Parenting

Science and Practice

ISSN: (Print) (Online) Journal homepage: www.tandfonline.com/journals/hpar20

The Future of Parenting Programs: II

Implementation

Jennifer E. Lansford, Theresa S. Betancourt, Kimberly Boller, Jill Popp, Elisa

Rachel Pisani Altafim, Orazio Attanasio & Chemba Raghavan

To cite this article: Jennifer E. Lansford, Theresa S. Betancourt, Kimberly Boller, Jill Popp, Elisa
Rachel Pisani Altafim, Orazio Attanasio & Chemba Raghavan (2022) The Future of Parenting
Programs: II Implementation, Parenting, 22:3, 235-257, DOI: 10.1080/15295192.2022.2086807

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PARENTING
2022, VOL. 22, NO. 3, 235–257
https://doi.org/10.1080/15295192.2022.2086807

REVIEW

The Future of Parenting Programs: II Implementation

Jennifer E. Lansford , Theresa S. Betancourt , Kimberly Boller , Jill Popp,
Elisa Rachel Pisani Altafim , Orazio Attanasio, and Chemba Raghavan

SYNOPSIS
This article examines the role that implementation science can
play in evidence-based parenting programs. Although parent­
ing programs can support parents in their caregiving roles,
adapting and taking an evidence-based approach from one
place to another without attending to implementation factors
may contribute to poor impact in a new setting.
Implementation science enables researchers to move beyond
monitoring and evaluation of outcomes of a parenting program
to understanding the process of putting the program into prac­
tice. Factors such as whether the program meets the needs of
families and communities, how to secure buy-in from key sta­
keholders, what training and supervision are needed for the
workforce, and ways that parenting programs can be integrated
in existing infrastructure are all critical to successful implemen­
tation. Quality improvement can be built into the implementa­
tion process through feedback loops that inform rapid changes
and testing cycles over time as a program is implemented. If
researchers lead initial implementation of parenting programs,
they must determine how the program can continue to work
when using community workers and local systems rather than
researchers. Open access components are especially important
for the implementation of parenting programs in low- and
middle-income countries to avoid prohibitive costs of proprie­
tary programs and to benefit from flexibility in adapting com­
ponents to meet the needs of particular local populations.
Parenting programs benefit when policy makers, program lea­
ders, and researchers attend not only to the what but also to the
how of implementation.

INTRODUCTION
Over the years there has been progress in understanding what parenting
programs work successfully to provide supports to parents in their caregiving
roles (Branco, Altafim, & Linhares, 2021/inpress; Jeong, Franchett, Ramos de
Oliveira, Rehmani, & Yousafzai, 2021). However, major gaps in knowledge
about how these parenting programs work has resulted in a failure to sustain
these programs with quality and at scale (Richter & Naicker, 2013). A critical
step isidentifying how different factors can enable or hinder the implementa­
tion process. Implementation science refers to the use of systematic data
collection and research methods to enhance the dissemination and sustain­

© 2022 The Author(s). Published with license by Taylor & Francis Group, LLC.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/
licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
236 LANSFORD ET AL.

ment of evidence-based practices into routine operations (Proctor &

Brownson, 2012). Support for the importance of implementation science is
evident in the healthcare industry where implementation research has been
used to increase the adoption and spread of evidence-based practices.
Additionally, the importance of implementation for early childhood develop­
ment programs has been documented, with calls for increased implementation
research aimed at improving services and outcomes for children and families
(Britto, Singh, Dua, Kaur, & Yousafzai, 2018). In a recent call to action as part
of an interagency vision, leading networks emphasized a coordinated global
effort to innovate, scale-up, generate evidence, and advocate for initiatives that
support parents and caregivers (https://covidaction.ecdan.org/parenting).
Additionally, the Early Childhood Development Action Network [ECDAN],
a network of organizations such as the Lego Foundation, UNICEF, and the
World Health Organization has called for global mobilization of resources to
support parents in their caregiving roles (ECDAN, 2021).
This article discusses how implementation science can be applied to evi­
dence-based parenting programs in community settings by considering ques­
tions such as: What considerations are needed for parenting programs’ large-
scale implementation to guarantee quality, fidelity, and sustainability? How
can researchers, practitioners, and policy makers work together to implement
parenting programs successfully? What are the benefits and challenges of these
relationships between researchers and implementers of programs and policies?
What strategies can help overcome implementation challenges, especially in
low- and middle-income countries (LMICs)?

