DOI: 10.1111/nyas.

15110

REVIEW

A meta-analytic review of the implementation characteristics

in parenting interventions to promote early child development

Marilyn N. Ahun1,2 Nazia Binte Ali2,# Elizabeth Hentschel2,3,#

Joshua Jeong2,4 Emily Franchett5 Aisha K. Yousafzai2

1
Department of Medicine, Faculty of Medicine
and Health Sciences, McGill University, Abstract
Montréal, Quebec, Canada
This review summarizes the implementation characteristics of parenting interven-
2
Department of Global Health and Population,
tions to promote early child development (ECD) outcomes from birth to 3 years.
Harvard T.H. Chan School of Public Health,
Boston, Massachusetts, USA We included 134 articles representing 123 parenting trials (PROSPERO record
3
Yale Child Study Center, Yale School of CRD42022285998). Studies were conducted across high-income (62%) and low-and-
Medicine, New Haven, Connecticut, USA
middle-income (38%) countries. The most frequently used interventions were Reach
4
Hubert Department of Global Health, Rollins
School of Public Health, Emory University, Up and Learn, Nurse Family Partnership, and Head Start. Half of the interventions were
Atlanta, Georgia, USA delivered as home visits. The other half used mixed settings and modalities (27%), clinic
5
Department of Applied Psychology, New York visits (12%), and community-based group sessions (11%). Due to the lack of data, we
University Steinhardt School of Culture,
Education, and Human Development, New were only able to test the moderating role of a few implementation characteristics in
York, New York, USA intervention impacts on parenting and cognitive outcomes (by country income level) in

Correspondence
the meta-analysis. None of the implementation characteristics moderated intervention
Marilyn N. Ahun, Department of Medicine, impacts on cognitive or parenting outcomes in low- and middle-income or high-income
Faculty of Medicine and Health Sciences,
McGill University, Montréal, QC, Canada.
countries. There is a significant need in the field of parenting interventions for ECD to
Email: [email protected] consistently collect and report data on key implementation characteristics. These data
are needed to advance our understanding of how parenting interventions are imple-
mented and how implementation factors impact outcomes to help inform the scale-up
of effective interventions to improve child development.

KEYWORDS
early child development, implementation, meta-analysis, parenting, systematic review

INTRODUCTION that 102 randomized controlled trials (RCTs) were implemented in

14 high-income countries (HICs) and 19 LMICs.2 Across a number
In 2007, a systematic review of parenting programs designed to pro- of reviews analyzing the effectiveness of parenting interventions on
mote early child development (ECD) outcomes reported six studies ECD outcomes, positive benefits on a range of child development
implemented in low- and middle-income countries (LMICs).1 In the outcomes and parenting knowledge and behaviors have been consis-
intervening years, there has been a substantial growth in research on tently reported.2–6 While evidence on the effectiveness of parenting
early parenting interventions globally, and a recent review reported interventions in improving child development has increased, far less
evidence is available on implementation characteristics, thus hinder-
ing efforts to replicate, adapt, and scale effective interventions or to
# These authors contributed equally to the manuscript.

This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any
medium, provided the original work is properly cited and is not used for commercial purposes.
© 2024 The Authors. Annals of the New York Academy of Sciences published by Wiley Periodicals LLC on behalf of The New York Academy of Sciences.

Ann NY Acad Sci. 2024;1533:99–144. wileyonlinelibrary.com/journal/nyas 99

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100 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

integrate these interventions within existing delivery platforms and of parenting interventions to improve child development have
systems.7 reported implementation evaluations from program development,
The goal of implementation research is to understand what, why, adaptation, and feasibility studies,18–21 efficacy studies and effec-
and how interventions work in real-world (i.e., outside of highly tiveness trials,22,23 and large-scale programs employing qualitative,
controlled experimental) settings.8 Characteristics pertaining to imple- quantitative, and mixed-methods approaches.24,25
mentation research include factors that influence implementation (e.g., Given the steady growth in reported implementation characteris-
community characteristics, collaboration and partnership, demand and tics and implementation evaluations, as well as increased global policy
ownership, policy levers), processes of implementation (e.g., theory and program momentum to promote ECD outcomes, it is timely to
of change, curriculum, behavior change techniques, cultural com- assess the current landscape of implementation research on parenting
petency, relevance to community priorities and needs, contextual- interventions designed to support child development. The objectives
ization of content and delivery, dosage, mode of delivery, delivery of this study are to conduct (1) a global systematic review of the
setting, training and supervision of delivery agents), and the cost reported implementation characteristics in parenting interventions to
of interventions.9,10 Data from implementation research can inform promote child development in the first 3 years of life and (2) a meta-
evidence-based decision-making on how to improve the effectiveness analysis to examine the moderating role of specific implementation
of interventions, adaptations, participation and engagement in pro- characteristics in intervention impacts on children’s cognitive devel-
grams, quality improvements, and capacity within systems to integrate opment outcomes and caregivers’ parenting practices. These findings
and sustain new interventions. For example, a policymaker may need to are intended to contribute to the development of recommendations
balance evidence and pragmatism when determining which early par- for future implementation evaluations and learning in the field that
enting program to roll-out, requiring evidence from implementation can facilitate informed decision-making about scaling early parenting
data such as the costs associated with different parenting programs, interventions.
identification of active ingredients (or common elements) of effective
parenting programs, or the gains and losses to be expected when modi-
fying dosage or modes of delivery. Data from implementation research METHODS
can also inform the replication of interventions in different contexts,
as well as facilitating the comparisons of interventions with similar This meta-analytic review builds on—and updates—a recent meta-
delivery approaches.11 analysis of parenting interventions to promote child development in
Reviews of parenting programs intended to promote child develop- the first 3 years of life.2 The primary aim of Jeong et al.’s meta-analysis
ment have identified some implementation characteristics associated was to quantify the pooled effectiveness of parenting interventions
with program effectiveness. For example, ECD benefits may be greater delivered during the first 3 years of life on ECD and parenting-related
in more disadvantaged settings or among more vulnerable children.2,12 outcomes.2 Additionally, the review also sought to explore whether
In addition to contextual features, common programmatic features effects on ECD and parenting outcomes differed by a selected set
found in effective parenting interventions (e.g., supportive supervision) of seven factors: country income level (HICs vs. LMICs), child age (<
have been qualitatively identified.13 Quantitatively, individual studies or ≥ 12 months), intervention content (whether or not the interven-
have focused on program characteristics such as delivery modality and tion included a responsive caregiving component), duration (< or ≥
age of infant at enrollment, with little evidence that these implementa- 12 months), delivery modality (individual vs. group vs. individual and
tion features are associated with program effectiveness in improving group), delivery setting (home vs. community vs. clinic vs. combination),
parent or child outcomes.2,14,15 Indeed, quantitative analysis of pro- and study quality (low vs. high risk of bias). The present review builds
gram characteristics associated with the engagement of families and on Jeong et al.’s work by including newly published articles and sum-
child and parent outcomes has often been restricted due to lim- marizing a more expansive set of 24 implementation characteristics
ited numbers of studies reporting implementation characteristics.16 reported across parenting interventions, as well as exploring the mod-
The few meta-analyses examining implementation characteristics have erating role of specific implementation characteristics hypothesized to
focused on intended dosage (i.e., duration2 and intensity4 ). Due to influence intervention impacts on child and caregiver outcomes.2,11,13
inadequate reporting of implementation characteristics in individual
studies and the lack of variability in the implementation features of
different interventions, it has been difficult to examine and draw con- Search strategy and selection criteria
clusions about their associations with ECD and parenting outcomes.3
Overall, these findings may lead us to hypothesize whether actual The present study adhered to the Preferred Reporting Items for Sys-
receipt and exposure of dose may be more important to test than the tematic Reviews and Meta-Analyses statement for standard reporting
report of intended dosage or whether the interaction of dosage with (PRISMA; see Table S1).26 This review was preregistered on the
other implementation characteristics (e.g., quality) matters. PROSPERO international prospective register of systematic reviews
In order to address this dearth of information, calls to improve (registration number CRD42022285998). See Table S2 for the final
implementation reporting and measurement of implementation review protocol used for the present study and notes regarding any
fidelity have been made.11,17 More recently, a growing number changes made from the initial prospectively registered protocol.
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ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 101

Jeong et al.’s review included articles identified through electronic read through the reference list of each identified article and searched
databases (MEDLINE, Embase, PsycINFO, CINAHL, Web of Science, the list of articles citing the identified article in Google Scholar to
and Global Health Library) searched from database inception until identify additional publications (e.g., working papers, publicly available
November 15, 2020, using a search strategy informed by search terms gray literature reports) reporting data on the same RCT of a given
and keywords used in prior systematic reviews related to parenting intervention. A thorough examination of each article’s supplementary
interventions2,3,4,27 and through consultations with a research librar- material was also conducted to ensure that all relevant information
ian. The present review used the same search strategy (Table S3) in the was extracted.
same six electronic databases to identify additional articles published
between November 15, 2020 and February 14, 2022. Details on the
search strategy and selection criteria are described in Jeong et al.2 and
Implementation characteristics
briefly summarized here.
The 24 implementation characteristics of interest encompassed data
Full-text, peer-reviewed articles were included if they met the fol-
about each intervention’s content (Nurturing Care Framework [NCF]
lowing criteria: (1) parenting interventions that aimed to improve
components [good health, adequate nutrition, responsive caregiving,
interactions, behaviors, knowledge, beliefs, attitudes, or practices of
security and safety, and opportunities for early learning];29 use of an
parents with their children in order to improve child development;
existing parenting intervention; use of a manual; theory of change
(2) evaluated using an RCT study design; (3) targeted children and
their parents during early childhood (pregnancy through the first 3 [i.e., use of a conceptual framework or formal testing of mediators

years of life); and (4) measured at least one ECD outcome after the of intervention impact]; and behavior change techniques), preparation

completion of the intervention (or shortly thereafter). Studies were (formative research and program adaptations), beneficiaries (nature of

excluded if they met any of the following criteria: (1) not a rele- intervention [universal vs. targeted]; primary beneficiaries; and inclu-
sion of additional caregivers), dosage (number, length, and frequency
vant parenting intervention focused on promoting child development;
of sessions and total number of contact hours), delivery modality (indi-
(2) nonrandomized study design (e.g., quasi-experimental studies); (3)
vidual, group, or some combination), delivery setting (home, clinic,
targeted a population of children who were, on average, older than
community, or some combination), intervention cost, and the char-
36 months; (4) targeted a population of children or parents who
acteristics (education and occupational status), training (length and
had a diagnosed illness or disability; and/or (5) did not measure at
frequency of refresher sessions), and supervision (frequency and edu-
least one ECD outcome. Parents were broadly defined as the legal
cation of supervisors) of delivery agents. In addition, we also extracted
guardian, biological parent, or adult caregiver responsible for the well-
data concerning whether an implementation evaluation (e.g., reach,
being of the child.28 Titles and abstracts of all identified articles were
fidelity, feasibility, acceptability) of each intervention had been con-
independently screened by two reviewers (J.J. and E.F.). If the title
ducted.
and abstract screening was insufficient for determining eligibility, the
The meta-analysis was conducted with those implementation
full-text article was reviewed for eligibility criteria. Any discrepan-
characteristics previously hypothesized to influence intervention
cies between the two reviewers regarding the eligibility of a study
impacts11,13 (Table 1): use of an existing parenting intervention cur-
were resolved through discussions among the reviewers, with input
riculum (yes/no), specification of an intervention theory of change
from another author (A.K.Y.) as needed until consensus was reached.
(yes/no), total number of NCF components addressed in intervention’s
For studies meeting the eligibility criteria, full-text articles were
curriculum, total number of behavior change techniques used, use
reviewed.
of direct caregiver engagement with their child—coupled with feed-
Data on implementation characteristics were extracted by M.N.A.,
N.B.A., and E.H. using a structured extraction form. The choice of back from delivery agent—as a behavior change technique (yes/no),

implementation characteristics to include in this review was guided use of demonstration or modeling of key behavior by delivery agent

by a previous review of implementation characteristics for integrated or a model caregiver as a behavior change technique (yes/no), use

nutrition and parenting interventions13 and the Consolidated Advice of social support from family members or from the community as a
behavior change technique (yes/no), nature of intervention, inclusion
on Reporting Early childhood development implementation research
of additional caregivers (yes/no), number of days of delivery agents’
(C.A.R.E.) guidelines.11 The structured extraction form was piloted
training, and frequency of supervision of delivery agents. Additionally,
with a small number of articles to ensure consistency and agreement
we built on Jeong et al.’s moderation analyses with intervention deliv-
across reviewers. Throughout the entire data extraction process, data
ery modality and setting by exploring the extent to which interactions
from a random subset of articles were independently extracted by
between intervention dosage (number, length, and frequency of ses-
two reviewers, and any issues were discussed and resolved during the
sions, total contact hours), delivery modality (individual, group, mixed),
weekly virtual team meetings. Any discrepancies between reviewers
and delivery setting (home, clinic, community, virtual, mixed) moder-
were resolved through discussions and consensus together with an
ated intervention impacts. The meta-analysis was conducted for HICs
additional reviewer (A.K.Y.). To ensure that all relevant information
and LMICs separately.2
on an intervention and how it was implemented was extracted, we
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102 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 1 Definitions of implementation characteristics.

Implementation
characteristic Operational definition Analytic definition
Existing parenting The curriculum of a given intervention is based on or Yes—indicates that an existing parenting intervention curriculum was
intervention informed by the curriculum and evidence generated used
curriculum from an existing parenting intervention.11 No—indicates that an existing parenting intervention curriculum was
not used
Intervention theory of The theory, conceptual model, framework, or proposed Yes—indicates that an intervention theory of change was clearly
change mediator(s) that explains how the intervention is specified
expected to prompt changes in target No—indicates that an intervention theory of change was not specified
behaviors/outcomes.11
Nurturing Care The inclusion of different Nurturing Care Framework <2—indicates that an intervention covered fewer than 2 (out of 7)
Framework components (i.e., good health, adequate nutrition, components
components responsive caregiving, security and safety, and ≥2—indicates that an intervention covered 2 or more (out of 7)
opportunities for early learning) in the intervention’s components
curriculum. This includes the two additional
categories of intervention content summarized in
this review: attachment and enabling caregiving.
Behavior change Techniques used to encourage behavior change in Total number of behavior change techniques used:
techniques caregivers. Examples include use of print or <3—indicates that an intervention used fewer than 3 (out of 8)
audio-visual media, provision or creation of prespecified behavior change techniques
play/reading materials, self-performance (i.e., ≥3—indicates that an intervention used 3 or more (out of 8)
caregivers directly engaging with their child and prespecified behavior change techniques
receiving feedback from delivery agent), Direct child engagement:
other-performance (i.e., caregivers observing Yes—indicates that an intervention used direct child engagement as a
delivery agent or another caregiver demonstrating behavior change technique
or modeling key behaviors), problem-solving, and No—indicates that an intervention did not use direct child engagement
social support.3 as a behavior change technique
Demonstration or modeling of key behavior:
Yes—indicates that an intervention used demonstration or modeling of a
key behavior as a behavior change technique
No—indicates that an intervention did not use demonstration or
modeling of a key behavior as a behavior change technique
Social support:
Yes—indicates that an intervention used social support (from family or
community members) as a behavior change technique
No—indicates that an intervention did not use social support (from
family or community members) as a behavior change technique
Intervention dosage The number, length, and frequency of sessions, as well Number of sessions: defined by the median split of the number of sessions
across delivery as the total contact hours of an intervention for each within each delivery modality and setting (lower half vs. upper half
modalities and of the following delivery modalities and settings: [including median])
settings individual home visits, individual clinic visits,
community-based group sessions, and sessions with Length (in minutes) of sessions: defined by the median length of sessions
mixed-delivery modalities and settings. within each delivery modality and setting (lower half vs. upper half
[including median])

