Effects of unconditional cash transfers on the outcome of treatment for severe acute malnutrition (SAM): a cluster-randomised trial in the Democratic Republic of the Congo

Emmanuel Grellety, Pélagie Babakazo, Amina Bangana, Gustave Mwamba, Ines Lezama, Noël Marie Zagre, Eric-Alain Ategbo, Emmanuel Grellety, Pélagie Babakazo, Amina Bangana, Gustave Mwamba, Ines Lezama, Noël Marie Zagre, Eric-Alain Ategbo

Abstract

Background: Cash transfer programs (CTPs) aim to strengthen financial security for vulnerable households. This potentially enables improvements in diet, hygiene, health service access and investment in food production or income generation. The effect of CTPs on the outcome of children already severely malnourished is not well delineated. The objective of this study was to test whether CTPs will improve the outcome of children treated for severe acute malnutrition (SAM) in the Democratic Republic of the Congo over 6 months.

Methods: We conducted a cluster-randomised controlled trial in children with uncomplicated SAM who received treatment according to the national protocol and counselling with or without a cash supplement of US$40 monthly for 6 months. Analyses were by intention to treat.

Results: The hazard ratio of reaching full recovery from SAM was 35% higher in the intervention group than the control group (adjusted hazard ratio, 1.35, 95% confidence interval (CI) = 1.10 to 1.69, P = 0.007). The adjusted hazard ratios in the intervention group for relapse to moderate acute malnutrition (MAM) and SAM were 0.21 (95% CI = 0.11 to 0.41, P = 0.001) and 0.30 (95% CI = 0.16 to 0.58, P = 0.001) respectively. Non-response and defaulting were lower when the households received cash. All the nutritional outcomes in the intervention group were significantly better than those in the control group. After 6 months, 80% of cash-intervened children had re-gained their mid-upper arm circumference measurements and weight-for-height/length Z-scores and showed evidence of catch-up. Less than 40% of the control group had a fully successful outcome, with many deteriorating after discharge. There was a significant increase in diet diversity and food consumption scores for both groups from baseline; the increase was significantly greater in the intervention group than the control group.

Conclusions: CTPs can increase recovery from SAM and decrease default, non-response and relapse rates during and following treatment. Household developmental support is critical in food insecure areas to maximise the efficiency of SAM treatment programs.

Trial registration: ClinicalTrials.gov, NCT02460848 . Registered on 27 May 2015.

Keywords: CMAM; Cash transfer; Cluster-randomised trial; Community-based management of acute malnutrition; Democratic Republic of the Congo; Malnutrition; Severe acute malnutrition.

Figures

Fig. 1
Fig. 1
Trial flow chart of the study. Recovery was defined as a WHZ ≥ −1.5 (WHO Growth Standards 2006) or MUAC ≥125 mm at two consecutive visits and absence of bilateral oedema for at least 14 days. Non-response was defined as not meeting the criteria for nutritional recovery at 12 weeks and default as failing to appear for two consecutive follow-up visits confirmed by a home visit. Defaulter was defined as a patient absent for two consecutive visits and confirmed as absent by a home visit at week 3. Relapse to MAM was defined as the development of a WHZ < –2.0 and ≥ –3.0 (WHO Growth Standards 2006) or MUAC <125 mm and ≥115 mm (without bilateral oedema) at least once during the monthly follow-up visits without the child developing SAM criteria during any other follow-up visit. Relapse to SAM was defined as development of a WHZ < −3.0 (WHO Growth Standards 2006) or MUAC <115 mm or presence of bilateral oedema at least once during the monthly follow-up visits. Unknown was defined as defaulter not confirmed by a home visit or as no information for children at the end of the trial. Withdrawal from the study was defined as participants who had to stop the study for personal reasons
Fig. 2
Fig. 2
Probability of failure to achieve and maintain nutritional recovery during treatment and follow-up to 6 months from enrolment in the two study groups. Failure of nutritional recovery was defined as dead, non-response to treatment after 12 weeks, a defaulter, a relapse to either SAM or MAM or unknown at 6 months from enrolment. Children were right censored where their nutritional recovery was defined as a WHZ ≥ −1.5 (WHO Growth Standards 2006) or MUAC ≥125 mm and absence of bilateral oedema and they did not relapse. Survival curves of the two groups were compared using the Cox regression analyses with robust estimates of the variance to account for clustering at the health centre level, and P value was performed with the robust score test (HR = 0.24, 95% CI 015 to 0.39; P < 0.001)

