The effects of cash transfers on adult and child mortality in low- and middle-income countries.

Poverty is an important social determinant of health that is associated with increased risk of death1-5. Cash transfer programmes provide non-contributory monetary transfers to individuals or households, with or without behavioural conditions such as children's school attendance6,7. Over recent decades, cash transfer programmes have emerged as central components of poverty reduction strategies of many governments in low- and middle-income countries6,7. The effects of these programmes on adult and child mortality rates remains an important gap in the literature, however, with existing evidence limited to a few specific conditional cash transfer programmes, primarily in Latin America8-14. Here we evaluated the effects of large-scale, government-led cash transfer programmes on all-cause adult and child mortality using individual-level longitudinal mortality datasets from many low- and middle-income countries. We found that cash transfer programmes were associated with significant reductions in mortality among children under five years of age and women. Secondary heterogeneity analyses suggested similar effects for conditional and unconditional programmes, and larger effects for programmes that covered a larger share of the population and provided larger transfer amounts, and in countries with lower health expenditures, lower baseline life expectancy, and higher perceived regulatory quality. Our findings support the use of anti-poverty programmes such as cash transfers, which many countries have introduced or expanded during the COVID-19 pandemic, to improve population health.

Teacher depressive symptoms and children's school readiness in Ghana.

This study investigated associations between kindergarten teachers' (N = 208) depressive symptoms and students' (Ghanaian nationals, N = 1490, Mage  = 5.8) school-readiness skills (early literacy, early numeracy, social-emotional skills, and executive function) across 208 schools in Ghana over one school year. Teachers' depressive symptoms in the fall negatively predicted students' overall school-readiness skills in the spring, controlling for school-readiness skills in the fall. These results were primarily driven by social-emotional skills (r = .1-.3). There was evidence of heterogeneity by students' fall skill levels; teacher depressive symptoms predicted more negative spring overall school readiness for children who had higher fall school-readiness skills. Findings underscore the importance of teachers' mental health in early childhood education globally, with implications for policy and practice.

Do Incentives Crowd Out Motivation? A Feasibility Study of a Community Vector-Control Campaign in Peru.

Incentives are a useful tool in encouraging healthy behavior as part of public health initiatives. However, there remains concern about motivation crowd out-a decline in levels of motivation to undertake a behavior to below baseline levels after incentives have been removed-and few public health studies have assessed for motivation crowd out. Here, we assess the feasibility of identifying motivation crowd out following a lottery to promote participation in a Chagas disease vector control campaign. We look for evidence of crowd out in subsequent participation in the same behavior, a related behavior, and an unrelated behavior. We identified potential motivation crowd out for the same behavior, but not for related behavior or unrelated behaviors after lottery incentives are removed. Despite some limitations, we conclude that motivation crowd out is feasible to assess in large-scale trials of incentives.

Minimum Wages around Birth and Child Health.

This paper studies the effects of minimum wages in Indonesia around the time of birth on child height-for-age Z scores (HAZ) up to five years of age. Using variations in annual fluctuations in real minimum wages in different Indonesian provinces, it finds that children exposed to increases in minimum wages in their birth years have higher HAZ in the first five years of their lives. The estimated impacts are based on difference-in-differences models with biological-mother fixed effects and year-of-birth fixed effects and are robust to inclusion of multiple time-varying factors. The impacts are prominent particularly among male children.

Medium-term protective effects of quality early childhood education during the COVID-19 pandemic in Ghana.

The COVID-19 pandemic led to extended school closures globally. Access to remote learning opportunities during this time was vastly unequal within and across countries. Higher-quality early childhood education (ECE) can improve later academic outcomes, but longer-term effects during crises are unknown. This study provides the first experimental evidence of how previously attending a higher-quality ECE program affected child engagement in remote learning and academic scores during pandemic-related school closures in Ghana. Children (N = 1668; 50.1% male; Mage  = 10.1 years; all Ghanaian nationals) who attended higher-quality ECE at age 4 or 5 years had greater engagement in remote learning (d = .14) in October 2020, but not better language and literacy and math scores. Previous exposure to higher-quality ECE may support educational engagement during crises.

