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:

1. The vouchers may have been too restrictive - the main meat available was chicken which is low in iron.
2. All 3 arms saw significant increases in intake of milk and eggs which are iron inhibitors 
3. Both cash arms saw a significant decrease in risk of getting malaria/fever whilst the FFV arm was no different from the CG
4. 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.