References

    1. Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, Ezzati M, Grantham-McGregor S, Katz J, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382:427–51. doi: 10.1016/S0140-6736(13)60937-X.
    1. World Health Organization, World Food Programme, United Nations System Standing Committee on Nutrition, United Nations Children's Fund . Community-based management of severe acute malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children's Fund. Geneva: World Health Organization; 2007.
    1. World Health Organization, United Nations Children's Fund . WHO child growth standards and the identification of severe acute malnutrition in infants and children. A joint statement by the World Health Organization and the United Nations Children's Fund. Geneva: World Health Organization; 2009.
    1. World Health Organization . Guideline update: technical aspects of the management of severe acute malnutrition in infants and children. Geneva: World Health Organization; 2013.
    1. Sen A. Poverty and famines: an essay on entitlement and deprivation. Oxford: Oxford University Press; 1981.
    1. Young H, Jaspars S. Nutrition, disease and death in times of famine. Disasters. 1995;19(2):94–109. doi: 10.1111/j.1467-7717.1995.tb00361.x.
    1. Devereux S. Sen's entitlement approach: critiques and counter-critiques. Oxf Dev Stud. 2001;29(3):245–63. doi: 10.1080/13600810120088859.
    1. Ruel M, Alderman H, the Maternal and Child Nutrition Study Group Nutrition-sensitive interventions and programmes: how can they help to accelerate progress in improving maternal and child nutrition? Lancet. 2013;382:536–51. doi: 10.1016/S0140-6736(13)60843-0.
    1. The High Level Panel on Humanitarian Cash Transfers. Doing cash differently: how cash transfers can transform humanitarian aid. Overseas Development Institute 2015. . Accessed 16 Jan 2017.
    1. Lagarde M, Haines A, Palmer N. The impact of conditional cash transfers on health outcomes and use of health services in low and middle income countries. A systematic review. Cochrane Database Syst Rev. 2009;4
    1. Leroy JL, Ruel M, Verhofstadt E. The impact of conditional cash transfer programmes on child nutrition: a review of evidence using a programme theory framework. J Dev Eff. 2009;1(2):103–29. doi: 10.1080/19439340902924043.
    1. Adato M, Hoddinott J. Conditional cash transfers in Latin America. International Food Policy Research Institue. Baltimore: Johns Hopkins University Press; 2010.
    1. Fernald LCH, Gertler P, Hidrobo M. Conditional cash transfer programs: effects on growth, health, and development in young children. In: Maholmes V, Kings RB, editors. The Oxford handbook of poverty and child development. New York: Oxford University Press; 2012.
    1. Glassman A, Duran D, Fleisher L, Singer D, Sturke R, Angeles G, Koblinsky M. Impact of conditional cash transfers on maternal and newborn health. J Health Popul Nutr. 2013;31(4 Suppl 2):S48.
    1. Van de Bold M, Quisumbing AR, Gillespie S. Women’s empowerment and nutrition: an evidence review. IFPRI discussion paper 01294. Washington, DC: International Food Policy Research Institute (IFPRI); 2013.
    1. Owusu-Addo E, Cross R. The impact of conditional cash transfers on child health in low- and middle-income countries: a systematic review. Int J Public Health. 2014;59(4):609–18. doi: 10.1007/s00038-014-0570-x.
    1. de Groot R, Palermo T, Handa S, Ragno LP, Peterman A. Cash transfers and child nutrition: what we know and what we need to know. Innocenti Working Paper No.2015-07, UNICEF Office of Research, Florence, 2015. . Accessed 16 Jan 2017.
    1. Miller CM, Tsoka M, Reichert K. Impact evaluation report: external evaluation of the Mchinji Social Cash Transfer Pilot. Center for International Health and Development, Boston University School of Public Health, Boston, MA, and Centre for Social Research University of Malawi, 2008. . Accessed 16 Jan 2017.
    1. Oxford Policy Management. Kenya Hunger Safety Net Programme monitoring and evaluation component: impact evaluation final report: 2009 to 2012. Oxford, UK, 2013. . Accessed 16 Jan 2017
