Knowledge, Attitudes & Practices

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Knowledge, Attitudes & Practices

Assessment on Early Nurturing of Children Report

Knowledge, Attitudes and Practices Assessment on Early Nurturing of Children ReportMinistry of Health, Rwanda and UNICEF Rwanda

Copyright @ Ministry of Health, Rwanda and United Nations Children’s Fund in Rwanda (UNICEF Rwanda)March 2014

Permission is required to reproduce any part of this publication. Please contact:Ministry of HealthP.O. Box 84 Kigali, RwandaTelephone: +250 577458Fax: +250 576853Email: [email protected]

Acknowledgements

This assessment was commissioned by the Ministry of Health and by UNICEF Rwanda and is the result of successfulcollaboration between a number of organizations and individuals. The assessment was conducted by Ipsos, Uganda. The research team was led by Virginia Nkwanzi-Isingoma with support from Nathaniel Mayende from Ipsos. Lead technical support was provided by Dr Fidele Ngabo at the Ministry of Health, and by Dr Rachel Sabates-Wheeler, UNICEF Rwanda. We would also like to acknowledge the generosity of all the women and men who devoted their time to sitting with enumerators and answering the survey questions.

Cover photograph: © UNICEF Rwanda 2011/NooraniDesign and print: Handmade Communications with technical support from Siddhartha (Sid) Shrestha

Knowledge, Attitudes & PracticesAssessment on Early Nurturing of Children Report

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1FOREWORD

Foreword

The overall objective of this assessment is to provide a comprehensive picture of current knowledge, attitudes and practices (KAP) in relation to the early nurturing of children in Rwanda. A more immediate purpose is to inform major nationwide campaigns of the Government of Rwanda. One such campaign is the ‘Thousand Days in the Land of a

Thousand Hills’ campaign. The objective of this campaign is to improve the nutritional status of vulnerable populations in Rwanda, to reduce morbidity and mortality, through a multi-sectoral approach. Programmatically, the campaign creates awareness of the need to focus on available, affordable and cost-effective solutions to improve nutrition during the first ‘1000 day window’ of opportunity. The results of this assessment will also inform the design of the upcoming Violence Against Children in Rwanda survey.

This KAP assessment gathered both qualitative and quantitative information covering a wide range of topics including: knowledge and practices in relation to antenatal and postnatal care; understanding children’s health and managing children’s illnesses and immunizations; child feeding; how parents interact with their children; and KAP in relation to the discipline and mistreatment of children.

The results point to a great need for further community education. This report recommends better educating caregivers on how to properly care for their children in areas of nutrition, hygiene, discipline and parenting practices, as well as ensuring improved attendance of antenatal care services. It also points to the need to educate fathers more about the importance of their involvement in child care. It is clear that radio plays an important role as a source of information within the communities and this would be an ideal channel for sensitizing communities on issues related to early nurturing. Community leaders and health workers are a useful resource for conveying messages on child care, in addition to existing community forums where child care issues are discussed.

We are convinced that by looking into the prevailing understanding and practices determining early child care and nurturing in Rwanda, the findings of this assessment will guide readers, planners and decision makers towards ensuring that all children can grow up in caring, protective and nurturing families and communities.

Dr. Agnes Binagwaho

Minister of Health

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2 KnOWlEDgE, AttituDEs AnD PRActicEs: AssEssmEnt On EARly nuRtuRing OF chilDREn REPORt

IncAmAke

Ubu bushakashatsi bwakoreshejwe na Ministeri y’Ubuzima hamwe na UNICEF mu Rwanda.1 Icy’ingenzi cyari kigamijwe ni ugushaka amakuru ku biriho byerekeye ubumenyi, imyifatire, n’imyitwarire bijyanye n’uko ababyeyi barera ndetse n’uko umwana atera imbere. Abasubije ibibazo muri ubu bushakashatsi ni abarezi b’abana

bafite imyaka 6 n’abatarayigezaho, hamwe n’abajyanama b’ubuzima baturutse mu turere 15 twatoranijwe mu ntara uko ari 5 mu gihugu. Imibare yakusanyijwe hakoreshejwe kubaza imbona nkubone mu ngo no kujya impaka mu matsinda. Ingo 2,000 ni zo zatoranijwe mu kubazwa imbona nkubone, muri izo ngo habajijwe abarezi 2,000 b’igitsina gore. Hiyongereyeho abarezi 600 b’igitsina gabo batoranijwe muri izo ngo 2,000. Amatsinda 12 yagiriwe mo ibiganirompaka – 10 y’abarezi b’igitsina gore na 2 y’abarezi b’igitsina gabo – hamwe n’amatsinda 10 y’abajyanama b’ubuzima yagize ibiganiro-mpaka ku buziranenge.

Ibyagezweho bigaragaza ko abagore bafite ubumenyi kurusha abagabo ku bijyanye n’uko umwana yitabwaho, by’umwihariko ku mwana ukiri mu nda ya nyina. Mu bijyanye no kwita ku mwana ataravuka, kenshi usanga abantu bazi byinshi ariko bagakora bike kandi ibikenerwa gukorwa birenze imyumvire y’abarezi. Abarezi bashyikirana n’abana mu buryo butandukanye, harimo guhagatira, kuririmba no gucyina. Nyamara ubu bushakashatsi bwerekanye ko ari abarezi b’igitsina gore – ababyeyi by’umwihariko – bashyikirana cyane n’abana. Uruhare rw’umugabo rugarukira ku guhahira no kurinda urugo. Si kenshi usanga ababyeyi b’abagabo bashyikirana n’abana mu bijyanye no kugabura, gukina no kubana nabo mu bikorwa nko kuririmba. Nyamara nkuko abasubije ibibazo babibona, hari ibyiza bizanwa n’ababyeyi b’abagabo bakunda gucyina n’abana babo, binongera umwuka mwiza mu rugo.

Umubare w’ababyarira kwa muganga uri hejuru mu miryango migari yakorewe mo ubushakashatsi. Ni uburyo bugikeneye gushishikarizwa. Imibare y’abana banditse mu buryo bw’amategeko yagaragaye muri ubu bushakashatsi iri hejuru y’impuzandengo yo mu rwego rw’igihugu. Ibi ariko ntibivuze ko iyandikishwa ry’abana ryazamutse hejuru kurusha. Ababyeyi bamwe babona ko iyo abayobozi mu midugudu babimenyeshejwe, umwana aba yanditswe bityo ntibakurikire uko bikorwa neza kugira ngo umwana agire icyemezo cy’amavuko. Haracyakenewe rero kwigisha imiryango ku buryo bwo kwandikisha abana.

Mu gihe hari ibyiza byinshi bikorwa mu kwita ku mwana nyuma y’ivuka – kuko ababyeyi bafite ubushobozi bwo kwita neza ku bana babo – ubumenyi ku bibazo bimwe na bimwe buracyari buke. Urugero: abarezi bakina n’abana batazi akamaro n’uburemere by’ibyo bakora. Ibindi bikorwa nko kuvura inzoka no gukingira nabyo birunvikana bikanakorwa mu baturage bakozweho ubushakashatsi.

Ibyabonetse byerekana ko indwara nk’iz’ubuhumekero (inkorora, ibicurane), impiswi na malariya ari byo bibazo by’ubuzima bisanzwe bigira ingaruka ku baturage bakoreweho ubushakashatsi. Kuri izi ndwara, ahanini, abatanze ibisubizo baha abana babo imiti bafite mu rugo nk’ibanze bityo bakivurira. Nyuma bitinze, kandi indwara idakize, nibwo bashaka umujyanama w’ubuzima cyangwa bakajya ku kigo nderabuzima. Mu gihe abatangaga ibisubizo

1 ubu bushakashatsi bwakozwe na ipsos, uganda. itsinda ry’abashakashatsi ryari riyobowe na Virginia nkwanzi-isingoma abifashijwemo na nathaniel mayende ndetse na collins Kweyamba. inkunga y’ikoranabuhanga yatanzwe na Dr Fidele ngabo wo muri ministeri y’ubuzima hamwe na Rachel sabates-Wheeler ubarizwa muri section ishinzwe Politike y’imbonezamubano n’ubushakashatsi muri unicEF-Rwanda.©

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bagaragaza ubumenyi buhagije mu guhangana n’indwara z’abana, haracyari kumva nabi n’ubumenyi buke ku mpamvu z’indwara zimwe na zimwe n’uburyo zavurwa. Ibyabonetse byerekana kandi ko urwego rw’imyumvire ku isuku n’isukura byateye imbere ariko kubishyira mu ngiro biracyari hasi. Bityo rero gushishikariza abantu gushyira mu ngiro isukura nyaryo, nko gukaraba intoki nyuma yo kwituma no gukaraba intoki mbere yo guteka no kugaburira uruhinja.

Ku byerekeye kugaburira umwana, ibyabonetse muri ubu bushakashatsi birasaba ko abarezi basobanukirwa neza ubwoko bw’indyo nyayo ku bana. Abana bataruzuza amezi 6 muri rusange baronswa gusa; mu basubizaga ,abenshi batanga imfashabere ku mezi 6 cyangwa hagati y’amezi 6 na 12. Iyo umwana atangiye guhabwa imfashabere, ingo zifite ubushobozi butandukanye mu mutungo zigaburira abana ku buryo butandukanye. Abana b’abakene bakunze kugaburirwa ibinyamisogwe n’igaburo ridahagije, ridahinduka kandi ridafite intungamubiri za ngombwa. Ubu bushakashatsi kandi bwasanze imibare y’abana bari mu byiciro biri hasi mu bukungu batabona amafunguro gatatu ku munsi. Ubu bushakashatsi bwavumbuye ikigereranyo cy’ubukene cya 47.6 % mu ngo z’abatanze ibisubizo. Icyiciro cy’ubukene gikomatanyijwe n’imirire mu miryango ituye mu byaro bishobora kuba ari byo bitera kuzingama kw’abana nkuko bigaragara mu nyandiko zo mu rwego rw’igihugu. Kuzamura imibereho y’imiryango mu byaro bizafata intera ndende kugirango habe impinduka.

Abarezi mu baturage bagezweho n’ubu bushakashatsi ntibasigira abana babo abandi babitaho. Aho bibaye abana basigaranwa n’abakecuru mu ngo, abandi bana bakuze, cyangwa abaturanyi. Abana bitabwaho bihagije bageze ku myaka y’ishuri cyangwa igihe bajyanywe mu mashuri y’incuke. Hanavuzwe ibigo byita ku bana bifashwa n’imiryango itegamiye kuri Leta, n’ibigo by’abihaye Imana, ariko ibi ntabwo ari itegeko kuri bose, ni umwihariko.

Ibyabonetse byerekana ko abana batozwa ubwitonzi bakubitwa agashyi, babatonganya, cyangwa baganirizwa n’ ababyeyi. Uretse ibi, abarezi berekanye ko inzira nziza yo gutoza umwana ubwitonzi ari ukumuvugisha no kumugira inama utifashishije uburyo bubabaza umubiri. Mu biganiro byo mu matsinda, abarezi n’abajyanama b’ubuzima nabo bavuze ko igihano kibabaza umubiri kitakigira akamaro. Ariko rero ibyakusanyijwe byose birerekana ko hakiri henshi bagihanisha abana ibihano bibabaza umubiri. Hakenewe gukangurira umuryango cyane uburyo buboneye bwo gutoza abana imico myiza kugira ngo duhindure buryo bubi bwo gutoza abana ubwitonzi bukorwa ubu.

Ibyabonetse bigaragaza ka hakenewe cyane kwigisha umuryango kurushaho. Iyi raporo irasaba ko abarezi bahugurwa neza kurushaho ku byerekeye uko bita ku bana bashinzwe, ndetse no kunoza uko ababyeyi bagana aho bisuzumishiriza batwite. Inerekana ibikenewe mu guhugura ababyeyi b’abagabo ku buremere n’agaciro byo kugira uruhare mu kwita ku bana. Bigaragara neza ko radiyo ifite akamaro gakomeye nk’isoko y’amakuru mu miryango kandi ko yaba umuyoboro mwiza wo guhugura imiryango. Abayobozi b’ibanze n’abajyanama b’ubuzima bakoreshwa mu gukwirakwiza ubutumwa bwerekeye uko umwana yitabwaho, byiyongera ku mahuriro yo mu miryango aho ibibazo byo kwita ku bana bivugirwa.


executIve summAry

This assessment was commissioned by the Ministry of Health and by UNICEF Rwanda.1 Its main objective was to generate information on existing knowledge, attitudes and practices (KAP) in relation to parenting and child development. The target respondents for the assessment were caregivers of children aged 6 years and below, as well as community

health workers from 15 districts in the 5 provinces of the country. Data were collected using face-to-face household interviews and focus group discussions. The target sample for the household interviews was 2,000 households, within which 2,000 female caregivers were interviewed. In addition, 600 male caregivers were selected systematically for interview from the random sample of 2,000 households. Twelve focus group discussions were conducted (10 with female caregivers and 2 with male caregivers) and 10 qualitative discussions were held with community health workers.

The results show that women are more knowledgeable than men on matters to do with child care, especially concerning pre-birth and antenatal care (ANC). In aspects of pre-birth and antenatal care, knowledge often does not equate to practice and practice is higher than caregivers’ understanding. Caregivers interact with children in various ways, including cuddling, singing and playing. The assessment, however, shows that it is female caregivers – especially mothers – who interact more with children. The role of the father is generally limited to that of breadwinner and protector. It is rare to find fathers interacting with children in terms of feeding, playing, and engaging in activities such as singing. There is, however, a positive perception towards fathers who do play with their children as, according to the respondents, it fosters close family bonds.

The incidence of hospital delivery is high within the communities studied. This is a trend that should still be encouraged. Incidences of child registration reported in this assessment are higher than the national average. This, however, does not necessarily mean birth registration is actually higher. It seems some parents consider the birth notifications given by community leaders to mean the child has been registered so they do not follow the correct procedure to get a birth certificate. There is, therefore, still a need to educate the community on the procedures for child registration.

While positive after birth child care practice is high – in that parents are mainly able to take care of their children well – knowledge on some of the issues is low. For example, caregivers play with children without consciously thinking of the importance of such activities. Other practices, such as deworming and immunization, are also understood and practised in the survey population.

The results show that diseases, such as respiratory infections (cough, flu), diarrhoea and malaria, are the most common health issues that affect the population studied. These illnesses are generally treated by self-medication where, as the first option, respondents give their children medicine that they have in the house. Only later, and if the illness persists, do respondents seek the services of a community health worker or visit a health facility. While respondents are fairly knowledgeable about managing childhood illnesses, there are misconceptions and gaps in knowledge with regard to the causes of certain illnesses and the best ways to treat them. The results also show there are high levels of awareness regarding hygiene and sanitation, but

1 the assessment was conducted by ipsos, uganda. the research team was led by Virginia nkwanzi-isingoma with support from nathaniel mayende and collins Kweyamba. technical support was provided by Dr Fidele ngabo at the ministry of health and by Rachel sabates-Wheeler from the social Policy and Research section, unicEF Rwanda.©

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the practice is still low. Therefore, a call to action is also needed to increase proper sanitation practices, such as washing hands after using the toilet and before cooking food or feeding the baby.

In terms of feeding, the results of this survey suggest that caregivers understand the correct type of nutrition for children. Children below 6 months are generally breastfed exclusively, with most respondents introducing complementary foods at 6 months or between 6 and 12 months. When complementary feeding is introduced, households with different economic capabilities feed their children differently. There is a prevalence of starchy foods being given to poor children and a more limited diet in terms of variety and nutritional content. This assessment also finds that a high percentage of children in the lower economic categories do not receive three meals a day. This study registered a poverty level of 47.6 per cent among respondent households. The poverty level, combined with the feeding regime of families in rural areas, may account for the stunted growth of children reported in national literature. Improving the living standards of families in rural areas will go a long way towards rectifying this situation.

Caregivers in the population assessed in this study do not ordinarily leave their children in the care of other people. In cases where this is done, the children are left in the care of other older females in the home or with older siblings or neighbours. Organized child care is restricted to when children reach school age or go to nursery schools. There was also mention of child care centres run by non-governmental organizations (NGOs) and faith-based institutions, but this was the exception rather than the norm. Although caregivers generally indicated that the best way to discipline a child is by talking and advising the child, without recourse to physical methods, the findings show children are often disciplined through slapping, caning and/or shouting, as well as by parents talking to the child. In focus group discussions, caregivers and community health workers also expressed the view that physical punishment of children is no longer seen as appropriate. However, the data collected indicate a high prevalence of the practice of physically punishing children. There is a need to sensitize the community further on the proper ways of disciplining children to help to change these disciplinary methods in practice.

The results point to a great need for further community education. This report recommends educating caregivers better on how to care for their children properly, as well as ensuring improved attendance at ANC services. It also points to the need to educate fathers more about the importance of their involvement in child care. It is clear that radio plays an important role as a source of information within the communities and this would be an ideal channel for sensitizing communities. Community leaders and health workers can be used to pass along messages on child care, in addition to existing community forums where child care issues are discussed.


contentsFOREWORD .................................................................................................................1

INCAMAKE .................................................................................................................2

EXECUTIVE SUMMARY................................................................................................4

LIST OF GLOSSARY ITEMS, ABBREVIATIONS AND ACRONYMS ...............................9

CHAPTER 1: INTRODUCTION .................................................................................... 10

CHAPTER 2: RESEARCH METHODS .......................................................................... 12

2.1 The target respondents ...................................................................................................................122.2 Approach .........................................................................................................................................122.3 Sample distribution and respondent selection ..........................................................................132.4 Data collection ................................................................................................................................142.5 Data analysis ...................................................................................................................................152.6 Challenges ........................................................................................................................................16

CHAPTER 3: LITERATURE REVIEW ............................................................................. 17

3.1 Introduction ....................................................................................................................................173.2 Antenatal care and early childhood development .....................................................................173.3 Postnatal care and early childhood development......................................................................183.4 Childhood growth and development ..........................................................................................193.5 Barriers to positive early childhood development experiences ...............................................213.6 Policy issues in relation to early childhood development ........................................................22

CHAPTER 4: STUDY FINDINGS ..................................................................................23

4.1 Introduction ....................................................................................................................................234.2 Demographic characteristics of respondents .............................................................................234.3 General health problems affecting the community ..................................................................264.4 Knowledge, attitudes and practices regarding hygiene and sanitation .................................324.5 Knowledge, attitudes and practices regarding child care from pre-birth to delivery .........334.6 Knowledge, attitudes and practices regarding child care after birth .....................................384.7 Knowledge, attitudes and practices regarding deworming .................................................... 404.8 Knowledge, attitudes and practices regarding immunization ............................................... 424.9 Knowledge, attitudes and practices regarding child registration .......................................... 424.10 Knowledge, attitudes and practices regarding feeding .......................................................... 434.11 Knowledge, attitudes and practices regarding child–parent interaction ............................494.12 Attitudes towards early childhood development .....................................................................514.13 Knowledge, attitudes and practices regarding child learning ...............................................514.14 The father’s role in parenting ......................................................................................................534.15 Leaving children in the care of others .......................................................................................554.16 Disciplinary measures and child abuse .....................................................................................574.17 Communication and sources of information ...........................................................................61©

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CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS ......................................63

ANNEX 1: TABLES ..................................................................................................... 67

Demographics ......................................................................................................................................67Health issues affecting the community ............................................................................................70Management of health issues .............................................................................................................72Antenatal and pre-birth care .............................................................................................................73

ANNEX 2: COMPARATIVE ANALYSIS OF THE RWANDAN KAP TO THE KAP OF OTHER COUNTRIES ..................................................................................... 76

ANNEX 3: SELECTED INDICATORS, DISAGGREGATED BY DISTRICT .......................78

lIst oF tAblesTABLE 1: Respondent distribution ....................................................................................................12TABLE 2: Sample distribution ............................................................................................................14TABLE 3: Index children in the sample ............................................................................................23TABLE 5: Economic categories using multi-dimensional poverty indicators ............................25TABLE 4: Poverty level by type of material used for the floor .......................................................25TABLE 6: Perceived health problems affecting the communities .................................................26TABLE 7: Common health issues: A comparison between male and female ..............................27TABLE 8: Perceived health problems and the perceived causes ................................................... 28TABLE 9: Actions taken by respondents to immediately respond to and treat

illnesses in their children ..................................................................................................29TABLE 10: Actions taken by respondents to treat children’s illnesses ....................................... 30TABLE 11: Treatment measures of various illnesses by respondents ...........................................31TABLE 12: Hygiene knowledge vs practice absolutes .....................................................................32TABLE 13: Knowledge and practice in relation to pre-birth care for the mother and child ....33TABLE 14: Comparing the knowledge and practices of male and female caregivers

during pregnancy ............................................................................................................ 34TABLE 15: Knowledge and practice of antenatal care ....................................................................36TABLE 16: Place of delivery of index child disaggregated by economic category .....................37TABLE 17: Knowledge and practices regarding child care after birth .........................................39TABLE 18: Deworming of children by province .............................................................................41TABLE 19: Deworming of children by economic category............................................................41TABLE 20: Reasons why respondents have never dewormed their children ..............................41TABLE 21: Reasons for lack of registration of children ................................................................. 42TABLE 22: Foods given to children before breakfast .................................................................... 44


TABLE 23: Foods given to children for breakfast .......................................................................... 44TABLE 24: Foods given to children before lunch ........................................................................... 45TABLE 25: Foods given to children for lunch ................................................................................. 45TABLE 26: Foods given to children before dinner ......................................................................... 46TABLE 27: Foods given to children for dinner ............................................................................... 46TABLE 28: Foods regularly given to children 7 to 11 months old ................................................47TABLE 29: Foods ordinarily fed to children aged 2 to 6 years ..................................................... 48TABLE 30: Activities done to develop children’s physical, emotional and mental abilities .... 50TABLE 31: Activities done to stimulate children aged 3 to 6 years old .......................................51TABLE 32: Perception towards child development practices ........................................................52TABLE 33: Importance of a father’s role in the development of their child ...............................53TABLE 34: Methods of disciplining children aged 2 to 3 years old .............................................57TABLE 35: Methods of punishing children aged 4 to 6 years .......................................................58TABLE 36: Attitudes towards physical punishment of children ..................................................58TABLE 37: The most common cases of child mistreatment in this community ........................59TABLE 38: Sources of information ....................................................................................................62TABLE 39: Household sample achievement by province ...............................................................67TABLE 40: Household sample achievement by district .................................................................67TABLE 41: Category of respondent demographics ........................................................................ 68TABLE 42: Disability status of female household respondents .................................................... 68TABLE 43: Respondents’ level of education: overall ...................................................................... 68TABLE 44: Respondents’ level of education by economic level .................................................. 68TABLE 45: Age groups .........................................................................................................................69TABLE 46: Respondents’ working status ..........................................................................................69TABLE 47: Respondents’ religion .......................................................................................................69TABLE 48: Households’ economic categories ..................................................................................70TABLE 49: The most common health issues affecting this community today ...........................70TABLE 50: Groups of people who are most affected by health issues ..........................................71TABLE 51: Health problems that affect children 0 to 6 years ........................................................71TABLE 52: In the past two weeks did any child below 6 years of age in this

household fall sick? ..........................................................................................................72TABLE 53: What were the symptoms of the illness that the child or children

suffered from? ...................................................................................................................72TABLE 54: What did you do immediately after you noticed the symptoms? .............................72TABLE 55: What did you do to treat the condition? .......................................................................73TABLE 56: What mothers should do before birth to ensure a child is healthy ..........................73TABLE 57: What mothers should do after birth to ensure a child is healthy .............................74TABLE 58: Where respondents went for ANC ................................................................................74TABLE 59: Where a pregnant woman should go for ANC ............................................................75TABLE 60: How many times should a pregnant woman go for ANC? ........................................75TABLE 61: Where respondents delivered their index child ...........................................................75

9list OF glOssARy itEms, ABBREViAtiOns AnD AcROnyms

lIst oF glossAry Items, AbbrevIAtIons And AcronymsANC Antenatal care

Caregiver A person (aged between 18 and 49 years) who is in charge of taking care of a child of 0 to 6 years

ECD Early childhood development

GoR Government of Rwanda

Index child the youngest child in the household between 1 and 6 years old, whose findings are representative of all children in that household

KAP Knowledge, attitudes and practices

NGOs Non-governmental organizations

NISR National Institute of Statistics Rwanda

Older caregiver A person (aged 50 years and above) who is in charge of taking care of a child of 0 to 6 years

ORS Oral rehydration salts

RDHS Rwanda Demographic Health Survey

UNICEF United Nations Children’s Fund

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chApter 1: IntroductIon

In the context of the Joint Action Plan for the Elimination of Malnutrition, the Government of Rwanda (GoR) requested that UNICEF Rwanda support an assessment of knowledge, attitudes and practices (KAP) in relation to the early nurturing of children. This assessment was conducted among parents and caregivers of children under 6 years old in 15 districts.

KAP studies are among well-established methodologies to investigate health behaviour, and are widely used to gather information for planning public health programmes in a range of countries. Few KAPs touch upon such an extensive and impressive array of issues as the Rwandan KAP on Early Nurturing of Children (Hygiene and sanitation; Child care from pre-birth to delivery; Child care after birth; Deworming; Immunization; Child registration; Feeding; Child–parent interaction; Early childhood development; Child learning; Parenting; Leaving children in the care of others; Disciplinary measures and child abuse; and Communication and sources of information).

The results reported here are in line with findings from similar KAP studies of other countries, for example the 2009 Baseline survey of the KAP of parents/guardians on early childhood development and primary education in Nepal found that the level of knowledge on all aspects of early childhood development (ECD) was lower than the levels of attitude and practice.2 (See Annex 2 for an overview of the KAP results in other countries.)

The overall purpose of the KAP assessment on the early nurturing of children was to document existing attitudes and practices towards young children in order to inform the messaging of a major nationwide campaign. The “Thousand Days in the Land of a Thousand Hills” campaign is aimed at raising awareness of family and child feeding practices in the first one thousand days of a child’s life, which are critical to preventing stunting.