PRINCIPLES OF IMPLEMENTATION SCIENCE RELATED TO PARENTING

PROGRAMS
Rigorous implementation science is often based on conceptual models that
characterize features of the external and internal implementation context.
Hybrid research designs have evolved to speed up the pipeline from interven­
tion development to large scale implementation, allowing simultaneous study
of implementation and effectiveness (Curran, Bauer, Mittman, Pyne, & Stetler,
2012). Mixed methods often are used, and outcomes may focus on stake­
holders at different levels of implementation, such as investigating outcomes at
the provider and agency leadership level (Proctor & Brownson, 2012).
Explicit strategies for improving implementation success may be tested,
including those focused on (1) moving national and sub-national policy into
local practice, (2) aligning national and sub-national policy goals with those of
local organizational leaders, and (3) motivating use of evidence-based prac­
tices. For example, high quality implementation requires that organizational
leaders have good relationships with policy makers to co-create strategic plans.
An implementation research project may explore an outcome such as buy-in
 PARENTING 237

from policy makers by comparing co-created implementation plans to a no-

treatment condition (see Design, article I and Uptake, article III).
Implementation science research on parenting programs may examine several
levels of the implementation ecosystem from the individual parent beneficiary
to the researcher andfront-line workers as well as supervisors, organizational/
agency leaders, and policy makers. At each level of the implementation
ecosystem, researchers and their partners can address implementation science
research questions that provide the most useful information necessary for
improving policies and programs for a given setting (see Figure 1).
Parenting programs can improve parenting outcomes (e.g., reducing
parent-to-child violence; Altafim & Linhares, 2016; Leijten et al., 2020).
However, to enable evidence-based strategies to have their intended
impact, lessons learned from implementation science in global health
and behavior change should be applied. Policy and financing alone do
not ensure high-quality implementation. Policy makers, program leaders,
and researchers must pay attention not only to what is being implemented
but also how it is implemented. For example, as part of a teacher training
evaluation, key questions include whether the evidence-based model’s
training requirements are achieved (number of teacher and supervisor
training hours, passing assessments and obtaining a credential, and
whether supervisors meet teachers with intended frequency). The devil
is in the details, and indicators like these determine whether an evidence-
based model was implemented as originally designed and tested, while
also allowing for flexibility and adaptation as needed without undermining
the core active ingredients.
Implementation science methods have shown early promise in devel­
oping and adapting global parenting programs (Baumann et al., 2015;
Lachman et al., 2016; Shenderovich et al., 2021). As the world emerges
from the COVID-19 pandemic lockdowns in 2020 and 2021 that inter­
rupted parenting and early childhood services, the field has an opportu­
nity to use implementation science methods more widely in comparing
service delivery options, such as returning to home visiting in person,
conducting “visits” virtually, or creating a hybrid of in-home and virtual
services as well as considering what elements are necessary for making
programs more resilient to system disruptions.
A refined implementation science of global parenting program delivery
would go beyond monitoring and evaluation to further elucidate key
factors in approach and lessons learned across a range of implementation
contexts and cultures. For instance, agency and individual staff “readiness
for change” or “stakeholder buy-in” for the use of evidence-based prac­
tices are two examples of critical policy constructs that could be examined
across a range of settings. Implementation science also contributes to
improving programs and policies by allowing researchers and agencies
 238
LANSFORD ET AL.

Figure 1. Adapted from Betancourt and Chambers (2016).

 PARENTING 239

to better assess what works for whom under what circumstances and the
mechanisms by which behavior change occurs when using evidence-based
programs, objectives that are held not just in implementation science but
also in realist evaluations (Pawson & Tilley, 1997). Additionally, develop­
ing parenting programs’ theory of change can help researchers and practi­
tioners to examine not just whether a program is effective, but also how,
why, and under what conditions a program does or does not work
(Center on the Developing Child, 2017; Schindler, Fisher, & Shonkoff,
2017).
Parenting programs require more research on strategies for quality
improvement and the sustainment of evidence-based practices. For exam­
ple, feedback loops where data are collected and applied immediately to
guide rapid improvements in service delivery can help to overcome
barriers as a program is scaled up and sustained. Particularly in LMICs
and when working with underserved or disenfranchised communities in
high-income countries, implementation of parenting programs should also
be closely tied to issues of social justice and equity, with attention to
power dynamics among the participants, service providers, and research­
ers (Baumann et al., 2019).
Globally, the impact of evidence-based programs on parenting has been
limited. One reason may be poor fit to context and lack of science-informed
systems for comparing one implementation strategy to another.
Unfortunately, there has been a tendency to adapt and then take an evidence-
based approach from one place to another without attending to situation-
specific factors that may reduce implementation quality and, ultimately, out­
comes. Quality improvement initiatives can be tested systematically (Arbour,
Mackrain, Fitzgerald, & Atwood, 2019). Implementation science in health care
has expanded greatly, driven by a demand for quality and efficiency in health
services. A potential solution to advance the fields of parenting and child
development is to apply lessons from implementation science in health to
global parenting policy, program development, and research. Systems sup­
ports for implementation may be more robust for parenting programs than for
some health interventions, because parenting programs can be situated not
just in the health sector but also in education, child protection, and others.
Implementation with experimentation at the core makes it possible to
course correct to improve quality of parenting programs over time. Good
implementation models not only build a community of practice but also test
a strategy for quality improvement and sustainment along the way, such as in
learning collaboratives or interagency collaborative teams. Parenting pro­
grams should attend to implementation process and outcome indicators at
the caregiver/parent level, the child level, the service provider level, and the
system level.
240 LANSFORD ET AL.

