Impact of conditional cash transfers on child nutritional outcomes among sub-Saharan African countries: a systematic review protocol : JBI Evidence Synthesis

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Impact of conditional cash transfers on child nutritional outcomes among sub-Saharan African countries: a systematic review protocol

Garoma, Desalegn Ararso; Abraha, Yosef Gebreyohannes; Gebrie, Serebe Abay; Deribe, Fasil Mengistu; Tefera, Mamuye Hadis; Morankar, Sudhakar

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JBI Database of Systematic Reviews and Implementation Reports 15(9):p 2295-2299, September 2017. | DOI: 10.11124/JBISRIR-2016-003251
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Review question/objective: 

: The objective of this review is to assess the impact of conditional cash transfers on child nutritional outcomes among sub-Saharan African countries. More specifically, the objectives are to assess the impact of conditional cash transfers on child anthropometry, micro-nutrient, and improvement in dietary diversity of households.


Childhood undernutrition remains a significant global problem, with long term consequences affecting their survival, health, development and well-being. Undernutrition is a consequence of consuming too few essential nutrients or using or excreting them more rapidly than they can be replaced.1 Of the 667 million children aged under five years worldwide, 159 million are stunted and 50 million are wasted.2 More than two billion children are suffering from micro-nutrient deficiencies.3 This phenomenon is responsible for the cause of 3.1 million child deaths annually, as of 2011.4

Stunting (low height-for-age), underweight (low weight-for-age), wasting (low weight-for-height) and deficiencies in key vitamins and minerals are some of the manifestations of child undernutrition.5 Anthropometry is the measurement of weight and height to estimate indices that are used to diagnose stunting, underweight and wasting. Stunting is also called a chronic malnutrition, which reflects the failure to reach linear skeletal growth potential and is considered the best indicator of the long-term, cumulative effect of undernutrition among children.6,7

All African countries have adopted the global targets for nutrition improvements as agreed by the World Health Assembly (WHA) in 2011, that is, to reduce stunting by 40%, underweight by 30% and wasting by five percent among children under five by 2025.8 Nutrition specific and nutrition sensitive interventions are the currently available packages to reduce the highest magnitude of stunting among sub-Saharan Africa (SSA).8

Despite the existence of practical and inexpensive nutrition interventions that have proven to be effective in diverse country contexts in reducing undernutrition, more than 40% percent of children in the SSA countries still remain chronically undernourished.9 The 40% stunting level among SSA is considered the highest severity level, according to World Health Organization classification of undernutrition.10

In the last decade, there has been a dramatic reduction of chronic undernutrition among East Asian and developing countries, by 42% and 25%, respectively. However, from 1970 to 2010, the overall reduction of undernutrition continued to be slow, by only six percent for SSA countries.11 However, between 2000 and 2015, the estimated number of stunted children in Africa increased from 52 million to 60 million.12

To ensure the sustainability of currently available nutrition interventions among children, addressing the underlying determinants of undernutrition requires urgent attention.13 It is hence important to address child undernutrition which is rooted in poverty, food security, gender inequality, and lack of access to health and other services.14

Conditional cash transfer programs (CCTs) is the most widely implemented social protection system in more than 13 SSA countries over the past years. In addition to this, more than 45 African countries have conditional in-kind transfers as of 2014. Conditional cash transfer provides cash payments to households (mothers or care givers) that comply with certain behavioral requirements, like sending children to school, attending educational talks or getting health care.15

Studies conducted at different countries have shown that CCT has had progressive successes in improving child health outcomes and also appear to be an effective way to increase the uptake of preventive health services and encourage some preventive behaviors. It also promotes the increased number of children enrollment in to schools and had resulted in reduction in child labor.16-19

A systematic review showed that there was 40% decrease in illness rates of children aged 0–35 months after just two years of a CCT program compared to baseline. The CCT program also resulted in a 14% net increase in the prevalence of preventive health care use by children among program participants compared to non-participants.20

A study conducted in Brazil to assess the effects of CCT program on child anthropometric indicators showed that children from families exposed to CCT were 26% more likely to have normal height for age than those from non-exposed families; this difference also applied to weight-for-age.21 However, no impact was seen in Honduras.13

In another study, CCT affected not only the overall level of consumption, but also the composition of food intake.22 There is evidence that households that receive CCTs spend more on food and, within the food basket, on higher quality sources of nutrients than do households that do not receive the transfer but have comparable overall income or consumption levels.23 Similarly, dietary intake beneficiary children aged 12 to 60 months consume more iron, zinc and vitamin A than non-beneficiary children.13 Conditional cash transfer programs have had a significant impact on household dietary diversity in Ghana, Kenya, Malawi and Zambia. While there has been no significant impact on household's diet diversity in some SSA countries, Lesotho and Tanzania,18 CCTs have shown inconsistent effects on child nutritional status and diet diversity of households.13,18

We did a preliminary search in JBI Database of Systematic reviews and Implementation Reports, International Prospective Register of Systematic Reviews (PROSPERO) and Cochrane Database of Systematic Reviews to determine if there are any existing reviews on this topic. We found two systematic reviews that focused on the impact of conditional cash transfers on child health in low- and middle-income countries. In the first systematic review, health service uptake was assessed for HIV patients and only a single study was included from Africa, and there was less attention on assessing child undernutrition.16 Sixteen studies were included from Latin America in the second systematic review and no study was from SSA.24

Further investigation of the impact of CCT on child nutritional outcomes in SSA is necessary for determining the actual effectiveness of nutrition interventions.

