Family Strengthening Intervention for Early Childhood Development and Violence Reduction (FSI-ECD + VP)

Project Summary

The Family Strengthening Intervention for Early Childhood Development and Violence Prevention (FSI-ECD+VP), also known in Rwanda as Sugira Muryango (SM) or Strengthen the Family, stems from early work with HIV affected families leading to the development of the Family Strengthening Intervention for Families/Children Affected by HIV/AIDS (R34MH084679) and has transformed to build parent capabilities, increase responsive parenting of both mothers and fathers, reduce family violence, support early childhood development, and strengthen family functioning. This intervention, the FSI-ECD+VP, informed by the World Health Organization (WHO) Care for Child Development package, (a) builds parenting skills and improves knowledge of ECD to create a safe, stimulating, and nourishing environment for the growth of young children with a focus on nutrition, health, and hygiene promotion; (b) coaches parents of young children in “serve and return” interactions and playful parenting; (c) develops a “family narrative” to build hope and highlight sources of resilience for addressing challenges and reducing the risk of violence; (d) strengthens problem-solving skills as well as the navigation of formal and informal community resources; and, (e) builds skills in parental emotion regulation and alternatives to harsh punishment. The FSI-ECD+VP integrates these core components into 12 modules and two booster/follow-up sessions through a home-visiting model and active coaching. Currently, in Rwanda, the intervention has targeted families in extreme poverty with young children aged 0-36 months across three districts with plans to expand to additional districts.We have reached over 10,000 Rwandan families since 2018. In Rwanda, we have integrated the intervention within poverty reduction/social projection initiatives with the Government of Rwanda’s existing structures. We are proudly collaborating with multiple funders and ministries in Rwanda to further strengthen our program to scale, including testing a continuous enrollment model and developing a digital dashboard to streamline the intervention effectiveness through an NIH-funded project to support scaling the intervention in collaboration with University of Rwanda, FXB-Rwanda, and digital partners to create this tool. This project, titled, Testing an mHealth Digital Dashboard to improve Quality of Delivery of Evidence-based Interventions that Promote Family Mental Health and Functioning in Rwanda (R01MH136200) is investigating dashboard-supported delivery of the intervention in terms of its reach, efficiency, and cost effectiveness to enhance our understanding of the FSI-ECD+VP program in Rwanda. In addition to the RPCA research in Rwanda on the FSI-ECD+VP, the intervention has been adapted to multiple global cultural contexts including Sierra Leone and Colombia. The RPCA works with global partners to license our intervention with rigor to ensure the adaptability of our research in multiple contexts.

Background and Aims

The intergenerational health consequences of the 1994 Rwandan Genocide persist within Rwanda and are further compounded by poverty. During the early 2000s, improvements in the country’s healthcare system and access to medical treatment decreased the country’s HIV prevalence; however, there remained a need for interventions to improve family functioning and prevent mental health problems in HIV-affected children. To address this need, a 2014 pilot randomized controlled trial of the home-visiting intervention, Family Strengthening Intervention (FSI-HIV), was conducted to improve caregiver-child relationships and promote mental health in families with caregivers living with HIV. From these pilot studies, an ECD-focused iteration of the intervention, the FSI-ECD+VP, was developed and informed by UNICEF and WHO Care for Child Development materials (Betancourt et. al., 2017). In Rwanda, the FSI-ECD+VP is referred to as Sugira Muryango (SM) or ‘Strengthen the Family.’In over 10 years of co-designing the evidence-based SM program, the project team has worked in partnership to advance the Government of Rwanda’s (GoR) goals for improving access to quality ECD programs and reducing violence in the home against partners and children. We have collaborated with the GoR, University of Rwanda (UoR) Centre for Mental Health, and other stakeholders to co-develop and rigorously test a home-visiting model delivered by community lay workers that has demonstrated holistic improvements for the families we serve.

In 2018-2019 a Cluster Randomized Trial (CRT) that enrolled 1,049 Ubudehe-1 families with at least one child between the ages of 6 to 36 months, we found that immediately after the intervention, families receiving SM demonstrated increased stimulation in the home, increased engagement in playful activities, decreased child exposure to harsh punishment, reduced IPV against mothers, and decreased symptoms of depression and anxiety in mothers and fathers (Betancourt et. al., 2020). At 12 months post-intervention, we found increased achievement of developmental milestones across various domains of child development and sustained reductions in IPV and harsh discipline against children (Jensen et. al., 2021).Our next step was to test a model for scaling and sustaining the FSI-ECD+VP using implementation science strategies and a Collaborative Team Approach (CTA). This strategic pathway to scale, called the Promoting Lasting Anthropometric Change and Young Children’s Development (PLAY) Collaborative, integrates the intervention into the GoR social protection system. Working with a core seed team of local Rwandan experts to serve as trainers and supervisors and with the Inshuti z’Umuryango (IZU), child protection community volunteers, for program delivery, Sugira Muryango extended the age eligibility criteria to include families with children from birth to six months of age.

