RWA Resources Kap

a
Knowledge, Attitudes
& Practices
Assessment on Early Nurturing of Children Report
Knowledge, Attitudes and Practices Assessment on Early Nurturing of Children Report
Ministry of Health, Rwanda and UNICEF Rwanda
Copyright @ Ministry of Health, Rwanda and United Nations Childrens Fund in Rwanda (UNICEF Rwanda)
March 2014
Permission is required to reproduce any part of this publication.

Please contact:
Ministry of Health
P.O. Box 84 Kigali, Rwanda
Telephone: +250 577458
Fax: +250 576853
Email: info@moh.gov.rw
Acknowledgements
This assessment was commissioned by the Ministry of Health and by UNICEF Rwanda and is the result of successful
collaboration between a number of organizations and individuals. The assessment was conducted by Ipsos, Uganda. The
research team was led by Virginia Nkwanzi-Isingoma with support from Nathaniel Mayende from Ipsos. Lead technical
support was provided by Dr Fidele Ngabo at the Ministry of Health, and by Dr Rachel Sabates-Wheeler, UNICEF Rwanda. We
would also like to acknowledge the generosity of all the women and men who devoted their time to sitting with enumerators
and answering the survey questions.
Cover photograph: UNICEF Rwanda 2011/Noorani

Design and print: Handmade Communications with technical support from Siddhartha (Sid) Shrestha
Knowledge,
Attitudes &
Practices
Assessment on Early
Nurturing of Children Report
UNICEF Rwanda 2011/ Noorani
FOREWORD 1
Foreword
T
he overall objective of this assessment is to provide a comprehensive picture of current
knowledge, attitudes and practices (KAP) in relation to the early nurturing of children
in Rwanda. A more immediate purpose is to inform major nationwide campaigns of the
Government of Rwanda. One such campaign is the Thousand Days in the Land of a
Thousand Hills campaign. The objective of this campaign is to improve the nutritional status of
vulnerable populations in Rwanda, to reduce morbidity and mortality, through a multi-sectoral
approach. Programmatically, the campaign creates awareness of the need to focus on available,
affordable and cost-effective solutions to improve nutrition during the first 1000 day window of
opportunity. The results of this assessment will also inform the design of the upcoming Violence
Against Children in Rwanda survey.
This KAP assessment gathered both qualitative and quantitative information covering a wide
range of topics including: knowledge and practices in relation to antenatal and postnatal care;
understanding childrens health and managing childrens illnesses and immunizations; child
feeding; how parents interact with their children; and KAP in relation to the discipline and
mistreatment of children.
The results point to a great need for further community education. This report recommends
better educating caregivers on how to properly care for their children in areas of nutrition,
hygiene, discipline and parenting practices, as well as ensuring improved attendance of antenatal
care services. It also points to the need to educate fathers more about the importance of their
involvement in child care. It is clear that radio plays an important role as a source of information
within the communities and this would be an ideal channel for sensitizing communities on
issues related to early nurturing. Community leaders and health workers are a useful resource
for conveying messages on child care, in addition to existing community forums where child
care issues are discussed.
We are convinced that by looking into the prevailing understanding and practices determining
early child care and nurturing in Rwanda, the findings of this assessment will guide readers,
planners and decision makers towards ensuring that all children can grow up in caring,
UNICEF Rwanda 2011/ Noorani

protective and nurturing families and communities.
Dr. Agnes Binagwaho

Minister of Health
2 Knowledge, Attitudes and Practices: Assessment on Early Nurturing of Children Report
Incamake
U
bu bushakashatsi bwakoreshejwe na Ministeri yUbuzima hamwe na UNICEF mu
Rwanda.1 Icyingenzi cyari kigamijwe ni ugushaka amakuru ku biriho byerekeye
ubumenyi, imyifatire, nimyitwarire bijyanye nuko ababyeyi barera ndetse nuko
umwana atera imbere. Abasubije ibibazo muri ubu bushakashatsi ni abarezi babana
bafite imyaka 6 nabatarayigezaho, hamwe nabajyanama bubuzima baturutse mu turere 15
twatoranijwe mu ntara uko ari 5 mu gihugu. Imibare yakusanyijwe hakoreshejwe kubaza imbona
nkubone mu ngo no kujya impaka mu matsinda. Ingo 2,000 ni zo zatoranijwe mu kubazwa
imbona nkubone, muri izo ngo habajijwe abarezi 2,000 bigitsina gore. Hiyongereyeho abarezi
600 bigitsina gabo batoranijwe muri izo ngo 2,000. Amatsinda 12 yagiriwe mo ibiganirompaka
10 yabarezi bigitsina gore na 2 yabarezi bigitsina gabo hamwe namatsinda 10 yabajyanama
bubuzima yagize ibiganiro-mpaka ku buziranenge.
Ibyagezweho bigaragaza ko abagore bafite ubumenyi kurusha abagabo ku bijyanye nuko
umwana yitabwaho, byumwihariko ku mwana ukiri mu nda ya nyina. Mu bijyanye no kwita
ku mwana ataravuka, kenshi usanga abantu bazi byinshi ariko bagakora bike kandi ibikenerwa
gukorwa birenze imyumvire yabarezi. Abarezi bashyikirana nabana mu buryo butandukanye,
harimo guhagatira, kuririmba no gucyina. Nyamara ubu bushakashatsi bwerekanye ko ari
abarezi bigitsina gore ababyeyi byumwihariko bashyikirana cyane nabana. Uruhare
rwumugabo rugarukira ku guhahira no kurinda urugo. Si kenshi usanga ababyeyi babagabo
bashyikirana nabana mu bijyanye no kugabura, gukina no kubana nabo mu bikorwa nko
kuririmba. Nyamara nkuko abasubije ibibazo babibona, hari ibyiza bizanwa nababyeyi
babagabo bakunda gucyina nabana babo, binongera umwuka mwiza mu rugo.
Umubare wababyarira kwa muganga uri hejuru mu miryango migari yakorewe mo
ubushakashatsi. Ni uburyo bugikeneye gushishikarizwa. Imibare yabana banditse mu buryo
bwamategeko yagaragaye muri ubu bushakashatsi iri hejuru yimpuzandengo yo mu rwego
rwigihugu. Ibi ariko ntibivuze ko iyandikishwa ryabana ryazamutse hejuru kurusha. Ababyeyi
bamwe babona ko iyo abayobozi mu midugudu babimenyeshejwe, umwana aba yanditswe
bityo ntibakurikire uko bikorwa neza kugira ngo umwana agire icyemezo cyamavuko.
Haracyakenewe rero kwigisha imiryango ku buryo bwo kwandikisha abana.
Mu gihe hari ibyiza byinshi bikorwa mu kwita ku mwana nyuma yivuka kuko ababyeyi bafite
ubushobozi bwo kwita neza ku bana babo ubumenyi ku bibazo bimwe na bimwe buracyari
buke. Urugero: abarezi bakina nabana batazi akamaro nuburemere byibyo bakora. Ibindi
bikorwa nko kuvura inzoka no gukingira nabyo birunvikana bikanakorwa mu baturage
bakozweho ubushakashatsi.
Ibyabonetse byerekana ko indwara nkizubuhumekero (inkorora, ibicurane), impiswi na
malariya ari byo bibazo byubuzima bisanzwe bigira ingaruka ku baturage bakoreweho
ubushakashatsi. Kuri izi ndwara, ahanini, abatanze ibisubizo baha abana babo imiti bafite
UNICEF Rwanda 2011/Mugabe
mu rugo nkibanze bityo bakivurira. Nyuma bitinze, kandi indwara idakize, nibwo bashaka
umujyanama wubuzima cyangwa bakajya ku kigo nderabuzima. Mu gihe abatangaga ibisubizo
1 Ubu bushakashatsi bwakozwe na Ipsos, Uganda. Itsinda ryabashakashatsi ryari riyobowe na Virginia
Nkwanzi-Isingoma abifashijwemo na Nathaniel Mayende ndetse na Collins Kweyamba. Inkunga
yikoranabuhanga yatanzwe na Dr Fidele Ngabo wo muri Ministeri yUbuzima hamwe na Rachel
Sabates-Wheeler ubarizwa muri Section ishinzwe Politike yimbonezamubano nubushakashatsi muri
UNICEF-Rwanda.
INCAMAKE 3
bagaragaza ubumenyi buhagije mu guhangana nindwara zabana, haracyari kumva nabi

nubumenyi buke ku mpamvu zindwara zimwe na zimwe nuburyo zavurwa. Ibyabonetse
byerekana kandi ko urwego rwimyumvire ku isuku nisukura byateye imbere ariko kubishyira
mu ngiro biracyari hasi. Bityo rero gushishikariza abantu gushyira mu ngiro isukura nyaryo,
nko gukaraba intoki nyuma yo kwituma no gukaraba intoki mbere yo guteka no kugaburira
uruhinja.
Ku byerekeye kugaburira umwana, ibyabonetse muri ubu bushakashatsi birasaba ko abarezi
basobanukirwa neza ubwoko bwindyo nyayo ku bana. Abana bataruzuza amezi 6 muri rusange
baronswa gusa; mu basubizaga ,abenshi batanga imfashabere ku mezi 6 cyangwa hagati yamezi
6 na 12. Iyo umwana atangiye guhabwa imfashabere, ingo zifite ubushobozi butandukanye mu
mutungo zigaburira abana ku buryo butandukanye. Abana babakene bakunze kugaburirwa
ibinyamisogwe nigaburo ridahagije, ridahinduka kandi ridafite intungamubiri za ngombwa.
Ubu bushakashatsi kandi bwasanze imibare yabana bari mu byiciro biri hasi mu bukungu
batabona amafunguro gatatu ku munsi. Ubu bushakashatsi bwavumbuye ikigereranyo
cyubukene cya 47.6 % mu ngo zabatanze ibisubizo. Icyiciro cyubukene gikomatanyijwe
nimirire mu miryango ituye mu byaro bishobora kuba ari byo bitera kuzingama kwabana
nkuko bigaragara mu nyandiko zo mu rwego rwigihugu. Kuzamura imibereho yimiryango
mu byaro bizafata intera ndende kugirango habe impinduka.
Abarezi mu baturage bagezweho nubu bushakashatsi ntibasigira abana babo abandi babitaho.
Aho bibaye abana basigaranwa nabakecuru mu ngo, abandi bana bakuze, cyangwa abaturanyi.
Abana bitabwaho bihagije bageze ku myaka yishuri cyangwa igihe bajyanywe mu mashuri
yincuke. Hanavuzwe ibigo byita ku bana bifashwa nimiryango itegamiye kuri Leta, nibigo
byabihaye Imana, ariko ibi ntabwo ari itegeko kuri bose, ni umwihariko.
Ibyabonetse byerekana ko abana batozwa ubwitonzi bakubitwa agashyi, babatonganya, cyangwa
baganirizwa n ababyeyi. Uretse ibi, abarezi berekanye ko inzira nziza yo gutoza umwana
ubwitonzi ari ukumuvugisha no kumugira inama utifashishije uburyo bubabaza umubiri. Mu
biganiro byo mu matsinda, abarezi nabajyanama bubuzima nabo bavuze ko igihano kibabaza
umubiri kitakigira akamaro. Ariko rero ibyakusanyijwe byose birerekana ko hakiri henshi
bagihanisha abana ibihano bibabaza umubiri. Hakenewe gukangurira umuryango cyane
uburyo buboneye bwo gutoza abana imico myiza kugira ngo duhindure buryo bubi bwo gutoza
abana ubwitonzi bukorwa ubu.
Ibyabonetse bigaragaza ka hakenewe cyane kwigisha umuryango kurushaho. Iyi raporo irasaba
ko abarezi bahugurwa neza kurushaho ku byerekeye uko bita ku bana bashinzwe, ndetse no
kunoza uko ababyeyi bagana aho bisuzumishiriza batwite. Inerekana ibikenewe mu guhugura
ababyeyi babagabo ku buremere nagaciro byo kugira uruhare mu kwita ku bana. Bigaragara
neza ko radiyo ifite akamaro gakomeye nkisoko yamakuru mu miryango kandi ko yaba
umuyoboro mwiza wo guhugura imiryango. Abayobozi bibanze nabajyanama bubuzima
bakoreshwa mu gukwirakwiza ubutumwa bwerekeye uko umwana yitabwaho, byiyongera ku
mahuriro yo mu miryango aho ibibazo byo kwita ku bana bivugirwa.
Executive Summary
T
his assessment was commissioned by the Ministry of Health and by UNICEF Rwanda.1
Its main objective was to generate information on existing knowledge, attitudes and
practices (KAP) in relation to parenting and child development. The target respondents for
the assessment were caregivers of children aged 6 years and below, as well as community
health workers from 15 districts in the 5 provinces of the country. Data were collected using face-
to-face household interviews and focus group discussions. The target sample for the household
interviews was 2,000 households, within which 2,000 female caregivers were interviewed.
In addition, 600 male caregivers were selected systematically for interview from the random
sample of 2,000 households. Twelve focus group discussions were conducted (10 with female
caregivers and 2 with male caregivers) and 10 qualitative discussions were held with community
health workers.
The results show that women are more knowledgeable than men on matters to do with child
care, especially concerning pre-birth and antenatal care (ANC). In aspects of pre-birth and
antenatal care, knowledge often does not equate to practice and practice is higher than caregivers
understanding. Caregivers interact with children in various ways, including cuddling, singing
and playing. The assessment, however, shows that it is female caregivers especially mothers
who interact more with children. The role of the father is generally limited to that of breadwinner
and protector. It is rare to find fathers interacting with children in terms of feeding, playing, and
engaging in activities such as singing. There is, however, a positive perception towards fathers
who do play with their children as, according to the respondents, it fosters close family bonds.
The incidence of hospital delivery is high within the communities studied. This is a trend that
should still be encouraged. Incidences of child registration reported in this assessment are
higher than the national average. This, however, does not necessarily mean birth registration
is actually higher. It seems some parents consider the birth notifications given by community
leaders to mean the child has been registered so they do not follow the correct procedure to get
a birth certificate. There is, therefore, still a need to educate the community on the procedures
for child registration.
While positive after birth child care practice is high in that parents are mainly able to take care
of their children well knowledge on some of the issues is low. For example, caregivers play with
children without consciously thinking of the importance of such activities. Other practices, such
as deworming and immunization, are also understood and practised in the survey population.
The results show that diseases, such as respiratory infections (cough, flu), diarrhoea and malaria,
are the most common health issues that affect the population studied. These illnesses are
generally treated by self-medication where, as the first option, respondents give their children
medicine that they have in the house. Only later, and if the illness persists, do respondents
seek the services of a community health worker or visit a health facility. While respondents
are fairly knowledgeable about managing childhood illnesses, there are misconceptions and
gaps in knowledge with regard to the causes of certain illnesses and the best ways to treat them.
The results also show there are high levels of awareness regarding hygiene and sanitation, but
1 The assessment was conducted by Ipsos, Uganda. The research team was led by Virginia Nkwanzi-
Isingoma with support from Nathaniel Mayende and Collins Kweyamba. Technical support was
provided by Dr Fidele Ngabo at the Ministry of Health and by Rachel Sabates-Wheeler from the
Social Policy and Research Section, UNICEF Rwanda.
EXECUTIVE SUMMARY 5
the practice is still low. Therefore, a call to action is also needed to increase proper sanitation
practices, such as washing hands after using the toilet and before cooking food or feeding the
baby.
In terms of feeding, the results of this survey suggest that caregivers understand the correct type
of nutrition for children. Children below 6 months are generally breastfed exclusively, with most
respondents introducing complementary foods at 6 months or between 6 and 12 months. When
complementary feeding is introduced, households with different economic capabilities feed
their children differently. There is a prevalence of starchy foods being given to poor children and
a more limited diet in terms of variety and nutritional content. This assessment also finds that
a high percentage of children in the lower economic categories do not receive three meals a day.
This study registered a poverty level of 47.6percent among respondent households. The poverty
level, combined with the feeding regime of families in rural areas, may account for the stunted
growth of children reported in national literature. Improving the living standards of families in
rural areas will go a long way towards rectifying this situation.
Caregivers in the population assessed in this study do not ordinarily leave their children in the
care of other people. In cases where this is done, the children are left in the care of other older
females in the home or with older siblings or neighbours. Organized child care is restricted
to when children reach school age or go to nursery schools. There was also mention of child
care centres run by non-governmental organizations (NGOs) and faith-based institutions, but
this was the exception rather than the norm. Although caregivers generally indicated that the
best way to discipline a child is by talking and advising the child, without recourse to physical
methods, the findings show children are often disciplined through slapping, caning and/or
shouting, as well as by parents talking to the child. In focus group discussions, caregivers and
community health workers also expressed the view that physical punishment of children is no
longer seen as appropriate. However, the data collected indicate a high prevalence of the practice
of physically punishing children. There is a need to sensitize the community further on the
proper ways of disciplining children to help to change these disciplinary methods in practice.
The results point to a great need for further community education. This report recommends
educating caregivers better on how to care for their children properly, as well as ensuring
improved attendance at ANC services. It also points to the need to educate fathers more about
the importance of their involvement in child care. It is clear that radio plays an important role
as a source of information within the communities and this would be an ideal channel for
sensitizing communities. Community leaders and health workers can be used to pass along
messages on child care, in addition to existing community forums where child care issues are
discussed.
Contents
FOREWORD..................................................................................................................1
INCAMAKE..................................................................................................................2
EXECUTIVE SUMMARY................................................................................................4
LIST OF GLOSSARY iTEMS, ABBREVIATIONS AND ACRONYMS................................9
CHAPTER 1: Introduction..................................................................................... 10
CHAPTER 2: Research Methods........................................................................... 12
2.1 The target respondents....................................................................................................................12

2.2 Approach .........................................................................................................................................12
2.3 Sample distribution and respondent selection...........................................................................13
2.4 Data collection.................................................................................................................................14
2.5 Data analysis....................................................................................................................................15
2.6 Challenges.........................................................................................................................................16
CHAPTER 3: Literature Review.............................................................................. 17
3.1 Introduction.....................................................................................................................................17
3.2 Antenatal care and early childhood development......................................................................17
3.3 Postnatal care and early childhood development......................................................................18
3.4 Childhood growth and development...........................................................................................19
3.5 Barriers to positive early childhood development experiences................................................21
3.6 Policy issues in relation to early childhood development.........................................................22
CHAPTER 4: Study Findings...................................................................................23
4.1 Introduction.....................................................................................................................................23
4.2 Demographic characteristics of respondents..............................................................................23
4.3 General health problems affecting the community...................................................................26
4.4 Knowledge, attitudes and practices regarding hygiene and sanitation..................................32
4.5 Knowledge, attitudes and practices regarding child care from pre-birth to delivery..........33
4.6 Knowledge, attitudes and practices regarding child care after birth......................................38
4.7 Knowledge, attitudes and practices regarding deworming..................................................... 40
4.8 Knowledge, attitudes and practices regarding immunization................................................ 42
4.9 Knowledge, attitudes and practices regarding child registration........................................... 42
4.10 Knowledge, attitudes and practices regarding feeding........................................................... 43
UNICEF Rwanda 2011/Pirozzi
4.11 Knowledge, attitudes and practices regarding childparent interaction.............................49

4.12 Attitudes towards early childhood development......................................................................51
4.13 Knowledge, attitudes and practices regarding child learning................................................51
4.14 The fathers role in parenting.......................................................................................................53
4.15 Leaving children in the care of others........................................................................................55
4.16 Disciplinary measures and child abuse......................................................................................57
4.17 Communication and sources of information............................................................................61
CONTENTS 7
CHAPTER 5: Conclusions and Recommendations.......................................63
ANNEX 1: Tables ...................................................................................................... 67
Demographics .......................................................................................................................................67
Health issues affecting the community .............................................................................................70
Management of health issues ..............................................................................................................72
Antenatal and pre-birth care ..............................................................................................................73
ANNEX 2: Comparative analysis of the Rwandan KAP to the

KAP of other countries...................................................................................... 76
ANNEX 3: Selected Indicators, Disaggregated by District........................ 78
List of Tables
Table 1: Respondent distribution.....................................................................................................12
Table 2: Sample distribution.............................................................................................................14
Table 3: Index children in the sample.............................................................................................23
Table 5: Economic categories using multi-dimensional poverty indicators.............................25
Table 4: Poverty level by type of material used for the floor........................................................25
Table 6: Perceived health problems affecting the communities..................................................26
Table 7: Common health issues: A comparison between male and female...............................27
Table 8: Perceived health problems and the perceived causes.................................................... 28
Table 9: Actions taken by respondents to immediately respond to and treat
illnesses in their children...................................................................................................29
Table 10: Actions taken by respondents to treat childrens illnesses........................................ 30
Table 11: Treatment measures of various illnesses by respondents............................................31
Table 12: Hygiene knowledge vs practice absolutes......................................................................32
Table 13: Knowledge and practice in relation to pre-birth care for the mother and child.....33
Table 14: C omparing the knowledge and practices of male and female caregivers
during pregnancy............................................................................................................. 34
Table 15: Knowledge and practice of antenatal care.....................................................................36
Table 16: Place of delivery of index child disaggregated by economic category......................37
Table 17: Knowledge and practices regarding child care after birth..........................................39
Table 18: Deworming of children by province..............................................................................41
Table 19: Deworming of children by economic category............................................................41
Table 20: Reasons why respondents have never dewormed their children...............................41
Table 21: Reasons for lack of registration of children.................................................................. 42
Table 22: Foods given to children before breakfast..................................................................... 44
Table 23: Foods given to children for breakfast........................................................................... 44

Table 24: Foods given to children before lunch............................................................................ 45
Table 25: Foods given to children for lunch.................................................................................. 45
Table 26: Foods given to children before dinner.......................................................................... 46
Table 27: Foods given to children for dinner................................................................................ 46
Table 28: Foods regularly given to children 7 to 11 months old.................................................47
Table 29: Foods ordinarily fed to children aged 2 to 6 years...................................................... 48
Table 30: Activities done to develop childrens physical, emotional and mental abilities..... 50
Table 31: Activities done to stimulate children aged 3 to 6 years old........................................51
Table 32: Perception towards child development practices.........................................................52
Table 33: Importance of a fathers role in the development of their child................................53
Table 34: Methods of disciplining children aged 2 to 3 years old..............................................57
Table 35: Methods of punishing children aged 4 to 6 years........................................................58
Table 36: Attitudes towards physical punishment of children...................................................58
Table 37: The most common cases of child mistreatment in this community.........................59
Table 38: Sources of information.....................................................................................................62
Table 39: Household sample achievement by province................................................................67
Table 40: Household sample achievement by district..................................................................67
Table 41: Category of respondent demographics......................................................................... 68
Table 42: Disability status of female household respondents..................................................... 68
Table 43: Respondents level of education: overall....................................................................... 68
Table 44: Respondents level of education by economic level................................................... 68
Table 45: Age groups..........................................................................................................................69
Table 46: Respondents working status...........................................................................................69
Table 47: Respondents religion........................................................................................................69
Table 48: Households economic categories...................................................................................70
Table 49: The most common health issues affecting this community today............................70
Table 50: Groups of people who are most affected by health issues...........................................71
Table 51: Health problems that affect children 0 to 6 years.........................................................71
Table 52: In the past two weeks did any child below 6 years of age in this
household fall sick?...........................................................................................................72
Table 53: W hat were the symptoms of the illness that the child or children
suffered from?....................................................................................................................72
Table 54: What did you do immediately after you noticed the symptoms?..............................72
Table 55: What did you do to treat the condition?........................................................................73
Table 56: What mothers should do before birth to ensure a child is healthy...........................73
Table 57: What mothers should do after birth to ensure a child is healthy..............................74
Table 58: Where respondents went for ANC.................................................................................74
Table 59: Where a pregnant woman should go for ANC.............................................................75
Table 60: How many times should a pregnant woman go for ANC?.........................................75
Table 61: Where respondents delivered their index child............................................................75
LIST OF GLOSSARY ITEMS, ABBREVIATIONS AND ACRONYMS 9
List of Glossary
Items, Abbreviations
and Acronyms
ANC Antenatal care

Caregiver A person (aged between 18 and 49 years) who is in charge of
taking care of a child of 0 to 6 years
ECD Early childhood development
GoR Government of Rwanda
Index child the youngest child in the household between 1 and 6 years old,
whose findings are representative of all children in that household
KAP Knowledge, attitudes and practices
NGOs Non-governmental organizations
NISR National Institute of Statistics Rwanda
Older caregiver A person (aged 50 years and above) who is in charge of taking care
of a child of 0 to 6 years
ORS Oral rehydration salts
RDHS Rwanda Demographic Health Survey
UNICEF United Nations Childrens Fund

Chapter 1:
Introduction
I
n the context of the Joint Action Plan for the Elimination of Malnutrition, the Government
of Rwanda (GoR) requested that UNICEF Rwanda support an assessment of knowledge,
attitudes and practices (KAP) in relation to the early nurturing of children. This assessment
was conducted among parents and caregivers of children under 6 years old in 15 districts.
KAP studies are among well-established methodologies to investigate health behaviour, and are
widely used to gather information for planning public health programmes in a range of countries.
Few KAPs touch upon such an extensive and impressive array of issues as the Rwandan KAP
on Early Nurturing of Children (Hygiene and sanitation; Child care from pre-birth to delivery;
Child care after birth; Deworming; Immunization; Child registration; Feeding; Childparent
interaction; Early childhood development; Child learning; Parenting; Leaving children in the
care of others; Disciplinary measures and child abuse; and Communication and sources of
information).
The results reported here are in line with findings from similar KAP studies of other countries,
for example the 2009 Baseline survey of the KAP of parents/guardians on early childhood
development and primary education in Nepal found that the level of knowledge on all aspects
of early childhood development (ECD) was lower than the levels of attitude and practice.2 (See
Annex 2 for an overview of the KAP results in other countries.)
The overall purpose of the KAP assessment on the early nurturing of children was to document
existing attitudes and practices towards young children in order to inform the messaging of a
major nationwide campaign. The Thousand Days in the Land of a Thousand Hills campaign is
aimed at raising awareness of family and child feeding practices in the first one thousand days
of a childs life, which are critical to preventing stunting.
The findings presented in this report will also help to define appropriate family- and community-
level interventions to ensure the optimum well-being of children in their early years and to
contribute to Rwandas long-term vision for children and for national development.
Data were gathered on a range of issues, such as: health problems affecting families and how
these are managed; hygiene and sanitation; KAP in relation to child care from pre-birth to
delivery; and KAP in relation to childparent interaction, the care and protection of children,
the fathers role in child care and disciplinary measures. Data collected are disaggregated
according to the gender, age, economic category and location of respondents.
To achieve the overall purpose of this assessment, specific objectives were developed, including
UNICEF Rwanda/2011/Noorani
to:
document existing KAP on ECD and the family (parenting, nurturing, nutrition, health care
and hygiene, protection, and stimulation of children) in Rwanda;
identify vulnerabilities and gaps in KAP among different socio-economic groupings and
geographic areas of Rwanda;
generate baseline data on existing attitudes and practices on ECD and, thereby, create a
framework for monitoring progress;
2 UNICEF and Tribhuvan University Research Centre for Educational Innovation and Development
(CERID), Baseline Survey of the Knowledge, Attitude and Practice (KAP) of Parents/Guardians on Early
Childhood Development and Primary Education in Nepal, UNICEF Nepal Country Office, Pulchowk,
Lalitpur, April 2009, <www.unicef.org/nepal/KAP_study_ECD_and_Education.pdf>, accessed 13
March 2014.
CHAPTER 1: INTRODUCTION 11
provide essential data to assist in the formulation of key messages and the identification of
key areas of focus for the Thousand Days campaign and future initiatives, including the
Every Child Needs a Family campaign and the Violence Against Children in Rwanda
study.
Four chapters follow the Introduction of this report.
Research methods: This chapter explains the methods used in data collection and data
analysis, and how the findings are presented.
Literature review: This chapter presents an overview of relevant literature from studies
conducted elsewhere. This helps to put the findings into context. It also informed the
formulation of the tools that were used to collect data.
Study findings: The findings are presented in a thematic manner representing the core
objectives of the KAP. Findings are disaggregated by gender, age of children, caregiver
status, other demographics and province. While most of the findings are quantitative,
supportive qualitative comments have also been included.
Conclusions and recommendations: This chapter presents the main conclusions and
recommendations as a result of this assessment.
Chapter 2:
Research Methods
2.1 The target respondents
U
NICEF Rwanda aims to improve the well-being of all children, with a particular focus
on children aged 0 to 6 years. To improve the well-being of this group, the direct
target of UNICEF Rwandas interventions are the mothers and caregivers of children
aged 0 to 6 years and other people concerned about children of this age. The target
respondents for this study, therefore, largely comprised caregivers of children aged 0 to 6 years.
The respondents were distributed as follows:
Table 1: Respondent distribution
Target respondents Sample size Description

Caregivers 2,000 interviews with female caregivers Mothers and caregivers of children 0 to 6
years
600 interviews with male spouses of the
interviewed female respondents Pre-birth expectant mothers
12 focus group discussions with Post birth 0 to 2 years and 3 to 6 years
caregivers
Community health 10 qualitative discussions with community Community health workers and ECD staff
workers health workers
2.2 Approach
This survey used both qualitative and quantitative methodologies of data collection and
analysis. The approaches were informed by the research objectives, which required in-depth
understanding of attitudes and behaviour, at the same time as providing measurable statistics.
Two methods of qualitative data collection were used to gather data from different sets of
respondents: interviews and focus group discussions. Each focus group discussion comprised
a minimum of 8 and a maximum of 12 participants. The group discussions were conducted
among the general public, involving primary caregivers and expectant mothers, as well as
with community health workers. Twelve focus groups were held with caregivers (2 with male
caregivers and 10 with female caregivers) and 10 focus groups were held with community health
workers.
The focus groups were conducted in the following districts: Bugesera, Kayonza, Ngoma,
Rwamagana, Nyarugenge, Gakenke, Gicumbi, Rulindo, Nyamagabe, Ngororero, Nyamasheke,
Rubavu. Qualitative discussions with community health workers were held in 10 of the above
UNICEF Rwanda/2011/Noorani
districts and focus group discussions were held in all 12 districts.

