The effect of nurturing care interventions on early child development and care: findings from a quasi-experimental study in a humanitarian setting

doi:10.21203/rs.3.rs-2718092/v1

Background

The objective of the study to determine if a nurturing care parenting programme delivered in a humanitarian setting in Rwanda to determine would benefit early development, learning and care outcomes for young children under 5 years and their caregivers compared to standard care.

Methodology

The parenting programme was implemented in Rwanda’s Mugombwa, Kansi and Kigeme refugee camp and host communities. Via a quasi-experimental research design, the study assessed the effects of intervention delivered as high dose (HD: 12 group sessions and 4 home visits) or low dose (LD: 6 group sessions and 2 home visits) on child and caregiver outcomes compared to the control group from similar settings receiving standard care. Child development outcomes were assessed using the Ages and Stages Questionnaires (ASQ). Parenting practices with respect to early learning and stimulation were assessed using standard questionnaires.

Findings

A total of 733 children and families were assessed: HD = 314, LD = 240, control = 179. No significant difference on child development scores between intervention and control groups was found. Caregivers exposed to HD and LD packages had significantly higher scores on early learning and stimulation practices compared to the control group respectively with 211(67.2%), 148 (61.7%) vs. 66 (36.9%), p < .001 caregivers engaged in 4 or more activities in the past 3 days. Similarly on responsive feeding items, a higher percentage of HD and LD group caregivers were engaged in positive behaviours compared to control group: 164 (52.2%), 108 (45%) vs 62 (34.6%), p = 0.001. No differences were found in the study arms in regard to caregiver mental health.

Conclusion

Parenting programmes in humanitarian settings can positively impact on nurturing care practices, even with a low dose, which are essential to strengthening children’s resilience living in at-risk conditions such as refugee settings. Further studies in such context are essential to strengthen the proof of concept from the study findings.

The first five years of life are the most important in terms of long-term learning, health and development, as brain growth peaks during this time. These years are critical for child children’s future health, long-term learning and behavior (Daelmans et al., 2017). Both negative and positive experiences in early years affect the brain pathways for cognition, self-esteem, emotional regulation, impulse control and planning abilities (Black et al., 2017). Many global health and social issues, such as mental illness, stunting/ obesity, heart disease, criminality, substance abuse, have their roots in early childhood (Liming & Grube, 2018; McKelvey et al., 2018). Adverse experiences also include forced migration and emergency due to disasters, war or conflict, with the potential of putting a generation at risk (Shah & Lombardy, 2021). Early life experiences, such as interaction with parents/caregivers, health and nutrition, and a loving, stable, low- stress and safe environment play a critical role in determining the capacity of baby’s brain development and learning. Such positive experiences lay a foundation for a baby’s future as a healthy, productive, well rounded adult. As baby’s first teachers, first nurturers and first protectors, the role of baby’s primary caregivers in creating a positive environment for baby’s growth and development is extremely important (Harvard, 2009, Britto et al., 2017). While nutrition and health care are vital, children also need a caring, responsive and protective environment to ensure they develop to their full potential. Building parents’ and caregivers’ confidence and capacity to raise happy, healthy children is the key to holistic child development (Irwin, Siddiqi, & Hertzman, 2007).

Globally, the number of children living in in conflicts and war zones is increasing. There are around 70.8 million forcibly displaced people worldwide, of which 25.9 million are refugees, 41.3 million are internally displaced, 3.5 million are asylum seekers, and children make almost 50% of the total affected population (UNHCR 2018). According to UNICEF, 29 million babies were born in crisis settings in 2018, (UNICEF 2019). In emergency response, ECD is the least prioritized area. Very little or no funding is allocated for child under five ECD. ECD was not considered in 60% of active humanitarian response (Theirworld, 2016).

