Using Implementation Science to Scale-out Evidence-based Home Visiting in Rwanda: Lessons Learned Using Integrated Approaches

• In Event: Implementation Science for Quality Improvement in Scale Up Programs in Bhutan, Rwanda, and the United States

Proposal

Rwanda recognizes that affordable, scalable, and effective interventions are needed to advance the prospects of extremely vulnerable children (Engle et al., 2011, Britto et al., 2017). In particular, children living in poverty are at risk for poor health and development in addition to exposure to family stress and violence, which can perpetuate intergenerational cycles of violence, poverty, and lost human capital (Richter et al., 2017; Shonkoff & Fisher, 2013). Sugira Muryango is a home-visiting intervention to support playful parenting, father engagement, improved nutrition, care seeking and family functioning—to promote early childhood development (ECD, positive parent-child relationships, and healthy child development amongst the most vulnerable families in Rwanda with a child birth to 36 months. It was developed as “deployment-focused” to be scalable and affordable in low-resource settings. Building off a strong evidence base that includes two pilots (Betancourt et al., 2018; Barrnhart et al., 2020) and an effectiveness trial (Betancourt et al., 2020), the most recent iteration seeks to reach 10,000 households using a government-supported workforce, the Friends of the Family social protection home visitor.

As Sugira Muryango moves to systemwide scale out, the four-phased multilevel Exploration, Preparation, Implementation, and Sustainment (EPIS) conceptual framework will be used to identify key factors that can be leveraged as the program is scaled (Aarons, Hurlburt & Horwitz, 2017). Within this framework, an evidence-based implementation strategy, the Promoting Lasting Anthropometric Change and Young Children’s Development (PLAY) Collaborative, will be used to engage local stakeholders and frontline providers and supervisors to ensure quality improvement and sustainability. The PLAY Collaborative utilizes a multilevel implementation strategy drawn from Interagency Collaborative Teams (Hurlburt, Aarons, Fettes, Willging, Gunderson, & Chaffin, 2014) and the IHI Breakthrough Learning Collaborative methodology (IHI, 2003) that engages stakeholders across the layers of the ecology of ECD delivery in Rwanda in order to reinforce knowledge sharing and problem solving, and strengthen intervention oversight, creating a community of practice amongst ECD stakeholders.

Quality improvement approaches will prioritize an integrated fidelity monitoring and supervision system to strengthen Sugira Muryango delivery over time; Plan-Do-Study-Act cycles, including Root Cause Analysis and Impact-Effort Matrices, to address attendance issues and spread solutions across the delivery catchment area; and, weekly PLAY Collaborative meetings across implementation levels to share challenges and problem solve as a community. Technological inputs such as WhatsApp to support supervision and transmit household-level data, video capture of active play sessions to rate active coaching as part of fidelity monitoring, and RedCap to generate weekly reports and capture run-chart data to be shared as part of PLAY Collaborative engagement and cross-site learning efforts. Using evidence from Phase 1 roll out (beginning November 2020), barriers and facilitators to implementing integrated quality improvement approaches will be presented and, using these lessons learned, evidence-informed changes to be utilized during Phase 2 implementation will be discussed.

Authors

• Ursula Kajani, Boston College

• Jean Marie Havugimana, FXBX Rwanda

• Jordan Farrar, Boston College