Adapting Reach Up and Learn in Crisis and Conflict Settings: An Exploratory Multiple Case Study Free

Using an exploratory multiple case study design,⁹  this article draws from implementation data and qualitative findings to present insights across 3 different Reach Up-adapted interventions. Narrative reports of implementation design and processes are drawn from authors’ first-hand experiences as program designers and implementors, and are coupled with client feedback and monitoring data. Costing data were collected for 2 of the 3 cases (Bangladesh and Venezuela Crisis Response, because data from Northeast Syria were not available at the time of publication).

Case studies were purposefully selected because they represent 3 recent examples of Reach Up adaptations led by the implementing organization, International Rescue Committee (IRC). IRC is a global humanitarian nonprofit organization that has been responding to humanitarian crises since 1933 and continues to help people survive, recover, and rebuild their lives in >40 countries worldwide. IRC’s geographical presence aligns with continual analyses of crisis conditions, humanitarian needs considering capacities of local organizations and government to respond to needs, and the availability of resources and funding to deliver programs with impact. Since 2015, ECD has been a key focus of IRC’s work with the overarching aim of improving young children’s cognitive, language, motor, and socioemotional skills. The majority of IRC’s ECD portfolio is funded by private foundations, with an emphasis on scaling in partnership with national governments (where possible), as well as local education, health, or child protection actors. IRC’s ECD team worked with the creators of the Jamaica Home Visiting program, now known as Reach Up and Learn and adapted to different contexts in 14+ countries,¹⁰  to adapt the program for humanitarian settings starting in Jordan in 2016, expanding to Syria in 2017, Bangladesh in 2020, and Venezuela in 2021. Human subjects ethical review was conducted by IRC’s institutional review board, which determined that the study was exempt as a secondary analysis of program monitoring data without direct personal identifiers.

The 3 case studies described in this section demonstrate early indications of the powerful potential of Reach Up adaptations for young children and their families in crisis and conflict settings. As highlighted in Table 1, they represent variations in population and location types (camp-based, internally displaced peri-urban, and nondisplaced peri-urban crisis-affected), and types of crises, modality, and length of intervention, among other key characteristics. Each case below includes a brief background of the specific context, crisis, and feasibility for the use of Reach Up, the rapid adaptation process, and key lessons learned. A final section focuses on the analysis of costs in Bangladesh and Venezuela.

With a history of persecution beginning in the early 1990s, the latest and most severe outbreak of violence in Myanmar has driven an estimated 884 000 Rohingya people into exile and statelessness since 2017.¹¹  Many of the displaced Rohingya now reside in 34 highly congested camps in Cox’s Bazar, Bangladesh. In an area vulnerable to natural disasters and where malnutrition already threatens young children, the COVID-19 pandemic added a third crisis to the country, resulting in compounding adversities. The urgent needs of young children and families in the refugee camps had first been identified through a series of community consultations and focus group discussions highlighting needs of pregnant and lactating women who were receiving minimal, and often low-quality, support for health, nutrition, and mental health, and no support for responsive caregiving, safety, and protection and early learning. In response to these findings and from the expressed feasibility and acceptability of home visiting, Reach Up emerged as a model to provide critical support for responsive caregiving and early learning, recognizing that adaptations and additions would be required. IRC also assessed the local landscape of ECD actors and identified International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) as a strong technical partner to support curriculum development, given their extensive expertise implementing, scaling, and studying Reach Up within Bangladesh.

Before IRC was able to begin the Reach Up adaptation for Cox’s Bazar, the COVID-19 pandemic struck, resulting in lockdowns and severe restrictions to camp access. In response, IRC worked with a Bangladeshi human-centered designer, icddr,b, and local IRC program staff to design a remote intervention that used phone calls and interactive voice response (IVR) messages to promote nurturing care, focusing particularly on health, nutrition, caregiver well-being, and play-based early learning opportunities.

The initial 4-month pilot reached a total of 434 households in 2020. In 2021, the team worked on prototyping, program improvement, and a redesigned platform reaching 2400 households. The content builds on Reach Up activities using household objects and commonly available materials. Play-kits including storybooks from icddr,b were also distributed to reinforce the messages. The team conducted formative research to identify key influencers of maternal behaviors, which highlighted the important role of fathers and mothers-in-law. In response, messages were tailored to these specific audiences and distributed via IVR. Caregivers reported that, after receiving IVR calls, they adjusted their infants’ diets, consulted with doctors after experiencing pregnancy complications, and engaged in more frequent and more diverse types of play with their children, promising indications of improvement in practices that enhance children’s development.

