Using lessons learnt from key stakeholders to increase support for scaling the Reach Up Early Childhood Parenting program

Introduction Sustainable implementation of early childhood programs requires resources, materials and methods that are adaptable, scalable and feasible for delivery through multiple sectors. Additional or modified program resources may be required to meet emerging needs, as programs go to scale. An active and effective monitoring, evaluation and learning (MEL) process may enable programs to be responsive to demands. The Reach Up: Early Childhood Parenting program, is designed primarily for disadvantaged children under 4 years of age in low- and middle-income countries (LMICs) to promote their development through playful caregiver interactions. The curriculum, training manuals and other materials and resources support implementers in the adaptation of the intervention, implementation, workforce training, monitoring and evaluation. This paper reports on how data collected from key informants drove modifications to program processes, materials and resources. Methods We conducted in-depth interviews with 14 key informants (including program managers, lead trainers, academics, consultants and workforce personnel) on their experiences with Reach Up across 15 LMICs where the program has been implemented. We also reviewed written records generated from (i) structured small group discussions at a Knowledge Exchange meeting of 31 Reach Up partners and (ii) notes from working groups formed at the meeting and tasked to continue working post-meeting to find solutions to support ongoing implementation. The transcripts from the in-depth interviews and the meeting records were analysed using thematic analysis with a mixture of pre-defined categories and data-driven sub-themes. Results The main findings indicated that there was a need to: (i) develop advocacy and communication resources and materials to aid prospective implementers and other stakeholders, to make decisions for implementation, (ii) revise and/or add to the content and format of the curriculum and add content in the training and other supporting manuals and (iii) enhance the training process. Conclusion: The feedback from the key global partners informed the development of new knowledge materials, resources and processes and modifications to existing program materials and resources. These will help to support advocacy, ongoing implementations, and the process of transitioning the Reach Up early childhood intervention to scale.


Introduction
The Lancet early childhood development series in 2016, the launch of the WHO, UNICEF and World Bank Nurturing Care Framework in 2018, the special issues of Annals of the New York Academy in 2018 and the Archives of Diseases in Childhood series in 2019, highlighted the significance of addressing early childhood development (ECD), especially for children in low-and middleincome countries (LMICs). Increasing numbers of LMIC have national ECD polices (1) with increased demand for scalable and sustainable ECD interventions.
To achieve lasting impact on early childhood development and caregiver skills and practices, interventions require a comprehensive package of resources and materials that are adaptable, scalable, promote sustainability, and feasible for implementation through multiple sectors. An active and effective monitoring, evaluation and learning (MEL) system can be important in understanding effective scaling. As Krapels et al., noted, this is needed to (i) facilitate strengthening of programs and inform the development of more effective designs, implementation and scale up and (ii) share information and knowledge gained from MEL processes with others working in the ECD and other behaviour change sectors (2).
The Measurement for Change (M4C) approach provides a framework that can be used to measure progress and respond to developing needs as necessary, to ensure continued effective adaptation and implementation and facilitate scaling of ECD interventions. The five interconnected objectives that currently inform the use of data collected for M4C are that it should be (i) dynamic (flexible to change and use iterative learning cycles), (ii) inclusive (engaging all stakeholders -children, families, community members, policy makers), (iii) informative (making decisions based on the data gathered from various sources), (iv) interactive (continually interacting with systems, processes and stakeholders and implementing changes based on these interactions) and (v) people-centred (be able to respond to the diverse needs of all stakeholders) (2) The framework, with focus on objective (ii) was used as the guiding approach for this study.
Studies on scale up of ECD programs have focused on examining of geographical coverage and reach, implementation characteristics such as dosage, frequency and mode of delivery, monitoring (supervision, fidelity), evaluation of intervention outcomes, financing and the workforce (3). In addition to monitoring implementation characteristics such as coverage, mode of delivery and impact, other elements of an intervention, such as the program material and resources and capacity to implement, may also affect its success. Research on this aspect of scaling ECD programs through evaluating and improving the processes, resources and materials to support achievement of scaling at other levels, is less common.
In this paper, we document lessons learnt from engagement with the Reach Up: Early Childhood Parenting program (commonly referred to as "Reach Up") implementation partners in multiple countries. We also discuss how this informed enhancements to the Reach Up package to support the needs of program managers and delivery staff as they expand to reach more families.
First, we present a brief overview of the Reach Up program. We then discuss Phase I, the evolution from the Jamaica Home Visit intervention (JHV) to Reach Up. Phase II (the formation of the global Reach Up community) and Phase III (using learnings from the global partners to make systematic changes to further scale the Reach Up package) are discussed in the Results section.