Frequency of sessions: defined by the mode frequency of sessions versus

all other frequencies of sessions within each delivery modality and
setting

Total contact hours: defined by the median total number of contact hours
within each delivery modality and setting (lower half vs. upper half
[including median])
Nature of intervention The target population of the intervention. Universal—indicates that the intervention was open to all primary
caregivers and their target children
Targeted—indicates that the intervention was specifically aimed at a
predetermined subgroup of primary caregivers and their target
children
(Continues)
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ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 103

TA B L E 1 (Continued)

Implementation
characteristic Operational definition Analytic definition
Inclusion of additional Other caregivers of the target child were explicitly Yes—other caregiver(s) was invited or encouraged to participate in
caregivers invited, encouraged, or welcome to participate in intervention
some part of the intervention alongside the primary No—other caregiver(s) was not invited or encouraged to participate in
beneficiary. intervention
Delivery agents’ Length of time during which delivery agents received 7 days or less—delivery agents were trained for 7 days or less on how to
training training on how to deliver the parenting intervention. deliver the parenting intervention
More than 7 days—delivery agents were trained for more than 7 days on
how to deliver the parenting intervention
Delivery agents’ Frequency with which delivery agents had contact Weekly—delivery agents had weekly contacts with their supervisors
supervision with their supervisor to monitor their delivery of Less frequently than weekly (i.e., fortnightly, monthly, etc.)—delivery
the intervention. agents had less frequent (e.g., fortnightly, monthly) contacts with their
supervisors

Outcomes heterogeneity in the average effect by the prespecified implementa-

tion characteristics. For continuous moderator variables, we generated
For parsimony, we focused the meta-analysis on the most commonly binary variables based on median split (we used the mode vs. all
reported outcomes from Jeong et al.’s review2 : children’s cognitive other categories for the frequency of intervention sessions vari-
development and caregivers’ parenting practices. able) and compared effect estimates according to these subgroups.
Two-sided p < 0.05 indicated a significant difference between a mod-
erator’s subgroups based on the regression of meta-analytic estimates
Meta-analysis onto each moderator in a separate model. To examine publication
bias, we used Egger’s regression test to test the null hypothesis of
Effect sizes on children’s cognitive development and caregivers’ par- small-study bias (i.e., the extent to which less precise or smaller
enting practices outcomes were estimated as the standardized mean sample studies yield greater effects than larger sample studies).31
difference (SMD) between the intervention and comparison (e.g., no All analyses were conducted using the robumeta 2.032 package in R
intervention, nonparenting intervention, standard of care) arms with version 4.0.3.33
respect to difference in mean values at endline after standardiza-
tion by their pooled standard deviation (SD). In multi-arm studies, the
comparison group was typically the intervention arm without any par- RESULTS
enting components and/or the standard of care. In cases where the
intervention arms consisted of parenting interventions with different Study selection and inclusion
delivery modalities, data from both arms were retained. For studies
that reported outcomes from multiple follow-up waves of assessments, From the updated search in electronic databases, a total of 1163
outcome measurements from the time point closest to intervention unique articles were identified. One additional article was identified
completion were used for the analyses. The magnitude of effect sizes from article references and two articles were identified during this arti-
was interpreted in the context of public health, pediatric, and early cle’s revision process. Out of these 1166 articles, 1125 were excluded
education interventions and the practical significance with respect to based on title and abstract screening. The full texts of the remaining 41
outcomes.30 articles were reviewed, and 16 articles were excluded for not meeting
Each outcome was examined in a separate model. Robust variance the inclusion criteria. The final set of articles from the updated search
estimation meta-analysis was used to account for multiple measure- comprised 25 articles describing 23 unique RCTs. This meta-analytic
ments per trial per outcome. This approach allows for the inclusion of review, therefore, reports on the implementation characteristics of
any number of dependent effect size estimates from a given study to 125 unique RCTs as described in 136 articles (111 articles from Jeong
contribute to the pooled effect size estimate for an outcome, resulting et al. [2021] and 25 articles from this updated search) (Figure 1).
in increased power and more precise estimates. Pooled effect size esti- Below, we present a summary of the studies’ characteristics, a narrative
mates were based on random effects models. p-Values < 0.05 denoted review of how many articles reported each implementation character-
statistical significance. Heterogeneity of the pooled effect size was istic as well as the data they reported for the characteristics, and a
assessed using the I2 statistic. meta-analysis of the moderating effect of a subset of implementation
We conducted moderator analyses on both outcomes using ran- characteristics on children’s cognitive development and caregiver’s
dom effects meta-regression models to explore potential sources of parenting practices in LMICs and HICs.
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104 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

IDENTIFICATION
Records identified through Records identified through manual
database search: n = 1163 search and revision process: n = 3

Records screened: n = 1166

Records excluded based on

title and abstract screening:
SCREENING

n = 1125

Full-text articles assessed

for eligibility: n = 41
Full-text articles omitted according to
exclusion criteria:
-no child development outcome measured
-average child age is greater than 3 years
-compared a parenting intervention against
another parenting intervention
-clinically targeted population
-restricted to parenting engagement while
ELIGIBILITY

infant is in neonatal intensive care unit

(NICU), content not generalizable outside of
NICU stay
n = 16

Articles retained from

updated search: n = 25

Articles added from Jeong et

al. 2021 meta-analysis:
n = 111
INCLUDED

Articles included in
systematic review: n = 136

FIGURE 1 PRISMA flow diagram of search results and included studies.

Study characteristics series on ECD—which galvanized scientific interest in parenting inter-

ventions, particularly in LMICs—was published in 2007.1,34–36 We then
Tables 2 and 3 present a summary of the reported implementation present the results of a meta-analysis summarizing the moderating role
characteristics across parenting interventions in LMICs and HICs, of specific implementation characteristics in intervention impacts on
respectively. Trials were implemented across a total of 41 countries, children’s cognitive development and caregivers’ parenting practices
with most occurring in HICs (76 trials in 18 countries) compared to outcomes in LMICs and HICs.
LMICs (49 trials in 23 countries). The most represented countries were
the United States of America (USA; 45 trials), Bangladesh (9 trials),
Australia (6 trials), Jamaica (6 trials), India (5 trials), and the United Narrative synthesis of implementation characteristics
Kingdom (UK; 5 trials). Studies were published between 1974 and
2022. Below, we present a narrative synthesis of key implementation The proportion of studies reporting data on each implementation char-
characteristics across all studies and discuss differences by country acteristic is presented in Figure 2 and the summary of reported data is
income level (HICs vs. LMICs) and date of publication (1974–2007 in Table 4.
[n = 36 articles] vs. 2008–2022 [n = 89 articles]), as the first Lancet
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 105

TA B L E 2 Implementation characteristics of parenting interventions in low- and middle-income countries.

Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Abessa et al.,56 Opportunities Existing BCTs: 3 home visits Targeted; Mal- Nurses (Health 35-day Nonspecified Acceptability
Ethiopia for early curriculum Materials, (varied nourished sector; training supervision (results
learning Performance frequency) children intervention reported)
(self, other), and 9 was
Social 30-min implemented
support clinic visits as added
(family) visits)
Abimpaye Adequate Manual BCTs: 3.5 home Universal Community 3.5-day 2 visits in 17 Reach, fidelity,
et al.,57 nutrition; Materials, visits and volunteers; training weeks by and
Rwanda Good health; Media 17 90-min vocational community acceptability
Opportuni- (audiovisual, weekly education family
ties for early print), group facilitator
learning; Performance, sessions
Responsive Social
caregiving; support
Security and (family)
safety
Aboud and Adequate Existing ToC: Bandura’s 6 weekly Universal Community 4-day training Nonspecified Reach and
Akhter,58 nutrition; curriculum social- group volunteers; with manual supervision fidelity
Bangladesh Opportuni- (manual) cognitive sessions some (results
ties for early learning secondary reported)
learning; theory education
Responsive BCTs:
caregiving; Performance
Security and (self, other),
safety Problem-
solving,
Social
support
(community)
Aboud et al.,59 Adequate Existing ToC: Bandura’s 3 10-min Universal Social workers 2−4-day Varied Reach and
Bangladesh nutrition; curriculum social- home or and training frequency of fidelity
Good health; (manual) cognitive clinic visits community with 1−3 supervision (results
Opportuni- learning and 14 volunteers; bimonthly reported)
ties for early theory group some refresher
learning; BCTs: Media sessions secondary sessions
Responsive (print), (varied education
caregiving Performance frequency) (Health
(self, other), sector;
Problem- intervention
solving was
implemented
as part of
routine visits)
Alarcão Adequate Existing ToC: Formative 66 60-min Targeted; Nurses Nonspecified Weekly Reach (results
et al.60 ; nutrition; curriculum Attachment research— home visits Low-income (Health sector) training supervision reported)
Fatori Attachment; (manual) theory, pilot (varied families and by senior
et al.,61 Enabling Bandura’s frequency) adolescent nurse and
Brazil caregiving; theory of mothers child
Good health; self-efficacy, psychologist
Opportuni- and
ties for early Bioecological
learning theory
BCTs: Social
support
(family,
community)
Alvarenga Responsive Existing ToC: Observa- 8 60-min Targeted; Nonspecified 1.6-day Weekly
et al.,62 caregiving curriculum tional monthly Low-income intervention training supervision
Brazil (manual) learning home visits families facilitators; with manual by researcher
BCTs: some under- and weekly (graduate
Performance graduate refresher education)
(self, other) education sessions
(Continues)
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106 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Andrew Opportunities Existing BCTs: Program 60 60-min Targeted; Nonspecified 21-day Weekly Reach (results
et al.,63 for early curriculum Performance adaptation— weekly Living in intervention training supervision reported)
India learning; (Reach Up and (self, other) nonspecified home visits low-income facilitators; with 2- to
Responsive Learn; manual; adapta- neighbor- some 3-day
caregiving available) tion hood secondary refresher
education sessions
(train-the-
trainer
model)
Ara et al.,64 Adequate Manual (available) BCTs: 12 home Universal Community 10-day Quarterly Fidelity
Bangladesh nutrition; Materials, visits volunteers; training supervision
Opportuni- Performance (varied some with manual by senior
ties for early (other), frequency) secondary counselor
learning Problem- education (graduate
solving, social education)
support
(family)
Araujo et al.,65 Opportunities Existing BCTs: 156 60-min Targeted; Community 4-day training Fortnightly
Peru for early curriculum Materials, weekly Low-income volunteers; (train-the- supervision
learning (Reach Up and Media (print), home visits families some trainer (secondary
Learn; manual; Performance secondary model) education)
available) (self, other) education
Attanasio Adequate Existing ToC: Tested Program 78 weekly Targeted; Nonspecified 14- to 42-day Monthly Reach and
et al.,66 nutrition; curriculum parental adaptation— home visits Low-income intervention training supervision fidelity
Colombia Opportuni- (Reach Up and investment target families facilitators with manual by mentor (results
ties for early Learn; manual; as group and 1-week (undergradu- reported)
learning; available) mechanism (cultural refresher ate
Responsive of change adapta- sessions education)
caregiving BCTs: tion) every 1−2
Materials, months
Media (print), (train-the-
Performance trainer
(self, other), model)
other
technique(s)
Baumgartner Adequate Existing ToC: Cognitive- Program 7 monthly Universal Community 7-day training Weekly Reach and
et al.,67 nutrition; curriculum behavioral adaptation— home visits volunteers with one supervision acceptability
Ghana Attachment; (Integrated therapy and curriculum and 14 (mothers) refresher by nurse (results
Enabling Mothers and attachment (content 60-min session reported)
caregiving; Babies Course; theory modifica- fortnightly (train-the-
Good health; manual; BCTs: Social tion) group trainer
Opportuni- available) support sessions model)
ties for early (family)
learning
Betancourt Adequate Existing ToC: Study- Formative 14 75-min Targeted; Community 21-day Weekly Fidelity
et al.68 ; nutrition; curriculum specific research— weekly Low-income volunteers training supervision
Jensen Good health; (Sugira theory of pilot home visits families with manual
et al.,40 Opportuni- Muryango; change Program (train-the-
Rwanda ties for early manual) model adaptation— trainer
learning; BCTs: curriculum model)
Responsive Performance (content
caregiving; (self), Social modifica-
Security and support tion) and
safety (family, target
community) group
(nonspec-
ified
adapta-
tion)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 107

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Brentani Opportunities Existing BCTs: Formative Biweekly Universal Community 10-day Weekly Fidelity and
et al.,69 for early curriculum Materials, research— home visits health training supervision acceptability
Brazil learning; (Reach Up and Performance pilot workers and with one by nurse and (results
Responsive Learn; manual; (other), Program nonspecified refresher child reported)
caregiving available) Problem- adaptation— intervention session development
solving, social target facilitators aide
support group (Health sector; supervisor
(family) (cultural intervention (secondary
adapta- was education)
tion) implemented
as part of
routine visits)
Chang et al.,70 Opportunities Existing BCTs: 5 25-min Universal Nurses and 3-day training Varied Reach and
Jamaica, for early curriculum Materials, clinic visits community with manual frequency of fidelity
Antigua, St. learning; (manual) Media (varied health supervision (results
Lucia Responsive (audiovisual, frequency) workers; reported)
caregiving print), some under-
Performance graduate
(self, other) education
(Health
sector)
Cooper Attachment; Existing Formative 16 60-min Universal Community 56-day Weekly Reach (results
et al.71 ; Enabling curriculum (The research— home visits volunteers; training supervision reported)
Murray caregiving; Social Baby; pilot (varied some primary with manual by community
et al.,72 Responsive manual) Program frequency) education clinical
South Africa caregiving adaptation— psychologist
curriculum (graduate
(content education)
modifica-
tion)
Dowdall Opportunities Existing ToC: Tested 11 75-min Universal Nonspecified 2-day training Weekly Reach (results
et al.,73 for early curriculum caregiver weekly intervention supervision reported)
South Africa learning; (manual) practices as group facilitators; by study
Responsive mechanisms sessions some author
caregiving of change secondary
BCTs: education
Materials,
Media
(audiovisual,
print),
Performance
(self, other)
Fernald Adequate Existing ToC: Study- 62 120-min Targeted; Nonspecified 14-day Supervision by
et al.74 ; nutrition; curriculum specific weekly Low-income intervention training program
Knauer Good health; (Educación theory of group families facilitators; with manual coordinator
et al.,75 Opportuni- Inicial [EI] change sessions some and annual
Mexico ties for early Program; model secondary refresher
learning; manual; BCTs: Media education sessions
Responsive available) (print),
caregiving Performance
(self, other),
Problem-
solving,
Social
support
(family)
Frongillo Adequate Existing BCTs: Media Formative 13 home Universal Community 3-day training Monthly Reach (results
et al.,76 nutrition; curriculum (audiovisual, research— visits health with supervision reported)
Bangladesh Good health; (manual; print), survey, (varied workers manual and by program
Responsive available) Performance in-depth frequency) (Health sector) quarterly organizers
caregiving (other), inter- refresher
Problem- views, sessions
solving, and focus
Social group
support discus-
(family, sions
community),
other
technique(s)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
108 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Galasso Adequate Existing ToC: Integrated Program 48 Universal Community Nonspecified Fidelity
et al.,77 nutrition; curriculum behavioral adaptation— fortnightly health training
Madagascar Good health; (Reach Up and model target home visits workers with
Opportuni- Learn; manual; BCTs: group bi-annual
ties for early available) Materials, (cultural refresher
learning; Media (print), adapta- sessions
Responsive Problem- tion)
caregiving solving
Gardner Adequate Existing BCTs: 24 30-min Targeted; Mal- Community Reach (results
et al.,78 nutrition; curriculum Materials, weekly nourished health reported)
Jamaica Opportuni- Media (print) home visits children workers;
ties for early some
learning; secondary
Responsive education
caregiving
Grantham- Adequate Existing BCTs: Materials 64 60-min Targeted; Mal- Community Varied
McGregor nutrition; curriculum weekly nourished health frequency of
et al.,79 Opportuni- home visits children workers supervision
Jamaica ties for early
learning
Grantham- Adequate Existing BCTs: Program Intervention Universal Nonspecified 21-day Weekly Reach (results
McGregor nutrition; curriculum Materials, adaptation— arm 1: 72 intervention training supervision reported)
et al.,14 Good health; (Reach Up and Performance curriculum 100-min facilitators; with manual by mentors
India Opportuni- Learn; manual; (self, other), (transla- weekly some under- and non- (some under-
ties for early available) Social tion of home visits graduate specified graduate
learning; support materi- Intervention education refresher education)
Responsive (community) als) and arm 2: 72 sessions
caregiving target 130-min (train-the-
group weekly trainer
(cultural group model)
adapta- sessions
tion)
Hamadani Adequate Existing BCTs: Program 86 home Targeted; Mal- Nonspecified 14-day Weekly Reach (results
et al.,80 nutrition; curriculum Materials, adaptation— visits nourished intervention training supervision reported)
Bangladesh Good health; (Jamaica Home Performance target (varied children facilitators
Opportuni- Visiting (other) group frequency)
ties for early Program; (cultural and 33.5
learning; manual) adapta- group
Responsive tion) sessions
caregiving (varied
frequency)
Hamadani Opportunities Existing BCTs: Formative 25 50-min Targeted; Mal- Community 10-day Fortnightly Fidelity and
et al.,81 for early curriculum Materials, research— fortnightly nourished health training supervision feasibility
Bangladesh learning; (Reach Up and Performance pilot clinic visits children workers and with manual by (results
Responsive Learn; manual; (self, other) Program social and non- nonspecified reported)
caregiving available) adaptation— workers; specified supervisors
target some refresher (graduate
group secondary sessions education)
(cultural education
adapta- (Health sector;
tion) intervention
was
implemented
as added
visits)
Hartinger Opportunities Existing BCTs: Materials Program 17 45-min Universal Nonspecified 1-day training
et al.,82 Peru for early curriculum adaptation— home visits intervention
learning; (Peru Wawa delivery held every facilitators;
Responsive Wasi National (nonspec- 3 weeks some under-
caregiving Program) ified graduate
changes education
to inter- (Education
vention sector)
delivery)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 109

