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.

You are What Your Parents Expect: Height and Local Reference Points.

Recent estimates are that about 150 million children under five years of age are stunted, with substantial negative consequences for their schooling, cognitive skills, health, and economic productivity. Therefore, understanding what determines such growth retardation is significant for designing public policies that aim to address this issue. We build a model for nutritional choices and health with reference-dependent preferences. Parents care about the health of their children relative to some reference population. In our empirical model, we use height as the health outcome that parents target. Reference height is an equilibrium object determined by earlier cohorts' parents' nutritional choices in the same village. We explore the exogenous variation in reference height produced by a protein-supplementation experiment in Guatemala to estimate our model's parameters. We use our model to decompose the impact of the protein intervention on height into price and reference-point effects. We find that the changes in reference points account for 65% of the height difference between two-year-old children in experimental and control villages in the sixth annual cohort born after the initiation of the intervention.

Does early nutrition predict cognitive skills during later childhood? Evidence from two developing countries.

The existing evidence linking early undernutrition to educational outcomes in developing countries is largely focused on assessing its impacts on grade attainment and achievement test scores, with limited evidence on the foundational cognitive skills required to perform well at school. We use unique data collected in Ethiopia and Peru as part of the Young Lives Study to investigate the relationship between early undernutrition and four foundational cognitive skills measured later in childhood, the first two of which measure executive functioning: working memory, inhibitory control, long-term memory, and implicit learning. We exploit the rich longitudinal data available to control for potential confounders at the household and individual level and for time-invariant community characteristics. We also take advantage of the availability of data for paired-siblings to obtain household fixed-effects estimates. In the latter specification, we find robust evidence that stunting at ~ age 5 is negatively related with executive functions measured years later, predicting reductions in working memory and inhibitory control by 12.6% and 5.8% of a standard deviation. Although the main cohort of Young Lives was around 12 years old when executive functions were measured, complementary results and analysis of the data available for the younger siblings suggest that the impact of stunting on executive functions-specifically, on working memory-starts at an earlier age. Our results shed light on the mechanisms that explain the relationship between early nutrition and school achievement tests suggesting that good nutrition is an important determinant of children's learning capacities.

Social Protection and Foundational Cognitive Skills during Adolescence: Evidence from a Large Public Works Program.

Many low- and middle-income countries have introduced public works programs (PWPs) to fight poverty. This paper provides the first evidence that children from families who benefit from PWPs show increased foundational cognitive skills. The results, based on unique tablet-based data collected as part of a long-standing longitudinal survey, show positive associations between participation in the Productive Safety Net Programme (PSNP) in Ethiopia during childhood with long-term memory and implicit learning, and suggestive evidence for working memory. These associations appear to be strongest for children whose households were still PSNP participants in the year of data collection. Evidence suggests that the association with implicit learning may be operating partially through children's time reallocation away from unpaid labor responsibilities, while the association with long-term memory may in part be due to the program's success in remediating nutritional deficits caused by early-life rainfall shocks.

Late-childhood foundational cognitive skills predict educational outcomes through adolescence and into young adulthood: evidence from Ethiopia and Peru.

We estimate associations between foundational cognitive skills (inhibitory control, working memory, long-term memory, and implicit learning) measured at age 12 and educational outcomes measured at ages 15 and 19-20 in Ethiopia and Peru, using the Young Lives data. The estimates adjust for rich sets of controls and include measurements of children's baseline abilities. For a subset of the outcomes, we exploit within-household variation. Working memory and long-term memory are consistently and positively associated with subsequent domain-specific cognitive achievement tests (measuring specifically numeracy, vocabulary and literacy achievement) in both countries, university enrolment in Peru (long-term memory) and lower secondary-school completion in Ethiopia (working memory). Inhibitory control predicts subsequent math-test scores in both countries, grade attainment (Ethiopia), and university enrolment (Peru). Value-added estimates show that these skills play roles during adolescence, with the memory-related skills predicting higher domain-specific test scores (Peru and Ethiopia) and grade attainment (Ethiopia), while inhibitory control has associations with math (both countries). These results provide additional evidence to justify the importance of promoting investments in cognitive skills throughout childhood and adolescence, and elucidate how such investments impact educational achievements.

Health and development from preconception to 20 years of age and human capital.

Optimal health and development from preconception to adulthood are crucial for human flourishing and the formation of human capital. The Nurturing Care Framework, as adapted to age 20 years, conceptualises the major influences during periods of development from preconception, through pregnancy, childhood, and adolescence that affect human capital. In addition to mortality in children younger than 5 years, stillbirths and deaths in 5-19-year-olds are important to consider. The global rate of mortality in individuals younger than 20 years has declined substantially since 2000, yet in 2019 an estimated 8·6 million deaths occurred between 28 weeks of gestation and 20 years of age, with more than half of deaths, including stillbirths, occurring before 28 days of age. The 1000 days from conception to 2 years of age are especially influential for human capital. The prevalence of low birthweight is high in sub-Saharan Africa and even higher in south Asia. Growth faltering, especially from birth to 2 years, occurs in most world regions, whereas overweight increases in many regions from the preprimary school period through adolescence. Analyses of cohort data show that growth trajectories in early years of life are strong determinants of nutritional outcomes in adulthood. The accrual of knowledge and skills is affected by health, nutrition, and home resources in early childhood and by educational opportunities in older children and adolescents. Linear growth in the first 2 years of life better predicts intelligence quotients in adults than increases in height in older children and adolescents. Learning-adjusted years of schooling range from about 4 years in sub-Saharan Africa to about 11 years in high-income countries. Human capital depends on children and adolescents surviving, thriving, and learning until adulthood.

