Food Assistance and Nutrition- a recent presentation of our research findings in Pakistan
Hello, I am Bridget Fenn, ENN’s long standing lead research investigator. I recently I gave a virtual presentation about the REFANI to participants at a research conference in Islamabad organised by Action Against Hunger. Despite the early start (5.30 a.m.), presenting remotely and missing the all-important human interaction afforded by face-to-face meetings, the presentation was very well received and there were plenty of questions and comments from the attendees…more about these below.
The REFANI Pakistan study was a four-arm parallel longitudinal cluster randomised controlled trial (cRCT) set in Sindh province, Pakistan undertaken by ENN in collaboration with Action Against Hunger. Study participants included the poorest households with a child aged 6-48 months of age. The interventions included two cash transfers (standard cash (SC) – 1500 Pakistani rupees (PKR) – approx. $14) and double cash (DC) – 3000 PKR-$28) and a fresh food voucher (FFV) – worth the same as the SC (1500 PKR), given every month over 6 consecutive months. The control group (CG) arm received no specific interventions apart from the Action Against Hunger programme in the area to which all arms had access. We hypothesised that FFVs would be more effective than the SC, and that the DC would be more effective than the SC - both in the short and medium term for reducing the risk of wasting-this was our main focus. The study showed a significant improvement in weight-based indicators in the DC arm and all three intervention arms saw a significant improvement in height-based indicators. On a less positive note, although haemoglobin (Hb) concentration increased in all study arms, the increase was significantly lower in the FFV arm compared to the CG which we were not expecting.
This was the first time the summary findings had been presented to such a wide and relevant audience in Pakistan. I was asked about the implications of these findings for scaling-up and linking with advocacy and, whether concrete recommendations could be made on the basis of these results. My response was that the results are very compelling and that this one study in Asia was the tip of the iceberg with more studies needed in order to be able to replicate and reproduce the results. Recognising that studies take time, I said this evidence can certainly be used as a springboard for organisations when considering what might be an appropriate amount of money in their cash programming and how to maximise the potential impact of FFVs. I also emphasised that it isn’t possible with this study to say at what point the amount of cash had an impact on being wasted i.e. where the tipping point is between the SC and DC amounts. This again would be a very interesting next study.
Regarding the advocacy question I referred the audience to the main objectives of the REFANI consortium which is to ensure more effective humanitarian interventions by strengthening the evidence base on the impact of cash and voucher-based food assistance to prevent undernutrition in emergencies. We certainly feel we have met this objective through the Pakistan study.
I was also asked about dietary diversity and what explanation we had for the Hb levels being lower in the FFV arm. I said that we had been expecting better results in the FFV arms given the evidence that vouchers are more effective than cash at improving dietary diversity. Although what we actually found in this study was that dietary diversity significantly increased in all three arms compared to the CG but was highest in the 2 cash arms. I thought that there could be a number of possible reasons for this:
- The vouchers may have been too restrictive - the main meat available was chicken which is low in iron.
- All 3 arms saw significant increases in intake of milk and eggs which are iron inhibitors
- Both cash arms saw a significant decrease in risk of getting malaria/fever whilst the FFV arm was no different from the CG
- Hydration/rehydration…
This last point needs more explanation. In this study we saw a (roughly) 50 % decrease in the prevalence of being wasted in all arms during the 6 month intervention. At baseline in the summer months when temperatures exceeded 50oc the prevalence of wasting was about 21%. I asked the question how much of this is explained by dehydration? Obviously the temperature is not the only factor that affects dehydration. A third of the study sample reported children having diarrhoea at baseline and this dropped by half after 6 months. I don’t know the answer to this but hope it will generate interest in the findings.
These very important study results will be published in the coming months and we will keep our network of readers informed when this happens.
More like this
FEX: A cluster RCT to measure the effectiveness of cash-based interventions on nutrition status, Sindh Province, Pakistan
View this article as a pdf By Bridget Fenn Bridget Fenn is an epidemiologist with a background in nutrition. She is currently a consultant for the Emergency Nutrition Network...
Resource: The cost of preventing undernutrition: cost, cost-efficiency and cost-effectiveness of three cash-based interventions on nutrition outcomes in Dadu, Pakistan
Abstract Cash-based interventions (CBIs) increasingly are being used to deliver humanitarian assistance and there is growing interest in the cost-effectiveness of cash...
