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. Author manuscript; available in PMC: 2023 Aug 5.
Published in final edited form as: Parent Sci Pract. 2022 Aug 5;22(3):235–257. doi: 10.1080/15295192.2022.2086807

The Future of Parenting Programs: II Implementation

Jennifer E Lansford 1, Theresa S Betancourt 2, Kimberly Boller 3, Jill Popp 4, Elisa Rachel Pisani Altafim 5, Orazio Attanasio 6, Chemba Raghavan 7
PMCID: PMC9683038  NIHMSID: NIHMS1845382  PMID: 36439707

INTRODUCTION

Over the years there has been progress in understanding what parenting programs work successfully to provide supports to parents in their caregiving roles (Branco et al., 2021; Jeong et al., 2021). However, major gaps in knowledge about how these parenting programs work has resulted in a failure to sustain these programs with quality and at scale (Richter & Naicker, 2013). A critical step is identifying how different factors can enable or hinder the implementation process. Implementation science refers to the use of systematic data collection and research methods to enhance the dissemination and sustainment of evidence-based practices into routine operations (Proctor & Brownson, 2012). Support for the importance of implementation science is evident in the healthcare industry where implementation research has been used to increase the adoption and spread of evidence-based practices. Additionally, the importance of implementation for early childhood development programs has been documented, with calls for increased implementation research aimed at improving services and outcomes for children and families (Britto et al., 2018). In a recent call to action as part of an interagency vision, leading networks emphasized a coordinated global effort to innovate, scale-up, generate evidence, and advocate for initiatives that support parents and caregivers (https://covidaction.ecdan.org/parenting). Additionally, the Early Childhood Development Action Network, a network of organizations such as the Lego Foundation, UNICEF, and the World Health Organization has called for global mobilization of resources to support parents in their caregiving roles (ECDAN, 2021).

This article discusses how implementation science can be applied to evidence-based parenting programs in community settings by considering questions such as: What considerations are needed for parenting programs’ large-scale implementation to guarantee quality, fidelity, and sustainability? How can researchers, practitioners, and policy makers work together to implement parenting programs successfully? What are the benefits and challenges of these relationships between researchers and implementers of programs and policies? What strategies can help overcome implementation challenges, especially in low- and middle-income countries (LMICs)?

PRINCIPLES OF IMPLEMENTATION SCIENCE RELATED TO PARENTING PROGRAMS

Rigorous implementation science is often based on conceptual models that characterize features of the external and internal implementation context. Hybrid research designs have evolved to speed up the pipeline from intervention development to large scale implementation, allowing simultaneous study of implementation and effectiveness (Curran et al., 2012). Mixed methods often are used, and outcomes may focus on stakeholders at different levels of implementation, such as investigating outcomes at the provider and agency leadership level (Proctor & Brownson, 2012).

Explicit strategies for improving implementation success may be tested, including those focused on (1) moving national and sub-national policy into local practice, (2) aligning national and sub-national policy goals with those of local organizational leaders, and (3) motivating use of evidence-based practices. For example, high quality implementation requires that organizational leaders have good relationships with policy makers to co-create strategic plans. An implementation research project may explore an outcome such as buy-in from policy makers by comparing co-created implementation plans to a no-treatment condition (see Design, article I and Uptake, article III). Implementation science research on parenting programs may examine several levels of the implementation ecosystem from the individual parent beneficiary to the researcher and front-line workers as well as supervisors, organizational/agency leaders, and policy makers. At each level of the implementation ecosystem, researchers and their partners can address implementation science research questions that provide the most useful information necessary for improving policies and programs for a given setting (see Figure 1).

Figure 1.

Figure 1.

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Adapted from Betancourt & Chambers (2016).