To stimulate better responses and to identify respondents behaviour, knowledge, attitudes,
perceptions, motivations, feelings and fears, various techniques were used. These included
indirect probing and word associations.
Indirect probing: Direct probing was avoided, hence most questions were asked in third
person format, for example; What do people feel about ? How do people in this area feel
about violence against children or child abuse? What are some of the problems affecting
CHAPTER 2: RESEARCH METHODS 13
children in this community? Do people in this community go for antenatal care when they are
pregnant? How are children of 0 to 6 years treated in this community?
Word associations: The participants were asked what comes to their mind when they hear
about nurturing or child rearing. What word would they use to describe a given situation of
violence against children?
The focus group discussions were organized in venues that were convenient for the participants
to access and which provided privacy. The respondents were asked for their consent to the
interview to ensure they were providing information freely. The purpose of the study and its
objectives were explained to all respondents before the focus groups began. The focus group
discussions were conducted in Kinyarwanda by experienced and well-trained moderators. The
male groups were moderated by male moderators and female groups by female moderators
to encourage free and informal discussions. All the discussion guides were translated to
Kinyarwanda before being used for data collection.
With regard to quantitative data collection, an assessment was conducted among mothers and
caregivers of children of 0 to 6 years in 15 selected districts in all provinces of Rwanda. The
assessment was conducted at the household level comprising a sample of 2,000 households,
within which 2,600 interviews were conducted with both men and women.
The main objective of a sampling methodology for any national KAP study is to establish
reliable data that can be used to understand behaviour and practices and to provide learning to
inform national programme implementation. It is, therefore, important to extract a sample that
adequately represents the population of interest in the 15 districts. A sample of 2,000 households,
from which 2,000 female caregivers and 600 male caregivers were interviewed, was selected.
The sample size was determined using the formula:
D * 1.962 pq
n=
B2
Where:
n is the required sample size
1.96 is the z value at 95percent confidence interval
p is the proportion of children younger than 5 years old
q=1p
B is the margin of error (5percent) and
D is the design effect (1.5) the effect of multi-stage cluster sampling.
The sample size was approximated to 2,000 households with domain of analysis being five (five
provinces) and non-response rate of 10percent. This was approved by the National Institute of
Statistics of Rwanda (NISR).
2.3 Sample distribution and respondent selection
The 15 districts included in the study were recommended by UNICEF based on the district
that UNICEF intends to support to model ECD service provision and authorized by NISR.
NISR provided the final minimum sample size that had to be achieved for each district to
achieve valid results. Over-sampling enabled us to achieve the desired sample sizes for the study.
NISR selected the enumeration areas and provided a sampling frame for the interviews within
the areas.
Table 2: Sample distribution
No of households
Province District Villages Population (random
selection)
Total 7,456 4,572,828 2,000
East Bugesera 585 294,013 150
Kayonza 418 255,119 100
Ngoma 473 277,129 125
Rwamagana 472 256,147 125
Kigali City Nyarugenge 356 247,090 100
Gasabo 494 398,282 125
North Gakenke 617 334,236 175
Gicumbi 629 360,237 175
Rulindo 494 264,981 125
South Nyamagabe 536 311,808 150
Kamonyi 319 287,881 75
Ruhango 533 280,625 150
West Ngororero 419 311,834 125
Nyamasheke 586 344,222 150
Rubavu 525 349,224 150
This KAP assessment focuses on children of 0 to 6 years. The respondents selected, therefore, were
primary caregivers of children of 0 to 6 years. The study had a selection criterion to ensure that the
appropriate respondents were interviewed. The assessment targeted female caregivers, especially
biological mothers of the children in question. In addition to interviewing mothers, other
caregivers, such as expectant mothers, caretakers/relatives and grandmothers to children of 0 to 6
years, were also interviewed. For the female caregivers, biological mothers made up 83percent of
the sample, with biological fathers comprising 92percent of the male caregiver sample. Attributes
specific to caregivers/mothers and the index child were observed. These are attributes that have the
potential to affect the way a caregiver takes care of the child or the way a child is perceived by the
caregiver. The overall descriptive attributes measured include disability status, education of the
caregiver, age, income level and religion of the household in which the child grows up.
2.4 Data collection
Prior to data collection a scoping visit was conducted, which provided an opportunity for the
team to make contact with key stakeholders, especially at the central government level. This
included, among others, getting information about ECD initiatives which then informed the
implementation processes. In liaison with the Ministry of Health and UNICEF Rwanda, permits
to conduct the assessment were granted by the NISR.
The different tools used for data collection included:
1. discussion guides
2. key informant interview guide
3. health workers discussion guide
4. caregivers discussion guide
5. semi-structured questionnaire
6. female caregivers questionnaire
7. male caregivers questionnaire
8. structured observation questionnaire.
CHAPTER 2: RESEARCH METHODS 15
Data collection tools were developed, translated, pre-tested and approved by UNICEF Rwanda
before being used in the field. Recruitment and training of the field team was led by the manager
and field manager. Only those interviewers who had worked on similar tasks and could speak
and understand both the local language (Kinyarwanda) and English were recruited.
The team that conducted household interviews comprised 65 interviewers and 13 team leaders/
supervisors, who were trained for a period of seven days using structured interviewer manuals.
The training ensured that the team understood the objectives of the assessment, the methodology
and the research tools. The training covered the objectives of the study, dos and donts, fieldwork
protocol and identifying respondents, among other areas. UNICEF staff also participated in
some of the training sessions.
2.5 Data analysis
During the focus group discussions, recordings and notes were taken and transcripts were
produced on the basis of these. The transcripts were then used to produce grids for analysis and
report writing. These findings were then analysed to bring out prevailing opinions, attitudes,
behaviours and practices to support the findings from the quantitative phase.
The supervisors reviewed and submitted questionnaires from the field to the office for coding. In
this way, the findings from the questionnaires were captured verbatim and given numeric codes.
After the coding process, the questionnaires were scanned for data capture. All questionnaires
were labelled and verified for accuracy and consistency. At least 10percent of the captured data
was checked manually for accuracy and consistency.
The following steps were followed during data cleaning and analysis:
1. A tabulation and data-processing plan was developed before the completion of fieldwork
and shared with the lead researcher.
2. Data were captured by scanning the questionnaires using data capture software.
3. Data cleaning was done using the processing plan earlier provided and the final output of
tables was generated. These tables followed the flow of the questionnaire.
4. The tables were checked to verify consistency. The checking also highlighted areas where
more cleaning and analysis was required.
5. Final tables were generated that displayed absolute numbers, percentages, averages,
correlations and t-tests (where applicable).
6. The final SPSS (Statistical Package for the Social Sciences software) data sets were then
generated.
Significance tests
Apart from presenting the numeric frequency statistics on knowledge and practice, significance
tests done to ascertain whether the differences between knowledge and practice are significant.
In addition, further analysis was done using correlations to ascertain whether an increase in
knowledge would lead to a significant change in practice.
A t-test (significance test) was done on each attribute for knowledge and practice using =0.05.
The hypotheses in each of the cases were:
H0: There is no significant difference between the means of the two variables.
HA: There is a significant difference between the means of the two variables.
For example, in relation to the knowledge and practice on after birth behaviour, the attribute on
immunization is analyzed for knowledge (the respondent knows that it is important to immunize
the baby) and practice (the respondent actually immunized the child). The null hypothesis is
rejected if the significance (t-test) is less than . In the example given, the null hypothesis was
there is no significant difference between knowledge and practice on immunization. Therefore,

the alternative hypothesis, which indicated significant difference, holds true for this question of
the survey as a true reflection of the situation at the time of data collection.
In addition, further analysis was done using correlations to ascertain whether an increase in
knowledge would lead to a significant change in practice. In the example of knowledge and
practice on immunization, the two attributes have a correlation r = 0.542 and this correlation is
statistically significant (significance of the correlation = 0.000).3
We therefore conclude, for these two cases, that there is a significant difference between
knowledge and practice of immunization. From an arithmetic point of view, knowledge is lower
than practice. There is also significant positive correlation between the two, which would mean
that an investment to increase knowledge would have a positive increase in practice.
2.6 Challenges
Rwanda is a hilly country, which brings with it challenges when implementing assessments at
household level. Many of the villages selected especially outside Kigali had homes built along
the hills. This posed a challenge in getting from one household to another, which could only be
done by walking. In most cases, this increased the originally planned time taken to conduct the
household interviews.
This assessment also encountered non-response rates of varying degrees on some of the
questions. Early theories in studies such as these assumed that non-response was absent. Recent
surveys have, however, seen an increase in the rate of persons not being measured4 or some
questions not being responded to. The social research literature in this area suggests that a
response rate of at least 50 percent is considered adequate for analysis and reporting. A response
of 60 percent is good; a response rate of 70 percent is very good.5 As we had very few non-
responses, we contend that the findings are representative of the population assessed as part of
this study, and a similar assessment following similar methodology would yield similar findings
to the ones contained in this report. The findings of this study also reflect findings in published
literature from NISR, which gives further confidence that the non-response rate did not affect
the quality of findings achieved.
3 For a full list of significance tests and correlation tests on after birth child care attributes contact
UNICEF Rwanda.
4 Groves, Robert M., Nonresponse Rates and Nonresponse Bias in Household Surveys, Public Opinion
Quarterly, vol.70, no. 5, 2012, pp. 646675.
5 Babbie, Earl, The Practice of Social Research, 11th ed., Wadsworth, Belmont, CA.
CHAPTER 3: LITERATURE REVIEW 17
Chapter 3:
Literature Review
3.1 Introduction
V
arious authors have written on the importance of the early years of childrens lives for
their subsequent well-being.6 According to the Convention on the Rights of the Child,
to which Rwanda is a signatory, any individual below the age of 18 is considered to
be a child. Throughout childhood, the individual undergoes various significant life
stages and lessons. These experiences and lessons have a huge impact on the persons later years.
In Rwanda, schooling begins for children at the age of 7.7 From this age onwards, the child is taught
in a formal setting. However, it is generally understood that children start learning immediately
at birth when they interact with parents and especially with their mothers. There is, however,
another school of thought which suggests that an individual starts learning while still in the
mothers womb, although we shall not be exploring this path within the context of this survey.8
It has been argued that a childs development from birth to age 6 is critical in the persons overall
development and that early success breeds later success.9 At these early stages, childrens experiences
shape their development. It is important to provide adequate stimulation, education and nurturing
at the appropriate stage of child development to help children to learn and develop.
The ECD policy of the GoR emphasizes the holistic nature of child development, recognizing
that children require stimulating play; early learning opportunities; good health care; a
nutritious, balanced diet; clean water; a hygienic environment; love; and safety and security
to grow up to become social, well-adapted and productive citizens. As no sector working alone
can address these complex requirements, the policy recognizes that it is essential for all sectors
of government and civil society in Rwanda to work together. An integrated approach to ECD
is proposed, involving sectors and agencies working on education, health, nutrition, sanitation
and child protection. A major part of the ECD intervention is to improve parents and caregivers
knowledge of, and skills in, child development, with an emphasis on infants and children up to
6 years old.

3.2 Antenatal care and early childhood
development
Traditionally, antenatal care (ANC) in Africa was left to expectant mothers and their attending
midwives. With the advancement of technology and the dissemination of knowledge, it is now
known that the lifestyle of an expectant mother has a significant impact on the unborn child. It
6 See Centre for Community Child Health, A Review of the Early Childhood Literature, February
2000, Commonwealth of Australia, and Githinji, Felicity W., and Anne Kanga, Early Childhood
Development Education in Kenya: A literature review on current issues, International Journal of
Current Research, vol. 3, no. 11, November 2011, pp. 129136.
7 Republic of Rwanda, Early Childhood Development Policy, Ministry of Education, Kigali, 2011.
8 InfoRefuge, Mother-Infant Bonding: The science of smell, <www.inforefuge.com/science-of-smell-
mother-infant-bonding>, accessed 10 October 2012.
9 Heckman, James J., Invest in the Very Young, 2nd ed., in Encyclopaedia on Early Childhood
Development, edited by Richard E. Tremblay, Michel Boivin and RDeV Peters, Centre of Excellence for
Early Childhood Development and Strategic Knowledge Cluster on Early Childhood Development,
Montreal, 2007, pp. 12.
is therefore generally advised that expectant mothers attend ANC and receive support to adapt
their lifestyles to ensure the healthy development of the unborn child.
In Rwanda, women are aware of the need to seek ANC. Expectant mothers are ordinarily
visited by a community health worker. These are people who, in addition to their day-to-
day personal activities, help communities by disseminating health information and treating
common ailments, such as malaria, coughs and flu. It is common for an expectant mother to be
visited by a community health worker several times and the advice given during such sessions
includes guidance to visit an antenatal clinic every three months, to eat healthy food, to engage
in activities that will exercise their bodies without overly straining them, and to sleep under
insecticide-treated mosquito nets. All this advice helps to protect the health of the mother and
of the unborn child.
Maternal nutrition is an important issue for the development of the unborn child. For proper
development, it is recommended that a mother follows a healthy diet. Appropriate foods are
generally found within the farms and markets in Rwanda. Ninety percent of the population
in Rwanda is engaged in agricultural production with such crops as plantains, sweet potatoes,
cassava, dry beans and sorghum grown.10 Therefore, save for economic constraints, it is possible
for expectant mothers to get a balanced diet.
An expectant mother also needs to be cared for. This responsibility generally falls upon the
unborn childs father, who, in most cases is the husband of the expectant mother. The father
should provide an environment that enables the proper care of the mother and of the unborn
child. It is also known that the emotional condition of the mother has an effect on the physical
and emotional health of the child even after birth. A Harvard Medical School report points out
that almost 25percent of cases of postpartum depression start during pregnancy.11 The report
goes on to discuss cases of depression after child birth. Such cases can be reduced by proper
ANC of the expectant mother.
Health centres and clinics are now prioritizing provision of antenatal care. For those expectant
mothers who do not go to hospitals, community health workers have been deployed within the
communities to educate the mothers on ANC, as well as postnatal care. In summary, exercise,
healthy food and a good living environment contribute to both a successful pregnancy and also
the safe delivery of a healthy baby.
3.3 Postnatal care and early childhood

development
In Rwanda, most births currently occur in hospitals, health centres or clinics. The government
has encouraged this strongly in an effort to reduce child mortality. Results indicate that infant
mortality in Rwanda declined from 86 deaths per 1,000 live births in 2005 to 76 per 1,000 in
2010.12 This is attributed to integrated approaches to maternal and child health care, part of
which includes hospital deliveries as opposed to home deliveries. The high rate of hospital
deliveries means, from the outset, a child born in Rwanda is primed to have a better chance at
life.
Infant development is the very first stage of development in a childs life after birth. There are
arguments about how long the stage lasts, but consensus seems to point to it being between 0
to 6 months. Borrowed from the Latin word infans meaning unable to speak or speechless,
UNICEF Rwanda 2014/Park
10 Maps of world, Rwanda, <www.mapsofworld.com/rwanda/economy/agriculture.html>, accessed

10 October 2012.
11 Harvard Health Publications, Harvard Medical School, Depression during pregnancy and after,
<www.health.harvard.edu/newsweek/Depression_during_pregnancy_and_after_0405.htm>,
accessed 17 March 2014.
12 National Institute of Statistics of Rwanda and the Ministry of Finance and Economic Planning,
Rwanda Demographic and Health Survey (RDHS) 2010, Rwanda, Kigali, February 2012.
the infancy stage is characterized by interaction between the infant and the parents/caregivers
which is critical to the childs cognitive and mental development.
It is a requirement in Rwanda that all children be registered at birth. In many cases, however,
birth registration is not correctly achieved. Often a birth notification is given by community
leaders, which caregivers sometimes assume to mean their childs birth is registered. However,
this is not the case and formal birth registration requires additional steps.
In addition, children need to be immunized. Immediately after birth, the child is put on an
immunization regime which lasts up to 23 months. The most important form of immunity a
child receives is through the mothers breast milk. Exclusive breastfeeding is recommended for
the first 6 months of the childs life, which constitute the infancy stage. It is worth noting that
exclusively breastfed infants are at lower risk of HIV transmission than mixed-fed infants if the
mother is HIV positive.13 Only after that, is it recommended to wean the child by introducing
other foods starting with liquids (e.g. milk, food supplements and porridge) progressing to
solid foods as the child enters the baby stage.
Breastfeeding is not a problem in many African communities and especially in Rwanda where
most mothers are not formerly employed and can therefore spend the first 6 months of their
babies lives with the baby. It is well documented that infants, and even children up to the
age of 3 years and beyond, feed on breast milk. However, with development, many women
are now joining the formal workforce and doing tasks that were previously reserved for men.
Balancing the demands of professional employment and breastfeeding is a challenge to many
working women. As such, they may not be able to exclusively breastfeed for the first 6 months
of their babies lives. There are food and milk supplements marketed to supplement breast milk
in such cases but mechanisms still need to be put in place to ensure the maximum amount
of interaction between mother and child. This is not only for feeding purposes, but also for
cognitive development as we shall see in the following discussion.
3.4 Childhood growth and development
This assessment focuses on activities that affect a childs growth and development from the
critical early stage ranging from birth to the age of 6 years. Generally, these early stages of a
childs life are directly controlled by parents (in most cases) and caregivers, such as siblings,
other relatives, nannies and even the community, as has been the case in most traditional
African societies.
How care is given in the early stages of a childs life is extremely important. According to the
ECD literature, the care given to a young child can be assessed on the basis of its quality, type
and timing.14 These three aspects are important to the child in that the correct type of care
and education must be given at the correct time (age) in order to spur the right mode of
development. This assessment sought to analyse these issues in Rwanda by finding out at what
ages respondents think children learn different things, for example: recognizing people, talking,
weaning, crawling, walking and even reading and writing. We also sought to find out what
measures parents take to ensure the proper development of their children, given that it is well
established that early childhood interventions of high quality have lasting effects on learning
and motivation.15
13 Buskens, Ineke., A. Jaffe and H. Mkhatshwa, Infant feeding practices: Realities and mind sets of
mothers in Southern Africa, AIDS Care, vol. 19, no. 9, October 2007, pp. 11011109.
14 Cleveland, Gordon, C. Corter, J. Pelletier, S. Colley, J. Bertrand and J. Jamieson, A Review of the State
of the Field of Early Childhood Learning and Development in Child Care, Kindergarten and Family
Support Programs, Atkinson Centre for Society and Child Development, Toronto, Canada, 2006.
15 Heckman, James J., Invest in the Very Young, 2nd ed., in Encyclopaedia on Early Childhood
Development, edited by Richard E. Tremblay, Michel Boivin and RDeV. Peters, Centre of Excellence
for Early Childhood Development and Strategic Knowledge Cluster on Early Childhood Development,
Montreal, 2007, pp. 12.
During the infancy stage of development, infants learn to recognize those around them,
especially the parents and caregivers. There is physical development when the childs muscles
start to strengthen. This development of muscles enables the development of other functions
and actions, such as grasping small objects. Infants need good quality nutrition, health care,
tenderness, touch and novelty in order to maximize their abilities and potential.16
The second stage of a childs life is what we refer to as baby development. This occurs between 6
and 24 months. These distinctions are, however, not as clear-cut as the age ranges may suggest.
For example, some infants may be weaned at 5 months or younger, others beyond 6 months.
Many babies are weaned off breast milk at the early stages in baby development. Nutrition of
children is an important measure of a childs health at this point.
Despite awareness of what constitutes good nutritional practice, there are still many cases
of stunted growth in children, both globally and specifically in Rwanda where 44percent of
children under the age of 5 are stunted.17 This can be attributed to the low economic status
of many households. Families are not able to provide the right quantity and quality of food.
This situation is more prevalent in the rural areas where 47percent of children are stunted,
as opposed to 22percent in urban areas. Apart from stunted growth, there are also cases of
children being underweight. It is, however, worth noting that there have been improvements in
the nutritional condition of children in Rwanda.18
The babys communication slowly transforms from non-verbal to verbal communication. Babies
repeat what is spoken to them and it is at this point that the child learns language(s). Babies will
also respond appropriately to friendly and angry voices. By the end of 24 months, they are able to
name things commonly found in their surroundings and can combine words in short sentences.
At this time, babies are also able to respond to commands.19 During this period of development,
babies spend most of their time watching the world around them, taking in information and
getting directly involved in what goes on. Babies can walk without support, talk in words that
are comprehensible and even do simple tasks on request such as, for example, eating food when
told to eat. Babies will increasingly imitate the actions of those around them.
The next stage is referred to as toddler development. This generally occurs between 2 and 3
years. Toddlers, at this point, are aware of what they like and assert their independence more
and more. Toddlers also learn a lot during this period. Unlike the previous stages, when children
learn by instinct, at this stage children consciously absorb knowledge and information.
During this period your toddler wants to do more on their own and does not like it when
you begin to establish limits on their behaviour. Tantrums can become frequent when your
toddler cant get what they want. This is a natural part of your childs social and emotional
development. Toddlers are also curious about other people and will tend to stare at anyone
who attracts their attention.20
After toddler development, children go through a pre-school period of development. In Rwanda,
this stage is between 4 and 6 years, just before children enter the formal education system.
Within the growth cycle of children, they undergo more than just physical growth and at this
point learning is equally important. Children learn through observing their environment.
This starts with the ability to recognize people, followed by speech development and, finally,
academic understanding.
16 Mesa Community College, Infants, Developmental Psychology Student Newsletter, Department of

