The Utilization of Implementation Science to Scale-up a Home-Visiting Intervention to Address Early Childhood Development in Rwanda

Background and Purpose: Investment in early childhood development (ECD) has seen long-term gains in overall development in human capital growth and future contribution to society. Rwanda has made impressive strides to recognize, uphold, and promote the rights of children. ECD services are one avenue to implement Rwanda’s vision and commitment to all children, with significant potential for long-term gains.

Sugira Muryango is a deployment focused, scalable home-visiting model that promotes positive parent-child relationships, positive relationships among caregivers in the home, and fosters child development. Sugira Muryango focuses on the core elements of child development—physical, cognitive, linguistic and socio-emotional—and builds on the WHO/UNICEF Care for Child Development Package, which has been delivered successfully across low-resource settings. Sugira Muryango additionally addresses key psychosocial issues including conflict resolution and violence prevention, while promoting a future-orientation with a focus on bolstering resilience. The Sugira Muryango program offers coaching to caregivers of young children to promote early stimulation and responsive parenting. The curriculum seeks to build parent knowledge of early brain development, responsive parenting, nutrition, hygiene and alternatives to harsh punishment.

Methods: Sugira Muryango has been delivered as an open trial (20 households, delivered by bachelor’s level psychologists), a small scale randomized control pilot (38 homes, delivered by community based lay workers), and a large cluster randomized trial (1040 homes, delivered by community based lay workers).

Across all iterations, quantitative data captured participant satisfaction and assessed Sugira Muryango feasibility and acceptability. In the 38 home pilot, fidelity monitoring via audiotaped intervention sessions was introduced to create real time quality improvement cycles. In the cluster randomized trial, fidelity monitoring was further strengthened by the use of supportive supervision structures utilizing individual, group and peer led supervision models, as well as the collection of implementation science data related to reach and sustainability.

Results: All Sugira Muryango iterations demonstrate strong satisfaction and program feasibility. Pilot outcomes reveal increased family unity, improved parent-child interactions, and a decrease in violent punishment. Outcomes related to program impact on substance abuse and intimate partner violence will be discussed as well.

Lessons learned from the open trial and pilot have informed the large cluster randomized trial to include: strengthening of fidelity monitoring practices, enhanced training and supervision of lay workers, and refinement of quantitative and qualitative measures of program implementation.  

Conclusions and Implications: Sugira Muryango represents an innovative early childhood development program given its delivery in the home by trained lay workers, intentional engagement of male caregivers, and use of implementation science ingredients related to fidelity monitoring, supportive supervision, and manualized training and data gathering to address early childhood development needs of vulnerable families in Rwanda. Processes illuminating programmatic transitions from open trial to pilot to scale-up will be discussed with recommendations for researchers implementing evidence-based interventions in low resource settings. Further, considerations regarding implementation science and the importance of attending to scalability when implementing interventions will be discussed as more researchers consider the translational nature of evidence-based research.