Integrating social protection and early childhood development: open trial of a family home-visiting intervention, Sugira Muryango

ABSTRACT

A pre-post design with 6–13-month follow-up assessed the feasibility and acceptability of a home-visiting intervention to promote early childhood development, improve parenting and shared decision-making, and reduce violence in impoverished Rwandan households. Twenty vulnerable families with a child 36-months or younger enrolled in Sugira Muryango. Measures of parenting, home environment, family-violence, decision-making, and health-status were administered at pre/post and follow-up. Families reported high satisfaction post-intervention. OMCI scores improved for 4.8% of mother-child dyads at post-intervention and 19.0% at follow-up, while 9.5% of dyads showed declines at both times. HOME Inventory scores improved for 9.5% and 14.3% of dyads at post-intervention and follow-up respectively and declined for 4.8% and 0.0%. Indicators for equal decision-making and child dietary-diversity improved at post-intervention and follow-up. Fewer mothers believed physical punishment was necessary at follow-up. Sugira Muryango shows promise for improving parenting, beliefs about harsh punishment, child nutritional status, and shared decision-making among vulnerable families.

KEYWORDS:

• Africa
• child development
• violence
• child health
• parenting

Acknowledgments

This study was funded by a grant from the World Bank Early Learning Partnership (ELP). The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily reflect the views of the World Bank, its Board of Executive Directors, or the governments they represent. The World Bank does not guarantee the accuracy of the information included in this work. This work was made possible by the collaboration of the Honourable Minister of Gender and Family Promotion and the Executive Secretary of the National Commission for Children. Theresa Betancourt conceptualized the study, obtained funding, led intervention development and interpretation of the data, and provided supervision. Laura Rawlings contributed to study design, significantly securing funding and writing and data interpretation. Catherine Kirk and Rose Wilder oversaw intervention implementation and data collection and made significant intellectual contributions to the manuscript content. Sylvere Mukunzi supported intervention development, data collection, intervention delivery, and made significant intellectual contributions to intervention and manuscript content. Robert Brennan contributed to study concept and design, data analysis, interpretation of the data, and drafting of the manuscript. Emily Franchett conducted data analyses and contributed to data interpretation and writing. Briana Wilson supported linkages to the VUP and management of the final stages of the ELP grant. Aisha Yousafzai contributed to the manuscript writing and assisted in further curriculum refinements. Vincent Sezibera supported clinical supervision during intervention delivery and contributed to intervention adaptation. Laetitia Nyirazinyoye provided thoughtful input during intervention development. Kalisa Godfrey, Josee Mukandanga, and Christian Ukundineza helped refine the curriculum, were engaged in direct services with families, and made contributions to the writing of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Theresa S. Betancourt, ScD, MA, is the Salem Endowed Professor in Global Practice at the Boston College School of Social Work and Director of the Research Program on Children and Adversity (RPCA). Her research includes the developmental and psychosocial consequences of concentrated adversity on children, youth and families; resilience and protective processes in child and adolescent mental health and child development; refugee families; and applied, cross-cultural mental health research. She is Principal Investigator of a 15-year prospective longitudinal study of war-affected youth in Sierra Leone (LSWAY). This research led to the development of the Youth Readiness Intervention (YRI), a group mental health intervention for war-affected youth that demonstrated effectiveness for improving emotion regulation, daily functioning and school functioning. Dr. Betancourt has also developed and evaluated the impact of a Family Strengthening Intervention for HIV-affected children and families and is leading the investigation of the Sugira Muryango home-visiting early childhood development (ECD) intervention to promote enriched parent-child relationships and prevent violence that can be integrated within poverty reduction/social protection initiatives in Rwanda. Domestically, she is engaged in community-based participatory research on family-based prevention of emotional and behavioural problems in refugee children and adolescents resettled in the U.S.

