Implementation of Reach Up early childhood parenting program: acceptability, appropriateness, and feasibility in Brazil and Zimbabwe

Young children need nurturing care, which includes responsive caregiver–child interactions and opportunities to learn. However, there are few extant large‐scale programs that build parents’ abilities to provide this. We have developed an early childhood parenting training package, called Reach Up, with the aim of providing an evidence‐based, adaptable program that is feasible for low‐resource settings. Implementation of Reach Up was evaluated in Brazil and Zimbabwe to inform modifications needed and identify challenges that implementers and delivery agents encountered. Interview guides were developed to collect information on the program's appropriateness, acceptability, and feasibility from mothers, home visitors, and supervisors. Information on adaptation was obtained from country program leads and Reach Up team logs, as well as quality of visits from observations conducted by supervisors. The program was well accepted by mothers and visitors, who perceived benefits for the children; training was viewed as appropriate, and visitors felt well‐prepared to conduct visits. A need for expansion of supervisor training was identified and the program was feasible to implement, although challenges were identified, including staff turnover; implementation was less feasible for staff with other work commitments (in Brazil). However, most aspects of visit quality were high. We conclude that the Reach Up program can expand capacity for parenting programs in low‐ and middle‐income countries.


Introduction
A recent series in the Lancet on early childhood development (ECD) introduced the concept of nurturing care as a comprehensive definition of the aspects of care young children need to support their development. Nurturing care includes adequate nutrition, access to health care, protection from violence, responsive interactions, and opportunities to learn. 1 Parents are the main provider of care for children aged 0-3 years; however, many families living in poverty and difficult circumstances do not have the resources and skills needed. Families need support from their communities and from government policies and programs to strengthen their ability to provide nurturing care.
There is growing evidence that programs to improve parents' skills in responsive caregiving and helping children learn lead to gains in child development (e.g., Refs. [2][3][4][5][6]. Relative to other programs, the Jamaica home visit (JHV) intervention has the most extensive evidence-with replications in Bangladesh and Colombia 5,7 -for medium-and long-term gains, [8][9][10][11] as well as adaptation and use at scale in the Peruvian Cuna Mas program. 12 Scale up of programs to support families to provide care has been identified as a key strategy to promote young child development. 13,14 The Reach Up early childhood parenting program is based on the JHV. The training package provides the tools to support agencies in implementing an evidence-based early childhood intervention. The overall aim was to facilitate building the capacity needed in governments, nongovernmental organizations, and other agencies to implement these programs (see Box 1). When evidence-based interventions are transported across countries and context, cultural adaptations can enhance participant attendance, retention, satisfaction, participation, and home practice 15 and have been shown to increase the effectiveness of the interventions in improving parenting behavior. 16 However, the literature on cultural adaptation of parenting programs largely focuses on programs targeting child behavior and on adapting evidence-based programs developed in high-income countries (HICs) for different ethnic groups 16,17 and/or across countries (most commonly other HICs). 18 The literature on transporting interventions developed for use in low-and middle-income countries (LMICs) across countries and contexts is limited. 19 Following initial development of the package, we collaborated with researchers and agencies in Brazil and Zimbabwe to implement the program. The objectives were to identify any modifications needed to the training materials and procedure, and to understand how the program was received by delivery agents, parents, and facilitators, as well as challenges to program implementation. Adaptation of materials for the implementation context and training of staff were conducted by the coun-try agencies in partnership with members of the Reach Up team. We collected information on program adaptation and program delivery (quality of visits), and obtained information through qualitative interviews with varying levels of staff involved in implementation and parents, to understand their opinions of the program and staff views of the training and implementation.
Below, we briefly describe the content of the program and discuss the adaptation process, program delivery, and qualitative data obtained from the implementation trials in Brazil and Zimbabwe.

Sample
Through our networks, we identified collaborators interested in piloting the Reach Up intervention. Proposals and funding for implementation were led by the country teams. Implementation began first in Brazil in the urban south west municipality of Sao Paolo. Following some adjustments to the package, the program was implemented in the rural district of Sanyati in Zimbabwe. Approach to implementation varied in each country, for example, in the personnel selected to conduct the home visits and the ratio of supervisors to home visitors (HVs) ( Table 1). For these analyses, we interviewed supervisors, HVs, and mothers to obtain information on their perceptions of the program. In Brazil, the principal investigator, 3 supervisors, 9 HVs, and 15 mothers were interviewed. In Zimbabwe, an agency leader, 2 supervisors, 15 HVs, and 70 mothers were interviewed. All supervisors were interviewed;

