Effectiveness Trial of a Family Home Visiting Intervention to Promote Early Child Development Among Families Served by the Social Protection System in Rwanda
Phase: NA
Conditions: Child Development, Social Protection
Sponsor: Boston College

 
 
 
 
 
 
 
 
Effectiveness Trial of a Family Home Visiting Intervention to Promote Early Child 
Development Among Families Served by the Social Protection System in Rwanda 
 
 
NCT02510313 
 
Finalized: October 8, 2019 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Sugira Muryango Study Protocol 
2 
A. Background 
 
Introduction 
Rwanda is invested in addressing indicators of underdevelopment in children. 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). Through its flagship 
social protection program Vision 2020 Umurenge Program (VUP), which targets the most 
vulnerable families in Rwanda (those with an Ubudehe 1 or 2 classification) the Rwandan 
government is working to address family violence, promotion of gender equality and increased 
attention to social safety nets. The VUP program is divided into two separate programs and the 
type of program a family qualifies for depends on criteria defined by the Rwandan government 
including the number of able-bodied adults in the household. The original program is  “classic 
public works” program (cPW), provides cash for manual labor, and a newer “expanded public 
works” (ePW) program provides cash for typically lighter labor and also provides access to 
livestock.  
 
Rwanda has 11.9 million inhabitants, approximately 53% under 19 years old. Rwanda has made 
great progress in addressing infant and child mortality reducing it from 196/1,000 in 2000 to 
50/1,000 in 2017. However, deficits remain including a high under-five stunting rate (38%). The 
country has faced compounded adversities including the 1994 genocide, the HIV/AIDS epidemic 
and extreme poverty. Although since the year 2000 the real GDP growth has averaged 8% per 
year, 39.1% of Rwandans live below the poverty line. These adverse factors create a series of 
challenges, including deficits in nutrition and early childhood development (ECD) education and 
implementation.  
 
Eighty-seven percent of children less than 6 months old are breastfed but stunting rates rise from 
18% at 6–8  months of age to 38% at 18–23 months of age and up to 49% in the lowest poverty 
quintile. Dietary diversity is limited in Rwanda, especially amongst poor children. In the early 
years, the need for nutrients to fuel brain development and physical growth is particularly high. 
A UNICEF/Rwanda Ministry of Health study found that a very limited diet for children—in 
terms of variety and nutritional content—is common in Rwanda, due both to poverty and poor 
feeding practices. The study found that a high percentage of children in the poorest households 
did not receive three meals a day and only 17% of children aged 6–23 months have a minimally 
acceptable diet. In addition, early childhood development knowledge, attitudes and practices of 
Rwandan parents are limited. A 2014 UNICEF study found that only 12% of primary caregivers 
for 2–3-year-old children engaged in three or more activities to promote learning or school 
readiness (e.g., singing songs, telling stories, teaching the child something new or looking at 

Sugira Muryango Study Protocol 
3 
pictures in books and magazines with the child). The ECD problem is compounded by the fact 
that violent discipline is prevalent. An Early Childhood Development and Family Services 
UNICEF baseline evaluation in 20 sites in Rwanda showed that 19.8% of children 0–11 months 
old and 80.7% of children 24–36 months old are exposed to some form of violent discipline; 
34.4% of caregivers believe that physical punishment is necessary to raise a child well. In 
addition, men are often not significantly involved in supporting children’s early development and 
decision making is not equally shared by men and women. 
 
Specific Aims 
The proposed study will investigate the effectiveness of Sugira Muryango, a family home-
visiting caregiver coaching model intended to promote child development, healthy caregiver-
child interactions and reduce caregivers’ use of harsh punishment among families living in 
extreme poverty in Rwanda. 
  
The study’s Specific Aims are:  
 
Aim 1. To test the effectiveness of Sugira Muryango in promoting child development (cognitive, 
socio-emotional, language and physical development), reducing harsh punishment and increasing 
father engagement in childcare in poverty-affected households participating in a social protection 
program (the VUP program):  
Hypothesis Aim 1 (a): Children in families participating in Sugira Muryango will 
demonstrate improved developmental outcomes. Specifically, children from families who 
received Sugira Muryango will score better on assessments of cognitive, language, and 
socioemotional development compared to children in the control group (CG).   
Hypothesis Aim 1 (b):  Children in families participating in Sugira Muryango will 
display improved physical growth compared to children in the control group (CG). 
Specifically, we expect to see improvement in weight-for-age, weight-for-height, upper 
middle arm circumference. We do not expect to see large improvements in height-for-age 
over this relative short time frame.  
Hypothesis Aim 1 (c): Caregivers who participate in Sugira Muryango will report lower 
levels of family violence (intimate partner violence and harsh discipline) compared to 
children in the control group (CG).  
Hypothesis Aim 1 (d): Among families with a father present in the child’s life, families 
receiving Sugira Muryango will show greater levels of father engagement in caring for 
the child compared to children in the control group (CG).   
 
 
Gaps in Knowledge 
Throughout sub-Saharan Africa, integrating scalable, cost-effective ECD and violence 
prevention programs into poverty-reduction and other social welfare programs has great potential 

Sugira Muryango Study Protocol 
4 
for promoting ECD and reducing familial violence in culturally diverse, low-resource settings. 
Data from the Sugira Muryango (SM) trial will support and advance the Rwandan government’s 
vision for comprehensive decentralized ECD to help eradicate poverty and violence against 
children. The objectives of this research seek to contribute to academia and research institutions’ 
roles and responsibilities outlined in the ECD Policy housed under the Ministry of Gender and 
Family Promotion (MIGEPROF, 2016). 
 
One of the key research questions of the impact evaluation of SM is whether or not the model is 
effective in improving children’s developmental outcomes including socio-emotional, cognitive 
and language development as well as nutritional status. The objective is to build the evidence 
base for incorporating key early years caregiving messages to support healthy child development 
within already established social protection programming in Rwanda, via impact, process, and 
costing data. If effective, Rwanda is poised to bring such an intervention to scale at a national 
level, providing an opportunity to share impact, costing, and process evaluations lessons 
globally. 
 
How this study addresses the Gaps 
Rwanda is facing significant challenges, including chronic malnutrition (stunting), early 
childhood development education and implementation, neonatal mortality, the quality of 
education, and prevention of violence against children. However, its strengths, political stability, 
strong governance, fiscal and administrative decentralization, and zero tolerance for corruption, 
set it among the prime locations where early childhood education interventions can have an 
immediate effect on the wellbeing of children and families and a long-term positive effect on the 
development of children and their ability to reach their full potential and fully contribute to 
Rwanda’s future development. As such, the present study addresses these gaps and challenges by 
assessing the delivery of SM, a deployment focused intervention to promote ECD and reduce 
family violence.  
 