PRE-IMPLEMENTATION CONSIDERATIONS
Emerging issues in implementation science include the role of context in adapta­
tion and implementation, standardized reporting of implementation research, the
importance of feasibility studies to inform scale-up and capacity building, fidelity
and program quality improvement, and intervention integration into existing
systems (Britto et al., 2018). Four key pre-implementation considerations are
especially important.
First, translate evidence to understand contextual issues. It is critical to conduct
a needs assessment to enhance understanding of the evidence base. This assess­
ment will necessitate examining evidence on parenting programs through existing
platforms and sectors (e.g., child protection, education, healthcare) but also bring­
ing together evidence that may sit in multiple sectors (e.g., parenting support
needs of families of children with disabilities). Gathering data on parenting from
existing data sources such as the Multiple Indicator Cluster Survey (mics.unicef.
org) may be an important first step in understanding what parents are already
doing in a variety of settings. Such an analysis can identify where to build on an
existing and strong foundation, but can also highlight gaps (UNICEF, 2021a). For
example, in the implementation evaluation of the Lady Health Worker (LHW)
Program in Pakistan, which combined parenting support and nutrition programs,
the content and delivery strategy were designed based on formative research,
which included an analysis of the LHW program to identify gaps in programs that
could then be addressed to strengthen parenting outcomes (Yousafzai, Rasheed, &
Siyal, 2018).
Second, assess norms and existing practices in specific contexts to address
feasibility of proposed parenting programs. Parents and the environments in
which they live, work, study, and conduct relationships are greatly affected by
a range of personal, social, and political factors (Richter & Naicker, 2013). Key
questions to address in an assessment of norms and practices include the
following: Will this program address the problems and goals of the commu­
nity, region, or country? How can buy-in be encouraged at multiple levels
from the family to the agency or organization to the community and larger
policy and funding context? The use of a strengths-based approach, promotion
of gender-equitable norms, promotion of child and adolescent participation,
inclusion of all parents, and reliance on the existing knowledge base on
parenting are all important (Soenens, Vansteenkiste, & Nelson, 2019;
UNICEF, 2021). These considerations may be especially important for families
facing systemic and personal challenges and in the context of emergencies and
humanitarian crises (Parra-Cardona et al., 2021).
The issue of gender can be especially challenging, as the majority of
parenting programs target mothers, and it has been difficult for many pro­
grams to recruit fathers. Two examples illustrate implementation considera­
tions that may be helpful in expanding parenting programs to include fathers.
 PARENTING 241

First, after initially having a hard time reaching fathers, the Better Parenting
Program in Jordan shifted to a strategy that involved having imams deliver the
messages of the parenting program during Friday prayers, which was effective
because the fathers respected the imams and were already attending the prayer
services (Al-Hassan & Lansford, 2014). Second, the Parenting for
Respectability Program in Uganda was successful in recruiting and retaining
fathers, which the research team attributed to having the first 10 sessions of the
21-session program exclusively for fathers (before bringing mothers in for
joint sessions), to capitalize on fathers’ preexisting desires to improve their
children’s behaviors and, thereby, family respectability, and to using partici­
patory and interactive methods for delivering the program (Siu et al., 2017).
Parenting programs may implicitly reinforce gender stereotypes by assuming
that mothers will be the primary recipients and must often explicitly shift to
gender neutral approaches or activities to address gender stereotypes
(Morawska, Baker, & Johnston, 2021).
Third, assess capacities and readiness of systems and structures to deliver
parenting programs. It is important to plan on implementing programs that
will sharpen the skills and competencies of parents, but it is also important to
assess capacities and readiness of systems on the ground to deliver parenting
programs. Parenting programs are likely to succeed if they employ
a combination of approaches. Key approaches to consider while planning
implementation include strengthening enabling environments, supporting
strengthened workforce capacities and integrated services, raising levels of
awareness, promoting gender norms and socialization, empowering families
and communities, and encouraging participation (UNICEF, 2021).
A comprehensive assessment of system readiness will take into account
where a country or program stands in each of these approaches. Challenges
may be identified in any of these approaches. For example, governments may
not prioritize the goals embodied in parenting programs, or may lack the
resources to devote to supporting parenting programs even if they desire to do
so. Therefore, it is important to understand what barriers and resources exist
to address gaps in parenting support. Global resources that focus on concrete
strategies to build positive parent-child relationships and manage parenting
stress are critical to consider (Cluver et al., 2020).
Fourth, evaluate existing policies, laws, and enabling environments that
form the implementation ecosystem for an evidence-based parenting pro­
gram. The cultural, political, economic, and historical environments sur­
rounding parents have an impact on families’ functioning (Vélez-Agosto,
Soto-Crespo, Vizcarrondo-Oppenheimer, Vega-Molina, & García Coll,
2017). For societies and economies to thrive, countries and businesses need
to support parents through family-friendly policies, which help to balance and
benefit both work and family life and typically provide time, resources, and
services needed by parents (UNICEF, 2018). Family-friendly policies include
242 LANSFORD ET AL.