Box 1.
What is known 1. Responsive interactions between a parent and child and the early learning environment in the home are critical components of the nurturing care needed for children to achieve their developmental potential. 1 2. Programs that train parents in responsive caregiving and how to help their child learn show benefits to child development that are sustained in the medium and long term. 2-6 3. There is a need for evidence-based parent-training programs to be implemented at scale in LMICs. [13][14] What this study adds 1. The Reach Up program was shown to be easily adaptable to different contexts and to be acceptable, appropriate, and feasible to implement in two LMICs. 2. Training and on-going supervision of program staff are essential to ensure the intervention is implemented at high quality. 3. It is important to pay attention to staff workloads when integrating parenting programs into other services.
information on selection of HVs and mothers for interviews is provided below. Ethical approval for the study was given by the University of the West Indies Ethics Committee, the Medical Research Council for Zimbabwe, and the Research and Ethics Committee of the School of Medicine, University of Sao Paolo. Written informed consent was obtained from all interviewees.

Intervention
The Reach Up training package contains a planning and adaptation manual, a curriculum for children 6-48 months old, a toy manual, a training manual with demonstration videos, and guidelines for supervisors (details are provided in Table 2). The goal of the intervention was to improve child development through building mothers' skills at, and enjoyment from, helping their children play and learn and to improve mother-child interactions. A trained HV engaged the mother and child in a play session to demonstrate play activities and to model behaviors that promote responsive interactions between mother and child. The visitor provides positive feedback and praise to both mother and child. The visit ends with a review of activities to continue between visits, and encouragement to continue the activities and to include them in daily routines. Play materials are left in the home, and are exchanged for new ones at the next visit.
Training. HVs attended 10-day training workshops. The workshop sessions involved brainstorming, watching videos of successful home visits with key methods highlighted, role playing, toy making, and discussions. Each session typically lasted for 1 hour and a half, with small breaks in between sessions. Toward the end of the training, the visitors practiced putting together the methods and activities learned in a complete visit. Following the workshops, visitors were accompanied on practice home visits. The interactive approach to training was similar to that used previously in Jamaica, but the training manual and films and supervisor and adaptation manuals were developed for the Reach Up package.
In Brazil, two groups of visitors were trained: child development agents (CDAs) and community health agents (CHAs). CHAs were an existing cadre of staff in the primary care "Family Health Strategy" model in Brazil, whereas the CDAs were a new cadre of staff employed specifically for this project. Both groups had a minimum of primary-level education and resided in the same communities as the families they visited. CDAs received training over a 10-day period; the CHAs were trained over five 2-day sessions due to their work commitments. The training of the CDAs was conducted by a Reach Up team member together with the in-country principal investigator (PI). A second team member took notes on the process, as this was the first  The curriculum is designed for use by community workers with primary education and gives activities and goals for each visit organized by materials needed, objectives of the visit, and things to do (activities). To support the visitor, there are brief reminders of steps in introducing an activity and some suggested dialogue. A weekly and fortnightly curriculum are available.

Toy manual
The toy manual gives step-by-step illustrated instructions on how to make all the play materials.

Supervisor manual
The supervisor manual provides guidelines for supervision and the evaluation checklist for observing home visits. It includes qualities of a supervisor, and their responsibilities, how to provide supportive feedback and build positive relationships with the visitors. The content is supported by short scenarios that depict challenges that supervisors and visitors may encounter, which are used as practice activities during supervisor training.
training workshop with the new manual and films. Following this, some of the layout of the training manual, and the order in which some content was introduced, was revised. The PI subsequently conducted the training of the CHAs 1 month after the initial training workshop. After 6 months of intervention, both groups of visitors received a 3-day refresher training from a Reach Up team member. In Zimbabwe, the HVs received a 10-day training workshop led by two Reach Up team members, with assistance from the supervisors for the program. A 3-day refresher workshop was provided by the supervisors after a 6-month interval before the start of the intervention.
Supervisors also attended the full intervention training and, in addition, received training in supportive supervision, including practice using scenarios around challenges that they, or the visitors, might encounter. They were also trained in the use of an observation checklist for monitoring the quality of visits. They were provided with the supervisor manual, with guidelines for supervision, and the observation checklist.
Delivery. Information on the sites and delivery of the intervention is provided in Table 1. Four hundred mothers and children were enrolled in Brazil. Ten CHAs employed to district health centers in Sao Paolo were each asked to include 10 Reach Up home visits each week to their usual work load; a small stipend, equivalent to approximately 30% of their regular monthly salary, was provided. The CHAs were employed at the health centers to conduct community visits that included visiting persons with infectious diseases and other health conditions, along with promoting child care and development.
Five CDAs were employed directly for the program by the research team at the University of Sao Paolo. These CDAs were asked to complete 20 home visits each week. For both categories of visitors, families to be visited were assigned by the project team. Supervisors were asked to accompany the visitors on one visit per month and had monthly group meetings with all visitors at the main research office to discuss challenges and share experiences. During the intervention, five of the part-time CHAs resigned from the program and four new part-time visitors were recruited and trained. Families were visited every 2 weeks from June 2015 to June 2016, and the length of the visits ranged from 20 to 50 minutes.
For the program in Zimbabwe, 200 mother-child pairs participated from areas near 12 ECD centers in Sanyati district. Twenty-four teaching assistants employed by the ECD centers conducted the home visits. The teaching assistants had a minimum of primary school education. Visitors conducted 4-5 visits per week. Supervisors accompanied the visitors on a home visit at least once a month and had monthly group meetings to discuss challenges and share experiences. In Zimbabwe, the intervention started from June 2015 and continues until June 2018; families are visited every 2 weeks and the length of the visits ranges from 30 to 50 minutes. At the time of the data collection, eight families were no longer participating in the intervention due to migration. During the intervention, two HVs resigned and two new visitors were recruited and trained.

