Casino-based cash transfers and fertility among the Eastern Band of Cherokee Indians in North Carolina: A time-series analysis.

Fertility decline remains a key concern among high-income countries. Prior research indicates that income supplementation through unconditional cash transfers (UCT) may correspond with increased fertility. We examine whether a casino-based UCT, in the form of per capita (percap) payments to members of the Eastern Band of Cherokee Indians (EBCI) corresponds with an acute increase in fertility. We use North Carolina vital statistics datasets from 1990 to 2006 and apply time-series analysis methods to examine the relation between specific months of percap payments (exposure) and monthly number of conceptions that result in live births (outcome) among the EBCI. We control for autocorrelation and monthly counts of births (arrayed by conception cohorts) among white women (ineligible for UCT receipt) in the study region. Results indicate an increase in conceptions that result in live births at 1 and 3 months after percap receipt among EBCI women aged ≥20 years (exposure month lag 1 coefficient = 1.74, p = 0.03; exposure month lag 3 coefficient = 1.60, p = 0.04). Exploratory analyses indicate that the observed fertility increase concentrates among primiparae EBCI women. We do not find any association between percap payment timing and births to EBCI women aged <20 years.

Does alleviating poverty increase cognitive performance? Short- and long-term evidence from a randomized controlled trial.

In this Registered Report, we investigated the impact of a cash transfer based poverty alleviation program on cognitive performance. We analyzed data from a randomized controlled trial conducted on low-income, high-risk individuals in Liberia where a random half of the participants (n = 251) received a $200 lump-sum unconditional cash transfer - equivalent approximately to 300% of their monthly income - while the other half (n = 222) did not. We tested both the short-term (2-5 weeks) and the long-term (12-13 months) impact of the treatment via several executive function measures. The observed effect sizes of cash transfers on cognitive performance (b = .13 for the short- and b = .08 for the long-term) were roughly three and four times smaller than suggested by prior non-randomized research. Bayesian analyses revealed that the overall evidence supporting the existence of these effects is inconclusive. A multiverse analysis showed that neither alternative analytical specifications nor alternative processing of the dataset changed the results consistently. However cognitive performance varied between the executive function measures, suggesting that cash transfers may affect the subcomponents of executive function differently.

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.

The impact of a poverty reduction intervention on infant brain activity.

Early childhood poverty is a risk factor for lower school achievement, reduced earnings, and poorer health, and has been associated with differences in brain structure and function. Whether poverty causes differences in neurodevelopment, or is merely associated with factors that cause such differences, remains unclear. Here, we report estimates of the causal impact of a poverty reduction intervention on brain activity in the first year of life. We draw data from a subsample of the Baby's First Years study, which recruited 1,000 diverse low-income mother-infant dyads. Shortly after giving birth, mothers were randomized to receive either a large or nominal monthly unconditional cash gift. Infant brain activity was assessed at approximately 1 y of age in the child's home, using resting electroencephalography (EEG; n = 435). We hypothesized that infants in the high-cash gift group would have greater EEG power in the mid- to high-frequency bands and reduced power in a low-frequency band compared with infants in the low-cash gift group. Indeed, infants in the high-cash gift group showed more power in high-frequency bands. Effect sizes were similar in magnitude to many scalable education interventions, although the significance of estimates varied with the analytic specification. In sum, using a rigorous randomized design, we provide evidence that giving monthly unconditional cash transfers to mothers experiencing poverty in the first year of their children's lives may change infant brain activity. Such changes reflect neuroplasticity and environmental adaptation and display a pattern that has been associated with the development of subsequent cognitive skills.

Effectiveness of unconditional cash transfers combined with lipid-based nutrient supplement and/or behavior change communication to prevent stunting among children in Pakistan: a cluster randomized controlled trial.