Robert T. Brennan, Ed.D., is a Research Associate at the Harvard T.H. Chan School of Public Health, known for his work in applying multivariate multilevel models, including developing models for dyadic analysis, models for comparing data from multiple outcome measures, and models for multigroup data on birth weight and mortality. He has made significant contributions to CPR instruction and the study of gender in the context of dual-earner families, recently co-authoring a chapter on the ‘Work-Family Interface’ in the APA Handbook of the Psychology of Women. His academic work on poverty and social justice began two decades ago as Senior Scientist on the Project on Human Development in Chicago Neighborhoods, followed by a study of a youth programme to raise community HIV competency in Tanzania. Since then, he has collaborated with Dr. Betancourt on projects in Rwanda, Uganda, Sierra Leone, India, and the United States with Somali and Bhutanese refugees.

Emily Franchett, MS, is an early childhood development research coordinator at the Harvard T H Chan School of Public Health. She previously worked with the Sugira Muryango programme as an intern and research assistant. Emily served as a 2012–14 Peace Corps Volunteer in Albania and holds a BA in Political Science from the University of Michigan and an MS in Global Health and Population from the Harvard T H Chan School of Public Health.

Kalisa Godfrey is an associate psychologist with a bachelor's degree in psychology and a strong background in general nursing. He has 10 years of experience working in social protection in Rwanda (five years in Rwandan health institutions and five years with the Family Strengthening Intervention with Partners in Health). He is currently operating as a Project officer with the Sugira Muryango Programme.

Catherine M. Kirk is the Director of Maternal and Child Health at Partners In Health/Inshuti Mu Buzima in Rwanda where she works closely with the Ministry of Health on programmes and research that aim to improve the quality of facility-based care for mothers and newborns as well as advises on child development and nutrition research and programming. She is also a Visiting Scholar at the Boston College School of Social Work and Adjunct Faculty at the University of Global Health Equity. Prior to joining Partners In Health, she worked with the Harvard T.H. Chan School of Public Health, the World Bank, UNICEF, and other organizations on the design, implementation, and evaluation of health, child development, and education programmes in sub-Saharan Africa and the United States.

Josee Mukandanga is a research assistant with six years of experience supporting studies in Rwanda focusing on the prevalence of mental health problems among children affected by HIV. She supported the pilot study testing the feasibility of the Family Strengthening Intervention for HIV–affected children and families through data collection. She is currently a member of the Sugira Muryango research team, where she has supported curriculum refinement, the delivery and supervision of the intervention.

Sylvere Mukunzi holds a bachelor's degree in clinical psychology from the former National University of Rwanda. He supported the Sugira Muryango programme as project coordinator. Previously he worked with Partners in Health on the Family Strengthening Intervention in Rwanda. He collaborated on a paper with colleagues and supervisors entitled, ‘Mental Health of Children Living in Foster Families in Rural Rwanda: The Role of HIV and the Family Environment.’ He additionally supported a 2014 baseline evaluation survey of Early Childhood Development and Family services in Rwanda in collaboration with UNICEF Rwanda and Imbuto Foundation.

Laura B. Rawlings is an economist with over 20 years of experience in the design, implementation and evaluation of human development programmes. She currently manages both operations and research, with a focus on developing innovative approaches for effective, scalable social protection systems in low resource settings. She was the team leader responsible for developing the World Bank's Social Protection and Labor Strategy 2012–2022 and was previously the manager of the Strategic Impact Evaluation Fund (SIEF). She also worked as the Sector Leader for Human Development in Central America where she was responsible for managing the World Bank's health, education and social protection portfolios. She began her career at the World Bank in the Development Research Group where she worked on the impact evaluation of social programmes. She has worked in Africa and Latin American leading numerous project and research initiatives in the areas of conditional cash transfers, public works, social funds, early childhood development and social protection systems. Prior to joining the World Bank she worked for the Overseas Development Council where she ran an education programme on development issues for staff in the US Congress. She has published numerous books and articles in the fields of evaluation and human development and is an adjunct professor in Georgetown University's Global Human Development program.

