ABSTRACT
BACKGROUND: The program "Santé Nutritionnelle à Assise Communautaire à Kayes" (SNACK) in Mali aimed to improve child linear growth through a set of interventions targeted to mothers and children during pregnancy and up to the child's second birthday. Distributions of cash to mothers and/or lipid-based nutrient supplement to children 6-23 mo of age were added to SNACK to increase attendance at community health centers (CHCs). OBJECTIVES: The aim of this study, which was embedded in a cluster-randomized impact evaluation of the program, was to assess the incentive value of the cash in relation to CHC attendance. METHODS: We used a mixed-methods approach. We collected quantitative data on cash receipt and CHC attendance in a midline survey of mother-child pairs (n = 3443). A program impact pathway analysis guided qualitative data collection and analysis. Twelve CHCs were purposively selected in study groups that received cash. We conducted semistructured continuous observations of cash distributions in 11 CHCs (n = 22) and semistructured qualitative interviews with frontline workers (FLWs) (n = 71) and mothers (n = 22) who were purposively selected from the midline survey. RESULTS: FLWs' knowledge of the objective and implementation plan of the cash program component was limited. A challenging physical environment and insufficient cash available for each distribution were identified as causes of irregularities in cash distributions. Most mothers mentioned having to return several times to receive their cash. Child health was identified as the main motivation to attend CHCs and cash was described as an additional benefit. CONCLUSION: Implementation constraints related to remoteness and inaccessibility may have undermined the incentive value of the cash transfers in the SNACK program. Additional research is needed to identify interventions that not only incentivize mothers to participate but that can be implemented effectively and with high quality in challenging contexts such as rural areas of Mali.
ABSTRACT
BACKGROUND: The popularity of nutrition-sensitive interventions calls for high-quality monitoring and evaluation tools. In this context, the Minimum Dietary Diversity for Women of Reproductive Age (MDD-W), validated as a proxy of micronutrient adequacy, does fill a gap. However, because it is a newly endorsed indicator, information on its linkages with other dimensions of food and nutrition security is still scarce. OBJECTIVE: The objective of this study was to investigate whether the MDD-W is related to household food insecurity and farm production diversity. METHODS: A cross-sectional survey on a representative sample of 5046 women of reproductive age was conducted in the region of Kayes, Mali, in 2013. Dietary diversity was assessed through qualitative 24-h recall, and MDD-W was computed. MDD-W equaled 1 if the women consumed at least 5 different food groups and 0 otherwise. Food insecurity was measured using the Household Food Insecurity Access Scale and the Household Hunger Scale (HHS), and a farm production diversity score (FPDS) was calculated based on a count of food crops/livestock groups produced. Logistic regressions were used to assess the relation between MDD-W and the indicators of household food security. RESULTS: Only 27% of women reached the MDD-W. These women consumed animal source foods and/or vitamin A-rich vegetables and fruits more frequently than did other women. Women from extremely food insecure households (moderate to severe hunger according to the HHS) were less likely to reach the MDD-W (OR: 0.70; 95% CI: 0.50, 0.97). One more group in the FPDS increased the odds of attaining the MDD-W (OR: 1.12; 95% CI: 1.06, 1.18). CONCLUSION: In the rural region of Kayes, Mali, women's dietary diversity, as measured by the MDD-W, was associated with household-level food security indicators. This study was registered at ISRCTN.org as ISRCTN08435964.