The Reach Up Early Childhood Parenting program
The Reach Up: Early Childhood Parenting program is based on the Jamaica Home Visiting (JHV) model developed in the 1970s (4)(5)(6). It was designed primarily for disadvantaged children under 4 years of age in low-and middle-income countries. In addition to helping parents promote their children's development, the program aims to build the mother's self-esteem and enjoyment of parenting (6). The format of delivery of the intervention is through a series of weekly or fortnightly home visits or small group sessions, using a structured curriculum. The activities are tailored to the child's ability and each play session includes the introduction of concepts (using homemade toys, songs and games) and language activities. The intervention is designed to be suitable for delivery by non-professionals, with a minimum of complete primary level education, such as community health workers and community members (e.g., Madre Guias -"mother guides" in Guatemala and Colombia). The initial Reach Up package comprised weekly and fortnightly curricula for ages 6-36 months, an Adaptation and Planning Manual for program implementers, a Toy manual, a Training manual with films to be used during training workshops and a Supervisor Manual. The intervention has been adapted and used in 17 countries: Bangladesh, Bolivia, Brazil, China, Colombia, Guatemala, India, Jamaica, Kenya, Liberia, Madagascar, Peru, Turkey, Zimbabwe and Jordan, Lebanon and Syria (for Syrian refugee families). At scale, in Peru, the national home visiting program, Cuna Más, was built on Reach Up, through the adapted Colombian model (7). The intervention has also been expanded to 11 counties in the western and central regions of China (8). The intervention has been adapted and implemented in diverse contexts and settings, such as in poor, rural and urban communities and humanitarian, conflict and displacement settings such as the implementations led by the International Rescue Committee (IRC) in the Middle East.
Adaptations done for context prior to implementation include the inclusion of local games and songs, adaptation of pictures and toys to reflect local people and activities, and addition of content to the curriculum (e.g., health, nutrition and hygiene messages) and training manual (e.g., stress management). Adaptation of implementation processes to fit country infrastructure, personnel and resources include mode of delivery (e.g., weekly to fortnightly visits), personnel (categories of workers used -healthcare workers, community leaders, pre-school teachers), engagement strategies (recruitment of participants, retention of workforce) and training.
Evaluations of implementation processes have been conducted in Jamaica (24), Bangladesh (14,25), Colombia (26) Brazil and Zimbabwe (27) and the Middle East (28). These have included evaluations of the adaptation and implementation processes, focussing on the acceptability, appropriateness, feasibility and effectiveness from the perspectives of caregivers (mothers) and implementation staff.

Scaling up the Reach Up intervention package
Scaling of the processes, resources and materials that make up the Reach Up intervention has occurred across three phases: • Phase I, the evolution from the Jamaica Home Visit intervention (JHV) to Reach Up, a comprehensive package of curricula, manuals and resource materials in 2014. • Phase II, implementation and evaluation in several countries leading to a knowledge exchange meeting and the formation of the global community in 2019 • Phase III, interconnected with Phase II, using learnings from global partners to make systematic changes to further scale the Reach Up package in 2021.
Phase I: from Jamaica home visit to Reach Up  Up to 2014 the JHV program was adapted for use in Bangladesh, Colombia (the first attempt to scale the intervention by linking to the conditional cash transfer program Familias en Acción) and Peru (adapted and implemented at scale through the Cuna Más program) (5). Randomized control trials conducted in Bangladesh (5-7, 29, 30) and Colombia (10), in addition to those in Jamaica (4,9,17) provided robust evidence that the program had benefits to children's development.

