Effects of multiannual, seasonal unconditional cash transfers on food security and dietary diversity in rural Burkina Faso: the Moderate Acute Malnutrition Out (MAM'Out) cluster-randomized controlled trial.

OBJECTIVE: To evaluate the impact of multiannual, seasonal unconditional cash transfers (UCT) provided within the Moderate Acute Malnutrition Out (MAM'Out) research project on households' food security and children's and caregivers' dietary diversity. DESIGN: A two-arm cluster-randomized controlled trial with sixteen villages in the intervention group and sixteen others in the control group. A monthly allowance of 10 000 XOF was transferred to caregivers of eligible children via a personal mobile phone account from July to November 2013 and 2014. SETTING: Tapoa province in the eastern region of Burkina Faso. PARTICIPANTS: Data on household food access (monthly adequate household food provisioning (MAHFP); household food insecurity access scale (HFIAS)) and maternal and child dietary diversity were analysed for 1143 households, 1219 caregivers of reproductive age (15-49 years) and 1247 under-5 children from both intervention and control groups. RESULTS: The mean women dietary diversity score in intervention caregivers and the mean dietary diversity score (DDS) in intervention children with inadequate minimum DDS at baseline were respectively 7 % (95 % CI 2, 11 %; P = 0·002) and 17 % (95 % CI 11, 23 %; P <0·001) higher compared with the control group. However, no difference was found in the intervention effect on household food security measured with HFIAS (relative risk = 1·03; 95 % CI 0·92, 1·15; P = 0·565) and MAHFP (relative risk = 0·98; 95 % CI 0·96, 1·01; P = 0·426). CONCLUSIONS: Multiannual, seasonalUCT increased dietary diversity in children and their caregivers. They can be recommended in actions aiming to improve maternal and child diet diversity.

Costs and cost-efficiency of a mobile cash transfer to prevent child undernutrition during the lean season in Burkina Faso: a mixed methods analysis from the MAM'Out randomized controlled trial.

BACKGROUND: This study assessed the costs and cost-efficiency of a mobile cash transfer implemented in Tapoa Province, Burkina Faso in the MAM'Out randomized controlled trial from June 2013 to December 2014, using mixed methods and taking a societal perspective by including costs to implementing partners and beneficiary households. METHODS: Data were collected via interviews with implementing staff from the humanitarian agency and the private partner delivering the mobile money, focus group discussions with beneficiaries, and review of accounting databases. Costs were analyzed by input category and activity-based cost centers. cost-efficiency was analyzed by cost-transfer ratios (CTR) and cost per beneficiary. Qualitative analysis was conducted to identify themes related to implementing electronic cash transfers, and barriers to efficient implementation. RESULTS: The CTR was 0.82 from a societal perspective, within the same range as other humanitarian transfer programs; however the intervention did not achieve the same degree of cost-efficiency as other mobile transfer programs specifically. Challenges in coordination between humanitarian and private partners resulted in long wait times for beneficiaries, particularly in the first year of implementation. Sensitivity analyses indicated a potential 6% reduction in CTR through reducing beneficiary wait time by one-half. Actors reported that coordination challenges improved during the project, therefore inefficiencies likely would be resolved, and cost-efficiency improved, as the program passed the pilot phase. CONCLUSIONS: Despite the time required to establish trusting relationships among actors, and to set up a network of cash points in remote areas, this analysis showed that mobile transfers hold promise as a cost-efficient method of delivering cash in this setting. Implementation by local government would likely reduce costs greatly compared to those found in this study context, and improve cost-efficiency especially by subsidizing expansion of mobile money network coverage and increasing cash distribution points in remote areas which are unprofitable for private partners.

Unconditional Seasonal Cash Transfer Increases Intake of High-Nutritional-Value Foods in Young Burkinabe Children: Results of 24-Hour Dietary Recall Surveys within the Moderate Acute Malnutrition Out (MAM'Out) Randomized Controlled Trial.

Background: Cash transfer programs have the potential to improve dietary intake by improving accessibility to food. However, quantitative data on the impact of cash transfer programs on children's energy and nutrient intakes are lacking.Objective: The aim of this study was to evaluate the effect of seasonal unconditional cash transfers on children's energy, micro- and macronutrient, and food group intakes during the lean season in Burkina Faso.Methods: Within the framework of the MAM'Out (Moderate Acute Malnutrition Out) cluster-randomized controlled trial, two 24-h dietary recall surveys were conducted in July and August 2014. Daily energy and macro- and micronutrient intakes, breastfeeding practices, and food group consumption were analyzed for 322 children aged 14-27 mo from an intervention group (benefiting from unconditional cash transfer during the lean season in 2013 and 2014) and a control group by using mixed linear, logistic, and Poisson regression models or a γ-generalized linear model with log-link. A dietary diversity score was calculated on the basis of 7 food groups.Results: Unconditional cash transfers during the lean season improved the diets of rural children through a higher consumption of eggs (11.3 ± 1.55 compared with 3.25 ± 0.79 g; P < 0.001), fat (20.6 ± 0.80 compared with 16.5 ± 0.89 g; P < 0.01), and vitamin B-12 (0.40 ± 0.02 compared with 0.34 ± 0.02 mg; P < 0.001) compared with controls and higher proportions of children consuming dairy products (OR: 4.14; 95% CI: 1.48, 11.6; P < 0.05), flesh foods (OR: 2.09; 95% CI: 1.18, 3.70; P < 0.05), and iron-rich or iron-fortified foods (OR: 2.23; 95% CI: 1.20, 4.13; P < 0.05). No difference was found in energy intake between the 2 groups. The minimum dietary diversity of two-thirds of the children who benefited from cash transfers was adequate compared with only one-third in the control group (P < 0.001).Conclusions: Unconditional seasonal cash transfer increases intakes of high-nutritional-value foods in Burkinabe children aged 14-27 mo. As such, their use can be recommended in actions addressing children's dietary intake during the lean season. This trial was registered at clinicaltrials.gov as NCT01866124.

