About this paper symposium

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Panel information
Panel 21. Social Policy

Paper #1
Frequency of parenting programs visits with increase in caregiver knowledge on child cognitive stimulation
Author information	Role
Ana Luiza Penna, Harvard T. H. Chan School of Public Health, Brazil	Presenting author
Iná S. Santos, Federal University of Pelotas, Center for Epidemiological Research, Brazil	Non-presenting author
Marcia C. Castro, Harvard T. H. Chan School of Public Health, Global Health and Population Department, Brazil	Non-presenting author
Christopher R. Sudfeld, Christopher R. Sudfeld, United States	Non-presenting author
Abstract
Early cognitive stimulation is strongly associated with children’s future cognitive abilities, as evaluated within multiple parenting programs. However, there is a wide variation in the magnitude of the impact of parenting programs effect sizes on numerous child developmental domains across trials. More evidence is needed to elucidate the role of dose on program efficacy and its variation across diverse settings. Dose may be understood as composed of frequency, intensity (i.e., length of home visit or group meeting) and duration of program receipt. The Criança Feliz (CF) program aims to support caregivers’ ability to provide care by increasing maternal knowledge and practice of age-appropriate stimulation activities to children 0-6 years old based on weekly home visits delivered by the social assistance system. The program was implemented in Brazil through a rapid scale-up in 2016. This study investigated the following questions: (1) is frequency of home visits in the CF program associated with a change in caregiver knowledge regarding optimal early cognitive stimulation activities; (2) were characteristics of caregivers and children associated with change in caregiver knowledge controlling for frequency of home visits received ; and (3) is the association between the frequency of home visits and change in caregiver knowledge modified by characteristics of caregivers and children? This was a secondary analysis utilizing data from a randomized controlled trial evaluating the impact of the CF program on 3242 families randomly selected within thirty cities. The present study uses anonymized data collected at the baseline (2018) and endline (2021) of the RCT follow-up. The main explanatory variable, frequency of home visits received, was stratified according to the observed distribution. We categorized frequency as: 0% (control group); 0-25% ; 26-50%; and more than 50% intervention visits completed. The preservation of initial group allocation allowed for a conservative analysis given deviation of home visits delivery protocol in the intervention and control groups, further addressing potential confounding by unobserved variables associated with likelihood of receiving home visits. We found that frequency of at least fifty percent of weekly home visits over 3 years of follow-up was associated with improved caregiver knowledge of age-specific child stimulation behavior (Table 1). Additionally, higher maternal education, age and socioeconomic status, as well as child age and gender were associated with greater increases in maternal knowledge during the follow-up period, while maternal age is negatively associated with changes in knowledge, controlling for frequency of home visits received (Table 2). The study did not identify effect modification of home visits frequency on gains in maternal knowledge by either maternal education, maternal age, child age, child gender, number of children, or family socioeconomic status at baseline. However, it is possible that the analysis was underpowered to detect effect modification since positive trends and large differences in change have been identified among higher frequency combined with higher strata of such characteristics.

