Cash and voucher assistance and children's nutrition status in Somalia

Engaging Fathers Through Nutrition Behavior Communication Change Does Not Increase Child Dietary Diversity in a Cluster Randomized Control Trial in Rural Ethiopia

BACKGROUND

Adding food vouchers or paternal nutrition behavior change communication (BCC) activities to maternal BCC may improve child diets and household food security but their effect is unknown.

OBJECTIVES

We assessed whether maternal BCC, maternal and paternal BCC, maternal BCC and a food voucher, or maternal and paternal BCC and a food voucher improved nutrition knowledge, child diet diversity scores (CDDS), and household food security.

METHODS

We implemented a cluster randomized control trial in 92 Ethiopian villages. Treatments were as follows: maternal (M) BCC only; maternal BCC and paternal BCC (M+P); maternal BCC and food vouchers (M+V); and maternal BCC, food vouchers, and paternal BCC (M+V+P). Effects were assessed using generalized estimating equations.

RESULTS

Maternal BCC and paternal BCC increased the maternal and paternal knowledge of optimal infant and young child feeding practices by 4.2-6.8 percentage points (P < 0.05) and by 8.3-8.4 percentage points (P < 0.01), respectively. Combining maternal BCC with either paternal BCC or the food voucher increased CDDS by 21.0%-23.1% (P < 0.05). The treatments M, M+V, and M+P increased the proportion of children who met minimum acceptable diet standards by 14.5, 12.8, and 20.1 percentage points, respectively (P < 0.01). Adding paternal BCC to the maternal BCC treatment or to the maternal BCC and voucher treatment did not lead to a larger increase in CDDS.

CONCLUSIONS

Increased paternal involvement does not necessarily translate into improvements in child feeding outcomes. Understanding the intrahousehold decision-making dynamics that underlie this is an important area for future research. This study was registered at clinicaltrials.gov as NCT03229629.

Analysis of dynamic change of nutrition status in primary school children of Furong District of Changsha City from 2019 to 2020

OBJECTIVE

To analyze the nutritional status of primary school children in Furong District of Changsha from 2019 to 2020.

METHODS

The physical examination data of students from 35 primary schools (grade 1-6) in Furong District of Changsha in Hunan Provincial People's Hospital from September 2019 to October 2020 were analyzed retrospectively. General information of all children was collected for statistical analysis of malnutrition among children of different gender and age groups.

RESULT

The overnutrition rate was 32.73% in 2020. This was 7.42% higher than 25.31% in 2019. The undernourishment rate was 4.70% in 2020. This was 3.94% lower than 8.64% in 2019. In 2019 and 2022, the obesity and overweight rates of boys were higher than those of girls (both P < 0.05). The rates of growth retardation (0.36%, 0.37%) for boys were higher than those for girls (0.27%, 0.24%). The rates of mild wasting (4.31%, 2.36%) were lower than those for girls (4.00%, 2.39%) in 2020 and 2019. The rates of moderate and severe wasting (4.06%, 1.98%) were higher than those for girls (2.75%, 1.47%). In 2020, the undernourishment rate for boys decreased by 4.02% compared to 2019. The undernourishment rate for girls decreased by 2.91% compared to 2019. The growth retardation rate for boys increased by 0.01% compared to 2019. The growth retardation rate for girls decreased by 0.03% compared to 2019. The mild wasting rate for boys decreased by 1.95% as compared to 2019. The mild wasting rate for girls decreased by 1.61% as compared to 2019. The moderate to severe emaciation rate in boys was 2.08% lower in 2020 than in 2019 and 1.28% lower in girls than in 2019. The malnutrition rates of children aged 6-11 decreased by 4.20%, 4.85%, 3.83%, 9.45%, 6.65%, and 6.45% in 2020 compared with that of 2019.

CONCLUSION

Compared to 2019, the primary school students in Furong District had abnormal nutritional status in 2020. It is necessary to strengthen the management of children's health care to ensure the healthy growth of children.

Effects of the COVID-19 pandemic on food insecurity in El Salvador during 2020

Objective.

This study sought to quantify the prevalence of food insecurity among Salvadorian households, to identify the determinants of food insecurity and to explore the impact of the COVID-19 pandemic on food insecurity.