parental leave, breastfeeding support, affordable accessible quality childcare,

and child benefits. These policies impact parents in all contexts, including in
the informal economy, and in contexts where families face systemic and
personal challenges, including in emergencies and humanitarian crises.
Estimates of cost and return on investment for a given intervention as
implemented in a real-world setting are also important foci for implementa­
tion science. Research questions may examine whether costs can be reduced by
providing services remotely and in hybrid formats. Robust evidence demon­
strates the capacity to provide evidence-based parenting support through
remote delivery. For example, in the first 12 weeks of COVID-19 lockdowns,
collaboration among eight international organizations reached 57 million
families across 180 countries by providing open-access online parenting
resources (Perks & Cluver, 2020); after 16 months, these resources had reached
196.7 million people in 114 languages. These online resources included
recommendations for parents based on randomized controlled trials of par­
enting programs in LMICs on how to foster positive parent-child relation­
ships, how to manage children’s misbehaviors, and how to handle parental
stress. International volunteers translated the resources into 55 languages and
shared them through social media and other online platforms. One caution,
however, is that the use of online resources requires careful implementation, as
in some cases low-income families do not have internet access or data
packages that allow them to access the resources. Furthermore, additional
evaluation is needed to determine what proportion of parents utilize
a substantial portion of online content and whether desired outcomes are
obtained, as programs that are effective when delivered face-to-face may not
work the same way or be as effective online.
UNICEF’s (2021) program implementation work now involves a 9-step
process: 1) Conduct a needs assessment; 2) Identify the program’s target
population(s); 3) Build coalitions that will join in advocacy for an enabling
environment; 4) Agree on delivery platforms; 5) Identify the “parenting work­
force”; 6) Enhance demand generation; 7) Pilot, adapt, and implement; 8)
Ensure monitoring and evaluation; 9) Develop detailed plans for taking parent­
ing programs to scale. This 9-step process highlights that to understand imple­
mentation, it is essential to understand the context in which a program will be
implemented. Steps 7 and 8 form the crux of implementation science and can
take a great deal of time, especially when adaptations need to be manualized. In
working through these steps, central questions involve who is ultimately
responsible, who pays for this work, who ensures that conflicts are resolved,
and who decides what is needed to bring rigor to the application of implemen­
tation science in a given setting. These steps tend to be highly relationship-
focused and require time and energy on the part of many stakeholders. The
specific areas to prioritize in the implementation process will depend on local
challenges and resources. For example, if a strong enabling environment
 PARENTING 243

already exists with relevant stakeholders buying into the program, then prio­
rities can be diverted to other areas, such as enhancing parents’ demand for the
program by demonstrating how they can benefit from it. Additionally, in some
contexts, strong outreach to parents may already exist on key issues such as
immunization or vitamin supplementation, which may help elevate the need to
prioritize less-addressed issues such as stimulation or child safety.

WORKFORCE, TRAINING, AND LEADERSHIP

The workforce, training, and leadership of parenting programs are central to
high-quality implementation (Bonsu, Hatipoglu, Neuman, Putcha, & Roland,
2021; U.S. Department of Health and Human Services, 2019). An initial
question is who is delivering the program (e.g., community health workers,
nurse home visitors, village elders, teachers). Deciding who should deliver the
program is critical in whether implementation is feasible and can be cost-
effective. For example, having professionals deliver the program has the
advantage of having leadership from individuals who are already educated
with respect to at least some aspects of working with families but the dis­
advantage of being more expensive than using paraprofessionals or lay people,
and communities may not have enough professionals available to fully staff
a program. It may be possible to recruit young people as agents of change in
delivering parenting programs, which can provide a career path for young
people and be part of a fruitful enabling environment for the parenting
program. A population-based approach that reaches the entire community/
region/country, requires that parenting programs offer leaders and frontline
service providers training and support for program implementation
(Pickering & Sanders, 2016). Most evidence-based parenting programs have
well-established training to prepare the workforce who will deliver the pro­
grams, ensuring their quality and fidelity (Haslam, Mejia, Sanders, & de Vries,
2016). Staff training is an efficient way to offer knowledge, background infor­
mation, and opportunities to practice skills and receive feedback in a safe
training context (Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005).
Initial training is not enough. To ensure that the trained professionals
implement a program, organizations need to motivate program engagement
and provide high-quality supervision and a supportive climate, including
administrative support, agency buy-in, and financial support (Asgary-Eden
& Lee, 2012). Ongoing supervision, quality improvement, and accountability
are essential, with referrals to services outside of the parenting program as
necessary. Supervision contributes to the adherence of an evidence-based
parenting program integrated into community settings (Stern, Alaggia,
Watson, & Morton, 2008). Some essential supervision components include: 1)
continually and supportively emphasizing the relevance of maintaining fidelity
and highlighting the program’s core components; 2) providing concrete
244 LANSFORD ET AL.

