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- Title
Evaluation of conditional cash transfers and mHealth audio messaging in reduction of risk factors for childhood malnutrition in internally displaced persons camps in Somalia: A 2 × 2 factorial cluster-randomised controlled trial.
- Authors
Grijalva-Eternod, Carlos S.; Jelle, Mohamed; Mohamed, Hani; Waller, Katie; Osman Hussein, Bishar; Barasa, Emmanuel; Solomon, Andrea; Mehjabeen, Sajia; Copas, Andrew; Fottrell, Edward; Seal, Andrew J.
- Abstract
Background: Cash transfer programmes are increasingly used in humanitarian contexts to help address people's needs across multiple sectors. However, their impact on the key objectives of reducing malnutrition and excess mortality remains unclear. mHealth interventions show great promise in many areas of public health, but evidence for their impact on reducing the risk factors for malnutrition is uncertain. We therefore implemented a trial to determine the impacts of 2 interventions in a protracted humanitarian context, a cash transfer conditionality and mHealth audio messages. Methods and findings: A 2 × 2 factorial cluster-randomised trial was implemented in camps for internally displaced people (IDP) near Mogadishu, Somalia, starting in January 2019. The main study outcomes were assessed at midline and endline and included coverage of measles vaccination and the pentavalent immunisation series, timely vaccination, caregiver's health knowledge, and child diet diversity. Twenty-three clusters (camps) were randomised to receive or not receive conditional cash transfers (CCTs) and an mHealth intervention, and 1,430 households were followed up over 9 months. All camps received cash transfers made at emergency humanitarian level (US$70/household/month) for 3 months followed by a further 6 months at a safety net level (US$35). To be eligible to receive cash, households in camps receiving CCT were required to take their children <5 years age to attend a single health screening at a local clinic and were issued with a home-based child health record card. Participants in camps receiving the mHealth intervention were asked (but not required) to listen to a series of audio messages about health and nutrition that were broadcast to their mobile phone twice a week for 9 months. Participants and investigators were not blinded. Adherence to both interventions was monitored monthly and found to be high (>85%). We conducted intention-to-treat analysis. During the humanitarian intervention phase, the CCT improved coverage of measles vaccination (MCV1) from 39.2% to 77.5% (aOR 11.7, 95% CI [5.2, 26.1]; p < 0.001) and completion of the pentavalent series from 44.2% to 77.5% (aOR 8.9, 95% CI [2.6, 29.8]; p = < 0.001). By the end of the safety net phase, coverage remained elevated from baseline at 82.2% and 86.8%, respectively (aOR 28.2, 95% CI [13.9, 57.0]; p < 0.001 and aOR 33.8, 95% CI [11.0, 103.4]; p < 0.001). However, adherence to timely vaccination did not improve. There was no change in the incidence of mortality, acute malnutrition, diarrhoea, or measles infection over the 9 months of follow-up. Although there was no evidence that mHealth increased Mother's knowledge score (aOR 1.32, 95% CI [0.25, 7.11]; p = 0.746) household dietary diversity increased from a mean of 7.0 to 9.4 (aOR 3.75, 95% CI [2.04, 6.88]; p < 0.001). However, this was not reflected by a significant increase in child diet diversity score, which changed from 3.19 to 3.63 (aOR 2.1, 95% CI [1.0, 4.6]; p = 0.05). The intervention did not improve measles vaccination, pentavalent series completion, or timely vaccination, and there was no change in the incidence of acute malnutrition, diarrhoea, measles infection, exclusive breastfeeding, or child mortality. No significant interactions between the interventions were found. Study limitations included the limited time available to develop and test the mHealth audio messages and the necessity to conduct multiple statistical tests due to the complexity of the study design. Conclusions: A carefully designed conditionality can help achieve important public health benefits in humanitarian cash transfer programmes by substantially increasing the uptake of child vaccination services and, potentially, other life-saving interventions. While mHealth audio messages increased household diet diversity, they failed to achieve any reductions in child morbidity, malnutrition, or mortality. Trial registration: ISRCTN ISRCTN24757827. Registered November 5, 2018. In a 2x2 factorial cluster-randomised controlled trial, Andrew Seal and colleagues evaluate the impact of conditional cash transfers and mHealth audio messaging on childhood malnutrition in internally displaced persons camps in Somalia. Author summary: Why was this study done?: The use of cash transfers in humanitarian emergencies is commonplace, but there is limited information on how they impact child mortality or acute malnutrition. Conditional cash transfers are not frequently used in humanitarian programming, despite their ability to promote healthy behaviours. mHealth, or mobile health, is a term used for the practice of medicine and public health supported by mobile devices. The use of complementary interventions, such as mHealth behaviour change communication, may help to increase the impact of cash transfers on health and nutrition outcomes. What did the researchers do and find?: During 2019, we conducted a 9-month, cluster-randomised controlled trial, in camps for displaced people near to Mogadishu in Somalia. Using a 2 × 2 factorial design, we studied the use of a cash conditionality and mHealth audio messages to improve health-seeking behaviour and reduce risk factors for malnutrition. The conditionality involved a one time point health screening, and 2 audio messages were broadcast to participant's phones, each week for 8 months. Cash conditionality significantly improved the coverage of measles and pentavalent vaccination, although timely vaccination for all antigens did not improve. The mHealth intervention did not improve any of the primary trial outcomes, although it was associated with a higher household diet diversity. What do these findings mean?: mHealth audio messages were well accepted, and further work to refine and iteratively test them may be useful. A carefully designed, simple, cash conditionality can substantially improve coverage of key public health interventions and help reduce the risk factors for malnutrition and excess mortality in a humanitarian context. Further work to scale up and test cash conditionality in different contexts is warranted.
- Subjects
SOMALIA; MOGADISHU (Somalia); REFUGEE camps; CONDITIONAL cash transfer programs; INTERNALLY displaced persons; SERVICES for caregivers; MOBILE health; COMMUNICATIVE disorders; ANKYLOGLOSSIA
- Publication
PLoS Medicine, 2023, Vol 19, Issue 2, p1
- ISSN
1549-1277
- Publication type
Article
- DOI
10.1371/journal.pmed.1004180