Methods.

A nationwide, representative random sample of 2358 households was used for this cross-sectional study. The Household Hunger Scale (HHS) was used to assess the prevalence of food insecurity during a 30-day period. For comparison, three items were used from the Household Food Insecurity Experience Scale (HFIES), which measures hunger occurring during a 12-month time frame. For determinant analysis, binary logistic regression was used for the HHS and ordered logistic regression for the HFIES.

Results.

The prevalence of food insecurity was 6.45% (152/2356) among Salvadorian households when the HHS was used, affecting 5.48% (129/2356) to a moderate degree and 0.98% (23/2356) to a severe degree. The prevalence significantly increased when the HFIES scale items were used, with 35.41% (835/2358) of households being affected, a figure closer to the national poverty level. Determinants of food insecurity according to the HHS included agricultural problems (P = 0.00, odds ratio [OR] =1.69), the household’s prepandemic income (P = 0.00, OR = 0.48) and higher educational levels (i.e. having a secondary education [P = 0.00, OR = 0.31], technical [P = 0.03, OR = 0.24] or university education [P = 0.00, OR = 0.05]). When using the HFIES, the determinants were similar (i.e. income, agricultural problems, educational level). In more than 94% (744/785) of households, participants reported that food insecurity was exacerbated by the COVID-19 pandemic.

Conclusions.

When compared with other relevant international studies, the prevalence of food insecurity identified using the HHS – only 6.45% – was low for El Salvador. However, when using the HFIES scale, the prevalence rose to 35.41% of households. Some determinants align with previous studies, namely income, educational level and agricultural problems. The COVID-19 pandemic appeared to have direct effects on food insecurity

Unconditional cash transfer to reduce the burden of unmet surgical needs

Recent years have seen scandals involving international humanitarian organizations. Short term surgical missions from high to low- and middle-income countries have been criticized as ‘parachute’ missions. There are significant surgical unmet needs in low- and middle-income countries. Universal health coverage has been underutilized in low- and middle-income countries for surgical conditions. We suggest a two-fold solution: first, restructuring of aid organizations by splitting them into smaller units to make them transparent and responsive to local needs. Secondly, unconditional cash transfer directly to beneficiaries giving them a choice to select physician and hospital for surgical treatment.

Exploring the temporal patterns and crisis-related risk factors for population displacement in Somalia (2016-2018)

Introduction

Over the past 30 years, south-central Somalia, Puntland (north-east) and Somaliland (north-west) have experienced recurring drought- and conflict-related crises. By the end of 2018, the number of internally displaced persons (IDPs) in the region had reached 2.6 million; most were displaced to larger towns under government control, where humanitarian assistance was more accessible. Understanding the drivers of crisis-related displacement can provide insight into how responses can best manage and respond to displacement to prevent downstream morbidity and mortality. We aimed to explore the temporal patterns and crisis-related risk factors for population displacement in Somalia from 2016 to 2018, a period of severe drought.

Methods

We conducted an ecological study of secondary panel data stratified by district and month. The study population included all people in the region from 2016 to 2018. The outcome was defined as the number of new out-migrating internally displaced persons (IDPs) per district-month. Exposure variables included armed conflict, rainfall, food insecurity and food security services. Lags at one, two and three months were generated to explore possible delayed effects. All univariate and multivariate analyses were conducted using negative binomial regression models with mixed effects incorporating the district as a random effect.

Results

From 2016 to 2018, the proportion of IDPs increased from 9% to 25% in Somalia, Puntland and Somaliland. We observed strong associations between IDP out-migration rate and failed rains at a three-month lag, food insecurity at a one-month lag, and the presence of therapeutic food services with no lag. IDP out-migration rate was not associated with armed conflict intensity, and cash- and rations-based food security services.

Discussion

This study identified temporal, and socially and biologically plausible associations between key crisis-related risk factors and displacement in Somalia. The findings suggest a sequence of events spanning a few months, where failed rains and consequent food insecurity likely prompted early population out-migration to larger urban centers where humanitarian services were more accessible. The presence of therapeutics-based food security services could represent a more general correlate of crisis severity and the decision to migrate.

