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Background: The program “Santé Nutritionnelle à Assise Communautaire à Kayes” (SNACK) in Mali aimed to improve child linear growth through a set of interventions targeted to mothers and children during pregnancy and up to the child’s second birthday. Distributions of cash to mothers and/or lipid-based nutrient supplement to children 6-23 mo of age were added to SNACK to increase attendance at community health centers (CHCs). Objectives: The aim of this study, which was embedded in a cluster-randomized impact evaluation of the program, was to assess the incentive value of the cash in relation to CHC attendance. Methods: We used a mixed-methods approach. We collected quantitative data on cash receipt and CHC attendance in a midline survey of mother-child pairs (n = 3443). A program impact pathway analysis guided qualitative data collection and analysis. Twelve CHCs were purposively selected in study groups that received cash. We conducted semistructured continuous observations of cash distributions in 11 CHCs (n = 22) and semistructured qualitative interviews with frontline workers (FLWs) (n = 71) and mothers (n = 22) who were purposively selected from the midline survey. Results: FLWs’ knowledge of the objective and implementation plan of the cash program component was limited. A challenging physical environment and insufficient cash available for each distribution were identified as causes of irregularities in cash distributions. Most mothers mentioned having to return several times to receive their cash. Child health was identified as the main motivation to attend CHCs and cash was described as an additional benefit. Conclusion: Implementation constraints related to remoteness and inaccessibility may have undermined the incentive value of the cash transfers in the SNACK program. Additional research is needed to identify interventions that not only incentivize mothers to participate but that can be implemented effectively and with high quality in challenging contexts such as rural areas of Mali.
The SNACK program consisted of a set of interventions including behavior change communication (BCC), cooking demonstrations, income-generating activities for women, screening and treatment for children suffering from acute malnutrition, blanket feeding during the lean season for mothers and children ≤59 mo old, and capacity-strengthening for nutrition actors. The CNA component provided mothers with a cash incentive during visits to CHCs for antenatal care (ANC), delivery, vaccination, and growth monitoring (∼$3.00–$12.00 depending on the type of visit, estimated by program implementers to cover the cost for transportation and consultation fees, or the cost for delivery at the CHC) and/or an LNS (Plumpy Doz). Eligibility criteria for women’s enrollment into the SNACK-CNA at the CHC were to be pregnant or to have a child <12 mo of age. Once enrolled, women would receive the cash for their child at each visit to the CHC until the child reached 24 mo of age. For the LNS, women would receive 4 pots of Plumpy Doz at each growth-monitoring visit, starting when their children were aged 6 mo and continuing until 24 mo of age. The present study was part of a larger impact evaluation of the SNACK-CNA project that used a cluster-randomized design. The impact evaluation of SNACK-CNA randomly assigned 76 CHCs and their associated catchment areas of 3 districts in Kayes (Bafoulabe, Diema, and Yelimane) into 4 arms. These were: 1) SNACK only, which received standard activities of the program and served as the control group; 2) SNACK + LNS, with standard program activities and LNS distributed monthly to children 6–23 mo of age at monthly growth-monitoring sessions; 3) SNACK + Cash, with standard activities and cash distributed during visits to the CHCs during pregnancy, labor and delivery, child vaccination, and monthly child growth-monitoring sessions (6–23 mo of age); and 4) SNACK + Cash + LNS, with standard activities, cash (as in arm 3), and LNS (as in arm 2). The schedule of distribution of cash and LNS, and their amounts, per study arm are presented in Table 1. Schedule of cash and LNS distribution during the first 1000 d, in the 4 study arms1 Baseline and endline quantitative surveys for the impact evaluation of the SNACK-CNA project were conducted in November 2013 (n = 5046) and November 2016 (n = 5098). The midline survey was conducted in all 4 arms in April 2015 (∼1 y after the start of the program) and the PE was conducted in the 2 arms that received the cash incentive (arms 3 and 4) in August 2015. Arms 3 and 4 were selected for the PE in order to focus the study on the incentive value of the cash of the SNACK-CNA program. We first designed a PIP to conceptualize the program and its different components. Mapping of the PIP was an iterative process starting with a review of program documents, followed by interviews and discussions with implementation partners [French National Research Institute for Sustainable Development (IRD), WFP, UNICEF, and implementing nongovernmental organizations (NGOs)], as well as health officers of the 3 districts of Kayes during a 2-d workshop held in Bamako 2 mo after the start of the program (May 2014). Through the review of program documents and the interviews and discussions with implementation partners in subgroups, we were able to describe the different program components (inputs, activities, actors, and intended results) as well as the mechanisms (mediators and effect modifiers) by which these components were hypothesized to work and lead to expected impacts (15, 16). With these data, we created a PIP for the entire