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Impact evaluation of a nutrition-sensitive social protection programme in northern Nigeria

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By Caroline Antoine, Stella Esedunme, Céline Sinitzky Billard, Sabi’u Suleiman Shehu and Gladys Esther Ahuwan

Caroline Antoine is a health referant for Action Contre La Faim (ACF), in charge of the development and deployment of the organisation’s health strategy. She has a decade of experience working in health in the humanitarian sector.

Stella Esedunme is the Action Against Hunger (AAH) Project Manager of the Child Development Grant Programme (CDGP) in Nigeria. She has expertise in community engagement, development, management of malnutrition and strengthening government capacity.

Céline Sinitzky Billard is Cash and Voucher Assistance and Social Protection Advisor for ACF. She is an agronomist with a Master’s degree in agro-economy and has extensive humanitarian experience across in Africa, Asia and the Middle East.

Sabi’u Suleiman Shehu was the Advocacy and Communications Officer for phase one of the CDGP. He has eight years’ experience in advocacy and communications and is currently Advocacy and Communications Manager for AAH Nigeria.

Gladys Esther Ahuwan is Nutrition and Health Manager for the CDGP who worked to implement the social behaviour change communication strategy in Jigawa.

The authors would like to acknowledge the e-Pact consortium and Oxford Policy Management, the UK Department for International Development (DFID), Jigawa State Government in Nigeria, and the Save the Children Nigeria Country Office for their roles in the evaluation of the CDGP programme.

This article presents the summary findings of the endline evaluation of the Child Development Grant Programme (CDGP) conducted by the e-Pact consortium¹ and led by Oxford Policy Management. It summarises information from the evaluation report, authored by the e-pact consortium, which can be accessed at www.opml.co.uk/projects/evaluation-child-development-grant-programme-cdgp

Location: Northern Nigeria

What we know: There is strong evidence that cash transfers can have a positive impact on food security, but the evidence of impact on nutrition is weaker.

What this article adds: The Child Development Grant Programme (CDGP) was implemented in Zamfara and Jigawa states in northern Nigeria between 2013 and 2019 to address widespread poverty and undernutrition. Pregnant women received monthly cash transfers until their offspring turned two years of age. Low-intensity or high-intensity social behaviour change communication (SBCC) was implemented to randomly selected programme areas. The programme was evaluated through a quantitative survey undertaken at baseline, midline and endline; a process evaluation; and a qualitative survey of key informants. Findings show that the programme reached its intended audience with cash transfers and SBCC interventions (with some spillover). Endline results show increased use of antenatal care services and facility-based births, and improvements in infant and young child feeding beliefs, attitudes and practices, especially in immediate, exclusive and appropriate breastfeeding and improved dietary diversity in infants aged 6-23 months. Indicators of child health improved, including uptake of vaccinations and incidence of diarrhoea and illness, some of which can be linked to improved water, health and sanitation practices. The prevalence of stunting in children under five years old declined by 5.4% at endline in CDGP areas, but no improvements were seen in indicators of wasting or underweight. Results show that cash plus SBCC can reduce child malnutrition and improve child health outcomes, although challenges remain in substantially improving anthropometric outcomes.

Introduction

The Child Development Grant Programme (CDGP) was a six-year, UK Department for International Development-funded programme that was implemented in northern Nigeria in Zamfara State by Save the Children and in Jigawa State by Action Against Hunger between 2013 and 2019. The programme targeted five local government authorities (LGAs); Anka and Tsafe in Zamfara, and Buji, Gagarawa and Kiri Kasama in Jigawa. The programme was implemented in a rural setting, where agricultural activities form the main source of livelihoods. Households are typically large (with an average household size of nine members recorded at endline) and organised around a male household head, living with one or more of his wives and their children. Rates of poverty and deprivation are high in northern Nigeria, with an estimated 64 million of the country’s extreme poor living in the region.² The significant burden of poverty, coupled with gaps in health-service provision, have contributed to extremely high prevalence of undernutrition. Around 37% of children under five years of age are stunted in Nigeria as a whole; in Northern Nigeria nearly half of all children are stunted, one third of children under five years old are underweight and one fifth are wasted.³

The programme aimed to address widespread poverty and undernutrition by providing an unconditional cash transfer of Nigerian Naira (NGN)3,500 per month (around US$10) to over 90,000 pregnant women. The transfer value was revised upwards in January 2017 to NGN4,000⁴ due to an average increase of 44% in the cost of a healthy nutritious diet in the programme area reported in 2016⁵ and subsequent advocacy efforts among stakeholders to adjust the transfer accordingly. Transfers were scheduled to begin once pregnancy was detected and last until the child turned two years old, thereby targeting the first 1,000 days of the child’s life. Alongside the cash transfer, communities in the programme were provided with education and advice about nutrition and health through a social and behaviour change communication (SBCC) component (cash+).

