Early Childhood Development and Family Services · Support to Early Childhood Development and Family services has emerged over the past three years as a key priority area for development

Early Childhood Development and Family Services

Baseline Evaluation in 20 Sites in Rwanda

Early Childhood Development and Family Services: Baseline Evaluation in 20 Sites in Rwanda

© United Nations Children’s Fund, Kigali, Rwanda

Cover photograph: © UNICEF/2014/Park

Design and layout: Handmade Communications

Early Childhood Development and Family ServicesBaseline Evaluation in 20 Sites in Rwanda

Early Childhood Development and Family Services: Baseline Evaluation in 20 Sites in Rwanda2

Contents

Acknowledgements 4

Introduction 5

1. ECD&F conceptual model 8

2. ECD&F programme objectives and indicators 91. Effective and responsive care of the young child by the primary caregiver,

family and community 92. Improved access to and use of quality ECD and other basic social services

for young children 10

3. Methods and study sites 11

4. Household and caregiver characteristics 13

5. Socio-economic characteristics 14

6. Effective and responsive care of the young child by the primary caregiver, family and community 15

a. Core family care practices 15Caregiving practices and the home environment 15Caregiver’s support for learning 16Exposure to books and playthings 17Inadequate care of young children 19Child disciplinary practices 20Family violence and conflict in the home 22Family decision-making about children 23Child development 23Caregiver health and well-being 24Maternal health history 26Communication for social and behaviour change 27

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Contents 3

b. Physical environment and well-being of young children 29Child health 29Diarrhoea 29Malaria 30Water and sanitation facilities 31Hand washing 33Safe stool disposal 35

Malnutrition 36Infant and young child feeding practices 37Food security and coping strategies 38

7. Improved access to and use of quality ECD and other basic social services for young children 40

Access to ECD services 40Health insurance 41Access to selected health services 42Birth registration 43

8. Overall conclusions and recommendations 44

Appendices 45©

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Acknowledgements

The ECD&F baseline evaluation was commissioned by UNICEF Rwanda and Imbuto Foundation. It is the result of a successful collaboration between a number of organizations and individuals. The evaluation was carried out under the leadership of an ECD&F baseline Technical Committee, and we wish to acknowledge the contribution of the committee members: Anastasie Nyirabahinde from MIGEPROF, Michel Ndakize from the National Institute of Statistics, Gladys Mutavu and Hubert Kagabo from Imbuto Foundation, and Oliver Petrovic, Solrun Engilbertsdottir, Erna Ribar, Rachel Sabates-Wheeler, Venerande Kabarere and Arpana Pandey from UNICEF Rwanda.

We would like to extend our gratitude to the implementing partners who, as part of the technical committee, supported the baseline design, including sampling and survey tool design, as well as data collection and analysis: Harvard T.H. Chan School of Public Health – Theresa S. Betancourt, Catherine Kirk, Günther Fink, Joshua Jeong and Shoshanna Fine; the University of Rwanda – Laetitita Nyirazinyoye and Vincent Sezibera; and Partners in Health – Sylvere Mukunzi, Christian Ukundineza, Felix R. Cyamatare and Hema Magge.

We would also like to express our gratitude to the Rwandan data collection team, and finally and most importantly, we would like to acknowledge the generosity of all the women, men and children who participated in this evaluation, giving their time to help us learn about children’s development in communities across the country.

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Introduction 5

Introduction

Support to Early Childhood Development and Family services has emerged over the past three years as a key priority area for development in Rwanda. This priority is outlined in the Early Childhood Development (ECD) Policy and its Strategic Plan, and the Economic Development and Poverty Reduction Strategy (EDPRS II 2013–2018). The EDPRS II defines ECD as a ‘foundational issue’ for sustainable development, and confirms the Government’s commitment to keeping ECD a high priority on the national agenda.

To respond to this government priority and translate national policies into action, UNICEF Rwanda and Imbuto Foundation, under the leadership

of the Ministry of Gender and Family Promotion (MIGEPROF) and in collaboration with other stakeholders, entered into a partnership to bring together multiple Early Childhood Development and Family (ECD&F) interventions, with the family at the heart of the approach. The ECD&F programme targets children younger than 7 years old in Rwanda, offering a combination of centre-based and home-based ECD interventions. The programme focuses on responding to community needs and relies on community ownership of the programme. Caregivers and children alike participate in the programme, and efforts to involve fathers in child rearing are emphasized. While some of the interventions, such as provision of centre-based ECD services, focus on targeted villages, others, such as child protection, health and nutrition, cover the whole sector/district. Social protection interventions, home-based ECD and water, sanitation and hygiene (WASH) services are geared towards the most deprived children and families in targeted villages as well as neighbouring communities.

The first ECD&F centre was opened in July 2013 in Kayonza District in the Eastern Province of Rwanda. An additional nine centres opened in 2014 and three more are in preparation. The programme’s goal is to build an ECD&F centre in each of Rwanda’s 30 districts.

In 2014, UNICEF Rwanda commissioned an ECD&F baseline evaluation to assess the ECD&F programme’s impact, in partnership with Imbuto Foundation and guided by an ECD&F Baseline Technical Committee, comprising MIGEPROF, MINEDUC, the National Institute of Statistics in Rwanda (NISR), Imbuto Foundation, the University of Rwanda, Harvard University, Partners in Health Rwanda (Inshuti Mu Buzima) and UNICEF.1 The evaluation’s implementing partners were Harvard University School of Public Health, Partners in Health and the University of Rwanda.2

The baseline evaluation’s key objectives included assessing the health and well-being of young children and families in the surveyed sites and establishing current conditions related to ECD&F to inform programmes in the selected areas. This summary report provides an overview of several domains that are critical to children’s health and development, including caregiver characteristics; children’s achievement of developmental milestones; children’s social-emotional well-being; opportunities for learning and stimulation; access to health and WASH services; nutrition; and child protection. The analysis focuses on key characteristics of household caregivers, such as wealth assets, and caregiver education and literacy. Key indicators from the baseline are summarized below.

1 The members of the ECD&F Baseline Technical Committee are: Anastasie Nyirabahinde – MIGEPROF; Michel Ndakize – National Institute of Statistics; Gladys Mutavu and Hubert Kagabo – Imbuto Foundation; and Oliver Petrovic, Erna Ribar, Solrun Engilbertsdottir, Rachel Sabates-Wheeler, Venerande Kabarere and Arpana Pandey – UNICEF Rwanda.

2 The implementing partners were: Theresa S. Betancourt, Catherine Kirk, Günther Fink, Joshua Jeong and Shoshanna Fine from Harvard University; Laetitita Nyirazinyoye and Vincent Sezibera from the University of Rwanda; and Sylvere Mukunzi, Christian Ukundineza, Felix R. Cyamatare and Hema Magge from Partners in Health.

The results presented in this summary report are not nationally representative, and should under no circumstances be quoted or used as nationally representative figures. The results only apply to the 20 sites evaluated (10 treatment and 10 control sites). The 20 sites were specifically selected to receive ECD&F interventions due to high levels of poverty and their rural locations.

This baseline evaluation provides pre-intervention indicators of child health and development outcomes to inform targeted programming within ECD&F programme sites, and allow for future impact evaluations of programme effectiveness.


This report provides an overview of the key findings of the ECD&F Baseline Evaluation Technical Report, which was validated by the Technical Committee in early 2015. The study results are not representative at national, province or district levels; they only apply to the 20 sites surveyed, all of which were selected specifically for their rural location and high levels of poverty. It should also be noted that the results are presented as averages which include all the 20 sites in 10 districts. The results do not reflect some of the differences and sometimes disparities which do exist between the selected sites/districts.

The results presented in this summary report should not be compared with nationally available statistics. The survey results pertain to two very specific age groups, 0–11 months and 24–35 months, in specifically targeted sites.

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Introduction 7

Table 1. Key indicators

Indicator Point estimate

Household characteristics

Mean household size (persons) 5.1

Mean number of children under 5 in household 1.5

Percentage of children living with both biological parents 77.6%

Percentage of children living in households with their biological mother 98.5%

Household assets

Percentage of children living in households with electricity 12.7%

Percentage of children living in households with radio 53.6%

Percentage of children living in households with mobile phone 64.5%

Percentage of children living in households with bike 17.7%

Percentage of children living in households with bed net 87.8%

Caregiving practices

Percentage of children 0–11 months old experiencing any inadequate care in the past week 32.6%

Percentage of children 24–35 months old experiencing any inadequate care in the past week 60.0%

Percentage of children 0–11 months old exposed to any violent discipline 19.8%

Percentage of children 24–35 months old exposed to any violent discipline 80.7%

Percentage of caregivers who believe physical punishment is necessary to raise a child well 34.4%

Father cares for child daily 62.9%

Support for learning

Primary caregiver engages in three activities to promote learning or school readiness in the past week 8.6%

Availability of children’s books in the household 1.6%

Availability of playthings in the household 19.5%

Access to ECD and community services

Percentage of children 0–11 months old who attend ECD programme 3.3%

Percentage of children 24–35 months old who attend ECD programme 9.7%

Percentage of households with children 4–6 years old who attend nursery or pre-primary school 27.4%

WASH

Percentage of households with an improved water source 76.5%

Percentage of households with an improved sanitation facility 69.1%

Percentage of households with a place for hand washing 5.9%

Percentage of households with a place for hand washing with water and soap/cleansing agent available 0.2%

Percentage of households with safe disposal of 0–11 month-old children’s faeces 62.3%

Child health

Percentage of children 0–11 months old who had diarrhoea in the past two weeks 29.4%

Percentage of children 24–35 months old who had diarrhoea in the past two weeks 28.7%

Percentage of caregivers of children 0–11 months old who sought any treatment for diarrhoea 59.7%

Percentage of caregivers of children 24–35 months old who sought any treatment for diarrhoea 73.5%

Percentage of children who received either ORS or RHF 22.1%

Percentage of children who slept under mosquito net last night 78.9%

Percentage of children 0–11 months old who had fever in the last two weeks 39.1%

Percentage of children 24–35 months old who had fever in the past two weeks 37.4%

Percentage of caregivers of children 0–11 months old who sought any treatment for fever 56.5%

Percentage of caregivers of children 24–35 months old who sought any treatment for fever 72.3%

Nutrition

Percentage of children 0–11 months old who are severely stunted (HAZ < -3) 5.8%

Percentage of children 24–35 months old who are severely stunted (HAZ < -3) 16.4%

Percentage of children 0–11 months old who are stunted (HAZ < -2) 15.9%

Percentage of children 24–35 months old who are stunted (HAZ < -2) 46.0%

Percentage of children younger than 6 months who are exclusively breastfeeding 90.0%

Percentage of children 6–11 months old who are receiving the minimum acceptable diet 12.7%


1. ECD&F conceptual model

The ECD&F model conceptually looks at children’s development holistically, and is essentially a socio-ecological template (see Figure 1). It is designed to transform children’s lives by, first of all, enhancing how their family members interact and the ways in which they nurture and care for the children. The transformation is further strengthened by supportive community action, quality social services and appropriate policy decisions that respond to the needs of the family and children. At the core is the individual child’s development, reflected in his or her achievement of key developmental milestones related to cognitive development, communication skills, motor development and social-emotional development. Most of these skills are developed rapidly, starting in utero

through the child’s first two years of life, the period often referred to as the first 1,000 days. This critical period of brain development lays the foundation for human development across the life span. In addition to the child’s development, good caregiving practices in the family are important for helping children to reach their development potential and achieve several of the core rights outlined in the Convention on the Rights of the Child,3 which Rwanda ratified in 1991.

The baseline evaluation was designed to include key indicators at several levels of the ECD&F conceptual model: child development outcomes, caregiving practices and the home environment, community programmes, and access to ECD and ECD-related services.

3 United Nations General Assembly, Convention on the Rights of the Child, United Nations, New York, 1989.

The ECD&F model is designed to transform children’s lives by enhancing the ways in which children are nurtured and cared for.

National and local decision makers

Social services

Community

Family

Policy dialogue and advocacy

Capacity development

Community mobilization

Capacity-building

Figure 1: ECD&F conceptual model

2. ECD&F programme objectives and indicators 9

2. ECD&F programme objectives and indicators

The baseline evaluation was specifically developed to support the development and future impact evaluation of the ECD&F programme. Building on the ECD&F conceptual model outlined above, the programme’s primary objective is to establish a system in which families and young children (in particular those living in the catchment areas of the model ECD centres in 10 districts) have access to quality ECD&F services. The programme aims to test an effective and sustainable strategy/model that is documented and advocated for government adaptation and scale-up nationwide. The sustainable model of ECD&F

interventions is ultimately to result in:

1. Effective and responsive care of the young child by the primary caregiver, family and community;

2. Improved access to and use of quality ECD and other basic social services for young children; and

3. Implementation of child-sensitive policies at all governance levels.

This ECD&F baseline was developed to respond to, and provide information on, key components of the first two objectives, which are outlined in more detail below.

1. Effective and responsive care of the young child by the primary caregiver, family and community

During the early years of human development, the basic architecture and function of the brain are established. Early experiences influence the quality of that architecture by laying either a strong or fragile foundation for the health, development and learning that follow. This means that the process of nurturing young children begins in the earliest stages of life and heavily depends on the home environment in which a child is raised. Two critical components of the home environment greatly influence the development of a young child: (1) physical environment – this will include adequate sanitation and clean drinking water, as well as availability of items to stimulate young child development, such as children’s books and playthings; and (2) the caregiver’s direct engagement with the child (core child-care practices and direct stimulation of child development).

In order to assess key interventions required for effective and responsible care, the ECD&F baseline has established the following key indicators to be tracked:

Core family care practices improved:

• Proportionofyoungchildrenlivinginhouseholdsinwhichprimarycaregivershaveengaged in activities to promote learning and school readiness

• Proportionofyoungchildrenlivinginhouseholdsinwhichfathershaveengagedinactivities to promote learning and school readiness

• Proportionofyoungchildrenlefthomealone/withinadequatecare• Proportionofchildrensubjecttoviolentdiscipliningpractices• Proportionofinfantsthatareappropriatelyfed

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Physical environment for young children improved:

• Incidenceofdiarrhoealdiseaseofchildren• Proportionofhouseholdsusingimprovedsourcesofdrinkingwater• Proportionofhouseholdsusingimprovedsanitationfacilities• Proportionofhouseholdswiththreeormorechildren’sbooks

2. Improved access to and use of quality ECD and other basic social services for young children

The ECD&F programme’s second objective outlines the importance of quality ECD and other basic services for young children. If family is the first line of influence to young children’s optimal growth, the second line relies on quality basic social services, which complement the family’s effort.

One of the basic principles of equity includes equal access to goods and services in accordance with individual needs, which vary according to the life cycle and current situation of individuals and groups. Services that provide young children with an opportunity to learn and interact with their peers are as important as is effective and responsive care of the child. It is essential that children are able to participate in some form of organized early learning programmes, which are the foundation of quality basic education. Such programmes provide children with basic cognitive and language skills, as well as sufficient social competency and emotional development to prepare them for learning in a school setting.4

Well-implemented, effective programmes can increase the odds that children – especially disadvantaged children – will have the kinds of experiences and interactions that produce long-term, positive benefits in academic achievements, social and emotional adjustments, economic productivity and responsible citizenship.5

The ECD&F baseline evaluation provides key information on the current situation of this second objective by assessing a number of key interventions along the following indicators:

• ProportionofparentssatisfiedwiththequalityofECD&Fservicesprovided• ProportionofECD&Fcaregiverssatisfiedwiththeirroleinthecommunity• Proportionofeligiblefamilieswithyoungchildrenbenefitingfromsocialprotection

measures• Proportionofyoungchildrenwithdiarrhoealand/oracuterespiratoryinfectionwho

get care• Proportionofyoungchildrenwhoreceivegrowthmonitoring

4 Irwin, Lori G., Arjumand Siddiqi, and Clyde Hertzman, ‘Early Childhood Development: A powerful equalizer’, World Health Organization, Geneva, 2007.

5 Woodhead, Martin, et al., ‘Equity and Quality? Challenges for early childhood and primary education in Ethiopia, India and Peru’, Working Paper in Early Childhood Development No. 55, Bernard van Leer Foundation, The Hague, November 2009.

The ECD&F study was implemented through a sample of two cohorts of children in 10 project sites and 10 matched control sites in Rwanda.

3. Methods and study sites 11

3. Methods and study sites

In the baseline evaluation, a quasi-experimental matching design was used in the 20 sites, the 10 intervention sites that were exposed to and planned for inclusion into the ECD&F programme and the 10 matched comparison/control sites that were not exposed. Both quantitative and qualitative methods were used to understand the present context of child development and knowledge of and access to ECD across the sites. The study was implemented through a sample of two cohorts of children (0–11 months old and 24–35 months old) selected in the 10 project sites and 10 matched control sites from the same 10 districts of Rwanda. As noted, half of the sample was selected to serve as comparison sites within the same districts, to allow for a future evaluation of the impact of

ECD&F interventions on children’s development. Between July and October 2014, a total of 884 households were visited, and 81 qualitative interviews were conducted to further contextualize the findings and understand dynamics related to knowledge, attitudes and experiences with services and practices seeking to promote child development in Rwanda. The baseline survey results are not nationally representative and the data are intended to be used primarily for programmatic purposes. The baseline survey methods are explained in further detail in Appendix 2.

“As you know, children under difficult conditions may think that they are not like any other children. They feel inferior to other children.” Mother, Ngoma District

Figure 2: Map of ECD&F sites included in the baseline evaluation

BugeseraRuhango

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International boundary

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ECD-F site

The ECD&F baseline evaluation was implemented through a sample of two cohorts of children in 10 project sites and 10 matched control sites in Rwanda.


All analysis presented in this summary report includes both cases and controls, as there were no differences between the two groups at the time of the baseline evaluation. The results of the qualitative study will be presented in a separate summary document; however, in this summary document some direct quotes from the qualitative study have been included.

The sites, which are all located in rural areas, were specifically targeted for high levels of poverty, among other criteria. (see Figure 2). Each ECD&F centre is built in a single umudugudu (village), but due to the population density of Rwanda, most serve more than one village.6 The intervention sites selected for the study included the actual village where the ECD&F centre is located, as well as the next closest site or sites, based on walking distance, to reach the target sample size of approximately 100 households per district. Matched comparison sites were selected at a similar level of wealth and access to health and education services, but without access to ECD&F centres due to geographic distances. In addition to these key characteristics, proximity to health facilities, major roads or other infrastructure was taken into consideration when selecting comparison sites that were most similar to ECD&F target sites. In total, 42 villages were included in the study; 20 intervention villages and 22 control villages (see Appendix 1 for further information on study sites). A total of 884 households were surveyed across the 20 project sites in 10 districts. (Please refer to Appendix 3 for an overview of the sample).

6 The Republic of Rwanda is divided into provinces, districts, sectors, cells and villages. The district is the basic political-administrative unit of the country.

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4. Household and caregiver characteristics 13

4. Household and caregiver characteristics

The average household size for the surveyed households in this baseline was 5.1, with an average of 1.5 children under 5 years and 2.8 children under 17 years in the household. Both numbers are slightly higher than the national average, which was to be expected given that sampling was restricted to households with at least one child under the age of 5. Nearly all children’s biological mothers resided in the household (98.5 per cent), and in the overwhelming majority of households there were two primary caregivers, most often including the biological father (78.3 per cent). The percentage of children not living with their biological father was highest in Nyarugenge District (31.3 per cent) and lowest in Gakenke (11.5 per cent).

