The impact of cash transfers on mental health in children and young people in low-income and middle-income countries: a systematic review and meta-analysis

Cash transfer, maternal and child health outcomes: a scoping review in sub-Saharan Africa

BACKGROUND

Cash Transfer (CT) programmes can improve maternal and child health outcomes in low- and middle-income countries. However, studies assessing the effectiveness of these programmes on maternal and child health outcomes (MCH), beyond nutritional outcomes and service utilisation, remain inconclusive.

OBJECTIVES

We synthesized current empirical evidence on the effectiveness of these programmes in improving MCH outcomes and suggested a framework for reporting such outcomes. We focused on sub-Saharan Africa because of substantial operational differences between regions, and the need for MCH advancement in this region.

METHODS

This review searched PubMed Central and Google Scholar and supplemented it with a backward citation search for studies conducted in sub-Saharan Africa for the period between 2000 and 2021. Only peer-reviewed studies on CT that reported health outcomes beyond nutritional outcomes and service utilisation among women of reproductive age and children below 18 years old were included.

RESULTS

Twenty-one articles reporting studies conducted in six sub-Saharan African countries were identified. All studies reported health outcome measures, and programmes targeted women of reproductive age and children under 18 years of age. Of the 21 articles, 1 reported measures of mortality, 13 reported measures of functional status; 3 reported subjective measures of well-being, and 4 reported behavioural health outcomes. Across all categories of reported measures, evidence emerges that cash transfer programmes improved some health outcomes (e.g. improved infant and child survival, reduced incidence of illnesses, improved cognitive and motor development, improved general health, delayed sexual debut, lower transactional sex, etc.), while in some of the studies, outcomes such as depression did not show significant improvements.

CONCLUSION

Cash Transfer programmes are effective and cost-effective, with a real potential to improve maternal and child health outcomes in sub-Saharan African countries. However, further research is needed to address implementation challenges, which include data collection, and programme management.

Health, economic and social impacts of the Brazilian cash transfer program on the lives of its beneficiaries: a scoping review

BACKGROUND

The Bolsa Família cash transfer Program (BFP) aims to break the poverty cycle by providing a minimum income to poor families conditioned on their investment in human capital (such as, education and health) and currently is the largest Program in the world in terms of the number of beneficiaries. Because there is a scarcity of reviews grouping studies on the impacts of the BFP, the objective of this scoping review was to identify and describe studies which evaluate the impact of the BFP on poverty, health, education, and other related outcomes.

METHODS

We searched for quantitative, qualitative, and mixed-method articles that assessed the impact of the BFP on any aspect of the beneficiaries' lives between 2003 and March 2021. We included quantitative articles that used experimental, quasi-experimental or pre and post comparison designs. We excluded articles that analyzed impacts on political outcomes. There was no age restriction for the participants. The search was done in seven electronic databases.

RESULTS

One thousand five hundred forty-six papers were identified and 94 fulfilled the inclusion criteria. Poverty and health outcomes were the most common outcomes studied. We found consistent evidence of the positive impact of the BFP on poverty reduction, as well as employment outcomes. We also found positive impacts in relation to mortality rates for children and adults, school dropout and school attendance among children and adolescents, and violence related outcomes such as homicide, suicide, crime, and hospitalization. However, we also found some evidence that BFP increased intimate partner violence and gender stereotypes among women and no evidence of impact on teenage pregnancy.

CONCLUSIONS

Overall, the studies included found that BFP showed positive impacts on most poverty, health and education outcomes. More studies are needed to confirm some results, especially about violence and stereotype against women as there were few evaluations on these outcomes.

What Should Personalised Mental Health Support Involve? Views of Young People with Lived Experience and Professionals from Eight Countries

Research demonstrates that young people value mental health support that is tailored to their needs and preferences, rather than a "one size fits all" offer, which is often not equitably accessible (National Children's Bureau, 2021). Understanding young people's lived experiences across different sociocultural contexts is important. The aim of this research was to conduct an international qualitative study on the views of young people with lived experience and professionals, on proposed aspects of personalised support for anxiety and/or depression. Participatory action focus groups were conducted with N = 120 young people with lived experience of anxiety and/or depression (14-24 years) and with N = 63 professionals in Brazil, India, Kenya, Pakistan, Portugal, South Africa, Turkey, and the United Kingdom. Data were analysed using the rigorous and accelerated data reduction (RADaR) technique. Overall, although some country-specific differences were found in terms of what aspects of support young people found to be most important, individual preferences were considered stronger, furthering the view that support should be personalised to the needs of the individual young person. Young people experiencing anxiety and/or depression should be able to choose for themselves which aspects of support they would prefer in their own care and support plans, with families and mental health professionals providing guidance where appropriate, rather than removing the young person from the decision-making process altogether. It should also be ensured that the aspects of personalised support can be understood by young people and professionals from different contexts, including marginalised and minoritised groups and communities.

Investigating the impact of poverty on mental illness in the UK Biobank using Mendelian randomization

It is unclear whether poverty and mental illness are causally related. Using UK Biobank and Psychiatric Genomic Consortium data, we examined evidence of causal links between poverty and nine mental illnesses (attention deficit and hyperactivity disorder (ADHD), anorexia nervosa, anxiety disorder, autism spectrum disorder, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, post-traumatic stress disorder and schizophrenia). We applied genomic structural equation modelling to derive a poverty common factor from household income, occupational income and social deprivation. Then, using Mendelian randomization, we found evidence that schizophrenia and ADHD causally contribute to poverty, while poverty contributes to major depressive disorder and schizophrenia but decreases the risk of anorexia nervosa. Poverty may also contribute to ADHD, albeit with uncertainty due to unbalanced pleiotropy. The effects of poverty were reduced by approximately 30% when we adjusted for cognitive ability. Further investigations of the bidirectional relationships between poverty and mental illness are warranted, as they may inform efforts to improve mental health for all.

Cash transfers and mental health in Egypt

The relationship between poverty and mental health is complex. Conditional cash transfers are seen as an important policy tool in reducing poverty and fostering social protection. Evidence on the impact of cash transfers on mental health is mixed. In this study, we assess the causal impact of Egypt's conditional cash transfer (CCT) programme Takaful on the main recipients' mental health. Using a regression discontinuity design, we find that receiving the Takaful CCT does not have a significant impact on the anxiety levels of mothers in our sample. In addition, we do not find supporting evidence that the programme has heterogeneous impacts on anxiety levels. We discuss possible explanations behind these null results.

Cash Transfers and After-School Programs: A Randomized Controlled Trial for Young Men at Risk of Violence Exposure in Wilmington, Delaware

We conducted a randomized controlled trial to determine whether an after-school program paired with a cash transfer (a conditional cash transfer) or a cash transfer alone (an unconditional cash transfer) can help improve health and economic outcomes for young men between the ages of 14 and 17 whose parents have low incomes and who live in neighborhoods with high crime rates. We find that receiving the cash transfer alone was associated with an increase in healthy behaviors (one of our primary outcome composite measures) and that the cash transfer paired with after-school programming was associated with an improvement in the financial health of participants (one of our secondary outcome composite measures). We find no differences in spending on alcohol, marijuana, cigarettes, or other drugs between either the treatment group and the control group. Neither the cash transfer alone nor the programming plus cash transfer had statistically significant effects on our other primary composite measures (physical and mental health or school attendance and disciplinary actions), or our other secondary composite measures (criminal justice engagement or social supports) but in most cases, confidence intervals were too large to rule out meaningful effects. Results suggest that cash transfers hold promise to improve the health of youth without any indication of any adverse effects.

Interventions targeting social determinants of mental disorders and the Sustainable Development Goals: a systematic review of reviews

Globally, mental disorders account for almost 20% of disease burden and there is growing evidence that mental disorders are socially determined. Tackling the United Nations Sustainable Development Goals (UN SDGs), which address social determinants of mental disorders, may be an effective way to reduce the global burden of mental disorders. We conducted a systematic review of reviews to examine the evidence base for interventions that map onto the UN SDGs and seek to improve mental health through targeting known social determinants of mental disorders. We included 101 reviews in the final review, covering demographic, economic, environmental events, neighborhood, and sociocultural domains. This review presents interventions with the strongest evidence base for the prevention of mental disorders and highlights synergies where addressing the UN SDGs can be beneficial for mental health.

Impact of cash transfer programs on healthcare utilization and catastrophic health expenditures in rural Zambia: a cluster randomized controlled trial

Background

Nearly 100 million people are pushed into poverty every year due to catastrophic health expenditures (CHE). We evaluated the impact of cash support programs on healthcare utilization and CHE among households participating in a cluster-randomized controlled trial focusing on adolescent childbearing in rural Zambia.