The findings presented in this report will also help to define appropriate family- and community-level interventions to ensure the optimum well-being of children in their early years and to contribute to Rwanda’s long-term vision for children and for national development.

Data were gathered on a range of issues, such as: health problems affecting families and how these are managed; hygiene and sanitation; KAP in relation to child care – from pre-birth to delivery; and KAP in relation to child–parent interaction, the care and protection of children, the father’s role in child care and disciplinary measures. Data collected are disaggregated according to the gender, age, economic category and location of respondents.

To achieve the overall purpose of this assessment, specific objectives were developed, including to:• document existing KAP on ECD and the family (parenting, nurturing, nutrition, health care

and hygiene, protection, and stimulation of children) in Rwanda;• identify vulnerabilities and gaps in KAP among different socio-economic groupings and

geographic areas of Rwanda;• generate baseline data on existing attitudes and practices on ECD and, thereby, create a

framework for monitoring progress;

2 unicEF and tribhuvan university Research centre for Educational innovation and Development (cERiD), Baseline Survey of the Knowledge, Attitude and Practice (KAP) of Parents/Guardians on Early Childhood Development and Primary Education in Nepal, unicEF nepal country Office, Pulchowk, lalitpur, April 2009, <www.unicef.org/nepal/KAP_study_EcD_and_Education.pdf>, accessed 13 march 2014.

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11chAPtER 1: intRODuctiOn

• provide essential data to assist in the formulation of key messages and the identification of key areas of focus for the “Thousand Days” campaign and future initiatives, including the “Every Child Needs a Family” campaign and the Violence Against Children in Rwanda study.

Four chapters follow the Introduction of this report.• Research methods: This chapter explains the methods used in data collection and data

analysis, and how the findings are presented.• Literature review: This chapter presents an overview of relevant literature from studies

conducted elsewhere. This helps to put the findings into context. It also informed the formulation of the tools that were used to collect data.

• Study findings: The findings are presented in a thematic manner representing the core objectives of the KAP. Findings are disaggregated by gender, age of children, caregiver status, other demographics and province. While most of the findings are quantitative, supportive qualitative comments have also been included.

• Conclusions and recommendations: This chapter presents the main conclusions and recommendations as a result of this assessment.


chApter 2: reseArch methods

2.1 the tArget respondents

UNICEF Rwanda aims to improve the well-being of all children, with a particular focus on children aged 0 to 6 years. To improve the well-being of this group, the direct target of UNICEF Rwanda’s interventions are the mothers and caregivers of children aged 0 to 6 years and other people concerned about children of this age. The target

respondents for this study, therefore, largely comprised caregivers of children aged 0 to 6 years.

The respondents were distributed as follows:

table 1: Respondent distribution

Target respondents Sample size Description

Caregivers 2,000 interviews with female caregivers

600 interviews with male spouses of the interviewed female respondents

12 focus group discussions with caregivers

Mothers and caregivers of children 0 to 6 years

Pre-birth – expectant mothers

Post birth – 0 to 2 years and 3 to 6 years

Community health workers

10 qualitative discussions with community health workers

Community health workers and ECD staff

2.2 ApproAch

This survey used both qualitative and quantitative methodologies of data collection and analysis. The approaches were informed by the research objectives, which required in-depth understanding of attitudes and behaviour, at the same time as providing measurable statistics. Two methods of qualitative data collection were used to gather data from different sets of respondents: interviews and focus group discussions. Each focus group discussion comprised a minimum of 8 and a maximum of 12 participants. The group discussions were conducted among the general public, involving primary caregivers and expectant mothers, as well as with community health workers. Twelve focus groups were held with caregivers (2 with male caregivers and 10 with female caregivers) and 10 focus groups were held with community health workers.

The focus groups were conducted in the following districts: Bugesera, Kayonza, Ngoma, Rwamagana, Nyarugenge, Gakenke, Gicumbi, Rulindo, Nyamagabe, Ngororero, Nyamasheke, Rubavu. Qualitative discussions with community health workers were held in 10 of the above districts and focus group discussions were held in all 12 districts.

To stimulate better responses and to identify respondents’ behaviour, knowledge, attitudes, perceptions, motivations, feelings and fears, various techniques were used. These included indirect probing and word associations.• Indirect probing: Direct probing was avoided, hence most questions were asked in third

person format, for example; What do people feel about …? How do people in this area feel about violence against children or child abuse? What are some of the problems affecting ©

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children in this community? Do people in this community go for antenatal care when they are pregnant? How are children of 0 to 6 years treated in this community?

• Word associations: The participants were asked what comes to their mind when they hear about nurturing or child rearing. What word would they use to describe a given situation of violence against children?

The focus group discussions were organized in venues that were convenient for the participants to access and which provided privacy. The respondents were asked for their consent to the interview to ensure they were providing information freely. The purpose of the study and its objectives were explained to all respondents before the focus groups began. The focus group discussions were conducted in Kinyarwanda by experienced and well-trained moderators. The male groups were moderated by male moderators and female groups by female moderators to encourage free and informal discussions. All the discussion guides were translated to Kinyarwanda before being used for data collection.

With regard to quantitative data collection, an assessment was conducted among mothers and caregivers of children of 0 to 6 years in 15 selected districts in all provinces of Rwanda. The assessment was conducted at the household level comprising a sample of 2,000 households, within which 2,600 interviews were conducted with both men and women.

The main objective of a sampling methodology for any national KAP study is to establish reliable data that can be used to understand behaviour and practices and to provide learning to inform national programme implementation. It is, therefore, important to extract a sample that adequately represents the population of interest in the 15 districts. A sample of 2,000 households, from which 2,000 female caregivers and 600 male caregivers were interviewed, was selected.

The sample size was determined using the formula:

n = D * 1.962 pq

B2

Where:n is the required sample size1.96 is the z value at 95 per cent confidence intervalp is the proportion of children younger than 5 years oldq = 1 – pB is the margin of error (5 per cent) andD is the design effect (1.5) – the effect of multi-stage cluster sampling.

The sample size was approximated to 2,000 households with domain of analysis being five (five provinces) and non-response rate of 10 per cent. This was approved by the National Institute of Statistics of Rwanda (NISR).

2.3 sAmple dIstrIbutIon And respondent selectIon

The 15 districts included in the study were recommended by UNICEF – based on the district that UNICEF intends to support to model ECD service provision – and authorized by NISR. NISR provided the final minimum sample size that had to be achieved for each district to achieve valid results. Over-sampling enabled us to achieve the desired sample sizes for the study. NISR selected the enumeration areas and provided a sampling frame for the interviews within the areas.


table 2: sample distribution

Province District Villages PopulationNo of households

(random selection)

Total 7,456 4,572,828 2,000

East Bugesera 585 294,013 150

Kayonza 418 255,119 100

Ngoma 473 277,129 125

Rwamagana 472 256,147 125

Kigali City Nyarugenge 356 247,090 100

Gasabo 494 398,282 125

North Gakenke 617 334,236 175

Gicumbi 629 360,237 175

Rulindo 494 264,981 125

South Nyamagabe 536 311,808 150

Kamonyi 319 287,881 75

Ruhango 533 280,625 150

West Ngororero 419 311,834 125

Nyamasheke 586 344,222 150

Rubavu 525 349,224 150

This KAP assessment focuses on children of 0 to 6 years. The respondents selected, therefore, were primary caregivers of children of 0 to 6 years. The study had a selection criterion to ensure that the appropriate respondents were interviewed. The assessment targeted female caregivers, especially biological mothers of the children in question. In addition to interviewing mothers, other caregivers, such as expectant mothers, caretakers/relatives and grandmothers to children of 0 to 6 years, were also interviewed. For the female caregivers, biological mothers made up 83 per cent of the sample, with biological fathers comprising 92 per cent of the male caregiver sample. Attributes specific to caregivers/mothers and the index child were observed. These are attributes that have the potential to affect the way a caregiver takes care of the child or the way a child is perceived by the caregiver. The overall descriptive attributes measured include disability status, education of the caregiver, age, income level and religion of the household in which the child grows up.

2.4 dAtA collectIon

Prior to data collection a scoping visit was conducted, which provided an opportunity for the team to make contact with key stakeholders, especially at the central government level. This included, among others, getting information about ECD initiatives which then informed the implementation processes. In liaison with the Ministry of Health and UNICEF Rwanda, permits to conduct the assessment were granted by the NISR.

The different tools used for data collection included:1. discussion guides2. key informant interview guide3. health workers’ discussion guide4. caregivers’ discussion guide5. semi-structured questionnaire6. female caregivers’ questionnaire7. male caregivers’ questionnaire8. structured observation questionnaire.

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Data collection tools were developed, translated, pre-tested and approved by UNICEF Rwanda before being used in the field. Recruitment and training of the field team was led by the manager and field manager. Only those interviewers who had worked on similar tasks and could speak and understand both the local language (Kinyarwanda) and English were recruited.

The team that conducted household interviews comprised 65 interviewers and 13 team leaders/supervisors, who were trained for a period of seven days using structured interviewer manuals. The training ensured that the team understood the objectives of the assessment, the methodology and the research tools. The training covered the objectives of the study, dos and don’ts, fieldwork protocol and identifying respondents, among other areas. UNICEF staff also participated in some of the training sessions.

2.5 dAtA AnAlysIs

During the focus group discussions, recordings and notes were taken and transcripts were produced on the basis of these. The transcripts were then used to produce grids for analysis and report writing. These findings were then analysed to bring out prevailing opinions, attitudes, behaviours and practices to support the findings from the quantitative phase.

The supervisors reviewed and submitted questionnaires from the field to the office for coding. In this way, the findings from the questionnaires were captured verbatim and given numeric codes. After the coding process, the questionnaires were scanned for data capture. All questionnaires were labelled and verified for accuracy and consistency. At least 10 per cent of the captured data was checked manually for accuracy and consistency.

The following steps were followed during data cleaning and analysis:1. A tabulation and data-processing plan was developed before the completion of fieldwork

and shared with the lead researcher.2. Data were captured by scanning the questionnaires using data capture software.3. Data cleaning was done using the processing plan earlier provided and the final output of

tables was generated. These tables followed the flow of the questionnaire.4. The tables were checked to verify consistency. The checking also highlighted areas where

more cleaning and analysis was required.5. Final tables were generated that displayed absolute numbers, percentages, averages,

correlations and t-tests (where applicable).6. The final SPSS (Statistical Package for the Social Sciences software) data sets were then

generated.

significance tests

Apart from presenting the numeric frequency statistics on knowledge and practice, significance tests done to ascertain whether the differences between knowledge and practice are significant. In addition, further analysis was done using correlations to ascertain whether an increase in knowledge would lead to a significant change in practice.

A t-test (significance test) was done on each attribute for knowledge and practice using α = 0.05. The hypotheses in each of the cases were:

H0: There is no significant difference between the means of the two variables.

HA: There is a significant difference between the means of the two variables.

For example, in relation to the knowledge and practice on after birth behaviour, the attribute on immunization is analyzed for knowledge (the respondent knows that it is important to immunize the baby) and practice (the respondent actually immunized the child). The null hypothesis is rejected if the significance (t-test) is less than α. In the example given, the null hypothesis was


“there is no significant difference between knowledge and practice on immunization”. Therefore, the alternative hypothesis, which indicated significant difference, holds true for this question of the survey as a true reflection of the situation at the time of data collection.

In addition, further analysis was done using correlations to ascertain whether an increase in knowledge would lead to a significant change in practice. In the example of knowledge and practice on immunization, the two attributes have a correlation r = 0.542 and this correlation is statistically significant (significance of the correlation = 0.000).3

We therefore conclude, for these two cases, that there is a significant difference between knowledge and practice of immunization. From an arithmetic point of view, knowledge is lower than practice. There is also significant positive correlation between the two, which would mean that an investment to increase knowledge would have a positive increase in practice.

2.6 chAllenges

Rwanda is a hilly country, which brings with it challenges when implementing assessments at household level. Many of the villages selected – especially outside Kigali – had homes built along the hills. This posed a challenge in getting from one household to another, which could only be done by walking. In most cases, this increased the originally planned time taken to conduct the household interviews.

This assessment also encountered non-response rates of varying degrees on some of the questions. Early theories in studies such as these assumed that non-response was absent. Recent surveys have, however, seen an increase in the rate of “persons not being measured”4 or some questions not being responded to. The social research literature in this area suggests that “a response rate of at least 50 percent is considered adequate for analysis and reporting. A response of 60 percent is good; a response rate of 70 percent is very good”.5 As we had very few non-responses, we contend that the findings are representative of the population assessed as part of this study, and a similar assessment following similar methodology would yield similar findings to the ones contained in this report. The findings of this study also reflect findings in published literature from NISR, which gives further confidence that the non-response rate did not affect the quality of findings achieved.

3 For a full list of significance tests and correlation tests on after birth child care attributes contact unicEF Rwanda.

4 groves, Robert m., ‘nonresponse Rates and nonresponse Bias in household surveys’, Public Opinion Quarterly, vol. 70, no. 5, 2012, pp. 646–675.

5 Babbie, Earl, The Practice of Social Research, 11th ed., Wadsworth, Belmont, cA.

17chAPtER 3: litERAtuRE REViEW

chApter 3: lIterAture revIew3.1 IntroductIon

Various authors have written on the importance of the early years of children’s lives for their subsequent well-being.6 According to the Convention on the Rights of the Child, to which Rwanda is a signatory, any individual below the age of 18 is considered to be a child. Throughout childhood, the individual undergoes various significant life

stages and lessons. These experiences and lessons have a huge impact on the person’s later years.

In Rwanda, schooling begins for children at the age of 7.7 From this age onwards, the child is taught in a formal setting. However, it is generally understood that children start learning immediately at birth when they interact with parents and especially with their mothers. There is, however, another school of thought which suggests that an individual starts learning while still in the mother’s womb, although we shall not be exploring this path within the context of this survey.8

It has been argued that a child’s development from birth to age 6 is critical in the person’s overall development and that “early success breeds later success”.9 At these early stages, children’s experiences shape their development. It is important to provide adequate stimulation, education and nurturing – at the appropriate stage of child development – to help children to learn and develop.

The ECD policy of the GoR emphasizes the holistic nature of child development, recognizing that children require stimulating play; early learning opportunities; good health care; a nutritious, balanced diet; clean water; a hygienic environment; love; and safety and security to grow up to become social, well-adapted and productive citizens. As no sector working alone can address these complex requirements, the policy recognizes that it is essential for all sectors of government and civil society in Rwanda to work together. An integrated approach to ECD is proposed, involving sectors and agencies working on education, health, nutrition, sanitation and child protection. A major part of the ECD intervention is to improve parents’ and caregivers’ knowledge of, and skills in, child development, with an emphasis on infants and children up to 6 years old.

3.2 AntenAtAl cAre And eArly chIldhood development

Traditionally, antenatal care (ANC) in Africa was left to expectant mothers and their attending midwives. With the advancement of technology and the dissemination of knowledge, it is now known that the lifestyle of an expectant mother has a significant impact on the unborn child. It

6 see centre for community child health, A Review of the Early Childhood Literature, February 2000, commonwealth of Australia, and githinji, Felicity W., and Anne Kanga, ‘Early childhood Development Education in Kenya: A literature review on current issues’, International Journal of Current Research, vol. 3, no. 11, november 2011, pp. 129–136.

7 Republic of Rwanda, Early Childhood Development Policy, ministry of Education, Kigali, 2011.8 infoRefuge, ‘mother-infant Bonding: the science of smell’, <www.inforefuge.com/science-of-smell-

mother-infant-bonding>, accessed 10 October 2012.9 heckman, James J., ‘invest in the Very young’, 2nd ed., in Encyclopaedia on Early Childhood

Development, edited by Richard E. tremblay, michel Boivin and RDeV Peters, centre of Excellence for Early childhood Development and strategic Knowledge cluster on Early childhood Development, montreal, 2007, pp. 1–2.

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is therefore generally advised that expectant mothers attend ANC and receive support to adapt their lifestyles to ensure the healthy development of the unborn child.

In Rwanda, women are aware of the need to seek ANC. Expectant mothers are ordinarily visited by a community health worker. These are people who, in addition to their day-to-day personal activities, help communities by disseminating health information and treating common ailments, such as malaria, coughs and flu. It is common for an expectant mother to be visited by a community health worker several times and the advice given during such sessions includes guidance to visit an antenatal clinic every three months, to eat healthy food, to engage in activities that will exercise their bodies without overly straining them, and to sleep under insecticide-treated mosquito nets. All this advice helps to protect the health of the mother and of the unborn child.

Maternal nutrition is an important issue for the development of the unborn child. For proper development, it is recommended that a mother follows a healthy diet. Appropriate foods are generally found within the farms and markets in Rwanda. Ninety percent of the population in Rwanda is engaged in agricultural production with such crops as plantains, sweet potatoes, cassava, dry beans and sorghum grown.10 Therefore, save for economic constraints, it is possible for expectant mothers to get a balanced diet.

An expectant mother also needs to be cared for. This responsibility generally falls upon the unborn child’s father, who, in most cases is the husband of the expectant mother. The father should provide an environment that enables the proper care of the mother and of the unborn child. It is also known that the emotional condition of the mother has an effect on the physical and emotional health of the child even after birth. A Harvard Medical School report points out that almost 25 per cent of cases of postpartum depression start during pregnancy.11 The report goes on to discuss cases of depression after child birth. Such cases can be reduced by proper ANC of the expectant mother.

Health centres and clinics are now prioritizing provision of antenatal care. For those expectant mothers who do not go to hospitals, community health workers have been deployed within the communities to educate the mothers on ANC, as well as postnatal care. In summary, exercise, healthy food and a good living environment contribute to both a successful pregnancy and also the safe delivery of a healthy baby.

3.3 postnAtAl cAre And eArly chIldhood development

In Rwanda, most births currently occur in hospitals, health centres or clinics. The government has encouraged this strongly in an effort to reduce child mortality. Results indicate that infant mortality in Rwanda declined from 86 deaths per 1,000 live births in 2005 to 76 per 1,000 in 2010.12 This is attributed to integrated approaches to maternal and child health care, part of which includes hospital deliveries as opposed to home deliveries. The high rate of hospital deliveries means, from the outset, a child born in Rwanda is primed to have a better chance at life.

Infant development is the very first stage of development in a child’s life after birth. There are arguments about how long the stage lasts, but consensus seems to point to it being between 0 to 6 months. Borrowed from the Latin word infans meaning ‘unable to speak’ or ‘speechless’,

10 maps of world, ‘Rwanda’, <www.mapsofworld.com/rwanda/economy/agriculture.html>, accessed 10 October 2012.

11 harvard health Publications, harvard medical school, ‘Depression during pregnancy and after’, <www.health.harvard.edu/newsweek/Depression_during_pregnancy_and_after_0405.htm>, accessed 17 march 2014.

12 national institute of statistics of Rwanda and the ministry of Finance and Economic Planning, Rwanda Demographic and Health Survey (RDhs) 2010, Rwanda, Kigali, February 2012.©

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the infancy stage is characterized by interaction between the infant and the parents/caregivers which is critical to the child’s cognitive and mental development.

It is a requirement in Rwanda that all children be registered at birth. In many cases, however, birth registration is not correctly achieved. Often a birth notification is given by community leaders, which caregivers sometimes assume to mean their child’s birth is registered. However, this is not the case and formal birth registration requires additional steps.

In addition, children need to be immunized. Immediately after birth, the child is put on an immunization regime which lasts up to 23 months. The most important form of immunity a child receives is through the mother’s breast milk. Exclusive breastfeeding is recommended for the first 6 months of the child’s life, which constitute the infancy stage. It is worth noting that exclusively breastfed infants are at lower risk of HIV transmission than mixed-fed infants if the mother is HIV positive.13 Only after that, is it recommended to wean the child by introducing other foods – starting with liquids (e.g. milk, food supplements and porridge) progressing to solid foods as the child enters the baby stage.

Breastfeeding is not a problem in many African communities and especially in Rwanda where most mothers are not formerly employed and can therefore spend the first 6 months of their babies’ lives with the baby. It is well documented that infants, and even children up to the age of 3 years and beyond, feed on breast milk. However, with development, many women are now joining the formal workforce and doing tasks that were previously reserved for men. Balancing the demands of professional employment and breastfeeding is a challenge to many working women. As such, they may not be able to exclusively breastfeed for the first 6 months of their babies’ lives. There are food and milk supplements marketed to supplement breast milk in such cases but mechanisms still need to be put in place to ensure the maximum amount of interaction between mother and child. This is not only for feeding purposes, but also for cognitive development as we shall see in the following discussion.

3.4 chIldhood growth And development

This assessment focuses on activities that affect a child’s growth and development from the critical early stage ranging from birth to the age of 6 years. Generally, these early stages of a child’s life are directly controlled by parents (in most cases) and caregivers, such as siblings, other relatives, nannies and even the community, as has been the case in most traditional African societies.

How care is given in the early stages of a child’s life is extremely important. According to the ECD literature, the care given to a young child can be assessed on the basis of its quality, type and timing.14 These three aspects are important to the child in that the “correct type of care and education” must be given at the “correct time (age)” in order to spur the “right mode of development”. This assessment sought to analyse these issues in Rwanda by finding out at what ages respondents think children learn different things, for example: recognizing people, talking, weaning, crawling, walking and even reading and writing. We also sought to find out what measures parents take to ensure the proper development of their children, given that it is well established that “early childhood interventions of high quality have lasting effects on learning and motivation”.15

13 Buskens, ineke., A. Jaffe and h. mkhatshwa, ‘infant feeding practices: Realities and mind sets of mothers in southern Africa’, AIDS Care, vol. 19, no. 9, October 2007, pp. 1101–1109.

14 cleveland, gordon, c. corter, J. Pelletier, s. colley, J. Bertrand and J. Jamieson, A Review of the State of the Field of Early Childhood Learning and Development in Child Care, Kindergarten and Family Support Programs, Atkinson centre for society and child Development, toronto, canada, 2006.

15 heckman, James J., ‘invest in the Very young’, 2nd ed., in Encyclopaedia on Early Childhood Development, edited by Richard E. tremblay, michel Boivin and RDeV. Peters, centre of Excellence for Early childhood Development and strategic Knowledge cluster on Early childhood Development, montreal, 2007, pp. 1–2.


During the infancy stage of development, infants learn to recognize those around them, especially the parents and caregivers. There is physical development when the child’s muscles start to strengthen. This development of muscles enables the development of other functions and actions, such as grasping small objects. Infants need good quality nutrition, health care, tenderness, touch and novelty in order to maximize their abilities and potential.16

The second stage of a child’s life is what we refer to as ‘baby development’. This occurs between 6 and 24 months. These distinctions are, however, not as clear-cut as the age ranges may suggest. For example, some infants may be weaned at 5 months or younger, others beyond 6 months. Many babies are weaned off breast milk at the early stages in baby development. Nutrition of children is an important measure of a child’s health at this point.

Despite awareness of what constitutes good nutritional practice, there are still many cases of stunted growth in children, both globally and specifically in Rwanda where 44 per cent of children under the age of 5 are stunted.17 This can be attributed to the low economic status of many households. Families are not able to provide the right quantity and quality of food. This situation is more prevalent in the rural areas where 47 per cent of children are stunted, as opposed to 22 per cent in urban areas. Apart from stunted growth, there are also cases of children being underweight. It is, however, worth noting that there have been improvements in the nutritional condition of children in Rwanda.18

The baby’s communication slowly transforms from non-verbal to verbal communication. Babies repeat what is spoken to them and it is at this point that the child learns language(s). Babies will also respond appropriately to friendly and angry voices. By the end of 24 months, they are able to name things commonly found in their surroundings and can combine words in short sentences. At this time, babies are also able to respond to commands.19 During this period of development, babies spend most of their time watching the world around them, taking in information and getting directly involved in what goes on. Babies can walk without support, talk in words that are comprehensible and even do simple tasks on request such as, for example, eating food when told to eat. Babies will increasingly imitate the actions of those around them.

The next stage is referred to as ‘toddler development’. This generally occurs between 2 and 3 years. Toddlers, at this point, are aware of what they like and assert their independence more and more. Toddlers also learn a lot during this period. Unlike the previous stages, when children learn by instinct, at this stage children consciously absorb knowledge and information.

During this period your toddler wants to do more on their own and does not like it when you begin to establish limits on their behaviour. Tantrums can become frequent when your toddler can’t get what they want. This is a natural part of your child’s social and emotional development. Toddlers are also curious about other people and will tend to stare at anyone who attracts their attention.20

After toddler development, children go through a pre-school period of development. In Rwanda, this stage is between 4 and 6 years, just before children enter the formal education system. Within the growth cycle of children, they undergo more than just physical growth and at this point learning is equally important. Children learn through observing their environment. This starts with the ability to recognize people, followed by speech development and, finally, academic understanding.

16 mesa community college, ‘infants’, Developmental Psychology Student Newsletter, Department of Psychology, 2012.

17 national institute of statistics of Rwanda and the ministry of Finance and Economic Planning, Rwanda Demographic and Health Survey (RDhs) 2010, Rwanda, Kigali, February 2012.

18 see national institute of statistics of Rwanda and the ministry of Finance and Economic Planning, Rwanda Demographic and Health Survey (RDhs) 2005, Rwanda, Kigali, July 2006 and national institute of statistics of Rwanda and the ministry of Finance and Economic Planning, Rwanda Demographic and Health Survey (RDhs) 2010, Rwanda, Kigali, February 2012.

19 child Development institute, ‘language Development in children’, <http://childdevelopmentinfo.com/child-development/language_development>, accessed 18 July 2012.

20 Aussie childcare network, ‘toddler social and Emotional Development’, <www.aussiechildcarenetwork.com/toddler_social_emotional_development.php>, accessed 18 July 2012.


As they grow up, children need to be raised in a secure and safe environment. When children feel safe at home they are free to explore and to learn new things, which is especially important as a lot of what children learn is through curiosity and experimentation. Parents and caregivers should, therefore, provide an environment where a child is free to play and to learn. The caregivers also play a significant role in the teaching of the child. As it is often said ‘the home is the first school’. The importance of parents, guardians and other caregivers knowing their roles is, therefore, paramount to the growth and development of the child. This is why it is essential to explore what caregivers understand their role(s) to be, as well as to understand common practices in child development.