In almost all instances, a child’s primary caregiver was his or her biological mother; 2 per cent of primary caregivers were the child’s biological father and 1 per cent were the child’s grandparents. Due to the small number of primary caregivers that were not the child’s biological mother, it was not possible to disaggregate results based on the primary caregiver’s relationship to the child.

The average age of primary caregivers with a child younger than 1 year was 30.1 years of age. Some 82 per cent of primary caregivers were living with their partner at the time of the study.

Overall, less than half of all primary caregivers surveyed completed primary school and only 6 per cent completed secondary school or higher. As was expected, primary caregivers from households in the lowest wealth quintile were much less likely to have completed primary school (21 per cent) than households from the highest wealth quintile (63 per cent). In all, 28 per cent of caregivers in the sample reported being unable to read and write, and illiteracy rates of 42 per cent were recorded in the lowest wealth quintile. Illiteracy was highest in Nyabihu, where more than half of primary caregivers reported being unable to read and write, and was followed by 41 per cent of primary caregiver respondents in Nyamasheke who were unable to read and write.

“I may not speak for all parents, but the few I have met dream of providing proper care to their children and always do their best to do so. It means any support available would help them to achieve this noble cause and their responsibility.” Mother, Gasabo District

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5. Socio-economic characteristics

Poverty was measured in two ways in the baseline evaluation. Data were collected following the Rwandan system of community-based poverty rankings known as Ubudehe.7 In order to have an additional measure of household well-being and poverty, an asset-based wealth index was also computed, based on the following assets: electricity, radio, phone, bike, flooring type, number of rooms for sleeping and owning livestock (cement floor was the single-best predictor of wealth, followed by electricity and bike ownership). Assets that best predicted household well-being overall were first identified. A household ranking was then generated based on this score, and households were divided into five ‘wealth quintiles’, with 20 per cent of households with the lowest ranking being

placed in the bottom quintile, and 20 per cent of households with the highest score being placed in the top quintile. It is important to highlight that asset-based quintiles represent – by construction – a relative rather than an absolute measure of wealth or poverty.

The overall ownership of assets was low for the households surveyed for the baseline, which was to be expected, as the sites were selected based on their levels of poverty, among other criteria. Given this, households in the higher wealth quintiles established within the study should not be considered well-off or rich. For example, the majority of households in the top two quintiles may have radios and cell phones, but have neither access to electricity nor own a bike.

Across all project sites, only 13 per cent of households had access to electricity and only 18 per cent of households owned a bike. In terms of durable assets, the two most common assets were cell phones and radios, which were owned by 65 per cent and 54 per cent of households, respectively. Across all assets, ownership increased with levels of caregiver education. The only durable assets owned by (marginally) more than 50 per cent of the surveyed population were radios and cell phones.

As noted above, information was also collected on Ubudehe categories. Considering, however, that Ubudehe categories are currently under revision by the Government of Rwanda, in the remainder of the analysis and information presented in this summary, the focus will be on the relative poverty measure – the asset wealth quintiles. However, the information related to health insurance by family members will include some information according to Ubudehe categories, as such categories are used for targeting of subsidized health insurance.

7 Ubudehe poverty ranking is a Rwandan-specific community targeting system.

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6. Effective and responsive care of the young child by the primary caregiver, family and community

The first objective of the ECD&F programme – namely, improving effective and responsive care of the young child by the primary caregiver, family and community – spans interventions across a number of integrated ECD areas. These areas and the corresponding results of the ECD&F baseline in the 20 sites (10 treatment sites and 10 control sites) are outlined below.

a. Core family care practices

Caregiving practices and the home environment

Research shows that positive caregiving can actually buffer the harmful effects of major stressors in a child’s life,8 such as living in an impoverished household. However, evidence shows that children in low- and middle-income countries are often left in the care of other young children and in turn have limited opportunities for stimulation and learning. The baseline evaluation provides data on caregiving practices using some of the internationally recognized indicators for the first time in Rwanda.

Two observational measures were used to assess caregiver-child interactions and the home environment, which have both either been developed for or tested in low-resource countries. The first tool, the Observation of Mother-Child Interactions (OMCI),9 is a five-minute assessment of a play activity between a caregiver and a child. The overall score is a sum of all 19 items on the OMCI, and high scores are indicative of a positive, stimulating interaction.

Caregivers were provided with a Kinyarwanda picture book and asked to play with their child as they normally would for a five-minute period. The caregiver’s behaviours, affect and communication were observed, in addition to the child’s behaviour, affect and interactions with the caregiver.

For the baseline evaluation, the mean overall score on the OMCI was 35.4, which is 62 per cent of the maximum total points possible on the assessment of 57. This indicates that there is room for improvement in supporting caregivers to engage in responsive parenting practices that can help promote children’s learning. Overall, the scores were higher among children 24–35 months old (40.5, or 71 per cent) than children 0–11 months old (29, or 51 per cent). Overall scores were similar across wealth quintiles and the primary caregiver’s education.

The second observational assessment, the HOME Inventory, is used to observe whether the home environment is safe, clean and provides opportunities for stimulation, exploration and learning. The main indicators from the HOME Inventory include:

• Father’sinvolvementinthedailycareofchildren

8 Shonkoff, Jack P., ‘Building a New Biodevelopmental Framework to Guide the Future of Early Childhood Policy’, Child Development, vol. 81, no. 1, 2010, pp. 357–367.

9 Twelve of the OMCI items are observations of the caregiver’s behaviour, language and affect, which form the caregiver’s score by summing the total points. Six items are observations of the child’s behaviour, communication and affect, in addition to one item that looks at the mutual enjoyment of the caregiver and child together; these seven items form the child’s score when summed.

“The major challenges we meet include poverty. In many cases, the child has the potential to grow and develop both physically and intellectually like any other child. But on closer analysis, you find that you have no means that can help in the growth and development of your children, then you become very worried and consequently the health of children is negatively affected.” Mother, Ngoma District

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• Primarycaregiver’ssupportforlearning10 • Theavailabilityofbooksandplaythingsinthehousehold

These indicators offer insight into the potential of the child’s environment to provide opportunities for stimulation and learning. The HOME Inventory provides great depth and breadth of information, which relies on observation as well as caregiver reports. The HOME Inventory Infant-Toddler form was used in the baseline evaluation, due to its focus on children 0–11 months old and 24–35 months old.

Very few children who participated in the survey were living without their biological father in the home. Fathers play an important role in children’s lives but, as in most countries, the majority of caregiving responsibilities seemed to have been left to the child’s mother. However, as seen in Figure 3, 62.9 per cent of fathers in the sample engaged in caring for their child daily. Fathers from the poorest wealth quintile were less likely to engage in their child’s care daily (52 per cent) than fathers from the wealthiest quintile (66 per cent). Fathers from households where the primary caregiver had completed primary school (65 per cent) or secondary school (58 per cent) were more likely to engage in care of the child every day than primary caregivers who had not completed any formal education (56 per cent). The indicator of father’s involvement as measured in the HOME Inventory showed slightly higher rates than other studies (for example, the Knowledge, Attitudes and Practices of Early Nurturing study implemented in Rwanda in 2013). This can be partly explained by the fact that this indicator is not exclusively about play – but takes into account whether the father spends some time every day caring for the child – for example, talking, walking and/or playing with the child.

Caregiver’s support for learning

Stimulation is essential for children’s brain development during their first few years of life. The opportunities for early learning help prepare children for success in school. The indicator on support for learning used in this survey comprises three activities: singing songs/telling stories, looking at pictures in printed materials, or teaching the child something new. Primary caregivers were asked if they practised these activities

10 This indicator differs from the standard UNICEF Multiple Indicator Cluster Survey (MICS) 5 Indicator due to the use of the HOME Inventory items, which are similar but not identical. The HOME Inventory served as the foundation for the MICS5 ECD Index; however, the indicator in the MICS5 is for all children 3 or 4 years old with whom an adult has engaged in four or more activities to promote learning and school readiness in the past three days. The indicator in this evaluation looks at children 24–35 months old whose primary caregiver has engaged in three activities in the past week.

0%

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Wealthiest quintile

Poorest quintile

24—35 months0—11 monthsFemalesMalesOverall

62.9 65.161.1

64.461.4

51.8

66.5

Figure 3: Percentage of children with father’s involvement

More efforts need to be invested in improving children’s environments so that they are more stimulating, and promote early learning.

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with their child in the week before the survey, or on a weekly basis. As seen in Figure 4, more effort needs to be invested in improving children’s environments so that they are more stimulating, and in promoting early learning. Only 12 per cent of primary caregivers of children 24–35 months old (the biological mother of the child 96 per cent of the time) engaged in three or more activities to promote learning or school readiness (singing songs or telling stories, teaching the child something new and looking at pictures in books and magazines with the child).

More than half of caregivers sang songs or told stories to their children weekly, and nearly half taught their child something new in the past week (this tended to include teaching children how to say words, or play games). However, less than a third of primary caregivers of children 24–35 months old reported looking at pictures in a book or magazine with the child in the past week. With the exception of teaching children something new in the past week, the other activities tended to occur more frequently in the highest wealth quintile compared with the lowest. Caregivers who had completed primary school participated more often in each of these activities than primary caregivers who had not completed any formal education. Along those lines, caregivers who could read and write engaged more often in the activities than caregivers who were illiterate.

Exposure to books and playthings

The survey also assessed the possession of books and toys in the households. Exposure to books provides a foundation for developing early literacy skills, and the presence of books in the home is important for future performance at school. Additionally, having toys or materials for play present in the home provides more opportunities for children to explore and learn in their home environment. In each household, caregivers were asked to show the interviewer what their children usually played with, including purchased toys, homemade toys, books or household objects used for play. The presence of children’s books was rare – less than 2 per cent of homes had three or more children’s books available (see Figure 6). There are increasing numbers of children’s books available in Kinyarwanda. However, they are not widely available and can be expensive to obtain for the poorest families.

Other books or materials that may be available in the home can also promote early literacy (see Figure 7). These include adult books, magazines or materials combining pictures and words, such as pamphlets, which are much more widely available in Rwanda.

Yes

No

87.8%

12.2%

Figure 4. Primary caregivers of children 24–35 months old who engaged in activities to promote learning or school readiness in the past week

0%

10%

20%

30%

40%

50%

60%

70%

80%

Caregiver literateCaregiver illiterateWealthiest quintilePoorest

47.8

68.1

50.4

60.3

Figure 5. Promoting learning: Caregivers singing songs or telling stories to child (24–35 months) at least weekly

“There are some parents with limited understanding, who think that when a child has eaten that’s enough, as if early childhood is only limited tor nutrition services.” Community Health Worker, Nyamasheke District

Figure 6. Household has three or more children’s books in the home

Yes

No

98.8%

1.2%


As shown in Figure 8, only 20 per cent of households had two or more playthings available for the child. During the assessment, caregivers were asked to show the interviewer what the child usually plays with in the house. Playthings included purchased toys or homemade objects.

When looking at the availability of any playthings, excluding books, less than half of households in the study were observed to have any playthings available for the child. Additionally, just 10 per cent of caregivers reported making something new or buying something for their child to play with in the household.

The opportunity to engage with other children of the same age also presents an opportunity for stimulation and learning through play. Nearly 60 per cent of children in the sample had a regular playmate that was his or her age. As expected, the percentage was much higher among children 24–35 months old (90 per cent) than children 0–11 months old (18 per cent). There was little variation in this indicator based on poverty levels or primary caregiver education.

Figure 7. Availability of items with pictures and words together to promote early literacy

0%

5%

10%

15%

20%

Primary education

No educationWealthiest quintile

Poorest quintile

24—35 months

0—11 months

Overall

9.3

4.1

14.6

4.9

16.3

2.3

9.5

Figure 8. Child has two or more playthings

Yes

No

80.5%

19.5%

“The mother goes to the field to dig or to work for money…in this case, she is obliged to leave the child behind. She may take the child with her when it is breastfeeding, but when the child has weaned it is left at home.” Mother, Nyabihu District Figure 9. Availability of playthings: child has any toys

0%

10%

20%

30%

40%

50%

60%

Caregiver secondary education

Caregiver no

education

Wealthiest quintile

Poorest quintile

24—35 months

0—11 months

Female child

Male child

41.7

34.9

18.4

58.0

27.3

50.0

32.8

50.6


Inadequate care of young children

Inadequate care is defined using the standard MICS5 definition of being left in the care of someone younger than 10 years old for more than one hour in the past week, or being left alone for one hour or more in the past week.11

As seen in Figure 10, out of all children under 1 year of age, 33 per cent of children experienced some form of inadequate care ; 27.1 per cent were left in the care of someone younger than 10 years old in the past week, and 9 per cent were left alone for more than one hour in the past week. Slightly fewer children in the wealthiest quintile experienced inadequate care (28 per cent) than children in the poorest wealth quintile (32 per cent), but variation was minimal across the five wealth quintiles.

Children 24–35 months old experienced inadequate care nearly twice as often as children 0–11 months old – 60 per cent and 33 per cent, respectively. More than half of children 24–35 months old were cared for by another child younger than 10 years old in the past week and 16 per cent were left alone for one hour or more in the past week. Inadequate

11 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.

0%

10%

20%

30%

40%

50%

60%

Left alone

Left in the care of a child <10

Any inadequate care

24—35 months0—11 monthsOverall

45.7

40.6

12.3

32.6

27.1

9.3

59.8

55.1

15.6

Figure 10. Inadequate care of young children

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

Wealthiest quintile

Poorest quintile

24—35 months

0—11 months

Overall

Mean days left alone in past weekMean days left in the care of a child under 10 in past week

3.2

2.7

3.43.2

3.4

2.2

1.8

2.4 2.4

1.7

Figure 11: Number of days in the past week that children were exposed to inadequate care

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care decreased as relative poverty decreased. Children 24–35 months old in the poorest wealth quintile experienced inadequate care more frequently (61 per cent) than children in the highest wealth quintile (53 per cent), but it was actually children in the middle (wealth quintile three) who experienced inadequate care most frequently (66 per cent). Interestingly, caregivers who completed primary education more often left their child with inadequate care (62 per cent) than caregivers with no education (57 per cent), possibly due to greater opportunities for employment outside the home for caregivers with some formal education.

Further examination of inadequate care looks at how many days children were exposed to inadequate care in the past week. As seen in Figure 11, among caregivers who reported inadequate care, children were left in the care of another child younger than 10 years old for an average of 3.4 days per week, which was consistent across wealth quintiles. Caregivers who reported that their child was left alone for one hour or more in the past week said that children were left alone for 2.2 days on average.

Child disciplinary practices

Child discipline is an integral part of child rearing in all cultures. It teaches children self-control and acceptable behaviour. Although the need for child discipline is broadly recognized, there is considerable debate regarding violent physical and psychological disciplinary practices and at the country level, definitions of what constitutes violent discipline vary.12 While there is no normative framework available for defining violent discipline, for research purposes,13 in Rwanda, this baseline used items from the MICS5’s Child Discipline module. Caregivers were asked about the way they tended to discipline the child in the past month. This child discipline module has been used in over 100 low- and middle-income country settings across the world to gather insight into children’s exposure to harsh disciplinary practices and abuse.14 It is based on an international definition of violent disciplinary practices, in line with the Convention of the Rights of the Child.

The use of violent discipline in this sample was common, with 81 per cent of caregivers of children 24–35 months old having used at least one form of violent discipline in the past month. It was not possible to determine clear trends across the wealth quintiles.

The type of violent discipline practices caregivers used with children 24–35 months old are further broken down in Figure 12. The most common type of violent discipline used was physical punishment (73 per cent), followed by the use of psychological aggression (49 per cent). Physical punishment15 was used more frequently with male children 24–35 months old (78 per cent) than with female children (70 per cent). Severe physical punishment, measured by two items (beating the child as hard as one could or hitting/slapping the child on the face, head or ears) was experienced by 4.9 per cent of children 24–35 months old. When comparing the wealthiest quintile with the poorest wealth quintile, use of physical punishment was nearly the same; however, the use of psychological aggression was higher in the poorest quintile (57 per cent) compared with the wealthiest quintile (41 per cent). Across children 24–35 months old, the use of only non-violent discipline methods was relatively low, at just 10 per cent.

12 United Nations Children’s Fund, ‘Child Disciplinary Practices at Home: Evidence from a Range of Low- and Middle-Income Countries’, UNICEF, New York, 2010.

13 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.14 United Nations Children’s Fund, ‘Hidden in Plain Sight: A statistical analysis of violence against children’, UNICEF, New

York, 2014.15 Physical punishment: (1) shaking the child; (2) spanking or hitting the child on the bottom with a bare hand; (3) slapping

the child on the hand, arm or leg; (4) hitting the child on the bottom with a hard object; (5) hitting the child on the face, head or ears; and (6) beating the child with an implement over and over as hard as one can.

“The reason why we are not always with our children is because we have to travel a long distance to work for food, to feed them. Sometimes I leave very early in the morning, for instance, to work… I continue working until 6 p.m. It means all this time I am not with my children to enable them to feel my affection and benefit from my close attention and care.” Mother, Gakenke District

While the use of violence in the parenting of young children was evident across study groups, only 34 per cent of caregivers reported that physical punishment was necessary to raise a child.

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Among those caregivers with a child younger than 1 year of age, 20 per cent endorsed using any form of violent discipline; the standard MICS indicator for violent discipline is for children 2–14 years old, and so this study provides some unique insight into the disciplinary practices used with infants. Due to the relatively small sample of children 0–11 months old exposed to violent discipline, further disaggregation of this indicator cannot be discussed. As seen in Figure 13, among children younger than 1 year of age, 10.4 per cent of primary caregivers reported using psychological aggression, 15.2 per cent using physical punishment and 0.9 per cent using severe physical punishment. The use of only non-violent forms of discipline was more common among children 0–11 months old (18 per cent) than children 24–25 months old (10 per cent).

While the use of violent disciplining practices in raising of young children was evident across study groups, only 34 per cent of caregivers reported that physical punishment was necessary to raise a child (see Figure 14).

Figure 12: Types of discipline (violent and non-violent) used with children 24–35 months old

0%

10%

20%

30%

40%

50%

60%

70%

80%

Only non-violent discipline

Severe physical punishment

Physical punishment

Psychological aggression

Wealthiest quintilePoorest quintileFemalesMalesOverall

49.4

73.4

4.910.2

46.6

77.5

4.79.1

51.7

70.1

5.111.2

56.8

71.6

8.411.5

40.5

71.6

1.4

12.1

“A parent should show affection and love to the child as this sharpens its mind.” Mother, Nyamasheke District

0%

5%

10%

15%

20%

Only non-violent disciplineSevere physical punishmentPhysical punishmentPsychological aggression

10.0%

15.0%

1.0%

18.0%

Figure 13: Types of discipline (violent and non-violent) used with children 0–11 months old

Figure 14. Caregiver beliefs about the use of physical punishment being necessary

Yes

No

66%

34%


Family violence and conflict in the home

Children’s exposure to family violence and serious conflicts between caregivers in the past week and six months was explored, as it is known that conflict in the home can have serious negative effects on early childhood development and both child and caregiver well-being. High rates of exposure to household conflict among children represent the sort of compounded adversity that can be highly detrimental to children’s development and future life trajectories.16, 17

In a typical week, nearly half of children surveyed were exposed to some form of conflict between caregivers who were married or living together, with 44 per cent of primary caregivers reporting that they argue about their relationship in the child’s presence in a typical week and 43 per cent reporting saying cruel things to each other in front of the child in a typical week (see Figure 15 for more details). Couples in the poorest wealth quintile argued in front of their children much more often (63 per cent) than couples in the wealthiest quintile (25 per cent). Some 60 per cent of caregivers from the poorest wealth quintile reported saying cruel things to each other in the child’s presence compared with 30 per cent from the wealthiest quintile. Caregivers who had completed at least primary school reported both of these behaviours less frequently than caregivers with no formal education; the same was observed with literacy.