Launched in 2018, the early childhood interventions such as early learning, responsive caregiving, safety and security, together with health and nutrition, came under nurturing care framework (NCF) to promote a holistic child development (WHO, UNICEF & World Bank, 2019). Especially in humanitarian contexts where children are exposed to multiple risk factors, early childhood interventions can act as a buffer against those (Murphy, Yoshikawa, Wuermli, 2018). Parents, primary caregivers have been recognized with a central role in making NCF operational, by providing nurturing care parenting practices to promote young children’s brain development and protecting from harmful effects of adversities children might face in such situations (WHO, UNICEF & World Bank, 2019; Lakkis et al., 2020; Murphy, Rodrigues, Costigan, et al., 2017). While ECD focused parenting intervention to strengthen the resilience of families and children in humanitarian response settings are of critical importance, the interest and scale of such interventions, is very low. The potential obstacles could be limited evidence about the effective ECD programs, their parameters such as implementation data describing the key process and factors essential for delivering high impact interventions, effective measurement tools, which could guide the set-up and roll out of such interventions in humanitarian contexts (Murphy, Yoshikawa, Wuermli, 2018; Durlak & DuPre, 2008).

World Vision in Rwanda (WVR) implemented a parenting project called Care and Comfort for Children (3C) for strengthening the resilience of families and communities to improve early childhood development outcomes of under-five age children living in refugee settings. The project served as an opportunity to fill the evidence gap by answering some questions that could inform the global community of practice regarding the critical components of ECD parenting program in refugee settings. The primary objective of the study was to examine the impact of the 3C ECD parenting program on under five children and their caregivers in a humanitarian setting in Rwanda. The 3C study objectives were primarily focused on assessing the effectiveness of an ECD parenting program in a humanitarian context, and answering the following questions:

Will children of caregivers who receive intervention demonstrate improved developmental outcomes compared to children who receive a standard service? Will the three study arms be significantly different in child development outcomes?

Will caregivers who receive intervention demonstrate improved caregiving practices for optimal ECD compared to caregivers who do not receive any service as indexed by change in i) engagement with play activities ii) quality of learning environment at home iii) responsive feeding practices?

Will caregivers exposed to the intervention have reduced symptoms of anxiety and depression compared to caregivers who do not receive any services? Will there be a difference between the two intervention groups?

Sample

The 3C project targeted refugees settled in the Mugombwa refugee camp, in Gisagara District, established in 2014, and three neighboring host sectors - Kansi, Kigeme, and Mugombwa. Mugombwa refugee camp has a population of 10,574 consisting of 2,260 households which have 2,014 under five age children. The host communities of Kansi, Kigeme, and Mugombwa, have a total of 61,399 population, with around 17% of population being children under five age (10,203). The project team intended to reach a total of 1,500 households with 3,000 children under five (CU5). The families were primarily selected based on their needs and interest to participate in the 3C project, and as per the set criteria. The eligibility criteria for households to be targeted were: Having at least 2 children aged under five age group; interested to participate in the project; belonging to the lowest wealth category, as defined by the Government for Rwandan population.

Research design and sampling framework

The study was designed as quasi-experimental research with pre-post evaluation. World Vision in Rwanda tested the effectiveness of the “Care and Comfort for Children” (3C) model, which aimed to build caregivers’ knowledge, skills and resilience-promoting practices at the household level. The research assessed the effect of ECD parenting program for children under five, particularly measuring the effect of HD and LD parenting packages on child and caregiver outcomes in refugee settings (host and camp). Details of the intervention and dosage have been included in the ‘intervention’ section.

The data collection was addressed in 3 study arms selected from host and camp communities. A sample size of 176 per group was identified at power of 0.80 and level of significance of 0.05 to detect a difference in 15 points between low dose group and control on a standard child development test (the Ages and Stages Questionnaire-3) based on a previous trial using ASQ 3 in India (Kvestad et al., 2015). Sample size was calculated using Stata v16. World Vision provided the list of households with children aged 0–5 years living in targeted intervention sites and control sites, and the research consultancy team selected the study respondents using random sampling approach.

