Reintegration of Children Into Family-based Care in Uganda
Condition: Parenting
Study type: Interventional

Summary: 
      The proposed study will be an individually randomized controlled trial with children (age 1
      to 13 years at the time of screening for inclusion in the study) living in residential care,
      reintegrated back into family-based care, in Uganda. It is designed to evaluate the impact of
      adding a household-based parenting program to a standardized reintegration package that
      includes individualized case management support and a reunification cash grant, aimed at
      improving the reintegration of children living in residential care back into family-based
      care. The study population will include children living in residential care facilities (RCFs)
      in Mpigi, Mukono, Masaka and Greater Masaka districts in Uganda.

      Study participants will be randomized to one of two arms of the study: the comparison arm and
      the intervention arm. The target sample size is 640 children with 320 in each arm of the
      study. Children assigned to the comparison arm will receive a standard reintegration package
      that includes individualized case management support and a reunification cash grant. Those in
      the intervention arm will receive the enhanced reintegration package that includes
      individualized case management support, reunification cash grant and a parenting
      intervention. Data will be collected at baseline (while the child is still living in the
      RCF), 6 months post-placement and 12 months post-placement.

      Data will be collected in the local language by a project trained local data collection
      partner on the following six domains of reintegration: Child health and development,
      Psychosocial health and wellbeing of the child and primary caregiver, Protection and safety
      of the child, Caregiver-child relationship, Child's and caregiver's sense of social and
      community belonging, Education access, quality, and achievement (where age-appropriate).

      The sources of data are a) interviews with primary caregiver, b) interviews with RCF
      caregiver, c) interviews with older children (8-13 years of age), d) standardized assessments
      of child cognitive functioning for all the study children, and e) focus groups and interviews
      with participants, parenting facilitators, and case managers.
    

Detailed description: 
      Background:

      There is an expanding global evidence base that illustrates the negative effects of placement
      in residential care on the physical, cognitive and socioemotional development of children
      (Smyke, 2007). Based on this evidence, legal and policy frameworks and programming have
      focused on reducing reliance on residential care and strengthening family-based environments
      for children (United Nations General Assembly, 2009). Recent care reform initiatives in
      Uganda promote the reunification and reintegration of children living in RCFs back into
      family-based care. Reintegration encompasses more than just the relocation of separated
      children into family-based care; it includes multiple dimensions of children's and families'
      wellbeing over time.

      Uganda's population is young and vulnerable, with as many as 80 to 90 percent of children
      living in RCFs have at least one living parent (Rotabi, 2016). In Uganda, a study by
      Walakira, Ddumba-Nyanzi, & Bukenya (2015) found that more than two-thirds of the children
      living in 28 RCFs had at least one living parent and many more had a contactable relative.
      Children enter residential care for a variety of reasons and while poverty is often a driving
      factor, other factors such as inadequate access to quality education, health care, or social
      services, disability, child behavior problems, parental alcohol or drug abuse and death of
      one or more caregiver, may also be contributing or precipitating factors.

      There have been several studies that have shown beneficial effects of parenting interventions
      on child cognitive outcomes in Uganda (e.g., Boivin et al., 2013). A recent systematic review
      of 12 randomized controlled trials (RCT) examining parenting inventions in low and middle
      income countries found evidence that parenting interventions positively affected a range of
      outcomes, including parent-child interactions, parental knowledge and attitudes, and reduced
      self-reported harsh or abusive parenting. The authors concluded that parenting interventions
      "hold some promise for improving parenting practices and reducing risk factors for child
      maltreatment in low and middle-income countries" (Knerr et al., 2013).

