This paper evaluates a large-scale maternal cash transfer program targeted to pregnant women and mothers of children under two. The program provides monthly cash transfers, and is supplemented with Social Behavior Change Communication (SBCC) in a random subset of villages. Both interventions lead to a large reduction in the proportion of children (moderately) stunted. Meanwhile, cash alone has no detectable impact on child outcomes. The effects are accompanied by improvements in dietary diversity, breastfeeding, hand-washing practices, prenatal care and food consumption. These results provide strong support for adding SBCC to maternal cash transfer programs in order to realize their impact.

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April 24, 2020
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The burden of food insecurity is large in Sub-Saharan Africa, yet the evidence-base on the relation between household food insecurity and early child development is extremely limited. Furthermore, available research mostly relies on cross-sectional data, limiting the quality of existing evidence. We use longitudinal data on preschool-aged children and their households in Ghana to investigate how being in a food insecure household was associated with early child development outcomes across three years. Household food insecurity was measured over three years using the Household Hunger Score. Households were first classified as “ever food insecure” if they were food insecure at any round. We also assessed persistence of household food insecurity by classifying households into three categories: (i) never food insecure; (ii) transitory food insecurity, if the household was food insecure only in one wave; and (iii) persistent food insecurity, if the household was food insecure in two or all waves. Child development was assessed across literacy, numeracy, social-emotional, short-term memory, and self-regulation domains. Controlling for baseline values of each respective outcome and child and household characteristics, children from ever food insecure households had lower literacy, numeracy and short-term memory. When we distinguished between transitory and persistent food insecurity, transitory spells of food insecurity predicted decreased numeracy (β = -0.176, 95% CI: -0.317; -0.035), short-term memory (β = -0.237, 95% CI: -0.382; -0.092), and self-regulation (β = -0.154, 95% CI: -0.326; 0.017) compared with children from never food insecure households. By contrast, children residing in persistently food insecure households had lower literacy scores (β = -0.243, 95% CI: -0.496; 0.009). No gender differences were detected. Results were broadly robust to the inclusion of additional controls. This novel evidence from a Sub-Saharan African country highlights the need for multi-sectoral approaches including social protection and nutrition to support early child development

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April 03, 2020
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Participatory development is designed to mitigate problems of political bias in pre-existing local government but also interacts with it in complex ways. Using a five-year randomized controlled study in 97 clusters of villages (194 villages) in Ghana, we analyze the effects of a major participatory development program on participation in, leadership of and investment by pre-existing political institutions, and on households’ overall socioeconomic well-being. Applying theoretical insights on political participation and redistributive politics, we consider the possibility of both cross-institutional mobilization and displacement, and heterogeneous effects by partisanship. We find the government and its political supporters acted with high expectations for the participatory approach: treatment led to increased participation in local governance and reallocation of resources. But the results did not meet expectations, resulting in a worsening of socioeconomic wellbeing in treatment versus control villages for government supporters. This demonstrates international aid’s complex distributional consequences. 

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April 02, 2020
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Developing countries are characterized by high rates of mortality and morbidity. A potential contributing factor is the low utilization of health systems, stemming from the low perceived quality of care delivered by health personnel. This factor may be especially critical during crises, when individuals choose whether to cooperate with response efforts and frontline health personnel. We experimentally examine efforts aimed at improving health worker performance in the context of the 2014–15 West African Ebola crisis. Roughly two years before the outbreak in Sierra Leone, we randomly assigned two social accountability interventions to government-run health clinics — one focused on community monitoring and the other gave status awards to clinic staff. We find that over the medium run, prior to the Ebola crisis, both interventions led to improvements in utilization of clinics and patient satisfaction. In addition, child health outcomes improved substantially in the catchment areas of community monitoring clinics. During the crisis, the interventions also led to higher reported Ebola cases, as well as lower mortality from Ebola — particularly in areas with community monitoring clinics. We explore three potential mechanisms: the interventions (1) increased the likelihood that patients reported Ebola symptoms and sought care; (2) unintentionally increased Ebola incidence; or (3) improved surveillance efforts. We find evidence consistent with the first: by improving the perceived quality of care provided by clinics prior to the outbreak, the interventions likely encouraged patients to report and receive treatment. Our results suggest that social accountability interventions not only have the power to improve health systems during normal times, but can additionally make health systems resilient to crises that may emerge over the longer run.

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March 06, 2020
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Globally, access to good quality abortion services and post-abortion care is a critical determinant for women’s survival after unsafe abortion. Unsafe abortions account for high levels of maternal death in Kenya. We explored women’s experiences and perceptions of their abortion and post-abortion care experiences in Kenya through person-centred care. This qualitative study included focus group discussions and in-depth interviews with women aged 18-35 who received safe abortion services at private clinics. Through thematic analyses of women’s testimonies, we identified gaps in the abortion care and person-centred domains which seemed to be important throughout the abortion process. When women received clear communication and personalised comprehensive information on abortion and post-abortion care from their healthcare providers, they reported more positive experiences overall and higher reproductive autonomy. Communication and supportive care were particularly valued during the post-abortion period, as was social support more generally. Further research is needed to design, implement and test the feasibility and acceptability of person-centred abortion care interventions in community and clinical settings with the goal of improving women’s abortion experiences and overall reproductive health outcomes.