Development of the Reach Up package
In a context of growing demand for scalable ECD programs and an increase in interest in the implementation of the JHV, the developers identified challenges with the expansion related to limited technical capacity of organizations as well as capacity of the Jamaica intervention team to provide support. One of the solutions identified was to develop a comprehensive training package that could be used by implementation partners.
With the support of a grant in 2014 from Grand Challenges Canada, a web-based package was developed. The curriculum layout was reorganized for easier use with drawings of toys and suggested text to introduce and explain activities included. A few new picture books, toys and activities were added to the curriculum to replace some toys and create more variety. The toy manual was revised with colourful drawings depicting step by step instructions. All pictures (used in books and puzzles) were redrawn with the use of vibrant colours to make them more attractive to young children. Three additional manuals to support implementation and training were developed (Adaptation and Planning manual, Training manual and Supervisor training manual). To facilitate the training, 23 short films (approximately 2-3 min each), were produced to show the methods used during visits and demonstrated specific materials and activities. Three 15-min films produced show the key steps in a home visit. All films are available in Bengali, English, French and Spanish.
A meta-analysis of impact evaluations of the JHV and Reach Up in several low-and middle-income countries, showed that the intervention improved child development across diverse settings (31).

Methods
We focussed on the inclusive aspiration of the Measurement for Change (M4C) framework as the intent of this paper is to highlight how learnings from Reach Up partners, who are critical stakeholders, contributed to the scaling of the Reach Up program resources.
The data we present in this paper were collected in Phase II of the Reach Up scale-up process. We used two approaches (i) interviews with key informants on their experiences with Reach Up in the different countries where the program has been implemented and (ii) review of written records generated from meetings with members of the global Reach Up community.
In November 2019, with funding from the LEGO Foundation, we convened a 3-day Knowledge Exchange Meeting to bring together 31 partners to discuss the findings from the intervention, including reflections on the challenges, successes and lessons learned from the implementation of Reach Up. The attendees at the Knowledge Exchange Meeting were program implementers familiar with the processes involved in the decision-making, adaptation and implementation of countryspecific interventions, the core team of Reach Up developers, and representatives from the LEGO Foundation, The World Bank and the Inter-American Development Bank who had been involved in supporting the implementation of Reach Up. We also asked country program leads to recommend team members who would be able to contribute to the discussions on country-specific adaptations and implementations.
Before the meeting, three researchers (JC-H, JS, and MK) obtained information from a purposive, non-random sample of 14 key informants over the period August to October 2019. Informants were chosen as they were experienced with the intervention and/or had first-hand knowledge of the processes involved in the decisionmaking, adaptation, and implementation of country-specific interventions. Reach Up developers identified persons from the existing network of partners who were experienced Reach Up trainers, country program leads who had conducted planning and adaptation of the intervention, or researchers who undertook evaluations of the intervention. We also asked program leads to recommend team members involved in frontline delivery, so that we could capture their "on the ground" experiences. The sample was deliberately restricted as the intention was to interview one key person involved in the planning and implementation of the respective programs, and to invite one or two additional key people to the Knowledge Exchange Meeting. One informant provided information for two separate country programs and two informants provided information for one country, but on different modes of delivery (groups and home visits). All persons who were approached agreed to be interviewed.
Thirteen interviews were conducted in English and one in Spanish, each lasting approximately 1 h. Due to geographical distance, the interviews were held via Zoom ® . A structured guide consisting of 28 questions was used during the process. The guide was divided into three main sections: Program Design (Adaptations and Program Materials), Implementation (Lessons Learned and Promoting Play) and Overall Reflections. Table 1 presents the questions related to the program design which is the focus of this paper. The participants were not provided with a copy of the interview guide prior or during the actual interview.
The interviews were recorded, and the interviewers also kept written notes throughout the interview. Transcriptions of the recordings were compared with the written notes, compiled, and saved as Microsoft Word documents. The  We also reviewed written records generated through two major sources (1) the Knowledge Exchange Meeting held in November 2019 where discussions and recommendations were documented and (2) the minutes of meetings from working groups formed at the meeting and tasked to continue working post-meeting to find solutions to support ongoing implementation. Working groups were formed to focus on three key areas -Adaptation, Capacity Building and Monitoring and Evaluation.

