The Effect of a Cash Transfer Program and Preventive Nutrition Packages on Household Welfare and Child Nutritional Status in Mali

Study Overview
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Brief Summary
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In the last two decades, cash transfer (CT) programs have emerged as a popular approach to long-term poverty alleviation. While the main goal of cash transfer programs is to reduce poverty, they also have the potential to improve many development outcomes, such as health and education. While many studies, mainly in Latin America and Asia, have investigated the impacts of CTs on poverty and food security and have, for the most part, found positive impacts, less is known about the impacts of CTs in Africa south of the Sahara, and, in particular, West Africa. Moreover, despite the fact that cash transfers have been shown to lead to decreases in poverty, improvements in household food security, and increases in health service utilization, impacts on children's nutritional status (including anthropometric measures) are generally small (Manley, Gitter, and Slavchevska 2013). Consequently, policymakers and governments are left with the question of how to design social safety nets, such as cash transfers, to achieve greater impact on diet quality, health, and nutrition. The overall goal of this research is to generate evidence and knowledge on an integrated program implemented by the Government of Mali that includes a combination of cash transfers and targeted nutrition interventions. The information generated will inform program implementers and policymakers about best options to improve food security and nutrition among vulnerable groups and individuals in West Africa. Specifically, the main objectives of the research are To provide evidence on the contribution of integrated social transfer programs to enhancing household welfare, food security, dietary diversity, and maternal and child nutrition in West Africa. To test different features and combinations of cash transfers and targeted nutrition interventions, and assess their impact on food security and maternal and child nutrition and health outcomes in Mali. To generate knowledge regarding the pathways of impact of these different program packages, identify the most effective and efficient modalities in the context of Mali, and derive lessons learned for other countries in the region.

Detailed Description
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The research entails two study designs: i) a repeated cross-sectional survey (baseline, midline and endline) in a sample of 1,440 children between 6 and 24 months of age, mainly to asses the program's impact on child nutrition and health outcomes; ii) a panel study following a cohort of 2,880 children over 3 years mainly focusing on the evaluation of household welfare outcomes. The study will be conducted in the 96 communes where the Jigisemejiri program is being implemented, situated in 5 regions of Mali: Sikasso, Koulikoro, Segou, Mopti and Kayes. Data will be collected at baseline (2014, T=0), midline (2016, T= 24 months) and endline (2018, T= 48 months). The program is implemented for 48 months. The experimental group receives the cash transfer and group counselling intervention for 36 months. During the last 12 months the experimental group does not receive any intervention. The control group receives no intervention during the first 36 months, but receives the cash transfer and group counselling during the last 12 months. In a subsample of communes from the experimental group, villages were randomized to either receive Preventive Nutrition Packages (PNP) or nothing. The impact of PNP is analyzed by comparing villages that received PNP and villages that did not receive PNP during the last 12 months of the program.

Official Title
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The Effect of a Cash Transfer Program and Preventive Nutrition Packages on Household Welfare and Child Nutritional Status in Mali

Conditions
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Poverty, Child Malnutrition

Intervention / Treatment
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* Other: Cash distribution during first 36 months
* Behavioral: Accompanying information sessions on health, child nutrition, household economics and education during first 36 months
* Dietary Supplement: Preventive Nutrition Packages during last 12 months
* Other: Cash distribution during the last 12 months
* Behavioral: Accompanying information sessions on health, child nutrition, household economics and education during the last 12 months


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Being a Household that is beneficiary of the Jigisemejiri program Having a child between 6 and 24 months of age Exclusion Criteria: Congenital malformations that hamper anthropometric measurements

