Highlights work of the Transfer Project and how government cash transfer programs in Zambia aimed at poverty reduction lowered the levels of perceived stress and poverty among poor households

1. unite for
children
Poverty and perceived stress: evidence from
two unconditional cash transfer programmes
in Zambia
Tia Palermo, Ph.D.
UNICEF Office of Research – Innocenti / Stony Brook University (SUNY)
With Lisa Hjelm, Jacob de Hoop, Ashu Handa, On Behalf of the CGP and MCT
Evaluation Teams
April 2017
Population Association of American Annual Meeting
Chicago

2. 2
Evaluation teams
Members of the CGP evaluation team:
Principal Investigators: David Seidenfeld (AIR) and Sudhanshu Handa (UNC); AIR: Juan Bonilla,
Rosa Castro Zarzur, Leah Prencipe, Dan Sherman, David Seidenfeld; UNICEF-Zambia: Charlotte
Harland Scott, Paul Quarles van Ufford; Government of Zambia: Vandras Luywa, Stanfield
Michelo, Manzunzo Zulu; DFID-Zambia: Kelley Toole; Palm Associates: Alefa Banda, Chiluba
Goma, Liseteli Ndiyoi, Gelson Tembo, NathanTembo); UNC: Sudhanshu Handa; UNICEF Office of
Research – Innocenti: Sudhanshu Handa, Tia Palermo, Amber Peterman, Leah Prencipe
Members of the MCP evaluation team:
Principal Investigators: David Seidenfeld (AIR) and Sudhanshu Handa (UNC); AIR: Juan Bonilla,
Alvaro Ballarin Cabrera, Thomas De Hoop, Gilbert Kiggundu, Nisha Rai, Hannah Reeves, Joshua
Sennett, Dan Sherman, Jonathan Sokoll, Amy Todd, Rosa Castro Zarzur; Palm Associates: Alefa
Banda, Liseteli Ndiyoi, Nathan Tembo; UNC: Sudhanshu Handa; UNICEF Office of Research -
Innocenti: Tia Palermo, Amber Peterman, Leah Prencipe
Hjelm L, de Hoop J, Handa S, Palermo T. (2017). Poverty and perceived stress: Evidence from two
unconditional cash transfer programs in Zambia. Social Science & Medicine, online ahead of print:
http://www.sciencedirect.com/science/article/pii/S0277953617300308

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The big picture:
Government
cash transfer
programs in
sub-Saharan
Africa
3
No Cash Transfers
After 2004
Prior to 2004
No data
Transfer Project

4. 4
The Transfer Project
• Who: Community of research, donor &and implementing partners –
focus on coordination in efforts and uptake of results
 UNICEF, FAO, UNC, Save the Children, National Governments
• Mission: Provide rigorous evidence on of government-run large-
scale (largely unconditional) SCTs
• Motivation:
 Income poverty has highly damaging impacts on human
development
 Cash empowers people living in poverty to make their own
decisions on how to improve their lives
 Evidence needed from African context
• Where: Ethiopia, Ghana, Kenya, Lesotho, Malawi, Madagascar,
South Africa, Tanzania, Zambia and Zimbabwe

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• Poverty linked to poor physical health (Marmot 2005, Leon and Walt
2001) and mental health (Lund et al., 2010).
• Mechanisms of impact:
• Social causation hypothesis: Chronic stress, malnutrition, substance
abuse, social exclusion, and exposure to trauma and violence (Johnson
et al., 1999; Lund et al., 2011)
• Chronic stressors can produce biological stress reactions, including
excessive inflammation (McEwen & Seeman, 1999) and thought to
accelerate the natural aging of the immune system (Aiello & Dowd, 2013).
• Poverty also affects exposure to stressful events and ability to cope
with stress (Adler et al., 1994; Cohen, 1988; Cohen & Janicki‐Deverts,
2012; Hamad et al., 2008).
Background

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• Sub-Saharan Africa: Poverty widespread and food insecurity a major
source of daily stress
• Relationship between stress, SES and stressful life events less
studied in SSA
• South Africa: perceived stress was linked to subjective social status, but
not to other SES indicators (education, employment, income) (Hamad et
al., 2008).
• Kenya: absence of rain (negative income shock) induced higher self-
perceived stress and cortisol levels (Chemin et al., 2013).
• Kenya: unconditional cash transfers reduced self-perceived stress but not
cortisol levels (overall impacts; Haushofer & Shapiro, 2016).
• No studies examining large-scale, government-run cash transfer
programmes and impacts on self-perceived stress in SSA
Background