In addition to conflict between caregivers who are married or living together, the survey asked about general conflict in the household, which could have been among any members of the household, including extended family, children or caregivers. Serious conflict was defined as either verbal or physical conflicts, and this indicator measured serious conflict over the past six months. Overall, 32 per cent of children were living in a household where there was serious conflict in the past six months, and 21 per cent of the time the primary caregiver was involved in serious conflict in the household. There was little variation in household conflict based on the child’s age. The primary caregiver’s level of education led to little variation in household conflict.

16 Hillis, Susan D., et al., ‘The Association between Adverse Childhood Experiences and Adolescent Pregnancy, Long-Term Psychosocial Consequences, and Fetal Death’, Pediatrics, vol. 113, no. 2, February 2004, pp. 320–327.

17 Shonkoff, Jack P., et al., ‘An Integrated Scientific Framework for Child Survival and Early Childhood Development’, Pediatrics, vol. 129, no. 2, 2012, pp. 1–13.

“Some of the challenges that hinder proper parenthood and good education of young children included drunkard fathers, or people who do not appreciate the value of a child; men who harass mothers in front of their children and threaten children to the extent that they do not have the peace of mind…this affects proper education of children as they are always worried and scared.” Mother, Ngoma District

0%

10%

20%

30%

40%

50%

60%

5 (wealthiest)4321 (poorest)Child 24—35 months

Child 0—11 months

47.7

38.4

59.6

46.4

39.342.0

30.4

Figure 15. Exposure to conflict between partners – in a typical week – saying cruel things to each other in child’s presence


Family decision-making about children

In the majority of households included in the evaluation, primary caregivers were living with their children in the home. Understanding how decisions are made about children’s participation in ECD programmes, health and nutrition are important for programme design. As shown in Figure 16, many decisions about children were made jointly between mothers and fathers or fell predominantly to the mother, particularly when it came to decisions about what children eat. Mothers and fathers tended to have different roles and priorities in household decision-making. Mothers were most likely to make the decisions pertaining to the immediate needs of the child: 76 per cent of mothers decided alone what the child ate, and 45 per cent of mothers decided alone on the appropriate action when the child was sick. However, on average, decision-making about the child’s attendance in ECD services was mostly reported to be shared between fathers and mothers equally, at 44 per cent. Regarding child’s attendance in ECD services, fathers appeared to demonstrate slightly greater exclusive decision-making (27 per cent) than mothers (24 per cent). In very few households (always less than 5 per cent), another member of the household, such as a grandmother or grandfather, was responsible for these decisions.

Across all three decisions evaluated in this study, households in the lowest wealth quintile were less likely to share decisions between the mother and the father than households in the highest wealth quintile. A similar trend was observed for the primary caregiver’s education – the percentage of decisions made jointly between a mother and father increased as the primary caregiver’s education level increased.

Child development

As child development is at the heart of the ECD&F programme, it was important that the ECD&F baseline evaluate a range of child development indicators, including communication, fine and gross motor skills, socio-emotional development, parent-child interactions, etc. As early childhood development is less explored in low-resource settings, Western standard tools to measure child development have to be relied upon. Two measures of child development were selected: the Ages and Stages Questionnaire

“…if the child…finds that parents are on good terms and consult each other before making any decision, the child will emulate this good example. The children will also learn good manners and to ask permission in case they want to visit their friends; they will first seek permission from their mom and dad because they feel free and at ease with their parents. Understanding in the family is the source of good education for the children as well as happiness in the family.” Mother, Ruhango District

0%

10%

20%

30%

40%

50%

60%

70%

80%

Others

Grandmother

Grandfather

Father and mother equally

Mother

Father

Decides what the child eatsDecides the action when the child is sickDecides whether child should attend ECD service

27.0

12.0

4.0

24.0

45.0

76.0

45.0

39.0

17.0

1.0 1.0 0.02.0 2.0 3.01.0 0.0 0.0

Figure 16: Decision-making in the household


Version 3 (ASQ-3) and the Ages and Stages Social-Emotional Questionnaire (ASQ:SE).18 Both have been used previously in low-resource settings,19, 20 ,21 and the ASQ-3 has been used previously in Rwanda.

While both measures hold tremendous value for evaluating the future impact of the ECD&F programme based on the baseline scores, as well as provide a large dataset on child developmental milestones for the 20 surveyed sites, the data presented here must be interpreted cautiously, as implications about developmental delay cannot be assumed based on comparison with the normative standards in the United States. However, at this time, such an approach is the best proxy available for providing estimates of the proportion of children whose development may be of concern.

The ASQ-3 measures five domains of development: gross motor skills, fine motor skills, communication skills, problem-solving skills and personal-social development. Because children’s development progresses rapidly in the first few years of life, there are 21 age-specific ASQ-3 forms. In this study, 11 age-specific forms, based on the child’s precise age in days and months, were used.

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/behaviour, five points if the child sometimes is able to, and ten points if the child is consistently able to perform the task/behaviour. The points are then added up for a maximum possible score of 300 on the ASQ-3, which represents the highest levels of development. Figure 17 shows the median scores on the ASQ-3, disaggregated by sex, age and wealth quintile. There is no difference in the median score between males and females. However, children from the poorest quintile had lower median scores than children from the wealthiest quintile. In addition, children 0–11 months had higher median scores than children 24–35 months.

When looking at each of the domains separately, 89.7 per cent of children 0–11 months are developmentally on-track in communication skills, 64.9 per cent on track in gross motor skills, 76.5 per cent on track in fine motor skills and 72.9 per cent on track in problem-solving skllls, as is shown in Figure 18. For children 24–35 months, 86.7 per cent are on-track in communication skills, 77.6 per cent in gross motor skills, 67.2 per cent in fine motor skills, and 81.2 per cent on track in problem-solving skills (see Figure 19).

Caregiver health and well-being

The health and well-being of a caregiver is important for the development of young children. In this study, a few indicators that are of importance for young children’s development were examined, including the mental health status of the primary caregiver, alcohol use by the primary caregiver, HIV status of the mother and complications during delivery.

Poor parental mental health, particularly maternal mental health, can lead to poorer developmental outcomes and nutritional status of children.22, 23 Alcohol abuse by caregivers

18 Squires, Jane, and Diane Bricker, ‘Ages and Stages Questionnaires’, Paul H. Brookes Publishing, Baltimore, Maryland, 2002.19 Fernald, Lia C. H., et al., ‘Examining Early Childhood Development in Low-Income Countries: A toolkit for the assessment of

children in the first five years of life’, The World Bank, Washington, D.C., 2009.20 Bornman, Juan, et al., ‘Successfully Translating Language and Culture when Adapting Assessment Measures’, Journal of

Policy and Practice in Intellectual Disabilities, vol. 7, no. 2, June 2010, pp. 111–118.21 Krebs, Nancy F., et al., ‘Complementary Feeding: A global network cluster randomized controlled trial’, BMC Pediatrics, vol.

11, no. 4, 2011.22 Patel, Vikram, et al., ‘Effect of Maternal Mental Health on Infant Growth in Low Income Countries: New evidence from

South Asia’, BMJ vol. 328, 2004, pp. 820–823.23 Wachs, Theodore D., Maureen M. Black, Patrice L. Engle, ‘Maternal Depression: A global threat to children’s health,

development, and behavior and to human rights’, Child Development Perspectives, vol. 3, no. 1, 2009, pp. 51–59.

“…when you play with the child and make it laugh, the child becomes happy and enjoys your company… the child says that even if my mother is poorly dressed, at least we are happy and able to tolerate our poverty until God will provide. Because of that warmth, the child is happy and content and has no problem.” Mother, Ngoma District


0

50

100

150

200

250

Wealthiest quintilePoorest quintile24—35 months0—11 monthsFemalesMales

210 210 215205 207

220

Figure 17. Median scores on the ASQ-3 disaggregated by sex, age and wealth quintile

0%

20%

40%

60%

80%

100%

Above cut-point (developmentally on-track)

Below cut-point (potential concern)

Personal social skillsProblem-solving skillsFine motor skillsGross motor skillsCommunication skills

10.3%

89.7%

35.1%

64.9%

23.5%

76.5%

27.1%

72.9%

26.1%

73.9%

Figure 18. Percentage of children 0–11 months old falling below and above the cut-point by ASQ-3 domains

0%

20%

40%

60%

80%

100%

Above cut-point (developmentally on-track)

Below cut-point (potential concern)

Personal social skillsProblem-solving skillsFine motor skillsGross motor skillsCommunication skills

13.3%

86.7%

22.4%

77.6%

32.8%

67.2%

18.8%

81.2%

21.6%

78.4%

Figure 19. Percentage of children 24–35 months old falling below and above the cut-point by ASQ-3 domains


and poor mental health can have negative effects on children from birth to adulthood.24, 25 For this baseline evaluation, the Hopkins Symptom Checklist (HSCL) was used to measure the primary caregiver’s symptoms of anxiety and depression. The tool has been validated previously in Rwanda and is a self-report measure.26 Scores above 1.75 were considered to be in the clinical range (i.e., likely suffering from depression and/or anxiety) based on a cut-point used in prior research on depression in Rwanda).27, 28

Among primary caregivers with a child younger than 1 year of age, 42.2 per cent indicated a score on the HSCL indicative of high levels of depression and anxiety symptoms. Of those with a child 24–35 months old, 40.7 per cent of caregivers displayed high levels of depression and anxiety symptoms. High levels of symptoms of anxiety and depression were more frequent in poor households. Poor caregiver mental health is well known to affect children’s development and so these high rates of poor mental health among caregivers require attention as a key area of intervention. Alcohol use was reported among 30 per cent of caregivers and was equally distributed among those with children younger than 1 year of age and those 24–35 months old.

Maternal health history

Two indicators related to the mother’s health were asked of all primary caregivers in this study. The first was whether the child was known to be exposed to HIV at birth due to maternal HIV infection and, secondly, whether the mother experienced any complications during delivery. Children exposed to HIV are at potential risk of developmental delays due to potentially compromised caregiving, and children with perinatal HIV infection may face

24 Hillis, Susan D., et al., ‘The Association between Adverse Childhood Experiences and Adolescent Pregnancy, Long-Term Psychosocial Consequencies, and Fetal Death’, Pediatrics, vol. 113, no. 2, February 2004, pp. 320–327.

25 Dube, Shanta R., et al., ‘Childhood Abuse, Household Dysfunction, and the Risk of Attempted Suicide throughout the Life Span: Findings from the adverse childhood experiences study’, Journal of the American Medical Association, vol. 286, no. 4, 2001, pp. 3089–3096.

26 Derogatis, Leonard R., et al., ‘The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory’, Behavioral Science, vol. 19, no. 1, January 1974, pp. 1–15.

27 Bolton, Paul, ‘Cross-Cultural Validity and Reliability Testing of a Standard Psychiatric Assessment Instrument without a Gold Standard’, Journal of Nervous & Mental Disease, vol. 189, no. 4, April 2001, pp. 238–242.

28 Bolton, Paul, Richard Neugebauer, and Lincoln Ndogoni, ‘Prevalence of Depression in Rural Rwanda Based on Symptom and Functional Criteria’, Journal of Nervous & Mental Disease, vol. 190, no. 9, 2002, pp. 631–637.

“Sometimes you may feel that you are not diligently fulfilling your responsibilities as a mother, like when you do not have anything to give to your child and the child starts crying, while others are alone and sad, in that case you feel that you have lost your pride as a parent.” Mother, Gasabo District

0%

10%

20%

30%

40%

50%

60%

70%

80%

Primary educationNo educationWealthiestPoorest

62.6

22.1

51.5

41.9

Figure 20. Primary caregiver displays high levels of depression/anxiety symptoms


additional developmental challenges.29, 30, 31 In Rwanda, national HIV prevalence is low compared with other countries in the region, at 3 per cent nationally and 2.3 per cent in rural areas.32 Overall, only 2 per cent of the children in the sample were born to biological mothers who were HIV-positive based on self-report of the primary caregiver, who was in most cases the biological mother. As shown in Figure 21, nearly all HIV-positive mothers (87 per cent) were aware of their HIV status during their pregnancy, and most received prevention of mother-to-child transmission (PMTCT) services (85 per cent).

Complications during the delivery of a child, such as pre-term delivery or low birth weight, can have negative effects on children’s developmental outcomes.33, 34 Hence, primary caregivers were asked to report if the mother experienced any complications. Nearly a quarter (22 per cent) of mothers experienced some form of complication, including requiring a Caesarean section, post-partum haemorrhage, pre-term delivery, etc. In Rwanda, uncomplicated deliveries are performed at health centres, and a delivery with any known complication requires referral and transfer to the district hospital.35

Communication for social and behaviour change

The ECD&F programme emphasizes communication campaigns to mobilize the community and support behaviour changes around effective and responsive care by the family. The baseline evaluation explored awareness of a number of communication initiatives focused on promoting parenting and child nutrition at the community level in Rwanda, including the 1,000 Days campaign of the Government of Rwanda supported by UNICEF, MIGEPROF’s Parenting Evening Talks (umugoroba w’ababyeyi) and the Ministry of Health’s community-based nutrition promotion programme with community health workers (CHWs). The 1,000 Days campaign is a social mobilization campaign aimed at improving nutrition among

29 Boivin, Michael J., et al., ‘A Year-Long Caregiver Training Program Improves Cognition in Preschool Ugandan Children with Human Immunodeficiency Virus’, Journal of Pediatrics, vol. 163, no. 5, 2013, pp. 1409–1416.

30 Boivin, Michael J., et al., ‘A Year-Long Caregiver Training Program to Improve Neurocognition in Preschool Ugandan HIV-Exposed Children’, Journal of Developmental and Behavioral Pediatrics, vol. 34, no. 4, 2013, pp. 269–278.

31 Filteau, Suzanne, ‘The HIV-Exposed, Uninfected African Child’, Tropical Medicine & International Health, vol. 14, no. 3, 2009, pp. 276–287.

32 Ministry of Health and ICF International, ‘Rwanda Demographic and Health Survey’, Ministry of Health, Kigali, 2012.33 Schonhaut, Luisa, Ivan Armijo, and Marcela Perez, ‘Gestational Age and Developmental Risk in Moderately and Late

Preterm and Early Term Infants’, Pediatrics vol. 135, no. 4, 2015, pp. 1–7.34 Burnett, Alice C., et al., ‘Executive Function in Adolescents Born <1000 g or <28 Weeks: A prospective cohort study’,

Pediatrics, vol. 135, no. 4, 2015, pp. e826–e34.35 Ministry of Health, ‘Services Packages for Health Facilities at Different Levels of Service Delivery’, Republic of Rwanda,

Kigali, 2011.

0%

20%

40%

60%

80%

100%

HIV+ mother received PMTCT services

HIV+ mother knew HIV+ status during pregnancy

Mother is HIV+

1.8

86.7 84.6

Figure 21: HIV exposure among children

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children under 5 years of age, in addition to pregnant/lactating mothers and school-going children. The Parenting Evening Talks are community conversations, for both men and women, where parents gather and discuss challenges that affect their families, including conflict.36 The Ministry of Health’s community-based nutrition programme provides monthly nutrition screening, cooking demonstrations and follow-up of malnourished patients.37

Overall, awareness of these programmes at the community level varied. For example, 36 per cent of the sample indicated that they had heard of the 1,000 Days campaign, 66 per cent had heard of the Parenting Evening Talks programme, and 50 per cent had heard of the cooking demonstrations by CHWs. However, it should be noted that the Parenting Evening Talks programme started in 2013, and the 1000 Days Campaign started in 2014, which will affect the level of awareness of these programmes. Awareness of all three programmes was higher at higher levels of wealth assets. For example, 20 per cent of primary caregivers from the poorest wealth quintile had heard of the 1,000 Days campaign, compared with 55 per cent of caregivers from the highest wealth quintile. While more primary caregivers overall were aware of the Parenting Evening Talks, only 57 per cent from the poorest wealth quintile were aware compared with 76 per cent from the wealthiest.

36 Ministry of Gender and Family Promotion, ‘Umugoroba w’Ababyeyi Strategy’, Republic of Rwanda, Kigali, 2014.37 Ministry of Health, ‘National Community Health Strategic Plan: July 2013–June 2018’, Republic of Rwanda, Kigali, 2013.

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b. Physical environment and well-being of young children

Child health

Child health has an important role in children’s development. The Millennium Development Goals (MDGs) set ambitious targets for improving child health and survival, and Rwanda has made great strides towards achieving health-related MDGs.38 Some critical interventions, such as immunizations, have led to tremendous improvements in child health and survival in Rwanda. Two indicators of children’s health were included on the ECD&F survey that are of particular concern in Rwanda – diarrhoea due to the interactions with malnutrition – and malaria, which remains a major threat to survival of children under 5.

Diarrhoea

Globally, diarrhoea is among the leading causes of mortality for children under 5.39 In Rwanda, it is the leading cause of death, accounting for nearly one in four deaths of children under 5. Most diarrhoea-related deaths occur as a result of dehydration from the loss of fluid and electrolytes. Dehydration from diarrhoea can be easily managed by treating the loss of fluids and electrolytes with oral rehydration salts (ORS) or a recommended homemade fluid (RHF) prepared with clean water, sugar and salts. In Rwanda, CHWs focused on child health are trained in Integrated Community Case Management (ICCM), which provides CHWs with education on ways to prevent and identify common childhood illnesses, including diarrhoea, and a basic package of curative treatments for malaria, diarrhoea and pneumonia.40

In the baseline survey, the prevalence of diarrhoea was estimated by asking mothers or caretakers whether their child under 5 years of age had an episode of diarrhoea in the two weeks prior to the survey. In cases where mothers reported that the child had diarrhoea, a series of questions were asked about the treatment of the illness.

38 Farmer, Paul E., et al., ‘Reduced Premature Mortality in Rwanda: Lessons from success’, BMJ, 2013, p. 346.39 National Institute of Statistics, ‘Fourth Population and Housing Census, Rwanda, 2012: Mortality thematic report’,

Government of Rwanda, Kigali, 2014.40 Ministry of Health, ‘National Community Health Strategic Plan: July 2013–July 2018’, Republic of Rwanda, Kigali, 2014.

Some critical interventions, such as immunizations, have led to tremendous improvements in child health and survival in Rwanda.

0%

5%

10%

15%

20%

25%

30%

ORS or RHFRHFORS

23.4

7.8

28.6

Figure 22: Type of treatment sought for diarrhoea among children 0–11 months old for whom treatment was sought

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Overall, 29 per cent of children 0–11 months old and 28.7 per cent of children 24–35 months old had diarrhoea in the two weeks preceding the survey, and caregivers sought some form of treatment in nearly two thirds of cases. Due to low numbers, it is not possible to reliably disaggregate further.

Out of those who sought treatment, 29 per cent of children 0–11 months old received a recommended treatment of ORS or RHF, as seen in Figure 22. As shown in Figure 23, 40 per cent of children 24–35 months old in the sample received either ORS or RHF to address loss of fluids and electrolytes caused by diarrhoea.