Psychology, 2012.
18 See National Institute of Statistics of Rwanda and the Ministry of Finance and Economic Planning,
Rwanda Demographic and Health Survey (RDHS) 2005, Rwanda, Kigali, July 2006 and National
Institute of Statistics of Rwanda and the Ministry of Finance and Economic Planning, Rwanda
Demographic and Health Survey (RDHS) 2010, Rwanda, Kigali, February 2012.
19 Child Development Institute, Language Development in Children, <http://childdevelopmentinfo.
com/child-development/language_development>, accessed 18 July 2012.
20 Aussie Childcare Network, Toddler Social and Emotional Development, <www.
aussiechildcarenetwork.com/toddler_social_emotional_development.php>, accessed 18 July 2012.
As they grow up, children need to be raised in a secure and safe environment. When children
feel safe at home they are free to explore and to learn new things, which is especially important
as a lot of what children learn is through curiosity and experimentation. Parents and caregivers
should, therefore, provide an environment where a child is free to play and to learn. The
caregivers also play a significant role in the teaching of the child. As it is often said the home is
the first school. The importance of parents, guardians and other caregivers knowing their roles
is, therefore, paramount to the growth and development of the child. This is why it is essential
to explore what caregivers understand their role(s) to be, as well as to understand common
practices in child development.
3.5 Barriers to positive early childhood

development experiences
There are various factors that hinder the proper growth and development of children in
Rwanda, some of the most important being high poverty levels and a lack of knowledge. Despite
understanding the importance of health care, especially ANC, a major factor deterring women
from attending ANC is poverty. Many expectant mothers forego formal ANC, with its associated
costs, for traditional methods.
The ultimate negative outcome of a poor environment for young children is child mortality.
However, it is important to note that under-five child mortality rates have been decreasing over
the years, falling from 152 deaths per 1,000 live births in 2005 to 76 per 1,000 live births in 2010.21
Of course, it is important to note that these are national average figures and rates vary according
to the socio-economic characteristics of the mothers and households. In Rwanda, there are
more deaths in rural areas than in urban areas, and more deaths in poorer households.22 It
is clear that poorer households do not have sufficient access to health care and health-related
information. Despite ongoing challenges, the positive trend is well recognized and a clear result
of the concerted efforts of the GoR and many other stakeholders in this area.
The GoR has also made steady progress with regard to hygiene and sanitation. Some of the
milestones achieved in Rwanda include the construction of water supply systems (651 km
by 2008), the sinking of boreholes, the erection of rain harvesting tanks and the building of
latrines.23 Other stakeholders have also contributed to improvements in hygiene, decreasing
pollution, sanitizing premises and using safe products for agricultural purposes. These efforts
are laudable, but their penetration into rural areas is still limited. In rural areas, people have
UNICEF Rwanda 2013/Shrestha

to walk long distances to access water sources, such as communal boreholes. The sanitation
situation in many rural households is also poor. Children in these rural homes are, ordinarily,
not clean and the environment within which they stay and play is also not hygienically safe.24
According to UNICEF Rwanda, these sanitation and health problems mean that children in
Rwanda continue to die from communicable diseases.25
These problems together hinder proper ECD. Some facets of the problems are being addressed
through the various programmes set up by the government to reduce poverty, improve
infrastructure, health and education, and to boost trade and employment.
Rwanda Demographic and Health Survey (RDHS) 2005, Rwanda, Kigali, July 2006 and National
Institute of Statistics of Rwanda and the Ministry of Finance and Economic Planning, Rwanda
Demographic and Health Survey (RDHS) 2010, Rwanda, Kigali, February 2012.
23 Karuhanga, James, Water Access, Sanitation Improved in 2008 Report, The New Times, 8 June
2009.
24 Paulson, Cindy, Sanitation is Rwandas Greatest Unmet Challenge, Water for People, 12 July 2012,
<http://waterforpeople.org/media-centre/in-the-media/sanitation-is-rwandas-greatest-unmet-
challenge.html>, accessed 11 October 2012.
25 See UNICEF, (2011), In Rwanda, education and health programmes provide children with a better
start in life. Retrieved July 23, 2012 from UNICEF: http://www.unicef.org/infobycountry/rwanda_58236.
html and UNICEF, (2011), Rwanda Water and Sanitation and Hygiene. Retrieved July 25, 2012, from
http://www.unicef.org/rwanda/hiv_aids.html
The GoR is also increasingly prioritizing a national ECD programme. This is in line with the
growing emphasis on ECD on national public policy agendas throughout sub-Saharan Africa.
While Rwanda has made major strides in ECD developing a new and comprehensive national
ECD policy there are still a number of challenges. There is clearly a lack of adequate human
resources to support the implementation of the ECD Policy and Strategic Plan, especially at
the decentralized levels. Clear, precise data on ECD is also lacking and there is generally little
knowledge and understanding of issues related to ECD in the country.26 While the vision of the
GoR is to expand access to child care facilities significantly, currently only 11percent of the 1.5
million children eligible for pre-primary school access those facilities.27
The challenges, in terms of awareness around ECD, are particularly acute in relation to parents
and caregivers. Many are not well informed on issues to do with child development. Children
are raised by default without considering what methods to use at what stages in the childs life.
Part of the difficulty in achieving the objectives of the ECD Policy is the wide range of issues
it covers, as well as the clear need for a cross-governmental, multi-sectoral approach to fully
address ECD needs across the nation.
3.6 Policy issues in relation to early childhood

development
Problems related to ECD are multi-faceted. This means that there is no one best way to address
all issues and solve all problems. Various approaches are needed. It is in recognition of this that
the ECD Policy of the GoR is meant to be used as a guide, giving clarity and direction to all
stakeholders and offering a coordinated, integrated approach. Furthermore, the GoR has put in
place various other policy instruments in support of ECD. Some of the policies include the Girls
Education Policy, the Special Needs Education Policy and the currently under revision Family
Policy, as well as the content of Vision 2020 itself, which speaks of nurturing a well-rounded
individual from childhood. These policy documents stand on the principle that interventions
in the early years have the potential to offset future negative trends.28
The overall aim of the ECD Policy and the others mentioned is to ensure the well-rounded
development of all children in Rwanda, emphasizing that parents and communities become
nurturing caregivers. It is on this principle that, while commenting on Rwandas overall
development at the ECD National Stakeholders Meeting, the first lady, Mrs Jeannette Kagame,
emphasized the importance of investing in the ECD Programme.29 Given the preferred multi-
sectoral approach in ECD, the role of civil society organizations in supporting ECD in Rwanda
is recognized as of paramount importance. Some of the organizations most active in this area
include CARE, Save the Children, Hope and Homes for Children, World Vision and UNICEF.
The strategies used vary but range from setting up child care centres, orphanages and
community education programmes to direct support for parents and caregivers. The most
important strategies focus on parenting. It is important for parents to build their knowledge
on child development issues. Specifically, parents should possess knowledge on child rights,
nutrition, nurture and stimulation, protection, health care and education. Parents with this
information are best placed to ensure their children are able to grow and develop fully to reach
their full potential.
26 These points emerged at the ECD Stakeholder meeting in 2012. See ECD Stakeholders, Early
Childhood Development in Rwanda: Working together in the implementation of the ECD Policy
and Strategic Plan, Early Childhood Development: Rights from the Start, Report of the National ECD
Stakeholders Meeting, 19 April 2012, Serena Hotel, Kigali.
27 Kabalira, Marie-Brigitte, Family Most Important for Early Childhood Development, The Rwanda Focus,
20 April 2012.
28 Republic of Rwanda, Early Childhood Development Policy, Ministry of Education, Kigali, 2011.
29 Gahiji, Innocent, Rwanda: Early Childhood Development a Valuable Investment First Lady, News
of Rwanda, 20 April 2012.
CHAPTER 4: STUDY FINDINGS 23
Chapter 4:
Study Findings
4.1 Introduction
T
he qualitative part of this assessment sought to determine the KAP of caregivers in relation

to ECD. Being an exploratory tool, the qualitative study revealed a range of issues that are
prevalent within the context of the family in Rwanda. Various assumptions were made
based on the qualitative outputs and these, together with the subsequent quantitative
findings, are discussed in this chapter. Data collected from the quantitative study were analysed
and are presented here using, primarily, descriptive statistics. Doing so enables us to provide
information on the absolute status of the parameters measured. Some instances required
inferential manipulations of data, such as when comparing the views of the two groups (male
and female) under study. Here we did some significance testing to validate the comparisons
(using t-tests).
The approach was to interview caregivers of children within the specified age range which was 0
to 6 years. Some households had several children. The assessment needed to focus on a particular
child whose findings would be representative of all children in a household, and consequently,
in the assessment. This child was referred to as the index child. The index child was identified
as the youngest child in the household who was between 1 and 6 years old.
When collecting data, interviewers listed the children in the household numbering them child1,
child2, child3 up to child n. The interviewer then identified the index child as the focus of the
interview from among the children in each household. A total of 2,000 index children for the
2,000 households visited were identified. Table3 is a summary of the proportions of the total
number of children that are index children.
Table 3: Index children in the sample
Number of index
Cumulative per cent
Category of children children in the Per cent (%) Valid per cent (%)
(%)
category
Total 2,000 100.0 100.0
Child one 1,750 87.5 87.5 87.5
Child two 217 10.9 10.9 98.4
Child three 28 1.4 1.4 99.8
Child four 5 .3 .3 100.0
4.2 Demographic characteristics of respondents
The survey achieved a total of 2,000 household interviews with female caregivers and 600
interviews with male caregivers. (See Annex 1 for summary tables.) The demographic
characteristics of the respondents generally match those of surveys conducted by NISR.
Comparative figures of previous studies conducted in Rwanda are presented alongside figures
for the current study.
Household size
According to the findings of the KAP, the average household size was found at 4.38 persons per
household, very close to the Rwanda Demographic Health Survey (RDHS) 2010 which puts the
average number of persons per household at 4.4.
Disability status
At least 96percent of respondents from the household survey had no perceivable disability and
also indicated having no disability that could hinder them from living normal lives. Ninety
seven per cent of the index children had no disabilities. Some 4percent of respondents were
physically disabled.
Education
At least 44percent of the respondents had primary level education, 25percent had secondary
education, 20percent attested to having no formal education and 11percent had attained above
the secondary level. The RDHS 2010 recorded that 58percent of respondents had attained some
primary education and a much lower proportion had attained education up to secondary level.
Working status/employment
About 65percent of the respondents had agricultural related employment, but 36percent were
subsistence farmers. Kigali had the highest proportion of civil servants at 28 per cent, while
respondents from the rest of the provinces were largely farmers. There is a similar trend across
the districts with regard to employment status.
According to economic levels, the majority of the poor are subsistence farmers (53percent),
15percent describe their working status as unemployed, 10percent work on other peoples
farms for food, while 10percent work on other peoples farms for money. About 85percent
of the upper economic category of respondents is made up of civil servants and 15percent by
commercial farmers. Table 46 in Annex 1 of this report describes respondents employment
status.
Religion
The majority (96percent) of respondents profess to being of a Christian faith (52.3percent

Catholic, 36.5percent protestant and 7.6percent Seventh Day Adventists). About 4percent of
the respondents are Muslims.
Poverty
There are various ways of determining poverty levels in studies of this kind. One of the key
attributes commonly used is the type of floor in the house. In the current assessment, using the
floor type of the house means that only 26.8percent of the respondents are classified as poor,
as indicated in Table4.
Following the criterion of using one attribute to measure poverty is, therefore, not ideal for this
assessment as it produces misleading results. This is because, from the outset, the data collection
tool did not make specific reference to the determination of household poverty levels. Had such
UNICEF Rwanda 2004
reference been made at the initial stage, more detailed information concerning the floor type
would have been sought, which could have given a conclusive indication of the poverty levels.
To solve this dilemma, the study adopted multi-dimensional poverty indicators based on various
attributes. Each attribute was weighted equally and the overall score per household was the sum
of the scores measured. As a result of these final scores, the households were graded from poor
Table 4: Poverty level by type of material used for the floor
Cumulative per cent

Frequency Per cent (%) Valid per cent (%)
(%)
Total 2,000 100.0 100.0
Concrete 437 21.9 21.9 21.9
Bricks 479 24.0 24.0 45.8
Wood 274 13.7 13.7 59.5
Tiles 274 13.7 13.7 73.2
Rammed earth 536 26.8 26.8 100.0
to upper class. The attributes used as poverty indicators are listed below. The respective weights
as absolute findings for each attribute are indicated in tables in the appendix section of this
report.
1. Access to basic health services
2. Access to clean water source
3. Level of education
4. Number of bedrooms
5. Total number of people in the household
6. Number of bedrooms by number of people in the household
7. Type of material used for construction of the roof for the dwelling unit
8. Type of material used for the floor
9. What the respondent does for a living
10. What energy the household mainly uses for cooking
11. What energy the household mainly uses for lighting
12. What kind of toilet facility members of the household usually use
Using the above attributes, the final output registered the following poverty levels for the
population studied in this assessment:
Table 5: Economic categories using multi-dimensional poverty indicators
Cumulative per cent

Frequency Per cent (%) Valid per cent (%)
(%)
Total (N) 2,000 100.0 100.0
Poor 951 47.6 47.6 47.6
Lower-middle 667 33.4 33.4 80.9
Upper-middle 369 18.5 18.5 99.4
Upper 13 0.7 0.7 100.0
The findings indicate that 47.6percent of the respondents can be categorized as poor. According
to the Third household integrated living conditions survey in Rwanda, poverty is estimated to
be 44.9percent nationally, with 22.1percent poor in urban areas and 48.7percent poor in rural
areas.30 The 47.6percent realized in the sample could be attributed to the fact that, although
the national average is 44.9percent, the respondents for this assessment were mainly in rural
areas, with a few urban respondents and only households with children of 0 to 6 years were
selected. This could explain why the level is higher than the national average (in addition to
using different poverty threshold criteria), but lower than the value expected if the assessment
had been done in a purely rural setting.
30 National Institute of Statistics of Rwanda, The Third Integrated Household Living Conditions Survey
(EICV3): Main indicators report, 2011.
It is critical to note that the upper category is comprised of only 13 observations and it is,
therefore, almost impossible to make inferences based on statistical analysis due to the small
sample size. To the extent that there are evident difference between the poor and non-poor,
inference and interpretation should be restricted to the first three categories only.
4.3 General health problems affecting the

community
The respondents were asked about the most common health problems affecting their
communities, their causes and who is affected most by these problems. In this way the survey
sought to understand the different health concerns people have.
Health problems experienced in communities
Findings indicate that common health problems are associated with disease and sickness.
Virtually all of the respondents mentioned at least one disease, and there were no responses
relating to the environment around the home, such as hygiene conditions. The main diseases
mentioned include malaria, cough, flu, diarrhoea and worms. Table6 presents findings on this
question.
Table 6: Perceived health problems affecting the communities
Province
Total (%) Northern (%) Eastern (%) Western (%) Kigali (%) Southern (%)
Total (N) 2,000 376 515 379 337 393
Malaria 46 50 43 41 45 53
Cough 4 39 49 36 39 42
Flu 34 31 38 29 37 34
Diarrhoea 31 38 33 37 22 25
Worms 23 31 16 28 19 20
Pneumonia 6 6 10 2 2 7
Skin diseases 3 2 3 2 1 6
Measles 2 0 2 1 1 7
Vomiting 2 1 3 1 1 3
The most common illnesses that appear to affect the communities are malaria, cough, flu and
diarrhoea with no major differences across provinces, although Kigali recorded a low percentage
of those that reported diarrhoea and worms as common health problems. This may be attributed
to the differences between rural and urban settings. The results of this survey are a reflection of
the prevalence of these diseases in communities. According to the RDHS 2010, the prevalence of
malaria, diarrhoea and pneumonia among children of 5 years and below was reported in 2010 at
15.68percent, 13.19percent and 3.63percent, respectively.31 Deaths from these diseases were
reported in 2007/8 as 14percent for pneumonia and 15percent for malaria.32
There are similar prevalence levels with both male and female respondents, with no significant
differences between the two groups as Table7 illustrates.
32 Hong, Rathavuth, Mohamed Ayad, Shea Rutstein and Ruilin Ren, Childhood Mortality in Rwanda:
Levels, trends and differentials Further analysis of the Rwanda demographic and health surveys
19922007/08, ICF Macro, Calverton, Maryland, USA, September 2009.
Table 7: Common health issues: A comparison between male and female
Gender of respondent
Health Problems Total (%)
Male (%) Female (%)
Total observations (N) 1,200 600 600
Malaria 51 52 49
Cough 34 31 37
Flu 32 32 32
Diarrhoea 31 32 30
Worms 22 20 24
Pneumonia 6 5 7
Measles 3 3 3
Vomiting 2 2 3
Skin diseases 2 2 2
The prevalence of the above diseases were confirmed in the qualitative discussions with
community health workers in each of the districts. While the community members mainly
mentioned symptoms, the health workers findings point to the actual illnesses affecting the
communities.
The community health workers expressed concern that more attention is not paid by the
community to seeking treatment for malaria, hence the poor results in terms of the adverse
effects experienced by the sufferers. Common illnesses, such as flu and cough, also tend to be
neglected by community members due to a belief that they are simple illnesses and they have
no cure. Such perceptions affect the health and well-being of the community and worsen health
conditions especially among children.
Malaria is the most common in my area. People here hardly seek medical assistance, so
they suffer with the disease for a really long time. It is only when we do our village patrols
that we find out when we interact with them. (Community Health Worker Bugesera)
Ailments like cough and flu that are treated as minor cases that are very common among
our people. Much as people have this belief that cough and flu have no cure, people should
not relax but should seek medical attention. (Community Health Worker Ngororero)
We mostly have coughs and malaria in our area. I most certainly think the cough is a
sign of tuberculosis although the people ignore it. We encourage everyone during our
sensitization campaigns to always take medical examinations for any health problem they
get. By so doing, this would reduce those hitherto undetected diseases that are hazardous
to human life. (Community Health worker Gicumbi)
The other health issue that is in this area is that there are many people that can cough
for almost a month. We keep on sensitizing them and counselling them but they object to
sending them to medical personnel. But the majority of them oblige, it is only a few that
object. (Community Health Worker Rubavu)
Although environmental issues were not highlighted as common health problems, on evaluating
the perceived causes of health problems, most of these were related to hygiene conditions within
the home and environmental factors. Table 8 lists the hygiene attributes that respondents
mentioned as causes of diseases.
Table 8: Perceived health problems and the perceived causes
Causes
Health Dirty water Poor Bad eating Spoilt or
Problems Mosquitoes Change of Un-boiled Un-immunized Dust
or stagnant hygiene habits rotten
(%) weather (%) water (%) children (%) (%)
water (%) (%) (%) foods (%)
Total (N) 675 928 612 107 313 191 19 98 23
Worms 17 19 31 24 39 39 37 15 22
Cough 33 62 42 57 38 47 47 60 30
Malaria 88 40 49 57 40 48 37 44 83
Flu 25 56 31 36 27 26 21 54 30
Diarrhoea 29 27 46 21 45 66 37 28 52
Pneumonia 7 10 5 7 3 8 0 4 0
Typhoid 1 1 1 4 1 1 0 0 17
Vomiting 3 2 2 5 4 4 5 1 0
There are misconceptions or gaps in knowledge among community members with regard to the
causes of certain illnesses. For instance, there is a perception that poor eating habits, or spoilt and
rotten foods, cause malaria. While some of these, such as poor eating habits, lower the immunity
of children hence making them vulnerable to illnesses these are not the direct causes of many
diseases. Communication may, therefore, be required to close the gap in knowledge by informing
parents and caregivers about the actual causes of specific illnesses, as well as educating them about
secondary causes or things that make children more vulnerable to illness generally.
As shown in Figure 1, findings reveal that the majority of caregivers perceive children of 0 to 6
years old to be most affected by these diseases, more than any other category.
50
44%
40 39%
37%
30 28%
20
10
5% 6%
1%
0
CHILDREN 3 TO 6 YEARS
DISABLED PEOPLE
EVERYONE
ELDERLY PEOPLE
CHILDREN 0 TO
6 MONTHS
CHILDREN 7 MONTHS
TO 2 YEARS
SCHOOLGOING CHILDREN
(7 TO 18 YEARS)
Figure 1: Groups of people most affected by health problems in the community
Although caregivers mentioned the occurrence of these diseases in the community generally, it
should also be noted that 79percent of caregivers indicated that they had not had an incident of
a child suffering an illness in the two weeks prior to the interview. Among the 371 that indicated
a recent incidence of illness in the home, Kigali (12.13 per cent) and Northern province
(11.86percent) had the lowest incidences, while Southern province (23.99percent) and Western
province (22.37percent) had the highest incidences. The disease symptoms indicated by the
caregivers mirror the common illnesses that recorded higher responses in the community
a confirmation of the prevalence of these health problems. Diarrhoea (35 per cent), cough
(35percent), fever (23percent) and vomiting (22percent) were the symptoms that recorded
the highest responses.
Management of illness
To understand how caregivers manage common illnesses that affect their children, all those that
attested to having incidences of illness in the home were probed on what they did when the child
fell sick. As shown in Table9, in most cases (61percent) self-medication is the immediate home
remedy that caregivers undertake when children fall sick. Twenty nine per cent of caregivers
brought children to the nearest health facility and 18 per cent bought medicine from the
nearest pharmacy/drug shop. The use of self-medication was highest in the Southern province
(72percent) and Kigali (78percent), while the Northern province had a higher rate of visiting
a health facility as the immediate response (64percent). About 5percent of the respondents
whose children fell ill prayed for the child as the first course of action.
Table 9: Actions taken by respondents to immediately respond to and treat illnesses in their
children
Practice
Action taken Treatment of the condition
Immediate action (%)
(%)
Total (N) 371 371
Gave some medicine that I had in the house 61 21
Took the child to the nearest health facility 29 48
Bought medicine from a pharmacy/drug shop 18 13
Gave oral rehydration salts (ORS) 18 8
Sought the services of a traditional herbalist 13 8
Sought the services of a community health worker 12 12
Gave herbal medicine 11 7
Gave zinc 10 7
Continued breast feeding 10 4
Gave the child plenty of fluids 7 4
Tepid sponging 7 1
Prayed for the child 5 2
Apart from the immediate course of action, on appreciating the symptoms and wishing to treat
the conditions, more caregivers took their children to the nearest health facility (48percent).
Only 12percent sought the services of a community health worker.
Although there is a general trend that the first course of action is to undertake self-medication
with the available medicine in the house, when a child exhibits symptoms of sickness there
are differences in responses. This is notable in the Northern province where the first course of
action is to take the child to the nearest health facility. In areas where the first course of action is
to give medicine at home, the second action varies between taking the child to the nearest health
facility and getting more medication from a pharmacy/drug shop. Only 12percent sought the
services of a community health worker. Eighty eight per cent of respondents mainly considered
their actions to be the correct way to treat the illness. Table10 shows the responses of caregivers
in terms of dealing with childrens illnesses, disaggregated by province and economic categories.
Table 10: Actions taken by respondents to treat childrens illnesses
Province Economic category
Total (%) Lower- Upper-

Northern Eastern Western Southern
Kigali (%) Poor (%) middle middle
(%) (%) (%) (%)
(%) (%)
Total (N) 371 44 110 83 45 89 177 127 67
Gave some medicine that I 21 18 23 16 24 24 23 20 18
had in the house
Took the child to the 48 59 40 64 42 39 48 50 43
nearest health facility
Bought medicine from a 13 9 16 5 13 19 14 12 15
pharmacy/drug shop
Gave ORS 8 0 10 8 4 9 5 9 10
Sought the services of a 8 7 7 0 9 16 9 7 6

traditional herbalist
Sought the services of a 12 11 13 6 11 18 8 16 16
community health worker
Gave herbal medicine 7 9 9 2 0 11 7 10 1
Gave zinc 7 2 5 7 16 8 7 8 6
Continued breast feeding 4 0 5 1 0 8 3 4 6
Gave the child plenty of 4 2 3 1 2 9 3 5 4

fluids
Tepid sponging 1 0 1 0 0 2 0 2 0
Prayed for the child 2 5 2 4 0 1 2 2 1
The findings show that caregivers, irrespective of their economic level, have some knowledge
about what to do when their children experience different types of illnesses. There is also a
tendency to take different measures depending on the symptoms of the illness, also indicating
some awareness of how to manage different illnesses. It is, for example, clearly positive that the
response to cases of diarrhoea include 69percent of caregivers who give ORS for diarrhoea,
58percent who give plenty of fluids and 86percent who continue breast feeding. However,
it also seems as if the understanding of the proper use of ORS is limited, as similarly high
percentages of caregivers give it for a cough.
It is also notable that in cases of respiratory problems, recourse to the traditional herbalist is more
prevalent than seeking the services of a community health worker or going to the nearest health
facility. The responses to respiratory problems are poor. For example, the response to difficulty
breathing, for example, includes much higher likelihood of praying for the child, continuing
breastfeeding, tepid sponging and seeking the services of a traditional herbalist than visiting
a community health worker or health facility. It is important that caregivers are sensitized on
how to respond to childrens illnesses immediately, based on the specific symptoms presented
by the illness.
As illustrated below, during the focus group discussions caregivers pointed out that ensuring
good feeding and proper hygiene are the main ways of preventing children from falling sick in
the first place.
Parents are getting more involved in the lives of their children today. At least they make
sure that the children do not sleep hungry and that they receive full medical treatment
when they fall sick. (Male caregiver Ngororero)
Table 11: Treatment measures of various illnesses by respondents
Treatment
Gave some medicine
Tepid sponging (%)
Prayed for the child

plenty of fluids (%)
Sought the services
Sought the services

health worker (%)
from a pharmacy/
the nearest health
Bought medicine
Continued breast
Took the child to

of a community
that I had in the
Total
drug shop (%)

Gave ORS (%)
Gave zinc (%)
of a traditional
Gave the child
medicine (%)
herbalist (%)
(%)
feeding (%)
Gave herbal
facility (%)
house (%)
(%)
Total (N) 371 95 63 305 40 50 66 88 283 77 29 117 27
Diarrhoea 41 69 63 42 58 86 73 62 42 81 69 53 81
Fever or hot 30 63 51 39 42 80 58 65 31 55 90 43 78
to the touch
Cough 41 61 48 49 55 80 55 59 43 74 69 57 78
Vomiting 29 65 44 35 55 72 55 56 24 53 62 44 81
Flu 26 49 46 33 58 70 50 50 27 68 62 45 70
Difficulty 9 45 30 12 38 66 38 36 11 44 59 23 70
breathing
Fast 8 35 33 14 25 56 35 33 8 47 59 21 67
breathing
Indrawn 6 36 29 9 30 54 29 30 8 43 59 20 67
chest*
Loss of 13 48 41 20 48 54 30 43 12 52 59 25 81
appetite
Stomach 8 42 30 12 35 54 29 35 8 44 59 24 74
aches
Unable 7 33 27 9 32 50 29 30 8 40 55 21 74
to eat or
breast feed
Skin rash 6 25 21 8 15 36 21 20 6 30 38 15 44
* An indrawn chest can be a sign of pneumonia.
You look for vegetables like carrots, tomatoes and fruits and you feed the child so that he
can grow. Well thats what we do. (Female older caregiver Gicumbi)
We make sure that the children observe proper hygiene and that they have regular meals.
(Female caregiver Kamonyi)
Parents of today are very selective in the food they give to their children. Cases of diseases
like Kwashiorkor have greatly reduced because of this. They talk of educating the children
also. Children now know they have to clean themselves and have also come to know the
foods that are nutritious for their bodies. (Female older caregiver Ngoma)
You find that most parents encourage their children to drink a lot. This is rather good
because then, a childs body becomes rehydrated. (Community health worker Kayonza)
Parents try very hard to feed their children well. You will find that foods like vegetables
and greens are always included on the menu. (Female caregiver Nyamagabe)
Caregivers also pointed out things that they should be doing for their children that they are
currently not doing. Some of the key behaviour gaps that were discovered in the focus groups
conducted with caregivers were: body hygiene, such as bathing and dressing in clean clothes;
feeding children food with the right nutritional value and not just concentrating on quantity;
and encouraging children to play.
Children need to be reminded that eating well does not just mean eating a lot, but also
eating a balanced diet. So growing fat may not necessarily be a sign of a healthy body but a
sick one. Many parents ignore such advice. (Community health worker Gakenke)
Parents are also not doing much with regard to the way that children wash their clothes
and even bathe. You find that they remain withdrawn for as long as the child has actually
bathed or washed. So you find cases of children contracting diseases as a result of poorly
washed clothes and bathing. (Community health worker Rugango)
Its such things as continuously teaching children how to be clean and to make sure that
they are taking a balanced diet. (Female caregiver Gakenke)
Parents also ought to remind their children that playing is healthy for their bodies.
The children should not only spend time seated watching television. (Female caregiver
Nyarugenge)
4.4 Knowledge, attitudes and practices regarding

hygiene and sanitation
This KAP also touches upon hygiene and sanitation, and the sanitation facilities most available
in the surveyed households are:
1. latrine/toilet (72percent)
2. bathroom (55percent)
3. dust bin (52percent
4. composite pit (19percent).
To gauge the caregivers understanding of sanitation, they were asked what they think should be
done to maintain proper hygiene in the community. The survey then looked at what is actually
practised. Analysing the data on a cumulative scale, 100percent of the respondents indicated
that, in order to maintain proper hygiene, people should wash hands with soap before feeding
children or preparing food and after using the latrine. Sixty seven per cent indicated that each
household must have a latrine.
Table 12: Hygiene knowledge vs practice absolutes
Which hygiene
What should people
practices are
in the community
commonly practiced
Activity (multiple responses possible per question) do to maintain
by people in this
proper hygiene?
community?
Knowledge (%)
Practice (%)
Total (N) 2,000 2,000
Washing hands with soap before feeding a child or preparing food 100 28
Washing hands with soap after using a latrine 64 46
Each household must have a latrine 67 54
Cleaning the latrines every day 61 33
Keeping water and soap for washing hands at the latrine 46 31
UNICEF Rwanda 2011/Noorani
Clearing bushes around the home 50 38

