Reach Up in Brazil

In her efforts to identify an intervention to promote early childhood stimulation in Brazil, Professor Alexandra Brentani from the Faculty of Medicine, University of São Paulo, through her networks, learned of the work of the UWI Child Development Research Group and the Reach Up program.

The intervention first began as a pilot in Brazil in the urban south west municipality of São Paolo, through funding provided by Maria Cecilia Vidigal Foundation and Grand Challenges Canada (GCC). It was tested through a randomized controlled trial, which included a total of 826 mother-child dyads.. At the time, the family health strategy (ESF) using community health agents was implemented as a primary care modality. Considering that the ESF coverage in Brazil was less than 30%, the intention was to test the relative effectiveness of implementing Reach Up as the ECD stimulation arm, through two delivery platforms – using Community Health Workers (CHWs) in areas covered by ESF and using agents from the community (CDAs) in areas not covered by ESF. In 2016, the Federal government launched the national ECD home visit program, the Programa Criança Feliz, nested in the Ministry of Social Development and using CDAs as the workforce.

The Reach Up adaptation was well received at the local level in São Paulo and was then transitioned to scale through the “Survive and Thrive Brazil: Boa Vista Early childhood program” in 39 vulnerable communities in Boa Vista, in the Amazon area in 2017. The project was funded by grand Challenges Canada, Maria Cecília Souto Vidigal Foundation and the Interamerican Development Bank. Implementation of the program was through two (2) delivery strategies, home visits delivered by the Programa Criança Feliz visitors and center-based group-meetings. This program was ongoing up to March 2020, when the COVID-19 pandemic began.

However, with the lockdowns and suspension of in-person interactions, the program was transitioned to remote delivery in June 2020. The Municipal Government of Boa Vista, in partnership with the Faculty of Medicine, University of São Paulo, (FMUSP) implemented the delivery of the content from the Reach Up Parent Manual to 4,000 families via audio, video and text messages.

In 2021, the research group created a Reach-up based methodology for the Programa Criança Feliz in a project funded by the LEGO Foundation and implemented it in 11 municipalities across Brazil, focusing on the improvement of the quality of the visits and the adaptation of the methodology to traditional communities and refugee settings.

Country team

Professor Alexandra Brentani

Department of Pediatrics, Faculty of Medicine University of São Paulo

Professor Günther Fink

Epidemiology and Household Economics, University of Basel, Household Economics and Health Systems Research Unit, Swiss Tropical and Public Health Institute

Implementation partners

Implementation of Reach Up is spear headed through faculty in the Department of Pediatrics and the Child Development Center, Faculty of Medicine, University of São Paulo, Bazil

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The mission of the Maria Cecilia Vidigal Foundation is to positively impact the development of children during their first years of life. The Foundation supported the pilot project in São Paulo in 2015

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Funded by the Government of Canada and other partners, Grand Challenges Canada funds innovators in low- and middle-income countries and Canada. Grand Challenges Canada through the Saving Brains (Grant 0583-03) supported the pilot project in São Paulo in 2015.

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The Reach Up program was designed to align with the Municipal Government of Boa Vista’s “Criança Feliz” program run by the Municipality Secretariat for Social Wellbeing and Health (SSWH).

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The Inter-American Development Bank (IDB) provides financial and technical support to national and sub-national governments and other entities in Latin America and the Caribbean. The IDB supported the conduct of the study in Boa Vista which began in 2020.

Communities we serve

In São Paulo the program is offered as research projects in Butantã and Jaguaré and in Boa Vista, participants from 43 B and C communities were recruited.

Map of communities served: Source: Brentani et al. Trials (2020) 21:390

Our Approach

Reach Up in Brazil, complements the existing government-run program, , the Criança Feliz (Happy Child) launched in 2016. We deliver the intervention through group sessions, home visits, or remote meetings.

Group sessions usually accommodate 8 mother/child dyads and are held at community social assistance centers. With the lockdowns and suspension of in-person interactions due to COVID-19, the program was transitioned to remote delivery in June 2020, using content from the Reach Up Parent Manual transmitted to caregivers via WhatsApp (video calls and messages) once per week, two phone calls per month and weekly text messages.

Key Stats

Since 2013, the Reach Up intervention has reached approximately 2,800 children in Sao Paulo (2013 and 2016) and Boa Vista (2017 and 2020). The children’s ages ranged between 0 – 36 months. The programs were delivered through fortnightly home visits and group sessions. Home visits lasted approximately 45 minutes and group sessions lasted 1 hour and 20 minutes. The various programs lasted 3 years, except for the 2016 home visiting modality in 2016 which lasted 12 months. The remote delivery, using weekly Whatsapp video calls and messages, twice monthly phone calls and weekly text messages, reached 4,000 families.