BACKGROUND: In Pakistan, the prevalence of stunting among children younger than 5 y has remained above WHO critical thresholds (≥30%) over the past 2 decades. OBJECTIVES: We hypothesized that an unconditional cash transfer (UCT) combined with lipid-based nutrient supplement (LNS) and/or social and behavior change communication (SBCC) will prevent stunting among children 6-23 mo of age. METHODS: This was a 4-arm, community-based cluster randomized controlled trial conducted in the district of Rahim Yar Khan, Pakistan. A total of 1729 children (UCT, n = 434; UCT + SBCC, n = 433; UCT + LNS, n = 430; and UCT + LNS + SBCC, n = 432) were enrolled at 6 mo of age and measured monthly for 18 mo until the age of 24 mo. RESULTS: At 24 mo of age, children who received UCT + LNS [rate ratio (RR): 0.85; 95% CI: 0.74, 0.97; P = 0.015) and UCT + LNS + SBCC (RR: 0.86; 95% CI: 0.77, 0.96; P = 0.007) had a significantly lower risk of being stunted compared with the UCT arm. No significant difference was noted among children who received UCT + SBCC (RR: 1.03; 95% CI: 0.91, 1.16; P = 0.675) in the risk of being stunted compared with the UCT arm. The pooled prevalence of stunting among children aged 6-23 mo was 41.7%, 44.8%, 38.5%, and 39.3% in UCT, UCT + SBCC, UCT + LNS, and UCT + LNS + SBCC, respectively. In pairwise comparisons, a significant impact on stunting among children in UCT + LNS (P = 0.029) and UCT + LNS + SBCC (P = <0.001) was noted compared with the UCT arm. CONCLUSIONS: UCT combined with LNS and UCT + LNS + SBCC were effective in reducing the prevalence of stunting among children aged 6-23 mo in marginalized populations. UCT + SBCC was not effective in reducing the child stunting prevalence. This trial was registered at clinicaltrials.gov as NCT03299218.

Who spent their COVID-19 stimulus payment? Evidence from personal finance software in Japan.

In response to the COVID-19 crisis, governments worldwide have been formulating and implementing different strategies to mitigate its social and economic impacts. We study the household consumption responses to Japan's COVID-19 unconditional cash transfer program. Owing to frequent delays in local governments' administrative procedures, the timing of the payment to households varied unexpectedly. Using this natural experiment, we analyze households' consumption responses to cash transfers using high-frequency data from personal finance management software that links detailed information on expenditure, income, and wealth. We construct three consumption measures: one captures the baseline marginal propensity to consume (MPC), and the other two are for the lower and the upper bound of MPC. Additionally, we explore heterogeneity in MPCs by household income, wealth, and population characteristics, as well as consumption categories. Our results show that households exhibit immediate and non-negligible positive responses in household expenditure. There is significant heterogeneity depending on various household characteristics, with liquidity constraint status being the most crucial factor, in line with the standard consumption theory. Additionally, this study provides policymakers with insights regarding targeted cash transfer programs, conditioning on labor income, and liquidity constraints.

Do cash transfers increase nutritional intakes? Experimental evidence from an unconditional cash transfer in Kenya.

Malnutrition due to persistent food insecurity has been a serious public health issue in Kenya. An unconditional cash transfer programme, the Hunger Safety Net Programme (HSNP), was launched in 2009 in northern Kenya to reduce extreme poverty and to mitigate food insecurity. This study investigates the impact of the HSNP, on expenditure on food, types of food consumed and nutritional intake. Focusing on nutritional intake as well as spending and consumption is important because an unconditional cash transfer, which does not specify how the transferred money must be used, does not guarantee nutritional intake improvement. Converting food consumption data to caloric intake and nutrient content using food consumption databases, we calculate the intake of five macro-nutrients, seven vitamins and seven minerals and then estimate the impacts on nutritional intake 12 and 24 months after treatment exposure. This study finds the increased total expenditure on food items. Specifically, the beneficiary households increased their expenditure on milk and milk products and that on sugar after 12 months and expenditure on roots and tubers after 24 months. For consumption amounts, however, the HSNP did not show significant increases in all food categories except sugar. On the other hand, the HSNP improved the nutritional intakes of some macro- and micro-nutrients. The results show that beneficiary households substantially increased their intake of fat by 25.2% after 24 months and their intake of vitamin B12 by 36.6% and calcium by 34.9% after 12 months. The result does not yield sufficiently strong evidence that poorer households significantly enjoy greater improvements than other households.

Effects of adding psychosocial stimulation for children of lactating mothers using an unconditional cash transfer platform on neurocognitive behavior of children in rural Bangladesh: protocol for a cluster randomized controlled trial.

