Objective: Conditional cash transfer programs are popular internationally and represent a large investment in child health. Evidence of their impact on child nutrition status remains weak and inconsistent, particularly for Bolsa Família, the Brazilian conditional cash transfer program and one of the world's largest. Our objective was to estimate the effect of the Brazilian conditional cash transfer program, Bolsa Família (BF), on child nutritional status as measured by length-for-age z-score (LAZ) and weight-for-age z-score (WAZ) at 24 months. Methods: We analyzed the 1703 children eligible for BF from the 2004 Pelotas Birth Cohort. Children were divided into three exposure groups by total amount of money their household received from BF in 24 months: no BF, low BF (≤R$1000) and high BF (>R$1000). Using a doubly robust semiparametric estimation method we estimated the effect of receiving low and high levels of BF on LAZ and WAZ at 24 months. Results: After adjustment for measured confounders, the expected difference in LAZ between children that received low or high levels of BF compared to no BF was −0.14 [95% confidence interval (CI): −0.27, −0.02] and −0.20 (95% CI: −0.33, −0.08) respectively. For WAZ the estimated differences were −0.04 (95% CI: −0.17, 0.08) for low levels versus no BF and −0.18 (95% CI: −0.30, −0.05) for high levels versus no BF. The expected difference in population LAZ had all eligible households received it and population LAZ under no BF was −0.15 (95% CI: −0.26, −0.04). Sensitivity analyses suggested only a strong confounder could explain away these results. Conclusions: Among participants of the 2004 Pelotas Birth Cohort, BF was associated with a reduction in LAZ and WAZ in 24 month old children.
Bibliographical noteFunding Information:
JAL was supported a Banting and Best Doctoral Award from the Canadian Institutes of Health Researhc. JSK is a Canada Research Chair in Health Disparities. ES is supported by a Chercheur boursier Junior 2 from the Fonds de recherche du Québec – Santé. AM, ISS and AJDB are supported by the CNPq. This article is based on data from the 2004 Pelotas Birth Cohort, conducted by the Postgraduate Program in Epidemiology at Universidade Federal de Pelotas, with the collaboration of the Brazilian Public Health Association (ABRASCO). The World Health Organization, National Support Program for Centers of Excellence (PRONEX), Brazilian National Research Council (CNPq), Brazilian Ministry of Health, and Children's Pastorate supported the study in its two first years.
We would like to thank Dr. Mark van der Laan for answering our questions about specific aspects of TMLE. The operation of guillimin, the supercomputer used in this study, is funded by the Canada Foundation for Innovation (CFI), ministère de l’Économie, de la Science et de l’Innovation du Québec (MESI) and the Fonds de Recherche du Québec - Nature et Technologies (FRQ-NT).
- Child growth
- Conditional cash transfer
- Doubly robust estimation
- Health policy
- Sensitivity analysis
- Targeted estimation