Family play, reading, and other stimulation and early childhood development in five low-and-middle-income countries.

This paper used longitudinal data from five studies conducted in Bangladesh, Bhutan, Cambodia, Ethiopia, and Rwanda to examine the links between family stimulation and early childhood development outcomes (N = 4904; Mage = 51.5; 49% girls). Results from random-effects and more conservative child-fixed effects models indicate that across these studies, family stimulation, measured by caregivers' engagement in nine activities (e.g., reading, playing, singing), predicted increments in children's early numeracy, literacy, social-emotional, motor, and executive function skills (standardized associations ranged from 0.05 to 0.11 SD). Study-specific models showed variability in the estimates, with null associations in two out of the five studies. These findings indicate the need for additional research on culturally specific ways in which caregivers may support early development and highlight the importance of promoting family stimulation to catalyze positive developmental trajectories in global contexts. RESEARCH HIGHLIGHTS: Research on the links between family stimulation and early childhood development in low-and-middle-income countries (LMICs) is limited. We used longitudinal data from studies conducted in five LMICs to examine the links between family stimulation and early childhood development outcomes. Results suggest that family stimulation predicted increments in children's numeracy, literacy, social-emotional, motor, and executive function skills. We found variability in the observed estimates, with null associations in two out of the five studies, suggesting the need for additional research in LMICs.

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.

Barker's Hypothesis Among the Global Poor: Positive Long-Term Cardiovascular Effects of in Utero Famine Exposure.

An influential literature on the Developmental Origins of Health and Disease (DOHaD) has documented that poor conditions in utero lead to higher risk of cardiovascular disease at older ages. Evidence from low-income countries (LICs) has hitherto been missing, despite the fact that adverse in utero conditions are far more common in LICs. We find that Malawians exposed in utero to the 1949 Nyasaland famine have better cardiovascular health 70 years later. These findings highlight the potential context specificity of the DOHaD hypothesis, with in utero adversity having different health implications among aging LIC individuals who were exposed to persistent poverty.

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.

Same environment, stratified impacts? Air pollution, extreme temperatures, and birth weight in South China.

This paper investigates whether associations between birth weights and prenatal ambient environmental conditions-pollution and extreme temperatures-differ by 1) maternal education; 2) children's innate health; and 3) interactions between these two. We link birth records from Guangzhou, China, during a period of high pollution, to ambient air pollution (PM10 and a composite measure) and extreme temperature data. We first use mean regressions to test whether, overall, maternal education is an "effect modifier" in the relationships between ambient air pollution, extreme temperature, and birth weight. We then use conditional quantile regressions to test for effect heterogeneity according to the unobserved innate vulnerability of babies after conditioning on other confounders. Results show that 1) the negative association between ambient exposures and birth weight is twice as large at lower conditional quantiles of birth weights as at the median; 2) the protection associated with college-educated mothers with respect to pollution and extreme heat is heterogeneous and potentially substantial: between 0.02 and 0.34 standard deviations of birth weights, depending on the conditional quantiles; 3) this protection is amplified under more extreme ambient conditions and for infants with greater unobserved innate vulnerabilities.

Returning to school after COVID-19 closures: Who is missing in Malawi?

During the early stages of the COVID-19 pandemic, almost all countries implemented school closures to prevent disease transmission. However, prolonged closures can put children at risk of leaving school permanently, a decision that can reduce their long-term potential and income. This study investigated the extent to which the COVID-19 pandemic and associated school closures reduced school attendance in Malawi, a low-income African country. We used longitudinal data from a cohort of adolescents interviewed before (2017/18; at age 10-16) and after (2021; at age 13-20) the pandemic school closures. Of those students who had been attending school prior to school closures, we find that 86% returned when schools re-opened. Dropouts were more pronounced among older girls: over 30% of those aged 17-19 did not return to school. This resulted in further lowering the gender parity index to the greater disadvantage of girls. We also found that students already lagging behind in school were more likely to dropout. Thus, our data suggest that the COVID-19 pandemic has magnified gender inequalities in schooling, at least partially erasing recent progress towards inclusive education. Urgent investments are needed to find and re-enroll lost students now, and to create more resilient and adaptable educational systems before the next pandemic or other negative shock arrives.

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.

Global estimates of the implications of COVID-19-related preprimary school closures for children's instructional access, development, learning, and economic wellbeing.

Observational data collected prior to the pandemic (between 2004 and 2019) were used to simulate the potential consequences of early childhood care and education (ECCE) service closures on the estimated 167 million preprimary-age children in 196 countries who lost ECCE access between March 2020 and February 2021. COVID-19-related ECCE disruptions were estimated to result in 19.01 billion person-days of ECCE instruction lost, 10.75 million additional children falling "off track" in their early development, 14.18 million grades of learning lost by adolescence, and a present discounted value of USD 308.02 billion of earnings lost in adulthood. Further burdens associated with ongoing closures were also forecasted. Projected developmental and learning losses were concentrated in low- and lower middle-income countries, likely exacerbating long-standing global inequities.

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.