7. 7
Study aim
• Examine whether two government cash transfer programs in Zambia
aimed at poverty reduction lowered the levels of perceived stress and
poverty among poor households

8. 8
Child/youth-level mediators
• School attendance/ labor force
participation
• Material well-being
• Stress
CashTransferProgram
Household/caregiver
mediators
Consumption
• Food Security
• Material well-being
Investment
• Business activity
• Livestock
• Work
Stress
Time use
Income
Children
• Nutritional status
• Morbidity/mortality
• Mental
health/emotional well-
being
• Cognitive skills
Adolescents and
youth
• Future expectations
• Morbidity
• Sexual debut
• HIV risk
• Pregnancy
• Marriage
• Mental Health
• Violence
• Risky Behaviors
• Distance/quality of facilities
• Prices
• Shocks
• Infrastructure
Moderators
Conceptual Framework for Impact of
Tanzania PSSN
• Health and social service availability
• Family/friends social support
Conceptual Framework

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Methods: Programs
• Zambia Multiple Category Cash Transfer Program (MCP)
• Targeted to following households: female headed and keeping orphans,
having a disabled member, headed by an elderly and keeping orphans, or
special cases of critically vulnerable households
• Zambia Child Grant Programme (CGP)
• Unconditional CT to households with a child <5 years
• Districts targeted with high rates of mortality, morbidity, stunting, and
wasting among children aged 0–3 years
• Both programmes:
• Implemented by the Ministry of Community Development, Mother and
Child Health
• 11 USD per month (estimated to cover cost of one meal per person per
day)

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Evaluation samples
• Sample for current analysis
• Female caregivers of children (main household survey respondents)
• MCP (n=2490)
• 3078 households in 92 communities in two districts: Luwingu & Serenje
• Baseline: Nov/Dec 2011 Follow-up: Nov/Dec 2013, Nov/Dec 2014 (36
months)
• CGP (n=2272)
• 2,515 households at baseline from 90 communities (randomized into
treatment & control arms) in three districts – Kaputa, Kalabo &
Shang’ombo
• Baseline December 2010
• Follow-up: September and October 2012 (24 months), June & July 2013
(30 months), and September & October 2013 (36 months).

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Measures: Outcomes
• Poverty-related outcomes:
• Household per capita monthly consumption expenditures
• Household Food Security Access Scale (HFIAS) (Coates et al., 2007)
• Number of nonproductive assets owned (10 items in CGP, 7 items in MCP)
• Perceived Stress Scale (Cohen et al., 1983)
• Concept of stress as an interaction between environmental demands & the
individual’s capacity to cope
• Validated in many countries globally; increasingly used in SSA but not
validated there
• 10 items (6 negatively phrased & 4 positively)
• Positive subscale did not perform well: subscales not consistently closely
correlated & positive subscale didn’t show consistent associations with
happiness & optimism

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Perceived Stress Scale (PSS)
In the last 4 weeks:
1) How often have you been upset because of something that happened
unexpectedly?
2) How often have you felt that you were unable to control the important things in
your life?
3) How often have you felt nervous and “stressed”?
4) How often have you felt confident about your ability to handle your personal
problems?
5) How often have you felt that things were going your way?
6) How often have you found that you could not cope with all the things that you had
to do?
7) How often have you been able to control irritations in your life?
8) How often have you felt that you were on top of things?
9) How often have you been angered because of things that were outside of your
control?
10) How often have you felt difficulties were piling up so high that you could not
overcome them?

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Statistical analysis
1) OLS on 36-month cross-sections to examine program impacts on
poverty-related outcomes & stress
2) OLS on 36-month cross-section examining determinants of stress
(among controls only)
• Robustness check: Individual fixed-effects OLS run using CGP (30 &
36 months)
• Standard errors adjusted for clustering at community level (level of
randomization)
• Controls (baseline values): age, marital status, total number of
household members, number of household members of different
age groups (0–5, 6–12, 13–18, 19–35, 36–55, 56–69, and 70+
years), food insecurity, baseline log of per capita expenditures, &
baseline asset ownership, district

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Panel A: CGP N All
Control
(proportion
/mean)
Treatment
(proportion
/mean)
p-value*
Characteristics of women
Age 2,272 29.79 29.64 29.95 0.65
Ever attended school 2,271 0.71 0.70 0.73 0.40
Highest grade completed 2,261 3.93 3.70 4.17 0.09
Married 2,266 0.73 0.72 0.74 0.73
Never married 2,266 0.10 0.10 0.11 0.78
Divorced 2,266 0.10 0.11 0.09 0.10
Widowed 2,266 0.06 0.06 0.07 0.87
Household demographics
Household size 2,273 5.71 5.65 5.77 0.51
Household food insecurity access
scale (HFIAS) (0-24)a 2,235 15.23 15.4 15.05 0.55
Severely food insecure
households
2,243 0.90 0.90 0.90 0.90
Total monthly per capita
household expenditures
2,271 39.82 38.87 40.79 0.46
Assets owned (0-10) 2,273 0.82 0.73 0.92 0.12
Results: Baseline characteristics (CGP)
*indicate tests for significant differences between control & treatment groups at baseline

