Cash-based interventions (CBIs), offer an interesting opportunity to prevent increases in wasting in humanitarian aid settings. However, questions remain as to the impact of CBIs on nutritional ...status and, therefore, how to incorporate them into emergency programmes to maximise their success in terms of improved nutritional outcomes. This study evaluated the effects of three different CBI modalities on nutritional outcomes in children under 5 y of age at 6 mo and at 1 y.
We conducted a four-arm parallel longitudinal cluster randomised controlled trial in 114 villages in Dadu District, Pakistan. The study included poor and very poor households (n = 2,496) with one or more children aged 6-48 mo (n = 3,584) at baseline. All four arms had equal access to an Action Against Hunger-supported programme. The three intervention arms were as follows: standard cash (SC), a cash transfer of 1,500 Pakistani rupees (PKR) (approximately US$14; 1 PKR = US$0.009543); double cash (DC), a cash transfer of 3,000 PKR; or a fresh food voucher (FFV) of 1,500 PKR; the cash or voucher amount was given every month over six consecutive months. The control group (CG) received no specific cash-related interventions. The median total household income for the study sample was 8,075 PKR (approximately US$77) at baseline. We hypothesized that, compared to the CG in each case, FFVs would be more effective than SC, and that DC would be more effective than SC-both at 6 mo and at 1 y-for reducing the risk of child wasting. Primary outcomes of interest were prevalence of being wasted (weight-for-height z-score WHZ < -2) and mean WHZ at 6 mo and at 1 y. The odds of a child being wasted were significantly lower in the DC arm after 6 mo (odds ratio OR = 0.52; 95% CI 0.29, 0.92; p = 0.02) compared to the CG. Mean WHZ significantly improved in both the FFV and DC arms at 6 mo (FFV: z-score = 0.16; 95% CI 0.05, 0.26; p = 0.004; DC: z-score = 0.11; 95% CI 0.00, 0.21; p = 0.05) compared to the CG. Significant differences on the primary outcome were seen only at 6 mo. All three intervention groups showed similar significantly lower odds of being stunted (height-for-age z-score HAZ < -2) at 6 mo (DC: OR = 0.39; 95% CI 0.24, 0.64; p < 0.001; FFV: OR = 0.41; 95% CI 0.25, 0.67; p < 0.001; SC: OR = 0.36; 95% CI 0.22, 0.59; p < 0.001) and at 1 y (DC: OR = 0.53; 95% CI 0.35, 0.82; p = 0.004; FFV: OR = 0.48; 95% CI 0.31, 0.73; p = 0.001; SC: OR = 0.54; 95% CI 0.36, 0.81; p = 0.003) compared to the CG. Significant improvements in height-for-age outcomes were also seen for severe stunting (HAZ < -3) and mean HAZ. An unintended outcome was observed in the FFV arm: a negative intervention effect on mean haemoglobin (Hb) status (-2.6 g/l; 95% CI -4.5, -0.8; p = 0.005). Limitations of this study included the inability to mask participants or data collectors to the different interventions, the potentially restrictive nature of the FFVs, not being able to measure a threshold effect for the two different cash amounts or compare the different quantities of food consumed, and data collection challenges given the difficult environment in which this study was set.
In this setting, the amount of cash given was important. The larger cash transfer had the greatest effect on wasting, but only at 6 mo. Impacts at both 6 mo and at 1 y were seen for height-based growth variables regardless of the intervention modality, indicating a trend toward nutrition resilience. Purchasing restrictions applied to food-based voucher transfers could have unintended effects, and their use needs to be carefully planned to avoid this.
ISRCTN registry ISRCTN10761532.
An estimated 49.5 million children under five years of age are wasted. There is a lack of robust studies on effective interventions to prevent wasting. The aim of this study was to identify and ...prioritise the main outstanding research questions in relation to wasting prevention to inform future research agendas.
A research prioritisation exercise was conducted following the Child Health and Nutrition Research Initiative method. Identified research gaps were compiled from multiple sources, categorised into themes and streamlined into forty research questions by an expert group. A survey was then widely circulated to assess research questions according to four criteria. An overall research priority score was calculated to rank questions.