Malaria

Remarkably, deaths from malaria declined nearly 90 per cent from 2005 to 2011.41 However, malaria still contributes to approximately 6 per cent of under-five deaths in Rwanda.42 Preventive measures, such as the use of insecticide-treated mosquito nets, can greatly reduce malaria morbidity. Additionally, prompt treatment with known-effective regimens drastically reduces the risk of mortality.

The percentage of households in Rwanda having a mosquito net is impressive. With the exception of the site in Nyabihu District, more than 80 per cent of all households included in the baseline evaluation owned at least one, with rates exceeding 90 per cent in many areas. The high coverage is likely due to the Rwanda Ministry of Health’s efforts to mass-distribute long-lasting insecticide-treated nets across the country, as part of the National Malaria Control Programme. Overall, ownership appeared to be more limited among the poorest households, with 74 per cent of households in the poorest wealth quintile owning a net, compared with 97 per cent of households in the top wealth quintile.

Among all children 0–11 months old in the sample, 79 per cent slept under a mosquito net the night before the survey. Moreover, children in that age cohort were reported to sleep under a mosquito net more frequently as relative poverty levels decreased: 65 per cent of children 0–11 months old from the poorest wealth quintile slept under a net, compared with 91 per cent in the wealthiest quintile. As the primary caregiver’s education levels increased, mosquito net usage also increased. Only 68 per cent of children 0–11 months

41 Farmer P, Nutt C, Wagner CM, Sekabaraga C, Nuthulanganti T, Weigel JL, et al. ‘Reduced premature mortality in Rwanda: lessons from success’. BMJ. 2013;346.

42 National Institute of Statistics ‘Fourth Population and Housing Census, Rwanda, 2012: Mortality Thematic Report’ Rwanda: Government of Rwanda, Kigali 2014.

0%

5%

10%

15%

20%

25%

30%

35%

40%

ORS and RHFRHFORS

29.1

15.1

39.5

Figure 23: Type of treatment sought for diarrhoea among children 24–35 months old for whom treatment was sought


old whose primary caregivers had not completed any formal education used a mosquito net, compared with 95 per cent of those whose caregivers had completed secondary school or higher. Similarly, 72 per cent of children whose caregivers were illiterate used mosquito nets compared with 81 per cent of children whose caregivers were literate.

When looking only at households that reported having a net, 90 per cent of children 0–11 months old were reported to have slept under a mosquito net the night preceding the survey.

In the two weeks preceding the survey, fever prevalence among children 0–11 months old was 39 per cent, and the primary caregiver sought treatment for the child’s fever in just more than half of those cases. Treatment-seeking for children 0–11 months old was also higher among households with health insurance coverage for at least one member (63 per cent) than in households with no insurance (47 per cent).

Water and sanitation facilities

Proper water, sanitation and hygiene are important components of early childhood development, affecting health, nutrition, education and protection outcomes. The baseline evaluation assessed households’ access to improved water and sanitation, and hygiene practices. Following international standards, improved water source is considered as any of the following of a household’s primary source of drinking water: piped water into dwelling/yard/plot, public tap/standpipe, tube well/borehole, protected dug well, protected spring and rainwater. Improved toilet facilities include flush to piped sewer system, flush to septic tank, flush to pit latrine, ventilated improved pit latrine, pit latrine with slab and composting toilet.

Of the households surveyed, 76.5 per cent reported access to an improved water source, and 69.1 per cent of households reported to have access to an improved sanitation facility. Not surprisingly, access to improved water sources and improved sanitation facilities increased as relative poverty decreased. Improved water sources were present for 69 per cent of households from the poorest wealth quintile, compared with 81 per cent in the highest wealth quintile. Differences in access to improved sanitation facilities were even greater, with half of households from the poorest wealth quintile having an improved sanitation facility, compared with 92 per cent in the highest wealth quintile. Access also increased with increased levels of primary caregiver education.

0%

20%

40%

60%

80%

100%

HH health insurance for at least 1 member

HH has no health insurance

Caregiver literate

Caregiver illiterate

WealthiestPoorest

64.5

90.8

71.7

80.7

65.1

86.5

Figure 24: Use of mosquito net night before survey (children 0–11 months old)


In terms of access to improved water and sanitation facilities, substantial variations were found across the 20 sites in the 10 districts. For water, more than 90 per cent of households had access to an improved water source in the sites in Ngoma, Nyabihu and Nyarugenge Districts, while less than a third of households had access to improved water in the Gakenke District. In terms of sanitation, access to improved sanitation facilities was

Of the households surveyed, 76.5 per cent reported access to an improved water source, and 69.1 per cent of households reported to have access to an improved sanitation facility.

0% 10% 20% 30% 40% 50%

Public tap/standpipe

Unprotected spring

Rainwater

Tanker truck

Surface water

Tube well or borehole

Protected spring

Piped into yard/plot

Protected dug well

Piped into dwelling

Other

Bottled water 0

0

1

1

2

2

2

5

5

16

22

44

Figure 25: Type of improved water source

0% 10% 20% 30% 40% 50% 60%

Pit latrine with slab

Pit latrine without slab/open pit

Ventilated improved pit latrine

Other

Composting toilet

Flush to pit latrine

Flush to septic tank

Flush to piped sewer system

None (bush, field, stream) 0

0

0

0

2

5

9

26

58

Figure 26: Type of improved sanitation facility

Table 2. Access to improved water and improved sanitation

Improved water (%) Improved sanitation (%)

Total 76.50 69.10

Household wealth quintile

1 (Poorest) 69.20 50.00

2 74.60 61.90

3 78.30 66.30

4 79.30 76.50

5 (Wealthiest) 81.40 92.40

Primary caregiver’s highest level of education

No education 76.20 60.00

Primary 75.20 66.90

Secondary and higher 84.30 89.90


highest in the site in Gasabo (84 per cent), and lowest in the surveyed sites in Gicumbi and Ruhango. Public taps were the most common source of drinking water, and latrines with slabs were the most common type of sanitation. A breakdown of the types of improved water sources is presented in Figure 25 and the types of improved sanitation facilities are displayed in Figure 26.

Of the households with unimproved water sources, 63 per cent appropriately treated water before drinking. Appropriate water treatment methods prior to drinking include boiling, bleaching, straining, filtering and solar disinfecting. Treating water is more common as relative levels of poverty decrease, with 57 per cent of households in the poorest wealth quintile appropriately treating water, compared with 78 per cent from the highest wealth quintile. By far the most common method for treating water was boiling, as shown in Figure 27.

Safe drinking water requires an improved water source or appropriate treatment of water from an unimproved water source, as well as safe storage of water in a closed container in order to prevent contamination. Less than half of the households surveyed stored water in a closed container. Far more households in the highest wealth quintile stored water in a closed container (69 per cent), compared with 33 per cent of households in the poorest wealth quintile. Large increases in safe water storage were also seen as the primary caregiver’s education increased, with only 29 per cent of households where the primary caregiver had not completed formal education storing water safely, compared with 43 per cent of those who had completed primary school and 76 per cent of those who had completed secondary school.

Hand washing

Hand washing is a critical component in battling diseases and malnutrition. In addition to asking households if they had a designated place for hand washing, surveyors verified the information by observation (see Figure 28). According to the standard MICS indicator for a place for hand washing, only those households that have a designated place with soap or another cleansing agent present are considered to have a place for hand washing. In the baseline survey, less than 1 per cent of households had a designated place for hand washing that excluded jerry cans or basins at which water and soap/cleansing agent were present. Only 6 per cent of households presented to the interviewer a designated place to wash hands; soap was only present at 27 per cent, water was available at 48 per cent, and only 4 per cent had both soap and water at the time of interview.

0%

20%

40%

60%

80%

100%

OtherAdd bleach/chlorineBoil

94.7

11.5

.8

Figure 27: Types of water treatment used among households that treat water

In the baseline survey, less than 1 per cent of households had a designated place for hand washing that excluded jerry cans or basins at which water and soap/cleansing agent were present.


Primary caregivers were also asked to report if there were times when they always wash their hands, and, if so, when those times were. Nearly all (93 per cent) of caregivers said there were specific times when they always washed their hands. Caregivers were then asked to list the times when they always washed their hands, and were not prompted about potential times to avoid social desirability bias. As shown in Figure 29, the most

0%

20%

40%

60%

80%

100%

Observed with soap/cleansing agent only

Observed with water only

Observed with both water andsoap/cleansing agent

Designated place observed

Of household with an observed place for handwashing

Of all households

5.90.2 1.6 2.8

100

3.9

26.9

48.1

Figure 28: Hand-washing facilities and availability of water and soap or other cleansing agents

Figure 29: Times when primary caregivers reported always washing their hands

0%

10%

20%

30%

40%

50%

60%

70%

80%

Other timesAfter cleaning child who defecated

After using the toilet

Before feeding child

After mealsBefore mealsBefore preparing food

7.6

69.7

8.715.5

34.1

2.7

48.3

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commonly mentioned time was before meals, and nearly all of the responses coded as other related to washing hands after work or being in the fields.

Safe stool disposal

Safe disposal of a child’s faeces is defined as the disposal of the child’s last stool by having the child use the toilet, or the faeces being put or rinsed into a toilet or latrine. Safe disposal of a child’s faeces was found in 62 per cent of households with a child 0–11 months old. Increases in the percentage of households who disposed of a child’s faeces in a safe manner were observed as relative poverty decreased; less than half of households in the poorest wealth quintile safely disposed of the faeces of children 0–11 months old, compared with 75 per cent of households in the highest wealth quintile. Safe disposal of faeces also increased as the primary caregiver’s literacy and level of education increased.

Figure 31 shows the methods used to dispose of children’s faeces. The most common method was putting/rinsing faeces into a toilet or latrine, which is a safe method of disposal. Unsafe practices such as throwing faeces into a ditch or the garbage allow for contamination of water and the transmission of diseases.

0%

10%

20%

30%

40%

50%

60%

70%

80%

Caregiver literateCaregiver illiterateWealthiestPoorest

48.4

74.5

58.4

65.1

Figure 30. Safe disposal of faeces of children 0–11 months old

0% 10% 20% 30% 40% 50% 60%

Pit latrine with slab

Pit latrine without slab/open pit

Ventilated improved pit latrine

Other

Composting toilet

Flush to pit latrine

Flush to septic tank

Flush to piped sewer system

None (bush, field, stream) 0

0

0

0

2

5

9

26

58

Figure 31: Methods of sanitary disposal of children’s faeces


Malnutrition

Proper nutrition is a good indicator of child’s overall health. Malnutrition contributes to poor health and poor development of young children. Undernourished children who survive are more likely to suffer from common illnesses43 and are less likely to reach their growth and developmental potential.44 A child is well nourished if he or she has access to sufficient and diverse foods and is not exposed to repeated illnesses, such as parasitic infections, which can prohibit the absorption of essential nutrients.

Rwanda has made great strides in reducing acute malnutrition, with national rates at 2 per cent in 2014/15 compared with 5 per cent in 2005. Likewise, incredible strides have been made in reducing stunting, from 51 per cent in 2005 to 38 per cent in 2014/15 (Demographic Health Surveys 2005 and 2014/15). Three measures of malnutrition in this report were calculated using measurements of children’s weight and height/length: stunting, wasting and underweight. World Health Organization Growth Standards were used as the reference point for determining children who were malnourished.45 Children whose height-for-age is more than two standard deviations below the median of the reference population are considered short for their age and are classified as moderately or severely stunted. Stunting is a reflection of chronic malnutrition as a result of failure to receive adequate nutrition over a long period and recurrent or chronic illness.

43 Schaible, Ulrich E., and Stefan H. E. Kaufmann, ‘Malnutrition and Infection: Complex mechanisms and global impact’, PLoS Medicine, vol. 4, no. 5, 2007, p. e115.

44 Grantham-McGregor, Sally, et al., ‘Developmental Potential in the First 5 Years for Children in Developing Countries’, The Lancet, vol. 369, no. 9555, 2007, pp. 60–70.

45 National Institute of Statistics of Rwanda (NISR), Ministry of Health (MOH), and ICF International, ‘Rwanda Demographic and Health Survey 2014–15: Key Indicators’. NISR, MOH, and ICF International, Rockville, Maryland, 2015.

“There are instances where a parent realizes that his/her children are going to go to bed on an empty stomach and asks other parents for foodstuffs or something to drink, or porridge for a child.” Mother, Rwamagana District

0%

10%

20%

30%

40%

50%

60%

70%

80%

Caregiver literate

Caregiver illiterate

WealthiestPoorest Female childMale child

49.7

43

52.6

41.8

61.2

39.9

Figure 32: Prevalence of stunting among children 24–35 months old

GAM

No GAM

MAM 4%

SAM 2%

94% 6%

Figure 33: Global acute malnutrition


Overall, 46 per cent of children 24–35 months old were stunted, and 16 per cent were severely stunted. As shown in Figure 32, stunting rates showed trends of decreasing as wealth increased, with children 24–35 months old whose caregivers were illiterate (61 per cent) being more often stunted than children whose caregivers were literate (40 per cent). As is expected, there were geographic differences in stunting rates; however, there were too few observations per project site to make inferences. Stunting rates were much lower for younger children, with an average of 16 per cent for children younger than 12 months observed in the sample.

Prevalence of underweight among children 24–35 months old was 12 per cent in the sample. Prevalence of wasting was not possible to measure due to extremely small number of observations among children 24–35 months old.

In addition, data on children’s middle upper arm circumference (MUAC) were collected. MUAC is commonly used as a quick screening tool to identify children who are moderately or severely malnourished. GAM (global acute malnutrition) is further broken down into two ‘zones’, a yellow zone for moderate acute malnutrition (MAM) and a red zone for severe acute malnutrition (SAM) zone. As shown in Figure 33, 6.5 per cent of all children sampled met criteria for GAM, 4.4 per cent were in the yellow/MAM zone and 2.2 per cent were in the red/SAM zone.

Infant and young child feeding practices

Good feeding practices, in addition to other factors such as exposure to illnesses, hygiene and access to improved sanitation, are important drivers of a child’s nutritional status. Breastfeeding for the first few years of life protects a child from infection, provides an ideal source of nutrients, and is economical and safe, particularly in settings where access to clean water is a challenge. The World Health Organization recommends exclusive breastfeeding until a child is 6 months old, with an introduction of complementary foods at that time. Ongoing breastfeeding until a child is 24 months old or even longer is also recommended because of the nutritional benefits.

Among children younger than 6 months of age in the sample, rates of exclusive breastfeeding were high (90 per cent). There was little variation in exclusive breastfeeding across wealth quintiles or caregiver education levels.

In the sample, 59 per cent of children were receiving the minimum meal frequency, and even in the highest wealth quintile, 31 per cent of children did not receive an adequate number of meals in the previous day.

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Appropriate complementary feeding of children from 6 months to 2 years of age is particularly important for growth and development and the prevention of undernutrition. Continued breastfeeding beyond 6 months of age should be accompanied by consumption of nutritionally adequate, safe and appropriate complementary foods that help meet nutritional requirements when breast milk is no longer sufficient. For children 6 months to 2 years of age, meeting the minimum acceptable diet requirements needs age-appropriate meal frequency and dietary diversity in addition to adequate breastfeeding or milk intake.

Table 3 indicates that only 13 per cent of children 6–11 months old were receiving the minimum acceptable diet (four meals per day including four or more food groups). This was primarily driven by a lack of dietary diversity. Fifty-nine per cent of children were receiving meals at a minimum frequency. Figure 34 shows that appropriate complementary feeding practices increase with wealth of the household. However, even in the wealthiest households one third of children were not receiving the minimum recommended meals in the previous day.

Table 3: Minimum acceptable diet for children 6–11 months old

Minimum acceptable diet Diet characteristics of children 6–11 months old

Minimum dietary diversity Minimum meal frequency (n=244)

Total N N Per cent N Per cent N Per cent

Total 244 31 (12.7%) 31 (12.7%) 143 58.6%

Food security and coping strategies

One potential contributor to a poor diet is food insecurity of the households. Items from Rwanda’s Comprehensive Food Security and Vulnerability Analysis (2012) were used to evaluate household food insecurity. Primary caregivers were asked whether they had to do any of the following in the past week because they did not have enough food or enough money to buy food: (1) Rely on less-preferred and less-expensive foods; (2) Borrow food, or rely on help from a friend or relative; (3) Limit portion size at mealtimes; (4) Restrict consumption by adults in order for small children to eat; (5) Reduce the number of meals eaten in a day. Endorsing any one of these behaviours categorized a household as food insecure in this survey.

Figure 34: Minimum meal frequency and dietary diversity by wealth quintile

52.9

13.7

54.2

6.3

53.1

6.1

63.6

11.4

69.2

25.0

0%

10%

20%

30%

40%

50%

60%

70%

80%

Minimum dietary diversity

Minimum meal frequency

Quintile 5 (wealthiest)Quintile 4Quintile 3Quintile 2Wealth quintile 1 (poorest)


Overall, 79 per cent of caregivers reported they did not have enough food or money to purchase food for at least one day in the past week. Not surprisingly, poorer households reported greater food insecurity than wealthier households. Some 93 per cent of households in the poorest wealth quintile reported not having enough food or money to purchase food in the past week, compared with 54 per cent of households in the wealthiest quintile. It is important to stress again that the wealth quintiles are a measure of relative poverty, and with more than half of the households in the ‘wealthiest’ quintile lacking enough food or money to buy food, these households were by no means wealthy. Food insecurity also varied by project sites.

The most common coping strategy was to rely on less preferred and less expensive foods, followed by limiting portion size at meal times. The least common strategy was borrowing food or relying on help from a friend or relative. Given the high rates of household food insecurity across the communities included in the survey, it is possible that this was not a feasible nor sustainable option for many families.

Figure 36. Coping strategies to address household food security

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

Reduced number of meals eaten in a day

Restricted consumption by adults in order for small children to eat

Limited portion size at mealtimes

Borrowed food or relied on help from friend or relative

Relied on less preferred and less expensive food

5 (wealthiest)4321 (poorest)

3.58

0.77

2.92

1.67

2.37

3.22

0.7

2.55

1.341.62

2.92

0.58

2.07

1.12 1.27

3.1

0.43

1.85

1.03 1.11

1.67

0.19

0.87

0.47 0.49

Figure 35: Household food insecurity during the past seven days

0%

20%

40%

60%

80%

100%

Caregiver literate

Caregiver not literate

PrimaryNo education


92.685.6 82.5 80.5

54.1

86.280.6

86.4

77.6


7. Improved access to and use of quality ECD and other basic social services for young children

The second objective of the ECD&F programme outlines the importance of quality ECD and other basic services for young children. If family is the first line of influence on young children’s optimal growth, quality basic social services are the second line of influence, which complement the family’s effort. These services and the corresponding results of the ECD&F baseline in the 20 sites in 10 districts are outlined in the following chapters.

Access to ECD services

Access to ECD services was defined as the proportion of children 0–11 months old and 24–35 months old who attended an early learning or early childhood education programme.

Access to ECD services was limited in this sample, with only 3.3 per cent of children 0–11 months old accessing services, followed by 9.7 per cent of children 24–35 months old (see Figure 37). Due to the small number of observations of children accessing ECD services, further disaggregation of this indicator could not be explored. It is important to note, however, that the only significant difference between intervention sites and comparison sites in the baseline evaluation was on access to ECD services; children in ECD&F intervention sites were significantly more likely to access ECD services, probably due to the initiation of some services at some ECD&F centres shortly before data collection.

