The Effectiveness and Cost-Effectiveness of CashPlus Interventions to Prevent Acute Malnutrition in Somalia: Evidence from an Adaptive Cluster Randomized Control Trial

  1. Nadia Akseer
  2. Kemish Kenneth Alier
  3. Samantha Grounds
  4. Sydney Garretson
  5. Sagal Mohamud
  6. Qundeel Khattak
  7. Marina Tripaldi
  8. Fabrizio Loddo
  9. Said Aden Mohamoud
  10. Adan Yusuf Mahdi
  11. Mohamoud Ali Nur
  12. Sadiq Mohamed Abdiqadir
  13. Emily Mitchell
  14. Andreas Kees
  15. Mohamed Billow Mahat
  16. Maimun Gure
  17. Dahir Isaq Jibril
  18. Dahir Gedi
  19. Michael Ocircan P’Rajom
  20. Meftuh Omer
  21. Abdullahi Farah
  22. Mohamed Abdirashid Osman
  23. Abdiaziz Mohamed Adan
  24. Farhan Mohamed Mohamoud
  25. Abdullahi Muse Mohamoud
  26. Abdifatah Ahmed Mohamed
  27. Abdulkadir Ali Abdi
  28. Adam Abdulkadir
  29. Shelley Walton
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Abstract

Background

Acute malnutrition affects millions of children under five (U5) and pregnant and lactating women (PLW) globally, especially in humanitarian settings. Although “CashPlus” interventions – cash or food transfers combined with complementary components – are widely implemented, evidence remains limited on which combinations and durations are most effective at preventing acute malnutrition.

Methods

We conducted a three-arm cluster-randomized trial within Save the Children’s ‘CashPlus for Nutrition’ program in Somalia. Monthly support was provided as: (1) cash alone (Arm 1), (2) cash plus social and behavior change communication (SBCC; Arm 2), or (3) cash plus an additional cash top-up (Arm 3). Thirty-three villages were randomized across arms, targeting ∼1,500 households. Primary outcomes included prevalence and incidence of acute malnutrition in children 6–59 months and mothers, assessed at baseline, midline (3 months), and endline (6 months), alongside economic evaluations of cost and cost-effectiveness. Market monitoring and qualitative data were also conducted.

Results

Child acute malnutrition prevalence was approximately 15% in each arm at baseline. After 3 months, prevalence declined by 2.0 percentage points in Arm 1 to 13.0% (95% CI: 10.3%–16.1%), representing a relative reduction of 13.3%. In Arm 2, prevalence declined by 5.9 percentage points to 9.1% (6.8%–11.8%), a relative reduction of 39.3%. In contrast, prevalence in Arm 3 remained essentially unchanged, with an increase to 15.1% (12.1%–18.6%). By endline, there was little change from midline in all arms.

Maternal malnutrition improved most in Arm 2, but differences were not statistically significant. All arms showed improvements in dietary diversity and food security, but only Arm 2 achieved sustained nutrition gains. Household livelihood conditions appeared to improve overall though monthly expenditures nearly doubled. Arm 2 was the most effective and cost effective.

Conclusion

Adding SBCC to cash transfers significantly improved child nutrition compared to cash alone, highlighting that integrated approaches can enhance nutritional outcomes and cost-effectiveness in humanitarian settings.

Registration

The cluster-RCT was registered retrospectively at ClinicalTrials.gov on October 14, 2025, ID: NCT06642012 .

Article activity feed

  1. Version published to 10.1101/2025.07.22.25331867 on medRxiv