Combined effects of conditional cash transfer program and environmental health interventions on diarrhea and malnutrition morbidity in children less than five years of age in Brazil, 2006-2016

Effectiveness of infrastructural interventions to improve access to safe drinking water in Latin America and the Caribbean on the burden of diarrhoea in children <5 years: a systematic literature review and narrative synthesis

Globally, Latin America and the Caribbean (LAC) has one of the lowest rates of equitable access to safely managed drinking water. This systematic literature review assessed the effectiveness of infrastructure interventions to provide equitable access to safely managed drinking water in LAC on the burden of diarrhoea in children <5 years. The review was conducted in February 2024 using Ovid MEDLINE, Embase, Global Health, and the Cochrane Library with inclusion criteria: quantitative study designs of intervention effectiveness on burden of diarrhoea in children; conducted in LAC; studies published since 1 January 2000; and full-text available in English. Study quality was assessed via the US Agency for Healthcare Research and Quality scale. Reported quantitative data for diarrhoea burden of disease were extracted, and thematic analysis informed a narrative synthesis. Six studies from three countries in LAC with >110,000 data-points were included. Water supply infrastructure interventions were effective at reducing the burden of diarrhoea in children <5 years. Household level, rather than community level, access to a piped water supply, a continuous reliable service with <1 day of service interruption per month, and cash transfer programs for environmental public health programs, were identified as key contributors to water infrastructure intervention effectiveness. Previous water supply infrastructure interventions which include the provision of a safe drinking water supply are effective in reducing burden of diarrhoea in children. Future studies are needed to develop a comprehensive understanding of the unique features which contribute to water infrastructure effectiveness.

Spatiotemporal analysis of diarrhea-related hospitalizations of children in Brazil's Midwest region from 2011 to 2020

OBJECTIVE

To examine spatiotemporal variability and identify clustering patterns of hospitalization rates for diarrhea in children younger than five years in Mato Grosso, Brazil, from 2011 to 2020.

METHODS

An ecological study was conducted using hospitalization records associated with diarrhea from the Brazilian Hospital Information System/Unified Health System. The relative risk of hospitalization for diarrhea in each municipality was calculated using SaTScan software considering a statistical significance level of 5% and 999 Monte Carlo replications.

RESULTS

A total of 13,315 diarrhea-associated hospitalizations for 5-year-old children were recorded. From 2011 to 2020, the annual rates for hospitalizations related to diarrhea decreased from 8.50 to 3.45/1,000 live births among children younger than one year and from 4.99 to 1.57 for children aged 1-4 years. Clusters of municipalities with high relative risk for hospitalizations due to diarrhea, statistically significant, predominated in the North, Northeast, and Southwest health administrative macro-regions of Mato Grosso for both age groups until 2016. From 2016 to 2020, clusters of the lowest relative risk were identified in the North and Center South health administrative macro-regions for children younger than five years.

CONCLUSION

Results showed that hospitalization rates for diarrhea in children younger than five years reduced with the presence of low-risk clusters in Mato Grosso in the final years of the study. Public health surveillance should incorporate spatial analysis to investigate the diarrhea-related morbidity.

Effectiveness of cash-plus programmes on early childhood outcomes compared to cash transfers alone: A systematic review and meta-analysis in low- and middle-income countries

BACKGROUND

To strengthen the impact of cash transfers, these interventions have begun to be packaged as cash-plus programmes, combining cash with additional transfers, interventions, or services. The intervention's complementary ("plus") components aim to improve cash transfer effectiveness by targeting mediating outcomes or the availability of supplies or services. This study examined whether cash-plus interventions for infants and children <5 are more effective than cash alone in improving health and well-being.

METHODS AND FINDINGS

Forty-two databases, donor agencies, grey literature sources, and trial registries were systematically searched, yielding 5,097 unique articles (as of 06 April 2021). Randomised and quasi-experimental studies were eligible for inclusion if the intervention package aimed to improve outcomes for children <5 in low- and middle-income countries (LMICs) and combined a cash transfer with an intervention targeted to Sustainable Development Goal (SDG) 2 (No Hunger), SDG3 (Good Health and Well-being), SDG4 (Education), or SDG16 (Violence Prevention), had at least one group receiving cash-only, examined outcomes related to child-focused SDGs, and was published in English. Risk of bias was appraised using Cochrane Risk of Bias and ROBINS-I Tools. Random effects meta-analyses were conducted for a cash-plus intervention category when there were at least 3 trials with the same outcome. The review was preregistered with PROSPERO (CRD42018108017). Seventeen studies were included in the review and 11 meta-analysed. Most interventions operated during the first 1,000 days of the child's life and were conducted in communities facing high rates of poverty and often, food insecurity. Evidence was found for 10 LMICs, where most researchers used randomised, longitudinal study designs (n = 14). Five intervention categories were identified, combining cash with nutrition behaviour change communication (BCC, n = 7), food transfers (n = 3), primary healthcare (n = 2), psychosocial stimulation (n = 7), and child protection (n = 4) interventions. Comparing cash-plus to cash alone, meta-analysis results suggest Cash + Food Transfers are more effective in improving height-for-age (d = 0.08 SD (0.03, 0.14), p = 0.02) with significantly reduced odds of stunting (OR = 0.82 (0.74, 0.92), p = 0.01), but had no added impact in improving weight-for-height (d = -0.13 (-0.42, 0.16), p = 0.24) or weight-for-age z-scores (d = -0.06 (-0.28, 0.15), p = 0.43). There was no added impact above cash alone from Cash + Nutrition BCC on anthropometrics; Cash + Psychosocial Stimulation on cognitive development; or Cash + Child Protection on parental use of violent discipline or exclusive positive parenting. Narrative synthesis evidence suggests that compared to cash alone, Cash + Primary Healthcare may have greater impacts in reducing mortality and Cash + Food Transfers in preventing acute malnutrition in crisis contexts. The main limitations of this review are the few numbers of studies that compared cash-plus interventions against cash alone and the potentially high heterogeneity between study findings.

CONCLUSIONS

In this study, we observed that few cash-plus combinations were more effective than cash transfers alone. Cash combined with food transfers and primary healthcare show the greatest signs of added effectiveness. More research is needed on when and how cash-plus combinations are more effective than cash alone, and work in this field must ensure that these interventions improve outcomes among the most vulnerable children.