The REFANI Pakistan study—a cluster randomised controlled trial of the effectiveness and cost-effectiveness of cash-based transfer programmes on child nutrition status: study protocol

Abstract

BackgroundCash-based transfer programmes are an emerging strategy in the prevention of wasting in children, especially targeted at vulnerable households during periods of food insecurity or during emergencies. However, the evidence surrounding the use of either cash or voucher transfer programmes in the humanitarian context and on nutritional outcomes is elusive. More evidence is needed not only to inform the global community of practice on best practices in humanitarian settings, but also to help strengthen national mitigation responses.Methods/DesignThe Research for Food Assistance on Nutrition Impact Pakistan study (REFANI-P) sets out to evaluate the impact of three cash-based interventions on nutritional outcomes in children aged less than five years from poor and very poor households in Dadu District. This four-arm parallel cluster randomised controlled trial is set among Action Against Hunger (ACF) programme villages in Dadu District, Sindh Province. Mothers are the target recipients of either seasonal unconditional cash transfers or fresh food vouchers. A comparison group receives ‘standard care’ provided by the ACF programme to which all groups have the same access. The primary outcomes are prevalence of wasting and mean weight-for-height Z-score (WHZ) in children. Impact will be assessed at 6 months and at 1 year from baseline. Using a theory-based approach we will determine ‘how’ the different interventions work by looking at the processes involved and the impact pathways following the theory of change developed for this context. Quantitative and qualitative data are collected on morbidity, health seeking, hygiene and nutrition behaviours, dietary diversity, haemoglobin concentration, women’s empowerment, household food security and expenditures and social capital. The direct and indirect costs of each intervention borne by the implementing organisation and their partners as well as by beneficiaries and their communities are also assessed.DiscussionThe results of this trial will provide robust evidence to help increase knowledge about the predictability of how different modalities of cash-based transfer work best to reduce the risk of child wasting during a season where food insecurity is at its highest. Evidence on costing and cost-effectiveness will further aid decisions on choice of modality in terms of effectiveness and sustainability.Trial registrationCurrent Controlled Trials ISRCTN10761532. Registered 26 March 2015.

A cash-based intervention and the risk of acute malnutrition in children aged 6–59 months living in internally displaced persons camps in Mogadishu, Somalia: A non-randomised cluster trial

“…In the abovementioned study in Pakistan, a reduced prevalence of acute malnutrition was observed only in the arm receiving double the amount of money that the standard CBI recipient received (US$28.00 versus US$14.00 per month); the amounts were designed to cover 20% and 10% of the energy requirements of a typical household, respectively [ 16 ]. However, in our study the cash transfer was designed to cover 100% of the energy requirements of the typical household [ 20 ], but despite this relatively larger transfer, we observed no associated impact on nutritional status.…”

“…Conducted by the Research on Food Assistance for Nutritional Impact (REFANI) consortium, the REFANI–Somalia study is 1 of 3 studies—the other 2 being in Niger and Pakistan [ 16 , 17 ]—that seek to contribute to the evidence base regarding the nutritional impact of humanitarian CBIs. Using a non-randomised cluster design, this study aimed to assess whether a CBI, allocated to beneficiaries following a vulnerability assessment, would improve child dietary diversity and reduce acute malnutrition risk in children aged 6–59 months living in IDP camps near Mogadishu, Somalia.…”

Impact evaluation of different cash-based intervention modalities on child and maternal nutritional status in Sindh Province, Pakistan, at 6 mo and at 1 y: A cluster randomised controlled trial

“…The trial design, setting, and characteristics of the study population have been previously described [16]. …”

Impact of nutrition interventions on pediatric mortality and nutrition outcomes in humanitarian emergencies: A systematic review

“…While more data on cash transfers are needed in specific regions, such as sub‐Saharan Africa, a growing quantity of evidence indicates that cash transfers may improve nutritional outcomes by increasing food supply, money spent on groceries and quality of food consumed . Two ongoing studies aim to assess impacts of cash transfer specifically on paediatric populations in emergency settings .…”