Procedures
Semistructured interview guides were used to conduct the interviews with the agency leaders, supervisors, HVs, and mothers from Brazil and Zimbabwe. In Brazil, mothers were selected based on the different types of visitors (i.e., CHAs or CDAs) conducting the home visits and on their availability for the interviews. CHAs and CDAs were also interviewed. In Zimbabwe, mothers were selected from each ECD center and, according to their availability for the interviews, at least five mothers were interviewed from each center. HVs from each center were also interviewed.
Data from the observation checklist completed by the supervisors were summarized as a measure of the quality of the visits. The checklist included information on the conduct of the visit, the relationship of the visitor with the mother and child, and the overall atmosphere of the visit. Each item was scored on a four-point scale. Definitions for each item on the checklist were provided to the supervisors, who were trained by a member of the Reach Up team in use of the checklist. The checklist was used by the supervisor to inform feedback to the visitor to improve visit quality, which would affect test-retest reliability. Inter-rater reliability data were not collected; however, prior work suggests that this would be in the range of adequate-to-high. 20 Interview guides. Guides for the semistructured interviews were developed using a framework approach. We developed a matrix that identified important aspects of implementation according to the content of the package and the process and context of implementation. For each of these, we identified the persons from whom we would need data. Then, we developed the questions that would need to be asked to obtain the information.
The interview guides for the mothers contained questions on the home visits, materials used in the intervention, activities conducted during the intervention, and their overall experience. For the HVs, questions focused on the training workshops, curriculum, toy manual, materials used in the intervention, activities conducted during the intervention, home visits, and the overall program. Supervisor interviews focused on the training workshops, how the HVs utilized the curriculum, supervisor guidelines, the toy manual, how the HVs utilized the materials used in the intervention, how the HVs conducted the activities during the intervention, how the HVs conducted the home visits, and their overall experience during the program ( Table 3). The interview guides were piloted with mothers, HVs, and supervisors from local programs in each country to ensure the questions were clear and captured the information needed.
Data collection Email logs. Data were also collected from email logs from the Reach Up lead trainers who assisted with the planning, adaptation, training, and implementation in these two sites. These email logs provided examples of the types of questions asked by the program leads and supervisors, the adaptations undertaken, and the successes and challenges experienced.
Brazil. Interviews were conducted from June to July 2016, over a 6-week period at the end of the intervention period. One research assistant (RA), who had not been involved in the study, interviewed the 3 supervisors, 15 mothers, and 9 HVs (four of five full time CDAs and five of ten part-time  CHAs, including two who had resigned). Mothers were interviewed at home; the HVs and supervisors were interviewed at the main research office. The interviews lasted between 45 minutes and 1 hour.
The RA had experience with conducting qualitative interviews. The content and process of the Reach Up intervention and the rationale for the questions on the interview guide were reviewed with the RA. The interviews were conducted in Portuguese and translated into English for analysis.
Zimbabwe. Data were collected from September to December 2016, while the intervention was taking place. The interviewers spent at least 4 days collecting data in each of the 24 ECD centers. Two experienced qualitative researchers and three research assistants not involved in the study interviewed 70 mothers, 15 HVs, and 2 supervisors. The interviews lasted between 45 minutes and 1 hour. Interviews for the mothers were conducted at home and for the visitors at the ECD centers. Supervisors were interviewed at the head office in Kadoma. The content and process of the Reach Up intervention and the rationale for the questions on the interview guide were explained to the researchers, who then trained the research assistants to conduct the interviews. Interviews were conducted in Shona and translated into English for analysis. Interviews with the PI in Brazil and agency lead in Zimbabwe were conducted by one of the authors (JS).