Connecting the food and agriculture sector to nutrition interventions for improved health outcomes

To achieve the Sustainable Development Goal of zero hunger, multi-sectoral strategies to improve nutrition are necessary. Building towards this goal, the food and agriculture sector must be considered when designing nutritional interventions. Nevertheless, most frameworks designed to guide nutritional interventions do not adequately capture opportunities for integrating nutrition interventions within the food and agriculture sector. This paper aims to highlight how deeply connected the food and agriculture sector is to underlying causes of malnutrition and identify opportunities to better integrate the food and agriculture sector and nutrition in low and middle income countries. In particular, this paper: (1) expands on the UNICEF conceptual framework for undernutrition to integrate the food and agriculture sector and nutrition outcomes, (2) identifies how nutritional outcomes and agriculture are linked in six important ways by defining evidence-based food and agriculture system components within these pathways: as a source of food, as a source of income, through food prices, women’s empowerment, women’s utilization of time, and women’s health and nutritional status, and (3) shows that the food and agriculture sector facilitates interventions through production, processing and consumption, as well as through farmer practices and behavior. Current frameworks used to guide nutrition interventions are designed from a health sector paradigm, leaving agricultural aspects not sufficiently leveraged. This paper concludes by proposing intervention opportunities to rectify the missed opportunities generated by this approach. Program design should consider the ways that the food and agriculture sector is linked to other critical sectors to comprehensively address malnutrition. This framework is designed to help the user to begin to identify intervention sites that may be considered when planning and implementing multi-sectoral nutrition programs.

International evidence to inform decision making on implementing urgent response social protection measures

This paper summarises evidence from a rapid review of international findings on the effects of cash transfers. The learnings were used to inform the design of urgent response social protection during the COVID-19 pandemic. The summary demonstrates that in response to widespread disruption, cash transfers have broad benefits for children, adults, and the wider economy. First, cash grants for child support have been shown to reduce hunger, increase dietary diversity, and reduce secondary school dropout. Transfers may also reduce child malnutrition. Second, there is some evidence that cash grants could encourage job search and economic activity. By contrast, there is little evidence that grants discourage adults from working, or increase spending on temptation goods (alcohol, tobacco). Third, for the wider economy, there is little evidence that grants will increase inflation, while some studies find that transfers create a fiscal multiplier and stimulate the local economy. Finally, we review evidence on design considerations and find that unconditional cash transfers (UCTs) are particularly well suited to rapid response when compared to conditional cash transfers (CCTs). Outside crisis settings, there is some evidence that getting recipients to enrol children in school or attend health check-ups improves these outcomes more than unconditional grants. However, the differences are small and the additional costs of implementing conditions outweigh these benefits in circumstances where response is required urgently. Comparing evidence on cash grants and food vouchers suggests both achieve similar improvements in nutrition; however, cash transfers are likely to be more cost-effective for governments, especially where a system to distribute grants is already set up.

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.

Cash assistance programming and changes over time in ability to meet basic needs, food insecurity and depressive symptoms in Raqqa Governorate, Syria: Evidence from a mixed methods, pre-posttest

Raqqa Governorate has been grappling with dual crisis-related burdens from the civil conflict and ISIS occupation. As part of a response to support households within this area, a three-month, unconditional cash assistance program was implemented by the International Rescue Committee to help households meet their basic needs. A quantitative, pre-posttest with 512 women at baseline (n = 456 at endline) was conducted in northern Raqqa Governorate between March-August 2018 to determine their experiences in this cash assistance program and to understand perceived change over time in food insecurity, perceived household serious needs and daily stressors, and depressive symptoms before and after cash was delivered. Forty women also completed in-depth interviews using a life line history technique at endline. Linear household fixed effects models demonstrated significant reductions in food insecurity (β = -0.95; 95%CI: -1.19--0.71), no change in perceived serious household needs and daily stressors (β = 0.12; 95%CI: -0.24-0.48), and increases in depressive symptoms (β = 0.89; 95%CI: 0.34-1.43) before and after the period of cash distribution. Although no causality can be inferred, short-term emergency cash assistance programming yielded significant improvements in food security, was highly acceptable and viewed favorably, and assisted women and their families to meet their basic needs in this emergency setting. However, before and after this form of cash assistance was implemented, no meaningful changes in the perceived levels of serious needs and stressors amongst households were observed, but potential increases in depressive symptoms for women were reported during this time period. Further work is needed to determine appropriate targeting, length, and dosage of cash, alongside any potential livelihood, psychosocial, or structural complementary programming to yield potential positive mental health benefits of a cash assistance program focused on meeting a population's basic needs while not inadvertently delaying or decreasing reach of life-saving cash assistance programming in emergencies.