To support continued efforts to scale the FSI-ECD+VP, the UoR and other partners developed a technology-enabled service delivery model using a digital tool that streamlines data collection, improves visibility of key program performance metrics, and serves as a resource for learning materials that can be used for continuous learning and training of a non-specialized workforce that is delivering the intervention. We conducted a four year follow-up longitudinal and spillover study to investigate the longer-term outcomes of the Sugira Muryango intervention in families who participated in the cluster randomized control trial (CRT), as well as the spillover effects for family members who did not directly receive the intervention. The follow-up examined long-term and sustained outcomes of the intervention. We are currently publishing this data. In the context of understanding important factors for scaling evidence-based interventions, our research team will investigate dashboard-supported delivery of SM in terms of its reach, efficiency, and cost effectiveness, funded by the National Institute of Mental Health (NIMH). In the process of scaling and iterative quality improvements, Sugira Muryango is regarded as a global pioneer for implementation methods, processes, systems, and evaluation. 

Aims of Current FSI-ECD+VP Studies:

• Collect outcomes measuring the program’s effectiveness, quality of program delivery, feasibility, and acceptability from program beneficiaries, the interventionists, their supervisors, and community stakeholders.
• Compare the trajectories of fidelity, competence, and self-efficacy between dashboard-supported delivery and standard deliveryInvestigate the impact of dashboard-supported delivery by comparing the difference in child and caregiver mental health outcomes with standard delivery.
• Analyze cost-effectiveness and return on investment of the intervention as delivered with and without the DashboardIdentify scalable pathways to accelerate integration of technology and evidence-based mental health services into policy and practice in Rwanda.
• Conduct social network analysis to understand how the characteristics of networks comprised of supervisors and interventionists affect trajectories over time.
  

Key Findings of Projects to Date

• The 2018-2019 Cluster Randomized Trial (CRT) showed improved parent-child relationships, improved child’s health-related caregiving practices (e.g., fever and diarrhea care-seeking), and increased dietary diversity among participating families. 
• Families showed improved hygiene behaviors (e.g., proper treatment of water), improved caregiver mental health, and reduced intimate partner violence (Betancourt et. al., 2020). 
• A 12-month follow-up found sustainment of many of these effects, including increased father engagement in caregiving practices, reduced harsh discipline of children, and reduced intimate partner violence. 
• Improvements in children’s gross motor, communication, personal-social, and problem-solving early development (Jensen et. al., 2021) were observed 12 months post-intervention,
• Community-based volunteers participating in the study described how training and supervision experiences helped them feel prepared to deliver Sugira Muryango and provided examples of how competence enabled them to deliver Sugira Muryango effectively.
• Using a single outcome, in this case the improvement in cognitive development per home-visit session, as an indication of efficiency comparable across similar interventions, this trial intervention costs US$456 per family. This cost will likely fall below US$200 if the intervention is scaled through government systems. 
• Cost-effectiveness analysis suggests that while SM generated a relatively small impact on markers of early development, it did so efficiently. 
• The observed improvements in cognitive development per home-visit are similar to other home-visiting interventions of longer duration.
• SM provides a model of home visiting for a resource constrained context.
• Through SM caregivers learned that strong relationships between partners and engagement of male caregivers in child care has positive impacts on children’s development. 
• Techniques taught by community lay workers improved communication, promoted positive parent–child interactions, and reduced intimate partner violence and violent discipline. 
• Quantitative analyses also found that daily hardships predict violent discipline and intimate partner violence. 
• When analyzing nonspecialists in the context of the SM intervention in Rwanda, age is significantly associated with higher initial fidelity and competence scores and smaller improvements in fidelity and competence over time, although this finding is interpreted in the presence of ceiling effects.
• Nonspecialists in a certain district were more likely to have higher initial fidelity and competence scores but also see smaller changes over time. This analysis is suggesting that fidelity and competence are theoretically distinct and must be measured separately, but linked together under the umbrella of quality of delivery.

Findings from our scale-up study and longitudinal data are currently submitted for peer-review.