Data analysis
Data from email logs were used to develop a list of adaptations made, and the successes or challenges the agencies may have had, with implementation. The qualitative interview data from the two countries were analyzed utilizing the framework approach. 21 The framework approach has five stages: familiarization, identifying the themes, indexing, charting, mapping, and interpretation. The analysis was done separately for each of the three groups of participants (mothers, HVs, and supervisors) and for each country. Within each group of participants, themes were categorized according to whether they related to the acceptability, appropriateness, or feasibility of the Reach Up intervention in terms of content, materials, and process of delivery. Transcripts were coded by hand and charts constructed to guide interpretation. Following this, analyses by country were integrated to form common themes and, in a final step, the analyses were compared across participants (the thematic frame Data from the evaluation checklists from supervised visits in Brazil and Zimbabwe were summarized as percentages for each question.

Results
The results are divided into three main sections based on the data collected: (1) agency feedback on the Reach Up Program and common adaptations; (2) in-depth interviews (mothers, HVs, and supervisors) conducted in Brazil and Zimbabwe; (3) and evaluation of the quality of visits in Zimbabwe.

Agency feedback on Reach Up program
Aspects of the Reach Up program that agency leads viewed as important were its rich evidence base and the ability to adapt the program to the different contexts and needs of the countries. In Brazil, the PI indicated the importance of being able to obtain assistance with the planning and adaptation of the materials. The ability to speak to the team through email and video conferencing helped with ensuring that planning and adaptation questions could be answered in a timely manner: The members of the team were friendly and they were available to speak if I had questions. They also helped with the adaptations . . . after the pilot project we realized that the toys had to be more attractive to the Brazilian mothers.
In Zimbabwe, another reason indicated by one of the agency leaders was the ability to integrate it with an existing ECD program for young children that they conducted through the ECD centers in Sanyati: We have ECD programs in the rural districts in Zimbabwe and when we heard about the Reach Up program we wanted to propose the possibility of integrating the stimulation program with what we were already doing in this district.
The JF Kapnek Trust also stated that the ability to change the delivery of the program from weekly to fortnightly improved the feasibility for integration. This was important in making the decision to implement the Reach Up program in this region.

Brazil.
A pilot study of the acceptability of the Reach Up toys and activities was conducted in Brazil, between November 2014 and February 2015 with 100 mothers who were not participants of the main study. Adaptations were then made to some of the toys as mothers felt they were not attractive. Colors and textures were used to make the toys more attractive. However, some changes had to be reversed as they affected the use of the toy to teach specific concepts. An example was plastic bottle tops used for a stacking activity and also to identify primary colors. The team wanted to add dots and stripes of different colors and were advised not to add decoration but stick to bottle tops in primary colors so as not to confuse the children.
An adaptation was made to the curriculum content to integrate some language activities as short messages for the mothers. We also worked with the Brazil team to adapt the curriculum from weekly to fortnightly visits to increase feasibility of implementation, and subsequently produced a fortnightly curriculum as part of the package. Training for the CHAs was also adapted to a series of 2-day workshops to accommodate their work schedule.
Zimbabwe. Fewer adaptations were done in Zimbabwe, mainly revision of the pictures to ensure they reflected the culture and the addition of local songs. The fortnightly curriculum was also used in Zimbabwe.
Examples of adaptations made to the Reach Up intervention program in Brazil, Zimbabwe and in additional countries where the program has now been implemented are given in Table 4.

