The dynamic relationship between cash transfers and child health: Can the child support grant in South Africa make a difference to child nutrition?

Public Health Nutrition, Volume 19, No. 2, Year 2016

Ukuhunyushwa

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.

I-AI Digest

Study Justification:

– Cash transfer programs targeting children are considered effective for addressing child poverty and improving child health outcomes in developing countries.
– The Child Support Grant (CSG) is the largest cash transfer program in South Africa targeting children from poor households.
– This study aims to investigate the association between the duration of CSG receipt and child growth at 2 years in three diverse areas of South Africa.

Study Highlights:

– High rates of stunting were observed in all three areas: Umlazi (28%), Rietvlei (20%), and Paarl (17%).
– Duration of CSG receipt had no effect on stunting.
– HIV exposure and low birth weight were associated with stunting, while maternal education had a protective effect.
– Despite the presence of the CSG, high rates of stunting among poor children continue unabated in South Africa.

Study Recommendations:

– 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.
– Further research is needed to identify and address the barriers to effective implementation of the CSG and to explore additional interventions that can improve child nutrition outcomes.

Key Role Players:

– Government agencies responsible for implementing and monitoring the CSG program.
– Non-governmental organizations (NGOs) working in the field of child health and poverty alleviation.
– Community health workers and social workers who can provide support and guidance to families receiving the CSG.

Cost Items for Planning Recommendations:

– Funding for research and evaluation of the CSG program.
– Resources for training and capacity building of government and NGO staff involved in the implementation of the CSG program.
– Budget allocation for additional interventions and social services to complement the CSG program and improve child nutrition outcomes.

Amandla Obufakazi

The strength of evidence for this abstract is 6 out of 10.
The evidence in the abstract is based on a cross-sectional study design, which limits the ability to establish causality. Additionally, the study only analyzed data from one point in time, which may not capture the long-term effects of the cash transfer program. To improve the strength of the evidence, a longitudinal study design could be implemented to track the impact of the Child Support Grant over time. This would provide more robust evidence on the association between the duration of CSG receipt and child growth. Additionally, including a control group of children from non-poor households would help to isolate the effects of the CSG on child nutrition. Finally, conducting further research to understand the reasons behind the high rates of stunting despite the presence of the CSG would provide valuable insights for improving child health outcomes in South Africa.

Abstract

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.

Izinto zokwakha

N/A

Emisha

Based on the information provided, it appears that the study is investigating the association between the duration of the Child Support Grant (CSG) receipt and child growth at 2 years in three diverse areas of South Africa. The study found that high rates of stunting were observed among poor children in South Africa, despite the presence of the CSG. HIV exposure, low birth weight, and maternal education were identified as factors associated with stunting.

In terms of innovations to improve access to maternal health, it is important to note that the study primarily focuses on the impact of the CSG on child nutrition rather than maternal health specifically. However, based on the findings, potential recommendations for innovations to improve access to maternal health could include:

1. Strengthening the provision of other important interventions and social services: The study suggests that the effect of the CSG on nutritional status may have been eroded by limited progress in the provision of other important interventions and social services. Innovations could focus on improving the availability and accessibility of healthcare services, including antenatal care, postnatal care, and nutrition counseling for pregnant women and new mothers.

2. Addressing food price inflation: The study suggests that food price inflation may have contributed to the high rates of stunting among poor children. Innovations could focus on implementing strategies to mitigate the impact of food price inflation, such as promoting local food production, improving food distribution systems, and providing subsidies or vouchers for nutritious food for pregnant women and new mothers.

3. Enhancing maternal education: The study found that maternal education had a protective effect on stunting. Innovations could focus on improving access to education for women, particularly in low-income communities, and providing education on maternal and child health, nutrition, and hygiene practices.

4. Integrating HIV prevention and treatment services: The study identified HIV exposure as a factor associated with stunting. Innovations could focus on integrating HIV prevention and treatment services with maternal health services, ensuring that pregnant women and new mothers receive comprehensive care and support for both maternal health and HIV prevention and treatment.

It is important to note that these recommendations are based on the information provided and may need to be further explored and tailored to the specific context and needs of the communities in South Africa.