Intervention

The 3C intervention main objectives were to strengthen: 1) Family & Caregiving Environments for Children 0–5; and 2) Community Environment for Children 0–5. WV Go Baby Go (GBG) parenting program (World Vision International, 2018) served as a foundation for the 3C project. The GBG model strengthens knowledge, skills and resilience-promoting parenting behaviours so they can provide nurturing care during the first 1,000 + days of life. The GBG is aligned with the Nurturing Care Framework and primarily focuses on early learning, responsive caregiving and safety and security of nurturing care domains. The 3C also included Sesame Workshop ECD materials for 4–6 age groups, which included videos from Sesame Workshop’s and “WASH UP!” series, along with the accompanying in-class activities and take-home activities.

The HD group received 12 caregiver group sessions, 4 home visits, while the LD group received 4 caregiver group sessions, 2 home visits. Bothe groups were exposed to 15 radio sessions, and 12 ECD SMS messages. The 3C was delivered by 44 trained and supported Community Facilitator (32 assigned for delivering HD and 12 for LD packages) and 9 Mentors (6 for HD and 3 for LD), who were refugees themselves and were recruited by camp leaders and local leaders. The 2 Project Staff (1 for host communities, 1 for camp) role was to train, monitor and supervise 3C implementation in host and camp settings for fidelity and quality, ad provide the workforce with supportive supervision, and address the emerging challenges.

The 3C project started in September 2020, and finished in January 2022. The following stages were: i) Preparations, which consumed six months for: ECD curriculum’s adaptation, translation (1.5 months); defining the high dose, and low dose packages; Sesame Workshop (SW) material adaptation and translation (6 months); training of the workforce in 3C and SW integrated curriculums for group sessions, and 3C home visiting curriculum; developing research and baseline protocol; and conducting baseline assessments (started in March, then stopped due to COVID-19, and restarted in July 2021); ii) Implementation stage lasted 7 months, starting from August 2021, till January 2022. Overall, 125 caregiver groups (12 caregivers per group) were established for HD (83 total) and LD (42 total) groups in host and camp communities; and iii) Evaluation, started in March 2022, and completed in 2 weeks.

Data collection measures/tools

Different tools were used to measure child and caregiver outcomes. The forms were translated into Kinyarwanda for data collection. The study used the following tools, explained below.

Child development: Child development outcomes were measured by Ages and Stages Questionnaire-3rd edition (Squires et al., 2009). The ASQ-3 comprises five domains of development: gross motor skills, fine motor skills, communication skills, problem-solving skills and personal-social development. Each domain includes 6 items. Different questionnaires are available for different age intervals. The ASQ has been used previously in Rwanda to assess developmental outcomes of pre-term infants (Kirk et al., 2017). For the current study, the forms were translated and back translated and approved by the publisher. Permission was also sought from the publisher for using the forms.

The ASQ-3 is scored by assigning points to each of the 30 items on the age-specific ASQ-3 form. An item is scored as zero points if the child is not yet able to perform the task/behavior, five points if the child sometimes is able to, and ten points if the child is consistently able to perform the task/behavior. The points are then added up for a maximum possible score of 300 on the ASQ-3.

A quick psychometric analysis was conducted prior to outcome analysis. Reliability analysis of ASQ 3 indicated a Cronbach alpha of 0.93 for the total score. For the individual domains, the reliability scores ranged from .67 for personal-social to .81 for the communication score. Further test of validity, we examined gender differences and for maternal education and preschool attendance. No differences were found between boys and girls except for communication domain with girls (Mean 38.6) scoring slightly higher than boys (Mean 34.7) (Supplementary Table S1). An examination with caregiver education and preschool attendance indicated significant differences in the right direction (Supplementary Tables: S2, S3). Children of mothers who were educated scored 13 points higher than children whose mothers were not educated, with a mean of 207 (SD 56.7) vs. mean 194.8 56.1 respectively, p = 0.009. Whereas, children who were attending preschool had a 34 points higher score on total ASQ 3 compared to those who were not, with a mean of 224.4 (SD 42.8) vs. 188.3 (SD 60.7), p = 0.000, respectively.

