Much of the focus surrounding HIV/AIDS has concerned those affected by the disease but little research had examined the issue of children more broadly affected by HIV due to caregiver illness and family social and economic stressors. In 2007, Dr. Betancourt launched a body of research to explore factors contributing to mental health and family functioning in children and families affected by HIV/AIDS. This study revealed that children affected by caregiver HIV/AIDS not only showed similar rates of distress (anxiety, depression, conduct problems) compared to children living with the HIV, but also were more likely to experience harsh punishment and had lower social support than children living with HIV. This early observational research was critical to later work in Rwanda to develop and evaluate a family-based preventive intervention for children affected by HIV, the Family Strengthening Intervention (FSI-HIV).
The Family Strengthening Intervention for Children Affected by HIV (FSI-HIV) is a manualized, modular intervention delivered in weekly home visit sessions (~90 minutes per session). Its four core components directly address the key risk factors for children affected by HIV. Core components are: psychoeducation about HIV and its effects on families (with supplementary psychoeducation on Rwandan Genocide-related trauma if a family raises the issue); skills development in communication, responsive parenting, and alternatives to violence and harsh punishment; a family strengths-based narrative to identify sources of resilience and help families find a sense of hope; and assistance in problem solving and navigating support systems. The FSI-HIV has been adapted to use with refugee populations and as an early childhood development intervention.
Since the time of our HIV/AIDS-focused work, the Government of Rwanda has made great strides in its focus on prevention and its investments to promote better outcomes for vulnerable children and families. In partnership with the World Bank, the RPCA began exploring the potential for an early childhood development version of the Family Strengthening Intervention (FSI-ECD) that could be integrated and tested within the alternate delivery platform of Rwanda’s flagship poverty reduction initiative, Vision 2020 Umurenge Program (VUP). The RPCA team conducted a Hybrid Implementation-Effectiveness Trial of the Family Strengthening Intervention for Early Childhood Development (FSI-ECD) to: (a) assess effectiveness of FSI-ECD in promoting responsive parenting, reducing violence and harsh punishment, and promoting early child development in families living in poverty; (b) assess the interaction between FSI-ECD and family-friendly cash for work initiatives in Rwanda; and (c) assess costs, barriers, and facilitators of integrating the FSI-ECD package into the VUP. In partnership with FXB-Rwanda, the delivery of the FSI-ECD is now recognized as the Sugira Muryango Program.
The main objectives of the Sugira Muryango home-visiting intervention are to build caregivers and parents’ skills and knowledge about early childhood development and link families to complementary community resources. Sugira Muryango works together with the strong network of basic health services and schools, cash transfers and early childhood programs to improve the lives and livelihoods of children and adults. Sugira Muryango seeks to achieve these objectives by promoting healthy child development and positive parent-child interactions.Its implementation is a structured interactive curriculum of 12 modules that promote best practices for good health, adequate nutrition and good hygiene, conflict resolution, intimate partner violence, strong communication, importance of father involvement as well as messages advocating for options to tough punishment. The modules use activities drawn from Rwandan culture (e.g., songs, proverbs) which help families adopt fundamental skills and integrate active education, including in-home parent-child interactions, to convey knowledge and skills.
The results of the most recent Sugira Muryango effectiveness trial, which involved the families of 1,084 children (50% female), demonstrate the impact of Sugira Muryango on early childhood development (ECD) and parenting: statistically significant increases in parent-child interactions and responsive parenting, less violence against children and mothers, child development improvements, maternal and parental mental health improvements, increased help seeking for child health problems, and greater play and stimulation in the home.
Based on the success of the Sugira Muryango Program, the RPCA was recently awarded a Scaling of an Evidence-Based Playful Parenting Intervention grant from the LEGO Foundation to reach all Ubudehe 1 (most extreme level of poverty) families in the Nyanza, Ngoma, and Rubavu districts of Rwanda, impacting over 10,000 children and more than 14,300 caregivers. In addition to reaching close to 10 times more children, this expansion study will enable the RPCA to test an updated curriculum encompassing families with young girls and boys aged birth-6 months. Additionally, the RPCA will deepen its attention to promoting and assessing gender dynamics in implementation as well as potential differenced in ECD outcomes in the scale up and expansion study, and to fcous particulary on factors that shape ECD outcomes, violences, and school readiness among girls. Moreover, the expansion study also utilizes a new workforce, the government-supported child protection workers, Inshuti z’Umuryango (IZU), to deliver the program to household beneficiaries.