AI Innovations Description

The study mentioned investigates the association between the duration of the Child Support Grant (CSG) receipt and child growth at 2 years in three diverse areas of South Africa. The objective of the study is to determine if the CSG, which is the largest cash transfer program targeting children from poor households in South Africa, has an impact on child nutrition.

The study found high rates of stunting among children in all three areas, and the duration of CSG receipt did not have an effect on stunting. Factors such as HIV exposure, low birth weight, and maternal education were associated with stunting. The study suggests 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.

To improve access to maternal health, it is recommended to consider the following:

1. Strengthen the effectiveness of cash transfer programs: The study highlights the need to assess and improve the impact of cash transfer programs on child nutrition. This could involve evaluating the adequacy of the grant amount, ensuring timely and consistent disbursement, and monitoring the utilization of funds for essential maternal and child health services.

2. Address underlying factors contributing to stunting: The study identifies factors such as HIV exposure, low birth weight, and maternal education as important determinants of stunting. Efforts should be made to prevent HIV transmission from mother to child, improve prenatal care to reduce low birth weight, and promote maternal education and empowerment.

3. Enhance the provision of comprehensive maternal and child health services: The study suggests that limited progress in the provision of other important interventions and social services may have contributed to the high rates of stunting. It is crucial to ensure access to quality healthcare services, including prenatal care, nutrition counseling, immunizations, and early childhood development programs.

4. Address food price inflation and promote food security: The study suggests that food price inflation may have eroded the impact of the cash transfer program on child nutrition. Efforts should be made to address food price inflation and promote food security through initiatives such as agricultural development, income generation programs, and social safety nets.

Overall, a comprehensive approach is needed to improve access to maternal health. This includes strengthening cash transfer programs, addressing underlying factors contributing to stunting, enhancing the provision of maternal and child health services, and promoting food security.

AI Innovations Methodology

Based on the provided information, the study investigates the association between the duration of the Child Support Grant (CSG) receipt and child growth at 2 years in three diverse areas of South Africa. The objective is to determine if the CSG, which is a cash transfer program targeting children from poor households, has an impact on child nutrition.

To improve access to maternal health, here are some potential recommendations:

1. Increase awareness: Implement campaigns and educational programs to raise awareness about the importance of maternal health and the available resources and services.

2. Improve healthcare infrastructure: Invest in improving healthcare facilities, especially in rural and underserved areas, by providing necessary equipment, supplies, and trained healthcare professionals.

3. Enhance transportation services: Develop transportation systems or initiatives to ensure pregnant women have access to healthcare facilities, especially in remote areas.

4. Strengthen community-based healthcare: Establish and support community-based healthcare programs that provide prenatal and postnatal care, as well as education on maternal health and nutrition.

5. Promote telemedicine: Utilize technology to provide remote access to healthcare services, allowing pregnant women to consult with healthcare professionals without the need for physical travel.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure the impact, such as the number of pregnant women accessing healthcare services, the reduction in maternal mortality rates, or the increase in prenatal care coverage.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including the number of healthcare facilities, the availability of transportation, and the percentage of pregnant women receiving prenatal care.

3. Implement interventions: Introduce the recommended innovations in targeted areas or communities. This could involve implementing awareness campaigns, improving healthcare infrastructure, or establishing community-based healthcare programs.

4. Monitor and evaluate: Continuously monitor the implementation of interventions and collect data on the selected indicators. This could involve surveys, interviews, or data collection from healthcare facilities.

5. Analyze data: Analyze the collected data to assess the impact of the interventions on improving access to maternal health. Compare the baseline data with the post-intervention data to identify any changes or improvements.

6. Adjust and refine: Based on the analysis, make adjustments and refinements to the interventions if necessary. This could involve scaling up successful initiatives or modifying strategies that did not yield the desired results.

7. Repeat the process: Continuously repeat the cycle of monitoring, evaluating, and refining the interventions to ensure ongoing improvement in access to maternal health.

By following this methodology, it would be possible to simulate the impact of the recommended innovations on improving access to maternal health and make informed decisions on which interventions are most effective.

Umbhali

Dima Health

Statistics:

Citations: 6

Identifiers:

DOI: 10.1017/S1368980015001147

ISSN: 13689800

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants

Study Countries:

South Africa

Study Design:

Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Quantitative

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