Caregiver nurturing practices: Parent engagement with early learning and stimulation included items from the UNICEF Multiple Indicator Cluster Survey (MICS) (UNICEF, 2021). It includes six different activities scored as yes or no (In the past 3 days, did you or any household member over 15 years of age engage in any of the following activities with your child: read books or looked at pictures together, told stories, sang songs, took child outside of the home compound, play with child, named or counted or drew things to or with child). A commonly used questionnaire in LMICs for responsive feeding practices was also administered. It included 8 different behaviors e.g., the caregiver encourages the child to eat during the meal, asks the child about the food reported as rarely, sometimes or always. Data was analyzed as percent of families reporting per group.

Learning environment at home: Selected items from the Home Observation for Measurement of Environment Inventory, Infant Toddler version (HOME-IT) was used to measure the quality of home environment across different domains: access to play materials, opportunities for outings, father involvement and participation in ECD center. Since the full scale was not used, analyses were completed per item.

Caregiver mental health: The Hopkins Symptoms Checklist (HSCL)-25, a widely used screening tool was used to measure caregiver mental health. The HSCL-25 measures symptoms of anxiety and depression. It consists of 25 items: Part I of the HSCL-25 has 10 items for anxiety symptoms; Part II has 15 items for depression symptoms. The scale for each question includes four categories of response ("Not at all," "A little," "Quite a bit," "Extremely," rated 1 to 4, respectively). Two scores are calculated: the total score is the average of all 25 items, while the depression score is the average of the 15 depression items. A mean score of 1.75 (sum score divided by the number of items) was defined as the cut-off point for syndromal depression and anxiety based on previous studies (Ngwino-Sengesho et al., 2021; Reider & Albert, 2013).

Data on socioeconomic status and other demographic variables such as maternal and paternal education and employment status, identification of primary caregiver was also collected.

Data collection procedures

The end line data was collected during 14–25 March 2022 period. An external consultant training the enumerators (total 17) in five days, including a two-day field practice, from 7–11 March 2022. Effectiveness data at endline was collected from a total of 733 families with 314 in the HD group, 240 in the LD and 179 in the control group. During data collection, each enumerator assessed at least 4 caregivers per day and the average length of interview per caregiver was 1-1.5 hours. The enumerators were supervised by the research team for technical and operational support. Identification of families was supported by ‘community guides’ who were part of the intervention delivery teams. Informed consent was obtained from the head of the household (legal guardian of the participants) prior to data collection.

Data was collected digitally using tablets with the questionnaires pre-programed in KOBO Collect. At the time of interviews, the data manager regularly checked consistency of data collected by enumerators to mitigate potential mistakes but also to confirm that the survey protocol was followed and provided comments to the field officers for correction and improvement. At the end of each workday, all enumerators submitted the collected data to the server for checking. The data manager first of all confirmed that coding of all sheets was done correctly. Following this crosschecking, the data manager provided feedback for each day to correct mistakes done by any enumerator.

Data analysis

Analysis was completed by an independent researcher using the Stata v17. Significance level was taken as p = < .05. Mean and standard deviation (SD) was computed for continuous variables and proportions for categorical. ASQ 3 was used as a continuous score. In addition to total score, domain specific scores were also calculated (communication, fine and gross motor, problem-solving and personal-social). For the maternal practices related to engagement with early learning, a dichotomous variable was created with ≥ 4 activities considered as yes. Generalized Linear Modeling was used assess the group differences. Analysis was adjusted for SES, caregiver education, and child sex.

Findings

The socio demographic characteristics of the research participants, collected from the three study arms (control, high/low dose) are presented below [Table 1]. No significant differences were found for number of members of children in household nor for caregiver education. Child characteristics i.e., age and sex were also non-significant. However, SES was different between the three groups with considerably lower ‘poorest’ category in the control group (6.9%) compared to 23.3% in HD and 26.7% in LD. The LD group had the highest percentage (28.3%) of the least poor category.