Parenting programs can improve parenting outcomes (e.g., reducing parent-to-child violence; Altafim & Linhares, 2016; Leijten et al., 2020). However, to enable evidence-based strategies to have their intended impact, lessons learned from implementation science in global health and behavior change should be applied. Policy and financing alone do not ensure high-quality implementation. Policy makers, program leaders, and researchers must pay attention not only to what is being implemented but also how it is implemented. For example, as part of a teacher training evaluation, key questions include whether the evidence-based model’s training requirements are achieved (number of teacher and supervisor training hours, passing assessments and obtaining a credential, and whether supervisors meet teachers with intended frequency). The devil is in the details, and indicators like these determine whether an evidence-based model was implemented as originally designed and tested, while also allowing for flexibility and adaptation as needed without undermining the core active ingredients.

Implementation science methods have shown early promise in developing and adapting global parenting programs (Baumann et al., 2015; Lachman et al., 2016; Shenderovich et al., 2021). As the world emerges from the COVID-19 pandemic lockdowns in 2020 and 2021 that interrupted parenting and early childhood services, the field has an opportunity to use implementation science methods more widely in comparing service delivery options, such as returning to home visiting in person, conducting “visits” virtually, or creating a hybrid of in-home and virtual services as well as considering what elements are necessary for making programs more resilient to system disruptions.

A refined implementation science of global parenting program delivery would go beyond monitoring and evaluation to further elucidate key factors in approach and lessons learned across a range of implementation contexts and cultures. For instance, agency and individual staff “readiness for change” or “stakeholder buy-in” for the use of evidence-based practices are two examples of critical policy constructs that could be examined across a range of settings. Implementation science also contributes to improving programs and policies by allowing researchers and agencies to better assess what works for whom under what circumstances and the mechanisms by which behavior change occurs when using evidence-based programs, objectives that are held not just in implementation science but also in realist evaluations (Pawson & Tilley, 1997). Additionally, developing parenting programs’ theory of change can help researchers and practitioners to examine not just whether a program is effective, but also how, why, and under what conditions a program does or does not work (Center on the Developing Child, 2017; Schindler et al., 2017).

Parenting programs require more research on strategies for quality improvement and the sustainment of evidence-based practices. For example, feedback loops where data are collected and applied immediately to guide rapid improvements in service delivery can help to overcome barriers as a program is scaled up and sustained. Particularly in LMICs and when working with underserved or disenfranchised communities in high-income countries, implementation of parenting programs should also be closely tied to issues of social justice and equity, with attention to power dynamics among the participants, service providers, and researchers (Baumann et al., 2019).

Globally, the impact of evidence-based programs on parenting has been limited. One reason may be poor fit to context and lack of science-informed systems for comparing one implementation strategy to another. Unfortunately, there has been a tendency to adapt and then take an evidence-based approach from one place to another without attending to situation-specific factors that may reduce implementation quality and, ultimately, outcomes. Quality improvement initiatives can be tested systematically (Arbour et al., 2019). Implementation science in health care has expanded greatly, driven by a demand for quality and efficiency in health services. A potential solution to advance the fields of parenting and child development is to apply lessons from implementation science in health to global parenting policy, program development, and research. Systems supports for implementation may be more robust for parenting programs than for some health interventions, because parenting programs can be situated not just in the health sector but also in education, child protection, and others.

Implementation with experimentation at the core makes it possible to course correct to improve quality of parenting programs over time. Good implementation models not only build a community of practice but also test a strategy for quality improvement and sustainment along the way, such as in learning collaboratives or inter-agency collaborative teams. Parenting programs should attend to implementation process and outcome indicators at the caregiver/parent level, the child level, the service provider level, and the system level.

PRE-IMPLEMENTATION CONSIDERATIONS

Emerging issues in implementation science include the role of context in adaptation and implementation, standardized reporting of implementation research, the importance of feasibility studies to inform scale-up and capacity building, fidelity and program quality improvement, and intervention integration into existing systems (Britto et al., 2018). Four key pre-implementation considerations are especially important.