    1. Seidenfeld D, Handa S, Tembo G, Michelo S, Harland Scott C, Prencipe L. The impact of an unconditional cash transfer on food security and nutrition: the Zambia Child Grant Programme. 2014. . Accessed 16 Jan 2017.
    1. Adato M, Bassett L. Social protection to support vulnerable children and families: the potential of cash transfers to protect education, health and nutrition, AIDS Care: Psychological and Socio-medical Aspects of AIDS/HIV 2009;21:S1:60–75.
    1. Handa S, Peterman A, Seidenfeld D, Tembo G. Income transfers and maternal health: evidence from a national randomized social cash transfer program in Zambia. Health Econ. 2016;25(2):225–36. doi: 10.1002/hec.3136.
    1. Agüero JM, Carter MR, Woolard I. The impact of unconditional cash transfers on nutrition: the South African Child Support Grant. Southern Africa Labour and Development Research Unit working paper number 06/08. Cape Town: SALDRU, University of Cape Town; 2006.
    1. Poulsen L, Fabre D. Cash transfer for protection of blanket feeding: Maradi and Tahoua Regions: independent final evaluation. 2011.
    1. Dunn S, Brewin M, Scek A. Cash and Voucher Monitoring Group final monitoring report of the Somalia Cash and Vvoucher Transfer Programme. Phase 2: April 2012–March 2013. Humanitarian Policy Group/Overseas Development Institute, 2012. . Accessed 16 Jan 2017
    1. Ministère du Plan et Suivi de la Mise en œuvre de la Révolution de la Modernité, en collaboration avec le Ministère de la Santé Publique . Enquête Démographique et de Santé, République Démocratique du Congo (EDS-RDC) 2013–2014. Rockville: Measure DHS; 2014.
    1. United Nations International Children Emergency Fund. Integrated management of acute malnutrition programme and stocks report. West and Central Africa Regional Office IMAM report, 2015. . Accessed 16 Jan 2017
    1. Lundy M, Gottret MV, Ostertag C, Best R, Ferris S. Participatory market chain analysis for smallholder producers. Good practice guide 4 (No. 357). The International Centre for Tropical Agriculture, 2007. . Accessed 16 Jan 2017.
    1. Holzmann P, Boudreau T, Holt J, Lawrence M, O’Donnell M. The household economy approach: a guide for programme planners and policy-makers. 2008.
    1. Kaliyaperumal K. Guideline for conducting a knowledge, attitude and practice (KAP) study. AECS Illumination. 2004;4(1):7–9.
    1. Burza S, Mahajan R, Marino E, Sunyoto T, Shandilya C, Tabrez M, Kumar K, Jha A, Mathew P, Salse N, et al. Seasonal effect and long-term nutritional status following exit from a community-based management of severe acute malnutrition program in Bihar, India. Eur J Clin Nutr. 2016;70:437–44. doi: 10.1038/ejcn.2015.140.
    1. Ministère de la Santé Publique, Secrétariat General. Protocole national de prise en charge intégrée de la malnutrition aigüe (PCIMA) République Démocratique du Congo, 2012. . Accessed 16 Jan 2017.
    1. WHO child growth standards. Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-forage: methods and development. Geneva: World Health Organization, 2006. . Accessed 16 Jan 2017.
    1. World Health Organization. Nutrition for Health. WHO child growth standards: growth velocity based on weight, length and head circumference: methods and development. World Health Organization, 2009. . Accessed 16 Jan 2017.
    1. Swindale A, Bilinsky P. Household Dietary Diversity Score (HDDS) for measurement of household food access: Indicator Guide version 2. Washington, DC: Food and Nutrition Technical Assistance Project (FANTA), Academy for Educational Development, 2006. . Accessed 16 Jan 2017
    1. World Food Programme, Vulnerability Analysis and Mapping Branch. Food consumption analysis calculation and use of the food consumption score in food security analysis: Version 1, 2008. . Accessed 16 Jan 2017.
    1. Kennedy G, Ballard T, Dop MC. Guidelines for measuring household and individual dietary diversity. 2011.
    1. Erba G. UNICEF’s Alternative Responses for Communities in Crisis (ARCC) programme – the largest humanitarian multi-purpose unconditional cash transfer program in the DRC. The Cash Learning Partnership 2016. . Accessed 16 Jan 2017