The pilot phase revealed key lessons about how to tailor an IVR intervention to the rapidly changing developmental needs of infants and toddlers. After the pilot, IRC began prototyping several enhancements to the program with the aim of improving caregiver experience and increasing scalability. Improvements included tailoring IVR messages initially designed for 2 broad categories of users (pregnant women and lactating women with infants aged <6 months) to specific stages of pregnancy and child’s age by month, allowing for integration of more age-appropriate play activities and reducing repetition. The example of peek-a-boo in Table 2 highlights the additional tailoring. Messages were also updated to include local terms. A sample of the new messages was tested with facilitators over WhatsApp, who consulted caregivers in both camps and host communities for their feedback. The improved content was integrated into the program in October 2021.

Given the longstanding evidence of the effectiveness of home visits,^12,13  IRC incorporated home visits as another enhancement to the program in October 2021 as COVID-19 cases reduced and lockdown restrictions eased. The visit structure is based on Reach Up, with an added emphasis on IVR message follow-up for confirmation of understanding. All 40 caregivers who received the home visits (from both camp and host communities) for 1 month were interviewed and rated the visits as highly valuable, and 98% of caregivers reported that the visits enabled them to practice the activities on their own.

Although the remote delivery model was identified as the most effective way to reach caregivers during the pandemic lockdowns, the in-person connection and modeling of activities during a home visit were seen as highly valuable and more likely to result in caregivers engaging in play activities. This points to the powerful potential of a blended model combining IVR and home visits to provide support to families while balancing considerations of access, feasibility, impact, cost, and scale, and will be the focus of future research.

With 4.8 million Syrian children born into war since 2011, multiple complex emergencies continue to drive internal displacement. On the basis of early successes in Jordan, Reach Up had been identified by the Syria child protection team as a modality for community-based violence prevention and identification, while also addressing the unmet developmental needs of children aged <3. In October 2019, the withdrawal of US troops and the subsequent Turkish offensive forced a wave of displacement in the Kurdish communities already hosting internally displaced persons from other parts of Syria. Local schools were converted to collective shelters for families. Six home visitors within IRC’s child protection team serving families in internally displaced persons camps reoriented their work to offer an ECD response in this acute emergency facing their own community.

The Syrian team’s initial adaptation of the Reach Up curriculum drew on the IRC-Jordan adaptation for Syrian refugees, with minor adjustments to printed materials and songs. During the acute emergency, Syrian home visitors and program managers, under intense pressure themselves because of increased security threats in their own neighborhoods, planned a response to support the newly displaced in their community by taking extra shifts to serve the families residing in the collective shelters. Recreational activities, including activities from Reach Up curriculum and social and emotional learning games for older children, were launched immediately at the end of October 2019. In December, the team held sessions with caregivers about the importance of early childhood and how Reach Up supports children’s learning. Female-headed households, mothers aged <18, unaccompanied children, young mothers with >4 children, and caregivers with particularly low education levels were prioritized as most in need of home visits. Thus, 144 highly vulnerable families were identified to receive visits, delivered from January to March 2020, when COVID-19 lockdowns began, and families were moved from collective shelters to camps or rented apartments.

Although pre–post surveys of caregivers were not feasible in the acute crisis setting, interviews with facilitators indicated positive perceptions. As 1 home visitor described:

“We started with activities for children of all ages. Often, we were using language activities; we hid things under some rugs and played with children while they were in their mothers’ laps, sometimes using socks to act like dolls and talk to children and tell stories. After that, they started to come and look at us. Some were trying to participate, and now that is going well, and 1 of the mothers said that she feels relieved when we are playing together with her child. But that took time and was challenging, because even we were so much affected emotionally by the emergency, and we were angry, as well, and feeling helpless.”

Because entire families were residing together in the communal shelters with all children out of school, home visitors wanted to engage caregivers and children of all ages in the household with a play-based response, introducing calming activities such as glitter jars. Home visitors drew from experiences with Reach Up, facilitating social and emotional learning games for school-aged children and psychological first aid. The latter was seen as particularly important for improving active listening skills and enabling them to make safe referrals to protection and other key services, which are crucial in building trust between home visitors and caregivers.

Venezuela’s prolonged socioeconomic crisis has resulted in hyperinflation, scarcity of food and medicine, and deterioration of health, education, and other basic services and infrastructure, including water and sanitation. More than 5.5 million Venezuelans have left the country in search of better conditions in neighboring countries. Those who remained have experienced minimal access to health or protection services, COVID-19 school closures, precarious housing, and insecure living and working environments marked by high levels of violent crime. Through IRC’s engagement with the community, caregivers reported high levels of stress in caring for young children with minimal, if any, focus on early learning and responsive caregiving. In 2020, IRC expanded support to the sole health provider in an indigenous Wayuu community to offer a Reach Up program integrated with existing holistic health services near the border.

