An emergency cash transfer program promotes weight gain and reduces acute malnutrition risk among children 6-24 months old during a food crisis in Niger

Cash transfers and nutrition education to improve dietary diversity among children aged 6-23 months in Grand Gedeh County, Liberia: a cluster-randomized trial

OBJECTIVES

To evaluate the efficacy of a cash transfer and nutrition education program on dietary diversity among children in Liberia. We hypothesized that a multi-pronged intervention would result in improved dietary diversity among children.

METHODS

We conducted a three-armed, cluster-randomized study in 42 communities (12 children per community) in Grand Gedeh County, Liberia, over a 12-month period. We randomly assigned communities to control (n = 14 communities), those that received both bimonthly cash transfers and a structured nutrition education program (n = 14 communities) and those that received bimonthly cash transfers alone (n = 14 communities). Community health assistants conducted bimonthly assessments in participants' homes. The primary outcome was the proportion of children aged 6-23 months who met minimum dietary diversity score (i.e., ≥4 food groups consumed per day). Secondary outcomes included meal frequency and healthcare utilization for illnesses (NCT04101487).

RESULTS

There were 599 children enrolled; 533 (88.9%) were retained through the trial period. The proportion of children who consumed ≥4 food groups per day did not differ among the three arms. However, children randomized to receive cash transfers had higher dietary diversity scores than the control group. Children in communities that received cash transfers alone and with nutrition education consumed significantly more meals per day and were less likely to have visits to clinics or hospitals for illnesses than children in control communities.

CONCLUSION

Bimonthly, unconditional cash transfers and nutrition education were associated with higher dietary diversity scores, greater meal frequency, and fewer healthcare visits for illnesses among children aged 6-23 months.

Behaviour change communication for child feeding in social assistance: A scoping review and expert consultation

To increase the effectiveness of social assistance on child nutrition, programmes are increasingly combined with behaviour change communication for improved infant and young child feeding (BCC for IYCF). Unfortunately, there is limited knowledge about which BCC strategies are most effective when combined with social assistance. A systematic scoping review and an expert consultation was conducted to (1) describe the landscape of BCC for IYCF strategies used in social assistance within low‐ and middle‐income countries and (2) to examine the effects of these BCC strategies on IYCF practices and child nutrition. Ten quantitative, three qualitative and four mixed methods studies were reviewed and complemented by 12 expert consultations carried out between August and October 2020. In most of the studies attendance in BCC for IYCF was conditional for receiving social assistance, although experts agreed that this conditionality may be counterproductive. A variety of BCC strategies were used with two being most common—group sessions with pre‐determined topics and individual counselling. Context‐specific adaptation, interactive delivery and building on existing IYCF knowledge emerged as crucial but was perceived as economically infeasible in social assistance programmes. Given the variety of BCC strategies and inconsistency in outcomes, it is impossible to draw conclusions regarding effectiveness. Nevertheless, tentative evidence suggests that the promotion of existing nutrition services, educational group sessions and individual counselling may be effective in improving IYCF. BCC for IYCF can make social assistance more beneficial, but may increase costs, demands on beneficiaries, and deviate from the original focus of the programmes.

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Findings suggest that integrating BCC for IYCF in social assistance programmes can be beneficial for young children, however, it may increase the costs of the programme, create additional demands on beneficiaries and may deviate the original focus of the programme.

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Most BCC for IYCF in social assistance programmes used two different behaviour change strategies (with group session with pre‐determined topics and individual nutrition counselling being most common). However, there is limited evidence on what BCC strategies (as part of social assistance) change behaviours most effectively.

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Formative research is important for the design and implementation of context‐specific BCC that builds on existing IYCF knowledge but can be time‐and resource‐consuming to develop and may thus be economically infeasible within social assistance programmes.