 
B. Study Design 
   
Intervention 
Sugira Muryango (SM) is a home-visiting model to support playful caregiving, involving all 
caregivers of the child with emphasis on father engagement whenever a father is present in the 
life of the child. SM also aims to improve nutrition, care seeking for child illness, family 
functioning, positive parent-child relationships, and healthy child development. The intervention 
builds on five core components: (a) builds playful caregiving skills and improves knowledge of 
ECD to create a safe, responsive and nourishing environment for the growth of young children 
with a focus on nutrition, health and hygiene promotion; (b) coaches parents of young children in 
“serve and return” interactions and playful caregiving; (c) develops a “family narrative” to build 

Sugira Muryango Study Protocol 
5 
hope and highlight sources of resilience for addressing challenges and reducing risks of violence; 
(d) strengthens problem-solving skills as well as the navigation of formal and informal 
community resources; and, (e) builds skills in parental emotion regulation, conflict resolution, 
and alternatives to harsh punishment  (Figure 1). 
 
 
 
Figure 1. Theory of Change 
  
The components of SM are informed by the WHO’s Care for Child Development package and 
integrated into 12 modules (Table 1), the core intervention, and two booster/follow-up sessions. 
Each module is delivered in the home of the family and care is taken when planning the home 
visits to ensure the presence of all primary caregivers of the child, including fathers. Each 
module takes 60–90 minutes to deliver. The 12 modules are delivered at a pace of one module 
per week over 3–4 months by well-trained lay interventionists (community-based volunteers 
referred to as CBVs) who are already embedded in the local community. Primary caregivers 
participate in the modules in interaction with their child(ren). All home visits include a 15-
minute “active play and communication” session where caregivers receive targeted feedback on 
parent-child interactions. The intervention also focuses on helping families to navigate both 
formal and informal supports. In this manner, SM connects families to existing resources, 
harnesses resilience, improves problem-solving skills, and can be delivered through existing 
service channels, such as the health system or child protection programs. Given its 
implementation with caregivers who lived during the time of the Rwandan genocide, SM is also 
trauma-informed by identifying the supports and sources of strength that helped parents make it 
through difficult times in the past while directing them toward a more hopeful future. 
  
Long Term 
(12-month)
Outcomes
Sugira Muryango 
Components
Father-engagement, active coaching 
& learning on nutrition, health, & 
hygiene
Coaching in responsive parenting & 
the importance of play
Building resilience & coping skills 
including a family narrative
Building skills in problem-solving & 
navigating formal/informal resources
Building skills in emotion regulation, 
stress management, alternatives to 
harsh discipline, & conflict resolution
Improved 
child physical 
& cognitive 
development
Sustained 
reductions in 
violence & 
responsive 
caregiving
Vulnerable 
families 
classified as 
Ubudehe 1 
with children 
ages birth–36 
months
Target
Increase in 
male & 
female 
caregiver 
engagement 
in play and 
other ECD 
activities
Improved 
health-related 
caregiver  
behaviors
Safer home 
environment
Reduced 
violence
Pre-to-Post 
Intervention
Outcomes
Risk Factors
Limited information 
about children’s 
developmental needs
Limited stimulation 
& learning 
Opportunities
Lack of future 
orientation & 
planning
Family social & 
economic stress
Risk of family 
violence

Sugira Muryango Study Protocol 
6 
An overview of module session topics is included below: 
  
Table 1. Sugira Muryango Modules, Themes and Goals  
Module 
Theme 
Goals 
Welcome 
Session 
  
• 
Introduce caregivers to Sugira Muryango 
• 
Explain Sugira Muryango goals and structure 
• 
Establish a plan for regular meetings together 
Module 1 
Family Narrative 
• 
Discuss the family’s priorities and goals 
• 
Learn about the family and their children (hopes/goals); 
Family Narrative 
• 
Introduce concepts related to family relationships and ECD 
and the importance of all caregivers in children’s lives. 
Module 2 
The importance of 
responsive caregiving 
• 
Coach on the importance of diverse play opportunities, 
responsive caregiving and brain development 
• 
Coach positive, responsive parent-child interactions and 
early stimulation 
• 
Expand and strengthen caregivers’ repertoire of stimulating 
activities for their children and toy making 
• 
Explain Serve & Return interactions and coach caregivers on 
this practice 
Module 3 
Building early 
communication skills 
• 
Coach on the importance of early communication skills and 
language development 
• 
Identify and practice ways to incorporate language learning 
into play and daily routines 
• 
Coach and practice additional techniques to support early 
speech and language development 
Module 4 
The importance of good 
nutrition 
• 
Learn about food consumption in the home 
• 
Identify nutritional practices that promote child health and 
growth, including the importance of deworming 
• 
Discuss ways to maximize nutrition from available foods 
Module 5 
The importance of good 
hygiene 
• 
Identify hygiene practices that promote good health 
• 
Coach on the obstacles to good hygiene and sanitation 
Module 6 
The importance of good 
health 
• 
Talk with caregivers about health practices in the home, 
particularly their response to sick children 
• 
Discuss the family’s Mutuelle de Sante health insurance 
coverage 
• 
Ensure immunizations are completed/take steps to complete 
immunizations 
Module 7 
Managing the stresses 
of caregiving and 
family life 
• 
Identify and coach caregivers on ways to effectively manage 
personal and household stresses and frustrations 
• 
Explain the importance of adults’ consistent emotional self-
control for young children 

Sugira Muryango Study Protocol 
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Module 8 
Resolving conflicts in 
the home 
• 
Identify and actively coach conflict resolution strategies that 
promote peace, resilience and well-being in the home 
• 
Coach on alternatives to harsh punishment and harmful 
impact of angry or violent responses to conflict on early 
childhood development 
• 
Coach on the role of positive, responsive caregiving in 
creating a safe environment for all family members 
Module 9 
The important role that 
everyone plays in 
raising a baby well 
• 
Discuss the diverse roles of all family members in supporting 
early childhood development 
• 
Highlight the important role of fathers in raising children 
• 
Coach on effective discipline strategies 
Module 10 
Good caregiving is 
better than being born 
well 
• 
Coach on the importance of a positive, nurturing parent-child 
relationship 
• 
Coach and practice skills related to responsive, stimulating 
child-caregiver play and interactions 
Module 11 
Making the home a 
place where a baby’s 
brain can grow 
• 
Discuss the importance of safety, cleanliness, and support in 
the home for young children’s early learning 
• 
Discuss and carry out active coaching on early stimulation 
activities 
Module 12 
With a united family, 
anything is possible 
• 
Review program goals and content 
• 
Address any remaining questions or concerns 
• 
Discuss how the family will use newly learned skills and 
strategies to promote healthy ECD going forward 
• 
Provide family with information on local health/support 
services 
  
  
Selection of Community Based lay workers 
Community Based lay worker (CBV) coaches are enrolled with assistance from local 
authorities and leaders in selected study locations. Approximately 118 CBVs will be recruited 
to deliver SM across the treatment arms. Their caseload of households is approximately 5 
households per CBV. 
  