Methods and findings

The trial recruited adolescent girls from 157 rural schools in 12 districts enrolled in grade 7 in 2016 and consisted of control, economic support, and economic support plus community dialogue arms. Economic support included 3 USD/month for the girls, 35 USD/year for their guardians, and up to 150 USD/year for school fees. Interviews were conducted with 3,870 guardians representing 4,110 girls, 1.5-2 years after the intervention period started. Utilization was defined as visits to formal health facilities, and CHE was health payments exceeding 10% of total household expenditures. The degree of inequality was measured using the Concentration Index. In the control arm, 26.1% of the households utilized inpatient care in the previous year compared to 26.7% in the economic arm (RR = 1.0; 95% CI: 0.9-1.2, p = 0.815) and 27.7% in the combined arm (RR = 1.1; 95% CI: 0.9-1.3, p = 0.586). Utilization of outpatient care in the previous 4 weeks was 40.7% in the control arm, 41.3% in the economic support (RR = 1.0; 95% CI: 0.8-1.3, p = 0.805), and 42.9% in the combined arm (RR = 1.1; 95% CI: 0.8-1.3, p = 0.378). About 10.4% of the households in the control arm experienced CHE compared to 11.6% in the economic (RR = 1.1; 95% CI: 0.8-1.5, p = 0.468) and 12.1% in the combined arm (RR = 1.1; 95% CI: 0.8-1.5, p = 0.468). Utilization of outpatient care and the risk of CHE was relatively higher among the least poor than the poorest households, however, the degree of inequality was relatively smaller in the intervention arms than in the control arm.

Conclusions

Economic support alone and in combination with community dialogue aiming to reduce early childbearing did not appear to have a substantial impact on healthcare utilization and CHE in rural Zambia. However, although cash transfer did not significantly improve healthcare utilization, it reduced the degree of inequality in outpatient healthcare utilization and CHE across wealth groups.

Trial Registration

https://classic.clinicaltrials.gov/ct2/show/NCT02709967, ClinicalTrials.gov, identifier (NCT02709967).

When money and mental health problems pile up: The reciprocal relationship between income and psychological distress

Background

Longitudinal studies suggest that socioeconomic status (SES) and mental health have a bidirectional relationship such that SES declines lead to a deterioration of mental health (social causation), while worsening mental health leads to SES declines (social drift). However, the dynamic relationship between income and psychological distress has not been sufficiently studied.

Methods

We use cross-lagged panel models with unit fixed effects (FE-CLPM) and data from a five-wave representative panel (n = 3103) of working-age (18-64) New York City adults. Yearly measures include individual earnings, family income (income-to-needs), and psychological distress. We also examine effects by age, gender, education, and racial/ethnic identification.

Results

We find significant bidirectional effects between earnings and distress. Increases in past-year individual earnings decrease past-month psychological distress (social causation effect [SCE], standardized β= -0.07) and increases in psychological distress reduce next-year individual earnings (social drift effect [SDE], β= -0.03). Family income and distress only have a unidirectional relationship from past-year family income to distress (SCE, β= -.03). Strongest evidence of bidirectional effects between earnings and distress is for prime working-age individuals (SCE, β= -0.1; SDE, β= -0.03), those with less than bachelor's degrees (SCE, β= -0.08; SDE, β= -0.05), and Hispanics (SCE, β= -0.06; SDE, β= -0.08). We also find evidence of reciprocal effects between family income and distress for women (SCE, β= -0.03; SDE, β= -0.05), and Hispanics (SDE, β= -0.04; SDE, β= -0.08).

Conclusions

Individual earnings, which are labor market indicators, may be stronger social determinants of mental health than family income. However, important differences in social causation and social drift effects exist across groups by age, education, gender, and racial/ethnic identities. Future research should examine the types of policies that may buffer the mental health impact of negative income shocks and the declines in income associated with worsening mental health, especially among the most vulnerable.

What Women Want: Mental Health in the Context of Violence Against Women in Sri Lanka-A Qualitative Study of Priorities and Capacities for Care

Insufficient evidence guides mental health service development for survivors of violence against women in Sri Lanka. Provider and survivor perspectives on (1) what constitutes mental health, (2) quality of care, and (3) priority areas and stakeholders for intervention were identified through framework analysis of 53 in-depth interviews. Desired care is chiefly psychosocial-not psychological-prioritizing socioeconomic, parenting, and safe environment needs in non-clinical community settings. Our evidence points strongly to the need to strengthen non-mental health community-based providers as "first contacts" and reassessment of health system-centric interventions which neglect preferred community responses and more holistic approaches accounting for women's full circumstances.

Using cash transfers to promote child health equity: an analysis of Lesotho's Child Grants Program

Cash transfers (CTs) are increasingly popular tools for promoting social inclusion and equity in children in sub-Saharan Africa. However, less is known about their implications for reducing the health gap between the beneficiary and non-beneficiary children in the community. Using Lesotho's Child Grants Program (CGP) as a case study, we aim to understand better the potential for CT programmes to reduce the gap in child health in the targeted communities. Using a triple difference model, we examine to what extent CGP improved child health outcomes in eligible households compared with non-eligible households in treatment communities vs control communities and to what extent this effect varied in different population subgroups. We find that the child health gap by beneficiary children's health outcomes catching-up on the health of non-beneficiary children narrowed but that eduction was not statistically significant. However, such a 'catch-up' effect among beneficiaries was observed for selected nutrition outcomes amongst female-headed households and subjective child health assessment for comparatively more food-secure households. This study highlights the potential and limitations of CT programmes like the CGP to address health inequalities in preschool children for selected population subgroups in the community.

The social determinants of mental health and disorder: evidence, prevention and recommendations

People exposed to more unfavourable social circumstances are more vulnerable to poor mental health over their life course, in ways that are often determined by structural factors which generate and perpetuate intergenerational cycles of disadvantage and poor health. Addressing these challenges is an imperative matter of social justice. In this paper we provide a roadmap to address the social determinants that cause mental ill health. Relying as far as possible on high-quality evidence, we first map out the literature that supports a causal link between social determinants and later mental health outcomes. Given the breadth of this topic, we focus on the most pervasive social determinants across the life course, and those that are common across major mental disorders. We draw primarily on the available evidence from the Global North, acknowledging that other global contexts will face both similar and unique sets of social determinants that will require equitable attention. Much of our evidence focuses on mental health in groups who are marginalized, and thus often exposed to a multitude of intersecting social risk factors. These groups include refugees, asylum seekers and displaced persons, as well as ethnoracial minoritized groups; lesbian, gay, bisexual, transgender and queer (LGBTQ+) groups; and those living in poverty. We then introduce a preventive framework for conceptualizing the link between social determinants and mental health and disorder, which can guide much needed primary prevention strategies capable of reducing inequalities and improving population mental health. Following this, we provide a review of the evidence concerning candidate preventive strategies to intervene on social determinants of mental health. These interventions fall broadly within the scope of universal, selected and indicated primary prevention strategies, but we also briefly review important secondary and tertiary strategies to promote recovery in those with existing mental disorders. Finally, we provide seven key recommendations, framed around social justice, which constitute a roadmap for action in research, policy and public health. Adoption of these recommendations would provide an opportunity to advance efforts to intervene on modifiable social determinants that affect population mental health.

Combining Asset Accumulation and Multifamily Group Intervention to Improve Mental Health for Adolescent Girls: A Cluster-Randomized Trial in Uganda

PURPOSE

The aim of this study is to expand the current knowledge on the relationship between poverty, family functioning, and the mental health of adolescent girls in families affected by poverty and HIV/AIDS in southern Uganda. The study investigates the association between family functioning and mental health and examines whether family functioning moderates the intervention effect on adolescent mental health.

METHODS

Longitudinal data were collected over the course of 24 months in a cluster randomized controlled trial conducted among N=1,260 girls aged 14-17 years in Uganda. Participants were randomized into control group (n=408 girls from n=16 schools), matched youth development accounts treatment, YDA (n=471 girls from n=16 schools), and integrated intervention combining YDA with multiple family group component (n=381 girls from n=15 schools).

RESULTS

We found a significant positive association between family functioning and mental health of adolescent girls in our sample. Moderator analyses suggests that effect of the intervention on Beck Hopelessness Scale was significantly moderated by family cohesion (χ2 (4) =21.43; p = .000), frequency of family communication (χ2 (4) =9.65; p = .047), and quality of child-caregiver relationship (χ2 (4) =11.12; p = .025). Additionally, the intervention effect on depression was moderated by the comfort of family communication (χ2 (4) =10.2; p = .037).

DISCUSSION

The study findings highlight the importance of family functioning when examining the link from poverty to adolescent mental health. The study contributes to the scarce evidence suggesting that asset-accumulation opportunities combined with a family strengthening component may improve parenting practices and adolescent mental health in poor households.

Links between Household-Level Income-Generating Agricultural Intervention and the Psychological Well-Being of Adolescent Girls in Human Immunodeficiency Virus-Affected Households in Southwestern Kenya: A Qualitative Inquiry

BACKGROUND

Adolescent girls may experience poor psychological well-being, such as social isolation, shame, anxiety, hopelessness, and despair linked to food insecurity.