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Helmizar Adequate Manual BCTs: Formative Weekly home Universal Community 2-day training Supervision by Fidelity
et al.,83 nutrition; Materials, research— visits and health with manual researchers
Indonesia Opportuni- Performance pilot 24 60-min workers and
ties for early (self), Social weekly (Education fieldworkers
learning; support group sector)
Responsive (family) sessions
caregiving
Jin et al.,84 Opportunities Existing BCTs: Media Program 2 45-min Universal Health Nonspecified
China for early curriculum (print), adaptation— home visits professionals training
learning (Care for Child Performance target held every with manual
Development; (self, other), group 6 months
manual) Problem- (cultural
solving adapta-
tion)
Khan et al.,85 Adequate Existing ToC: Formative 4 10-min Targeted; Nonspecified Nonspecified Implementation
Pakistan nutrition; curriculum Theoretical research— clinic visits Low-income intervention training evaluation
Enabling (manual) domains focus held every families facilitators; with manual described in
caregiving; framework group 3 months secondary study
Opportuni- BCTs: Materials discus- education protocol.
ties for early sions (Health sector; Results have
learning Program intervention not yet been
adaptation— was published
target implemented
group as part of
(cultural routine visits)
adapta-
tion)
Luo et al.,86 Adequate Existing ToC: Tested 24 Universal Community 7-day training Supervision Reach and
China nutrition; curriculum caregiver fortnightly health with manual every 3 fidelity
Good health; (manual) practices as home visits workers (train-the- months by (results
Opportuni- mechanisms trainer official from reported for
ties for early of change model) National reach only)
learning BCTs: Health
Materials, Commission
Media (print),
Performance
(other), Social
support
(family),
other
technique(s)
Luoto et al.,41 Adequate Existing ToC: Study- Formative Intervention Universal Community 16-day Weekly Reach and
Kenya nutrition; curriculum specific research— arm 1: 4 health training supervision fidelity
Enabling (Singla et al. theory of pilot 60-min workers; with by SWAP (results
caregiving; 2015 and change Program fortnightly secondary monthly (NGO) staff reported).
Good health; Yousafzai et al. model adaptation— home visits education refresher Published
Opportuni- 2014 curricula; BCTs: curriculum and 12 (Health sector) sessions separate
ties for early manual; Materials, (content 90-min (train-the- implementa-
learning; available) Media (print), modifica- fortnightly trainer tion
Responsive Performance tion) group model) evaluation
caregiving (self, other), sessions paper(s)
Problem- Intervention
solving, arm 2: 16
Social 90-min
support fortnightly
(family, group
community), sessions
other
technique(s)
Muhoozi Adequate Existing BCTs: 3 420-min Targeted; Nonspecified Nonspecified Supervision of Reach (results
et al.87 ; nutrition; curriculum Materials, group Low-income intervention training every session reported)
Atukunda Good health; (manual; Performance sessions families and facilitators; by study
et al.,88 Opportuni- available) (self, other) (varied children at undergradu- author
Uganda ties for early frequency) risk of ate (graduate
learning stunting education education)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
110 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Nahar et al.89 ; Adequate Existing BCTs: 60-min clinic Targeted; Nonspecified Nonspecified Reach (results
Nahar nutrition; curriculum Materials, visits Low-income intervention training reported)
et al.90 ; Opportuni- (Reach Up and Performance (varied families and facilitators;
Nahar ties for early Learn; manual; (other) number malnour- some
et al.,91 learning available) and ished secondary
Bangladesh frequency) children education
recovering
from acute
infection
Nair et al.,92 Opportunities Existing Formative Home visits Targeted; Occupational Supervision by Fidelity
India for early curriculum research— and clinic Nonspecific therapists study author
learning (manual; pilot visits at-risk (graduate
available) families education)
Pitchik et al.,42 Adequate Existing ToC: Cognitive- Formative Intervention Universal Community 8-day training Fortnightly Reach, fidelity,
Bangladesh nutrition; curriculum behavioral research— arm 1: 9 health with nine supervision and
Enabling (Reach Up and therapy, pilot, 22.5-min workers; refresher acceptability
caregiving; Learn, Thinking behavioral in-depth monthly secondary sessions (results
Good health; Healthy, and activation, inter- home visits education reported).
Opportuni- WASH-Benefits and health- views, and 9 Published
ties for early Intervention; behavior and focus 52.5-min (Health sector) separate
learning; manual) theories group monthly implementa-
Responsive discus- group tion
caregiving; BCTs: sions sessions evaluation
Safety and Materials, paper(s)
security Media (print), Program Intervention
Performance adaptation— arm 2: 18
(self, other), curriculum 52.5-min
Problem- (content fortnightly
solving, modifica- group
Social tion) and sessions
support delivery
(family, (nonspec-
community) ified
changes
to inter-
vention
delivery)
Powell and Adequate Existing BCTs: 60-min Targeted; Community 56-day Weekly Fidelity
Grantham- nutrition; curriculum Materials, fortnightly Socially health training supervision
McGregor,51 Good health; (Jamaica Home Performance home visits vulnerable workers; by nurse
Jamaica Opportuni- Visiting (self, other) families some
ties for early Program; secondary
learning; manual) education
Responsive
caregiving Health sector;
intervention
was
implemented
as part of
routine visits
and
monitoring
indicators
were
integrated
into service
Powell et al.93 ; Adequate Existing BCTs: Program 50 30-min Targeted; Mal- Community 14-day Fortnightly Reach and
Baker- nutrition; curriculum Materials, adaptation— weekly nourished health training supervision fidelity
Hanningham Good health; (Jamaica Home Performance curriculum home visits children workers; (results
et al.,94 Opportuni- Visiting (other), Social (content some reported for
Jamaica ties for early Program; support modifica- secondary reach only)
learning; manual) (family) tion) education
Responsive
caregiving
(Continues)
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ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 111

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Health sector;
intervention
was
implemented
as part of
routine visits
and
monitoring
indicators
were
integrated
into service
Premand and Adequate Manual BCTs: Media 18 home Targeted; Nonspecified 14-day Nonspecified Reach (results
Barry,95 nutrition; (AV), visits and Low-income intervention training supervision reported)
Niger Attachment; Performance 54 group families facilitators
Good health; (other), Social sessions all
Opportuni- support held
ties for early (community) monthly
learning;
Safety and
security
Rockers Adequate Existing BCTs: Program 23 Universal Nonspecified 5-day training Reach (results
et al.,96 nutrition; curriculum Performance adaptation— fortnightly intervention with manual reported)
Zambia Enabling (Care for Child (self) nonspecified home visits facilitators; (train-the-
caregiving; Development adapta- and 20 some trainer
Good health; and the tion fortnightly secondary model)
Opportuni- Essential group education
ties for early Package from sessions
learning Care
International;
manual;
available)
Shi et al.,97 Adequate Existing BCTs: Media Program 2 120-min Universal Nonspecified Nonspecified Nonspecified Reach (results
China nutrition; curriculum (print) adaptation— clinic visits intervention training supervision reported)
Opportuni- nonspecified held every facilitators
ties for early adapta- 4 months
learning tion
Singla et al.,98 Adequate Existing ToC: Bandura’s Formative 1.5 45-min Universal Community 14-day Weekly or Fidelity and
Uganda nutrition; curriculum social- research— home visits volunteers; training fortnightly acceptability
Good health; (manual; cognitive feedback and 13 some with manual supervision (results
Enabling available) learning on 75-min secondary by Plan reported).
caregiving; theory program fortnightly education Uganda staff Published
Opportuni- BCTs: Media develop- group (undergradu- separate
ties for early (print), ment sessions ate implementa-
learning; Performance education) tion
Responsive (self, other), evaluation
caregiving; Problem- paper(s)
Security and solving,
safety Social
support
(family,
community),
other
technique(s)
Sudfeld Adequate Existing BCTs: Program 35-min home Universal Community 7-day training Fortnightly Reach, fidelity,
et al.,99 nutrition; curriculum Performance adaptation— visits held health with manual supervision and
Tanzania Good health; (Care for Child (self), curriculum every 4−6 workers; and one by field acceptability
Opportuni- Development; Problem- (content weeks secondary refresher coordinator (results
ties for early manual) solving, modifica- education session (undergradu- reported)
learning; Social tion) and (Health sector; ate
Responsive support target intervention education)
caregiving (family) group was
(cultural implemented
adapta- as added
tion) visits)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
112 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Tofail et al.,100 Adequate Existing BCTs: Program 35.5 weekly Universal Nonspecified 21-day Reach and
Bangladesh nutrition; curriculum Materials, adaptation— home visits intervention training fidelity
Opportuni- (Reach Up and Performance target facilitators; with manual (results
ties for early Learn; manual; (other) group secondary reported for
learning; available) (cultural education reach only)
Responsive adapta-
caregiving tion)
Valades Attachment; Existing ToC: Study- Program 16 60-min Targeted; Nonspecified 7-day training Monthly
et al.,101 El Enabling curriculum specific adaptation— home visits Adolescent intervention (train-the- supervision
Salvador caregiving; (Thula Sana; theory of curriculum (varied mothers facilitators; trainer by local
Responsive manual; change (content frequency) secondary model) coordinator
caregiving available) model modifica- education and senior
BCTs: tion) (Health sector) manager from
Performance local
(self, other), implementing
Social partner
support
(family)
Vally et al.102 ; Opportunities Existing BCTs: Formative 8 90-min Targeted; Nonspecified Weekly Reach (results
Murray for early curriculum Materials, research— weekly Socially training supervision reported)
et al.,103 learning; (manual; Media pilot group vulnerable
South Africa Responsive available) (audiovisual), Program sessions families
caregiving Performance adaptation—
(self, other), nonspecified
Social adapta-
support tion
(family)
Vazir et al.,104 Adequate Existing ToC: Bandura’s Formative 30 home Universal Community 7-day training Supervision by Reach and
India nutrition; curriculum social- research— visits volunteers; with nutrition fidelity
Opportuni- cognitive in-depth (varied secondary refresher graduates (results
ties for early learning inter- frequency) education sessions (undergradu- reported for
learning; theory BCTs: views and every 3 ate reach only)
Responsive Materials, focus months education)
caregiving Media (print), group
Performance discus-
(other), sions
Problem-
solving,
Social
support
(family)
Waber Adequate Existing BCTs: Program Home visits Targeted; Mal- Nonspecified Nonspecified
et al.,105 nutrition; curriculum Performance adaptation— nourished intervention training
Colombia Opportuni- (Infant (other) nonspecified children facilitators
ties for early Education adapta-
learning; Curriculum of tion
Responsive the HIgh Scope
caregiving Foundation)
Walker Adequate Manual (available) BCTs: 76 45-min Targeted; Low Community 14-day Weekly
et al.,106 nutrition; Materials, weekly birthweight health training supervision
Jamaica Good health; Performance home visits children workers; with manual
Opportuni- (self, other) secondary
ties for early education
learning; (Health sector)
Responsive
caregiving
Wallander Opportunities Existing BCTs: Formative 18 37.5-min Targeted; Nonspecified 5-day training Nonspecified
et al.,107 for early curriculum Materials, research— fortnightly Children at intervention with manual supervision
India, learning; (Partners for Performance pilot home visits risk of devel- facilitators and one
Pakistan, Responsive Learning; (other), Social Program opmental refresher
and Zambia caregiving manual; support adaptation— delay session
available) (family) delivery (train-the-
(nonspec- trainer
ified model)
changes
to inter-
vention
delivery)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 113

TA B L E 2 (Continued)
Theory of Delivery
Characteristics of change (ToC) agents’
parenting and behavior Type of characteristics
Nurturing Care curriculum or change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Yousafzai Adequate Existing ToC: Homan’s Formative 24 20.5-min Universal Community 2- to 5-day Fortnightly Reach, fidelity,
et al.38 ; nutrition; curriculum interaction research— monthly health training supervision and
Yousafzai Good health; (Care for Child theory, family job home visits workers; with manual by early acceptability
et al.,108 Opportuni- Development; systems analysis and 24 some and 1-day childhood (results
Pakistan ties for early manual) theory, and Program 80-min secondary refresher development reported).
learning; Bandura’s adaptation— monthly education sessions facilitators Published
Responsive social- curriculum group (Health sector) every 6 (undergradu- separate
caregiving; cognitive (content sessions months ate implementa-
Security and learning modifica- education) tion
safety theory BCTs: tion) evaluation
Materials, paper(s)
Performance
(self),
Problem-
solving,
Social
support
(family,
community)

Note: Missing information (i.e., empty or partially completed cells) indicates that data were not clearly reported.
a We included two constructs relevant to nurturing care which are not included in the Nurturing Care Framework: attachment and enabling caregiving (i.e., interventions that directly targeted

caregivers’ mental health and psychosocial well-being).

b Characteristics of parenting curriculum or manual include: “Existing curriculum” indicates that the curriculum of a given intervention is based on the curriculum and evidence generated from an

existing parenting intervention. The name of the specific intervention (as indicated in the published article) is also listed. “Manual” indicates that a manual detailing the content of intervention
sessions was used either to train delivery agents or to guide their implementation of each session or both. “Available” indicates that the manual detailing a given intervention’s curriculum is included
in the article’s supplementary material, made available on a website whose link is provided in the article, or reported as being available upon reasonable request to the article’s author(s).
c Behavior change techniques refer to the strategies used by the intervention/service to facilitate behavior change in caregivers. We used the categories specified in Briscoe and Aboud46 and Aboud

and Yousafzai3 : “materials” = provision of materials such as books or play objects; “media (audiovisual)” = use of media such as radio/audio or TV/video to convey messages; “media (print)” = use of
print media such as pamphlets, posters, flipcharts to convey messages; “performance (other)” = use of demonstrations by delivery agents or another caregiver to model a behavior; “performance
(self)” = caregiver themselves practicing with their child and getting feedback or coaching; “problem-solving” = identification of barriers and facilitators to behavior change and solutions to over-
coming barriers; “social support (family)” = leveraging caregivers’ relationship with family members as a source of support to facilitate behavior change; “social support (community)” = leveraging
caregivers’ relationship with community members and resources as a source of support to facilitate behavior change; “other technique(s)” = other behavior change techniques described by authors
that do not fall into any of the aforementioned categories.
d Intervention preparation refers to research activities that aim to determine how best to fit aspects of program design, content, and implementation to the environmental and cultural contexts, as

well as the needs of program beneficiaries (i.e., formative research) and any changes made to an intervention’s curriculum, delivery, or other implementation characteristics to make it more suitable
for a specific target group or context (i.e., program adaptations). Formative research is categorized according to the type of research method that was used (feedback on program development,
focus group discussions, in-depth interviews, job analysis, pilot, survey). Program adaptation is categorized according to the component of an intervention (curriculum, delivery, target group) that
was adapted, and the specific adaptation made if specified by authors.

