Diffusing and scaling evidence‐based interventions: eight lessons for early child development from the implementation of perinatal home visiting in South Africa

Abstract

Most low- and middle-income countries lack resources with which to implement public health programs. As such, there is a necessity to facilitate programing that judiciously makes use of what resources there are. However, despite evidence for the efficacy of many interventions, translating these into real-world effectiveness, and then into scalability, is complex and has often been neglected. We draw on a case study of Philani+ (a maternal and child health intervention implemented in South Africa) to distil eight features of health programing that aid intervention effectiveness. We argue that implementation science should turn its attention to the human resource "process" features of interventions. We describe the importance of staff selection (rigorous selection and hiring procedures); training (developing a set of common core pragmatic problem-solving skills); monitoring (feedback about quality); community and institutional support (rapport with intervention communities); the importance of stable leadership (consistent leadership focusing on how to optimize the potential of staff); the importance of implementing with sustainable, long-term change in mind; and, finally, we describe how cultivating consistency within an organization requires disciplined action and disciplined focus on the organization's vision.

The Irie Classroom Toolbox: developing a violence prevention, preschool teacher training program using evidence, theory, and practice

“…This discipline hierarchy also incorporates teachers’ use of choice and problem‐solving skills that were identified as enablers to intervention implementation through the process evaluation. Problem‐solving skills have been reported to be an important implementation strategy in integrated nutrition and stimulation interventions in LMICs and for effective scaling of evidence‐based perinatal interventions in South Africa …”

“…Problem-solving skills have been reported to be an important implementation strategy in integrated nutrition and stimulation interventions in LMICs and for effective scaling of evidence-based perinatal interventions in South Africa. 42,43 The enablers to intervention implementation included factors that promoted teachers' skills, motivation, and opportunity. Teachers valued interactive training methods, including rehearsal, practice and feedback, over more passive methods such as watching videos and discussion; this preference for hands-on training activities has also been reported for early childhood parenting interventions in LMICs and is a key characteristic of effective programs.…”

Developmental health in the context of an early childhood program in Brazil: the “Primeira Infância Melhor” experience

“…For example, visitors achieved good involvement of families doing the activities during the visits, but appeared to often provide poor explanations regarding the importance of such activities to child development, lack the necessary materials and rarely stimulate language development. This reinforces the need for developing systematic and valid strategies to assess implementation fidelity, as well as qualified monitoring and community support, which is critical to successful dissemination of ECD programs, as PIM, in community settings 11 . While implementation accuracy is paramount, it is also important to understand the results of HVP impact on ECD more broadly, as families vary widely according to their needs, adherence to program and their own goal-setting, home stability, as well as educational and work attainments 32 .…”

“…Features of ECD programs, such as health service provision, and focus on responsible caregiving as well as safe and language-rich environments showed meaningful results in promoting child development outcomes 5,7 . Evidence also reinforces the importance of the maintenance of program standards, ongoing training and assistance to the intervention providers, as well as continued quality monitoring and improvement to ensure the effectiveness of population programs and services targeting diverse needs of ECD 11 . Indeed, lack of fidelity in program implementation could be a factor contributing to its limited success 11 .…”

“…Evidence also reinforces the importance of the maintenance of program standards, ongoing training and assistance to the intervention providers, as well as continued quality monitoring and improvement to ensure the effectiveness of population programs and services targeting diverse needs of ECD 11 . Indeed, lack of fidelity in program implementation could be a factor contributing to its limited success 11 . Children and families in poverty seem to benefit more from broad programs that combine center-based care, social welfare and education for both children and parents 7 .…”