Implementation evaluation of a nurturing care intervention in a humanitarian setting in Rwanda

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This study examines program implementation to understand delivery processes. Methods: We employed Proctor’s implementation outcomes, including measures of acceptability, fidelity, and quality of dose delivered. A customized questionnaire was administered post-intervention by trained research assistants, and qualitative interviews were conducted to explore the experiences of families, the delivery team, and community stakeholders. Additionally, program monitoring and documentation, such as monthly reports, were included in the analysis. Qualitative analysis followed a deductive approach. Findings: Implementation data from caregiver surveys indicated that the majority of families received 50% of the intended dosage for group sessions in both the high and low dose arms. Program records showed that over 90% of eligible caregivers attended the sessions, with families expressing a preference for the shared space and activities during the first half of the group sessions. However, in terms of home visits, more than half of the families had never received one. Qualittaive data revealed acceptability of the intervention and professional development opportunities through mentorshp as key to engagement of the delivery staff. Conclusion: Continuous monitoring and adaptation of delivery strategies are essential for improving early childhood development outcomes in humanitarian settings like Rwanda. nurturing care humanitarian setting implementation evaluation Figures Figure 1 Background In situations of adversity, such as forced migration and emergencies resulting from conflicts, early childhood experiences can be profoundly affected, placing an entire generation at risk [1]. To address these challenges, early childhood interventions grounded in the nurturing care framework [2] have emerged as a potential buffer against the detrimental impact on brain development and the subsequent developmental difficulties faced by children in such contexts [3-4]. Despite recognizing the urgent need for interventions to bolster the resilience of families and children in these settings, prioritizing their uptake has proven challenging [5]. A significant barrier has been the lack of evidence regarding the implementation of programs, specifically addressing the 'why' and 'how,' and the settings and contexts in which these interventions can be effective [6]. To support resilience building in early childhood within refugee settings, World Vision Rwanda (WVR) employed an innovative, evidence-based, child-focused parenting program designed to reach 3,000 caregivers with children under the age of 5 in underserved populations residing in camps and host communities, including the Mugombwa Congolese Refugee Camp and three nearby Sector Host Communities (Kansi, Kigembe, Mugombwa) [7]. In an attempt to contribute evidence of implementation research for nurturing care [8], the intervention was delivered in varying doses: high and low in both settings (host and camp). The high dose arm included 12 caregiver group sessions, with additional sessions for fathers if their participation in caregiver sessions was limited, along with a minimum of 4 home visits. The low dose arm comprised 4 caregiver group sessions, and a minimum of 2 home visits. It featured fewer in-person caregiver group sessions and placed more emphasis on targeted messaging to encourage behavioral and attitudinal change, supported by socially distanced home visits (a minimum of 2). All groups also received radio sessions. An evaluation of the program revealed notable improvements in caregiving practices in both the high and low dose arms compared to a control group. However, these changes did not result in significant enhancements in early childhood development (ECD) outcomes. The aim of the current study is to evaluate the implementation in high and low doses arms, uncovering valuable insights regarding the processes of program delivery. Through this evaluation, we aim to understand how the program was implemented, identify challenges faced, and discern the factors contributing to the observed changes in caregiving practices and their impact on ECD outcomes. Methods Population Rwanda, a tiny land area in East Africa, hosts more than 170,000 refugees in 6 camps scattered across the country (Fig. 1 ). The camps are home to Congolese and Burundian refugees. Renewed hostilities in the DRC in 2012–2013 and security issues following the Burundian election in 2015 have forced thousands to flee to Rwanda for safety. The conditions in Rwanda’s 6 refugee camps vary greatly. Some of those in the Gihembe refugee camp, for instance, have been refugees for more than 20 years whereas the more than 55,000 Burundian refugees in Mahama camp have only been refugees since 2015, when the camp was built ( https://www.kiva.org/blog/building-the-economy-within-rwandas-refugee-camps ). Rwanda hosted a total of 127,382 refugees and asylum seekers at the end of August 2021. The population of concern included mainly persons from the Democratic Republic of the Congo (61) [ 9 ]. Study setting The study setting included host and camps for both the intervention groups. The intervention group included host communities in cells that were selected in each of the three sectors namely Mugombwa, Kansi (high dose) and Kigembe (low dose). For camp setting, Mugombwa was considered in the intervention group. The Kigeme camp was established in 2012 and has a population of 17,000. The 61% of the population in Mugombwa resides in adequate dwelling compared to 42 in Kigeme [ 10 – 11 ]. Intervention model The Care and Comfort for Children (3C) intervention model aims to build knowledge, skills and resilience-promoting techniques to improve parenting practices at the household level. The 3C package is built on World Vision (WV) designed evidence-based parenting program approach called Go Baby Go (GBG) for young age children’s ECD. The curriculum, utilizing behavior change communication, appreciative inquiry and positive deviance approaches [ 12 ], was contextualized, and further enhanced to meet the developmental needs of 0–5 aged refugee children. A previous evaluation of Go Baby Go model in Armenia by World Vision (WV) Armenia demonstrated it to be effective for child developmental outcomes with pronounced benefits for the most vulnerable families [ 13 ]. The GBG model adaptation for 3C also included video segments from Sesame Workshop’s “I Elmo” and “WASH UP!” series, along with accompanying in-class activities and take-home activities”. The interventions were delivered from April 2021 to January 2022. The 3C reached out to 1500 caregivers with children under 5 age: 1000 caregiver residing in cap community, and 500 in refugee host communities. The 3C was delivered through two modalities: 12 contextualized group, skills-based learning sessions for primary caregivers , focused on enhancing nurturing care through sensitive and responsive parenting and play and communication. Individualized home-based visits seek to support caregivers and families by reaching the most vulnerable household and reinforcing learning and application through in-depth dialogue and mentorship. The 3Cs Community Facilitators (CFs) were selected from the camp and the host community. The recruitment process was supported by camp leaders and local leaders. Key criteria selection were to be trusted members of the community, comply with child and adult safeguarding policy and WV refuges setting specific policies and having secondary school certificate with good communication skills. The 3Cs mentors were selected among the CFs based on their performance and their ability to mentor others. The role of the mentors was largely to ensure the fidelity and quality of intervention through reflection meetings, supervision visits (mentors and Project Officers (POs) supporting 3CFs) and completing caregiver satisfaction checklists. Implementation features of both interventions have been described in Table 1 below. The dosage was significantly different between the two groups. Rest of the features were quite similar. Table 1 Important implementation features of the two interventions Feature of implementation High dose Low dose Content Group sessions • Structured curriculum based on the Go Baby Go and Learning Roots curriculum • Few take-away messages for practice • Low-cost material • Videos from Sesame Workshop with accompanying in-class activity and take-home activity • Radio messages • SMS messages • Structured curriculum based on the Go Baby Go and Learning Roots curriculum • Few take-away messages for practice • Low-cost material • Videos from Sesame Workshop with accompanying in-class activity and take-home activity • Radio messages • SMS messages Content Home visits • Structured curriculum based on the Go Baby Go curriculum • Few doable messages • Low-cost material • Structured curriculum based on the Go Baby Go curriculum • Few doable messages • Low-cost material Dosage delivery Intensity, frequency and duration • 12 group sessions and 4 home visits in 9 months • Group session duration: 90–120 mins • Group size: 13–115 • Home visit duration: 30 mins • 4 group sessions and 2 home visits in 9 months • Group session duration: 90–120 mins • Group size: 3–15 • Home visit duration: 30 mins Delivery strategy • Opportunities for caregivers to discuss, watch and practice play activities together • Opportunity to receive coaching and feedback • Problem solving • ECD corner where children play under adult’s supervision while caregivers participate join group session • Watching videos • Opportunities for caregivers to discuss, watch and practice play activities together • Opportunity to receive coaching and feedback • Problem solving • ECD corner where children play under adult’s supervision while caregivers participate join group session • Watching videos Frontline delivery team • Community facilitators and mentors recruited from the respective setting • Criteria for hiring included” • Having Advanced level certificate (A2) in education, social sciences or arts or any other related field, • Having a good oral and communication skills in Kinyarwanda language and some skills in English language, • Demonstrated a good conduct/behavior in the community, • Presenting a background check from the camp president or from the local leader • Compliance with child and adult safeguarding policy • Being community based Training Master training • No. of days: 5 • Training team: WV TSO and Sesame Workshop trainers • Training team experience: Several years of experience in ECD • Modality: virtual Training Community facilitators • No. of days: 5 for each group • Training team: WVR team • Training team experience: 5 and 15 years in community-based projects • Modality: face to face Supervision • No. of feedback sessions per month: 1 • Modality: Face to face and WhatsApp group • CF to supervisor ratio: 1: 6 • Supervisor experience: 15 years of operational management • Strategy: problem-solving, peer-to-peer support Adapted from: Yousafzai & Aboud (2014) Note: ECD = early childhood development, TSO = Technical Service Office Design and evaluation framework A mixed-methods approach was employed. The following indicators were assessed using the Proctor et al’s (2015) [ 14 ] framework: Reach: the proportion of intended population who participated in the intervention Fidelity: if intervention was delivered as planned Dose delivered : The number of intended units of intervention delivered or provided. Quality of the dose delivered : The extent to which the intervention delivery staff (community facilitators) delivered the intervention with quality i.e., core conditions covered. Dose received (exposure): The extent of active engagement in and receptiveness, use of intervention activities, materials or recommended resources. Acceptability (satisfaction): Satisfaction of the staff, caregivers and the community with the intervention. Enablers and challenges: Enablers and challenges identified while delivering the intervention. Measures To collect data on dose received and satisfaction, a set of items were developed by the external consultant in collaboration with the project team and included in the end line survey. Additionally, program records, such as monthly intervention reports, were examined to assess attendance rates and to identify ongoing challenges and facilitators. For qualitative data, topic guides for FGDs and KIIs were designed to capture different aspects of implementation including training, supervision, motivation, delivery, uptake and experience with the intervention. A range of stakeholders were approach including mothers, father, the intervention delivery staff, their mentors, project team and faith leaders for interviews. Data collection procedures Data collection was conducted by a team of 17 enumerators from March 14 to March 25, 2022. Enumerators received five days of training near the field site, led by an external consultant, from March 7 to March 11, 2022. Data was collected digitally using tablets with the questionnaires pre-programed in KOBO Collect. At the time of interviews, the data manager regularly checked consistency of data collected by enumerators to mitigate potential mistakes, and also to confirm that the survey protocol was followed, and provided comments to the field officers for correction and improvement. For the qualitative aspect, data was collected through key informant interviews and focus group discussions. The KII and FGD topic guides guided the interviews. The data collection team consisted of senior WV Rwanda members - one was directly engaged with the 3C intervention, and one was not, to provide a balanced perspective. The intervention delivery team identified and invited the 3C participants for the interviews. The consultant interviewed the project manager and officer via a face-to-face meeting. The project team shared the translated notes with the consultant for thematic