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More than 250 million children under five—most in sub-Saharan Africa and south Asia—may not reach their developmental potential due to poverty, poor health and nutrition, and inadequate care. In Rwanda, strong governance and political will have helped reduce child mortality by >75% since 2000 but some gaps still remain, especially in rural areas. In partnership with the Rwandan Government, we developed the PLAY Collaborative implementation strategy to scale delivery of an evidence-based, home-visiting intervention, Sugira Muryango, to families living in extreme poverty across three rural Districts of Rwanda.
Methods
This Hybrid Type II Implementation-Effectiveness trial evaluated the PLAY Collaborative while testing whether intervention effectiveness is maintained when delivered by child protection volunteers. We assessed implementation outcomes (e.g., adoption, acceptability, appropriateness, etc.) immediately post-intervention. Effectiveness outcomes (e.g., stimulating care, father engagement, child development, family violence, health and hygiene) were collected at baseline, immediate post-intervention, and 12-month follow-up. The present study reports intervention effectiveness results at one-year follow-up.
Results
The PLAY Collaborative supported 2,461 child protection volunteers to deliver Sugira Muryango to 8,745 households. All implementation outcomes received moderate-to-high ratings. We observed high quality of delivery that improved with routine supervision. Linear mixed models of outcomes at one-year follow-up revealed that caregivers in families receiving Sugira Muryango significantly increased their involvement of their children in daily activities (d=0.34, 95% CI: 0.14-0.55) and provided significantly more stimulating care (playing, storytelling, singing; d=0.38, 0.15-0.61) to their children. Sugira Muryango households significantly improved safe water storage (OR=2.39, 95% CI: 1.33-4.30) and water treatment practices (OR=3.62, 95% CI: 1.88-6.98). Contrary to expectation, caregivers reported significantly more fever (OR=1.95, 95% CI: 1.13-3.37) and cough symptoms (OR=2.41, 95% CI: 1.41-4.12) in their children and fathers had significantly lower odds of being involved in decisions about what the child eats (OR=0.51, 95% CI: 0.26-1.00). Child development outcomes did not significantly improve overall; however, we explored intervention effects by child age based on prior research suggesting that parenting programs may be especially beneficial for children under one year, as these children are more dependent on their parents for stimulation. These follow-up analyses stratifying the sample by child age (younger than 12 months at baseline vs 12 months or older at baseline) revealed that the younger age group significantly improved their problem-solving skills compared to controls (d=0.41, 95% CI: 0.07-0.74).
Conclusions and Implications
The PLAY Collaborative implementation strategy successfully coordinated delivery of Sugira Muryango to 8,745 families while overcoming implementation barriers. Families maintained improvements in stimulating care that are likely to have contributed to significant improvements in child development outcomes. Delivery of the intervention during the COVID-19 pandemic (May to November 2021) may have played a role in reporting of child health symptoms as intervention families received additional coaching on COVID-19 symptoms. Following the Dynamic Sustainability Framework, this study provided critical evidence to guide further iteration and improve fit between the intervention and implementation context.