Organisational Structure

During the impact evaluation project in São Paulo SP, we trained and empowered two groups of home visitors – CHAs who were the existing cadre of staff in the primary care FHS program and CDAs, a new cadre of staff employed specifically by the research team at the University of Sao Paulo, for the project. During the Transition to Scale project, in Boa Vista in Roraima, the Program was implemented at the Social Assistance Sector, the Familia que Acolhe Program, using social visitors to deliver the visits and facilitate group meetings. Group sessions are held at community social assistance centers.

Community Social Assistance Centre (Courtesy of Alexandra Brentani)

Cultural Adaptations

Between 2014 and 2016, the Reach Up curriculum was adapted to the Brazilian context. We translated the training manual, toy manual, supervisor manual, and train-the-trainer video voiceovers into Portuguese. The adaptation included addition of short messages to the caregivers to the language activities and the revision of visit frequency (fortnightly rather than weekly). Based on feedback from 100 participants (who were not a part of the projects), modifications were made to some of the toys and materials. Additionally, instead of 10 consecutive days, the training was modified to a series of 5-day workshops. Transition to scale phase In 2017, in order to align with the Programa Criança Feliz, the national ECD policy, we extended the curriculum from Pregnancy to 36 months. Reach up was used as the PCF methodology in the municipality of Boa Vista, Roraima, in the north region of Brazil. Besides de home visits, we delivered the Program in small group meetings at the social service units. The extended version of the curriculum was also adapted to group meetings, with the reduction of activities per meeting (1 or 2 instead of 3 to 4). The toy kit was also reduced for the delivery at scale. During the curriculum adaptation, all toy activities that were used only once in the curriculum were substituted by other activities with toys used more frequently. We used 6 figures to talk about and 1 scene to talk about, 8 books, 13 puzzles, 12 sorting and matching cards, 18 plastic toys, and fewer pretend toys (tea set, doll house, truck and 2 roads, shop, butterfly lace board, village and cardboard farm were not included in the curriculum). In 2021, to be able to serve the large migrant and refugee population from the refugee shelters in Boa Vista, we tested the feasibility and acceptability of Reach Up in small groups. Since the length of stay in the shelters is relatively short (3 months in average), the Parent Manual was used so that the parents could continue practicing the activities with the children after leaving the shelter and because the activities require less toys, and many of them can be made by the caregiver or facilitator. To avoid the cultural and language barriers since most of the refuges came from Venezuela and speak Spanish instead of Portuguese, the different delivery strategies were tested, using a previously trained employee from the shelter to facilitate the meetings and using one person from the refugee community, who received the Reach Up training before facilitating the meetings.

Outcomes

Impact on children:
For the Sao Paulo trial, the primary outcome of interest was children’s cognitive development after 12 months of intervention. In per-protocol (PP) analysis, the CDA programme resulted in a 0.22 standard deviation increase in children’s development (Brentani, et al, 2021).
Cognition
Expressive and receptive language
Impact on caregivers, supervisors and home visitors:
In Smith et al’s study (2018) on the acceptability, appropriateness and feasibility of Reach Up in Brazil, supervisors, home visitors and mothers were interviewed. The mothers felt that they had support to help their child to develop, increased their confidence as parents and helped their child to develop for e.g. improvement in children’s readiness for school.

The supervisors and home visitors believed that the Reach Up materials (training manual, curriculum, etc), was effective in enabling them to carry out the intervention.

The home visitors felt that based on the training they received, they were well prepared to deliver the program.

Research & Publications

Brentani, A., Scolezze Ferrer, A., Bessa, L., et al (2020). Survive and Thrive in Brazil: The Boa Vista Early Childhood Program: study protocol of a stepped-wedge, randomized controlled trial. Trials, Published on 07 May 2020 Brentani, A., Walker, S., Chang-Lopez, S., Grisi, S., Powell, C. and Fink, G. (2021). A home-visit based early childhood stimulation programme in Brazil – a randomized controlled trial. Health Policy and Planning, 1-10. Rubio-Codina, Marta and Lopez Boo, Florencia (2022) What Have We Learned from the Hybrid Delivery of ECD Services During the Pandemic? IDB Publication. http://dx.doi.org/10.18235/0004411 Smith, J.A., Baker-Henningham, H., Brentani, A., Mugweni, R., Walker, S.P. (2018). Implementation of Reach Up early childhood parenting program: acceptability, appropriateness, and feasibility in Brazil and Zimbabwe. Ann N Y Acad Sci 2018;1419:120-40. Smith, J.A,. Chang, S.M., Brentani, A., et al (2023); A Remote Parenting Program and Parent and Staff Perspectives: A Randomized Trial. Pediatrics May 2023; 151 (Supplement 2): e2023060221F. 10.1542/peds.2023-060221F