analyses. With the prior consent from the participants, the discussions were audio-recorded and later transcribed for analysis. Data management and analysis At the end of each workday, all enumerators submitted the collected data to the server for checking. The data manager first of all confirmed that coding of all sheets was done correctly. Following this crosschecking, the data manager provided feedback for each day in order to correct mistakes done by some enumerators. The independent consultant completed quantitative data analysis using the Stata v17. For the qualitative analysis, an inductive approach was followed. A total of 12 interviews were conducted (mothers: 4, fathers: 2, faith leaders: 2, CFs: 1, Mentors 1, project officers: 2). The consultant and support team members coded the notes according to the implementation outcomes. Data was triangulated between coders to create a dictionary. Findings Reach The data from the project progress reports indicate that the attendance in group sessions of the targeted caregivers was high, ranging from 78–97% (Table 2 ). In the last session in January 2022, the high dose model reached 954 out of the expected 986 caregivers, while the low dose model reached 507 out of the expected 528 caregivers. Majority of the caregivers were mothers (90%), but a few fathers (about 10% of the total participants) also attended the sessions. Data for home visits was not available. Table 2 Reach of the two intervention models High dose Low dose Month Session No. Expected no. of caregivers No. attended % Session No. Expected no. of caregivers No. attended % Apr-21 1 546 508 93 May-21 1 582 456 78 1 548 534 97 Aug-21 1,2 556 497 89 Sep-21 3,4,5 NA NA - 2 NA NA - Oct-21 6,7 1038 977 94 Nov-21 8,9 876 851 97 3 528 490 93 Dec-21 10,11 986 961 97 Jan-22 12 986 954 97 4 528 507 96 Note: NA = Not available Fidelity and quality of dose delivered Program records documented in the quarterly progress reports captured the delivered dose. The reports reveal that both models delivered the intended dosage, i.e., 12 group sessions in HD and 4 group sessions in LD. The intervention was rolled out in April 2021 for HD and in May for LD, but disrupted due to COVD-19 and other logistic concerns in the camps. The project resumed in August 2021. The team delivered the remaining 11 HD sessions once every 15 days, while they delivered the 3 LD sessions once every 2 months. Regarding quality, we collected data on the interactions of the CF with the caregivers during the group sessions using 3 items (respect, listening carefully, using understandable language). Among the 3 items, we found a significant difference between HD and LD: CF treated caregiver with respect. In HD, 60% reported "most of the time," compared to 51% in LD (Table 3 ). A similar difference was seen in overall satisfaction with the CF: 57% in HD vs. 43% in LD were highly satisfied. Table 3 Quality of the dose delivered as reported by the caregivers High dose Low dose p-value N = 314 N = 240 Satisfaction with the community facilitator Very satisfied 180 (57.3) 103 (42.9) 0.006 Satisfied 126 (40.1) 131 (54.6) He/she treated the family with respect Most of the time 189 (60.2) 122 (50.8) 0.024 Some of the time 116 (36.9) 102 (42.5) He/she listened carefully to the family Most of the time 195 (62.1) 124 (51.7) 0.084 Some of the time 108 (34.4) 106 (44.2) He/she spoke to the family in a manner that was easy to understand Most of the time 191 (60.8) 120 (50.0) 0.058 Some of the time 115 (36.6) 113 (47.1) Note: Data is presented as N (%) The above findings triangulate with the qualitative data. Caregivers from the HD group appreciated the skills of the CF and were pleased with the way they interacted with them. “ Community Facilitators were so much skilled and delivered sessions very well .” [Mother, High dose, camp] “ They were respecting each of us and they were encouraging us to participate .” [Mother, High dose, camp] “They were taking care of our children before joining us for video sessions ” [Mother, Low dose, host] A mother was pleasantly surprised at the knowledge of the CFs while one was pleased with the fact that they were similar to them. “ I wonder when they learnt all they taught us. ” [Mother, High dose, camp] “It was so great to see same refugees as us, conducting sessions. ” [Mother, High dose, camp] “ I was so happy because the CF was my neighbour, and I could consult her easily ”. [Mother, Low dose, host] Similar sentiments were shared by the fathers about the CF. Facilitators were able to respond to all questions and showed confidence and clarity in the training to the audience. [Father, HD host, FGD] The facilitators were able to communicate effectively, and participants appreciate the way messages were delivered in training. [Father, HD host, FGD] In addition, the facilitators could use phone to call the parents or reach out to them through village leader. [Father, HD host, FGD] Dose received Implementation data on group sessions indicated that for LD, 85% of the families attended 25–50% (1–2 sessions) of the delivered dose, while in HD, the majority of the caregivers attended about 50–75% (5–8 sessions) of the delivered dose (Table 4 ). When questioned about what the most enjoyable part of the group sessions was, three-fourth of the caregivers in both intervention groups responded part 1: interacting only with caregivers. In contrast to group sessions, the dose received for home visits was strikingly low with more than 50% of the caregivers not having received even a single home visit. A higher number of caregivers in the host setting reported receiving no home visits compared to camp setting (75% vs. 30.4% in HD and 61.5% vs. 49.6% in LD). The overall satisfaction with the programme was higher for the HD compared to LD with 63.7% caregivers, reporting being “highly satisfied” compared to 45% respectively. Table 4 Quantitative evidence on dose received High dose Low dose p-value N = 314 N = 240 Dose received (exposure) No. of group sessions attended* Never 1–2 sessions 3–4 sessions 5-8 sessions 0 (0.6) 6 (1.9) 22 (7.0) 284 (90.4) 9 (3.8) 206 (85.8) 19 (7.9) 6 (2.5) - No. of home visits received None 174 (55.4) 132 (55.0) < 0.001 1–2 session 65 (20.7) 87 (36.3) 3–4 session 47 (15.0) 15 (6.3) 5–8 sessions 28 (8.9) 6 (2.5) Received SMS 94 (29.9) 63 (26.3) 0.292 Listened to the radio programme 173 (55) 127 (52.9) 0.356 Part of the group sessions most enjoyed ECD corners Part 1: only with caregivers Part 2: Video activities with caregivers and children Any other 5 (1.6) 232 (73.9) 52 (16.6) 25 (8.0) 6 (2.5) 176 (73.3) 41 (17.1) 17 (7.1) 0.867 Dose received (satisfaction) Satisfaction with the 3C programme Very satisfied 200 (63.7) 108 (45.0) < 0.001 Satisfied 106 (33.8) 127 (52.9) Note: Data is presented as N (%) *Total no. of sessions for high dose was 12 and for low dose 4. Qualitative data from the interviews revealed that the caregivers’ engagement with the content and enactment on the advice from all stakeholders including mothers, fathers, faith leaders, CFs and 3C programme team (Table 5 ). The engagement with the 3C intervention yielded various benefits, such as changes in parenting beliefs and practices, particularly testimonials from families with children with disabilities, and, importantly, a sense of community. Table 5 Qualitative evidence about dose received Theme Quote Change in parenting beliefs and practices My niece I live with I’ve started to care and treat her well after joining this program before I though as I am not her father, I don’t care . [CF, FGD] Yes, we know about the program, and we learned how to care a child with few means that we have, and we have realized that supporting the kid allows her/him to develop holistically ! [Mother, HD camp, FGD] We thought we love our children, but we came to know that were abusing them by beating and terrifying them ! [Mother, HD camp, FGD] I always felt that I can’t get time to talk to my children, feeling always busy, but after 3Cs session I got the importance to talking to them, listening to their stories, their frustrations. Now I do my best and I am getting time to talk to them even play with them . [Mother, HD host, FGD] I am feeing now that I am a supportive mother . [Mother, HD host, FGD] I am putting in practice what I learnt, not only at home but also at ECD centre where I work as a cook . [Mother, LD camp, FGD] I used to leave home and let my kid crying but now I play with her and leave her playing with other children I shared with other members of the family so that all of us can care the little ones . [Mother, LD camp, FGD] Before the training, I was in bad relationship with my wife, but for the sake of children ‘well-being’, I always come home early and have good time with my wife and children. [Father, HD host, FGD] I did observe some changes, when I was visiting families and just in the few time I spent there, I realized that between children and parents the relationship and the way they are communicating has changed positively. Example: In quartier 5 there is one Dad who was beating children for any mistake and children did not like him at all. Through different visits I tried to show him how he is abusing his own children and I made my visit consistent. There is a week now his children came to see me and said: thank you very much Pasto, Dad is no longer beating us. [Faith leader 2, IDI] Uptake of the intervention and responsiveness In my daily work I deal with parents and I could use all of the opportunities to talk to them on this. During our reconciliation program that gathers genocide survivors and those who committed genocide, parenting was one of the topics and we discussed about this [the 3C programme] several times. [Faith leader 1, IDI] Usually, the responsibility of parenting was assigned to mother but as fathers we ‘re surprised to hear how the role of father is key in caring for children . [Father, HD host, FGD] Recommending to families and friends I shared the learning with my neighbours who have not been able to attend sessions . [Mother, LD camp, FGD] I shared the new learning with other members of the family so that all of us can provide better care the little ones . [Mother, LD camp, FGD]. I shared [the messages] with my neighbours who have not been able to attend sessions. [Mother, LD camp, FGD] I shared with my neighbour who used to quarrel with her children so often and I told her about the abusive relationship. . .she is now improving at least as neighbours we are no longer hearing quarrels from their house. [Mother, HD camp, FGD] I did share with my husband . [Mother, LD host, FGD] I did share my older children . [Mother, LD host, FGD] I did share with my closest neighbour who used to beat her son . [Mother, LD host, FGD] I told to my neighbour who was beating the child that, the stick hurts but do not correct/ help change behaviours. Now, he knows how to discipline the child appropriately. [Father, HD host, FGD] I tell my neighbours how important to hug affectionately the children and show them love when back home. [Father, HD host, FGD] One of my neighbours used to quarrel with her wife, but I approached him and let told him that their conflict is affecting the children, and now they have stopped quarrelling . [Father, HD camp, FGD] Testimonies from families with children with developmental issues One of the caregivers who has 3 years kid who can’t talk yet she took the kid to different doctors and the last doctor they visited in Kigali had told them that the only medicine is to talk so often to the kid, when we are discussing the importance of talking to children she cried and revealed that in front of others ! [CF, FGD] One the families who has a child with disability, after getting the sessions, testified how they changed the way they were treating that kid and said: before the sessions we had we couldn’t allow her to have meals with us, she was served the last and we couldn’t have some conversations with her . [CF, FGD] Beliefs and practices about corporal punishment One of the caregivers testified that “after getting the session and know the importance of talking, listening and playing with children, now there is a big difference as he thought being a good parent is to be serious every time and beating children seriously ” [CF, FGD] One father whose wife lives with mental disabilities said that he was so hard to his children to the extent they were fearing him very much and loved the house helper more than their Dad. Now I have started playing with them, talking and listening to them so often and I can see now that there is a great relationship and love among us. [CF, FGD] “ I am no longer beating my child and telling her bad words”, one the mothers testified I wish my parents could have had these sessions, cause even now that I have my own children, I do remember all f the bad words they were always telling us. Now with the sessions that I received I talk to my children often and we have developed the friendship . [Mother, HD camp, FGD] Sense of community One the caregivers who lost her 12-year kid, others put some funds together as a group paid a visit to comfort the family ! [CF, FGD] Even the relationship among caregivers improved so much, 2 of the caregivers had issues between them and they found themselves in the same group session and little by little they came to understanding each other and getting back to socialize. [CF, FGD] Note: CF = community facilitator, FGD = focus group discussion, HD = high dose, LD = low dose, IDI = in-depth interview Enablers and challenges Several factors were identified as facilitating and or challenging the intervention delivery by the community facilitators and mentors. These included viewing the project as an opportunity to serve the community, benefiting from professional development provided by the project team, and having a strong relationship with the community [Table 6 ]. Table 6 Enablers and challenges shared by CFs and mentors for intervention delivery Factor Community Facilitator Mentor Serving their community The greatest