resources to facilitate implementation as per the staff training and manual; 3)

maintaining a collaborative environment rather than a hierarchical one; 4) and
engaging in mutual problem solving (Stern et al., 2008).
If researchers lead initial implementation of parenting programs, they must
work with the community, policy leaders, and funders to determine how the
program will continue with staff from the community. Training professionals
who already work in settings that provide public services may ensure the
sustainability of the program when researchers and those they hire are no
longer involved in the program. Implementing parenting programs that can
sustain quality and fidelity while also expanding use and reach is a challenge
that may be resolved by offering incentives to the workforce and families while
fostering a shared culture of learning. Training, careful fidelity monitoring,
and staff supervision are necessary for implementing evidence-based inter­
ventions with quality and at scale (Martin, Steele, Lachman, & Gardner, 2021;
Roben, Dozier, Caron, & Bernard, 2017).
Involving the government and stakeholders from the beginning of the
research and implementation is one way to ensure scaling and sustainability
when researchers leave the field. For example, in Brazil, a researcher-led
randomized controlled trial showed that the ACT Raising Safe Kids Program
was efficacious for improving parenting practices (Altafim & Linhares, 2019).
After these positive findings, another research project focused on implementing
the program in a partnership between the university and the city hall of Pelotas,
with the program being implemented by municipality professionals (Murray
et al., 2019). These professionals (i.e., psychologists, social workers, and school
coordinators) were trained and supervised by the researchers, and were key
factors in maintaining the program, providing a path to long-term sustainabil­
ity. After the acceptance and positive evaluation of the program by the parti­
cipants (Martins et al., 2020), the city decided to incorporate the program into
existing services in the public system (Prefeitura Municipal de Pelotas, 2019).

DELIVERING SERVICES PARENTS NEED AND HOW THEY WANT TO RECEIVE

THEM
Parents, especially new parents, are often tired and too busy to think about the
services and supports they need and advocate to find and get them. A strong
and inclusive implementation analysis that looks at the individual programs
that are available, and the broader array of entry points parents can take to
access them, benefits policy makers, program operators, communities, par­
ents, and children. Implementation researchers can address questions about
how to determine what parents need as supports, how to make these supports
accessible, and gather data to inform who should be eligible for a program.
What parents want and need is sometimes aligned but sometimes not.
A challenge in implementing parenting programs can be persuading parents
 PARENTING 245

that they can benefit from the program. Sometimes there is resistance because
of inherent tensions between parents’ world views and what the research
evidence suggests. To address this tension, it may be important to engage
parents through strengthened community engagement and using a wide vari­
ety of modalities including digital, hybrid, or low tech modalities, such as the
radio (Kohrt et al., 2018; Yoshikawa et al., 2020). It is also important to bear in
mind that the research base itself often excludes underrepresented or margin­
alized communities so what the research evidence suggests as best practice
may not be so with a particular community or group of parents.
Program implementers must work closely with program developers, pro­
gram managers, communities, and parents to ensure that the essential ele­
ments of evidence-based programs are offered and received by parents. Too
often, programs designed by academics, government, or multi-lateral organi­
zations do not consider what parents want and need because the focus is on
achieving fidelity to the program (for example, weekly parent group socializa­
tion and mental health support activities aimed at improving the parent-child
relationship). The co-creation process of parenting programs involving
researchers, practitioners, and parents, and designing and testing within
existing programs, assure that the strategies are relevant in a real-world
context and have scaling potential (Schindler et al., 2017). By clarifying the
program’s theory of change, researchers and practitioners can work with
parents to prioritize maintaining a program’s core functions, even if the
form must be altered (Fletcher et al., 2016; Hawe, Shiell, & Riley, 2004). The
multiphase optimization strategy (MOST), which uses factorial experiments to
help establish which elements of an intervention are essential, may be espe­
cially useful in making sure that key functions of adapted programs are
maintained (Collins, Dziak, & Li, 2009). In implementation science, MOST
can help with scaling, adapting interventions to different contexts, and opti­
mizing implementation itself (Guastaferro & Collins, 2021).
Obtaining fidelity across all service requirements (number of service hours,
delivery by a fully trained service provider, duration of the program) happens
rarely, yet desired changes in parenting often occur (Wasik, Mattera, Lloyd, &
Boller, 2013). This does not mean that implementation researchers should
encourage program managers to abandon core fidelity goals when adapting
implementation as part of scale-up, but rather determine whether changes to
service delivery approaches that take parent needs into account increase pro­
gram engagement and ultimately improve outcomes of the program. A rapid
cycle of learning and continuous feedback evaluations facilitates modification of
strategies based on whom the strategy benefits (Schindler et al., 2017).
Successful implementation of parenting programs merits consideration of
risk and protective factors outside the scope of the program that can make
families fragile or resilient. For example, mental health issues, violence, and
substance use detract from positive parenting (Chassin, Hussong, Rothenberg,
246 LANSFORD ET AL.