CBVs are selected from the local community using a three-tiered process. First, FXB staff 
members, referred to as SM expert supervisors, meet with local officials and leaders to discuss 
SM and introduce the CBV role. Community meetings are held so that community members 
can learn about the program and express an interest in being considered for the role of CBV. 
Second, each SM supervisor collates the potential CBVs (either those nominated by village 
leaders or those who directly express interest) onto a list and conducts a screening interview 
over the phone using a structured screening guide. Third, the SM supervisor travels to the study 
districts to conduct an in-depth in-person interview. Once CBVs are selected, they are invited to 
participate in an intensive three-week training held in their study district.  

Sugira Muryango Study Protocol 
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In addition to the formal selection procedure, CBVs must meet the following inclusion criteria: 
CBVs selected to deliver the Sugira Muryango intervention must: (a) live in the sector of 
beneficiary households they will deliver the intervention to, (b) be Rwandan, (c) be aged 18 or 
older; (d) be able to write, read, and count in Kinyarwanda; (e) be committed to young children 
and family values; (f) have the required amount of time to carry out the Sugira Muryango 
intervention with a select number of households, (e) be recommended and approved by local 
community and authorities. 
  
Training, supervision and fidelity monitoring 
Prior to the start of the intervention CBVs undergo extensive three-week training on the SM 
intervention model taught by Boston based staff and bachelor-level Expert Supervisors who 
have previous experience with SM. Six bachelor-level Expert Supervisors will continue to 
supervise the CBVs for a ratio of approximately 1:17. 
  
Supervision and fidelity monitoring are integrated processes intended to support quality of 
program delivery by the CBVs. All CBVs engage in face-to-face supervision during the first 
three weeks of the intervention, and each supervisor shadows each CBVs once in the home. 
Telephone supervision and peer support groups occur weekly throughout the intervention and 
group supervision is held once a month. During each home visit the CBVs ask for the 
caregivers’ permission to audiotape the home-based sessions. These recordings are reviewed by 
an expert supervisor who provide targeted feedback to home visitors to strengthen their work on 
active coaching and father engagement. This fidelity monitoring feedback loop informs the 
supervision of the CBVs so knowledge and skills pertaining to high quality delivery are 
supported. 
  
Recruitment and Study Population 
The targeted study population (referred to as “beneficiaries”) are families with at least one child 
aged 6–36 months, who are eligible for Rwanda’s social protection program Vision 2020 
Umurenge Program (VUP) and live in one of the selected districts: Nyanza, Ngoma, and 
Rubavu. 
  
Family inclusion criteria are (a) living in the Rubavu, Ngoma or Nyanza District of Rwanda. 
Inclusion criteria for families are: (b) being VUP-eligible (according to the Rwandan 
government), (c) having at least one child aged 6–36 months living in the home, and (d) having 
at least one caregiver who is willing to discuss and enhance their caregiving practices by 
interacting with a home-visiting coach (CBV). 
 
Further caregiver inclusion criteria are: (a) is aged 18 or older and cares for child(ren) and (b) 
lives in the same household as child(ren). We will enroll both single and dual caregiver families 

Sugira Muryango Study Protocol 
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to reflect population dynamics. Legal guardians may be parents, aunts, uncles, grandparents, or 
foster parents. 
  
Family exclusion criteria are not meeting inclusion criteria, caregiver having severe cognitive 
impairments which preclude their ability to speak to the research questions under study, or 
families or caregivers are in the midst of crisis (e.g., a caregiver with active suicidal attempts or 
psychosis). Families with ongoing crisis or disability will be referred to appropriate services. 
  
Consent Procedures 
During household enrollment, Laterite – the local data collection subcontractor - uses VUP lists 
to go door to door to assess household eligibility and offer participation in the SM home visiting 
intervention. If a household is eligible and wants to enroll, the field team consents the primary 
and secondary caregivers and the VUP head of household if different from the primary and 
secondary caregiver. The primary caregiver also provides consent for the child ages 6–36 
months. If a caregiver is absent, the team make a plan to come back either later in the day or the 
next day. The field team gives each home a week for this to be completed before replacing the 
home. Given that most Ubudehe 1 individuals (those eligible for VUP public works) are 
illiterate, the consents are orally communicated to the caregivers. The caregivers either sign their 
name or make a mark (thumbprint) on the consent form. The Laterite field team carries 
additional copies of the consent in case the family would like to keep a copy. The consent forms 
are stored in a portable lock box until they are transferred to Kigali and stored in locking file 
cabinets at the FXB-Rwanda office. Study participants are reconsented prior to each follow-up 
data collection timepoint. 
  
Randomization Plan 
Families’ participation in the VUP and selection into cPW and ePW is determined by 
governmental policies and was not under the control of the research team. Lists of families 
participating in the VUP program were obtained from government staff in each district. 
 
Nonoverlapping, geographically defined clusters were created comprising at least 30 families 
participating in the cPW program or ten families participating in the ePW program, with some 
clusters containing both ≥30 cPW and ≥10 ePW households. Clusters were formed from one or 
more contiguous villages such that one CBV could provide services to all participating families 
in the cluster. Villages within the same cluster were selected to be as close to each other and as 
far apart from other clusters as possible. Due to the relative scarcity of the ePW families, 100% 
of clusters containing at least 10 ePW families were sampled for participation in the study. 
Clusters which contained cPW families (including combined clusters containing ePW families) 
were randomly sampled for inclusion into our study until we reached our target sample size of 
≥1,040 households. Randomization was performed by Laterite and occurred at the cluster level 
within strata defined by public works type (ePW only, combined ePW/cPW, and cPW only) and 

Sugira Muryango Study Protocol 
10 
geographic sector. Within strata, clusters were assigned random numbers and placed on a ranked 
list. The first half of clusters on the randomly ranked list were assigned to treatment. In case of 
an uneven number of clusters per strata, a lottery was used to round the number assigned to 
treatment up or down. After assignment of the cluster, households were contacted by the data 
collection contractor and invited to participate in the study. Clusters were retained if at least five 
families in the cPW strata or at least one family in the ePW strata enrolled and had at least one 
child aged 6–36 months. We retained 48 ePW-only clusters, 38 ePW/cPW clusters, and 112 
cPW-only clusters (Cluster sampling strategy, Figure 2).  
  