Ages Eligible for Study
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Minimum Age: 6 Months
Maximum Age: 5 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Other
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: Control and comparison group -cash transfer program<br>The program is implemented during 48 months. During the first 36 months the control group does not receive any intervention. During the last 12 months eligible beneficiaries receive cash transfer and accompanying information sessions on health, child nutrition, household economics every three months (identical to experimental group). | Other: Cash distribution during the last 12 months<br>* Three-monthly distribution of Cash (30,000 FCFA/trimester) to households that are beneficiary of the Jigisemejiri program.<br>Behavioral: Accompanying information sessions on health, child nutrition, household economics and education during the last 12 months<br>* Large group gatherings of cash beneficiaries are organized in parallel to the cash distributions. During these meetings, local NGOs present and discuss a topic related to health, child nutrition, household economics or education.<br>|
| Experimental: Jigisemejiri cash transfer program<br>Unconditional cash is distributed every 3 months to beneficiaries of the Jigisemejiri program. During cash handouts, information sessions on health, child nutrition, households economics and education are organized by local NGOs. | Other: Cash distribution during first 36 months<br>* Three-monthly distribution of Cash (30,000 FCFA/trimester) to households that are beneficiary of the Jigisemejiri program.<br>Behavioral: Accompanying information sessions on health, child nutrition, household economics and education during first 36 months<br>* Large group gatherings of cash beneficiaries are organized in parallel to the cash distributions. During these meetings, local NGOs present and discuss a topic related to health, child nutrition, household economics or education.<br>|
| Experimental: Jigisemejiri - Preventive Nutrition packages<br>Households belonging to the experimental group who previously received Cash transfer and information sessions on health, child nutrition, households economics and education for 36 months, with children and/or pregnant/lactating women receiving rations of fortified flour (PNP) during the last 12 months of the project | Other: Cash distribution during first 36 months<br>* Three-monthly distribution of Cash (30,000 FCFA/trimester) to households that are beneficiary of the Jigisemejiri program.<br>Behavioral: Accompanying information sessions on health, child nutrition, household economics and education during first 36 months<br>* Large group gatherings of cash beneficiaries are organized in parallel to the cash distributions. During these meetings, local NGOs present and discuss a topic related to health, child nutrition, household economics or education.<br>Dietary Supplement: Preventive Nutrition Packages during last 12 months<br>* Fortified flour supplements for children (Supercereal Plus)and pregnant/lactating mothers (super Cereal)<br>|
| Active Comparator: Control and comparison group - Preventive Nutrition packages<br>Households belonging to the experimental group who previously received Cash transfer and information sessions on health, child nutrition, households economics and education for 36 months, with children and/or pregnant/lactating women | Other: Cash distribution during first 36 months<br>* Three-monthly distribution of Cash (30,000 FCFA/trimester) to households that are beneficiary of the Jigisemejiri program.<br>Behavioral: Accompanying information sessions on health, child nutrition, household economics and education during first 36 months<br>* Large group gatherings of cash beneficiaries are organized in parallel to the cash distributions. During these meetings, local NGOs present and discuss a topic related to health, child nutrition, household economics or education.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Child Height-for-age Z-score | To calculate WHZ scores the 2006 WHO growth reference will be used | After 24 months of program implementation | 
| Value of household consumption | The household consumption includes food and non-food related economic consumption | After 24 months of program implementation | 
| Household dietary diversity | The household dietary diversity is estimated by a dietary diversity score counting food groups | After 24 months of program implementation | 
| Child Height-for-age Z-score | To calculate HAZ scores the 2006 WHO growth reference will be used (only in cross-sectional survey) | After 48 months of program implementation (only in cross-sectional survey) | 
| Value of household consumption | The household consumption includes food and non-food related economic consumption | After 48 months of program implementation | 
| Household dietary diversity | The household dietary diversity is estimated by a dietary diversity score counting food groups | After 48 months of program implementation | 
| Child Weight-for-Height Z-score | To calculate WHZ scores the 2006 WHO growth reference will be used (only in cross-sectional survey) | After 48 months of program implementation (only in cross-sectional survey) | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Child Weight-for-height Z-score | To calculate WHZ scores the 2006 WHO growth reference will be used | After 24 months of program implementation | 
| Prevalence of child wasting | To calculate WHZ scores the 2006 WHO growth reference will be used | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Prevalence of child stunting | To calculate WHZ scores the 2006 WHO growth reference will be used | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Child hemoglobin concentration |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Prevalence of child anemia |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Body Mass Index of primary caregiver of index child |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Early child development |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Child morbidity (acute respiratory infections, fever, vomiting, diarrhea) |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Caregiver's knowledge and practices related to Infant and Young Child Feeding (IYCF), child health and hygiene |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Household assets and savings |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Educational level of Household members |  | After 24 months and 48 months of program implementation | 
| Household food security | Measured by the Household Food Insecurity Access Scale (HFIAS) | After 24 months and 48 months of program implementation | 
| Household composition | This entails the household size, the number of one parent households, monogamous and polygamous households, number of infants and children. | After 24 months and 48 months of program implementation | 
| Household agricultural production | The composition and quantity of all crops grown by the houshold over the last year is being recalled | After 24 months and 48 months of program implementation | 
| Cognitive function of the head of household | Measured by spatial Stroop test and digit span test (forward and backward) | After 24 months of program implementation | 
| Well-being of household members | Well-being is assessed by measuring stress, anxiety, psychological well-being, partner violence, marital quality, depression, occurrence of disputes and resource allocation. | After 24 months and 48 months of program implementation | 
| Women's empowerment | Measured by pro-WEAI instrument adapted to local context | After 24 months and 48 months of program implementation | 
| Child dietary diversity | Child dietary diversity is estimated by a dietary diversity score counting food groups consumed | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Professional occupation of household members | We assess if household members have different formal and informal professional occupations or main revenue generating activities between intervention and control group | After 24 months and 48 months of program implementation | 
| Child Mid-upper Arm Circumference |  | After 24 months and 48 months (only in cross-sectional survey) of program implementation | 
| Maternal hemoglobin concentration |  | After 48 months (only in cross-sectional survey) of program implementation | 
| Maternal anemia |  | After 48 months (only in cross-sectional survey) of program implementation | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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behavior change communication, cash transfer, household welfare, child nutrition status