Summary of in-depth interviews
Acceptability. The major themes on acceptability that emerged from the interviews were focused on acceptability of the materials, the home visiting delivery method, and the intervention benefits to the children and to the mothers themselves. Acceptability of the Reach Up materials and the play activities was a main theme for the mothers and HVs (Table 5). Overall, 60% (7 of 15 Brazil and 50 of 70 Zimbabwe) of the mothers interviewed stated that their view of the toys was at first unsure but then they began to appreciate the value of the play materials and activities for their children. In Brazil, some mothers (n = 5) also saw benefits of the intervention to their children's development. Mothers in Zimbabwe (n = 29) also commented on the benefits of the intervention to the development of their children, as one mother in Zimbabwe stated:   r In Brazil, health care workers and child development agents were used. In Zimbabwe, paraprofessionals who worked as teaching assistants were utilized to conduct the home visits. In Guatemala, Madre Guias, or mother guides, are used as they are seen as community leaders. a Adaptation was led by the local investigators with detailed knowledge of the context, in consultation with the Reach Up team to ensure concepts remained clear. Pictures were redrawn by local artists. In Brazil, toy materials were also piloted with mothers similar to those in the program.
The use of recyclable materials to make the toys was perceived as innovative by the mothers and visitors, as they never thought about using these materials to make the toys (Table 5). Mothers also believed that they could make toys from recyclable materials for their children and wanted a toy-making workshop to be included in future plans for the program. They also noted the need to improve the durability of the materials. When asked about the play materials, the HVs had both positive and negative comments. The positive comments focused more on the acceptability by the children who participated in the intervention and also on the availability of the materials locally as they were recyclable and inexpensive ( Table 5). The HVs stated that most materials were liked by mothers, including the soft toys (ball and doll), some plastic toys (bottle tops), puzzles, books, pictures-to-talk-about, and blocks. However, a few HVs also stated that some mothers did not accept the materials and this influenced their ability to do the activities. The effect seen on the children in terms of their development, especially their improved speech and vocabulary, also influenced the acceptability of the intervention to the mothers and HVs. As one HV from Brazil stated: What I liked most was to see the development of children, you arrive at first and the mother says 'Look, he does not talk many things' and after a year you can see these children talking every word. We also could see the improved connection between mother and her child-which is our focus.
One mother from Zimbabwe also stated:   was seen by the supervisors as important for the success of the program. The mothers felt that they had support to help their child to develop and this support also helped them to increase their confidence as parents. As one mother in Brazil stated: . . . .my child is my first one, so I don't know what a child should be doing when she is one-year-old, if she should be talking or not, what is normal but the agent she knew, she would say let us teach him one more word.
All of the mothers interviewed believed that the intervention helped their child. Improvement in their children's readiness for school was also mentioned, mainly by mothers in Zimbabwe. As one mother from Zimbabwe stated: The program actually helped my child through improving her social skills and language skills. She is going to be a star when she starts school.
When the HVs were asked what they liked most about the program, the majority 88% (8 of 9) in Brazil and 100% (15 of 15) in Zimbabwe liked seeing the development of the child ( Table 5).
The importance of relationships between the supervisor and visitor, and the visitor and the mother, was also highlighted in the interviews with the supervisors. The supervisors reported that they spent time during the intervention helping to motivate the visitors. The relationship between the visitor and the families was emphasized by the supervisors as important for the success of the intervention. As one supervisor from Brazil stated: It is very pleasant, the bond between agents and the families, they share intimate things, the trust, they share their problems, I am sure it will be fruitful.
The supervisors also believed that other regions within Brazil and Zimbabwe could benefit from the intervention. The major challenges they reported in the field related to perceived lack of commitment, from some mothers and HVs.
Appropriateness. The main themes on appropriateness of the intervention that were stated in the interviews were about the importance of the training workshops, the need for additional training sessions, and the perceptions of the Reach Up tools, such as the curriculum, toy manual, and the supervisor manual. The training was perceived as important to the success of the interventions. The visitors and supervisors believed that the training they received prepared them for the home visits and they knew what they needed to do in the field. The role playing and practice sessions helped to improve the visitor's confidence ( Table 6). As one HV stated: When I did the first visit I identified a lot with the training we had done, the simulations were very close to reality.
Most of the HVs interviewed stated that the training workshop helped them feel prepared for the home visits, approximately 80% (7 of 9) in Brazil and 100% (15 of 15) in Zimbabwe. They felt the training workshops helped to increase their confidence, knowledge, and skills. However, the HVs wanted additional training on building a positive relationship with the mother, dealing with an uncooperative child and dealing with problems that occur in communities (e.g., violence in communities) ( Table 6).
Supervisors also felt that there was a need for further training of the HVs on how to use the curriculum as they felt they spent a lot of time at the beginning of the intervention encouraging the HVs to complete the objectives and to focus on the key concepts for each activity.
The curriculum was perceived as an important guide with step-by-step instructions, and both visitors and supervisors believed that it was an important tool in the field (Table 6). Over 50% of the HVs (5 of 9 Brazil and 11 of 15 Zimbabwe) stated that the curriculum was clear, easy to use, with appropriate content. As one HV from Zimbabwe stated: It is very useful. Sometimes I had doubts about a game, so I checked the curriculum to see which game was that . . . . I always took it to the visit.
However, the HVs also had some negative comments, mainly about the durability ( Table 6).
Most of the HVs were able to complete the objectives required; however, on occasion, they were unable to do so. The reasons given included lack of interest from the child or mother, loss of toys and materials, and lack of time ( Table 6). Ease of use of the curriculum, time management, preparation before the visit, the relationship and cooperation of the mother, and the positive interaction with the child were factors reported that facilitated completing the objectives.
The manuals provided in the Reach Up program were perceived as effective in enabling the visitors and supervisors to implement the intervention. The  supervisors believed that the manuals provided were adequate for the home visits; however, they needed more guidelines on their supervisory role in the field. As one supervisor from Brazil stated: I think we need to train a bit more on things that happen during the visits which are unexpected, beyond the curriculum itself.
However, as the interventions progressed and the familiarity with the concepts and methods increased, the HVs were able to conduct the activities appropriately and the supervisors felt that they had the appropriate tools and experience to help guide the HVs successfully.