Cash-based assistance and the nutrition status of pregnant and lactating women in the Somalia food crisis: A comparison of two transfer modalities

Background

Large-scale emergency assistance programmes in Somalia use a variety of transfer modalities including in-kind food provision, food vouchers, and cash transfers. Evidence is needed to better understand whether and how such modalities differ in reducing the risk of acute malnutrition in vulnerable groups, such as the 800,000 pregnant and lactating women affected by the 2017/18 food crisis.

Methods

Changes in diet and acute malnutrition status were assessed among pregnant and lactating women receiving similarly sized household transfers over a four-month period (total value of ~US$450 per household) delivered either as food vouchers or as mixed transfers consisting of in-kind food, vouchers, and cash. Baseline and endline comparisons were conducted for 514 women in Wajid, Somalia. Primary study outcomes were Minimum Dietary Diversity for Women, meal frequency, and mid-upper arm circumference (MUAC), with MUAC<21.0 cm classified as acute malnutrition. Adjusted analyses consisted of difference-in-difference analysis using linear and logistic regression models with inverse probability weighting based on propensity scores to account for the non-randomized design.

Findings

No significant difference in change in dietary quality was observed between food voucher and mixed transfer recipients; a significant difference in change in mean meal frequency was observed (0.3 meals/day, CI: 0.1–0.5, p = 0.001) and the mixed transfer group had significantly greater meal frequency at endline (p<0.001). Mean MUAC increased significantly among both voucher (0.9cm, CI: 0.6–1.3, p = 0.001) and mixed transfer recipients (1.3cm, CI: 1.1–1.5, p = 0.001) over the intervention period in adjusted analysis, however, the difference in magnitude of change between the two groups was not statistically significant (0.4cm, CI: -0.1–0.08, p = 0.086).

Conclusions

Within the context of the 2017/18 Somalia food crisis, the modality of assistance provided to pregnant and lactating women (mixed transfers or food-vouchers) made no difference in preventing acute malnutrition and protecting nutritional status.

Cash and voucher assistance and children's nutrition status in Somalia

To address ongoing food insecurity and acute malnutrition in Somalia, a broad range of assistance modalities are used, including in‐kind food, food vouchers, and cash transfers. Evidence of the impact of cash and voucher assistance (CVA) on prevention of acute malnutrition is limited in humanitarian and development settings. This study examined the impact of CVA on prevention of child acute malnutrition in 2017/2018 in the context of the Somalia food crisis. Changes in diet and acute malnutrition were measured over a 4‐month period among children age 6–59 months from households receiving household transfers of approximately US$450 delivered either as food vouchers or a mix of in‐kind food, vouchers, and cash. Baseline to endline change in children's dietary diversity, meal frequency, minimum acceptable diet (MAD), mid‐upper arm circumference (MUAC), and acute malnutrition (MUAC < 12.5 cm) were compared using difference‐in‐difference analysis with inverse probability weighting. There were no statistically significant changes in dietary diversity, meal frequency, or the proportion of children with MAD for either intervention group. Adjusted change in mean MUAC showed increases of 0.5 cm (confidence interval [CI; 0.0, 0.7 cm]) in the food voucher group and 0.1 cm (CI [−0.1, 0.4]) in the mixed transfer group. In adjusted analysis, prevalence of acute malnutrition among children under 5 years increased by 0.7% (CI [−13.4, 14.4%]) among food voucher recipients and decreased by 4.8% (CI [−9.9, 8.1%]) in mixed transfer recipients. The change over time in both mean MUAC and acute malnutrition prevalence was similar for both interventions, suggesting that cash and vouchers had similar effects on child nutrition status.