Endogenous inclusion in the Demographic and Health Survey anthropometric sample: Implications for studying height within households.

Development economists study both anthropometry and intra-household allocation. In these literatures, the Demographic and Household Surveys (DHS) are essential. The DHS censors its anthropometric sample by age: only children under five are measured. We document several econometric consequences, especially for estimating birth-order effects. Child birth order and mothers' fertility are highly correlated in the age-censored anthropometric subsample. Moreover, family structures and age patterns that permit within-family comparisons of siblings' anthropometry are unrepresentative. So strategies that could separate birth order and fertility in other data cannot here. We show that stratification by mother's fertility is important. We illustrate this by comparing India and sub-Saharan Africa (SSA). Children in India born to higher-fertility mothers are shorter, on average, than children of lower-fertility mothers. Yet, later-born children in India are taller, adjusted for age, than earlier-born children of the same sibsize. In SSA, neither of these associations is large.

Genetic risks, adolescent health, and schooling attainment.

We provide new evidence on the effect of adolescent health behaviors/outcomes (obesity, depression, smoking, and attention deficit hyperactivity disorder [ADHD]) on schooling attainment using the National Longitudinal Study of Adolescent to Adult Health. We take two different approaches to deal with omitted variable bias and reverse causality. Our first approach attends to the issue of reverse causality by estimating the effect of health polygenic scores (PGSs) on schooling. Second, we estimate the effect of adolescent health using sibling fixed-effects models that control for unmeasured genetic and family factors shared by siblings. We use the PGSs as additional controls in the sibling fixed-effects models to reduce concerns about residual confounding from sibling-specific genetic differences. We find consistent evidence across both approaches that being genetically predisposed to smoking and smoking regularly in adolescence reduces schooling attainment. Estimates for depression are more imprecise, but also suggest that a high genetic risk of depression and adolescent depression reduce schooling attainment. We find mixed evidence for ADHD. Our estimates suggest that having a high genetic risk for ADHD reduces grades of schooling, but we do not find any statistically significant negative effects of ADHD. Finally, we find no consistent evidence for a detrimental effect of obesity on schooling attainment.

Assessment of an adolescent-girl-focused nutritional educational intervention within a girls' empowerment programme: a cluster randomised evaluation in Zambia.

OBJECTIVE: Adolescent girls are at risk for both macro- and micronutrient deficiencies affecting growth, maternal and child health. This study assessed the impact of an adolescent-girl-tailored nutritional education curriculum on nutritional outcomes, including knowledge, dietary behaviour, anthropometry and anaemia. DESIGN: A cluster-randomised evaluation was conducted with two study arms: girls in mentor-led weekly girls' groups receiving sexual and reproductive health and life-skills training assigned to an age-appropriate nutritional curriculum and control girls in the weekly girls' groups without the nutritional education. The primary analysis was intent-to-treat (ITT) generalised least squares regression. Secondary analysis using two-stage, instrumental-variables estimation was also conducted. SETTING: The intervention and evaluation were conducted in urban and rural areas across four of ten provinces in Zambia. PARTICIPANTS: In total, 2660 girl adolescents aged 10-19 years were interviewed in 2013 (baseline) and annually through 2017. RESULTS: ITT results indicate that exposure to the nutritional educational programme did not meaningfully change outcomes for adolescents or their children. Intervention adolescents were no more likely to correctly identify healthy foods (P = 0·51) or proper infant-feeding practices (P = 0·92); were no less likely to be stunted (P = 0·30) or underweight (P = 0·87) and no less likely to be anaemic (P = 0·38). Outcomes for children of intervention participants were not improved, including being breastfed (P = 0·42), stunted (P = 0·21), wasted (P = 0·77) or anaemic (P = 0·51). CONCLUSIONS: Even a high-quality nutritional educational intervention tailored to adolescents within an empowerment programme does not assure improved nutritional outcomes; adolescent preferences, resource control and household dynamics require consideration in the context of nutritional educational programmes.