The prioritised questions have a strong focus on interventions. The importance of the early stages of life in determining later experiences of wasting was highlighted. Other important themes included the identification of at-risk infants and young children early in the progression of wasting and the roles of existing interventions and the health system in prevention.
These results indicate consensus to support more research on the pathways to wasting encompassing the in-utero environment, on the early period of infancy and on the process of wasting and its early identification. They also reinforce how little is known about impactful interventions for the prevention of wasting.
This exercise provides a five-year investment case for research that could most effectively improve on-the-ground programmes to prevent child wasting and inform supportive policy change.
Risk of death from undernutrition is thought to be higher in younger than in older children, but evidence is mixed. Research also demonstrates sex differences whereby boys have a higher prevalence of ...undernutrition than girls. This analysis described mortality risk associated with anthropometric deficits (wasting, underweight and stunting) in children 6–59 months by age and sex. We categorised children into younger (6–23 months) and older (24–59 months) age groups. Age and sex variations in near‐term (within 6 months) mortality risk, associated with individual anthropometric deficits were assessed in a secondary analysis of multi‐country cohort data. A random effects meta‐analysis was performed. Data from seven low‐or‐middle‐income‐countries collected between 1977 and 2013 were analysed. One thousand twenty deaths were recorded for children with anthropometric deficits. Pooled meta‐analysis estimates showed no differences by age in absolute mortality risk for wasting (RR 1.08, p = 0.826 for MUAC < 125 mm; RR 1.35, p = 0.272 for WHZ < −2). For underweight and stunting, absolute risk of death was higher in younger (RR 2.57, p < 0.001) compared with older children (RR 2.83, p < 0.001). For all deficits, there were no differences in mortality risk for girls compared with boys. There were no differences in the risk of mortality between younger and older wasted children, supporting continued inclusion of all children under‐five in wasting treatment programmes. The risk of mortality associated with underweight and stunting was higher among younger children, suggesting that prevention programmes might be justified in focusing on younger children where resources are limited. There were no sex differences by age in mortality risk for all deficits.
Key points
There is a high risk of mortality associated with child wasting. We found no difference in mortality risk between children 6–23 months and children 24–59 months, indicating the need to include all children under 5 years in wasting treatment programmes.
For underweight and stunting, younger children had a significantly higher risk of mortality than older children. Where resources are limited, prevention programmes may be justified in targeting younger children.
Despite sex differences in the prevalence of wasting, stunting and underweight, there were no differences in mortality risk between girls and boys in both younger and older age groups.
BackgroundWe used the United Nations High Commissioner for Refugees Standardised Expanded Nutrition Survey data to evaluate the effect of a change in food ration on child growth in refugee camps in ...eastern Chad.MethodsWe compared trends of wasting and stunting prevalence over time and the association between the coexistence of being both stunted and wasted using Pearson’s χ2 test. We analysed the effect of an approximate 50% reduction in the general food distribution, with the introduction of a 20 g daily ration of small quantity lipid-based nutrient supplements given to all children aged 6–23 months, on child growth. This was done using interrupted time-series analysis to observe differences in levels and trends in mean height-for-age z-score (HAZ) and weight-for-height z-score (WHZ) over time and by age group (6–24 months and 24–59 months).ResultsOverall the prevalence of stunting and wasting decreased significantly over time. The odds of being both stunted and wasted was 1.38 higher than having one or the other condition separately (p<0.001, 95% CI=1.29 to 1.47). Trends in mean HAZ and WHZ before and after a ration change in 2014 indicate that growth had either slowed down or worsened. In the period following the ration change, children 24–59 months saw a significant decrease in mean HAZ of 0.04 per year (p=0.02, 95% CI=−0.07 to –0.01) and for the younger age group, there was a significant decrease in mean WHZ of 0.06 per year (p=0.03, 95% CI=−0.12 to –0.01).ConclusionsThe dual burden of stunting and wasting is a considerable challenge in refugee camp settings. Changes to the food distribution had adverse effects on child growth for both age groups. Broadening the scope of interventions aimed at children in camps is essential when tackling malnutrition with increased efforts essential during periods of wider food assistance shortages.