Intervention content ponents. Some interventions also included content that did not fit
into any of the NCF components, so we created two additional cate-
Across HICs and LMICs, over 70% of studies reported data on interven- gories: enabling caregiving (i.e., interventions that support the mental
tion content, including the NCF components addressed, whether the health, psychosocial, or educational/financial well-being of caregivers)
intervention curriculum was based on an existing parenting interven- and attachment (i.e., interventions based on attachment theory). Only
tion and detailed in a manual, and the behavior change techniques used 16–17% of interventions included content addressing either of these
to encourage changes in caregivers’ interactions, behaviors, knowl- new categories. Overall, interventions ranged from including one to six
edge, beliefs, attitudes, or practices to promote child development. components, with a median of one component, the provision of early
This proportion was lower in studies published up to 2007 (64%) rela- learning opportunities. The most frequent combination was opportu-
tive to those published more recently (>85%) and higher among those nities for early learning and responsive caregiving. The majority of
from LMICs (>80%). However, only half of all studies reported the studies (94%) reported using an existing parenting intervention cur-
intervention’s theory of change, conceptual framework, or proposed riculum. The most frequently reported intervention was the Reach Up
mediators (defined as a conceptual model that clearly maps out how, and Learn/Jamaica Home Visiting program (n = 13), followed by the
why, and under what circumstances an intervention’s components lead Nurse Family Partnership (n = 4) and Head Start (n = 4) programs.
to change in a particular outcome), ranging from 37% (studies from Fifty percent of studies reported using an underlying theory of
LMICs) to 58% (studies from HICs) across subgroups. change. The most commonly reported theory of change models were
Overall, the most frequently included NCF component was oppor- Bandura’s social–cognitive learning and self-efficacy theories, fam-
tunities for early learning, with 78% of interventions including an early ily systems theory, and Bowlby’s theory of human attachment. The
learning component (n = 98). A total of 64 interventions, or 51% of social–cognitive learning and self-efficacy theories emphasize obser-
interventions, included both responsive care and early learning com- vational learning within the social context, while attachment-based
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
114 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 3 Implementation characteristics of parenting interventions in high-income countries.

Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Anzman- Adequate Existing BCTs: Media 4 home visits Universal Nurses; some Reach and
Frasca nutrition; curriculum (audiovisual, (varied undergradu- acceptability
et al.,109 Good health; (manual) print) frequency) ate (results
USA Opportuni- Performance and 3 clinic education reported)
ties for early (other), visits
learning; Problem-
Responsive solving, other
caregiving technique(s)
Barlow Responsive Existing ToC: Family 72 weekly Targeted; Nonspecified Nonspecified Nonspecified Reach and
et al.,110 UK caregiving curriculum partnership home visits Nonspecific intervention training supervision acceptability
model at-risk facilitators with manual (results
BCTs: Other families reported)
technique(s)
Barrera Opportunities Existing ToC: 28 90-min Targeted; Low Therapists Reach (results
et al.,111 for early curriculum Transactional weekly birthweight reported)
Canada learning; model of early home visits children
Responsive home
caregiving intervention
BCTs: Problem-
solving, Social
support
(community),
other
technique(s)
Brooks-Gunn Good health; Existing ToC: Tested devel- Program Home visits Targeted; Low Nonspecified Reach (results
et al.112 ; Opportuni- curriculum opmentally adaptation— (varied birthweight intervention reported)
Infant ties for early (Infant Health appropriate target frequency) and preterm facilitators
Health and learning and positive social group (non- and children
Develop- Development interactions as specified fortnightly
ment Program; mechanisms of adaptation) group
Program,113 manual) change sessions
USA BCTs: Problem-
solving, Social
support
(community);
other
technique(s)
Caughy Adequate Existing ToC: 6 home visits Universal Nonspecified Reach (results
et al.,114 nutrition; curriculum Study-specific (varied intervention reported).
USA Enabling (Healthy Steps theory of frequency), facilitators Published
caregiving; for Young change model group separate
Good health; Children BCTs: Materials, sessions implementa-
Opportuni- Program; Media (print), (varied tion
ties for early manual; Social support frequency), evaluation
learning; available) (community) 9 clinic paper(s)
Security and visits
safety (varied
frequency),
and
telephone
calls
(varied
frequency)
Cheng Opportunities BCTs: 5 60-min Universal Nurses; some
et al.,115 for early Performance monthly undergradu-
Japan learning; (self) home visits ate education
Responsive (Health
caregiving sector)
Constantino Attachment; Existing BCTs: Media 10 90-min Targeted; Nonspecified 21-day
et al.,116 Opportuni- curriculum (audiovisual, weekly Socially intervention training
USA ties for early (manual) print), group vulnerable facilitators;
learning; Performance sessions families graduate
Responsive (self), Social education
caregiving support
(community),
other
technique(s)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 115

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Cronan Opportunities Existing ToC: Ramey and 18 30-min Targeted; Nonspecified Nonspecified Supervision by Fidelity and
et al.,117 for early curriculum Ramey’s (1992) weekly Low-income intervention training faculty acceptability
USA learning (manual; principles of home visits families facilitators; with manual members (results
available) early education some under- and weekly (graduate reported)
interventions graduate refresher education)
BCTs: Materials, education sessions
Media (print),
Performance
(self, other),
Social support
(community)
Demeusy Attachment; Existing ToC: Home visits Targeted; Clinicians Nonspecified Weekly Reach and
et al.,118 Enabling curriculum Child−parent (varied Nonspecific (graduate training supervision fidelity
USA caregiving; (Child−parent psychotherapy frequency at-risk education) with manual (results
Opportuni- psychotherapy, and and families and reported)
ties for early interpersonal interpersonal number) nonspecified
learning psychotherapy, psychotherapy intervention
and Parents as BCTs: Social facilitators
Teachers; support (family, and clinicians
manual; community),
available) other
technique(s)
Dozier Attachment; Existing ToC: Tested 10 60-min Targeted; Social workers Nonspecified Fidelity
et al.,119 Responsive curriculum caregiver weekly Socially or supervision
USA caregiving (Attachment practices as home visits vulnerable psychologists
and mechanisms of families
Biobehavioral change
Catch-Up BCTs: Media
Intervention; (audiovisual),
manual) Performance
(self)
Drotar Adequate Existing ToC: 37 monthly Universal Nonspecified 6-day training Reach and
et al.,120 nutrition; curriculum Study-specific home visits intervention with manual fidelity
USA Good health; (Parents as theory of and 12 facilitators
Opportuni- Teachers; change model group
ties for early manual; BCTs: Media sessions
learning; available) (audiovisual,
Responsive print)
caregiving
Eddy et al.,121 Security and Existing ToC: Ecological Home visits Targeted; Teachers and Nonspecified Reach and
USA safety curriculum model of child and group Low-income community supervision acceptability
(Relief Nursery development sessions families volunteers (results
Program; BCTs: reported)
manual) Performance
(self, other),
Social support
(family,
community)
Feil et al.,122 Opportunities Existing BCTs: Media Formative 11 30-min Targeted; Nonspecified 2-day training Supervision by Reach and
USA for early curriculum (audiovisual), research— weekly Low-income intervention with manual project acceptability
learning; (Play and Performance pilot internet- families facilitators; supervisor (results
Responsive Learning (self), Social Program based some under- reported)
caregiving Strategies support (family) adaptation— sessions graduate
Program; curriculum education
manual) (content
modifica-
tion and
translation
of
materials)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
116 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Fergusson Enabling Existing ToC: Program 176 120-min Targeted; Nonspecified 35-day Reach (results
et al.,123 caregiving; curriculum Study-specific adaptation— weekly Socially intervention training reported)
New Security and (Early Start; theory of delivery home visits vulnerable facilitators;
Zealand safety New change model (changes to families some under-
Zealand-based BCTs: Social cadre of graduate
Family Support support delivery education
Service) (community) agent)
Field et al.,124 Opportunities Existing BCTs: Materials, Program 12 30-min Targeted; Nonspecified
USA for early curriculum Media (print), adaptation— fortnightly Low-income intervention
learning; Performance curriculum home visits families and facilitators;
Responsive (self, other) (content and 180 adolescent some under-
caregiving modifica- 240-min mothers graduate
tion) group education
sessions
Finlayson Opportunities Existing BCTs: Media 5 home visits Targeted; 2-day training Fidelity and
et al.,125 for early curriculum (audiovisual, and 5 clinic preterm Physiotherapists feasibility
Australia learning (Supporting print), visits children or (results
Play, Performance occupational reported)
Exploration, (self), Social thera-
and Early support pists(Health
Development (family), other sector)
Intervention; technique(s)
manual)
Goldfeld Opportunities Existing BCTs: Materials, Formative 4 clinic visits Universal Nurses (Health 2-day training Fidelity and
et al.,126 for early curriculum Media research— (varied sector) with three acceptability
Australia learning; (manual) (audiovisual, pilot frequency) refresher (results
Responsive print), sessions reported)
caregiving Performance (train-the-
(self, other) trainer
model)
Goodson Enabling Existing ToC: 130 Targeted; Nonspecified Supervision by Reach (results
et al.,44 USA caregiving; curriculum Study-specific fortnightly Low-income intervention CCDP reported)
Security and (Head Start; theory of home visits families facilitators; technical
safety manual; change model and 130 some under- assistance
available) BCTs: Materials, 90-min graduate contractor
Media (print), group education
Performance sessions
(self, other)
Guedney Attachment; Existing ToC: Parental Program 44 home Targeted; Psychologists; Nonspecified Weekly Reach (results
et al.,127 Enabling curriculum empowerment, adaptation— visits Socially undergradu- training supervision reported)
France caregiving (manual; attachment delivery (varied vulnerable ate with manual by
available) security, and (nonspeci- frequency) families education psychiatrists
Fraiberg’s fied and psy-
developmental changes to chotherapists
guidance interven- (graduate
concepts tion education)
BCTs: Materials, delivery)
Media
(audiovisual),
Performance
(self)
Guttentag Good health; Existing ToC: Tested 55 90-min Targeted; Low Nonspecified 3-day training Weekly Fidelity and
et al.,128 Opportuni- curriculum caregiver home visits maternal intervention (train-the- supervision acceptability
USA ties for early (manual; practices as (varied education facilitators; trainer by site (results
learning; available) mechanisms of frequency) undergradu- model) supervisors reported for
Responsive change ate (graduate acceptability
caregiving; BCTs: Media education education) only)
Security and (audiovisual),
safety Performance
(self, other),
Problem-
solving, other
technique(s)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 117

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Havighurst Attachment; Existing ToC: Emotional Formative 6 120-min Universal Nonspecified Nonspecified Fortnightly Reach and
et al.,129 Enabling curriculum socialization research— weekly intervention training supervision fidelity
Australia caregiving (Tuning in to theory pilot group facilitators; by study (results
Toddlers; BCTs: Materials, sessions graduate authors reported for
manual) Media education (graduate reach only)
(audiovisual, education)
print),
Performance
(other), Social
support
(community),
other
technique(s)
Heinicke Attachment; Existing ToC: Attachment Program 60-min Targeted; Mental health Weekly Reach and
et al.,130 Enabling curriculum and object adaptation— weekly Low-income professionals supervision fidelity
USA caregiving; (Steps Toward relationship delivery home visits families (Health (results
Responsive Effective, theory (nonspeci- and 60-min sector; reported for
caregiving Enjoyable BCTs: fied group intervention reach only)
Parenting Performance changes to sessions was
[STEEP] (self, other), interven- (varied implemented
intervention; Problem- tion frequency). as part of
manual; solving, Social delivery) Total routine visits)
available) support (family, number of
community), sessions is
other 48
technique(s)
Hepworth Attachment; Existing ToC: Attachment Formative 10 60-min Targeted; Nonspecified Nonspecified Weekly Reach (results
et al.,131 Responsive curriculum theory research— home visits Socially intervention training supervision reported)
USA caregiving (Head Start; BCTs: in-depth (varied vulnerable facilitators; with manual by
manual) Performance interviews frequency) families graduate and weekly ABC/Infant−Caregiver
(self), other education refresher Project staff
technique(s) sessions (graduate
education)
High et al.,132 Opportunities Existing BCTs: Materials, 5 clinic visits Targeted; Nonspecified Reach (results
USA for early curriculum Media (print) held every Low-income Doctors/pediatricians
training reported)
learning 3 months families (Health
sector)
Huebner,39 Opportunities Existing ToC: Program 2 60-min Universal Librarians Nonspecified Fidelity (results
USA for early curriculum Study-specific adaptation— group (Education training reported)
learning; (Dialogic theory of delivery sessions sector)
Responsive Reading change model (changes to held every
caregiving Program) BCTs: Media cadre of 3 weeks
(audiovisual, delivery
print), agent)
Performance
(self, other),
Problem-
solving
Hutchings Opportunities Existing ToC: Bandura’s 12 group Targeted; Nonspecified Nonspecified Weekly Reach and
et al.,133 UK for early curriculum social-cognitive sessions Low-income intervention training supervision fidelity
learning (Incredible learning theory families facilitators with manual by director of (results
Years Toddler BCTs: Social and childcare center for reported)
Parent support workers evidence-
Program; (community) (Education based early
manual; sector) intervention
available) (graduate
education)
Hutton Opportunities Existing BCTs: Media Varied Targeted; N/A; mobile N/A: mobile Feasibility
et al.,134 for early curriculum (Rx (audiovisual), number, Socially application application (results
USA learning for Success other frequency, vulnerable reported)
[mobile technique(s) and length families
application]) of sessions
(mobile
application-
based
interven-
tion)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
118 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Jacobs Enabling Existing ToC: Tested 118 home Targeted; Nonspecified Reach and
et al.,135 caregiving; curriculum caregiver visits Adolescent intervention fidelity
USA Opportuni- (Healthy practices as (varied mothers facilitators (results
ties for early Families mechanisms of frequency) reported).
learning; Massachusetts; change Published
Security and manual) separate
safety implementa-
tion
evaluation
paper(s)
Johnson Opportunities Existing BCTs: Media Formative Weekly home Targeted; Teachers Nonspecified
et al.,136 for early curriculum (audiovisual), research— visits and Low-income training
USA learning; Performance survey fortnightly families
Responsive (self, other), group
caregiving Social support sessions
(family,
community),
other
technique(s)
Kaaresen Opportunities Existing ToC: Program 4 60-min Targeted; Low Nurses Supervision by Reach and
et al.,137 for early curriculum Transactional adaptation— home visits birthweight coordinator fidelity
Norway learning; (Mother−Infant model of child curriculum (varied children nurse and (results
Responsive Transaction development (content frequency) child reported for
caregiving Program) BCTs: modifica- and 7 psychologist reach only)
Performance tion) 60-min
(self, other), daily clinic
Social support visits
(family)
Kalinauskiene Attachment; Existing BCTs: Media Program 6 90-min Targeted; Psychologists; Nonspecified
et al.,138 Opportuni- curriculum (print), adaptation— monthly First-time graduate training
Lithuania ties for early (Video- Performance curriculum home visits mothers education with manual
learning; feedback (self), Social (translation
Responsive intervention to support of
caregiving; promote (family), other materials)
Security and positive technique(s)
safety parenting;
manual;
available)
Kaminski Opportunities Existing ToC: Formative 175.5 Targeted; Nonspecified Nonspecified Nonspecified Reach and
et al.,45 USA for early curriculum Study-specific research— 120-min Low-income intervention training supervision fidelity. Imple-
learning; (Legacy for theory of pilot weekly families facilitators; with manual mentation
Responsive Children; change model Program group undergradu- evaluation
caregiving; manual) BCTs: adaptation— sessions ate described in
Security and Performance target and education study
safety (self, other), group (non- individual protocol.
Social support specified sessions in Results have
(community) adaptation) a not yet been
community published
setting
Kitzman Enabling Existing ToC: Bronfen- Formative 10 home Targeted; Nurses; under- Supervision by
et al.,139 caregiving; curriculum brenner’s research— visits Socially graduate registered
USA Good health; (Nurse Family theory of pilot vulnerable education nurse
Responsive Partnership human ecology, families
caregiving; Program; Bowlby’s
Opportuni- manual) theory of
ties for early human
learning; attachment,
Security and and Bandura’s
safety theory of
self-efficacy
BCTs: Problem-
solving, Social
support (family,
community)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 119