Effectiveness of an Integrated Nutrition Rehabilitation on Growth and Development of Children under Five Post 2018 Earthquake in East Lombok, Indonesia

Background: In August 2018 Lombok Island in Indonesia was hit by a 7 Richter scale earthquake. This study aimed to assess the effectiveness of comprehensive nutrition disaster rehabilitation, based on the holistic integrated early child development concept, on the growth and development of children under five. Methods: A community-based intervention was performed in the East Lombok district; four villages in two sub-districts were randomly allocated into intervention or control groups. Mothers of 6–49-month-old children in the intervention group (n = 240) attended parenting classes (twice weekly) and received shredded fish/liver/anchovy and optimized complementary feeding/food-based recommendations, developed using linear programming. Health staff from the public health center and teachers from early childhood education (ECE) centers delivered parenting sessions on health–nutrition and care–education. The control group (n = 240) received existing health services. Indicators measured at baseline and the end line point were weight, length/height, hemoglobin, feeding practices, psychosocial care (HOME) and maternal stress (SRQ). At the end line point, child development was assessed using BSID-III. Results: At the end line point, maternal stress and child morbidity (cough) were lower and dietary diversity (+1) in 6–23-month-old children, and weight-for-age Z-score (+0.26) and social emotional score (+10 points) in ≥24-month-old children were higher in the intervention group. Conclusions: The nutrition rehabilitation intervention delivered through ECE centers has a positive effect on the growth and development of children under five in post-disaster conditions.

Impact of conditional and unconditional cash transfers on health outcomes and use of health services in humanitarian settings: a mixed-methods systematic review

BACKGROUND

Cash transfers, payments provided by formal or informal institutions to recipients, are increasingly used in emergencies. While increasing autonomy and being supportive of local economies, cash transfers are a cost-effective method in some settings to cover basic needs and extend benefits of limited humanitarian aid budgets. Yet, the extent to which cash transfers impact health in humanitarian settings remains largely unexplored. This systematic review evaluates the evidence on the effect of cash transfers on health outcomes and health service utilisation in humanitarian contexts.

METHODS

Studies eligible for inclusion were peer reviewed (quantitative,qualitative and mixed-methods). Nine databases (PubMed, EMBAS, Medline, CINAHL, Global Health, Scopus, Web of Science Core Collection, SciELO and LiLACS) were searched without language and without a lower bound time restriction through 24 February 2021. The search was updated to include articles published through 8 December 2021. Data were extracted using a piloted extraction tool and quality was assessed using The Joanna Briggs Critical Appraisal Tool. Due to heterogeneity in study designs and outcomes, results were synthesised narratively and no meta-analysis was performed.

RESULTS

30 673 records were identified. After removing duplicates, 17 715 were double screened by abstract and title, and 201 in full text. Twenty-three articles from 16 countries were included reporting on nutrition outcomes, psychosocial and mental health, general/subjective health and well-being, acute illness (eg, diarrhoea, respiratory infection), diabetes control (eg, blood glucose self-monitoring, haemoglobin A1C levels) and gender-based violence. Nineteen studies reported some positive impacts on various health outcomes and use of health services, 11 reported no statistically significant impact on outcomes assessed and 4 reported potential negative impacts on health outcomes.

DISCUSSION

Although there is evidence to suggest a positive relationship between cash transfers and health outcomes in humanitarian settings, high-quality empirical evidence, that is methodologically robust, investigates a range of humanitarian settings and is conducted over longer time periods is needed. This should consider factors influencing programme implementation and the differential impact of cash transfers designed to improve health versus multipurpose cash transfers.

PROSPERO REGISTRATION NUMBER

CRD42021237275.

Patterns of wasting among pregnant and lactating women in Uganda, 2015-2018: analysis of Nutrition surveillance data

BACKGROUND

Maternal nutrition is closely linked to the survival and development of children during the first 1000 days of life. Maternal wasting, a measure of malnutrition, is measured using the mid-upper arm circumference. However, in 2019, the rate and distribution of wasting among pregnant and lactating women was not known. We described annual trends and distribution of wasting among pregnant and lactating women (PLW), Uganda, 2015-2018, to inform programming on targeted nutritional interventions.

METHODS

We analyzed nutrition surveillance data from the District Health Information System for all PLW from 2015 to 2018. We used the World Health Organization standard thresholds to determine wasting among PLW by year and region, drawing choropleth maps to demonstrate the geographic distribution of wasting among PLW. We used logistic regression to assess wasting trends.

RESULTS

During 2015-2018, 268,636 PLW were wasted (prevalence = 5.5%). Of the 15 regions of Uganda, Karamoja (prevalence = 21%) and Lango (prevalence = 17%) registered the highest prevalence while Toro (prevalence = 2.7%) and Kigezi (prevalence = 2.0%) registered the lowest prevalence. The national annual prevalence of wasting among PLW declined by 31% from 2015 to 2018 (OR = 0.69, p < 0.001). Regions in the north had increasing trends of wasting over the period [Lango (OR = 1.6, p < 0.001) and Acholi (OR = 1.2, p < 0.001)], as did regions in the east [(Bugisu (OR = 3.4, p < 0.001), Bukedi (OR = 1.4, p < 0.001), and Busoga (OR = 1.3, p < 0.001)]. The other 11 regions showed declines.