Avoiding stagnant water around the home 50 34
Keeping the childrens clothes clean 40 26
Keeping utensils clean 30 23
Disposing of childrens faeces in the latrine 34 27
Having a rack for utensils in the home 23 13
With regard to hygiene, there are significant differences between what people know and what
they practise. Knowledge is higher than the claimed practice of the activities in all cases. The
biggest gap between knowledge and practice is with regard to washing hands with soap before
preparing food for the baby. While 100percent think it is important to wash their hands with
soap before preparing food for the baby, only 28 per cent actually practise this behaviour.
In addition only 46percent claimed to wash their hands with soap after using the latrine as
opposed to the 67percent who have knowledge in this area.
Among all the activities related to hygiene, the data show a significant difference between
knowledge and practice. Hypothesis testing results in the rejection of all null hypotheses
measured on the hygiene attributes which stated that there is no significant difference
between the means of the two variables. All the attributes are also significantly positively
correlated.
During the interviews, the researchers observed index child defecation in 52 per cent of the
households. Twelve percent defecated on the floor in the compound/house. In a few of the cases
(8percent) children defecated in a potty and in the toilet the first time. In 5percent of cases,
children defecated on a piece of paper placed on the floor by the caregiver. In 28percent of cases
the childs bottom was not cleaned after defecation. Cleaning the childs bottom was mostly
done by the mother (34percent), while only 7percent of the time was this done by other female
adults in the household. Most of the people (97percent) did not wash hands immediately after
wiping a childs bottom, but carried on as usual with what they were doing. It was more common
for the female, older children (25percent) to clear the childs stool immediately than for the
female adults to do it (16percent). In some of the households (30percent) the childs stools were
not cleared immediately.
Water for hand washing mostly came from a container in the compound and laundry water
(16percent). Few persons got water for hand washing under a tap (12percent). A comparably
high proportion of the respondents (24percent) had soap for hand washing kept near a water
source. Fewer persons (13percent) had soap for hand washing kept at some distance from the
water source. Some 16percent of the respondents did not use soap while washing hands.
Table 13: Knowledge and practice in relation to pre-birth care for the mother and child
Action taken Practice (%) Knowledge (%)

Total (N) 2,000 2,000
Prevention of common illnesses, such as malaria 72 74
HIV test 81 65
ANC from an approved health facility 52 43
Iron supplements 24 26
Vitamin A 59 44
Proper eating practices 21 22
Immunization against tetanus 40 37
Antenatal lessons 33 35
Avoided stress 42 35
Enough rest 34 32
Staying in a clean environment 35 29
Delivered in a recommended health facility 26 30
Had a delivery plan 23 25
Prepared the home for the new baby 17 26
Prepared older siblings to accept the baby 8 16

child care from pre-birth to delivery
Pre-birth knowledge
As shown in Table13, the caregivers practice before birth is high in only three of the aspects that
were tested: taking VitaminA supplements (59percent), the prevention of illnesses (72percent)
and knowing the HIV status of the mother (81percent). In most of the cases, knowledge does
not exactly match practice. As an example, 43 per cent indicated the need to attend antenatal
services from an approved provider, and more than 52percent of the caregivers indicated having
attended antenatal services from an approved health provider. Likewise, less than 44percent of
the caregivers indicated the need for VitaminA supplementation for the mother, while 59percent
claimed to have taken it during pregnancy. The most substantial differences between knowledge
and practice appear to be in the following categories: getting an HIV test and taking VitaminA.
The seeming disconnect between knowledge and practice in absolute terms could imply that some
of the behaviour is practised without fully understanding the reasons and because the health
workers and medical practitioners influence respondents to do so.
A comparison was made between male and female caregivers. The results indicate that female
caregivers are more knowledgeable about most of the things that should be done before child
birth than the male caregivers. This difference was significant in some cases.
Table 14: Comparing the knowledge and practices of male and female caregivers during
pregnancy
Knowledge Practice
Gender of respondent Gender of respondent
Pearson Pearson
Total Female Significance Total Female Significance
Male (%) correlation Male (%) correlation
(%) (%)
Total (N) 1,200 600 600 1,200 600 600
Prevention of 69 64 74 0.106 0.000 73 71 75 0.045 0.117
common illnesses,
such as malaria
Know HIV Status 61 58 65 0.72 0.013 79 74 84 0.124 0.000
ANC from an 39 36 41 0.05 0.086 46 43 49 0.064 0.028
approved health
facility
Iron supplements 25 24 27 0.037 0.206 24 22 27 0.048 0.093
Vitamin A 44 42 45 0.030 0.295 57 51 62 0.108 0.000
Supplementation
Proper feeding 22 22 22 -0.008 0.781 22 24 20 -0.042 0.143
practices
Immunization 35 32 39 0.068 0.019 39 36 43 0.065 0.025
against tetanus
Taking antenatal 32 29 34 0.054 0.062 32 28 37 0.096 0.001
lessons
Avoiding stress 36 35 37 0.017 0.548 38 33 43 0.106 0.000
Having enough rest 33 33 33 0.004 0.903 31 31 32 0.020 0.494
Staying in a clean 32 33 31 -0.016 0.577 32 28 37 0.101 0.000
environment
Delivering in a 28 24 31 0.076 0.008 24 22 25 0.039 0.174
recommended
health facility
Delivery plan 25 26 24 -0.013 0.641 23 21 24 0.038 0.190
Preparing the home 28 28 28 -0.007 0.797 19 20 17 -0.034 0.236
for the new baby
Preparing older 16 15 16 0.014 0.633 9 7 11 0.068 0.019
siblings to accept
the baby
The results shown in Table 14 point to two main issues: a) that the female caregivers may not
inform their partners because they consider it the responsibility of the women to ensure a
healthy pregnancy and b) that men may not be attending ANC clinics with their partners during
pregnancy. In addition, because most of the behaviour has to be practised by the woman, the
male caregivers need to play more of a support role. As a result, some of the practices may not
apply or the men may pay less attention to them than the women do.
From the qualitative focus groups it was established that female caregivers prefer to go for
antenatal services with their partners/husbands so that they can both take HIV tests and also to
be informed together about the progress of the pregnancy. Expectant mothers also prepare for
birth by saving money and monitoring their calendar, both for their next antenatal visits and
for the expected date of delivery. Some of the other changes made by expectant mothers include
undertaking less strenuous work and eating well.
A woman that finds she is pregnant needs to inform her husband right away so that the
husband is not caught by surprise, especially in cases where the woman does not stay with
the husband. (Female caregiver Gakenke)
She goes with the partner to know the progress. And throughout the whole period, she goes
with the partner for tests and they are told when to go back. But the good thing is that you
dont go there once. If I went with my spouse today, I will keep going there for treatment so
that we produce a healthy child. (Female caregiver Bugesera)
The other small things I do. I prepare myself. I look for clothes. And keep observing the
calendar so that when the time for giving birth reaches, I deliver in the presence of medical
personnel. (Female caregiver Rulindo)
The parent does other things. On knowing that she is pregnant, the woman looks for money
to buy the babys clothing and that sort of thing. (Female older caregiver Rwamagana)
Such a woman like [] has said she begins preparing herself financially if she has no
husband. If she has a husband, then he had better start saving money for the delivery and
to finance the pregnancy period. (Female caregiver Gakenke)
It is not good for a woman to do strenuous work even in the early stages of a pregnancy.
So the mother, on noticing she is pregnant, begins to limit the amount of work she does in
a day. (Female caregiver Gicumbi)
About eating, you just try because so many ladies want to be selective. So we end up
failing to get what our bodies need. (Female caregiver Rwamagana)
The views of community health workers with regard to the care of expectant mothers do not
substantially differ from those of caregivers. However, they tend to emphasize proper hygiene,
cleanliness and proper eating more than the caregivers.
I encourage cleanliness so much. Cleanliness is very vital for a pregnant mother. Also
discouraging them from strenuous work. They should not be shouted at. They should also
desist from being angry most of the time because it affects the babys brain. (Community
health worker Ruhango)
The advice we gave them while in the meeting was that it was bad to assault a pregnant
mother as this greatly affects the unborn baby. (Community health worker Rubavu)
A pregnant mother should desist from taking alcohol; we discourage them from using
tobacco even taking the traditional drugs that are not recommended by medical personnel.
(Community health worker Ngororero)
I would still emphasize that she makes all the antenatal visits she ought to make while
pregnant. (Community health worker Nyamasheke)
This digging that we do is sometimes tiresome and I would not encourage a pregnant
woman to dig as much as she has been digging before becoming pregnant. (Community
health worker Rulindo)
The expectant mother has to take porridge more often so that she can generate breast
milk. (Community health worker Gicumbi)
She takes as many fruits as she can. These fruits are readily available here since its a
village. They are very nutritious for the baby also. For example fruits like jackfruits,
pineapples, oranges, paw paws and guavas. (Community health worker Rulindo)
Knowledge, attitudes and practices regarding antenatal care
Effectively all biological mothers of children 0 to 6 years (99percent) have had ANC at least once
when expecting their index child: 74percent mentioned taking ANC from a health centre in
the district and 48percent at the main hospital. A high proportion have the correct knowledge
about ANC. For most of the behaviour related to ANC, the practice is arithmetically higher than
the knowledge, except for getting ANC services at the main hospital. This difference is, however,
not statistically significant when the attributes are analysed as a unit.
Table 15: Knowledge and practice of antenatal care
Antenatal care Knowledge (%) Practice (%)

Total (N) 2,000 2,000
At home with visiting doctor, nurse or midwife 9 13
Health centre in the district 74 82
Main hospital in the district 48 48
At the clinic in the village 21 29
At community health workers home 17 20
Did not have any ANC services 2 1
The null hypotheses were tested on the attributes indicated in Table15. The results failed to reject
the null hypothesis on three of the attributes. The null hypothesis read there is no significant
difference between the means of the two variables the two variables being knowledge and
practice as tested on the particular attribute. For the following attributes there is no difference
between knowledge and practice, concerning where an expectant mother should go for ANC:
1. at home with visiting doctor, nurse or midwife
2. at the clinic in the village
3. at community health workers home.
The following attributes, on the other hand, show differences between knowledge and practice:
4. health centre in the district
5. main hospital in the district
6. did not take any ANC services.
Results indicate high usage of health centres and clinics, which may be attributed to the
proximity of these facilities. For all the respondents, the health centre and a village clinic is
estimated to be within an average of 3km reach and a main hospital within 5km reach. Overall,
respondents indicated that an expectant mother should attend ANC services at a health facility
four times during her pregnancy.
The practice of delivering at a recognized health unit was found to be high at a national level
with at least 86percent of the respondents indicating that they delivered at a health facility in
the district. This practice is common across all the provinces and there are also no differences
by education level and age. There are some differences according to economic category as shown
in Table16. Interesting to note is the difference between the incidence of delivery in hospital
for those from the poor (26percent) and the upper-middle economic categories (38percent).
Table 16: Place of delivery of index child disaggregated by economic category
Economic category
Total (%) Lower-middle Upper-middle
Poor (%)
(%) (%)
Total (N) 1,987 951 667 369
At home with visiting doctor, nurse or midwife 2 3 2 1
Health centre in the district 54 59 50 51
Main hospital in the district 32 26 37 38
At the clinic in the village 4 3 5 4
At community health workers home 1 1 0 1
No response 6 8 6 4
Although most deliveries happen at a recognized health centre or hospital, the challenge of
health centres being overstretched was mentioned by caregivers, which may cause some mothers
to choose to deliver at home.
They deliver in a health facility or in the hospital. Only that the challenge with our health
centre is that there are few maternity wards. There are mothers that find them full and are
forced to return home and deliver there. (Community health worker Bugesera)
We have few health centres with maternity services. So you find a lot of women in pain
waiting to be attended to. This is what pushes some of them to even deliver at home. But I
think the first thing is to breast feed the baby. (Female caregiver Gakenke)
Findings reveal that mothers rely on health practitioners advice on safe delivery. Female
caregivers attribute most successful deliveries to their regular attendance of antenatal services.
There are also perceptions that if a mother eats well and does not get involved in heavy work,
then her chances of delivering safely are high.
When a mother visits the doctor, he will tell her that you are like this and this. That is
the only way the mother can get to know she will have a successful delivery, otherwise how
would she know if she doesnt visit the doctor? (Female caregiver Ngoma)
If she has been making her antenatal visits regularly, then she will know everything. In
that, if she followed what the doctor advised her to do, then she will be sure to have a
successful delivery. (Female caregiver Bugesera)
For a mother to know she will have a successful delivery, the doctor keeps updating
her through the regular antenatal visits. These people are always in touch with her. But
community health workers also keep track of the progress. If she doesnt make the antenatal
visits, the baby may end up being poorly positioned in the womb due to the natural herbs
they take. And thats why most of them end up delivering by caesarean section. (Female
caregiver Nyamasheke)
For me I think if the pregnant woman has been eating well and doing less laborious work,
then she will be sure of a successful delivery. Much as I discourage laborious work, I still
dont encourage that the pregnant mother spends the whole day sitting down. She should do
some physical exercise in the form of the small chores at home. (Male caregiver Rubavu)
I think a successful delivery is all by the mercy of God. However, the pregnant mother has
to adhere to the doctors advice and simply pray to God. (Female caregiver Ruhango)
Female caregivers recognize that the period close to the delivery date is critical and that is when
most preparations and monitoring are done by the mother and those that take care of her. Some
of the preparations include: maintaining proper hygiene practices, eating well and dressing in
an appropriate manner.
Female caregivers also pointed out challenges relating to fathers not taking care of the mother
and the babies, in terms of providing the financial and material support needed. In such cases, the
women themselves take the initiative to ensure that they have made the necessary arrangements,
for example, that clothes for the baby are available and that the hospital is notified on time.
Like I have told you, most women here make antenatal visits and thats why almost all
deliveries in this village have been successful. (Community health worker Bugesera)
Mothers in our village make antenatal visits. So the doctor advises them on what to do.
But all in all, the mother has to be extra clean. She also has to observe what she eats as well
as having the funds readily available. (Female caregiver Kamonyi)
A mother preparing to give birth That period is very important. Because whether
you like it or not it has to happen. There are some that show responsibility while other
husbands dont even listen. You tell him something and he ignores you. Babies clothes,
money for maternity care, there is also money to look for the babies requirements, and so
on. Say even the food he will feed on reaching the eating age. We tell them all that but only
a few listen. (Female caregiver Nyamasheke)
We are lucky that the health centre is near. So personnel at the health centre are simply
put on the alert and the mother strictly begins to eat, walk, talk, sleep and dress according
to the doctors instructions. This is why deliveries that occur from home are highly risky
because it is highly probable that the mother will not know all this. (Female caregiver
Nyarugenge)

child care after birth
Caregivers do many things to contribute to the growth and development of their children.
The responses of mothers and fathers reveal their understanding of what caregivers should
do while taking care of children. In most cases, the practice of the various activities is higher
(arithmetically) than the knowledge about them. The means of the attributes pertaining to
knowledge and practice were compared using the t-test with the null hypothesis33 indicating
no significant difference between the means of the attributes. Findings are mixed, with some
attributes rejecting the null hypothesis and others failing to reject the null hypotheses.34 The
correlation analyses, however, find positive and significant correlations between knowledge and
practice on the after-birth attributes. This means that the higher the knowledge concerning a
particular attribute, the higher the likelihood that caregivers will practise positive behaviour.
It also means that an increase in knowledge about a certain positive behaviour will lead to an
increase in good practices.
Table17 indicates higher practice than knowledge for all of the aspects of after-birth child care.
This may imply that caregivers undertake the right practices but have limited knowledge on the
importance of these practices. In order to ascertain the significance of the difference between
knowledge and practice, a t-test was done on each attribute for knowledge and practice using
= 0.05.
33 H0: There is no significant difference between the means of the two variables. HA: There is a
significant difference between the means of the two variables.
34 For a full list of significance tests and correlation tests on after birth child care attributes contact
UNICEF Rwanda.
Results indicate a significant difference between knowledge and practice for most of the
attributes that were tested in relation to after-birth behaviours. The attributes which were found
to have a significant difference between practice and knowledge were:
1. immunizing the baby against vaccine-preventable diseases
2. keeping the baby warm by not bathing the baby immediately
3. keeping the baby warm using the mothers chest
4. keeping the baby warm with appropriate clothes
5. registration of the baby
6. going for postnatal visit for review of mother and baby
7. breastfeeding exclusively for 6 months
8. hand washing with soap
9. keeping the child in a clean environment
10. vitamin A supplementation
11. adherence to prescribed medication
12. proper feeding for the child.
For all the above behaviours, the practice was found to be higher than the knowledge, indicating
that caregivers feel or know that they should do them, but they may not know why they are
doing these things. It further indicates that an increase in knowledge will significantly increase
practice of the behaviour. For some of the behaviours, there was no significant difference between
knowledge and practice, although arithmetically the percentages are different. The behaviours
that were found to have no significant difference between knowledge and practice are:
1. breastfeeding the baby within the first hour of delivery
2. clean cord care
3. both mother and child sleeping under the mosquito net
4. growth monitoring
5. promptly seeking health care in case of illness
6. proper eating by the breastfeeding mother
7. taking the child for circumcision (in case of boys).
Table 17: Knowledge and practices regarding child care after birth
Knowledge Significance
Caregivers of children aged 0 to 6 years Practice (%)
(%) (t-test)
Total (N) 2,000 2,000
Immunizing the baby against vaccine preventable diseases 78 87 0.000
Breastfeeding the baby within the first hour of delivery 42 62 0.100
Keeping the baby warm by not bathing the baby immediately 30 53 0.000
Keeping the baby warm using the mothers chest 21 45 0.018
Keeping the baby warm with appropriate clothes 28 51 0.000
Registration of the baby 37 57 0.000
Going for postnatal visit for review of mother and baby 23 44 0.000
Clean cord care 21 39 0.126
Breastfeeding exclusively for 6 months 37 57 0.000
Both mother and child sleeping under the mosquito net 33 53 0.105
Hand washing with soap 31 50 0.000
Keeping the child in a clean environment 26 45 0.000
Growth monitoring 24 43 0.090
Vitamin A supplementation 38 54 0.025
Promptly seeking health care in case of illness 23 44 0.356
Adherence to prescribed medication 21 40 0.018
Proper feeding for the child 24 46 0.000
Taking the child for circumcision (in case of boys) 10 21 0.106
In most of the households sampled, the female caregivers were found to be more knowledgeable
about child care after birth than the males. This could be attributed to the higher level of
exposure to information among the women in relation to motherhood and child rearing, since
more mothers than fathers attended antenatal services. In addition, mothers are generally more
involved in child care than fathers are.
Findings from the focus group discussions confirm the level of knowledge that exists among the
caregivers with regard to care for the child and the mother after birth. The key aspects that they
pointed out as important were: breastfeeding immediately after delivery, that the mother should
have a lot to drink and eat (with millet porridge being very prominently mentioned), taking the
baby for a medical examination and ensuring that the mother gets enough rest.
Although there is high knowledge and practice among the female caregivers, the responses
relating to what should happen after child birth were all skewed towards what women should
do, indicating the perceived passive role of male caregivers. Fathers are perceived to have more
of an economic and cultural role, such as naming the child and providing for the welfare of the
mother.
First and foremost, breastfeeding them while they are still infants. I have to make sure
that the children are breastfed to full term. You then resort to ensuring that they eat and
that they are healthy. (Female caregiver Rulindo)
When she has just given birth, she does the very first breastfeeding. Breast milk has
something it adds to the infants body. (Female caregiver Gakenke)
On giving birth, the mother needs to be given a lot of fluids such that she recovers the
energy she lost while delivering. (Female caregiver Gicumbi)
What I know is that the baby is breastfed as soon as it is born. That saying that the mother
is given a primus beer to generate breast milk is false. What we discovered is that you
give her well prepared porridge and then breast milk will come. (Female older caregiver
Gicumbi)
The baby is immediately taken for medical examination by the doctors while the mother
is given some rest. Nobody is allowed to see the mother at this moment. (Female caregiver
Rwamagana)
The mother hands over the child to the father such that they chose a surname for him/her.
The Christian name is chosen by the mother but the surname aah... that is a fathers role.
(Female older caregiver Gicumbi)
Porridge for the mother is a must. You know that porridge, especially when it is millet, is
very nutritious especially in regard to recovering the energy and the lost body fluids which
are in turn converted into milk. (Female caregiver Rulindo)
The mother is given a cupful of millet porridge immediately. This is to help her regain
energy and also generate milk for the very first breastfeeding. (Female caregiver Rulindo)

deworming
Deworming of children is one of the key child care practices that ought to be observed by parents
and caregivers of children. In this assessment, the claimed practice of deworming is very high at
89percent for children aged 1 to 6 years, with no significant variations by province. Variations
by level of poverty are however evident with 100percent of caregivers in the upper economic
category having dewormed their children (note that there were very few (13) observations for
the upper economic category).
Table 18: Deworming of children by province
Province
Total (%)
Northern (%) Eastern (%) Western (%) Kigali (%) Southern (%)
Total (N) 2,000 376 515 379 337 393
Yes 89 86 90 91 90 89
No 6 10 5 4 4 9
No response 4 5 4 5 6 2
Table 19: Deworming of children by economic category
Economic category
Poor (%)
(%) (%)
Total (N) 1,987 951 667 369
Yes 89 87 90 94
No 6 9 6 1
No response 4 4 4 5
Most of the respondents who have never dewormed their children fall into the poor and lower-
middle economic categories. As shown in Table20, for those who have never dewormed their
children, the key reasons for not doing so were cost (20percent), they considered that children
were still young (15percent), and a lack of knowledge about deworming (9percent). There is
however, a small proportion of caregivers (3percent) who indicated that they did not deworm
because the child had not fallen sick.
Table 20: Reasons why respondents have never dewormed their children
Economic category
Reason Total (%) Lower-middle Upper-middle
Poor (%)
(%) (%)
Total (N) 127 83 39 5
It is very expensive 20 25 10 0
My children are still young 15 12 23 0
I do not know about deworming 9 10 10 0
My child did not fall sick 3 1 8 0
There was no time 3 5 0 0
Dont know 6 5 10 0
No response 45 45 38 100
Responses relating to cost and waiting for a child to fall sick point to the lack of knowledge about
deworming, as deworming medicine should be given as a routine treatment when the child is
due for deworming regardless of symptoms. There may also be lack of knowledge that a child
suffering from worms may not fall sick, but show other symptoms.
Focusing on those who claimed to have dewormed their children, 6 in every 10 usually deworm
every three months (60 per cent). At least 89 per cent reported using medicine from health
workers while 7 per cent use herbs and 4 per cent use either herbs or medicine from health
workers, whichever is available to them at the time of deworming.

immunization
There is high claimed knowledge of the types of immunization that a child should have at
91percent and there are no significant differences by region or by poverty levels. Those who
knew about immunization pointed out the reasons for immunization as: ensuring the child
grows up healthy (57 per cent), prevention of death (53 per cent) and prevention of health
impacts that may occur later in life (45percent).
In households where both male and female caregivers were interviewed, the perception of the
need for immunization is not different, apart from the understanding that it prevents future
health problems that may affect the child. With regard to this parameter, responses from female
caregivers were 11percent higher than those from males.
As already noted, in each of the households assessed an index child was identified. This was
the basis for analysis in this section, although the respondents were asked questions relating to
the immunization of other children in the household as well. Results indicate a high incidence
of immunization practice among the households sampled, with 92percent claiming to have
immunized their index child. Of those that claimed to have immunized, 93percent said they
had the immunization cards. However, only 73percent of these could show the immunization
cards when the interviewer requested to see them.
With regard to the category of caregivers, there was no outstanding difference with regard
to having immunized their children. However, there was a proportion of children that were
not fully immunized, possibly because they had not yet reached the age to complete all the
immunizations required.

child registration
In our sample, childrens birth registration rate is high as indicated by the 76percent who
claimed to have registered their index children. However, as indicated in Table17, the average
across the whole sample is 57 per cent, approximating better the national average. Although
these results may indicate a growth in registration, figures need to be treated with caution
as some respondents may have shown their interviewer their birth notification form rather
than the birth certificate which is the correct proof of registration. The assessment found that
registration of childrens birth was high irrespective of the category of caregiver, although the
biological mothers of the children are more likely than other categories of caregiver (such as
grandmothers and other relatives) to know if the child was registered or not. With regard to
Table 21: Reasons for lack of registration of children
Total (%) Northern (%) Eastern (%) Western (%) Kigali (%) Southern (%)
Total (N) 326 59 101 54 39 73
Did not know the process 29 24 31 19 54 23
Did not know where to register 26 17 28 24 0 45
Did not know that I have to register 23 5 20 11 10 59
the child
There is no need to register the child 20 14 32 13 28 8
Did not want to register the baby 19 14 17 33 18 15
I have to travel far to register 18 5 9 13 3 55
The cost of registration is high 16 17 5 15 0 38
No response 18 34 20 7 8 15
provinces, Kigali had the highest claimed birth registration at 82percent, while the lowest was
Eastern province at 72percent.
Those who had not registered children were hindered by a lack of knowledge of the registration
process (29percent), lack of knowledge of where to register (26percent) and not understanding
the need for registration (23percent). Table21 shows, however, that some caregivers think that
it is not important to register children and some did not want to register their children.