SNACK-CNA program that included all program components, from inputs, processes, outputs, and outcomes to impacts (Figure 1). PIP for the SNACK-CNA program, Mali. The cash pathway is represented by the shaded box. We identified 3 pathways: the cash transfer pathway, the BCC pathway, and the lipid-based nutrient supplement pathway. We elaborated a second PIP that was specific to the CNA cash pathway, which shows the flow of all activities from program delivery to utilization, outlining the institutions and actors involved, sequencing of program activities, and expected impact of the program (Figure 2). AM, Acute Malnutrition; ANC, antenatal care; ASACO, community association for community health; BCC, behavior change communication; CHC, community health center; CHV, community health volunteer; CNA, Cash for Nutrition Awareness; EHA, Essential Hygiene Actions; ENA, essential nutrition action; IYCF, infant and young child feeding; MoH, Ministry of Health; NGO, nongovernmental organization; PDoz, Plumpy Doz; PIP, Program Impact Pathway; SNACK, Santé Nutritionnelle à Assise Communautaire à Kayes; WFP, World Food Programme. We identified 3 hypothesized pathways of impact of the SNACK-CNA program on maternal and child health and nutrition outcomes: 1) the cash; 2) the LNS; and 3) the BCC (of the SNACK program) pathway. This study focused on the cash pathway, which was intended to incentivize caregivers to participate in SNACK-CNA activities and enhance its overall impacts. The 4 key steps along the cash PIP (Figure 2) included: 1) knowledge and understanding of the program objectives and design by frontline workers (FLWs) (Box 1); 2) cash procurement and management (Box 2); 3) cash distribution (Box 3); and 4) cash utilization (Box 4). We used the PIP to inform PE data collection (identifying key respondents and processes to analyze), and to identify bottlenecks (during data analysis) along these 4 key steps of the cash pathway (Table 2). Program impact pathway for the cash component of the SNACK-CNA program, Mali. The cash pathway includes knowledge and understanding of program design (Box 1), cash procurement and management (Box 2), cash distribution (Box 3), and cash use (Box 4). NGO agents are paid by local NGOs, accountants by the ASACO, heads of CHCs and HW by the Ministry of Health and/or ASACO, and CHVs are volunteers. ANC, antenatal care; ASACO, community association for community health; BCC, behavior change communication; CHC, community health center; CHV, community health volunteer; HW, health worker; NGO, nongovernmental organization; SNACK, Santé Nutritionnelle à Assise Communautaire à Kayes; WFP, World Food Programme. Methods to study the steps in the PIP for the cash component of the SNACK-CNA program, Mali1 The overall objective of this study was to ascertain if and how the cash provided through the CNA component incentivized mothers to follow the recommended schedule of preventive health and nutrition services for themselves and their child. To meet the overall study objective, we addressed the following specific research objectives along the PIP for the cash component: The PE sampling scheme used a combination of random and purposive sampling and was an extension of the quantitative midline impact survey, which followed the same principles as the baseline survey. Sample size calculation for the main study estimated the need for 5016 mother–child pairs to be surveyed at baseline. Mother–child pairs were randomly selected using a multistage cluster selection process: at the first stage, in each of the 76 CHC catchment areas, 6 enumeration areas (EAs) were randomly selected with a probability proportional to population size. At the second stage, all households with eligible mother–infant pairs were listed within each EA during a census and a total of 11 households per EA was randomly selected, for a total of ≥66 mother–child pairs included per EA. In case of several eligible children per mother, only 1 child was randomly selected to be surveyed. For the midline quantitative survey, which aimed to assess implementation of the program and uptake by beneficiaries, we estimated that a smaller sample size of 836 mother–child pairs per arm was sufficient (3344 in 4 arms). The same multistage cluster selection process was used: 4 EAs (out of 6 surveyed at baseline) were randomly selected per CHC catchment area; then, within each EA, 4 households were randomly selected from the census of eligible households, and the remaining were included using the itineraries method, until reaching a total of 11 households per EA and 44 mother–child pairs per EA. A total of 3443 mother–child (0–23 mo of age) pairs living in 1933 households randomly selected in the 4 arms of the intervention were surveyed. Quantitative data that covered topics such as household characteristics, program exposure, and maternal and child health and nutrition were collected using structured questionnaires. In addition, questions and modules relevant to the PE were included in the midline survey, on topics such as 1) program awareness, 2) receipt, barriers and facilitators for uptake, and use of cash and/or LNS, and 3) attendance at health services at the CHCs. Quantitative data collection was conducted using Computer Assisted Program Interviews (SurveyCTO) and data management using R version 3.2.1 (R Core Team). In the 2 study arms selected for the PE (i.e., arm 3: SNACK + Cash and arm 4: SNACK + Cash + LNS), 2 CHCs and their associated catchment areas in each of the 3 districts were purposively selected (n = 12), including 1 with the highest burden (representing the most difficult program implementation situation) and 1 with a