Neither the families nor the enumerators who conducted the assessments knew about a family’s 
assignment to treatment versus control before they had completed the baseline assessment. All 
caregivers gave written informed consent for themselves and their eligible children ages 6–36 
months. 
 
 

Sugira Muryango Study Protocol 
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cPW = expanded public works; cPW = classic public works; 1Clusters had to include 10 ePW households to be 
eligible as an ePW cluster; 2Cluster had to include  30 ePW households to be eligible as a cPW cluster;  
3Randomization within strata of Public Works x Sector did not necessarily guarantee even numbers in the treatment 
and control arms  
 
Figure 2. Cluster sampling strategy and flow Chart of Participants in the Sugira Muryango 
Open Trial.  
  
Note: Although each cluster had a 50% chance of being assigned to receive treatment, we were 
not guaranteed an equal number of treatment and control clusters because randomization 
occurred within relatively small strata that sometimes contained an odd number of clusters. 
  
Study Visits 
Data collection occurs at three timepoints referred to as baseline, midline (4 months post 
intervention) and endline (12 months after midline). All assessments are carried out in the homes 
of the families or at a central point in the village.  
 
At each time point, the caregiver who states that he or she knows the child best —most often the 
biological mother—provides reports on child development, health, feeding practices. This 
“primary caregiver” also participates in the assessment of caregiver-child interactions and 
provides information about the household including family composition, economic status, 
household assets, social protection, and finances. Both the primary caregiver, their intimate 
partner or other secondary caregivers living in the households (e.g. grandparents, adoptive 
parents, aunts and uncles) respond to a battery of questionnaires that cover aspects of caregiver 
mental health, trauma exposures, daily hardships, family functioning, decision making, alcohol 
consumption, and intimate partner violence. Measures were drawn from previous pilot and 
research studies in Rwanda (Betancourt et al. 2018) and followed a rigorous translation protocol, 
including forward- and back-translation from English to Kinyarwanda. 
 
The order in which the different surveys (The Report on the Child, the Caregiver Report on the 
Household, and the Caregiver Report on Self) are administered depends on whether the child is 
able to be assessed. If the child is present and awake, the Report on the Child is administered 
first, then the other surveys follow. If the child is asleep or not available, the enumerator starts 
with the caregiver surveys instead. Due to the sensitive nature of the intimate partner violence 
questions in the Caregiver Report on Self, this survey is conducted only by enumerators of the 
same gender as the respondent and in as private a location as possible. In the case that a survey is 
not completed during the first visit—because there is a mismatch in the genders of the 
enumerator and respondent, for example—an follow up appointment is communicated to the 
household immediately and an enumerator will return at the earliest opportunity.  
 

Sugira Muryango Study Protocol 
12 
Participants attend appointments for the child assessment on the Malawi Development 
Assessment Tool (MDAT) and anthropometric measurements at central location. A community 
health worker selects a safe place—such as an office, a church, or school—to serve as the data 
collection site. Participants are notified in advance regarding the location and timing of these 
assessments.  
 
Enumerator training for baseline data collection occurred from January 29, 2018 to February 9, 
2018. Training for surveys completed at the household included an overview of the study’s 
objectives and methodology, sampling and replacement strategies, research ethics, the field 
team’s responsibilities, adverse event reporting and the risk of harm protocol, and a thorough 
review of the survey instruments. A separate training occurred for those enumerators overseeing 
the MDAT and collection of Anthropometrics. After the training, an additional day of piloting all 
measures occurred in the field. A three-day refresher training occurred from April 18 to April 20, 
2018. Prior to collection of midline data, a refresher training was held between August 1 and 
August 8, 2018. As there were no major changes to household survey questions, no pilot was 
done in advance of midline data collection. A three-day refresher training was also held for the 
MDAT enumerators and a midline pilot of the MDAT occurred to test for interrater reliability. 
 
 
 
Key measures collected at baseline (wave 1), midline (wave 2) and endline (wave 3) 
 
Treatment status variable 
Household treatment status is considered the main predictor of all outcomes.  
 
Public Works program 
The household’s public work (VUP) status is considered an important design-variable.  
 
Child anthropometrics 
Children’s physical growth status is used as a proxy for their nutritional status and assessed using 
measures of standardized height-for-age (HAZ), standardized weight-for-age (WAZ), 
standardized weight-for-height (WHZ), and middle upper arm circumference (MUAC). Height is 
measured in centimeters to the nearest 0.1 cm. Weight is measured in kilograms to the nearest 1 
gram. Middle upper arm circumference is measured in centimeters to the nearest 0.1 cm. 
Standardization is done using software provided by the World Health Organization. Outcomes 
related to children’s HAZ, WAZ, WHZ and MUAC are treated as continuous. 
 
Malawi Developmental Assessment Tool 
Child development across domain of gross motor, fine motor, language and socio-emotional 
development is assessed using the Malawi Developmental Assessment Tool (MDAT) tool. 

Sugira Muryango Study Protocol 
13 
MDAT was developed for use in Malawi with the aim to develop a culturally appropriate tool for 
use in rural Africa (Gladstone et al. 2010). MDAT is an observational task-based assessment 
where a trained rater assesses the child’s ability to perform different tasks. The MDAT has been 
tested in several African countries where it has shown good reliability and validity. We calculate 
a standardized continuous score for each domain Fine motor, Gross motor, Language, and 
Socioemotional using standardizations provided by the MDAT team.  
 
Ages and Stages Questionnaire 
The Ages and Stages Questionnaire 3 (ASQ-3) uses a series of parent-completed questionnaires 
that are designed to screen the developmental performance of children in the areas of gross 
motor skills, fine motor skills, communication, and problem solving (Squires & Bricker, 2009). 
We administer the ASQ-3 through oral interviews with the caregiver who states that the know 
the child best (“the primary caregiver”). The ASQ-3 is scored using standard guidelines for 
standardization resulting in create binary outcome variables for each domain indicating whether 
or not the child showed “developmental delay” vs. “no developmental delay”.  
 
