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.
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.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
SUPPORTIVE_CARE
Masking
NONE
Enrollment
319
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.
Community and Health-Centre Settings, Ngoma District
Ngoma, Eastern Province, Rwanda
Community and Health-Centre Settings, Nyagatare District
Nyagatare, Eastern Province, Rwanda
Community and Health-Centre Settings, Musanze District
Ruhengeri, Northern Province, Rwanda
Community and Health-Centre Settings, Nyamagabe District
Nyamagabe, Southern Province, Rwanda
Community and Health-Centre Settings, Nyabihu District
Nyabihu, Western Province, Rwanda
Change in Family Resilience
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months
Change in Parenting Practices
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months
Change in Parent Couple Functioning
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months
Change in Youth Family-System Functioning
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months
Change in Post-Traumatic Stress Symptoms
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months.
Change in Borderline Traits
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months.
Change in Aggression
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months.
Change in Forgiveness and Community Relations
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months.
Change in Socioemotional Skills
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.
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Time frame: Baseline to immediate post-intervention endline, up to 5 months.
Change in Livelihood and Household Economic Functioning
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.
Time frame: Baseline to immediate post-intervention endline, up to 5 months.