Using Home Visiting to Support Early Childhood Development in Rwanda: Moving the Sugira Muryango Family Strengthening Intervention from Effectiveness to Expansion

Background: When working with war-affected populations experiencing multiple forms of adversity which serve to reinforce each other, there are special considerations regarding how problems are addressed and participants protected. Interventions that target the entire family unit are especially important given the prevalence of extended, multi-generational household configurations in low- and middle-income countries. Further, the family represents an integral component of one’s social support system and is emerging as an intervention site for translational research. Ecologically-informed family-based preventive interventions represent an important avenue for harnessing family strengths and better equipping families with the tools to protect against outside shocks.

Methods: We use data collected as part of a cluster randomized trial (CRT, n=1049 households) testing the impact of a home visiting parenting intervention, Sugira Muryango (Strengthen the Family), in Rwanda. The trial is linked to the Rwandan national social protection program, thus reaching the poorest households with children aged 6-36 months. Sugira Muryango is delivered by trained lay workers and integrates promotion of early childhood development with violence prevention. The curriculum is delivered via active coaching in the family’s home and covers responsive parenting as well as active education and problem solving to promote family functioning, reduce conflict and violence in the home, increase father engagement, and improve family health and hygiene.

Results: Results comparing baseline with post-intervention outcomes suggest that using lay workers as home visitors, participation in Sugira Muryango is associated with improvements in caregiver behaviors related to responsive parenting and family health, as well as improved child developmental outcomes. Sugira Muryango, for example, was associated with increased stimulation and positive parenting, improved child health and development outcomes, improved caregiver mental health (depression and anxiety), and reduced family violence including intimate partner violence and harsh discipline. Analysis of qualitative key informant interviews with Sugira Muryango coaches revealed several barriers (e.g. scheduling, entrenched poverty of families) and facilitators (e.g. training, supportive supervision, alignment of intervention content and family needs) to program delivery that will be presented as well.

Having secured multi-stakeholder funding, Sugira Muryango is set to be expanded to reach over 10,000 households using a multi-level implementation science strategy referred to as a Collaborative Team Approach. Strengthened government engagement will transfer Sugira Muryang delivery from community-based volunteers to an existing government workforce based in each village. Lessons learned from the prior CRT as well as robust implementation science approaches will be discussed as Sugira Muryango moves from an effectiveness trial to a government-supported expansion program.

Implications: A lay worker delivered intervention led to improvements in a broad range of child and caregiver outcomes. Understanding the mechanisms by which early parenting programs like Sugira Muryango improve child development outcomes is important for optimization and scale up of programs to reach vulnerable families at large. Innovative use of implementation science strategies like integrated fidelity monitoring and supportive supervision to create feedback loops of quality improvement are especially critical for ensuring programs are delivered as intended when taken to scale or overseen by governments.