& Sternberg, 2019; Letourneau, Dennis, Cosic, & Linder, 2017; Neppl, Diggs, &
Cleveland, 2020; Suchman, DeCoste, & Dias, 2019). Even if families are not
targeted for participation in a parenting program based on these factors, and
even if these risk factors are not explicitly addressed as part of the program,
programs need to leave space to address these needs.

PROGRAM FLEXIBILITY IN LOW- AND MIDDLE-INCOME COUNTRIES: OPEN

ACCESS, COSTS, AND IMPLEMENTATION SUPPORTS
Flexibility and adaptation are necessary and are supported by open access,
reasonable costs, technology, and technical supports. Open access compo­
nents are especially important for the implementation of parenting pro­
grams in LMICs. Proprietary programs are often cost prohibitive. For
example, although Triple P (Sanders & Mazzucchelli, 2018) and Nurse-
Family Partnership (Olds & Yost, 2020) have strong evidence bases docu­
menting their effectiveness, the components are available only at a steep
financial cost (for example, $8,000 per family for Nurse-Family Partnership)
(Zaveri, Burwick, & Maher, 2021). Direct comparisons between costs of
different parenting programs are complicated by several factors. For exam­
ple, some costs are fixed regardless of the number of families reached,
whereas other costs are dependent on the number of program participants.
Some costs are incurred only at start-up, whereas others are steady-state
costs that continue through the life of the program (Zaveri et al., 2021).
Some programs also include different modes, such as universal versus
targeted components, and costs vary as a function of which modes are
adopted. A comparison of costs to deliver seven home visit parenting
programs in Latin America and the Caribbean revealed a range of $110 to
$302 per participant (Leer, Boo, Expósito, & Powell, 2021). Thus, an impor­
tant implementation consideration is what the financial costs would be to
deliver a program as intended.
In part because of financial considerations, Triple P and Nurse-Family
Partnership are less commonly used in LMICs than programs that are open
access, such as Care for Child Development (CCD), Parenting for Lifelong
Health (PLH) (Lucas, Richter, & Daelmans, 2018; Ward et al., 2020), and
Reach Up based on the Jamaica Home Visit program (Grantham-McGregor &
Smith, 2016; Walker, Chang, Smith, & Baker-Henningham, 2018). CCD, for
example, has been integrated into existing health, education, child protection,
and other sectors in at least 19 LMICs with evidence for benefits to responsive
caregiving (Lucas et al., 2018).
PLH was designed with the explicit intention of making evidence-based
parenting programs available in LMICs that would not be able to afford
expensive proprietary programs (Parenting for Lifelong Health, 2021). PLH
training manuals, videos, and other materials are all available open access.
 PARENTING 247