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Kochanska Opportunities Existing ToC: Tested 9 30-min Targeted; Fidelity (results

et al.,140 for early curriculum caregiver home visits Low-income reported)
USA learning; (manual) practices as held every families
Responsive mechanisms of 7−10 days
caregiving change BCTs:
Media
(audiovisual,
media),
Performance
(self, other)
Kohlhoff Attachment; Existing ToC: Attachment 13 45-min Targeted; Clinicians 5-day training Ongoing Reach and
et al.,141 Opportuni- curriculum theory BCTs: clinic visits Children with manual supervision acceptability
Australia ties for early (Parent−Child Media held twice with high by PCIT (results
learning Interaction (audiovisual), a week levels of International reported)
Therapy— Performance behavior Level II
Toddler; (self), other problems trainer
manual; technique(s)
available)
Kristensen Responsive Existing BCTs: Social 4 25-min Universal Nurses; under- 60-day Reach and
et al.,142 caregiving curriculum support (family) home visits graduate training fidelity
Denmark (Newborn education with manual (results
Behavioral (Health reported)
Observations; sector;
manual; intervention
available) was
implemented
as part of
routine visits)
Kynø et al.,143 Opportunities Existing ToC: Theory of 4 60-min Targeted; Nurses; under- Nonspecified Regular Fidelity and
Norway for early curriculum mutual home visits preterm graduate training supervision acceptability
learning; (Mother−Infant transaction (varied children education with non- by nurse (results
Responsive Transaction BCTs: frequency) specified research reported for
caregiving Program; Performance and 7 refresher assistant acceptability
manual) (other), Social 60-min sessions (graduate only).
support (family) daily clinic education) Published
visits separate
implementa-
tion
evaluation
paper(s)
Larson Opportunities Existing BCTs: Media Formative Varied Targeted; N/A; mobile N/A: mobile Fidelity and
et al.,144 for early curriculum (audiovisual), research— number, Socially application application acceptability
USA learning; (Háblame Bebé other pilot frequency, vulnerable (results
Responsive [mobile technique(s) Program and length families reported)
caregiving application]) adaptation— of sessions
delivery (mobile
(nonspeci- application-
fied based
changes to interven-
interven- tion)
tion
delivery)
Leung et al.,145 Opportunities Existing BCTs; Materials, 60 120-min Targeted; Social workers Nonspecified Varied Reach and
Hong Kong for early curriculum (Fun Media (print), group Nonspecific and training frequency of fidelity
learning; to Learn for the Performance session at-risk nonspecified with manual supervision (results
Responsive Young [FLY] (self, other), (varied families intervention reported for
caregiving program; Social support frequency) facilitators reach only)
manual) (family)
Leung et al.,146 Opportunities Existing BCTs: Materials, Formative 40 120-min Targeted; Social workers; Nonspecified Regular Reach and
Hong Kong for early curriculum Media (print), research— group Socially undergradu- training supervision fidelity
learning (Parent and Performance pilot sessions vulnerable ate with manual by (results
Child (self, other), held twice families education psychologist reported for
Enhancement Problem- a week (graduate reach only)
[PACE] solving, Social education)
Program; support (family)
manual)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
120 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Love et al.,147 Good health; Existing ToC: Home visits Targeted; Undergraduate Nonspecified Reach and
USA Opportuni- curriculum Study-specific and group Low-income education training fidelity
ties for early (Early Head theory of sessions families (Education with manual (results
learning Start; manual; change model sector) and non- reported)
available) BCTs: specified
Materials, refresher
Media (print), sessions
Performance
(self, other),
Problem-
solving, Social
support (family,
community)
Lozoff Opportunities Existing BCTs: Materials, 60-min Targeted; Iron- Nonspecified Nonspecified Weekly
et al.,148 for early curriculum Media (print), weekly deficient intervention training supervision
Chile learning; (manual; Performance home visits anemic facilitators with manual by
Responsive available) (self, other), children psychologist
caregiving Problem-
solving, other
technique(s)
Madden Opportunities Existing ToC: Instrumental 46 30-min Targeted; Nonspecified Nonspecified Nonspecified Reach and
et al.,149 for early curriculum (The conceptualism home visits Low-income intervention training supervision fidelity
USA learning; Mother−Child BCTs: held twice families facilitators; with manual (results
Responsive Home Program; Materials, a week secondary reported)
caregiving manual; Performance education
available) (self, other)
McGillion Responsive Existing BCTs: Media 30 15-min Targeted; N/A; N/A: Reach (results
et al.,150 UK caregiving curriculum (audiovisual), daily Socially video-based video-based reported)
Social support at-home vulnerable intervention intervention
(family) practice families
sessions
McManus Responsive Existing ToC: Formative 3.5 60-min Targeted; Clinicians 2-day training Nonspecified
et al.,151 caregiving curriculum Study-specific research— weekly Children at supervision
USA (Newborn theory of pilot home visits risk of devel-
Behavioral change model opmental
Observations; BCTs: delay
manual) Performance
(self, other)
Mendelsohn Opportunities Existing BCTs: Materials, 12 37.5-min Targeted;
et al.,152 for early curriculum Media clinic visits Children at Doctors/pediatricians;
USA learning; (Video (audiovisual), risk of devel- graduate
Responsive Interaction Performance opmental education
caregiving Project; (other), Social delay (Health
manual; support (family) sector)
available)
Mendelsohn Opportunities Existing BCTs: Materials, 12 37.5-min Targeted; Reach (results
et al.,153 for early curriculum Media clinic visits Children at Doctors/pediatricians; reported)
USA learning; (Bellevue (audiovisual), risk of devel- graduate
Responsive Project for Performance opmental education
caregiving Early Language (other), Social delay (Health
and Literacy support (family) sector)
Success;
manual;
available)
Norr et al.,154 Adequate Existing ToC: Ecological Formative 12 monthly Targeted; Community Nonspecified Varied
USA nutrition; curriculum model of child research— home visits Low-income health training supervision
Good health; (REACH- development pilot families and workers; with frequency by
Opportuni- Futures; BCTs: Problem- Program socially some primary manual and nurse (under-
ties for early manual; solving, other adaptation— vulnerable education refresher graduate
learning; available) technique(s) delivery families sessions education)
Responsive (changes to every 4−6
caregiving; cadre of months
Security and delivery
safety agent)
(Continues)
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ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 121

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

O’Farrelly Attachment; Existing ToC: Attachment 6 90-min Targeted; Health 5-day training Supervision by Reach, fidelity,
et al.155 ; Opportuni- curriculum theory and fortnightly Children professionals with manual clinical and
O’Farrelly ties for early (Video- Bandura’s home visits with high (Health supervisor acceptability
et al.,156 UK learning; feedback social-cognitive levels of sector) (results
Responsive intervention to learning theory behavior reported)
caregiving promote BCTs: Media problems
positive (audiovisual),
parenting; Performance
manual; (self), Social
available) support (family)
Olds et al.,157 Good health; Existing ToC; Bronfen- 75 75-min Targeted; Nurses (Health Nonspecified Reach and
USA Opportuni- curriculum brenner’s home visits Socially sector) training fidelity
ties for early (Nurse Family theory of (varied vulnerable (results
learning; Partnership human ecology, frequency) families reported for
Responsive Program; Bowlby’s reach only)
caregiving; manual) theory of
Security and human
safety attachment,
and Bandura’s
theory of
self-efficacy
BCTs: Social
support (family,
community)
Olds et al.,158 Good health; Existing ToC; Bronfen- Program 88 72-min Targeted; Nurses; under- 30-day Nonspecified Reach (results
USA Opportuni- curriculum brenner’s adaptation— home visits Low-income graduate training supervision reported)
ties for early (Nurse Family theory of delivery families education with manual
learning; Partnership human ecology, (changes to and
Responsive Program; Bowlby’s cadre of nonspecified
caregiving; manual) theory of delivery intervention
Security and human agent) facilitators;
safety attachment, secondary
and Bandura’s education
theory of (Health
self-efficacy sector)
BCTs: Social
support (family,
community)
Pisoni et al.,159 Responsive Existing BCTs: Other 6 67.5-min Targeted; Nonspecified Reach (results
Italy caregiving curriculum technique(s) clinic visits preterm Doctors/pediatrictraining reported)
(varied children neuropsychi- with manual
frequency) atrists;
graduate
education
Pontoppidan Opportunities Existing BCTs: Media 8 120-min Universal 3-day training Bi-annual
et al.,160 for early curriculum (print), group with manual supervision
Denmark learning (Incredible Performance sessions (train-the- by Incredible
Years Program (other), Social trainer Years
for Children support (family) model) program
from Infancy to mentor
Pre-
adolescence;
manual;
available)
Raby et al.,161 Attachment; Existing ToC: Attachment Formative 10 60-min Targeted; Nonspecified Nonspecified Weekly
USA Responsive curriculum theory BCTs: research— home visits Socially intervention training supervision
caregiving (Attachment Performance pilot (varied vulnerable facilitators with manual by ABC-T
and (self, other), frequency) families expert
Biobehavioral Problem-
Catch-Up solving, Social
Intervention; support (family)
manual)
(Continues)
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122 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Ramírez Responsive BCTs: Media 45-min group Universal Nonspecified Reach (results
et al.,162 caregiving (audiovisual), session intervention reported)
USA Performance and 45-min facilitators
(self), Problem- individual
solving, Social visits in lab
support (family) setting.
Total
number of
sessions is
22
Rauh et al.,163 Responsive Existing BCTs: 4 60-min Targeted; Low Nurse Regular Acceptability
USA caregiving curriculum Performance home visits birthweight supervision (results
(Mother−Infant (self, other) (varied children by project reported)
Transaction frequency) director
Program; and 7
manual; 60-min
available) daily clinic
visits
Riggs et al.,164 Enabling Existing ToC: Tested Home visits Targeted; Nonspecified Nonspecified Reach and
USA caregiving; curriculum caregiver (varied Nonspecific intervention training fidelity
Opportuni- (Infant Mental practices as frequency, at-risk facilitators (results
ties for early Health-Home mechanisms of length, and families (Health sector) reported)
learning; Visiting change number)
Responsive Program; BCTs: Media
caregiving manual; (audiovisual),
available) Performance
(self), Problem-
solving, Social
support
(community)
Robling Opportunities Existing ToC: Bronfen- Program 64 home Universal Nurse Nonspecified Supervision by Reach and
et al.,165 UK for early curriculum brenner’s adaptation— visits training nurses or fidelity
learning; (Family Nurse theory of curriculum (varied with manual midwives (results
Security and Partnership human ecology, (translation frequency) (graduate reported)
safety program; Bowlby’s of education)
manual; theory of materials)
available) human and target
attachment, group (non-
and Bandura’s specified
theory of adaptation)
self-efficacy
BCTs:
Performance
(other)
Roggman Opportunities Existing ToC: Weekly home Targeted; Nonspecified Fidelity and
et al.,166 for early curriculum Study-specific visits and Low-income intervention acceptability
USA learning; (Early Head theory of weekly families facilitators (results
Responsive Start) change model group reported)
caregiving BCTs: sessions
Materials,
Performance
(self)
Santelices Attachment; Manual BCTs: Media 4 60-min Universal Researchers; Nonspecified
et al.,167 Responsive (audiovisual), home visits graduate supervision
Chile caregiving; Performance (varied education
Security and (self) frequency)
safety and 6
120-min
weekly
group
sessions in
clinic
setting
(Continues)
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ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 123

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Sawyer Good health; Existing BCTs: Media 75-min clinic Universal Nurses; under- 4-day training Reach (results
et al.,168 Opportuni- curriculum (audiovisual) visits graduate reported)
Australia ties for early (South education
learning; Australia
Security and Postnatal
safety Home-Visiting
Program;
manual;
available)
Scarr and Opportunities Existing BCTs: Materials, 46 Targeted; Nonspecified Nonspecified
McCartney,169 for early curriculum Performance fortnightly Nonspecific intervention training
Bermuda learning (Mother−Child (other) home visits at-risk facilitators; with manual
Home Program; families secondary
manual) education
Schaub Good health; Existing ToC: Bronfen- 10 home Targeted; Nonspecified Nonspecified
et al.,170 Opportuni- curriculum brenner’s visits and Nonspecific intervention training
Switzerland ties for early (Parent as process-person monthly at-risk facilitators; with annual
learning; Teachers) context-time group families undergradu- refresher
Security and model BCTs: sessions ate sessions
safety Social support education
(community),
other
technique(s)
Schwarz Good health Existing BCTs: Media 15-min home Targeted; Nurses and Nonspecified Weekly Reach and
et al.,171 curriculum (audiovisual), visits Low-income community training supervision fidelity
USA (manual; Problem- families health with manual by (results
available) solving, Social workers; and weekly pediatrician, reported for
support graduate refresher nurse reach only)
(community), education sessions practitioner,
other and
technique(s) psychologists
(graduate
education)
Sierau Attachment; Existing ToC: Bronfen- Formative 52 90-min Targeted; Social workers, 16-day Weekly Reach (results
et al.,172 Enabling curriculum brenner’s research— home visits Socially midwives, or training supervision reported).
Germany caregiving; (Pro-King theory of pilot (varied vulnerable nurses; some with manual by nurse Published
Opportuni- (based on human ecology, Program frequency) families undergradu- (train-the- (undergradu- separate
ties for early Nurse Family Bowlby’s adaptation— ate or some trainer ate implementa-
learning; Partnership theory of delivery graduate model) education) tion
Responsive program); human (changes to education evaluation
caregiving; manual) attachment, cadre of (Health and paper(s)
Security and and Bandura’s delivery social
safety theory of agent) sectors)
self-efficacy
BCTs:
Performance
(self, other),
Social support
(family,
community)
Slade et al.,173 Adequate Existing ToC: Formative 60-min home Targeted; Nurses; 3-day training Weekly
USA nutrition; curriculum Study-specific research— visits First-time graduate with supervision
Good health; (Minding the theory of pilot (varied mothers education manual and by nurse
Opportuni- Baby; manual; change model frequency) quarterly supervisor,
ties for early available) BCTs: Media refresher social work
learning; (audiovisual), sessions supervisor,
Responsive Performance and program
caregiving; (self), Social director
Security and support (family,
safety community),
other
technique(s)
(Continues)
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124 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Spieker Attachment; Existing ToC: Formative 10 67.5-min Targeted; Nonspecified 3.75-day Reach and
et al.,174 Responsive curriculum Study-specific research— weekly Socially intervention training fidelity
USA caregiving (Promoting theory of feedback on home visits vulnerable facilitators; with manual (results
First change model program families graduate and weekly reported).
Relationships; BCTs: Media develop- education refresher Published
manual; (audiovisual, ment (Social sessions separate
available) print), Program sector) implementa-
Performance adaptation— tion
(self) target evaluation
group (non- paper(s)
specified
adaptation)
Twohig Attachment Existing BCTs: Media 3 67.5-min Targeted; Doctors (child Nonspecified
et al.,175 curriculum (audiovisual), clinic visits preterm psychiatrist); training
Ireland (Video Performance (varied children graduate
Interaction (self), Social frequency) education
Guidance and support
Working Model (family), other
of the Child technique(s)
Interview;
manual;
available)
Van Zeijl Attachment Existing BCTs: Media 6 90-min Targeted; Nonspecified Nonspecified Reach and
et al.,176 the curriculum (print), home visits Children intervention training fidelity
Netherlands (Screening and Performance (varied with high facilitators; (results
Intervention of (self), Social frequency) levels of undergradu- reported)
Problem support (family) behavior ate
Behavior in problems education
Toddlerhood;
manual;
available)
Velderman Attachment Existing BCTs: Media 4 90-min Targeted; Nonspecified
et al.,177 the curriculum (print), home visits Mothers intervention
Netherlands (manual; Performance held every with facilitators;
available) (self) 3−4 weeks insecure undergradu-
attachment ate
education
Wagner Opportunities Existing ToC: Monthly Targeted; Nonspecified Fidelity and
et al.,178 for early curriculum Study-specific home visits Low-income intervention acceptability
USA learning; (manual) theory of and group families facilitators; (results
Security and change model sessions undergradu- reported)
safety BCTs: ate
Performance education
(other), Social
support
(community)
Wake et al.,179 Opportunities Existing ToC: Social Formative 6 120-min Targeted; Nonspecified 3-day training Reach and
Australia for early curriculum (You interactionist research— weekly Children at intervention acceptability
learning; Make the model of pilot group risk of devel- facilitators (results
Responsive Difference language Program sessions opmental reported)
caregiving Intervention) acquisition adaptation— delay
BCTs: curriculum
Materials, (content
Media modifica-
(audiovisual), tion) and
Performance delivery
(other), Social (nonspeci-
support (family) fied
changes to
interven-
tion
delivery)
Walkup Adequate Existing BCTs: Problem- Formative 25 60-min Targeted; Nonspecified Nonspecified Reach (results
et al.,180 nutrition; curriculum solving, other research— home visits Socially intervention training reported)
USA Good health (Family Spirit; technique(s) pilot vulnerable facilitators with manual
manual; families
available)
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 125