OBJECTIVES

This study aimed to investigate the experiences with and perceived effects of a household-level income-generating agricultural intervention on the psychological well-being of adolescent girls in human immunodeficiency virus (HIV)-affected households in southwestern Kenya.

METHODS

We conducted 62 in-depth interviews with HIV-affected adolescent girls and caregiver dyads in Adolescent Shamba Maisha (NCT03741634), a sub-study of adolescent girls and caregivers with a household member participating in Shamba Maisha (NCT01548599), a multisectoral agricultural and finance intervention trial aimed to improve food security and HIV health indicators. Participants were purposively sampled to ensure diversity in terms of age and location. Data were audiotaped, transcribed, translated, and uploaded into Dedoose (Sociocultural Research Consultants, LLC) software for management. Data were analyzed thematically based on reports from Dedoose.

RESULTS

We found evidence that a household-level structural intervention aimed at increasing food and financial security among persons living with HIV can contribute to better psychological well-being among adolescent girls residing in these households. The intervention also affected: 1) reduction of social isolation, 2) reduction of shame and stigma, 3) increased attendance and concentration in school, 4) improved caregiver mental health, and 5) reduced parental aggression and improved household communication. These associations were reported more commonly among those in the intervention arm than the control arm.

CONCLUSIONS

This study extends existing research by demonstrating how multisectoral structural interventions delivered at a household level can improve the psychological well-being of adolescents. We recommend that future research test livelihood interventions designed specifically for adolescent girls that integrate food-security interventions with other elements to address the social and psychological consequences of food insecurity holistically. This trial was registered at clinicaltrials.gov as NCT03741634.

Effectiveness of community mobilisation and group-based interventions for preventing intimate partner violence against women in low- and middle-income countries: A systematic review and meta-analysis

Background

Intimate partner violence (IPV) is a challenge affecting one in three women in their lifetime, and gender-transformative interventions have been identified as a promising prevention strategy. We systematically reviewed and meta-analysed randomised controlled trials (RCTs) of community-level or group-based interventions to prevent IPV in lower- and middle-income countries, seeking to answer the following research question: do community- or group-based gender-transformative interventions reduce IPV, compared to a control arm of status-quo programming?

Methods

We conducted a systematic search from the inception of all databases employed until 20 July 2021. Eligible study outcomes included past-year experience of physical, sexual, emotional or economic IPV self-reported by women and perpetration of physical or sexual IPV self-reported by men. We assessed study risk of bias using the updated Cochrane tool for RCTs. We estimated the pooled odds ratio (OR) using a multilevel random-effects meta-analysis and also conducted a multilevel meta-regression to analyse how study characteristics moderated the effect size.

Results

After screening 7363 unique records, we included 30 studies on 27 unique RCTs. Our meta-analysis suggested that community-level or group-based interventions reduced the odds of women experiencing IPV in the past year: pooled adjusted odds ratio (aOR) = 0.78; 95% confidence interval (CI) = 0.63-0.97. While there was significant heterogeneity in the effect sizes between trials (I2 = 83%), potentially reflecting the diverse contexts of the included trials, our meta-regression did not indicate a significant association between intervention effectiveness and intervention type or target population. There was evidence of significant associations between effectiveness and intervention components and duration.

Discussion

There is strong evidence that community-level and group-based interventions reduce IPV against women. Unpacking what intervention modalities are effective in which contexts can further inform prevention strategies.

Registration

PROSPERO (CRD42021290193).

Sociodemographic predictors of depression and anxiety symptomatology among parents in rural Côte d'Ivoire

BACKGROUND

In Côte d'Ivoire, cocoa farming is a widespread practice in rural households, an occupation with increased risks of depression and anxiety exacerbated by economic instability. We used the Goldberg-18 Depression and Anxiety diagnostic tool to identify predictors of depressive and anxiety symptomatology among a sample of parents in rural cocoa farming communities.

METHODS

In a cross-sectional survey, the Goldberg-18 was administered to Ivorian parents (N = 2471). Confirmatory factor analysis (CFA) was conducted to confirm the factor structure of the assessment tool, and Ordinary Least Squares (OLS) regression with clustered standard errors was used to identify sociodemographic predictors of symptomatology.

RESULTS

CFA showed adequate fit statistics for a two-factor model measuring depressive and anxiety symptoms. Among respondents, 87 % screened positive for requiring further referral for clinical diagnosis. Sociodemographic predictors of depressive and anxiety symptoms were similar for males and females. For the total sample, higher monthly income, more years of education, and belonging to the Mandinka ethnic group predicted fewer depressive and anxiety symptoms. In contrast, higher depressive and anxiety symptomatology were associated with age. Single marital status predicted increased anxiety but not depressive symptoms for the full sample model and the female only sample, but not the male sample.

LIMITATIONS

This is a cross-sectional study.

CONCLUSIONS

The Goldberg-18 measures distinct domains of depressive and anxiety symptoms in a rural Ivorian sample. Age and single marital status are predictors of increased symptoms. Higher monthly income, higher education, and certain ethnic affiliations are protective factors.

The impact of poverty-reduction intervention on child mental health mediated by family relations: Findings from a cluster-randomized trial in Uganda

Reviews that synthesize global evidence on the impact of poverty reduction interventions on child and adolescent mental health (CAMH) report inconclusive results and highlight the need to unpack the mechanisms that connect poverty-reduction to CAMH. To address this gap, we examine the proposition that family relations is an important relational factor transmitting effect of poverty on CAMH, and test whether family relations mediate the effect of poverty-reduction intervention on depression, hopelessness, and self-concept among AIDS orphans in Uganda. We use longitudinal data collected over the course of 48 months in a cluster-randomized controlled trial conducted among N = 1410 AIDS orphans from n = 48 schools in Uganda. To examine the relationship between intervention, latent mediator (family relations and support) and CAMH outcomes (Beck Hopelessness Scale (BHS), Tennessee Self-Concept Scale (TSCS), and Depression), we ran structural equation models adjusting for clustering of individuals within schools. Relative to the control group, participants in both treatment arms reported lower levels of hopelessness and depression, and significantly higher levels of self-concept. They also report significantly higher levels of latent family relationship in all three models. In both treatment arms, the direct effect of the intervention on all three outcomes is still significant when the latent family relations mediator is included in the analyses. This suggests partial mediation. In other words, in both treatment arms, the significant positive effect of the intervention on children's depression, hopelessness, and self-concept is partially mediated by their family relationship quality. Our findings support the argument put forward by the Family Stress Model showing that the poverty-reduction program improves children's mental health functioning by improving family relationships. The implications of our study extend beyond the narrow focus of poverty reduction, suggesting that asset-building interventions have broader impacts on family dynamics and child mental health.

Exploring potential mental health spillover effects among caregivers and partners of youth in Sierra Leone: A qualitative study

Given the large mental health treatment gap in low- and middle-income countries (LMICs), particularly in post-conflict settings like Sierra Leone, and the limited healthcare infrastructure, understanding the wider benefits of evidence-based mental health interventions within households is critical. This study explored potential mental health spillover effects - the phenomenon of beneficial effects among nonparticipants - among cohabitating caregivers and partners of youth who participated in an evidence-based mental health intervention in Sierra Leone. We recruited a sub-sample of cohabitating caregivers and partners (N = 20) of youth intervention participants; caregivers had enrolled in a larger study investigating indirect benefits of the evidence-based intervention in Sierra Leone (MH117359). Qualitative interviews were conducted at two time points to explore the following: (a) potential mental health spillover effects and (b) through which mechanisms spillover may have occurred. Two trained coders reviewed transcripts and analyzed qualitative data, assisted by MaxQDA. Qualitative findings suggested that spillover effects likely occurred and supported three potential mechanisms: decreased caregiving burden, behavior changes among Youth Readiness Intervention participants and improved interpersonal relationships. Mental health spillover effects may occur following youth intervention participation in a post-conflict LMIC. Investing in evidence-based services may offer indirect benefits that extend beyond those directly receiving services.

Structural and Intermediary Social Determinants of Health and the Emotional and Behavioral Health of US Children

Children grow up in homes where varying environmental and socioeconomic contexts have a bearing on their emotional and behavioral health (EBH). This study used data from a representative sample of the child supplement of the US National Health Information Survey (NHIS) and applied the social determinants of health (SDoH) framework to explore factors associated with child EBH. We conducted a path analysis of the child's EBH measured by the strengths and difficulties questionnaire (SDQ) from their macro and socioeconomic contexts, e.g., policy, household, and other health system risk factors. For children in the sample, aged 4 to 17 years old (n = 9205), most path relationships to child SDQ scores were statistically significant. The total effects from a child's visit to a mental health specialist (0.28) and child's age (0.22) had the highest coefficients to child SDQ scores. A modified model showed a better fit with X2 (4) = 22.124, RMSEA = 0.021, and 90% CI [0.013-0.03], CFI = 0.98. Findings indicate that child factors such as being older, the use of mental healthcare services, and family socioeconomic status were significantly associated with EBH, calling attention to the need for more responsive policy and behavioral health interventions that address household/familial and child-level factors, critical determinants of child wellbeing.