BackgroundIf effective interventions are to be used to address child mortality and malnutrition, then it is important that we understand the different pathways operating within the framework of child ...health. More attention needs to be given to understanding the contribution of social influences such as intimate partner violence (IPV).AimTo investigate the relationship between maternal exposure to IPV and child mortality and malnutrition using data from five developing countries.MethodsPopulation data from Egypt, Honduras, Kenya, Malawi and Rwanda were analysed. Logistic regression analysis was used to generate odds ratios of the associations between several categories of maternal exposure to IPV since the age of 15 and three child outcomes: under-2-year-old (U2) mortality and moderate and severe stunting (<–2 Z-score height-for-age and <–3 Z-score height-for-age) in 6–59-month-old children. Analyses were adjusted for potential confounders, and the role of mediating factors was explored.ResultsThe prevalence of physical and/or sexual IPV since the age of 15 years ranged from 15.5% (Honduras) to 46.2% (Kenya). For child stunting, prevalence ranged from 25.4% (Egypt) to 58.0% (Malawi) and for U2 mortality from 3.6% (Honduras) to 15.2% (Rwanda). In Kenya, maternal exposure to IPV was associated with higher U2 mortality (adjusted odds ratio (OR)=1.42, 95% CI 1.18 to 1.71) and child stunting (adjusted OR=1.36, 95% CI 1.16 to 1.61). In Malawi and Honduras, marginal associations were observed between IPV and severe stunting and U2 mortality, respectively, with strength of associations varying by type of violence.ConclusionThe relationship between IPV and U2 mortality and stunting in Kenya, Honduras and Malawi suggests that, in these countries, IPV plays a role in child malnutrition and mortality. This contributes to a growing body of evidence that broader public health benefits may be incurred if efforts to address IPV are incorporated into a wider range of maternal and child health programmes; however, the authors highlight the need for more research that can establish temporality, use data collected on the basis of the study's objectives, and further explore the causal framework of this relationship using more advanced statistical analysis.
To assess the effect of an unconditional cash transfer (CT) implemented as part of an emergency response to food insecurity during a declared state of emergency.
Pre-post intervention observational ...study involving two rounds of data collection, i.e. baseline (April 2012) and final survey (September 2012), on the same cohort of 'poor' and 'very poor' households enrolled by Save the Children in an unconditional CT programme.
Aguié district, Maradi, Niger.
Households with a non-acutely malnourished child aged 6-36 months (n 412).
The study showed that the living standards of 'poor' and 'very poor' households improved, as indicated by a reduction in poverty-related indicators and an improvement in household food security. Anthropometric outcomes for children aged 6-36 months improved significantly, despite a decline in child health and women's well-being and autonomy. Risk factors for becoming acutely malnourished post-intervention were being from a very poor household at baseline, starting the lean season with low weight-for-height Z-score (WHZ <-1) and the presence of co-morbidity.
The results of the study are consistent with the published evidence regarding the general impact of CT and suggest it is plausible that giving cash during an emergency can help safeguard living standards of the very poor and poor. While improvements in childhood nutrition status were seen it is not possible to attribute these to the CT programme. However, knowledge of the risk factors for acute malnutrition in a particular setting can be used to influence the design of future CT interventions for which a controlled trial would be recommended if feasible.
To determine which interventions can reduce linear growth retardation (stunting) in children aged 6-36 months over a 5-year period in a food-insecure population in Ethiopia.
We used data collected ...through an operations research project run by Save the Children UK: the Child Caring Practices (CCP) project. Eleven neighbouring villages were purposefully selected to receive one of four interventions: (i) health; (iii) nutrition education; (iii) water, sanitation and hygiene (WASH); or (iv) integrated comprising all interventions. A comparison group of three villages did not receive any interventions. Cross-sectional surveys were conducted at baseline (2004) and for impact evaluation (2009) using the same quantitative and qualitative tools. The primary outcome was stunted growth in children aged 6-36 months measured as height (or length)-for-age Z-scores (mean and prevalence). Secondary outcomes were knowledge of health seeking, infant and young child feeding and preventive practices.
