studies reported on child age, with a mean age of 1.32 years (range: 10 weeks gestation-6 years). Of the 13 studies that reported on marital status, the percentage of those who were partnered (e.g., in a committed relationship, married, cohabitation) ranged from 47 to 100%. Fifteen studies reported on income (e.g., monthly/yearly household income) of which three comprised entirely of those from low-income backgrounds (Baggett et al., 2010; Ehrensaft et al., 2016; Zuckerman et al., 2022) while one sampled participants (64%) who were low-income earners according to federal poverty level classifications (Breitenstein et al., 2021). Of the 12 studies that reported on ethnic or racial background, five studies had samples where more than half of the participants were of White backgrounds (range: 55.20–88.00%). Of the 20 studies that reported on highest level of educational attainment, nine studies had samples where more than half of the participants had completed a tertiary level education (e.g., Bachelor degree or higher; range: 50.50–80.88%).

We identified 22 unique interventions, with all studies reporting on a single intervention. All interventions were standardized and validated. Online program durations ranged from one week to six months (M = 9.28 weeks). The average number of modules per intervention was 6.89 (range: 4–10 modules, n = 9). Of the 21 studies that reported the level of guidance provided, 9 (42.86%) reported on entirely self-guided programs, while 12 (57.14%) reported on partially self-guided programs, which included a combination of human support and self-guided program elements. For the partially self-guided content, guided program support was delivered asynchronously in four studies and synchronously in two studies. Six study interventions delivered a combination of synchronous and asynchronous human support methods. Researchers were the primary providers of guided intervention content (n = 6), followed by mental health professionals (n = 3), and a combination of peers and mental health professionals (n = 3). Programs delivery method varied: 13 studies were web-based, four mobile phone-based, three app-based, and two via a combination of delivery methods. The mean follow-up period was 23.79 weeks (range 1.5 weeks- 21 months, n = 17) depending on the particular outcome category. Eight studies reported on more than one follow-up period.

For parent socioemotional outcomes, 13 studies reported on parent depression, nine reported on parent stress, nine reported on parent self-efficacy, eight reported on parent anxiety, seven reported on parent social support, and five reported on parent satisfaction. All included parent outcomes were from validated self-report questionnaires. At the relational level, of the 6 studies that reported on parent–child interaction, three used parent-reported questionnaires (Breitenstein et al., 2021; Ehrensaft et al., 2016; Na & Chia, 2008); two used observational data (Baggett et al., 2010; Park & Bang, 2022); and one study used parent-reported and observational (Mogil et al., 2022).

All studies included a control group. Control groups varied, 17 included inactive (care as usual) controls and five included active controls with access to additional information resources. Identified studies with controls that experienced care beyond the usual and access to static informational resources were excluded from this study.

Overall, the quality of included studies was largely rated high (90.90%, n = 20); with some of moderate quality (9.09%, n = 2) and no studies of low quality. See Fig. 2 for visual representation of study quality and Supplementary Material 5 for a tabular depiction.

Meta-analysis of the effectiveness of online parenting programs was evaluated using 134 total effects across seven outcomes (see Table 3 for study outcomes). As presented in Figs. 3, 4, 5, 6, 7, 8 and 9, meta-analyses were conducted for six parental outcomes—depression, anxiety, stress, social support, self-efficacy, and satisfaction—and one relational outcome, parent–child interaction. Statistically significant reductions in parent depression (d = − 0.299, t = − 3.394, df = 12.506, p = 0.005) and parent anxiety (d = − 0.321, t = –3.15, df = 9.921, p = 0.01) were observed following completion of a universal online parenting program. Significant increases in parent self-efficacy (d = − 0.632, t = -3.139, df = 7.912, p = 0.014) were also observed. These significant effects were all small-to-moderate. The effect on improved parent–child interactions at post-intervention approached significance (d = 0.28, t = − 2.074, df = 5.22, p = 0.09). Online parenting programs did not produce a significant effect on outcomes of parent social support (d = 0.289, t = 1.738, df = 5.975, p = 0.133), parent satisfaction (d = 0.601, t = 1.772, df = 3.994, p = 0.151) and parent stress (d = 0.109, t = 0.658, df = 8.874, p = 0.527). As described in the methods, adjustments were made in effect size estimation to adjust for cases where multiple-dependent effects/samples were contributed by the same study. To ensure interpretability of results, we endeavored not to synthesize effects from different socioemotional outcomes. The exception to this was for analyses focussed primarily on secondary factors, such as parent sex and time effects, presented below.