Feasibility
The major theme that emerged surrounding the feasibility of implementation of the Reach Up intervention for the mothers was the ability to integrate with their daily lifestyle. Overall, mothers were able to conduct the activities during the week and opportunities for mothers to practice the activities between visits either daily or several times per week varied from 73% (11 of 15) mothers in Brazil to 93% (65 of 70) mothers in Zimbabwe. The demonstrations by the visitors helped mothers to know the methods they could use to do the activities with their children ( Mothers felt the program could be improved by including toy-making workshops and providing more books and puzzles. Overall, the mothers in both countries enjoyed the program and thought it should continue and be implemented throughout the country. For the visitors, their perceptions on the ability to complete the objectives, the strategies to find the recyclable materials, and the challenges to program process were main themes from their interviews ( Table 7). The ability to complete the activities for each visit was perceived by the visitors as possible mainly through the relationship with the mothers and children. As one HV from Brazil stated: We noticed that when the mother stayed and participated, when I leave the toys in the house, they played. Otherwise when the mother was not participating the child did not do the activity during the week.
Preparation before the visit also improved the success of the visits and this was highlighted by the supervisors and visitors. Through conversations with each other and advice from supervisors, the visitors were able to overcome challenges with implementation ( Table 7).
The sourcing of the required amount of recyclable materials was a challenge in both countries, and a variety of sources were utilized, including local shops, restaurants, friends, and family members. In Brazil, the quantity of the toys to be produced and replaced was a challenge as some toys such as blocks and puzzle pieces needed to be replaced frequently. In Zimbabwe, they had a similar challenge and also had difficulty obtaining some of the materials needed. In Zimbabwe, through seeking help with this from the local community, the program became a community activity and helped to build the relationship the supervisors and visitors had with the community.
For supervisors, identifying the quantities of materials needed and the challenges in completing the program were the main themes. The supervisors reported that proper training, organized toy production, good relationships between visitors and mothers, and emphasizing to the mothers the importance of spending time with their child are critical to the success of the program. The feasibility of the implementation of the program was perceived as possible once the important components are available.

Evaluation of the quality of visits in Zimbabwe and Brazil
The observation checklist was used to measure the quality of the home visits. In Zimbabwe, the supervisors observed each HV conducting a visit at least once per month. In Brazil, the supervisors conducted supervisory visits monthly for the CDAs; however, there were few observations conducted for the CHAs, so the available information reflects the quality of visits for the CDAs. The summary of the checklists provided in Table 8 highlights the areas that are the focus of the visits.
In Zimbabwe, overall the visitors conducted the visits well with most aspects being done adequately or well for over 90% of visits. The interaction between the caregiver and visitor and the visitor and child was "warm". The interactions between the visitor and child were "very good", with over   HVs pulling out of the program after the training HVs repeating mistakes highlighted before 80% of these interactions being "very warm, understanding, and cooperative". The visitors were also "very good" when responding to the child's cues in 83.6% of visits. The visitor shared responsibility for the activities with the mother 97.3% of the time and the overall atmosphere of the visit was "happy to very happy" 94.7% of the time. However, there were areas that needed improvement especially with the interaction with the caregiver. In 36.8% of visits, the mothers' opinion was either not sought or sought only little of the time. Encouragement of the mothers was either not done or done only little of the time in 11.7% of the visits and was done most of the time in only 35.7% of visits.
In Brazil, the visitors also conducted the visits adequately or well for over 90% of the visits. The interactions between the visitors and the child were "warm, understanding, and cooperative" for 93.7% of the visits, and few of the interactions with the child were rated none or little of the time. Interactions between the visitors and the caregiver were "warm and cooperative" 96.8% of the time. The overall visits were "happy to very happy" 96.9% of the time. The areas for improvement were similar to those in Zimbabwe and included "seeking the caregiver's opinion", which was done most of the time in only 43.8% of the visits, and "encouragement of the caregiver", which was done most of the time in 56.3% of the visits.