Data analysis Interviews with key informants
The data from the interviews with the key informants were analysed using a qualitative content analysis framework. Specifically, we used thematic analysis, following Braun and Clarke's (32) recommended five phases for identifying, analysing and reporting patterns within data -(i) familiarization with data, (ii) generating initial codes, (iii) searching for and generating themes, (iv) reviewing themes and (v) defining and naming themes. We applied a mixture of deductive coding (pre-defined categories) and inductive coding (datadriven sub-themes). We first identified nine pre-defined themes based on the main section headings and corresponding questions on the structured interview guide -Adaptation, Integration, Manuals, Curricula, Training Process, Implementation, Workforce, Monitoring and Evaluation and Promoting Play. In this paper, we present the analysis from four of the pre-defined themes related to the Reach Up processes, material and resources -Adaptation, Training process, Manuals, and Curricula.
Two researchers (JC-H and JS), working independently, manually coded nine and six transcripts, respectively. The researchers were currently working with the Reach Up program and therefore understood the context of the review. At this stage, each researcher coded their respective transcripts using the initial codes they identified.
Following the individual coding of the transcripts, the researchers reviewed, and met to discuss each other's extracted supporting quotes. Any discrepancies were resolved through discussions and consensus and consultation with an arbitrator (SW). Based on the initial coding, we identified 39 sub-themes to which data could be coded, and formulated definitions for each ( Table 2). The coded texts were then combined under each category and sub-theme and saved as the final output of the coding process.

Review of meeting records
One researcher (JC-H) reviewed the compiled notes from the Knowledge Exchange Meeting and minutes of three of the working group meetings (Adaptation, Capacity Building and Monitoring and Evaluation) to identify discussions surrounding the resources and materials and extract relevant statements, decisions and future actions.
Similar to the coding process for the interviews, the nine pre-defined themes were used in the process. The notes from the Knowledge Exchange Meeting, and the Adaptation, Capacity Building and Monitoring and Evaluation working groups were read and sentences and/or paragraphs were highlighted and labelled with the most appropriate theme according to the codebook.

Results
Three male and eleven female key informants were interviewed from NGOs, and academic and funding institutions, from various regions across the world (Table 3).
Findings for Phases II and III of the Reach Up material and resources scale up are presented in this section. For Phase II, we present (i) the background to the formation of the global community and (ii) the systems used to share lessons and make resources accessible to implementation partners. For Phase III, we (i) highlight the learnings from the interviews with the key Reach Up partners and the review of the records of the Knowledge Exchange and working groups' meetings, and (ii) describe the adaptations made to some of the Reach Up materials and the addition of new knowledge goods and resources.

Phase II: formation of global Reach Up community
The formation of the global Reach Up community began with the participants who attended the Knowledge Exchange Meeting in November 2019. The group included Reach Up developers, implementation program leads, government representatives, lead trainers and academic researchers from Bangladesh, Bolivia, Brazil, China, Colombia, Guatemala, India, Jamaica, Jordan, Madagascar, Peru, Turkey and Zimbabwe. The 3 days of activities included

Adaptation
In the survey you shared that you adapted the (indicate which -curriculum, training materials, supervision materials, play materials, etc. for families). Can you please share with me how you determined that these adaptations were necessary?
Can you please tell me how the adaptations were made, including who was involved in the process (consultants, government officials, trainers, front line workers)?
Did you have an opportunity to test/pilot the adaptations of the materials before full implementation? (If yes, continue). What aspects were you able to test/pilot before the start of the intervention?

Programme materials
What do you think about the Reach Up Curriculum? (e.g., objectives, layout presentations on experiences with home visiting (four countries) and group modalities (three countries), sharing of results from a pre-meeting survey and a summary of the indepth interviews, in-session working groups (more detailed discussion focussed on adaptation and preparing to implement, workforce capacity, implementation, and learning), gallery walks (comprising notes from working group discussions mounted on flip charts for participants to review and add comments), and other networking activities.