As shown in Fig. 10, evidence for publication bias was first assessed using funnel plot analyses to depict the relationship between effect sizes (Cohen’s d) and standard errors. No outcomes assessed showed significant levels bias via an Egger's regression test (see Table 4). Additional outcomes (i.e., anxiety, self-efficacy) appear to show bias in their funnel plots under visual inspection, however this is of course subjective and was not corroborated by statistical tests.

As shown in Table 4, a sensitivity analysis of study design (experimental vs. quasi-experimental) demonstrated a significant influence only within the parent satisfaction outcome (t = − 5.561, p = 0.021). Two outcomes, parent anxiety and social support, included only studies with experimental designs and so could not be included in this analysis. For the inactive vs. minimally active control group sensitivity analysis, significant differences were observed between the studies with each type of control for parent self-efficacy and social support. To estimate the impact on overall results, meta-analyses for these two outcomes were re-run using only studies with inactive controls. This yielded minor increases in the intervention vs. control effect, as expected. There was no change in findings of significance for self-efficacy, which had already been demonstrated, but there was a change for social support, demonstrating that with a purer comparison between online universal parenting programs and inactive controls, there is a significant positive influence on social support (d = 0.407, p = 0.038). Finally, when comparing program efficacy outcomes for self-guided vs. partially self-guided program delivery, parent satisfaction displayed a significant sensitivity.

To assess the maintenance of effects over time post-intervention, study sample effect sizes were grouped into short-term (0–3 months), medium-term (4–6 months), and long-term (7–24 months) evaluations. To obtain a suitable degree of statistical power, all outcomes were aggregated to perform this analysis. Pair-wise time group comparisons using t-tests demonstrated a minor (non-significant) decrease in effect from short to-medium-term time frames post-intervention (t = 1.29, df = 51.63, p = 0.204), followed by a significant reduction in effect when comparing both short- (t = 5.18, df = 78.65, p < 0.001) and medium-term effects to long-term outcomes (t = 3.67, df = 42.959, p < 0.001). See Fig. 11 for a visual representation of these data.

At the combined outcome level, we identified no significant difference between parent sex (t = − 0.185, df = 3.39, p = 0.864) or between interventions with partially self-guided programs and entirely self-guided programs (t = 1.24, df = 19.14, p = 0.231). At the outcome-specific level, a significant difference in intervention outcome was observed between parent sex for social support, and for unguided vs. partially guided studies for parent satisfaction, as shown in Table 4.

Despite similarities with prior studies, our findings vary in important ways. First, our effect sizes are generally smaller or did not reach statistical significance. This difference is unsurprising considering the inclusion of solely universal programs, while other meta-analyses have included varied program types (i.e., selective, indicated, treatment), with many actively excluding universal programs (Baumel et al., 2016; Cai et al., 2022; Florean et al., 2020; Li et al., 2021; Thongseiratch et al., 2020). The typically more modest observable effects of universal programs represent a challenge in demonstrating efficacy in statistical terms, generally requiring larger sample sizes. By taking advantage of recently published primary research, this meta-analysis represents the first study to combine sufficient evidence to estimate population-wide efficacy of online parenting programs on a broad range of socioemotional outcomes. Programs applied to general populations typically have smaller individual effects relative to programs targeting higher-risk populations (McLaren, 2019; Rose, 2001; Werner-Seidler et al., 2017). Herein lies the prevention paradox: a preventative measure which brings great benefit to the population overall may offer little to each participating individual, yet small changes in the mean of whole-of-population distributions can result in marked societal benefits and reduce the need for costly subsequent targeted measures (Rose, 1981, 1985).