Table 1

Socio-demographic characteristics by study arms
	Control	High dose	Low dose	p-value
	N = 179	N = 314	N = 240	p-value
No. of people the household	6.4 ± 2.3	6.0 ± 2.1	6.4 ± 2.2	0.18
No. of children ≤ 17 years old living in the household	3.5 ± 1.6	3.6 ± 1.7	3.7 ± 1.6	0.49
If mother has ever attended school
Yes	120 (69.0)	238 (75.8)	168 (70.0)	0.17
No	54 (31.0)	76 (24.2)	72 (30.0)	0.17
Wealth Index (tertiles)
Very poor	41 (23.6)	119 (37.9)	94 (39.2)	< 0.001
Poor	84 (48.3)	96 (30.6)	55 (22.9)
Least poor	49 (28.2)	99 (31.5)	91 (37.9)
Child sex
Male	90 (50.3)	160 (51.0)	118 (49.2)	0.92
Female	89 (49.7)	154 (49.0)	122 (50.8)
Child age
8–24 months	79 (44.1)	107 (34.1)	80 (33.3)	0.096
25–48 months	72 (40.2)	137 (43.6)	103 (42.9)
49–66 months	28 (15.6)	70 (22.3)	57 (23.8)
Note: Data is presented as Mean (SD) or N (%) as appropriate

The results below answer the study proposed research questions. Outcome analysis indicated that there were no significant differences between intervention and control groups in total ASQ 3 scores, and also between the HD and LD receiving groups [Table 2].

Table 2

Child development scores on ASQ-3 by study arms
	Control N = 179	High dose N = 314	Low dose N = 240	Total N = 733	p-value
Communication	38.3(17.7)	37.3 (14.2)	36.4 (18.1)	36.6 (18.6)	0.315
Gross motor	42.4 (14.3)	41.5 (11.4)	40.7 (14.6)	42.5 (15.0)	0.276
Fine motor	42.2 (15.1)	42.6 (12.1)	42.9 (15.5)	42.8 (15.9)	0.633
Problem solving	33.5 (11.9)	33.0 (9.6)	32.5 (12.3)	33.6 (12.6)	0.387
Personal social	40.8 (14.8)	40.8 (11.8)	40.9 (15.2)	42.1 (15.6)	0.912
Total	202.9 (50.8)	201.1 (40.6)	199.2 (52.0)	203.5 (53.4)	0.498
Note: Data is presented as Mean (SD), and adjusted for SES, maternal education, child sex and preschool attendance

Examination of the ASQ scores with age revealed an increased score for the older age groups in the intervention groups compared to control [Table 3]. However, the differences were not significant. The only significant positive trend was identified in personal social domain among 25–48 months old children in favor of the intervention group.

Table 3

ASQ 3 scores by child age groups
8–24 months	Control N = 78	High dose N = 105	Low dose N = 80	p-value
Communication	31.4 (18.3)	28.7 (17.02)	25.9 (16.9)	0.142
Gross motor	35.7 (17.3)	35.1 (17.71)	30.6 (18.6)	0.101
Fine motor	40.1 (17.2)	40.8 (19)	38.1 (16.4)	0.503
Problem solving	31.5 (13.9)	31.5 (14.08)	27.6 (13.6)	0.114
Personal social	41.8 (17.9)	42.7 (17.5)	35.9 (18.5)	0.029
Total	187.0 (64.6)	185.4 (62.31)	164.1 (54.9)	0.026
25–48 months	Control N = 73	High dose N = 139	Low dose N = 102	p-value
Communication	38.1 (21.6)	38.2 (23)	40.1 (21.2)	0.776
Gross motor	49.4 (14.1)	50.7(12.7)	51.4 (9.5)	0.572
Fine motor	40.5 (18.8)	43.5 (15.3)	44.2 (14.4)	0.29
Problem solving	33.8 (14.2)	36.5 (13.8)	36.6 (13.3)	0.347
Personal social	41.2 (14.5)	45.9 (13.6)	46.7 (12.2)	0.017
Total	208.5 (59.5)	220.1 (58.5)	224.7 (44.9)	0.149
49–66 months	Control N = 28	High dose N = 70	Low dose N = 57	p-value
Communication	45.7 (11.4)	45.8 (12.4)	45.4 (11.5)	0.978
Gross motor	40.5 (15.2)	41.0 (15.4)	40.4 (15.2)	0.976
Fine motor	44.8 (12.6)	47.1 (13.5)	47.7 (13.2)	0.629
Problem solving	33.2 (8.7)	34.5 (8.3)	33.9 (7.4)	0.76
Personal social	35.5 (15.6)	38.4 (14.9)	40.0 (14.6)	0.432
Total	203.75 (33.46)	212.57 (41.93)	213.77 (37.85)	0.511
Note: Data presented as Mean (SD)

