Reach Up Origins: Jamaica Home Visit Programme

The Reach Up Early Childhood parenting program: origins, content and implementation

Susan P Walker, Susan M Chang, Joanne A Smith, Helen Baker-Henningham and the Reach Up Team, Caribbean Institute for Health Research, The University of the West Indies, Kingston, Jamaica and School of Psychology, Bangor University, UK (HBH)


Nurturing care in early childhood requires responsive interactions and opportunities to learn. There are few large scale programs in low and middle income countries that support parents’ ability to provide responsive care and activities that help children learn. The Reach Up training program was developed to increase capacity of implementing agencies to deliver effective parenting programs for children up to age 3 years. The program provides a comprehensive training package for trainers, supervisors, and home visitors. Based on the Jamaica Home Visit intervention which has substantial impact evidence, Reach Up has been used in several countries where it has provided evidence of its feasibility and lessons that can guide future implementation.

We developed the Reach Up Early Childhood Parenting Program and accompanying training package to provide an effective, adaptable program, feasible for low resource settings. Our aim is to facilitate building the capacity needed to implement these programs. In this article we describe the origins and content of the program and discuss the process of adapting and implementing the program with lessons learned from implementation in several countries.

The Reach Up Early Childhood Parenting Program is based on the Jamaica Home Visit (JHV) intervention designed by Sally Grantham-McGregor. The JHV has substantial evidence showing benefits to children’s development and to parenting practices that promote development (Grantham-McGregor & Smith, 2016). The intervention has been successfully adapted and evaluated in Bangladesh and Colombia with benefits to children’s development (Attanasio et al., 2014; Hamadani, Huda, Khatun, & Grantham-McGregor, 2006; Nahar et al., 2012), and was adapted and implemented at a large scale by the Peruvian government through its Cuna Mas program (Rubio-Codina, Tomé & Araujo, 2016). There is also evidence from 3 small cohorts in Jamaica that benefits continue into later childhood with one cohort providing evidence of wide ranging gains in adulthood to education, mental health and income and reductions in violent behavior (Grantham-McGregor, Powell, Walker, Chang, & Fletcher, 1994; Walker, Chang, Younger, & Grantham-McGregor, 2010; Walker, Chang, Vera-Hernandez, & Grantham-McGregor, 2011).

Core principles of the JHV/Reach Up Early Childhood Parenting Program

  • Works through parents by building a positive relationship to support them in strengthening skills to promote child development.
  • Aims to build mothers’ skills, self-esteem and enjoyment in helping her child play and learn.
  • Home visitor is trained to listen to the mother, seek her opinions and ask about things she already does with her child and to acknowledge these and give encouragement and praise.
  • Uses a structured curriculum of develpmentally appropriate activities
  • Uses an interactive approach of demonstration and modelling and practice of activities to build skills.
  • Emphasises praise for parent and child.

The intervention is guided by core principles and was developed so that it could be delivered by para-professionals with a minimum of completed primary education. The visits begin with some time catching up with how the family has been and how the mother and child have progressed with the activities from the last visit. The visitor then engages the mother and child in a play session. The home visotor introduces new activities through an interactive approach: observing what the child does, demonstrating and describing the activity to mother and child, helping the child with the activity, encouraging mother and child to practise, giving positive feedback and celebrating success. The visit ends with review of activities to continue during the week and encouragement to continue the activities and to try and include them in daily routines.

The home visitors model desired actions and demonstrateactivities to encourage mothers to respond to their child’s vocalisations and actions. They demonstrate ways to talk about and show her child objects and activities in their environment, and how to introduce new activities and concepts. The visitors promote giving praise, celebrating the child’s achievements and efforts, and showing love throughout the visit.

The JHV uses a structured curriculum with activities arranged in order of difficulty; children usually move on to the next set of activities each week (Grantham-McGregor & Smith, 2016). Many activities build on earlier ones, so that if a child can already do one the visitors can introduce the next step. An activity can be also be broken down in steps if it is difficult for the child. Activities and play materials are specifically designed for the intervention, and include blocks, dolls, sets of puzzles, sorting and matching activities, and books. Toys were designed with locally available and affordable materials in mind such as cardboard and plastic bottles. Simple picture books and pictures are used to support language development activities.

Many of the activities for children under 2 years support abilities described by Uzgiris & Hunt (1978) including object permanence, causation, imitation of gestures and vocalization, and exploration of objects. For older children, activities were informed by Francis Palmer’s concept curriculum (Palmer, 1971) and were designed to facilitate teaching concepts such as size, quantity, colour, shape, position, and classification. Additional activities were included to facilitate the development of problem solving, attention and persistence, language and general knowledge.