In addition to asking about access to ECD services for the index child (0–11 months old or 24–35 months old), the survey also asked about access to nursery school or pre-primary education for children 4–6 years old in the household. More than a quarter (27 per cent) of children 4–6 years old attended a nursery or pre-primary classes, the mean age of children attending nursery being 5 years of age. The percentage of children attending nursery or pre-primary classes increase with wealth, mother’s education and literacy.

“We usually love to see our children excited to go to school. However, we can’t afford to cater to our children’s scholastic needs due to the curse of poverty.” Mother, Rwamagana District

In the sample, access to ECD services was limited, with only 3.3 per cent of children 0–11 months old accessing services, followed by 9.7 per cent of children 24–35 months old.

“There is a nursery school; [however] it is very far and young children in my village cannot walk that long distance. Even this child of mine aged 5 years cannot manage to walk that distance… Let us hope that in the future our children will access school facilities.” Mother, Gasabo District

Figure 37. Child attendance at any organized learning or ECD programme

0%

20%

40%

60%

80%

100%

No

Yes

24-35 months0-11 monthsOverall

6.4

93.6

3.3

96.7

9.7

90.3


Health insurance

Rwanda’s health system is financed both by state funds and by individuals’ contributions through health insurance and direct fees for services. Health insurance is provided through a variety of programmes, the largest of which is the Community-Based Health Insurance Scheme, known as mutuelle de santé, which has increased access to health services and contributed to drastic reductions in child morbidity and mortality.46, 47 Mutuelle de santé was launched in 2003, after a small pilot, as an innovative programme to increase access to care and decrease out-of-pocket expenditures in a way that would be sustainable for the health system. Mutuelle de santé provides access to a core package of services, and enrolled participants pay only a minimal flat-rate co-payment when visiting health centres, as well as a percentage of the cost of services at district hospitals. Annual subscription fees are based on a sliding scale, depending on Ubudehe status.

A series of questions regarding health insurance coverage was asked in the survey to assess household health insurance coverage, coverage of individual members of the household and the type of insurance coverage. It should be noted that the figures of insurance coverage reported in this summary are somewhat below the levels reported nationally. The timing of the survey contributed to lower levels of enrolment than expected. The mutuelle de santé programme begins enrolment each year in July and households are required to pay the premium for the entire year upon enrolment, which can lead to delays in registration and gaps in insurance coverage. Health insurance coverage increased significantly throughout the data collection period, with higher rates of any household health insurance coverage in October, when the study finished, compared with August, when the study began.

Overall, 60.8 per cent of the sample indicated that any household member had health insurance. Most of the insurance coverage observed (92.7 per cent) was insurance through mutuelle. Insurance coverage was lower in the poorest households – nearly twice as many households in the highest wealth quintile (79 per cent) had some insurance coverage, compared with 43 per cent in the lowest wealth quintile. Forty-two per cent had no health insurance. When poor households do have health insurance coverage, it is almost always through the mutuelle programme; 99 per cent of households in the poorest wealth quintile with health insurance were covered by mutuelle.

46 Farmer, Paul E., et al., ‘Reduced Premature Mortality in Rwanda: Lessons from success’, BMJ, 2013, p. 346.47 Logie, Dorothy E., Michael Rowson, and Felix Ndagije, ‘Innovations in Rwanda’s Health System: Looking to the future’, The

Lancet, vol. 372, no. 9634, 2008, pp. 256–261.

Figure 39: Health insurance coverage by month of data collection

0%

10%

20%

30%

40%

50%

60%

70%

80%

October

September

August

Index child covered by insuranceAny member of the household is insured

48.5 52.0

77.9

41.8 44.2

67.3

Figure 38: Health insurance coverage among children in this study

Insu

red

Uni

nsur

ed

52% 48%

“Unfortunately I stopped taking [my child] back to the health facility due to limited financial means; it is not because I hate my child; it is because I do not have means and there is nothing else I can do.” Mother, Nyabihu District


Of insured households, 28 per cent did not have full coverage for all members of the household. In addition, among households with insurance, not all children were covered; overall, about half of the children were covered by health insurance (see Figure 39).

Access to selected health services

The baseline evaluation also assessed children’s access to selected key routine health services – i.e., deworming, growth monitoring and home visits by CHWs.

Deworming is important for young children, as worms and other parasitic infections are endemic in Rwanda. Persistent infection with worms and other parasites has detrimental effects on children’s health, nutrition and subsequent development. Overall, 59 per cent of children in the sample received deworming treatment in the past six months ; the percentage was higher among children 24–35 months old (86 per cent) compared with 33.6 per cent of those younger than 1 year of age. Children in wealthier households were more often dewormed in the past six months (66 per cent) compared with children from the poorest wealth quintile (55 per cent).

Given Rwanda’s focus on addressing high levels of chronic malnutrition, monthly growth monitoring is part of standard care for children under 5 according to the National Community Health Strategic Plan and the National Food and Nutrition Policy.48, 49 The growth of approximately 60 per cent of the children surveyed was monitored. This was consistent across poverty levels and primary caregiver education, with some geographic variation across the project sites.

CHWs are central to the Rwandan health system. With tens of thousands of CHWs across the country, they are the frontline for prevention, detection, referral and treatment in the case of common childhood illnesses. Routine (monthly) home visits by community health workers are part of the national programme. More than one third of children included in the sample were visited by the CHW within the month prior to the survey.

48 Ministry of Health, ‘National Community Health Strategic Plan: July 2013–July 2018’, Republic of Rwanda, Kigali, 2013.49 Ministry of Local Government, Ministry of Health, and Ministry of Agriculture and Livestock Resources, ‘Rwanda National

Food and Nutrition Policy’, Republic of Rwanda, Kigali, 2013.

“You know the government health programme provides for community health workers. Community health workers support parents by sensitizing them on how they should bring up their children. For instance, I know how to care for and bring up my children, how to prepare a balanced diet, how to save children from injuries and fractures, child hygiene, washing clothes for the child, teach good behaviour and politeness to the child; as you know, bringing up a child does not mean providing food only. You also help the child to develop its thinking capacity so as to develop it intellectually.” Mother, Gasabo District

Figure 40: Child dewormed in past six months

0%

20%

40%

60%

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100%

WealthiestPoorest24—35 months0—11 months

33.6

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Birth registration

The International Convention on the Rights of the Child states that every child has the right to a name and a nationality and the right to protection from being deprived of his or her identity. As outlined in the Integrated Child Rights Policy50 from the Rwanda Ministry of Gender and Family Promotion, all children born in Rwanda must be registered within 15 days of birth. Based on this policy, it would be assumed that all children enrolled in the study should have been registered with the local authorities, as the minimum age of children in the study was 18 days.

Only 62 per cent of caregivers in the study reported that their child had a birth certificate, although 76 per cent of caregivers reported that their child’s birth was registered with the civil authorities. Fewer children in the poorest wealth quintile were registered (67 per cent), compared with more than 76 per cent in each of the other four wealth quintiles. Some variation in birth registration by project site was reported, with more than half of the children in the sites surveyed in Ruhango District not being registered, compared with only 8 per cent of children in the sites in Gakenke District who were not registered at the time of study.

50 Ministry of Gender and Family Promotion, ‘Integrated Child Rights Policy’, Republic of Rwanda, Kigali, 2011.

Figure 41: Child registered with civil authorities, by wealth quintile

0%

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40%

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100%


6776 77

81 80

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8. Overall conclusions and recommendations

This summary report of the ECD&F baseline evaluation shows an interesting picture of great promise as well as some challenges for Rwanda’s progressive ECD policy. In many analysed domains, Rwanda’s remarkable progress made over the past years is strongly apparent: an overwhelming majority of households have access to improved water and improved sanitation, and access to mosquito nets in their homes. All these are key interventions for improving child health, and undoubtedly are key drivers of the large improvements in child survival achieved in the country over the past two decades. As an increasingly large

percentage of infants survive, Rwanda’s policy focus gradually shifts towards improving other aspects of children’s early life experiences in order to ensure that children will be able to fully reach their developmental potential. The Government of Rwanda recognizes this need and highlights the importance of ECD through the national ECD policy and strategy. In addition, ECD and nutrition have been recognized as foundational requirements for achieving ambitious economic development goals for the country.

As previously noted, the ECD&F baseline evaluation is not nationally representative and the sites sampled for the study were selected for their high levels of poverty and rural location. For children growing up in these impoverished communities, targeted ECD services have the potential to bring about more positive changes. As the results presented in this report show, children’s home environments are not always ideal: many primary caregivers lack basic education and struggle with stress/anxiety, food availability remains limited, and malnutrition continues to affect nearly half of 2-year-olds in the surveyed sites. Malnutrition is surely still compounded by inadequate hygiene practices and limited use of proper treatments to address dehydration caused by diarrhoea. While the country mobilizes to address the challenges of chronic malnutrition, immediate interventions to promote stimulation and cognitive development are essential to counteract the negative effects of undernutrition and high rates of poverty and daily stressors, particularly in the lives of poor families. Further support to caregivers can help to counteract the damage done by living in environments of compounded adversity and help children reach their full developmental potential.51

The contexts of child rearing and caregiver well-being are closely related. In the households surveyed, parental interactions with children were sometimes limited and frequently involved harsh discipline, few early learning materials, and limited access to early learning centres. In addition, caregivers faced numerous challenges, including physically difficult work in settings far from home. There are, however, opportunities to integrate both preventative programmes to reduce violence and to enhance parenting interactions at the household level, as well as opportunities to re-examine options for work and childcare among Rwanda’s most vulnerable families.

Given the array of ECD models being explored, it appears that both generalized models like ECD centres as well as more targeted models like family home visiting for especially vulnerable families are needed. Given such investments, the Government of Rwanda and UNICEF are poised to make timely and critical contributions to supporting families and promoting child development in children living in poverty, and have an excellent opportunity to evaluate the impact of innovative approaches to delivery of ECD services in Rwanda.

51 Shonkoff, Jack P., ‘Building a New Biodevelopmental Framework to Guide the Future of Early Childhood Policy’, Child Development, vol. 81, no. 1, 2010, pp. 357–367.©

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Appendices 45

Appendices

Appendix 1: Study sites 46

Appendix 2: Study methods and data analysis 47

Enrolment 47

Selection and training of data collectors 47

Data collection procedures 47

Study instruments 49

Data analysis 50

Appendix 3: Sample and sampling plan 51

Appendix 4: Primary indicator definitions 53

Appendix 5: 95% confidence intervals for main indicators 57

Appendix 6: Comparison of intervention and control sites 60

Appendix 7: Site profiles 61

Minazi Sector (Gakenke District) site profile 61

Gikomero Sector (Gasabo District) site profile 62

Miyove Sector (Gicumbi District) site profile 63

Zaza Sector (Ngoma District) site profile 64

Bigogwe Sector (Nyabihu District) site profile 65

Kizibere Sector (Nyamagabe District) site profile 66

Cyato Sector (Nyamasheke District) site profile 67

Mageragere Sector (Nyarugenge District) site profile 68

Mbuye Sector (Ruhango District) site profile 69

Munyiginya Sector (Rwamagana District) site profile 70


Appendix 1: Study sites

The selection of communities to receive the first ECD&F centres was conducted in close collaboration with the Government of Rwanda and district authorities, in particular vice-mayors in each implementing district. A three-step process was used with clear criteria implemented at each step for identifying ECD&F sites. These steps were as follows:

1. Identification of sectors for ECD&F services based on the following criteria:

a. A sizeable population of children between 0 and 6/7 years of age (before primary school entry)

b. Limited support from government, non-governmental organizations and faith-based organizations to ECD facilities and services

c. Active Vision Umurenge Programme (VUP) social protection programmes (VUP 1 or 2 ranking indicating that they were some of the first sectors selected to receive the VUP programme)

2. Pre-selection of two potential communities within the identified sector based on the following criteria:

a. Location within the community at maximum 500 metres walking distance from households where the ECD&F centre could be constructed

b. Availability of basic social services (health centre/CHWs; primary or nine years basic education school) in the neighbourhood at two kilometres maximum walking distance from households

c. Land or space available for construction or rehabilitation of basic ECD facilities (30 m x 30 m minimum)

3. A meeting at the district office between UNICEF, district authorities and other stakeholders to discuss the modelling of ECD services and a visit to the two pre-selected potential sites to reach a final decision for site selection.

The average percentage of poor households (defined as those in Ubudehe category 1 or 2) in the ECD&F treatment sites was 30 per cent, according to national Ubudehe data from 2012, and it was 33 per cent in the comparison sites. The average number of households in each village was similar according to the 2010 national database, with an average of 164 homes in ECD&F sites and 153 households in comparison sites.

Table 4: Study sites

District Sector ECD&F intervention sites Comparison/control sites

Gankenke Minazi Munyana CellKanka,* Nyabitare, Kivuba

Gakenke CellKabuga, Nyarubuye

Gasabo Gikomero Murambi Cell Twina*Gasagara CellRugwiza

Gicaca CellNtaganzwa, Nyagasozi

Gicumbi Miyove Miyove CellNyamiyaga,* Murehe

Mubuga CellKacyiru

Ngoma Zaza Ruhinga CellNyagahandagazi,* Gasebeya

Nyagatugunda CellJyambere, Kizenga, Rebero

Nyabihu Bigogwe Kijote CellBikingi*

Rega CellKagano, Ngaregare

Nyamagabe Kibirizi Bugarura CellMuyange,* Uwinyana

Ruhunga CellGakoma, Nyagishubi

Nyamasheke Cyato Rugali CellKarambo,* Rwumba, Rubeho

Bisumo CellKayo, Mutuntu

Nyarugenge Mageragere Nyarurenzi CellIterambere*

Kankuba CellKankuba, Karukina

Ruhango Mbuye Nyakarekare CellJali,* Nyakarekare

Kizibere CellRuhuha, Bereshi, Kizibere

Rwamagana Munyiginga Cyimbazi CellNtunga*Cyarukamba CellKagarama

Cyarukamba CellNdago Nyarubuye CellKiyovu, Kabeza

* Indicates the umudugudu where the ECD&F centre is located.

Appendices 47

Appendix 2: Study methods and data analysis

Enrolment

For the baseline evaluation, eligibility criteria of the randomly sampled households were reviewed during recruitment; particular attention was paid to reviewing a formal document indicating the birth date of the child (see Figure 42). During this process, 402 randomly sampled households were determined to be ineligible for the study. Of 900 eligible households, two refused to participate in the study, 12 were unable to be interviewed after multiple attempts, and two children had passed away (response rate 98.2 per cent). The final sample consisted of 884 caregiver-child pairs.

Key informant interviews were completed with 41 caregivers and 40 ECD stakeholders across all 20 project sites in 10 districts. Nearly all of the caregivers interviewed were mothers, as they are predominantly responsible for raising young children, but two participants were fathers. The diverse group of ECD stakeholders included teachers from nursery schools and early primary schools, CHWs or community health coordinators, village leaders including village chiefs, religious leaders, women leading parenting evening talks (umugoroba w’ababyeyi) and cell or sector local authorities.

Selection and training of data collectors

Data collectors were selected based on prior experience with quantitative data collection, with a preference for candidates who had previous household data collection experience or experience working with children. The data collection team consisted of 12 Rwandan data collectors and two field coordinators. The team received extensive training, including six full days of didactic and practice-based training at the Rwinkwavu PIH Centre for Training and Operational Research and several supervised pilot interviews. Debriefings were held weekly during the piloting to discuss any challenges with the survey instrument or study procedures. The training covered study procedures, research ethics, qualitative interview methods, introduction to ECD and ECD assessment, and extensive review of the study tools and use of the handheld data collection devices. This was done to ensure that data collectors were comfortable with the study procedures and administration of the survey on Android tablets and the instruments delivered using paper surveys – the Home Observation for the Measurement of the Environment (HOME inventory) and the Observation of Mother-Child Interactions (OMCI). Additionally, training focused on ensuring consistency between data collectors. The Harvard T. H. Chan School of Public Health evaluation manager and a master’s-level child development specialist (in addition to a nutritionist from Partners in Health/Inshuti Mu Buzima who provided training in anthropometric assessments) conducted all training.

Data collection procedures

Fieldwork for the study took place between June and October 2014. Piloting of the assessment tool occurred between June and July 2014, qualitative interviews were done in July, August and October 2014, and the baseline quantitative assessments were conducted between 18 August and 31 October 2014. Interviewers were paired during piloting, but worked individually during the baseline assessments for logistical reasons. Recruitment and interviews were conducted in the participant’s homes, but anthropometric assessments were conducted at a central location so that two trained research assistants gathered anthropometric data. Participants received a cash incentive as compensation for their time. Each household was given 2,000 RWF for completing the household interview and 1,000 RWF for completing the anthropometric assessments. During each assessment, caregivers dedicated about half the day to being available

Lists of eligible households created by study team with community health workers

1,302 households randomly sampled from the lists for review

900 eligible households visited by the study team

217 household ineligible after reviewing birth dates

185 households ineligible for other reasons (moved, duplicate)

2 households refused to participate in the study

2 children were found to have passed away

12 households were unable to be interviewed after multiple attempts

884 participating households

Figure 42: Baseline enrolment


Table 5: Study measures

Construct Measure


Socio-economic status Demographic and Health Surveys Wealth Index52

Daily hardships Daily Hardships/Adversities Scale53

Family composition Adapted Southern Africa Labour and Development Research Unit Survey

Caregiver characteristics

Mental health Hopkins Symptom Checklist – 25 items54 (validated in Rwanda)

Alcohol use WHO AUDIT,55 selected items

Education level UNICEF Multiple Indicator Cluster Survey Round 5 (MICS5),56 selected items from woman’s background section

Household decision-making Selected items from UNICEF and Harvard University Study in the Democratic Republic of the Congo


Appropriate caregiving MICS5,57 selected items ECD Module

Child discipline MICS5,58 Child Discipline Module

Family trust and unity (Kwizerana) Locally derived scale59

Caregiver-child relationship Observation of Mother-Child Interaction (OMCI)60

Home environment Home Observation for the Measurement of the Environment (HOME Inventory)61

Children’s exposure to conflict in home Co-parenting Relationship Scale, selected items; some items from Daily Hardships62 Measure

Access to ECD services MICS-5,63 selected items ECD Module; Young Lives Study ECD Module64

Child development

Overall child development (motor, communication, problem-solving and personal-social skills)

Ages and Stages Questionnaire (ASQ-3)65

Social-emotional development Ages and Stages Social Emotional Questionnaire (ASQ:SE)66

Nutrition, health and WASH

Water, sanitation and hygiene MICS-5 WASH Module;67 Rwanda Demographic and Health Survey68

Health status and health service access Rwanda Demographic and Health Survey69

Stunting and wasting Height, weight, middle-upper arm circumference (MUAC)70, 71

Dietary intake MICS-5,72 24-hour dietary recall from nutrition section

Household food security Rwanda Comprehensive Food Security and Vulnerability Analysis and Nutrition Survey,73 selected items adapted

52 Rutstein, Shea O., and Kiersten Johnson, ‘The DHS Wealth Index’, ORC Macro, Calverton, Maryland, 2004.53 Layne, Christopher M., et al., ‘Adolescent Post-War Adversities Scale’, Unpublished instrument, University of California, Los Angeles, 1998.54 Derogatis, Leonard R., et al., ‘The Hopkins Symptom Checklist (HSCL): A self-report symptom inventory’, Behavioral Science, vol. 19, no. 1, January 1974, pp.