Figure 1: Locations where the CDGP was implemented

 

The programmes tested two SBCC approaches:

1. Low-intensity SBCC, delivered through posters, radio messaging, text messaging, health talks and food demonstrations;

2. High-intensity SBCC, delivered through support groups and one-to-one counselling for women receiving the transfer, in addition to all of the components of low-intensity SBCC.

The cash + approach was expected to contribute to improved food security and the adoption of positive practices and behaviours to support maternal and child health through the pathways illustrated in Figure 2. The programme aimed to protect 42,000 people from hunger and extreme poverty, and specifically to reduce stunting among 94,000 children in target households (by an increase in height-for-age z-score (HAZ) of 1 standard deviation by endline) and under-five child mortality by 3-5%.

Figure 2: The CDGP theory of change

Methodology of the impact evaluation

There is strong evidence from elsewhere that cash transfers have an impact on food security, but the evidence of impact on nutrition is weaker. The programme was therefore designed with an independent evaluation and research component to generate evidence of nutrition impact. The evaluation, conducted by Oxford Policy Management (OPM), aimed to describe the impact of the programme on intended outcomes using quantitative, process and qualitative evaluation methods.

The quantitative evaluation was based on a household survey carried out before the programme started (baseline; August to October 2014), two years later (midline; October to December 2016) and towards the end of the programme (endline; August to October 2018). This survey aimed to measure the effect of the programme on child nutrition; knowledge and practices regarding healthy behaviours and nutrition; and livelihoods activities. This component was set up as a cluster randomised controlled trial (RCT) in which communities were randomly assigned to groups either receiving CDGP interventions (treatment groups; both receiving cash transfer with one receiving low-intensity SBCC and the other high-intensity SBCC) or none (control group).

An evaluation of the processes of the programme combined analysis of programme data with interviews with programme implementers and other stakeholders to understand how the programme worked, challenges faced during implementation, and factors influencing its impact. A longitudinal qualitative study was also undertaken that followed a small group of households that received the programme over three rounds of data collection. Through individual discussions, this component explored household members’ views about the programme and its impact on their lives, including those relating to culture, behaviour and power relations. Detailed methodology of the qualitative and quantitative components of the evaluation can be found in the full report.⁶

Main findings

Programme intervention

The CDGP was successful in reaching its intended recipients of women who were pregnant up to the second birthday of child; nine out of every 10 women who were pregnant during the baseline period reported having received cash transfers from the programme by endline. On average, beneficiaries stopped receiving transfers when the child was 24 months of age, as intended. The level of exposure to SBCC channels was relatively high, with the majority of men and women in CDGP communities reporting having accessed at least one of the low-intensity channels. Many men and women assigned to receive the low-intensity version reporting having accessed some of the high-intensity channels, suggesting little differentiation between the two versions in practice. For women, the SBCC channels most frequently reported were posters, followed by food demonstrations. For their husbands, radio and posters were most frequently reported.

Impact on knowledge, attitudes and practices related to maternal health and infant and young child feeding (IYCF)

Maternal health and antenatal care (ANC) services

The CDGP led to significant increases in the use of ANC services in CDGP communities for women who were pregnant at endline. Fifty-one per cent of women who were pregnant when interviewed in CDGP communities reported utilising ANC services, compared with 36% of pregnant women in non-CDGP communities. Children born in CDGP communities were 11 percentage points more likely to have been delivered at health facilities compared with children in non-CDGP communities. This is similar to the findings at midline, indicating a continuation of these positive impacts over time. Nevertheless, only one in every four children who were born after the CDGP midline survey were delivered at a health facility. This may be due to limited availability of skilled staff at health facilities in the evaluation communities; delivery of children was only possible in around 60% of facilities in evaluation areas. The qualitative study also found that the costs of accessing health facilities (for example, cost of transport) were a key influence on attendance.

Knowledge of healthy breastfeeding and IYCF practices

Findings reveal improvements in beliefs and attitudes regarding a range of health issues, including early initiation of breastfeeding, exclusive breastfeeding, the benefits of colostrum, and the fact that it is not advisable to give water to a baby under six months of age. These improvements were observed for both men and women at midline and endline, indicating a positive persistent shift across all household members. Findings also show improvements in breastfeeding practices (immediate, exclusive and appropriate breastfeeding) and improved dietary diversity for children aged 6-23 months (53% of this age group had foods from the recommended number of food groups in CDGP areas compared to 37% in non-CDGP areas).