Prior to developing the Reach Up program, with support from Grand Challenges Canada, the JHV had been adapted and used in Bangladesh, Colombia, and Peru. There was an increasing desire internationally, to scale up programs to reach the many families in need, however, policy makers and program implementers needed guidance on how to deliver effective parenting programs. We recognized the need for a more comprehensive training package that would make it easier to train trainers, and for these trainers to be able to train home visitors. The goal was to increase the capacity of implementing agencies including NGOs and governments to deliver programs that enhance nurturing care for children under 3 years.

The Reach Up Program

The existing JHV training materials included the curriculum and an instruction manual that explained how to make the toys. The curriculum is designed for use by community workers with primary education and gives activities and goals for each visit. The manual was updated using simple language and pictures, with plans for each visit organized by Materials needed, Objectives of the visit, and Things to Do. To support the home visitor, the curriculum incudes brief reminders of the steps for introducing an activity and some suggested dialogue. We produced a curriculum for weekly visits, as in the original JHV, and a fortnightly curriculum (biweekly visits) which may be more feasible for use in larger scale programs.

Curriculum Manuals

The original toy manual was revised and extended, and templates were produced or revised for other play materials including books, pictures, puzzles, and classification games. We developed three additional manuals to facilitate training and implementation. The manuals are: 1) an adaptation and planning guide; 2) a training manual with accompanying training films; and 3) a manual on supervision to be used to train supervisors and that supervisors could have to refer to for guidance. These are designed for use by persons who will adapt the program and prepare for its implementation, and for those who will conduct training of visitors and supervisors. Training Content The training manual includes a suggested training schedule, aims and activities for each training session, and guides for using various aids e.g. flipchart and films, in the training sessions. The content includes topics such as how children develop and the importance of parents, how to conduct a successful home visit, how to use the curriculum, how to demonstrate specific activities and toy making.

Training is interactive and includes brainstorming, demonstrations of good interactions by the trainer in person and in films, role plays, and small group activities. Towards the end of the training, the trainees practice putting together the methods and activities learned as a complete visit. Following the workshop training, visitors are accompanied on practice home visits.

Training Films

Scripts for the training films were developed by the Reach Up team in collaboration with Development Media International who produced the films. Filming was done in Jamaica, Peru, and Bangladesh with a Reach Up team member on site for all films to ensure they were consistent with the program’s approach and methods. The films show home visitors interacting with a parent and child. Three 15-minute films (one in each country) demonstrate key steps in a home visit such as the intial interaction and discussion of the past week, demonstration of a play and language activity, and the ending with a song and review of new activities and encouragement. There are 28 short films of approximately 2-3 minutes that show methods used (e.g. Building a positive relationship with the parent, praise, enjoying the visit and having fun) and demonstrate specific activities (e.g. blocks, puzzles). The films are available in English, Spanish, French and Bengali and some additional translations have been done by those implementing the program (e.g. Portuguese, Mandarin).

In an effort to support continued implementation quality, the Reach Up package is made available to organizations that agree to have someone experienced in the program provide feedback on adaptation and conduct the training of trainers. The program has been implemented in 11 countries across Asia, Africa and Latin America and we are now collaborating with the International Rescue Committee in the expansion of early childhood services for Syrian refugees. Collaborations are also planned to reach disadvantaged families in the USA and UK. We are continuing to develop a network of lead trainers needed for the expansion of the program. As the program is implemented in new countries we aim to build training capacity in the implementing team. Our goal is to have lead trainers available in different regions who could support adaptation and training in further countries.

Author Bios

Susan P Walker PhD is a professor and Director of the Caribbean Institute for Health Research at The University of the West Indies, Jamaica. Her work with the Child Development Research Group at UWI involves rigorous evaluations of interventions to promote children’s development in low resource settings, and has been critical in driving global attention to the importance of stimulation for children under 3 years. She is an internationally recognized expert in global child development and was lead author in papers in the Lancet series (2007, 2011) on child development.

Susan M Chang, PhD is a senior lecturer at the Caribbean Institute for Health Research at The University of the West Indies, Jamaica. She has extensive experience in developmental assessments and in the adaptation of psychometric instruments in Jamaica and other developing countries. Her research activities are focused on the impact of low-cost psychosocial interventions on the cognitive, academic and behavioural development of vulnerable children.