Impacts of cash transfer and "cash plus" programs on self- perceived stress in Africa: Evidence from Ghana, Malawi, and Tanzania

Poverty and poor mental health are closely linked. Cash transfers have significantly expanded globally. Given their objectives around poverty reduction and improving food security, a major chronic stressor in Africa, cash transfers may affect mental health outcomes. We examine impacts of three large-scale government cash transfer or cash plus programs in Ghana, Malawi, and Tanzania on self-perceived stress using an innovative, newly adapted measure for rural African settings. Linear regression models were used to estimate treatment impacts. We find that cash transfers reduced self-perceived stress in Malawi, but programs in Ghana and Tanzania had no impacts on self-perceived stress. These mixed findings, combined with recent reviews on cash transfers and mental health, suggest that cash transfers may play a role in improving mental health. However, cash alone may not be sufficient to overcome many challenges related to poverty, and complementary programming may also be needed to improve mental health.

Effects of a Combination Economic Empowerment and Family Strengthening Intervention on Psychosocial Well-being Among Ugandan Adolescent Girls and Young Women: Analysis of a Cluster Randomized Controlled Trial (Suubi4Her)

PURPOSE

Economic empowerment and family strengthening interventions have shown promise for improving psychosocial well-being in a range of populations. This study investigates the effect of a combination economic and family strengthening intervention on psychosocial well-being among Ugandan adolescent girls and young women (AGYW).

METHODS

We harnessed data from a three-arm cluster randomized controlled trial among AGYW aged 14-17 years in 47 Ugandan secondary schools. Schools were randomized to either a youth development account intervention (YDA) [N = 16 schools], YDA plus a multiple family group intervention (YDA + MFG) [N = 15 schools], or bolstered standard of care (BSOC) [N = 16 schools]. We estimated the effect of each intervention (BSOC = referent) on three measures of psychosocial well-being: hopelessness (Beck's Hopelessness Scale), self-concept (Tennessee Self-Concept Scale), and self-esteem (Rosenberg Self-Esteem Scale) at 12 months following enrollment using multi-level linear mixed models for each outcome.

RESULTS

A total of 1,260 AGYW (mean age, 15.4) were enrolled-471 assigned to YDA (37%), 381 to YDA + MFG (30%), and 408 to usual care (32%). Over the 12-month follow-up, participants assigned to the YDA + MFG group had significantly greater reductions in hopelessness and improvements in self-esteem outcomes compared to BSOC participants. Those enrolled in the YDA arm alone also had significantly greater reductions in hopelessness compared to BSOC participants.

DISCUSSION

Combination interventions, combining economic empowerment (represented here by YDA), and family-strengthening (represented by MFG) can improve the psychosocial well-being of AGYW. The long-term effects of these interventions should be further tested for potential scale-up in an effort to address the persistent mental health treatment gap in resource-constrained settings.

Making an economic argument for investment in global mental health: The case of conflict-affected refugees and displaced people

Mental health expenditure accounts for just 2.1% of total domestic governmental health expenditure per capita. There is an economic, as well as moral, imperative to invest more in mental health given the long-term adverse impacts of mental disorders. This paper focuses on how economic evidence can be used to support the case for action on global mental health, focusing on refugees and people displaced due to conflict. Refugees present almost unique challenges as some policy makers may be reluctant to divert scarce resources away from the domestic population to these population groups. A rapid systematic scoping review was also undertaken to identify economic evaluations of mental health-related interventions for refugees and displaced people and to look at how this evidence base can be strengthened. Only 11 economic evaluations focused on the mental health of refugees, asylum seekers and other displaced people were identified. All but two of these intervention studies potentially could be cost-effective, but only five studies reported cost per quality-adjusted life year gained, a metric allowing the economic case for investment in refugee mental health to be compared with any other health-focused intervention. There is a need for more consistent collection of data on quality of life and the longer-term impacts of intervention. The perspective adopted in economic evaluations may also need broadening to include intersectoral benefits beyond health, as well as identifying complementary benefits to host communities. More use can be also made of modelling, drawing on existing evidence on the effectiveness and resource requirements of interventions delivered in comparable settings to expand the current evidence base. The budgetary impact of any proposed strategy should be considered; modelling could also be used to look at how implementation might be adapted to contain costs and take account of local contextual factors.

Do cash transfers alleviate common mental disorders in low- and middle-income countries? A systematic review and meta-analysis

A large literature has demonstrated the link between poverty and mental ill-health. Yet, the potential causal effects of poverty alleviation measures on mental disorders are not well-understood. In this systematic review, we summarize the evidence of the effects of a particular kind of poverty alleviation mechanism on mental health: the provision of cash transfers in low- and middle-income countries. We searched eleven databases and websites and assessed over 4,000 studies for eligibility. Randomized controlled trials evaluating the effects of cash transfers on depression, anxiety, and stress were included. All programs targeted adults or adolescents living in poverty. Overall, 17 studies, comprising 26,794 participants in Sub-Saharan Africa, Latin America, and South Asia, met the inclusion criteria of this review. Studies were critically appraised using Cochrane's Risk of Bias tool and publication bias was tested using funnel plots, egger's regression, and sensitivity analyses. The review was registered in PROSPERO (CRD42020186955). Meta-analysis showed that cash transfers significantly reduced depression and anxiety of recipients (dpooled = -0.10; 95%-CI: -0.15, -0.05; p<0.01). However, improvements may not be sustained 2-9 years after program cessation (dpooled = -0.05; 95%-CI: -0.14, 0.04; ns). Meta-regression indicates that impacts were larger for unconditional transfers (dpooled = -0.14; 95%-CI: -0.17, -0.10; p<0.01) than for conditional programs (dpooled = 0.10; 95%-CI: 0.07, 0.13; p<0.01). Effects on stress were insignificant and confidence intervals include both the possibility of meaningful reductions and small increases in stress (dpooled = -0.10; 95%-CI: -0.32, 0.12; ns). Overall, our findings suggest that cash transfers can play a role in alleviating depression and anxiety disorders. Yet, continued financial support may be necessary to enable longer-term improvements. Impacts are comparable in size to the effects of cash transfers on, e.g., children's test scores and child labor. Our findings further raise caution about potential adverse effects of conditionality on mental health, although more evidence is needed to draw robust conclusions.

Potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people: A conceptual framework and lines of enquiry for research and policy

Mental health is inextricably linked to both poverty and future life chances such as education, skills, labour market attachment and social function. Poverty can lead to poorer mental health, which reduces opportunities and increases the risk of lifetime poverty. Cash transfer programmes are one of the most common strategies to reduce poverty and now reach substantial proportions of populations living in low- and middle-income countries. Because of their rapid expansion in response to the COVID-19 pandemic, they have recently gained even more importance. Recently, there have been suggestions that these cash transfers might improve youth mental health, disrupting the cycle of disadvantage at a critical period of life. Here, we present a conceptual framework describing potential mechanisms by which cash transfer programmes could improve the mental health and life chances of young people. Furthermore, we explore how theories from behavioural economics and cognitive psychology could be used to more specifically target these mechanisms and optimise the impact of cash transfers on youth mental health and life chances. Based on this, we identify several lines of enquiry and action for future research and policy.

COVID-19 Recession: Young Adult Food Insecurity, Racial Disparities, and Correlates

PURPOSE

The COVID-19 pandemic has inflicted devastating health, social, and economic effects globally. This study examines the experiences of young adults in the United States with respect to food insecurity during the pandemic and factors associated with higher and lower risk for young adult food insecurity.

METHODS

Using the U.S. Census Bureau's Household Pulse Survey, a nationally representative survey collecting information on people's experiences throughout the pandemic, we analyzed prevalence of, and factors associated with young adult food insecurity during the pandemic.

RESULTS

Overall, 13% of young adults aged 18-25 years reported often or sometimes not having enough to eat in the last 7 days at a given time during pandemic, on average, with Black and Hispanic young people facing higher rates of food insecurity (22% and 15%, respectively) than White non-Hispanic peers (11%). Over the observed pandemic period, we find a decline in food insecurity among young adults corresponding with economic policy actions. Factors associated with a higher risk of food insecurity include lower household income, expected job loss, renting as opposed to owning housing, behind on rent or mortgage payment, lack of confidence in an ability to pay next month's rent or mortgage, delayed medical care, and feeling worried or depressed.