motivation was to train members of our communities/ our relatives our neighbours and see them changing their behaviours on the way they treat their children Respect and love from caregivers and Feeling that I am providing my support in my community behaviour change was another great motivation We enjoyed seeing them putting into practice what they learnt We built good relationships with caregivers Caregivers are appreciating us so much up to know Yes, and very much, testimonies and success stories on behaviour change from the caregivers of my own community were pushing me to continue The trust from my community has upgraded Caregivers’ attendance was also motivating Professional support and development opportunities Project staff were supporting We had all of the materials we needed We were getting incentives regularly Skills improvement Yes, they built our capacity (before joining 3Cs, I couldn’t stand in front of people, but now I am so much confident I can face any audience) We received monthly incentives ( I have some savings and I am so happy for that) Project staff appreciated our efforts Regular supervision Strengthening relationship The relationship with built and maintained (with families). By home visit we could interact more and get to know them better and be able to support Preparing sessions together, anticipate questions from caregivers and try to answer all of them as a group Praising the person before saying areas of improvement Letting them know that if I enter for observation, it’s a normal thing not playing the policeman Being from the same community Being in the same community supported us to make informal visits and supervision Curiosity of the caregivers Fathers themselves were curious to know what the mothers having been learning and some of them were asking about the topics learnt Challenges Cultural beliefs Most of the fathers still think that beating children is the best parenting practice The relationship has been changing all over the sessions as it wasn’t easy from the beginning regarding providing feedback to our colleagues/friends, neighbours.. .but as we continued to be supported by project staff, CF got to understand that the purpose is to improve on sessions delivery Providing constructive feedback on the 1st and 2nd session wasn’t easy, facilitators thought we were blaming them Contamination of the interventions We have not been able to explain to caregivers in low dose why they are not getting the same number of sessions like those in high dose Note: CF = community facilitator The intervention manager also identified the community-based nature of the intervention staff as a strength. “ We recruited the CFs with the help of a local NGO, and we made sure they were from the community. That helped them to build a relationship with the community.” [Intervention manager, IDI] Similarly, professional development of the staff was a motivator for the mentors and the CFs, but also for the project management as expressed by the manager in the interview. “ You can’t imagine, I am so much happy, (Q: Being an educationist) yes being an educationist. Seeing people growing and improving, it really gives so much excitement, and during the sessions for them to … testify… [Project manager, IDI] Recommendations Several recommendations emerged from the qualitative interviews from the stakeholders around father’s engagement, similar advice for children of older age, need of greater number of sessions in the low dose group and the continuation of job for the CFs (Table 7 ). Table 7 Recommendations from the stakeholders about the programme Theme Quote Father engagement Fathers want to receive the same package as mothers so that they can support their children confidently . [CF, FGD] Giving fathers the same number/same content as what we got as fathers attended only 1 session . [Mother, LD camp, FGD] Give fathers same sessions as mothers . [Mother, LD camp, FGD] Need for more and customized sessions We wish we could get refreshers. [Mother, LD camp, FGD] We want to receive many sessions as others who got many. [Mother, LD camp, FGD] Refresher training should be organised at certain time intervals . [Father, HD host, FGD] Increase faith leader meetings. [Faith leader 2, IDI] To get the same content for children upper 5 years, it’s not easy to raise them as well . [Mother HD camp, FGD] We want sessions for kids above 5 years. [Mother, LD camp, FGD] Have sessions for only single mothers. [Mother, LD camp, FGD] Delivery strategy To invite both mothers and fathers and get the same sessions. [Mother HD camp, FGD] To conduct sessions to both parents/caregivers in the family, so that they can put into practice together what they learn . [Faith leader 1, IDI] Continued job opportunity Continuing this job could be the great thing for us and continue contributing to their behaviour change. [CF, FGD] Note: CF = community facilitator, FGD = focus group discussion, HD = high dose, LD = low dose, IDI = in = depth interview Discussion The objective of the study was to present the implementation evaluation findings of an intervention delivered in a humanitarian setting in Rwanda, in high and low dose. A prior evaluation of 3C, assessing its impact, had shown the intervention’s effectiveness in promoting early learning practices, responsive feeding and attitude towards corporal punishment [ 7 ]. Data about adoption of practices in this study aligns with the previous findings. With respect to fidelity of dose delivered, majority of families received at least 50% of the intended dosage for group sessions in both high and low dose groups. However, for the home-visits, more than half of the families reported that they had never received one. The programme records indicate over 90% of expected families attending the group sessions. This means that the desired change in practices was achieved with delivering the intended dosage for group sessions, with minimal home-visits. Studies using groups as the delivery modality have found benefits for child development and practices. A randomized controlled study in Kenya found that group sessions resulted in greater benefits compared to a mix of groups and home visits, when compared to the control group. [ 15 ] While, another randomized-controlled study in India examining the effects of groups vs. home visits found no difference in the effect size of both delivery strategies [ 16 ]. Similarly, a trial in Bangladesh found integration of a group-based intervention in a public health system to be effective for ECD outcomes [ 17 ]. The low delivery rate of home visits can be attributed to the challenges of delivering home visit, especially when workforce is voluntary, and burden is high [ 18 – 19 ]. This challenge has been reported from other at scale studies e.g., in a study in Colombia, 34% of all targeted families had not received any visits [ 20 ]. Another finding was that families reported the first half of the group session (which the program team had assumed would be in favor of Sesame Workshop sessions) as the most enjoyable part. This could be interpreted as an opportunity for caregivers to have a safe and secure shared space for learning and sharing. Similar observation was reported by another study where the sense of ‘comradery’ and opportunities for peer learning was appreciated by the participant mother in group session [ 21 ]. While families from both groups were very satisfied with the programme and the CF, the families in the high dose group had a slightly higher percentage. This could be related to the fact that CFs in HD group had more sessions and time to build a relationship compared to the LD groups. The enablers reported by the intervention delivery team (CFs and mentors) were related to opportunity for professional development and serving the community. The growth of the teams acted as motivator for the project team too. These factors i.e., a comprehensive skill-based training and relationship with the caregivers have been found important in an implementation evaluation of their pilot RCT by other community-based studies [ 21 – 23 ]. The 3C study has several strengths. Firstly, it is one of the few studies to deliver a nurturing care intervention in a humanitarian setting, highlighting its relevance, feasibility and potential impact in such contexts. Secondly, the study collected data on implementation evaluation, providing valuable insights into the delivery processes of the intervention, which can inform future program planning and implementation in similar settings. Additionally, the study used a mixed-methods approach, combining quantitative and qualitative data, to provide a comprehensive understanding of the intervention's implementation and its effects. There were several limitations of the study. The qualitative data was collected by the intervention staff due to budget constraints, which can induce bias. However, they were not involved with the data analysis. The data from both quantitative and qualitative sources was collected toward the end. Ideally, we would have liked data throughout the project cycle to inform the process of implementation. Also, thought checklists to observe the quality of intervention (groups and home visits) were provided, they were not used due to the workload of the mentors and lack of training by project officers. Nonetheless, the findings are very valuable for the field of ECD interventions specifically the benefits of the programme with different dosages. The study's recommendations for scaling up the intervention in similar settings include: recruiting intervention delivery staff (CFs) from the community; providing professional development opportunities for CFs; offering mentorship and supportive supervision through in-person and social media contacts; focusing on building relationships with the community and modeling the same for CFs; using group sessions as the main delivery modality with home visits for vulnerable families; leveraging contacts with faith leaders to deliver key messages; continuing to distribute learning items like toys to families; and ensuring project progress reports include a summary of intervention delivery features beyond attendance in group sessions. These recommendations aim to enhance program effectiveness, sustainability, and cost-effectiveness. With respect to monitoring and evaluation, we believe the team’s capacity (ability to record data, interpret, report) is crucial for ensuring ECD programs are not just effectively implemented but also evaluated, and for future similar initiatives. In conclusion, while the nurturing care program showed acceptability and engagement from delivery staff, challenges in achieving fidelity to intended dosage and home visitation were noted. Continuous monitoring and adaptation of delivery strategies are essential for improving early childhood development outcomes in similar contexts. Declarations Ethics Approval and consent to participate The study was approved by the Institutional Review Board of College of Medicine and Health Sciences, University of Rwanda (Approval No. 180/CMHS IRB/2022). Informed consent was obtained from the head of the household (legal guardian of the participants) for participation in the study. Research activities were conducted in accordance with the institutional guidelines. Consent for publication Not applicable. Competing interests Authors have no competing interests to declare. MAR was contracted as an external consultant for the evaluation. Funding The study was co-funded by USAID (Award No. SPRMCO20CA0158) and World Vision US. Author Contribution VS: conceptualization, methodology, funding acquisition, supervision, writing-original draftAT: methodology, writing-review and editingMU: methodology, investigation, data curation, project administration, writing-review and editingAG: investigation, writing-review and editingJAH: investigation, writing-review and editingJSS: resources, writing-review and editingCF: funding acquisition, resources, writing-review and editingMAR: formal analysis, writing-original draft Acknowledgments The authors would like to express their sincere regard to the families who participated in the study. We are grateful to the community facilitators who implemented the intervention and the enumerators who collected the data. We also acknowledge support of World Vision Rwanda National Office and UNHCR for conducting the study. Availability of data and materials The datasets generated and/or analysed during the current study are not publicly available given the sensitive nature of information but are available from the corresponding author on reasonable request. References Shah S, Lombardi J. Editorial Note. J Educ Emergencies. 2021;7(1):5–12. https://doi.org/10.33682/m5tn-wvc9 . WHO, UNICEF, The World Bank Group., Nurturing care for early childhood development: a framework for helping children survive and thrive to transform health and human potential . 2018. Geneva. Murphy KM, Rodrigues K, Costigan J, Annan J. Raising children in conflict: An integrative model of parenting in war. Peace and conflict. J Peace Psychol. 2017;23(1):46. http://dx.doi.org/10.1037/pac0000195 . Lakkis NA, Osman MH, Aoude LC, Maalouf CJ, Issa HG, Issa GM. A pilot intervention to promote positive parenting in refugees from Syria in Lebanon and Jordan. Front Psychiatry. 2020;11:257. Murphy KM, Yoshikawa H, Wuermli AJ. Implementation research for early childhood development programming in humanitarian contexts. Ann N Y Acad Sci. 2018;1419(1):90–101. Durlak JA, DuPre EP. Implementation matters: A review of research on the influence of implementation on program outcomes and the factors affecting implementation. Am J Community Psychol. 2008;41:327–50. Sargsyan V, Tenorio A, Uwera M, et al. The benefits of nurturing care interventions on early child development and care: findings from a quasi-experimental study in a humanitarian setting. BMC Pediatr. 2023;23:419. https://doi.org/10.1186/s12887-023-04239-z . Ahun MN, Ali NB, Hentschel E, Jeong J, Franchett E, Yousafzai AK. A meta-analytic review of the implementation characteristics in parenting interventions to promote early child development. Ann N Y Acad Sci. 2024;1–46. 