3.5 bArrIers to posItIve eArly chIldhood development experIences

There are various factors that hinder the proper growth and development of children in Rwanda, some of the most important being high poverty levels and a lack of knowledge. Despite understanding the importance of health care, especially ANC, a major factor deterring women from attending ANC is poverty. Many expectant mothers forego formal ANC, with its associated costs, for traditional methods.

The ultimate negative outcome of a poor environment for young children is child mortality. However, it is important to note that under-five child mortality rates have been decreasing over the years, falling from 152 deaths per 1,000 live births in 2005 to 76 per 1,000 live births in 2010.21 Of course, it is important to note that these are national average figures and rates vary according to the socio-economic characteristics of the mothers and households. In Rwanda, there are more deaths in rural areas than in urban areas, and more deaths in poorer households.22 It is clear that poorer households do not have sufficient access to health care and health-related information. Despite ongoing challenges, the positive trend is well recognized and a clear result of the concerted efforts of the GoR and many other stakeholders in this area.

The GoR has also made steady progress with regard to hygiene and sanitation. Some of the milestones achieved in Rwanda include the construction of water supply systems (651 km by 2008), the sinking of boreholes, the erection of rain harvesting tanks and the building of latrines.23 Other stakeholders have also contributed to improvements in hygiene, decreasing pollution, sanitizing premises and using safe products for agricultural purposes. These efforts are laudable, but their penetration into rural areas is still limited. In rural areas, people have to walk long distances to access water sources, such as communal boreholes. The sanitation situation in many rural households is also poor. Children in these rural homes are, ordinarily, not clean and the environment within which they stay and play is also not hygienically safe.24 According to UNICEF Rwanda, these sanitation and health problems mean that children in Rwanda continue to die from communicable diseases.25

These problems together hinder proper ECD. Some facets of the problems are being addressed through the various programmes set up by the government to reduce poverty, improve infrastructure, health and education, and to boost trade and employment.

21 national institute of statistics of Rwanda and the ministry of Finance and Economic Planning, Rwanda Demographic and Health Survey (RDhs) 2005, Rwanda, Kigali, July 2006 and national institute of statistics of Rwanda and the ministry of Finance and Economic Planning, Rwanda Demographic and Health Survey (RDhs) 2010, Rwanda, Kigali, February 2012.


23 Karuhanga, James, ‘Water Access, sanitation improved in 2008 – Report’, The New Times, 8 June 2009.

24 Paulson, cindy, ‘sanitation is Rwanda’s greatest unmet challenge’, Water for People, 12 July 2012, <http://waterforpeople.org/media-centre/in-the-media/sanitation-is-rwandas-greatest-unmet-challenge.html>, accessed 11 October 2012.

25 see unicEF, (2011), In Rwanda, education and health programmes provide children with a better start in life. Retrieved July 23, 2012 from unicEF: http://www.unicef.org/infobycountry/rwanda_58236.html and unicEF, (2011), Rwanda – Water and Sanitation and Hygiene. Retrieved July 25, 2012, from http://www.unicef.org/rwanda/hiv_aids.html

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The GoR is also increasingly prioritizing a national ECD programme. This is in line with the growing emphasis on ECD on national public policy agendas throughout sub-Saharan Africa. While Rwanda has made major strides in ECD – developing a new and comprehensive national ECD policy – there are still a number of challenges. There is clearly a lack of adequate human resources to support the implementation of the ECD Policy and Strategic Plan, especially at the decentralized levels. Clear, precise data on ECD is also lacking and there is generally little knowledge and understanding of issues related to ECD in the country.26 While the vision of the GoR is to expand access to child care facilities significantly, currently only 11 per cent of the 1.5 million children eligible for pre-primary school access those facilities.27

The challenges, in terms of awareness around ECD, are particularly acute in relation to parents and caregivers. Many are not well informed on issues to do with child development. Children are raised ‘by default’ without considering what methods to use at what stages in the child’s life. Part of the difficulty in achieving the objectives of the ECD Policy is the wide range of issues it covers, as well as the clear need for a cross-governmental, multi-sectoral approach to fully address ECD needs across the nation.

3.6 polIcy Issues In relAtIon to eArly chIldhood development

Problems related to ECD are multi-faceted. This means that there is no ‘one best way’ to address all issues and solve all problems. Various approaches are needed. It is in recognition of this that the ECD Policy of the GoR is meant to be used as a guide, giving clarity and direction to all stakeholders and offering a coordinated, integrated approach. Furthermore, the GoR has put in place various other policy instruments in support of ECD. Some of the policies include the Girls’ Education Policy, the Special Needs Education Policy and the currently under revision Family Policy, as well as the content of Vision 2020 itself, which speaks of nurturing a well-rounded individual from childhood. These policy documents stand on the principle that “interventions in the early years have the potential to offset future negative trends”.28

The overall aim of the ECD Policy and the others mentioned is to ensure the well-rounded development of all children in Rwanda, emphasizing that parents and communities become nurturing caregivers. It is on this principle that, while commenting on Rwanda’s overall development at the ECD National Stakeholders Meeting, the first lady, Mrs Jeannette Kagame, emphasized the importance of investing in the ECD Programme.29 Given the preferred multi-sectoral approach in ECD, the role of civil society organizations in supporting ECD in Rwanda is recognized as of paramount importance. Some of the organizations most active in this area include CARE, Save the Children, Hope and Homes for Children, World Vision and UNICEF.

The strategies used vary but range from setting up child care centres, orphanages and community education programmes to direct support for parents and caregivers. The most important strategies focus on parenting. It is important for parents to build their knowledge on child development issues. Specifically, parents should possess knowledge on child rights, nutrition, nurture and stimulation, protection, health care and education. Parents with this information are best placed to ensure their children are able to grow and develop fully to reach their full potential.

26 these points emerged at the EcD stakeholder meeting in 2012. see EcD stakeholders, ‘Early childhood Development in Rwanda: Working together in the implementation of the EcD Policy and strategic Plan’, Early Childhood Development: Rights from the Start, Report of the national EcD stakeholders meeting, 19 April 2012, serena hotel, Kigali.

27 Kabalira, marie-Brigitte, ‘Family most important for Early childhood Development, The Rwanda Focus, 20 April 2012.

28 Republic of Rwanda, Early Childhood Development Policy, ministry of Education, Kigali, 2011.29 gahiji, innocent, ‘Rwanda: Early childhood Development a Valuable investment – First lady’, News

of Rwanda, 20 April 2012.

23chAPtER 4: stuDy FinDings

chApter 4: study FIndIngs4.1 IntroductIon

The qualitative part of this assessment sought to determine the KAP of caregivers in relation to ECD. Being an exploratory tool, the qualitative study revealed a range of issues that are prevalent within the context of the family in Rwanda. Various assumptions were made based on the qualitative outputs and these, together with the subsequent quantitative

findings, are discussed in this chapter. Data collected from the quantitative study were analysed and are presented here using, primarily, descriptive statistics. Doing so enables us to provide information on the absolute status of the parameters measured. Some instances required inferential manipulations of data, such as when comparing the views of the two groups (male and female) under study. Here we did some significance testing to validate the comparisons (using t-tests).

The approach was to interview caregivers of children within the specified age range which was 0 to 6 years. Some households had several children. The assessment needed to focus on a particular child whose findings would be representative of all children in a household, and consequently, in the assessment. This child was referred to as the ‘index child’. The index child was identified as the youngest child in the household who was between 1 and 6 years old.

When collecting data, interviewers listed the children in the household numbering them child1, child2, child3 up to child ‘n’. The interviewer then identified the index child as the focus of the interview from among the children in each household. A total of 2,000 index children for the 2,000 households visited were identified. Table 3 is a summary of the proportions of the total number of children that are index children.

table 3: index children in the sample

Category of childrenNumber of index

children in the category

Per cent (%) Valid per cent (%) Cumulative per cent (%)

Total 2,000 100.0 100.0

Child one 1,750 87.5 87.5 87.5

Child two 217 10.9 10.9 98.4

Child three 28 1.4 1.4 99.8

Child four 5 .3 .3 100.0

4.2 demogrAphIc chArActerIstIcs oF respondents

The survey achieved a total of 2,000 household interviews with female caregivers and 600 interviews with male caregivers. (See Annex 1 for summary tables.) The demographic characteristics of the respondents generally match those of surveys conducted by NISR. Comparative figures of previous studies conducted in Rwanda are presented alongside figures for the current study.

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household size

According to the findings of the KAP, the average household size was found at 4.38 persons per household, very close to the Rwanda Demographic Health Survey (RDHS) 2010 which puts the average number of persons per household at 4.4.

Disability status

At least 96 per cent of respondents from the household survey had no perceivable disability and also indicated having no disability that could hinder them from living normal lives. Ninety seven per cent of the index children had no disabilities. Some 4 per cent of respondents were physically disabled.

Education

At least 44 per cent of the respondents had primary level education, 25 per cent had secondary education, 20 per cent attested to having no formal education and 11 per cent had attained above the secondary level. The RDHS 2010 recorded that 58 per cent of respondents had attained some primary education and a much lower proportion had attained education up to secondary level.

Working status/employment

About 65 per cent of the respondents had agricultural related employment, but 36 per cent were subsistence farmers. Kigali had the highest proportion of civil servants at 28 per cent, while respondents from the rest of the provinces were largely farmers. There is a similar trend across the districts with regard to employment status.

According to economic levels, the majority of the poor are subsistence farmers (53 per cent), 15 per cent describe their working status as ‘unemployed’, 10 per cent work on other peoples’ farms for food, while 10 per cent work on other peoples’ farms for money. About 85 per cent of the upper economic category of respondents is made up of civil servants and 15 per cent by commercial farmers. Table 46 in Annex 1 of this report describes respondents’ employment status.

Religion

The majority (96 per cent) of respondents profess to being of a Christian faith (52.3 per cent Catholic, 36.5 per cent protestant and 7.6 per cent Seventh Day Adventists). About 4 per cent of the respondents are Muslims.

Poverty

There are various ways of determining poverty levels in studies of this kind. One of the key attributes commonly used is the type of floor in the house. In the current assessment, using the floor type of the house means that only 26.8 per cent of the respondents are classified as poor, as indicated in Table 4.

Following the criterion of using one attribute to measure poverty is, therefore, not ideal for this assessment as it produces misleading results. This is because, from the outset, the data collection tool did not make specific reference to the determination of household poverty levels. Had such reference been made at the initial stage, more detailed information concerning the floor type would have been sought, which could have given a conclusive indication of the poverty levels.

To solve this dilemma, the study adopted multi-dimensional poverty indicators based on various attributes. Each attribute was weighted equally and the overall score per household was the sum of the scores measured. As a result of these final scores, the households were graded from poor ©

UN

ICEF

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anda

200

4


to upper class. The attributes used as poverty indicators are listed below. The respective weights as absolute findings for each attribute are indicated in tables in the appendix section of this report.1. Access to basic health services2. Access to clean water source3. Level of education4. Number of bedrooms5. Total number of people in the household6. Number of bedrooms by number of people in the household7. Type of material used for construction of the roof for the dwelling unit8. Type of material used for the floor9. What the respondent does for a living10. What energy the household mainly uses for cooking11. What energy the household mainly uses for lighting12. What kind of toilet facility members of the household usually use

Using the above attributes, the final output registered the following poverty levels for the population studied in this assessment:

table 5: Economic categories using multi-dimensional poverty indicators

Frequency Per cent (%) Valid per cent (%) Cumulative per cent (%)

Total (N) 2,000 100.0 100.0

Poor 951 47.6 47.6 47.6

Lower-middle 667 33.4 33.4 80.9

Upper-middle 369 18.5 18.5 99.4

Upper 13 0.7 0.7 100.0

The findings indicate that 47.6 per cent of the respondents can be categorized as poor. According to the Third household integrated living conditions survey in Rwanda, poverty is estimated to be 44.9 per cent nationally, with 22.1 per cent poor in urban areas and 48.7 per cent poor in rural areas.30 The 47.6 per cent realized in the sample could be attributed to the fact that, although the national average is 44.9 per cent, the respondents for this assessment were mainly in rural areas, with a few urban respondents and only households with children of 0 to 6 years were selected. This could explain why the level is higher than the national average (in addition to using different poverty threshold criteria), but lower than the value expected if the assessment had been done in a purely rural setting.

30 national institute of statistics of Rwanda, The Third Integrated Household Living Conditions Survey (EICV3): Main indicators report, 2011.

table 4: Poverty level by type of material used for the floor

Frequency Per cent (%) Valid per cent (%) Cumulative per cent (%)

Total 2,000 100.0 100.0

Concrete 437 21.9 21.9 21.9

Bricks 479 24.0 24.0 45.8

Wood 274 13.7 13.7 59.5

Tiles 274 13.7 13.7 73.2

Rammed earth 536 26.8 26.8 100.0


It is critical to note that the ‘upper’ category is comprised of only 13 observations and it is, therefore, almost impossible to make inferences based on statistical analysis due to the small sample size. To the extent that there are evident difference between the poor and non-poor, inference and interpretation should be restricted to the first three categories only.

4.3 generAl heAlth problems AFFectIng the communIty

The respondents were asked about the most common health problems affecting their communities, their causes and who is affected most by these problems. In this way the survey sought to understand the different health concerns people have.

health problems experienced in communities

Findings indicate that common health problems are associated with disease and sickness. Virtually all of the respondents mentioned at least one disease, and there were no responses relating to the environment around the home, such as hygiene conditions. The main diseases mentioned include malaria, cough, flu, diarrhoea and worms. Table 6 presents findings on this question.

table 6: Perceived health problems affecting the communities

Province

Total (%) Northern (%) Eastern (%) Western (%) Kigali (%) Southern (%)

Total (N) 2,000 376 515 379 337 393

Malaria 46 50 43 41 45 53

Cough 4 39 49 36 39 42

Flu 34 31 38 29 37 34

Diarrhoea 31 38 33 37 22 25

Worms 23 31 16 28 19 20

Pneumonia 6 6 10 2 2 7

Skin diseases 3 2 3 2 1 6

Measles 2 0 2 1 1 7

Vomiting 2 1 3 1 1 3

The most common illnesses that appear to affect the communities are malaria, cough, flu and diarrhoea with no major differences across provinces, although Kigali recorded a low percentage of those that reported diarrhoea and worms as common health problems. This may be attributed to the differences between rural and urban settings. The results of this survey are a reflection of the prevalence of these diseases in communities. According to the RDHS 2010, the prevalence of malaria, diarrhoea and pneumonia among children of 5 years and below was reported in 2010 at 15.68 per cent, 13.19 per cent and 3.63 per cent, respectively.31 Deaths from these diseases were reported in 2007/8 as 14 per cent for pneumonia and 15 per cent for malaria.32

There are similar prevalence levels with both male and female respondents, with no significant differences between the two groups as Table 7 illustrates.


32 hong, Rathavuth, mohamed Ayad, shea Rutstein and Ruilin Ren, Childhood Mortality in Rwanda: Levels, trends and differentials – Further analysis of the Rwanda demographic and health surveys 1992–2007/08, icF macro, calverton, maryland, usA, september 2009.


table 7: common health issues: A comparison between male and female

Health Problems Total (%)Gender of respondent

Male (%) Female (%)

Total observations (N) 1,200 600 600

Malaria 51 52 49

Cough 34 31 37

Flu 32 32 32

Diarrhoea 31 32 30

Worms 22 20 24

Pneumonia 6 5 7

Measles 3 3 3

Vomiting 2 2 3

Skin diseases 2 2 2

The prevalence of the above diseases were confirmed in the qualitative discussions with community health workers in each of the districts. While the community members mainly mentioned symptoms, the health workers’ findings point to the actual illnesses affecting the communities.

The community health workers expressed concern that more attention is not paid by the community to seeking treatment for malaria, hence the poor results in terms of the adverse effects experienced by the sufferers. Common illnesses, such as flu and cough, also tend to be neglected by community members due to a belief that they are simple illnesses and they have no cure. Such perceptions affect the health and well-being of the community and worsen health conditions especially among children.

“Malaria is the most common in my area. People here hardly seek medical assistance, so they suffer with the disease for a really long time. It is only when we do our village patrols that we find out when we interact with them.” (Community Health Worker – Bugesera)

“Ailments like cough and flu that are treated as minor cases that are very common among our people. Much as people have this belief that cough and flu have no cure, people should not relax but should seek medical attention.” (Community Health Worker – Ngororero)

“We mostly have coughs and malaria in our area. I most certainly think the cough is a sign of tuberculosis although the people ignore it. We encourage everyone during our sensitization campaigns to always take medical examinations for any health problem they get. By so doing, this would reduce those hitherto undetected diseases that are hazardous to human life.” (Community Health worker – Gicumbi)

“The other health issue that is in this area is that there are many people that can cough for almost a month. We keep on sensitizing them and counselling them but they object to sending them to medical personnel. But the majority of them oblige, it is only a few that object.” (Community Health Worker – Rubavu)

Although environmental issues were not highlighted as common health problems, on evaluating the perceived causes of health problems, most of these were related to hygiene conditions within the home and environmental factors. Table 8 lists the hygiene attributes that respondents mentioned as causes of diseases.


table 8: Perceived health problems and the perceived causes

Health Problems

Causes

Mosquitoes (%)

Change of weather (%)

Dirty water or stagnant water (%)

Un-boiled water (%)

Poor hygiene

(%)

Bad eating habits (%)

Un-immunized children (%)

Dust (%)

Spoilt or rotten

foods (%)

Total (N) 675 928 612 107 313 191 19 98 23

Worms 17 19 31 24 39 39 37 15 22

Cough 33 62 42 57 38 47 47 60 30

Malaria 88 40 49 57 40 48 37 44 83

Flu 25 56 31 36 27 26 21 54 30

Diarrhoea 29 27 46 21 45 66 37 28 52

Pneumonia 7 10 5 7 3 8 0 4 0

Typhoid 1 1 1 4 1 1 0 0 17

Vomiting 3 2 2 5 4 4 5 1 0

There are misconceptions or gaps in knowledge among community members with regard to the causes of certain illnesses. For instance, there is a perception that poor eating habits, or spoilt and rotten foods, cause malaria. While some of these, such as poor eating habits, lower the immunity of children – hence making them vulnerable to illnesses – these are not the direct causes of many diseases. Communication may, therefore, be required to close the gap in knowledge by informing parents and caregivers about the actual causes of specific illnesses, as well as educating them about secondary causes or things that make children more vulnerable to illness generally.

As shown in Figure 1, findings reveal that the majority of caregivers perceive children of 0 to 6 years old to be most affected by these diseases, more than any other category.

0

10

20

30

40

50

EVER

YON

E

DIS

ABLE

D P

EOPL

E

ELD

ERLY

PEO

PLE

SCH

OO

LGO

ING

CH

ILD

REN

(7

TO 1

8 YE

ARS)

CH

ILD

REN

3 T

O 6

YEA

RS

CH

ILD

REN

7 M

ON

THS

TO

2 Y

EARS

CH

ILD

REN

0 T

O6

MO

NTH

S

28%

44%

37%

5% 6%

1%

39%

Figure 1: groups of people most affected by health problems in the community

Although caregivers mentioned the occurrence of these diseases in the community generally, it should also be noted that 79 per cent of caregivers indicated that they had not had an incident of a child suffering an illness in the two weeks prior to the interview. Among the 371 that indicated a recent incidence of illness in the home, Kigali (12.13 per cent) and Northern province


(11.86 per cent) had the lowest incidences, while Southern province (23.99 per cent) and Western province (22.37 per cent) had the highest incidences. The disease symptoms indicated by the caregivers mirror the common illnesses that recorded higher responses in the community – a confirmation of the prevalence of these health problems. Diarrhoea (35 per cent), cough (35 per cent), fever (23 per cent) and vomiting (22 per cent) were the symptoms that recorded the highest responses.

management of illness

To understand how caregivers manage common illnesses that affect their children, all those that attested to having incidences of illness in the home were probed on what they did when the child fell sick. As shown in Table 9, in most cases (61 per cent) self-medication is the immediate home remedy that caregivers undertake when children fall sick. Twenty nine per cent of caregivers brought children to the nearest health facility and 18 per cent bought medicine from the nearest pharmacy/drug shop. The use of self-medication was highest in the Southern province (72 per cent) and Kigali (78 per cent), while the Northern province had a higher rate of visiting a health facility as the immediate response (64 per cent). About 5 per cent of the respondents whose children fell ill prayed for the child as the first course of action.

table 9: Actions taken by respondents to immediately respond to and treat illnesses in their children

Action takenPractice

Immediate action (%) Treatment of the condition (%)

Total (N) 371 371

Gave some medicine that I had in the house 61 21

Took the child to the nearest health facility 29 48

Bought medicine from a pharmacy/drug shop 18 13

Gave oral rehydration salts (ORS) 18 8

Sought the services of a traditional herbalist 13 8

Sought the services of a community health worker 12 12

Gave herbal medicine 11 7

Gave zinc 10 7

Continued breast feeding 10 4

Gave the child plenty of fluids 7 4

Tepid sponging 7 1

Prayed for the child 5 2

Apart from the immediate course of action, on appreciating the symptoms and wishing to treat the conditions, more caregivers took their children to the nearest health facility (48 per cent). Only 12 per cent sought the services of a community health worker.

Although there is a general trend that the first course of action is to undertake self-medication with the available medicine in the house, when a child exhibits symptoms of sickness there are differences in responses. This is notable in the Northern province where the first course of action is to take the child to the nearest health facility. In areas where the first course of action is to give medicine at home, the second action varies between taking the child to the nearest health facility and getting more medication from a pharmacy/drug shop. Only 12 per cent sought the services of a community health worker. Eighty eight per cent of respondents mainly considered their actions to be the correct way to treat the illness. Table 10 shows the responses of caregivers in terms of dealing with children’s illnesses, disaggregated by province and economic categories.


table 10: Actions taken by respondents to treat children’s illnesses

Total (%)

Province Economic category

Northern (%)

Eastern (%)

Western (%) Kigali (%) Southern

(%) Poor (%)Lower-middle (%)

Upper-middle (%)

Total (N) 371 44 110 83 45 89 177 127 67

Gave some medicine that I had in the house

21 18 23 16 24 24 23 20 18

Took the child to the nearest health facility

48 59 40 64 42 39 48 50 43

Bought medicine from a pharmacy/drug shop

13 9 16 5 13 19 14 12 15

Gave ORS 8 0 10 8 4 9 5 9 10

Sought the services of a traditional herbalist

8 7 7 0 9 16 9 7 6

Sought the services of a community health worker

12 11 13 6 11 18 8 16 16

Gave herbal medicine 7 9 9 2 0 11 7 10 1

Gave zinc 7 2 5 7 16 8 7 8 6

Continued breast feeding 4 0 5 1 0 8 3 4 6

Gave the child plenty of fluids

4 2 3 1 2 9 3 5 4

Tepid sponging 1 0 1 0 0 2 0 2 0

Prayed for the child 2 5 2 4 0 1 2 2 1

The findings show that caregivers, irrespective of their economic level, have some knowledge about what to do when their children experience different types of illnesses. There is also a tendency to take different measures depending on the symptoms of the illness, also indicating some awareness of how to manage different illnesses. It is, for example, clearly positive that the response to cases of diarrhoea include 69 per cent of caregivers who give ORS for diarrhoea, 58 per cent who give plenty of fluids and 86 per cent who continue breast feeding. However, it also seems as if the understanding of the proper use of ORS is limited, as similarly high percentages of caregivers give it for a cough.

It is also notable that in cases of respiratory problems, recourse to the traditional herbalist is more prevalent than seeking the services of a community health worker or going to the nearest health facility. The responses to respiratory problems are poor. For example, the response to difficulty breathing, for example, includes much higher likelihood of praying for the child, continuing breastfeeding, tepid sponging and seeking the services of a traditional herbalist than visiting a community health worker or health facility. It is important that caregivers are sensitized on how to respond to children’s illnesses immediately, based on the specific symptoms presented by the illness.

As illustrated below, during the focus group discussions caregivers pointed out that ensuring good feeding and proper hygiene are the main ways of preventing children from falling sick in the first place.

“Parents are getting more involved in the lives of their children today. At least they make sure that the children do not sleep hungry and that they receive full medical treatment when they fall sick.” (Male caregiver – Ngororero)


“You look for vegetables like carrots, tomatoes and fruits and you feed the child so that he can grow. Well that’s what we do.” (Female older caregiver – Gicumbi)

“We make sure that the children observe proper hygiene and that they have regular meals.” (Female caregiver – Kamonyi)

“Parents of today are very selective in the food they give to their children. Cases of diseases like Kwashiorkor have greatly reduced because of this. They talk of educating the children also. Children now know they have to clean themselves and have also come to know the foods that are nutritious for their bodies.” (Female older caregiver– Ngoma)

“You find that most parents encourage their children to drink a lot. This is rather good because then, a child’s body becomes rehydrated.” (Community health worker – Kayonza)

“Parents try very hard to feed their children well. You will find that foods like vegetables and greens are always included on the menu.” (Female caregiver – Nyamagabe)

Caregivers also pointed out things that they should be doing for their children that they are currently not doing. Some of the key behaviour gaps that were discovered in the focus groups conducted with caregivers were: body hygiene, such as bathing and dressing in clean clothes; feeding children food with the right nutritional value and not just concentrating on quantity; and encouraging children to play.

table 11: treatment measures of various illnesses by respondents

Total (%)

Treatment

Gav

e O

RS (

%)

Gav

e zi

nc (

%)

Gav

e so

me

med

icin

e th

at I

had

in th

e ho

use

(%)

Gav

e th

e ch

ild

plen

ty o

f flui

ds (

%)

Cont

inue

d br

east

fe

edin

g (%

)

Gav

e he

rbal

m

edic

ine

(%)

Soug

ht th

e se

rvic

es

of a

com

mun

ity

heal

th w

orke

r (%

)

Took

the

child

to

the

near

est h

ealth

fa

cilit

y (%

)

Soug

ht th

e se

rvic

es

of a

trad

ition

al

herb

alis

t (%

)

Tepi

d sp

ongi

ng (

%)

Boug

ht m

edic

ine

from

a p

harm

acy/

dr

ug s

hop

(%)

Pray

ed fo

r the

chi

ld

(%)

Total (N) 371 95 63 305 40 50 66 88 283 77 29 117 27

Diarrhoea 41 69 63 42 58 86 73 62 42 81 69 53 81

Fever or hot to the touch

30 63 51 39 42 80 58 65 31 55 90 43 78

Cough 41 61 48 49 55 80 55 59 43 74 69 57 78

Vomiting 29 65 44 35 55 72 55 56 24 53 62 44 81

Flu 26 49 46 33 58 70 50 50 27 68 62 45 70

Difficulty breathing

9 45 30 12 38 66 38 36 11 44 59 23 70

Fast breathing

8 35 33 14 25 56 35 33 8 47 59 21 67

Indrawn chest*

6 36 29 9 30 54 29 30 8 43 59 20 67

Loss of appetite

13 48 41 20 48 54 30 43 12 52 59 25 81

Stomach aches

8 42 30 12 35 54 29 35 8 44 59 24 74

Unable to eat or breast feed

7 33 27 9 32 50 29 30 8 40 55 21 74

Skin rash 6 25 21 8 15 36 21 20 6 30 38 15 44

* An indrawn chest can be a sign of pneumonia.