Therefore, this review will be important in filling the evidence gap which is important for future planning of child nutrition interventions among SSA countries.

Inclusion criteria

Types of participants

This review will consider studies that include households having children of under five years, which have received cash or in kind nutritional supplements for complying with certain preventive health requirements for children. Only studies conducted in SSA countries will be eligible for inclusion. Sub-Saharan African countries cover the area of the African continent which lies south of the desert and includes 42 countries located on the SSA mainland, in addition to six island nations.25

Exclusion criteria

Children under five years with any chronic health conditions (e.g. tuberculosis or HIV) will be excluded in this systematic review.

Types of intervention(s)

This review will consider studies that assess the impact of conditional cash transfer of families who receive regular payments or nutritional supplements conditional on families’ compliance with preventive health requirements, compared with non-CCT families that receive normal services, with no intervention of cash or nutrition supplements. A CCT is one of the social protection systems which can be implemented through providing cash payments or in-kind transfers to families that comply with certain behavioral requirements23


This review will compare the impact of CCT of families who receive payments or nutritional supplements to non-CCT families that do not receive cash or nutrition supplements.


This review will consider studies with primary outcomes that measure anthropometric and micronutrient status. These outcomes will be measured by: weight-for-height, height-for-age and weight-for-age of two standard deviations below the median values of the international reference for anthropometric values. Improved levels of micronutrient status of (vitamin A, iron, and minerals) will be used to indicate the micronutrient status of a child. Undernutrition is a consequence of consuming too few essential nutrients, or using or excreting them more rapidly than they can be replaced.1 The secondary outcome will include improvement in dietary diversity of households. Dietary diversity of households is a “proxy” indicator of the nutrient adequacy of a child and refers to the increasing variety of foods across and within the food groups.25

Types of studies

The review will consider both experimental and epidemiological study designs including randomized controlled trials, non-randomized controlled trials, quasi-experimental studies, before and after studies, prospective and retrospective cohort studies, case control studies and analytical cross sectional studies for inclusion.

Search strategy

The search strategy aims to find both published and unpublished studies. A three-step search strategy will be utilized in this review. An initial limited search of MEDLINE, Embase and CINAHL will be undertaken followed by an analysis of the text words contained in the title and abstract, and of the index terms used to describe the article. A second search using all identified keywords and index terms will then be undertaken across all included databases. Thirdly, the reference lists of all identified articles will be searched for additional studies. Studies published in English from 2000 to 2016 will be considered for inclusion in this review and unpublished documents will also be considered, based on their relevance. Because, the programmatic implementation of cash transfer in Africa had begun after 2000.

The databases to be searched include: MEDLINE, Embase and CINAHL.

The search for unpublished studies will include: gray literature reports through WHO nutrition intervention library, Google and ProQuest Dissertations and Theses.

Initial keywords to be used will be: conditional cash transfer, undernutrition, anthropometry, dietary diversity of households, sub-Saharan Africa.

Study selection

Following the search, all identified citations will be collated and uploaded in to bibliographic software or citation management system and duplicates removed. Studies that may meet the inclusion criteria after screening of titles and abstracts by two independent reviewers will be retrieved in full and their details imported into the Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI) and assessed against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal and the results of the search will be reported in full in the final report and presented in a PRISMA flow diagram.

Assessment of methodological quality

Papers selected for retrieval will be assessed by two independent reviewers for methodological quality prior to inclusion in the review using standardized critical appraisal instruments from JBI SUMARI.26 Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer. Following critical appraisal, studies that do not meet a certain quality threshold will be excluded and the decision to exclude will be based on the list of assessment criteria.

Data extraction

Data will be extracted from papers included in the review using the standardized data extraction tool available in JBI-SUMARI26 by two independent reviewers. The data extracted will include specific details about the interventions, populations, study methods and outcomes of significance to the review question and specific objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of primary studies will be contacted for clarification or missing information.

Data synthesis

Papers will, where possible be pooled in statistical meta-analysis using JBI SUMARI. All results will be subject to double data entry. Effect sizes expressed as odds ratio (for categorical data) and weighted mean differences (for continuous data) and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard Chi-square and also explored using subgroup analyses based on the different study designs included in this review. Where statistical pooling is not possible the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.


The authors acknowledge the Ethiopian Public Health Institute and Jimma University for their financial and technical support.


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conditional cash transfer; sub-Saharan Africa; undernutrition