      Study Rationale:

      While there is a growing interest and emphasis in finding ways to transition children from
      residential care to family-based care, there is very little rigorous evidence that identifies
      specific interventions that help to facilitate this process, especially within sub-Saharan
      Africa. The proposed study aims to contribute to the evidence base by determining whether
      provision of a household-based parenting program contributes to reintegration success in
      Uganda. The six 'domains' of reintegration success are based on the following outcomes:

        1. Child Health and Development Child

           a. Child anthropometry including height, weight, BMI; access to food and health care;
           child cognitive development; protective factors and resilience (only for older children)

        2. Psychosocial Health and Wellbeing:

             1. Child internalizing and externalizing behaviors; self-esteem (only for older
                children); child depressive symptoms (only for older children);

             2. Caregiver's self-esteem; symptoms of mental disorders; quality of marriage;
                parental stress; loneliness

        3. Child Protection and Safety

             1. Child attitudes towards physical punishment (only for older children); experiences
                of physical, emotional, sexual abuse, and neglect (only for older children)

             2. Caregiver attitudes towards physical punishment; experiences of physical,
                emotional, sexual abuse, and neglect

        4. Caregiver-Child Relationship

           a. Caregiver's involvement, monitoring and supervision of the child; caregiver's
           parenting behaviors; disturbances in attachment in young children; parent-child activity
           scale

        5. Social and Community Belonging

             1. Child's social support (only for older children); sense of community belonging
                (only for older children)

             2. Caregiver's social support; sense of community belonging

        6. Education Access, Quality, and Achievement

             1. Child's school enrollment, attendance, progression, and grades (if feasible);

             2. Child's satisfaction and happiness with school (only for older children

      Study Partners:

      The study is part of the Coordinating Comprehensive Care for Children (4Children), which is a
      five-year United States Agency for International Development (USAID)-funded consortium of
      organizations led by Catholic Relief Services (CRS) with partners IntraHealth, Maestral,
      Pact, Plan International, and Westat. 4Children is designed to improve health and wellbeing
      outcomes for orphans and vulnerable children (OVC). 4Children's Keeping Children in Healthy
      and Protective Families (KCHPF) project is supported by the Displaced Children and Orphans
      Fund (DCOF). It focuses on strengthening family care among households where there is a high
      risk of child separation, or where children can be reintegrated into family-based care after
      having been placed in residential care. Westat is leading the data collection effort, in
      close collaboration with our partner, the Department of Social Work and Social Administration
      at Makerere University, which will serve as the local research partner. Westat also lead
      protocol development and will be responsible for sampling, data management, data analysis,
      and preparation of the final report and publication. The study protocol was approved by
      Mildmay, on May 17th, 2017.

      Site Selection:

      All RCFs known to district authorities in the districts of Greater Masaka, Mpigi, and Mukono
      were evaluated for inclusion in the study. These three districts were selected for the study
      given their proximity to Kampala and the fact that these districts do not have currently
      active, externally-funded family reintegration programs. Additionally, the Ministry of
      Gender, Labor and Social Development (MGLSD) and the authorities in these districts
      (including the Probation and Social Welfare Officers [PSWOs]) have indicated their support of
      the KCHPF project.

      Enrollment Procedures:

      A team of case managers affiliated with the KCHPF project will review the child records at
      each of the participating RCFs and complete bio-data forms on all of the children. This form
      will include information on the child's background, identity of the child's birth family or
      next of kin, as well as the family's location, circumstances and ability to be reunified with
      the child. Using this information, the case managers will conduct a rapid assessment that
      will allow KCHPF team to determine which children are potentially eligible for inclusion,
      pending further follow up with and assessment of the family. The information, aggregated over
      the RCFs, will be sent to Westat to help plan sample selection and randomization. Case
      managers will conduct family tracing efforts on potentially eligible children to assess the
      family's capacity and suitability for reunification. Those who meet the eligibility criteria
      and agree to being reunified by the KCHPF project will be included in the sampling frame.

      All enrolled child-caregiver pairs will be randomized to the comparison or intervention arms
      of the study. The components of the reintegration packages provided in each arms are
      described below.

      'Esanyu Mu Maka' will be delivered on a household level. The primary caregiver will be
      required to attend all sessions. In addition, all adults who participate in caring for the
      reintegrated child and ensuring her/his wellbeing will be invited to participate in the
      program. This will include neighbors if the neighbors also share in the caregiving of the
      child. Each visit will be about an hour long and will be participatory with discussions
      regarding home practice activities during the previous week, working through illustrated
      stories together, role-playing new parenting skills, and assignment of home practice for the
      following session. Caregiver and family participation in the parenting sessions will be
      documented in the parenting M&E system and may be used in the analysis. The 'Esanyu Mu Maka'
      curriculum will cover the list of topic shown below. However, given the broad age range of
      children being reintegrated (1 to 13 years), the curriculum will be customized to address the
      specific needs of caregivers of children 1 to 3 years, 4 to 7 years, and 8 to 13 years.