Violent disciple 
Children’s exposure to violent and nonviolent discipline was assessed using the MICS Child 
Development and Child Disciplinary modules. Exposure to violent disciplinary practices was 
defined as having experienced as a cumulative score of the number of forms of violent discipline  
 
Intimate Partner Violence  
Intimate partner violence among parents who are currently married, cohabitating, and/or in a 
relationship was assessed using an adapted and abbreviated version of the revised Conflict 
Tactics Scale (CTS-2: Strauss, 2004) previously used in Rwanda (Chaudhury et al. 2016). The 
CTS-2 assesses caregivers’ self-reported victimization and perpetration of emotional 
neglect/abuse, physical assault, and sexual assault. Given the short interval between the baseline 
and midline data collection, the scale was adapted so that caregivers report on events that 
occurred within the last three months and ever (as opposed to 12 months in the original scale). 
For events that had happened, caregivers further report on the frequency of that event using the 
following scale: 0=”not at all”; 1= “once:”; 2 =”Twice”; 3 = “3-5 times”; 4 = “6-10 times” ; 5 = 
“11-20 times”; 6 = “>20 times.” Overall, the same events are asked for victimization and 
perpetration with the exception that two additional sexual assault questions were asked about for 
victimization (detailed below). The following examples refer to victimization. After the 
questions about victimizations, caregivers were asked similar question for perpetration stated as 
“You [left you or forgot] your partner” etc. 
 
Two items assess emotional abuse or neglect: “Your partner used abusing language toward you” 
and “She/he left you or forgot you.” Seven items assess physical abuse : “She/he shoved you,” 

Sugira Muryango Study Protocol 
14 
“She/he grabbed you,” “She/he hit you,” “She/he used a knife or any other weapon,”  “She/he hit 
you with an object that could cause injuries,”  “She/he pushed you into a wall,”  “She/he kicked 
you.” Sexual abuse is assessed using three items for victimization: “She/he forced you have 
sexual intercourse when you didn’t want,”  “Have you ever had intercourse with him/her because 
you were afraid of what she/could do if you refused” and “Has he/she ever forced you to take 
part into sexual activities that you found shameful or disrespectful?” For perpetration only one 
item assessed sexual violence “You used forceful means to be able to have sexual intercourses 
with your partner.” In line with the recommendation for community samples we use a count of 
events as the outcome variable (Strauss, 2004). We counted only physical and sexual abuse 
events given the milder nature of the emotional abuse/neglect items. An alternative approach is 
to recode the frequency score of violent events in into midpoint scores as described by the 
creators of the CTS2. This, however, is not recommended since this score has been found to be 
extremely skewed (Strauss, 2004).  
  
Father engagement in childcare 
Father engagement in childcare is measured using the following item “Does the father of the 
child spends some time every day caring for the child?” which is reported by the primary 
caregiver of the child (usually the mother). The response is recorded as a binary “yes/no” 
outcome variable.  
 
Other procedures at Midline (4 months post-intervention) 
 
Qualitative Interviews 
A subsample of 40 caregivers who receive the intervention participate in qualitative interviews to 
assess their experience of the program using an IRB approved interview protocol. A subsample 
of N=40 CBVs participate in qualitative interviews to assess their experience of delivering the 
program. 
 
Quantitative data collection 
Post intervention, CBVs complete a fidelity, acceptability, and utility measure to gauge how 
effectively they felt the training prepared them to deliver the intervention, as well as how often 
they used the skills learned during their professional and personal life. This measure was 
adapted from Aarons, Ehrhard et al. (2015) to assess the implementation science behind 
training lay workers to deliver technical interventions. 
  
  
Quality Control 
 
Field Supervision  

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Throughout data collection, the field supervisor for the surveys at the household chooses one 
sub-team to accompany each day to confirm that interviews are conducted in the right 
households, protocols are followed, and ethical considerations are met. A chain of command 
allows enumerators to raise issues to the field coordinator, who then reports them immediately to 
the field supervisor, who communicates them to the data manager for the final decision.  
 
At the end of each day, the field supervisors update the log of surveys completed and issues to be 
cleaned in the data and compile a daily field report for the data manager. The teams for both the 
surveys at the household and the MDAT and anthropometric assessments also attend a daily 
debrief session led by the senior field supervisor and data manager. During the debrief, the team 
discusses issues from the day’s surveys, and the data manager provides solutions and 
communicates any changes in the survey. Before heading to the field each morning, the team 
meets with the data manager who updates the list of households with any replacements from the 
previous day, reviews the schedule, and addresses quality concerns from the data collected in the 
previous days.  
 
Real-time Completion Tracking  
Laterite uses SurveyCTO’s feature of real-time publishing of form submission data into Google 
Sheets to track the progress of data collection compared to the targets in the field plan. 
Dashboards are created to track the completion of the required surveys for each household 
(household completion status) and then the completion of surveys for all households in a cluster 
(cluster completion status.) The cluster completion status is shared with the Boston College team 
in real time, which allowed them to start the intervention in the households of completed clusters 
as soon as possible. The Google Sheets were also used to track replacements of caregivers and 
households and flag duplicate surveys.  
 
Routine Monitoring  
Laterite uses proprietary audit algorithms to review survey metadata to flag unusual submissions 
such as those with changes of location, early or late starting times, comparatively short or long 
durations, and simultaneous submissions. Concerning surveys are flagged to the Data Manager 
and Senior Field Supervisors for further investigation. In addition to the real-time monitoring 
using Google Sheets, Laterite routinely monitors the cleaned data for survey duplication, 
household and caregiver replacement, household dropout, child dropout and mortality, and 
household survey completion. Laterite reports this information to Boston College in the Weekly 
Data Collection Reports.  
 
Audio Audits  
Audio from a sample of all surveys conducted at the household are automatically recorded using 
the in-built recording feature of SurveyCTO. The questions that triggered the audit are pre-
selected and recordings are reviewed to assess whether (i) the interviews actually took place; (ii) 

Sugira Muryango Study Protocol 
16 
enumerators are following proper interview procedures such as: explaining confidentiality and 
sticking to the script while asking sensitive questions; (iii) enumerators are asking questions with 
a respectful tone and without pushing the respondent or leading them towards a certain response; 
and (iv) explaining to the respondents that they could opt out of taking part (or answering 
questions in some parts of) in the survey. A random sample of 5% of all surveys are recorded for 
each question.  
 
No audio audits are set for the MDAT and anthropometrics surveys since the proper 
administration of these assessments relies less on enumerator-participant dialogue. These surveys 
are instead administered under supervised conditions and enumerator behavior is closely 
monitored.  
 
