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

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.

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

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)