First, translate evidence to understand contextual issues. It is critical to conduct a needs assessment to enhance understanding of the evidence base. This assessment will necessitate examining evidence on parenting programs through existing platforms and sectors (e.g., child protection, education, healthcare) but also bringing together evidence that may sit in multiple sectors (e.g., parenting support needs of families of children with disabilities). Gathering data on parenting from existing data sources such as the Multiple Indicator Cluster Survey (mics.unicef.org) may be an important first step in understanding what parents are already doing in a variety of settings. Such an analysis can identify where to build on an existing and strong foundation, but can also highlight gaps (UNICEF, 2021). For example, in the implementation evaluation of the Lady Health Worker (LHW) Program in Pakistan, which combined parenting support and nutrition programs, the content and delivery strategy were designed based on formative research, which included an analysis of the LHW program to identify gaps in programs that could then be addressed to strengthen parenting outcomes (Yousafzai et al., 2018).

Second, assess norms and existing practices in specific contexts to address feasibility of proposed parenting programs. Parents and the environments in which they live, work, study, and conduct relationships are greatly affected by a range of personal, social, and political factors (Richter L, Naicker, 2013). Key questions to address in an assessment of norms and practices include the following: Will this program address the problems and goals of the community, region, or country? How can buy-in be encouraged at multiple levels from the family to the agency or organization to the community and larger policy and funding context? The use of a strengths-based approach, promotion of gender-equitable norms, promotion of child and adolescent participation, inclusion of all parents, and reliance on the existing knowledge base on parenting are all important (UNICEF, 2021; Soenens et al., 2019). These considerations may be especially important for families facing systemic and personal challenges and in the context of emergencies and humanitarian crises (Parra-Cardona et al., 2021).

The issue of gender can be especially challenging, as the majority of parenting programs target mothers, and it has been difficult for many programs to recruit fathers. Two examples illustrate implementation considerations that may be helpful in expanding parenting programs to include fathers. First, after initially having a hard time reaching fathers, the Better Parenting Program in Jordan shifted to a strategy that involved having imams deliver the messages of the parenting program during Friday prayers, which was effective because the fathers respected the imams and were already attending the prayer services (Al-Hassan & Lansford, 2014). Second, the Parenting for Respectability Program in Uganda was successful in recruiting and retaining fathers, which the research team attributed to having the first 10 sessions of the 21-session program exclusively for fathers (before bringing mothers in for joint sessions), to capitalize on fathers’ pre-existing desires to improve their children’s behaviors and, thereby, family respectability, and to using participatory and interactive methods for delivering the program (Siu et al., 2017). Parenting programs may implicitly reinforce gender stereotypes by assuming that mothers will be the primary recipients and must often explicitly shift to gender neutral approaches or activity address gender stereotypes (Morawska et al., 2021).

Third, assess capacities and readiness of systems and structures to deliver parenting programs. It is important to plan on implementing programs that will sharpen the skills and competencies of parents, but it is also important to assess capacities and readiness of systems on the ground to deliver parenting programs. Parenting programs are likely to succeed if they employ a combination of approaches. Key approaches to consider while planning implementation include strengthening enabling environments, supporting strengthened workforce capacities and integrated services, raising levels of awareness, promoting gender norms and socialization, empowering families and communities, and encouraging participation (UNICEF, 2021). A comprehensive assessment of system readiness will take into account where a country or program stands in each of these approaches. Challenges may be identified in any of these approaches. For example, governments may not prioritize the goals embodied in parenting programs, or may lack the resources to devote to supporting parenting programs even if they desire to do so. Therefore, it is important to understand what barriers and resources exist to address gaps in parenting support. Global resources that focus on concrete strategies to build positive parent-child relationships and manage parenting stress are critical to consider (Cluver et al., 2020).