The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia.

BACKGROUND: Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls' social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year intervention included weekly, mentor-led, girls group meetings on health, life skills and financial education. Additional intervention components included a health voucher redeemable for general wellness and reproductive health services and an adolescent-friendly savings account. METHODS: A cluster-randomized-controlled trial with longitudinal observations evaluated the impact of AGEP on key indicators immediately and two years after program end. Baseline data were collected from never-married adolescent girls in 120 intervention clusters (3515 girls) and 40 control clusters (1146 girls) and again two and four years later. An intent-to-treat analysis assessed the impact of AGEP on girls' social, health and economic assets, sexual behaviors, education and fertility outcomes. A treatment-on-the-treated analysis using two-stage, instrumental variables regression was also conducted to assess program impact for those who participated. RESULTS: The intervention had modest, positive impacts on sexual and reproductive health knowledge after two and four years, financial literacy after two years, savings behavior after two and four years, self-efficacy after four years and transactional sex after two and four years. There was no effect of AGEP on the primary education or fertility outcomes, nor on norms regarding gender equity, acceptability of intimate partner violence and HIV knowledge. CONCLUSIONS: Although the intervention led to sustained change in a small number of individual outcomes, overall, the intervention did not lead to girls acquiring a comprehensive set of social, health and economic assets, or change their educational and fertility outcomes. It is important to explore additional interventions that may be needed for the most vulnerable girls, particularly those that address household economic conditions. Additional attention should be given to the social and economic environment in which girls are living. TRIAL REGISTRATION: ISRCTN29322231. Trial Registration Date: March 04, 2016; retrospectively registered.

Relationship between early-life nutrition and ages at menarche and first pregnancy, and childbirth rates of young adults: Evidence from APCAPS in India.

India's Integrated Child Development Services (ICDS) provides daily supplementary nutrition and other public health services to women and children. We estimated associations between exposure to early-childhood ICDS nutrition and adult reproductive outcomes. During 1987-1990, a balanced protein-calorie supplement called "upma"-made from locally available corn-soya ingredients-was rolled out by subdistricts near Hyderabad and offered to pregnant women and children under age 6 years. In a controlled trial, 15 villages received the supplement and 14 did not. We used data from a 2010-2012 resurvey of adults born during the trial (n = 715 in intervention and n = 645 in control arms). We used propensity score matching methods to estimate the associations between birth in an intervention village and menarcheal age, age at first pregnancy, and fertility of adults. We found that women born in the intervention group during the trial, as compared with the control group, had menarche 0.45 (95% confidence interval [CI: 0.22, 0.68]; p < .001) years later and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later. Married women from the intervention group had menarche 0.36 (95% CI [0.09, 0.64]; p < .01) years later, first cohabitation with partner 0.8 (95% CI [0.27, 1.33]; p < .01) years later, and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later than married women in the control group. There was no significant difference between intervention and control group women regarding whether they had at least one childbirth or the total number of children born. The findings were similar when we employed inverse propensity score weighted regression models.

Impact of the NREGS on Children's Intellectual Human Capital.

This paper uses panel data from the Young Lives Survey to examine the effect of the world's largest public works program and India's flagship social protection program, the National Rural Employment Guarantee Scheme (NREGS), on children's learning outcomes such as grade progression, reading comprehension test scores, writing test scores, math test scores, and Peabody Picture Vocabulary Test (PPVT) scores. We find that the program has strong positive effects on these outcomes in both the short-and-medium run. Finally, the impact estimates reported here are robust to a number of econometric concerns such as -program placement, selective attrition, and type I error.

Longitudinal causal impacts of preschool teacher training on Ghanaian children's school readiness: Evidence for persistence and fade-out.

