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A Review of Frameworks and Tools for Scaling Up Social Interventions

On 20 July 2023 by SPP

Author: Rowland Ekpo Edet

Advisor: Asst. Prof. Pobsook Chamchong, PhD

Co-advisor: Asst. Prof. Ora-orn Poocharoen, PhD

 

Background

Violence against children (VAC) is a global public health concern, with over 1 billion children affected annually. In Asia and Africa, most children have been exposed to physical and psychological abuse at some point in their lives (Swedo et al., 2019). Child maltreatment can manifest in various forms, such as sexual abuse, emotional abuse, physical abuse, and exploitation (Fry et al., 2012). Child abuse can cause serious lifelong consequences, including increased risk of self-harm, suicide, aggression, substance abuse, low self-esteem, depression, anxiety, early sexual activity, multiple partners, domestic violence, and various health issues like heart disease, cancer, and respiratory disease (Hughes et al., 2017; Belsky & De Haan, 2011; Shonkoff and Fisher, 2013; Dunne et al., 2015).

The prevention of violence against children has been accorded significant priority and has been integrated into the WHO Guidelines on Parenting Interventions identifies evidence-based parenting programs as effective in reducing and preventing VAC. However, many parenting interventions are not scaled up. Successful programs exist but are expensive to adopt and for profit making (McCoy et al., 2021).

Consequently, Parenting for Lifelong Health (PLH) is a low-cost social intervention and parenting program developed by universities and international organizations to support young children’s lifelong health and is available for free to LMICs. Hence, there is a need to have guiding frameworks for scaling up social interventions like PLH in Thailand and designing an advocacy plan. These two elements will support the design of scaling-up strategies for Thailand.

 

Research Questions

1.   What international literature exists on frameworks and tools for scaling up social interventions, specifically evidence-based parenting support programs and programs aimed at preventing violence against children?

2.   What are good practices from HICs and LMICs in scaling up social learning theory-based interventions, particularly parenting programs?

 

Methodology

The review conducted a thorough search for literature on frameworks and tools for scaling up social interventions and health promotion programs. The search strategy involved exploring academic databases and grey literature from international organizations. Articles and documents are included if (1) they are published in English, (2) identify framework and tools for scaling up social interventions/public health and health promotion interventions, (3) they have real-life examples applications, and, (4) they have policy recommendations for scaling up. Exclusion criteria are (1) non-English language papers, (2) settings not related to healthcare or social programs, (3) where there is no framework/tool explicitly stated.  After screening and excluding irrelevant papers, 77 publications were identified as pertinent to the study. Using MAXQDA, full documents were coded based on the original guiding questions in the research protocol: context for the application of the framework/tool (HICs/LMICs, sector delivery context); methodologies, if any (of the study); characteristics of the scaling up; factors related to success and failures; policy recommendations; information on the publication (author(s), title, publication year, source type).

 

Analysis of Findings

Brief Discussion on the Scale-up Literature

This scoping review identified 18 studies on frameworks and models for scaling up, with the majority focusing on High-Income Country (HIC) contexts. Some notable frameworks include those by WHO/ExpandNET, Wolfensohn Center for Development, Management Systems International, and Spring Impact. Other documents in the review covered various aspects of scaling up, such as policymakers’ views, citizen participation, case studies, meta- analyses, and theories. Factors influencing scaling up and frameworks for categorizing constraints were also analyzed. While most literature is from HICs, there are valuable lessons to learn from.

Frameworks for Scaling Up

The review identified 18 frameworks focused on scaling up social interventions in low-and middle-income countries. These models are The Framework for going to Full Scale (Barker et al., 2016), The Community-to-Community Mentoring (CCM) model (Delafield et al., 2016), Diffusion of Innovation (Vitalis et al., 2016), Scaleup Readiness Assessment Framework (Nguyen et al., 2020), Intervention Scalability Assessment Tool (Milat et al., 2020), Shiffmanand Smith’s (2007) policy prioritization framework, Exploration, Preparation, Implementation, and Sustainment (Aaron et al., 2014), Implementability of healthcare interventions (Klaic et al., 2022), Triple P Implementation Framework (McWilliam et al., 2016), Interactive Systems Framework (Wandersman et al., 2008), ExpandNet (WHO, 2010), Context and Implementation of Complex Interventions framework (Pfadenhauer et al., 2017), Consolidated Framework For Implementation Research (Damschroder et al., 2009), Assess, Innovate, Develop, Engage, and Devolve (Bradley et al., 2012), Theoretical Domains Framework (Cane et al., 2012), Dynamic Sustainability framework (Chambers et al., 2017), RE-AIM (Glasgow et al., 2019), Non- adoption, abandonment, scale-up, spread, and sustainability framework (Greenhalgh et al., 2017).

The review identified different models for disseminating innovation in healthcare systems: mechanistic, social, and ecological. It highlights that most frameworks for scaling up interventions follow a mechanistic approach, emphasizing sequential and structured processes. However, newer paradigms recognize the complexity of scaling up and advocate for continuous learning, adaptation, and understanding of interdependencies. The passage also mentions the ‘blueprint’ approach, which focused on replication and expansion, and the ‘social learning’ approach, which emphasizes reflexivity and adaptation within networks. It emphasizes the importance of defining scalable units and the role of intermediary organizations in scaling up interventions. Additionally, it mentions various pathways to scaling up and the relevance of complexity and systems thinking.

