Implementation barriers of Brazil’s national home visitation program for early childhood development: A qualitative evaluation

This research delves into the challenges faced in implementing home visitation programs for early childhood development, focusing on the Programa Criança Feliz (PCF) in Brazil. We aimed to better understand what barriers are hindering PCF from creating a greater positive impact on its primary outcomes. This is a cross-sectional qualitative study. We conducted qualitative interviews and focus group discussions in 11 Brazilian municipalities. The study participants were asked about expectations of the workforce, curriculum content, training, and supervision, working conditions, program design, favorable environment, and quality monitoring and assurance. Data analysis followed the Framework Method approach. The codebook followed the categorization from the Home Visiting Workforce Needs Assessment framework and the Consolidated Framework for Implementation Research framework. A total of 38 participants took part in the 6 focus group discussions and 11 key informant interviews. A range of challenges impeding PCF implementation were identified. The home visitation guidelines lack a clear structured curriculum for the home visitors to follow. Some home visitors felt overburdened due to a lack of training, limited materials, long commutes to visits, and a high number of families to visit. High turnover rates of home visitors further contribute to the difficulties. Hard-to-reach communities and families were often excluded from the program because the home visit quota goals do not consider travel time to distant communities. The cascading training structure of PCF often results in the home visitors being trained by individuals with little or no training in child development, pedagogy, or the program structure. Our findings reveal barriers created by the content and implementation of PCF, shedding light on the need for tailored strategies to overcome these challenges. These results provide practical, transferable insights for home visitation and analogous early-childhood programs operating in resource-constrained settings, with applicability to other contexts contingent on contextual similarity.