from EVIDENCE to POLICY Learning what works for better programs and policies November 2021 RWANDA: Can parenting programs improve child development and prevent violence against women and children? Children need a safe, nurturing, healthy, and stimulating envi- be adapted to address family violence as well? Can these services ronment to thrive and reach their full potential. But millions of be effectively delivered through government social safety net pro- EARLY CHILDHOOD DEVELOPMENT children living in poverty don’t receive enough stimulation or grams which often target poor, vulnerable families? good nutrition in their first years of life, and poverty also makes The World Bank’s Strategic Impact Evaluation Fund (SIEF) them more likely to experience neglect and violence in the home. supported a randomized evaluation in Rwanda that examined Domestic violence, however, is rarely addressed in programs pro- the effectiveness of a parenting program delivered in the home to moting young children’s development, which also typically focus families with children between the ages of 6 and 36 months, as on mothers, with little attention on fathers. Previous research part of a wider social protection program targeted to poor fami- suggests home-based parenting programs can lead to positive im- lies. Community-based coaches visited families once a week for provements in children’s brain development. Can these programs 12 weeks to provide male and female caregivers with play-based “active coaching” to enhance their interactions with their chil- dren, as well as counselling on responsive caregiving, nutrition, hygiene, emotion regulation, and nonviolent interactions among household members. The evaluation found that the program had positive impacts: it led to improvements in children’s gross mo- tor skills, communication and problem-solving skills, and social emotional development. Males became much more involved in childcare, females experienced less intimate partner violence, and children experienced a reduction in violent disciplining. These findings indicate a potential for improving children’s development and the overall home environment by adding components on par- enting, conflict resolution, and non-violent discipline to existing social protection programs. Photo: A’Melody Lee / World Bank Context Rwanda has made huge strides in its economic and social develop- the Rwandan government established a social protection program ment over the last decade, including improvements in child de- called the ‘Vision 2020 Umurenge Programme’ in 2007 to ad- velopment and nutrition. Despite this progress, significant chal- dress poverty and human-capital related disparities. The program lenges remain. Thirty-three percent of children under age 5 are offers direct support, such as cash transfers to the poorest and stunted, or too short for their age indicating malnutrition, and 9 most vulnerable households, as well as cash for work support. In percent are severely stunted, according to a 2019-2020 nationally 2017, the government established the National Early Childhood representative survey. Malnutrition rates are much higher in rural Development Program (NECDP) to coordinate and expand an areas than in urban areas. To combat these and other challenges, array of early childhood development initiatives, including early childhood development centers and home-based services for the by previous research indicating violent discipline was a key chal- most poor and vulnerable families. lenge to child development in Rwanda. The program evaluated in this study, Sugira Muryango (‘Strengthen the Family’), builds on an evidence-based approach Why a focus on violence reduction? to improving child development, following UNICEF and WHO’s Care for Child Development package and Nurturing Care Frame- A previous survey of parents of children aged 24-35 months in Rwanda found… work. The core curriculum used for the Sugira Muryango pro- gram was originally developed and tested in HIV/AIDS-affected • 81 percent used at least one form of violent discipline in the past month Rwandan families with school-aged children and included non- • 73 percent used physical punishment violent parenting and caregiver conflict-resolution strategies. The • 49 percent used psychological aggression • 10 percent only used non-violent discipline methods decision to include violence reduction in the program was driven Evaluation Researchers conducted a cluster randomized evaluation to mea- issues such as family conflict and housing insecurity. sure the effect of the Sugira Muryango program on child develop- Three-month and six-month “booster” visits, each approxi- ment and growth, violence in the home, and father’s engagement mately 1-hour long, took place in November 2018 to December with children. Study participants were families with children 2018 and March 2019, respectively. The aim of these visits was to aged 6–36 months in 284 geographical clusters in three districts, reconnect with families, identify and address ongoing challenges, Nyanza, Ngoma and Rubavu, in different areas of the country. To and engage caregivers in an active play session as modelled in each be eligible, families had to be beneficiaries of a social protection of the home-visiting sessions implemented earlier. program that targets families living in extreme poverty (Ubudehe Coaches were selected from the local community