1–15.55 Babor, Thomas F., et al., ‘The Alcohol Use Disorders Identification Test (AUDIT): Guildelines for use in primary care’, World Health Organization, Geneva, 2001.56 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.57 Ibid.58 Ibid.59 Betancourt, Theresa S., et al., ‘Nothing Can Defeat Combined Hands (Abashize hamwe ntakibananira): Protective processes and resilience in Rwandan children

and families affected by HIV/AIDS’, Social Science & Medicine, vol. 73, no. 5, 2011, pp. 693–701.60 Rasheed, Muneera A., and Aisha K. Yousafzai, ‘The Development and Reliability of an Observational Tool for Assessing Mother-Child Interaction in Field Studies:

Experience from Pakistan’, 16th European Conference on Developmental Psychology, Lausanne, Switzerland, 2013.61 Bradley, Robert H., and Bettye M. Caldwell, ‘The HOME Inventory and Family Demographics’, Developmental Psychology, vol. 20, no. 2, March 1984, pp. 315–320.62 Layne, Christopher M., et al., ‘Adolescent Post-War Adversities Scale’, Unpublished instrument, University of California, Los Angeles, 1998.63 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.64 University of Oxford and Ethiopian Development Research Insitute, ‘Young Lives: An international study of childhood poverty – Ethiopia household questionnaire’,

Oxford University, Oxford, UK, 2006.65 Squires, Jane, and Diane Bricker, ‘Ages and Stages Questionnaires’, Paul H. Brookes Publishing, Baltimore, Maryland, 2002.66 Squires, Jane, Diane Bricker, and Elizabeth Twombly, ‘Ages and Stages Questionnaires: Social-Emotional’, Paul H. Brookes Publishing, Baltimore, Maryland, 2002.67 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.68 Ministry of Health and ICF International, ‘Rwanda Demographic and Health Survey’, Ministry of Health, Kigali, 2012.69 Ibid.70 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.71 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 4’, UNICEF, New York, 2009, available at <www.childinfo.org/mic4_background.html>.72 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.73 National Institute of Statistics, ‘Comprehensive Food Security and Vulnerability Analysis (CFSVA) and Nutrition Survey 2012’, Republic of Rwanda and United

Nations World Food Programme, Kigali, 2013.

Appendices 49

for participating in the research study, representing about one full day of opportunity cost for the caregivers. The incentives were reviewed and approved by the Rwanda National Ethics Committee.

Quantitative data collection was done with tablets using the KoboCollect platform, except for two observational measures (the HOME Inventory and the OMCI), which were administered using paper forms. Observational measures were entered into a Microsoft Access database. All qualitative interviews were audio-recorded and transcribed into Kinyarwanda before translation into English.

Study instruments

The ECD&F Baseline Assessment Tool comprised several internationally recognized measures covering household characteristics, child development, nutrition, health, caregiving practices and access to services. The battery of instruments was based on several internationally recognized tools, such as the ECD module of the Multiple Indicator Cluster Survey,52 indicators from Demographic and Health Surveys,53 and the widely used Ages and Stages Questionnaire (ASQ).54 Measures were selected that evaluated key areas of ECD&F intervention and are intended for use as part of a longitudinal evaluation to assess the impact of the ECD&F programme.

Extensive background research was conducted to select and adapt measures that were appropriate for the Rwandan context, particularly for child development indicators. To select appropriate measures for ECD and parenting outcomes, the implementing partners drew from their prior qualitative research on family functioning and mental health in children affected by HIV. In that prior work55, 56, 57 they used a rapid qualitative assessment approach that had been successfully employed in previous cross-cultural research the team conducted in Uganda. In formative research on parent-child relationships in Rwanda on vulnerable households affected by HIV, children (N=71) and their caregivers (N=57) were

52 United Nations Children’s Fund, ‘Multiple Indicator Cluster Surveys: Round 5’, UNICEF, New York, 2012.

53 Ministry of Health and ICF International, ‘Rwanda Demographic and Health Survey’, Ministry of Health, Kigali, 2012.

54 Squires, Jane, and Diane Bricker, ‘Ages and Stages Questionnaires’, Paul H. Brookes Publishing, 2004.

55 Betancourt, Theresa S., et al., ‘Nothing Can Defeat Combined Hands (Abashize hamwe ntakibananira): Protective processes and resilience in Rwandan children and families affected by HIV/AIDS’, Social Science & Medicine, vol. 73, no. 5, 2011, pp. 693–701.

56 Betancourt, Theresa S., et al., ‘Family-Based Prevention of Mental Health Problems in Children Affected by HIV and AIDS: An open trial’, AIDS, vol. 28, supplement 3, 2014, pp. S359–S68.

57 Betancourt, Theresa S., et al., ‘HIV and Child Mental Health: A case-control study in Rwanda’, Pediatrics, vol. 134, no. 2, August 2014, pp. e464–e472.

interviewed to identify several categories of locally defined emotional and behavioural problems in children and conducted a second qualitative study adding focus group methodologies to understand local perceptions of good parenting.

The formative research also identified and examined strengths and sources of resilience that contribute to positive caregiver-child relationships despite adversity. These qualitative data were used to select, adapt and/or create measures of parenting and protective resources in Rwandan families facing adversity. The process of selecting measures followed a series of systematic steps, beginning with an extensive search of the literature for standardized measures used in other low-resource settings. Items for measures of constructs were then compared related to good parenting and child emotional and behavioural development to indicator lists for each locally defined construct per qualitative data. Measures were then forward translated with the highest agreement and new items added if necessary to capture local constructs. When no standard measure matched at least 50 per cent of the items on an identified scale, new scales were created based on qualitative data and subjected to rigorous validation exercises.

For the ECD&F baseline evaluation, a thorough formal literature review was conducted to create a list of potential measures. These potential measures were discussed with experts in child development assessment in the global context and with Rwandan partners. Next, the research team used qualitative data and the previous systematic process to review and adapt measures to the Rwandan context. A rigorous translation protocol was followed: dual forward translation by independent translation, committee review of both translations to identify the ideal language, and then back translation into English by a translator who had no prior knowledge of the measure. Any discrepancies were reviewed by the local research team and piloted before inclusion in the final assessment battery. Throughout, the ECD&F technical committee reviewed, adapted and approved the final battery of measures.

Following the selection, adaptation and translation of measures, the battery was piloted with caregivers of children 0–11 months old and 24–35 months old in Kayonza, Gasabo and Nyarugenge Districts in June and July 2014. In the pilot testing the overall length of the quantitative battery was evaluated, as well as any issues with sensitivity of the questions or poor comprehension of the domains assessed. Cognitive testing was also applied, whereby individual items were reviewed with


participants (mainly mothers) in terms of comprehension and whether the response options were being interpreted correctly. Each item was then revised and pilot-tested in this manner until no further discrepancies were indicated.

Data analysis

Quantitative analysis was done using STATA. Descriptive statistics were used to present the data and bivariate analyses were conducted to assess for differences between disaggregated groups based on age, sex, wealth quintile, Ubudehe status, literacy, maternal education and planned ECD interventions (treatment and control villages). Findings are presented in tables and figures throughout the text. Following MICS5 reporting guidelines, indicators with a small number of observations are displayed using the following rules:

1. For indicators with less than 25 observations, the number of observations will be displayed in the table but percentages will not be calculated or discussed. They will be represented by (*) in all tables.

2. For indicators with between 25 and 49 observations, data will be surrounded by parentheses in the table and interpretations will be limited.

Qualitative analysis was done using Grounded Theory and a four-step analytical strategy derived from Thematic Content Analysis. First, all data were subjected to an open-coding process without prior assumption of any theoretical frameworks. Key themes were then distilled. Second, a coding scheme was iteratively developed, organized according to key themes, e.g., ‘family level barriers to ECD participation’, ‘poverty’, and ‘parenting’. Third, team members from Harvard and the University of Rwanda trained in the coding scheme independently coded the transcripts and examined and improved their inter-rater reliability. The code book was then refined to strengthen reliability. Fourth, team members coded the dataset in the online qualitative data-coding programme Dedoose using the robust coding scheme. Results provided crucial contextual information on child rearing and ECD access in Rwanda. The primary research question guiding the analysis was: What, if any, are the barriers and facilitators for families and young children accessing ECD services in Rwanda? Using an ecological framework, barriers were categorized at the individual child, caregiver, family, community, and societal, cultural and policy levels.

Appendices 51

Appendix 3: Sample and sampling plan

The study team gathered data on each sector in order to establish objective criteria for the selection of comparison sites. Additional data on intervention sites and potential comparison sites were gathered through meetings with local authorities as well as poverty data from the most recent national Ubudehe database from 2012.

The number of villages included per sector varied depending on the number of households in each village. It was estimated that a village with more than 150 households would have enough children within the desired age range to meet the target sample size, and so an additional intervention or comparison village was selected only for villages having fewer than 150 households. During enumeration, some villages with more than 150 households did not have sufficient children in the target age range and in those instances an additional village was selected.

The target respondents for the quantitative portion of the study were caregivers of children 0–11 months old and 24–35 months old, and their children, to allow for a focused comparison on two distinct age categories of interest to the national ECD policy and allow for adequate sample size among children over the age of 2 years and under the age of 2 years in order to examine the impact of ECD&F centres over time. While ECD&F centres serve the full age range of children leading up to primary school, it was important to limit the age range of children included in the sample for measurement purposes. The planned interventions for child development are comprehensive, and will affect children from a variety of age ranges. In terms of physical growth and stunting, the most critical age range is the period from 6 months to 24 months of age, when most growth faltering occurs. To be able to measure improvements in this age range, children under the age of 1 were defined as the first target population for this study. To capture improvements in children’s cognitive and socio-emotional development after age 2, cohorts of children in the 24–35 month age range were also enrolled. A planned second follow-up, two years after baseline, will include these children when they are age 24–35 months, allowing for comparison to the first wave of 24–35 months at baseline, as well as children 48–59 months old. The tools selected can be used for the entire age range throughout two waves of follow-up.

It is important to highlight that the resulting sample is not directly comparable to other nationally representative surveys, such as the 2010 Rwanda Demographic and Health Survey (DHS), both because of the explicit focus

on the 0–11 month and 24–35 month age brackets (rather than sampling all children under 5) and because of the geographic focus on the 10 target districts.

To select children and caregivers for the quantitative portion of the baseline assessment, a two-stage sampling process was used. In the first step, study villages were identified as described in further detail above. In the second step, CHWs and village-level leaders assisted the study team with identifying eligible households. For each village, lists of eligible households were first based on CHW record books that contain information on all children under 5 in every village. These initial lists were collected following site visits to each study sector between April and June 2014. Because there was often not very precise age information on these lists, each list was updated within one week prior to data collection to ensure that all eligible children were included in the sampling list. In each study site, a random sample of caregivers and their children were drawn from these lists using a random number generator. The study team visited these randomly selected households during recruitment. Only caregivers confirmed to meet the eligibility criteria that provided informed consent for them and their child to participate were enrolled. Inclusion criteria for the quantitative portion of the study were that participants had to be the primary caregiver and legal guardian of a child between the ages of 0–11 months or 24–35 months and live in the same household as the index child. Legal guardians could be biological parents, aunts, uncles, grandparents or foster parents. Households were excluded if they did not live within one of the sites selected for the study and did not have children between the ages of 0–11 months and 24–35 months living in their household for whom they were the primary caregiver/legal guardian.

The target sample size was between 800 and 1,000 caregiver and child pairs. Because this was the first evaluation of its kind in Rwanda and the main outcome of interest, child development, had not been measured before, sample sizes were estimated based on similar trials from other settings. According to the 2010 Rwanda DHS, average rural household size is only 4.558 (5.5 if you restrict to households with children). The study team assumed that they would encounter a similar household structure and that the age distribution would be about the same as it was in the DHS data. As a result, they

58 Ministry of Health and ICF International, ‘Rwanda Demographic and Health Survey’, Ministry of Health, Kigali, 2013.


assumed that they would get about 13 children under the age of 1 (<12 months) and 15 children aged 2 (24–35 months) for every 100 households. They assumed that target villages would be only 100 households and would sample all children under 1 and between the ages of 2 and 3. They thus estimated that they would get approximately 20*(13+15) = 560 children in total across the 10 treatment and 10 control sites. Assuming that on average villages have about 150 households, this approach would allow them to make their 800–1,000 family target.

Qualitative interviews were conducted with caregivers of children under age 7 (the age range served by ECD&F) who were in Ubudehe categories 1 or 2, as well as ECD stakeholders (including local leaders, civil servants, CHWs and teachers). ECD&F centres aim to target the poorest households, as part of UNICEF’s commitment to promoting equity. However, a case study on the first pilot ECD&F centre in Kayonza District revealed that barriers to participating for children from the poorest households remained. To better understand how to reach these priority households, qualitative interviews were conducted with caregivers from households in Ubudehe 1 and 2. Selection of stakeholders was done through purposive sampling. With the help of local authorities, lists

of ECD stakeholders were created and from these lists the study group sampled to get diverse representation of different stakeholders across the 10 ECD&F project sites. When multiple stakeholders were listed in a community holding the same position, such as CHWs, a random number generator was used to select the stakeholder. For caregiver selection, purposive sampling was used by working with village and other community leaders to identify households with young children in Ubudehe 1 or 2.

A total of 884 households were surveyed across the 20 sites in 10 districts. A household was considered to be the individuals living within one compound. As Table 6 shows, a roughly equal proportion of households was sampled from each project site, with a slightly larger proportion of children in the younger age range and in treated areas. The sampling target of at least 80 children was reached in all 10 districts.59

59 The analysis presented is descriptive; even though two measures are said to be associated, the reader cannot assume that one variable causes the other variable. There might be some other factors that could help explain certain associations, and such factors will be explored in further analysis of the data planned for late 2015/early 2016.

Table 6: Spatial distribution of sample

Number of households Children 0–11 months Children 24–35 months Children in treated areas Children in control areas

N Per cent of sample





Total 884 100.0% 455 51.5% 429 48.5% 452 51.1% 432 48.9%

Project site

Gakenke 96 10.9% 48 (5.4%) 48 (5.4%) 46 (5.2%) 50 5.7%

Gasabo 81 9.2% 41 (4.6%) 40 (4.5%) 54 6.1% 27 (3.1%)

Gicumbi 85 9.6% 48 (5.4%) 37 (4.2%) 43 (4.9%) 42 (4.8%)

Ngoma 86 9.7% 43 (4.9%) 43 (4.9%) 43 (4.9%) 43 (4.9%)

Nyabihu 81 9.2% 45 (5.1%) 36 (4.1%) 40 (4.5%) 41 (4.6%)

Nyamagabe 93 10.5% 44 (5.0%) 49 (5.5%) 45 (5.1%) 48 (5.4%)

Nyamasheke 99 11.2% 47 (5.3%) 52 5.9% 51 5.8% 48 (5.4%)

Nyarugenge 84 9.5% 43 (4.9%) 41 (4.6%) 42 (4.8%) 42 (4.8%)

Ruhango 87 9.8% 49 (5.5%) 38 (4.3%) 43 (4.9%) 44 (5.0%)

Rwamagana 92 10.4% 47 (5.3%) 45 (5.1%) 45 (5.1%) 47 (5.3%)

Appendices 53

Appendix 4: Primary indicator definitions

Indicator name Indicator definition Numerator Denominator


Poor household Proportion of households in Ubudehe category 1 or 2

Number of households in Ubudehe 1 and 2 Number of households

Birth registration Proportion of children 0–11 months old and 24–35 months old whose births are reported registered

Number of children 0–11 months old and 24–35 months old whose births are reported registered

Number of children 0–11 months old and 24–35 months old

Reporting primary caregiver characteristics

Marital status of primary caregiver Proportion of primary caregivers who are currently married or living with a partner

Number of primary caregivers who are married or living with a partner

Number of primary caregivers

Primary caregiver’s level of education: primary

Proportion of primary caregivers who completed primary school

Number of primary caregivers who have completed primary school or higher


Primary caregiver’s level of education: secondary

Proportion of primary caregivers who completed secondary school

Number of primary caregivers who have completed secondary school or higher


Primary caregiver literacy Proportion of primary caregivers who self-reported not being able to read or write

Number of primary caregivers who report not being able to read or write


Early childhood development

Child development

Potential developmental delay/developmental concern

Proportion of children 0–11 months old and 24–35 months old scoring below cut-off for age-specific ASQ-3 in one or more domain of development

Number of children 0–11 months old and 24–35 months old scoring below age-specific cut-point in one or more of the ASQ-3 domains

Number of children 0–11 months old and 24–35 months old with age-specific ASQ-3 completed

Potential social-emotional health issue

Proportion of children 0–11 months old and 24–35 months old scoring above cut-off for age-specific ASQ:SE social-emotional development

Number of children 0–11 months old and 24–35 months old scoring above age-specific cut-point on the ASQ:SE

Number of children 0–11 months old and 24–35 months old with age-specific ASQ:SE completed


Inadequate care Proportion of children experiencing any inadequate care in the past week (left alone or in the care of another child younger than 10 years of age for more than one hour at least once in the last week)

Number of children 0–11 months old and 24–35 months old who experienced inadequate care in the past week


Violent discipline Proportion of children who experienced psychological aggression or physical punishment during the last one month

Number of children 0–11 months old and 24–35 months old who experienced psychological aggression or physical punishment in the last one month



Father’s support for child’s care Proportion of fathers who are engaged in the child’s care daily

Number of fathers engaged in child’s care daily for children 0–11 months old and 24–35 months old

Number of fathers

Support for learning* (not MICS standard indicator)

Primary caregiver engaged in three activities to promote learning or school readiness in the past week. The three activities are: 1) Singing songs/telling stories 2) Teaching child something new 3) Looking at pictures in books, magazines, or calendars with child

Number of primary caregivers who engaged in three activities to promote learning or school readiness in the past week


Availability of children’s books Proportion of children 0–11 months old and 24–35 months old who have three or more children’s books

Number of children 0–11 months old and 24–35 months old who have three or more children’s books


Availability of playthings Proportion of children 0–11 months old and 24–35 months old who play with two or more types of playthings

Number of children aged 0–11 months old and 24–35 months old who play with two or more types of playthings


Playmates Proportion of children 0–11 months old and 24–35 months old who have regular playmates his/her age

Number of children 0–11 months old and 24–35 months old who have regular playmates his/her age




Access to ECD services

Access to ECD Proportion of children 0–11 months old and 24–35 months old who attend an early learning or early childhood education programme

Number of children 0–11 months and 24–35 months old who attend an early learning or early childhood education programme


Access to nursery/pre-primary Proportion of households with a child 4–6 years old where the child attends nursery or pre-primary school

Number of households with a child age 4–6 years old where the child attends nursery or pre-primary school

Number of households with a child between 4 and 6 years of age

Water, sanitation and hygiene

Use of improved drinking water sources

Proportion of households using improved sources of drinking water

Number of households using improved sources of drinking water

Number of households surveyed

Water treatment Proportion of households using unimproved drinking water who use an appropriate treatment method

Number of households using unimproved drinking water who use an appropriate treatment method

Number of households using unimproved drinking water sources

Storage of water in closed container Proportion of households that store water in closed containers

Number of households that store drinking water in closed containers


Use of improved sanitation Proportion of households using an improved sanitation facility which are not shared

Number of households using improved sanitation facilities


Place for hand washing* (not MICS standard indicator)

Proportion of households with a place for hand washing, excluding jerry cans, buckets, or other mobile places

Number of households where a specific place for hand washing was observed


Water and soap present at designated place for hand washing

Proportion of households with a designated place for hand washing with water and soap/cleansing agent available

Number of households where water and soap/cleansing agent were both observed

Number of households where a specific place for hand washing was observed

Safe disposal of child’s faeces Proportion of children 0–11 months old whose last stools were disposed of safely

