Scaling up home-visiting to promote early childhood development and prevent violence in Rwanda: a hybrid type-2 effectiveness-implementation trial

Background: Children in impoverished families-especially those affected by violence-face risks to healthy development. In the years of strong economic recovery since the 1994 Genocide Against the Tutsi, the Rwandan Government has invested in early child development, social and child protection and violence prevention, but few strategies for scaling evidence-based interventions (EBIs) in these areas have been studied. Methods: We present a Hybrid Type-2 Implementation-Effectiveness study of the PLAY Collaborative implementation strategy to engage government and other stakeholders in scaling Sugira Muryango (SM, "Strong Family") to families eligible for social protection in three rural districts. SM promotes nurturing care of children under three while reducing family violence. We assessed delivery quality (fidelity, competence) and perceptions of the PLAY Collaborative (e.g, feasibility, leadership, organisation, sustainability). An embedded trial of 538 households (778 caregivers, 555 children) tested SM effectiveness when delivered by child protection volunteers. Results: Child protection volunteers delivered SM with high fidelity and competence that improved with time and routine supervision. The PLAY Collaborative was rated moderately to highly across implementation outcomes. The embedded trial revealed improvements in children's stimulation at home (d = 0.20, 95% CI: 0.04-0.36) as caregivers involved them more in daily activities (d = 0.37, 95% CI: 0.18-0.57) and provided more learning materials (d = 0.37, 95% CI: 0.16-0.59). SM families increased stimulating care (e.g. singing, playing; d = 0.26, 95% CI: 0.07-0.46); involved fathers more in caregiving (IRR = 1.18, 95% CI: 1.03-1.37); reduced harsh discipline (OR = 0.34, 95% CI: 0.14-0.82); and increased dietary diversity (d = 0.25, 95% CI: 0.04-0.45). SM caregivers reported improved mental health (d = -0.13, 95% CI: -0.26 to -0.01). SM households increased safe water storage (OR = 3.14, 95% CI: 1.64-6.03) and water treatment (OR = 3.56, 95% CI: 1.80-7.05) practices. Conclusions: The PLAY Collaborative successfully overcame implementation barriers and maintained effectiveness across most outcomes while scaling delivery to N = 8,745 families, highlighting the value of systematically investigating implementation strategies while scaling an EBI as integrated into existing social and child protection systems.