Fourth, evaluate existing policies, laws, and enabling environments that form the implementation ecosystem for an evidence-based parenting program. The cultural, political, economic, and historical environments surrounding parents have an impact on families’ functioning (Vélez-Agosto et al., 2017). For societies and economies to thrive, countries and businesses need to support parents through family-friendly policies, which help to balance and benefit both work and family life and typically provide time, resources, and services needed by parents (UNICEF, 2018). Family-friendly policies include parental leave, breastfeeding support, affordable accessible quality childcare, and child benefits. These policies impact parents in all contexts, including in the informal economy, and in contexts where families face systemic and personal challenges, including in emergencies and humanitarian crises.

Estimates of cost and return on investment for a given intervention as implemented in a real-world setting are also important foci for implementation science. Research questions may examine whether costs can be reduced by providing services remotely and in hybrid formats. Robust evidence demonstrates the capacity to provide evidence-based parenting support through remote delivery. For example, in the first 12 weeks of COVID-19, lockdowns, collaboration among eight international organizations reached 57 million families across 180 countries by providing open-access online parenting resources (Perks & Cluver, 2020); after 16 months, these resources had reached 196.7 million people in 114 languages. These online resources included recommendations for parents based on randomized controlled trials of parenting programs in LMICs on how to foster positive parent-child relationships, how to manage children’s misbehaviors, and how to handle parental stress. International volunteers translated the resources into 55 languages and shared them through social media and other online platforms. One caution, however, is that the use of online resources requires careful implementation, as in some cases low-income families do not have internet access or data packages that allow them to access the resources. Furthermore, additional evaluation is needed to determine what proportion of parents utilize a substantial portion of online content and whether desired outcomes are obtained, as programs that are effective when delivered face-to-face may not work the same way or be as effective online.

UNICEF’s (2021) program implementation work now involves a 9-step process: 1) Conduct a needs assessment; 2) Identify the program’s target population(s); 3) Build coalitions that will join in advocacy for an enabling environment; 4) Agree on delivery platforms; 5) Identify the ‘parenting workforce’; 6) Enhance demand generation; 7) Pilot, adapt, and implement; 8) Ensure monitoring and evaluation; 9) Develop detailed plans for taking parenting programs to scale. This 9-step process highlights that to understand implementation, it is essential to understand the context in which a program will be implemented. Steps 7 and 8 form the crux of implementation science and can take a great deal of time, especially when adaptations need to be manualized. In working through these steps, central questions involve who is ultimately responsible, who pays for this work, who ensures that conflicts are resolved, and who decides what is needed to bring rigor to the application of implementation science in a given setting. These steps tend to be highly relationship-focused and require time and energy on the part of many stakeholders. The specific areas to prioritize in the implementation process will depend on local challenges and resources. For example, if a strong enabling environment already exists with relevant stakeholders buying into the program, then priorities can be diverted to other areas, such as enhancing parents’ demand for the program by demonstrating how they can benefit from it. Additionally, in some contexts, strong outreach to parents may already exist on key issues such as immunization or vitamin supplementation, which may help elevate the need to prioritize less-addressed issues such as stimulation or child safety.

WORKFORCE, TRAINING, AND LEADERSHIP

The workforce, training, and leadership of parenting programs are central to high-quality implementation (Bonsu et al., 2021; U. S. Department of Health and Human Services, 2019). An initial question is who is delivering the program (e.g., community health workers, nurse home visitors, village elders, teachers). Deciding who should deliver the program is critical in whether implementation is feasible and can be cost-effective. For example, having professionals deliver the program has the advantage of having leadership from individuals who are already educated with respect to at least some aspects of working with families but the disadvantage of being more expensive than using paraprofessionals or laypeople, and communities may not have enough professionals available to fully staff a program. It may be possible to recruit young people as agents of change in delivering parenting programs, which can provide a career path for young people and be part of a fruitful enabling environment for the parenting program. A population-based approach that reaches the entire community/region/country, requires that parenting programs offer leaders and frontline service providers training and support for program implementation (Pickering & Sanders, 2016). Most evidence-based parenting programs have well-established training to prepare the workforce who will deliver the programs, ensuring their quality and fidelity (Haslam et al., 2016). Staff training is an efficient way to offer knowledge, background information, and opportunities to practice skills and receive feedback in a safe training context (Fixsen et al., 2005).