CONCLUSION

The trend of wasting among PLW nationally declined during the study period. Lango and Acholi regions, both of which were experiencing a nutrition state of emergency during this period, had both high and rising rates of wasting, as did the Karamoja region, which experienced the highest wasting rates. We recommended that the Ministry of Health increases its focus on nutrition monitoring for PLW and conduct an analysis to clearly identify the factors underlying malnutrition specific for PLW in these regions.

Systematic Review on the Impact of Conditional Cash Transfers on Child Health Service Utilisation and Child Health in Sub-Saharan Africa

Background: Conditional cash transfers (CCTs) are interventions which provide assistance in the form of cash to specific vulnerable groups on the condition that they meet pre-defined requirements. The impact of conditional cash transfers on children's access to health services and on their overall health has not been established in sub-Saharan Africa.

Method: We conducted a systematic review aimed at summarising the available information on the impact of conditional cash transfers on health service utilisation and child health in sub-Saharan Africa. We searched databases for peer-reviewed articles, websites of organisations involved in implementing conditional cash transfer programmes, and Google scholar to identify grey literature. Records were selected based on predefined eligibility criteria which were drawn from a programme impact framework. Records were eligible if one of the following outcomes was evaluated: health services utilisation, immunisation coverage, growth monitoring, anthropometry, illness reported, and mortality. Other records which reported on important intermediate outcomes or described mechanisms significantly contributing to impact were also included in the review. Data items were extracted from eligible records into an extraction form based on predefined data items. Study quality indicators were also extracted into a quality assessment form.

Results: Thematic narrative synthesis was conducted using data from nine included records. The review included five cluster randomised evaluations, one quasi-experimental clustered study, one randomised trial at the individual level, one mixed-method study and one purely qualitative study. There was insufficient evidence of an impact of conditional cash transfers on health service utilisation. There was also not enough evidence of an impact on nutritional status. No impact was observed on health status based on illness reports, nor on immunisation rates. None of the included records evaluated the impact on childhood mortality.

Conclusions: The findings of this review suggest that a positive impact may be observed in health service utilisation and nutrition, however, this may not translate into improved child health. Further research is needed to understand the mechanisms and pathways by which these interventions work, explore the effect of contextual factors on their impact, and assess their cost implication especially within resource-constrained settings.

The food of life: an evaluation of the impact of cash grant receipt and good parenting on child nutrition outcomes in South Africa and Malawi

Social protection interventions (inclusive of cash grant receipt and care provision) have been found to be effective in response to some of the negative implications of the HIV epidemic on children and families. This study explores the impact of cash grant receipt and care provision (operationalised as good parenting) on child nutritional outcomes. In this cross-sectional study, 854 children and younger adolescents (5–15 years) and caregivers affected by HIV, attending community-based organisations in South Africa and Malawi, were interviewed. Interviews comprised inventories on socio-demographic information, family data, cash grant receipt and child nutrition. Parenting was measured using a composite scale. Logistic regression and marginal effects analyses were used to explore the associations between differing levels of social protection (none; either cash or good parenting; cash and good parenting) and child nutritional outcomes. One hundred and sixty children (20.3%) received neither cash nor good parenting; 501 (63.5%) received either cash or good parenting and 128 (16.2%) received both cash and good parenting. In comparison to no intervention, receipt of either cash or good parenting was significantly associated with child non-stunting, the child having sufficient food, and the child not looking thin. Three (3/7) nutritional outcomes showed increased improvement amongst children receiving both cash and good parenting care including child-reported non-hunger, child non-stunting and parental report of sufficient food. Marginal effects analyses further identified an additive effect of cash and good parenting on child nutritional outcomes. This study indicates that receipt of combined cash and good parenting, when compared to cash grant receipt alone, has positive effects on nutrition-related child outcomes.

