Professor Susan Walker

Publication/source: JAMA Network Open 9 (2), e2556024, 2026

Snippet: Importance There is substantial evidence that programs that build parents' abilities to support early learning benefit children's development. Evidence is needed on how to integrate and scale these programs within government services. Objective To determine whether a parenting program implemented by government primary health care services and combining in-person and remote delivery benefits children's development and parenting attitudes and behaviors. Design, Setting, and Participants In this single-blind randomized …

Publication/source: Health Policy and Planning, czag057, 2026

Snippet: This study aimed to evaluate the impact of the Survive and Thrive program on neonatal mortality and child development in Boa Vista, Brazil. Between November 2017 and May 2021, the program to support pregnant women as well as mothers of children under age 3 was rolled out in three phases. Neighborhoods were selected either for home visits or for group meetings held at Social Assistance Reference Centers. To allow for an evaluation of the program, the timing of the rollout was randomized at the neighborhood level. To assess the impact of the program on neonatal mortality, we used complete vital registration data from the period 2010 to 2010, and estimated differences in child mortality before and after the program were launched. Impact on child development was assessed through a detailed assessment of 744 children born in 2019 using the Caregiver Reported Early Child Development Index and Regional Project on Child Development Indicators instruments. Home visits resulted in a significant improvement in child development [d = 0.28, 95% Confidence Interval (CI) (−0.013, 0.57), P-value of .06] and reduction of neonatal mortality [Risk Ratio (RR) 0.58, 95% CI (0.36, 0.93), P-value of .02]. No impacts were found for the group meetings. The findings indicate that a home visiting program beginning in pregnancy can significantly reduce neonatal mortality and improve child development in poor urban neighborhoods of Brazil.

Publication/source: Implementation Science Communications, 2026

Snippet: Background Programa Criança Feliz (PCF) is Brazil’s home visitation program aimed at enhancing early childhood development. Evaluations of the program have found significant program challenges and implementation barriers, including the lack of a structured curriculum, insufficient training, and little supervisory support. This study tests the revised content of the home visits and new implementation strategies aimed at addressing these barriers and enhancing the quality of PCF home visits. Methods The implementation strategies were piloted across 8 diverse municipalities in an implementation feasibility trial. The strategy bundle included a 40-hour initial training for home visitors using demonstration and simulation-based methods (based on the Reach Up methodology), an 8-hour supervision-focused training module for supervisors, and standardized home visit guidelines and an activities compendium. The new strategies were assessed using a one group pre-post analysis along with mixed methods to assess the extent to which they were acceptable, feasible, and associated with a change in home visit quality. A paired t-test and an independent t-test analysis were used to assess the change in home visit quality. The implementation outcomes were assessed with qualitative analysis and the Framework Method approach. Results The proposed home visitation guidelines, material, training, and supervision process were determined to be highly acceptable, feasible, and associated with improved quality of home visits. The home visit quality scores significantly increased by 14.68 points (SD= 14.89, CI 95%: 7.27–22.08, p= 0.0006), according to the paired t-test. The study participants provide insightful suggestions for adaptations that can occur before testing the strategies more broadly. Key suggested adaptations included adjusting activity difficulty to individual developmental levels rather than age alone, shortening training duration to improve staff access, and incorporating guidance for culturally diverse and traditional communities. Conclusion The findings suggest three transferable design principles for home visitation and paraprofessional-delivered public health programs: reducing excessive discretion through structured, age-appropriate visit guidance; externalizing quality through experiential training methods such as demonstration and role-play; and embedding feedback loops through structured supervision and monitoring. These principles may generalize to programs facing heterogeneous staff preparation, high turnover, and limited supervisory capacity.

Publication/source: Child: Care, Health and Development 50 (1), e13189, 2024

Snippet: Early childhood is a critical period for child development. Effective approaches to support families in low‐resource settings in the use of responsive and stimulating parenting are needed. The aim of this study was to examine the effects of the Reach Up early childhood parenting programme on children's development, parenting attitudes and practices, when delivered through early childhood development (ECD) centres in Zimbabwe. A cluster randomised controlled trial was conducted in Sanyati, a rural district in Zimbabwe. Twenty‐four of 51 available centres were randomised to intervention (n = 12) or control (n = 12) groups. Sixteen mothers with a child aged 12–30 months were recruited from each centre's catchment area (n = 189 intervention; n = 193 control). The intervention comprised two home visits per month delivered by centre teaching assistants over a period of 27 months. Primary outcomes were child Developmental Quotient (DQ), Language, Eye and Hand coordination, Performance and Practical Reasoning subscale scores assessed at follow‐up. Secondary outcomes were mothers' attitudes about child development, parenting practices and maternal depressive symptoms all measured at baseline and follow‐up. Intention to treat analyses was conducted using mixed‐effects regression models with the standard error adjusted for cluster and inverse proportionality weights to adjust for attrition. Significance was set at P < 0.05. A total of 285 (74.6%) of 382 children enrolled were tested, with 97 children lost to follow‐up. The intervention improved the children's DQ by 3.55 points (95% CI 0.82 to 6.28), Eye and Hand by 3.58 (95% CI 0.59 to 6.56) and Practical Reasoning by 4.19 (95% CI 0.96 to 7.42). No significant improvements to Performance or Language scores, parenting attitudes, parenting practices and depressive symptoms were identified. A home visiting intervention delivered by ECD teaching assistants promoted children's development. This suggests that outreach from preschools may be an effective platform for delivery of parenting interventions.

Publication/source: Frontiers in Public Health 11, 1151826, 2023

Snippet: Sustainable implementation of early childhood programs requires resources, materials and methods that are adaptable, scalable and feasible for delivery through multiple sectors. Additional or modified program resources may be required to meet emerging needs, as programs go to scale. An active and effective monitoring, evaluation and learning (MEL) process may enable programs to be responsive to demands. The Reach Up: Early Childhood Parenting program, is designed primarily for disadvantaged children under 4 years of age in low- and middle-income countries (LMICs) to promote their development through playful caregiver interactions. The curriculum, training manuals and other materials and resources support implementers in the adaptation of the intervention, implementation, workforce training, monitoring and evaluation. This paper reports on how data collected from key informants drove modifications to program processes, materials and resources. We conducted in-depth interviews with 14 key informants (including program managers, lead trainers, academics, consultants and workforce personnel) on their experiences with Reach Up across 15 LMICs where the program has been implemented. We also reviewed written records generated from (i) structured small group discussions at a Knowledge Exchange meeting of 31 Reach Up partners and (ii) notes from working groups formed at the meeting and tasked to continue working post-meeting to find solutions to support ongoing implementation. The transcripts from the in-depth interviews and the meeting records were analysed using thematic analysis with a mixture of pre-defined categories and data-driven sub-themes. The main findings indicated that there was a need to: (i) develop advocacy and communication resources and materials to aid prospective implementers and other stakeholders, to make decisions for implementation, (ii) revise and/or add to the content and format of the curriculum and add content in the training and other supporting manuals and (iii) enhance the training process. The feedback from the key global partners informed the development of new knowledge materials, resources and processes and modifications to existing program materials and resources. These will help to support advocacy, ongoing implementations, and the process of transitioning the Reach Up early childhood intervention to scale.