DISCUSSION

Our analyses reveal alarming levels of food insecurity among young adults, especially Black and Hispanic young people. Policy actions should include multifaceted and sustained interventions with a focus on supporting historically disenfranchised youth and their communities. These should prevent and address food and housing insecurity and mental health needs holistically.

Combining cash transfers and cognitive behavioral therapy to reduce antisocial behavior in young men: A mediation analysis of a randomized controlled trial in Liberia

BACKGROUND

Interventions that combine cognitive behavioral therapy (CBT) with unconditional cash transfers (UCT) reduce the risk of antisocial behavior (ASB), but the underlying mechanisms are unclear. In this paper, we test the role of psychological and cognitive mechanisms in explaining this effect. We assessed the mediating role of executive function, self-control, and time preferences.

METHODS

We used data from the Sustainable Transformation of Youth in Liberia, a community-based randomized controlled trial of criminally engaged men. The men were randomized into: Group-1: control (n = 237); and Group-2: CBT+UCT (n = 207). ASB was measured 12-13 months after the interventions were completed, and the following mediators were assessed 2-5 weeks later: (i) self-control, (ii) time preferences and (iii) executive functions. We estimated the natural direct effect (NDE) and the natural indirect effect (NIE) of the intervention over ASB.

RESULTS

Self-control, time preferences and a weighted index of all three mediators were associated with ASB scores, but the intervention influenced time preferences only [B = 0.09 95%CI (0.03; 0.15)]. There was no evidence that the effect of the intervention on ASB was mediated by self-control [BNIE = 0.007 95%CI (-0.01; 0.02)], time preferences [BNIE = -0.02 95%CI (-0.05; 0.01)], executive functions [BNIE = 0.002 95%CI (-0.002; 0.006)] or the weighted index of the mediators [BNIE = -0.0005 95%CI (-0.03; 0.02)].

CONCLUSIONS

UCT and CBT lead to improvements in ASB, even in the absence of mediation via psychological and cognitive functions. Findings suggest that the causal mechanisms may involve non-psychological pathways.

Developing and testing unconditional cash transfer strategies among young adults with first-episode psychosis in South Africa: a study protocol for a pilot randomised control trial (PRS-FEP trial)

INTRODUCTION

Access to mental health services is a challenge, especially for young people who are over-represented in the unemployment and poverty index in South Africa. Therefore, continuing care is a problem after hospital discharge for young people with first-episode psychosis (FEP) due to a lack of clinical engagement and follow-up, for which they need support, including financial, to improve their outcomes. This pilot randomised control trial (RCT) aims to assess the feasibility and acceptability of financial support, in the form of an unconditional cash transfer (UCT), among young patients with FEP to prevent relapse.

METHODS AND ANALYSIS

This study will use a 1:1 ratio two-arm open-label pilot RCT of 60 young participants (18-29 years) with FEP in remission, who will be recruited from specialised psychiatric facilities in KwaZulu-Natal Province, South Africa. This study will implement an UCT and assess its feasibility, acceptability and preliminary clinical outcomes (ie, medication adherence, relapse, quality of life, personal and social function). The follow-up time will be 3 months, the outcomes being measured at baseline, months 1 and 3. Descriptive and conventional content analysis will be done for quantitative and qualitative data, respectively.

ETHICS AND DISSEMINATION

The study obtained provisional approval from the Biomedical Research Ethics Committee at the University of KwaZulu-Natal(#BREC/00004117/2022). Also is registered on the South African National clinical trial registry (#DOH-27-092022-5894) and approved by the KwaZulu-Natal department of health (#NHRD Ref: KZ_2002209_033). The results from this investigation will be actively disseminated through peer-reviewed journal publications, conference presentations and stakeholder engagement.

TRIAL REGISTRATION NUMBER

DOH-27-092022-5894.

The impact of employment programs on common mental disorders: A systematic review

BACKGROUND

While employment programs were not created with the intent to improve common mental disorders (CMDs), they may have a positive impact on the prevalence, incidence, and severity of CMD by reducing poverty and increasing access to economic mobility.

AIM

To examine and synthesize the available quantitative evidence of the impact of employment programs on outcomes of CMD.

METHODS

Embase, Econlit, Global Health, MEDLINE, APA PsychINFO, and Social Policy and Practice were searched for experimental and quasi-experimental studies which investigated the impact of employment programs on primary and secondary outcomes of a CMD. A narrative synthesis according to Popay was conducted. The methodological quality of studies was assessed with the Cochrane Risk of Bias tool and the Newcastle-Ottawa Assessment Scale.

RESULTS

Of the 1,327 studies retrieved, two randomized controlled trials, one retrospective cohort, one pilot study with a non-randomized experimental design, and one randomized field experiment were included in the final review. Employment programs generally included multiple components such as skills-based training, and hands-on placements. Depression and anxiety were the CMDs measured as primary or secondary outcomes within included studies. Findings regarding the impact of employment programs on CMD were mixed with two studies reporting significantly positive effects, two reporting no effects, and one reporting mixed effects. The quality among included studies was good overall with some concerns regarding internal validity.

CONCLUSION

Employment programs may support a decrease in the prevalence, incidence, and severity of CMDs. However, there is high heterogeneity among study effects, designs, and contexts. More research is needed to gain further insight into the nature of this association and the mechanisms of impact. This review highlights the potential for employment programs and other poverty-reduction interventions to be utilized and integrated into the wider care, prevention, and treatment of common-mental disorders.

Adverse childhood experiences and global mental health: avenues to reduce the burden of child and adolescent mental disorders

Mental disorders are one of the largest contributors to the burden of disease globally, this holds also for children and adolescents, especially in low- and middle-income countries. The prevalence and severity of these disorders are influenced by social determinants, including exposure to adversity. When occurring early in life, these latter events are referred to as adverse childhood experiences (ACEs).In this editorial, we provide an overview of the literature on the role of ACEs as social determinants of mental health through the lenses of global mental health. While the relation between ACEs and mental health has been extensively explored, most research was centred in higher income contexts. We argue that findings from the realm of global mental health should be integrated into that of ACEs, e.g. through preventative and responsive psychosocial interventions for children, adolescents and their caregivers. The field of global mental health should also undertake active efforts to better address ACEs in its initiatives, all with the goal of reducing the burden of mental disorders among children and adolescents globally.

The Impact of Monetary Poverty Alleviation Programs on Children's and Adolescents' Mental Health: A Systematic Review and Meta-Analysis Across Low-, Middle-, and High-Income Countries

Poverty alleviation programs, such as cash transfers and monetary grants, may not only lift people out of poverty but, some argue, may improve mental health as well. However, to date, the impact of such programs on children and adolescents' mental health is unclear. We carried out a systematic review and meta-analysis of poverty alleviation interventions providing monetary support and reporting mental health outcomes in 0-19 year olds in low-, middle-, and high-income countries. We searched 11 databases for research published between January 1, 1990 and June 1, 2020 and included interventions offering unconditional and/or conditional monetary support and reporting mental health outcomes. After screening 7,733 unique articles, we included 14 papers (16,750 children and adolescents at follow-up) in our narrative summary. We meta-analyzed data on internalizing symptoms from 8 papers (13,538 children and adolescents analyzed). This indicated a small but significant reduction in adolescents' internalizing problems postintervention compared to control (odds ratio 0.72, 95% confidence interval 0.59-0.88, p < .01; I² = 67%, τ² = 0.05, p < .01). Our narrative synthesis provides further support for the overall effectiveness of cash programs but also notes that monetary support alone may not be sufficient in extreme risk settings and that imposing conditions may be actively harmful for the mental health of adolescent girls. We provide causal evidence that monetary interventions reduce internalizing symptoms of adolescents experiencing poverty. We recommend that future programming thoughtfully considers whether to apply conditions as part of their interventions and highlight the importance of providing additional comprehensive support for children and adolescents living in extreme risk settings.

From surviving to thriving: integrating mental health care into HIV, community, and family services for adolescents living with HIV

Adolescents are a crucial generation, with the potential to bring future social and economic success for themselves and their countries. More than 90% of adolescents living with HIV reside in sub-Saharan Africa, where their mental health is set against a background of poverty, familial stress, service gaps, and an HIV epidemic that is now intertwined with the COVID-19 pandemic. In this Series paper, we review systematic reviews, randomised trials, and cohort studies of adolescents living with and affected by HIV. We provide a detailed overview of mental health provision and collate evidence for future approaches. We find that the mental health burden for adolescents living with HIV is high, contributing to low quality of life and challenges with adherence to antiretroviral therapy. Mental health provision is scarce, infrastructure and skilled providers are missing, and leadership is needed. Evidence of effective interventions is emerging, including specific provisions for mental health (eg, cognitive behavioural therapy, problem-solving, mindfulness, and parenting programmes) and broader provisions to prevent drivers of poor mental health (eg, social protection and violence prevention). We provide evidence of longitudinal associations between unconditional government grants and improved mental health. Combinations of economic and social interventions (known as cash plus care) could increase mental health benefits. Scalable delivery models include task sharing, primary care integration, strengthening families, and a pyramid of provision that differentiates between levels of need, from prevention to the care of severe disorders. A turning point has now been reached, from which complacency cannot persist. We conclude that there is substantial need, available frameworks, and a growing evidence base for action while infrastructure and skill acquisition is built.