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Panel B: MCP N All
Control
(proportion
/mean)
Treatment
(proportion
/mean)
p-value*
Characteristics of women
Age 2,490 51.62 51.26 51.98 0.50
Ever attended school 2,481 0.61 0.63 0.60 0.42
Highest grade completed 2,458 3.03 3.09 2.98 0.64
Married 2,474 0.29 0.30 0.29 0.83
Never married 2,474 0.05 0.06 0.04 0.01
Divorced 2,474 0.14 0.14 0.14 0.96
Widowed 2,474 0.51 0.50 0.53 0.37
Household demographics
Household size 2,490 5.16 5.18 5.14 0.84
Household food insecurity access
scale (HFIAS) (0-24)a 2,431 14.68 14.61 14.75 0.76
Severely food insecure
households
2,459 0.81 0.78 0.83 0.09
Total monthly per capita
household expenditure
2,490 48.63 48.79 48.48 0.91
Assets owned (0-7) 2,490 0.54 0.58 0.51 0.35
Results: Baseline characteristics (MCP)
*indicate tests for significant differences between control & treatment groups at baseline

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Results: Program Impacts on Poverty & Stress
Perceived Stress
Scale
(0-24)
Expenditure per
capita
Household Food
Insecurity Access Scale
(0-27)
Number of non-
productive assets
owned
Panel A:
CGP
(1) (2) (3) (4)
Treatment effect 0.07 10.43*** -2.86*** 0.72***
(t-statistic) (0.21) (4.32) (-7.63) (6.29)
Number of
observations 2,273 2,273 2,269 2,272
Control mean (sd) 7.60 (4.20) 50.98 (36.97) 13.50 (5.20) 0.86 (1.44)
Treatment mean (sd) 7.70 (4.03) 62.52 (37.56) 10.54 (4.84) 1.71 (1.80)
Panel B:
MCP
Treatment effect -0.42 16.68*** -3.02*** 0.37***
(t-statistic) (-1.17) (4.76) (-6.94) (5.73)
Number of
observations 2,490 2,490 2,490 2,490
Control mean (sd) 9.92 (4.73) 60.54 (40.53) 14.50 (5.54) 0.49 (0.87)
Treatment mean (sd) 9.58(4.64) 76.87(53.62) 11.52(5.11) 0.84(0.97)
T-statistics are based on standard errors clustered at the community level.
*** p<0.001, ** p<0.01, * p<0.05.

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Results: Determinants of Stress
CGP MCP
Cross-sectional
OLS regression
(1)
Fixed-effect
regression
(2)
Cross-sectional
OLS regression
(3)
Age 0.02 - 0.01
(1.58) - (0.64)
Education (attended school) 0.48 - -0.16
(1.74) - (-0.52)
Any death in the household 0.53 1.63** -0.61
(0.58) (2.91) (-0.84)
Household Food Insecurity Access
Scale (0-27) 0.15** 0.12** 0.27***
(3.21) (2.77) (6.36)
Expenditure per capita 0.01 0.00 -0.00
(1.78) (1.04) (-0.78)
Number of non-productive assets
owneda -0.01 -0.23 -0.08
(-0.05) (-1.37) (-0.42)
Number of women (observations) 1,139 1,145 (2,285) 1,227
R-squared 0.09 0.04 0.18
Notes: Robust t-statistics in parentheses based. Cross-sectional models control for marital status,
district, household size and household demographics.
*** p<0.001, ** p<0.01, * p<0.05; Constant not presented for space considerations

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Discussion
• Program successful in reducing poverty-related outcomes
• No impacts on perceived stress
• Why no impacts on stress?
• Program doesn’t reduce stress?
• Relative SES (instead of absolute poverty) could be more
important determinant of stress
• Grant amount insufficient to affect stress levels
• PSS, developed in Western setting, not adequately capturing
stress in poor, rural SSA setting
• “Stress” may not be used & understood in same way (Pike & Patil,
2006)
• A context-specific stress scale based on local conditions & expectations
may better capture the experience of stress (Ice et al., 2012).