Discussion
We have reported on implementation of Reach Up, a home-visiting early stimulation program for use with young children and their families in LMICs. The aspects of implementation included were the rationale for adopting the intervention, the adaptations made in several user countries, the acceptability, appropriateness, and feasibility of implementing the intervention according to mothers, HVs, and supervisors in two countries, Brazil and Zimbabwe, and the fidelity of intervention implementation.
Our study focused on transporting an evidencebased intervention originally developed for the Jamaican setting to other LMICs. There are a growing number of models or frameworks to categorize adaptations to evidence-based interventions for different cultural contexts. [22][23][24] The cultural sensitivity model 24 categorizes adaptations into surface and deep structure adaptations. The majority of adaptations made to the Reach Up package involved surface structure adaptations, for example, matching the program materials to fit the characteristics of the new context. These adaptations included adaptations in language (translation of materials), delivery personnel (e.g., use of health workers and preschool staff), and materials (e.g., changing pictures to reflect the culture and adapting the toys according to availability of resources and to promote acceptability). Stirman et al. developed a framework for coding adaptations that includes coding changes to the content (e.g., tailoring, adding, removing, reordering, and substitutions), context (e.g., delivery personnel and format of delivery), and training and evaluation (e.g., how staff are trained). 25 Adaptations to the Reach Up package included all of these elements. Content was added (e.g., health and   nutrition messages), reordered (e.g., the introduction of some play activities was delayed), substituted (e.g., local games and songs were used instead of the original material), and tailored (e.g., different materials used to make toys and/or toys adapted to make them more acceptable). Changes were also made to the delivery personnel to fit with the organizational context and the staff available, and to the format of delivery (e.g., every two weeks, rather than weekly visits). Changes to staff training were minimal and mostly involved changes to the schedule to accommodate work commitments. When transporting evidence-based interventions, adaptations are required to ensure a good cultural fit and to ensure the intervention fits into the adopting agency's method of functioning to promote adoption and sustainability. 26 However, for continued effectiveness across contexts, it is important that the core components of the intervention are maintained, 27,28 and the involvement of persons who have a thorough understanding of the intervention can help to ensure that adaptations are appropriate. This was recognized as a strength by the implementing teams in Zimbabwe and Brazil. Results from the in-depth interviews indicated that the Reach Up intervention was acceptable and appropriate according to mothers, HVs, and supervisors. Although there were some initial reservations related to the intervention, specifically relating to the toys made from recycled materials from the mothers and HVs, these reservations were quickly overcome when it was evident that the children enjoyed playing with the materials and were seen to benefit from them in terms of improved development. This acceptability was also shown by the retention of mothers and children in the intervention, and by the fact that the mothers either started to make toys themselves (in Zimbabwe) or expressed an interest to do so (in Brazil). HVs and mothers also reported enjoying the intervention and benefiting from it. This is similar to the perceptions of mothers who participated in an intervention program in rural Malawi. 29 The importance of tangible and observable benefits of intervention, both to the program recipients and to the staff delivering the program, has been documented previously. 30,31 The HVs reported increased confidence and increased respect in their communities in both Brazil and Zimbabwe, and this concurs with a previous qualitative evaluation in Jamaica, which found that health workers and nurses reported benefits to themselves in terms of job satisfaction, confidence, interpersonal skills, and knowledge. 32 The importance of interventions being fun and enjoyable is an under-reported factor in the literature on preventative interventions, and is important for participant engagement. 33 The Reach Up package was also feasible to implement, although several challenges were identified in both countries. Enabling factors included the provision of a clear, structured curriculum and training in how to use it, which included demonstration, rehearsal, and practice, with feedback and ongoing supervision. These factors have been identified as key to successful early child development programs. 34,35 In addition, over 70% of mothers in both countries reported that they were able to do the play activities with their child at home either every day or several times per week.
Staff turnover was a particular challenge in Brazil. One of the objectives of the Brazilian project was to compare using the already existing cadre of CHAs to creating a new cadre specifically dedicated to the intervention. Half of the HVs who were employed in the health sector dropped out from the intervention during the study, whereas staff turnover was not a problem with the full time CDAs-this is despite the fact that the CHAs received a stipend equivalent to 30% of their salary for conducting the visits. The interviews showed that the main reason was the high burden of existing work so the CHAs felt they did not have enough time to conduct the visits. In addition, other urgent health matters, such as combating dengue fever and immunization promotion, were prioritized and this affected commitment to the intervention. Ensuring that the additional responsibilities are feasible in context and do not overburden staff or interfere with their existing duties is one of the key challenges in integrating interventions into existing services. The number of visits assigned to the health workers in Brazil may have been too many; it was higher than that assigned to the teaching assistants in Zimbabwe, although greater distances between visits in Zimbabwe need to be taken into account.
