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Project Summary

This project stems from the Family Strengthening Intervention for Families/Children Affected by HIV/AIDS and has transformed to engage fathers, reduce violence, and overall strengthen the family. This program is called,聽Sugira Muryango聽(SM) or Strengthen the Family. This is an expansion / scale up study that is set to reach nearly 10,000 of the most vulnerable households categorized by the Government in Rwanda across three districts by the end of 2023. This intervention also can be integrated within poverty reduction/social projection initiatives in Rwanda and other low-resource settings. Sugira Muryango (SM) is a home-visiting program that uses active coaching to build parent capabilities and increase responsive parenting of both mothers and fathers to promote early childhood development (ECD) and prevent violence. SM has targeted families in extreme poverty with young children aged 0-36 months. This scale out implementation science hybrid design project enables the RPCA and collaborators at the University of Rwanda and FXB-Rwanda to expand SM to younger children; increase delivery by almost tenfold the number of children impacted by the intervention; increase the use of technology to accelerate feedback; and test an evidence-based implementation strategy, the Promoting Lasting Anthropometric Change and Young Children鈥檚 Development (PLAY) Collaborative, to engage local stakeholders and frontline providers and supervisors to ensure quality improvement and sustainability.聽In the process of scaling and iterative quality improvements, Sugira Muryango is regarded as a global pioneer for implementation methods, processes, systems, and evaluation.聽

The FSI-ECD Intervention

The Family Strengthening Intervention for Early Childhood Development (FSI ECD) is a home-visiting model to support playful parenting, father engagement, improved nutrition, care seeking, and family functioning in order to promote ECD, positive parent-child relationships, and healthy child development. The intervention, informed by the World Health Organization (WHO) Care for Child Development package, (a) builds parenting skills and improves knowledge of ECD to create a safe, stimulating, and nourishing environment for the growth of young children with a focus on nutrition, health, and hygiene promotion; (b) coaches parents of young children in 鈥渟erve and return鈥� interactions and playful parenting; (c) develops a 鈥渇amily narrative鈥� to build hope and highlight sources of resilience for addressing challenges and reducing the risk of violence; (d) strengthens problem-solving skills as well as the navigation of formal and informal community resources; and, (e) builds skills in parental emotion regulation and alternatives to harsh punishment. Sugira Muryango integrates these core components into 12 modules and two booster/follow-up sessions.

What separates the Sugira Muryango program from similar projects is the methodological rigor, the holistic comprehensiveness of the intervention content, a well-defined theory of change, the emphasis on implementation features, and the methodological rigor. It is rare that programs incorporate elements that aim to enhance Early Childhood Development and violence reduction.

Study Design

To evaluate this new iteration of SM program,聽this time extending the age eligibility criteria to include families with children from birth to 6 months of age and delivered by a government volunteer workforce聽within the PLAY Collaborative implementation strategy, we utilized a Hybrid Type-II Effectiveness-Implementation design that blends components of a clinical effectiveness trial with implementation science research methodology (Curran et. al, 2012). This Hybrid trial utilized the EPIS conceptual model, which guides the anticipation, identification, and response to common issues when transitioning evidence-based practices to larger delivery systems such as those in the public sector.

The embedded trial used a quasi-experimental wait-list control design with randomization at the cluster level (each sector either received treatment or 鈥渃are as usual鈥�), to minimize the risk of diffusion of the treatment (i.e., treatment families sharing practices learned with others who did not receive the treatment). Quantitative and qualitative data were collected at two timepoints (baseline and post-intervention), and quantitative data were collected again 12 months after the intervention ended. Data collection is conducted by local research assistants blind to site and family condition assignments. The aim of the SM Expansion study is to investigate implementation processes and impact of the SM intervention at multiple levels: family level, interventionist level, supervisor level, and district level.聽Our study participants included caregivers, children (0 - 36 months), interventionists (i.e., IZUs), and members of the PLAY Collaborative.聽

Measurement & Metrics

At each data collection time point, the participant identified as the primary caregiver (i.e., the caregiver who knows the child best鈥攎ost often the biological mother) reports on child development, health, and feeding practices. This primary caregiver also participates in the assessment of caregiver-child interactions and provides information about the household, including family composition, economic status, household assets, social protection services, and finances. Both the primary caregivers and their intimate partner or other secondary caregivers living in the households (e.g., grandparents, adoptive parents, aunts, and uncles) respond to a battery of questionnaires that cover aspects of caregivers鈥� mental health, trauma exposures, daily hardships, family functioning, decision making, alcohol consumption, and intimate partner violence. Measures were drawn from previous pilot and research studies in Rwanda (Barnhart et al., 2020; Betancourt et al., 2018; Betancourt et al., 2020; Jensen et al., 2021). Measures were forward- and backward-translated from English to Kinyarwanda and were cognitively tested to ensure comprehension and cultural relevance. Survey assessments include read-aloud procedures to address literacy issues, and child development outcomes were assessed using direct observations and caregiver reports. Dissemination and Implementation data were collected from caregivers, interventionists workforce, and members of the PLAY Collaborative team to evaluate program satisfaction, acceptability, appropriateness, and other constructs related to the implementation process (i.e., collaboration, sustainability, leadership, organizational climate identity, and functioning).

Key Findings & Plan for Scale

In 2018-2019, a large Cluster Randomized Trial enrolled 1049 Ubudehe-1 families (1084 children, 1497 caregivers) with at least one child 6 to 36 months old, delivered by well-trained and supervised lay workers, demonstrated that families receiving the intervention showed significant improvements. Immediately after implementation of the 2018-2019 Cluster Randomized Trial (CRT), families that received the program showed improved parent-child relationships, improved child鈥檚 health-related caregiving practices (e.g., fever and diarrhea care-seeking), and increased dietary diversity. Moreover, SM families showed improved hygiene behaviors (e.g., proper treatment of water), improved caregiver mental health, and reduced intimate partner violence (Betancourt et. al., 2020). A 12-month follow-up found sustainment of many of these effects, including increased father engagement in caregiving practices, reduced harsh discipline of children, and reduced intimate partner violence. In addition, after 12 months the intervention was effective in improving children鈥檚 gross motor, communication, personal-social, and problem-solving early development (Jensen et. al., 2021). Knowledge from the earlier Family Strengthening Intervention for HIV-affected families as well as the prior evaluations of SM have shown evidence of its effectiveness and informed the adaptation of the SM intervention as it is currently constituted.

Over the coming months, we plan to have immediate post intervention and one year most intervention results of our scale up study to inform future implications and further scale of this project to reach more families in need in Rwanda.聽

In addition to this scale-up project, we are investigating the longitudinal and spillover effects of the FSI ECD programme. For more information on this project, please click here.