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February 27, 2020
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Over 700 million people live on less than US$1.90 per day. Many of these families depend on insecure and fragile livelihoods. Globally nearly half of all deaths in children under five are attributable to undernutrition, translating into the loss of about three million young lives a year. Recent research has shown that holistic livelihoods programs, such as the Graduation Approach can have a wide range of benefits for these poor families, from increasing household consumption and income to improving food security and mental health. The Graduation model provides families with a range of services, including income-generating assets, training, access to savings accounts, consumption support, and coaching visits, and variations of the model have been successfully replicated in several contexts. The aim of this research in Burkina Faso is to rigorously evaluate whether an adapted Graduation program design, which focuses on strengthening the household’s ability to cope with crises, leads to improvements in child nutrition and household food security. This brief summarizes findings from the midline survey, which suggest that the program successfully reduced child malnutrition and increased household consumption, food diversity, and investments in durable goods after one year. Some impacts were present across multiple program groups, while others were only present among households that received the full multi-dimensional set of interventions.

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February 25, 2020
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Context: A growing body of evidence indicates that nonclinical health care facility staff provide support beyond their traditional roles, particularly in low- and middle-income countries. It is important to examine the role of health facility cleaners in Kenya—from their perspective—to better understand their actual and perceived responsibilities in maternity care.

Methods: In-depth, face-to-face interviews using a semistructured guide were conducted with 14 cleaners working at three public health facilities in Nairobi and Kiambu Counties, Kenya, in August and September 2016. Results were coded and categorized using a thematic content analysis approach.

Results: Cleaners reported performing a range of services beyond typical maintenance responsibilities, including providing emotional, informational and instrumental support to maternity patients. They described feeling disrespected when patients were untidy or experienced bleeding; however, such examples revealed cleaners' need to better understand labor and childbirth processes. Cleaners also indicated a desire for training on interpersonal skills to improve their interactions with patients.

Conclusion: Cleaners' direct involvement in maternity patients' care is an alarming symptom of overburdened health facilities, insufficient staffing and inadequate training. This key yet overlooked cadre of health care staff deserves appropriate support and further research to understand and alleviate health system shortcomings, and to improve the quality of maternity health care provision.

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February 12, 2020
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¿Pueden los cursos de educación sexual en línea mejorar el conocimiento, las actitudes y el comportamiento de los estudiantes en materia de salud sexual? ¿Estos cursos también tienen efectos positivos en los compañeros de los estudiantes que toman el curso? Los investigadores evaluaron el impacto de un curso de educación sexual en línea sobre el conocimiento y el comportamiento sexual de los estudiantes de escuelas secundarias urbanas colombianas. El programa de educación tuvo un impacto significativo en conocimiento y actitudes. No se encontraron impactos en las medidas de comportamiento auto informadas, pero el programa condujo a una reducción en la incidencia de enfermedades de transmisión sexual entre las mujeres sexualmente activas. Además, los resultados mostraron un aumento significativo en la redención de cupones para condones entre los estudiantes del grupo de tratamiento.

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February 12, 2020
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This brief draws on mixed-methods data collected in 2019 as part of the Gender and Adolescence: Global Evidence (GAGE) programme—a unique longitudinal mixed-methods research and impact evaluation study that is focusing on what works to support the development of adolescents’ capabilities during the second decade of life (10–19 years) (GAGE consortium, 2019 forthcoming). In Cox’s Bazar, GAGE partnered with researchers from Yale University and the World Bank to implement the Cox’s Bazar Panel Survey (CBPS) in order to provide accurate data to humanitarian and government stakeholders involved in the response to the influx of refugees.

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December 30, 2019
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Violence against women and children are closely linked global epidemics that have lifelong impacts on human welfare. This study examines the impact of adding cash transfers to a mentoring intervention targeted to girls in early adolescence. Girl Empower has positive impacts on some important outcomes, but is ineffective in protecting girls from sexual violence. Cash transfers, tied to attendance, enhanced program impacts on child marriage, teen pregnancy, and risky sexual behavior. Future research is needed to understand whether cash affects these outcomes directly or through an interaction effect.

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December 12, 2019
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Little evidence exists on women’s experiences of care during abortion care, partly due to limitations in existing measures. Moreover, globally, the development and rapid growth in the availability of medication abortions (MA) has radically changed the options for safe abortions for women. It is therefore important to understand how women’s experiences of care may differ across medication and manual vacuum aspiration (MVA) abortions. This study uses a validated person-centered abortion care scale (categorized as low, medium, and high levels, with high levels representing the greatest level of person-centered care) to assess women’s experiences of care undergoing medication abortions vs. MVA. This paper reports on a cross-sectional study of 353 women undergoing abortions at one of six family planning clinics in Nairobi County, Kenya in 2018. Comparing abortion types, we found that the MVA sample was more likely to report “high” levels of person-centered abortion care compared to the MA sample (36.3% vs. 23.0%, p = 0.005). No differences were detected with respect to Respectful and Supportive Care; however, the MVA sample was significantly more likely to report “high” levels of Communication and Autonomy compared to the MA sample (23.6% vs. 11.2%, p<0.0001). In multivariable ordered logistic regression, we found that the MVA sample had a 92% greater likelihood of reporting higher person-centered abortion care scores compared to MA clients (aOR1.92, CI: 1.17–3.17). Being employed and reporting higher self-rated health were associated with higher person-centered abortion care scores, while reporting higher levels of stigma were associated with lower person-centered abortion care scores. Our findings suggest that more efforts are needed to improve the domain of Communication and Autonomy, particularly for MA clients.