Another problem related to the sourcing of materials for the toys, making sufficient toys and transporting the necessary materials to the intervention sites. In some countries, some of the play materials (e.g., the books, puzzles, and blocks) have been manufactured locally but transporting the materials can still be a problem, especially to rural and/or dispersed areas. Challenges around building positive supportive relationships between HVs and mothers and HVs and supervisors were also evident. HVs reported difficulties in engaging some mothers in the intervention and both HVs and supervisors reported that lack of commitment to the program by mothers was a challenge. Community health workers and nurses who implemented an ECD intervention in health centers in Jamaica also reported that mothers' attitude or behavior was a challenge. 32 Positive relationships are a key component for program effectiveness and hence future training needs to include a greater focus on the skills required, for example, reflective listening, showing empathy, using open-ended questions, and collaborative working. 36 Additional further training needs identified by supervisors were training in supervisory skills and problem solving. The importance of supervision was highlighted by Tomlinson et al., who have indicated that for interventions at scale the development of soft skills of the leadership team is essential. 35 The monitoring of the quality of the home visits using a supervisor checklist in Zimbabwe and Brazil showed that most aspects of the intervention were implemented adequately or very well. The aspects of quality that were rated lowest related to the HVs' interaction with the mother (asking the mother's opinion in both countries and encouraging the mother, and using a collaborative approach in Zimbabwe). Other studies have also highlighted low quality for aspects of the HVs' interaction with the caregiver in home visiting ECD programs, 20,32 suggesting that these skills may need additional time to develop and/or a greater focus needs to be given to these skills during initial training. Conversely, HVs scored very highly on their interactions with the child.
The strengths of the study include the inclusion of the perspectives of multiple participants, including mothers, HVs, and supervisors. The perspectives of the program recipients (mothers) and front-line delivery staff (HVs and supervisors) about the acceptability, appropriateness, and feasibility of the content and process of delivery of the intervention will affect their engagement in the intervention and are critical for program success.
These perspectives are also important to help identify barriers and enablers to implementation and thus inform further development of the intervention materials. Interviews were conducted by persons who were not involved in intervention implementation to reduce the likelihood that participants would only give favorable comments and responses.
Limitations of the study include the fact that mothers and HVs were selected according to their availability for interview. It is possible that these participants did not represent the views of the wider group; for example, more enthusiastic and willing mothers may have been more available for interview. However, within all groups of participants, positive and negative points were made about the intervention content and/or process. The data presented on the quality of the home visits are based on supervisor checklists designed primarily to help supervisors provide high-quality feedback to the HVs and to identify training needs. Further although the visitors knew the supervisors well, the presence of the supervisor may have affected the visitor's actions. The information is, however, useful in providing an overview of the strengths and weaknesses of intervention delivery.
In conclusion, the Reach Up program can be used to build capacity for implementation of parenting programs in LMICs. The program and materials were well accepted and training was appropriate. Implementation was feasible when delivered by CDAs in Brazil and teaching assistants in Zimbabwe and quality of implementation was good. Adaptability of the program is a strength and will facilitate use in other countries. The study also identified some aspects that need expansion such as supervisor training. The challenges with implementation by persons already employed to health services highlight the need for attention to staff workloads when integrating with existing services. Scale up in many settings may require expansion of existing cadres of staff or establishment of a new cadre of delivery agents. evidence and evaluations on implementation processes, and to identify gaps and future research directions to advance effectiveness and scale-up of interventions that promote young children's development. A workshop was held on December 4 and 5, 2017 at and sponsored by the New York Academy of Sciences to discuss and develop the content of this paper and the others of the special issue. Funding for open access of the special issue is gratefully acknowledged from UNICEF and the New Venture Fund.
The development of the Reach Up package and the implementation research were funded by Grand Challenges Canada. We thank the mothers, visitors, and supervisors for their participation.
J.S. drafted the paper with contributions from H.B.H., S.W., and A.B., A.B. and R.M. led the evaluation and collection of data for the Brazil and Zimbabwe studies, respectively. All authors read and approved the final manuscript before submission. J.S. has taken responsibility for the integrity of the data provided.