using a 1) based on the government’s poverty-ranking system, have one three-step process: (1) nomination from community members, or more child(ren) aged 6–36 months, and be willing to partici- (2) a phone screening and (3) an intensive in-person interview. pate in a home-based parenting program. Among eligible families, Coaches then received intensive training and support. They par- 541 were randomly assigned to the treatment group and received ticipated in a 3-week training (120 hours total), followed by close the Sugira Muryango program, while 508 families comprised the supervision that included in-person supervision during the first comparison group who continued to receive social protection pro- three weeks of program delivery, weekly telephone supervision gram support, but not Sugira Muryango. (approximately 12 hours total), and monthly in-person group Sugira Muryango is a relatively brief yet comprehensive pro- supervision. Additionally, weekly in-person peer support groups, gram. For twelve weeks, community-based coaches visited fami- facilitated by lead coaches, complemented supervision strategies lies weekly in families’ homes unless caregivers preferred to hold and served as an opportunity for lead coaches to obtain audio the sessions elsewhere for privacy reasons. Each visit included a recordings of home visits that could be used for quality improve- 15-minute active play session in which caregivers received real- ment of implementation and further on-the-job training and sup- time feedback on their interactions with their children, as well port to coaches. Coaches also received training on confidentiality as a home-visiting module lasting 60 minutes that involved the and risk of harm protocols. They were responsible for five house- participation of caregivers and children. Coaches encouraged both holds each and received a monthly stipend. female and male caregivers (present in the home) to actively par- The research team used multiple widely used measurement ticipate and engage in childcare and household-related decisions. tools to measure the impact of the program on child development, The coaches also helped families navigate formal social protec- including the Ages and Stages Questionnaires (ASQ-3), which are tion programs to promote child health and nutrition including a series of age-specific questionnaires designed to screen for de- supplemental nutrition for malnourished children and informal velopmental delay of children in the areas of gross motor skills, support, such as from neighbors and extended family, to address fine motor skills, communication, problem solving, and social- This policy note is based on “Effect of a home-visiting parenting program to promote early childhood development and prevent violence: a cluster-randomized trial in Rwanda,”Jensen SKG, Placencio-Castro M, Murray SM, et al. BMJ Global Health (2021) and “Promoting parent-child relationships and preventing violence via home-visiting: a pre-post cluster randomised trial among Rwandan families linked to social protection programmes,” Betancourt et al. BMC Public Health (2020) emotional skills. Researchers also used the Malawi Development male caregivers to report on their own perpetration of abuse with- Assessment Tool (MDAT) a brief, observational, task-based tool, in the last 3 months. designed to be culturally appropriate for use in rural Africa, to as- Trained enumerators conducted the assessments in the Kin- sess child development across domains of gross motor, fine motor, yarwanda language in the family’s home, except anthropometric language, and socioemotional development. To measure anthro- measurements which were taken at local health clinics. Baseline pometric (physical) growth, the research team used measures of standardized height-for-age (HAZ), standardized weight-for-age (WAZ), standardized weight-for- height (WHZ) and middle-up- per-arm circumference (MUAC). Researchers also asked caregiv- ers to report on children’s food consumption, health service utili- zation, and hygiene behaviors such as handwashing. The researchers assessed fathers’ engagement based on whether the father spends time every day caring for the child, with response options ‘yes/no’ reported by the primary caregiver. Violent and nonviolent discipline practices were assessed using the UNICEF Multiple Indicator Cluster Survey Child Development and Child Disciplinary modules, as reported by the primary caregivers. Ex- posure to violent disciplinary practices included being shouted or screamed at, called demeaning names, shaken, spanked, slapped, or beaten. Intimate partner violence was assessed by the Rwanda Photo: A’Melody Lee / World Bank Demographic and Health Survey’s Domestic Violence Module assessments were conducted between April 2018 and June 2018, among caregivers who reported being currently married, cohabi- with a first follow-up assessment taking place immediately after the tating, or in a relationship. The research team also asked female program ended from August to September 2018. The 12-month caregivers to report experiences of physical or sexual abuse and follow-up took place between August and September 2019. Findings Children in the program demonstrated better cogni- One of the largest impacts of the program was an in- tive and social development compared to their peers crease in fathers’ engagement with their children. in the