“Children need to be reminded that eating well does not just mean eating a lot, but also eating a balanced diet. So growing fat may not necessarily be a sign of a healthy body but a sick one. Many parents ignore such advice.” (Community health worker – Gakenke)

“Parents are also not doing much with regard to the way that children wash their clothes and even bathe. You find that they remain withdrawn for as long as the child has actually bathed or washed. So you find cases of children contracting diseases as a result of poorly washed clothes and bathing.” (Community health worker – Rugango)

“It’s such things as continuously teaching children how to be clean and to make sure that they are taking a balanced diet.” (Female caregiver – Gakenke)

“Parents also ought to remind their children that playing is healthy for their bodies. The children should not only spend time seated watching television.” (Female caregiver – Nyarugenge)

4.4 knowledge, AttItudes And prActIces regArdIng hygIene And sAnItAtIon

This KAP also touches upon hygiene and sanitation, and the sanitation facilities most available in the surveyed households are:1. latrine/toilet (72 per cent)2. bathroom (55 per cent)3. dust bin (52 per cent4. composite pit (19 per cent).

To gauge the caregivers’ understanding of sanitation, they were asked what they think should be done to maintain proper hygiene in the community. The survey then looked at what is actually practised. Analysing the data on a cumulative scale, 100 per cent of the respondents indicated that, in order to maintain proper hygiene, people should wash hands with soap before feeding children or preparing food and after using the latrine. Sixty seven per cent indicated that each household must have a latrine.

table 12: hygiene knowledge vs practice absolutes

Activity (multiple responses possible per question)

What should people in the community

do to maintain proper hygiene? Knowledge (%)

Which hygiene practices are

commonly practiced by people in this

community? Practice (%)

Total (N) 2,000 2,000

Washing hands with soap before feeding a child or preparing food 100 28

Washing hands with soap after using a latrine 64 46

Each household must have a latrine 67 54

Cleaning the latrines every day 61 33

Keeping water and soap for washing hands at the latrine 46 31

Clearing bushes around the home 50 38

Avoiding stagnant water around the home 50 34

Keeping the children’s clothes clean 40 26

Keeping utensils clean 30 23

Disposing of children’s faeces in the latrine 34 27

Having a rack for utensils in the home 23 13© U

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With regard to hygiene, there are significant differences between what people know and what they practise. Knowledge is higher than the claimed practice of the activities in all cases. The biggest gap between knowledge and practice is with regard to washing hands with soap before preparing food for the baby. While 100 per cent think it is important to wash their hands with soap before preparing food for the baby, only 28 per cent actually practise this behaviour. In addition only 46 per cent claimed to wash their hands with soap after using the latrine as opposed to the 67 per cent who have knowledge in this area.

Among all the activities related to hygiene, the data show a significant difference between knowledge and practice. Hypothesis testing results in the rejection of all null hypotheses measured on the hygiene attributes which stated that “there is no significant difference between the means of the two variables”. All the attributes are also significantly positively correlated.

During the interviews, the researchers observed index child defecation in 52 per cent of the households. Twelve percent defecated on the floor in the compound/house. In a few of the cases (8 per cent) children defecated in a potty and in the toilet the first time. In 5 per cent of cases, children defecated on a piece of paper placed on the floor by the caregiver. In 28 per cent of cases the child’s bottom was not cleaned after defecation. Cleaning the child’s bottom was mostly done by the mother (34 per cent), while only 7 per cent of the time was this done by other female adults in the household. Most of the people (97 per cent) did not wash hands immediately after wiping a child’s bottom, but carried on as usual with what they were doing. It was more common for the female, older children (25 per cent) to clear the child’s stool immediately than for the female adults to do it (16 per cent). In some of the households (30 per cent) the child’s stools were not cleared immediately.

Water for hand washing mostly came from a container in the compound and laundry water (16 per cent). Few persons got water for hand washing under a tap (12 per cent). A comparably high proportion of the respondents (24 per cent) had soap for hand washing kept near a water source. Fewer persons (13 per cent) had soap for hand washing kept at some distance from the water source. Some 16 per cent of the respondents did not use soap while washing hands.

table 13: Knowledge and practice in relation to pre-birth care for the mother and child

Action taken Practice (%) Knowledge (%)

Total (N) 2,000 2,000

Prevention of common illnesses, such as malaria 72 74

HIV test 81 65

ANC from an approved health facility 52 43

Iron supplements 24 26

Vitamin A 59 44

Proper eating practices 21 22

Immunization against tetanus 40 37

Antenatal lessons 33 35

Avoided stress 42 35

Enough rest 34 32

Staying in a clean environment 35 29

Delivered in a recommended health facility 26 30

Had a delivery plan 23 25

Prepared the home for the new baby 17 26

Prepared older siblings to accept the baby 8 16


4.5 knowledge, AttItudes And prActIces regArdIng chIld cAre From pre-bIrth to delIvery

Pre-birth knowledge

As shown in Table 13, the caregivers’ practice before birth is high in only three of the aspects that were tested: taking Vitamin A supplements (59 per cent), the prevention of illnesses (72 per cent) and knowing the HIV status of the mother (81 per cent). In most of the cases, knowledge does not exactly match practice. As an example, 43 per cent indicated the need to attend antenatal services from an approved provider, and more than 52 per cent of the caregivers indicated having attended antenatal services from an approved health provider. Likewise, less than 44 per cent of the caregivers indicated the need for Vitamin A supplementation for the mother, while 59 per cent claimed to have taken it during pregnancy. The most substantial differences between knowledge and practice appear to be in the following categories: getting an HIV test and taking Vitamin A. The seeming disconnect between knowledge and practice in absolute terms could imply that some of the behaviour is practised without fully understanding the reasons and because the health workers and medical practitioners influence respondents to do so.

A comparison was made between male and female caregivers. The results indicate that female caregivers are more knowledgeable about most of the things that should be done before child birth than the male caregivers. This difference was significant in some cases.

table 14: comparing the knowledge and practices of male and female caregivers during pregnancy

Knowledge Practice

TotalGender of respondent

Pearson correlation Significance Total

Gender of respondentPearson

correlation SignificanceMale (%) Female

(%) Male (%) Female (%)

Total (N) 1,200 600 600 1,200 600 600

Prevention of common illnesses, such as malaria

69 64 74 0.106 0.000 73 71 75 0.045 0.117

Know HIV Status 61 58 65 0.72 0.013 79 74 84 0.124 0.000

ANC from an approved health facility

39 36 41 0.05 0.086 46 43 49 0.064 0.028

Iron supplements 25 24 27 0.037 0.206 24 22 27 0.048 0.093

Vitamin A Supplementation

44 42 45 0.030 0.295 57 51 62 0.108 0.000

Proper feeding practices

22 22 22 -0.008 0.781 22 24 20 -0.042 0.143

Immunization against tetanus

35 32 39 0.068 0.019 39 36 43 0.065 0.025

Taking antenatal lessons

32 29 34 0.054 0.062 32 28 37 0.096 0.001

Avoiding stress 36 35 37 0.017 0.548 38 33 43 0.106 0.000

Having enough rest 33 33 33 0.004 0.903 31 31 32 0.020 0.494

Staying in a clean environment

32 33 31 -0.016 0.577 32 28 37 0.101 0.000

Delivering in a recommended health facility

28 24 31 0.076 0.008 24 22 25 0.039 0.174

Delivery plan 25 26 24 -0.013 0.641 23 21 24 0.038 0.190

Preparing the home for the new baby

28 28 28 -0.007 0.797 19 20 17 -0.034 0.236

Preparing older siblings to accept the baby

16 15 16 0.014 0.633 9 7 11 0.068 0.019


The results shown in Table 14 point to two main issues: a) that the female caregivers may not inform their partners because they consider it the responsibility of the women to ensure a healthy pregnancy and b) that men may not be attending ANC clinics with their partners during pregnancy. In addition, because most of the behaviour has to be practised by the woman, the male caregivers need to play more of a support role. As a result, some of the practices may not apply or the men may pay less attention to them than the women do.

From the qualitative focus groups it was established that female caregivers prefer to go for antenatal services with their partners/husbands so that they can both take HIV tests and also to be informed together about the progress of the pregnancy. Expectant mothers also prepare for birth by saving money and monitoring their calendar, both for their next antenatal visits and for the expected date of delivery. Some of the other changes made by expectant mothers include undertaking less strenuous work and eating well.

“A woman that finds she is pregnant needs to inform her husband right away so that the husband is not caught by surprise, especially in cases where the woman does not stay with the husband.” (Female caregiver – Gakenke)

“She goes with the partner to know the progress. And throughout the whole period, she goes with the partner for tests and they are told when to go back. But the good thing is that you don’t go there once. If I went with my spouse today, I will keep going there for treatment so that we produce a healthy child.” (Female caregiver – Bugesera)

“The other small things I do. I prepare myself. I look for clothes. And keep observing the calendar so that when the time for giving birth reaches, I deliver in the presence of medical personnel.” (Female caregiver – Rulindo)

“The parent does other things. On knowing that she is pregnant, the woman looks for money to buy the baby’s clothing and that sort of thing.” (Female older caregiver – Rwamagana)

“Such a woman like […] has said she begins preparing herself financially if she has no husband. If she has a husband, then he had better start saving money for the delivery and to finance the pregnancy period.” (Female caregiver – Gakenke)

“It is not good for a woman to do strenuous work even in the early stages of a pregnancy. So the mother, on noticing she is pregnant, begins to limit the amount of work she does in a day.” (Female caregiver – Gicumbi)

“About eating, you just try because so many ladies want to be selective. So we end up failing to get what our bodies need.” (Female caregiver – Rwamagana)

The views of community health workers with regard to the care of expectant mothers do not substantially differ from those of caregivers. However, they tend to emphasize proper hygiene, cleanliness and proper eating more than the caregivers.

“I encourage cleanliness so much. Cleanliness is very vital for a pregnant mother. Also discouraging them from strenuous work. They should not be shouted at. They should also desist from being angry most of the time because it affects the baby’s brain.” (Community health worker – Ruhango)

“The advice we gave them while in the meeting was that it was bad to assault a pregnant mother as this greatly affects the unborn baby.” (Community health worker – Rubavu)

“A pregnant mother should desist from taking alcohol; we discourage them from using tobacco even taking the traditional drugs that are not recommended by medical personnel.” (Community health worker – Ngororero)

“I would still emphasize that she makes all the antenatal visits she ought to make while pregnant.” (Community health worker – Nyamasheke)


“This digging that we do is sometimes tiresome and I would not encourage a pregnant woman to dig as much as she has been digging before becoming pregnant.” (Community health worker – Rulindo)

“The expectant mother has to take porridge more often so that she can generate breast milk.” (Community health worker – Gicumbi)

“She takes as many fruits as she can. These fruits are readily available here since it’s a village. They are very nutritious for the baby also. For example fruits like jackfruits, pineapples, oranges, paw paws and guavas.” (Community health worker – Rulindo)

Knowledge, attitudes and practices regarding antenatal care

Effectively all biological mothers of children 0 to 6 years (99 per cent) have had ANC at least once when expecting their index child: 74 per cent mentioned taking ANC from a health centre in the district and 48 per cent at the main hospital. A high proportion have the correct knowledge about ANC. For most of the behaviour related to ANC, the practice is arithmetically higher than the knowledge, except for getting ANC services at the main hospital. This difference is, however, not statistically significant when the attributes are analysed as a unit.

table 15: Knowledge and practice of antenatal care

Antenatal care Knowledge (%) Practice (%)

Total (N) 2,000 2,000

At home with visiting doctor, nurse or midwife 9 13

Health centre in the district 74 82

Main hospital in the district 48 48

At the clinic in the village 21 29

At community health workers’ home 17 20

Did not have any ANC services 2 1

The null hypotheses were tested on the attributes indicated in Table 15. The results failed to reject the null hypothesis on three of the attributes. The null hypothesis read “there is no significant difference between the means of the two variables” – the two variables being knowledge and practice as tested on the particular attribute. For the following attributes there is no difference between knowledge and practice, concerning where an expectant mother should go for ANC:1. at home with visiting doctor, nurse or midwife2. at the clinic in the village3. at community health workers’ home.

The following attributes, on the other hand, show differences between knowledge and practice:4. health centre in the district5. main hospital in the district6. did not take any ANC services.

Results indicate high usage of health centres and clinics, which may be attributed to the proximity of these facilities. For all the respondents, the health centre and a village clinic is estimated to be within an average of 3 km reach and a main hospital within 5 km reach. Overall, respondents indicated that an expectant mother should attend ANC services at a health facility four times during her pregnancy.

The practice of delivering at a recognized health unit was found to be high at a national level with at least 86 per cent of the respondents indicating that they delivered at a health facility in the district. This practice is common across all the provinces and there are also no differences by education level and age. There are some differences according to economic category as shown


in Table 16. Interesting to note is the difference between the incidence of delivery in hospital for those from the poor (26 per cent) and the upper-middle economic categories (38 per cent).

table 16: Place of delivery of index child disaggregated by economic category

Total (%)Economic category

Poor (%) Lower-middle (%)

Upper-middle (%)

Total (N) 1,987 951 667 369

At home with visiting doctor, nurse or midwife 2 3 2 1

Health centre in the district 54 59 50 51

Main hospital in the district 32 26 37 38

At the clinic in the village 4 3 5 4

At community health workers’ home 1 1 0 1

No response 6 8 6 4

Although most deliveries happen at a recognized health centre or hospital, the challenge of health centres being overstretched was mentioned by caregivers, which may cause some mothers to choose to deliver at home.

“They deliver in a health facility or in the hospital. Only that the challenge with our health centre is that there are few maternity wards. There are mothers that find them full and are forced to return home and deliver there.” (Community health worker – Bugesera)

“We have few health centres with maternity services. So you find a lot of women in pain waiting to be attended to. This is what pushes some of them to even deliver at home. But I think the first thing is to breast feed the baby.” (Female caregiver – Gakenke)

Findings reveal that mothers rely on health practitioners’ advice on safe delivery. Female caregivers attribute most successful deliveries to their regular attendance of antenatal services. There are also perceptions that if a mother eats well and does not get involved in heavy work, then her chances of delivering safely are high.

“When a mother visits the doctor, he will tell her that you are like this and this. That is the only way the mother can get to know she will have a successful delivery, otherwise how would she know if she doesn’t visit the doctor?” (Female caregiver – Ngoma)

“If she has been making her antenatal visits regularly, then she will know everything. In that, if she followed what the doctor advised her to do, then she will be sure to have a successful delivery.” (Female caregiver – Bugesera)

“For a mother to know she will have a successful delivery, the doctor keeps updating her through the regular antenatal visits. These people are always in touch with her. But community health workers also keep track of the progress. If she doesn’t make the antenatal visits, the baby may end up being poorly positioned in the womb due to the natural herbs they take. And that’s why most of them end up delivering by caesarean section.” (Female caregiver – Nyamasheke)

“For me I think if the pregnant woman has been eating well and doing less laborious work, then she will be sure of a successful delivery. Much as I discourage laborious work, I still don’t encourage that the pregnant mother spends the whole day sitting down. She should do some physical exercise in the form of the small chores at home.” (Male caregiver – Rubavu)

“I think a successful delivery is all by the mercy of God. However, the pregnant mother has to adhere to the doctor’s advice and simply pray to God.” (Female caregiver – Ruhango)


Female caregivers recognize that the period close to the delivery date is critical and that is when most preparations and monitoring are done by the mother and those that take care of her. Some of the preparations include: maintaining proper hygiene practices, eating well and dressing in an appropriate manner.

Female caregivers also pointed out challenges relating to fathers not taking care of the mother and the babies, in terms of providing the financial and material support needed. In such cases, the women themselves take the initiative to ensure that they have made the necessary arrangements, for example, that clothes for the baby are available and that the hospital is notified on time.

“Like I have told you, most women here make antenatal visits and that’s why almost all deliveries in this village have been successful.” (Community health worker – Bugesera)

“Mothers in our village make antenatal visits. So the doctor advises them on what to do. But all in all, the mother has to be extra clean. She also has to observe what she eats as well as having the funds readily available.” (Female caregiver – Kamonyi)

“A mother preparing to give birth … That period is very important. Because whether you like it or not it has to happen. There are some that show responsibility while other husbands don’t even listen. You tell him something and he ignores you. Babies’ clothes, money for maternity care, there is also money to look for the babies’ requirements, and so on. Say even the food he will feed on reaching the eating age. We tell them all that but only a few listen.” (Female caregiver – Nyamasheke)

“We are lucky that the health centre is near. So personnel at the health centre are simply put on the alert and the mother strictly begins to eat, walk, talk, sleep and dress according to the doctor’s instructions. This is why deliveries that occur from home are highly risky because it is highly probable that the mother will not know all this.” (Female caregiver – Nyarugenge)

4.6 knowledge, AttItudes And prActIces regArdIng chIld cAre AFter bIrth

Caregivers do many things to contribute to the growth and development of their children. The responses of mothers and fathers reveal their understanding of what caregivers should do while taking care of children. In most cases, the practice of the various activities is higher (arithmetically) than the knowledge about them. The means of the attributes pertaining to knowledge and practice were compared using the t-test with the null hypothesis33 indicating no significant difference between the means of the attributes. Findings are mixed, with some attributes rejecting the null hypothesis and others failing to reject the null hypotheses.34 The correlation analyses, however, find positive and significant correlations between knowledge and practice on the after-birth attributes. This means that the higher the knowledge concerning a particular attribute, the higher the likelihood that caregivers will practise positive behaviour. It also means that an increase in knowledge about a certain positive behaviour will lead to an increase in good practices.

Table 17 indicates higher practice than knowledge for all of the aspects of after-birth child care. This may imply that caregivers undertake the right practices but have limited knowledge on the importance of these practices. In order to ascertain the significance of the difference between knowledge and practice, a t-test was done on each attribute for knowledge and practice using α = 0.05.

33 H0: there is no significant difference between the means of the two variables. HA: there is a significant difference between the means of the two variables.

34 For a full list of significance tests and correlation tests on after birth child care attributes contact unicEF Rwanda.


Results indicate a significant difference between knowledge and practice for most of the attributes that were tested in relation to after-birth behaviours. The attributes which were found to have a significant difference between practice and knowledge were:1. immunizing the baby against vaccine-preventable diseases2. keeping the baby warm by not bathing the baby immediately3. keeping the baby warm using the mother’s chest4. keeping the baby warm with appropriate clothes5. registration of the baby6. going for postnatal visit for review of mother and baby7. breastfeeding exclusively for 6 months8. hand washing with soap9. keeping the child in a clean environment10. vitamin A supplementation11. adherence to prescribed medication12. proper feeding for the child.

For all the above behaviours, the practice was found to be higher than the knowledge, indicating that caregivers feel or know that they should do them, but they may not know why they are doing these things. It further indicates that an increase in knowledge will significantly increase practice of the behaviour. For some of the behaviours, there was no significant difference between knowledge and practice, although arithmetically the percentages are different. The behaviours that were found to have no significant difference between knowledge and practice are:1. breastfeeding the baby within the first hour of delivery2. clean cord care3. both mother and child sleeping under the mosquito net4. growth monitoring5. promptly seeking health care in case of illness6. proper eating by the breastfeeding mother7. taking the child for circumcision (in case of boys).

table 17: Knowledge and practices regarding child care after birth

Caregivers of children aged 0 to 6 years Knowledge (%) Practice (%) Significance

(t-test)

Total (N) 2,000 2,000

Immunizing the baby against vaccine preventable diseases 78 87 0.000

Breastfeeding the baby within the first hour of delivery 42 62 0.100

Keeping the baby warm by not bathing the baby immediately 30 53 0.000

Keeping the baby warm using the mother’s chest 21 45 0.018

Keeping the baby warm with appropriate clothes 28 51 0.000

Registration of the baby 37 57 0.000

Going for postnatal visit for review of mother and baby 23 44 0.000

Clean cord care 21 39 0.126

Breastfeeding exclusively for 6 months 37 57 0.000

Both mother and child sleeping under the mosquito net 33 53 0.105

Hand washing with soap 31 50 0.000

Keeping the child in a clean environment 26 45 0.000

Growth monitoring 24 43 0.090

Vitamin A supplementation 38 54 0.025

Promptly seeking health care in case of illness 23 44 0.356

Adherence to prescribed medication 21 40 0.018

Proper feeding for the child 24 46 0.000

Taking the child for circumcision (in case of boys) 10 21 0.106


In most of the households sampled, the female caregivers were found to be more knowledgeable about child care after birth than the males. This could be attributed to the higher level of exposure to information among the women in relation to motherhood and child rearing, since more mothers than fathers attended antenatal services. In addition, mothers are generally more involved in child care than fathers are.

Findings from the focus group discussions confirm the level of knowledge that exists among the caregivers with regard to care for the child and the mother after birth. The key aspects that they pointed out as important were: breastfeeding immediately after delivery, that the mother should have a lot to drink and eat (with millet porridge being very prominently mentioned), taking the baby for a medical examination and ensuring that the mother gets enough rest.

Although there is high knowledge and practice among the female caregivers, the responses relating to what should happen after child birth were all skewed towards what women should do, indicating the perceived passive role of male caregivers. Fathers are perceived to have more of an economic and cultural role, such as naming the child and providing for the welfare of the mother.

“First and foremost, breastfeeding them while they are still infants. I have to make sure that the children are breastfed to full term. You then resort to ensuring that they eat and that they are healthy.” (Female caregiver – Rulindo)

“When she has just given birth, she does the very first breastfeeding. Breast milk has something it adds to the infant’s body.” (Female caregiver – Gakenke)

“On giving birth, the mother needs to be given a lot of fluids such that she recovers the energy she lost while delivering.” (Female caregiver – Gicumbi)

“What I know is that the baby is breastfed as soon as it is born. That saying that the mother is given a primus beer to generate breast milk is false. What we discovered is that you give her well prepared porridge and then breast milk will come.” (Female older caregiver – Gicumbi)

“The baby is immediately taken for medical examination by the doctors while the mother is given some rest. Nobody is allowed to see the mother at this moment.” (Female caregiver – Rwamagana)

“The mother hands over the child to the father such that they chose a surname for him/her. The Christian name is chosen by the mother but the surname aah... that is a father’s role.” (Female older caregiver – Gicumbi)

“Porridge for the mother is a must. You know that porridge, especially when it is millet, is very nutritious especially in regard to recovering the energy and the lost body fluids which are in turn converted into milk.” (Female caregiver – Rulindo)

“The mother is given a cupful of millet porridge immediately. This is to help her regain energy and also generate milk for the very first breastfeeding.” (Female caregiver – Rulindo)

4.7 knowledge, AttItudes And prActIces regArdIng dewormIng

Deworming of children is one of the key child care practices that ought to be observed by parents and caregivers of children. In this assessment, the claimed practice of deworming is very high at 89 per cent for children aged 1 to 6 years, with no significant variations by province. Variations by level of poverty are however evident with 100 per cent of caregivers in the upper economic category having dewormed their children (note that there were very few (13) observations for the upper economic category).


table 18: Deworming of children by province

Total (%)Province

Northern (%) Eastern (%) Western (%) Kigali (%) Southern (%)

Total (N) 2,000 376 515 379 337 393

Yes 89 86 90 91 90 89

No 6 10 5 4 4 9

No response 4 5 4 5 6 2

table 19: Deworming of children by economic category



Upper-middle (%)

Total (N) 1,987 951 667 369

Yes 89 87 90 94

No 6 9 6 1

No response 4 4 4 5

Most of the respondents who have never dewormed their children fall into the poor and lower-middle economic categories. As shown in Table 20, for those who have never dewormed their children, the key reasons for not doing so were cost (20 per cent), they considered that children were still young (15 per cent), and a lack of knowledge about deworming (9 per cent). There is however, a small proportion of caregivers (3 per cent) who indicated that they did not deworm because the child had not fallen sick.

table 20: Reasons why respondents have never dewormed their children

Reason Total (%)Economic category


Upper-middle (%)

Total (N) 127 83 39 5

It is very expensive 20 25 10 0

My children are still young 15 12 23 0

I do not know about deworming 9 10 10 0

My child did not fall sick 3 1 8 0

There was no time 3 5 0 0

Don’t know 6 5 10 0

No response 45 45 38 100

Responses relating to cost and waiting for a child to fall sick point to the lack of knowledge about deworming, as deworming medicine should be given as a routine treatment when the child is due for deworming regardless of symptoms. There may also be lack of knowledge that a child suffering from worms may not fall sick, but show other symptoms.