Initial training is not enough. To ensure that the trained professionals implement a program, organizations need to motivate program engagement and provide high-quality supervision and a supportive climate, including administrative support, agency buy-in, and financial support (Asgary-Eden & Lee, 2012). Ongoing supervision, quality improvement, and accountability are essential, with referrals to services outside of the parenting program as necessary. Supervision contributes to the adherence of an evidence-based parenting program integrated into community settings (Stern et al., 2008). Some essential supervision components include: 1) continually and supportively emphasizing the relevance of maintaining fidelity and highlighting the program’s core components; 2) providing concrete resources to facilitate implementation as per the staff training and manual; 3) maintaining a collaborative environment rather than a hierarchical one; 4) and engaging in mutual problem solving (Stern et al., 2008).

If researchers lead initial implementation of parenting programs, they must work with the community, policy leaders, and funders to determine how the program will continue with staff from the community. Training professionals who already work in settings that provide public services may ensure the sustainability of the program when researchers and those they hire are no longer involved in the program. Implementing parenting programs that can sustain quality and fidelity while also expanding use and reach is a challenge that may be resolved by offering incentives to the workforce and families while fostering a shared culture of learning. Training, careful fidelity monitoring, and staff supervision are necessary for implementing evidence-based interventions with quality and at scale (Martin et al., 2021; Roben et al., 2017).

Involving the government and stakeholders from the beginning of the research and implementation is one way to ensure scaling and sustainability when researchers leave the field. For example, in Brazil, a researcher-led randomized controlled trial showed that the ACT Raising Safe Kids Program was efficacious for improving parenting practices (Altafim & Linhares, 2019). After these positive findings, another research project focused on implementing the program in a partnership between the university and the city hall of Pelotas, with the program being implemented by municipality professionals (Murray et al., 2019). These professionals (i.e., psychologists, social workers, and school coordinators) were trained and supervised by the researchers, and were key actors in maintaining the program, providing a path to long-term sustainability. After the acceptance and positive evaluation of the program by the participants (Martins et al., 2020), the city decided to incorporate the program into existing services in the public system (Prefeitura Municipal de Pelotas, 2019).

DELIVERING SERVICES PARENTS NEED AND HOW THEY WANT TO RECEIVE THEM

Parents, especially new parents, are often tired and too busy to think about the services and supports they need and advocate to find and get them. A strong and inclusive implementation analysis that looks at the individual programs that are available, and the broader array of entry points parents can take to access them, benefits policy makers, program operators, communities, parents, and children. Implementation researchers can address questions about how to determine what parents need as supports, how to make these supports accessible, and gather data to inform who should be eligible for a program. What parents want and need is sometimes aligned but sometimes not. A challenge in implementing parenting programs can be persuading parents that they can benefit from the program. Sometimes there is resistance because of inherent tensions between parents’ world views and what the research evidence suggests. To address this tension, it may be important to engage parents through strengthened community engagement and using a wide variety of modalities including digital, hybrid, or low tech modalities, such as the radio (Kohrt et al., 2018; Yoshikawa et al., 2020). It is also important to bear in mind that the research base itself often excludes underrepresented or marginalized communities so what the research evidence suggests as best practice may not be so with a particular community or group of parents.

Program implementers must work closely with program developers, program managers, communities, and parents to ensure that the essential elements of evidence-based programs are offered and received by parents. Too often, programs designed by academics, government, or multi-lateral organizations do not consider what parents want and need because the focus is on achieving fidelity to the program (for example, weekly parent group socialization and mental health support activities aimed at improving the parent-child relationship). The co-creation process of parenting programs involving researchers, practitioners, and parents, and designing and testing within existing programs, assure that the strategies are relevant in a real-world context and have scaling potential (Schindler et al., 2017). By clarifying the program’s theory of change, researchers and practitioners can work with parents to prioritize maintaining a program’s core functions, even if the form must be altered (Fletcher et al., 2016; Hawe et al., 2004). The multiphase optimization strategy (MOST), which uses factorial experiments to help establish which elements of an intervention are essential, may be especially useful in making sure that key functions of adapted programs are maintained (Collins et al., 2009). In implementation science, MOST can help with scaling, adapting interventions to different contexts, and optimizing implementation itself (Guastaferro & Collins, 2021).

