An implementation strategy bundle to improve home visit quality of the national child development program in Brazil:...

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.

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.

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.

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.