feeding
Knowledge of when infants should be introduced to solids is high. About 41 per cent of the
respondents indicated that infants should be introduced to solid foods and fluids at 6 months,
and a further 34percent indicated that the infant should be older than 6 months but less than
1 year. In practice, 38percent of the respondents introduced other foods at 6 months, while
30percent introduced them when the child was older than 6 months but less than 1 year. In
households where both male and female caregivers were interviewed, there is no significant
difference between the recall of when the children were introduced to solid foods between males
and female respondents, although the females exhibit higher recall.
During the 30-minute observation, the index child was mostly fed by the mother (44percent).
Only 9 per cent of other female adults fed the index child. The child was mostly fed with a
meal served with hands (24percent). Liquid food served with hands was least fed to the child
(7percent). At least 69percent of the mothers/caregivers that fed an infant did not wash their
hands immediately before. The children were mostly fed on porridge, sweet potatoes or Irish
potatoes, milk and rice while the interviewer was at the household.
Ordinarily, a child should have three meals a day and at least a snack, a drink or fruit in between
meals. These meals should be rich in nutrients, including carbohydrates, vitamins and proteins,
to help the child to grow strong and healthy. This section presents findings on feeding practices
in the population assessed in this study. The assessment explored various attitudes and opinions
towards early childhood feeding.
Good feeding minimizes cases of child illness greatly. It is better to feed children with foods
they like eating such that they eat and get satisfied. I make sure that I buy a variety of foods
when I go to the market. (Female caregiver Bugesera)

Now to me, I dont only advise children but also to older people about nutrition. Good
feeding is not only to children but even to old people. We teach them how to use fruits
like pawpaws. We even teach them how to mix soya and milk and other important foods.
We teach about other important foods that help their bodies to grow and stay healthy.
(Community health worker Bugesera)
In our days, babies used to not eat any type of food until when a baby was above six
months, unlike today. (Community health worker Nyamagabe)
We mostly advise them [caregivers] to take good care of them [their children] by feeding
them well. (Community Health Worker Rulindo)
[To improve the health of your children] you look for vegetables like carrots, tomatoes,
fruits and you feed the child so that he can grow well. Thats what we do. (Female caregiver
Gakenke)
We teach them and tell them what to do but poverty inhibits them from implementing this
because you at least need a little money to ensure that your child is fed well. (Community
health worker Ngororero)
The woman who has a 3-month-old baby is supposed to drink a lot and breastfeed the
baby more and more times a day because from the time that child is born to 3 months, the
baby only needs to be breast fed and I believe the milk that is given to the baby from the
mothers breasts has enough nutrients. The baby has to breastfeed 8 to 12 times a day since
its the only food it feeds on. (Female caregiver Bugesera)
Another thing that results in a child not growing is the feeding. In cases when the child is
not fed well his growth is retarded. (Male caregiver Ngororero)
Types of foods given to children of different ages on the previous day
This section presents findings on the foods that were given to the respondents children on the
day prior to the assessment visit.
Before breakfast, respondents do not commonly give their children anything to eat. Out of the
115 children in the sample who are below 6 months, only 25percent were given anything before
breakfast the day before the interview and the majority of those (12percent) were given breast milk.
The majority of those who did give their children food before breakfast generally belonged to the
upper economic category. They gave foods such as milk (37percent), breast milk (21percent),
fruits (12percent) and porridge (11percent). Other foods given before breakfast are as indicated
in Table22.
Table 22: Foods given to children before breakfast
Age group of children

Food given before breakfast 0 to 6 months 7 to 11 months 1 to 2 years 2 to 6 years
(%) (%) (%) (%)
Total number of observations 115 77 981 1,246
None 75 52 74 60
Breast milk 12 19 8 1
Milk 7 9 6 11
Breast milk and fruits 3 0 0 0
Water 2 1 2 0
Fruits 2 5 2 3
Porridge 1 3 2 3
Other* 3 6 9 11
* Includes: rice, bananas, biscuits, sweet potatoes or Irish potatoes, vegetables, Cerelac (an instant
baby porridge), dry tea, chips, juice, meat, eggs or bread.
At breakfast, about 57percent of children aged 0 to 6 months are mostly fed on breast milk. The
incidences of breastfeeding for breakfast reduces as the children grow older to 38percent for
those aged 7 to 11 months, 17percent for those aged 1 to 2 years and 4percent for those aged 2
to 6 years. On the other hand, feeding children on porridge increases as the children grow older
as indicated in Table23.
Table 23: Foods given to children for breakfast
0 to 6 7 to 11 1 to 2 years 2 to 6 years
Breakfast
months (%) months (%) (%) (%)
None 19 13 19 26
Porridge 15 32 42 67
Milk 3 8 9 10
Other* 8 8 13 19
* Includes: rice, fruits, meat, biscuits, yogurt, dry tea, bread, fruits, bananas and beans, cassava and beans,
pottage, porridge and bread, sweet potatoes or Irish potatoes, vegetables, milk and water, rice and beans.
As was the case for foods given before breakfast, the poor did not seem to give their children
food before lunch significantly, apart from breast milk (5 per cent) for those who were
breastfeeding. Those who did give other foods before lunch belong to the middle and upper
economic categories. Such foods included breast milk (13percent) for babies below 6months
and milk for the other age groups (see Table24).
Table 24: Foods given to children before lunch
Age group of the child

Before lunch 0 to 6 7 to 11 1 to 2 years 2 to 6 years
None 71 55 70 57
Milk 3 14 9 9
Porridge 5 6 4 3
Fruits 2 6 6 6
Juice 0 5 2 6
Other* 7 6 7 6
* Includes: rice, biscuits, Cerelac (an instant baby porridge), vegetables, water, milk and breast milk,
bananas and beans, sweet potatoes or Irish potatoes, beans or soya beans, bananas, water, pottage.
Foods given at lunchtime are shown in Table25. Foods rich in starch are the most common
foods given to children for lunch. It is notable that it is more common for children of all age
groups to have no lunch than no breakfast.
Table 25: Foods given to children for lunch
0 to 6 7 to 11 1 to 2 years After 2 to 6
Lunch
months (%) months (%) (%) years (%)
None 48 21 24 29
Fruits 7 1 2 1
Sweet potatoes or Irish potatoes 7 10 15 22
Milk 6 9 2 2
Beans or soya beans 4 0 1 0
Juice 2 0 0 0
Rice 2 4 9 11
Milk and bread 2 0 0 0
Bananas 1 4 8 13
Vegetables 1 4 3 1
Porridge 0 8 3 2
Other* 6 19 19 25
* Includes: milk and breast milk, bananas and beans, porridge and milk, cassava or cassava bread,
biscuits, potatoes and beans, rice and beans, cassava and beans, beans or soya beans, meat, Cerelac
(an instant baby porridge), fish, bananas and vegetables, cassava bread and vegetables, umumece
(small, sweet bananas), phosphatine (a supplement women take), potatoes and vegetables, spaghetti,
posho (maize meal), rice and vegetables, rice and meat, rice and peas.
As was the case for meals served before lunch and before breakfast, not many respondents in the
poor category give meals before dinner. The majority of those who do belong to the middle and
upper economic categories.
Table 26: Foods given to children before dinner
Before dinner
None 75 64 76 75
Milk 3 5 5 6
Porridge 2 3 3 5
Bananas 2 1 1 0
Fruits 1 8 5 7
Other* 8 10 9 5
Juice 1 3 3 3
* Includes: porridge and bread, rice, beans or soya beans, cassava or cassava bread, biscuits, yogurt,
maize, eggs, water, dry tea, meat, rice and beans, pottage.
Foods given to children for dinner are comparable to those given for lunch. They consist mainly
of starchy foods. Table27 shows the top five foods given to children for dinner.
Table 27: Foods given to children for dinner
Dinner
None 45 21 27 31
Milk 8 6 7 3
Fruits 5 6 3 2
Porridge 3 8 4 2
Bananas 3 5 6 12
Cassava or cassava bread 3 1 1 3
Porridge and milk 2 3 0 0
Rice 0 3 8 11
Vegetables 0 8 1 1
Other* 6 26 28 14
* Includes: dry tea, beans or soya beans, juice, yogurt, milk and fruits, milk and water, phosphatine,
spaghetti, posho (maize meal), maize, biscuits, Cerelac (an instant baby porridge), bananas and
beans, bananas and vegetables, rice and vegetables, rice and meat, rice and fish, fish meat, rice and
beans, potatoes and beans, cassava bread and vegetables, milk and bread, potatoes and vegetables,
Irish potatoes and meat, rice and ground nuts, rice and potatoes, cassava and beans.
As is the case with lunch, a fairly high percentage of children of all age groups are not fed at
dinnertime. In addition, it is notable that a high prevalence of infants aged 0 to 6 months old
appear to not be fed at the three main mealtimes. It should be noted that this is likely to be
an incorrect interpretation. Although breastfeeding is included as a response category, some
caregivers did not consider this a food unless prompted. In this case, respondents were not
prompted for food categories so this could account for the impression that a large percentage of
0 to 6 month olds are not fed.
Foods ordinarily given to children
This section presents findings on foods ordinarily given to the respondents children on a day to
day basis and the number of times children are ordinarily fed in a day. Results here differ from
the previous section which reports only on the specific foods given to children on the day prior
to the interview.
Children 0 to 6 months are ordinarily fed on breast milk (90percent). In cases where children
receive supplementary feeding, they are fed on foods such as cows milk (14percent), and/or
porridge (9percent). As it is recommended for children from 0 to 6 months to be exclusively
breastfed, the finding that 90percent of children of this age are breastfed is a positive one. In
addition, this trend is consistent across the various economic categories.
Children aged 7 to 11 months receive a much wider variety of meals. This, of course, reflects the
fact that complementary feeding has already started at this age. Respondents indicated that they
started giving their children alternative foods at 6 months, and between 6 months and 1 year.
Apart from breast milk, which is still given to 72percent of children, the foods ordinarily given
in this age category include porridge (52percent), milk (40percent), fruits (33percent), and
sweet or Irish potatoes (19percent).
In observing these meals, it appears that children in these categories receive (from alternative
foods) vitamins from fruits, carbohydrate from porridge and potatoes, and protein from milk.
The incidences of children fed on carbohydrate-rich foods are more than those who are fed
foods that are rich in other nutrients. More food varieties are, however, given by caregivers in
the upper economic categories than in the lower ones. Table28 highlights the differences.
Table 28: Foods regularly given to children 7 to 11 months old
What type of food do you feed children between 7 to 11 months regularly?

Economic category
Poor (%) Upper (%)
middle (%) middle (%)
Total number of observations 1,359 693 428 230 8
Breast milk 72 74 70 73 75
Porridge 52 58 54 30 50
Milk 40 35 45 49 75
Fruits 33 29 42 29 12
Sweet potatoes or Irish potatoes 19 18 22 13 12
Vegetables 12 14 12 5 50
Bananas 9 10 10 5 12
Meat 9 9 8 8 12
Biscuits 7 7 7 4 0
Water 4 4 4 2 25
Beans or soya beans 4 4 7 0 0
Fish 4 2 5 7 38
Eggs 4 3 5 6 25
Children from upper economic groups are fed on more varieties of foods which represents a
more balanced diet than the children of poor caregiver. Children in poor households mainly
receive protein from milk and breast milk. Those in middle and upper economic categories
receive proteins from sources such as milk, fish, meat and eggs, as well as breast milk.
For children aged 1 to 2 years, the dependence on breast milk drops to 20 per cent and is
replaced by porridge (50percent). The varieties of foods given are more diverse, ranging from
the aforementioned porridge and breast milk, to potatoes (42 per cent), milk (32 per cent),
fruits (27 per cent), bananas (23 per cent), and beans (21 per cent) among others. There is a
general tendency for the varieties and amounts to increase across the four economic levels under
consideration. Given this scenario, it is easy to assume perfect nutrition until we consider the
number of meals per day that the children receive which shows poor households giving their
children fewer than three meals per day. Although quantities were not inquired about, it is the
assumption of this survey that food quantities in poor households are generally less than in
well-to-do households.
For children aged 2 to 6 years, porridge is replaced by potatoes as the overall main food given
(46 per cent). The varieties given are outlined in Table 29 (indicating the main foods, but
excluding those appearing in smaller percentages).
Table 29: Foods ordinarily fed to children aged 2 to 6 years
What type of food do you feed children of 2 to 6 years regularly?

Economic category
Poor (%)
middle (%) middle (%)
Porridge 43 43 46 38
Potatoes (sweet, Irish) 46 55 43 27
Rice 25 18 30 32
Fruits 25 16 31 39
Beans or soya beans 25 31 19 21
Milk 23 14 31 34
Vegetables 20 22 18 19
Bananas 19 22 19 14
Cassava or cassava bread 12 16 9 8
Meat 10 5 11 20
Juice 8 8 8 7
Fish 5 3 6 7
Eggs 5 2 4 13
Biscuits 4 2 5 8
Chips 2 1 3 2
Meals served in a day
When asked how many meals per day children aged 0 to 6 months receive, about 92percent
indicated breast milk while about 7percent indicated breast milk and other foods. The failure to
indicate an absolute number of meals may be accounted for by the fact that lactating mothers do
not count the number of times they breastfeed their babies, especially babies in the category in
question (0 to 6 months old). It is likely that this also helps explain the high rates of 0 to 6 month
olds appearing on the feeding tables above as not being fed at mealtimes.
For children aged 1 to 2 years, only 10percent of the respondents indicated that they give their
children in this age category three meals per day and a snack. About 28 per cent give three
meals per day, 18percent give one meal per day and a further 18percent give two meals per
day. This scenario indicates poor nutrition. Children may be getting the correct foods, but not
in the correct amounts or with the right number of meals, which compromises the growth and
development of the children. This poor nutrition may be because some households, especially
the poor ones, cannot afford to provide three meals a day and snacks in between meals.
For children aged 2 to 6 years, about 42percent of the respondents give their children three
meals per day. Some 10 per cent give three meals and two snacks. The rest of the sample of
caregivers provides fewer than three meals per day for their children of this age.
It should be noted that these findings are limited because they are based on a set of pre-coded
responses. They present a different picture to the number of meals per day, per age group, that
are found in Tables 22 to 27, which relate the foods given to children on the day prior to the
interviews. Tables 28 and 29 may well give more realistic information on the meals that children
of different age groups are missing. Tables 23, 25 and 17 show, for example, that 26percent
of 2 to 6 year olds get no breakfast, 29 per cent get no lunch and 31 per cent get no dinner.
Comparable figures for 1 to 2 year olds are less but still show 19percent getting no breakfast,
24percent getting no lunch and 27percent getting no dinner.

childparent interaction
The relationship between the child and the parent/caregiver is an important factor with regard
to the development of children, especially at the early stages of their lives. This study sought,
among other things, to establish caregivers KAP in relation to childparent interaction and
nurturing at different stages in the childs life. The caregivers were presented with different
activities and asked which ones they had engaged in with their children of different ages and the
level of importance that they attached to them.
Mothers were observed with their children for a period of 30 minutes, but their consistent
presence with their child was generally low. A low percentage of mothers (only 20 per cent)
were present with their children for 80percent of the observed 30 minutes. Only 4percent of
mothers were present with their children for all of the observed 30 minutes. In cases where the
mother was absent during the observation, the majority of the respondents (33percent) had no
one else there looking after the child. In 30percent of the cases female adults were taking care
of the children in the absence of the mother. A comparably small proportion of female youth
(16percent) assumed this role. This role of a mother as the main caregiver also came out in
qualitative discussions.
The findings seem to suggest that parents interact with children more when they are still at
a young age (aged 0 to 1 year old) than in the later years (aged 2 to 6 years old). At the age of
1year old and above, the level of interaction between the caregivers starts to decrease, perhaps
because children are exploring the environment around them. In general, parents indicate that
interacting with the child is important, however, they do not fully understand what specific
forms of interaction help in the development of their children. This is illustrated in Table30.
The most practised activity is taking children for immunization (73.3percent) while the least
practised is drawing the childs attention to people, things or animals in and around the home
(50.8 per cent). All the activities listed were considered important by the respondents. The
highest rated in terms of importance is taking children for immunization (96.8percent) while
the least rated (though still getting a high score) is drawing the childs attention to animals,
different things and people at 80.9percent. Various reasons were given for the importance given
to the various activities. The most prominent reason given for a number of the activities is for
brain development and stimulation.
Although the practice and attitudes towards child development and stimulation are high, most
parents may not attach a reason to the kind of behaviour rated of high importance. For example,
54 per cent of the caregivers teach children values and they attach 88.6 per cent rating to
this for level of importance however, only 13percent could list at least one reason for this
behaviour. Similarly, reading a book or telling story to a child, playing simple games with a
Table 30: Activities done to develop childrens physical, emotional and mental abilities
Main reason for rating the attribute

Respondent who did Importance attached Respondents that
Activity
the activity (%) to the activity (%) Reason mentioned the reason
(%)
Age 0 to 6 Months
Touch, hold or caress the child 72.40 86.00 For brain development 62
and stimulation
Talk and/or sing to the child 68.10 83.80 To help the child 41
recognize the voices of
the parents early
Take children for immunization 73.30 95.40 For brain development 40
and stimulation
Breastfeed exclusively 60.40 93.70 For brain development 51
and stimulation
Age 6 to 12 Months
Draw the childs attention to people, things or 50.80 80.90 It helps the child to 31
animals in and around the home learn the environment
around them
Talk, read, tell a story and/or sing to the child 63.40 85.70 To help the child learn 28
Play simple games with the child (e.g. peek-a-boo) 65.00 86.50 To help the child learn 19
Take children for immunization 55.30 96.80 For brain development 38
and stimulation
Age 1 to 2 Years
Encourage the child to learn language (e.g. names 61.70 88.30 To help the child learn 24
of familiar people and objects, animal sounds,
simple words and phrases)
Talk, read, tell a story and/or sing to the child 63.80 86.90 To help the child learn 27
Provide simple toys for the child (e.g. a spoon, 53.90 81.80 For brain development 18
a plate, a ball, doll can be self-made or a and stimulation
household object)
Age 2 to 4 Years
Read or tell a story to the child 60.50 86.00 For brain development 18
and stimulation
Encourage the child to play and interact with other 61.30 89.20 To improve 18
children relationships and
family unity
Help/encourage the child to hold a pencil, draw 54.30 86.90 To prepare the child for 30
shapes and things school
Encourage the child to learn and use new words, 53.00 87.40 To help the child learn 25
expressions phrases new words
Do simple games or creative activities with the 54.60 83.30 To develop the childs 21
child (e.g. ball games, building blocks, moulding, talents and prospects
colouring)
Teach the child basic values (e.g. sharing food, 54.90 88.60 Increase the childs self 13
sharing toys, not hitting other children) esteem
child, providing simple toys to a child and encouraging a child to play and interact with others
are thought to be important but few caregivers understand why these are important.
In most of the cases, for a mother or a caregiver, interacting with a child is a natural process,
hence it happens spontaneously and may, most of the time, be driven by emotion without
knowing that it may have a positive impact on the development of children and their abilities
in the future.
Caregivers who have children between the ages of 3 and 6 years were asked about activities they
had engaged in to stimulate and play with the child. Practice in relation to child stimulation is
low among caregivers as indicated by the fact that only 40percent of those questioned claimed
to have practised at least one of the activities listed in Table31.
With regard to the particular activities, there are also variations in the degree of practice between
activities as indicated in Table31. The most commonly practised activity is playing games with
the child (61percent). In most of the activities, women are the most involved, as fathers were
only mentioned in relation to one activity reading a book or looking at pictures with the child.
Table 31: Activities done to stimulate children aged 3 to 6 years old
Main person who did activity with

Activity Total Yes = 501
the child
Overall
percentage of
Practice (%) Person the person
who did the
activity (%)
Played any game with the child 61 Mother 27
Sang a song to the child 57 Mother 49
Told stories to the child 52 Mother 49
Read book or look at pictures with child 40 Father 41
Took the child outside of the home for a walk 35 Mother 43
Drew pictures with the child 27 Mother 34
Named or counted objects with the child 23 Mother 40
4.12 Attitudes towards early childhood development
Caregivers were presented with different statements in relation to ECD in order to gauge their
perceptions towards it. Based on the findings, shown in Table 32, we see a general, positive
attitude towards ECD among caregivers. The key knowledge areas that appeared with strong
positive perceptions are: playing with children, providing toys for them to play with, encouraging
children to eat on their own, and encouraging children to ask questions.

child learning
Once children start interacting with their environment, they learn various things. According to
the caregivers, children start learning at an early age of 4 months. The responses indicate that
respondents believe that children first learn hearing and vision at about 5 months of age, walking
at 8 months, understanding and using simple words at slightly over 1 year, and socializing with
other children at 1 years.
During the focus group discussions, however, parents expressed the view that children should
start learning from the time they can talk and interact well with the environment around them.
It seems, from the qualitative findings, that parents perceive learning to start when the child is
older, at the point where they can be more actively taught certain things.
I think by the age of 3 years the child can talk, they can listen and also recall some things.
So I also feel the age of 3 is ok for a child to start schooling. (Female caregiver Nyamagabe)
Any age between 3 and 6 depending on the level you want the child to start from. If its
nursery, 3 years, if its primary, then 6 years is appropriate. (Female caregiver Gakenye)
We used to start school really late. Some would start primary when they are 11 years. But
today, by 5 to 6 years, the child is already in school. (Male caregiver Ngororero)
Table 32: Perception towards child development practices
Total
Statement Response Number of Percentages
responses (%)
A mother and/or father should talk or sing to the baby Agree 1,188 59
when it is still in the womb
Disagree 600 30
Do not know 212 11
Children should not learn to read or write their name until Agree 690 35
they are in primary school
Disagree 1,148 57
Do not know 162 8
Children must not try to eat by themselves until they are Agree 581 29
two years old
Disagree 1,248 62
Do not know 171 9
If parents are too gentle with their children, the children Agree 603 30
will not listen when they try to discipline them
Disagree 1,149 57
Do not know 248 12
Children will learn better if they are exposed to a lot of Agree 995 50
language
Disagree 721 36
Do not know 284 14
Beating children may negatively affect self-confidence, Agree 1,002 50
including encouraging them to beat others
Disagree 762 38
Do not know 236 12
Parents should take time to play and interact with their Agree 1,536 77
children
Disagree 256 13
Do not know 208 10
Parents should encourage children to ask questions so Agree 1,421 71
that they can learn
Disagree 362 18
Do not know 217 11
Parents should provide things for their children to play Agree 1,282 64
with (e.g. household objects, self-made toys or toys from
the shop) Disagree 302 15
Do not know 416 21
The fathers role is to discipline children, pay school fees Agree 934 47
and buy home requirements for the child. The mothers
role is to care for the childs health and nutrition. Disagree 121 6
Do not know 945 47
You may take the child to school at the age of 2 just to play with the rest. The child can then
start school at the age of 3. (Female caregiver Bugesera)
There is a relationship between the parents perceptions of when the child should start learning
and when they take the child to school. Most of the caregivers felt that the children are ready to
go to school as soon as they are 3 years old and they may not wait for the child to show any sign
of maturity to go to school. This may imply that some caregivers think learning starts in school.
You can tell by the way the child looks at his other colleagues as they come back from
school. The child will begin taking an interest in what they do and also demanding that
he also starts studying. You can give it a try and take him for the first day. If they say they
liked it on returning home, the child can then start school regardless of his age. Why not?
(Female caregiver Gicumbi)
Some of them dont show any signs that they are ready but the moment they reach 3, you
just take them to school. (Female caregiver Nyarugenge)
The child will even start showing interest in writing wherever they find, wanting to be
near any one writing something, carrying books and things of the sort. (Female caregiver
Gicumbi)
For me, I just take him to school as soon as I see that he has reached 3. Because he begins
to become very destructive at home. So the best place for him is school where he finds his
fellow children. (Male caregiver Ngororero)
The child will begin admiring fellow children as they come from school and you will also
see it that indeed the child must start school.
You dont wait for any other sign, when a child reaches 3 or 6 years depending on the
age you want him to start school, you take him to school there and then. (Male caregiver
Nyamasheke)
When the child reaches the school-going age, it is a duty of both parents to select a school
that will contribute to the childs development. The father should ensure that the child has
all the school requirements and that he always reaches school. The husband takes centre
stage as regards the responsibility of educating the child. (Female caregiver Rulindo)
4.14 The fathers role in parenting
Respondents had various opinions on the fathers role in parenting. The main point that stands
out is that in many households the father is the breadwinner and protector. He provides for the
family and takes care of the basic needs of all the family members and children.
Table 33: Importance of a fathers role in the development of their child
Attribute Importance (%)