Knowledge sharing
Since the formation of the global community, we have established systems for sharing learnings with, and making resources available and accessible to, Reach Up partners. Networking and communication among the partners have been strengthened through: • The knowledge goods produced and the new and amended materials were shared with Reach Up partners at a webinar in November 2021. • A Bi-annual Newsletter to share information about implementation in the different countries, provide updates on workshops and meetings and links to reports, journal articles, evaluations, information from funding agencies, etc. • A group was formed on the instant messaging platform, WhatsApp ® , which included country representatives, implementers, funders and Reach Up team members in Jamaica. The platform has become a place for active exchange of ideas and where members can seek possible solutions for implementation challenges.

Phase III: learnings from key Reach Up partners
The results from the coding of the four categories related to the Reach Up material and resources -Adaptation, Training process, Manuals and Curricula -are presented in this section. Table 4 summarises the key findings from the interviews with the key informants and the discussions at the Knowledge Exchange Meeting and Working Groups, while Table 5 presents some of the perspectives and recommendations from the key informants.

Implementation challenges and suggested solutions
A few key informants identified challenges with integrating the program within an existing system. Cost and increased staff workload were mentioned, but the bureaucratic systems at State-run institutions was the main challenge experienced with integration. Suggestions made by the key informants to engage policy makers and minimize bureaucratic challenges are mentioned in Table 6. Adaptation challenges included accessing/finding materials to make the toys, acceptability/suitability of toys and in some instances, costs associated with procuring the required material. The main workforce challenge was staff turnover experienced curing program delivery. Inadequate compensation and heavy workload were the two main factors contributing to staff turnover. Unfortunately, not many solutions were offered, as this issue was often out of the control of the key informants.
Some key informants also noted that the workforce was affected by distance/location of families and the weather. In two countries, challenges related to the safety of the home visitors were of concern: TABLE 4 Key findings from interviews and meeting discussions.

Source
What was learnt Key informant interviews • Involving decision makers at the government level is a critical component for the effective implementation and eventual scaling of the intervention. And as part of this engagement process, the key informants emphasized that advocacy and communication resources and material must be available.
• There was a need to make revisions and/or modifications to the curriculum (e.g., develop additional sections with activities) and messages for other age groups (e.g., 0-5 months and 37-48 months).
▪ There was also demand for additional content in the supervisor and training material (e.g., additional guidelines for trainers).  Other challenges and suggested solutions by the key informants include supervision, working relationships, cultural norms and relationships with families (Table 6).

Adaptations/additions and changes to scale the Reach Up package
After the in-depth interviews, further discussions at the Knowledge Exchange Meeting and feedback from the working groups, the following changes to the Reach Up package and resources to support scaling, were made. These were done with input from members of the global community. Tables 7, 8 provide a fuller description of the new knowledge goods produced and the

Discussion
In this paper, we report on how learnings from key stakeholders contributed to the enhancement of Reach Up materials and resources to support effective adaptation and implementation and facilitate scaling the program across new and within existing countries/regions. Information was collected from Reach Up global community stakeholders (consultants, funders, researchers, home visitors and supervisors) who had first-hand knowledge of the processes involved in the decision-making, adaptation, and/or implementation of the intervention.
The Nurturing Care Framework Handbook recommends the formation of communities of practice to facilitate innovation and scale up of ECD interventions (34). The global Reach Up community (officially formed in 2019) is one such network of implementers, program managers and researchers who have led on the initiation, adaptation, implementation, monitoring and evaluation of the intervention in various settings and countries. Similar to others (14,27,35,36) we found that an important part of the adaptation process is the incorporation of feedback from implementers and delivery agents to inform modifications to existing, program material and resources and the development of new resources that can facilitate scale-up.

Theoretical background
Focus on the rationale for the Jamaica Home Visit/Reach up design and methods (theoretical background and content of the curriculum).