Obtaining fidelity across all service requirements (number of service hours, delivery by a fully trained service provider, duration of the program) happens rarely, yet desired changes in parenting often occur (Wasik et al., 2013). This does not mean that implementation researchers should encourage program managers to abandon core fidelity goals when adapting implementation as part of scale-up, but rather determine whether changes to service delivery approaches that take parent needs into account increase program engagement and ultimately improve outcomes of the program. A rapid cycle of learning and continuous feedback evaluations facilitates modification of strategies based on whom the strategy benefits (Schindler et al., 2017).

Successful implementation of parenting programs merits consideration of risk and protective factors outside the scope of the program that can make families fragile or resilient. For example, mental health issues, violence, and substance use detract from positive parenting (Chassin et al., 2019; Letourneau et al., 2017; Neppl et al., 2020; Suchman et al., 2019). Even if families are not targeted for participation in a parenting program based on these factors, and even if these risk factors are not explicitly addressed as part of the program, programs need to leave space to address these needs.

PROGRAM FLEXIBILITY IN LOW- AND MIDDLE-INCOME COUNTRIES: OPEN ACCESS, COSTS, AND IMPLEMENTATION SUPPORTS

Flexibility and adaptation are necessary and are supported by open access, reasonable costs, technology, and technical supports. Open access components are especially important for the implementation of parenting programs in LMICs. Proprietary programs are often cost prohibitive. For example, although Triple P (Sanders & Mazzucchelli, 2018) and Nurse-Family Partnership (Olds & Yost, 2020) have strong evidence bases documenting their effectiveness, the components are available only at a steep financial cost (for example, $8,000 per family for Nurse-Family Partnership) (Zaveri et al., 2021). Direct comparisons between costs of different parenting programs are complicated by several factors. For example, some costs are fixed regardless of the number of families reached, whereas other costs are dependent on the number of program participants. Some costs are incurred only at start-up, whereas others are steady-state costs that continue through the life of the program (Zaveri et al., 2021). Some programs also include different modes, such as universal versus targeted components, and costs vary as a function of which modes are adopted. A comparison of costs to deliver seven home visit parenting programs in Latin America and the Caribbean revealed a range of $110 to $302 per participant (Leer et al., 2021). Thus, an important implementation consideration is what the financial costs would be to deliver a program as intended.

In part because of financial considerations, Triple P and Nurse-Family Partnership are less commonly used in LMICs than programs that are open access, such as Care for Child Development (CCD), Parenting for Lifelong Health (PLH) (Lucas et al., 2018; Ward et al., 2020), and Reach Up based on the Jamaica Home Visit program (Grantham-McGregor & Smith, 2016; Walker et al., 2018). CCD, for example, has been integrated into existing health, education, child protection, and other sectors in at least 19 LMICs with evidence for benefits to responsive caregiving (Lucas et al., 2018).

PLH was designed with the explicit intention of making evidence-based parenting programs available in LMICs that would not be able to afford expensive propriety programs (Parenting for Lifelong Health, 2021). PLH training manuals, videos, and other materials are all available open access. Implementers are asked to complete straightforward evaluations and convey feedback to the PLH developers to improve the program over time. This process of continual feedback enables PLH to remain evidence driven in its implementation. Reach Up is another example of an open access parenting program designed to improve the ability of agencies implementing parenting programs to deliver them effectively (Walker et al., 2018). An evaluation of Reach Up in Brazil and Zimbabwe collected data from mothers, home visitors, and supervisors on the program’s appropriateness, acceptability, and feasibility (Smith et al., 2018). Attention to challenges in implementation and modifications needed was important to guiding efforts to expand the program beyond Jamaica, where it was originally developed, to these new countries.