10.1111/nyas.15110 . UNHCR, Operational update Rwanda. August 2021. 2021a. https://reporting.unhcr.org/document/559 . UNHCR. Rwanda Mugombwa camp profile. 2021b. https://data2.unhcr.org/en/documents/details/86481 . UNHCR. Rwanda Mugombwa camp profile. 2021c. https://data2.unhcr.org/en/documents/details/86480 . World Vision. Go Baby Go! Parenting program. 2015. https://www.wvi.org/maternal-newborn-and-child-health/go-baby-go . Rosales A, Sargsyan V, Abelyan K, Hovhannesyan A, Ter-Abrahanyan K, Jillson KQ, Cherian D. Behavior change communication model enhancing parental practices for improved early childhood growth and development outcomes in rural Armenia–A quasi-experimental study. Prev Med Rep. 2019;14:100820. Proctor E, Silmere H, Raghavan R, Hovmand P, Aarons G, Bunger A, Griffey R, Hensley M. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Mental Health Mental Health Serv Res. 2011;38:65–76. https://doi.org/10.1007/s10488-010-0319-7 . Luoto JE, Garcia IL, Aboud FE, Singla DR, Fernald LC, Pitchik HO, Saya UY, Otieno R, Alu E. Group-based parenting interventions to promote child development in rural Kenya: a multi-arm, cluster-randomised community effectiveness trial. Lancet Global Health. 2021a;9(3):e309–19. Grantham-McGregor S, Adya A, Attanasio O, Augsburg B, Behrman J, Caeyers B, Day M, Jervis P, Kochar R, Makkar P, Meghir C. Group sessions or home visits for early childhood development in India: a cluster RCT. Pediatrics. 2020;146(6). Mehrin SF, Hasan MI, Tofail F, Shiraji S, Ridout D, Grantham-McGregor S, Hamadani JD, Baker-Henningham H. Integrating a group-based, early childhood parenting intervention into primary health care services in rural Bangladesh: a cluster-randomized controlled trial. Front Pead. 2022;10:886542. Ssewanyana D, Martin MC, Angwenyi V, Kabue M, Proulx K, Zhang L, Malti T, Njoroge E, Nasambu C, Marangu J, Odhiambo R. Stakeholders’ perspectives of enablers and barriers to successfully implementing an integrated early childhood development program in an informal urban settlement in Kenya. SAGE Open. 2023;13(4). https://doi.org/10.1177/21582440231208986 . Wilton KS, Vachon A, Murphy KM, Al Aqra A, Ensour A, Ibrahim I, Tahhan A, Hoyer K, Powell C. Home visiting in the Middle East: reflections on the implementation of Reach Up and Learn. J Educ Emergencies. 2021;7(1):80. https://doi.org/10.33682/pzjw-p1nc . Araujo MC, Dormal M, Grantham-McGregor S, Lazarte F, Rubio-Codina M, Schady N. Home visiting at scale and child development. J Public Econ Plus. 2021;2:100003. Luoto JE, Garcia IL, Aboud FE, Singla DR, Zhu R, Otieno R, Alu E. An implementation evaluation of a group-based parenting intervention to promote early childhood development in rural Kenya. Front Public Health. 2021b;9:653106. Ponguta LA, Issa G, Aoudeh L, Maalouf C, Nourallah S, Khoshnood K, Zonderman AL, Katsovich L, Moore C, Salah R, Al-Soleiti M. Implementation evaluation of the Mother‐Child Education Program among refugee and other vulnerable communities in Lebanon. New Dir Child Adolesc Dev. 2019;167:91–116. Kohli-Lynch M, Hardy VP, Salazar RB, Bhopal SS, Brentani A, Cavallera V, Goh E, Hamadani JD, Hughes R, Manji K, Milner KM. Human resources and curricula content for early child development implementation: multicountry mixed methods evaluation. BMJ Open. 2020;10(4):e032134. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 19 Nov, 2024 Reviewers agreed at journal 10 Sep, 2024 Reviewers agreed at journal 10 Sep, 2024 Reviewers agreed at journal 19 Apr, 2024 Reviewers invited by journal 19 Apr, 2024 Editor assigned by journal 23 Mar, 2024 Submission checks completed at journal 23 Mar, 2024 First submitted to journal 21 Mar, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4141378","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":282925407,"identity":"68d0e1cf-d230-427e-b8d4-c48bb582970d","order_by":0,"name":"Viktoria Sargsyan","email":"data:image/png;base64,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","orcid":"","institution":"World Vision International, Global Education Sector Team","correspondingAuthor":true,"prefix":"","firstName":"Viktoria","middleName":"","lastName":"Sargsyan","suffix":""},{"id":282925408,"identity":"8f5a812b-0c11-4370-b087-f8571775af3b","order_by":1,"name":"Mediatrice Uwera","email":"","orcid":"","institution":"World Vision Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Mediatrice","middleName":"","lastName":"Uwera","suffix":""},{"id":282925409,"identity":"07ed2f45-e0ef-4e97-b488-f3319e62c90e","order_by":2,"name":"Andre Gasirikare","email":"","orcid":"","institution":"World Vision Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Andre","middleName":"","lastName":"Gasirikare","suffix":""},{"id":282925410,"identity":"4e02a460-4629-4b09-83b0-40761a3cfdaf","order_by":3,"name":"Jean Aime Habyarimana","email":"","orcid":"","institution":"World Vision Rwanda","correspondingAuthor":false,"prefix":"","firstName":"Jean","middleName":"Aime","lastName":"Habyarimana","suffix":""},{"id":282925411,"identity":"710bfc51-8088-432f-bdc6-8a1fef9af7a4","order_by":4,"name":"Jennifer S Salcido","email":"","orcid":"","institution":"World Vision","correspondingAuthor":false,"prefix":"","firstName":"Jennifer","middleName":"S","lastName":"Salcido","suffix":""},{"id":282925412,"identity":"ce75939f-c369-42d8-99ed-7c64742b6484","order_by":5,"name":"Christy Felner","email":"","orcid":"","institution":"World Vision","correspondingAuthor":false,"prefix":"","firstName":"Christy","middleName":"","lastName":"Felner","suffix":""},{"id":282925413,"identity":"282a9a08-af36-4e5d-8f41-06e81c1e32fb","order_by":6,"name":"Muneera A. Rasheed","email":"","orcid":"","institution":"University of Bergen","correspondingAuthor":false,"prefix":"","firstName":"Muneera","middleName":"A.","lastName":"Rasheed","suffix":""}],"badges":[],"createdAt":"2024-03-21 07:03:42","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4141378/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4141378/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":53544298,"identity":"e8657524-9671-4ec6-a0e4-9f8e6022b4b5","added_by":"auto","created_at":"2024-03-27 09:29:36","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":162160,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRefugee camps in Rwanda\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSource: https://www.unhcr.org/rw/where-we-work\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-4141378/v1/c13b523ae4b169cf1b5a4e7b.jpeg"},{"id":53544656,"identity":"a14c7fa0-517c-47cb-88ac-ecc17402b0b7","added_by":"auto","created_at":"2024-03-27 09:37:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":500050,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4141378/v1/e6ffe7b0-2404-465e-81dd-2964117b25c1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementation evaluation of a nurturing care intervention in a humanitarian setting in Rwanda","fulltext":[{"header":"Background","content":"\u003cp\u003eIn situations of adversity, such as forced migration and emergencies resulting from conflicts, early childhood experiences can be profoundly affected, placing an entire generation at risk [1]. To address these challenges, early childhood interventions grounded in the nurturing care framework [2] have emerged as a potential buffer against the detrimental impact on brain development and the subsequent developmental difficulties faced by children in such contexts [3-4].\u003c/p\u003e\n\u003cp\u003eDespite recognizing the urgent need for interventions to bolster the resilience of families and children in these settings, prioritizing their uptake has proven challenging [5]. A significant barrier has been the lack of evidence regarding the implementation of programs, specifically addressing the \u0026apos;why\u0026apos; and \u0026apos;how,\u0026apos; and the settings and contexts in which these interventions can be effective [6]. To support resilience building in early childhood within refugee settings, World Vision Rwanda (WVR) employed an innovative, evidence-based, child-focused parenting program designed to reach 3,000 caregivers with children under the age of 5 in underserved populations residing in camps and host communities, including the Mugombwa Congolese Refugee Camp and three nearby Sector Host Communities (Kansi, Kigembe, Mugombwa) [7].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn an attempt to contribute evidence of implementation research for nurturing care [8], the intervention was delivered in varying doses: high and low in both settings (host and camp). The high dose arm included 12 caregiver group sessions, with additional sessions for fathers if their participation in caregiver sessions was limited, along with a minimum of 4 home visits. The low dose arm comprised 4 caregiver group sessions, and a minimum of 2 home visits. It featured fewer in-person caregiver group sessions and placed more emphasis on targeted messaging to encourage behavioral and attitudinal change, supported by socially distanced home visits (a minimum of 2). All groups also received radio sessions.\u003c/p\u003e\n\u003cp\u003eAn evaluation of the program revealed notable improvements in caregiving practices in both the high and low dose arms compared to a control group. However, these changes did not result in significant enhancements in early childhood development (ECD) outcomes. The aim of the current study is to evaluate the implementation in high and low doses arms, uncovering valuable insights regarding the processes of program delivery. Through this evaluation, we aim to understand how the program was implemented, identify challenges faced, and discern the factors contributing to the observed changes in caregiving practices and their impact on ECD outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003e\u003cstrong\u003ePopulation\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eRwanda, a tiny land area in East Africa, hosts more than 170,000 refugees in 6 camps scattered across the country (Fig.\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). The camps are home to Congolese and Burundian refugees. Renewed hostilities in the DRC in 2012\u0026ndash;2013 and security issues following the Burundian election in 2015 have forced thousands to flee to Rwanda for safety. The conditions in Rwanda\u0026rsquo;s 6 refugee camps vary greatly. Some of those in the Gihembe refugee camp, for instance, have been refugees for more than 20 years whereas the more than 55,000 Burundian refugees in Mahama camp have only been refugees since 2015, when the camp was built (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.kiva.org/blog/building-the-economy-within-rwandas-refugee-camps\u003c/span\u003e\u003c/span\u003e). Rwanda hosted a total of 127,382 refugees and asylum seekers at the end of August 2021. The population of concern included mainly persons from the Democratic Republic of the Congo (61) [\u003cspan class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eStudy setting\u003c/h3\u003e\n\u003cp\u003eThe study setting included host and camps for both the intervention groups. The intervention group included host communities in cells that were selected in each of the three sectors namely Mugombwa, Kansi (high dose) and Kigembe (low dose). For camp setting, Mugombwa was considered in the intervention group. The Kigeme camp was established in 2012 and has a population of 17,000. The 61% of the population in Mugombwa resides in adequate dwelling compared to 42 in Kigeme [\u003cspan class=\"CitationRef\"\u003e10\u003c/span\u003e\u0026ndash;\u003cspan class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n\u003ch2\u003eIntervention model\u003c/h2\u003e\n\u003cp\u003eThe Care and Comfort for Children (3C) intervention model aims to build knowledge, skills and resilience-promoting techniques to improve parenting practices at the household level. The 3C package is built on World Vision (WV) designed evidence-based parenting program approach called Go Baby Go (GBG) for young age children\u0026rsquo;s ECD. The curriculum, utilizing behavior change communication, appreciative inquiry and positive deviance approaches [\u003cspan class=\"CitationRef\"\u003e12\u003c/span\u003e], was contextualized, and further enhanced to meet the developmental needs of 0\u0026ndash;5 aged refugee children. A previous evaluation of Go Baby Go model in Armenia by World Vision (WV) Armenia demonstrated it to be effective for child developmental outcomes with pronounced benefits for the most vulnerable families [\u003cspan class=\"CitationRef\"\u003e13\u003c/span\u003e]. The GBG model adaptation for 3C also included video segments from Sesame Workshop\u0026rsquo;s \u0026ldquo;I \u003cimg src=\"data:image/png;base64,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\" alt=\"\" /\u003e Elmo\u0026rdquo; and \u0026ldquo;WASH UP!\u0026rdquo; series, along with accompanying in-class activities and take-home activities\u0026rdquo;. The interventions were delivered from April 2021 to January 2022.\u003c/p\u003e\n\u003cp\u003eThe 3C reached out to 1500 caregivers with children under 5 age: 1000 caregiver residing in cap community, and 500 in refugee host communities. The 3C was delivered through two modalities: \u003cem\u003e12 contextualized group, skills-based learning sessions for primary caregivers\u003c/em\u003e, focused on enhancing nurturing care through sensitive and responsive parenting and play and communication. \u003cem\u003eIndividualized home-based visits\u003c/em\u003e seek to support caregivers and families by reaching the most vulnerable household and reinforcing learning and application through in-depth dialogue and mentorship.