BACKGROUND: There is sufficient evidence that psychosocial stimulation (PS) benefits children's neurocognitive behavior, however, there is no information on how it works when delivered through an Unconditional Cash Transfer (UCT) platform for poor rural population in developing countries. The objective of this study is to measure effects of adding PS for children of lactating mothers enrolled to receive UCT with health education (HE) on neurocognitive behavior of children in rural Bangladesh. METHODS: The study will be conducted at 11 unions of Ullapara sub-district in Bangladesh. The study is a cluster randomized controlled trial with three-arms; (i) PS and UCT with HE (ii) UCT with HE and iii) Comparison arm. The cluster will be considered as an old Ward of a Union, the lowest tier of local government system in rural Bangladesh. There are three old Wards in a union. These three clusters will be randomized to one of the three arms. Similarly, randomization will be done for each 11 Unions and then 11 clusters will be assigned to an arm. Eighteen participants will be recruited from each cluster randomly (n = 196 in each arm). The intervention designed for one year includes UCT with HE for the poor as a safety net program in rural Bangladesh with or without PS. An age-based curriculum of PS is already available for Bangladeshi children and this will be administered by trained local women; play leaders (PL) in intervention clusters. The government of Bangladesh is providing UCT of taka 500 ($6.25) as maternity allowance per month with HE. The primary outcomes will be cognitive, motor and language composite scores measured by Bayley-III and behavior using Wolke's behavior rating scale. The secondary outcomes will be children and mothers' growth, family food security status, health seeking behavior, mothers' depressive symptoms and self-esteem and violence against mothers. DISCUSSION: The study will provide a unique opportunity to assess an integrated early childhood development intervention using UCT platform to mitigate developmental delays in poor vulnerable children of rural Bangladesh. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03281980, registered on September 13, 2017.

Mobile-Based Nutrition Counseling and Unconditional Cash Transfers for Improving Maternal and Child Nutrition in Bangladesh: Pilot Study.

BACKGROUND: Inappropriate feeding practices, inadequate nutrition knowledge, and insufficient access to food are major risk factors for maternal and child undernutrition. There is evidence to suggest that the combination of cash transfer and nutrition education improves child growth. However, a cost-effective delivery platform is needed to achieve complete, population-wide coverage of these interventions. OBJECTIVE: This study aimed to assess the feasibility, acceptability, and perceived appropriateness of an intervention package consisting of voice messaging, direct counseling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of a child's life in a poor rural community in Bangladesh. METHODS: We conducted a mixed-methods pilot study. We recruited 340 pregnant or recently delivered, lactating women from rural Bangladesh. The intervention consisted of an unconditional cash transfer combined with nutrition counseling, both delivered on a mobile platform. The participants received a mobile phone and BDT 787 per month (US $10). We used a voice messaging service to deliver nutrition-related messages. We provided additional nutrition counseling through a nutrition counselor from a call center. We carried out cross-sectional surveys at baseline and at the end of the study, focus group discussions, and in-depth interviews with participants and their family members. RESULTS: Approximately 89% (245/275) of participants reported that they were able to operate the mobile phones without much trouble. Charging of the mobile handsets posed some challenges since only approximately 45% (124/275) households in our study had electricity at home. Approximately 26% (72/275) women reported they had charged their mobile phones at their neighbor's house, while 34% (94/275) reported that they charged it at a marketplace. Less than 10% (22/275) of women reported difficulties understanding the voice messages or direct counseling through mobile phones, while only 3% (8/275) of women reported they had some problems withdrawing cash from the mobile bank agent. Approximately 87% (236/275) women reported spending the cash to purchase food for themselves and their children. CONCLUSIONS: The nature of our study precludes any conclusion about the effectiveness of the intervention package. However, the high coverage of our intervention and the positive feedback from the mothers were encouraging and support the feasibility, acceptability, and appropriateness of this program. Further research is needed to determine the efficacy and cost-effectiveness of mobile-based nutrition counseling and unconditional cash transfers in improving maternal and child nutrition in Bangladesh.

Using Photo-Elicitation Methods to Understand Resilience Among Ultra-Poor Youth and Their Caregivers in Malawi.

Unconditional cash transfer programs are a form of structural intervention to address poverty, a "fundamental cause" of disease. Such programs increasingly aim to build resilience to sustain improved outcomes and provide a solid foundation for longer term transformations. As such, there is a need to understand what resilience means in specific contexts. The goal of this formative study was to explore local experiences of resilience and vulnerability among 11 youth-caregiver dyads ( n = 22) who were beneficiaries of the Malawi Social Cash Transfer Program in Balaka district. We used a photo-elicitation approach informed by the participatory, visual methodology photovoice to guide the study and conducted an iterative content analysis using thematic coding of transcripts and photos. Participants took pictures of their daily struggles and shocks and participated in audio-recorded discussions to reflect on the photos using an adapted version of the SHOWeD method. We found that participants characterized resilience as a tireless process of using all available individual, family, and community resources at all times in pursuit of survival and well-being. In the context of daily struggles, resilience was an essential part of survival. Shocks, mostly health-related, were depicted through staged images candidly highlighting individual and environmental vulnerabilities. Community support was an essential component of resilience for both daily struggles and shocks. Using photo-elicitation methods facilitated an intergenerational, community-driven reflection on the meaning of resilience and the multilevel determinants of health in a context of extreme poverty. Findings can inform the design of resilience-focused cash transfer programs to improve health equity.