Before beginning the adaptation of Reach Up, the ECD team conducted design research to better understand cultural norms and traditions, parenting practices, perceptions of play, specific play activities, and key health and environmental conditions. Mothers, fathers, other caregivers (aunts, sisters, grandmothers), community leaders, and staff from the local partner organization were interviewed and participated in focus group discussions. Through these discussions, IRC confirmed that most women stay home during the day, and play and stimulation to promote early learning for 0- to 3-year-olds was not a common practice. Most play activities mentioned were for older children (eg, flying kites). Key health, nutrition, and child safety risks were also documented for supplemental messaging.

To ensure that the intervention would be feasible and desirable to caregivers, IRC facilitated a codesign process with the local partner, leading to the design of a 9-month program allowing caregivers the choice of participating in home visits or group sessions on a weekly basis. During 2021, each facilitator conducted ∼1 group session and 8 home visits per week, working shortened days because of security concerns. Four days each week were dedicated to delivering sessions and 1 day was for making toys, group discussions, and supervision.

Because home visits often included multiple children aged <3 together with older siblings (because of COVID-19 school closures), the team opted for a single curriculum following the structure and layout of a Reach Up group session originally created for the Family, Women, and Infancy Program in Colombia.¹⁴  This made it easier for promoters to deliver multiple age-appropriate activities at 1 time. The final version of the curriculum consists of 24 sessions, each with a song, a play activity, a language activity (designed according to age groups: 0–5 months, 6–11, 12–24, and 25–36), and a key message to discuss with participants. Considering the shortage of recyclable materials for toy making, some of the plastic toys in the classic Reach Up curriculum were adapted to be made with wooden sticks (Fig 1). A local carpenter was contracted to make wooden toys such as blocks.

Feedback from caregivers in the community informed adaptations. For example, they were asked to select their favorite types of illustrations and colors from sample mood boards and define the color schemes and styles for the storybooks on the basis of their preferences. The team also tested infographics with caregivers on nutrition and positive discipline to check understanding and conducted a rehearsal group session to test the structure and layout of the curriculum.

Because children’s books were not available in the community, IRC adapted Reach Up’s books to reflect Wayuu homes and community settings. The books stimulate language and deliver key messages related to development and health. For example, the book “Baby is Hungry” shows a picture of a mother washing her infant’s hands before eating, particularly important during the COVID-19 pandemic, and shows a second caregiver helping keep the infant away from the open cooking fire because design research indicated a high incidence of childhood burns.

Program content was also expanded to include topics raised in community consultations, such as hygiene and hand-washing, nutrition, exclusive breastfeeding, positive discipline, safety in the home, and caregiver well-being. Some of these messages are delivered through an infographic on clarifying appropriate (eg, putting away toys) and inappropriate (eg, cooking on an open fire) household chores and objects for small children.

To monitor the intervention, IRC conducted caregiver pre–post surveys and qualitative interviews. One caregiver participant explained, “In general, because of the daily housework, one says, ‘Oh, I don't have time for this,’ and [Wapuushii] has helped one to learn that, I mean, there is time for everything; that just as suddenly I have the time for cooking, I have to take the time to dedicate a song to them, read with them, sing to them, play games, etc.” Caregivers and facilitators highlighted language development as a key area of growth for children in the program. Feedback from the implementing partner also demonstrated high utilization and satisfaction with Reach Up and complementary lactation counseling services.

The interventions in Bangladesh and Venezuela were costed using an ingredients-based approach to estimate the actual cost of the intervention, including programmatic costs that are closely linked to program activities and all other overheads and shared costs, divided by the number of clients reached (Table 3). Cost data from Bangladesh during the initial pilot in 2020 reaching 430 households, versus the redesigned IVR platform launched in 2021 that now reaches 2400 households with an average of 3 caregivers (mother, father, and mothers-in-law) and 2 children per household, demonstrated that costs decreased with scale, from $85 to $21 per household per month. Cost of pilot phases in both countries included design research, curriculum adaptation, and initial training of trainers. In Venezuela, costs include a 9-month pilot Reach Up intervention for 197 caregivers, as well as lactation counseling, folic acid supplementation, and psychological counseling services provided in the community clinic for a total of 743 caregivers, resulting in $40 per household per month. Costs per caregiver may appear high during pilot phases when adaptation and startup require more human resources; however, as seen in Bangladesh, costs per caregiver can be reduced through iterations on design, as well as using blended modalities to reach more caregivers.