Focusing on those who claimed to have dewormed their children, 6 in every 10 usually deworm every three months (60 per cent). At least 89 per cent reported using medicine from health workers while 7 per cent use herbs and 4 per cent use either herbs or medicine from health workers, whichever is available to them at the time of deworming.


4.8 knowledge, AttItudes And prActIces regArdIng ImmunIzAtIon

There is high claimed knowledge of the types of immunization that a child should have at 91 per cent and there are no significant differences by region or by poverty levels. Those who knew about immunization pointed out the reasons for immunization as: ensuring the child grows up healthy (57 per cent), prevention of death (53 per cent) and prevention of health impacts that may occur later in life (45 per cent).

In households where both male and female caregivers were interviewed, the perception of the need for immunization is not different, apart from the understanding that it prevents future health problems that may affect the child. With regard to this parameter, responses from female caregivers were 11 per cent higher than those from males.

As already noted, in each of the households assessed an index child was identified. This was the basis for analysis in this section, although the respondents were asked questions relating to the immunization of other children in the household as well. Results indicate a high incidence of immunization practice among the households sampled, with 92 per cent claiming to have immunized their index child. Of those that claimed to have immunized, 93 per cent said they had the immunization cards. However, only 73 per cent of these could show the immunization cards when the interviewer requested to see them.

With regard to the category of caregivers, there was no outstanding difference with regard to having immunized their children. However, there was a proportion of children that were not fully immunized, possibly because they had not yet reached the age to complete all the immunizations required.

4.9 knowledge, AttItudes And prActIces regArdIng chIld regIstrAtIon

In our sample, children’s birth registration rate is high – as indicated by the 76 per cent who claimed to have registered their index children. However, as indicated in Table 17, the average across the whole sample is 57 per cent, approximating better the national average. Although these results may indicate a growth in registration, figures need to be treated with caution as some respondents may have shown their interviewer their birth notification form rather than the birth certificate which is the correct proof of registration. The assessment found that registration of children’s birth was high irrespective of the category of caregiver, although the biological mothers of the children are more likely than other categories of caregiver (such as grandmothers and other relatives) to know if the child was registered or not. With regard to

table 21: Reasons for lack of registration of children

Total (%) Northern (%) Eastern (%) Western (%) Kigali (%) Southern (%)

Total (N) 326 59 101 54 39 73

Did not know the process 29 24 31 19 54 23

Did not know where to register 26 17 28 24 0 45

Did not know that I have to register the child

23 5 20 11 10 59

There is no need to register the child 20 14 32 13 28 8

Did not want to register the baby 19 14 17 33 18 15

I have to travel far to register 18 5 9 13 3 55

The cost of registration is high 16 17 5 15 0 38

No response 18 34 20 7 8 15

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provinces, Kigali had the highest claimed birth registration at 82 per cent, while the lowest was Eastern province at 72 per cent.

Those who had not registered children were hindered by a lack of knowledge of the registration process (29 per cent), lack of knowledge of where to register (26 per cent) and not understanding the need for registration (23 per cent). Table 21 shows, however, that some caregivers think that it is not important to register children and some did not want to register their children.

4.10 knowledge, AttItudes And prActIces regArdIng FeedIng

Knowledge of when infants should be introduced to solids is high. About 41 per cent of the respondents indicated that infants should be introduced to solid foods and fluids at 6 months, and a further 34 per cent indicated that the infant should be older than 6 months but less than 1 year. In practice, 38 per cent of the respondents introduced other foods at 6 months, while 30 per cent introduced them when the child was older than 6 months but less than 1 year. In households where both male and female caregivers were interviewed, there is no significant difference between the recall of when the children were introduced to solid foods between males and female respondents, although the females exhibit higher recall.

During the 30-minute observation, the index child was mostly fed by the mother (44 per cent). Only 9 per cent of ‘other’ female adults fed the index child. The child was mostly fed with a meal served with hands (24 per cent). Liquid food served with hands was least fed to the child (7 per cent). At least 69 per cent of the mothers/caregivers that fed an infant did not wash their hands immediately before. The children were mostly fed on porridge, sweet potatoes or Irish potatoes, milk and rice while the interviewer was at the household.

Ordinarily, a child should have three meals a day and at least a snack, a drink or fruit in between meals. These meals should be rich in nutrients, including carbohydrates, vitamins and proteins, to help the child to grow strong and healthy. This section presents findings on feeding practices in the population assessed in this study. The assessment explored various attitudes and opinions towards early childhood feeding.

“Good feeding minimizes cases of child illness greatly. It is better to feed children with foods they like eating such that they eat and get satisfied. I make sure that I buy a variety of foods when I go to the market.” (Female caregiver – Bugesera)

“Now to me, I don’t only advise children but also to older people about nutrition. Good feeding is not only to children but even to old people. We teach them how to use fruits like pawpaws. We even teach them how to mix soya and milk and other important foods. We teach about other important foods that help their bodies to grow and stay healthy.” (Community health worker – Bugesera)

“In our days, babies used to not eat any type of food until when a baby was above six months, unlike today.” (Community health worker – Nyamagabe)

“We mostly advise them [caregivers] to take good care of them [their children] by feeding them well.” (Community Health Worker – Rulindo)

“[…To improve the health of your children] you look for vegetables like carrots, tomatoes, fruits and you feed the child so that he can grow well. That’s what we do.” (Female caregiver – Gakenke)

“We teach them and tell them what to do but poverty inhibits them from implementing this because you at least need a little money to ensure that your child is fed well.” (Community health worker – Ngororero)

“The woman who has a 3-month-old baby is supposed to drink a lot and breastfeed the baby more and more times a day because from the time that child is born to 3 months, the

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baby only needs to be breast fed and I believe the milk that is given to the baby from the mother’s breasts has enough nutrients. The baby has to breastfeed 8 to 12 times a day since it’s the only food it feeds on.” (Female caregiver – Bugesera)

“Another thing that results in a child not growing is the feeding. In cases when the child is not fed well his growth is retarded.” (Male caregiver – Ngororero)

types of foods given to children of different ages on the previous day

This section presents findings on the foods that were given to the respondents’ children on the day prior to the assessment visit.

Before breakfast, respondents do not commonly give their children anything to eat. Out of the 115 children in the sample who are below 6 months, only 25 per cent were given anything before breakfast the day before the interview and the majority of those (12 per cent) were given breast milk.

The majority of those who did give their children food before breakfast generally belonged to the upper economic category. They gave foods such as milk (37 per cent), breast milk (21 per cent), fruits (12 per cent) and porridge (11 per cent). Other foods given before breakfast are as indicated in Table 22.

table 22: Foods given to children before breakfast

Food given before breakfast Age group of children

0 to 6 months (%)

7 to 11 months (%)

1 to 2 years (%)

2 to 6 years (%)

Total number of observations 115 77 981 1,246

None 75 52 74 60

Breast milk 12 19 8 1

Milk 7 9 6 11

Breast milk and fruits 3 0 0 0

Water 2 1 2 0

Fruits 2 5 2 3

Porridge 1 3 2 3

Other* 3 6 9 11

* includes: rice, bananas, biscuits, sweet potatoes or irish potatoes, vegetables, cerelac (an instant baby porridge), dry tea, chips, juice, meat, eggs or bread.

At breakfast, about 57 per cent of children aged 0 to 6 months are mostly fed on breast milk. The incidences of breastfeeding for breakfast reduces as the children grow older to 38 per cent for those aged 7 to 11 months, 17 per cent for those aged 1 to 2 years and 4 per cent for those aged 2 to 6 years. On the other hand, feeding children on porridge increases as the children grow older as indicated in Table 23.

table 23: Foods given to children for breakfast

Breakfast 0 to 6 months (%)

7 to 11 months (%)

1 to 2 years (%)

2 to 6 years (%)


None 19 13 19 26


Porridge 15 32 42 67

Milk 3 8 9 10

Other* 8 8 13 19

* includes: rice, fruits, meat, biscuits, yogurt, dry tea, bread, fruits, bananas and beans, cassava and beans, pottage, porridge and bread, sweet potatoes or irish potatoes, vegetables, milk and water, rice and beans.


As was the case for foods given before breakfast, the poor did not seem to give their children food before lunch significantly, apart from breast milk (5 per cent) for those who were breastfeeding. Those who did give other foods before lunch belong to the middle and upper economic categories. Such foods included breast milk (13 per cent) for babies below 6 months and milk for the other age groups (see Table 24).

table 24: Foods given to children before lunch

Before lunch Age group of the child

0 to 6 months (%)

7 to 11 months (%)

1 to 2 years (%)

2 to 6 years (%)


None 71 55 70 57

Milk 3 14 9 9


Porridge 5 6 4 3

Fruits 2 6 6 6

Juice 0 5 2 6

Other* 7 6 7 6

* includes: rice, biscuits, cerelac (an instant baby porridge), vegetables, water, milk and breast milk, bananas and beans, sweet potatoes or irish potatoes, beans or soya beans, bananas, water, pottage.

Foods given at lunchtime are shown in Table 25. Foods rich in starch are the most common foods given to children for lunch. It is notable that it is more common for children of all age groups to have no lunch than no breakfast.

table 25: Foods given to children for lunch

Lunch 0 to 6 months (%)

7 to 11 months (%)

1 to 2 years (%)

After 2 to 6 years (%)


None 48 21 24 29


Fruits 7 1 2 1

Sweet potatoes or Irish potatoes 7 10 15 22

Milk 6 9 2 2

Beans or soya beans 4 0 1 0

Juice 2 0 0 0

Rice 2 4 9 11

Milk and bread 2 0 0 0

Bananas 1 4 8 13

Vegetables 1 4 3 1

Porridge 0 8 3 2

Other* 6 19 19 25

* includes: milk and breast milk, bananas and beans, porridge and milk, cassava or cassava bread, biscuits, potatoes and beans, rice and beans, cassava and beans, beans or soya beans, meat, cerelac (an instant baby porridge), fish, bananas and vegetables, cassava bread and vegetables, umumece (small, sweet bananas), phosphatine (a supplement women take), potatoes and vegetables, spaghetti, posho (maize meal), rice and vegetables, rice and meat, rice and peas.

As was the case for meals served before lunch and before breakfast, not many respondents in the poor category give meals before dinner. The majority of those who do belong to the middle and upper economic categories.


table 26: Foods given to children before dinner

Before dinner 0 to 6 months (%)

7 to 11 months (%)

1 to 2 years (%)

2 to 6 years (%)


None 75 64 76 75


Milk 3 5 5 6

Porridge 2 3 3 5


Bananas 2 1 1 0

Fruits 1 8 5 7

Other* 8 10 9 5

Juice 1 3 3 3

* includes: porridge and bread, rice, beans or soya beans, cassava or cassava bread, biscuits, yogurt, maize, eggs, water, dry tea, meat, rice and beans, pottage.

Foods given to children for dinner are comparable to those given for lunch. They consist mainly of starchy foods. Table 27 shows the top five foods given to children for dinner.

table 27: Foods given to children for dinner

Dinner 0 to 6 months (%)

7 to 11 months (%)

1 to 2 years (%)

2 to 6 years (%)


None 45 21 27 31


Milk 8 6 7 3

Fruits 5 6 3 2


Porridge 3 8 4 2

Bananas 3 5 6 12

Cassava or cassava bread 3 1 1 3

Porridge and milk 2 3 0 0

Rice 0 3 8 11

Vegetables 0 8 1 1

Other* 6 26 28 14

* includes: dry tea, beans or soya beans, juice, yogurt, milk and fruits, milk and water, phosphatine, spaghetti, posho (maize meal), maize, biscuits, cerelac (an instant baby porridge), bananas and beans, bananas and vegetables, rice and vegetables, rice and meat, rice and fish, fish meat, rice and beans, potatoes and beans, cassava bread and vegetables, milk and bread, potatoes and vegetables, irish potatoes and meat, rice and ground nuts, rice and potatoes, cassava and beans.

As is the case with lunch, a fairly high percentage of children of all age groups are not fed at dinnertime. In addition, it is notable that a high prevalence of infants aged 0 to 6 months old appear to not be fed at the three main mealtimes. It should be noted that this is likely to be an incorrect interpretation. Although breastfeeding is included as a response category, some caregivers did not consider this a food unless prompted. In this case, respondents were not prompted for food categories so this could account for the impression that a large percentage of 0 to 6 month olds are not fed.


Foods ordinarily given to children

This section presents findings on foods ordinarily given to the respondents’ children on a day to day basis and the number of times children are ordinarily fed in a day. Results here differ from the previous section which reports only on the specific foods given to children on the day prior to the interview.

Children 0 to 6 months are ordinarily fed on breast milk (90 per cent). In cases where children receive supplementary feeding, they are fed on foods such as cow’s milk (14 per cent), and/or porridge (9 per cent). As it is recommended for children from 0 to 6 months to be exclusively breastfed, the finding that 90 per cent of children of this age are breastfed is a positive one. In addition, this trend is consistent across the various economic categories.

Children aged 7 to 11 months receive a much wider variety of meals. This, of course, reflects the fact that complementary feeding has already started at this age. Respondents indicated that they started giving their children alternative foods at 6 months, and between 6 months and 1 year. Apart from breast milk, which is still given to 72 per cent of children, the foods ordinarily given in this age category include porridge (52 per cent), milk (40 per cent), fruits (33 per cent), and sweet or Irish potatoes (19 per cent).

In observing these meals, it appears that children in these categories receive (from alternative foods) vitamins from fruits, carbohydrate from porridge and potatoes, and protein from milk. The incidences of children fed on carbohydrate-rich foods are more than those who are fed foods that are rich in other nutrients. More food varieties are, however, given by caregivers in the upper economic categories than in the lower ones. Table 28 highlights the differences.

table 28: Foods regularly given to children 7 to 11 months old

What type of food do you feed children between 7 to 11 months regularly?



Upper-middle (%) Upper (%)

Total number of observations 1,359 693 428 230 8

Breast milk 72 74 70 73 75

Porridge 52 58 54 30 50

Milk 40 35 45 49 75

Fruits 33 29 42 29 12

Sweet potatoes or Irish potatoes 19 18 22 13 12

Vegetables 12 14 12 5 50

Bananas 9 10 10 5 12

Meat 9 9 8 8 12

Biscuits 7 7 7 4 0

Water 4 4 4 2 25

Beans or soya beans 4 4 7 0 0

Fish 4 2 5 7 38

Eggs 4 3 5 6 25

Children from upper economic groups are fed on more varieties of foods which represents a more balanced diet than the children of poor caregiver. Children in poor households mainly receive protein from milk and breast milk. Those in middle and upper economic categories receive proteins from sources such as milk, fish, meat and eggs, as well as breast milk.

For children aged 1 to 2 years, the dependence on breast milk drops to 20 per cent and is replaced by porridge (50 per cent). The varieties of foods given are more diverse, ranging from


the aforementioned porridge and breast milk, to potatoes (42 per cent), milk (32 per cent), fruits (27 per cent), bananas (23 per cent), and beans (21 per cent) among others. There is a general tendency for the varieties and amounts to increase across the four economic levels under consideration. Given this scenario, it is easy to assume perfect nutrition until we consider the number of meals per day that the children receive which shows poor households giving their children fewer than three meals per day. Although quantities were not inquired about, it is the assumption of this survey that food quantities in poor households are generally less than in well-to-do households.

For children aged 2 to 6 years, porridge is replaced by potatoes as the overall main food given (46 per cent). The varieties given are outlined in Table 29 (indicating the main foods, but excluding those appearing in smaller percentages).

table 29: Foods ordinarily fed to children aged 2 to 6 years

What type of food do you feed children of 2 to 6 years regularly?



Upper-middle (%)

Porridge 43 43 46 38

Potatoes (sweet, Irish) 46 55 43 27

Rice 25 18 30 32

Fruits 25 16 31 39

Beans or soya beans 25 31 19 21

Milk 23 14 31 34

Vegetables 20 22 18 19

Bananas 19 22 19 14

Cassava or cassava bread 12 16 9 8

Meat 10 5 11 20

Juice 8 8 8 7

Fish 5 3 6 7

Eggs 5 2 4 13

Biscuits 4 2 5 8

Chips 2 1 3 2

meals served in a day

When asked how many meals per day children aged 0 to 6 months receive, about 92 per cent indicated breast milk while about 7 per cent indicated breast milk and other foods. The failure to indicate an absolute number of meals may be accounted for by the fact that lactating mothers do not count the number of times they breastfeed their babies, especially babies in the category in question (0 to 6 months old). It is likely that this also helps explain the high rates of 0 to 6 month olds appearing on the feeding tables above as not being fed at mealtimes.

For children aged 1 to 2 years, only 10 per cent of the respondents indicated that they give their children in this age category three meals per day and a snack. About 28 per cent give three meals per day, 18 per cent give one meal per day and a further 18 per cent give two meals per day. This scenario indicates poor nutrition. Children may be getting the correct foods, but not in the correct amounts or with the right number of meals, which compromises the growth and development of the children. This poor nutrition may be because some households, especially the poor ones, cannot afford to provide three meals a day and snacks in between meals.


For children aged 2 to 6 years, about 42 per cent of the respondents give their children three meals per day. Some 10 per cent give three meals and two snacks. The rest of the sample of caregivers provides fewer than three meals per day for their children of this age.

It should be noted that these findings are limited because they are based on a set of pre-coded responses. They present a different picture to the number of meals per day, per age group, that are found in Tables 22 to 27, which relate the foods given to children on the day prior to the interviews. Tables 28 and 29 may well give more realistic information on the meals that children of different age groups are missing. Tables 23, 25 and 17 show, for example, that 26 per cent of 2 to 6 year olds get no breakfast, 29 per cent get no lunch and 31 per cent get no dinner. Comparable figures for 1 to 2 year olds are less but still show 19 per cent getting no breakfast, 24 per cent getting no lunch and 27 per cent getting no dinner.

4.11 knowledge, AttItudes And prActIces regArdIng chIld–pArent InterActIon

The relationship between the child and the parent/caregiver is an important factor with regard to the development of children, especially at the early stages of their lives. This study sought, among other things, to establish caregivers’ KAP in relation to child–parent interaction and nurturing at different stages in the child’s life. The caregivers were presented with different activities and asked which ones they had engaged in with their children of different ages and the level of importance that they attached to them.

Mothers were observed with their children for a period of 30 minutes, but their consistent presence with their child was generally low. A low percentage of mothers (only 20 per cent) were present with their children for 80 per cent of the observed 30 minutes. Only 4 per cent of mothers were present with their children for all of the observed 30 minutes. In cases where the mother was absent during the observation, the majority of the respondents (33 per cent) had no one else there looking after the child. In 30 per cent of the cases female adults were taking care of the children in the absence of the mother. A comparably small proportion of female youth (16 per cent) assumed this role. This role of a mother as the main caregiver also came out in qualitative discussions.

The findings seem to suggest that parents interact with children more when they are still at a young age (aged 0 to 1 year old) than in the later years (aged 2 to 6 years old). At the age of 1 year old and above, the level of interaction between the caregivers starts to decrease, perhaps because children are exploring the environment around them. In general, parents indicate that interacting with the child is important, however, they do not fully understand what specific forms of interaction help in the development of their children. This is illustrated in Table 30.

The most practised activity is taking children for immunization (73.3 per cent) while the least practised is drawing the child’s attention to people, things or animals in and around the home (50.8 per cent). All the activities listed were considered important by the respondents. The highest rated in terms of importance is taking children for immunization (96.8 per cent) while the least rated (though still getting a high score) is drawing the child’s attention to animals, different things and people at 80.9 per cent. Various reasons were given for the importance given to the various activities. The most prominent reason given for a number of the activities is for brain development and stimulation.

Although the practice and attitudes towards child development and stimulation are high, most parents may not attach a reason to the kind of behaviour rated of high importance. For example, 54 per cent of the caregivers teach children values – and they attach 88.6 per cent rating to this for level of importance – however, only 13 per cent could list at least one reason for this behaviour. Similarly, reading a book or telling story to a child, playing simple games with a

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child, providing simple toys to a child and encouraging a child to play and interact with others are thought to be important but few caregivers understand why these are important.

In most of the cases, for a mother or a caregiver, interacting with a child is a natural process, hence it happens spontaneously and may, most of the time, be driven by emotion without knowing that it may have a positive impact on the development of children and their abilities in the future.

Caregivers who have children between the ages of 3 and 6 years were asked about activities they had engaged in to stimulate and play with the child. Practice in relation to child stimulation is

table 30: Activities done to develop children’s physical, emotional and mental abilities

Activity Respondent who did the activity (%)

Importance attached to the activity (%)

Main reason for rating the attribute

ReasonRespondents that

mentioned the reason (%)

Age 0 to 6 Months

Touch, hold or caress the child 72.40 86.00 For brain development and stimulation

62

Talk and/or sing to the child 68.10 83.80 To help the child recognize the voices of

the parents early

41

Take children for immunization 73.30 95.40 For brain development and stimulation

40

Breastfeed exclusively 60.40 93.70 For brain development and stimulation

51

Age 6 to 12 Months

Draw the child’s attention to people, things or animals in and around the home

50.80 80.90 It helps the child to learn the environment

around them

31

Talk, read, tell a story and/or sing to the child 63.40 85.70 To help the child learn 28

Play simple games with the child (e.g. peek-a-boo) 65.00 86.50 To help the child learn 19

Take children for immunization 55.30 96.80 For brain development and stimulation

38

Age 1 to 2 Years

Encourage the child to learn language (e.g. names of familiar people and objects, animal sounds, simple words and phrases)

61.70 88.30 To help the child learn 24

Talk, read, tell a story and/or sing to the child 63.80 86.90 To help the child learn 27

Provide simple toys for the child (e.g. a spoon, a plate, a ball, doll – can be self-made or a household object)

53.90 81.80 For brain development and stimulation

18

Age 2 to 4 Years

Read or tell a story to the child 60.50 86.00 For brain development and stimulation

18

Encourage the child to play and interact with other children

61.30 89.20 To improve relationships and

family unity

18

Help/encourage the child to hold a pencil, draw shapes and things

54.30 86.90 To prepare the child for school

30

Encourage the child to learn and use new words, expressions phrases

53.00 87.40 To help the child learn new words

25

Do simple games or creative activities with the child (e.g. ball games, building blocks, moulding, colouring)

54.60 83.30 To develop the child’s talents and prospects

21

Teach the child basic values (e.g. sharing food, sharing toys, not hitting other children)

54.90 88.60 Increase the child’s self esteem

13


low among caregivers as indicated by the fact that only 40 per cent of those questioned claimed to have practised at least one of the activities listed in Table 31.

With regard to the particular activities, there are also variations in the degree of practice between activities as indicated in Table 31. The most commonly practised activity is playing games with the child (61 per cent). In most of the activities, women are the most involved, as fathers were only mentioned in relation to one activity – reading a book or looking at pictures with the child.

table 31: Activities done to stimulate children aged 3 to 6 years old

Activity Total Yes = 501 Main person who did activity with the child

Practice (%) Person

Overall percentage of the ’person’ who did the activity (%)

Played any game with the child 61 Mother 27

Sang a song to the child 57 Mother 49

Told stories to the child 52 Mother 49

Read book or look at pictures with child 40 Father 41

Took the child outside of the home for a walk 35 Mother 43

Drew pictures with the child 27 Mother 34

Named or counted objects with the child 23 Mother 40

4.12 AttItudes towArds eArly chIldhood development

Caregivers were presented with different statements in relation to ECD in order to gauge their perceptions towards it. Based on the findings, shown in Table 32, we see a general, positive attitude towards ECD among caregivers. The key knowledge areas that appeared with strong positive perceptions are: playing with children, providing toys for them to play with, encouraging children to eat on their own, and encouraging children to ask questions.

4.13 knowledge, AttItudes And prActIces regArdIng chIld leArnIng

Once children start interacting with their environment, they learn various things. According to the caregivers, children start learning at an early age of 4 months. The responses indicate that respondents believe that children first learn hearing and vision at about 5 months of age, walking at 8 months, understanding and using simple words at slightly over 1 year, and socializing with other children at 1½ years.

During the focus group discussions, however, parents expressed the view that children should start learning from the time they can talk and interact well with the environment around them. It seems, from the qualitative findings, that parents perceive learning to start when the child is older, at the point where they can be more actively taught certain things.

“I think by the age of 3 years the child can talk, they can listen and also recall some things. So I also feel the age of 3 is ok for a child to start schooling.” (Female caregiver –Nyamagabe)

“Any age between 3 and 6 depending on the level you want the child to start from. If its nursery, 3 years, if its primary, then 6 years is appropriate.” (Female caregiver –Gakenye)

“We used to start school really late. Some would start primary when they are 11 years. But today, by 5 to 6 years, the child is already in school.” (Male caregiver – Ngororero)


“You may take the child to school at the age of 2 just to play with the rest. The child can then start school at the age of 3.” (Female caregiver – Bugesera)

There is a relationship between the parent’s perceptions of when the child should start learning and when they take the child to school. Most of the caregivers felt that the children are ready to go to school as soon as they are 3 years old and they may not wait for the child to show any sign of maturity to go to school. This may imply that some caregivers think learning starts in school.

“You can tell by the way the child looks at his other colleagues as they come back from school. The child will begin taking an interest in what they do and also demanding that he also starts studying. You can give it a try and take him for the first day. If they say they liked it on returning home, the child can then start school regardless of his age. Why not?” (Female caregiver – Gicumbi)

“Some of them don’t show any signs that they are ready but the moment they reach 3, you just take them to school.” (Female caregiver – Nyarugenge)

table 32: Perception towards child development practices

Statement ResponseTotal

Number of responses

Percentages (%)

A mother and/or father should talk or sing to the baby when it is still in the womb

Agree 1,188 59

Disagree 600 30

Do not know 212 11

Children should not learn to read or write their name until they are in primary school

Agree 690 35

Disagree 1,148 57

Do not know 162 8

Children must not try to eat by themselves until they are two years old

Agree 581 29

Disagree 1,248 62

Do not know 171 9

If parents are too gentle with their children, the children will not listen when they try to discipline them

Agree 603 30

Disagree 1,149 57

Do not know 248 12

Children will learn better if they are exposed to a lot of language

Agree 995 50

Disagree 721 36

Do not know 284 14

Beating children may negatively affect self-confidence, including encouraging them to beat others

Agree 1,002 50

Disagree 762 38

Do not know 236 12

Parents should take time to play and interact with their children

Agree 1,536 77

Disagree 256 13

Do not know 208 10

Parents should encourage children to ask questions so that they can learn

Agree 1,421 71

Disagree 362 18

Do not know 217 11

Parents should provide things for their children to play with (e.g. household objects, self-made toys or toys from the shop)

Agree 1,282 64

Disagree 302 15

Do not know 416 21

The father’s role is to discipline children, pay school fees and buy home requirements for the child. The mother’s role is to care for the child’s health and nutrition.