Throughout data collection, Kinyarwanda-speaking data auditors review the audio recordings to 
confirm that there is dialogue between the enumerator and the respondents (i.e., that responses 
are not entered without actually asking the questions) and that enumerators are following proper 
interview procedures like explaining confidentiality and ensuring privacy for sensitive questions 
and asking questions in a respectful tone without pushing the respondent or leading them toward 
a certain response. Issues identified by the auditors are recorded and relayed to the data manager 
for proper follow-up and resolution with the field supervisors.  
  
C. Data Management 
  
Data Collection 
Questionnaires and child assessments are administered verbally in Kinyarwanda. Data are 
entered into SurveyCTO directly on Android tablets by trained independent local enumerators 
blinded to intervention status. Once the data are initially processed and de-identified, they are 
uploaded to a secure, password-protected Box folder. The data are further backed up to a secure 
server at Boston College.  
   
Database 
Data collection includes the collection of quantitative data regarding intervention effectiveness, 
dissemination and implementation (D&I) data regarding key domains of implementation science 
(e.g. acceptability, appropriateness, feasibility), qualitative data via face-to-face key informant 
interviews, and fidelity data collected throughout intervention delivery.  
 
Quantitative study data and D&I survey data are collected using SurveyCTO, a secure mobile 
data collection platform that can be used offline. The SurveyCTO mobile application, referred to 
as SurveyCTO Collect, allows an enumerator to collect participant data using a password 
protected mobile phone or tablet, which is then uploaded to the secure SurveyCTO server. 
SurveyCTO has a built-in data monitoring and visualization tool that allows Field Coordinators 

Sugira Muryango Study Protocol 
17 
and Field Supervisors, who are based in the field during data collection, to monitor the uploading 
of study data as well as any inconsistencies in the data. Data will be regularly uploaded from 
tablets to the password protected SurveyCTO cloud-based server. Whenever form data is 
transmitted via a 3G or other internet network, it is encrypted in transit.  
 
Qualitative key informant interviews are collected from primary caregivers (SM beneficiaries), 
CBVs, local and national government officials and other ECD and nutrition stakeholders such as 
International and local nonprofit organization and and international funding agencies. The aim of 
these interviews is to identify best practices and quality of early childhood and nutrition services 
delivery in Rwanda. A semi-structured interview guide is used to guide the qualitative 
interviews.  
  
D. Data Analysis 
 
Primary Outcomes 
 
See Measures section for detailed information about the variables.  
         
The table below outlines study primary predictors, control variables and moderators (possibly 
mediators if relevant). 
 
 
Questionnaire / Scale 
PRIMARY PREDICTOR VARIABLES 
 
Treatment status [Treatment vs. Not] 
 
OTHER PREDICTOR VARIABLES [design variables] 
 
Cluster 
 
VUP-status [classic public works vs. expanded public works] 
Government records 
OUTCOME VARIABLES 
 
Malawi Developmental Assessment Tool (MDAT) 
 
Gross motor [standardized score] 
MDAT 
Fine motor [standardized score] 
MDAT 
Language [standardized score] 
MDAT 
Social [standardized score] 
MDAT 
Ages and Stages Questionnaire (ASQ-3) 
 
Gross motor [delayed/not delayed] 
ASQ-3 
Fine motor [delayed/not delayed] 
ASQ-3 
Communication [delayed/not delayed] 
ASQ-3 

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Personal social [delayed/not delayed] 
ASQ-3 
Problem solving [delayed/not delayed] 
ASQ-3 
Anthropometrics 
 
Height-for-age (HAZ) 
Anthropometrics 
Weight-for-age (WAZ) 
Anthropometrics 
Weight-for-height (WHZ) 
Anthropometrics 
Middle upper arm circumference (MUAC) 
Anthropometrics 
"Father engagement " 
 
" father spends time every day caring for the child" 
HOME 
Family Violence 
 
Violent discipline [cumulative score, 0-7] 
MICS-5 Hash discipline module 
Intimate partner violence 
 
Victimization physical and sexual abuse past 3 months  
[cumulative score 0-7]* 
Conflict Tactics Scale- CTS2 
Perpetration physical and sexual abuse past 3 months  
[cumulative score 0-7]** 
Conflict Tactics Scale- CTS2 
*Among cohabitating or married mothers only 
**Among cohabitating or married fathers only 
***Among cohabitating or married caregivers only 
 
Table 2. Study predictor and outcome variables.  
 
Data Analysis Plan  
 
Standard descriptive statistics will be used to describe the study sample. Frequencies and 
percentages will be reported for categorical variables and mean, median, standard deviation, 
interquartile range, maximum and minimum values will be reported for continuous variables. 
Anthropometric data will be cleaned for extreme out-of-range values. Scales will be created from 
individual items according to scoring instructions for each scale. All scales will be evaluated for 
psychometric properties. Visual inspection of histograms and other plots will be used to identify 
outliers.    
 
Continuous Outcomes MDAT, WAZ, MUAC, WHZ: The goal is to determine the efficacy of SM 
at 12 months from study initiation. Measurements of all outcome variables (see Table 2 and 
Section B), are taken at baseline, midline (4 months post baseline), and endline (12 months post 
midline). Subjects are randomized (Section B) into a treatment group (SM) and CG. 
Effectiveness will be determined if the slope of the response variable for the SM group is 
significantly different than the slope of the CG group. To test this hypothesis, we will fit a linear 

Sugira Muryango Study Protocol 
19 
mixed effect model with a MDAT subscale, for example, as the response variable and the 
primary predictors are treatment group (SM vs CG), time and their two-way interaction included 
as fixed effects. Mixed effect models also known as hierarchical linear models (HLM) or multi-
=level models are a flexible tool for analyzing associations and changes over time in longitudinal 
studies when there are clusters of correlated data in the outcome variable. This design has three 
levels of nesting, families are measured within measurement waves, and measurement waves are 
nested within randomization cluster or region. Since, we expect region and time level effects 
subject-specific slopes and intercepts will be modeled as random effects nested within 
randomization cluster also modeled as a random effect. Additionally, there may be due to VUP 
program (recall we stratify the randomization of clusters within public works cluster). Type of 
VUP program will be model as a fixed effect. A mathematical representation of this model is:  
 
  Yijkm = B0 + b0i + B1*TreatmentGroup + B2*Time +  b1i*Time +  B3*Time*Treatment 
group  + b2k + b3k*time + B4m*PubicWorksGroup + e 
 