Beneficiaries' perceptions and reported use of unconditional cash transfers intended to prevent acute malnutrition in children in poor rural communities in Burkina Faso: qualitative results from the MAM'Out randomized controlled trial.

BACKGROUND: Acute malnutrition is a public health issue worldwide, and particularly in the Eastern region of Burkina Faso. Following a needs assessment, unconditional seasonal, multiannual cash transfers were implemented as a safety net to prevent childhood undernutrition. The objectives of this study were to explore the types of purchases made by beneficiaries of this cash transfer program and to understand the perceived effects of and changes induced by regular cash transfers in the daily lives of women, and at the household and community level. METHODS: The design of this study was a two-arm cluster randomized controlled trial. Qualitative data were collected each month during the cash transfer period for two years, leading to a total of more than 300 interviews and focus group discussions with various participants: beneficiary mothers, heads of households, mothers-in-law, co-wives, key members of the community, and participants of the control group. RESULTS: The two main types of expenses reported were food and health care for the child and the whole family. The program was also associated with positive perceived changes at the household level, mainly related to gender equality and improvement of women's status, and has promoted an increase in dignity and social integration of the poorest at the community level through cash sharing. Unexpected effects of this program included some women planning new pregnancies and some individuals not expecting the transfers to end. CONCLUSION: Although the transfers were unconditional, the cash was mainly used to improve the children's and households' food security and health, which correspond to two main underlying causes of undernutrition. Therefore, spending mainly in these areas can help to prevent undernutrition in children. TRIAL REGISTRATION: ClinicalTrials.gov , identifier: NCT01866124 , registered May 7, 2013.

Investments in children's health and the Kenyan cash transfer for orphans and vulnerable children: evidence from an unconditional cash transfer scheme.

Child mortality is one of the most pressing global health and policy issues in the developing world. The leading drivers of death-pneumonia, diarrhea and malaria-are preventable and treatable. However, these illnesses are exacerbated by a lack of accessible nutrition, water, basic and preventive health services, and sanitary living conditions-all factors which are more likely to disproportionately impact the poor. We examine whether Kenya's largest social protection impacts children's incidence of upper respiratory illness. The Kenya Cash Transfer for Orphans and Vulnerable Children was designed to support orphans affected by HIV/AIDS and has covered over 240,000 households as of 2014. Using longitudinal, cluster-randomized program data from 2007 to 2009, we run a generalized linear latent and mixed method estimation model on a sample of children 0-7 years and under-5 years of age. We find that the program is associated with a decrease in illness in children 0-7 years of age (P < 0.05), but found no effects on a stratified sample of under-5 children. Furthermore, no impacts on health care seeking in the event of illness were detected. This study is one of few examining children's health using data from a large scale unconditional cash transfer program. With the widespread adoption of over 123 cash transfer programs across sub-Saharan Africa, these findings suggest social cash transfer programs are capable of promoting the multidimensional well-being for the world's most vulnerable populations.

Poverty and perceived stress: Evidence from two unconditional cash transfer programs in Zambia.

INTRODUCTION: Poverty is a chronic stressor that can lead to poor physical and mental health. This study examines whether two similar government poverty alleviation programs reduced the levels of perceived stress and poverty among poor households in Zambia. METHOD: Secondary data from two cluster randomized controlled trials were used to evaluate the impacts of two unconditional cash transfer programs in Zambia. Participants were interviewed at baseline and followed over 36 months. Perceived stress among female caregivers was assessed using the Cohen Perceived Stress Scale (PSS). Poverty indicators assessed included per capita expenditure, household food security, and (nonproductive) asset ownership. Fixed effects and ordinary least squares regressions were run, controlling for age, education, marital status, household demographics, location, and poverty status at baseline. RESULTS: Cash transfers did not reduce perceived stress but improved economic security (per capita consumption expenditure, food insecurity, and asset ownership). Among these poverty indicators, only food insecurity was associated with perceived stress. Age and education showed no consistent association with stress, whereas death of a household member was associated with higher stress levels. CONCLUSION: In this setting, perceived stress was not reduced by a positive income shock but was correlated with food insecurity and household deaths, suggesting that food security is an important stressor in this context. Although the program did reduce food insecurity, the size of the reduction was not enough to generate a statistically significant change in stress levels. The measure used in this study appears not to be correlated with characteristics to which it has been linked in other settings, and thus, further research is needed to examine whether this widely used perceived stress measure appropriately captures the concept of perceived stress in this population.