\u003c/p\u003e\n\u003cp\u003eThe 3Cs Community Facilitators (CFs) were selected from the camp and the host community. The recruitment process was supported by camp leaders and local leaders. Key criteria selection were to be trusted members of the community, comply with child and adult safeguarding policy and WV refuges setting specific policies and having secondary school certificate with good communication skills. The 3Cs mentors were selected among the CFs based on their performance and their ability to mentor others. The role of the mentors was largely to ensure the fidelity and quality of intervention through reflection meetings, supervision visits (mentors and Project Officers (POs) supporting 3CFs) and completing caregiver satisfaction checklists.\u003c/p\u003e\n\u003cp\u003eImplementation features of both interventions have been described in Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e below. The dosage was significantly different between the two groups. Rest of the features were quite similar.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eImportant implementation features of the two interventions\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eFeature of implementation\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eHigh dose\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eLow dose\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eContent\u003c/p\u003e\n\u003cp\u003eGroup sessions\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Structured curriculum based on the \u003cem\u003eGo Baby Go\u003c/em\u003e and \u003cem\u003eLearning Roots\u003c/em\u003e curriculum\u003c/p\u003e\n\u003cp\u003e\u0026bull; Few take-away messages for practice\u003c/p\u003e\n\u003cp\u003e\u0026bull; Low-cost material\u003c/p\u003e\n\u003cp\u003e\u0026bull; Videos from Sesame Workshop with accompanying in-class activity and take-home activity\u003c/p\u003e\n\u003cp\u003e\u0026bull; Radio messages\u003c/p\u003e\n\u003cp\u003e\u0026bull; SMS messages\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Structured curriculum based on the \u003cem\u003eGo Baby Go\u003c/em\u003e and \u003cem\u003eLearning Roots\u003c/em\u003e curriculum\u003c/p\u003e\n\u003cp\u003e\u0026bull; Few take-away messages for practice\u003c/p\u003e\n\u003cp\u003e\u0026bull; Low-cost material\u003c/p\u003e\n\u003cp\u003e\u0026bull; Videos from Sesame Workshop with accompanying in-class activity and take-home activity\u003c/p\u003e\n\u003cp\u003e\u0026bull; Radio messages\u003c/p\u003e\n\u003cp\u003e\u0026bull; SMS messages\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eContent\u003c/p\u003e\n\u003cp\u003eHome visits\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Structured curriculum based on the \u003cem\u003eGo Baby Go\u003c/em\u003e curriculum\u003c/p\u003e\n\u003cp\u003e\u0026bull; Few doable messages\u003c/p\u003e\n\u003cp\u003e\u0026bull; Low-cost material\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Structured curriculum based on the \u003cem\u003eGo Baby Go\u003c/em\u003e curriculum\u003c/p\u003e\n\u003cp\u003e\u0026bull; Few doable messages\u003c/p\u003e\n\u003cp\u003e\u0026bull; Low-cost material\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDosage delivery\u003c/p\u003e\n\u003cp\u003eIntensity, frequency and duration\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; 12 group sessions and 4 home visits in 9 months\u003c/p\u003e\n\u003cp\u003e\u0026bull; Group session duration: 90\u0026ndash;120 mins\u003c/p\u003e\n\u003cp\u003e\u0026bull; Group size: 13\u0026ndash;115\u003c/p\u003e\n\u003cp\u003e\u0026bull; Home visit duration: 30 mins\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; 4 group sessions and 2 home visits in 9 months\u003c/p\u003e\n\u003cp\u003e\u0026bull; Group session duration: 90\u0026ndash;120 mins\u003c/p\u003e\n\u003cp\u003e\u0026bull; Group size: 3\u0026ndash;15\u003c/p\u003e\n\u003cp\u003e\u0026bull; Home visit duration: 30 mins\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDelivery strategy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Opportunities for caregivers to discuss, watch and practice play activities together\u003c/p\u003e\n\u003cp\u003e\u0026bull; Opportunity to receive coaching and feedback\u003c/p\u003e\n\u003cp\u003e\u0026bull; Problem solving\u003c/p\u003e\n\u003cp\u003e\u0026bull; ECD corner where children play under adult\u0026rsquo;s supervision while caregivers participate join group session\u003c/p\u003e\n\u003cp\u003e\u0026bull; Watching videos\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Opportunities for caregivers to discuss, watch and practice play activities together\u003c/p\u003e\n\u003cp\u003e\u0026bull; Opportunity to receive coaching and feedback\u003c/p\u003e\n\u003cp\u003e\u0026bull; Problem solving\u003c/p\u003e\n\u003cp\u003e\u0026bull; ECD corner where children play under adult\u0026rsquo;s supervision while caregivers participate join group session\u003c/p\u003e\n\u003cp\u003e\u0026bull; Watching videos\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFrontline delivery team\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026bull; Community facilitators and mentors recruited from the respective setting\u003c/p\u003e\n\u003cp\u003e\u0026bull; Criteria for hiring included\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u0026bull; Having Advanced level certificate (A2) in education, social sciences or arts or any other related field,\u003c/p\u003e\n\u003cp\u003e\u0026bull; Having a good oral and communication skills in Kinyarwanda language and some skills in English language,\u003c/p\u003e\n\u003cp\u003e\u0026bull; Demonstrated a good conduct/behavior in the community,\u003c/p\u003e\n\u003cp\u003e\u0026bull; Presenting a background check from the camp president or from the local leader\u003c/p\u003e\n\u003cp\u003e\u0026bull; Compliance with child and adult safeguarding policy\u003c/p\u003e\n\u003cp\u003e\u0026bull; Being community based\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTraining\u003c/p\u003e\n\u003cp\u003eMaster training\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026bull; No. of days: 5\u003c/p\u003e\n\u003cp\u003e\u0026bull; Training team: WV TSO and Sesame Workshop trainers\u003c/p\u003e\n\u003cp\u003e\u0026bull; Training team experience: Several years of experience in ECD\u003c/p\u003e\n\u003cp\u003e\u0026bull; Modality: virtual\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTraining\u003c/p\u003e\n\u003cp\u003eCommunity facilitators\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026bull; No. of days: 5 for each group\u003c/p\u003e\n\u003cp\u003e\u0026bull; Training team: WVR team\u003c/p\u003e\n\u003cp\u003e\u0026bull; Training team experience: 5 and 15 years in community-based projects\u003c/p\u003e\n\u003cp\u003e\u0026bull; Modality: face to face\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSupervision\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" align=\"left\"\u003e\n\u003cp\u003e\u0026bull; No. of feedback sessions per month: 1\u003c/p\u003e\n\u003cp\u003e\u0026bull; Modality: Face to face and WhatsApp group\u003c/p\u003e\n\u003cp\u003e\u0026bull; CF to supervisor ratio: 1: 6\u003c/p\u003e\n\u003cp\u003e\u0026bull; Supervisor experience: 15 years of operational management\u003c/p\u003e\n\u003cp\u003e\u0026bull; Strategy: problem-solving, peer-to-peer support\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003eAdapted from: Yousafzai \u0026amp; Aboud (2014)\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\"\u003eNote: ECD\u0026thinsp;=\u0026thinsp;early childhood development, TSO\u0026thinsp;=\u0026thinsp;Technical Service Office\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\n\u003ch2\u003eDesign and evaluation framework\u003c/h2\u003e\n\u003cp\u003eA mixed-methods approach was employed. The following indicators were assessed using the Proctor et al\u0026rsquo;s (2015) [\u003cspan class=\"CitationRef\"\u003e14\u003c/span\u003e] framework:\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003eReach: the proportion of intended population who participated in the intervention\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eFidelity: if intervention was delivered as planned\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cem\u003eDose delivered\u003c/em\u003e: The number of intended units of intervention delivered or provided.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003e\u003cem\u003eQuality of the dose delivered\u003c/em\u003e: The extent to which the intervention delivery staff (community facilitators) delivered the intervention with quality i.e., core conditions covered.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eDose received (exposure): The extent of active engagement in and receptiveness, use of intervention activities, materials or recommended resources.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eAcceptability (satisfaction): Satisfaction of the staff, caregivers and the community with the intervention.\u003c/p\u003e\n\u003c/li\u003e\n\u003cli\u003e\n\u003cp\u003eEnablers and challenges: Enablers and challenges identified while delivering the intervention.\u003c/p\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/li\u003e\n\u003c/ul\u003e\n\u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n\u003ch2\u003eMeasures\u003c/h2\u003e\n\u003cp\u003eTo collect data on dose received and satisfaction, a set of items were developed by the external consultant in collaboration with the project team and included in the end line survey. Additionally, program records, such as monthly intervention reports, were examined to assess attendance rates and to identify ongoing challenges and facilitators. For qualitative data, topic guides for FGDs and KIIs were designed to capture different aspects of implementation including training, supervision, motivation, delivery, uptake and experience with the intervention. A range of stakeholders were approach including mothers, father, the intervention delivery staff, their mentors, project team and faith leaders for interviews.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n\u003ch2\u003eData collection procedures\u003c/h2\u003e\n\u003cp\u003eData collection was conducted by a team of 17 enumerators from March 14 to March 25, 2022. Enumerators received five days of training near the field site, led by an external consultant, from March 7 to March 11, 2022. Data was collected digitally using tablets with the questionnaires pre-programed in KOBO Collect. At the time of interviews, the data manager regularly checked consistency of data collected by enumerators to mitigate potential mistakes, and also to confirm that the survey protocol was followed, and provided comments to the field officers for correction and improvement.\u003c/p\u003e\n\u003cp\u003eFor the qualitative aspect, data was collected through key informant interviews and focus group discussions. The KII and FGD topic guides guided the interviews. The data collection team consisted of senior WV Rwanda members - one was directly engaged with the 3C intervention, and one was not, to provide a balanced perspective. The intervention delivery team identified and invited the 3C participants for the interviews. The consultant interviewed the project manager and officer via a face-to-face meeting. The project team shared the translated notes with the consultant for thematic analyses. With the prior consent from the participants, the discussions were audio-recorded and later transcribed for analysis.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n\u003ch2\u003eData management and analysis\u003c/h2\u003e\n\u003cp\u003eAt the end of each workday, all enumerators submitted the collected data to the server for checking. The data manager first of all confirmed that coding of all sheets was done correctly. Following this crosschecking, the data manager provided feedback for each day in order to correct mistakes done by some enumerators. The independent consultant completed quantitative data analysis using the Stata v17. For the qualitative analysis, an inductive approach was followed. A total of 12 interviews were conducted (mothers: 4, fathers: 2, faith leaders: 2, CFs: 1, Mentors 1, project officers: 2). The consultant and support team members coded the notes according to the implementation outcomes. Data was triangulated between coders to create a dictionary.\u003c/p\u003e\n\u003c/div\u003e"},{"header":"Findings","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eReach\u003c/h2\u003e \u003cp\u003eThe data from the project progress reports indicate that the attendance in group sessions of the targeted caregivers was high, ranging from 78\u0026ndash;97% (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). In the last session in January 2022, the high dose model reached 954 out of the expected 986 caregivers, while the low dose model reached 507 out of the expected 528 caregivers. Majority of the caregivers were mothers (90%), but a few fathers (about 10% of the total participants) also attended the sessions. Data for home visits was not available.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eReach of the two intervention models\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003eHigh dose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eLow dose\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSession No.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExpected no. of caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNo. attended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003eSession No.