Home visiting programs to improve early childhood development and maternal mental health

Country of Implementation:



São Paulo Municipality



Target Beneficiary:

Mothers; 0-2 years

Delivery Intermediaries:

Lady Healthcare Worker/Community Healthcare Worker; Non-Medical Professionals


To improve parent-child interactions in urban slums in Brazil.

Innovation Description:

Evaluation of efficacy and cost-effectiveness of two platforms for home visiting programs: one delivered by newly trained Community Development Agents  and one delivered by already employed Community Health Agents.

Stage of Innovation:

Proof of Concept

Home visiting programs to improve early childhood development and maternal mental health


São Paulo Municipality



Target Beneficiary

Mothers; 0-2 years

Delivery Intermediaries

Lady Healthcare Worker/Community Healthcare Worker; Non-Medical Professionals


To improve parent-child interactions in urban slums in Brazil.

Innovation Description

Evaluation of efficacy and cost-effectiveness of two platforms for home visiting programs: one delivered by newly trained Community Development Agents  and one delivered by already employed Community Health Agents.

Stage of Innovation

Proof of Concept

Innovation Summary

0583 logo fmuspBrazil has made remarkable progress with respect to child nutrition and child survival over the past decade, with particularly impressive results in large urban areas. According to the latest estimates, infant mortality has dropped to about 11 deaths per 1000 in Sao Paulo. [1] However, Brazil continues to struggle with a remarkably high degree of income inequality and large socioeconomic disparities. The majority of children growing up in the poor urban settlements of Brazil are not only exposed to a high burden of adverse environmental exposures, but also generally lack the social and family support children and mothers in traditional rural societies benefit from.

This project proposes to introduce a home-visiting program to teach parents in the poor urban setting of Sao Paulo’s western region, proper parent-child interactions and stimulation techniques. It will evaluate the efficacy and cost-effectiveness of two platforms for delivering this home visiting program: a program delivered by a newly trained cadre of Child Development Agents, and the same program, but delivered by Community Health Agents already employed by the government as part of the existing Family Health Strategy (PSF) initiative.


  • 400 children will receive the home visiting program.
  • 5 child development agents will be hired and trained.
  • 15 community health workers, employed by PSF, will be trained in child stimulation.


In this project, feasibility, impact and cost-effectiveness of home visiting programs in poor urban families living in Sao Paulo will be assessed. Home visiting programs do not only have the potential to improve maternal well-being, [2, 3] but have also been proven effective in increasing early life stimulation and child development. [4] We will consider two delivery platforms for home visiting programs: 1) the introduction of a newly trained cadre of Child Development Agents (CDAs); and 2) the integration of home visiting programs into the Family Health Strategy (PSF).  The PSF is a government-lead initiative to link health facility staff to their communities by providing monthly home visits performed by Community Health Agents (CHA). These CHAs will be trained on child development and provided with additional financial incentives for home visits.

The project will assess the developmental impact of both delivery mechanisms and combine impact data with detailed costing data to evaluate both the effectiveness and relative cost-effectiveness of both platforms.

Several recent studies from a wide range of countries such as Bangladesh, [5] China, [6] Jamaica, [7, 8] and South Africa [9] have demonstrated that home visiting programs can be highly effective in improving child developmental outcomes. The principal common feature of home visiting programs is that trained child development or community agents meet with mothers or parents on a regular basis to observe the interactions between caregivers and their children, and to provide practical guidance on how to interact with them.

At the core of these visiting programs is a detailed curriculum, which contains key topics of child health and development to be covered at each home visit. Detailed information and supporting materials for each session have been developed for the original Jamaica study and are currently being adapted to the Brazilian context.

In this project, 800 children of ages 10-14 months will be randomly selected, and divided into four groups: two treatments (I and II) and two control. In Group I, children will be visited on a bi-monthly basis by a newly trained CDA for a period of 12 months. In Group II, children will receive similar visits by CHAs Five CDAs will be hired full-time for a period of 12 months through the University Hospital, and each will be responsible for approximately 40 children (~ 5 visits per day). Already employed through the health system, ten CHAs will be selected and trained, and will support about 20 mother-child dyads each.

CDAs and CHAs will have similar demographics, and receive the same training on early childhood stimulation.