TA B L E 3 (Continued)
Delivery
Characteristics of Theory of change agents’
parenting (ToC) and Type of characteristics
Nurturing Care curriculum or behavior change intervention (integration Delivery
Framework manual techniques Intervention Dosage and and primary into existing agents Delivery agents Implementation
Author component(s)a (availability)b (BCTs)c preparationd delivery beneficiaries service) (training) (supervision) evaluation

Wasik et al.,181 Adequate Existing BCTs: Materials, 50-min home Targeted; Nonspecified Nonspecified
USA nutrition; curriculum (The Social support visits Children at intervention training
Good health; Family (family, (varied risk of devel- facilitators; with manual
Opportuni- Education community), frequency) opmental secondary
ties for early Program & other and 50-min delay education
learning; Child technique(s) group
Responsive Development sessions
caregiving; Center (varied
Security and Program; frequency)
safety manual;
available)
Weisleder Opportunities Existing ToC: Family 15 27.5-min Targeted; Nonspecified Nonspecified Nonspecified Reach (results
et al.,182 for early curriculum investment clinic visits Low-income intervention training supervision reported)
USA learning; (Video model and families facilitators;
Responsive Interaction family stress undergradu-
caregiving Project and model ate
Building Blocks; BCTs: Materials, education
manual; Media (print),
available) Performance
(self)
Whitt and Responsive Existing ToC: 5 27.5-min Targeted; Doctors (pedia-
Casey,183 caregiving curriculum Study-specific clinic visits First-time trician);
USA theory of (varied mothers graduate
change model frequency) education
BCTs: (Health
Performance sector)
(other)

Note: Missing information (i.e., empty or partially completed cells) indicates that data were not clearly reported.
a We included two constructs relevant to nurturing care which are not included in the Nurturing Care Framework: attachment and enabling caregiving (i.e., interventions that directly targeted

caregivers’ mental health and psychosocial well-being).

b Characteristics of parenting curriculum or manual include: “Existing curriculum” indicates that the curriculum of a given intervention is based on the curriculum and evidence generated from an

existing parenting intervention. The name of the specific intervention (as indicated in the published article) is also listed. “Manual” indicates that a manual detailing the content of intervention
sessions was used either to train delivery agents or to guide their implementation of each session or both. “Available” indicates that the manual detailing a given intervention’s curriculum is included
in the article’s supplementary material, made available on a website whose link is provided in the article, or reported as being available upon reasonable request to the article’s author(s).
c Behavior change techniques refer to the strategies used by the intervention/service to facilitate behavior change in caregivers. We used the categories specified in Briscoe and Aboud46 and Aboud

and Yousafzai3 : “materials” = provision of materials such as books or play objects; “media (audiovisual)” = use of media such as radio/audio or TV/video to convey messages; “media (print)” = use of
print media such as pamphlets, posters, flipcharts to convey messages; “performance (other)” = use of demonstrations by delivery agents or another caregiver to model a behavior; “performance
(self)” = caregiver themselves practicing with their child and getting feedback or coaching; “problem-solving” = identification of barriers and facilitators to behavior change and solutions to over-
coming barriers; “social support (family)” = leveraging caregivers’ relationship with family members as a source of support to facilitate behavior change; “social support (community)” = leveraging
caregivers’ relationship with community members and resources as a source of support to facilitate behavior change; “other technique(s)” = other behavior change techniques described by authors
that do not fall into any of the aforementioned categories.
d Intervention preparation refers to research activities that aim to determine how best to fit aspects of program design, content, and implementation to the environmental and cultural contexts, as

well as the needs of program beneficiaries (i.e., formative research) and any changes made to an intervention’s curriculum, delivery, or other implementation characteristics to make it more suitable
for a specific target group or context (i.e., program adaptations). Formative research is categorized according to the type of research method that was used (feedback on program development,
focus group discussions, in-depth interviews, job analysis, pilot, survey). Program adaptation is categorized according to the component of an intervention (curriculum, delivery, target group) that
was adapted, and the specific adaptation made if specified by authors.

theories focus on the dynamic interactions between parents and chil- the use of interactive drama (i.e., community-based approach that
dren and improving parental self-esteem for childcare. In most cases, used theater and interactive techniques to promote positive behavioral
the behavior change techniques employed in studies reflected the con- changes in village or rural areas).
cepts highlighted in the theory of change. The total number of behavior
change techniques used ranged from zero to eight, with a median of
three. In both LMIC and HIC studies, the most commonly used behav- Intervention preparation
ior change technique involved direct caregiver engagement with their
child (e.g., a caregiver playing with, talking/singing to, or otherwise Few studies reported data on the preparatory work performed before
meaningfully interacting with their child as part of an intervention interventions were implemented, with only 27–36% of studies indi-
activity) coupled with delivery agent’s feedback (n = 67, 54%) followed cating whether formative research or program adaptations had been
by modeling of the intended behavior by the delivery agent or a model conducted. These data were reported by a greater proportion of stud-
caregiver (n = 64, 51%). Around 30 studies (24%) included new behav- ies published recently (24–38%) and those from LMICs (34–53%). In
ior change techniques such as diary keeping, text reminders/telephone this review, we define formative research as research activities that
follow-ups to encourage parents to engage in specific behaviors, and aim to determine how best to fit aspects of program design, content,
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
126 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 4 Key findings on implementation characteristics.

Implementation characteristic Key finding(s)

Intervention content
Characteristics of parenting curriculum Most intervention curricula were based on an existing parenting curriculum and used a
structured manual to guide intervention delivery; however, only 43% of these manuals are
publicly available.
Intervention theory of change Most interventions reported using the following theories of change: social-cognitive learning
theory, family systems theory, Bowlby’s theory of human attachment, and Bandura’s
theory of self-efficacy.
Nurturing Care Framework (NCF) Intervention’ content covered 1−6 NCF components (median = 1). Opportunities for early
components learning, responsive care, and adequate nutrition were the most frequently used
components. The most common combination was opportunities for early learning and
responsive care.
Behavior change techniques Interventions used 0−8 behavior change techniques (median = 3). The most frequently used
techniques were the use of direct caregiver engagement with their child coupled with
delivery agent’s feedback, modeling and demonstration of the intended behavior by the
delivery agent or a model caregiver, and the use of play materials or books.
Intervention preparation
Formative research Studies primarily used pilot studies and qualitative research to conduct formative research
before implementing interventions.
Program adaptations Interventions that used existing parenting intervention curricula made adaptations to the
content, delivery modality, and primary beneficiaries of the intervention to make it more
suitable for their study contexts.
Intervention beneficiaries
Nature of intervention Most studies targeted their intervention to a specific group of beneficiaries. The most
frequently targeted groups were low-income families, socially vulnerable families (i.e.,
combination of low levels of education, low-income, and low socioeconomic status), and
malnourished children.
Primary beneficiaries Mothers were the primary beneficiaries of most interventions (96%). The remaining
interventions indicated that the child’s primary caregiver was the intervention beneficiary
without specifying the nature of that caregiver’s relationship to the target child.
Inclusion of additional caregivers In the 38% of studies that actively included an additional caregiver, most included fathers,
while the others included fathers and another caregiver (e.g., target child’s grandparent,
sibling, or an unspecified adult family member).
Intervention dosage across delivery modalities and settings
Intervention dosage across delivery The most frequently used delivery modality and setting were individual home visits,
modalities and settings followed by mixed settings and modalities (e.g., sessions consisted of both individual home
visits and community-based group sessions), individual clinic visits, and community-based
group sessions. Interventions using individual home visits were the most intensive, with an
average of 21 1-h sessions held weekly. Community-based group session interventions
had an average of 10 2-h sessions held weekly, while interventions using individual clinic
visits consisted of, on average, 5 47-min sessions occurring on a varied frequency based on
child’s age or families’ availability. There were not enough data to summarize the dosage of
interventions with mixed delivery settings and modalities.
Characteristics, training, and supervision of delivery agents
Delivery agent’s level of education Most delivery agents had an undergraduate education. The other most commonly reported
levels of education were some secondary (i.e., the delivery agent completed some years of
secondary school but did not graduate) and having a graduate degree.
Delivery agent’s occupational status The most frequently reported occupations of delivery agents were community health
workers, nurses, and doctors.
Integration of delivery agents Most delivery agents were working in the health sector, suggesting that interventions that
were integrated into existing systems tended to be integrated into the health sector.
Duration of delivery agent training The average length of delivery agents’ training was 7 days. Some studies used a manual to
guide training activities. In a small percentage (13%) of studies, a train-the-trainer
approach was used whereby researchers trained a group of individuals (e.g., supervisors)
who then trained delivery agents.
(Continues)
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 127

TA B L E 4 (Continued)

Implementation characteristic Key finding(s)

Frequency of refresher training for delivery One in four studies reported conducting refresher training sessions throughout intervention
agents delivery to maintain the skills of delivery agents. The frequency of refresher trainings
varied, with most studies holding them on a weekly basis.
Level of education of delivery agents’ Most supervisors had a graduate degree.
supervisors
Frequency of delivery agents’ supervision Most studies reported a weekly supervision frequency; however, there were little data on
the modality (e.g., coaching, constructive feedback) of supervision.
Intervention cost
Intervention cost Few studies reported costing data, limiting the ability to make meaningful comparisons
across interventions.
Implementation evaluation
Reach The reach of most interventions was assessed by the number of sessions the primary
beneficiary attended.
Fidelity The fidelity of an intervention was assessed in a variety of ways including testing delivery
agents’ competencies during and after training, examining the extent to which caregivers
engaged with the intervention and practiced key behaviors at home, and assessing
delivery agents’ compliance with intervention content. In most studies, fidelity was either
assessed by supervisors using a checklist developed by the researchers or by delivery
agents self-reporting the extent to which they delivered the intervention as planned.
Feasibility Only three studies assessed the feasibility of the intervention. Across these studies,
feasibility was conceptualized in various ways including the recruitment rate of
participants, retention and attrition of participants, intervention completion rates, and
participant-reported adherence to the intervention.
Acceptability Most studies assessed acceptability through surveys or in-depth interviews and reported
that both caregivers and delivery agents found the intervention to be acceptable.

FIGURE 2 Proportion of studies reporting data on implementation characteristics.

 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
128 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

and implementation to the environmental and cultural contexts, as well ents were invited as additional caregivers. Studies from HICs mostly
as the needs of program beneficiaries.37 This, therefore, included stud- invited fathers as additional caregivers, while studies from LMICs
ies that reported conducting preliminary qualitative or quantitative mostly invited multiple additional caregivers, commonly fathers and
research in the region(s) of interest prior to implementing the parent- grandmothers.
ing intervention. Program adaptations were defined as any changes
made to an intervention’s curriculum, delivery, or other implemen-
tation characteristics to make it more suitable for a specific target Intervention dosage across delivery modalities and
group or context. About one-third of studies (36%) reported program settings
adaptations, and the most common types of adaptations were of the
intervention curriculum (n = 17; e.g., including culturally appropriate Information on the dosage (i.e., number, length, and frequency of ses-
play activities38 ), followed by delivery (n = 7; e.g., changing delivery sions and total contact hours) and delivery modality and setting of
agents from university-based research staff to children’s librarians39 ), interventions was reported by nearly all studies, with the exception of
and the target population (n = 5; e.g., adapting an intervention devel- session length, which was reported by 66% of studies (62–66% across
oped for HIV/AIDS-affected families with school-aged children for subgroups of country income level and publication date). We provide a
non-HIV/AIDS-affected families with young children40 ). nuanced presentation of intervention dosage by comparing these data
across delivery modalities and settings. Although all studies reported
the setting within which the intervention had been delivered and the
Intervention beneficiaries modality used, 19 studies did not report enough data on intervention
dosage and are, therefore, not summarized here. Out of the n = 106
The nature (i.e., universal [30%] vs. targeted [70%]) of interventions trials that specified intervention dosage, 51 were conducted individu-
was reported across all studies. The majority of studies from HICs used ally in a home setting, 13 were conducted individually in a clinic setting,
targeted interventions (63 out of 76, 83%), while universal interven- 16 were conducted in groups in a community setting, and 26 were con-
tions were more common among studies from LMICs (25 out of 49, ducted in more than one setting and with different delivery modalities
51%). Targeted groups included low-income families (n = 27), socially (e.g., individual home visits and group sessions in clinic setting, individ-
vulnerable families (i.e., combination of low levels of education, low ual home visits and group sessions in community setting, individual and
income, and low socioeconomic status) (n = 18), malnourished chil- group sessions in community setting).
dren (n = 11), low birth weight/preterm babies (n = 8), children at risk Across delivery modalities, home visiting interventions were the
of developmental delay (n = 6), children with behavioral problems (n most intensive in both HICs and LMICs (Table 5). In LMICs, home vis-
= 3), first-time low-income mothers (n = 3), adolescent mothers (n = iting interventions had a median of 30 sessions that lasted 55 min on
3), and nonspecific at-risk families (n = 7). Studies from HICs mostly average (SD = 18.0) and were mostly held at least once a week. In HICs,
targeted low-income and socially vulnerable families, while malnour- there were fewer home visiting sessions (median = 15) of longer length
ished children were more commonly targeted in studies from LMICs. (mean = 65 min, SD = 27.6), and the frequency was more likely to be
In all the studies targeting malnourished children in LMICs, parenting varied. On the other end, interventions consisting of clinic visits con-
interventions were bundled with nutrition services (e.g., micronutrient sisted of fewer (median = 4.5 in LMICs and 6 in HICs) and shorter
supplements, treatment for acute malnutrition) to reduce the adverse (mean = 51.3 min, SD = 48.7 in LMICs and mean = 44.3 min, SD =
effects of undernutrition and improve developmental outcomes. Out of 17 in HICs) sessions. In both LMICs and HICs, the nature of clinic vis-
89 studies published post-2007, 55 (62%) targeted their interventions its varied, whereby some leveraged caregivers taking their child in for
to specific groups. a well- or sick-baby visit as an opportunity to share parenting mes-
All studies reported data on the primary beneficiaries of the inter- sages, while others consisted of health workers inviting caregivers to
vention, which in most cases (96%), was the mother of the target the clinic to attend parenting sessions. The most common frequency
child. Only 38% of studies indicated whether additional caregivers of clinic sessions in LMICs was every 3–4 months (reported by 50%
had been invited to participate, and differences in the proportion of studies), whereas most clinic-based interventions in HICs (67%) had
of studies reporting this across subgroups reflected both temporal varied frequencies of sessions, with the most common reasons for vari-
changes (1974–2007 [25%] vs. 2008–2022 [45%]) and cultural differ- ation being the child’s age (e.g., more frequent sessions when child was
ences (HICs [37%] vs. LMICs [42%]) in the role of other caregivers young and decreasing frequency as they grew older), families’ needs,
besides the mother in caring for young children. In most cases, the addi- and caregivers’ availability. In both LMICs and HICs, group-based inter-
tional caregiver(s) was the target child’s father (n = 16) or the target ventions in community settings were mostly held on a weekly basis
child’s father and another caregiver (n = 12): fathers and grandparents but consisted of fewer overall sessions (median = 13.5 in LMICs and
(mostly grandmothers), fathers and nonspecified adult family mem- median = 9 in HICs) that lasted for longer (mean = 139.6 min, SD =
bers, and fathers and target child’s sibling. Thirteen studies reported 126.3 in LMICs and mean = 107.1 min, SD = 23.6 in HICs), compared
inviting nonspecific other family members, one study invited a grand- to home visiting interventions in both contexts. For interventions that
parent, and five studies did not clarify whether mothers or fathers combined delivery modalities and settings, it was difficult to determine
were the primary beneficiary, but simply indicated that other par- the intensity of sessions because fewer than half of studies provided
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 129

TA B L E 5 Intervention dosage by delivery setting and modality across subgroups of country-income level.