      The qualitative data component will provide additional contextual data on the satisfaction
      and feasibility of the intervention components for children and caregivers as well as the
      program implementers (parenting facilitators and case managers), and the effect of the
      individual intervention components on the reintegration process from the perspectives of the
      target audience and implementers. These data will also help provide insight into local values
      or concepts, barriers and facilitators to implementing what was learned in the parenting
      program, and an understanding of the elements that participants value in terms of
      reintegration. Data will be collected from focus groups and child-friendly individual
      activity-based approaches with reunified children from both comparison and intervention arms.

      Data Management: Quantitative data will be collected by trained interviewers on Google Nexus
      tablets using Open Data Kit (ODK) software. Tablets will be password protected with encrypted
      hard drives. At the end of each data collection day, the data on each tablet will be
      transferred to Westat via a secure file transfer protocol (FTP).

      Data Analysis A primary objective of the study is to determine whether there is an
      association between the parenting intervention and the six domains of reintegration among
      reunified children and their caregivers. The outcomes across the six outcome domains of
      reintegration will be summarized using mean, median, and standard deviation for continuous
      measures, and frequency and percentage for categorical measures, both within and across the
      two groups. The investigators will then conduct Analysis of Variance (ANOVA) to examine
      effects of participation in the parenting program on the outcome variables. In addition,
      based on preliminary analysis, the investigators may select covariates, and conduct Analysis
      of Covariance (ANCOVA). For outcome variables that are categorical, Chi-square tests will be
      conducted. To examine the changes over time within and across the groups, the investigators
      plan to conduct Generalized Linear Mixed Models (GLMM) with repeated measures at multiple
      time points.

      For the main analysis to assess whether participation in a household-based parenting program
      results in higher rates of reintegration, the investigators will consider several options for
      the main analysis. One possibility will be to develop a scale using factor analysis to
      analyze the various domains that constitute reintegration. Exploratory Factor Analysis (EFA)
      will help us identify items that measure reintegration success conceptually, and have strong
      contributions to specific constructs. The investigators will use information based on EFA as
      well as the known conceptual framework for these domains to decide the number of factors and
      items in each factor. Confirmatory Factor Analysis (CFA) will then be performed to validate
      the factor structure developed based on findings from the EFA. Another possibility will be to
      conduct multivariate GLMM to form composites of the outcome variables that can be analyzed
      together. That is, variables within each dimension and across the dimension can be
      conceptualized, categorized and then entered as dependent variables in the multivariate GLMM
      analysis to examine the effect of the intervention on outcomes over time. The investigators
      will also use GLMM to examine whether the improvement in outcomes over time in the
      intervention group are significantly greater than the improvement in outcomes in the
      comparison group.
    

Intervention name(s): Standardized reintegration package; Enhanced reintegration package
Intervention type(s): Behavioral; Behavioral
Intervention description(s): Participants assigned to this comparison arm will receive a standardized reintegration package that includes individualized case management support and a reunification cash grant Individualized case management will consist of a caseworker-developed individualized care plan with routine caseworker visits at the household level. Home visitation will begin during the family assessment and preparation stages and continue throughout the 15-month post-reunification follow-up period. For the cash grant, the family of each enrolled child will receive a reunification cash grant in the Ugandan Shilling equivalent of $125, administered in two equal disbursements. It is designed to offset the cost of child care.; Participants assigned to this arm will receive an enhanced reintegration package that consists of the parenting program, individualized case management, and the reunification grant. will be delivered at the household level by project trained parenting facilitators. The program will consist of approximately 13 bi-weekly sessions, which will be delivered over the course of 7 months. The individualized case management and the reunification grant will be similar to those in the comparison arm.
Other intervention name(s): 'Esanyu Mu Maka' or Happiness in the Home
Allocation: Randomized
Intervention model: Parallel Assignment
Intervention model description: Participants are assigned to either of the two arms in parallel for the duration of the study
Masking: Single (Outcomes Assessor)
Primary purpose: Prevention
Keywords: reintegration, reunification, child development