Synthesis of Factors that Influence Scaling-up

The factors will help guide the analysis of challenges and opportunities for scaling PLH programs in Thailand, including the advocacy plan for the program. We grouped the factors into three categories: factors that influence scaling up; factors pertaining to change in practice; and factors pertaining to change in culture. These factors are:

  1. Window for scale-up
  2. Advocacy
  3. Engagement mechanism
  4. Characteristics of intervention
  5. Implementation capacity
  6. Governance constraints
  7. External catalysts
  8. Political will
  9. Resources
  10. Leadership
  11. Collaborations
  12. Research and M&E
  13. Training and supervision
  14. Perceived need for intervention
  15. Sociocultural environment

Good Practices on Scaleup of Social Interventions

Strengthening Families Program

The Strengthening Families Program (SFP) was developed in the 1980s as a substance misuse prevention program for families with children aged 6-11. It aims to improve family relationships, parenting techniques, and reduce problematic behavior in children. SFP is delivered in group settings through 14 sessions, focusing on topics such as communication and problem-solving. It emphasizes the importance of multiple systems (family, school, community) in shaping youth development. Numerous studies have shown the effectiveness of SFP in improving family functioning and reducing problem behaviors in youth (Spoth et al., 2014; Kumpfer et al., 2012; Allen et al., 2007; Murta et al. 2021). The program has been implemented worldwide, and adapted to different cultural contexts. Evaluations in various countries have demonstrated positive outcomes in terms of family unity, parenting practices, and reduced substance abuse.

Triple

Triple P is a parenting program that teaches parents skills to manage their children’s behavior and promote their development. It follows the principles of positive parenting, emphasizing positive relationships, reinforcement, and boundaries. The program has different levels of assistance, ranging from providing information to intensive support.

Studies across different countries show that Triple P improves parenting practices, reduces behavior problems, and prevents child maltreatment. It is effective, acceptable, and accessible for diverse cultural backgrounds (Bodenmann et al., 2018; Markie-Dadds and Sanders, 2006; Sanders et al., 2014; Au et al., 2014). The program has been found to be successful in various settings and has positive outcomes in improving parenting skills and child behavior (Sumargi et al., 2015; Gagné et al , 2023; Arkan et al., 2020).

Parenting for Lifelong Health (PLH) in the Filipino Context

The Parenting for Lifelong Health (PLH) program aims to reduce child abuse, improve parenting practices, and promote positive parenting techniques in low- and middle-income countries. It consists of group-based sessions covering topics such as child development, discipline, communication, and stress management. Multiple studies have shown that the program is effective in reducing child abuse and enhancing parenting practices (Lachman et al., 2016; Alampay et al., 2018; Gardner et al., 2019; McCoy et al., 2021). It emphasizes cultural adaptation, involvement of fathers, and cost-effectiveness. The program has been adapted and implemented in the Philippines, with the Masayang Pamilya Para sa Batang Pilipino (MaPa) program and MaPa Teens program. These programs have shown positive outcomes in reducing violence against children, improving parenting behavior, and promoting healthy relationships among adolescents. The findings provide valuable insights for policymakers and practitioners in developing effective parenting programs in low- and middle-income countries.

Preschool Parenting Program in Thailand

The Preschool Parenting Program is an intervention aimed at promoting early childhood development by involving parents in their child’s growth. It is based on the Developmental Surveillance and Promotion Manual (DSPM) and emphasizes positive discipline and attachment between caregivers and children. The program consists of four activities conducted over four months, targeting children aged 3 to 6 years, and involves trained facilitators such as teachers and nurses. Research has shown that the program effectively improves children’s emotional intelligence and strengthens the bond between parents and children. It has been found to enhance the emotional quotient (EQ) of early childhood subjects and can be implemented in other healthcare settings in Thailand to support childhood development (Chonchaiya & Pruksananonda, 2008; Inpracha et al., 2021; Sakulthong & Charleekrua, 2022). Additionally, the program has been shown to increase positive discipline practices and improve parent-child relationships, leading to better behavior in children. The emotional bond between mothers and children is crucial for intellectual and social development, making research in this area valuable for identifying effective ways to strengthen this bond and positively impact early childhood development.

 

Conclusion and Recommendations

The GPI team in Thailand is working on scaling their positive parenting program through the health system, starting with expanding their partnerships in the Northeast region. They are also establishing a Community of Practice to share information and collaborate on positive parenting. Additionally, they are addressing the specific needs of displaced families in Mae Sot due to the conflict in Myanmar. The team has engaged with the Project Steering Committee (PSC) and conducted a workshop to gather input on advocacy and adoption strategies. The workshop included five key questions designed to guide the framework for scaling up, with inputs from the core team, experts like Jamie and MSI, and knowledge-sharing across the GPI community.

Hence, the review recommends the following:

It is important to differentiate between scale-up strategies and advocacy strategies. Advocacy is a subset of the scaling plan and focuses on systematic transformation. Advocacy plays a crucial role in promoting the adoption of ideas during the scaling-up process.

To understand the challenges and opportunities for scaling up the PLH program in Thailand, it is essential to identify the child protection ecosystem and examine alignment with existing policies and outcomes across different agencies. This investigation can help integrate PLH into relevant parts of the ecosystem.

Some specific actions to broaden the focus of PLH in Thailand include training parents and caregivers on positive parenting skills, providing support to struggling parents and caregivers through counseling and mental health services, and developing programs to address problem behavior in children, such as teaching emotional management and problem-solving skills.

It is important to identify the risks involved in scaling up efforts, including the potential pitfalls of relying too heavily on a single approach or strategy. Diversification and considering alternative approaches can help mitigate such risks.

 

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