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References (1 of 2)
• Adler, N.E., Boyce, T., Chesney, M.A., Cohen, S., Folkman, S., Kahn, R.L., et al. (1994). SES and health: the
challenge of the gradient. American Psychologist, 49, 15-23.
• Aiello, A.E., & Dowd, J.B. (2013). Socio-economic Status and Immunosenescence. In Jos A. Bosch, J.A., Anna C.
Phillips, A.C. & Lord, J.M (Eds.), Immunosenescence, New York, Springer, pp. 145-157.
• American Institutes for Research. (2011). Zambia’s Child Grant Program: Baseline Report. Washington, DC:
American Institutes for Research.
• American Institutes for Research. (2012). Zambia’s Multiple Category Cash Transfer Program: Baseline Report.
Washington, DC: American Institutes for Research.
• Chemin, M., De Laat, J., & Haushofer, J. (2013). Negative rainfall shocks increase levels of the stress hormone
cortisol among poor farmers in Kenya. Available at SSRN 2294171: http://ssrn.com/abstract=2294171 or
http://dx.doi.org/10.2139/ssrn.2294171.
• Cohen, S. (1988). Perceived stress in a probability sample of the United States. In S. Spacapan, & S. Oskamp
(Eds.), The Social Psychology of Health. Newbury Park, CA, Sage, pp 31-67.
• Cohen, S., Janicki-Deverts, D., & Miller, G.E. (2007). Psychological stress and disease. JAMA, 298, 1,685-1,687.
• Dole, N., Savitz, D.A., Hertz-Picciotto, I., Siega-Riz, A.M., McMahon, M.J., & Buekens, P. (2003). Maternal stress
and preterm birth. American Journal of Epidemiology, 157, 14-24.
• Haushofer, Johannes, and Jeremy Shapiro. "The short-term impact of unconditional cash transfers to the poor:
Experimental Evidence from Kenya." The Quarterly Journal of Economics 131.4 (2016): 1973-2042.
• Ice, G.H., Sadruddin, A.F., Vagedes, A., Yogo, J., & Juma, E. (2012). Stress associated with caregiving: An
examination of the stress process model among Kenyan Luo elders. Social Science & Medicine, 74, 2,020-2,027.
• Leon, David A., and Gillian Walt. Poverty, inequality, and health: an international perspective. Oxford University
Press, 2001.

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References (2 of 2)
• Lobel, M., Dunkel-Schetter, C., & Scrimshaw, S.C. (1992). Prenatal maternal stress and prematurity: a prospective
study of socioeconomically disadvantaged women. Health Psychology, 11, 32-40.
• Lund, C., Breen, A., Flisher, A.J., Kakuma, R., Corrigall, J., Joska, J.A., et al. (2010). Poverty and common mental
disorders in low and middle income countries: a systematic review. Social Science & Medicine, 71, 517-528.
• Lund, C., De Silva, M., Plagerson, S., Cooper, S., Chisholm, D., Das, J., et al. (2011). Poverty and mental disorders:
breaking the cycle in low-income and middle-income countries. The Lancet, 378, 1,502-1,514.
• Marmot, Michael. "Social determinants of health inequalities." The Lancet 365.9464 (2005): 1099-1104.
• McEwen, B.S., & Seeman, T. (1999). Protective and damaging effects of mediators of stress: elaborating and testing
the concepts of allostasis and allostatic load. Annals of the New York Academy of Sciences, 896, 30-47.
• Pike, I.L., & Patil, C.L. (2006). Understanding women’s burdens: preliminary findings on psychosocial health among
Datoga and Iraqw women of northern Tanzania. Culture, Medicine and Psychiatry, 30, 299-330.
• Rondó, P., Rezende, G., Lemos, J., & Pereira, J. (2013). Maternal stress and distress and child nutritional status.
European journal of clinical nutrition, 67, 348-352.
• Torche, F. (2011). The effect of maternal stress on birth outcomes: exploiting a natural experiment. Demography, 48,
1,473-1,491.

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Acknowledgements
The CGP and MCP impact evaluations were commissioned
by the Government of Zambia (GRZ) through the Ministry of
Community Development, Mother and Child Health to the
American Institutes of Research (AIR) and the University of
North Carolina at Chapel Hill (UNC) and funded by a
consortium of donors including DFID, UNICEF, Irish Aid, and
the Government of Finland. Palermo, Handa, and Hjelm
received additional funding from the Swedish International
Development Cooperation for analysis of the data and
drafting of the manuscript.

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Asante
Zikomo
Grazie!
Ghana LEAP 1000
(© Michelle Mills)

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• Briefs:
http://www.cpc.unc.edu/projects/transfer/publications/briefs
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For more information
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