Preschool programs have expanded rapidly in low- and middle-income countries, but there are widespread concerns about whether they are of sufficient quality to promote children's learning and development. We conducted a large school-randomized control trial ('Quality Preschool for Ghana' - QP4G) of a one-year teacher training and coaching program, with and without parental-awareness meetings, designed to improve preschool quality and child development. We followed 3,435 children in 240 schools in the Greater Accra Region of Ghana, a country with universal pre-primary education. A previous study reported positive impacts of teacher training (but not teacher training plus parental-awareness meetings) at the end of the implementation year on some dimensions of classroom quality, teacher well-being, and children's school readiness (Wolf et al., [2019] Journal of Research on Educational Effectiveness, 12, 10-37). The present study analyzed a new round of data collected 1 year after the end of implementation to assess (a) the extent of persistence in impacts on child development and (b) whether such impacts vary by select child, household, and school characteristics. We found impacts of the teacher training intervention on children's overall school readiness were sustained (d = 0.13), but were only marginally statistically significant. When broken down by domain, impacts on social-emotional skills specifically persisted. Persistent negative effects of teacher training plus parental-awareness meetings varied by the literacy status of the male parent such that negative impacts were concentrated in children in households with non-literate male heads.

Early Childhood Teachers' Lives in Context: Implications for Professional Development in Under-Resourced Areas.

This study explores the personal, professional, and contextual conditions faced by early childhood education (ECE) teachers in under-resourced settings and how these relate to teacher responsiveness to professional development (PD): namely, teacher attrition (a sign of PD failure when occurring shortly after PD), take-up of offered PD, adherence to PD training/materials, and quality of implementation. We use data from six disadvantaged districts in the Greater Accra Region of Ghana and PD focused on implementation of a national, play-based curriculum. Descriptive statistics indicate that ECE teachers (n = 302) face a multitude of barriers to high quality teaching across the bioecological model. Multilevel mixed effects models find that teachers with low job satisfaction are more likely to leave the school within the academic year. Teachers with moderate to severe depression are less likely to attend PD trainings. Senior teachers and those with poverty risks are less likely to adhere to PD material. Teachers with many time demand barriers are more likely to adhere to material. They also implement the content at higher observed quality as do teachers with bachelor's degrees and early childhood development (ECD) training. Take-up of PD also predicts quality of implementation. Practice and research implications are discussed.

Investing in the foundation of sustainable development: pathways to scale up for early childhood development.

Building on long-term benefits of early intervention (Paper 2 of this Series) and increasing commitment to early childhood development (Paper 1 of this Series), scaled up support for the youngest children is essential to improving health, human capital, and wellbeing across the life course. In this third paper, new analyses show that the burden of poor development is higher than estimated, taking into account additional risk factors. National programmes are needed. Greater political prioritisation is core to scale-up, as are policies that afford families time and financial resources to provide nurturing care for young children. Effective and feasible programmes to support early child development are now available. All sectors, particularly education, and social and child protection, must play a role to meet the holistic needs of young children. However, health provides a critical starting point for scaling up, given its reach to pregnant women, families, and young children. Starting at conception, interventions to promote nurturing care can feasibly build on existing health and nutrition services at limited additional cost. Failure to scale up has severe personal and social consequences. Children at elevated risk for compromised development due to stunting and poverty are likely to forgo about a quarter of average adult income per year, and the cost of inaction to gross domestic product can be double what some countries currently spend on health. Services and interventions to support early childhood development are essential to realising the vision of the Sustainable Development Goals.

Early-Life Nutrition Is Associated Positively with Schooling and Labor Market Outcomes and Negatively with Marriage Rates at Age 20-25 Years: Evidence from the Andhra Pradesh Children and Parents Study (APCAPS) in India.