Prevalence of stressful life events and associations with symptoms of depression, anxiety, and post-traumatic stress disorder among people entering care for HIV in Cameroon

BACKGROUND

Exposure to stressors increases the risk of mental health disorders. People living with HIV (PLWH) are particularly affected by poor mental health which can contribute to adverse HIV treatment outcomes.

METHODS

We estimated the prevalence of recent stressful life events (modified Life Events Survey) among a cohort of PLWH entering HIV care at three public health care facilities in Cameroon and quantified the association of seven types of stressful life events with symptoms of depression (Patient Health Questionnaire-9 scores>9), anxiety (General Anxiety Disorder-7 scores>9), and PTSD (PTSD Checklist for DSM-5 scores>30) using separate log-binomial regression models.

RESULTS

Of 426 PLWH enrolling in care, a majority were women (59%), in relationships (58%), and aged 21 to 39 years (58%). Recent death of a family member (39%) and severe illness of a family member (34%) were the most commonly reported stressful life events. In multivariable analyses, more stressful life event types, a negative relationship change, death or illness of a friend/family member, experience of violence, work-related difficulties, and feeling unsafe in one's neighborhood were independently associated with at least one of the mental health outcomes assessed. The greatest magnitude of association was observed between work-related difficulties and PTSD (adjusted prevalence ratio: 3.1; 95% confidence interval: 2.0-4.8).

LIMITATIONS

Given the design of our study, findings are subject to recall and social desirability bias.

CONCLUSIONS

Stressful life events were common among this population of PLWH entering care in Cameroon. Evidence-based interventions that improve coping, stress management, and mental health are needed.

Impact of Cash Transfers on the Use of Oral Health Services and Oral Health Outcomes: A Systematic Review

OBJECTIVE

The objective of the present study was to summarize the evidence available on the impact of cash transfers on the use of oral health services and oral health outcomes.

MATERIALS AND METHODS

9 databases were searched for studies on cash transfers and oral health: PubMed, Embase, The Cochrane Library, CINAHL, EconLit, Dentistry and Oral Sciences Source, Scopus, Web of Science, and LILACS. We conducted a systematic review of studies that evaluated the impact of cash transfers on the use of oral health services and other oral health outcomes.

RESULTS

Three studies with more than 13,000 participants conducted in Brazil and Argentina were included. One study from Brazil found that participants in the Bolsa Familia Program (BFP) were more likely not to use oral health services (aPR: 6.18; 95% CI: 3.07-12.45; P < 0.001) and had a higher probability of presenting dental caries (aPR: 2.00; 95% CI: 1.47-2.69) and severe caries (aRR: 1.53; 95% CI: 1.18-2.00). Another study conducted in Brazil found that the BFP was associated with fewer dental caries among those enrolled in the first 2 years of the BFP as well as after six years. On the other hand, the Argentina study found that the Universal Child Allowance program did not have a statistically significant average treatment effect (ATE = -0.05; P > 0.05) on the use of dental health services.

CONCLUSION

There is a lack of evidence about the impact of CT on the use of oral health services and oral health outcomes. The evidence suggests that cash transfers might not have a positive impact on the use of oral health services. The results regarding the impact of receiving cash transfers on dental caries are contradictory. However, more evidence is needed to draw stronger conclusions for policy taking.

REGISTRATION

The protocol was registered in PROSPERO (CRD42021268234).

Psychological patterns of poverty in Russia: Relationships among socioeconomic conditions, motivation, self-regulation and well-being

This article aims to extend our understanding of the link between socioeconomic conditions and psychological variables. It focuses on the effects of five distinct socioeconomic indicators on a range of psychological variables in samples of 162 individuals living below the poverty line and 188 of their more well-off counterparts in Russia. Participants completed a questionnaire containing measures of socioeconomic indicators (i.e., income, education, perceived deprivation, subjective socioeconomic status, and childhood socioeconomic status) and psychological variables representing self-regulation, motivation, and well-being. Our main findings include: (a) significant effects of socioeconomic status on all psychological variables, which are in line with other studies seeking to answer similar questions, (b) varying importance of different socioeconomic indicators for different psychological variables, and (c) centrality of all socioeconomic indicators except childhood socioeconomic status, and of values of openness to change and self-transcendence, satisfaction with life and self-esteem in the network of relationships between socioeconomic indicators and psychological variables.

Effects of Adolescent-Focused Integrated Social Protection on Depression: A Pragmatic Cluster-Randomized Controlled Trial of Tanzania's Cash Plus Intervention

We assessed the impacts of Tanzania's adolescent-focused Cash Plus intervention on depression. In this pragmatic cluster-randomized controlled trial, 130 villages were randomly allocated to an intervention or control arm (1:1). Youth aged 14-19 years living in households receiving governmental cash transfers were invited to participate. The intervention included an intensive period (a 12-session course) and an aftercare period (9 months of mentoring, productive grants, and strengthened health services). We examined intervention impacts on a depressive symptoms scale (10-item Center for Epidemiologic Studies Depression Scale score (range, 0-30)) and rates of depressive symptomatology (score ≥10 points on the scale), recorded at study baseline (April-June 2017), midline (May-July 2018), and endline (June-August 2019). Using intention-to-treat methodology, we employed logistic and generalized linear models to estimate effects for binary and continuous outcomes, respectively. Quantile regression was used to estimate effects across the scale. From 2,458 baseline participants, 941 intervention and 992 control adolescents were reinterviewed at both follow-ups. At endline, the intervention reduced the odds of depressive symptomatology (adjusted odds ratio = 0.67, 95% confidence interval: 0.52, 0.86), with an undetectable mean scale difference (risk difference = -0.36, 95% confidence interval: -0.84, 0.11). Quantile regression results demonstrated an intervention effect along the upper distribution of the scale. Integration of multisectoral initiatives within existing social protection systems shows potential to improve mental health among youth in low-resource settings.

The impact of unconditional cash transfers on morbidity and health-seeking behaviour in Africa: evidence from Ghana, Malawi, Zambia and Zimbabwe

Unconditional cash transfers have demonstrated widespread, positive impacts on consumption, food security, productive activities and schooling. However, the evidence to date on cash transfers and health-seeking behaviours and morbidity is not only mixed, but the evidence base is biased towards conditional programmes from Latin America and is more limited in the context of Africa. Given contextual and programmatic design differences between the regions, more evidence from Africa is warranted. We investigate the impact of unconditional cash transfers on morbidity and health-seeking behaviour using data from experimental and quasi-experimental study designs of five government cash transfer programs in Ghana, Malawi, Zambia and Zimbabwe. Programme impacts were estimated using difference-in-differences models with longitudinal data. The results indicate positive programme impacts on health seeking when ill and on health expenditures. Our findings suggest that while unconditional cash transfers can improve health seeking when ill, morbidity impacts were mixed. More research is needed on longer-term impacts, mechanisms of impact and moderating factors. Additionally, taken together with existing evidence, our findings suggest that when summarizing the impacts of cash transfers on health, findings from conditional and unconditional programmes should be disaggregated.

Access to primary and secondary health care services for people living with diabetes and lower-limb amputation during the COVID-19 pandemic in Lebanon: a qualitative study

Background

People living with chronic conditions and physical disabilities face many challenges accessing healthcare services. In Lebanon, in 2020, the COVID-19 pandemic and concomitant economic crisis further exacerbated the living conditions of this segment of the population. This study explored the barriers to accessing healthcare services among people living with diabetes and lower-limb amputation during the pandemic.

Methods

We conducted semi-structured, in-depth phone interviews with users of the Physical Rehabilitation Program, offered by the International Committee of the Red Cross. We used a purposive sampling technique to achieve maximum variation. Interviews were audio-recorded, transcribed, translated, and analyzed using thematic analysis following the “codebook” approach. Transcripts were coded and grouped in a matrix that allowed the development of themes and sub-themes inductively and deductively generated.

Results

Eight participants (7 males, 1 female) agreed to be interviewed and participated in the study between March and April, 2021. Barriers to healthcare services access were grouped according to five emerging themes: (1) economic barriers, included increasing costs of food, health services and medications, transportation, shortage of medications, and limited income; (2) structural barriers: availability of transportation, physical environment, and service quality and availability; (3) cultural barriers: marginalization due to their physical disabilities; favoritism in service provision; (4) personal barriers: lack of psychosocial support and limited knowledge about services; (5) COVID-19 barriers: fear of getting sick when visiting healthcare facilities, and heightened social isolation due to lockdowns and physical distancing.

