Family Relations, Parent-Child Relation, Psychological Trauma, Stress Disorders, Post-Traumatic
Conditions
Keywords
Rwanda, post-genocide, societal healing, family resilience, family systems, multifamily therapy, cluster randomized trial, intergenerational trauma
Brief summary
This cluster-randomized waitlist-control trial evaluated Multifamily Healing Spaces (MFHS), a culturally adapted behavioral family intervention for genocide-affected communities in Rwanda. Community members across five districts were screened through a staged triage process. Individuals with acute or severe clinical concerns were routed to clinical referral, those with individual mental-health needs were prioritized for Resilience-Oriented Therapy, and families were invited to MFHS when at least one screened family member met criteria for family communication difficulties. Twenty eligible clusters were randomly selected and then allocated to MFHS or waitlist control. The baseline cohort included 319 family members aged 12 years or older. The trial tested whether MFHS improved family resilience, parenting, couple and youth family-system outcomes, and secondary mental health, psychosocial, community, and livelihood outcomes from baseline to immediate post-intervention endline.
Detailed description
MFHS is a group-based, trauma-informed, family-systems intervention developed for post-genocide Rwanda. It combines psychoeducation, structured dialogue, family communication and problem-solving exercises, parenting and couple-relational work, and youth voice and identity activities. The intervention was delivered in intergenerational, whole-family, parent-only, and youth-only formats. MFHS comprised 18 core 3-hour meeting occasions, with parent-only and youth-only sessions delivered in parallel, plus four planned follow-up sessions where relevant. Participants were identified through a broader Rwanda societal-healing screening process. Screening was conducted at the individual level, but MFHS invitation occurred at the family level: if any screened individual met the MFHS family-communication criterion, that person's family was invited. The audited screening workbook contained 4,214 adult/community screening records. After referral/triage for severe clinical flags and other staged interventions, 839 screened individuals were staged to MFHS. At the cell level, 56 eligible cells had enough staged MFHS-screened individuals to form a group; those cells contained 794 staged MFHS-screened individuals. Twenty trial clusters were randomly selected from the eligible cells and then allocated to MFHS or waitlist control. The final baseline cohort included 319 family members in 20 clusters: 167 in MFHS clusters and 152 in waitlist-control clusters. The primary manuscript analysis is a baseline-cohort intention-to-treat analysis. All baseline-assessed participants were retained in their final fielded cluster allocation. Missing endline outcomes for 36 participants were handled through multiple imputation. Effects were estimated with baseline-adjusted cluster-level Analysis of Covariance (ANCOVA) weighted by baseline cluster size, with complete-case and unweighted analyses retained as sensitivity checks.
Interventions
BEHAVIORALMultifamily Healing Spaces
MFHS is a culturally adapted, group-based family intervention for genocide-affected communities in Rwanda. It includes 18 core 3-hour meeting occasions in intergenerational, whole-family, parent-only, and youth-only formats. Sessions focus on trauma-informed psychoeducation, family communication and problem solving, shared meaning-making, parenting, couple relationships, youth voice, and family and community resilience. Groups were facilitated by trained facilitators, including a therapist and community volunteer, with facilitator training and supervision.
Sponsors
Alexandros Lordos, PhD
Centre for Sustainable Peace and Democratic Development
University of Rwanda
Interpeace
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
SUPPORTIVE_CARE
Masking
NONE
Masking description
Baseline enumerators and participants were intended to be unaware of condition assignment during baseline outcome measurement. After allocation, masking could not be assured because local implementation required allocation lists before groups could be convened, and endline masking was difficult to maintain because participants could disclose their allocation status.
Intervention model description
Cluster-randomized parallel-group waitlist-control trial. Twenty eligible community/cell clusters were randomly selected from 56 MFHS-eligible cells and then randomly allocated to MFHS or waitlist control. Outcomes were assessed at baseline and immediate post-intervention endline.
Eligibility
Sex/Gender
ALL
Age
12 Years to No maximum
Healthy volunteers
No
Inclusion criteria
* Member of a family living in or connected to a selected MFHS-eligible cluster/cell in one of the five study districts in Rwanda. * Aged 12 years or older. * Family invited because at least one screened family member met the staged MFHS criterion for family communication difficulties after higher-priority clinical and individual mental-health triage. * Able and willing to participate in baseline assessment and, if allocated to MFHS, family/group sessions. * Written informed consent, assent, and/or caregiver permission obtained according to age and local ethics requirements.