  • Grand Challenges Canada

Key Partners

  • Dr. Gunther Fink, Harvard School of Public Health, USA
  • Dr. Susan Chang-Lopez, TMRI, University of West Indies, Jamaica
  • Dr. Christine Powell, University of West Indies, Jamaica


Key Drivers

Integration of Research Project into Health System

One enabling factor is the tight integration of the research project into the larger health system, which will be beneficial for the recruitment and training of health workers and when it comes to connecting with families.


Lack of Stability and Trust

The main challenge faced by the project is the general lack of stability and trust in the targeted areas. Families residing in informal settlements, often illegal, tend to move frequently, and are often not willing to receive or interact with strangers.

Evaluation Methods

The project will be set up as a three-arm randomized controlled trial. 600 mother-child dyads will be randomly selected for the pilot evaluation study, with 200 dyads in each group: Intervention I (CDA), Intervention II (CHA), and control group.

Prior to the beginning of the intervention, all 600 mother-child dyads will be visited at home. Conditional on the caregivers consent, study staff will collect data on children’s height and weight, and complete a basic child development questionnaire. At the end of the 12-month intervention period, a second (endline) assessment will be conducted by graduate students at children’s home. As part of the endline survey, maternal mental health will also be assessed (Edinburgh Scale), as well as the children’s home environment.

In this project the following aspects of the intervention will be assessed: 1) feasibility, 2) impact and 3) cost-effectiveness of the home visiting programs.


  • The content delivered adheres to the curriculum and training.
  • The intervention’s quality is maintained.
  • Mothers adhere to the program and stay engaged.


  • The intervention changes the mother-child interactions and improves the degree to which children in poor urban settings develop during the first year of life.


  • The developmental impact of both delivery mechanisms will be assessed, and combined with detailed costing data to evaluate effectiveness and relatively cost-effectiveness of both platforms.
  • Quantitative data on cost and developmental impact will be combined with qualitative feedback from mothers and community workers.


  1. Secretaria Municipal de Saúde. Boletim Ceinfo Junho 2013.
  2. Tandon SD, Leis JA, Mendelson T, et al. Six-Month Outcomes from a Randomized Controlled Trial to Prevent Perinatal Depression in Low-Income Home Visiting Clients. Matern. Child Health J. 2013 doi: 10.1007/s10995-013-1313 -y[published Online First: Epub Date]|.
  3. Carta JJ, Lefever JB, Bigelow K, et al. Randomized trial of a cellular phone-enhanced home visitation parenting intervention. Pediatrics 2013;132 Suppl 2:S167-73 doi: 10.1542/peds.2013-1021Q[published Online First: Epub Date]|.
  4. Engle PL, Fernald LCH, Alderman H, et al. Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries. The Lancet 2011;378(9799):1339-53.
  5. Aboud FE, Akhter S. A cluster-randomized evaluation of a responsive stimulation and feeding intervention in bangladesh. Pediatrics 2011;127(5):e1191-7 doi: 10.1542/peds.2010-2160[published Online First: Epub Date]|.
  6. Jin X, Sun Y, Jiang F, et al. “Care for Development” intervention in rural China: a prospective follow-up study. J.Dev. Behav. Pediatr. 2007;28(3):213-8 doi: 10.1097/dbp.0b013e31802d410b[published Online First: Epub Date]|.
  7. Grantham-McGregor SM, Powell CA, S. P. Walker, et al. Nutritional Supplementation, Psychosocial Stimulation, and Mental Development of Stunted Children: The Jamaican Study. The Lancet 1991;338(8758):1-5
  8. Walker SP, Chang SM, Powell CA, et al. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet 2005;366(9499):1804-07
  9. Cooper PJ, Tomlinson M, Swartz L, et al. Improving quality of mother-infant relationship and infant attachment in socioeconomically deprived community in South Africa: randomised controlled trial. BMJ 2009;338:b974 doi:10.1136/bmj.b974[published Online First: Epub Date]|.
  10. Villar J, Altman DG, Purwar M, et al. The objectives, design and implementation of the INTERGROWTH-21st BJOG: An International Journal of Obstetrics & Gynaecology 2013;120:9-26 doi: 10.1111/1471- 0528.12047[published Online First: Epub Date]|.
  11. Fernandes M, Stein A, Newton C, et al. Operation Manual: Cognition, Language, Motor & Behaviour Assessment. In: Project I-s, ed., 2012.


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