Conclusion

The underlying economic crisis has worsened the conditions of people living with diabetes and lower-limb amputation. The pandemic has made these individuals more vulnerable to external and contextual factors that cannot be addressed only at an individual level. In the absence of a protective legal framework to mitigate inequalities, we provide recommendations for governments and nongovernmental institutions to develop solutions for more equitable access to healthcare for this segment of the population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07921-7.

Cash, COVID-19 and aid cuts: a mixed-method impact evaluation among South Sudanese refugees registered in Kiryandongo settlement, Uganda

OBJECTIVES

In this paper, we estimate the impact after 4-8 months of a large one-off unconditional cash transfer delivered to refugees during a time of dual shocks: the COVID-19 pandemic and cuts to monthly aid. We focus on four key outcomes: (1) health-seeking behaviour; (2) COVID-19 specific preventive health practices; (3) food security and (4) psychological well-being.

METHODS

We use both quantitative and qualitative data to understand the impact of a cash transfer in this context. Quantitatively, we use a baseline survey of 1200 households (Q4 2019) and follow-up with three rounds of phone surveys in Q2 and Q3 2021, capturing at least half the sample in each round. We exploit an experimental variation in the timing of the cash transfer to assess the effect of the cash transfer through ordinary least squares regressions of intention to treat. Controlling for key baseline characteristics, we analyse the effect of the cash transfer on health access, COVID-19 health practices, food security and psychological well-being. Qualitatively, we make use of a longitudinal, small-n sample of refugee respondents, each of whom we interviewed up to 15 times between February and September 2020 to understand change over time and to go deeper into key topics.

RESULTS

We do not find a statistically significant effect (6.2%, p=0.188) of receiving the cash transfer on preventative measures against COVID-19. However, households receiving the cash transfer were more food secure, with a 14.4% (p=0.011) improvement on the food security index, have better psychological well-being (24.5%, p=0.003) and are more likely to seek healthcare in the private health facilities (10.4%, p=0.057) as compared with control households. We do not find significant results on the value of food consumption. Overall, we find stronger treatment effects for households that were the first to receive the cash transfers.

CONCLUSION

Taken together, we find significant support for the importance of cash transfers to refugee households mitigating against declines in food security and mental well-being in the face of shocks.

Material resources and well-being - Evidence from an Ethiopian housing lottery

Do better material conditions improve well-being and mental health? Or does any positive relationship merely reflect that well-being promotes economic success? We compare winners and losers from a large Ethiopian housing lottery in a preregistered analysis. Winners gain access to better housing, experience a substantial increase in wealth, and report higher levels of overall life satisfaction and lower levels of financial distress. However, we find no average effects of winning on psychological distress. Our results suggest that not all aspects of well-being and mental health are equally sensitive to economic conditions.

Unconditional cash transfers for reducing poverty and vulnerabilities: effect on use of health services and health outcomes in low- and middle-income countries

BACKGROUND

Unconditional cash transfers (UCTs; provided without obligation) for reducing poverty and vulnerabilities (e.g. orphanhood, old age, or HIV infection) are a social protection intervention addressing a key social determinant of health (income) in low- and middle-income countries (LMICs). The relative effectiveness of UCTs compared with conditional cash transfers (CCTs; provided only if recipients follow prescribed behaviours, e.g. use a health service or attend school) is unknown.

OBJECTIVES

To assess the effects of UCTs on health services use and health outcomes in children and adults in LMICs. Secondary objectives are to assess the effects of UCTs on social determinants of health and healthcare expenditure, and to compare the effects of UCTs versus CCTs.

SEARCH METHODS

For this update, we searched 15 electronic academic databases, including CENTRAL, MEDLINE and EconLit, in September 2021. We also searched four electronic grey literature databases, websites of key organisations and reference lists of previous systematic reviews, key journals and included study records.

SELECTION CRITERIA

We included both parallel-group and cluster-randomised controlled trials (C-RCTs), quasi-RCTs, cohort studies, controlled before-and-after studies (CBAs), and interrupted time series studies of UCT interventions in children (0 to 17 years) and adults (≥ 18 years) in LMICs. Comparison groups received either no UCT, a smaller UCT or a CCT. Our primary outcomes were any health services use or health outcome.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened potentially relevant records for inclusion, extracted data and assessed the risk of bias. We obtained missing data from study authors if feasible. For C-RCTs, we generally calculated risk ratios for dichotomous outcomes from crude frequency measures in approximately correct analyses. Meta-analyses applied the inverse variance or Mantel-Haenszel method using a random-effects model. Where meta-analysis was impossible, we synthesised results using vote counting based on effect direction. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included 34 studies (25 studies of 20 C-RCTs, six CBAs, and three cohort studies) involving 1,140,385 participants (45,538 children, 1,094,847 adults) and 50,095 households in Africa, the Americas and South-East Asia in our meta-analyses and narrative syntheses. These analysed 29 independent data sets. The 24 UCTs identified, including one basic universal income intervention, were pilot or established government programmes or research experiments. The cash value was equivalent to 1.3% to 81.9% of the annualised gross domestic product per capita. All studies compared a UCT with no UCT; three studies also compared a UCT with a CCT. Most studies carried an overall high risk of bias (i.e. often selection or performance bias, or both). Most studies were funded by national governments or international organisations, or both. Throughout the review, we use the words 'probably' to indicate moderate-certainty evidence, 'may/maybe' for low-certainty evidence, and 'uncertain' for very low-certainty evidence. Health services use We assumed greater use of any health services to be beneficial. UCTs may not have impacted the likelihood of having used any health service in the previous 1 to 12 months, when participants were followed up between 12 and 24 months into the intervention (risk ratio (RR) 1.04, 95% confidence interval (CI) 1.00 to 1.09; I² = 2%; 5 C-RCTs, 4972 participants; low-certainty evidence). Health outcomes At one to two years, UCTs probably led to a clinically meaningful, very large reduction in the likelihood of having had any illness in the previous two weeks to three months (RR 0.79, 95% CI 0.67 to 0.92; I² = 53%; 6 C-RCTs, 9367 participants; moderate-certainty evidence). UCTs may have increased the likelihood of having been food secure over the previous month, at 13 to 36 months into the intervention (RR 1.25, 95% CI 1.09 to 1.45; I² = 85%; 5 C-RCTs, 2687 participants; low-certainty evidence). UCTs may have increased participants' level of dietary diversity over the previous week, when assessed with the Household Dietary Diversity Score and followed up 24 months into the intervention (mean difference (MD) 0.59 food categories, 95% CI 0.18 to 1.01; I² = 79%; 4 C-RCTs, 9347 participants; low-certainty evidence). Despite several studies providing relevant evidence, the effects of UCTs on the likelihood of being moderately stunted and on the level of depression remain uncertain. We found no study on the effect of UCTs on mortality risk. Social determinants of health UCTs probably led to a clinically meaningful, moderate increase in the likelihood of currently attending school, when assessed at 12 to 24 months into the intervention (RR 1.06, 95% CI 1.04 to 1.09; I² = 0%; 8 C-RCTs, 7136 participants; moderate-certainty evidence). UCTs may have reduced the likelihood of households being extremely poor, at 12 to 36 months into the intervention (RR 0.92, 95% CI 0.87 to 0.97; I² = 63%; 6 C-RCTs, 3805 participants; low-certainty evidence). The evidence was uncertain for whether UCTs impacted livestock ownership, participation in labour, and parenting quality. Healthcare expenditure Evidence from eight cluster-RCTs on healthcare expenditure was too inconsistent to be combined in a meta-analysis, but it suggested that UCTs may have increased the amount of money spent on health care at 7 to 36 months into the intervention (low-certainty evidence). Equity, harms and comparison with CCTs The effects of UCTs on health equity (or unfair and remedial health inequalities) were very uncertain. We did not identify any harms from UCTs. Three cluster-RCTs compared UCTs versus CCTs with regard to the likelihood of having used any health services or had any illness, or the level of dietary diversity, but evidence was limited to one study per outcome and was very uncertain for all three.

AUTHORS' CONCLUSIONS

This body of evidence suggests that unconditional cash transfers (UCTs) may not impact a summary measure of health service use in children and adults in LMICs. However, UCTs probably or may improve some health outcomes (i.e. the likelihood of having had any illness, the likelihood of having been food secure, and the level of dietary diversity), two social determinants of health (i.e. the likelihoods of attending school and being extremely poor), and healthcare expenditure. The evidence on the relative effectiveness of UCTs and CCTs remains very uncertain.

