Impact of conditional and unconditional cash transfers on health outcomes and use of health services in humanitarian settings: a mixed-methods systematic review

Background Cash transfers, payments provided by formal or informal institutions to recipients, are increasingly used in emergencies. While increasing autonomy and being supportive of local economies, cash transfers are a cost-effective method in some settings to cover basic needs and extend benefits of limited humanitarian aid budgets. Yet, the extent to which cash transfers impact health in humanitarian settings remains largely unexplored. This systematic review evaluates the evidence on the effect of cash transfers on health outcomes and health service utilisation in humanitarian contexts. Methods Studies eligible for inclusion were peer reviewed (quantitative, qualitative and mixed-methods). Nine databases (PubMed, EMBAS, Medline, CINAHL, Global Health, Scopus, Web of Science Core Collection, SciELO and LiLACS) were searched without language and without a lower bound time restriction through 24 February 2021. The search was updated to include articles published through 8 December 2021. Data were extracted using a piloted extraction tool and quality was assessed using The Joanna Briggs Critical Appraisal Tool. Due to heterogeneity in study designs and outcomes, results were synthesised narratively and no meta-analysis was performed. Results 30 673 records were identified. After removing duplicates, 17 715 were double screened by abstract and title, and 201 in full text. Twenty-three articles from 16 countries were included reporting on nutrition outcomes, psychosocial and mental health, general/subjective health and well-being, acute illness (eg, diarrhoea, respiratory infection), diabetes control (eg, blood glucose self-monitoring, haemoglobin A1C levels) and gender-based violence. Nineteen studies reported some positive impacts on various health outcomes and use of health services, 11 reported no statistically significant impact on outcomes assessed and 4 reported potential negative impacts on health outcomes. Discussion Although there is evidence to suggest a positive relationship between cash transfers and health outcomes in humanitarian settings, high-quality empirical evidence, that is methodologically robust, investigates a range of humanitarian settings and is conducted over longer time periods is needed. This should consider factors influencing programme implementation and the differential impact of cash transfers designed to improve health versus multipurpose cash transfers. PROSPERO registration number CRD42021237275.


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(cash transfer* or income supplement* or (mone* adj3 (incentiv* or grant* or transfer*)) or (social adj (welfare* or assistance*)) or voucher* or food stamp* or mobile money or e-cash* or e-transfer* or e-wallet* or cash* or CCT or coupon* or direct payment* or ((conditional or unconditional or restricted or unrestricted) adj3 transfer*)).ti,ab. or Social Welfare/ or exp food assistance/ 33559 2 (Genocide* or war or warfare or (armed adj2 (intervention or conflict)) or conflict affected or displaced or displacement or refugee* or asylum* or migra* or (emergency adj2 (response* or relief*)) or humanitarian or disaster* or (relief adj2 (plan* or Work* or effort*)) or mass casualty or disaster* or hurricane* or typhoon* or storm* or tornado* or blizzard* or flood* or drought* or cyclone* or rain* or wind* or heatwave* or cold wave* or fire* or wildfire* or tsunami* or avalanche* or landslide* or rockslide* or mudslide* or tidal wave* or typhoon* or volcanic eruption* or volcan* or earthquake* or famine* or starv* or food insecurity or homeless* or housing insecurity or (outbreak* and disease*) or epidemic* or pandemic* or ((crop* or agriculture) adj3 (fail* or devast*))).ti,ab. or (relief work/ or exp mass casualty incident/ or exp armed conflicts/ or refugees/ or exp extreme weather/ or exp natural disasters/ or exp disease outbreaks/ or exp food security/ or exp food insecurity/ or exp genocide/ or exp warfare/ or exp homeless persons/ or exp famine/) 1215745 3 1 and 2 2801

results
cash transfer" or coupon or voucher or "social welfare" or "mobile money" or "direct payment" [Words] and disaster or war or humanitarian or famine or refugee or storm or "armed conflict" [Words] BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance Selection process 8 Specify the methods used to decide whether a study met the inclusion criteria of the review, including how many reviewers screened each record and each report retrieved, whether they worked independently, and if applicable, details of automation tools used in the process.
Page 5-7 Data collection process 9 Specify the methods used to collect data from reports, including how many reviewers collected data from each report, whether they worked independently, any processes for obtaining or confirming data from study investigators, and if applicable, details of automation tools used in the process.
Page 5-7 Data items 10a List and define all outcomes for which data were sought. Specify whether all results that were compatible with each outcome domain in each study were sought (e.g. for all measures, time points, analyses), and if not, the methods used to decide which results to collect.
Page 5-6 10b List and define all other variables for which data were sought (e.g. participant and intervention characteristics, funding sources). Describe any assumptions made about any missing or unclear information.
Page 7 Study risk of bias assessment 11 Specify the methods used to assess risk of bias in the included studies, including details of the tool(s) used, how many reviewers assessed each study and whether they worked independently, and if applicable, details of automation tools used in the process.
Page 7 Effect measures 12 Specify for each outcome the effect measure(s) (e.g. risk ratio, mean difference) used in the synthesis or presentation of results. Page 6-7 Synthesis methods 13a Describe the processes used to decide which studies were eligible for each synthesis (e.g. tabulating the study intervention characteristics and comparing against the planned groups for each synthesis (item #5)).
Page 6-7 13b Describe any methods required to prepare the data for presentation or synthesis, such as handling of missing summary statistics, or data conversions. Page 7 BMJ Publishing Group Limited (BMJ) disclaims all liability and responsibility arising from any reliance 13d Describe any methods used to synthesize results and provide a rationale for the choice(s). If meta-analysis was performed, describe the model(s), method(s) to identify the presence and extent of statistical heterogeneity, and software package(s) used.
Page 7 13e Describe any methods used to explore possible causes of heterogeneity among study results (e.g. subgroup analysis, meta-regression). Page 7 13f Describe any sensitivity analyses conducted to assess robustness of the synthesized results. NA

Reporting bias assessment
14 Describe any methods used to assess risk of bias due to missing results in a synthesis (arising from reporting biases). Page 7 Certainty assessment 15 Describe any methods used to assess certainty (or confidence) in the body of evidence for an outcome. Page 7

RESULTS
Study selection 16a Describe the results of the search and selection process, from the number of records identified in the search to the number of studies included in the review, ideally using a flow diagram.
Page 7-8, Figure 1 16b Cite studies that might appear to meet the inclusion criteria, but which were excluded, and explain why they were excluded. NA

Registration and protocol
24a Provide registration information for the review, including register name and registration number, or state that the review was not registered.
Page 5 24b Indicate where the review protocol can be accessed, or state that a protocol was not prepared. Page 5 24c Describe and explain any amendments to information provided at registration or in the protocol. Page 5 Support 25 Describe sources of financial or non-financial support for the review, and the role of the funders or sponsors in the review. Page 18 Competing interests 26 Declare any competing interests of review authors. Page 18 Availability of data, code and other materials 27 Report which of the following are publicly available and where they can be found: template data collection forms; data extracted from included studies; data used for all analyses; analytic code; any other materials used in the review.

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