Mothers exposed to the intervention had significantly higher scores on early learning and stimulation practices compared to the control group respectively with 211(67.2%), 148 (61.7%) vs. 66 (36.9%), p < .001 mothers engaged in 4 or more activities in the past 3 days. The findings were significant for all play and stimulation items (Fig. 1). Significant differences were found between HD and LD group only for two activities: sang songs (77.7% vs. 69.2%, p = 0.024) and talked about things that interested the child (86.6% vs. 79.6%, p = 0.028). For the other caregivers in the house, significant differences were found for all play and stimulation activities except one item with greater number of other caregivers in the intervention groups reporting engaged in play and stimulation activities compared to control [Figure 1].

With respect to father’s engagement, no difference was found in any of the seven items. Also, the analysis by child sex indicated similar effects for boys and girls.

With regard to responsive caregiving, the results show a significantly greater number of caregivers in the intervention groups, both HD and LD, reporting responsive feeding behaviors on all of the 8 items when compared to the control group [Figure 2]. Examination by child sex revealed similar effects for both.

With respect to play with toys, greater number of children in both intervention groups had homemade toys compared to children in the control group (60.3% vs. 90.1% in HD and 88.3% in LD, p = 0.000) and also toys from shop (22.4 vs. 80.3% for HD and 79.2 in LD, p = 0.000) [Table 4]. Attendance in ECD centers (for children between 2–4 years) was significantly different for intervention group compared to control (28.2% vs. 42.3 in HD, 53.3% in LD, p = 0.000). However, there was no difference in ECD centre attendance for the older age group. This was true for boys and girls.

Table 4: Scores on items related to learning environment at home by intervention and control

Study arms

Control

N=174

High dose

N=314

Low dose

N=240

p-value

The child plays with

Homemade toys

Toys from shop

Household items

105 (60.3)

39 (22.4)

154 (88.5)

283 (90.1)

252 (80.3)

287 (91.5)

212 (88.3)

190 (79.2)

218 (90.8)

.000

.128

No. of picture books for the child

0.17 (0.4)

4.3 (0.22)

(0.12)

0.000

Time spent with child during play in a day

None

About 15 mins

About 30 mins

About 60 mins

More than 60 mins

14 (8.1)

47 (27.0)

44 (25.3)

32 (18.4)

27 (15.5)

1 (.32)

69 (21.9)

95 (30.3)

60 (19.1)

85 (27.0)

5 (2.1)

60 (25.0)

81 (33.8)

33 (13.8)

50 (20.8)

0.000

Talks with child when busy

Showed/taught child something new past week

Found something new for child to play with

104 (59.7)

69 (39.6)

23 (13.2)

218 (69.4)

164 (52.3)

174 (72.5)

171 (71.3)

104 (43.3)

0.019

0.000

Attendance in ECD program (all)

Age group 25-48 months

Age group 49-66 months

49 (28.2)

25 (34.3)

22 (81.5)

133 (42.3)

62 (44.6)

64 (91.4)

128 (53.3)

64 (62.8)

54 (94.7)

0.000

0.140

Note: Data is presented as N (%) or Mean (SD) as appropriate and adjusted for SES, maternal education, child sex and preschool attendance.

Analysis of caregiver mental health data, measuring at risk for depression and anxiety, indicated no significant differences between the three study arms with 5.6% in control, 3.5% in HD and 3.3% in LD found at-risk of depression (p = 0.43), and with 5.59% in control, 4.14% in HD and 3.75% in LD for experiencing an anxiety (p > 0.5).