Table 1: IYCF practices for endline children (born after the midline, before the endline)

The qualitative research revealed enablers and barriers to exclusive breastfeeding. Uptake of exclusive breastfeeding was enabled by seeing other women and members of the community adopting this practice, especially since it went against tradition. This snowball effect was felt by non-beneficiaries of the CDGP, as well as those directly involved in the SBCC activities. Engagement of husbands in SBCC channels was also found to be an important factor in the uptake of messages, according to beneficiaries and local key informants. The role of the CDGP’s community volunteers in providing continuous support, answering questions and showing women the best ways to breastfeed (not only “telling us what to do”) was also found to be a deciding factor for many. Barriers to the adoption of exclusive breastfeeding in CDGP communities included traditional beliefs (such as the view that the first milk, or colostrum, is harmful), the religious practice of giving rubutu (prayer water) to the baby after birth, and the opposition of other influential people, especially older women. To overcome this, traditional birth attendants, female preachers and male religious leaders were urged to encourage women to practice health-seeking behaviours and to help counsel women on IYCF practices in their communities. Overall, many respondents in all research communities reported having adopted the new breastfeeding practices themselves, supporting their wives to do so, or that they would advise other women to do so, because they believed it was better for the baby’s health and nutrition.

Maternal and child nutritional status and health

The ultimate goal of the CDGP was to improve maternal and child health and nutrition. Findings show that the CDGP led to investments in child health, corresponding to the broad set of SBCC messages delivered. Considering the sample of ‘midline’ children first (which includes children who would have been directly exposed to the CDGP), at endline we find a continuation of many of the impacts first observed at midline. So, for children born after the baseline and before the midline, impacts were seen on the uptake of vaccinations (76% of children received the measles vaccination in CDGP areas versus 64% in non-CDGP areas); reduction in the incidence of diarrhoea (22% in CDGP communities versus 32% in non-CDGP communities) and reduction in the proportion of children who had recently suffered an illness or injury (61% in CDGP areas versus 73% in non-CDGP areas); and the proportion of children given deworming medication in the last six months prior to the endline survey (49% in CDGP communities and 37% in non-CDGP communities). Similar impacts also arise for the ‘endline child’ (children born after the baseline, before the midline) demonstrating that the programme had a sustained effect in increasing the uptake of immunisations and other positive health outcomes. This shows that investments in health were sustained for the younger siblings of children initially exposed to the programme, even once the transfers ended. This points to a sustained programme effect.

The impact of the CDGP on reducing the incidence of diarrhoea is consistent with other findings, including improvements in households having access to an improved water source and increases in the uptake of exclusive breastfeeding among children aged under six months. A link between exclusive breastfeeding and diarrhoea was also noticed by respondents in the qualitative midline and endline studies, who reported observing fewer episodes of diarrhoea in their children after introducing exclusive breastfeeding. General improvements in hygiene practices around the home may also be part of the explanation. The qualitative results show increased adoption of a number of positive practices, including hand-washing, covering food, keeping utensils clean and draining stagnant water around the house, and respondents (qualitative endline) reported these are low-cost, sustainable behaviours. This may help explain why the quantitative results show reduced diarrhoea for the ‘endline’ child, for whom households in CDGP communities are mostly no longer receiving transfers.

Regarding the impact of the CDGP on children’s nutritional status, measured by anthropometric indicators, at midline the quantitative results showed a positive impact of the CDGP on child height-for-age. Figure 3 reports impacts on these indicators at endline for the sample ‘midline’ children, who are aged between 21 and 49 months at the time of the endline survey. The CDGP has also successfully achieved a positive impact on reducing the prevalence of stunting among this sample of children (figure 3).

There was no impact on wasting (weight-for-height) or the proportion of children who are underweight (low weight-for-age). This is in contrast to the results of the midline evaluation, where a small increase was found in wasting associated with the CDGP. It is possible that early improvements in nutrition may have contributed to an increase in a child’s height, but were not sufficient to overcome continued lack of access to adequate nutrition, even in CDGP communities. This may then have prevented children’s weight gains from keeping up with their height gains.

Figure 3: Effect of the CDGP on stunted, wasted and underweight for midline children (born after the baseline, before the midline)

Source: CDGP baseline, midline and endline survey data.

Notes: 1. The sample is women who were pregnant at the time of the baseline survey in 2014. The same people were interviewed at midline and endline.

2. The left panel shows unweighted estimates of mean levels in non-CDGP and CDGP communities, by wave. The right panel shows the effect of the CDGP, where the number and square are the point estimates and the line is the 95% confidence interval. The effect is estimated by OLS regression with LGA and tranche fixed effects, adjusted for baseline characteristics of the household and of the woman. In addition, we control for child gender. SEs are clustered at the village level. The effect of the CDGP is statistically significant at the 5% level if the confidence interval does not overlap with the vertical line. The line indicates zero effect.

3. Means, effects and differences are measured in percentage points (PP) for binary and categorical indicators. For continuous indicators, they are measured in the relevant unit of measurement.

4. All Z-scores are computed using 2006 WHO growth charts and cleaned by the standards described therein (WHO, 2006).

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Caroline Antoine, Stella Esedunme, Céline Sinitzky Billard, Sabi’u Suleiman Shehu and Gladys Esther Ahuwan (). Impact evaluation of a nutrition-sensitive social protection programme in northern Nigeria. Field Exchange 62, April 2020. p60. www.ennonline.net/fex/62/nutritionsensitivesocialprotectionprogramme

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