Theory of change
Provides an overview of the intervention delivery with the inputs needed (including human resources and materials) and the connections between each segment of the intervention. As the program is adapted in each context, the suitable staff needed to deliver the intervention need to be trained and the families identified for intervention. The long-term outcomes include benefits to families and staff as well as capacity building for the organizations who implement the program. The ultimate impact includes benefits to families and children with the developmental potential of these children realized.
Power Point presentation and slide bank A structured presentation that can be used to support global conversations with main target audience (governments, funders, NGOs) who may be interested in implementing Reach Up. It includes an overview of the program with key principles, evidence, materials. It can be adapted depending on audience with sections more focused towards policymakers and others on implementation. There are additional slides organized by topic (e.g., adapting for context, Reach Up evidence) that can be used as templates for slides in other presentations

Resource/manual Adaptation/additions made to resource/manual
Toy Manual Additions/revisions to the Toy Manual included: • Reorganized by age group and type of toy • Improved instructions -include numbered lists of steps to make toys and measurements of materials needed to make the toys • Deletion of some toys from the list that were made from materials that are often difficult to source.

Training Manual
The main additions/revisions to the Training Manual were: • The "Importance of Play, " referencing LEGO's playful parenting framework, was added to the introductory section of the manual, to support the rationale for the program. Training session 1 "Introduction to the Programme" also included information and activities on the importance of play and the characteristics of play.
• Improved sections/statements on working with extended family members, practice activities that include other family members and on how to treat other family members • Revised and/or added questions to be asked after viewing training videos, e.g., new questions "What developmental domains does this activity help?" and "What concept words were used?" • Added lists of materials by names, descriptions, drawings and age as they appear in the curriculum.
• Added a new set of practice activities (using blocks and cardboard farm animals) to support the extension of the curriculum for children 36-48 months.
• A new flip chart with instructions on how to build a positive relationship with the mother/caregiver was included (e.g., sit at the same level, The expansion of the Reach Up program has been driven by networking, partnerships and collaborations over many years. Some of our partners are champions and leaders of Reach Up through their advocacy and interaction with decision makers (including government policy makers), contributing to adaptations in new countries and/or to extending coverage in countries where the program has already been implemented. Networking at the global community meeting in November 2019 also led to new collaborations and projects between implementers. For example, the International Rescue Committee (IRC) connected with the team from the International Centre for Diarrhoeal Disease Research (ICDDR,b) in Bangladesh to adapt the intervention for Rohingya refugees, and with a team from Bogazici University in Turkey for the Syrian refugee populations in that country.
The feedback from the key stakeholders informed the development of new resources that can be used to present and discuss the features of the intervention with policy makers and other potential users. Content developed include the theoretical background of the curriculum and the theory of change to facilitate communication of the development and mode of action of Reach Up. The PowerPoint presentations and the short film (with footage of training sessions and home visits in various countries) provide target audiences with a better "feel" for the intervention. Overall, the new advocacy products are available to help with communicating and engaging with prospective implementers, including policy makers, community members and funders.
Reach Up is designed to strengthen the capacity of parents and other caregivers to promote the development of their children through interactions with implementation staff who play a key role in the success of the program. Therefore, it is essential that the package provides the content and resources to guide, support and build capacity among the workforce. This was addressed through modifications to the curriculum, training resources and new materials related to workforce competencies and motivation. The Reach Up curriculum was designed to be delivered by facilitators with limited educational qualifications and no special knowledge of children's development. The inclusion of information from the LEGO Foundation's Playful Parenting Framework (33) provides facilitators with some theoretical knowledge applicable to the intervention, as well as understanding of benefits of playful parenting in promoting child development.
Key informants feedback also led to improvements in guidance for supervisors/mentors who support frontline delivery staff to maintain quality. The Supervisor Training manual was enhanced with additional content on building positive, respectful relationships, and providing positive feedback for home visitors and a new Supervisor Handbook developed.