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eExpected no. of caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo. attended\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eApr-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e546\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e508\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMay-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e582\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e456\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e548\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAug-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1,2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e556\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e497\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e89\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSep-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3,4,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOct-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1038\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e977\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNov-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8,9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e876\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e851\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e490\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e93\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDec-21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10,11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e961\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJan-22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e986\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e954\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e528\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e507\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eNote: NA\u0026thinsp;=\u0026thinsp;Not available\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eFidelity and quality of dose delivered\u003c/h2\u003e \u003cp\u003eProgram records documented in the quarterly progress reports captured the delivered dose. The reports reveal that both models delivered the intended dosage, i.e., 12 group sessions in HD and 4 group sessions in LD. The intervention was rolled out in April 2021 for HD and in May for LD, but disrupted due to COVD-19 and other logistic concerns in the camps. The project resumed in August 2021. The team delivered the remaining 11 HD sessions once every 15 days, while they delivered the 3 LD sessions once every 2 months. Regarding quality, we collected data on the interactions of the CF with the caregivers during the group sessions using 3 items (respect, listening carefully, using understandable language). Among the 3 items, we found a significant difference between HD and LD: CF treated caregiver with respect. In HD, 60% reported \"most of the time,\" compared to 51% in LD (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). A similar difference was seen in overall satisfaction with the CF: 57% in HD vs. 43% in LD were highly satisfied.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality of the dose delivered as reported by the caregivers\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh dose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eLow dose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction with the community facilitator\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e180 (57.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e103 (42.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.006\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e126 (40.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e131 (54.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHe/she treated the family with respect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e189 (60.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e122 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.024\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome of the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e116 (36.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e102 (42.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHe/she listened carefully to the family\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e195 (62.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e124 (51.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome of the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e108 (34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e106 (44.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHe/she spoke to the family in a manner that was easy to understand\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMost of the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e191 (60.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e120 (50.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSome of the time\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e115 (36.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e113 (47.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c7\" namest=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"7\"\u003eNote: Data is presented as N (%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe above findings triangulate with the qualitative data. Caregivers from the HD group appreciated the skills of the CF and were pleased with the way they interacted with them.\u003c/p\u003e \u003cp\u003e \u003cb\u003e\u0026ldquo;\u003c/b\u003e \u003cem\u003eCommunity Facilitators were so much skilled and delivered sessions very well\u003c/em\u003e.\u0026rdquo; [Mother, High dose, camp]\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThey were respecting each of us and they were encouraging us to participate\u003c/em\u003e.\u0026rdquo; [Mother, High dose, camp]\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;They were taking care of our children before joining us for video sessions\u003c/em\u003e\u0026rdquo; [Mother, Low dose, host]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA mother was pleasantly surprised at the knowledge of the CFs while one was pleased with the fact that they were similar to them.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI wonder when they learnt all they taught us.\u003c/em\u003e\u0026rdquo; [Mother, High dose, camp]\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;It was so great to see same refugees as us, conducting sessions.\u003c/em\u003e\u0026rdquo; [Mother, High dose, camp]\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI was so happy because the CF was my neighbour, and I could consult her easily\u003c/em\u003e\u0026rdquo;. [Mother, Low dose, host]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSimilar sentiments were shared by the fathers about the CF.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eFacilitators were able to respond to all questions and showed confidence and clarity in the training to the audience.\u003c/em\u003e [Father, HD host, FGD]\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe facilitators were able to communicate effectively, and participants appreciate the way messages were delivered in training.\u003c/em\u003e [Father, HD host, FGD]\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eIn addition, the facilitators could use phone to call the parents or reach out to them through village leader.\u003c/em\u003e [Father, HD host, FGD]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDose received\u003c/h2\u003e \u003cp\u003eImplementation data on group sessions indicated that for LD, 85% of the families attended 25\u0026ndash;50% (1\u0026ndash;2 sessions) of the delivered dose, while in HD, the majority of the caregivers attended about 50\u0026ndash;75% (5\u0026ndash;8 sessions) of the delivered dose (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). When questioned about what the most enjoyable part of the group sessions was, three-fourth of the caregivers in both intervention groups responded part 1: interacting only with caregivers. In contrast to group sessions, the dose received for home visits was strikingly low with more than 50% of the caregivers not having received even a single home visit. A higher number of caregivers in the host setting reported receiving no home visits compared to camp setting (75% vs. 30.4% in HD and 61.5% vs. 49.6% in LD). The overall satisfaction with the programme was higher for the HD compared to LD with 63.7% caregivers, reporting being \u0026ldquo;highly satisfied\u0026rdquo; compared to 45% respectively.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuantitative evidence on dose received\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh dose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLow dose\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;240\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDose received (exposure)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of group sessions attended*\u003c/p\u003e \u003cp\u003eNever\u003c/p\u003e \u003cp\u003e1\u0026ndash;2 sessions\u003c/p\u003e \u003cp\u003e3\u0026ndash;4 sessions\u003c/p\u003e \u003cp\u003e5-8 sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.6)\u003c/p\u003e \u003cp\u003e6 (1.9)\u003c/p\u003e \u003cp\u003e22 (7.0)\u003c/p\u003e \u003cp\u003e284 (90.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (3.8)\u003c/p\u003e \u003cp\u003e206 (85.8)\u003c/p\u003e \u003cp\u003e19 (7.9)\u003c/p\u003e \u003cp\u003e6 (2.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo. of home visits received\u003c/p\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e174 (55.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e132 (55.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;2 session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (20.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e87 (36.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u0026ndash;4 session\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e47 (15.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;8 sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (8.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReceived SMS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (29.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eListened to the radio programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e173 (55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.356\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePart of the group sessions most enjoyed\u003c/p\u003e \u003cp\u003eECD corners\u003c/p\u003e \u003cp\u003ePart 1: only with caregivers\u003c/p\u003e \u003cp\u003ePart 2: Video activities with caregivers and children\u003c/p\u003e \u003cp\u003eAny other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5 (1.6)\u003c/p\u003e \u003cp\u003e232 (73.9)\u003c/p\u003e \u003cp\u003e52 (16.6)\u003c/p\u003e \u003cp\u003e25 (8.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (2.5)\u003c/p\u003e \u003cp\u003e176 (73.3)\u003c/p\u003e \u003cp\u003e41 (17.1)\u003c/p\u003e \u003cp\u003e17 (7.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.867\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDose received (satisfaction)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfaction with the 3C programme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVery satisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e200 (63.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108 (45.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSatisfied\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e106 (33.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e127 (52.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eNote: Data is presented as N (%)\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e*Total no. of sessions for high dose was 12 and for low dose 4.\u003c/p\u003e \u003cp\u003eQualitative data from the interviews revealed that the caregivers\u0026rsquo; engagement with the content and enactment on the advice from all stakeholders including mothers, fathers, faith leaders, CFs and 3C programme team (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). The engagement with the 3C intervention yielded various benefits, such as changes in parenting beliefs and practices, particularly testimonials from families with children with disabilities, and, importantly, a sense of community.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQualitative evidence about dose received\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChange in parenting beliefs and practices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMy niece I live with I\u0026rsquo;ve started to care and treat her well after joining this program before I though as I am not her father, I don\u0026rsquo;t care\u003c/em\u003e. [CF, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes, we know about the program, and we learned how to care a child with few means that we have, and we have realized that supporting the kid allows her/him to develop holistically\u003c/em\u003e! [Mother, HD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe thought we love our children, but we came to know that were abusing them by beating and terrifying them\u003c/em\u003e! [Mother, HD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI always felt that I can\u0026rsquo;t get time to talk to my children, feeling always busy, but after 3Cs session I got the importance to talking to them, listening to their stories, their frustrations. Now I do my best and I am getting time to talk to them even play with them\u003c/em\u003e. [Mother, HD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI am feeing now that I am a supportive mother\u003c/em\u003e. [Mother, HD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI am putting in practice what I learnt, not only at home but also at ECD centre where I work as a cook\u003c/em\u003e. [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI used to leave home and let my kid crying but now I play with her and leave her playing with other children I shared with other members of the family so that all of us can care the little ones\u003c/em\u003e. [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eBefore the training, I was in bad relationship with my wife, but for the sake of children \u0026lsquo;well-being\u0026rsquo;, I always come home early and have good time with my wife and children.