Number of Session frequencyb (% of

sessions Length of sessions (minutes) studies) Total contact hours
Home visits LMICs Median = 30 55.1 (18.0) c
Weekly (45%) 42.98 (45.1)
(n = 26a ) Mode = 16
HICs Median = 15 64.5 (27.6) Variedd (35%) 39.7 (75.2)
(n = 37a ) Mode = 10
Clinic visits LMICs Median = 4.5 51.3 (48.7) Every 3−4 months (40%) 6.9 (9.4)
(n = 5a ) Mode = 2
HICs Median = 6 44.3 (17.0) Variedd (67%) 6.3 (2.6)
(n = 10a ) Mode = 5
Group sessions LMICs Median = 13.5 139.6 (126.3) Weekly (38%) 52.4 (60.7)
(n = 5a ) Mode = 3
HICs Median = 9 107.1 (23.6) Weekly (83%) 36.7 (45.0)
(n = 8a ) Mode = 6
Mixed delivery LMICs Median = 19.5 111.4 (31.7) Fortnightly (57%) 22.7 (12.5)
modalities and (n = 13a ) Mode = 10.5
settings
HICs Median = 13 145.7 (61.1) Variedd (100%) 129.1 (265.0)
(n = 21a ) Mode = 10

Note: Numbers represent Mean (SD) unless otherwise specified.

Abbreviations: HICs, high-income countries; LMICs, low- and middle-income countries.
a
These values represent the number of studies that reported the delivery setting in which the intervention was conducted. Within these reported values,
there was variation in the number of studies that subsequently reported the number, length, or frequency of sessions, and for which we could calculate the
total contact hours.
b
This column presents the most frequently reported session frequency and the percentage of studies reporting that frequency.
c
Includes trials with sessions occurring at least once a week (i.e., daily, biweekly, weekly).
d
Reasons for variation in session frequency included child’s developmental stage, families’ needs, and caregivers’ availability.

data on the length of the different types of sessions (mean = 111.4 min, trainings. A similar pattern was observed for reporting of supervision
SD = 31.7 in LMICs and mean = 145.7 min, SD = 61.1 in HICs). data, with 60% of studies indicating that delivery agents had been
Finally, it is worth noting that three recent studies in Bangladesh, supervised and only 39% specifying how frequently this supervision
India, and Kenya had two intervention arms with the same curricu- occurred. Overall, a greater proportion of studies published between
lum delivered via different modalities and settings, namely, individual 2008 and 2022 (29–83%) and those conducted in LMICs (37–92%)
home visits versus group sessions in community settings in India14 reported data on the training and supervision of delivery agents.
and group sessions in community settings versus mixed delivery (indi- The educational status of delivery agents was often unreported, but
vidual home visits and group community-based sessions) in Kenya41 among studies that did report educational status, undergraduate was
and Bangladesh.42 Both the India and Kenya studies compared the the most common (n = 18), followed by some secondary (n = 15), and
effectiveness of the two intervention arms (home vs. group and group graduate (n = 13). This differed greatly by country income level, as
vs. mixed delivery) and found that both interventions led to signifi- all but one of the studies that reported working with a delivery agent
cant improvements in ECD and parenting outcomes compared to the with an undergraduate degree were based in HICs. In LMIC-based
control but did not significantly differ from each other.14,41 studies, the most frequently reported levels of education were sec-
ondary, some secondary, and some primary. The occupational status of
delivery agents also varied greatly. For example, all interventions in
Characteristics, training, and supervision of delivery
which doctors were the delivery agents occurred in HICs, whereas the
agents
most commonly reported delivery agent status in LMICs was commu-

There was great variation in the proportion of studies reporting infor- nity health worker (n = 15). The remaining studies in LMICs reported

mation on the characteristics, training, and supervision of delivery working with community volunteers (e.g., mothers of older children

agents. For example, although most studies specified the profession from the community; n = 7) and health and social workers (e.g., nurse,

or status of delivery agents, fewer indicated their level of education occupational therapist, social worker; n = 9) as delivery agents. Eigh-

(58%) or details about the integration of delivery agents into an exist- teen studies from LMICs did not specify the occupational status of

ing service (29%). Likewise, even though 76% of studies indicated that delivery agents.

delivery agents had received training on how to deliver the parenting The length of delivery agents’ training ranged from 1 to 60 days, with

intervention, only 44% specified how long they had been trained for a mean of ∼12 days and a median of 7 days. Overall, 43% of studies

and fewer than 25% indicated whether they had received refresher reported using a training manual (n = 54) and 13% reported using a
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
130 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

cascade model or train-the-trainer approach (n = 17). One in four stud- Only five studies specified using an independent—and blinded in
ies (n = 30) reported conducting refresher training sessions to maintain four out of the five—team for implementation evaluation, all of them
the skills of delivery agents. The frequency of these refresher trainings published after 2007, with three conducted in LMICs23,41,42 and the
varied across studies: weekly (n = 5), fortnightly (n = 2), monthly (n = 3), other two in HICs.44,45 However, of the 53 studies that reported eval-
quarterly (n = 1), biannually (n = 4), and annually (n = 3). With respect uating intervention fidelity, only 38% reported their findings and most
to supervisor education, 26 studies reported the education of super- reported that delivery agents delivered the intervention as intended.
visors, with 65% (n = 17) of those studies indicating that supervisors Across the three studies that reported assessing the feasibility of the
had graduate-level education. One study from LMICs reported supervi- intervention, feasibility was conceptualized as the recruitment rate
sors with secondary-level education. Weekly supervision was the most of participants, retention and attrition of participants, intervention
commonly reported supervision frequency (n = 29). completion rates, and participant-reported adherence to the interven-
tion. Overall, these data suggest that the interventions demonstrated
feasibility in their respective contexts.
Intervention cost

Twenty-one studies (17%) reported conducting an analysis of the inter-

Meta-analysis of moderating role of implementation
vention’s cost, but only 15 provided data on the actual cost of the
characteristics on intervention impacts
intervention per child or family. Only six studies (three each in HICs and
LMICs) reported data on the cost-effectiveness, benefit–cost ratios, or
Sixty-five studies provided a total of 68 effect sizes of intervention
returns on investment associated with the parenting intervention.
impacts on children’s cognitive development. There was a moder-
ate positive impact of parenting interventions on improving cognitive
Implementation evaluation development (SMD = 0.31 [95% CI: 0.23−0.38], p < 0.001; I2 = 87.8%,
p < 0.001; Figure 3). Egger’s regression test was nonsignificant (p =
Finally, 76% of studies indicated that some aspect of the intervention’s 0.602), suggesting minimal publication bias. For parenting practices,
implementation (e.g., reach, fidelity, feasibility, acceptability) was eval- 39 studies provided 54 effect sizes, with a moderate positive meta-
uated and 57% reported the results of this evaluation. Again, studies analytic impact of parenting interventions on improving parenting
published from 2008 to 2022 were more likely to report these data practices (0.34 [0.24−0.44], p < 0.001; I2 = 92.3%, p < 0.001; Figure 4).
(66–82%). Although more studies from LMICs reported conducting an Again, there was minimal publication bias (p from Egger’s regression
implementation evaluation (83% vs. 74% in HICs), studies conducted in test = 0.475). Similar to the findings from Jeong et al.,2 country income
HICs were more likely to report the results of the evaluation (58% vs. level moderated intervention impacts on children’s cognitive develop-
45% in LMICs). ment (HIC: 0.17 [0.10−0.24] vs. LMIC: 0.38 [0.27−0.49]) and parenting
Among the n = 95 studies that reported evaluating the interven- practices (HIC: 0.09 [0.00−0.17] vs. LMIC: 0.48 [0.36−0.60]), such that
tion’s implementation, the characteristics assessed were the interven- parenting interventions conducted in LMICs had greater effects on
tion’s reach (i.e., proportion of the intended population participating both outcomes.
in the intervention13 ; 75%), fidelity (i.e., extent to which the deliv-
ered program is implemented as intended, as indicated in the original
protocol13 ; 56%), acceptability (i.e., the perception among stake- Moderation analyses
holders [e.g., beneficiaries, delivery agents] that an intervention is
agreeable43 ; 25%), and feasibility (i.e., the extent to which an inter- Tables 6 and 7 present the meta-analytic effects on children’s cogni-
vention can be carried out in a particular setting or organization43 ; tive development and caregivers’ parenting practices stratified by 12
3%). Studies that asked for caregiver—and in some cases delivery implementation characteristics in LMICs and HICs, respectively. Only
agent—feedback about the intervention through surveys or qualitative studies reporting data on a given implementation characteristic were
in-depth interviews reported that most found the intervention to be included in the respective moderator analysis, leading to differences
acceptable. With respect to fidelity, studies reported using different in the number of studies included in each model. We found that none
constructs to determine the extent to which the intervention was deliv- of these implementation characteristics moderated the effect of par-
ered as planned, including testing delivery agents’ competencies during enting interventions on children’s cognitive development or parenting
and after training, examining the extent to which caregivers engaged practices in LMICs or HICs. We also found no significant moderating
with the intervention and practiced key behaviors at home, and assess- effect of intervention dosage across delivery modality and delivery set-
ing delivery agents’ compliance with intervention content. This latter ting in LMICs or HICs. This same pattern of results was found in Jeong
construct was mostly evaluated by supervisors using fidelity checklists et al. (2021).
or delivery agents self-reporting the extent to which they delivered the Table 8 presents a summary of the narrative review and meta-
intervention as planned. analysis findings.
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 131

TA B L E 6 Subgroup results for the effect of parenting interventions in low- and middle-income countries on children’s cognitive development
and caregivers’ parenting practices stratified by implementation processes.

Cognitive development Parenting practices

Moderator
n SMD (95% CI) p-value n SMD (95% CI) p-value
Use of existing parenting intervention
No 15 0.41 (0.20, 0.62) p ≥ 0.05 8 0.45 (0.17, 0.72) p ≥ 0.05
Yes 19 0.37 (0.21, 0.53) 12 0.48 (0.32, 0.65)
Length of delivery agents’ training
7 days or less 17 0.39 (0.21, 0.56) p ≥ 0.05 12 0.49 (0.31, 0.67) p ≥ 0.05
More than 7 days 12 0.37 (0.13, 0.62) 8 0.52 (0.27, 0.78)
Frequency of delivery agents’ supervision
Less frequently than weekly 13 0.56 (0.30, 0.82) p ≥ 0.05 – – –
(i.e., fortnightly, monthly,
etc.)
Weekly 10 0.31 (0.20, 0.41) – –
Use of intervention theory of change
No 26 0.39 (0.26, 0.51) p ≥ 0.05 13 0.45 (0.29, 0.61) p ≥ 0.05
Yes 12 0.36 (0.12, 0.60) 10 0.52 (0.30, 0.74)
Total number of behavior change techniques used
Less than 3 14 0.28 (0.18, 0.38) p ≥ 0.05 5 0.36 (0.21, 0.50) p ≥ 0.05
3 or more 24 0.42 (0.26, 0.58) 18 0.51 (0.36, 0.66)
Use of self-performance as a behavior change technique
No 19 0.29 (0.20, 0.38) p ≥ 0.05 7 0.35 (0.18, 0.53) p ≥ 0.05
Yes 19 0.45 (0.25, 0.64) 16 0.52 (0.36, 0.68)
Use of demonstrations/modeling as a behavior change technique
No 14 0.29 (0.16, 0.42) p ≥ 0.05 6 0.50 (0.12, 0.88) p ≥ 0.05
Yes 24 0.42 (0.26, 0.58) 17 0.48 (0.35, 0.61)
Use of social support as a behavior change technique
No 23 0.42 (0.25, 0.59) p ≥ 0.05 11 0.38 (0.23, 0.53) p ≥ 0.05
Yes 15 0.33 (0.24, 0.41) 12 0.58 (0.39, 0.77)
Inclusion of additional caregivers in intervention
No 25 0.41 (0.24, 0.57) p ≥ 0.05 13 0.38 (0.25, 0.52) p ≥ 0.05
Yes 13 0.33 (0.23, 0.43) 10 0.61 (0.39, 0.83)

Cognitive development Parenting practices

Moderator
n SMD (95% CI) p-value n SMD (95% CI) p-value
Nature of intervention
Universal 20 0.32 (0.17–0.47) p ≥ 0.05 13 0.53 (0.34–0.72) p ≥ 0.05
Targeted 18 0.45 (0.28–0.63) 10 0.41 (0.25–0.58)
Individual home visits: frequency of sessions
Other frequencies (i.e., 6 0.20 (0.03, 0.37) p ≥ 0.05 – – –
fortnightly, monthly, varied,
etc.)
Weekly 8 0.42 (0.23, 0.61) – –

Note: p-Value corresponds to test of subgroup differences. Only studies reporting data on a given implementation characteristic were included in the respec-
tive moderator analysis, leading to differences in the number of studies included in each model. The moderator analyses for the individual home visits (number
and length of sessions and total contact hours), individual clinic visits, community-based group sessions, and sessions with mixed delivery modalities and/or
settings variables were not conducted because there were less than 4 degrees of freedom in the models.
Abbreviations: n, number of RCTs represented in subgroup analysis; SMD, standardized mean difference.
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
132 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

TA B L E 7 Subgroup results for the effect of parenting interventions in high-income countries on children’s cognitive development and
caregivers’ parenting practices stratified by implementation processes.