The use of cash transfers for HIV prevention--are we there yet?

Poverty and social inequality are significant drivers of the HIV epidemic and are risk factors for acquiring HIV. As such, many individuals worldwide are at risk for new HIV infection, especially young women in East and Southern Africa. By addressing these drivers, social protection programmes may mitigate the impact of poverty and social inequality on HIV risk. There is reason to believe that social protection can be used successfully for HIV prevention; social protection programmes, including cash transfers, have led to positive health outcomes and behaviour in other contexts, and they have been used successfully to promote education and increased income and employment opportunities. Furthermore, cash transfers have influenced sexual behaviour of young women and girls, thereby decreasing sexual risk factors for HIV infection. When HIV outcomes have been measured, several randomised controlled trials have shown that indirectly, cash transfers have led to reduced HIV prevalence and incidence. In these studies, school attendance and safer sexual health were directly incentivised through the cash transfer, yet there was a positive effect on HIV outcomes. In this review, we discuss the growth of social protection programmes, their benefits and impact on health, education and economic potential, and how these outcomes may affect HIV risk. We also review the studies that have shown that cash transfers can lead to reduced HIV infection, including study limitations and what questions still remain with regard to using cash transfers for HIV prevention.

The impact of Zambia's unconditional child grant on schooling and work: results from a large-scale social experiment.

This paper reports the impact on child schooling and work of the Government of Zambia's Child Grant Program (CGP), an unconditional cash transfer program targeted to households with children under age 3 years in three districts of the country. Although the CGP's focus is on very young children, we look to see if the program has impacts on older children who are not the explicit target group. We use data from a large-scale social experiment involving 2,519 households, half of whom were randomized out to a delayed-entry control group, that was implemented to assess the impact of the program. We find that the CGP has no discernable impact on school enrollment of children age 7-14. However when we break the sample by older (11-14) and younger (7-10) children - based on the grade structure of the Zambian schooling system - we find a significant impact among children age 11-14 which coincided with the exact age range where sharp drop-out begins to occur in Zambia with point estimates in the range of 7-8 percentage points. Finally, we provide evidence on the potential pathways through which the unconditional cash transfer impacts on enrollment. Households in the CGP spend more on education, and in particular on uniforms and shoes, two items cited as key barriers to school enrollment in study areas.

A multilevel analysis of the effect of Malawi's Social Cash Transfer Pilot Scheme on school-age children's health.

OBJECTIVE: The primary goal was to examine whether Malawi Social Cash Transfer Pilot Scheme, initially implemented in a rural district in central Malawi, improved health outcomes for children aged 6-17. Secondary goals were to examine the effects of individual child- (orphan status and gender) and household-level factors (number of working-age adults and sick adults) on health outcomes. Another secondary goal was to examine whether orphan status modified the cash transfer effect on health outcomes. METHODS: This multilevel study used panel data collected in 2007-08 from a randomized controlled evaluation study of phase one of the programme. The analyses included 1197 children aged 6-17 in 486 households. The four outcomes of interest were: illness in the past month, illness that stopped normal activities in the past month, missing school due to illness or injury in the past month and health care use for worst illness in the past year. FINDINGS: Approximately two-thirds of children in cash transfer eligible households were orphans. Compared with children in non-beneficiary households, those in beneficiary households had a 37% lower odds of child illness (P<0.05), 42% lower odds of illness that stopped normal activities (P<0.01) and substantially higher odds of utilizing health services for a serious illness (odds ratio=10.98; P<0.01). An increase in the household number of working-age adults was associated with 34% lower odds of child illness (P<0.01). An increase in the household number of sick adults increased the odds of child illness by 97% (P<0.01) and serious illness by 49% (P<0.01). No statistically significant differences were observed by orphan status and child's gender. Consistent differential programme effects by orphan status were not observed. CONCLUSION: Unconditional cash transfer programmes to poor households have the potential to improve health outcomes for all vulnerable children aged 6-17.