Agree 934 47

Disagree 121 6

Do not know 945 47


“The child will even start showing interest in writing wherever they find, wanting to be near any one writing something, carrying books and things of the sort.” (Female caregiver – Gicumbi)

“For me, I just take him to school as soon as I see that he has reached 3. Because he begins to become very destructive at home. So the best place for him is school where he finds his fellow children.” (Male caregiver – Ngororero)

“The child will begin admiring fellow children as they come from school and you will also see it that indeed the child must start school.”

“You don’t wait for any other sign, when a child reaches 3 or 6 years depending on the age you want him to start school, you take him to school there and then.” (Male caregiver – Nyamasheke)

“When the child reaches the school-going age, it is a duty of both parents to select a school that will contribute to the child’s development. The father should ensure that the child has all the school requirements and that he always reaches school. The husband takes centre stage as regards the responsibility of educating the child.” (Female caregiver – Rulindo)

4.14 the FAther’s role In pArentIng

Respondents had various opinions on the fathers’ role in parenting. The main point that stands out is that in many households the father is the breadwinner and protector. He provides for the family and takes care of the basic needs of all the family members and children.

table 33: importance of a father’s role in the development of their child

Attribute Importance (%)

Children 0 to 2 years

Attending ANC sessions 83

Show love and affection to the child and play with it 92

Talk to the child, tell stories 88

Help mother or caretaker in child care duties (e.g. bathing, diaper changing, getting dressed)

85

Provide for day-to-day necessities such as soap, food, clothes 91

Buying toys 77

Children 2 to 6 years

Providing things the child needs (e.g. food, clothes, paying fees) 89

Disciplining the child 91

Showing the child the environment (both inside and outside the home) 80

Playing with the child 79

Teaching the child to do different things 88

Taking the child to day care or nursery school 83

The female caregivers feel that the role of the father in the development of the child is critical. The most important role of the father is indicated by the percentage of respondents indicating that an action is important. When the child is young (0 to 2 years), the most important role of the father is seen as showing love and affection to the child and playing with it (92 per cent). This is closely followed by providing for the child’s day-to-day necessities (91 per cent). Eighty five per cent of female caregivers also expect the father to be more supportive with regard to child care duties like bathing, diaper changing and dressing.


As the child gets older (2 to 6 years), the father’s role is seen as most important with regard to discipline (again scoring 91 per cent) and providing the things the child needs such as food and clothes (89 per cent). Teaching the child (88 per cent) and playing with the child (79 per cent) have lower scores but are still clearly classified as important.

While men’s role as the breadwinner and provider is clear, there is also a strong perception that fathers should be involved in the lives of their children. These findings were affirmed during the focus group discussions by both male and female caregivers. Female caregivers also expressed concern about men working away from home and the fact that they spend very little time with their families. This is a serious limitation on the father’s interaction with the children.

“We encourage men to spare time and be with the children. We tell them to always spare time within a week to be with the children. Get an hour or two and be with the children. It helps the children not to fear their fathers such that in case a child faces a challenge, they feel free to approach their fathers. It also strengthens the bond between father and child.” (Community health worker – Bugesera)

“To a child who is young as we heard earlier, the husband has to help the wife since we heard earlier that the wife has a bigger responsibility and so the husband has to help his wife in bringing up that child just like [respondents’ name] said, our colleague said. If this doesn’t happen, then there will be a problem.” (Female caregiver – Gakenke)

“The man is the lord of the house. He must be the problem solver regardless of the nature of the problem in the home. The man also has to spare some time to play with the children. This creates a sense of parental love for the children and also brings out the essence of physical exercises much more.” (Male caregiver – Rubavu)

“The man ought to be the image of the family in the community events and gatherings. And the children have to imitate this so that they also grow into equally active members of the community.” (Male caregiver – Ngororero)

“The man has a huge responsibility to ensure there is harmony in the home. Both between him, the wife, the children and the neighbours. This indeed facilitates a child’s proper growth since they will grow up peaceful and loving.” (Female caregiver – Rulindo)

“The man also has the duty to ensure the children’s school fees are all cleared/” (Female caregiver – Nyarugenge)

“The man has to mentor and groom the boy child in into a responsible and caring man.” (Female caregiver – Gakenke)

“The father also has to bear in mind that the children have to survive after him. So, he has to amass property for the children to inherit. It is advisable that he does this when children are still infants because when they reach the age of 6 and above, they then begin to admire and so the father has more to provide for.” (Male caregiver – Ngororero)

“When it comes to husbands, very few can spare time for their children. A man is working in Kigali and his family is here. He only comes very briefly and on a few occasions. So you find a child being unable to identify his father right from the time he is born. Some men do not even provide for their families at all. If a man is working far from home, they ought to at least spare a Sunday for their families. And on coming home, they shouldn’t simply sit and look on as visitors. They should take a moment with the children, play with them and even teach them traits that could otherwise not be taught by the mother.” (Female caregiver – Gicumbi)


4.15 leAvIng chIldren In the cAre oF others

A mother or caregiver may not be able to be with the child at all times. There are times when the mother may need to attend to other things and this may necessitate leaving the child in the care of other people. In the current study, 82 per cent of the caregivers indicated that they have not had to leave the child in the care of anyone to do other things. Those children who were left at home, were largely left in the care of other relatives, siblings or house helpers.

CHILD NOT LEFT IN THE CARE OF OTHERS

CHILD LEFT IN THE CARE OF OTHERS

N = 1,977

18%

82%

Figure 2: incidence of leaving children in the care of other people

Of those who left children in the care of others, the majority of respondents indicated that children are sometimes left in the care of other people. As shown in Figure 3, only 22 per cent leave the children with others on a daily basis. This means that most of time the mothers are with their children at home.

0

5

10

15

20

25

30

35

40

WH

ENEV

ER N

ECES

SARY

RARE

LY

ON

CE

OR

TWIC

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WEE

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EVER

Y D

AY

22.8%25.3%

37.8%

14.2%

N = 360

Figure 3: how often caregivers leave their children in the care of others


Organized child care facilities

The incidence of attending organized care or pre-school is low in the communities that were sampled for this study. Only 12 per cent of caregivers take their children to organized child care facilities. Formal child care facilities are located in the urban areas.

For the majority who do not take their children to organized child care centres, the main reasons provided are protection for the children, because parents feel they are too young to be out of the family setting (16 per cent), a preference for having the children at home (12 per cent) or fear that children might get sick (5 per cent). Some parents also felt that the child care centres are expensive (14 per cent), while others did not know where the centres were located (14 per cent).

YES, HOME-BASEDNOYES, CENTRE-BASED

7% 5%88%

Figure 4: Attendance at organized child care facilities

Although attendance of organized centre-based care is low, 43 per cent of the respondents indicated that such places exist. The majority of these (55 per cent) indicated nursery or pre-primary schools, 30 per cent indicated centre-based day care (church, mosque, NGO, etc.), while 16 per cent indicated home-based day care.

From the focus group discussions, caregivers indicated that they ordinarily rely on neighbours to look after their children if they are going somewhere.

“If there are neighbours nearby, the parent, especially the mother, can leave the child with them when she is going to the garden. She can also leave the child with the elder sisters or brothers at home. This mostly happens when the mother is not going to take long in the garden. When she is to take a long time, she carries the child on her back and goes with him to the garden.” (Male caregiver – Ngororero)

The availability of nursery schools is perceived positively by caregivers as places where a child can start picking up knowledge early. Nursery schools are also perceived as safe environments for the child.

“It’s a really good feeling. You take a child to a nursery when they can neither talk nor read and after a short while, they come reading to you this, asking you that. The nursery schools are really good establishments and enable a child to begin thinking and reasoning at an early age. It is a very secure place to leave a child especially for parents that go to the garden for example, and they have no one to leave their child with. The child also gets to learn something at the end of the day.” (Female caregiver –Rulindo)

“When a child enrols for nursery school at a younger age, they are able to learn more and faster. Enrolling a child for school when they are 6 or even beyond, you find that they will need some time to cope with one that could have started a bit earlier. The younger one will have grasped English by the age of 6 while the one aged 6 is just starting school.” (Female caregiver – Bugesera)


4.16 dIscIplInAry meAsures And chIld Abuse

Disciplining children is part of ECD. The discipline techniques used are important as they affect the child’s physical and psychological development, including informing their behaviour towards other people. The survey’s findings showed different ways in which primary caregivers discipline children and a high proportion indicated that both light and heavy punishments were used. The disciplinary measures varied by the age of the child as well as by the economic status of households.

Disciplining children 0 to 1 year old

Overall, talking to the child (33 per cent) is the most common method of discipline for children in this age group. Other forms of discipline are slapping the child (27 per cent) and shouting at the child (15 per cent). These options are practised in different proportions by caregivers of different economic categories. Caregivers in the upper economic categories favour talking (33 per cent) and shouting (67 per cent), but not slapping (0 per cent). Within the other economic categories, the use of slapping is significant, in addition to talking and shouting.

Disciplining children 2 to 3 years old

The trend is similar to the methods used on children aged between 0 and 1, save for the upper economic category caregivers who, instead of slapping, use other physical forces such as biting, shaking and pushing (33 per cent). Talking is, however, still the most common (53 per cent), followed by slapping (47 per cent), shouting (25 per cent), and beating with implements, such as sticks and belts (21 per cent). The more abusive forms of discipline such as burning, insulting the child and denying food are rare but also more prevalent in the lower (poor and lower-middle) economic categories. Table 34 illustrates this.

table 34: methods of disciplining children aged 2 to 3 years old

Total (%) Poor (%) Lower-middle (%)

Upper-middle (%)

Total (N) 1,037 494 355 188

Talking to them 53 53 52 57

Slapping with hands 47 50 51 31

Shouting at them 25 28 25 18

Beating with implements like sticks, belts, rods, etc.

21 24 21 14

Denying privileges 8 10 7 5

Time out (naughty corners) 8 9 7 8

Other physical forces like biting, shaking, kicking, pushing

5 5 4 7

Denying food 4 5 4 2

Insulting the child 4 5 4 0

Burning 2 2 3 1

Sending the child away from home 1 1 0 0

Disciplining children 4 to 6 years old

As Table 35 shows, in this age category, slapping is the most used form of punishment (63 per cent) as opposed to talking to the child as occurs in the previous age categories. For this age group, only the upper economic category, out of the four, favours talking over slapping. All other economic categories more commonly use slapping over both talking and shouting. Overall, slapping is followed by talking to them (51 per cent), beating with implements, such as sticks and


belts (35 per cent), and shouting at them (27 per cent). In addition, slightly higher percentages of caregivers admit to burning and insulting the children from the poor, lower-middle and upper-middle economic categories. It would therefore appear that forms of punishment become more abusive as the child grows from 0 to 6 years. This finding holds for all economic categories.

table 35: methods of punishing children aged 4 to 6 years

Total (%)

Economic category


Upper-middle (%)

Total (N) 909 461 275 173

Slapping with hands 63 59 68 68

Talking to them 51 54 52 42

Beating with implements like sticks, belts, rods, etc.

35 42 29 30

Shouting at them 27 28 27 27

Denying privileges 17 21 9 17

Other physical forces like biting, shaking, kicking, pushing

14 15 13 12

Denying food 12 17 6 8

Time out (naughty corners) 9 8 8 12

Insulting the child 5 5 6 5

Sending the child away from home 5 5 5 5

Burning 4 4 5 3

In households where both male and female caregivers were interviewed, there were no differences in the approach to disciplining children between them.

During observations, 26 per cent of the caretakers were seen correcting or reprimanding a child for an action, with 2 per cent of the caretakers denying the child food, 6 per cent slapping lightly and a similar proportion slapping heavily. About half of the respondents believe that children must be punished in order to develop properly. There are variations by economic category on this response. The results seem to suggest that the more economically affluent caregivers are, the less they favour physically punishing children. This is reflected in the evidence gathered in relation to the methods of disciplining children.

table 36: Attitudes towards physical punishment of children



Upper-middle (%)

Total (N) 1,987 951 667 369

Yes (positive attitude towards physical punishment)

50 52 46 48

No (negative attitude towards physical punishment)

49 47 52 51

No response 1 1 2 1

Comparison of the findings from the household interviews and the focus group discussions, however, show divergent views with regard to the means of disciplining children used by parents and caregivers. In focus group discussions both male and female caregivers emphasized talking to the child instead of beating and shouting at them.


“The way parents discipline their children, they get them seated, like we are seated, while they are eating and you talk to them and counsel them. The counselling (is) meant to develop the child. But for the cane, that era ended.” (Female caregiver – Rwamagana)

“There are times when he is playing with other children and you get to hear that he is saying bad words to his friends and insulting them. In such a situation, I sit him down threaten him and tell him the dangers of saying bad words and insulting others.” (Female caregiver – Nyamagabe)

“The parent of long ago used to discipline using the cane and that is all they knew. But we have realized that the cane is not the solution. Because you can threaten the child using the mouth. You tell him today that he went wrong and you will find that the child will actually listen to you. That is why we keep telling them that the cane instead escalates the situation and they can use other ways to punish a child.” (Female caregiver – Kayonza)

“There are also cases where you find parents refusing to allow children to go to school. Instead, they make the children work at home. We hear this when we attend meetings in our associations.” (Male caregiver – Rubavu)

“There is also another punishment where a child is made to work for other people and they pay money to the child’s parent.” (Male caregiver – Ngororero)

“Among the Rwandese, when a child is still young, they are not caned. You sit there and call on all the children and then talk to the child who is in the wrong. You do that once, twice and by the third time, they would have understood their mistake.” (Community health worker – Gakenke)

child abuse within communities

About 19 per cent of caregivers indicated that they were aware of cases of child abuse in the community. Awareness was higher among the upper economic category respondents (31 per cent) than in the middle and poor categories (18 per cent among the poor, 20 per cent among lower-middle and 16 per cent among upper-middle economic categories). Of those who

table 37: the most common cases of child mistreatment in this community



Upper-middle (%)

Total 368 177 133 58

Fights among parents 6 5 8 10

Denial of love and care by parents/guardians

4 4 5 3

Physical assaults (beatings, kicks, slaps etc.)

5 7 4 5

Denial of meals 3 5 2 2

Denial of breastfeeding 0 1 0 0

Child labour 12 14 9 7

Not allowing children to play with other children

6 5 7 7

Denial of education 23 29 22 12

Denial of appropriate clothing 5 3 4 12

Denial of medical care 11 10 12 14

Defilement 7 5 8 14

Child-to-child sex 8 7 10 10

Feeding with alcoholic drinks 3 3 4 2


are aware of child mistreatment, the indication of such incidences is higher in the southern province (31 per cent) and lowest in Kigali (11 per cent). The highest awareness levels of child mistreatment were found in the Nyamagabe and Ruhango districts (41 per cent in both) while the lowest are in Nyarugenge and Nyamasheke (7 per cent in both). Some of the cases of abuse were as a result of domestic violence as indicated from the focus group discussion with female caregivers in Rulindo.

In households where both male and female respondents were interviewed, there are differences in responses between men and women. However, from an overall perspective, denial of education ranks highest among ways in which children are mistreated (23 per cent) and it is a particularly prevalent form of mistreatment in the poor and lower-middle economic categories. This is followed by child labour (12 per cent) and the denial of medical care (11 per cent).

“It happened that a man and his wife had a misunderstanding and got divorced. Because of that the child, who came home late, carried the blame. The father locked him out and went ahead slapping him.” (Female caregiver – Rulindo)

“People use excessive force when punishing children. You find someone with a very big stick caning a child even for no good reason.” (Male caregiver – Ngororero)

If a child is abused in the community, respondents would first talk to the parents about it (42 per cent) then report to the local leaders (20 per cent) and, lastly, report to the police (17 per cent). Talking to parents was also the approach caregivers would follow according to findings from the male/female sample, followed by reporting to the police. When asked what was the most important thing to do was in cases where a child is being abused, respondents indicated that talking to the parents was most important (32 per cent), followed by reporting to local leaders (22 per cent) and then to the police (21 per cent).

There was a perception that poverty in the home is a major reason why some parents mistreat their children (49 per cent). Other reasons mentioned for the abuse of children include misunderstanding among parents (46 per cent), insecurity in the community (32 per cent), being orphans (31 per cent), broken families (17 per cent) and living in child-headed households (17 per cent). To protect children from mistreatment, it was suggested that sensitization of the public about children’s rights (28 per cent) and enforcement of laws by punishing parents who mistreat their children (18 per cent) be undertaken by the government. Other suggestions were counselling the parents and children (15 per cent), taking children to school (10 per cent) and ensuring that parents stay with their children to try to understand their behaviour (5 per cent). Respondent feel that the responsibility for protecting children against mistreatment lies with the parents (63 per cent), the community (23 per cent), local leaders (20 per cent) and the government (16 per cent).

Contrary to the findings in the assessment in relation to the methods used to discipline children, the prevailing opinion is that parents and caregivers are not in favour of physical punishment. For the majority, the most preferred means of disciplining a child is through talking to them and advising them on the right things to do. These opinions were shared by the community health workers and both male and female caregivers.

“Disciplining a child may not necessarily imply a cane. You may use a very small stick if it necessitates so, cane him once and after talk to him. Or simply talk to him. Caning him with the small stick would only come in when the offence is a bit grave and only a cane can show him that what he did is bad. But a stick is highly discouraged.” (Female caregiver – Gicumbi)

“I think the habit of caning children when they do something wrong is not very effective. That is why it is even phasing out. You know with caning, the child perceives it as a way of simply inflicting pain on him rather than disciplining him.” (Female caregiver – Bugesera)


“I totally discourage caning, totally. In my area, there are very few parents that still cane their children and we are sensitizing them continuously to stop it.” (Female caregiver – Ngoma)

“Before the child is three, it makes no sense disciplining him. Except that some children can become naughty when they reach the age of two, so for such an age you simply threaten them and hit them with very simple slaps as you caution them never to act the same way again. You could find that a child does not want to share with others, he does not listen to elders and other small things. There is no need to really beat a child at such an age sincerely.” (Female community health worker – Ngororero)

“On reaching the age of 3, you can sit a child down, counsel them and discipline them without necessarily caning them. Because at this age, the child can at least distinguish between what is good and bad.” (Female community health worker – Rulindo)

“Caning – it depends on the type of child. Some children just have to be caned first to understand. So you find parents of such a child caning their children. We, however, emphasize to them that there are many ways they can explore disciplining a child. We have come up with many of them and are sharing them with the parents. We want to do away with caning completely.” (Male community health worker – Gakenke)

“I find the use of the stick as a way of worsening the situation. There is a time you find that even if he is misbehaving, but after counselling, children will always get back to their senses. The first time, second time and third time of counselling will always discipline the child better than caning him. The stick just worsens the situation. A child is a child.” (Female caregiver – Rwamagana)

“Where the issue of caning worsens the situation is that the people that use the cane are the parents that take some alcohol. So they cane the child unconsciously because they have taken some alcohol. When a person is drunk they never mind which part of the body they beat. He can cane where he shouldn’t have caned and ends up harming the child.” (Female caregiver – Gakenke)

4.17 communIcAtIon And sources oF InFormAtIon

Radio is the most used source of information to find out about what is happening in the community (72 per cent) and about child care (53 per cent). This is especially so within the poor households and for the households from the middle economic categories. Upper economic level households mostly rely on TV as the main source of information. Other sources of information are neighbours, community health workers, friends, local village leaders and family members.

Overall, the radio is the most trusted source of information. Specifically, radio is the most trusted source of information on what is happening in the community (44 per cent), as well as on child care (31 per cent). Others sources of information on child care include community health workers (16 per cent), health facilities (11 per cent), local village leaders (8 per cent), and family members (7 per cent).

Almost 89 per cent of all the households interviewed own a working radio, rather divergent from the RDHS 2010 which found that 63 per cent of Rwandan households own a radio. Overall, in 52 per cent of the households that own a radio, it is the father who decides the programmes that people in the home should listen to, while in 33 per cent of cases it is the mother who decides. However, considering the different economic categories, we see some differences. In the upper economic category households, both the father (46 per cent) and mother (46 per cent) decide which programmes are listened to, while in middle and poor households the father most commonly decides. Analysing only those households where both female and male respondents were interviewed, these trends remain unchanged.

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table 38: sources of information

Sources of information Events in the community (%) Child care (%)

Base size 2,000 2,000

Radio 72 53

Community health workers 31 31

Neighbours 39 27

Health facilities 24 26

Friends 34 25

Local village leaders 36 24

Family members 28 22

TV 32 18

Religious leaders 25 14

School children 15 14

Mothers’ associations 11 11

Mobile phones 14 9

Women’s groups 11 9

Ceremonies (weddings, funerals etc.) 7 8

Newspapers 14 7

Traditional leaders 10 6

Market days 10 6

Road shows 8 6

Posters 6 5

Youth groups 6 5

Booklets 5 5

NGOs/community-based organizations 5 4

Fliers/leaflets 4 3

63chAPtER 5: cOnclusiOns AnD REcOmmEnDAtiOns

chApter 5: conclusIons And recommendAtIonshealth issues

The most prevalent illnesses in the communities studied are respiratory infections (cough, flu), diarrhoea and malaria. Caregivers perceive that children aged 0 to 3 years of age are the most affected by respiratory infections while those 4 to 6 years old are most likely to contract malaria. These diseases are attributed to the change in the climate, as well as poor

hygiene and sanitation practices in the home. The results indicate that caregivers have a fairly good understanding of the causes of diseases, how to prevent them and how to manage them when they occur. However, there are some misconceptions and gaps in knowledge, particularly with regard to the causes of illness and the most appropriate treatments.

Self-medication by administering medicine at home (61 per cent), going to the nearest health facility (29 per cent) and buying drugs at the nearest facility are the immediate remedies undertaken when children fall sick. It is important to note that most respondents will treat the symptoms. However, after self-medication most respondents will seek the services of professional medical workers. Also observed is a high degree of preventative measures where children younger than 6 years old are fed with foods that are perceived to support proper child growth and a strong belief that proper hygiene and sanitation in homes is paramount.

There is an indication that almost all caregivers seek treatment, whether self-medication or professional, for their children’s diseases. Generally, the knowledge and attitude towards treating sick children is high among the caregivers. The prevalence of the practice of self-medication, might imply that most households are not close to professional medical personnel.

hygiene and sanitation

Respondents understand the importance of maintaining proper hygiene and the practices that should be undertaken to maintain proper hygiene. Despite this awareness, there are low levels of actual practice of these activities. For example, 100 per cent of the respondents were aware of the importance of washing hands with soap before feeding a child or preparing food, but only 28 per cent practised this behaviour. About 64 per cent understand the need for washing hands after using the toilet but only 46 per cent practised it. This state of affairs points to the need for re-education and a call to action to improve sanitation in the community.

Pre-birth child care

Women were found to be more knowledgeable than men in terms of what should be done during pregnancy in order to ensure the health of the unborn child. However, the caregivers’ knowledge on some pre-birth aspects is still low. About 75 per cent of the female caregivers and close to a third of the male caregivers know that it is important for expectant mothers to protect themselves against common illness, such as malaria. Knowledge of the need to test for HIV is also relatively high. These two aspects are also highly practised by the female caregivers and supported by male caregivers.

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However, gaps in knowledge are observed, especially with regard to taking iron tablets, the need for healthy eating practices, and the importance of having a delivery plan and delivering in a recommend health facility. Fortunately, most expectant mothers receive antenatal services from designated health facilities; 99 per cent of expectant mothers had used antenatal services at least once when expecting their index child. In addition, the practice of delivery at recognized health facilities is high with at least 86 per cent delivering at a health facility in the district. Overall, the more people are aware of the importance of carrying out pre-birth activities, the higher the likelihood that these activities are practised.

child care after birth

As with pre-birth care, women were found to be more knowledgeable than their male counterparts in the area of after-birth care. However, knowledge and practice levels are relatively low for most of the aspects for both male and female caregivers with the only exception being knowing the importance of immunizing the child (78 per cent knowledge; 87 per cent practice) and breastfeeding the baby within the first hour of delivery (42 per cent knowledge; 62 per cent practice).

Notable are the low levels of knowledge and practice of other aspects of after-birth child care, such as clean cord care, keeping the baby warm using the mother’s chest and keeping the baby in a clean environment. It is also important to note that the level of practice after birth is higher than what is known. This might imply that most women practise positive behaviours without being aware of their importance.

The practice of deworming is high with 89 per cent of caregivers of children aged 1 to 6 years old claiming to carry it out. There is a variation by economic category, however, with 87 per cent of the poor and 90 per cent of the lower-middle economic category practising deworming. The key reason for not deworming was cited as cost. There is also a high claimed knowledge of immunization (91 per cent) and a good understanding of the reasons for this by both male and female caregivers. Another positive finding is that there is a high incidence of the practice of immunization.

Feeding practices

The findings indicate respondents are aware of good feeding practices that enable the proper development of children. Over 90 per cent of the respondents who have children aged 0 to 6 months old exclusively breastfeed them. This is a high proportion, although the ideal situation would be 100 per cent exclusive breastfeeding. Only 7 per cent of mothers of children aged 0 to 6 months mentioned feeding their children breast milk as well as other foods, especially porridge and fruits. Other children above 6 months are fed on foods rich in nutrients, such as carbohydrates and proteins. Such foods include porridge, potatoes, beans, vegetables, bananas and milk.

