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, Sugira Muryango (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’s Development (PLAY) Collaborative, to engage local stakeholders and frontline providers and supervisors to ensure quality improvement and sustainability.
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 “serve and return” interactions and playful parenting; (c) develops a “family narrative” 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
Sugira Muryango uses a clustered randomized control trial design and mixed models approach with a hybrid type 2 implementation design (i.e., a focus on intervention efficacy and implementation outcomes).
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. In the process of scaling and iterative quality improvements, Sugira Muryango is regarded as a global pioneer for implementation methods, processes, systems, and evaluation.
Measurement & Metrics
A four-arm cluster randomized trial (CRT) will enroll 1,040 VUP-eligible families with children aged 6-36 months to compare outcomes among children and parents in families receiving: (1) Control/Classic VUP, (2) Expanded VUP, (3) Combined Classic VUP plus Sugira Muryango and (4) Combined Expanded VUP plus Sugira Muryango. A cost analysis will provide practical information on the feasibility and cost of integrating Sugira Muryango into VUP programming and a process evaluation will produce useful implementation tools for dissemination and scale-up. Study Aims are to (1) assess effectiveness of Sugira Muryango in promoting responsive parenting, reducing violence and harsh punishment and promoting early child development in families living in poverty; (2) to assess the interaction between Sugira Muryano and classic/expanded VUP programming and (3) to assess costs, barriers and facilitators of integrating the Sugira Muryango package into VUP or other government programming, such as the Ministry of Gender and Family Promotion (MIGEPROF), which holds the early childhood development mandate. This initiative seeks to promote cross sectoral and ministerial collaboration, a key pillar of the Government of Rwanda. Key outcomes include: Physical, cognitive, and language development indicators for children. Parental engagement in ECD activities, parental mental health, the reduction of intimate partner violence and harsh parenting discipline, father engagement, as well as dissemination and implementation measures. Sugira Muryango uses a mixed-methods approach, which includes: observations, surveys, quantitative measurements, longitudinal modeling, focus groups, key stakeholder interviews, among others.
Key Findings & Plan for Scale
Findings from our pilot study indicate that Families receiving Sugira Muryango improved on core outcomes of parent-child relationships assessed using the Home Observation for Measurement of the Environment (Cohen’s d = 0.87, 95% CI: 0.74, 0.99) and the Observation of Mother-Child Interaction (Cohen’s d = 0.29, 95% CI: 0.17, 0.41). We also saw reductions in harsh discipline on items from the UNICEF MICS (OR = 0.30: 95% CI: 0.19, 0.47) and in violent victimisation of female caregivers by their partners (OR = 0.49, 95% CI: 0.24, 1.00) compared with UC. Moreover, children in families receiving SM had a 0.45 higher increase in food groups consumed in the past 24 h (Cohen’s d = 0.35, 95% CI: 0.22, 0.47), increased care seeking for diarrhoea (OR = 4.43, 95% CI: 1.95, 10.10) and fever (OR = 3.28, 95% CI: 1.82, 5.89), and improved hygiene behaviours such as proper treatment of water (OR = 3.39, 95% CI: 2.16, 5.30) compared with UC. Finally, Sugira Muryango was associated with decreased caregiver depression and anxiety (OR = 0.58, 95% CI: 0.38, 0.88).
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.
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.
The LEGO Foundation, Oak Foundatio, Grand Challenges Canada, the ELMA foundation, Echidna giving, OAK Foundation, USAID, Partnership PLUS
Rwanda National Commission for Children, FXB Rwanda, University of Rwanda, Rwanda National Child Development Agency
Based in Kigali, Rwanda
Facts & Figures
The current scale up trial includes nearly 10,000 households from the most vulnerable communities in Rwanda.