Where, Yijkm represents the value of the  ith family (i = 1  . . . I), at the jth time point (j=1, . . . 3), 
in the kth cluster (k = 1,  . . 200) and m is the VUP indicator with levels expanded public works, 
classic public works and mixed. The set of b0i variables represent subject-specific intercepts and 
are assumed b0i ~ N(0, σI). The bi1 are subject specific slopes and assumed b1i ~ N(0, σslopes), the 
b2k are randomization cluster intercepts and assumed b2k ~ N(0, σregion) and the b3k ~are region 
specific slopes and assumed b3k ~ N(0, σsregion). The value e represents residual variation and is 
assumed e ~ N(0,σ). Efficacy will be based on the likelihood ratio test for inclusion of the 
Time*Treatment interaction (null hypothesis B3 = 0). Random effects will be subject to a limited 
amount of model building as we would like to simplify the model where appropriate. For 
example, we would want to test if we can assume a common cluster slope versus a unique slope 
for each cluster. Cluster and subject-specific effects will be dropped from the model based on a 
Likelihood Ratio Test (LRT) for their inclusion. The estimation procedure while model building 
random effects will be Restricted Maximum Likelihood (REML). The primary hypothesis test 
which is based on the inclusion of a fixed effect will require models estimated by maximum 
likelihood. Because of randomization we have controlled in theory for all variables observed and 
unobserved, however treatment group imbalance may still be present. We explore treatment 
group characteristics for in-balance. However, previous work has showed baseline differences to 
be minimal.  
 
Model assumptions and alternative tactics:  Model assumptions will be verified. In particular we 
will examine the distributions of the residuals to verify that normality assumptions hold. 
Residual plots will reveal violations of the normality assumptions. Panel plots will be examined 
to look at functional shape assumptions within subject. In the case of non-normality of outcomes, 
we will consider response transformations or the use of models that do not require the normality 
assumptions including the class of generalized linear mixed effect models. If the linearity 

Sugira Muryango Study Protocol 
20 
assumption does not hold across time (baseline, 3 months, and 12 months) we can treat time as a 
categorical variable to examine differences between the treatment groups at individual time 
points focusing on the 12-month group differences adjusted for baseline. If examination of panel 
plots reveals a large amount of heterogeneity among trajectories of the outcomes by subjects we 
can use Growth Mixture Models which first identify clusters of similar trajectories from which 
we can test for treatment group differences in terms of membership in the clusters of similar 
trajectories.  
 
Outliers will be flagged through visual inspection and standardized residual values greater than 
3. A sensitivity analysis will be done to determine if outlier removal changes the coefficient 
values. If we find that outliers are having an oversized effect on the estimated coefficient values 
we will give preference to the models where the outliers are removed. However, we will present 
both results.  
 
Some responses are scales or derivations of scales in particular the MDAT and the ASQ. We will 
examine the psychometric performance of these scales. We are especially concerned with 
internal consistency and item reliability. If these scales do not show at a minimal amount of 
internal consistency (Cronbach’s Alpha > 0.6) these items will not be considered for analysis. If 
particular items are an issue they may be dropped from the scale. Research, in areas like Rwanda 
suffer because standard scales have not been validated on these populations.  
 
Binary Outcome ASQ, shared decision making, father engagement: The analysis for these 
outcomes will be similar to the analyses above with accommodations being made for the fact the 
ASQ is a binary outcome. In particular, we will have to make use of mixed effect logistic 
regression models a form of generalized linear mixed models (GLMM) with a binomial 
distribution and a logistic link. Outside of accounting for the correct distribution of the response 
variable the analysis will follow the methods outlined in the previous MDAT section.  
 
Model Assumptions and Alternative Tactics: We will examine Pearson residuals to assess 
goodness of fit. Alternative methods include the use of quasi-binomial mixed effects regression 
(in the case of over dispersion). However, such models do not have a full likelihood and instead 
of LRT test we will have to rely on the Wald-type type test for regression coefficients.  
 
In fitting logistic mixed effect regression models, it is possible that we may run into numerical 
difficulties in computing a likelihood ratio test, so score type tests may be needed. This is more 
likely to occur in the case of testing for variance components.  
 
Count Outcomes, harsh discipline, physical and sexual violence: These metrics count types of 
harsh discipline action or physical and sexual abuse as suffered or inflicted. Our experience with 
these scales is that there are more values of zero than what would be predicted by a standard 

Sugira Muryango Study Protocol 
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Poisson distribution. Our analysis will make use of Zero Inflated Poisson (ZIP) models (Everitt, 
& Hothorn, 2005; Long, 1997). These models belong to the more general class of mixture models. 
In particular they model the binomial probability of a count of zero versus a count greater than 
zero and the Poisson probability for counts greater than zero. In particular we will fit mixed 
effect models as described in the continuous variable sections but under the ZIP distribution 
assumption.  
 
A key difference between a mixture model and more standard probability distributions is the 
fixed effects structure and tests for significance can vary between the two parts (binomial and 
Poisson). Likelihood ratio testing for the Time*Treatment group interaction will be performed 
for both components of the mixture model. A significant result of the LRT test for the binomial 
portion would indicate that the probability of no violence (inflicted or suffered) differed between 
the treatment groups. A significant result of the LRT on the Poisson portion of the ZIP model 
would indicate that among those who inflicted or suffered harsh discipline or violence the mean 
amount of violence differed between the treatment groups. The two portions are contained in a 
single likelihood function and parameter estimation is done simultaneously.  
 
Model Assumptions and Alternative Tactics: The key assumption in these models is the ZIP 
distribution of the response variables. We will visually inspect the distribution of the outcome 
variables to verify that we are fitting the correct model. Alternative distributions could be 
Poisson, Quasi-Poisson, Binomial (data dichotomized due to lack of variability), or Negative 
Binomial. These are non-mixture models and modeling will follow the process outlined in the 
continuous outcomes section.  
 
Secondary Outcomes: Stunting measured by Height-for-Age is an important outcome. However, 
we do not expect to see significant changes in this variable in the 12-month timespan. We do 
expect to see a reduction in stunting even if it does not achieve statistical significance. Using the 
models described in data analysis plan we can extract the coefficient for the time by treatment 
group interaction as an estimate of the size of the effect of SM on stunting. Effect sizes of other 
secondary outcomes will be reported similarly.  
   
Missing Data   
We will apply the ITT principle to all of our analyses. Unless a subject dies, the ITT convention 
is to keep them in the study; HLM handles this well since the linearity assumption allows us to 
estimate subject-specific parameters so long as we have at least two data points. The method of 
mitigating bias due to missingness known as full-information maximum likelihood estimation 
(FIMLE) can be problematic in mixed effects linear models. Principled methods of multiple 
imputation such as chained equations will be employed. 
 