\u003c/em\u003e [Father, HD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI did observe some changes, when I was visiting families and just in the few time I spent there, I realized that between children and parents the relationship and the way they are communicating has changed positively. Example: In quartier 5 there is one Dad who was beating children for any mistake and children did not like him at all. Through different visits I tried to show him how he is abusing his own children and I made my visit consistent. There is a week now his children came to see me and said: thank you very much Pasto, Dad is no longer beating us.\u003c/em\u003e [Faith leader 2, IDI]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUptake of the intervention and responsiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eIn my daily work I deal with parents and I could use all of the opportunities to talk to them on this. During our reconciliation program that gathers genocide survivors and those who committed genocide, parenting was one of the topics and we discussed about this\u003c/em\u003e [the 3C programme] \u003cem\u003eseveral times.\u003c/em\u003e [Faith leader 1, IDI]\u003c/p\u003e \u003cp\u003e\u003cem\u003eUsually, the responsibility of parenting was assigned to mother but as fathers we \u0026lsquo;re surprised to hear how the role of father is key in caring for children\u003c/em\u003e. [Father, HD host, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecommending to families and friends\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eI shared the learning with my neighbours who have not been able to attend sessions\u003c/em\u003e. [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI shared the new learning with other members of the family so that all of us can provide better care the little ones\u003c/em\u003e. [Mother, LD camp, FGD].\u003c/p\u003e \u003cp\u003e\u003cem\u003eI shared\u003c/em\u003e [the messages] \u003cem\u003ewith my neighbours who have not been able to attend sessions.\u003c/em\u003e [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI shared with my neighbour who used to quarrel with her children so often and I told her about the abusive relationship. . .she is now improving at least as neighbours we are no longer hearing quarrels from their house.\u003c/em\u003e [Mother, HD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI did share with my husband\u003c/em\u003e. [Mother, LD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI did share my older children\u003c/em\u003e. [Mother, LD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI did share with my closest neighbour who used to beat her son\u003c/em\u003e. [Mother, LD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI told to my neighbour who was beating the child that, the stick hurts but do not correct/ help change behaviours. Now, he knows how to discipline the child appropriately.\u003c/em\u003e [Father, HD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eI tell my neighbours how important to hug affectionately the children and show them love when back home.\u003c/em\u003e [Father, HD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eOne of my neighbours used to quarrel with her wife, but I approached him and let told him that their conflict is affecting the children, and now they have stopped quarrelling\u003c/em\u003e. [Father, HD camp, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTestimonies from families with children with developmental issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOne of the caregivers who has 3 years kid who can\u0026rsquo;t talk yet she took the kid to different doctors and the last doctor they visited in Kigali had told them that the only medicine is to talk so often to the kid, when we are discussing the importance of talking to children she cried and revealed that in front of others\u003c/em\u003e! [CF, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eOne the families who has a child with disability, after getting the sessions, testified how they changed the way they were treating that kid and said: before the sessions we had we couldn\u0026rsquo;t allow her to have meals with us, she was served the last and we couldn\u0026rsquo;t have some conversations with her\u003c/em\u003e. [CF, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeliefs and practices about corporal punishment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOne of the caregivers testified that \u0026ldquo;after getting the session and know the importance of talking, listening and playing with children, now there is a big difference as he thought being a good parent is to be serious every time and beating children seriously\u003c/em\u003e\u0026rdquo; [CF, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eOne father whose wife lives with mental disabilities said that he was so hard to his children to the extent they were fearing him very much and loved the house helper more than their Dad. Now I have started playing with them, talking and listening to them so often and I can see now that there is a great relationship and love among us.\u003c/em\u003e [CF, FGD]\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eI am no longer beating my child and telling her bad words\u0026rdquo;, one the mothers testified\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eI wish my parents could have had these sessions, cause even now that I have my own children, I do remember all f the bad words they were always telling us. Now with the sessions that I received I talk to my children often and we have developed the friendship\u003c/em\u003e. [Mother, HD camp, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSense of community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eOne the caregivers who lost her 12-year kid, others put some funds together as a group paid a visit to comfort the family\u003c/em\u003e! [CF, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eEven the relationship among caregivers improved so much, 2 of the caregivers had issues between them and they found themselves in the same group session and little by little they came to understanding each other and getting back to socialize.\u003c/em\u003e [CF, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote: CF\u0026thinsp;=\u0026thinsp;community facilitator, FGD\u0026thinsp;=\u0026thinsp;focus group discussion, HD\u0026thinsp;=\u0026thinsp;high dose, LD\u0026thinsp;=\u0026thinsp;low dose, IDI\u0026thinsp;=\u0026thinsp;in-depth interview\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eEnablers and challenges\u003c/h2\u003e \u003cp\u003eSeveral factors were identified as facilitating and or challenging the intervention delivery by the community facilitators and mentors. These included viewing the project as an opportunity to serve the community, benefiting from professional development provided by the project team, and having a strong relationship with the community [Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEnablers and challenges shared by CFs and mentors for intervention delivery\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCommunity Facilitator\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMentor\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eServing their community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eThe greatest motivation was to train members of our communities/ our relatives our neighbours and see them changing their behaviours on the way they treat their children\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eRespect and love from caregivers and\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eFeeling that I am providing my support in my community behaviour change was another great motivation\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe enjoyed seeing them putting into practice what they learnt\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eWe built good relationships with caregivers\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCaregivers are appreciating us so much up to know\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eYes, and very much, testimonies and success stories on behaviour change from the caregivers of my own community were pushing me to continue\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eThe trust from my community has upgraded\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eCaregivers\u0026rsquo; attendance\u003c/em\u003e was also motivating\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProfessional support and development opportunities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eProject staff were supporting\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe had all of the materials we needed\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe were getting incentives regularly\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eSkills improvement\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eYes, they built our capacity (before joining 3Cs, I couldn\u0026rsquo;t stand in front of people, but now I am so much confident I can face any audience)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe received monthly incentives ( I have some savings and I am so happy for that)\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eProject staff appreciated our efforts\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eRegular supervision\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrengthening relationship\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eThe relationship with built and maintained (with families). By home visit we could interact more and get to know them better and be able to support\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003ePreparing sessions together, anticipate questions from caregivers and try to answer all of them as a group\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003ePraising the person before saying areas of improvement\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eLetting them know that if I enter for observation, it\u0026rsquo;s a normal thing not playing the policeman\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBeing from the same community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eBeing in the same community supported us to make informal visits and supervision\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCuriosity of the caregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFathers themselves were curious to know what the mothers having been learning and some of them were asking about the topics learnt\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eChallenges\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCultural beliefs\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMost of the fathers still think that beating children is the best parenting practice\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eThe relationship has been changing all over the sessions as it wasn\u0026rsquo;t easy from the beginning regarding providing feedback to our colleagues/friends, neighbours.. .but as we continued to be supported by project staff, CF got to understand that the purpose is to improve on sessions delivery\u003c/em\u003e\u003c/p\u003e \u003cp\u003e\u003cem\u003eProviding constructive feedback on the 1st and 2nd session wasn\u0026rsquo;t easy, facilitators thought we were blaming them\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContamination of the interventions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWe have not been able to explain to caregivers in low dose why they are not getting the same number of sessions like those in high dose\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003eNote: CF\u0026thinsp;=\u0026thinsp;community facilitator\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe intervention manager also identified the community-based nature of the intervention staff as a strength.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWe recruited the CFs with the help of a local NGO, and we made sure they were from the community. That helped them to build a relationship with the community.\u0026rdquo;\u003c/em\u003e [Intervention manager, IDI]\u003c/p\u003e \u003cp\u003eSimilarly, professional development of the staff was a motivator for the mentors and the CFs, but also for the project management as expressed by the manager in the interview.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eYou can\u0026rsquo;t imagine, I am so much happy, (Q: Being an educationist) yes being an educationist.\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eSeeing people growing and improving, it really gives so much excitement, and during the\u003c/h2\u003e \u003cp\u003e \u003cem\u003esessions for them to \u0026hellip; testify\u0026hellip;\u003c/em\u003e [Project manager, IDI]\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eRecommendations\u003c/h2\u003e \u003cp\u003eSeveral recommendations emerged from the qualitative interviews from the stakeholders around father\u0026rsquo;s engagement, similar advice for children of older age, need of greater number of sessions in the low dose group and the continuation of job for the CFs (Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRecommendations from the stakeholders about the programme\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuote\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFather engagement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eFathers want to receive the same package as mothers so that they can support their children confidently\u003c/em\u003e. [CF, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eGiving fathers the same number/same content as what we got as fathers attended only 1 session\u003c/em\u003e. [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eGive fathers same sessions as mothers\u003c/em\u003e. [Mother, LD camp, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeed for more and customized sessions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eWe wish we could get refreshers.\u003c/em\u003e [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe want to receive many sessions as others who got many.