Implementers are asked to complete straightforward evaluations and convey

feedback to the PLH developers to improve the program over time. This
process of continual feedback enables PLH to remain evidence driven in its
implementation. Reach Up is another example of an open access parenting
program designed to improve the ability of agencies implementing parenting
programs to deliver them effectively (Walker et al., 2018). An evaluation of
Reach Up in Brazil and Zimbabwe collected data from mothers, home visitors,
and supervisors on the program’s appropriateness, acceptability, and feasibil­
ity (Smith, Baker-Henningham, Brentani, Mugweni, & Walker, 2018).
Attention to challenges in implementation and modifications needed was
important to guiding efforts to expand the program beyond Jamaica, where
it was originally developed, to these new countries.
In addition to cost barriers, sometimes proprietary programs also lack the
flexibility of open access to adapt the components to meet the needs of local
populations. However, evaluation of the implementation of parenting pro­
grams should be planned from the outset of the program, with the flexibility to
make changes in implementation in response to barriers identified in the
evaluation. For example, the Pakistan Early Child Development Scale-Up
trial evaluated not just the effectiveness, but the implementation of the pro­
gram, including questions regarding the impact of the program on existing
services, time and demands on the workforce, donor commitment, commu­
nication among stakeholders, and other contributors to successes and failures
in implementation (Yousafzai et al., 2018).
Another example of moving beyond the initial RCT to implementation
science approaches comes from the work of the Sugira Muryango (SM)
program in Rwanda. The SM intervention, also called Family Strengthening
Intervention for ECD as it is being adapted in Sierra Leone (Desrosiers,
Schafer, Esliker, Jambai, & Betancourt, 2021), integrated Care for Child
Development content with a tested strengths-based and father-engaged
home visiting intervention that had been tested originally among HIV/AIDS
affected families (Betancourt et al., 2020; Jensen et al., 2021). SM is a 12-week
home-visiting parenting program to promote early childhood development
that uses active coaching by community-based lay workers to improve parent-
child interactions. To identify and reach vulnerable households with a child
under the age of 3 years, the intervention was integrated with the Rwandan
government’s Vision Umurenge Poverty Reduction Strategy (VUP) (Johnson,
Betancourt, Habyarimana, Asiimwe, & Murray, 2020). At present, the team is
working with the government and the University of Rwanda to test a strategy
to scale the intervention to all households eligible for the VUP with a child
under the age of 3 using a Collaborative Team Approach (CTA). The CTA
strategy is focused on transferring ownership of the program to Rwandan
stakeholders and comprises an expert Rwandan Seed Team for training and
supervision, cross-site learning across all three District teams, a common
248 LANSFORD ET AL.

charter committing all stakeholders to quality improvement along with the

scale up, and use of Plan-Do-Study-Act cycles (Leis & Shojania, 2017) to
identify barriers and enhance facilitators to delivery and sustainment of
evidence-based practices. In the Play Collaborative scale out study, the strategy
is focused on enhancing ownership and buy in for the program at all levels
from the national to district, sector, cell, and village, and the CTA implemen­
tation science research questions are focused on understanding issues of
burden, incentives, cost, and quality as the evidence-based practice is being
delivered by existing community child protection workers (Galler, 2021;
Johnson et al., 2020). A digital dashboard tool is also being developed to
make implementation quality data more readily available for government
leaders, community-level managers, and Seed Teams.
Evaluating the implementation process itself is one way to understand why
a particular program may succeed in one context but fail in another (Ridde,
Pérez, & Robert, 2020). Unlike efficacy and effectiveness trials that are con­
cerned with the outcomes in the intervention group versus a control group,
rapid cycle implementation studies test strategies designed to increase uptake
and sustainability of the intervention (Bauer & Kirchner, 2020). For example,
communication strategies focused on recruiting parents to participate in
a program can be tested in implementation evaluations and altered as needed
to facilitate program uptake. To take full advantage of the results of imple­
mentation studies, interventions must be flexible enough to adapt to overcome
implementation barriers. Implementation evaluations may also reveal areas
where not enough information exists on implementation systems and sup­
ports to indicate whether a particular approach is advisable, flagging an area in
need of additional data collection.
Both technology and technical supports are important for program devel­
opers, practitioners, and researchers in implementation. Technical supports
can include people and approaches to guide implementation. Technology,
which can incorporate data collection and analysis management information
systems, can be used by everyone involved in the implementation to stream­
line the process. Frontiers of Innovation (2021) at Harvard’s Center on the
Developing Child, for example, provides a data system for designing, testing,
and refining interventions with a community of learners who are committed
to accelerating innovation and adopting strategies to implement interventions
at scale. Likewise, Saving Brains (2021) through Grand Challenges Canada
connects innovators seeking to improve maternal and child health and devel­
opment in LMICs with funders, networks, and resources to advance imple­
mentation of novel interventions. These kinds of supports make it more
feasible to evaluate the implementation of parenting programs in different
contexts rather than merely applying an existing proprietary program in a new
context. These programs promote meetings including international research­
ers, innovators, and practitioners engaged in shared learning to accelerate
 PARENTING 249

innovation to impact at scale. Communities like these that work globally to

help teams acquire skills and knowledge are crucial to strengthen the inter­
ventions and implementation strategies that focus on families facing
adversities.