Power and Sample Size   

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Assuming the linear mixed effect model described above. The following values were used to 
calculate statistical power. We assumed a total of 200 clusters with 5 families per cluster. We 
assume a linear relationship over time. The significance level is set at 0.05. The statistical test 
was the likelihood ratio test for the inclusion of the time by treatment group interaction. The ICC 
was set at 0.10. A variable for public works type which was categorical with 3 levels was 
included in the model. Within public works type a ratio 1:1:2 for expanded:both:classic was 
assumed. Variability was set to one so that effect sizes may interpreted as “Cohen-Like” effect 
sizes. We found that we have at least 90% power to detect an effect size of 0.25 and at least 80% 
power to detect an effect size of 0.22. GLIMMPSE software was used for these calculations. 
 
E. Safety & Adverse Events 
 
Risks to Subjects 
 
The following risks were identified and submitted to the Boston College IRB:  
1. Participation in the intervention may lead adults to confront stressful personal or family 
issues or generate concern about social harm resulting from loss of confidentiality, which 
may elicit distress in some participants.  
2. In some cases, fatigue from the psychosocial assessment administered pre/post-
intervention and at 12-months follow-up may occur.  
3. There is a small risk of loss of confidentiality. 
4. Participation in the intervention may create issues within the community if a household 
receiving the SM intervention is viewed as receiving additional services or monetary 
support.  
 
We consider most risks associated with participation in the study to be unlikely. Two previous 
pilots of SM have been carried out with vulnerable families in Rwanda. Previous study iterations 
have demonstrated that processes related to confidentiality are upheld throughout the entire 
study. Further, no participants have indicated distress or fatigue with the assessments. Weekly 
field reports from the Laterite enumerators have not indicated any issue with the assessments, 
length of time to administer, issues with confidentiality, or distress caused. 
 
There are other risks we consider to be likely: intimate partner violence in the home and tensions 
with neighbors due to participation in the intervention. The CBVs have received comprehensive 
training on recognizing intimate partner violence in the home as well as how to 
activate our risk of harm protocol to ensure we assess the harm and make the necessary referrals. 
The other risk related to community tensions due to participation have resulted in several study 
changes. First, in the event that an issue arises with a neighbor, the CBV immediately alerts their 
supervisor and the village leader or elder to better understand the source of the issue. During this 
time, the intervention is paused. The family is then given the option to conduct the intervention 

Sugira Muryango Study Protocol 
23 
offsite at the local government offices at the cell level. As a preemptive measure, all supervisors 
have traveled to the field to meet with the village leader and Cell official to further communicate 
the SM as a coaching intervention and not an intervention where goods or money 
are provided to families. 
 
 
Monitoring 
A Risk of Harm decision tree, along with flagged questions from the assessment battery, 
provides a structured protocol for monitoring and responding to adverse effects on participants. 
Interventionist supervisors have daily phone check-ins with the interventionists as well as weekly 
face-to-face meetings. These check-ins provide an opportunity for monitoring families in the 
study and ensuring all study risks are addressed appropriately. Further, these check-ins allow the 
supervisor to anticipate any potential risks and work with the interventionist to initiate support or 
a referral to mitigate any potential risks. 
 
Stopping Procedures if relevant. 
The intervention will be paused or stopped if a participant is experiencing active psychosis or is 
experiencing harm as a result of participation in the intervention. While these instances are 
expected to be rare, formal procedures are in place. If an adverse event or risk of harm is 
detected, a study supervisor works with the CBV to collect as much information on the issue, and 
then conducts an in-person assessment of the situation. Depending on the case, this assessment 
may include discussion with local CHWs and village leaders to gain further information about 
the participant or family.  
 
F. Study Limitations 
 
A primary study limitation is the reliance on caregiver-reported measures, which could suffer 
from differential bias because parents who are exposed to the intervention may be more 
knowledgeable about or more pressured to provide a socially desirable answer. However, the 
quality monitoring approaches utilized by study enumerators (described in detail above) provide 
important checks for ensuring the data are collected as intended and that enumerators are not 
engaging in any sort of behaviors to coerce specific answers from caregivers. A second study 
limitation regards the reliance on western created measures to assess primary and secondary 
study outcomes. Extensive work was done to refine and adapt measures to fit the Rwandan 
context with assessment questions forward and back translated into Kinyarwanda following best 
practices (Van Ommeren et al., 1999) though two pilot studies (Betancourt et al. 2017 and other 
forth coming manuscripts). Further, psychometric analysis of study measures assessing primary 
and secondary study outcomes indicate strong reliability and validity.  
 
 

Sugira Muryango Study Protocol 
24 
G. Compensation 
 
Incentivization of CBVs 
CBVs receive several types of incentives given their role in delivering SM. The incentive rate 
was established based on learning from what other similar programs require for a volunteer 
coach as well as considerations regarding the CBV scope of work. Calculated at a per household 
rate, CBVs will receive 1,200 Rwandan Francs each week per household in their caseload to 
cover cell phone airtime, transportation, and the family visit. CBVs also receive 2,000 Rwandan 
Francs to cover transportation for weekly peer support groups over the course of 12 weeks. To 
cover their participation in a three-week intensive training, CBVs receive an additional 75,000 
Rwandan Francs. Non-monetary incentives include an umbrella, branded t-shirt, mobile phone, 
lockbox for sensitive materials (intervention manual, intervention workbook, notes from 
supervision), rain boots, a branded bag, a branded identification badge, and materials needed to 
deliver the intervention.  
 
Incentivization of Household Beneficiaries 
Household beneficiaries will receive 5000 Rwandan Francs for each timepoint of data collection 
(baseline, post-intervention, and 12-months follow-up). Households selected to participate in 
qualitative interviews will receive an additional 3000 Rwandan Francs for each qualitative 
interview. Households selected to participate in the D&I measures will receive an additional 
3000 Rwandan Francs for each time point (pre- and post-intervention). Families are reimbursed 
in cash once they have completed the assessment or interview. 
 
H. Provisions for vulnerable subjects 
 
All household beneficiaries in the study have an Ubudehe 1 poverty categorization. As such, all 
study procedures are created and implemented with provisions for vulnerable participants. 
Specifically, risk of harm/adverse event procedures are in place to identify any risk of harm 
situations related or not related to participation in the study. Further, funds are available if any 
participant requires a referral or transfer to a higher level of care, such as transport to and 
treatment at a district hospital, for example.  
 
I. Data archiving and dissemination 
 
Results from the trial will be published in peer-reviewed journal articles and presented at high 
level conferences. A formal dissemination event involving study funders and stakeholders will 
be held in Kigali, Rwanda. Study quantitative data will also be uploaded to the World Bank 
Microdata Catalog as part of study funding deliverables.  
 
 

Sugira Muryango Study Protocol 
25 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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