The objective of the study was to assess the effectiveness of an ECD parenting program in a humanitarian context, answering some research questions in line with the global evidence gap for ECD programming in humanitarian settings. The research questions explored the impact of 3C delivered in high and low dose packages compared with the control group with similar socio-demographic characteristics receiving standard services. Findings indicated no significant differences between the intervention and control groups on main outcome measure i.e., ASQ 3. The lack of differences on the outcomes could be attributed to different factors such as the length of the intervention. A previous evaluation of the Go Baby Go parenting project in Armenia found benefits for child development (a non-humanitarian context) (Rosales et a., 2019) The study duration was similar as the 3C (8 months of implementation, with maximum six direct interactions with the targeted beneficiaries), but it could be that the context was different and there was a difference in the quality of implementation. Moreover, in Armenia study, the outcome measurement tool, used for final evaluation (Bayley Scales of Infant Development-III) could be more sensitive than ASQ-3. Although, a parenting intervention trial from Rwandan context (Jensen et al., 2021) reported differences using ASQ 3 but it was used as a parent report measure, while the 3C study used direct child performance, which could increase tool sensitivity. However, enumerators’ capacity to apply psychometric tools with quality and reliability could be a potential reason for data quality. Some studies report poor agreement between parent and assessor scores on ASQ 3 (Shrestha et al., 2020). In fact, the Jensen et al. study reported no benefits with a direct assessment measure (Malawi Development Assessment Tool).

There were statistically significant differences between the intervention groups on maternal practices for early learning and responsive caregiving and feeding with both showing significant higher percentage of caregivers reporting positive practices. This result could indicate that even a LD intervention, with fewer direct interactions with caregivers and delivered in a lower frequency (one group meeting per 1.5-2 months) could produce change in nurturing care parenting practices. No differences were found for caregiver mental health between intervention and control groups. This could be due to multiple support intervention and services available for caregivers in both intervention and control settings.

The evidence on practices from suggests a positive change in general parenting and interaction with children. Since change in practice is the main pathway to ECD outcomes, we can assume that given greater intensity or length of intervention these could have translated to outcomes for children. The positive change in family practices is in line with the overwhelming evidence on parenting interventions in community-based settings (Britto et al., 2017). With respect to evidence from humanitarian settings, a pilot randomized controlled trial was conducted in refugee camps in Lebanon aimed to evaluate the benefits of parenting education programme delivered through group sessions. The authors found positive changed in maternal disciplinary practices (Ponguta et al., 2020).

There were several limitations of the study including baseline data not being available, using cross-sectional data and an outcome measure which was not validated for the setting. Nonetheless, the findings are valuable for the field of ECD interventions specifically the benefits of the programme with different dosages. It can be concluded that parenting programmes in humanitarian settings delivered by staff trained from the community can have a positive effect. Moving forward, a RCT is recommended with two intervention arms (HD and LD) for a more robust evaluation. A comprehensive implementation evaluation needs to be integrated to be able to answer burning questions for ECD in humanitarian settings.

Ethics Approval and consent to participate

The study was approved by the Institutional Review Board of College of Medicine and Health Sciences, University of Rwanda (Approval No. 180/CMHS IRB/2022). Informed consent was obtained from the head of the household (legal guardian of the participants) for participation in the study. Research activities were conducted in accordance with the institutional guidelines.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and/or analysed during the current study are not publicly available given the sensitive nature of information but are available from the corresponding author on reasonable request.

Competing interests

Authors have no competing interests to declare.

Funding

The study was co-funded by USAID (Award No. SPRMCO20CA0158) and World Vision US.

Author contributions

VS: conceptualization, methodology, funding acquisition, supervision, writing-original draft

AT: methodology, writing-review and editing

MU: methodology, investigation, data curation, project administration, writing-review and editing

AG: investigation, writing-review and editing

JAH: investigation, writing-review and editing

JSS: resources, writing-review and editing

CF: funding acquisition, resources, writing-review and editing

MAR: formal analysis, writing-original draft

Acknowledgments

The authors would like to express their sincere regard to the families who participated in the study. We are grateful to the community facilitators who implemented the intervention and the enumerators who collected the data. We also acknowledge support of World Vision Rwanda National Office and UNHCR for conducting the study.

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No competing interests reported.

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The effect of nurturing care interventions on early child development and care: findings from a quasi-experimental study in a humanitarian setting

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