Amhara, Ethiopia.
Children aged 6-36 months.
The WASH intervention group was the only group to show a significant increase in mean height-for-age Z-score (+0·33, P = 0·02), with a 12·1 % decrease in the prevalence of stunting, compared with the baseline group. This group also showed significant improvements in mothers' knowledge of causes of diarrhoea and hygiene practices. The other intervention groups saw non-significant impacts for childhood stunting but improvements in knowledge relating to specific intervention education messages given.
The study suggests that an improvement in hygiene practices had a significant impact on stunting levels. However, there may be alternative explanations for this and further evidence is required.
BackgroundIt is well known that high ambient temperatures are associated with increased mortality, even in temperate climates, but some important details are unclear. In particular, how ...heat–mortality associations (for example, slopes and thresholds) vary by climate has previously been considered only qualitatively.MethodsAn ecological time-series regression analysis of daily counts of all-cause mortality and ambient temperature in summers between 1993 and 2006 in the 10 government regions was carried out, focusing on all-cause mortality and 2-day mean temperature (lags 0 and 1).ResultsAll regions showed evidence of increased risk on the hottest days, but the specifics, in particular the threshold temperature at which adverse effects started, varied. Thresholds were at about the same centile temperatures (the 93rd, year-round) in all regions—hotter climates had higher threshold temperatures. Mean supra-threshold slope was 2.1%/°C (95% CI 1.6 to 2.6), but regions with higher summer temperatures showed greater slopes, a pattern well characterised by a linear model with mean summer temperature. These climate-based linear-threshold models capture most, but not all, the association; there was evidence for some non-linearity above thresholds, with slope increasing at highest temperatures.ConclusionEffects of high daily summer temperatures on mortality in English regions are quite well approximated by threshold-linear models that can be predicted from the region's climate (93rd centile and mean summer temperature). It remains to be seen whether similar relationships fit other countries and climates or change over time, such as with climate change.
Evidence from impact evaluations of community-based nutrition interventions addressing the question of 'what works' to reduce linear growth retardation (stunting) is growing but consensus is mixed. ...Whilst the number of such impact evaluations is increasing, especially by non-governmental organisations, many studies fail to be publicised due to unclear and/or limited positive outcomes, denying experiences of lessons learnt. Those that are published need to be scrutinised to understand the methods used in deciding the validity of the reported outcomes, since impact evaluations in operation settings can suffer a number of limitations. The author uses as an example an integrated community-based non-randomised controlled impact evaluation to highlight some of the problems and issues encountered in carrying out impact evaluations in operational settings and how results need careful interpretation. In this Save the Children UK study, the only intervention to show a positive significant impact in reducing linear growth retardation (stunting) in children 6-36 months was water, sanitation and hygiene. A comprehensive analysis of the nature, reliability and robustness of the study was necessary to determine the validity of the results. This article looks at the important factors that may have been influential in these outcomes, including key issues generally faced in impact evaluations that threaten both the external and internal validity through bias, confounding, contamination and spillover effects as well as implementation problems encountered. The main issues in this evaluation were lack of randomisation and power, alongside implementation issues, resulting in potential confounding and bias possibly producing spurious results. Agencies involved in community-based impact evaluations should engage in robust methods and systematic reporting to create a stronger evidence base and as such be prepared to increase the transparency of their work.
The cost of preventing undernutrition Trenouth, Lani; Colbourn, Timothy; Fenn, Bridget ...