Children 0 to 2 years
Attending ANC sessions 83
Show love and affection to the child and play with it 92
Talk to the child, tell stories 88
Help mother or caretaker in child care duties (e.g. bathing, diaper changing, getting 85
dressed)
Provide for day-to-day necessities such as soap, food, clothes 91
Buying toys 77
Children 2 to 6 years
Providing things the child needs (e.g. food, clothes, paying fees) 89
Disciplining the child 91
Showing the child the environment (both inside and outside the home) 80
Playing with the child 79
Teaching the child to do different things 88
Taking the child to day care or nursery school 83
The female caregivers feel that the role of the father in the development of the child is critical.
The most important role of the father is indicated by the percentage of respondents indicating
that an action is important. When the child is young (0 to 2 years), the most important role of
the father is seen as showing love and affection to the child and playing with it (92percent). This
is closely followed by providing for the childs day-to-day necessities (91percent). Eighty five per
cent of female caregivers also expect the father to be more supportive with regard to child care
duties like bathing, diaper changing and dressing.
As the child gets older (2 to 6 years), the fathers role is seen as most important with regard to
discipline (again scoring 91percent) and providing the things the child needs such as food and
clothes (89percent). Teaching the child (88percent) and playing with the child (79percent)
have lower scores but are still clearly classified as important.
While mens role as the breadwinner and provider is clear, there is also a strong perception that
fathers should be involved in the lives of their children. These findings were affirmed during the
focus group discussions by both male and female caregivers. Female caregivers also expressed
concern about men working away from home and the fact that they spend very little time with
their families. This is a serious limitation on the fathers interaction with the children.
We encourage men to spare time and be with the children. We tell them to always spare
time within a week to be with the children. Get an hour or two and be with the children. It
helps the children not to fear their fathers such that in case a child faces a challenge, they
feel free to approach their fathers. It also strengthens the bond between father and child.
(Community health worker Bugesera)
To a child who is young as we heard earlier, the husband has to help the wife since we
heard earlier that the wife has a bigger responsibility and so the husband has to help his
wife in bringing up that child just like [respondents name] said, our colleague said. If this
doesnt happen, then there will be a problem. (Female caregiver Gakenke)
The man is the lord of the house. He must be the problem solver regardless of the nature
of the problem in the home. The man also has to spare some time to play with the children.
This creates a sense of parental love for the children and also brings out the essence of
physical exercises much more. (Male caregiver Rubavu)
The man ought to be the image of the family in the community events and gatherings. And
the children have to imitate this so that they also grow into equally active members of the
community. (Male caregiver Ngororero)
The man has a huge responsibility to ensure there is harmony in the home. Both between
him, the wife, the children and the neighbours. This indeed facilitates a childs proper
growth since they will grow up peaceful and loving. (Female caregiver Rulindo)
The man also has the duty to ensure the childrens school fees are all cleared/ (Female
caregiver Nyarugenge)
The man has to mentor and groom the boy child in into a responsible and caring man.
(Female caregiver Gakenke)
The father also has to bear in mind that the children have to survive after him. So, he has
to amass property for the children to inherit. It is advisable that he does this when children
are still infants because when they reach the age of 6 and above, they then begin to admire
and so the father has more to provide for. (Male caregiver Ngororero)
When it comes to husbands, very few can spare time for their children. A man is working
in Kigali and his family is here. He only comes very briefly and on a few occasions. So you
find a child being unable to identify his father right from the time he is born. Some men
do not even provide for their families at all. If a man is working far from home, they ought
to at least spare a Sunday for their families. And on coming home, they shouldnt simply
sit and look on as visitors. They should take a moment with the children, play with them
and even teach them traits that could otherwise not be taught by the mother. (Female
caregiver Gicumbi)
4.15 Leaving children in the care of others
A mother or caregiver may not be able to be with the child at all times. There are times when the
mother may need to attend to other things and this may necessitate leaving the child in the care
of other people. In the current study, 82percent of the caregivers indicated that they have not
had to leave the child in the care of anyone to do other things. Those children who were left at
home, were largely left in the care of other relatives, siblings or house helpers.
N = 1,977
18%
CHILD LEFT IN THE CARE OF OTHERS
82%
CHILD NOT LEFT IN THE CARE OF OTHERS
Figure 2: Incidence of leaving children in the care of other people
Of those who left children in the care of others, the majority of respondents indicated that
children are sometimes left in the care of other people. As shown in Figure 3, only 22percent
leave the children with others on a daily basis. This means that most of time the mothers are
with their children at home.
40
N = 360 37.8%
35
30
25.3%
25 22.8%
20
15 14.2%
10
0
ONCE OR TWICE A WEEK
WHENEVER NECESSARY
EVERY DAY
RARELY
Figure 3: How often caregivers leave their children in the care of others
Organized child care facilities
The incidence of attending organized care or pre-school is low in the communities that were
sampled for this study. Only 12percent of caregivers take their children to organized child care
facilities. Formal child care facilities are located in the urban areas.
For the majority who do not take their children to organized child care centres, the main reasons
provided are protection for the children, because parents feel they are too young to be out of the
family setting (16percent), a preference for having the children at home (12percent) or fear
that children might get sick (5percent). Some parents also felt that the child care centres are
expensive (14percent), while others did not know where the centres were located (14percent).
7% 88% 5%
YES, CENTRE-BASED NO YES, HOME-BASED
Figure 4: Attendance at organized child care facilities
Although attendance of organized centre-based care is low, 43 per cent of the respondents
indicated that such places exist. The majority of these (55percent) indicated nursery or pre-
primary schools, 30percent indicated centre-based day care (church, mosque, NGO, etc.), while
16percent indicated home-based day care.
From the focus group discussions, caregivers indicated that they ordinarily rely on neighbours
to look after their children if they are going somewhere.
If there are neighbours nearby, the parent, especially the mother, can leave the child with
them when she is going to the garden. She can also leave the child with the elder sisters or
brothers at home. This mostly happens when the mother is not going to take long in the
garden. When she is to take a long time, she carries the child on her back and goes with him
to the garden. (Male caregiver Ngororero)
The availability of nursery schools is perceived positively by caregivers as places where a child
can start picking up knowledge early. Nursery schools are also perceived as safe environments
for the child.
Its a really good feeling. You take a child to a nursery when they can neither talk nor
read and after a short while, they come reading to you this, asking you that. The nursery
schools are really good establishments and enable a child to begin thinking and reasoning
at an early age. It is a very secure place to leave a child especially for parents that go to the
garden for example, and they have no one to leave their child with. The child also gets to
learn something at the end of the day. (Female caregiver Rulindo)
When a child enrols for nursery school at a younger age, they are able to learn more and
faster. Enrolling a child for school when they are 6 or even beyond, you find that they will
need some time to cope with one that could have started a bit earlier. The younger one will
have grasped English by the age of 6 while the one aged 6 is just starting school. (Female
caregiver Bugesera)
4.16 Disciplinary measures and child abuse
Disciplining children is part of ECD. The discipline techniques used are important as they
affect the childs physical and psychological development, including informing their behaviour
towards other people. The surveys findings showed different ways in which primary caregivers
discipline children and a high proportion indicated that both light and heavy punishments were
used. The disciplinary measures varied by the age of the child as well as by the economic status
of households.
Disciplining children 0 to 1 year old
Overall, talking to the child (33percent) is the most common method of discipline for children
in this age group. Other forms of discipline are slapping the child (27percent) and shouting
at the child (15 per cent). These options are practised in different proportions by caregivers
of different economic categories. Caregivers in the upper economic categories favour talking
(33percent) and shouting (67percent), but not slapping (0percent). Within the other economic
categories, the use of slapping is significant, in addition to talking and shouting.
Disciplining children 2 to 3 years old
The trend is similar to the methods used on children aged between 0 and 1, save for the upper
economic category caregivers who, instead of slapping, use other physical forces such as biting,
shaking and pushing (33percent). Talking is, however, still the most common (53percent),
followed by slapping (47percent), shouting (25percent), and beating with implements, such as
sticks and belts (21percent). The more abusive forms of discipline such as burning, insulting the
child and denying food are rare but also more prevalent in the lower (poor and lower-middle)
economic categories. Table34 illustrates this.
Table 34: Methods of disciplining children aged 2 to 3 years old
Lower- Upper-middle
Total (%) Poor (%)
middle (%) (%)
Total (N) 1,037 494 355 188
Talking to them 53 53 52 57
Slapping with hands 47 50 51 31
Shouting at them 25 28 25 18
Beating with implements like sticks, belts, rods, 21 24 21 14
etc.
Denying privileges 8 10 7 5
Time out (naughty corners) 8 9 7 8
Other physical forces like biting, shaking, 5 5 4 7
kicking, pushing
Denying food 4 5 4 2
Insulting the child 4 5 4 0
Burning 2 2 3 1
Sending the child away from home 1 1 0 0
Disciplining children 4 to 6 years old
As Table35 shows, in this age category, slapping is the most used form of punishment (63percent)
as opposed to talking to the child as occurs in the previous age categories. For this age group,
only the upper economic category, out of the four, favours talking over slapping. All other
economic categories more commonly use slapping over both talking and shouting. Overall,
slapping is followed by talking to them (51percent), beating with implements, such as sticks and
belts (35percent), and shouting at them (27percent). In addition, slightly higher percentages of
caregivers admit to burning and insulting the children from the poor, lower-middle and upper-
middle economic categories. It would therefore appear that forms of punishment become more
abusive as the child grows from 0 to 6 years. This finding holds for all economic categories.
Table 35: Methods of punishing children aged 4 to 6 years
Economic
category
Total (%)
Lower-middle Upper-middle
Poor (%)
(%) (%)
Total (N) 909 461 275 173
Slapping with hands 63 59 68 68
Talking to them 51 54 52 42
Beating with implements like sticks, 35 42 29 30
belts, rods, etc.
Shouting at them 27 28 27 27
Denying privileges 17 21 9 17
Other physical forces like biting, 14 15 13 12
shaking, kicking, pushing
Denying food 12 17 6 8
Time out (naughty corners) 9 8 8 12
Insulting the child 5 5 6 5
Sending the child away from home 5 5 5 5
Burning 4 4 5 3
In households where both male and female caregivers were interviewed, there were no differences
in the approach to disciplining children between them.
During observations, 26percent of the caretakers were seen correcting or reprimanding a child
for an action, with 2percent of the caretakers denying the child food, 6percent slapping lightly
and a similar proportion slapping heavily. About half of the respondents believe that children
must be punished in order to develop properly. There are variations by economic category on
this response. The results seem to suggest that the more economically affluent caregivers are,
the less they favour physically punishing children. This is reflected in the evidence gathered in
relation to the methods of disciplining children.
Table 36: Attitudes towards physical punishment of children
Economic category
Poor (%)
(%) (%)
Total (N) 1,987 951 667 369
Yes (positive attitude towards physical 50 52 46 48
punishment)
No (negative attitude towards physical 49 47 52 51
punishment)
No response 1 1 2 1
Comparison of the findings from the household interviews and the focus group discussions,
however, show divergent views with regard to the means of disciplining children used by parents
and caregivers. In focus group discussions both male and female caregivers emphasized talking
to the child instead of beating and shouting at them.
The way parents discipline their children, they get them seated, like we are seated, while
they are eating and you talk to them and counsel them. The counselling (is) meant to
develop the child. But for the cane, that era ended. (Female caregiver Rwamagana)
There are times when he is playing with other children and you get to hear that he is saying
bad words to his friends and insulting them. In such a situation, I sit him down threaten
him and tell him the dangers of saying bad words and insulting others. (Female caregiver
Nyamagabe)
The parent of long ago used to discipline using the cane and that is all they knew. But we
have realized that the cane is not the solution. Because you can threaten the child using the
mouth. You tell him today that he went wrong and you will find that the child will actually
listen to you. That is why we keep telling them that the cane instead escalates the situation
and they can use other ways to punish a child. (Female caregiver Kayonza)
There are also cases where you find parents refusing to allow children to go to school.
Instead, they make the children work at home. We hear this when we attend meetings in
our associations. (Male caregiver Rubavu)
There is also another punishment where a child is made to work for other people and they
pay money to the childs parent. (Male caregiver Ngororero)
Among the Rwandese, when a child is still young, they are not caned. You sit there and call
on all the children and then talk to the child who is in the wrong. You do that once, twice
and by the third time, they would have understood their mistake. (Community health
worker Gakenke)
Child abuse within communities
About 19 per cent of caregivers indicated that they were aware of cases of child abuse in
the community. Awareness was higher among the upper economic category respondents
(31percent) than in the middle and poor categories (18percent among the poor, 20percent
among lower-middle and 16percent among upper-middle economic categories). Of those who
Table 37: The most common cases of child mistreatment in this community
Economic category
Poor (%)
(%) (%)
Total 368 177 133 58
Fights among parents 6 5 8 10
Denial of love and care by parents/ 4 4 5 3
guardians
Physical assaults (beatings, kicks, 5 7 4 5
slaps etc.)
Denial of meals 3 5 2 2
Denial of breastfeeding 0 1 0 0
Child labour 12 14 9 7
Not allowing children to play with 6 5 7 7
other children
Denial of education 23 29 22 12
Denial of appropriate clothing 5 3 4 12
Denial of medical care 11 10 12 14
Defilement 7 5 8 14
Child-to-child sex 8 7 10 10
Feeding with alcoholic drinks 3 3 4 2
are aware of child mistreatment, the indication of such incidences is higher in the southern
province (31percent) and lowest in Kigali (11percent). The highest awareness levels of child
mistreatment were found in the Nyamagabe and Ruhango districts (41percent in both) while
the lowest are in Nyarugenge and Nyamasheke (7percent in both). Some of the cases of abuse
were as a result of domestic violence as indicated from the focus group discussion with female
caregivers in Rulindo.
In households where both male and female respondents were interviewed, there are differences
in responses between men and women. However, from an overall perspective, denial of
education ranks highest among ways in which children are mistreated (23percent) and it is a
particularly prevalent form of mistreatment in the poor and lower-middle economic categories.
This is followed by child labour (12percent) and the denial of medical care (11percent).
It happened that a man and his wife had a misunderstanding and got divorced. Because
of that the child, who came home late, carried the blame. The father locked him out and
went ahead slapping him. (Female caregiver Rulindo)
People use excessive force when punishing children. You find someone with a very big stick
caning a child even for no good reason. (Male caregiver Ngororero)
If a child is abused in the community, respondents would first talk to the parents about
it (42 per cent) then report to the local leaders (20 per cent) and, lastly, report to the police
(17percent). Talking to parents was also the approach caregivers would follow according to
findings from the male/female sample, followed by reporting to the police. When asked what
was the most important thing to do was in cases where a child is being abused, respondents
indicated that talking to the parents was most important (32percent), followed by reporting to
local leaders (22percent) and then to the police (21percent).
There was a perception that poverty in the home is a major reason why some parents mistreat
their children (49 per cent). Other reasons mentioned for the abuse of children include
misunderstanding among parents (46 per cent), insecurity in the community (32 per cent),
being orphans (31percent), broken families (17percent) and living in child-headed households
(17percent). To protect children from mistreatment, it was suggested that sensitization of the
public about childrens rights (28percent) and enforcement of laws by punishing parents who
mistreat their children (18percent) be undertaken by the government. Other suggestions were
counselling the parents and children (15percent), taking children to school (10percent) and
ensuring that parents stay with their children to try to understand their behaviour (5percent).
Respondent feel that the responsibility for protecting children against mistreatment lies with
the parents (63 per cent), the community (23 per cent), local leaders (20 per cent) and the
government (16percent).
Contrary to the findings in the assessment in relation to the methods used to discipline children,
the prevailing opinion is that parents and caregivers are not in favour of physical punishment.
For the majority, the most preferred means of disciplining a child is through talking to them and
advising them on the right things to do. These opinions were shared by the community health
workers and both male and female caregivers.
Disciplining a child may not necessarily imply a cane. You may use a very small stick if
it necessitates so, cane him once and after talk to him. Or simply talk to him. Caning him
with the small stick would only come in when the offence is a bit grave and only a cane can
show him that what he did is bad. But a stick is highly discouraged. (Female caregiver
Gicumbi)
I think the habit of caning children when they do something wrong is not very effective. That
is why it is even phasing out. You know with caning, the child perceives it as a way of simply
inflicting pain on him rather than disciplining him. (Female caregiver Bugesera)
I totally discourage caning, totally. In my area, there are very few parents that still cane their
children and we are sensitizing them continuously to stop it. (Female caregiver Ngoma)
Before the child is three, it makes no sense disciplining him. Except that some children can
become naughty when they reach the age of two, so for such an age you simply threaten
them and hit them with very simple slaps as you caution them never to act the same way
again. You could find that a child does not want to share with others, he does not listen
to elders and other small things. There is no need to really beat a child at such an age
sincerely. (Female community health worker Ngororero)
On reaching the age of 3, you can sit a child down, counsel them and discipline them
without necessarily caning them. Because at this age, the child can at least distinguish
between what is good and bad. (Female community health worker Rulindo)
Caning it depends on the type of child. Some children just have to be caned first to
understand. So you find parents of such a child caning their children. We, however,
emphasize to them that there are many ways they can explore disciplining a child. We have
come up with many of them and are sharing them with the parents. We want to do away
with caning completely. (Male community health worker Gakenke)
I find the use of the stick as a way of worsening the situation. There is a time you find
that even if he is misbehaving, but after counselling, children will always get back to their
senses. The first time, second time and third time of counselling will always discipline
the child better than caning him. The stick just worsens the situation. A child is a child.
(Female caregiver Rwamagana)
Where the issue of caning worsens the situation is that the people that use the cane are
the parents that take some alcohol. So they cane the child unconsciously because they have
taken some alcohol. When a person is drunk they never mind which part of the body they
beat. He can cane where he shouldnt have caned and ends up harming the child. (Female
caregiver Gakenke)
4.17 Communication and sources of information
UNICEF Rwanda 2007/Pirozzi

Radio is the most used source of information to find out about what is happening in the
community (72percent) and about child care (53percent). This is especially so within the poor
households and for the households from the middle economic categories. Upper economic level
households mostly rely on TV as the main source of information. Other sources of information
are neighbours, community health workers, friends, local village leaders and family members.
Overall, the radio is the most trusted source of information. Specifically, radio is the most
trusted source of information on what is happening in the community (44 per cent), as well
as on child care (31percent). Others sources of information on child care include community
health workers (16percent), health facilities (11percent), local village leaders (8percent), and
family members (7percent).
Almost 89 per cent of all the households interviewed own a working radio, rather divergent
from the RDHS 2010 which found that 63percent of Rwandan households own a radio. Overall,
in 52percent of the households that own a radio, it is the father who decides the programmes
that people in the home should listen to, while in 33 per cent of cases it is the mother who
decides. However, considering the different economic categories, we see some differences. In
the upper economic category households, both the father (46percent) and mother (46percent)
decide which programmes are listened to, while in middle and poor households the father most
commonly decides. Analysing only those households where both female and male respondents
were interviewed, these trends remain unchanged.
Table 38: Sources of information
Events in the community

Sources of information Child care (%)
(%)
Base size 2,000 2,000
Radio 72 53
Community health workers 31 31
Neighbours 39 27
Health facilities 24 26
Friends 34 25
Local village leaders 36 24
Family members 28 22
TV 32 18
Religious leaders 25 14
School children 15 14
Mothers associations 11 11
Mobile phones 14 9
Womens groups 11 9
Ceremonies (weddings, funerals etc.) 7 8
Newspapers 14 7
Traditional leaders 10 6
Market days 10 6
Road shows 8 6
Posters 6 5
Youth groups 6 5
Booklets 5 5
NGOs/community-based organizations 5 4
Fliers/leaflets 4 3
CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 63
Chapter 5:
Conclusions and
Recommendations
Health issues
T
he most prevalent illnesses in the communities studied are respiratory infections (cough,
UNICEF Rwanda 2013/Shrestha

flu), diarrhoea and malaria. Caregivers perceive that children aged 0 to 3 years of age are
the most affected by respiratory infections while those 4 to 6 years old are most likely to
contract malaria. These diseases are attributed to the change in the climate, as well as poor
hygiene and sanitation practices in the home. The results indicate that caregivers have a fairly
good understanding of the causes of diseases, how to prevent them and how to manage them
when they occur. However, there are some misconceptions and gaps in knowledge, particularly
with regard to the causes of illness and the most appropriate treatments.
Self-medication by administering medicine at home (61percent), going to the nearest health
facility (29 per cent) and buying drugs at the nearest facility are the immediate remedies
undertaken when children fall sick. It is important to note that most respondents will treat
the symptoms. However, after self-medication most respondents will seek the services of
professional medical workers. Also observed is a high degree of preventative measures where
children younger than 6 years old are fed with foods that are perceived to support proper child
growth and a strong belief that proper hygiene and sanitation in homes is paramount.
There is an indication that almost all caregivers seek treatment, whether self-medication or
professional, for their childrens diseases. Generally, the knowledge and attitude towards treating
sick children is high among the caregivers. The prevalence of the practice of self-medication,
might imply that most households are not close to professional medical personnel.
Hygiene and sanitation
Respondents understand the importance of maintaining proper hygiene and the practices that
should be undertaken to maintain proper hygiene. Despite this awareness, there are low levels
of actual practice of these activities. For example, 100percent of the respondents were aware of
the importance of washing hands with soap before feeding a child or preparing food, but only
28percent practised this behaviour. About 64percent understand the need for washing hands
after using the toilet but only 46percent practised it. This state of affairs points to the need for
re-education and a call to action to improve sanitation in the community.
Pre-birth child care
Women were found to be more knowledgeable than men in terms of what should be done
during pregnancy in order to ensure the health of the unborn child. However, the caregivers
knowledge on some pre-birth aspects is still low. About 75percent of the female caregivers and
close to a third of the male caregivers know that it is important for expectant mothers to protect
themselves against common illness, such as malaria. Knowledge of the need to test for HIV is
also relatively high. These two aspects are also highly practised by the female caregivers and
supported by male caregivers.
However, gaps in knowledge are observed, especially with regard to taking iron tablets, the need
for healthy eating practices, and the importance of having a delivery plan and delivering in a
recommend health facility. Fortunately, most expectant mothers receive antenatal services from
designated health facilities; 99percent of expectant mothers had used antenatal services at least
once when expecting their index child. In addition, the practice of delivery at recognized health
facilities is high with at least 86percent delivering at a health facility in the district. Overall,
the more people are aware of the importance of carrying out pre-birth activities, the higher the
likelihood that these activities are practised.
Child care after birth
As with pre-birth care, women were found to be more knowledgeable than their male
counterparts in the area of after-birth care. However, knowledge and practice levels are relatively
low for most of the aspects for both male and female caregivers with the only exception being
knowing the importance of immunizing the child (78percent knowledge; 87percent practice)
and breastfeeding the baby within the first hour of delivery (42percent knowledge; 62percent
practice).
Notable are the low levels of knowledge and practice of other aspects of after-birth child care,
such as clean cord care, keeping the baby warm using the mothers chest and keeping the baby
in a clean environment. It is also important to note that the level of practice after birth is higher
than what is known. This might imply that most women practise positive behaviours without
being aware of their importance.
The practice of deworming is high with 89percent of caregivers of children aged 1 to 6 years
old claiming to carry it out. There is a variation by economic category, however, with 87percent
of the poor and 90percent of the lower-middle economic category practising deworming. The
key reason for not deworming was cited as cost. There is also a high claimed knowledge of
immunization (91percent) and a good understanding of the reasons for this by both male and
female caregivers. Another positive finding is that there is a high incidence of the practice of
immunization.
Feeding practices
The findings indicate respondents are aware of good feeding practices that enable the proper
development of children. Over 90percent of the respondents who have children aged 0 to 6
months old exclusively breastfeed them. This is a high proportion, although the ideal situation
would be 100percent exclusive breastfeeding. Only 7percent of mothers of children aged 0
to 6 months mentioned feeding their children breast milk as well as other foods, especially
porridge and fruits. Other children above 6 months are fed on foods rich in nutrients, such as
carbohydrates and proteins. Such foods include porridge, potatoes, beans, vegetables, bananas
and milk.
It is very evident from the data that the gap in feeding practices lies in the number of meals
given to the children per day. Some respondents indicated one meal, others two, while some
mentioned the ideal three meals per day. Only 28percent of 1 to 2 year olds get three meals a day
while 18percent get one meal a day in this age group. This number of meals could be explained
by the feeding schedules of the respondents. Most of those interviewed were from the rural areas
where the ordinary daily regime is to work in the morning and have the first meal of the day in
the mid-morning or sometimes early afternoon. Children in such households would become
attuned into this regime and the total number of meals per day would eventually go down. This
is confirmed in the findings of this assessment when caregivers report what children ate the
day before. The data show that children aged 2 to 6 years old are more likely to have nothing for
breakfast, lunch and dinner than 1 to 2 year olds.
CHAPTER 5: CONCLUSIONS AND RECOMMENDATIONS 65
In addition, the majority of those interviewed are subsistence farmers with little income. This
proportion of the population mainly resides in rural areas, where poverty rates are higher. It is
therefore highly likely that the majority of those interviewed may not be able to afford to give
their families (including children) three meals per day. This state of affairs is likely to account for
the perceived stunted growth among children in the rural areas explained in national statistics.
Knowledge of when complementary feeding should be introduced is high among the survey
population. However, the practice of introducing complementary foods at the right age (6
months) is higher than the knowledge. The reason for this may be a combination of the
aforementioned factors on feeding, but is principally the inability of the mother to continue
exclusive breastfeeding as the child grows and demands more and more food. In addition, child
care in African society has a long tradition of practices. Mothers, by practice, would start to give
their babies complementary foods when they reach a given age without consciously thinking of
the importance of the practice.
Childparent interaction
The survey shows high levels of interaction between children and parents/caregivers. Although
knowledge about childparent interaction is low, it is positively correlated to practice. Parents
do certain things, such as holding and playing with their children, without consciously thinking
of the importance of such activities. In most cases, it is the mother who is present and taking
care of the child and interacting with the child. The mother is assisted by other females in the
household.
The type of interaction changes as the child grows older. At the very young ages of 0 to 6 months,
the most common form of childparent interaction is touching, holding and caressing the child.
As the child grows older, other forms of interaction come into play. These include singing to the
child, talking to the child and teaching the child basic things, such as language and behaviour.
Other practices in child care that were mentioned include immunization and breastfeeding. The
fathers role in this respect is generally limited to providing for the family and taking a strong role
in disciplining the child. However, there is also great importance attached to fathers spending
time with their children, playing with them and showing them love and affection, a finding
from both the quantitative and qualitative assessments. While this is seen as very important, it
seems that there are limitations to how much time fathers spend with their children in practice.
Organized child care
Respondents are aware of organized child care in the form of nursery schools and day-care
centres organized by churches and NGOs. The practice of attendance at organized child care
centres is low, however, as very few respondents (12percent) take their children to day care.
The majority of these respondents leave older children alone and younger children in the
care of grandmothers and other siblings at home. A few children are left with caretakers. The
main reason given by respondents for why their children do not attend organized child care
is because the children are still too young and need to be close to the family. Overall, very few
(11.5percent) of the children attend any form of organized child care and the majority of those
who do actually attend nursery school.
Disciplining children and child abuse
The respondents interviewed understand that it is a violation of a childs rights when a child
is abused or physically punished. Respondents advocate for talking to children as a way of
correcting and educating them. Despite this understanding, forms of punishment that harm
the child are still commonly practised within the survey population. These include slapping,
caning, beating and shouting at the child. Also notable are the differences between the economic
categories and the fact that, generally, forms of discipline become more abusive as the child
grows older. In fact, almost half the respondents believed that a child should be physically
punished in order to grow up properly.
These forms of punishment were also perceived to be child abuse. Other forms of child abuse
common in the survey population are the denial of education, child labour and the denial of
medical care. According to the respondents, the responsibility of protecting children against
abuse rests with the parents, the community, local leaders and the government.
Communication and sources of information
Radio is the most common source of information on child care and what is happening in the
community, especially within poor households and households in the middle economic category.
Upper economic level households mostly rely on TV as the main source of information. Most of
the households visited own a working radio.
ANNEX 1: TABLES 67
Annex 1: Tables
Demographics
Table 39: Household sample achievement by province
UNICEF Rwanda 2008

Sample
Province
achievement(%)
Total (N) 2,000
Northern 19
Eastern 25
Western 19
Kigali 17
Southern 20
Table 40: Household sample achievement by district
Sample
District
achievement(%)
Total (N) 2,000
Bugesera 8%
Gakenke 6%
Gasabo 8%
Gicumbi 6%
Kamonyi 7%
Kayonza 7%
Ngoma 7%
Ngororero 6%
Nyamagabe 7%
Nyamasheke 6%
Nyarugenge 8%
Rubavu 6%
Ruhango 6%
Rulindo 6%
Rwamagana 6%
Table 41: Category of respondent demographics
Province Economic category