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.

Unconditional Cash Transfers Do Not Prevent Children's Undernutrition in the Moderate Acute Malnutrition Out (MAM'Out) Cluster-Randomized Controlled Trial in Rural Burkina Faso.

Background: Limited evidence is available on the impact that unconditional cash transfer (UCT) programs can have on child nutrition, particularly in West Africa, where child undernutrition is still a public health challenge.Objective: This study examined the impact of a multiannual, seasonal UCT program to reduce the occurrence of wasting (weight-for-height, midupper arm circumference), stunting (height-for-age), and morbidity among children <36 mo old in Tapoa Province, in the eastern region of Burkina Faso.Methods: The study was designed as a 2-arm cluster-randomized controlled trial, with 32 villages randomly assigned to either the intervention or the control group. The study population comprised households that were classified as poor or very poor according to household economy approach criteria and that had ≥1 child <1 y of age at inclusion. The intervention consisted of seasonal UCTs, provided monthly from July to November, over 2 y (2013 and 2014). A monthly allowance of 10,000 West African Financial Community of Africa francs (∼US$17) was given by mobile phone to mothers in participating households. Anthropometric measurements and morbidity were recorded on a quarterly basis.Results: We found no evidence that multiannual, seasonal UCTs reduced the cumulative incidence of wasting in young children [incidence rate ratio: 0.92 (95% CI: 0.64, 1.32); P = 0.66]. We observed no significant difference (P > 0.05) in children's anthropometric measurements and stunting between the 2 groups at the end point. However, children in the intervention group had a lower risk [21% (95% CI: 18.6%, 21.3%); P < 0.001] of self-reported respiratory tract infections than did children in the control group.Conclusions: We found that seasonal UCTs in the framework of safety nets did not result in a significant decrease in the incidence of acute malnutrition among children in Tapoa Province. Cash transfers combined with complementary interventions targeted to child nutrition and health should be investigated further. This trial was registered at clinicaltrials.gov as NCT01866124.

The MAM'Out project: a randomized controlled trial to assess multiannual and seasonal cash transfers for the prevention of acute malnutrition in children under 36 months in Burkina Faso.

BACKGROUND: Wasting is a public health issue but evidence gaps remain concerning preventive strategies not primarily based on food products. Cash transfers, as part of safety net approach, have potential to prevent under-nutrition. However, most of the cash transfer programs implemented and scientifically evaluated do not have a clear nutritional objective, which leads to a lack of evidence regarding their nutritional benefits. METHODS/DESIGN: The MAM'Out research project aims at evaluating a seasonal and multiannual cash transfer program to prevent acute malnutrition in children under 36 months, in terms of effectiveness and cost-effectiveness in the Tapoa province (Eastern region of Burkina Faso, Africa). The program is targeted to economically vulnerable households with children less than 1 year old at the time of inclusion. Cash is distributed to mothers and the transfers are unconditional, leading to beneficiaries' self-determination on the use of cash. The study is designed as a two-arm cluster randomized intervention trial, based on the randomization of rural villages. One group receives cash transfers via mobile phones and one is a control group. The main outcomes are the cumulative incidence of acute malnutrition and the cost-effectiveness. Child anthropometry (height, weight and MUAC) is followed, as well as indicators related to dietary diversity, food security, health center utilization, families' expenses, women empowerment and morbidities. 24 h-food recalls are also carried out. Individual interviews and focus group discussions allow collecting qualitative data. Finally, based on a theory framework built a priori, the pathways used by the cash to have an effect on the prevention of under-nutrition will be assessed. DISCUSSION: The design chosen will lead to a robust assessment of the effectiveness of the proposed intervention. Several challenges appeared while implementing the study and discrepancies with the research protocol, mainly due to unforeseen events, can be highlighted, such as delay in project implementation, switch to e-data collection and implementation of a supervision process. TRIAL REGISTRATION: ClinicalTrials.gov, identifier: NCT01866124, registered May 7, 2013.