Public mental health: required actions to address implementation failure in the context of COVID-19

Mental disorders account for at least 18% of global disease burden, and the associated annual global costs are projected to be US$6 trillion by 2030. Evidence-based, cost-effective public mental health (PMH) interventions exist to prevent mental disorders from arising, prevent associated impacts of mental disorders (including through treatment), and promote mental wellbeing and resilience. However, only a small proportion of people with mental disorders receive minimally adequate treatment. Compared with treatment, there is even less coverage of interventions to prevent the associated impacts of mental disorders, prevent mental disorders from arising, or promote mental wellbeing and resilience. This implementation failure breaches the right to health, has increased during the COVID-19 pandemic, and results in preventable suffering, broad impacts, and associated economic costs. In this Health Policy paper, we outline specific actions to improve the coverage of PMH interventions, including PMH needs assessments, collaborative advocacy and leadership, PMH practice to inform policy and implementation, training and improvement of population literacy, settings-based and integrated approaches, use of digital technology, maximising existing resources, focus on high-return interventions, human rights approaches, legislation, and implementation research. Increased interest in PMH in populations and governments since the onset of the COVID-19 pandemic supports these actions. Improved implementation of PMH interventions can result in broad health, social, and economic impacts, even in the short-term, which support the achievement of a range of policy objectives, sustainable economic development, and recovery.

The relationship between multidimensional poverty, income poverty and youth depressive symptoms: cross-sectional evidence from Mexico, South Africa and Colombia

Whereas monetary poverty is associated with increased risk of depressive symptoms in young people, poverty is increasingly understood as a multidimensional problem. However, it is yet to be understood how the associations between different dimensions of poverty and youth mental health differ across countries. We examine the relationship between multidimensional, as well as income poverty, and depressive symptoms in young people (age 11-25 years) across three middle-income countries. Based on harmonised data from surveys in Colombia, Mexico and South Africa (N=16 173) we constructed a multidimensional poverty index that comprised five deprivations We used Poisson regression to examine relationships between different forms of poverty with depressive symptoms across the countries. Multidimensional poverty was associated with higher rates of depressive symptoms in the harmonised dataset (IRR (incidence rate ratio)=1.25, 95% CI 1.10 to 1.42), in Mexico (IRR=1.34, 95% CI 1.11 to 1.64) and Colombia (IRR=2.01, 95% CI 1.30 to 3.10) but not in South Africa, a finding driven by a lack of associations between child labour and health insurance coverage with depressive symptoms. There was only an association with income poverty and depressive symptoms in South Africa, not in Colombia or Mexico. Depressive symptoms were associated with individual deprivations such as school lag, child labour and lack of access to health services in the harmonised dataset, but not with household deprivations, such as parental unemployment and housing conditions, though the opposite pattern was observed in South Africa. Our findings suggest that the importance of specific dimensions of poverty for mental health varies across countries, and a multidimensional approach is needed to gain insights into the relationship between youth depression and poverty.

Cash transfers and the mental health of young people: Evidence from South Africa's child support grant

This study examines the longitudinal impact of the South African Child Support Grant (CSG) on risk for depression and life satisfaction among young people (15-19 years). We analysed data from the last three waves of the National Income Dynamics Study (NIDS), a nationally representative panel survey that took place every two years from 2008 to 2017. We used an instrumental variable (IV) approach that exploits multiple changes in age eligibility from 1998 to 2012. Depressive symptoms were assessed using an 8-item version of the Centre for Epidemiological Studies Depression Scale; participants who scored above 8 were considered at risk for depression. Life satisfaction was rated on a scale of 1 ('very dissatisfied') to 10 ('very satisfied'); participants who scored 8 or above were classified as satisfied. We also examined impacts on educational deficit (≥2 years behind) and not being in education, employment or training (NEET) as secondary outcomes, as these are also important for mental health. Age eligibility strongly predicted CSG receipt at Wave 3. In instrumental variable models, CSG receipt did not influence the risk for depression (β = 0.10, SE = 0.10, p = 0.316), nor life satisfaction (β = -0.07, SE = 0.09, p = 0.420) at Wave 3, nor at Waves 4 or 5. Some improvements in educational deficit were observed at Wave 3 among CSG beneficiaries compared to non-beneficiaries. These results were robust to multiple specifications. CSG receipt did not improve the psychological wellbeing of adolescents and young adults, nor did it improve their education or employment outcomes. Our findings highlight the need to identify alternative social policies that address the root causes of youth social disadvantage, in conjunction with targeted approaches to improve the mental health of young South Africans living in poverty.

Conditional cash transfers and adolescent mental health in Brazil: Evidence from the 2004 Pelotas Birth Cohort

BACKGROUND

Young people living in poverty are at higher risk of mental disorders, but whether interventions aimed to reduce poverty have lasting effects on mental health has not been well established. We examined whether exposure to Brazil's conditional cash transfers programme (CCT), Bolsa Família (BFP), during childhood reduces the risk of mental health problems in early adolescence.

METHODS

We used data from 2063 participants in the 2004 Pelotas Birth Cohort study. Propensity score matching (PSM) estimated the association between BFP participation at age 6 and externalising problems (Strengths and Difficulties Questionnaire - SDQ and violent behaviour) and socio-emotional competencies (Development and Well-Being Assessment questionnaire, and the Nowick-Strickland Internal-External Scale) at age 11.

RESULTS

PSM results suggest that programme participation at age of six was not significantly associated with externalising problems (P = 0.433), prosocial behaviour (P = 0.654), violent behaviour (P = 0.342), social aptitudes (P = 0.281), positive attributes (P = 0.439), or locus of control (P = 0.148) at the age of 11 years.

CONCLUSIONS

Participation in BFP during childhood was not associated with improved or worsened mental health in early adolescence. While we cannot fully discard that findings may be due to adverse selection, results suggest that CCTs alone may not be sufficient to improve mental health outcomes and would be prudent to assess whether mental health interventions as an addition to CCTs may be helpful.

Cash Transfer Programmes in Pakistan through a Child Well-Being Lens

This paper analyses data from a qualitative study undertaken with children and their families in two cash transfer programmes (CTPs) in Pakistan. Using a three-dimensional child well-being model that distinguishes material, relational and subjective dimensions, it argues that CTPs have helped extremely poor families sustain their basic dietary needs and marginally increase their health spending. Additional conditional payments have led to increased primary school enrolments, but CTPs have failed to address the distinctive vulnerabilities of children, including their nutritional needs, relational well-being and social status. A more holistic and child-sensitive approach to social protection would be the way forward to improve child well-being in line with the United Nations Charter on Rights of Children (UNCRC) to which Pakistan is a signatory.

Application of an antiracism lens in the field of implementation science (IS): Recommendations for reframing implementation research with a focus on justice and racial equity

Background

Despite the promise of implementation science (IS) to reduce health inequities, critical gaps and opportunities remain in the field to promote health equity. Prioritizing racial equity and antiracism approaches is critical in these efforts, so that IS does not inadvertently exacerbate disparities based on the selection of frameworks, methods, interventions, and strategies that do not reflect consideration of structural racism and its impacts.

Methods

Grounded in extant research on structural racism and antiracism, we discuss the importance of advancing understanding of how structural racism as a system shapes racial health inequities and inequitable implementation of evidence-based interventions among racially and ethnically diverse communities. We outline recommendations for explicitly applying an antiracism lens to address structural racism and its manifests through IS. An anti-racism lens provides a framework to guide efforts to confront, address, and eradicate racism and racial privilege by helping people identify racism as a root cause of health inequities and critically examine how it is embedded in policies, structures, and systems that differentially affect racially and ethnically diverse populations.

Results

We provide guidance for the application of an antiracism lens in the field of IS, focusing on select core elements in implementation research, including: (1) stakeholder engagement; (2) conceptual frameworks and models; (3) development, selection, adaptation of EBIs; (4) evaluation approaches; and (5) implementation strategies. We highlight the need for foundational grounding in antiracism frameworks among implementation scientists to facilitate ongoing self-reflection, accountability, and attention to racial equity, and provide questions to guide such reflection and consideration.

Conclusion

We conclude with a reflection on how this is a critical time for IS to prioritize focus on justice, racial equity, and real-world equitable impact. Moving IS towards making consideration of health equity and an antiracism lens foundational is central to strengthening the field and enhancing its impact.

Plain language abstract

There are important gaps and opportunities that exist in promoting health equity through implementation science. Historically, the commonly used frameworks, measures, interventions, strategies, and approaches in the field have not been explicitly focused on equity, nor do they consider the role of structural racism in shaping health and inequitable delivery of evidence-based practices/programs. This work seeks to build off of the long history of research on structural racism and health, and seeks to provide guidance on how to apply an antiracism lens to select core elements of implementation research. We highlight important opportunities for the field to reflect and consider applying an antiracism approach in: 1) stakeholder/community engagement; 2) use of conceptual frameworks; 3) development, selection and adaptation of evidence-based interventions; 4) evaluation approaches; 5) implementation strategies (e.g., how to deliver evidence-based practices, programs, policies); and 6) how researchers conduct their research, with a focus on racial equity. This is an important time for the field of implementation science to prioritize a foundational focus on justice, equity, and real-world impact through the application of an anti-racism lens in their work.