Cognitive development Parenting practices

Moderator
n SMD (95% CI) p-value n SMD (95% CI) p-value
Use of existing parenting intervention
No – – – – – –
Yes – – – –
Length of delivery agents’ training
7 days or less – – – – – –
More than 7 days – – – –
Frequency of delivery agents’ supervision
Less frequently than weekly – – – – – –
(i.e., fortnightly, monthly,
etc.)
Weekly – – – –
Use of intervention theory of change
No 10 0.18 (−0.01, 0.38) p ≥ 0.05 6 0.15 (−0.11, 0.42) p ≥ 0.05
Yes 17 0.17 (0.08, 0.25) 10 0.07 (−0.03, 0.17)
Total number of behavior change techniques used
Less than 3 26 0.16 (0.09, 0.23) p ≥ 0.05 7 0.14 (−0.03, 0.30) p ≥ 0.05
3 or more 15 0.18 (0.05, 0.31) 9 0.07 (−0.06, 0.19)
Use of self-performance as a behavior change technique
No 15 0.17 (0.07, 0.27) p ≥ 0.05 – – –
Yes 12 0.16 (0.03, 0.29) – –
Use of demonstrations/modeling as a behavior change technique
No 26 0.16 (0.03, 0.28) p ≥ 0.05 – – –
Yes 15 0.17 (0.07, 0.27) – –
Use of social support as a behavior change technique
No – – – – – –
Yes – – – –
Inclusion of additional caregivers in intervention
No 15 0.17 (0.00, 0.27) p ≥ 0.05 – – –
Yes 12 0.17 (0.02, 0.30) – –

Cognitive development Parenting practices

Moderator
n SMD (95% CI) p-value n SMD (95% CI) p-value
Nature of intervention
Universal – – – – – –
Targeted – – – –
Individual home visits: frequency of sessions
Other frequencies (i.e., – – – – – –
fortnightly, monthly, varied,
etc.)
Weekly – – – –

Note: p-Value corresponds to test of subgroup differences. Only studies reporting data on a given implementation characteristic were included in the respec-
tive moderator analysis, leading to differences in the number of studies included in each model. The moderator analyses for the individual home visits (number
and length of sessions and total contact hours), individual clinic visits, community-based group sessions, and sessions with mixed delivery modalities and/or
settings variables were not conducted because there were less than 4 degrees of freedom in the model.
Abbreviations: n, number of RCTs represented in subgroup analysis; SMD, standardized mean difference.
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 133

FIGURE 3 Forest plot for the effect of parenting interventions on cognitive development.

DISCUSSION sector (e.g., community health workers, nurses, doctors). Most inter-
ventions were delivered individually to caregivers in their homes on a
We conducted the largest and most comprehensive systematic review weekly basis, with an average of 21 1-h sessions. With respect to the
of the implementation characteristics of parenting interventions to meta-analysis, none of the identified implementation characteristics
promote child development in the first 3 years of life, including the significantly moderated intervention impacts on children’s cognitive
first meta-analysis of the extent to which these implementation char- development and parenting practices in LMICs or HICs.
acteristics moderated intervention impacts on child and caregiver Overall, the findings of the narrative review suggest that although
outcomes in HIC and LMIC contexts. For the most part, interven- there has been an increase in the reporting of certain intervention
tions were administered by delivery agents working in the health implementation characteristics in recent years, significant gaps still
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
134 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

FIGURE 4 Forest plot for the effect of parenting interventions on parenting practices.

remain in our understanding of how interventions are implemented self-efficacy theories, family systems theory, and Bowlby’s theory of
and how these characteristics may influence intervention outcomes. human attachment. These are helpful theories for identifying the pro-
For example, most studies reported the occupational status of the cess of change through which an intervention can lead to behavior
delivery agents who administered the intervention, yet less than a changes in caregivers.46 To improve our understanding of how to moti-
third specified if and how the intervention had been integrated into vate and sustain effective caregiving practices, future studies should
the existing roles and responsibilities of delivery agents. Addition- not only conceptualize a theory of change within which to ground an
ally, although the majority of interventions reported using an existing intervention, but also the specific behavior change techniques that are
curriculum and manual to guide sessions, only half of them specified being implemented to promote behavior change in caregivers.3,11 Iden-
the theory of change, conceptual framework, or proposed mediator(s) tifying these techniques will not only improve understanding of how
that explained the mechanisms through which the intervention was parenting interventions are leading to expected changes in caregivers’
expected to encourage changes in target behaviors or outcomes. Stud- parenting behaviors, it will also advance scientific understanding of
ies that reported a theory of change tended to focus on social and how specific parenting behaviors mediate intervention impacts on ECD
psychological theories such as Bandura’s social–cognitive learning and outcomes.
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 135

TA B L E 8 Summary of findings.

Narrative review Meta-analysis

∙ Most interventions used evidence-informed and structured ∙ Parenting interventions had a moderate positive impact on children’s
curriculum. However, only half of studies specified underlying theory cognitive development (0.31 [0.23–0.38])a and caregivers’ parenting
of change. The most reported theories were social-cognitive learning practices (0.34 [0.24–0.44]).a These effects were moderated by
theory, family systems theory, Bowlby’s theory of human attachment, country income level, with interventions in LMICs having greater
and Bandura’s theory of self-efficacy. impacts on both outcomes compared to those in HICs.
∙ All studies included a component of the Nurturing Care Framework, ∙ We tested whether 12 implementation characteristicsb moderated
with more than half of them including content related to the these meta-analytic effects in interventions conducted in LMICs and
responsive caregiving and early learning opportunities components. HICs. None of the identified implementation characteristics were
∙ Across interventions in LMICs and HICs, the most commonly used significant moderators.
behavior change techniques were direct caregiver engagement with
child coupled with delivery agent’s feedback and modeling of the
intended behavior by the delivery agent or a model caregiver.
∙ Approximately one-third of studies reported information on
preparatory work before interventions were implemented. Formative
research primarily consisted of pilot studies and program adaptations
mainly consisted of changes to the intervention’s content.
∙ Mothers were the primary beneficiaries of most interventions. Only
38% of studies indicated whether additional caregivers had been
invited to participate. Additional caregivers were usually fathers and
grandmothers of the target child.
∙ Half of interventions used individual home visits, 12% used individual
clinic visits, 11% used community-based group sessions, 25% used
mixed settings and modalities, and 2% had multiple intervention arms
with different settings and modalities. Two interventions compared
the effectiveness of different delivery modalities (home vs. group and
group vs. mixed delivery) on child and parent outcomes and found no
significant differences.
∙ Recent interventions (post-2007) and those conducted in HICs were
more likely to be targeted to a specific group, whereas interventions
in LMICs were more likely to be universal. The most frequently
targeted groups were low-income families, socially vulnerable
families, and malnourished children.
∙ Considerable variation in reporting about training and supervision of
delivery agents. Most delivery agents worked in health sector (i.e.,
community health workers, nurses, doctors). Delivery agents in HICs
were more likely to have an undergraduate or higher level of
education, whereas those in LMICs usually had secondary or some
secondary education. On average, delivery agents received 7 days of
training on intervention content and most of them received weekly
supervision.
∙ Close to 60% of interventions reported findings from their
implementation evaluations. These evaluations primarily focused on
assessing intervention reach, fidelity, and acceptability. Overall,
delivery agents delivered the intervention as intended and both
caregivers and delivery agents had positive impressions of the
intervention.

a
Numbers represent standardized mean differences and their 95% confidence intervals.
b
The 12 implementation characteristics were: (1) use of an existing parenting intervention curriculum; (2) specification of an intervention theory of change;
(3) total number of NCF components addressed; (4) total number of behavior change techniques used; (5) use of direct caregiver engagement with their
child as a behavior change technique; (6) use of demonstration or modeling of key behavior by delivery agent or a model caregiver as a behavior change
technique; (7) use of social support from family members or from the community as a behavior change technique; (8) nature of intervention; (9) inclusion of
additional caregivers; (10) number of days of delivery agents’ training; (11) frequency of supervision of delivery agents; and (12) intervention dosage (number,
length, and frequency of sessions, total contact hours) across delivery modalities (individual, group, mixed) and settings (home, clinic, community, virtual,
mixed).

One key component of implementation research is conducting haps because it is not included in the reporting guidelines for RCTs,
preparatory research to better understand and adapt to the contextual or because the program was developed or previously implemented in
variables that can influence the implementation of an intervention in that setting. Regardless, preparatory research is helpful for identifying
a given setting. Researchers do not often report this information, per- solutions to existing implementation challenges or an extension of the
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
136 ANNALS OF THE NEW YORK ACADEMY OF SCIENCES

intervention to a different workforce.47 Documenting this information the characteristics of interest. It is, therefore, not clear whether the
would be useful to other researchers who might face similar changes. lack of significant findings is due to the limited number of studies
This information could also be useful when integrating interventions included in the meta-analysis or that these implementation character-
into existing systems, as this helps to ensure efficient integration that istics play no moderating role in the impact of parenting interventions
aligns with the current roles and responsibilities of the target system on child and parent outcomes. For example, one study tested home vis-
without overburdening delivery agents. For example, Yousafzai et al.23 iting frequency as a moderator of intervention effectiveness and found
and Phuka et al.48 identified issues related to strengths, knowledge that more frequent home visits (i.e., weekly compared to fortnightly or
gaps in the content being delivered by the workforce, and high deliv- monthly) were associated with improved developmental outcomes,51
ery agent workloads as part of their preparatory research in Pakistan whereas Jeong et al.’s meta-analysis found no significant moderating
and Malawi, respectively. Solutions to these and other challenges in effects of a handful of implementation characteristics on parenting
the use of volunteers, such as lack of experience and expertise and the intervention effectiveness.2 Additional data are needed to understand
high rate of turnover, require preparatory research. Another challenge whether and how this and other implementation characteristics may
that benefits from preparatory research concerns how to integrate be associated with intervention impacts on parenting and other ECD
an intervention into a larger system. Many small-scale programs use outcomes. Specifically, increased reporting of implementation features
an existing workforce but seek to eventually integrate the program will permit further nuanced analyses to understand the interactions
throughout the system. Preparatory research in this case requires between dosage, delivery, modality, delivery setting, and quality of an
detailed information on the training of an expanded workforce, training intervention, as well as whether and how they may be associated with
and deployment of supervisors, and the development of an information program effectiveness. Hypothesis testing of implementation features
system. Moreover, if the country has a national policy on early child- in diverse contexts (e.g., humanitarian emergencies) for future parent-
hood, then accountability to integrate parenting interventions within ing trials is also necessary to determine how best to maximize their
the system requires monitoring and costing information. impacts on caregiver and child outcomes across contexts. Finally, con-
With respect to intervention context, further research is also sensus building on terms such as “quality” in parenting interventions
needed on the costing of parenting interventions. Specifically, inter- is required, as well as the use of standardized tools to measure these
ventions need to report two key pieces of information: (1) the cost constructs.
of implementing the intervention, so as to inform efforts to scale Given the dearth of data on implementation features to allow for
up delivery and (2) the cost-effectiveness of the intervention, to quantitative analyses, we echo recent calls to improve implementa-
determine how much financial investment is needed to achieve signif- tion reporting and measurement of implementation fidelity.11,17,52 To
icant impacts on child and caregiver outcomes.49 A group of authors advance our evidence base from efficacy trials and small-scale pilot
recently developed an economic evaluation framework that enabled studies and to inform decisions on implementation in existing services
direct value-for-money comparisons of 12 parenting interventions (11 or to transition to scale, we recommend the use of tools such as the
of which met inclusion criteria for this review) across settings and C.A.R.E. and TIDieR (Template for Intervention Description and Repli-
found significant variation in incremental cost-effectiveness ratios, cation) guidelines to document factors affecting implementation, how
ranging from $US 29 to $US 5063 per standard deviation increase interventions are introduced into systems, and implications for scale
in ECD (cognitive, language, motor, and socioemotional) outcomes.50 and sustainability.11,53 Additional tools are also needed to evaluate the
Similar to our review, Verguet and colleagues’ analysis was lim- implementation of interventions, including their reach, fidelity, accept-
ited by a scarcity of costing data across studies. There is clearly a ability, feasibility, and quality.52 A little over half of the studies included
need for more comprehensive and standardized collection of costing in this review reported the results of their implementation evaluations,
data—both in the short- and long-term—to better understand the eco- with more recent (i.e., post-2007) studies and those conducted in HICs
nomic impacts and benefits of investing in interventions to promote being more likely to report such data. The majority of studies reported
ECD. data on intervention reach and fidelity. Efforts are needed to develop
In addition to summarizing the implementation characteristics of core, high-quality metrics of implementation characteristics to facili-
parenting interventions, we sought to identify the active ingredients tate the evaluation and comparison of intervention implementation.52
of interventions in LMIC and HIC contexts by analyzing the extent to The lack of implementation metrics in the field may also be a bar-
which specific features moderated intervention impacts on children’s rier to the effective integration of parenting interventions into existing
cognitive development and caregivers’ parenting practices outcomes. systems and for improving impact at-scale for which implementation
By examining the moderating role of potential active ingredients (or metrics could offer insights on actions needed for iterative design
common elements) in how effective an intervention is in improving modifications needed for quality improvements.54 Moreover, the lack
outcomes of interest, our hope was to provide valuable informa- of implementation data is an impediment to reaching consensus on how
tion that could be used to facilitate decision-making regarding the we can define and measure a “high-quality” parenting program. Lessons
key components to include in a parenting program. As with prior can be drawn from the field of early childhood education where there
attempts to quantitatively analyze the moderating role of implemen- has been an increased focus on defining quality (structural and pro-
tation characteristics,16 our study was significantly restricted by the cess), developing standardized tools (e.g., the Measuring Early Learning
small numbers of studies in both LMICs and HICs reporting data on Environments scale55 ), and analyzing how quality moderates child
 17496632, 2024, 1, Downloaded from https://nyaspubs.onlinelibrary.wiley.com/doi/10.1111/nyas.15110 by National Institutes Of Health Malaysia, Wiley Online Library on [06/01/2025]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ANNALS OF THE NEW YORK ACADEMY OF SCIENCES 137

outcomes. Such an effort will enable future comparisons of parenting and understand why and how parenting interventions to promote ECD
programs implemented in diverse settings. work in real-world settings.
Our review has many strengths, including a comprehensive sum-
AUTHOR CONTRIBUTIONS
mary of how parenting interventions are implemented in diverse
M.N.A. and A.K.Y. were responsible for the conceptualization of the
settings and a meta-analysis of how different implementation char-
study. J.J. and E.F. prepared and executed the search strategy and con-
acteristics are associated with intervention impacts on two key child
ducted article screening and identification. M.N.A., N.B.A., and E.H.
and caregiver outcomes across LMICs and HICs. Nevertheless, there
were responsible for data extraction, with input from A.K.Y. M.N.A.
are some limitations that should be noted. Due to the lack of prior
ran the meta-analysis and prepared all tables and figures. M.N.A. pre-
empirical data on how the selected implementation characteristics may
pared the first draft of the manuscript with input from N.B.A., E.H., and
moderate intervention impacts on child and caregiver outcomes, we
A.K.Y. All authors reviewed the manuscript and contributed to subse-
were limited in our reliance on the use of median split (and mode for
quent drafts of the paper during the revision process, led by M.N.A.
the frequency of intervention sessions variable) to determine binary
The corresponding author, M.N.A., had full access to all the data in
categories in the meta-analysis. As suggested earlier, the adoption of
the study and had final responsibility for the decision to submit for
standardized reporting of implementation characteristics—such as the
publication.
C.A.R.E. and TIDieR guidelines11,53 —can help improve the documenta-
tion of implementation features and thus facilitate future analyses on
ACKNOWLEDGMENTS
how implementation influences intervention impact and effectiveness.
M.N.A. was supported by a postdoctoral fellowship from the Canadian
Due to the small number of studies reporting implementation data,
Institutes of Health Research (#181899).
we focused our moderation analysis on one child and one caregiver
outcome. Additionally, this review contains a few studies reporting on
COMPETING INTERESTS
parenting interventions that have been implemented at scale. This is
The authors declare no competing interests.
likely due to our exclusion of nonrandomized study designs, a decision
that was made to ensure that we could examine the moderating role
ORCID
of implementation characteristics on the causal impact of an interven-
Marilyn N. Ahun https://orcid.org/0000-0002-1062-7240
tion on a given outcome in a randomized trial. Our review, therefore,
Joshua Jeong https://orcid.org/0000-0002-4130-468X
presents a limited analysis of how implementation features moderate
the effectiveness of interventions implemented at different levels of
PEER REVIEW
scale. Overall, the limitations of our meta-analysis are primarily due to
The peer review history for this article is available at: https://publons.
the limitations of the available data. The reported findings are, there-
com/publon/10.1111/nyas.15110
fore, likely to change as more data on interventions’ implementation
characteristics are reported. Additionally, ensuring that future stud-
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