Vincent Sezibera is Clinical Psychologist, with a PhD in Psychology, and an Associate Professor of Psychology, in the Department of Clinical Psychology at the University of Rwanda (UR). Prof. Sezibera is currently the Acting Director of the Centre for Mental Health, College of Medicine and Health Sciences (CMHS). He specializes in Post-Traumatic Stress Disorder (PTSD) and child and adolescent traumatic grief. In particular, he has conducted research on trauma and bereavement among young survivors of the 1994 genocide against Tutsi in Rwanda. He has conducted a number of research studies and has developed treatment protocols on Post-Traumatic Stress Disorder (PTSD) and Complicated Grief (CG) treatment. his ongoing research assesses the effectiveness of these treatment protocols within the population of traumatized survivors of the 1994 genocide. In addition, he has also interest in studding the impact of HIV/AIDS on the mental health of children. The studies have demonstrated that HIV-affected children are at risk of higher depression, anxiety and multiple other mental health issues. As a professor, courses taught include psychopathology, Cognitive and Behavioural Therapy, Personality theories; and grief and mourning.

Christian Ukundineza is a project officer at Francois-Xavier Bagnoud International with the Sugira Muryango programme. He supports the training and supervision of community-based volunteers and works with beneficiary families to connect them with community resources. Previously he was a research assistant at Partners in Health, supporting the Family Strengthening Intervention. He received a bachelor's degree in Applied Biochemistry from the University of Rwanda College of Sciences and Technology, formerly the Kigali Institute of Science and Technology, and a master's degree in Project Management from Mount Kenya University.

Rose Wilder is an international development practitioner with five years’ experience engaging a multitude of stakeholders at various stages of programme life cycles, with a specific focus on East Africa. As an interculturalist, she is firmly committed to community-driven programming, accounting for and empowering local voices and customs. Rose arrived in Kigali, Rwanda as the full-time Programme Manager in January 2016; after the 22-module intervention was completed and just as the 15-module iteration of the Sugira Muryango intervention was ending. Managing the day-to-day field implementation, she supported the follow-up data collection for the 22-module iteration of the Sugira Muryango intervention, as well as post-assessment and follow-up data collection for the 15-module intervention sample.

Briana Wilson is a Senior Social Protection Specialist in the World Bank's Social Protection and Jobs Global Practice. She specializes in monitoring and evaluating social protection interventions and over the last decade has contributed to designing government interventions in Africa, Latin America and Europe and Central Asia. She also supports the World Bank's global results agenda.

Aisha Yousafzai, PhD, is an Associate Professor of Global Health in the Department of Global Health and Population at the Harvard T. H. Chan School of Public Health. She has extensive experience in evaluating early childhood interventions in south Asia, East Africa, and in Central and East Europe. Her research focus is on the strengthening of early child development (ECD) outcomes using existing health, nutrition and community platforms in low- and middle-income countries. Her work also comprises implementation research to inform scaling-up effective models of interventions that support ECD. In addition, she has served on ECD advisory groups for a number of UN agencies and non-government organizations.

ORCID

Theresa S. Betancourt http://orcid.org/0000-0002-3683-4440

Notes

1 ‘Social protection is a set of policies and programmes aimed at preventing or protecting all people against poverty, vulnerability, and social exclusion throughout their lifecycles, with a particular emphasis towards vulnerable groups’ (Inter Agency Social Protection Assessments (ISPA), 2017).

2 In Rwanda, Ubudehe categorization is a household-based categorization used since 2002 as the basis for targeting access to social benefits and services. Ubudehe categorization is based on community-based social-economic mapping. Initially, six categories were identified to stratify the population according to social and economic wellbeing. Ubudehe categories 1 and 2 were considered the most vulnerable. In 2014, Ubudehe categories were reviewed and the 2015 Ubudehe categorization re-ranked Rwandan households into 4 categories, with 1 being the most socially and economically vulnerable households.

Additional information

Funding

This study was funded by The World Bank Early Learning Partnership under Grant Number 7170035.