It is very evident from the data that the gap in feeding practices lies in the number of meals given to the children per day. Some respondents indicated one meal, others two, while some mentioned the ideal three meals per day. Only 28 per cent of 1 to 2 year olds get three meals a day while 18 per cent get one meal a day in this age group. This number of meals could be explained by the feeding schedules of the respondents. Most of those interviewed were from the rural areas where the ordinary daily regime is to work in the morning and have the first meal of the day in the mid-morning or sometimes early afternoon. Children in such households would become attuned into this regime and the total number of meals per day would eventually go down. This is confirmed in the findings of this assessment when caregivers report what children ate the day before. The data show that children aged 2 to 6 years old are more likely to have nothing for breakfast, lunch and dinner than 1 to 2 year olds.

65chAPtER 5: cOnclusiOns AnD REcOmmEnDAtiOns

In addition, the majority of those interviewed are subsistence farmers with little income. This proportion of the population mainly resides in rural areas, where poverty rates are higher. It is therefore highly likely that the majority of those interviewed may not be able to afford to give their families (including children) three meals per day. This state of affairs is likely to account for the perceived stunted growth among children in the rural areas explained in national statistics.

Knowledge of when complementary feeding should be introduced is high among the survey population. However, the practice of introducing complementary foods at the right age (6 months) is higher than the knowledge. The reason for this may be a combination of the aforementioned factors on feeding, but is principally the inability of the mother to continue exclusive breastfeeding as the child grows and demands more and more food. In addition, child care in African society has a long tradition of practices. Mothers, by practice, would start to give their babies complementary foods when they reach a given age without consciously thinking of the importance of the practice.

child–parent interaction

The survey shows high levels of interaction between children and parents/caregivers. Although knowledge about child–parent interaction is low, it is positively correlated to practice. Parents do certain things, such as holding and playing with their children, without consciously thinking of the importance of such activities. In most cases, it is the mother who is present and taking care of the child and interacting with the child. The mother is assisted by other females in the household.

The type of interaction changes as the child grows older. At the very young ages of 0 to 6 months, the most common form of child–parent interaction is touching, holding and caressing the child. As the child grows older, other forms of interaction come into play. These include singing to the child, talking to the child and teaching the child basic things, such as language and behaviour. Other practices in child care that were mentioned include immunization and breastfeeding. The fathers’ role in this respect is generally limited to providing for the family and taking a strong role in disciplining the child. However, there is also great importance attached to fathers spending time with their children, playing with them and showing them love and affection, a finding from both the quantitative and qualitative assessments. While this is seen as very important, it seems that there are limitations to how much time fathers spend with their children in practice.

Organized child care

Respondents are aware of organized child care in the form of nursery schools and day-care centres organized by churches and NGOs. The practice of attendance at organized child care centres is low, however, as very few respondents (12 per cent) take their children to day care. The majority of these respondents leave older children alone and younger children in the care of grandmothers and other siblings at home. A few children are left with caretakers. The main reason given by respondents for why their children do not attend organized child care is because the children are still too young and need to be close to the family. Overall, very few (11.5 per cent) of the children attend any form of organized child care and the majority of those who do actually attend nursery school.

Disciplining children and child abuse

The respondents interviewed understand that it is a violation of a child’s rights when a child is abused or physically punished. Respondents advocate for talking to children as a way of correcting and educating them. Despite this understanding, forms of punishment that harm the child are still commonly practised within the survey population. These include slapping, caning, beating and shouting at the child. Also notable are the differences between the economic categories and the fact that, generally, forms of discipline become more abusive as the child


grows older. In fact, almost half the respondents believed that a child should be physically punished in order to grow up properly.

These forms of punishment were also perceived to be child abuse. Other forms of child abuse common in the survey population are the denial of education, child labour and the denial of medical care. According to the respondents, the responsibility of protecting children against abuse rests with the parents, the community, local leaders and the government.

communication and sources of information

Radio is the most common source of information on child care and what is happening in the community, especially within poor households and households in the middle economic category. Upper economic level households mostly rely on TV as the main source of information. Most of the households visited own a working radio.

67AnnEX 1: tABlEs

Annex 1: tAbles demogrAphIcs

table 39: household sample achievement by province

Province Sample achievement (%)

Total (N) 2,000

Northern 19

Eastern 25

Western 19

Kigali 17

Southern 20

table 40: household sample achievement by district

District Sample achievement (%)

Total (N) 2,000

Bugesera 8%

Gakenke 6%

Gasabo 8%

Gicumbi 6%

Kamonyi 7%

Kayonza 7%

Ngoma 7%

Ngororero 6%

Nyamagabe 7%

Nyamasheke 6%

Nyarugenge 8%

Rubavu 6%

Ruhango 6%

Rulindo 6%

Rwamagana 6%

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table 41: category of respondent demographics

Total (%)

Province Economic category

Northern (%)

Eastern (%)

Western (%)

Kigali (%)

Southern (%)

Poor (%)

Lower-middle (%)

Upper-middle (%)

Upper (%)

Total (N) 2,000 376 515 379 337 393 951 667 369 13

Pregnant mother 5 5 7 3 4 5 5 3 8 0

Newly delivered mother 3 5 3 3 3 3 4 4 2 0

Biological mother of children of 0 to 6 years

84 85 82 90 90 77 84 84 85 100

Caretaker/relative of children 0 to 6 years

5 3 5 3 2 12 4 8 4 0

Grandmother/father of children of 0 to 6 years

2 3 3 1 0 3 3 1 1 0

table 42: Disability status of female household respondents

Total (%)Province


Total (N) 2,000 376 515 379 337 393

No disability 96 97 98 96 99 90

Physically disabled 3 2 1 2 0 6

Mentally handicapped 1 0 1 0 0 3

Speech impairment 1 0 1 1 0 5

Visual impairment 1 0 0 2 0 2

Hearing impairment 0 0 0 0 0 0

table 43: Respondents’ level of education: overall

Total (%)Province


Total (N) 2,000 376 515 379 337 393

No formal education 20 30 24 16 4 23

Primary 44 51 49 54 19 44

Secondary 25 13 18 22 52 23

College or vocational school 5 3 7 2 6 4

University 6 3 2 6 19 6

table 44: Respondents’ level of education by economic level




Total (N) 2,000 951 667 369 13

Secondary 25 11 33 44 8

Primary 44 55 47 17 0

No formal education 20 32 11 5 0

College or vocational school 5 2 6 8 8

University 6 0 3 26 84

69AnnEX 1: tABlEs

table 45: Age groups

Age (years) Total (%)Province


Total (N) 2,000 376 515 379 337 393

15–19 2 2 2 2 1 2

20–24 12 21 12 10 11 7

25–29 36 36 32 48 43 29

30–34 16 18 18 13 13 16

35–39 9 7 11 10 9 8

40–44 3 2 3 2 1 6

45–49 1 1 1 0 1 2

50–54 1 1 0 1 0 1

55–59 0 0 0 0 0 1

Over 59 3 3 4 1 1 3

No response 17 9 17 13 20 25

table 46: Respondents’ working status




Total (N) 2,000 951 667 369 13

Working on other peoples’ farms for money 6 10 3 0 0

Subsistence farming 36 53 29 5 0

Commercial farming 15 2 20 39 15

Petty trader 4 3 10 0 0

Working on other peoples’ farms for food 8 14 4 0 0

Part-time worker 5 2 9 5 0

Unemployed 10 15 9 0 0

Civil servant 14 1 13 48 85

Craftsman 2 1 3 3 0

table 47: Respondents’ religion

Total (%) Economic category



Total (N) 2,000 951 667 369 13

Catholic 52 55 53 45 39

Protestant 36 36 33 43 38

Muslim 4 2 6 4 23

Seventh Day Adventist

8 7 8 8 0


table 48: households’ economic categories

Economic category Frequency Per cent (%) Valid per cent (%)

Cumulative per cent (%)

Total (N) 2,000 100.0 100.0

Poor 951 47.5 47.5 47.5

Lower-middle 667 33.3 33.3 80.8

Upper-middle 369 18.5 18.5 99.3

Upper 13 0.7 0.7 100.0

heAlth Issues AFFectIng the communIty

table 49: the most common health issues affecting this community today




Total (N) 2,000 951 667 369 13

Worms 23 25 22 19 0

Cough 42 40 39 50 46

Malaria 46 46 48 42 69

Flu 34 30 38 36 69

Diarrhoea 31 32 33 27 15

Red eye 1 1 1 1 0

Pneumonia 6 8 4 3 0

Typhoid 1 1 1 1 0

Vomiting 2 2 2 2 0

Polio 1 1 1 1 0

Measles 2 2 4 0 0

Tetanus 0 0 0 1 0

Chicken pox 1 1 1 0 0

HIV 1 0 0 2 0

Diabetes 0 0 0 0 0

Skin diseases 3 2 2 4 8

Headache 0 0 0 0 0

Kwashiorkor 0 0 0 0 0

Angina 1 1 0 0 0

Umusonge (Pneumonia) 0 0 0 0 0

Gripe 0 0 0 0 0

Bronchitis 0 0 0 1 0

Igituntu (TB) 0 0 0 0 0

Cholera 0 0 0 0 0

Do not know 2 2 2 2 0

71AnnEX 1: tABlEs

table 50: groups of people who are most affected by health issues

Total (%) Economic category



Total (N) 2,000 951 667 369 13

Children 0 to 6 Months 28 27 28 28 15

Children 7 months to 2 Years 44 44 46 41 69

Children 3 to 6 years 37 37 36 37 54

School going children (7 to 18 years) 5 5 4 6 8

Elderly people 6 4 7 8 0

Disabled people 1 1 1 1 0

Everyone 39 39 36 41 46

table 51: health problems that affect children 0 to 6 years

Disease Cumulative response (%)

Total (N) 1,151

Worms 30

Cough 45

Malaria 47

Flue 46

Diarrhoea 34

Red eyes 1

Pneumonia 9

Typhoid 1

Vomiting 2

Polio 1

Measles 4

Tetanus 0

Chicken pox 1

HIV 0

Diabetes 0

Skin diseases 5

Headache 0

Kwashiorkor 0

Angina 1

Gripe 0

Do not know 2

No response 0


mAnAgement oF heAlth Issues

table 52: in the past two weeks did any child below 6 years of age in this household fall sick?




Total (N) 2,000 951 667 369 13

No 79 78 79 81 92

Yes 19 19 19 18 0

No response 2 3 2 1 8

table 53: What were the symptoms of the illness that the child or children suffered from?



Upper-middle (%)

Total (N) 371 177 127 67

Diarrhoea 41 41 46 28

Fever or hot to touch 30 28 39 18

Cough 41 44 44 30

Vomiting 29 25 35 27

Flu 26 21 34 24

Difficulty in breathing 9 5 17 6

Fast breathing 8 4 15 3

Indrawn chest 6 3 13 3

Loss of appetite 13 9 20 9

Stomach aches 8 5 13 6

Unable to eat or breast feed 7 5 12 1

Skin rash 6 3 9 4

table 54: What did you do immediately after you noticed the symptoms?



Upper-middle (%)

Total (N) 371 177 127 67

Gave ORS 18 15 26 12

Gave zinc 10 8 13 9

Gave some medicine that I had in the house 61 57 66 63

Gave the child plenty of fluids 7 5 7 13

Continued breast feeding 10 5 18 6

Gave herbal medicine 11 8 18 3

Sought the services of a community health worker 12 6 24 3

Took the child to the nearest health facility 29 31 33 15

Sought the services of a traditional herbalist 13 16 13 4

Tepid sponging 7 5 14 0

Bought medicine from a pharmacy/drug shop 18 14 26 16

Prayed for the child 5 4 9 1

73AnnEX 1: tABlEs

table 55: What did you do to treat the condition?



Upper-middle (%)

Total (N) 371 177 127 67

Gave ORS 8 5 9 10

Gave zinc 7 7 8 6

Gave some medicine that I had in the house 21 23 20 18

Gave the child plenty of fluids 4 3 5 4

Continued breast feeding 4 3 4 6

Gave herbal medicine 7 7 10 1

Sought the services of a community health worker 12 8 16 16

Took the child to the nearest health facility 48 48 50 43

Sought the services of a traditional herbalist 8 9 7 6

Tepid sponging 1 0 2 0

Bought medicine from a pharmacy/drug shop 13 14 12 15

Prayed for the child 2 2 2 1

AntenAtAl And pre-bIrth cAre

table 56: What mothers should do before birth to ensure a child is healthy

What things should mothers do to ensure that a child is healthy pre-birth?




Total (N) 2,000 951 667 369 13

Mother should protect herself against common illnesses, such as malaria

74 72 75 80 54

Know HIV status of the mother 65 65 68 62 85

Receive ANC from an approved health facility 43 39 43 51 69

Take iron supplements 26 21 30 31 31

Take vitamin A 44 40 46 51 38

Ensure proper eating practices 22 16 25 29 62

Immunization against tetanus 37 32 38 45 31

Take antenatal lessons 35 30 37 42 54

Avoid stress 35 30 35 46 46

Have enough rest 32 31 33 34 62

Stay in a clean environment 29 23 30 41 38

Deliver in a recommended health facility 30 24 33 37 46

Delivery plan 25 18 28 35 46

Prepare the home for the new baby 26 21 29 33 23

Prepare older siblings to accept the baby 16 11 19 23 46

No responses 1 1 1 1 0


table 57: What mothers should do after birth to ensure a child is healthy

What things should mothers do to ensure that a child is healthy after birth?




Total (N) 2,000 951 667 369 13

Immunizing the baby against vaccine preventable diseases

76 78 75 75 46

Breastfeeding the baby within the first hour of delivery 42 39 47 40 69

Keeping the baby warm by not bathing the baby immediately

30 28 34 28 38

Keeping the baby warm using the mothers’ chest 23 21 21 27 31

Keeping the baby warm with appropriate clothes 28 25 29 37 38

Registration of the baby 36 29 41 48 23

Go for postnatal visit for review of mother and baby 24 19 27 31 62

Clean cord care 21 17 24 26 15

Breastfeeding exclusively for 6 months 37 31 41 46 69

Both mother and child sleeping under the mosquito net 34 31 32 45 46

Hand washing with soap 31 26 34 37 46

Keeping the child in a clean environment 26 23 30 30 23

Growth monitoring 24 22 23 29 85

Vitamin A supplementation 36 34 37 42 31

Prompt health care seeking in case of illness 23 17 27 33 23

Adherence to prescribed medication 21 14 26 28 31

Proper eating by the breastfeeding mother 25 22 26 30 38

Proper feeding for the child 25 20 26 31 69

Take child for circumcision 10 5 14 1% 23


table 58: Where respondents went for Anc

For your index child where did you go for antenatal care?




Total (N) 2,000 951 667 369 13

At home with visiting doctor, nurse or midwife 13 12 14 16 0

Health centre in the district 82 85 79 79 85

Main hospital in the district 48 42 52 55 77

At the clinic in the village 29 24 30 38 54

At community health workers’ home 20 22 18 18 15

Did not take any ANC services 1 1 1 1 0


75AnnEX 1: tABlEs

table 59: Where a pregnant woman should go for Anc

Where should a pregnant woman go for health care?




Total (N) 2,000 951 667 369 13






Did not take any ANC services 2 2 3 2 0


table 60: how many times should a pregnant woman go for Anc?

How many times should a pregnant woman go for ANC?

Economic category

Total Poor Lower-middle Upper-middle Upper

How many times should a pregnant woman go for ANC? 4 4 4 4 4

table 61: Where respondents delivered their index child

Where did you deliver your index child?




Total (N) 2,000 951 667 369 13








Annex 2: compArAtIve AnAlysIs oF the

rwAndAn kAp to the kAp oF other countrIes

© U

NIC

EF R

wan

da 2

013/

Mug

abe

Below are some of the central findings of the Rwandan KAP are compared to KAP results from other countries.

Child care from pre-birth to delivery: The Rwandan KAP found that caregivers’ knowledge of some pre-birth aspects is low. Similarly, a 2013 Health and Nutrition

KAP conducted in rural Kenya among pregnant women attending and not-attending ANC clinics highlighted that substantial opportunities exist for antenatal KAP improvement among women in rural Kenya, some of which they believed could occur with greater ANC attendance.35

Management of childhood illnesses: The Rwandan KAP demonstrated that generally knowledge and attitude towards treating sick children is high among the caregivers, with the majority seeking self-medication when a child falls sick by administering medicine at home (61 per cent), going to the nearest health facility (29 per cent) and buying drugs at the nearest facility. A 2010 KAP study about malaria and its control in rural northwest Tanzania, demonstrated that health facilities were the first option for malaria treatment (47 per cent) rather than administering medicine at home.36 Another study on caretaker’s perceptions, attitudes and practices regarding childhood illnesses in western Tanzania demonstrated that a health facility was the first point of care for childhood malaria for the majority of the respondents (73 per cent).37 Likewise, a KAP of mothers on symptoms and sign of integrated management of childhood illnesses (IMCI) strategy conducted in child health clinics in Dar es Salaam in Tanzania showed that 98 per cent of mothers took their children to health facilities once sick.38 However, these results need to be interpreted with extreme caution as the KAP was conducted at a health clinic in an urban setting.

Feeding: Exclusive breastfeeding trends vary greatly in sub-Saharan countries. For example, breastfeeding is near universal in Zambia while only 37 per cent of infants under 6 months are exclusively breastfed in Mozambique. At the same time, several studies have found commonalities regarding breastfeeding KAP among sub-Saharan countries.39 The findings from the Rwandan KAP indicate respondents are aware of good feeding practices that enable the proper development of children. Over 90 per cent of the respondents who have children 0

35 Perumal, nandita, et al., ‘health and nutrition Knowledge, Attitudes and Practices of Pregnant Women Attending and not-Attending Anc clinics in Western Kenya: A cross sectional analysis’, BMC Pregnancy & Childbirth, vol. 13, no. 1, pp. 146–158, also available at <www.ncbi.nlm.nih.gov/pmc/articles/Pmc3716969/>.

36 mazigo, humphrey, et al., ‘Knowledge, Attitudes, and Practices about malaria and its control in Rural northwest tanzania’, Malaria Research and Treatment, vol. 2010, pp. 9, also available at <www.hindawi.com/journals/mrt/2010/794261/>.

37 Kaatano, godfrey, A.i.s. muro and m. medard, ‘caretaker’s Perceptions, Attitudes and Practices Regarding childhood Febrile illness and Diarrhoeal Diseases among Riparian communities of lake Victoria, tanzania’, Tanzania Health Research Bulletin, vol. 8, no. 3, 2006, pp. 155–161, also available at <www.bioline.org.br/request?rb06029>.

38 Juma, Athumani, ‘Knowledge, Attitudes and Practices of mothers on symptoms and signs of integrated management of childhood illnesses (imci) strategy at Buguruni Reproductive and child health clinics in Dar es salaam’, Tanzania Medical Students’ Association, 2007/08, also available at <www.ajol.info/index.php/dmsj/article/viewFile/49589/35917>.

39 magawa, Rita, ‘Knowledge, Attitudes and Practices Regarding Exclusive Breastfeeding in southern Africa – Part 1’, consultancy Africa intelligence, 3 December 2012, also available at <www.consultancyafrica.com/index.php?option=com_content&view=article&id=1181:knowledge-attitudes-and-practices-regarding-exclusive-breastfeeding-in-southern-africa-part-1&catid=61:hiv-aids-discussion-papers&itemid=268>.

77AnnEX 2: cOmPARAtiVE AnAlysis OF thE RWAnDAn KAP tO thE KAP OF OthER cOuntRiEs

to 6 months old exclusively breastfeed them, and the practice of introducing complementary foods at the right age (6 months) is higher than the knowledge. On the other hand, a cross-sectional study of the prevalence and predictors of exclusive breastfeeding among women in a western region in Tanzania, demonstrated that knowledge of early breastfeeding was higher (86 per cent) than practice (58 per cent). A multivariate analysis in the same study demonstrated that women with adequate knowledge of exclusive breastfeeding and women who delivered at health facilities were more likely to exclusively breastfeed compared to others.40 A KAP survey on water, sanitation, hygiene and nutrition in seven states of southern Sudan demonstrated both low knowledge and practice of exclusive breastfeeding.41

Several KAP studies in sub-Saharan Africa have demonstrated the importance of family members in child care and infant feeding. For example, a KAP in Malawi highlighted the influence of grandmothers with regard to decisions on introducing premature complementary feeding. Grandmothers’ and fathers’ lack of information on and support for exclusive breastfeeding have been reported as a significant barrier to the continuation of breastfeeding.42 Likewise, a 2007 Somali KAP study of infant and young child feeding and health-seeking practice found that KAP on breastfeeding are mainly controlled by culture through maternal grandmothers and other elderly women in the community, and are generally unsatisfactory.43

Hygiene and sanitation: Despite the Rwandan KAP recording high awareness of the importance of maintaining proper hygiene and hygiene practices, it recorded low levels of actual practice of these activities. For example, 100 per cent of the respondents were aware of the importance of washing hands with soap before feeding a child or preparing food, but only 28 per cent practised this.

Likewise, a study conducted in several sub-Saharan African countries (i.e. Kenya, Senegal, Tanzania, and Uganda) reported that only 17 per cent of participants washed their hands with soap after using the toilet.44 Similarly, a KAP survey on water, sanitation, hygiene and nutrition in southern Sudan demonstrated that hand washing with soap before eating, after defecating and before preparing food was generally practised by a small fraction of the community. The low rate of hand washing was attributed to low awareness of the oral-faecal contamination chain.45

Communication and sources of information: This KAP demonstrated that the radio is the most common source of information on child care and what is happening in the community, especially within poor households and households in the middle economic category. Likewise, radio is an important source of information in many other sub-Saharan African countries. For example, a study on information and socioeconomic factors associated with early breastfeeding practices in rural and urban settings in Tanzania demonstrated that ownership of a radio was positively associated with exclusive and predominant breastfeeding in the rural area.46

40 nkala, tiras E. and sia E. msuya, ‘Prevalence and Predictors of Exclusive Breastfeeding among Women in Kigoma Region, Western tanzania: A community based cross-sectional study, International Breastfeeding Journal, vol. 6, no. 17, pp. 7, 9 november 2011, also available at <www.internationalbreastfeedingjournal.com/content/6/1/17>.

41 Knowledge, Attitudes and Practices (KAP) Survey on Water, Sanitation, Hygiene and Nutrition in 7 States of Southern Sudan: Final Report, Juba, April 2010, unicEF WEs & health and nutrition sections, southern sudan, also available at <www.bsf-south-sudan.org/sites/default/files/KAPstudyforssD_FinalReportApril2010.doc>.

42 Kerr, Rachel B., P.R. Berti and m. chirwa, ‘Breastfeeding and mixed Feeding Practices in malawi: timing, reasons, decision makers, and child health consequences’, Food and Nutrition Bulletin, vol. 28, no. 1, pp. 90–99, march 2007, also available at <www.ncbi.nlm.nih.gov/pubmed/17718016>.

43 Food security Analysis unit, somalia (FsAu), Somali Knowledge, Attitude and Practices Study (KAPS): Infant and young child feeding and health seeking practices, December 2007, also available at <http://ethnomed.org/clinical/pediatrics/somali_knowledge_attitude_practices_study_dec07.pdf>.

44 Vivas, Alyssa, et al., ‘Knowledge, Attitudes, and Practices (KAP) of hygiene among school children in Angolela, Ethiopia’, Journal of Preventive Medicine and Hygiene, vol. 51, no. 2, pp. 73–79, also available at <www.ncbi.nlm.nih.gov/pmc/articles/Pmc3075961>.

45 Knowledge, Attitudes and Practices (KAP) Survey on Water, Sanitation, Hygiene and Nutrition in 7 States of Southern Sudan: Final Report, Juba, April 2010, unicEF WEs & health and nutrition sections, southern sudan, also available at <www.bsf-south-sudan.org/sites/default/files/KAPstudyforssD_FinalReportApril2010.doc>.

46 shirima, Restituta, mehari gebre-medhin and ted greiner, ‘information and socioeconomic Factors Associated with Early Breastfeeding Practices in Rural and urban morogoro, tanzania’, Acta Paediatrica, vol. 90, no. 8, pp. 936–942, also available at <www.ncbi.nlm.nih.gov/pubmed/11529546>.