Paper #2
Blueprint for Enhancing Implementation Quality of Criança Feliz Program in Brazil: An Implementation Science Approach
Author information	Role
Dr. Gabriela Buccini, Ph.D., School of Public Health, University of Nevada, Department of Social and Behavioral Health, United States	Presenting author
Keishmer Cardoso, School of Public Health, University of Nevada, Department of Social and Behavioral Health, United States	Non-presenting author
Lidia Godoi, School of Public Health, University of São Paulo,Department of Policy, Management, and Health, Brazil	Non-presenting author
Rebecca Dunne, School of Public Health, University of Nevada, Department of Epidemiology and Biostatistics, United States	Non-presenting author
Rafael Pérez-Escamilla, Yale School of Public Health, Department of Social and Behavioral Sciences, Mexico	Non-presenting author
Abstract
Brazil’s Criança Feliz Program (PCF) is one of the largest early childhood development home-visiting programs globally. The PCF provides (1) home visits based on the Care for Child Development curriculum, and (2) complementary multisectoral actions to mitigate socio-vulnerabilities of participating families. After seven years of scaling up, implementation barriers led to poor fidelity and quality of home visits, and a lack of complementary multisectoral actions (Buccini et al., 2021, 2024), which to a large extent, have prevented PCF from achieving the intended impact on parenting skills and child development (Santos et al., 2022). As PCF begins the second scaling-up phase, we hypothesized that implementation science methods such as the program impact pathway (PIP) could inform quality improvements to enhance implementation strategies (i.e., activities used to enhance the adoption, implementation, and sustainability). PIP is an approach to evaluate implementation that derives from “intimate knowledge of the program” obtained during interviews with implementers and participants (Pérez-Escamilla et al., 2014). The goal is to identify critical quality control points (CQCP) defined as factors that promote or hinder a program from being delivered properly and achieving intended outcomes (Buccini et al., 2019). Thus, we conducted a PIP analysis to (1) identify CQCPs that need to be monitored throughout the scaling-up and (2) specify implementation strategies for enhancing implementation quality. The PIP analysis integrated inductive and deductive coding of retrospective (e.g. documents, reports, and codebooks from in-depth interviews) and prospective data (e.g. workshop) to identify CQCPs and corresponding implementation barriers. Opportunities to address barriers within each CQCP were independently coded using the nine categories from the Expert Recommendations for Implementation Change (ERIC) taxonomy (evaluative and iterative strategies; providing interactive assistance; adapting and tailoring to context; developing stakeholder interrelationships; training and educating stakeholders; supporting teams; utilizing financial strategies; changing the infrastructure; and engaging the demand side; Waltz et al., 2015). Then, a blueprint of discrete strategies was specified across the CQCPs with opportunities for enhancing implementation quality. We identified seven CQCPs: hiring municipal workforce; staff training; home visits; complementary multisectoral actions; municipal supervision; technical assistance and monitoring; and funding. Implementation strategies facilitating the scale-up were “providing assistance” and “supporting teams”. Examples of a discrete strategy used within the PCF included on-the-job training to influence the knowledge of supervisors and home visitors (CQCP 5) (Table 1). Opportunities for enhancing implementation quality were “financial strategies” and “evaluative and iterative strategies.” Examples of a discrete strategy that could be used to enhance implementation quality was the development of a formal implementation blueprint to clarify multisectoral roles (CQCP 4) (Table 2). Strategies within “changes in infrastructure” and “engaging consumer strategies” were not used during PCF implementation, but they were considered opportunities for enhancing implementation quality. Our analysis identified seven CQCPs necessary for PCF to achieve the intended implementation and program outcomes. The combined use of the PIP and the ECRIC taxonomy generated a meaningful blueprint of implementation strategies to enhance implementation quality, which may support the sustainability of large-scale early childhood home-visiting programs worldwide.

Paper #3
Feasibility of an online program to promote parents’ well-being and early childhood development in Brazil
Author information	Role
Dr. Patricia Alvarenga, Ph.D., Institute of Psychology, Federal University of Bahia, Brazil	Presenting author
Antonio Carlos Santos da Silva, Institute of Psychology, Federal University of Bahia, Brazil	Non-presenting author
Abstract
Parenting programs aim to create a positive interaction cycle between parents and children based on sensitive and assertive parenting practices that favor full children's socio-emotional development from the earliest years of life. Online programs can overcome challenges, such as physical distance and lack of time, often hindering participants' retention in face-to-face interventions. This study evaluated the feasibility of a self-administered online intervention to promote parents' well-being and early childhood development in Brazil. Parapais em Ação (Parents in Action) is a bigenerational 10-week online program offered through the Moodle platform of the Federal University of Bahia/Brazil. The first six weeks focus on parents' self-care, life skills, and healthy lifestyle habits, and the last four address parenting practices. The psychoeducational activities comprise videos and true or false questions, which do not require high reading and writing skills. The self-administered version of the intervention, evaluated in the current study, consists of online activities, and the mixed version includes weekly 30-minute videoconferences with a psychologist via the Google Meet platform. After the study's dissemination on social media, 44 mothers and fathers (39 mothers) with children between 3 and 6 years old were randomly assigned to the self-administered intervention or waitlist condition. Ten intervention participants completed at least five weeks of the program and were compared to 10 waitlist participants who completed pre and post-tests regarding subjective well-being (PANAS and LSS), mental health (DASS-2), parenting practices (PAFAS), and child behavior (SDQ). Demand, acceptability, and implementation were assessed by retention rates, engagement in online activities, a satisfaction questionnaire, and two questions on a Likert scale answered by participants each week of the program about their understanding and usefulness of the intervention content. Preliminary results revealed low retention rates between enrollment and intervention completion. Of the 10 participants who underwent the intervention, the eight who completed the ten weeks were highly satisfied with it and reported that the content was understandable and useful. The two participants, who completed 5 and 9 weeks of intervention each, reported high satisfaction and occasional difficulties understanding the content. The analysis of engagement in online activities is ongoing. Figure 1(a)-(f) displays the preliminary results of the program effects on parents' well-being. There was a reduction in symptoms of depression, anxiety, and stress from the pre-test to the post-test in seven parents who underwent the intervention. At the same time, the mean scores of the ten waitlist participants did not indicate a reduction in symptoms, except for stress, which showed a slight reduction. The effects on subjective well-being were not expressive, although there was a reduction in negative affect for 5 participants. The results suggest that the self-administered version of the program is effective in reducing symptoms of common mental disorders such as anxiety, depression, and stress in parents but may be insufficient for improving levels of subjective well-being, particularly life satisfaction and positive affect. These issues will be addressed in a randomized clinical trial that will assess whether the mixed version of the program can increase the effectiveness of the intervention.

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