Number of children 0–11 months old whose last stools were disposed of safely

Number of children 0–11 months old

Health

Maternal health

Poor primary caregiver mental health

Proportion of primary caregivers with poor mental health as measured by scoring above 1.75 on the Hopkins Symptom Checklist

Number of primary caregivers with poor mental health as measured by scoring above 1.75 on the Hopkins Symptom Checklist


Use of alcohol Proportion of primary caregivers who reported consuming alcohol

Number of primary caregivers who reported consuming alcohol


Complicated delivery Proportion of mothers of children aged 0–11 months and 24–35 months who experienced complications during delivery (including requiring a Caesarean section)

Number of mothers of children 0–11 months old and 24–35 months old who experienced complications during delivery


Child health

Diarrhoea prevalence Proportion of children 0–11 months old and 24–35 months old whose primary caregiver reported that they had diarrhoea in the two weeks preceding the survey

Number of children 0–11 months and 24–35 months old whose primary caregiver reported that they had diarrhoea in the two weeks preceding the survey


Care-seeking for diarrhoea Proportion of primary caregivers of children 0–11 months and 24–35 months who had diarrhoea in the past two weeks who sought any form of treatment for the child

Number of primary caregivers of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks who sought any form of treatment for the child

Number of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks

Diarrhoea treatment with ORS Proportion of primary caregivers of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks who treated the child’s diarrhoea with ORS

Number of primary caregivers of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks who treated the child’s diarrhoea with ORS


Diarrhoea treatment with RHF Proportion of primary caregivers of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks that treated the child’s diarrhoea with a RHF

Number of primary caregivers of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks who treated the child’s diarrhoea with a RHF


Diarrhoea treatment with ORS or RHF

Proportion of primary caregivers of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks who treated the child’s diarrhoea with ORS or RHF

Number of primary caregivers of children 0–11 months old and 24–35 months old who had diarrhoea in the past two weeks who treated the child’s diarrhoea with ORS or RHF


Appendices 55


Children who slept under an mosquito net

Proportion of children 0–11 months old and 24–35 months old who slept under a mosquito net the night preceding the survey

Number of children 0–11 months old and 24–35 months old who slept under a mosquito net the night preceding the survey


Prevalence of fever Proportion of children 0–11 months old and 24–35 months old whose primary caregiver reported that they had a fever in the two weeks preceding the survey

Number of children 0–11 months old and 24–35 months old whose primary caregiver reported that they had a fever in the two weeks preceding the survey


Care-seeking for fever Proportion of primary caregivers of children 0–11 months old and 24–35 months old who had a fever in the past two weeks that sought any form of treatment for the child

Number of primary caregivers of children 0–11 months old and 24–35 months old who had a fever in the past two weeks that sought any form of treatment for the child

Number of children 0–11 months old and 24–35 months old who had a fever in the past two weeks

Access to health services

Dewormed Proportion of children 0–11 months old and 24–35 months old who received any drug with intestinal worms in the past six months

Number of children 0–11 months old and 24–35 months old who received any drug with intestinal worms in the past six months


CHW home visit Proportion of children 0–11 months old and 24–35 months old who were visited by a community health worker in the past month

Number of children 0–11 months old and 24–35 months old who were visited by a community health worker in the past month


Child growth monitoring Proportion of children 0–11 months old and 24–35 months old whose growth was monitored by a health provider in the past month

Number of children 0–11 months old and 24–35 months old whose growth was monitored by a health provider in the past month


Health insurance coverage

Any health insurance coverage Proportion of households where any member of the households are insured

Number of households where any member of the households are insured

Number of households

Child health insurance coverage Proportion of children 0–11 months old and 24–35 months old who are covered by any time of health insurance

Number of children 0–11 months old and 24–35 months old who are covered by any time of health insurance


Mutuelle de santé coverage Proportion of insured households that are covered by the national mutuelle de santé programme

Number of insured households that are covered by the national mutuelle de santé programme

Number of insured households

Full health insurance coverage Proportion of insured households where every member of the household is covered by health insurance

Number of insured households where every member of the household is covered by health insurance

Number of insured households

Nutrition

Malnutrition

Stunting prevalence Proportion of children 0–11 months old and 24–35 months old who fall below (a) minus two standard deviations (moderate and severe) (b) below minus three standard deviations (severe) of the median height for age of the WHO standard

Number of children 0–11 months old and 24–35 months old who fall below (a) minus two standard deviations (moderate and severe) (b) below minus three standard deviations (severe) of the median height for age of the WHO standard


Underweight prevalence Proportion of children 0–11 months old and 24–35 months old who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard

Number of children 0–11 months old and 24–35 months old who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for age of the WHO standard


Wasting prevalence Proportion of children 0–11 months old and 24–35 months old who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard

Number of children 0–11 months old and 24–35 months old who fall below (a) minus two standard deviations (moderate and severe) (b) minus three standard deviations (severe) of the median weight for height of the WHO standard




Global acute malnutrition Proportion of children 0–11 months old and 24–35 months old with a Mid-Upper Arm Circumference (MUAC) less than 125mm (moderate and sever) or less than 115 mm (severe)

Number of children 0–11 months old and 24–35 months old with a MUAC less than 125mm (moderate and sever) or less than 115 mm (severe)


Exclusive breastfeeding Proportion of infants under 6 months of age who are exclusively breastfed (receiving breast milk, and not receiving any other fluids or foods, with the exception of oral rehydration solution, vitamins, mineral supplements and medicines)

Number of infants under 6 months of age who are exclusively breastfed (receiving breast milk, and not receiving any other fluids or foods, with the exception of oral rehydration solution, vitamins, mineral supplements and medicines)

Number of infants younger than 6 months old

Minimum acceptable diet Proportion of children 6–11 months old who received the minimum meal frequency and minimum dietary diversity during the previous day

Number of children 6–11 months old who received the minimum meal frequency and minimum dietary diversity during the previous day


Minimum meal frequency Proportion of children 6–11 months old who received solid, semi-solid and soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the previous day Breastfeeding children: solid, semi-solid, or soft foods, two times for infants 6–8 months old, and three times for children 9–11 months old Non-breastfeeding children: solid, semi-solid, or soft foods, or milk feeds, four times for children 6–11 months old

Number of children age 6–11 months who received solid, semi-solid and soft foods (plus milk feeds for non-breastfed children) the minimum number of times or more during the previous day.

Number of children aged 6–11 months

Minimum dietary diversity Proportion of children 6–11 months old who received foods from four or more food groups during the previous day

Number of children 6–11 months old who received foods from four or more food groups during the previous day


Food insecurity

Household food insecurity Proportion of households who did not have enough food or money to buy food at least one day during the past week

Number of households who did not have enough food or money to buy food at least one day during the past week

Number of households

Appendices 57

Appendix 5: 95% confidence intervals for main indicators


95% confidence interval

Standard error


Mean household size (persons) 5.1 5.0, 5.3 0.1

Mean number of children under 18 in household 2.8 2.7, 2.9 0.1

Mean number of children under 5 in household 1.5 1.46, 1.54 0.02

Percentage with a second caregiver for the child living in the household 87.6% 85.4%, 89.8% 11.1%

Percentage of children living with both biological parents 77.6% 74.8%, 80.4% 1.4%

Percentage of children living in households with their biological mother 98.5% 97.7%, 99.3% 0.4%

Percentage of children living in households with their biological father 78.3% 75.6%, 81.0% 1.4%

Percentage of children living in a households in Ubudehe category 1 or 2 23.2% 20.4%, 26.0% 1.4%

Percentage of children registered with civil authorities 75.9% 73.1%, 78.8% 1.4%

Household assets

Percentage of children living in households with electricity 12.7% 10.5%, 14.9% 1.1%

Percentage of children living in households with radio 53.6% 50.3%, 56.9% 1.7%

Percentage of children living in households with mobile phone 64.5% 61.3%, 67.7% 1.6%

Percentage of children living in households with bike 17.7% 15.2%, 20.2% 1.3%

Percentage of children living in households with bed net 87.8% 85.7%, 90.0% 1.1%

Reporting primary caregiver characteristics

Percentage of primary caregivers who are the child’s biological mother 96.3% 95.0%, 97.5% 0.6%

Mean age of primary caregiver 30.1 29.6, 30.5 0.25

Percentage of primary caregivers who are currently married or living with a partner 82.6% 79.9%, 85.3% 1.4%

Percentage of primary caregivers who completed primary school 39.3% 36.0%, 42.6% 1.7%

Percentage of primary caregivers who completed secondary school 5.5% 4.0%, 7.0% 0.8%

Percentage of primary caregivers who are illiterate 27.6% 24.6%, 30.6% 1.5%

Decision-making in the household

Percentage of households in which both mothers and fathers decide together if a child attends ECD services 44.4% 41.1%, 47.7% 1.7%

Percentage of households in which both mothers and fathers decide together the action when a child is sick 38.8% 35.5%, 42.0% 1.6%

Percentage of households in which both mothers and fathers decide together what a child eats 17.2% 14.7%, 19.7% 1.3%

Percentage of households in which the mother decides if a child attends ECD services 23.6% 20.8%, 26.4% 1.4%

Percentage of households in which the mother decides the action when a child is sick 45.3% 42.1%, 48.6% 1.7%

Percentage of households in which the mother decides what a child eats 75.5% 72.6%, 78.3% 1.5%

Percentage of households in which the father decides if a child attends ECD services 27.3% 24.3%, 30.2% 1.5%

Percentage of households in which the father decides the action when a child is sick 12.4% 10.2%, 14.6% 1.1%

Percentage of households in which the father decides what a child eats 3.9% 2.6%, 5.1% 0.7%

Early childhood development

Child development

Percentage of children 0–11 months below cut-off for age-specific ASQ-3 in one or more domain of development 62.4% 57.9%, 67.0% 2.3%

Percentage of children 24–35 months below cut-off for age-specific ASQ-3 in one or more domain of development 52.0% 47.2%, 56.9% 2.5%

Percentage of children 0–11 months above cut-off for age-specific ASQ:SE social-emotional development 52.3% 47.2%, 57.4% 2.6%

Percentage of children 24–35 months above cut-off for age-specific ASQ:SE social-emotional development 60.0% 55.4%, 64.7% 2.4%


Percentage of children 0–11 months experiencing any inadequate care in the past week 32.6% 28.3%, 36.9% 2.2%

Percentage of children 24–35 months experiencing any inadequate care in the past week 60.0% 55.2%, 64.6% 2.4%

Percentage of children 0–11 months old exposed to any violent discipline 19.8% 16.2%, 23.5% 1.9%




Standard error

Percentage of children 24–35 months old exposed to any violent discipline 80.7% 77.0%, 84.5% 1.9%

Percentage of caregivers who believe physical punishment is necessary to raise a child well 34.4% 31.3%, 37.6% 1.6%

Percentage of caregivers who argue during a typical week about relationship in child’s presence 44.0% 40.0%, 48.0% 2.0%

Percentage of caregivers who say cruel things to each other during a typical week in child’s presence 43.2% 39.1%, 47.2% 2.1%

Percentage of caregivers who have had serious conflict in the home during the past six months 31.7% 28.6%, 34.8% 1.6%

Percentage of interviewed caregivers who have gotten into serious conflict with other household mothers during the past six months 21.1% 18.4%, 23.8% 1.4%


Father cares for child daily 62.9% 59.6%, 66.2% 1.7%

Primary caregiver engages in three activities to promote learning or school readiness in the past week 8.6% 6.7%, 10.5% 9.6%

Availability of children’s books in the household 1.6% 0.78%, 2.47% 0.4%

Percentage of children 0–11 months old with availability of playthings in the household 5.5% 3.4%, 7.6% 1.1%

Percentage of children 24–35 months old with availability of playthings in the household 34.3% 29.8%, 38.8% 2.3%

Percentage of children 24–35 months old who have regular playmates his or her age 89.9% 87.1%, 92.8% 1.5%

Access to ECD and community services

Percentage of children 0–11 months old who attend ECD programme 3.3% 1.7%, 5.0% 0.8%

Percentage of children 24–35 months old who attend ECD programme 9.7% 6.9%, 12.5% 1.4%

Percentage of households with children 4 to 6 years old who attend nursery or pre-primary school 27.4% 22.8%, 32.0% 2.4%

Mean age of child attending nursery or pre-primary school 5.0 4.8, 5.1 0.08

Percentage of caregivers who have heard of the 1,000 Days campaign 35.5% 32.3%, 38.6% 1.6%

Percentage of caregivers who have heard of Parenting Evening Talks programme 65.7% 62.5%, 68.8% 1.6%

Percentage of caregivers who have heard of cooking demonstrations by CHWs 50.0% 46.7%, 53.3% 1.7%

WASH

Percentage of households with an improved water source 76.5% 73.7%, 79.3% 1.4%

Percentage of households with an unimproved water source that treat water appropriately before drinking 63.3% 56.7%, 69.9% 3.4%

Percentage of households that store water in closed containers 43.8% 40.5%, 47.0% 1.7%

Percentage of households with an improved sanitation facility 69.1% 66.0%, 72.1% 1.6%

Percentage of households with a place for hand washing 5.9% 4.4%, 7.5% 0.8%

Percentage of households with a place for hand washing with water and soap/cleansing agent available 0.2% 0%, 0.54% 0.2%

Percentage of households with safe disposal of 0–11 month old children’s faeces 62.3% 57.9%, 66.8% 2.3%

Health

Maternal health

Percentage of primary caregivers with poor mental health 41.5% 38.3%, 44.8% 1.7%

Percentage of primary caregivers who ever consume alcohol 30.1% 27.1%, 33.2% 1.5%

Percentage of mothers who are HIV+ 1.8% 0.8%, 2.6% 0.5%

Percentage of mothers who knew HIV+ status during pregnancy 86.7% 69.5%, 1.0% 8.8%

Percentage of mother who received prevention of mother to child transmission of HIV services 84.6% 65.0%, 1.0% 10.0%

Percentage of mothers who experienced complications during delivery (including needing a Caesarean section) 22.4% 19.7%, 25.2% 1.4%

Child health

Percentage of children 0–11 months old who had diarrhoea in the past two weeks 29.4% 25.2%, 33.6% 2.1%

Percentage of children 24–35 months old who had diarrhoea in the past two weeks 28.7% 24.4%, 33.0% 2.2%

Percentage of caregivers of children 0–11 months old who sought any treatment for diarrhoea 59.7% 51.2%, 68.2% 4.3%

Percentage of caregivers of children 24–35 months old who sought any treatment for diarrhoea 73.5% 65.6%, 81.5% 4.1%

Percentage of children who received oral rehydration salts (ORS) 17.0% 12.4%, 21.6% 2.4%

Percentage of children who received recommended homemade fluid (RHF) 7.5% 4.2%, 10.7% 1.7%

Percentage of children who received either ORS or RHF 22.1% 17.0%, 27.2% 2.6%

Percentage of children who slept under mosquito net last night 78.9% 76.2%, 81.6% 1.4%

Appendices 59



Standard error

Percentage of children 0–11 months old who slept under mosquito net last night among households that have nets 90.2% 87.2%, 93.1% 1.5%

Percentage of children 24–35 months old who slept under mosquito net last night among households that have nets 89.6% 86.5%, 92.7% 1.6%

Percentage of children 0–11 months old who had fever in the past two weeks 39.1% 34.6%, 43.6% 2.3%

Percentage of children 24–35 months old who had fever in the past two weeks 37.4% 32.8%, 42.0% 2.3%

Percentage of caregivers of children 0–11 months old who sought any treatment for fever 56.5% 49.2%, 63.8% 3.7%

Percentage of caregivers of children 24–35 months who sought any treatment for fever 72.3% 65.4%, 79.3% 3.5%

Percentage of children 0–11 months old who were dewormed in the past six months 33.6% 29.3%, 38.0% 2.2%

Percentage of children 24–35 months old who were dewormed in the past six months 85.6% 82.3%, 89.0% 1.7%

Percentage of children 0–11 months old who were visited by CHW in the past month 34.9% 30.5%, 39.3% 2.2%

Percentage of children 24–35 months old who were visited by CHW in the past month 31.4% 27.0%, 35.9% 2.3%

Percentage of children 0–11 months old who were growth monitored in the past month 59.4% 54.9%, 63.9% 2.3%

Percentage of children 24–35 months old who were growth monitored in the past month 60.9% 56.2%, 65.6% 2.4%

Health insurance coverage

Percentage of households with any member insured 60.8% 57.6%, 64.0% 1.6%

Percentage of insured households with index child insured 52.3% 49.0%, 55.6% 1.7%

Percentage of insured households covered by mutuelle 92.7% 90.5%, 94.9% 1.1%

Percentage of insured households with all members insured 71.9% 68.1%, 75.7% 1.9%

Nutrition

Percentage of children 0–11 months old who are severely stunted 5.8% 3.7%, 8.0% 1.1%

Percentage of children 24–35 months old who are severely stunted 16.4% 12.9%, 20.0% 1.8%

Percentage of children 0–11 months old who are stunted 15.9% 12.5%, 19.3% 1.7%

Percentage of children 24–35 months old who are stunted 46.0% 41.3%, 50.7% 2.4%

Percentage of children 0–11 months old who are severely underweight 3.0% 1.4%, 4.6% 0.8%

Percentage of children 24–35 months old who are severely underweight 1.9% 0.6%, 3.2% 0.7%

Percentage of children 0–11 months old who are underweight 8.0% 5.5%, 10.6% 1.3%

Percentage of children 24–35 months old who are underweight 12.0% 8.9%, 15.1% 1.6%

Percentage of children 0–11 months old who are severely wasted 0.9% 0.02%, 1.8% 0.5%

Percentage of children 24–35 months old who are severely wasted 0.0% 0.0%, 0.0% 0.0%

Percentage of children 0–11 months old who are wasted 2.8% 1.2%, 4.3% 0.8%

Percentage of children 24–35 months old who are wasted 1.4% 0.3%, 2.6% 0.6%

Percentage of children 0–11 months old with global acute malnutrition 12.0% 9.0%, 15.0% 1.5%

Percentage of children 24–35 months old with global acute malnutrition 0.7% 0.0%, 1.5% 0.4%

Percentage of children younger than 6 months old who are exclusively breastfeeding 90.0% 85.9%, 94.0% 2.1%

Percentage of children 6–11 months old who are receiving the minimum acceptable diet 12.7% 8.5%, 16.9% 2.1%

Percentage of households who did not have enough food or money to buy food at least one day during the past week 79.3% 76.6%, 82.0% 1.4%


Appendix 6: Comparison of intervention and control sites

Further analyses were performed to compare the inter-vention sites with an ECD&F centre to the comparison sites on primary indicators. Linear regressions with clustering by project sites were performed to assess if means were significantly different between intervention and comparison sites. The sampling procedure to match intervention and comparison sites on key characteristics worked well, as the two sites were not significantly dif-ferent on any of the major indicators, with the exception of access to ECD services. Children in the interven-

tion (‘treatment’) sites were significantly more likely to attend ECD services than children in the comparison (‘control’) sites. Due to the staggered roll-out of the ECD&F centres across the ten project sites, some ECD&F centres had opened prior to the launch of the baseline evaluation but none had been operational for more than three months (see Table 7) and programmes have yet to be fully operationalized so it is not expected that they would have yet had a significant impact on children’s development.