Annex 3: selected IndIcAtors,

dIsAggregAted by dIstrIct

lIst oF tAbles

TABLE 1: Groups of people most affected by health problems in the community ..................79TABLE 2: Actions taken by respondents to immediately respond to and treat illnesses

in their children ................................................................................................................79TABLE 3: What should people in the community do to maintain proper hygiene? .............. 80TABLE 4: Which hygiene practices are commonly practiced by people in this

community? ......................................................................................................................81TABLE 5: Foods given to children before breakfast .....................................................................82TABLE 6: Foods given to children for lunch? ................................................................................83TABLE 7: The role of a father development of 0–2 year old children .........................................85TABLE 8: The role of a father development of 2–6 year old children ....................................... 86TABLE 9: How often caregivers have had to leave children in the care of another person ....87TABLE 10: Sources of information to find out about what is happening in your

community ........................................................................................................................87TABLE 11: Most trusted source of information about what is happening in your

community ........................................................................................................................ 88TABLE 12: Sources of information to find out about what child care .........................................89TABLE 13: Most trusted source of information about child care ................................................ 90

Select data segregation by district criteria:1. Groups of people most affected by health problems in the community2. Actions taken by respondents to immediately respond to and treat illnesses

in their children3. Hygiene knowledge vs. practice absolutes4. Foods given to children before breakfast5. Foods given to children for lunch6. Foods regularly given to children 7–11 months old7. Importance of a father’s role in the development of their child8. How often caregivers have had to leave the child in the care of another person9. Sources of information

79AnnEX 3: sElEctED inDicAtORs, DisAggREgAtED By DistRict

tab

le 1

: gro

up

s o

f p

eo

ple

mo

st a

ffe

cte

d b

y h

ea

lth p

rob

lem

s in

th

e c

om

mu

nit

y

Dis

trict

Tota

lN

yaru

geng

eG

asab

oN

yam

agab

eRu

hang

oKa

mon

yiRu

bavu

Ngo

rore

roN

yam

ashe

keRu

lindo

Gak

enke

Gic

umbi

Rwam

agan

aKa

yonz

aN

gom

aBu

gese

ra

Tota

l20

0016

916

813

312

513

512

512

712

712

612

412

611

313

113

813

3

Child

ren

0 –

6 M

onth

s28

%33

%35

%47

%21

%24

%21

%9%

17%

8%33

%47

%37

%35

%28

%17

%

Child

ren

7 M

onth

s –

2 Ye

ars

44%

44%

35%

51%

30%

46%

54%

46%

59%

20%

48%

53%

47%

40%

43%

49%

Child

ren

3–6

year

s37

%34

%24

%41

%36

%31

%32

%49

%23

%39

%46

%46

%32

%47

%39

%39

%

Scho

ol g

oing

chi

ldre

n (7

– 1

8 ye

ars)

5%3%

0%12

%5%

4%4%

5%2%

4%9%

3%5%

8%4%

8%

Elde

rly p

eopl

e6%

6%4%

14%

7%7%

1%6%

6%3%

6%2%

9%5%

7%8%

Dis

able

d pe

ople

1%1%

0%3%

2%1%

1%2%

0%0%

1%1%

0%1%

1%0%

Ever

yone

39%

32%

39%

21%

41%

47%

28%

45%

61%

56%

48%

33%

25%

37%

41%

28%

tab

le 2

: Ac

tion

s ta

ken

by

resp

on

de

nts

to

imm

ed

iate

ly re

spo

nd

to

an

d t

rea

t ill

ne

sse

s in

th

eir

ch

ildre

n

Dis

trict

Tota

lN

yaru

geng

eG

asab

oN

yam

agab

eRu

hang

oKa

mon

yiRu

bavu

Ngo

rore

roN

yam

ashe

keRu

lindo

Gak

enke

Gic

umbi

Rwam

agan

aKa

yonz

aN

gom

aBu

gese

ra

Tota

l37

121

2447

1626

1461

825

109

2529

2333

Gav

e O

RS18

%5%

4%79

%13

%0%

0%5%

0%0%

10%

11%

20%

31%

17%

9%

Gav

e Zi

nc10

%0%

8%30

%0%

12%

7%5%

0%8%

30%

0%12

%7%

13%

3%

Gav

e so

me

med

icin

e th

at I

had

in th

e ho

use

61%

67%

88%

85%

75%

46%

57%

54%

50%

4%60

%11

%56

%69

%74

%73

%

Gav

e th

e ch

ild p

lent

y of

flui

ds7%

10%

8%15

%13

%4%

21%

2%13

%4%

10%

11%

8%0%

9%0%

Cont

inue

d br

east

feed

ing

10%

0%4%

47%

0%0%

0%2%

0%0%

0%11

%12

%21

%9%

0%

Gav

e he

rbal

med

icin

e11

%0%

0%30

%19

%4%

0%8%

0%8%

10%

11%

16%

14%

9%9%

Soug

ht th

e se

rvic

es o

f a

com

mun

ity H

ealth

wor

ker

12%

0%0%

36%

25%

8%0%

2%0%

12%

30%

11%

20%

14%

13%

0%

Took

the

child

to th

e ne

ares

t he

alth

faci

lity

29%

19%

17%

32%

13%

50%

29%

21%

25%

92%

20%

33%

20%

31%

30%

0%

Soug

ht th

e se

rvic

es o

f a

tradi

tiona

l her

balis

t13

%0%

0%40

%6%

4%0%

2%0%

40%

0%22

%32

%3%

13%

6%

Tepi

d sp

ongi

ng7%

0%0%

28%

0%0%

0%2%

13%

4%10

%22

%8%

3%17

%0%

Boug

ht m

edic

ine

from

a d

rug

shop

18%

14%

13%

51%

13%

8%14

%10

%25

%8%

0%0%

16%

28%

13%

21%

Pray

ed fo

r the

chi

ld5%

0%0%

28%

0%0%

7%0%

0%0%

0%0%

12%

3%0%

3%


tab

le 3

: Wh

at

sho

uld

pe

op

le in

th

e c

om

mu

nit

y d

o t

o m

ain

tain

pro

pe

r hyg

ien

e?

Dis

trict

Tot

al

Nya

ruge

nge

Gas

abo

Nya

mag

abe

Ruha

ngo

Kam

onyi

Ruba

vuN

goro

rero

Nya

mas

heke

Rulin

doG

aken

keG

icum

biRw

amag

ana

Kayo

nza

Ngo

ma

Buge

sera

Tota

l20

0016

916

813

312

513

512

512

712

712

612

412

611

313

113

813

3

Was

hing

han

ds w

ith s

oap

befo

re

feed

ing

a ch

ild o

r pre

parin

g 10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%10

0%

Was

hing

han

ds w

ith s

oap

afte

r us

ing

a la

trine

64

%67

%72

%56

%77

%73

%50

%72

%73

%59

%39

%62

%58

%68

%61

%70

%

Each

hou

seho

ld m

ust h

ave

a la

trine

67

%77

%78

%46

%65

%71

%42

%64

%78

%52

%70

%74

%65

%66

%78

%69

%

Clea

ning

the

latri

nes

ever

y da

y 61

%69

%72

%59

%65

%63

%43

%90

%74

%39

%56

%46

%51

%56

%61

%67

%

Keep

ing

wat

er a

nd s

oap

for

was

hing

han

ds a

t the

latri

ne a

re46

%49

%57

%49

%54

%53

%28

%65

%42

%40

%20

%30

%40

%53

%48

%48

%

Clea

ring

bush

es a

roun

d th

e ho

me

50%

61%

67%

47%

31%

57%

42%

45%

51%

52%

45%

44%

47%

50%

54%

52%

Avoi

ding

sta

gnan

t wat

er a

roun

d th

e ho

me

50%

53%

61%

51%

50%

51%

42%

45%

61%

53%

42%

44%

43%

53%

57%

41%

Bath

ing

at le

ast 2

to 3

tim

es

a da

y 33

%48

%55

%50

%31

%39

%21

%29

%33

%10

%12

%27

%26

%40

%34

%30

%

Keep

ing

the

child

ren’

s cl

othe

s cl

ean

40

%44

%55

%41

%46

%36

%35

%43

%24

%33

%27

%24

%35

%42

%43

%55

%

Keep

ing

uten

sils

cle

an

30%

40%

37%

40%

26%

38%

22%

33%

30%

17%

23%

25%

26%

29%

33%

20%

Dis

posi

ng o

f chi

ldre

n’s

faec

es in

th

e la

trine

34

%36

%45

%47

%32

%36

%30

%38

%39

%29

%26

%14

%33

%37

%41

%30

%

Hav

ing

a ra

ck fo

r ute

nsils

in

arou

nd th

e ho

me

23%

31%

42%

34%

18%

26%

26%

31%

19%

16%

14%

6%14

%21

%21

%13

%


tab

le 4

: Wh

ich

hyg

ien

e p

rac

tice

s a

re c

om

mo

nly

pra

cti

sed

by

pe

op

le in

th

is c

om

mu

nit

y?

Dis

trict

Tot

al

Nya

ruge

nge

Gas

abo

Nya

mag

abe

Ruha

ngo

Kam

onyi

Ruba

vuN

goro

rero

Nya

mas

heke

Rulin

doG

aken

keG

icum

biRw

amag

ana

Kayo

nza

Ngo

ma

Buge

sera

Tota

l 20

0016

916

813

312

513

512

512

712

712

612

412

611

313

113

813

3

Was

hing

han

ds w

ith s

oap

befo

re

feed

ing

a ch

ild o

r pre

parin

g 28

%50

%42

%20

%29

%27

%26

%19

%21

%19

%13

%28

%19

%22

%43

%35

%

Was

hing

han

ds w

ith s

oap

afte

r us

ing

a la

trine

46

%54

%64

%59

%31

%49

%77

%56

%27

%40

%22

%24

%32

%44

%57

%44

%

Each

hou

seho

ld m

ust h

ave

a la

trine

54

%59

%75

%36

%48

%54

%27

%38

%60

%50

%73

%58

%52

%51

%57

%61

%

Clea

ning

the

latri

nes

ever

y da

y 33

%49

%47

%41

%21

%33

%32

%30

%30

%15

%17

%25

%27

%31

%48

%40

%

Keep

ing

wat

er a

nd s

oap

for

was

hing

han

ds a

t the

latri

ne a

re31

%37

%38

%35

%26

%33

%52

%28

%24

%21

%22

%20

%30

%27

%31

%32

%

Clea

ring

bush

es a

roun

d th

e ho

me

38%

44%

42%

40%

16%

45%

25%

32%

30%

43%

64%

29%

33%

35%

43%

47%

Avoi

ding

sta

gnan

t wat

er a

roun

d th

e ho

me

34%

31%

50%

35%

26%

33%

21%

25%

32%

42%

28%

30%

34%

37%

43%

36%

Bath

ing

at le

ast 2

to 3

tim

es

a da

y 22

%38

%29

%33

%15

%24

%34

%7%

11%

9%11

%13

%15

%27

%35

%15

%

Keep

ing

the

child

ren’

s cl

othe

s cl

ean

26

%38

%32

%28

%28

%24

%18

%28

%20

%11

%15

%17

%24

%24

%36

%36

%

Keep

ing

uten

sils

cle

an

23%

31%

30%

34%

11%

24%

58%

21%

20%

10%

15%

13%

13%

20%

26%

16%

Dis

posi

ng o

f chi

ldre

n’s

faec

es in

th

e la

trine

27

%37

%38

%32

%7%

24%

49%

24%

31%

25%

22%

6%19

%27

%35

%29

%

Hav

ing

a ra

ck fo

r ute

nsils

in

arou

nd th

e ho

me

13%

21%

20%

23%

2%16

%14

%21

%7%

7%8%

2%8%

11%

22%

8%

No

resp

onse

1%

0%3%

2%2%

3%1%

1%0%

1%0%

0%0%

0%1%

1%


tab

le 5

: Fo

od

s g

ive

n t

o c

hild

ren

be

fore

bre

akf

ast

Dis

trict

Tota

lN

yaru

geng

eG

asab

oN

yam

agab

eRu

hang

oKa

mon

yiRu

bavu

Ngo

rore

roN

yam

ashe

keRu

lindo

Gak

enke

Gic

umbi

Rwam

agan

aKa

yonz

aN

gom

aBu

gese

ra

Tota

l58

983

7724

5739

5620

3724

2817

2931

2443

Porr

idge

11%

2%3%

17%

4%18

%0%

25%

27%

13%

32%

6%21

%3%

8%23

%

Pota

toes

or I

rish

8%7%

12%

25%

7%3%

7%0%

8%4%

0%6%

3%6%

13%

12%

Milk

37%

39%

40%

50%

54%

46%

25%

15%

8%4%

18%

47%

48%

55%

46%

44%

Rice

3%2%

0%0%

4%3%

11%

5%5%

0%11

%0%

3%0%

0%0%

Wat

er5%

7%0%

0%9%

3%23

%0%

0%4%

0%6%

3%0%

0%2%

Spag

hetti

0%0%

0%0%

0%0%

0%0%

0%0%

4%0%

0%0%

4%0%

Frui

ts12

%6%

8%21

%9%

8%0%

5%19

%13

%7%

18%

17%

19%

25%

26%

Vege

tabl

es2%

0%4%

8%0%

5%0%

0%3%

4%0%

0%3%

3%0%

0%

Brea

st m

ilk21

%16

%23

%0%

23%

31%

9%60

%11

%58

%21

%29

%17

%23

%29

%2%

Dry

tea

2%4%

3%0%

0%0%

0%5%

0%0%

0%0%

7%0%

0%7%

Bana

nas

5%1%

3%4%

5%5%

4%5%

8%4%

11%

18%

3%6%

0%5%

Chip

s1%

7%0%

0%0%

0%0%

0%0%

0%0%

0%0%

0%0%

0%

Bean

s or

soy

a be

ans

1%0%

0%0%

0%3%

0%0%

3%4%

7%0%

0%0%

0%2%

Juic

e6%

14%

4%0%

5%3%

13%

0%5%

8%7%

12%

3%0%

0%2%

Fish

0%0%

0%0%

2%0%

0%0%

0%0%

0%0%

0%0%

0%0%

Mea

t1%

2%1%

0%2%

0%0%

0%3%

0%0%

0%3%

0%0%

0%

Eggs

2%2%

12%

0%0%

0%2%

0%0%

0%0%

0%0%

0%0%

0%

Brea

d1%

0%0%

0%4%

0%0%

0%8%

0%0%

0%0%

3%0%

5%

Potta

ge1%

1%1%

4%0%

0%0%

0%0%

0%0%

0%0%

3%0%

0%

Bisc

uits

2%5%

3%0%

0%0%

5%0%

0%0%

0%0%

0%0%

4%7%

Yogu

rt0%

0%3%

0%0%

0%0%

0%0%

0%0%

0%0%

0%0%

0%

Oth

er6%

4%8%

0%7%

3%8%

0%3%

8%15

%13

%9%

4%0%


tab

le 6

: Fo

od

s g

ive

n t

o c

hild

ren

fo

r lu

nc

h?

Dis

trict

Tota

lN

yaru

geng

eG

asab

oN

yam

agab

eRu

hang

oKa

mon

yiRu

bavu

Ngo

rore

roN

yam

ashe

keRu

lindo

Gak

enke

Gic

umbi

Rwam

agan

aKa

yonz

aN

gom

aBu

gese

ra

Tota

l15

4414

313

089

103

104

9912

079

105

8911

689

9876

104

Porr

idge

4%1%

7%0%

1%8%

5%3%

5%6%

7%3%

7%3%

0%2%

Pota

toes

or I

rish

29%

13%

18%

45%

24%

14%

10%

38%

35%

8%25

%55

%42

%30

%37

%51

%

Milk

4%5%

5%1%

8%3%

5%5%

9%4%

4%0%

4%2%

8%3%

Rice

16%

23%

19%

24%

20%

12%

42%

3%3%

14%

13%

13%

19%

16%

7%7%

Wat

er0%

0%0%

0%0%

1%0%

1%0%

0%0%

0%0%

0%0%

0%

Spag

hetti

1%1%

4%0%

0%3%

8%0%

0%0%

3%0%

0%0%

3%0%

Frui

ts2%

1%1%

1%7%

1%0%

1%4%

3%11

%2%

4%1%

3%0%

Vege

tabl

es3%

2%3%

2%1%

5%0%

8%0%

6%4%

3%6%

1%4%

2%

Brea

st m

ilk4%

3%5%

0%3%

7%1%

1%5%

12%

3%5%

4%6%

5%1%

Bana

nas

17%

7%14

%36

%10

%17

%6%

8%13

%10

%37

%41

%16

%18

%20

%8%

Chip

s1%

3%2%

0%0%

0%0%

0%0%

0%0%

1%1%

0%0%

0%

Bean

s or

soy

a be

ans

2%1%

0%0%

3%0%

1%2%

4%1%

3%4%

3%2%

4%5%

Juic

e1%

1%0%

0%0%

1%1%

2%1%

0%0%

0%0%

1%1%

0%

Cass

ava

or c

assa

va b

read

3%2%

0%0%

1%2%

4%3%

0%5%

6%9%

8%1%

5%7%

Fish

1%1%

2%1%

1%3%

0%2%

0%1%

0%0%

0%0%

0%0%

Mea

t2%

4%6%

0%5%

0%1%

1%6%

0%2%

0%0%

1%0%

1%

Eggs

1%0%

0%2%

0%1%

1%0%

4%0%

0%1%

1%0%

0%0%

Brea

d0%

0%0%

1%0%

0%1%

0%4%

0%1%

0%0%

1%0%

0%

Posh

o1%

0%0%

1%1%

0%0%

2%0%

0%2%

0%1%

2%1%

13%

Mai

ze0%

0%0%

0%0%

1%0%

1%0%

0%0%

1%1%

0%0%

0%

Bisc

uits

1%0%

0%6%

3%0%

2%0%

1%2%

0%0%

1%0%

0%0%

Gro

undn

uts

and

peas

0%1%

0%0%

2%0%

0%1%

0%0%

0%2%

0%1%

1%0%

Yogu

rt0%

0%1%

1%0%

0%0%

0%0%

1%0%

0%2%

0%0%

0%

Cere

lac

1%10

%0%

0%1%

0%1%

1%0%

0%0%

0%0%

0%0%

0%

All f

oods

18%

10%

15%

2%23

%18

%10

%28

%16

%45

%9%

9%16

%21

%17

%27

%

Milk

and

bre

ast m

ilk0%

0%0%

0%0%

1%0%

1%0%

0%0%

0%0%

0%0%

0%

Eggs

and

pot

atoe

s0%

0%0%

0%0%

0%0%

0%0%

1%0%

0%1%

0%0%

0%

Milk

and

frui

ts0%

1%0%

0%0%

0%0%

0%0%

0%0%

0%1%

0%0%

0%

Bana

nas

and

bean

s2%

1%2%

0%1%

3%0%

0%3%

0%11

%7%

1%3%

4%0%

Yam

0%0%

0%0%

0%0%

0%0%

0%1%

0%0%

0%0%

0%0%

Rice

and

bea

ns5%

3%12

%3%

4%11

%7%

6%5%

6%0%

1%0%

6%3%

4%

Porr

idge

and

milk

0%0%

0%0%

0%0%

0%0%

0%1%

1%0%

0%0%

0%0%

Bana

nas

and

vege

tabl

es2%

3%3%

0%2%

4%0%

0%1%

0%1%

1%0%

2%0%

4%


Dis

trict

Tota

lN

yaru

geng

eG

asab

oN

yam

agab

eRu

hang

oKa

mon

yiRu

bavu

Ngo

rore

roN

yam

ashe

keRu

lindo

Gak

enke

Gic

umbi

Rwam

agan

aKa

yonz

aN

gom

aBu

gese

ra

Tota

l15

4414

313

089

103

104

9912

079

105

8911

689

9876

104

Rice

and

pot

atoe

s1%

3%1%

1%0%

0%3%

0%0%

0%0%

0%0%

0%0%

0%

Rice

and

ban

ana

0%1%

0%1%

0%0%

0%0%

0%0%

0%0%

1%0%

0%1%

Pota

toes

and

bea

ns6%

1%3%

4%5%

16%

0%15

%3%

6%2%

6%6%

10%

8%11

%

Brea

st m

ilk a

nd fr

uits

0%0%

0%0%

0%0%

0%1%

1%1%

0%0%

0%1%

0%0%

Brea

d an

d ve

geta

bles

0%0%

0%0%

0%0%

0%0%

0%1%

1%0%

0%2%

0%1%

Cass

ava

brea

d an

d ve

geta

ble

1%0%

1%0%

1%1%

1%0%

0%3%

0%0%

0%2%

3%3%

Milk

and

bre

ad0%

0%0%

0%0%

1%0%

1%0%

0%0%

0%0%

0%0%

0%

Rice

and

pea

s1%

1%3%

0%1%

1%0%

1%0%

0%0%

0%0%

0%0%

3%

Carr

ots

0%0%

0%0%

0%0%

0%0%

0%0%

1%0%

0%0%

0%0%

Umam

ahor

o0%

0%0%

0%1%

0%0%

2%0%

0%0%

0%0%

0%0%

0%

Umum

ece

0%0%

0%0%

0%1%

0%0%

0%0%

0%0%

0%0%

0%1%

Pota

toes

and

veg

etab

les

3%9%

2%1%

2%8%

0%5%

1%0%

2%1%

0%2%

1%0%

Cass

ava

and

bean

s1%

0%0%

0%3%

0%0%

2%1%

0%0%

3%0%

5%1%

2%

Rice

and

veg

etab

les

2%7%

0%6%

1%0%

3%0%

0%1%

1%1%

0%2%

4%0%

Rice

and

mea

t2%

2%3%

3%1%

0%10

%0%

0%2%

4%1%

4%5%

0%0%

Oth

er5%

3%0%

3%2%

1%4%

1%0%

0%0%

1%3%

0%0%


tab

le 7

: th

e ro

le o

f a

fa

the

r de

velo

pm

en

t o

f 0

-2 y

ea

r old

ch

ildre

n

D

istri

ct

Nya

ruge

nge

Gas

abo

Nya

mag

abe

Ruha

ngo

Kam

onyi

Ruba

vuN

goro

rero

Nya

mas

heke

Rulin

doG

aken

keRw

amag

ana

Kayo

nza

Ngo

ma

Buge

sera

Atte

ndin

g an

te-n

atal

car

e se

ssio

ns

Valid

N

850

7710

444

625

4656

3859

8385

6957

65

Mea

n 3.

94.

44.

44.

53.

74.

42.

14.

54.

34.

62.

53.

73.

73.

94.

0

Perc

enta

ge

Scor

e77

%87

%89

%90

%74

%88

%43

%89

%86

%91

%51

%75

%73

%78

%79

%

Sho

w lo

ve a

nd a

ffect

ion

to th

e ch

ild a

nd p

lay

with

it

Valid

N

858

7910

644

695

4754

4059

8182

6362

67

Mea

n 4.

54.

84.

84.

63.

95.

04.

94.

74.

24.

73.

94.

54.

34.

54.

3

Perc

enta

ge

Scor

e89

%96

%95

%92

%78

%10

0%97

%94

%85

%95

%77

%90

%86

%91

%87

%

Tal

k to

the

child

, tel

l sto

ries

Valid

N

844

8010

343

655

4854

3454

8284

7154

67

Mea

n 4.

34.

74.

64.

53.

95.

04.

74.

44.

64.

83.

54.

24.

14.

13.

9

Perc

enta

ge

Scor

e85

%94

%91

%90

%78

%10

0%95

%89

%91

%96

%69

%83

%81

%81

%78

%

Hel

p m

othe

r or c

aret

aker

in c

hild

ca

re d

utie

s (e

.g. b

athi

ng, d

iape

r ch

angi

ng, g

ettin

g dr

esse

d)

Valid

N

843

7510

744

665

4553

3754

8181

7157

67

Mea

n 4.

34.

34.

64.

84.

04.

44.

34.

24.

54.

44.

14.

34.

34.

54.

0

Perc

enta

ge

Scor

e86

%85

%91

%97

%81

%88

%86

%83

%89

%88

%83

%86

%86

%90

%80

%

Prov

ide

for d

ay-to

-day

ne

cess

ities

suc

h as

soa

p, fo

od,

clot

hes

Valid

N

817

7510

343

595

4451

3553

8380

6951

66

Mea

n 4.

54.

44.

74.

84.

44.

84.

44.

44.

74.

64.

74.

24.

44.

54.

6

Perc

enta

ge

Scor

e90

%88

%94

%97

%87

%96

%88

%88

%94

%93

%93

%84

%88

%89

%92

%

Buyi

ng to

ys

Valid

N

814

7310

542

625

4752

3650

7578

6757

65

Mea

n 4.

04.

14.

44.

34.

14.

24.

94.

23.

84.

12.

54.

03.

94.

23.

7

Perc

enta

ge

Scor

e80

%82

%89

%86

%82

%84

%97

%84

%77

%81

%50

%81

%79

%85

%74

%


tab

le 8

: th

e ro

le o

f a

fa

the

r de

velo

pm

en

t o

f 2-

6 ye

ar o

ld c

hild

ren

D

istri

ct

Nya

ruge

nge

Gas

abo

Nya

mag

abe

Ruha

ngo

Kam

onyi

Ruba

vuN

goro

rero

Nya

mas

heke

Rulin

doG

aken

keRw

amag

ana

Kayo

nza

Ngo

ma

Buge

sera

Prov

idin

g th

ings

the

child

nee

ds

– fo

od, c

loth

es, p

ayin

g fe

es

Valid

N

875

7198

4863

642

5131

5088

8585

8077

Mea

n 4.

54.

44.

64.

33.

74.

84.

44.

64.

54.

94.

94.

54.

34.

64.

7

Perc

enta

ge

Scor

e90

%89

%92

%86

%75

%97

%88

%93

%90

%98

%97

%89

%87

%93

%94

%

Dis

cipl

inin

g ch

ild

Valid

N

900

7910

449

626

4347

3153

8692

8090

78

Mea

n 4.

54.

64.

54.

34.

25.

04.

74.

84.

54.

94.

24.

44.

44.

64.

7

Perc

enta

ge

Scor

e90

%92

%91

%86

%83

%10

0%95

%95

%89

%98

%83

%89

%88

%93

%94

%

Show

ing

the

child

the

envi

ronm

ent (

thin

g in

and

ou

tsid

e th

e ho

me)

Valid

N

860

7510

043

596

4045

2749

8686

8185

78

Mea

n 4.

04.

34.

24.

34.

34.

74.

74.

63.

74.

62.

84.

14.

04.

03.

4

Perc

enta

ge

Scor

e80

%86

%83

%85

%86

%93

%95

%91

%74

%91

%55

%81

%80

%80

%67

%

Play

ing

with

chi

ld

Valid

N

878

7610

151

586

4152

2950

8689

8086

73

Mea

n 4.

04.

34.

44.

54.

44.

74.

94.

34.

04.

52.

44.

03.

94.

03.

6

Perc

enta

ge

Scor

e80

%86

%87

%90

%87

%93

%97

%86

%79

%91

%47

%80

%78

%79

%72

%

Teac

hing

the

child

to d

o di

ffere

nt

thin

gs

Valid

N

854

7198

4461

640

4630

5084

8380

8477

Mea

n 4.

44.

34.

44.

74.

44.

74.

94.

64.

54.

74.

24.

34.

44.

34.

5

Perc

enta

ge

Scor

e89

%86

%89

%95

%88

%93

%98

%92

%90

%94

%83

%87

%89

%86

%90

%

Taki

ng th

e ch

ild to

day

car

e or

nu

rser

y sc

hool

Va

lidN

82

268

9543

546

3647

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tab

le 1

2: s

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tab

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Documents

Knowledge, Attitudes & Practices