Background: India's Integrated Child Development Services (ICDS) is among the world's largest public nutritional programs, providing daily nutritional supplements and other public health and educational services to pregnant and nursing women, children aged <6 y, and adolescent girls. Objective: We estimated the long-term association between early-childhood ICDS nutrition and adult outcomes. Methods: We used follow-up data from a controlled nutritional trial conducted during 1987-1990 in 29 villages near the city of Hyderabad. In 15 intervention villages, a balanced protein-calorie supplement-made from locally available corn-soya ingredients and called upma-was offered to pregnant women and to children <6 y old. No supplement was offered in the 14 control villages. During 2010-2012, adults born during the trial were re-surveyed (n = 715 in the intervention arm and n = 645 in the control arm). We used probit regression and propensity score-matching methods to estimate the association between birth in an intervention village and rates of secondary and graduate education completion, marriage, and employment or enrollment in higher education of these adults. Results: Adults born in the intervention group during the trial, compared with the control group, were 9% (95% CI: 0.04, 0.14; P < 0.01) more likely to complete secondary school and 11% (95% CI: 0.06, 0.15; P < 0.01) more likely to complete graduate education, were 6% (95% CI: -0.11, -0.01; P < 0.05) less likely to be ever-married at age 20-25 y, and were 5% (95% CI: 0, 0.11; P < 0.05) more likely to be employed or enrolled in higher education. The estimated associations for graduate education completion and employment-study rates were greater for men, whereas the associations for secondary education and ever-married rates were greater for women. Conclusion: Exposure to nutritional supplement in utero or during the first 3 y of life was associated with improved adult educational and employment outcomes and lower marriage rates in India.

Linear Growth through 12 Years is Weakly but Consistently Associated with Language and Math Achievement Scores at Age 12 Years in 4 Low- or Middle-Income Countries.

Background: Whether linear growth through age 12 y is associated with language and math achievement at age 12 y remains unclear. Objective: Our objective was to investigate associations of linear growth through age 12 y with reading skill, receptive vocabulary, and mathematics performance at age 12 y in 4 low- or middle-income countries (LMICs). Methods: We analyzed data from the Young Lives Younger Cohort study in Ethiopia (n = 1275), India (n = 1350), Peru (n = 1402), and Vietnam (n = 1594). Age 1, 5, 8, and 12 y height-for-age z scores (HAZ) were calculated. Language and math achievement at age 12 y was assessed with the use of country-specific adaptations of the Peabody Picture Vocabulary Test, the Early Grades Reading Assessment, and a mathematics test; all test scores were standardized by age within country. We used path analysis to examine associations of HAZ with achievement scores. Twelve models were examined at each age (3 tests across 4 countries). Results: Mean HAZ in each country was <-1.00 at all ages. Overall, linear growth through age 12 y was associated with 0.4-3.4% of the variance in achievement scores. HAZ at 1 y was positively and significantly associated with the test score in 11 of the 12 models. This association was significantly mediated through HAZ at 5, 8, and 12 y in 9 of the models. HAZ at 5, 8, and 12 y was positively and significantly associated with test scores in 8, 8, and 6 models, respectively. These associations were mediated through HAZ at older ages in 6 of the HAZ at 5-y models and in 6 of the HAZ at 8-y models. Conclusion: Child relative linear growth between ages 1 and 12 y was weakly but consistently associated with language and math achievement at age 12 y in 4 LMICs.

Child stunting is associated with weaker human capital among native Amazonians.

OBJECTIVES: We assessed associations between child stunting, recovery, and faltering with schooling and human capital skills in a native Amazonian society of horticulturalists-foragers (Tsimane'). METHODS: We used cross-sectional data (2008) from 1262 children aged 6 to 16 years in 53 villages to assess contemporaneous associations between three height categories: stunted (height-for-age Z score, HAZ<-2), moderately stunted (-2 ≤ HAZ≤-1), and nonstunted (HAZ>-1), and three categories of human capital: completed grades of schooling, test-based academic skills (math, reading, writing), and local plant knowledge. We used annual longitudinal data (2002-2010) from all children (n = 853) in 13 villages to estimate the association between changes in height categories between the first and last years of measure and schooling and academic skills. RESULTS: Stunting was associated with 0.4 fewer completed grades of schooling (∼24% less) and with 13-15% lower probability of showing any writing or math skills. Moderate stunting was associated with ∼20% lower scores in local plant knowledge and 9% lower probability of showing writing skills, but was not associated with schooling or math and writing skills. Compared with nonstunted children, children who became stunted had 18-21% and 15-21% lower probabilities of showing math and writing skills, and stunted children had 0.4 fewer completed grades of schooling. Stunted children who recovered showed human capital outcomes that were indistinguishable from nonstunted children. CONCLUSIONS: The results confirm adverse associations between child stunting and human capital skills. Predictors of growth recovery and faltering can affect human capital outcomes, even in a remote, economically self-sufficient society.