Total Lower- Upper-
(%) Northern Eastern Western Kigali Southern Poor Upper
middle middle
(%) (%) (%) (%) (%) (%) (%)
(%) (%)
Total (N) 2,000 376 515 379 337 393 951 667 369 13
Pregnant mother 5 5 7 3 4 5 5 3 8 0
Newly delivered mother 3 5 3 3 3 3 4 4 2 0
Biological mother of children of 0 84 85 82 90 90 77 84 84 85 100
to 6 years
Caretaker/relative of children 0 5 3 5 3 2 12 4 8 4 0
to 6 years
Grandmother/father of children of 2 3 3 1 0 3 3 1 1 0
0 to 6 years
Table 42: Disability status of female household respondents
Province
Total (%)
Total (N) 2,000 376 515 379 337 393
No disability 96 97 98 96 99 90
Physically disabled 3 2 1 2 0 6
Mentally handicapped 1 0 1 0 0 3
Speech impairment 1 0 1 1 0 5
Visual impairment 1 0 0 2 0 2
Hearing impairment 0 0 0 0 0 0
Table 43: Respondents level of education: overall
Province
Total (%)
Total (N) 2,000 376 515 379 337 393
No formal education 20 30 24 16 4 23
Primary 44 51 49 54 19 44
Secondary 25 13 18 22 52 23
College or vocational school 5 3 7 2 6 4
University 6 3 2 6 19 6
Table 44: Respondents level of education by economic level
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Secondary 25 11 33 44 8
Primary 44 55 47 17 0
No formal education 20 32 11 5 0
College or vocational school 5 2 6 8 8
University 6 0 3 26 84
ANNEX 1: TABLES 69
Table 45: Age groups
Province
Age (years) Total (%)
Total (N) 2,000 376 515 379 337 393
1519 2 2 2 2 1 2
2024 12 21 12 10 11 7
2529 36 36 32 48 43 29
3034 16 18 18 13 13 16
3539 9 7 11 10 9 8
4044 3 2 3 2 1 6
4549 1 1 1 0 1 2
5054 1 1 0 1 0 1
5559 0 0 0 0 0 1
Over 59 3 3 4 1 1 3
No response 17 9 17 13 20 25
Table 46: Respondents working status
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Working on other peoples farms for money 6 10 3 0 0
Subsistence farming 36 53 29 5 0
Commercial farming 15 2 20 39 15
Petty trader 4 3 10 0 0
Working on other peoples farms for food 8 14 4 0 0
Part-time worker 5 2 9 5 0
Unemployed 10 15 9 0 0
Civil servant 14 1 13 48 85
Craftsman 2 1 3 3 0
Table 47: Respondents religion
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Catholic 52 55 53 45 39
Protestant 36 36 33 43 38
Muslim 4 2 6 4 23
Seventh Day 8 7 8 8 0
Adventist
Table 48: Households economic categories
Valid per cent Cumulative per

Economic category Frequency Per cent (%)
(%) cent (%)
Total (N) 2,000 100.0 100.0
Poor 951 47.5 47.5 47.5
Lower-middle 667 33.3 33.3 80.8
Upper-middle 369 18.5 18.5 99.3
Upper 13 0.7 0.7 100.0
Health issues affecting the community
Table 49: The most common health issues affecting this community today
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Worms 23 25 22 19 0
Cough 42 40 39 50 46
Malaria 46 46 48 42 69
Flu 34 30 38 36 69
Diarrhoea 31 32 33 27 15
Red eye 1 1 1 1 0
Pneumonia 6 8 4 3 0
Typhoid 1 1 1 1 0
Vomiting 2 2 2 2 0
Polio 1 1 1 1 0
Measles 2 2 4 0 0
Tetanus 0 0 0 1 0
Chicken pox 1 1 1 0 0
HIV 1 0 0 2 0
Diabetes 0 0 0 0 0
Skin diseases 3 2 2 4 8
Headache 0 0 0 0 0
Kwashiorkor 0 0 0 0 0
Angina 1 1 0 0 0
Umusonge (Pneumonia) 0 0 0 0 0
Gripe 0 0 0 0 0
Bronchitis 0 0 0 1 0
Igituntu (TB) 0 0 0 0 0
Cholera 0 0 0 0 0
Do not know 2 2 2 2 0
ANNEX 1: TABLES 71
Table 50: Groups of people who are most affected by health issues
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Children 0 to 6 Months 28 27 28 28 15
Children 7 months to 2 Years 44 44 46 41 69
Children 3 to 6 years 37 37 36 37 54
School going children (7 to 18 years) 5 5 4 6 8
Elderly people 6 4 7 8 0
Disabled people 1 1 1 1 0
Everyone 39 39 36 41 46
Table 51: Health problems that affect children 0 to 6 years
Cumulative response
Disease
(%)
Total (N) 1,151
Worms 30
Cough 45
Malaria 47
Flue 46
Diarrhoea 34
Red eyes 1
Pneumonia 9
Typhoid 1
Vomiting 2
Polio 1
Measles 4
Tetanus 0
Chicken pox 1
HIV 0
Diabetes 0
Skin diseases 5
Headache 0
Kwashiorkor 0
Angina 1
Gripe 0
Do not know 2
No response 0
Management of health issues
Table 52: In the past two weeks did any child below 6 years of age in this household fall sick?
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
No 79 78 79 81 92
Yes 19 19 19 18 0
No response 2 3 2 1 8
Table 53: What were the symptoms of the illness that the child or children suffered from?
Economic category
Poor (%)
(%) (%)
Total (N) 371 177 127 67
Diarrhoea 41 41 46 28
Fever or hot to touch 30 28 39 18
Cough 41 44 44 30
Vomiting 29 25 35 27
Flu 26 21 34 24
Difficulty in breathing 9 5 17 6
Fast breathing 8 4 15 3
Indrawn chest 6 3 13 3
Loss of appetite 13 9 20 9
Stomach aches 8 5 13 6
Unable to eat or breast feed 7 5 12 1
Skin rash 6 3 9 4
Table 54: What did you do immediately after you noticed the symptoms?
Economic category
Poor (%)
(%) (%)
Total (N) 371 177 127 67
Gave ORS 18 15 26 12
Gave zinc 10 8 13 9
Gave some medicine that I had in the house 61 57 66 63
Gave the child plenty of fluids 7 5 7 13
Continued breast feeding 10 5 18 6
Gave herbal medicine 11 8 18 3
Sought the services of a community health worker 12 6 24 3
Took the child to the nearest health facility 29 31 33 15
Sought the services of a traditional herbalist 13 16 13 4
Tepid sponging 7 5 14 0
Bought medicine from a pharmacy/drug shop 18 14 26 16
Prayed for the child 5 4 9 1
ANNEX 1: TABLES 73
Table 55: What did you do to treat the condition?
Economic category
Poor (%)
(%) (%)
Total (N) 371 177 127 67
Gave ORS 8 5 9 10
Gave zinc 7 7 8 6
Gave some medicine that I had in the house 21 23 20 18
Gave the child plenty of fluids 4 3 5 4
Continued breast feeding 4 3 4 6
Gave herbal medicine 7 7 10 1
Sought the services of a community health worker 12 8 16 16
Took the child to the nearest health facility 48 48 50 43
Sought the services of a traditional herbalist 8 9 7 6
Tepid sponging 1 0 2 0
Bought medicine from a pharmacy/drug shop 13 14 12 15
Prayed for the child 2 2 2 1
Antenatal and pre-birth care
Table 56: What mothers should do before birth to ensure a child is healthy
What things should mothers do to ensure that a child is healthy pre-birth?

Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Mother should protect herself against common illnesses, 74 72 75 80 54
such as malaria
Know HIV status of the mother 65 65 68 62 85
Receive ANC from an approved health facility 43 39 43 51 69
Take iron supplements 26 21 30 31 31
Take vitamin A 44 40 46 51 38
Ensure proper eating practices 22 16 25 29 62
Immunization against tetanus 37 32 38 45 31
Take antenatal lessons 35 30 37 42 54
Avoid stress 35 30 35 46 46
Have enough rest 32 31 33 34 62
Stay in a clean environment 29 23 30 41 38
Deliver in a recommended health facility 30 24 33 37 46
Delivery plan 25 18 28 35 46
Prepare the home for the new baby 26 21 29 33 23
Prepare older siblings to accept the baby 16 11 19 23 46
No responses 1 1 1 1 0
Table 57: What mothers should do after birth to ensure a child is healthy
What things should mothers do to ensure that a child is healthy after birth?
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Immunizing the baby against vaccine preventable 76 78 75 75 46
diseases
Breastfeeding the baby within the first hour of delivery 42 39 47 40 69
Keeping the baby warm by not bathing the baby 30 28 34 28 38
immediately
Keeping the baby warm using the mothers chest 23 21 21 27 31
Keeping the baby warm with appropriate clothes 28 25 29 37 38
Registration of the baby 36 29 41 48 23
Go for postnatal visit for review of mother and baby 24 19 27 31 62
Clean cord care 21 17 24 26 15
Breastfeeding exclusively for 6 months 37 31 41 46 69
Both mother and child sleeping under the mosquito net 34 31 32 45 46
Hand washing with soap 31 26 34 37 46
Keeping the child in a clean environment 26 23 30 30 23
Growth monitoring 24 22 23 29 85
Vitamin A supplementation 36 34 37 42 31
Prompt health care seeking in case of illness 23 17 27 33 23
Adherence to prescribed medication 21 14 26 28 31
Proper eating by the breastfeeding mother 25 22 26 30 38
Proper feeding for the child 25 20 26 31 69
Take child for circumcision 10 5 14 1% 23
Table 58: Where respondents went for ANC
For your index child where did you go for antenatal care?
Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
At home with visiting doctor, nurse or midwife 13 12 14 16 0
Health centre in the district 82 85 79 79 85
Main hospital in the district 48 42 52 55 77
At the clinic in the village 29 24 30 38 54
At community health workers home 20 22 18 18 15
Did not take any ANC services 1 1 1 1 0
ANNEX 1: TABLES 75
Table 59: Where a pregnant woman should go for ANC
Where should a pregnant woman go for health care?

Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Did not take any ANC services 2 2 3 2 0
Table 60: How many times should a pregnant woman go for ANC?
How many times should a pregnant woman go for ANC?

Economic category
Total Poor Lower-middle Upper-middle Upper
How many times should a pregnant woman go for ANC? 4 4 4 4 4
Table 61: Where respondents delivered their index child
Where did you deliver your index child?

Economic category
Poor (%) Upper (%)
(%) (%)
Total (N) 2,000 951 667 369 13
Annex 2: Comparative
Analysis of the
Rwandan KAP to the KAP
of Other Countries
B
elow are some of the central findings of the Rwandan KAP are compared to KAP
results from other countries.
Child care from pre-birth to delivery: The Rwandan KAP found that caregivers
knowledge of some pre-birth aspects is low. Similarly, a 2013 Health and Nutrition
KAP conducted in rural Kenya among pregnant women attending and not-attending ANC
clinics highlighted that substantial opportunities exist for antenatal KAP improvement among
women in rural Kenya, some of which they believed could occur with greater ANC attendance.35
Management of childhood illnesses: The Rwandan KAP demonstrated that generally knowledge
and attitude towards treating sick children is high among the caregivers, with the majority seeking
self-medication when a child falls sick by administering medicine at home (61percent), going to
the nearest health facility (29percent) and buying drugs at the nearest facility. A 2010 KAP study
about malaria and its control in rural northwest Tanzania, demonstrated that health facilities were
the first option for malaria treatment (47percent) rather than administering medicine at home.36
Another study on caretakers perceptions, attitudes and practices regarding childhood illnesses
in western Tanzania demonstrated that a health facility was the first point of care for childhood
malaria for the majority of the respondents (73 per cent).37 Likewise, a KAP of mothers on
symptoms and sign of integrated management of childhood illnesses (IMCI) strategy conducted
in child health clinics in Dar es Salaam in Tanzania showed that 98percent of mothers took their
children to health facilities once sick.38 However, these results need to be interpreted with extreme
caution as the KAP was conducted at a health clinic in an urban setting.
Feeding: Exclusive breastfeeding trends vary greatly in sub-Saharan countries. For example,
breastfeeding is near universal in Zambia while only 37 per cent of infants under 6 months
are exclusively breastfed in Mozambique. At the same time, several studies have found
commonalities regarding breastfeeding KAP among sub-Saharan countries.39 The findings
from the Rwandan KAP indicate respondents are aware of good feeding practices that enable
the proper development of children. Over 90percent of the respondents who have children 0
35 Perumal, Nandita, et al., Health and Nutrition Knowledge, Attitudes and Practices of Pregnant
Women Attending and Not-Attending ANC Clinics in Western Kenya: A cross sectional analysis, BMC
Pregnancy & Childbirth, vol. 13, no. 1, pp.146158, also available at <www.ncbi.nlm.nih.gov/pmc/
articles/PMC3716969/>.
36 Mazigo, Humphrey, et al., Knowledge, Attitudes, and Practices about Malaria and Its Control in
Rural Northwest Tanzania, Malaria Research and Treatment, vol. 2010, pp. 9, also available at <www.
hindawi.com/journals/mrt/2010/794261/>.
37 Kaatano, Godfrey, A.I.S. Muro and M. Medard, Caretakers Perceptions, Attitudes and Practices
Regarding Childhood Febrile Illness and Diarrhoeal Diseases among Riparian Communities of Lake
Victoria, Tanzania, Tanzania Health Research Bulletin, vol. 8, no. 3, 2006, pp. 155161, also available
at <www.bioline.org.br/request?rb06029>.
38 Juma, Athumani, Knowledge, Attitudes and Practices of Mothers on Symptoms and Signs of
Integrated Management of Childhood Illnesses (IMCI) Strategy at Buguruni Reproductive and Child
Health Clinics in Dar es Salaam, Tanzania Medical Students Association, 2007/08, also available at
<www.ajol.info/index.php/dmsj/article/viewFile/49589/35917>.
39 Magawa, Rita, Knowledge, Attitudes and Practices Regarding Exclusive Breastfeeding in Southern
Africa Part 1, Consultancy Africa Intelligence, 3 December 2012, also available at <www.
consultancyafrica.com/index.php?option=com_content&view=article&id=1181:knowledge-
attitudes-and-practices-regarding-exclusive-breastfeeding-in-southern-africa-part-1&catid=61:hiv-
aids-discussion-papers&Itemid=268>.
ANNEX 2: COMPARATIVE ANALYSIS OF THE RWANDAN KAP TO THE KAP OF OTHER COUNTRIES 77
to 6 months old exclusively breastfeed them, and the practice of introducing complementary
foods at the right age (6 months) is higher than the knowledge. On the other hand, a cross-
sectional study of the prevalence and predictors of exclusive breastfeeding among women in
a western region in Tanzania, demonstrated that knowledge of early breastfeeding was higher
(86percent) than practice (58percent). A multivariate analysis in the same study demonstrated
that women with adequate knowledge of exclusive breastfeeding and women who delivered at
health facilities were more likely to exclusively breastfeed compared to others.40 A KAP survey
on water, sanitation, hygiene and nutrition in seven states of southern Sudan demonstrated both
low knowledge and practice of exclusive breastfeeding.41
Several KAP studies in sub-Saharan Africa have demonstrated the importance of family members
in child care and infant feeding. For example, a KAP in Malawi highlighted the influence of
grandmothers with regard to decisions on introducing premature complementary feeding.
Grandmothers and fathers lack of information on and support for exclusive breastfeeding have
been reported as a significant barrier to the continuation of breastfeeding.42 Likewise, a 2007
Somali KAP study of infant and young child feeding and health-seeking practice found that
KAP on breastfeeding are mainly controlled by culture through maternal grandmothers and
other elderly women in the community, and are generally unsatisfactory.43
Hygiene and sanitation: Despite the Rwandan KAP recording high awareness of the importance of
maintaining proper hygiene and hygiene practices, it recorded low levels of actual practice of these
activities. For example, 100percent of the respondents were aware of the importance of washing
hands with soap before feeding a child or preparing food, but only 28percent practised this.
Likewise, a study conducted in several sub-Saharan African countries (i.e. Kenya, Senegal,
Tanzania, and Uganda) reported that only 17percent of participants washed their hands with
soap after using the toilet.44 Similarly, a KAP survey on water, sanitation, hygiene and nutrition
in southern Sudan demonstrated that hand washing with soap before eating, after defecating
and before preparing food was generally practised by a small fraction of the community. The low
rate of hand washing was attributed to low awareness of the oral-faecal contamination chain.45
Communication and sources of information: This KAP demonstrated that the radio is the
most common source of information on child care and what is happening in the community,
especially within poor households and households in the middle economic category. Likewise,
radio is an important source of information in many other sub-Saharan African countries. For
example, a study on information and socioeconomic factors associated with early breastfeeding
practices in rural and urban settings in Tanzania demonstrated that ownership of a radio was
positively associated with exclusive and predominant breastfeeding in the rural area.46
40 Nkala, Tiras E. and Sia E. Msuya, Prevalence and Predictors of Exclusive Breastfeeding among
Women in Kigoma Region, Western Tanzania: A community based cross-sectional study,
International Breastfeeding Journal, vol. 6, no. 17, pp.7, 9 November 2011, also available at <www.
internationalbreastfeedingjournal.com/content/6/1/17>.
41 Knowledge, Attitudes and Practices (KAP) Survey on Water, Sanitation, Hygiene and Nutrition in 7
States of Southern Sudan: Final Report, Juba, April 2010, UNICEF WES & Health and Nutrition Sections,
Southern Sudan, also available at <www.bsf-south-sudan.org/sites/default/files/KAPStudyforSSD_
FinalReportApril2010.doc>.
42 Kerr, Rachel B., P.R. Berti and M. Chirwa, Breastfeeding and Mixed Feeding Practices in Malawi:
Timing, reasons, decision makers, and child health consequences, Food and Nutrition Bulletin, vol.
28, no. 1, pp. 9099, March 2007, also available at <www.ncbi.nlm.nih.gov/pubmed/17718016>.
43 Food Security Analysis Unit, Somalia (FSAU), Somali Knowledge, Attitude and Practices Study (KAPS):
Infant and young child feeding and health seeking practices, December 2007, also available at
<http://ethnomed.org/clinical/pediatrics/somali_knowledge_attitude_practices_study_dec07.pdf>.
44 Vivas, Alyssa, et al., Knowledge, Attitudes, and Practices (KAP) of Hygiene among School Children
in Angolela, Ethiopia, Journal of Preventive Medicine and Hygiene, vol. 51, no. 2, pp. 7379, also
available at <www.ncbi.nlm.nih.gov/pmc/articles/PMC3075961>.
45 Knowledge, Attitudes and Practices (KAP) Survey on Water, Sanitation, Hygiene and Nutrition in 7
States of Southern Sudan: Final Report, Juba, April 2010, UNICEF WES & Health and Nutrition Sections,
Southern Sudan, also available at <www.bsf-south-sudan.org/sites/default/files/KAPStudyforSSD_
FinalReportApril2010.doc>.
46 Shirima, Restituta, Mehari Gebre-Medhin and Ted Greiner, Information and Socioeconomic
Factors Associated with Early Breastfeeding Practices in Rural and Urban Morogoro, Tanzania,
Acta Paediatrica, vol. 90, no. 8, pp. 936942, also available at <www.ncbi.nlm.nih.gov/
pubmed/11529546>.
Annex 3: Selected
Indicators,
Disaggregated by
District
S
elect data segregation by district criteria:
1. Groups of people most affected by health problems in the community
2. Actions taken by respondents to immediately respond to and treat illnesses
in their children
3. Hygiene knowledge vs. practice absolutes
4. Foods given to children before breakfast
5. Foods given to children for lunch
6. Foods regularly given to children 711 months old
7. Importance of a fathers role in the development of their child
8. How often caregivers have had to leave the child in the care of another person
9. Sources of information
List of tables
Table 1: Groups of people most affected by health problems in the community...................79
Table 2: A ctions taken by respondents to immediately respond to and treat illnesses
in their children.................................................................................................................79
Table 3: What should people in the community do to maintain proper hygiene?............... 80
Table 4: W hich hygiene practices are commonly practiced by people in this
community?.......................................................................................................................81
Table 5: Foods given to children before breakfast......................................................................82
Table 6: Foods given to children for lunch?.................................................................................83
Table 7: The role of a father development of 02 year old children..........................................85
Table 8: The role of a father development of 26 year old children........................................ 86
Table 9: How often caregivers have had to leave children in the care of another person.....87
Table 10: Sources of information to find out about what is happening in your
community.........................................................................................................................87
Table 11: Most trusted source of information about what is happening in your
community......................................................................................................................... 88
Table 12: Sources of information to find out about what child care..........................................89
Table 13: Most trusted source of information about child care................................................. 90
Table 1: Groups of people most affected by health problems in the community
District
Total Nyarugenge Gasabo Nyamagabe Ruhango Kamonyi Rubavu Ngororero Nyamasheke Rulindo Gakenke Gicumbi Rwamagana Kayonza Ngoma Bugesera
Total 2000 169 168 133 125 135 125 127 127 126 124 126 113 131 138 133
Children 0 6 Months 28% 33% 35% 47% 21% 24% 21% 9% 17% 8% 33% 47% 37% 35% 28% 17%
Children 7 Months 2 Years 44% 44% 35% 51% 30% 46% 54% 46% 59% 20% 48% 53% 47% 40% 43% 49%
Children 36 years 37% 34% 24% 41% 36% 31% 32% 49% 23% 39% 46% 46% 32% 47% 39% 39%
School going children (7 18 5% 3% 0% 12% 5% 4% 4% 5% 2% 4% 9% 3% 5% 8% 4% 8%

years)
Elderly people 6% 6% 4% 14% 7% 7% 1% 6% 6% 3% 6% 2% 9% 5% 7% 8%
Disabled people 1% 1% 0% 3% 2% 1% 1% 2% 0% 0% 1% 1% 0% 1% 1% 0%
Everyone 39% 32% 39% 21% 41% 47% 28% 45% 61% 56% 48% 33% 25% 37% 41% 28%
Table 2: Actions taken by respondents to immediately respond to and treat illnesses in their children
District
Total 371 21 24 47 16 26 14 61 8 25 10 9 25 29 23 33
Gave ORS 18% 5% 4% 79% 13% 0% 0% 5% 0% 0% 10% 11% 20% 31% 17% 9%
Gave Zinc 10% 0% 8% 30% 0% 12% 7% 5% 0% 8% 30% 0% 12% 7% 13% 3%
Gave some medicine that I had 61% 67% 88% 85% 75% 46% 57% 54% 50% 4% 60% 11% 56% 69% 74% 73%
in the house
Gave the child plenty of fluids 7% 10% 8% 15% 13% 4% 21% 2% 13% 4% 10% 11% 8% 0% 9% 0%
Continued breast feeding 10% 0% 4% 47% 0% 0% 0% 2% 0% 0% 0% 11% 12% 21% 9% 0%
Gave herbal medicine 11% 0% 0% 30% 19% 4% 0% 8% 0% 8% 10% 11% 16% 14% 9% 9%
Sought the services of a 12% 0% 0% 36% 25% 8% 0% 2% 0% 12% 30% 11% 20% 14% 13% 0%
community Health worker
Took the child to the nearest 29% 19% 17% 32% 13% 50% 29% 21% 25% 92% 20% 33% 20% 31% 30% 0%
health facility
Sought the services of a 13% 0% 0% 40% 6% 4% 0% 2% 0% 40% 0% 22% 32% 3% 13% 6%

traditional herbalist
Tepid sponging 7% 0% 0% 28% 0% 0% 0% 2% 13% 4% 10% 22% 8% 3% 17% 0%
Bought medicine from a drug 18% 14% 13% 51% 13% 8% 14% 10% 25% 8% 0% 0% 16% 28% 13% 21%
shop
Prayed for the child 5% 0% 0% 28% 0% 0% 7% 0% 0% 0% 0% 0% 12% 3% 0% 3%

ANNEX 3: SELECTED INDICATORS, DISAGGREGATED BY DISTRICT
79
Table 3: What should people in the community do to maintain proper hygiene?
District
Total 2000 169 168 133 125 135 125 127 127 126 124 126 113 131 138 133
Washing hands with soap before 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
feeding a child or preparing
Washing hands with soap after 64% 67% 72% 56% 77% 73% 50% 72% 73% 59% 39% 62% 58% 68% 61% 70%
using a latrine
Each household must have a 67% 77% 78% 46% 65% 71% 42% 64% 78% 52% 70% 74% 65% 66% 78% 69%
latrine
Cleaning the latrines every day 61% 69% 72% 59% 65% 63% 43% 90% 74% 39% 56% 46% 51% 56% 61% 67%
Keeping water and soap for 46% 49% 57% 49% 54% 53% 28% 65% 42% 40% 20% 30% 40% 53% 48% 48%
washing hands at the latrine are
Clearing bushes around the 50% 61% 67% 47% 31% 57% 42% 45% 51% 52% 45% 44% 47% 50% 54% 52%
home
Avoiding stagnant water around 50% 53% 61% 51% 50% 51% 42% 45% 61% 53% 42% 44% 43% 53% 57% 41%
the home
Bathing at least 2 to 3 times 33% 48% 55% 50% 31% 39% 21% 29% 33% 10% 12% 27% 26% 40% 34% 30%
a day
Keeping the childrens clothes 40% 44% 55% 41% 46% 36% 35% 43% 24% 33% 27% 24% 35% 42% 43% 55%
clean
Keeping utensils clean 30% 40% 37% 40% 26% 38% 22% 33% 30% 17% 23% 25% 26% 29% 33% 20%
Disposing of childrens faeces in 34% 36% 45% 47% 32% 36% 30% 38% 39% 29% 26% 14% 33% 37% 41% 30%
the latrine
Having a rack for utensils in 23% 31% 42% 34% 18% 26% 26% 31% 19% 16% 14% 6% 14% 21% 21% 13%
around the home
Table 4: Which hygiene practices are commonly practised by people in this community?
District
Total 2000 169 168 133 125 135 125 127 127 126 124 126 113 131 138 133
Washing hands with soap before 28% 50% 42% 20% 29% 27% 26% 19% 21% 19% 13% 28% 19% 22% 43% 35%
feeding a child or preparing
Washing hands with soap after 46% 54% 64% 59% 31% 49% 77% 56% 27% 40% 22% 24% 32% 44% 57% 44%
using a latrine
Each household must have a 54% 59% 75% 36% 48% 54% 27% 38% 60% 50% 73% 58% 52% 51% 57% 61%
latrine
Cleaning the latrines every day 33% 49% 47% 41% 21% 33% 32% 30% 30% 15% 17% 25% 27% 31% 48% 40%
Keeping water and soap for 31% 37% 38% 35% 26% 33% 52% 28% 24% 21% 22% 20% 30% 27% 31% 32%
washing hands at the latrine are
Clearing bushes around the 38% 44% 42% 40% 16% 45% 25% 32% 30% 43% 64% 29% 33% 35% 43% 47%
home
Avoiding stagnant water around 34% 31% 50% 35% 26% 33% 21% 25% 32% 42% 28% 30% 34% 37% 43% 36%
the home
Bathing at least 2 to 3 times 22% 38% 29% 33% 15% 24% 34% 7% 11% 9% 11% 13% 15% 27% 35% 15%
a day
Keeping the childrens clothes 26% 38% 32% 28% 28% 24% 18% 28% 20% 11% 15% 17% 24% 24% 36% 36%
clean
Keeping utensils clean 23% 31% 30% 34% 11% 24% 58% 21% 20% 10% 15% 13% 13% 20% 26% 16%
Disposing of childrens faeces in 27% 37% 38% 32% 7% 24% 49% 24% 31% 25% 22% 6% 19% 27% 35% 29%
the latrine
Having a rack for utensils in 13% 21% 20% 23% 2% 16% 14% 21% 7% 7% 8% 2% 8% 11% 22% 8%
around the home
No response 1% 0% 3% 2% 2% 3% 1% 1% 0% 1% 0% 0% 0% 0% 1% 1%
81
Table 5: Foods given to children before breakfast
District
Total 589 83 77 24 57 39 56 20 37 24 28 17 29 31 24 43
Porridge 11% 2% 3% 17% 4% 18% 0% 25% 27% 13% 32% 6% 21% 3% 8% 23%
Potatoes or Irish 8% 7% 12% 25% 7% 3% 7% 0% 8% 4% 0% 6% 3% 6% 13% 12%
Milk 37% 39% 40% 50% 54% 46% 25% 15% 8% 4% 18% 47% 48% 55% 46% 44%
Rice 3% 2% 0% 0% 4% 3% 11% 5% 5% 0% 11% 0% 3% 0% 0% 0%
Water 5% 7% 0% 0% 9% 3% 23% 0% 0% 4% 0% 6% 3% 0% 0% 2%
Spaghetti 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 4% 0% 0% 0% 4% 0%
Fruits 12% 6% 8% 21% 9% 8% 0% 5% 19% 13% 7% 18% 17% 19% 25% 26%
Vegetables 2% 0% 4% 8% 0% 5% 0% 0% 3% 4% 0% 0% 3% 3% 0% 0%
Breast milk 21% 16% 23% 0% 23% 31% 9% 60% 11% 58% 21% 29% 17% 23% 29% 2%
Dry tea 2% 4% 3% 0% 0% 0% 0% 5% 0% 0% 0% 0% 7% 0% 0% 7%
Bananas 5% 1% 3% 4% 5% 5% 4% 5% 8% 4% 11% 18% 3% 6% 0% 5%
Chips 1% 7% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Beans or soya beans 1% 0% 0% 0% 0% 3% 0% 0% 3% 4% 7% 0% 0% 0% 0% 2%
Juice 6% 14% 4% 0% 5% 3% 13% 0% 5% 8% 7% 12% 3% 0% 0% 2%
Fish 0% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Meat 1% 2% 1% 0% 2% 0% 0% 0% 3% 0% 0% 0% 3% 0% 0% 0%
Eggs 2% 2% 12% 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Bread 1% 0% 0% 0% 4% 0% 0% 0% 8% 0% 0% 0% 0% 3% 0% 5%
Pottage 1% 1% 1% 4% 0% 0% 0% 0% 0% 0% 0% 0% 0% 3% 0% 0%
Biscuits 2% 5% 3% 0% 0% 0% 5% 0% 0% 0% 0% 0% 0% 0% 4% 7%
Yogurt 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Other 6% 4% 8% 0% 7% 3% 8% 0% 3% 8% 15% 13% 9% 4% 0%