comparison group. The program was well-attended by fathers and led to a sig- Children experienced improvements in their cognitive devel- nificant relative increase in fathers’ involvement in childcare. opment based on the ASQ-3 questionnaires. When using the Program fathers were 1.5 times more likely to have spent time ASQ-3 measurement tool, researchers estimated statistically sig- caring for their children in the previous 24 hours than fathers nificant improvements of 0.29, 0.14, 0.16, and 0.15 standard in the comparison group. deviations in children’s gross motor, communication, problem Researchers believe flexible scheduling and messaging solving, and social-emotional scores, respectively. The fact that about the importance of fathers in ensuring a nurturing and these effects persisted one year after the program ended suggests safe environment for young children to grow and thrive may the program can generate benefits that persist in the short run. have been key to the program’s success in this area. There were no significant differences between the treatment and comparison groups in fine motor development, nor were there The program also prompted families to rely less on any significant differences observed in any child development harsh discipline tactics like spanking, yelling, or using domain when using the other measurement tool, the MDAT. demeaning names, and it appeared to reduce violence against women as well. The rate of harsh discipline in families within the program was groups that children consumed, suggesting an improvement 25 percent smaller than the rate of harsh discipline in families in dietary diversity. They also reported much higher rates of in the control group. Likewise, the rate of mothers who re- seeking care for diarrhea and fevers when children were sick ported experiencing physical or emotional abuse by a partner and handwashing practices. Nevertheless, immediately after was 38 percent smaller in the Sugira Muryango group com- the program and one year later, children in households that pared with the control group. Interestingly, however, fathers received the program were indistinguishable from children themselves did not report less perpetration of violence towards without the program in terms of their height-for-age, weight- their partners. for-age, and measures of wasting. A behavioral approach such as the Sugira Muryango program, with active coaching on nur- Though it improved reported dietary diversity, turing care, may not be enough or may need to be combined healthcare seeking for diarrhea, and hygiene in the with nutrition programs to cause measurable improvements home, the program didn’t have an immediate impact in anthropometric growth, particularly among extremely vul- on children’s physical growth. nerable households and already malnourished children. The study’s authors speculate that including nutrition-specific or The curriculum addressed child feeding, nutrition, and hy- nutrition-sensitive complements to the program may be need- giene with the aim of improving children’s health and growth, ed to address child stunting. and indeed parents reported an increase in the number of food Conclusion Overall, the parenting program appears to have increased chil- designed to be relatively brief and delivered by non-specialized dren’s cognitive and socioemotional development and father’s workers with strong monitoring and quality supervision to engagement in caregiving. It also reduced violence against ensure fidelity. It will be important in future research to test women and harsh discipline against children. These findings whether the program can be scaled up to reach large numbers show that home-based parenting programs can not only im- of families in extreme poverty with the existing government prove children’s cognitive development but also foster a more workforce. In Rwanda, such human resources exist, including nurturing and less violent home environment. These results the inshuti z’umuryango (“friends of the family”) child protec- also support the importance of involving all family members, tion workers and other community health workers. Similarly, including fathers and other male caregivers in the household, future research would also tackle the challenge of using existing in programs that focus on providing nurturing care to children. social protection platforms to deliver these interventions and Moreover, the findings show that integrated parenting and address malnutrition among children. social protection programs hold promise. This program was The Strategic Impact Evaluation Fund, part of the World Bank Group, supports and disseminates research evaluating the impact of development projects to help allevi- ate poverty. The goal is to collect and build empirical evidence that can help governments and development organizations design and implement the most appropriate and effective policies for better educational, health, and job opportunities for people in low and middle income countries. For more information about who we are and what we do, go to: http://www.worldbank.org/sief. The Evidence to Policy note series is produced by SIEF with generous support from the British government’s Foreign, Commonwealth and Devel- opment Office and the London-based Children’s Investment Fund Foundation (CIFF). THE WORLD BANK, STRATEGIC IMPACT EVALUATION FUND 1818 H STREET, NW, WASHINGTON, DC 20433