Article Text

Effect of a home-visiting parenting program to promote early childhood development and prevent violence: a cluster-randomized trial in Rwanda
  1. Sarah KG Jensen1,
  2. Matias Placencio-Castro2,
  3. Shauna M Murray1,
  4. Robert T Brennan1,3,
  5. Simo Goshev4,
  6. Jordan Farrar1,
  7. Aisha Yousafzai5,
  8. Laura B Rawlings6,
  9. Briana Wilson6,
  10. Emmanuel Habyarimana7,
  11. Vincent Sezibera8,
  12. Theresa S Betancourt1
  1. 1School of Social Work, Boston College, Chestnut Hill, Massachusetts, USA
  2. 2Lynch School of Education and Human Development, Boston College, Chestnut Hill, Massachusetts, USA
  3. 3Women's Study Research Center, Brandeis University, Waltham, Massachusetts, USA
  4. 4Academic Research Services, Boston College, Chestnut Hill, Massachusetts, USA
  5. 5Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
  6. 6The World Bank, Washington, District of Columbia, USA
  7. 7FXB Rwanda, Kigali, Rwanda
  8. 8Center for Mental Health, University of Rwanda, Kigali, Rwanda
  1. Correspondence to Dr Theresa S Betancourt; Theresa.betancourt{at}


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.

  • child health
  • intervention study

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Supplementary materials


  • Handling editor Valery Ridde

  • Contributors TSB conceptualised the study, obtained funding, led intervention development, provided supervision and review of the manuscript. SKGJ had full access to the data and lead the analyses, interpreted results and lead the writing of the manuscript. MPC conducted data analyses, created tables, and contributed to data interpretation and writing and had full access to the data. SMM oversaw intervention implementation, data collection and made significant intellectual contributions to the manuscript content. RTB contributed to study concept and design, statistical consultation and drafting of the manuscript. SG provided expert advice and help with data imputation and analysis. JF oversaw the integrated fidelity monitoring and supervision process and provided critical review of manuscript content.AY contributed subject matter expertise and critical review of manuscript content. LBR and BW contributed to policy dialog management with government counterparts, study design, securing funding, data interpretation and writing. EH oversaw intervention implementation and policy dialog management with local government. VS contributed to intervention adaptation, facilitated contact and dialog with local partners and made significant intellectual contributions to the intervention and manuscript content.

  • Funding World Bank Early Learning Partnership, Strategic Impact Evaluation Fund, World Bank Japan Trust Fund, USAID Rwanda, Network of European Foundations and ELMA Foundation.

  • Disclaimer The World Bank Group (WBG) authors contributed to study design and writing of the manuscript. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors. They do not necessarily reflect the views of the WBG, its Board of Executive Directors, or the governments they represent. The WBG does not guarantee the accuracy of the information included in this work. The remaining funders, USAID Rwanda, ELMA Foundation, and the Network of European Foundations played no role in study design, data collection, data analysis, data interpretation, or writing of the report.

  • Competing interests None declared.

  • Patient and public involvement statement Design of the intervention was carried out with input and routine consultation from stakeholders at the Ministry of Gender and Family Promotion and the National Early Childhood Development Program in Rwanda. We engaged with village leaders and the Ministry of Local Government (MINALOC), which runs the Poverty Reduction Strategy, the Vision Umurenge Program, prior to and during the study implementation to discuss recruitment of participants and to inform them of the process and outcomes. Representatives from the data collection firm, Laterite, and our collaborators at the University of Rwanda, were closely involved in developing and refining the research-questions, study design, selection of measures and assessment tools, and ethical procedures. During implementation, we worked closely with our field-based implementation partner, FXB-Rwanda, who provided training and supervision to the community-based coaches to discuss ongoing implementation and emerging issues. At the end of the study, we communicated results at a local dissemination event which included all key stakeholders, including the Government of Rwanda and other organisations that implement child development programs in Rwanda. "The event included a facilitated discussion with program stakeholders, including local government officials and study interventionists, as well as a presentation, led by the Principal Investigator, on program outcomes, lessons learned and next steps.

  • Patient consent for publication Not required.

  • Ethics approval Procedures and research protocols related trial (registration number NCT02510313) received ethics approval from the Harvard T. H. Chan School of Public Health (IRB16-1570) and Boston College Institutional Review Boards (19.017), as well as the Rwanda National Ethics Committee (no approval number provided), National Commission for Science and Technology (no approval number provided), and the National Institute of Statistics of Rwanda (no approval number provided).

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement Data are available on request. Data can be made available on request and will be made publicly available via the World Bank’s data catalog at a later date.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.