Again, in contrast to Spencer et al. (2020), the only other meta-analysis of universal programs, we did not observe significant changes in parent confidence or parent stress. This inconsistent finding may be explained by Spencer’s inclusion of parents with a child 0–18 years, while the current review included only parents of younger children (≤ 5 years). Only through comparison with a control group can intervention effects and natural changes over time be teased apart. Additionally, and unlike the present review, Spencer included both within-group and between-group study designs. Due to the lack of control groups against which to anchor results, within-group studies are likely to yield inflated results due to normative changes.

Like Spencer et al. (2020), but unlike prior meta-analyses that focused only on selected and/or indicated populations, we were unable to examine child-specific outcomes due to limited data availability, pointing to a lack of evidence examining universal self-directed parenting programs for children aged 0–5 years. This highlights the need for further investigation into the impact of such universal programs in the earliest years, relative to more intensive programs (Flujas-Contreras et al., 2019). Prior meta-analyses have not been limited to self-directed (entirely self-directed and partially self-directed programs) online parenting programs, with many providing direct professional support, longer training length, and greater program intensity. Considering these differences, cautious cross-study comparisons must be made.

Even though few studies assessed dyadic or relational outcomes, programs that assessed relational health showed improvement in parent–child interaction following program participation, with effects approaching significance. We would expect additional study and data in this area to highlight some true benefits. This calls for additional research as only four studies were included in the meta-analysis, but past primary research has associated poor parental mental health with adverse parenting of offspring (Borre & Kliewer, 2014; Harvey et al., 2011; Sturge-Apple et al., 2011). However, relational health was variably assessed in the included studies, typically completed via parent-report questionnaires, with minimal studies including follow-up assessments, highlighting the need for more nuanced attention to measurement of dyadic interactions. Furthermore, there were few studies of father-child relationships. This is noteworthy considering the current study found no evidence to suggest that these programs are any less efficacious for fathers relative to mothers.

Notably, no digital programs focused primarily on strengthening the parent–child relationship, and few studies evaluated program impacts on parent–child interaction, despite the health of this relationship being seminal to the future mental health and well-being of both generations. This highlights an important gap in knowledge and practice in universal parenting programs, and is in stark contrast to significant research investments in relational health in high-risk populations (Bergsund et al., 2021). It may be that universal relational programs have been examined in less depth, due to the perceived non-critical nature of these dyads. Given the economic benefit of early intervention and prevention at the public health level further examination of the relational impacts of universal programs remains necessary (Heckman, 2012). Furthermore, given the centrality of the parent–child bond to child development across the lifecourse, additional investment in new digitally facilitated approaches focusing on this bond are likewise warranted.

Sensitivity and moderator analyses yielded interesting findings in the present review. Firstly, we found no intervention efficacy differences between partially guided and completely self-guided programs. This is a notable result given the considerably reduced cost and resources of entirely self-guided programs relative to partially guided programs. Through these analyses, we also observed a statistically significant decline in program efficacy over time. This suggests that, following the completion of the main program, additional refresher content or other initiatives may be required to sustain program efficacy (Furlong & McGilloway, 2012).

Of particular interest were results of a sensitivity analysis assessing the impact of programs on inactive vs. (minimally) active control groups. This analysis demonstrated sensitivity of results to control type for parent self-efficacy and social support. For each of these outcomes, the meta-analysis was then repeated after removing active controls, yielding significance for both outcomes and larger effect sizes. For social support, this is notable as the main analysis including all controls did not yield significance. This finding is intuitive and emphasises the importance of carefully considering the potential influence of differing control conditions when examining program efficacy.