Joanne A Smith is a Lecturer at the Caribbean Institute for Health Research of the University of the West Indies, Mona, Jamaica. She graduated with a PhD in Nutrition in 2014 from the University of the West Indies. She is a project coordinator for the Reach Up program, where she assists in the training and implementation of the program in the various user countries.

Helen Baker-Henningham, PhD is a Reader in the School of Psychology at Bangor University and has a visiting appointment at the Caribbean Institute for Health Research, UWI. Her research involves designing, implementing and evaluating early childhood interventions to promote child development, behavior and mental health and to prevent violence against children in low and middle-income countries.

Reach Up Team

The Reach Up program was developed by Sally Grantham-McGregor, Susan Chang-Lopez, Christine Powell, Susan Walker, Helen Baker-Henningham, Jena Hamadani, Marta Rubio-Codina, Joanne Smith, Amika Wright, Kristy Fernandez.

Reference List

Attanasio, O. P., Fernandez, C., Fitzsimons, E. O., Grantham-McGregor, S. M., Meghir, C., & Rubio-Codina, M. (2014). Using the infrastructure of a conditional cash transfer program to deliver a scalable integrated early child development program in Colombia: cluster randomized controlled trial. BMJ, 349, g5785.

Black, M. M., Walker, S. P., Fernald, L. C. H., Andersen, C. T., DiGirolamo, A. M., Lu, C. et al. (2017). Early childhood development coming of age: science through the life course. Lancet, 389, 77-90.

Grantham-McGregor, S., Powell, C., Walker, S., Chang, S., & Fletcher, P. (1994). The long-term follow-up of severely malnourished children who participated in an intervention program. Child Dev., 65, 428-439.

Grantham-McGregor, S. & Smith, J.A. (2016). Extending The Jamaican Early Childhood Development Intervention. Journal of Applied Research on Children: Informing Policy for Children at Risk, 7, Article 4. Grantham-McGregor, S. M., Powell, C. A., Walker, S. P., & Himes, J. H. (1991). Nutritional supplementation, psychosocial stimulation, and mental development of stunted children: the Jamaican Study. Lancet, 338, 1-5.

Hamadani, J. D., Huda, S. N., Khatun, F., & Grantham-McGregor, S. M. (2006). Psychosocial stimulation improves the development of undernourished children in rural Bangladesh. Journal of Nutrition, 136, 2645-2652.

Nahar, B., Hossain, M. I., Hamadani, J. D., Ahmed, T., Huda, S. N., Grantham-McGregor, S. M. et al. (2012). Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomised trial. Eur.J Clin.Nutr., 66, 701-709.

Palmer, F. (1971). Concept Training Curriculum For Children Ages Two To Five, vol 1-V. Stony Brook: State University of New York.

Powell, C., Baker-Henningham, H., Walker, S., Gernay, J., & Grantham-McGregor, S. (2004). Feasibility of integrating early stimulation into primary care for undernourished Jamaican children: cluster randomised controlled trial. BMJ, 329, 89-91.

Rubio-Codina, M., Tomé, R., & Araujo, M.C. (2016) Los primeros años de vida de los niños peruanos: una fotografía sobre el bienestar y el desarrollo de los niños del Programa Nacional Cuna Más. Inter-American Development Bank Technical Note IDB-TN-1093.

Smith, J.A., Henningham-Baker, H., Brentani, A., Mugweni, R. & Walker, S.P. (2018). Implementation of Reach Up early childhood parenting program. Appropriateness, Acceptability, Feasibility in Brazil and Zimbabwe. Ann. N. Y. Acad. Sci, in press.

Uzgiris, I.C. & Hunt, J.M. (1978). Assessment in Infancy: Ordinal Scales of Psychological Development. Chicago: University of Illinois Press.

Walker, S. P., Chang, S. M., Vera-Hernandez, M., & Grantham-McGregor, S. (2011). Early childhood stimulation benefits adult competence and reduces violent behavior. Pediatrics, 127, 849-857.

Walker, S. P., Chang, S. M., Younger, N., & Grantham-McGregor, S. M. (2010). The effect of psychosocial stimulation on cognition and behaviour at 6 years in a cohort of term, low-birthweight Jamaican children. Developmental Medicine and Child Neurology, 52, e148-e154.

Walker, S. P., Powell, C., Chang, S. M., Baker-Henningham, H., Grantham-McGregor, S., Vera-Hernandez, M., Lopez-Boo, F. (2015). Delivering parenting interventions through health services in the Caribbean: impact, acceptability and costs. IDB Working Paper Series. IDB-WP-642 Washington DC, Inter-American Development Bank.