Scaling Out Evidence-Based ECD Home-Visiting in Rwanda: The Evolution and Adaptability of Sugira Muryango

• In Event: Global Parenting Interventions: Advances in Measurement and Scale Up

Abstract

Rwanda has one of the highest rates of stunting (38%) in all of sub-Saharan Africa. This reality is in strong contrast to its ambition to be an upper middle-income country by 2035. Rwanda is invested in addressing stunting and similar indicators of underdevelopment in children, and recognizes that affordable, scalable, and effective interventions that address early childhood development (ECD) are needed to advance the prospects of vulnerable children (Britto et al., 2017). Since 2007, the Sugira Muryango father-engaged home visiting program to improve child development and reduce violence has undergone two pilots (Betancourt et al., 2018; Barrnhart et al., 2020) and an effectiveness trial (Betancourt et al., 2020) with a 10,000 household expansion program underway to test strategies for sustainment while maintaining quality and fidelity to evidence-based components.

The evolution of Sugira Muryango illuminates two critical insights: innovative approaches are needed to sustain and scale evidence-based programs and it is imperative that evidence-based programs evolve over time within dynamic and complex systems. For example, in the first pilot, the first 10 families received a 22-module version of Sugira Muryango, which was refined into a 15-module version delivered to the final 10 households. This iterative process resulted in a low-literacy sensitive intervention manual which used illustration to model core components of play, dietary diversity, health and hygiene promotion, shared decision making, reduced violence and father engagement. The second pilot utilized a pre-post design with a randomized comparison group (38 households) and deployed a 12-module curriculum delivered by community-based lay workers supervised by the prior cadre of interventionists. A Cluster Randomized Trial with 1,049 households incorporated robust fidelity monitoring protocols, targeted supervision to support quality improvement feedback loops, and added a 3- and 6-month booster session. With deepened government partnerships, a 10,000 household expansion study will allow Sugira Muryango to be delivered via a government-supported workforce. An evidence-based 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.

Outcomes across study phases will be presented as well as key programmatic adaptations that have supported program scalability. This information will be framed within the dynamic ECD landscape in Rwanda which has heavily informed all program decision making. Recommendations and lessons learned from each phase will also be presented.

Group Authors

As per Anne Perdue please consider these flash talks as one session. They should either be accepted or rejected as a whole.

Flash talks should be ordered as follows: 1707093, 1705221, 1705962, 1707008, 1705220, 1705994, 1706107, 1706048

Authors

• Jordan Farrar, Boston College
  Presenting Author

• Theresa Stichick Betancourt, Boston College
  Non-Presenting Author

• Sarah Jensen, Boston College
  Non-Presenting Author