\u003c/em\u003e [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eRefresher training should be organised at certain time intervals\u003c/em\u003e. [Father, HD host, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eIncrease faith leader meetings.\u003c/em\u003e [Faith leader 2, IDI]\u003c/p\u003e \u003cp\u003e\u003cem\u003eTo get the same content for children upper 5 years, it\u0026rsquo;s not easy to raise them as well\u003c/em\u003e. [Mother HD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eWe want sessions for kids above 5 years.\u003c/em\u003e [Mother, LD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eHave sessions for only single mothers.\u003c/em\u003e [Mother, LD camp, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDelivery strategy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eTo invite both mothers and fathers and get the same sessions.\u003c/em\u003e [Mother HD camp, FGD]\u003c/p\u003e \u003cp\u003e\u003cem\u003eTo conduct sessions to both parents/caregivers in the family, so that they can put into practice together what they learn\u003c/em\u003e. [Faith leader 1, IDI]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eContinued job opportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eContinuing this job could be the great thing for us and continue contributing to their behaviour change.\u003c/em\u003e [CF, FGD]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote: CF\u0026thinsp;=\u0026thinsp;community facilitator, FGD\u0026thinsp;=\u0026thinsp;focus group discussion, HD\u0026thinsp;=\u0026thinsp;high dose, LD\u0026thinsp;=\u0026thinsp;low dose, IDI\u0026thinsp;=\u0026thinsp;in =\u0026thinsp;depth interview\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe objective of the study was to present the implementation evaluation findings of an intervention delivered in a humanitarian setting in Rwanda, in high and low dose. A prior evaluation of 3C, assessing its impact, had shown the intervention\u0026rsquo;s effectiveness in promoting early learning practices, responsive feeding and attitude towards corporal punishment [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Data about adoption of practices in this study aligns with the previous findings.\u003c/p\u003e \u003cp\u003eWith respect to fidelity of dose delivered, majority of families received at least 50% of the intended dosage for group sessions in both high and low dose groups. However, for the home-visits, more than half of the families reported that they had never received one. The programme records indicate over 90% of expected families attending the group sessions. This means that the desired change in practices was achieved with delivering the intended dosage for group sessions, with minimal home-visits. Studies using groups as the delivery modality have found benefits for child development and practices. A randomized controlled study in Kenya found that group sessions resulted in greater benefits compared to a mix of groups and home visits, when compared to the control group. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] While, another randomized-controlled study in India examining the effects of groups vs. home visits found no difference in the effect size of both delivery strategies [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Similarly, a trial in Bangladesh found integration of a group-based intervention in a public health system to be effective for ECD outcomes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe low delivery rate of home visits can be attributed to the challenges of delivering home visit, especially when workforce is voluntary, and burden is high [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. This challenge has been reported from other at scale studies e.g., in a study in Colombia, 34% of all targeted families had not received any visits [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnother finding was that families reported the first half of the group session (which the program team had assumed would be in favor of Sesame Workshop sessions) as the most enjoyable part. This could be interpreted as an opportunity for caregivers to have a safe and secure shared space for learning and sharing. Similar observation was reported by another study where the sense of \u0026lsquo;comradery\u0026rsquo; and opportunities for peer learning was appreciated by the participant mother in group session [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. While families from both groups were very satisfied with the programme and the CF, the families in the high dose group had a slightly higher percentage. This could be related to the fact that CFs in HD group had more sessions and time to build a relationship compared to the LD groups.\u003c/p\u003e \u003cp\u003eThe enablers reported by the intervention delivery team (CFs and mentors) were related to opportunity for professional development and serving the community. The growth of the teams acted as motivator for the project team too. These factors i.e., a comprehensive skill-based training and relationship with the caregivers have been found important in an implementation evaluation of their pilot RCT by other community-based studies [\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe 3C study has several strengths. Firstly, it is one of the few studies to deliver a nurturing care intervention in a humanitarian setting, highlighting its relevance, feasibility and potential impact in such contexts. Secondly, the study collected data on implementation evaluation, providing valuable insights into the delivery processes of the intervention, which can inform future program planning and implementation in similar settings. Additionally, the study used a mixed-methods approach, combining quantitative and qualitative data, to provide a comprehensive understanding of the intervention's implementation and its effects. There were several limitations of the study. The qualitative data was collected by the intervention staff due to budget constraints, which can induce bias. However, they were not involved with the data analysis. The data from both quantitative and qualitative sources was collected toward the end. Ideally, we would have liked data throughout the project cycle to inform the process of implementation. Also, thought checklists to observe the quality of intervention (groups and home visits) were provided, they were not used due to the workload of the mentors and lack of training by project officers. Nonetheless, the findings are very valuable for the field of ECD interventions specifically the benefits of the programme with different dosages.\u003c/p\u003e \u003cp\u003eThe study's recommendations for scaling up the intervention in similar settings include: recruiting intervention delivery staff (CFs) from the community; providing professional development opportunities for CFs; offering mentorship and supportive supervision through in-person and social media contacts; focusing on building relationships with the community and modeling the same for CFs; using group sessions as the main delivery modality with home visits for vulnerable families; leveraging contacts with faith leaders to deliver key messages; continuing to distribute learning items like toys to families; and ensuring project progress reports include a summary of intervention delivery features beyond attendance in group sessions. These recommendations aim to enhance program effectiveness, sustainability, and cost-effectiveness. With respect to monitoring and evaluation, we believe the team\u0026rsquo;s capacity (ability to record data, interpret, report) is crucial for ensuring ECD programs are not just effectively implemented but also evaluated, and for future similar initiatives.\u003c/p\u003e \u003cp\u003eIn conclusion, while the nurturing care program showed acceptability and engagement from delivery staff, challenges in achieving fidelity to intended dosage and home visitation were noted. Continuous monitoring and adaptation of delivery strategies are essential for improving early childhood development outcomes in similar contexts.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003cstrong\u003eEthics Approval and consent to participate\u003c/strong\u003e \u003cp\u003e The study was approved by the Institutional Review Board of College of Medicine and Health Sciences, University of Rwanda (Approval No. 180/CMHS IRB/2022). Informed consent was obtained from the head of the household (legal guardian of the participants) for participation in the study. Research activities were conducted in accordance with the institutional guidelines.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003c/p\u003e\u003cp\u003e \u003ch2\u003eCompeting interests\u003c/h2\u003e \u003cp\u003eAuthors have no competing interests to declare. MAR was contracted as an external consultant for the evaluation.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe study was co-funded by USAID (Award No. SPRMCO20CA0158) and World Vision US.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eVS: conceptualization, methodology, funding acquisition, supervision, writing-original draftAT: methodology, writing-review and editingMU: methodology, investigation, data curation, project administration, writing-review and editingAG: investigation, writing-review and editingJAH: investigation, writing-review and editingJSS: resources, writing-review and editingCF: funding acquisition, resources, writing-review and editingMAR: formal analysis, writing-original draft\u003c/p\u003e\u003ch2\u003eAcknowledgments\u003c/h2\u003e \u003cp\u003eThe authors would like to express their sincere regard to the families who participated in the study. We are grateful to the community facilitators who implemented the intervention and the enumerators who collected the data. We also acknowledge support of World Vision Rwanda National Office and UNHCR for conducting the study.\u003c/p\u003e\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e \u003cp\u003eThe datasets generated and/or analysed during the current study are not publicly available given the sensitive nature of information but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eShah S, Lombardi J. Editorial Note. 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BMJ Open. 2020;10(4):e032134.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"nurturing care, humanitarian setting, implementation evaluation","lastPublishedDoi":"10.21203/rs.3.rs-4141378/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4141378/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: In a humanitarian context in Rwanda, a nurturing care parenting program was delivered in high and low doses, revealing similar changes in care practices compared to the control group but no significant improvements in early childhood development outcomes. This study examines program implementation to understand delivery processes.\u003c/p\u003e\n\u003cp\u003eMethods: We employed Proctor’s implementation outcomes, including measures of acceptability, fidelity, and quality of dose delivered. A customized questionnaire was administered post-intervention by trained research assistants, and qualitative interviews were conducted to explore the experiences of families, the delivery team, and community stakeholders. Additionally, program monitoring and documentation, such as monthly reports, were included in the analysis. Qualitative analysis followed a deductive approach.\u003c/p\u003e\n\u003cp\u003eFindings: Implementation data from caregiver surveys indicated that the majority of families received 50% of the intended dosage for group sessions in both the high and low dose arms. Program records showed that over 90% of eligible caregivers attended the sessions, with families expressing a preference for the shared space and activities during the first half of the group sessions. However, in terms of home visits, more than half of the families had never received one. Qualittaive data revealed acceptability of the intervention and professional development opportunities through mentorshp as key to engagement of the delivery staff.\u003c/p\u003e\n\u003cp\u003eConclusion: Continuous monitoring and adaptation of delivery strategies are essential for improving early childhood development outcomes in humanitarian settings like Rwanda.\u003c/p\u003e","manuscriptTitle":"Implementation evaluation of a nurturing care intervention in a humanitarian setting in Rwanda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-03-27 09:29:31","doi":"10.21203/rs.3.rs-4141378/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"154959630560068724939437645619499030451","date":"2024-11-19T14:07:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337684500118885891247537173859041265512","date":"2024-09-10T12:58:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"259689506664548876068833386581294906683","date":"2024-09-10T12:53:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"cf0374f0-2a59-480b-b0a9-bba81489d5a4","date":"2024-04-19T14:37:24+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-04-19T14:22:51+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-03-23T05:36:25+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-03-23T05:36:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Conflict and Health","date":"2024-03-21T07:02:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"conflict-and-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"conf","sideBox":"Learn more about [Conflict and Health](http://conflictandhealth.biomedcentral.com/)","snPcode":"13031","submissionUrl":"https://submission.nature.com/new-submission/13031/3","title":"Conflict and Health","twitterHandle":"@Conflict_Health","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2327be1b-7b68-47db-8498-e57032ab48ed","owner":[],"postedDate":"March 27th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T15:08:46+00:00","versionOfRecord":[],"versionCreatedAt":"2024-03-27 09:29:31","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4141378","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4141378","identity":"rs-4141378","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}