FEX: Research Study of the cost, cost-efficiency and cost-effectiveness of three cash-based interventions in Pakistan
Research snapshot1 Cash-based interventions (CBIs) are increasingly being used to deliver humanitarian assistance and there is growing interest in the cost-effectiveness of...
FEX: The REFANI Project in Pakistan: adapting research to a multi-sectoral programme for impact measurement
By Zvia Shwirtz, Bridget Fenn, Riccardo Mioli, Ghulam Murtaza Sangrasi and Maureen Gallagher Zvia Shwirtz is currently the REFANI Communications and Research Uptake Officer,...
Research on Food Assistance for Nutritional Impact (REFANI)
Bridget Fenn, the REFANI Pakistan Principal Investigator, talks about the results of REFANI at the ACF hosted Research for Nutrition Conference 2017. What is REFANI? The...
Blog post: Research on multi-sectoral programming: reflections on a cash and WASH, nutrition integrated approach
Cliquez ici pour lire en français Some time ago I had the opportunity to attend a regional event for sharing multi-sectoral nutrition approaches, organized by ACF and...
FEX: Literature review on impact of cash transfers on nutritional outcomes
By Bridget Fenn and Ellyn Yakowenko Bridget Fenn is an epidemiologist with a background in nutrition. She is currently a consultant for the Emergency Nutrition Network (ENN)...
en-net: length of benefit exposure to cash transfer program and improvement in HAZ mean score
Is there any article or study related to relationship between length of benefiting from a programme (cash or food distribution) and HAZ score? Thanks in advance. Thanks. it...
en-net: Stratified randomization
Hi, Can someone (especially: epidemiologist) check my though on Stratified Randomization for one study? Thanks in advance. Our team is going to implement a one nutrition...
FEX: Impact evaluation of child caring practices project on stunting in Ethiopia
Summary of research1 Location: Ethiopia What we know already: Health, nutrition and water, sanitation and hygiene programmes impact on child nutrition. Evaluation of impact...
FEX: Comparison of milk free v milk containing RUTF in SAM treatment in Zambia
Summary of published research1 Location: Zambia What we know: Global SAM treatment relies on internationally produced RUTF that is expensive. RUTF formulations that exclude...
FEX: Methodological challenges for operational research in the humanitarian context
By Stephanie Stern and Melchior de Roquemaurel Stephanie Stern leads the Action Against Hunger LAB project which aims to reinforce the impact and uptake of knowledge. Before...
FEX: Prebiotics for severe wasting: Evidence from a randomised controlled trial in Pakistan
View this article as a pdf This is a summary of the following paper: Batool M, Saleem, J, Zakar R et al. (2023) Double-blind parallel treatment randomized controlled trial of...
en-net: % of Stunting prevelence or Mean WHZ score
Hi, We are developing one programme one nutrition sensitive social protection programme on maternity cash transfer with intensive behaviour change communication. Below were...
FEX: Impact on birth weight and child growth of women’s groups with and without transfers of food or cash during pregnancy in Nepal
View this article as a pdf Research snapshot1 While the links between undernutrition in pregnancy and birth outcomes have long been established, understanding of the...
NEX: Filling the Nutrient Gap in Pakistan: Insights to address malnutrition
Dr Aliahmad Khan is a nutritionist with the World Food Programme Pakistan Country Office in Islamabad. Muhammad Aslam Shaheen is Chief of Nutrition and SUN Focal Point in...
FEX: The long-term impacts of multiple micronutrient supplementation in children aged 24 to 59 months in Pakistan
View this article as a pdf This is a summary of the following paper: Khan A, Ul-Haq Z, Fatima S et al. (2023) Long-Term Impact of Multiple Micronutrient Supplementation on...
en-net: Potential Negative Impacts of Cash Transfers on Nutrition Status
Dear All I am looking for information on the potential negative impacts of cash transfers on the nutrition status. I would grateful if you can share with me...
en-net: Prevention of MAM through Ag/Food Security, Social Protection/ECD and WASH
I am on a team of 4 people doing a series of technical briefs for the CMAM forum (http://www.cmamforum.org). I am focusing on Preventing Moderate Acute Malnutrition (MAM)...
FEX: Multi-sector, nutrition-sensitive response to drought emergency in Pakistan
By Ali Dino Kunbher, Shafqat Ullah and Dr Mazhar Alam View this article as a pdf Click here to listen to an interview with the authors on the ENN podcast channel Ali Dino...