Table 6: Foods given to children for lunch?
District
Total 1544 143 130 89 103 104 99 120 79 105 89 116 89 98 76 104
Porridge 4% 1% 7% 0% 1% 8% 5% 3% 5% 6% 7% 3% 7% 3% 0% 2%
Potatoes or Irish 29% 13% 18% 45% 24% 14% 10% 38% 35% 8% 25% 55% 42% 30% 37% 51%
Milk 4% 5% 5% 1% 8% 3% 5% 5% 9% 4% 4% 0% 4% 2% 8% 3%
Rice 16% 23% 19% 24% 20% 12% 42% 3% 3% 14% 13% 13% 19% 16% 7% 7%
Water 0% 0% 0% 0% 0% 1% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0%
Spaghetti 1% 1% 4% 0% 0% 3% 8% 0% 0% 0% 3% 0% 0% 0% 3% 0%
Fruits 2% 1% 1% 1% 7% 1% 0% 1% 4% 3% 11% 2% 4% 1% 3% 0%
Vegetables 3% 2% 3% 2% 1% 5% 0% 8% 0% 6% 4% 3% 6% 1% 4% 2%
Breast milk 4% 3% 5% 0% 3% 7% 1% 1% 5% 12% 3% 5% 4% 6% 5% 1%
Bananas 17% 7% 14% 36% 10% 17% 6% 8% 13% 10% 37% 41% 16% 18% 20% 8%
Chips 1% 3% 2% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 0% 0% 0%
Beans or soya beans 2% 1% 0% 0% 3% 0% 1% 2% 4% 1% 3% 4% 3% 2% 4% 5%
Juice 1% 1% 0% 0% 0% 1% 1% 2% 1% 0% 0% 0% 0% 1% 1% 0%
Cassava or cassava bread 3% 2% 0% 0% 1% 2% 4% 3% 0% 5% 6% 9% 8% 1% 5% 7%
Fish 1% 1% 2% 1% 1% 3% 0% 2% 0% 1% 0% 0% 0% 0% 0% 0%
Meat 2% 4% 6% 0% 5% 0% 1% 1% 6% 0% 2% 0% 0% 1% 0% 1%
Eggs 1% 0% 0% 2% 0% 1% 1% 0% 4% 0% 0% 1% 1% 0% 0% 0%
Bread 0% 0% 0% 1% 0% 0% 1% 0% 4% 0% 1% 0% 0% 1% 0% 0%
Posho 1% 0% 0% 1% 1% 0% 0% 2% 0% 0% 2% 0% 1% 2% 1% 13%
Maize 0% 0% 0% 0% 0% 1% 0% 1% 0% 0% 0% 1% 1% 0% 0% 0%
Biscuits 1% 0% 0% 6% 3% 0% 2% 0% 1% 2% 0% 0% 1% 0% 0% 0%
Groundnuts and peas 0% 1% 0% 0% 2% 0% 0% 1% 0% 0% 0% 2% 0% 1% 1% 0%
Yogurt 0% 0% 1% 1% 0% 0% 0% 0% 0% 1% 0% 0% 2% 0% 0% 0%
Cerelac 1% 10% 0% 0% 1% 0% 1% 1% 0% 0% 0% 0% 0% 0% 0% 0%
All foods 18% 10% 15% 2% 23% 18% 10% 28% 16% 45% 9% 9% 16% 21% 17% 27%
Milk and breast milk 0% 0% 0% 0% 0% 1% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0%
Eggs and potatoes 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 1% 0% 0% 0%
Milk and fruits 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0%
Bananas and beans 2% 1% 2% 0% 1% 3% 0% 0% 3% 0% 11% 7% 1% 3% 4% 0%
Yam 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0%
Rice and beans 5% 3% 12% 3% 4% 11% 7% 6% 5% 6% 0% 1% 0% 6% 3% 4%
Porridge and milk 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 0% 0% 0% 0% 0%
Bananas and vegetables 2% 3% 3% 0% 2% 4% 0% 0% 1% 0% 1% 1% 0% 2% 0% 4%

83
District
Total 1544 143 130 89 103 104 99 120 79 105 89 116 89 98 76 104
Rice and potatoes 1% 3% 1% 1% 0% 0% 3% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Rice and banana 0% 1% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 1%
Potatoes and beans 6% 1% 3% 4% 5% 16% 0% 15% 3% 6% 2% 6% 6% 10% 8% 11%
Breast milk and fruits 0% 0% 0% 0% 0% 0% 0% 1% 1% 1% 0% 0% 0% 1% 0% 0%
Bread and vegetables 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 0% 0% 2% 0% 1%
Cassava bread and vegetable 1% 0% 1% 0% 1% 1% 1% 0% 0% 3% 0% 0% 0% 2% 3% 3%
Milk and bread 0% 0% 0% 0% 0% 1% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0%
Rice and peas 1% 1% 3% 0% 1% 1% 0% 1% 0% 0% 0% 0% 0% 0% 0% 3%
Carrots 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0%
Umamahoro 0% 0% 0% 0% 1% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0%
Umumece 0% 0% 0% 0% 0% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1%
Potatoes and vegetables 3% 9% 2% 1% 2% 8% 0% 5% 1% 0% 2% 1% 0% 2% 1% 0%
Cassava and beans 1% 0% 0% 0% 3% 0% 0% 2% 1% 0% 0% 3% 0% 5% 1% 2%
Rice and vegetables 2% 7% 0% 6% 1% 0% 3% 0% 0% 1% 1% 1% 0% 2% 4% 0%
Rice and meat 2% 2% 3% 3% 1% 0% 10% 0% 0% 2% 4% 1% 4% 5% 0% 0%
Other 5% 3% 0% 3% 2% 1% 4% 1% 0% 0% 0% 1% 3% 0% 0%
Table 7: The role of a father development of 0-2 year old children
District
Nyarugenge Gasabo Nyamagabe Ruhango Kamonyi Rubavu Ngororero Nyamasheke Rulindo Gakenke Rwamagana Kayonza Ngoma Bugesera
Attending ante-natal care ValidN 850 77 104 44 62 5 46 56 38 59 83 85 69 57 65

sessions
Mean 3.9 4.4 4.4 4.5 3.7 4.4 2.1 4.5 4.3 4.6 2.5 3.7 3.7 3.9 4.0
Percentage 77% 87% 89% 90% 74% 88% 43% 89% 86% 91% 51% 75% 73% 78% 79%
Score
Show love and affection to the ValidN 858 79 106 44 69 5 47 54 40 59 81 82 63 62 67

child and play with it
Mean 4.5 4.8 4.8 4.6 3.9 5.0 4.9 4.7 4.2 4.7 3.9 4.5 4.3 4.5 4.3
Percentage 89% 96% 95% 92% 78% 100% 97% 94% 85% 95% 77% 90% 86% 91% 87%
Score
Talk to the child, tell stories ValidN 844 80 103 43 65 5 48 54 34 54 82 84 71 54 67
Mean 4.3 4.7 4.6 4.5 3.9 5.0 4.7 4.4 4.6 4.8 3.5 4.2 4.1 4.1 3.9
Percentage 85% 94% 91% 90% 78% 100% 95% 89% 91% 96% 69% 83% 81% 81% 78%
Score
Help mother or caretaker in child ValidN 843 75 107 44 66 5 45 53 37 54 81 81 71 57 67

care duties (e.g. bathing, diaper
changing, getting dressed) Mean 4.3 4.3 4.6 4.8 4.0 4.4 4.3 4.2 4.5 4.4 4.1 4.3 4.3 4.5 4.0
Percentage 86% 85% 91% 97% 81% 88% 86% 83% 89% 88% 83% 86% 86% 90% 80%
Score
Provide for day-to-day ValidN 817 75 103 43 59 5 44 51 35 53 83 80 69 51 66

necessities such as soap, food,
clothes Mean 4.5 4.4 4.7 4.8 4.4 4.8 4.4 4.4 4.7 4.6 4.7 4.2 4.4 4.5 4.6
Percentage 90% 88% 94% 97% 87% 96% 88% 88% 94% 93% 93% 84% 88% 89% 92%
Score
Buying toys ValidN 814 73 105 42 62 5 47 52 36 50 75 78 67 57 65
Mean 4.0 4.1 4.4 4.3 4.1 4.2 4.9 4.2 3.8 4.1 2.5 4.0 3.9 4.2 3.7
Percentage 80% 82% 89% 86% 82% 84% 97% 84% 77% 81% 50% 81% 79% 85% 74%
Score
85
Table 8: The role of a father development of 2-6 year old children
District
Nyarugenge Gasabo Nyamagabe Ruhango Kamonyi Rubavu Ngororero Nyamasheke Rulindo Gakenke Rwamagana Kayonza Ngoma Bugesera
Providing things the child needs ValidN 875 71 98 48 63 6 42 51 31 50 88 85 85 80 77

food, clothes, paying fees
Mean 4.5 4.4 4.6 4.3 3.7 4.8 4.4 4.6 4.5 4.9 4.9 4.5 4.3 4.6 4.7
Percentage 90% 89% 92% 86% 75% 97% 88% 93% 90% 98% 97% 89% 87% 93% 94%
Score
Disciplining child ValidN 900 79 104 49 62 6 43 47 31 53 86 92 80 90 78
Mean 4.5 4.6 4.5 4.3 4.2 5.0 4.7 4.8 4.5 4.9 4.2 4.4 4.4 4.6 4.7
Percentage 90% 92% 91% 86% 83% 100% 95% 95% 89% 98% 83% 89% 88% 93% 94%
Score
Showing the child the ValidN 860 75 100 43 59 6 40 45 27 49 86 86 81 85 78

environment (thing in and
outside the home) Mean 4.0 4.3 4.2 4.3 4.3 4.7 4.7 4.6 3.7 4.6 2.8 4.1 4.0 4.0 3.4
Percentage 80% 86% 83% 85% 86% 93% 95% 91% 74% 91% 55% 81% 80% 80% 67%
Score
Playing with child ValidN 878 76 101 51 58 6 41 52 29 50 86 89 80 86 73
Mean 4.0 4.3 4.4 4.5 4.4 4.7 4.9 4.3 4.0 4.5 2.4 4.0 3.9 4.0 3.6
Percentage 80% 86% 87% 90% 87% 93% 97% 86% 79% 91% 47% 80% 78% 79% 72%
Score
Teaching the child to do different ValidN 854 71 98 44 61 6 40 46 30 50 84 83 80 84 77

things
Mean 4.4 4.3 4.4 4.7 4.4 4.7 4.9 4.6 4.5 4.7 4.2 4.3 4.4 4.3 4.5
Percentage 89% 86% 89% 95% 88% 93% 98% 92% 90% 94% 83% 87% 89% 86% 90%
Score
Taking the child to day care or ValidN 822 68 95 43 54 6 36 47 28 50 85 80 81 74 75

nursery school
Mean 4.3 4.6 4.5 5.0 4.5 4.5 4.9 4.6 4.1 4.4 2.8 3.9 4.0 4.2 4.9
Percentage 85% 93% 90% 99% 89% 90% 97% 91% 81% 87% 56% 79% 81% 84% 97%
Score
Table 9: How often caregivers have had to leave children in the care of another person
District
Total Nyarugenge Gasabo Nyamagabe Ruhango Kamonyi Rubavu Ngororero Nyamasheke Rulindo Gakenke Gicumbi Rwamagana Kayonza Ngoma
How often have you had to leave 82 26% 74% 25% 35% 17% 15% 15% 18% 33% 0% 27% 26% 60% 10% 22%
(child)in the care of another
person?_Child 1 91 29% 11% 22% 10% 63% 42% 11% 32% 22% 29% 9% 26% 40% 35% 33%
136 43% 16% 53% 50% 17% 42% 74% 50% 44% 71% 55% 48% 0% 55% 44%
Table 10: Sources of information to find out about what is happening in your community
District
1916 16700% 165 12600% 118 13000% 122 12000% 124 12200% 118 12500% 105 13000% 125 11900%
Family members 16% 32% 26% 13% 18% 20% 10% 14% 27% 4% 8% 26% 13% 11% 9% 4%
TV 22% 47% 49% 34% 23% 20% 52% 11% 11% 8% 7% 6% 15% 14% 14% 8%
Radio 62% 63% 77% 66% 75% 67% 61% 65% 66% 66% 67% 52% 51% 55% 64% 31%
Posters 7% 4% 9% 13% 6% 6% 16% 4% 3% 4% 1% 1% 10% 7% 9% 8%
Booklets 4% 4% 3% 8% 9% 3% 8% 1% 3% 2% 3% 1% 3% 5% 10% 2%
School children 10% 17% 9% 6% 6% 8% 10% 3% 15% 1% 17% 16% 9% 8% 15% 8%
Youth groups 4% 3% 1% 9% 6% 3% 11% 0% 2% 1% 4% 0% 2% 6% 6% 4%
Fliers/leaflets 3% 5% 1% 6% 5% 3% 6% 0% 1% 2% 0% 0% 3% 1% 8% 0%
Newspapers 9% 16% 14% 6% 12% 8% 15% 5% 8% 2% 10% 14% 6% 8% 11% 0%
NGOs/CBOs 4% 7% 5% 2% 4% 4% 9% 1% 0% 5% 5% 1% 2% 5% 8% 1%
Religious leaders 16% 17% 10% 10% 26% 12% 14% 11% 17% 19% 20% 18% 11% 14% 15% 21%
Mothers associations 8% 8% 5% 14% 3% 8% 11% 13% 2% 9% 3% 0% 11% 11% 12% 17%
Traditional leaders 7% 7% 7% 6% 6% 7% 7% 1% 4% 2% 14% 14% 8% 5% 10% 11%
Women groups 7% 4% 5% 2% 6% 5% 3% 17% 3% 7% 18% 1% 4% 8% 13% 13%
Mobile phones 10% 19% 10% 4% 14% 6% 22% 1% 8% 7% 17% 10% 9% 7% 14% 5%
Community health workers 23% 11% 18% 23% 29% 22% 13% 18% 34% 55% 27% 9% 25% 25% 29% 18%
Health facilities 16% 12% 13% 13% 12% 16% 7% 6% 25% 38% 16% 10% 17% 17% 16% 26%
Local village leaders 30% 31% 40% 21% 20% 27% 11% 15% 57% 34% 58% 42% 27% 28% 27% 16%
Road shows 6% 12% 5% 5% 4% 3% 8% 0% 4% 2% 5% 12% 7% 5% 8% 3%
Market days 6% 9% 4% 6% 8% 4% 5% 1% 6% 2% 10% 18% 7% 8% 7% 3%
Ceremonies (weddings, funerals 5% 10% 4% 3% 4% 4% 11% 0% 6% 2% 4% 10% 6% 5% 5% 2%

etc)
Friends 27% 41% 31% 22% 27% 24% 23% 19% 26% 21% 31% 39% 25% 25% 22% 20%
Neighbours 31% 49% 28% 16% 18% 25% 30% 22% 35% 40% 43% 51% 28% 30% 22% 20%
87
Table 11: Most trusted source of information about what is happening in your community
District
1918 163 158 129 121 124 123 120 124 125 121 124 103 128 134 121
Family members 4% 12% 5% 6% 2% 6% 6% 5% 2% 0% 2% 6% 7% 2% 1% 0%
TV 9% 12% 20% 11% 13% 8% 37% 4% 6% 6% 3% 3% 5% 5% 3% 2%
Radio 46% 33% 42% 37% 57% 48% 41% 63% 56% 52% 50% 42% 44% 43% 54% 27%
Posters 2% 0% 0% 9% 2% 2% 1% 3% 1% 1% 0% 1% 3% 1% 1% 0%
Booklets 1% 0% 0% 8% 0% 2% 2% 1% 0% 0% 1% 0% 2% 1% 1% 0%
School children 1% 2% 2% 5% 0% 2% 1% 0% 2% 0% 1% 0% 1% 2% 1% 0%
Youth groups 0% 0% 0% 2% 0% 0% 0% 1% 0% 0% 0% 0% 2% 0% 0% 0%
Fliers/leaflets 0% 0% 0% 2% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 0% 0%
Newspapers 1% 1% 1% 1% 4% 1% 0% 0% 1% 0% 1% 1% 1% 1% 1% 0%
NGOs/CBOs 0% 0% 0% 2% 0% 0% 2% 0% 0% 0% 1% 0% 1% 0% 0% 0%
Women groups 1% 1% 1% 0% 2% 1% 0% 1% 0% 0% 2% 0% 1% 1% 1% 7%
Mobile phones 0% 0% 0% 0% 0% 1% 2% 1% 2% 0% 0% 0% 0% 0% 1% 2%
Road shows 0% 0% 1% 1% 0% 0% 0% 0% 0% 0% 0% 0% 2% 1% 0% 0%
Market days 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 1% 1% 2% 0% 2%

etc)
Friends 2% 1% 3% 1% 2% 1% 2% 3% 3% 3% 0% 1% 0% 5% 1% 2%
Neighbours 4% 5% 3% 0% 2% 5% 5% 0% 7% 6% 5% 14% 7% 4% 2% 4%
Table 12: Sources of information to find out about what child care
District
1916 167 165 126 118 130 122 120 124 122 118 125 105 130 125 119
Family members 16% 32% 26% 13% 18% 20% 10% 14% 27% 4% 8% 26% 13% 11% 9% 4%
TV 22% 47% 49% 34% 23% 20% 52% 11% 11% 8% 7% 6% 15% 14% 14% 8%
Radio 62% 63% 77% 66% 75% 67% 61% 65% 66% 66% 67% 52% 51% 55% 64% 31%
Posters 7% 4% 9% 13% 6% 6% 16% 4% 3% 4% 1% 1% 10% 7% 9% 8%
Booklets 4% 4% 3% 8% 9% 3% 8% 1% 3% 2% 3% 1% 3% 5% 10% 2%
School children 10% 17% 9% 6% 6% 8% 10% 3% 15% 1% 17% 16% 9% 8% 15% 8%
Youth groups 4% 3% 1% 9% 6% 3% 11% 0% 2% 1% 4% 0% 2% 6% 6% 4%
Fliers/leaflets 3% 5% 1% 6% 5% 3% 6% 0% 1% 2% 0% 0% 3% 1% 8% 0%
Newspapers 9% 16% 14% 6% 12% 8% 15% 5% 8% 2% 10% 14% 6% 8% 11% 0%
NGOs/CBOs 4% 7% 5% 2% 4% 4% 9% 1% 0% 5% 5% 1% 2% 5% 8% 1%
Women groups 7% 4% 5% 2% 6% 5% 3% 17% 3% 7% 18% 1% 4% 8% 13% 13%
Mobile phones 10% 19% 10% 4% 14% 6% 22% 1% 8% 7% 17% 10% 9% 7% 14% 5%
Road Shows 6% 12% 5% 5% 4% 3% 8% 0% 4% 2% 5% 12% 7% 5% 8% 3%
Market Days 6% 9% 4% 6% 8% 4% 5% 1% 6% 2% 10% 18% 7% 8% 7% 3%

etc)
Friends 27% 41% 31% 22% 27% 24% 23% 19% 26% 21% 31% 39% 25% 25% 22% 20%
Neighbours 31% 49% 28% 16% 18% 25% 30% 22% 35% 40% 43% 51% 28% 30% 22% 20%
89
Table 13: Most trusted source of information about child care
District
Total 1928 162 163 130 121 129 125 116 125 125 120 122 105 130 132 123
Family members 7% 14% 15% 1% 2% 2% 34% 3% 5% 0% 3% 8% 3% 3% 4% 1%
TV 4% 7% 8% 5% 9% 5% 3% 3% 5% 2% 3% 0% 1% 1% 5% 2%
Radio 32% 22% 33% 37% 24% 36% 38% 56% 46% 38% 32% 7% 28% 31% 39% 16%
Posters 1% 1% 0% 2% 1% 0% 0% 3% 1% 0% 2% 0% 1% 2% 0% 1%
Booklets 1% 0% 0% 2% 2% 2% 1% 2% 0% 1% 0% 0% 3% 2% 1% 0%
School children 4% 9% 2% 5% 9% 4% 8% 3% 6% 2% 1% 0% 4% 2% 2% 2%
Youth groups 1% 0% 1% 2% 1% 1% 1% 1% 0% 0% 0% 0% 1% 1% 1% 1%
Fliers/leaflets 0% 0% 0% 5% 1% 1% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%
Newspapers 1% 0% 1% 4% 0% 0% 1% 1% 1% 0% 0% 0% 2% 1% 0% 0%
NGOs/CBOs 0% 0% 0% 3% 0% 0% 1% 0% 0% 0% 0% 0% 1% 0% 0% 0%
Women groups 1% 1% 1% 1% 0% 2% 0% 2% 2% 2% 2% 0% 3% 0% 1% 7%
Mobile phones 1% 0% 1% 4% 2% 2% 0% 1% 2% 0% 1% 1% 1% 2% 0% 0%
Other 6% 4% 4% 5% 4% 6% 4% 3% 5% 6% 8% 21% 13% 12% 3% 8%


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Cover photograph: UNICEF Rwanda 2011/Noorani

UNICEF Rwanda 2011/ Noorani

Dr. Agnes Binagwaho

bagaragaza ubumenyi buhagije mu guhangana nindwara zabana, haracyari kumva nabi

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

CHAPTER 2: Research Methods........................................................................... 12

2.1 The target respondents....................................................................................................................12

CHAPTER 3: Literature Review.............................................................................. 17

CHAPTER 4: Study Findings...................................................................................23

4.11 Knowledge, attitudes and practices regarding childparent interaction.............................49

CHAPTER 5: Conclusions and Recommendations.......................................63

ANNEX 1: Tables ...................................................................................................... 67

ANNEX 2: Comparative analysis of the Rwandan KAP to the

ANNEX 3: Selected Indicators, Disaggregated by District........................ 78

Table 23: Foods given to children for breakfast........................................................................... 44

UNICEF Rwanda 2013/Mugabe

ECD Early childhood development

GoR Government of Rwanda

KAP Knowledge, attitudes and practices

NGOs Non-governmental organizations

NISR National Institute of Statistics Rwanda

ORS Oral rehydration salts

RDHS Rwanda Demographic Health Survey

UNICEF United Nations Childrens Fund

Table 1: Respondent distribution

Target respondents Sample size Description

districts and focus group discussions were held in all 12 districts.

2.3 Sample distribution and respondent selection

Table 2: Sample distribution

2.4 Data collection

2.5 Data analysis

there is no significant difference between knowledge and practice on immunization. Therefore,

UNICEF Rwanda 2013/Mugabe

3.3 Postnatal care and early childhood

10 Maps of world, Rwanda, <www.mapsofworld.com/rwanda/economy/agriculture.html>, accessed

3.4 Childhood growth and development

16 Mesa Community College, Infants, Developmental Psychology Student Newsletter, Department of

3.5 Barriers to positive early childhood

UNICEF Rwanda 2013/Shrestha

3.6 Policy issues in relation to early childhood

UNICEF Rwanda 2013/Mugabe

Table 3: Index children in the sample

4.2 Demographic characteristics of respondents

The majority (96percent) of respondents profess to being of a Christian faith (52.3percent

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

Cumulative per cent

Table 5: Economic categories using multi-dimensional poverty indicators

Cumulative per cent

4.3 General health problems affecting the

Health problems experienced in communities

Table 6: Perceived health problems affecting the communities

Table 7: Common health issues: A comparison between male and female

Table 8: Perceived health problems and the perceived causes

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

Table 10: Actions taken by respondents to treat childrens illnesses

Province Economic category

Total (%) Lower- Upper-

Sought the services of a 8 7 7 0 9 16 9 7 6

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

Gave the child plenty of 4 2 3 1 2 9 3 5 4

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

Table 11: Treatment measures of various illnesses by respondents