This article highlights implementation experiences from 3 distinct cases that respond to the urgent and unmet need for ECD programming in conflict and crisis settings through the adaptation of Reach Up. Recommendations summarized in Table 4 offer lessons from these cases by extending and expanding the framework offered by Murphy et al (2018).⁵  These approaches center around promoting nurturing care through the holistic integration of health, nutrition, and protection activities (in line with the Nurturing Care Framework). The common characteristics found across the interventions in Syria, Bangladesh, and Venezuela that led to their successes are:

1. cultural adaptation based on a holistic understanding of needs of children and caregivers in the targeted community;

2. the integration of child and family safety and linkages to complementary services on the basis of the needs and priorities of the targeted communities; and

3. the importance of designing for scale through the use of blended models and costing analyses.

A key commonality across the 3 cases is the important role of locally led adaptation and contextualization that reflect client needs, culture, traditions, and values. This ensures that the Reach Up programs not only address the needs of affected communities, but that the communities themselves are empowered to integrate responsive caregiving into their everyday lives. Across the 3 cases, feasibility of cultural and program adaptation, a key consideration highlighted by Murphy et al (2018), varied. Each country underwent a process of contextualization and adaptation of Reach Up content and materials to respond to the cultural and contextual reality of each setting. Additionally, each team selected a delivery modality specific to the needs of the caregivers in their context. Because of COVID-19 restrictions on physical access to caregivers in Bangladesh, IRC used an opt-in, phone-based delivery modality, leveraging health partner registries of caregiver phone numbers for initial outreach. In Syria, families could be reached in collective shelters. In Venezuela, facilitators reached caregivers through group sessions in a trusted local health clinic or home visits, on the basis of caregiver choice. In protracted crisis settings such as the Venezuela crisis, there was more time for cultural adaptation of the intervention around the specific safety, health, and nutrition needs of the community, making detailed changes to books and creating unique infographics. Whereas in acute emergencies like in Syria, skilled home visitors adapted immediately, drawing on their own experiences serving families in conflict. In Bangladesh, cultural adaptation had been previously done by icddr,b for Bangladeshi families, but the IRC team contributed expertise on serving Rohingya refugees and field testing yielded important insights.

Each case highlighted the critical importance of considering family, and particularly child safety and protection in crisis and humanitarian settings. ECD facilitators and home visitors must be trained in where and how to refer caregivers to existing services to meet their basic needs for safety. In Syria, trained home visitors working within the child protection team make referrals and promote safe and responsive caregiving alongside early learning activities. In Venezuela, infographics and visuals were designed to support facilitators in explaining home safety and positive discipline messages. Other complementary messaging, such as exclusive breastfeeding and complementary feeding, that were included received positive feedback in Venezuela and Bangladesh. The ability to integrate referrals and complementary messaging that addresses basic needs builds trust between clients and ECD service providers, increasing the likelihood that caregivers engage in early learning activities.

Analyzing the cost of Reach Up helps prepare and design for scale. For example, the costing analysis in Bangladesh demonstrated that costs decreased with scale; nonetheless, the analysis also revealed that the largest cost driver is human resources, which is an essential ingredient for facilitator-based programming and is critical to quality delivery. Thus, careful consideration of cost drivers should identify practical strategies to reduce costs for increased uptake and scale, without threatening fidelity, quality, and impact.

The methodology of exploratory multiple case analysis used in this article is a key limitation in that it does not adhere to more conventional standards of qualitative or mixed-method research, and does not allow for an in-depth analysis of program processes or effects. This methodology was selected because of the highly unstable contexts and relative novelty of these programs, where rigorous qualitative or quantitative research had not yet been implemented. Although this approach entails significant limitations, it offers early insights that may be used to inform future research.

Randomized controlled trials and mixed-methods research are needed to better understand program effects, minimum dosage, and how conflict and crisis affect delivery and outcomes of the intervention. Cost effectiveness studies are critical to bolster the case for ECD programming in resource-constrained crisis settings.

Through an exploratory multiple case study analysis, this article provides recommendations for effective cultural adaptation, including integrating child and family safety into programs and designing for scale through costing analysis. These examples of Reach Up adaptations highlight the need for holistic ECD services in crisis settings and can serve as a starting point for the development of robust ECD responses to improve short- and long-term outcomes of young children and families affected by crisis and conflict.

COVID-19

coronavirus disease 2019

ECD

early childhood development

IRC

International Rescue Committee

IVR

interactive voice response

icddr,b

International Centre for Diarrhoeal Disease Research, Bangladesh