Health policy and planning,
07/2018, Letnik:
33, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Cash-based interventions (CBIs) increasingly are being used to deliver humanitarian assistance and there is growing interest in the cost-effectiveness of cash transfers for preventing undernutrition ...in emergency contexts. The objectives of this study were to assess the costs, cost-efficiency and costeffectiveness in achieving nutrition outcomes of three CBIs in southern Pakistan: a ‘double cash’ (DC) transfer, a ‘standard cash’ (SC) transfer and a ‘fresh food voucher’ (FFV) transfer. Cash and FFVs were provided to poor households with children aged 6–48 months for 6 months in 2015. The SC and FFV interventions provided $14 monthly and the DC provided $28 monthly. Cost data were collected via institutional accounting records, interviews, programme observation, document review and household survey. Cost-effectiveness was assessed as cost per case of wasting, stunting and disability-adjusted life year (DALY) averted. Beneficiary costs were higher for the cash groups than the voucher group. Net total cost transfer ratios (TCTRs) were estimated as 1.82 for DC, 2.82 for SC and 2.73 for FFV. Yet, despite the higher operational costs, the FFV TCTR was lower than the SC TCTR when incorporating the participation cost to households, demonstrating the relevance of including beneficiary costs in cost-efficiency estimations. The DC intervention achieved a reduction in wasting, at $ 4865 per case averted; neither the SC nor the FFV interventions reduced wasting. The cost per case of stunting averted was $1290 for DC, $882 for SC and $883 for FFV. The cost per DALY averted was $ 641 for DC, $434 for SC and $563 for FFV without discounting or age weighting. These interventions are highly cost-effective by international thresholds. While it is debatable whether these resource requirements represent a feasible or sustainable investment given low health expenditures in Pakistan, these findings may provide justification for continuing Pakistan’s investment in national social safety nets.
On recourt de plus en plus aux interventions axées sur les transferts monétaires (CBI) pour fournir une aide humanitaire et l’on s’intéresse davantage à la rentabilité des transferts monétaires pour prévenir la dénutrition dans les situations d’urgence. Les objectifs de la présente étude étaient d’évaluer les coûts et la rentabilité des résultats nutritionnels de trois CBI dans le sud du Pakistan: un virement «double caisse» (DC), un virement «cash standard» (SC) et un virement en «bons d’aliments frais» (FFV). En 2015, des espèces et des bons FFV ont été fournis pendant 6 mois aux ménages démunis avec des enfants âgés de 6 à 48 mois. Les interventions SC et FFV fournissaient 14 $par mois tandis que les DC pourvoyaient 28 $par mois. Les données sur les coûts ont été recueillies au moyen de registres comptables institutionnels, d’entrevues, d’observations de programmes, d’examens de documents et d’enquêtes auprès des ménages. Le rapport coût-efficacité a été évalué en fonction du coût par cas de consomption, de retard de croissance et d’année de vie ajustée sur l’incapacité (DALY) évités. Les coûts des bénéficiaires étaient plus élevés dans les groupes recevant de l’argent liquide en comparaison au groupe bénéficiant de bons. Les ratios de transfert total des coûts nets (TCTR) ont été estimés à 1, 82 pour les DC; 2, 82 pour les SC et 2, 73 pour les FFV. Cependant, malgré les coûts d’exploitation plus élevés, le FFV TCTR était plus bas que le SC TCTR lorsqu’il intégrait le coût de participation aux frais des ménages, démontrant ainsi la pertinence d’inclure les frais des bénéficiaires dans les estimations de rentabilité. L’intervention DC a permis de réduire la consomption, à raison de 4865 $par cas évité; ni les interventions SC, ni les interventions FFV n’ont permis de réduire la consomption. Le coût par cas de retard de croissance évité était de 1290 $pour les DC; 882 $pour les SC et 883 $pour les FFV. The cost per DALY averted was $641 for DC, $434 for SC and $563 for FFV without discounting or age weighting. These interventions are highly costeffective by international thresholds. While it is debatable whether these resource requirements represent a feasible or sustainable investment given low health expenditures in Pakistan, these findings may provide justification for continuing Pakistan’s investment in national social safety nets. Le coût par DALY évité était de 641 $pour les DC; 434 $pour les SC et 563 $pour les FFV sans actualisation ou pondération selon l’ âge. Ces interventions sont très rentables selon les normes des seuils internationaux. Bien que l’on puisse se poser la question de savoir si ces besoins en ressources représentent un investissement réalisable ou durable compte tenu des modiques dépenses de santé du Pakistan, ces conclusions peuvent justifier le fait que le Pakistan continue d’investir dans des systèmes nationaux de sécurité sociale.