    1. World Health Organization. WHO Child Growth Standards: methods and development: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age. World Health Organisation, 2006. . Accessed 16 Jan 2017.
    1. Van den Broeck J, Cunningham SA, Eeckels R, Herbst K. Data cleaning: detecting, diagnosing, and editing data abnormalities. PLoS Med. 2005;2 doi: 10.1371/journal.pmed.0020267.
    1. Andersen R. Modern methods for robust regression. Sage University Paper Series on quantitative applications in the social sciences. Thousand Oaks: Sage Publishing; 2008.
    1. Akakpo K, Randriamamonjy J. Comprehensive food security and vulnerability analysis (CFSVA): Democratic Republic of Congo. World Food Programme, Department of Food Security Analysis (VAM), 2014. . Accessed 16 Jan 2017
    1. Trehan I, Manary MJ. Management of severe acute malnutrition in low-income and middle-income countries. Arch Dis Child. 2015;100:283–7. doi: 10.1136/archdischild-2014-306026.
    1. O'Neill SM, Fitzgerald A, Briend A, Van Den Broeck J. Child mortality as predicted by nutritional status and recent weight velocity in children under two in rural Africa. J Nutr. 2012;142:520–5. doi: 10.3945/jn.111.151878.
    1. Van Den Broeck J, Eeckels R, Vuylsteke J. Influence of nutritional status on child mortality in rural Zaire. Lancet. 1993;341:1491–5. doi: 10.1016/0140-6736(93)90632-Q.
    1. Van Den Broeck J, Eeckels R. Effect of malnutrition on child mortality. Lancet. 1994;344:273. doi: 10.1016/S0140-6736(94)93041-4.
    1. Bahwere P, Mtimuni A, Sadler K, Theresa B, Collins S. Long term mortality after community and facility based treatment of severe acute malnutrition: Analysis of data from Bangladesh, Kenya, Malawi and Niger. J Public Health Epidemiol. 2012;4:215–25. doi: 10.5897/JPHE11.212.
    1. Grellety E, Shepherd S, Roederer T, Manzo ML, Doyon S, Ategbo EA, Grais RF. Effect of mass supplementation with ready-to-use supplementary food during an anticipated nutritional emergency. PloS One. 2012;7(9) doi: 10.1371/journal.pone.0044549.
    1. Abbeddou S, Hess SY, Yakes Jimenez E, Somé JW, Vosti SA, Guissou RM, Ouédraogo JB, Brown KH. Comparison of methods to assess adherence to small‐quantity lipid‐based nutrient supplements (SQ‐LNS) and dispersible tablets among young Burkinabé children participating in a community‐based intervention trial. Matern Child Nutr. 2015;11(S4):90–104. doi: 10.1111/mcn.12162.
    1. Golden MH. Proposed recommended nutrient densities for moderately malnourished children. Food Nutr Bull. 2009;30(3 suppl3):S267–342. doi: 10.1177/15648265090303S302.
    1. Kehoe SH, Chheda PS, Sahariah SA, Baird J, Fall CH. Reporting of participant compliance in randomized controlled trials of nutrition supplements during pregnancy. Matern Child Nutr. 2009;5(2):97–103. doi: 10.1111/j.1740-8709.2008.00178.x.
    1. Arimond M, Ruel MT. Dietary diversity is associated with child nutritional status: evidence from 11 demographic and health surveys. J Nutr. 2004;134(10):2579–85.
    1. Moursi MM, Arimond M, Dewey KG, Treche S, Ruel MT, Delpeuch F. Dietary diversity is a good predictor of the micronutrient density of the diet of 6- to 23-month-old children in Madagascar. J Nutr. 2008;138:2448–53. doi: 10.3945/jn.108.093971.
    1. Lutter CK, Daelmans BM, de Onis M, Kothari M, Ruel MT, Arimond M, Deitchler M, Dewey KG, Blössner M, Borghi E. Undernutrition, poor feeding practices, and low coverage of key nutrition interventions. Pediatrics. 2011;128:e1418–27. doi: 10.1542/peds.2011-1392.
    1. Golden MH. The nature of nutritional deficiency in relation to growth failure and poverty. Acta Paediatrica. 1991;80(s374):95–110. doi: 10.1111/j.1651-2227.1991.tb12012.x.
    1. Chang CY, Trehan I, Wang RJ, Thakwalakwa C, Maleta K, Deitchler M, Manaryet MJ. Children successfully treated for moderate acute malnutrition remain at risk for malnutrition and death in the subsequent year after recovery. J Nutr. 2013;143:215–20. doi: 10.3945/jn.112.168047.