Table 7: Intervention (treatment) and comparison (control) sites

Children < 12 months (N=455) Children < 24–35 months (N=429)

Control sites mean

Treated sites mean

Equal means test (p-value)a)

Control sites mean

Treated sites mean

Equal means test (p-value)a)

Child outcomes

Child is stunted 0.164 0.155 0.857 0.465 0.455 0.847

Child is underweight 0.080 0.080 0.996 0.122 0.118 0.907

ASQ total score 202 208 0.156 197.8 196.2 0.715


Caregiver is illiterate 0.234 0.277 0.524 0.317 0.276 0.545

Asset quintile 2.954 3.067 0.565 2.868 2.981 0.533

Household is Ubudehe 1 or 2 0.189 0.231 0.299 0.279 0.220 0.275

Household has health insurance 0.671 0.601 0.366 0.626 0.533 0.259

Household as food insecurity 0.778 0.782 0.943 0.804 0.811 0.874

Family unity and daily hardship score 3.000 2.983 0.879 3.052 3.024 0.769

Uses violent discipline 0.204 0.193 0.810 0.804 0.810 0.887

Access to improved water 0.755 0.777 0.821 0.720 0.807 0.388

Access to improved sanitation 0.667 0.710 0.333 0.668 0.717 0.450

Any reading materials 0.226 0.205 0.681 0.324 0.374 0.322

Any toys 0.190 0.178 0.779 0.565 0.594 0.628

OMCI total score 29.0 28.9 0.881 40.4 40.5 0.917

ECD access

Child currently attends ECD programme 0.000 0.063 0.031 0.023 0.171 0.034

Notes: a) p-values are based on a two-sample equal means test with standard errors clustered at the district level. Bold p-values indicate that means are statistically different (p-value < 0.05).

Appendices 61

Appendix 7: Site profiles

Minazi Sector (Gakenke District) site profile

Gakenke District is located in the Northern Province of Rwanda, in a very mountainous region of the country. The ECD&F centre is located in Minazi Sector, Munyana Cell, and Kanka Village. According to local leaders, the ECD&F centre is accessible to approximately four villages. For the purposes of this evaluation, only the three closest villages were included, which were Kanka, Kivuba and Nyabitare. The ECD&F centre is very close to a health centre, as well as to the sector offices. The comparison villages were chosen from Murambi Cell, located within the same sector, but geographically isolated from the ECD&F centre. While Murambi Cell does not have a health centre, it does have a health post to facilitate close access to health services. The villages included in the comparison site were Kabuga and Nyarubuye. Data from the 2012 National Ubudehe

Database are provided for the villages included in the study below.

Selected indicators are presented for Gakenke in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.

Indicator Obs Point estimate Standard error 95% confidence interval

Birth registration 96 91.7% 2.8% 86.1%, 97.2%

Household wealth quintile (mean) 96 2.73 0.14 2.45, 3.01

Potential developmental delay/concern 96 51.0% 5.1% 41.0%, 61.0%

Potential social-emotional health concern 91 51.7% 5.2% 41.4%, 62.0%

Inadequate care 96 40.6% 5.0% 30.8%, 50.4%

Violent discipline 96 45.8% 5.1% 35.9%, 55.8%

Support for learning 95 5.6% 2.3% 0.8%, 9.8%

Availability of playthings 96 16.7% 3.8% 9.2%, 24.1%

Attendance at nursery/pre-primary 33 15.2% 6.2% 2.9%, 27.4%

Use of improved water source 96 32.3% 4.8% 22.9%, 41.6%

Water treatment 65 73.8% 5.5% 63.1%, 84.5%

Water storage 96 45.8% 5.1% 35.9%, 55.8%

Improved sanitation 96 72.9% 4.5% 64.0%, 81.8%

Place for hand washing 96 4.2% 2.0% .02%, 8.2%

Poor caregiver mental health 96 20.8% 4.1% 12.7%, 29.0%

Diarrhoea prevalence 96 17.7% 3.9% 10.1%, 25.3%

Children who slept under a mosquito net last night 96 90.6% 3.0% 84.8%, 96.5%

Fever prevalence 96 24.0% 4.4% 15.4%, 32.5%

Dewormed 96 51.0% 5.1% 41.0%, 61.0%

Child health insurance coverage 96 66.7% 4.8% 57.2%, 76.1%

Stunting (24–35 months) 48 54.2% 7.2% 40.1%, 68.3%

Global acute malnutrition 96 5.2% 2.3% 0.8%, 9.7%

Exclusive breastfeeding 96 95.7% 4.3% 87.3%, 100%

Minimum acceptable diet 25 12.0% 6.5% 0%, 24.7%

Food insecurity 96 62.5% 4.9% 52.8%, 72.2%

Village Number of households

Per cent in Ubudehe 1 and 2

Sampling

Kabuga 186 17% Comparison

Kanka 72 28% ECD+F

Kivuba 109 35% ECD+F

Nyabitare 89 30% ECD+F


Gikomero Sector (Gasabo District) site profile

Gasabo District is located in Kigali Province in the centre of the country. Kigali City spans a portion of Gasabo District; however, the sector included in the baseline evaluation is in a rural area of the district. The ECD&F centre is located in Gikomero Sector, Munini Cell, Twina Village. According to local leaders, the ECD&F centre is accessible to three villages in the sector. Only the two closest villages were included in the baseline, which were Twina and Rugwiza. The sector’s health centre is located a short distance down the road from the ECD&F centre in Munini Cell. The comparison villages were chosen from Gicaca Cell, located within the same sector, but geographically isolated from the ECD&F centre. While Gicaca Cell does not have a health centre, it does have a health post to facilitate close access to health services. The villages included in the comparison site were

Ntaganzwa and Nyagasozi. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Gasabo in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 80 51.3% 5.6% 40.3%, 62.2%






Water treatment 15 20.0% 10.3% 0%, 40.2%

Water storage 81 48.2% 5.6% 37.3%, 59.0%


Place for hand washing 81 6.2% 2.7% 0.9%, 11.4%





Dewormed 80 63.8% 5.4% 53.2%, 74.3%


Stunting (24–35 months) 40 42.5% 7.8% 27.2%, 57.8%

Global acute malnutrition 81 2.5% 1.7% 0%, 5.8%

Exclusive breastfeeding 14 (*) (*) (*)


Food insecurity 81 70.4% 5.1% 60.4%, 80.3%



Sampling

Ntganzwa 231 45% Comparison

Nyagasozi 181 48% Comparison

Rugwiza 186 15% ECD+F

Twina 183 47% ECD+F

Appendices 63

Miyove Sector (Gicumbi District) site profile

Gicumbi District is located in the Northern Province of Rwanda. The project site is located in Miyove Sector, which is a rural area of the district, a decent distance from Gicumbi Town which is home to Gihembe Refugee Camp, one of five camps for refugees from the Democratic Republic of the Congo. The ECD&F centre is located in Nyamiyaga Village (Miyove Cell), which was established around 2009 or 2010 by the government to integrate members of a historically marginalized population with other households relocated from areas considered to be at high risk of erosion. To support this effort, the households closest to the centre were constructed by members of the community. The ECD&F centre is accessible to four other villages in Miyove Cell, in addition to Nyamiyaga. The only health centre in the sector is located in Miyove Cell. The

comparison village of Kacyiru was selected from Mubuga Cell, which is in close proximity to the health centre. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Gicumbi in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 85 37.7% 5.3% 27.3%, 47.9%






Water treatment 12 (*) (*) (*)

Water storage 85 35.3% 5.2% 25.1%, 45.5%







Dewormed 85 50.6% 5.4% 40.0%, 61.2%


Stunting (24–35 months) 37 56.8% 8.1% 40.8%, 72.7%



Minimum acceptable diet 24 20.8% 8.3% 4.5%, 37.1%

Food insecurity 85 87.1% 3.6% 79.9%, 94.2%



Sampling

Kacyiru 201 35% Comparison

Murehe 107 36% ECD+F

Nyamiyaga 118 34% ECD+F


Zaza Sector (Ngoma District) site profile

Ngoma District is located among the rolling hills of the Eastern Province. The project site is located in Zaza Sector, which, while rural, is only about 23 kilometres from the medium-sized town of Kibungo. The ECD&F centre is in Ruhinga Cell, Nyagahandagazi Village, directly behind the Sangaza Health Centre. According to local leaders, the centre is easily accessible to two other villages, Gasebeya and Busasamana. Only the two closest villages, Nyagahandagazi and Gasebeya, were included in the baseline evaluation. The comparison villages were chosen from Nyagatugunda Cell, located within the same sector, but geographically isolated from the ECD&F centre. While Nyagatugunda Cell does not have a health centre, the selected villages have close access to Zaza Health Centre in the neighbouring cell. Three villages were sampled in the comparison site,

including Jyambere, Kizenga and Rebero. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Ngoma in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 84 44.1% 5.4% 33.4%, 54.7%







Water storage 84 39.3% 5.3% 28.8%, 49.7%







Dewormed 84 57.1% 5.4% 46.6%, 67.7%


Stunting (24–35 months) 42 40.5% 7.6% 25.6%, 55.3%

Global acute malnutrition 85 3.5% 2.0% 0%, 7.5%



Food insecurity 84 76.2% 4.6% 67.1%, 85.3%



Sampling

Jyambere 73 21% Comparison

Kizenga 94 6% Comparison

Rebero 82 5% Comparison

Gasebeya 83 33% ECD+F

Nyagahandagazi 105 10% ECD+F

Appendices 65

Bigogwe Sector (Nyabihu District) site profile

Nyabihu District is located in the fertile Western Province of Rwanda. The project site is located in Bigogwe Sector, which straddles a national tarmac road and is a short distance past Rwanda’s second-largest city of Musanze. The ECD&F centre is located in Kijote Cell, Bikingi Village. Bikingi Village is very large in comparison to other Rwandan villages, with approximately 600 households. Therefore, it is unlikely that children from other villages will have access to the centre, given capacity limits on the number of children that can be reasonably served by a single facility. Some large infrastructure exists in Bikingi, including a large market and a health centre. The comparison villages were chosen from Rega Cell, located within the same sector, but geographically isolated from the ECD&F centre. While Rega Cell does not have a health centre, it is the only other cell in the sector with

the same proximity to the tarmac road. Two villages were sampled in the comparison site, including Kagano and Ngaregare. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Nyabihu in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 81 53.1% 5.5% 42.2%, 64.0%




Attendance at nursery/pre-primary 39 2.6% 2.5% 0%, 7.5%



Water storage 81 34.6% 5.3% 24.2%, 44.9%


Place for hand washing 81 2.5% 1.7% 0%, 5.8%





Dewormed 81 53.1% 5.5% 42.2%, 64.0%


Stunting (24–35 months) 36 50.0% 8.3% 33.7%, 66.3%



Minimum acceptable diet 23 (*) (*) (*)

Food insecurity 81 92.6% 2.9% 86.9%, 98.3%



Sampling

Kagano 136 24% Comparison

Ngangare 156 28% Comparison

Bikingi 623 25% ECD+F


Kizibere Sector (Nyamagabe District) site profile

Nyamagabe District is located in the Southern Province of Rwanda, which is the poorest of Rwanda’s five provinces. Kizibere Sector is the location of the project site and the Kigeme Refugee Camp is located in the area. The ECD&F centre was constructed in Bugarura Cell, Muyange Village. The Kibirizi Health Centre is located in Bugarura Cell, which is also home to a ‘model village’ that is being established in Uwinyana Village. Three villages will have access to the centre, according to the local leaders, and those include Muyange, Nyakibyeyi and Uwinyana. The two closest villages were included in the baseline evaluation, which are Muyange and Uwinyana. The comparison villages were chosen from Ruhunga Cell, located within the same sector, but geographically isolated from the ECD&F centre. While Ruhunga Cell does not have a health centre, it is located closer to the tarmac road, which facilitates access to the district

hospital and is also home to the sector offices. Two villages were sampled in the comparison site, including Gakoma and Nyagishubi. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Nyamagabe in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 92 44.6% 5.2% 34.4%, 54.7%







Water storage 92 48.9% 0.5% 38.7%, 59.1%







Dewormed 92 56.5% 5.2% 46.4%, 66.7%


Stunting (24–35 months) 48 37.5% 7.0% 23.8%, 51.2%




Food insecurity 92 84.8% 3.7% 77.4%, 92.1%



Sampling

Gakoma 226 81% Comparison

Nyagishubi 180 91% Comparison

Muyange 188 82% ECD+F

Uwinyana 141 84% ECD+F

Appendices 67

Cyato Sector (Nyamasheke District) site profile

Nyamasheke District is located in the Western Province on the shores of Lake Kivu. Nyamasheke is isolated, as it is also surrounded in large part by the Nyungwe Forest. The project site is located in Cyato Sector, which is remotely located on the fringe of Nyungwe Forest. The only electricity in the sector is in Mutongo Cell, where the sector offices and Yove Health Centre are located. The ECD&F centre was built in Rugali Cell, Karambo Village, and will serve four other villages in the cell (Rwumba, Rubeho, Gakenke and Gashihe). However, only the three villages closest to the ECD&F centre (Karambo, Rwumba and Rubeho) were included in the baseline. Comparison villages were chosen from Bisumo Cell, which is located within the same sector, but is geographically isolated from the ECD&F centre. Bisumo Cell is more remote than Rugali, but has its own health post. Three villages were

sampled from Ruhunga Cell, Gakoma and Nyagishubi. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Nyamasheke in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 99 41.4% 5.0% 31.7%, 51.1%







Water storage 99 41.4% 5.0% 31.7%, 51.1%







Dewormed 97 65.0% 4.8% 55.5%, 74.4%


Stunting (24–35 months) 52 63.5% 6.7% 50.4%, 76.5%




Food insecurity 99 82.8% 3.8% 75.4%, 90.3%



Sampling

Kayo 130 22% Comparison

Mutuntu 156 17% Comparison

Karambo 77 1% ECD+F

Rubeho 94 6% ECD+F

Rwumba 100 10% ECD+F


Mageragere Sector (Nyarugenge District) site profile

Nyarugenge District is located in Kigali Province and is largely urban with a good deal of the district falling within Kigali city limits. However, Mageragere Sector, where the project site is located, is rural along the Nyabarongo River. The ECD&F centre is located in Nyarurenzi Cell, Iterambere Village. According to local leaders, three other villages will be able to access the ECD&F centre, these being Gikuyu, Nyayirondo and Nyarurenzi. Only Iterambere Village was included in the baseline evaluation. There is a very large health centre located in Nyarurenzi Cell, as well as opportunities for off-farm employment in shops and a nearby mine. The comparison villages were chosen from Kankuba Cell, which is located within the same sector, but geographically isolated from the ECD&F centre. Kankuba Cell was chosen because it is home to the Butamwa Health Centre and similarly offers opportunities for

off-farm employment. Two villages were sampled from Kankuba Cell (Kankuba and Karukina). Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Nyarugenge in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.



Household wealth quintile (mean) 84 3.50 17% 3.16, 3.84



Inadequate care 83 47.0% 5.5% 36.2%, 57.7%


Support for learning 76 2.6% 1.8% 0%, 6.2%



Use of improved water source 84 97.6% 1.7% 94.4%, 100%


Water storage 84 54.8% 5.4% 44.1%, 65.4%







Dewormed 83 62.7% 5.3% 52.2%, 73.1%


Stunting (24–35 months) 41 34.2% 7.4% 19.6%, 48.7%




Food insecurity 84 78.6% 4.5% 69.8%, 87.3%



Sampling

Kankuba 114 77% Comparison

Karukina 147 31% Comparison

Iterambere 264 17% ECD+F

Appendices 69

Mbuye Sector (Ruhango District) site profile

Ruhango District is located in the Southern Province, which is the poorest region of the country. The project site is located in Mbuye Sector, which lacks piped water and electricity across the entire sector. The ECD&F centre is located in Nyakarekare Cell, Jali Village. This is the newest of the ECD&F sites included in the baseline evaluation and ground breaking at the site happened just a few months prior to data collection. The ECD&F centre will be accessible to two villages in addition to Jali – Nyakarekare and Nyaruyonga. Only Jali and Nyakarekare, which are the two closest villages to the ECD&F centre, were included in the baseline evaluation. There is a health centre very close to the ECD&F centre in Nyakarekare Cell. The comparison villages were chosen from Kizibere Cell, which is located within the same sector, but geographically isolated from the ECD&F centre. Kizibere Cell was chosen because it also has a health centre in

the area. Three villages were sampled from Kizibere Cell, these being Ruhuha, Bereshi and Kizibere. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Ruhango in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 86 47.7% 5.4% 37.1%, 58.2%






Water treatment 28 57.1% 9.4% 38.8%, 75.5%

Water storage 86 44.2% 5.4% 33.7%, 54.7%







Dewormed 86 69.8% 5.0% 60.1%, 79.5%


Stunting (24–35 months) 37 46.0% 8.2% 29.9%, 62.0%



Minimum acceptable diet 3o 20.0% 7.3% 5.7%, 34.3%

Food insecurity 86 75.6% 4.6% 66.5%, 84.7%



Sampling

Kizibere 193 22% Comparison

Ruhuha 143 23% Comparison

Bereshi 143 30% Comparison

Jali 143 41% ECD+F

Nyakarekare 270 21% ECD+F


Munyiginya Sector (Rwamagana District) site profile

Rwamagana District is located in the Eastern Province of Rwanda. The project site is in Munyiginya Sector, which straddles the tarmac road heading east out of Kigali. The ECD&F centre is located in Cyimbazi Cell, Ntunga Village, which is right on the border with Cyarukamba Cell. The ECD&F centre is a short distance from the tarmac road, which provides residents of the area with opportunities for off-farm employment. The centre is accessible to seven villages across Cyimbazi and Cyarukamba Cells, according to local leaders. These villages are Ntunga, Agatare, Akabuye, Nyagakombe, Kagarama, Kabenda and Rweza. Only the two closest villages of Ntunga and Kagarama were included in the baseline evaluation. The comparison villages were chosen from two cells, two villages (Kiyovu and Kabeza) in Nyarubuye Cell and Ndago in Cyarukamba Cell. These sites were chosen because they are located within the same sector, but geographically isolated from the ECD&F centre. While Cyarukamba has some villages that will be able to access the ECD&F centre, Ndago is located too far for households to access it and was included because, unlike

much of the rest of Munyiginya Sector outside of Cyimbazi and Cyarukamba, opportunities for off-farm employment exist due to its location on the tarmac road. The nearest health facilities are located outside of Munyiginya Sector in the nearby town of Rwamagana, which is also home to the provincial hospital for the Eastern Province. Data from the 2012 National Ubudehe Database are provided for the villages included in the study below.

Selected indicators are presented for Rwamagana in the table below. For each indicator, 95 per cent confidence intervals were calculated due to the small number of observations in an individual project site. For proportions, the Wald-type confidence interval was calculated.






Inadequate care 92 52.2% 5.2% 42.0%, 62.4%






Water treatment 28 82.1% 7.2% 68.0%, 96.3%

Water storage 92 44.6% 5.2% 34.4%, 54.7%







Dewormed 92 58.7% 5.1% 48.6%, 68.8%


Stunting (24–35 months) 45 33.3% 7.0% 19.6%, 47.1%



Minimum acceptable diet 30 13.3% 6.2% 1.2%, 25.5%

Food insecurity 92 83.7% 3.9% 76.1%, 91.2%



Sampling

Ndago 86 34% Comparison

Kabeza 222 17% Comparison

Kiyovu 123 15% Comparison

Kagarama 129 29% ECD+F

Ntunga 144 13% ECD+F

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Early Childhood Development and Family Services · Support to Early Childhood Development and Family services has emerged over the past three years as a key priority area for development