Reorienting Nurturing Care for Early Childhood Development during the COVID-19 Pandemic in Kenya: A Review

In Kenya, millions of children have limited access to nurturing care. With the Coronavirus disease 2019 (COVID-19) pandemic, it is anticipated that vulnerable children will bear the biggest brunt of the direct and indirect impacts of the pandemic. This review aimed to deepen understanding of the effects of COVID-19 on nurturing care from conception to four years of age, a period where the care of children is often delivered through caregivers or other informal platforms. The review has drawn upon the empirical evidence from previous pandemics and epidemics, and anecdotal and emerging evidence from the ongoing COVID-19 crisis. Multifactorial impacts fall into five key domains: direct health; health and nutrition systems; economic protection; social and child protection; and child development and early learning. The review proposes program and policy strategies to guide the reorientation of nurturing care, prevent the detrimental effects associated with deteriorating nurturing care environments, and support the optimal development of the youngest and most vulnerable children. These include the provision of cash transfers and essential supplies for vulnerable households and strengthening of community-based platforms for nurturing care. Further research on COVID-19 and the ability of children's ecology to provide nurturing care is needed, as is further testing of new ideas.

Food transfers, electronic food vouchers and child nutritional status among Rohingya children living in Bangladesh

Objective

To examine associations between receipt of an electronic food voucher (e-voucher) compared to food rations on the nutritional status of Rohingya children living in refugee camps in Bangladesh.

Methods

This is an associational study using cross-sectional data. We measured heights and weights of 523 children aged between 6 and 23 months in households receiving either a food ration consisting of rice, pulses, vegetable oil (362 children) or an e-voucher (161 children) that could be used to purchase 19 different foods. Data were also collected on the characteristics of their mothers and the households in which they lived, including household demographics, consumption and expenditure, coping strategies, livelihoods and income profiles, and access to assistance. Associations between measures of anthropometric status (height-for-age z scores, stunting, weight-for-height z scores, wasting, weight-for-age z scores and mid-upper arm circumference) and household receipt of the e-voucher were estimated using ordinary least squares regressions. Control variables included child, maternal, household and locality characteristics. The study received ethical approval from the Institutional Review Board of the International Food Policy Research Institute, Washington DC.

Results

Household receipt of an e-voucher was associated with improved linear growth in children. This association is robust to the inclusion of maternal, household and location characteristics. The magnitude of the association is 0.38 SD (CI: 0.01, 0.74), and statistically significant at the five percent level. We cannot reject the null hypothesis that these associations differ by child sex. Receipt of an e-voucher is not associated with stunting when a full set of control variables are included. There is no association between receipt of e-vouchers and weight-for-length, weight-for-age or mid-upper arm circumference. We cannot reject the null hypothesis that these associations differ by child sex.

Conclusions

In a humanitarian assistance setting, Rohingya refugee camps in Bangladesh, household receipt of an electronic food voucher instead of a food ration is associated with improvements in the linear growth of children between 6 and 23 months but not in measures of acute undernutrition or other anthropometric outcomes. Our associational evidence indicates that transitioning from food rations to electronic food vouchers does not adversely affect child nutritional status.

Cash transfer programs have differential effects on health: A review of the literature from low and middle-income countries

BACKGROUND

Cash transfer programs have grown increasingly popular and are now used as interventions to target a wide array of health outcomes across many diverse settings. However, cash transfer experiments have yielded mixed results, highlighting gaps in our understanding of how these programs work. In particular, we do not yet know whether cash transfers are more effective for certain health outcomes compared to others, or are more effective for some population subgroups compared to others. Here, we ask whether the effects of cash transfers on health outcomes differ across study subgroups.

METHODS

We reviewed the literature on cash transfer experiments conducted in low and middle income countries, published in English between 1985 and 2015. We documented whether the investigators reported either i) stratum-specific estimates or ii) the interaction term between subgroups and exposure to the intervention. For studies that presented stratum-specific estimates without statistical tests for heterogeneity, we assessed heterogeneity across subgroups with a Cochran Q test.

RESULTS

Of the 56 studies we reviewed, 40 reported effects on study subgroups. The majority of the cash transfer interventions had different magnitudes of effects on health across subgroups. This heterogeneity was often underreported or not formally analyzed. We find substantial heterogeneity of cash transfers on child health and on adult health yet little heterogeneity of cash transfers on sexual and reproductive health.

CONCLUSIONS

Accounting for the heterogeneous impacts of cash transfers during program design and evaluation is necessary to better target cash transfer programs and generate more precise data on their effects.