Like other ECD programs, challenges remain around retention of staff, especially in contexts where Reach Up is integrated into existing services and is delivered by an existing cadre of workers (24, 35, 37, 37). Competing responsibilities and/or additional duties and lack of motivation (often linked to inadequate compensation and benefits), have been cited as the main contributing factors. While quality relationships, as described above can help to motivate staff, we have now included a list of proposed monetary and non-monetary incentives intended to help program managers develop strategies appropriate for their context.
With restrictions on travel due to the COVID-19 pandemic beginning in early 2020, face-to-face training was suspended and the suggestions from members of the global community for more adaptable train the trainers' workshops using technology was fasttracked. Two virtual workshops were held during 2021 and feedback from participants is being used to continue to integrate virtual delivery into training options. Opportunities to shorten the face-to-face training time, using a blended approach with a combination of virtual and face-to-face sessions, and offering the training in phases, are now possible.
We will monitor the use, of the new knowledge goods, through continued engagement and knowledge sharing with stakeholders. Use of a more structured approach to inform scaling of the intervention, was discussed at the knowledge meeting in 2019. For example, in addition to the implementation of the current systems for sharing learnings and making resources accessible (e.g., WhatsApp ® , Dropbox ® , etc.) the global partners considered development of a Reach Up learning consortium. This would provide a systematic process for what information to collect, how this will be collected, co-ordinated, analysed and reported. An initial step towards developing a learning consortium will focus on within country scaling.
Reach Up is a "living program" and further resources and extensions may be developed informed by continued learnings from implementation partners and other stakeholders. For example, the use of tablet-based applications to support home visitors to select appropriate activities for a child and collect data for program monitoring is being tested in China, Brazil and Jordan and may be important in supporting quality delivery at scale. One extension to date, is the Parent Manual (38) developed in response to the COVID-19 pandemic and demand from partners for ways to continue to provide parenting services. The Parent Manual can be used directly by parents and also provides content from the Reach Up curriculum that can be delivered through text and video messaging, radio and telephone calls. It also includes content on materials in the home that can be used for all activities in this new manual. This addition is important as providing play materials can be a challenge as programs scale.
Experiences with the integration into government services such as the primary care program in Brazil, the nutrition program in Madagascar, Peru's Cuna Más program, Colombia's FAMI program and ChinaREACH in China, have had mixed results that provide lessons for scaling and suggest large-scale replications of the Reach Up program are possible. The revision and extension of the Reach Up program resources and materials reported here, should help to address some scaling challenges and many of the knowledge goods produced may also be useful for other ECD programs.
The study has a few limitations. There was ongoing networking and interactions prior, during and after projects are implemented, between co-authors and country partners. Therefore, the data may be influenced by social desirability bias. We selected individuals from the existing network of Reach Up partners who were country program leads and trainers. Thus the views of other groups, for example policy makers, front line workers and families in the program, were not included.
This paper illustrates the importance of including the perspectives of key stakeholders in intervention evaluation and using the Frontiers in Public Health 12 frontiersin.org information in program enhancement so that materials and resources can support scaling. The findings from this study add another dimension to the ongoing debate about "what will be scaled up and how" (39). This case study of Reach Up demonstrates the value of a community of program partners and in-country stakeholders who can exchange experiences and evidence to inform transitioning to largescale programs.

Data availability statement
The datasets presented in this article are not readily available because in order to maintain the confidentiality of the key informants, the interview transcripts will not be made available.
Requests to access the datasets should be directed to jacqueline. coore@uwimona.edu.jm.

Ethics statement
The studies involving human participants were reviewed and approved by Ethics Committee, The University of the West Indies, Mona, Kingston, Jamaica. The participants provided their written informed consent to participate in this study.

Author contributions
JC-H, JS, HB-H, and SW contributed to the conceptual design of the paper. JC-H, JS, and MK were responsible for data collection. JC-H and JS conducted data analysis. SC led the revision of the program materials. JC-H, JS, MK, HB-H, SC, and SW contributed to the interpretation of the findings. JC-H drafted the paper with assistance from all co-authors. All authors contributed to the article and approved the submitted version.

Funding
The LEGO Foundation supported the Knowledge Exchange Meeting held in November 2019, the conduct of this study and publication. The Foundation was not involved in data collection, analysis, or interpretation.