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Objective Cash transfer programmes targeting children are considered an effective strategy for addressing child poverty and for improving child health outcomes in developing countries. In South Africa, the Child Support Grant (CSG) is the largest cash transfer programme targeting children from poor households. The present paper investigates the association of the duration of CSG receipt with child growth at 2 years in three diverse areas of South Africa. Design The study analysed data on CSG receipt and anthropometric measurements from children. Predictors of stunting were assessed using a backward regression model. Setting Paarl (peri-urban), Rietvlei (rural) and Umlazi (urban township), South Africa, 2008. Subjects Children (n 746), median age 22 months. Results High rates of stunting were observed in Umlazi (28 %), Rietvlei (20 %) and Paarl (17 %). Duration of CSG receipt had no effect on stunting. HIV exposure (adjusted OR=2·30; 95 % CI 1·31, 4·03) and low birth weight (adjusted=OR 2·01, 95 % CI 1·02, 3·96) were associated with stunting, and maternal education had a protective effect on stunting. Conclusions Our findings suggest that, despite the presence of the CSG, high rates of stunting among poor children continue unabated in South Africa. We argue that the effect of the CSG on nutritional status may have been eroded by food price inflation and limited progress in the provision of other important interventions and social services.
The present study was cross-sectional, assessing the uptake and duration of receipt of the CSG and nutritional outcomes in children aged 2 years during 2008. The sampling frame for the study was participants from the South African sites of a multi-country cluster-randomised intervention trial (PROMISE-EBF; ClinicalTrials.gov: {“type”:”clinical-trial”,”attrs”:{“text”:”NCT00397150″,”term_id”:”NCT00397150″}}NCT00397150) that was undertaken from 2005 to 2008 to assess the effectiveness of community-based workers in promoting and improving exclusive breast-feeding. In the trial, follow-up of children ended at 24 weeks of age where final outcome data were collected. Details of the multi-country study have been published elsewhere( 25 ). The trial found no effect of peer support visits on uptake of the CSG at 24 weeks of age. Results of CSG receipt by arm were 54 % in the infant feeding arm and 46 % in CSG arm, but these results were not significant (relative risk=1·0; 95 % CI 0·9, 1·2). After the trial ended (2007), a new cross-sectional study (the present one) was conducted to measure uptake and duration of receipt of the CSG and nutritional outcomes. For the present cross-sectional study, participants from the trial were traced when the children were aged between 9 months and 3 years (median age 22 months). A total of 871 out of 1148 participants were traced. Due to some mothers having either moved or not being available during the day (because of work), or having incomplete data, there were 746 participants ultimately included. The study was conducted in three diverse areas in South Africa: (i) peri-urban Paarl; (ii) rural Rietvlei; and (iii) Umlazi, an urban township in Durban. Paarl is a town of about 130 000 inhabitants in the Drakenstein Local Municipality in the Western Cape Province( 26 ). Unemployment and poverty affect a large number of people within the municipal area, with an estimated 23 % of working-age residents being unemployed( 26 ). In terms of key child health outcomes, Paarl fares better than the other two sites with an infant mortality rate of 30/1000 live births, compared with Umlazi (68/1000 live births) and Rietvlei (99/1000 live births); and an antenatal HIV prevalence of 7 %, compared with Umlazi’s 47 % and Rietlvei’s 28 %( 27 ). Umlazi is the largest township in KwaZulu-Natal Province and the second largest in South Africa after Soweto. The population is estimated at 550 000 inhabitants( 28 ). This area experiences typical township problems, which include severe housing shortages, overcrowding, high rates of unemployment and crime, a large number of informal settlements and little economic development( 29 ). Rietvlei falls under the Umzimkhulu Municipality in KwaZulu-Natal. The predominantly rural municipal area falls within the former Transkei homeland area. The population of Umzimkhulu is estimated at 179 654 people( 30 ). Due in large part to the high levels of poverty that exist in the municipality, 52 % of individuals within Umzimkhulu Municipality have no income( 30 ). Furthermore, Umzimkhulu still faces severe backlogs with respect to water, sanitation and electricity provision; and road infrastructure remains poor and provides only limited access to the area. The percentage of people in Umzimkhulu living below the household subsistence level is 90 %, which is much higher than the national average of 65 %( 30 ). Data collectors received comprehensive training including three days of training on collecting anthropometric measurements. Reproducibility and validity exercises were conducted for length and height measurements. Evaluation and supervision were done monthly. Children under 2 years old were measured in the supine position, while those over 2 years were measured standing up. Depending on the study site, length measurements were taken to the nearest 0·1 cm using either the TALC roller mat infantometer (Oxford, UK) or the Shorr Height-Length Measuring Board (Olney, MD, USA). Height for children >2 years old was measured using a custom-made stadiometer validated and used by the MRC Nutrition Unit, Cape Town. Standard WHO guidelines( 31 ) were followed to conduct measurement procedures. The acceptable technical error of measurement for a data collector was a value less than two times that of the data collector supervisor. Anthropometric data were cleaned in accordance with WHO guidelines( 31 ). Length-for-age Z-score (LAZ) and HAZ were calculated and categorised in accordance with the 2006 WHO reference standards( 31 ). For the current analysis we used data from 746 young children with information on CSG receipt and anthropometric data at 2 years of age. In addition to data collected during the cross-sectional study, we also extracted baseline sociodemographic characteristics and 12-week infant feeding data from the PROMISE-EBF trial data set for the 746 children traced for the present study. These data were linked to the cross-sectional data using unique participant identifiers. The main outcome of interest was stunting, which was defined as HAZ <−2 (height-for-age <–2 sd below the median height-for-age of the reference population). Grant receipt was defined as the mother being in receipt of the CSG on behalf of the index child at any point during the study (12 weeks, 24 weeks and 2 years). Duration of CSG receipt, the primary exposure, was defined as the age of child (in months) at the 2-year visit minus the child’s age (in months) at first reported receipt of the grant. This was further dichotomised as exposure to the CSG for 18 months or longer and less than 18 months. We chose the 18 month cut-off point because it has been validated by a previous longitudinal study which reported strong associations between 18 months’ duration of CSG receipt and HAZ for children under 3 years of age( 20 ). Exclusive breast-feeding was defined as the infant receiving no other food or liquid except for medicines in the 24 h prior to the 12-week data collection interview in the PROMISE-EBF trial( 32 ). Student’s t test was used to assess mean differences in Z-scores while Pearson’s χ 2 test was used to examine associations in the cross-tabulations. Predictors of stunting were determined using backward logistic regression analysis. To assess confounding, factors were included in the model based on biological plausibility and known epidemiological risk factors, such as sociodemographic characteristics (socio-economic status, mother’s educational level, geographical area, maternal age, marital status) and exclusive breast-feeding status at 12 weeks. The model was adjusted for clustering using the sandwich estimator of variance( 33 ), which estimates standard errors under a generalised estimation equations (GEE approach), to account for the community-randomised trial design of the PROMISE-EBF trial. The statistical software package STATA version 11 (2007) was used for analyses. Statistical testing was performed at the 5 % significance level.
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