In addition to cost barriers, sometimes proprietary programs also lack the flexibility of open access to adapt the components to meet the needs of local populations. However, evaluation of the implementation of parenting programs should be planned from the outset of the program, with the flexibility to make changes in implementation in response to barriers identified in the evaluation. For example, the Pakistan Early Child Development Scale-Up trial evaluated not just the effectiveness, but the implementation of the program, including questions regarding the impact of the program on existing services, time and demands on the workforce, donor commitment, communication among stakeholders, and other contributors to successes and failures in implementation (Yousafzai et al., 2018).

Another example of moving beyond the initial RCT to implementation science approaches comes from the work of the Sugira Muryango (SM) program in Rwanda. The SM intervention, also called Family Strengthening Intervention for ECD as it is being adapted in Sierra Leone (Desrosiers et al., 2021), integrated Care for Child Development content with a tested strengths-based and father-engaged home visiting intervention that had been tested originally among HIV/AIDS affected families (Betancourt et al., 2020; Jensen et al., 2021). SM is a 12-week home-visiting parenting program to promote early childhood development that uses active coaching by community-based layworkers to improve parent-child interactions. To identify and reach vulnerable households with a child under the age of 3 years, the intervention was integrated with the Rwandan government’s Vision Umurenge Poverty Reduction Strategy (VUP) (Johnson et al., 2020). At present, the team is working with the government and the University of Rwanda to test a strategy to scale the intervention to all households eligible for the VUP with a child under the age of 3 using a Collaborative Team Approach (CTA). The CTA strategy is focused on transferring ownership of the program to Rwandan stakeholders and comprises an expert Rwandan Seed Team for training and supervision, cross-site learning across all three District teams, a common charter committing all stakeholders to quality improvement along with the scale up, and use of Plan-Do-Study-Act cycles (Leis & Shojania, 2017) to identify barriers and enhance facilitators to delivery and sustainment of evidence-based practices. In the Play Collaborative Scale out study, the strategy is focused on enhancing ownership and buy in for the program at all levels from the national to district, sector, cell, and village, and the CTA implementation science research questions are focused on understanding issues of burden, incentives, cost, and quality as the evidence-based practice is being delivered by existing community child protection workers (Galler, 2021; Johnson et al., 2020). A digital dashboard tool is also being developed to make implementation quality data more readily available for government leaders, community-level managers, and Seed Teams.

Evaluating the implementation process itself is one way to understand why a particular program may succeed in one context but fail in another (Ridde et al., 2020). Unlike efficacy and effectiveness trials that are concerned with the outcomes in the intervention group versus a control group, rapid cycle implementation studies test strategies designed to increase uptake and sustainability of the intervention (Bauer & Kirchner, 2020). For example, communication strategies focused on recruiting parents to participate in a program can be tested in implementation evaluations and altered as needed to facilitate program uptake. To take full advantage of the results of implementation studies, interventions must be flexible enough to adapt to overcome implementation barriers. Implementation evaluations may also reveal areas where not enough information exists on implementation systems and supports to indicate whether a particular approach is advisable, flagging an area in need of additional data collection.

Both technology and technical supports are important for program developers, practitioners, and researchers in implementation. Technical supports can include people and approaches to guide implementation. Technology, which can incorporate data collection and analysis management information systems, can be used by everyone involved in the implementation to streamline the process. Frontiers of Innovation (2021) at Harvard’s Center on the Developing Child, for example, provides a data system for designing, testing, and refining interventions with a community of learners who are committed to accelerating innovation and adopting strategies to implement interventions at scale. Likewise, Saving Brains (2021) through Grand Challenges Canada connects innovators seeking to improve maternal and child health and development in LMICs with funders, networks, and resources to advance implementation of novel interventions. These kinds of supports make it more feasible to evaluate the implementation of parenting programs in different contexts rather than merely applying an existing proprietary program in a new context. These programs promote meetings including international researchers, innovators, and practitioners engaged in shared learning to accelerate innovation to impact at scale. Communities like these that work globally to help teams acquire skills and knowledge are crucial to strengthen the interventions and implementation strategies that focus on families facing adversities.