We restricted our review to include a homogenous group of studies (i.e., experimental and quasi-experimental universal online programs and parents with a child aged 0–5), differing from other meta-analyses that have aggregated heterogenous data (e.g., Baumel et al., 2016; Thongseiratch et al., 2020). Additionally, we assessed a nuanced subset of digital parenting programs, namely self-guided and partially self-guided programs, due to their significantly greater potential for reach and funding (Spencer et al., 2020). Further, our meta-analysis builds on these prior studies through the examination of unique parent socioemotional outcomes not previously reported on at the universal level: parent self-efficacy, social support, parent anxiety, and parent–child interaction. Compared to prior meta-analyses, the scope of our search was also considerably larger, including a rigorous examination of a wide range of outcomes, at multiple follow-up time intervals, yielding some insight into the trajectory of parent-specific outcomes.

Despite these strengths, limitations must be noted. There was some variety in control groups used, with some receiving purely care as usual treatment and others receiving informational resources as part of their participation. Further, there can also be marked differences in what constitutes case-as-usual in different countries and regions. For example, care and availability of support services is probably better in metropolitan areas and developed countries, which may have some impact on results. Further, most relational and child-specific outcomes could not be examined due to a lack of included studies reporting on them. Given child-specific outcomes have previously been meta-analyzed, this limitation points towards a lack of evidence examining universal-specific program outcomes for parents and children aged 0–5. This in turn brings to light the need for further investigation into the impact of such universal programs in the earliest years. The dearth of universal programs focused primarily on strengthening the parent–child relationship is of concern, given health economic evidence highlighting the centrality of this relationship to the well-being of both generations, and the importance of early intervention (Heckman, 2012). This underscores an important gap in knowledge and practice in universal parenting programs, in contrast to significant research investments in relational health in high-risk populations (selective prevention, indicated prevention, and treatment programs) (Bergsund et al., 2021). Finally, there is a lack of clarity in program evaluation and what a robust approach should include before public dissemination (e.g., relational assessment looking at attachment outcomes, interactional quality using observational measures, and longitudinal child development including socioemotional functioning). Current studies appear to be failing to evaluate programs using such robust approaches.

There is clear benefit in considering future research strategies that better clarify “what works for whom” within universal interventions, defining the levels of evaluation within a stratified model, that enables new knowledge of outcomes relative to pre-existing risk and vulnerability, including parents impacted by clinical depression and anxiety, histories of trauma, and attachment disruption. Longer-term outcome pathways for the general population warrant attention.

We suggest future research place greater focus on universal preventative programs to reduce later service system burden, which has public health significance. Once developed, these programs should be easily accessible, scalable, affordable, available ongoingly, and delivered flexibly and on-demand, providing greater program reach for those unable to attend through traditional in-person means. It is critical to distinguish effective universal support for well-being in the adaptation to parenting from targeted support for early mental health disorders including post-partum depression.

Future investment is needed in the formation and sustained evaluation of specific evidence-based public health programs pertaining to enhancing relational health and inhibiting early relational trauma. Investment in online universal relational interventions is an efficient way to utilize limited resources relative to other selective and indicated health initiatives. These programs will likely be relationally protective, resiliency-building within the relationship, while enhancing child health and well-being, thus reducing risk factors. Formation of such universal online relational programs may act as a socioemotional health preventative measure for the parent, child, and their relationship. While early relational health is routinely a feature of research and included in treatment programs for high-risk dyads; there appears to be an absence of specific universal parenting programs highlighting this content. Program elements that focus on enhancing parental awareness of their role in promoting early relational trust may assist with prevention of relational trauma, especially in the face of challenge.

In population health terms, our results suggest short-term small-to-moderate effects across several outcomes from online parenting education programs. Such effects are significant; however, these effects appear not to endure over time. Further development of practice and policy surrounding universally accessed parenting programs should work to ensure that learned behaviours and skills are retained over time. This will likely require refresher content and long-term access to program materials for participants.

In time, these programs may both provide early support for parents of young children and play a screening function, offering early triage to indicated supports, and potentially reducing the need for later targeted measures. Taken together, our findings support a future focus on the development of universally available, population health online preventative programs for parents. This is due to their capacity to reduce later public service system burden. Such programs would optimally be accessible, scalable, and affordable, with flexible delivery and ongoing access providing greater program reach, especially for those unable to attend through traditional in-person means.