现金干预 （CBIs） 越来越多地用于人道主义援助, 在紧急情况 下采用现金支付预防营养不足的成本效果也逐渐成为研究关 注点。本研究的目的是评估巴基斯坦南部三种CBIs在实现营 养结局方面的成本、成本效率和成本效果。这三种CBIs分别 是双倍现金支付 （DC）、标准现金支付 （SC） 和免费食品券 （FFV） 。2015年向家中有648月龄儿童的贫困家庭提供现金 和FFVs, 为期6个月。SC和FFV干预每月提供14美元, DC每月 提供28美元。通过机构会计记录、访谈、项目观察、文件回 顾和家庭调查收集成本数据。成本效果为每避免一例消瘦、 发育迟缓和失能调整生命年 （DALY） 的成本。现金组的受益 人成本高于食品券组。DC、SC和FFV的净总成本支付比 （TCTR） 分别为1.82、2.82和2.73。尽管FFV的运行成本较 高, 在计入家庭参与成本时, 其TCTR低于SC, 显示有必要将受 益人成本计入成本效率。DC干预减少了消瘦, 每避免一例消 瘦成本为4865美元；SC和FFV干预都未能减少消瘦。DC、SC 和FFV每避免一例发育迟缓的成本分别为1290美元、882美元 和883美元；每DALY的成本分别为641美元、434美元和563 美元, 未考虑折现或年龄权重。以国际标准来看, 这三种干预 具有很高的成本效果。尽管在巴基斯坦低卫生支出的背景下, 上述干预的资源需求是否可行或可持续还存在争议, 本研究发 现可为巴基斯坦继续投入国家社会保障体系提供积极证据。
Las intervenciones basadas en dinero en efectivo (IBDEs) están siendo usadas cada vez más para entregar ayuda humanitaria y existe un creciente interés en la relación costo-efectividad de las transferencias en dinero en efectivo para prevenir la desnutrición en contextos de emergencia. Los objetivos de este estudio fueron evaluar los costos, la costo-eficiencia y la costo-efectividad para lograr los resultados nutricionales de tres IBDEs en el sur de Pakistán: una transferencia de ‘efectivo doble’ (ED), una transferencia ‘efectivo-estándar’ (EE) y una transferencia de ‘vale de comida fresca’ (VCF). El dinero en efectivo y los VCFs fueron proporcionados a hogares pobres con niños de 6-48 meses durante 6 meses en 2015. Las intervenciones EE y VCF proporcionaron $14 mensuales y la ED proporcionó $28 mensuales. Los datos de costos fueron recolectados por medio de registros de contaduría institucionales, entrevistas, observación de programa, revisión de documentos y encuesta de hogar. La costo-efectividad se evaluó como el costo por caso de emaciación evitado, retraso del crecimiento evitado y año de vida ajustados por discapacidad (AVAD) evitado. Los costos de los beneficiarios fueron mayores para los grupos de dinero en efectivo que para el grupo de vale. El costo total neto de las relaciones de transferencia (CTRTs) se estimaron como 1.82 para ED, 2.82 para EE y 2.73 para VCF. Sin embargo, a pesar de los mayores costos de operación, el CTRT para VCF fue inferior al CTRT para EE al incorporar el costo de participación en los hogares demostrando la importancia de incluir los costos de los beneficiarios en las estimaciones del costo-eficiencia. La intervención de ED logró una reducción en la emaciación, a $4865 por caso evitado; ni el EE ni las intervenciones por VCF redujeron la emaciación. El costo por caso de retraso en el crecimiento evitado fue de $1290 por ED, $882 por EE y $883 por VCF. El costo por AVAD evitado fue de $641 por ED, $434 por EE y $563 por VCF sin descontar o ponderar por edad. Estas intervenciones son altamente costo-efectivas por umbrales internacionales. Si bien es discutible si estas necesidades de recursos representan una inversión factible o sostenible dados los bajos gastos de salud en Pakistán, estos hallazgos pueden proporcionar una justificación para continuar la inversión en redes nacionales de seguridad social de Pakistán.
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