USES OF EXISTING INFRASTRUCTURE

The successful implementation of parenting programs needs to identify the appropriate channels to reach and engage with parents in an authentic and productive manner that improves adaptation and implementation of current and future programs and policies. This process requires participation and ownership in the communities where the parenting programs are implemented. A potential avenue that could and in many contexts should be used is to piggyback new parenting programs on existing delivery systems (for example, physical health, education, social protection). Such an approach might facilitate the implementation of effective interventions while at the same time making them less expensive to establish and run. Recruiting local implementation agencies and individuals can be key to the success of the intervention. The existing infrastructure and social protection programs do not necessarily need to be linked to parenting programs but can be taken from other existing platforms that have successfully reached people at scale.

Four evidence-based examples illustrate how parenting policy and programming can be integrated into existing platforms. First, starting in the mid-1990s, Conditional Cash Transfers (CCT) have become widespread social protection programs in many contexts. An important aspect of these programs is the fact that they often include requirements that families engage in specific activities (such as participating in an educational program) as one of the conditions to receive the cash. These activities are often coordinated by participants who are elected by local communities. In the case of Mexico’s PROGRESA CCT, these individuals are known as Promotoras, while in the case of the Colombian Familias en Accion, they are known as Madres Lideres (Andrew et al., 2018; Fernald et al., 2017). In both cases, these individuals (usually women) serve as the point of contact between the program and the participants, are strong leaders, and are widely recognized and respected in the community. An important by-product of these CCTs, therefore, is the identification of agents in the community who convey important messages and serve as a communication link to the intended participants in specific interventions. Second, in the case of Colombia, a pilot intended to deliver the Reach Up parenting program at scale hired the Madres Lideres as home visitors to deliver the program, making the content of the program clearer to the potential participants (Andrew et al., 2018).

Third, in India, a similar role is played by the Anganwadi Workers, who run small community nurseries and are given a number of other tasks such as disseminating information about health and nutrition as part of the national Integrated Child Development Services (ICDS) program. These workers are important for implementation success because they are known in and knowledgeable about the community (Rao & Kaul, 2018). Fourth, in Colombia, a similar role is played by the “community mothers” running the Hogares Comunitarios, small community nurseries that are widespread and have been in operation since the mid-1980s, with 69,000 women serving over a million children and their families (Colombian Institute of Family Welfare, 2021).

As demonstrated by these examples, the use and involvement of local agents, possibly already engaged in programs funded by government and other stakeholders, may help to reduce the implementation costs of programs designed to address other issues such as economic stability. Using existing programs facilitates the incorporation of training and ongoing supervision and quality improvement structures. Parenting programs can be integrated with nutrition and health interventions, as has been done with the Lively Minds intervention in Ghana and Uganda (Attanasio et al., 2019). Measurement of the impact of new, integrated programs is key, both for monitoring and evaluation. In this respect, the use of existing infrastructure can facilitate the use of administrative data and therefore make the availability of appropriate measures easier to achieve.

CONCLUSIONS

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

SYNOPSIS.

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

Acknowledgements

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

Footnotes

Conflict of Interest Disclosures

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

Ethical Principles

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

Contributor Information

Jennifer E Lansford, Center for Child and Family Policy, Duke University, Box 90545, Durham, NC 27708, USA.

Theresa S Betancourt, Boston College.

Kimberly Boller, Nicholson Foundation.

Jill Popp, LEGO Foundation.

Elisa Rachel Pisani Altafim, University of São Paulo.

Orazio Attanasio, Yale University.

Chemba Raghavan, UNICEF.

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