Exclusion criteria
* Individuals with suicidality, psychosis, or severe substance-use flags were routed for clinical interview or hospital referral rather than MFHS as first-line allocation. * Individuals meeting higher-priority individual mental-health criteria were routed to Resilience-Oriented Therapy before the MFHS screening stage. * Individuals or families unable to provide consent/assent or safely participate in group family sessions were not enrolled. * Remaining individuals with social-conflict indicators after earlier stages were routed to sociotherapy rather than MFHS.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Change in Family Resilience | Baseline to immediate post-intervention endline, up to 5 months | Family resilience was measured with the Walsh Family Resilience Questionnaire. The local version included 32 items forming belief systems, organization patterns, and communication/problem solving subscales. Subscale scores range from 1 to 5, with higher scores indicating stronger family resilience processes. |
| Change in Parenting Practices | Baseline to immediate post-intervention endline, up to 5 months | Parenting practices were measured with the Parenting Practices Questionnaire. The local version included 20 items forming authoritative warmth/involvement, authoritative democratic participation, and authoritarian verbal hostility subscales. Subscale scores range from 1 to 5, with higher scores indicating more of the named parenting behavior. |
| Change in Parent Couple Functioning | Baseline to immediate post-intervention endline, up to 5 months | Parent couple functioning was measured with parent-only measures of dyadic adjustment, dyadic happiness, sexual relationship decision-making power, and preference for boys over girls. Dyadic adjustment domains range from 0 to 3 and dyadic happiness ranges from 1 to 5, with higher scores indicating better couple functioning. Sexual relationship decision-making power ranges from 1 to 3, with higher scores indicating more respondent decision-making authority. Preference for boys over girls ranges from 1 to 4, with higher scores indicating stronger preference for boys over girls. |
| Change in Youth Family-System Functioning | Baseline to immediate post-intervention endline, up to 5 months | Youth family-system functioning was measured with youth-only family enmeshment and personal accountability scores. Family enmeshment was measured with seven items ranging from 1 to 5, with higher scores indicating greater over-involvement or lower differentiation. Personal accountability was measured with eight items ranging from 1 to 4, with higher scores indicating greater youth responsibility and accountability. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Change in Post-Traumatic Stress Symptoms | Baseline to immediate post-intervention endline, up to 5 months. | Post-traumatic stress symptoms were measured with four genocide-adapted items from the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Items were rated from 0 to 4, with higher scores indicating greater post-traumatic stress symptoms. |
| Change in Borderline Traits | Baseline to immediate post-intervention endline, up to 5 months. | Borderline traits were measured with the McLean Screening Instrument for Borderline Personality Disorder. The 10 yes/no items are summed to a total score ranging from 0 to 10, with higher scores indicating more borderline-personality features. |
| Change in Aggression | Baseline to immediate post-intervention endline, up to 5 months. | Aggression was measured with physical and verbal aggression items from the Aggression Questionnaire. Items were averaged to scores ranging from 1 to 5, with higher scores indicating greater aggression. |
| Change in Forgiveness and Community Relations | Baseline to immediate post-intervention endline, up to 5 months. | Forgiveness and community relations were measured with forgiveness of others, social cohesion, perceived community threat, and intergenerational harmony scores. Forgiveness of others used retained items derived from the Heartland Forgiveness Scale and ranges from 1 to 4, with higher scores indicating greater forgiveness. Social cohesion ranges from 1 to 4, with higher scores indicating greater social cohesion. Perceived community threat ranges from 1 to 4, with higher scores indicating greater perceived threat. Intergenerational harmony ranges from 1 to 4, with higher scores indicating stronger intergenerational harmony. |
| Change in Socioemotional Skills | Baseline to immediate post-intervention endline, up to 5 months. | Socioemotional skills were measured with locally developed emotional wellbeing, collaboration, and self-management subscales. Subscale scores range from 1 to 4. In the scoring, higher scores indicate greater socioemotional difficulty, so lower scores indicate improvement. |
| Change in Livelihood and Household Economic Functioning | Baseline to immediate post-intervention endline, up to 5 months. | Livelihood and household economic functioning were measured with parent-only economic security, partner economic support, and food-insecurity indicators. Economic security and partner economic support scores range from 0 to 3, with higher scores indicating greater economic security or partner support. Short-term Food Security Consumption Coping Strategy Index scores range from 0 to 84 and long-term scores range from 0 to 12, with higher scores indicating worse food insecurity. |
Countries
Rwanda
Contacts
PRINCIPAL_INVESTIGATORAlexandros Lordos, PhD
University of Cyprus
Outcome results
None listed