Birth seasons and heights among girls and boys below 12 years of age: lasting effects and catch-up growth among native Amazonians in Bolivia.

BACKGROUND: Seasons affect many social, economic, and biological outcomes, particularly in low-resource settings, and some studies suggest that birth season affects child growth. AIM: To study a predictor of stunting that has received limited attention: birth season. SUBJECTS AND METHODS: This study uses cross-sectional data collected during 2008 in a low-resource society of horticulturists-foragers in the Bolivian Amazon, Tsimane'. It estimates the associations between birth months and height-for-age Z-scores (HAZ) for 562 girls and 546 boys separately, from birth until age 11 years or pre-puberty, which in this society occurs ∼13-14 years. RESULTS: Children born during the rainy season (February-May) were shorter, while children born during the end of the dry season and the start of the rainy season (August-November) were taller, both compared with their age-sex peers born during the rest of the year. The correlations of birth season with HAZ were stronger for boys than for girls. Controlling for birth season, there is some evidence of eventual partial catch-up growth, with the HAZ of girls or boys worsening until ∼ age 4-5 years, but improving thereafter. By age 6 years, many girls and boys had ceased to be stunted, irrespective of birth season. CONCLUSION: The results suggest that redressing stunting will require attention to conditions in utero, infancy and late childhood.

Conditional cash transfers for primary education: Which children are left out?

Conditional cash transfer (CCT) programs to increase primary-school enrollment and attendance among low-income households have been shown to benefit children and households, but to date little is known about who joins such programs. We test three hypotheses about predictors of CCT program participation in indigenous societies in Bolivia, focusing on attributes of the household (ethnicity), parents (modern human capital), and children (age, sex). We model whether children receive a transfer from Bolivia's CCT program (Bono Juancito Pinto), using data from 811 school-age children and nine ethnic groups. Children from the group least exposed to Westerners (Tsimane') are 18-22 percentage points less likely to participate in the program than children from other lowland ethnic groups. Parental modern human capital and child sex do not predict participation. We discuss possible mechanisms underlying the findings and conclude that the Tsimane's current lower returns to schooling are the most likely explanation.

Family structure and child development in Chile: A longitudinal analysis of household transitions involving fathers and grandparents.

BACKGROUND: Adults support child development economically, socially, and emotionally. Household transitions may disrupt these support structures, impacting child development. OBJECTIVE: We document the large portion of children in Chile that experience biological-father and grandparent household transitions, and test if these transitions are associated with child vocabulary and behavior and if income could be a mechanism behind our findings. METHODS: We apply first-differences and lagged-dependent-variable analyses to a large, nationally representative, longitudinal survey of over 5,000 Chilean children. RESULTS: We find that children whose mothers separated from their parents' homes within the two years between two survey rounds have worse age-normalized Peabody Picture Vocabulary Test scores than children in households without such transitions. Changes in income per capita do not explain these associations. When fathers enter households between the two survey rounds there is a gain in income per capita but no association between father entrance and child's vocabulary score. Similarly, there is no significant association between fathers separating from the household and child vocabulary, though father departure is associated with lower income per capita. We find no association between household transitions and Child Behavioral Checklist (CBCL) scores. CONCLUSIONS: These findings provide evidence that Chilean grandparents promote language development when coresiding with their grandchildren and that Chilean fathers are an important source of household income. CONTRIBUTION: Our study examines fathers and grandparents simultaneously. We are able to take the directionality (i.e., movement in or out of the home) of biological father transitions into account.