Effect of a home-visiting parenting program to promote early childhood development and prevent violence: a cluster-randomized trial in Rwanda

Sarah Kg Jensen, Matias Placencio-Castro, Shauna M Murray, Robert T Brennan, Simo Goshev, Jordan Farrar, Aisha Yousafzai, Laura B Rawlings, Briana Wilson, Emmanuel Habyarimana, Vincent Sezibera, Theresa S Betancourt, Sarah Kg Jensen, Matias Placencio-Castro, Shauna M Murray, Robert T Brennan, Simo Goshev, Jordan Farrar, Aisha Yousafzai, Laura B Rawlings, Briana Wilson, Emmanuel Habyarimana, Vincent Sezibera, Theresa S Betancourt

Abstract

Introduction: Families living in extreme poverty require interventions to support early-childhood development (ECD) due to broad risks. This longitudinal cluster randomised trial examines the effectiveness of Sugira Muryango (SM), a home-visiting intervention linked to Rwanda's social protection system to promote ECD and reduce violence compared with usual care (UC).

Methods: Families with children aged 6-36 months were recruited in 284 geographical clusters across three districts. Cluster-level randomisation (allocated 1:1 SM:UC) was used to prevent diffusion. SM was hypothesised to improve child development, reduce violence and increase father engagement. Developmental outcomes were assessed using the Ages and Stages Questionnaire (ASQ-3) and the Malawi Development Assessment Tool (MDAT) and anthropometric assessments of growth. Violence was assessed using questions from UNICEF Multiple Indicators Cluster Survey (MICS) and Rwanda Demographic and Health Surveys (DHS). Father engagement was assessed using the Home Observation for Measurement of the Environment. Blinded enumerators conducted interviews and developmental assessments.

Results: A total of 541 SM families and 508 UC families were enrolled and included in the analyses. Study attrition (2.0% children; 9.6% caregivers) was addressed by hot deck imputation. Children in SM families improved more on gross motor (d=0.162, 95% CI 0.065 to 0.260), communication (d=0.081, 95% CI 0.005 to 0.156), problem solving (d=0.101, 95% CI 0.002 to 0.179) and personal-social development (d=0.096, 95% CI -0.015 to 0.177) on the ASQ-3. SM families showed increased father engagement (OR=1.592, 95% CI 1.069 to 2.368), decreased harsh discipline (incidence rate ratio, IRR=0.741, 95% CI 0.657 to 0.835) and intimate partner violence (IRR=0.616, 95% CI:0.458 to 0.828). There were no intervention-related improvements on MDAT or child growth.

Conclusion: Social protection programmes provide a means to deliver ECD intervention.

Trial registration number: NCT02510313.

Keywords: child health; intervention study.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Sugira Muryango theory of change. Reprinted with remission from Betancourt et al- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201751/.
Figure 2
Figure 2
Study timeline.
Figure 3
Figure 3
Cluster sampling strategy and flow chart of participants in the Sugira Muryango trial. Although each cluster had a 50% chance of being assigned to receive Sugira Muryango, we were not guaranteed an equal number of Sugira Muryango and usual care clusters because randomisation occurred within relatively small strata that sometimes contained an odd number of clusters. ePw, expanded public works; cPW, classic public works.

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