    1. Kerac M, Bunn J, Chagaluka G, Bahwere P, Tomkins A, Collins S, Seal A. Follow-up of post-discharge growth and mortality after treatment for severe acute malnutrition (FuSAM study): a prospective cohort study. Plos One. 2014;9 doi: 10.1371/journal.pone.0096030.
    1. Ashraf H, Alam NH, Chisti MJ, Mahmud SR, Hossain MI, Ahmed T, Salam MA, Gyr N. A follow-up experience of 6 months after treatment of children with severe acute malnutrition in Dhaka, Bangladesh. J Trop Pediatr. 2012;58:253–7. doi: 10.1093/tropej/fmr083.
    1. Khanum S, Ashworth A, Huttly SR. Growth, morbidity, and mortality of children in Dhaka after treatment for severe malnutrition: a prospective study. Am J Clin Nutr. 1998;67:940–5.
    1. Chisti MJ, Graham SM, Duke T, Ahmed T, Faruque ASG, Ashraf H, Bardhan PK, Shahid AS, Shahunja KM, Salamet MA. Post-discharge mortality in children with severe malnutrition and pneumonia in Bangladesh. Plos One. 2014;9 doi: 10.1371/journal.pone.0107663.
    1. Reneman L, Derwig J. Long-term prospects of malnourished children after rehabilitation at the Nutrition Rehabilitation Centre of St Mary's Hospital, Mumias, Kenya. J Trop Pediatr. 1997;43:293–6. doi: 10.1093/tropej/43.5.293.
    1. Somasse Y, Dramaix M, Bahwere P, Donnen P. Relapses from acute malnutrition and related factors in a community-based management programme in Burkina Faso. Matern Child Nutr. 2015
    1. Trehan I, Banerjee S, Murray E, Ryan KN, Thakwalakwa C, Maleta KM, Manary MJ. Extending supplementary feeding for children younger than 5 years with moderate acute malnutrition leads to lower relapse rates. J Pediatr Gastroenterol Nutr. 2015;60:544–9. doi: 10.1097/MPG.0000000000000639.
    1. Langendorf C, Roederer T, De Pee S, Brown D, Doyon S, Mamaty AA, Touré LWM, Manzo ML, Grais RF. Preventing acute malnutrition among young children in crises: a prospective intervention study in Niger. PLoS Med. 2014;11 doi: 10.1371/journal.pmed.1001714.
    1. Golden MH. Nutritional and other types of oedema, albumin, complex carbohydrates and the interstitium. Paediatr Int Child Health. 2015;35:90–109. doi: 10.1179/2046905515Y.0000000010.
    1. Margolies A, Hoddinott J. Costing alternative transfer modalities. J Dev Eff. 2014
    1. Humanitarian Outcomes team . Final evaluation of the unconditional cash and voucher response to the 2011–12 crisis in Southern and Central Somalia. New York: UNICEF; 2012.
    1. Cash Learning Partnership. Ban Ki-moon — give people cash not goods as best form of assistance in emergency. Cash Learning Partnership (CaLP) press release, 2016. . Accessed 16 Jan 2017.
    1. UN General Assembly. One humanity: shared responsibility — Report of the Secretary-General for the World Humanitarian Summit. United Nations Seventieth session 2016. . Accessed 16 Jan 2017.
    1. Heikens GT, Schofield WN, Dawson S, Grantham-McGregor SM. The Kingston project. I. Growth of malnourished children during rehabilitation in the community, given a high energy supplement. Eur J Clin Nutr. 1989;43:145–60.
    1. Isanaka S, Nombela N, Djibo A, Poupard M, Van Beckhoven D, Gaboulaud V, Guerin PJ, Grais RF. Effect of preventive supplementation with ready-to-use-therapeutic food on the nutritional status, mortality and morbidity of children 6 to 60 months in Niger: a cluster randomized trial. JAMA. 2009;301(3):277–85. doi: 10.1001/jama.2008.1018.
    1. Walker SP, et al. Growth in length of children recovering from severe malnutrition. Eur J Clin Nutr. 1988;42:395–404.
    1. Golden MH. Is complete catch-up possible for stunted malnourished children? Eur J Clin Nutr. 1994;48(Suppl 1):S58–70.
    1. Martorell R, Khan LK, Schroeder DG. Reversibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nutr. 1994;48(Suppl 1):S45–57.
    1. Grellety E, Golden MH. Weight-for-height and mid-upper-arm circumference should be used independently to diagnose acute malnutrition: policy implications. BMC Nutr. 2016;2:1–17. doi: 10.1186/s40795-016-0049-7.

Source: PubMed

Sponsors et collaborateurs

Les conditions médicales

Interventions en matière de drogue

3
S'abonner