USES OF EXISTING INFRASTRUCTURE

The successful implementation of parenting programs needs to identify the
appropriate channels to reach and engage with parents in an authentic and
productive manner that improves adaptation and implementation of cur­
rent and future programs and policies. This process requires participation
and ownership in the communities where the parenting programs are
implemented. A potential avenue that could and in many contexts should
be used is to piggyback new parenting programs on existing delivery
systems (for example, physical health, education, social protection). Such
an approach might facilitate the implementation of effective interventions
while at the same time making them less expensive to establish and run.
Recruiting local implementation agencies and individuals can be key to the
success of the intervention. The existing infrastructure and social protection
programs do not necessarily need to be linked to parenting programs but
can be taken from other existing platforms that have successfully reached
people at scale.
Four evidence-based examples illustrate how parenting policy and pro­
gramming can be integrated into existing platforms. First, starting in the
mid-1990s, Conditional Cash Transfers (CCT) have become widespread social
protection programs in many contexts. An important aspect of these programs
is the fact that they often include requirements that families engage in specific
activities (such as participating in an educational program) as one of the
conditions to receive the cash. These activities are often coordinated by
participants who are elected by local communities. In the case of Mexico’s
PROGRESA CCT, these individuals are known as Promotoras, while in the
case of the Colombian Familias en Accion, they are known as Madres Lideres
(Andrew et al., 2018; Fernald et al., 2017). In both cases, these individuals
(usually women) serve as the point of contact between the program and the
participants, are strong leaders, and are widely recognized and respected in the
community. An important by-product of these CCTs, therefore, is the identi­
fication of agents in the community who convey important messages and serve
as a communication link to the intended participants in specific interventions.
Second, in the case of Colombia, a pilot intended to deliver the Reach Up
parenting program at scale hired the Madres Lideres as home visitors to deliver
the program, making the content of the program clearer to the potential
participants (Andrew et al., 2018).
250 LANSFORD ET AL.

Third, in India, a similar role is played by the Anganwadi Workers, who run
small community nurseries and are given a number of other tasks such as
disseminating information about health and nutrition as part of the national
Integrated Child Development Services (ICDS) program. These workers are
important for implementation success because they are known in and knowl­
edgeable about the community (Rao & Kaul, 2018). Fourth, in Colombia,
a similar role is played by the “community mothers” running the Hogares
Comunitarios, small community nurseries that are widespread and have been
in operation since the mid-1980s, with 69,000 women serving over a million
children and their families (Colombian Institute of Family Welfare, 2021).
As demonstrated by these examples, the use and involvement of local agents,
possibly already engaged in programs funded by government and other stake­
holders, may help to reduce the implementation costs of programs designed to
address other issues such as economic stability. Using existing programs facil­
itates the incorporation of training and ongoing supervision and quality
improvement structures. Parenting programs can be integrated with nutrition
and health interventions, as has been done with the Lively Minds intervention in
Ghana and Uganda (Attanasio et al., 2020). Measurement of the impact of new,
integrated programs is key, both for monitoring and evaluation. In this respect,
the use of existing infrastructure can facilitate the use of administrative data and
therefore make the availability of appropriate measures easier to achieve.

CONCLUSIONS
Implementation science provides a perspective on understanding how parenting
programs are put into practice in everyday settings, which can improve quality
and success, especially when attempting to transfer a program from one location
to another or scale the program beyond its original beneficiaries. Understanding
the needs of families and communities, securing buy-in from key stakeholders,
planning training and supervision of the workforce, and building a culture of
continual feedback and improvement are possible within frameworks that focus
not just on what programs are implement but how they are implemented. When
researchers work with policy makers, practitioners, and community members
from the outset, the implementation process and likelihood of sustainability
improve, with benefits extending to parents, children, and communities.x

AFFILIATIONS AND ADDRESSES

Jennifer E Lansford, Center for Child and Family Policy, Duke University, Box 90545, Durham,
NC 27708, USA, [email protected]. Theresa S Betancourt is at Boston College, Kimberly
Boller is at the Nicholson Foundation, Jill Popp is at the LEGO Foundation, Elisa Rachel Pisani
Altafim is at University of São Paulo, Orazio Attanasio is at Yale University, and Chemba
Raghavan is at UNICEF.
 PARENTING 251

ARTICLE INFORMATION

Conflict of Interest Disclosures

Each author signed a form for disclosure of potential conflicts of interest. No authors reported
any financial or other conflicts of interest in relation to the work described.

Ethical Principles
The authors affirm having followed professional ethical guidelines in preparing this work. This
ms. did not have any patient involvement or require ethics approval.

Funding
None.

Role of the Funders/Sponsors

None.

Acknowledgements
We thank UNICEF and the LEGO Foundation for generous support of the preparation of this
Special Issue on The Future of Parenting Programs. We acknowledge support in the prepara­
tion of this manuscript from Erica Wong, UNICEF. The ideas and opinions expressed herein
are those of the authors alone, and endorsement by the authors’ institutions or funding
agencies is not intended and should not be inferred.

ORCID
Jennifer E. Lansford http://orcid.org/0000-0003-1956-4917
Theresa S. Betancourt http://orcid.org/0000-0002-3683-4440
Kimberly Boller http://orcid.org/0000-0001-7213-6861
Elisa Rachel Pisani Altafim http://orcid.org/0000-0002-5732-0473

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