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November 25, 2019
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Globally, violence against women is a leading cause of premature death and morbidity for women and almost one-third of women report experiencing intimate partner violence (IPV) or sexual violence by a non-partner at some point in their life. Yet rigorous evidence on scalable and effective ways to reduce IPV is limited, in part because measuring IPV is challenging. Current standards of practice for reducing gender-based violence are also relatively limited in scope, focusing mainly on changing gender norms. Designing and testing new approaches has the potential to yield more effective solutions. IPA’s Intimate Partner Violence Initiative, a partnership with the International Rescue Committee, exists to address these challenges. The initiative designs and tests innovative solutions to IPV, leverages existing research to identify factors that contribute to IPV and works to address methodological and measurement challenges in violence research and related fields. With our academic and implementing partners, IPA has identified a number of effective solutions, including mass media campaigns, coupling women’s economic empowerment with gender dialogue, and teaching secondary school students soft skills. Results from several initiative-supported studies are forthcoming. Further research will be needed to validate results in new contexts and at scale, and to design and evaluate new ideas.

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October 22, 2019
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Objective: Despite the recognized importance of person-centered care, very little information exists on how person-centered maternity care (PCMC) impacts newborn health.

Methods: Baseline and follow-up data were collected from women who delivered in government health facilities in Nairobi and Kiambu counties in Kenya between August 2016 and February 2017. The final analytic sample included 413 respondents who completed the baseline survey and at least one follow-up survey at 2, 6, 8, and/or 10 weeks. Data were analyzed using descriptive, bivariate, and multivariate statistics. Logistic regression was used to assess the relationship between PCMC scores and outcomes of interest.

Results: In multivariate analyses, women with high PCMC scores were significantly less likely to report newborn complications than women with low PCMC scores (adjusted odds ratio [aOR] 0.39, 95% confidence interval [CI] 0.16–0.98). Women reporting high PCMC scores also had significantly higher odds of reporting a willingness to return to the facility for their next delivery than women with low PCMC score (aOR 12.72, 95% CI 2.26–71.63). The domains of Respect/Dignity and Supportive Care were associated with fewer newborn complications and willingness to return to a facility.

Conclusion: PCMC could improve not just the experience of the mother during childbirth, but also the health of her newborn and future health-seeking behavior.

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September 20, 2019
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Objectives: This study aimed to assess the accuracy of pregnant women’s perceptions of maternity facility quality and the association between perception accuracy and the quality of facility chosen for delivery.

Design: A cohort study.

Setting: Nairobi, Kenya.

Participants: 180 women, surveyed during pregnancy and 2 to 4 weeks after delivery.

Primary outcome measures: Women were surveyed during pregnancy regarding their perceptions of the quality of all facilities they were considering during delivery and then, after delivery, about their ultimate facility choice. Perceptions of quality were based on perceived ability to handle emergencies and complications. Delivery facilities were assigned a quality index score based on a direct assessment of performance of emergency ‘signal functions’, skilled provider availability, medical equipment and drug stocks. ‘Accurate perceptions’ was a binary variable equal to one if a woman’s ranking of facilities based on her quality perception equalled the index ranking. Ordinary least squares and logistic regressions were used to analyse associations between accurate perceptions and quality of the facility chosen for delivery.

Results: Assessed technical quality was modest, with an average index score of 0.65. 44% of women had accurate perceptions of quality ranking. Accurate perceptions were associated with a 0.069 higher delivery facility quality score (p=0.039; 95%CI: 0.004 to 0.135) and with a 14.5% point higher probability of delivering in a facility in the top quartile of the quality index (p=0.015; 95%CI: 0.029 to 0.260).

Conclusions: Patient misperceptions of technical quality were associated with use of lower quality facilities. Larger studies could determine whether improving patient information about relative facility quality can encourage use of higher quality care.

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July 30, 2019
English

Innovations for Poverty Action (IPA) is a research and policy non-profit that discovers and promotes effective solutions to global poverty problems. IPA brings together researchers and decision-makers to design, rigorously evaluate, and refine these solutions and their applications, ensuring that the evidence created is used to improve the lives of the world’s poor. Since our founding in 2002, IPA has worked with over 600 leading academics to conduct over 830 evaluations in 52 countries. Future growth will be concentrated in focus countries, such as Myanmar, where we have local and international staff, established relationships with government, NGOs, and the private sector, and deep knowledge of local issues.

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July 08, 2019

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