median value for burden (an average program implementation situation). This was based on 2 indicators: the distance of each CHC from the central CHC and the workload of staff at that center (calculated by the population the CHC covered divided by the reported number of staff at the CHC at baseline). One CHC was replaced owing to a flood in the area prohibiting access during the time of the survey. PE data collection methods included the focused ethnographic methods of semistructured individual qualitative interviews, semistructured continuous observations, and group free listing (Table 2). Respondent mothers were identified for qualitative interviews based on responses given in the midline survey. Thus, the qualitative and quantitative data were linked, allowing for mixed-methods analysis. We conducted interviews with all of the FLWs (n = 71) involved in program implementation at the selected CHCs. Topics covered included aspects such as the FLW's understanding and conceptualization of the program’s purpose, objectives, and methods for achieving impact; their perceived role and workload, operational activities, job motivation, and satisfaction; and any barriers they encountered in carrying out the program as planned. For mothers’ interviews, 2 mothers in each CHC catchment area were selected based on responses given in the midline survey (n = 24). Three criteria were used for the selection of mothers: 1) having ever attended the CHC for pregnancy and/or growth monitoring of the child; 2) knowledge of the SNACK-CNA program; and 3) having a child between 6 and 23 mo of age at the time of the interview (so that they had the potential to have experienced all program services). Mothers meeting these criteria were then stratified by receipt of the cash transfer into: 1) receiving cash at least once since the start of the program, or 2) never having received cash. One mother in each stratum was then randomly selected for the interview. Topics covered included maternal perception about the cash incentive, the costs they had incurred by participating in the program, their satisfaction with the program, uses of cash, and barriers and facilitators to the uptake of the program. All interviews were conducted using a semistructured interview guide digitally recorded by enumerators and simultaneously transcribed and translated from Bambara into French by the same interviewer. Cash distributions were observed twice in each of the 12 CHCs during the 2-mo duration of data collection. In 1 CHC, however, no cash distribution could be observed because none were conducted within the 2-mo data collection period, despite requesting the CHC's cash distribution schedule and arriving for data collection on the day the distribution was scheduled to be held. In each of the 11 CHCs where observations were conducted, 2 independent observers conducted observations of the cash distribution and all services and activities that occurred therein (n = 22) (17). Observations were documented with written narrative summaries by the 2 independent observers, conducted with a “blank slate,” and not guided or directed by the observer. A group debriefing session was held with the independent observers and a facilitator on the same day as the observation, and content was typed in Microsoft Word. Free listing is a technique used to generate data that describes how discrete domains (with list-able content) are categorized by a group of people (18). The order in which the items fall in the list, and the number of times items appear across multiple lists, can represent the “saliency” of items. More salient words are assumed to appear more frequently across respondents or appear at the beginning of a list. Opportunistic groups of ≤10 program participants in each CHC catchment area, gathered outside of the CHCs, were purposively selected to participate in free listing (n = 24) to generate a list of the users and uses of the cash transfers. Free-listing data were directly translated into French at the time of data collection and recorded on forms by hand, which were later typed into Microsoft Excel. Descriptive statistics and comparison between study arms using data from the midline survey were performed using Stata 15.1 (Statacorp). All analyses were weighted according to the population size of each EA and adjusted for the multistage cluster design using the svy command. The linearization method was used to estimate CIs around prevalence estimates. We used thematic analysis to code and analyze the qualitative interview transcript data using an a priori list of codes related to the research questions (19). Coding was an iterative process that was open to incorporating new themes that emerged from the interviews. Observations were analyzed using grounded theory; the researchers coded them without a predefined list and marked themes as they emerged from the data (20). The frequencies of responses from the free listing were coded using a list generated from the responses given, and data were analyzed using Stata 13 (StataCorp LP). Interview and observation data were analyzed using NVivo 11 (QSR International). Three different researchers performed the coding and analysis for the interviews, observations, and free listing, whereas 2 researchers supervised the coding and conducted the analysis. The overall study protocol was reviewed and approved by the ethics committee of the Faculty of Medicine, Pharmacy and Onto-Stomatology (FMPOS, Bamako) of the University of Bamako, also known as the University of Mali (N°2013/105/CE/FMPOS), and the Comité Consultatif de Déontologie et d'Ethique of the IRD.
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