Ann Weber

Socioeconomic Gradients and Child Development in a Very Low Income Population: Evidence from Madagascar.

Our objectives were to document and examine socioeconomic gradients across a comprehensive set of child development measures in a population living in extreme poverty, and to interpret these gradients in light of findings from the neuroscience literature. We assessed a nationally representative sample of 3-6-year-old children (n = 1332) from 150 communities of Madagascar using standard tests of development. We found that children whose families were in the top wealth quintile or whose mothers had secondary education performed significantly better across almost all measures of cognitive and language development and had better linear growth compared with children of women in the lowest wealth quintile or women with no education. These differences between children of low and high socioeconomic position were greatest for receptive language, working memory, and memory of phrases. The mean difference in the scores between children in the highest and lowest socioeconomic status categories doubled between age 3 and age 6, and the biggest gaps across socioeconomic position by age 6 were in receptive language and sustained attention. Our results suggest that even within the context of extreme poverty, there are strong associations between family socioeconomic status and child development outcomes among preschool children, and that the language and executive function domains exhibit the largest gradients.

Does alleviating poverty affect mothers’ depressive symptoms? A quasi-experimental investigation of Mexico’s Oportunidades programme

BACKGROUND Depression is a major cause of disability, particularly among women; poverty heightens the risk for depression. Beyond its direct effects, maternal depression can harm childrens health and development. This study aimed to assess the effects of a large-scale anti-poverty programme in Mexico (Oportunidades) on maternal depressive symptoms. METHODS In 2003, 5050 women living in rural communities who had participated in Oportunidades since its inception were assessed and compared with a group of 1293 women from matched communities, whose families had received no exposure to Oportunidades at the time of assessment but were later enrolled. Self-reported depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). Ordinary least squares regressions were used to evaluate the treatment effect of programme participation on depression while adjusting for covariates and clustering at the community level. RESULTS Women in the treatment group had lower depressive symptoms than those in the comparison group (unadjusted mean CES-D scores: 16.9 ± 9.8 vs 18.6 ± 10.2). In multivariable analyses, programme participation was associated with lower depression whilst controlling for maternal age, education and household demographic, ethnicity and socio-economic variables [β= -1.7 points, 95% confidence interval (95% CI) -2.46 to -0.96, P < 0.001]. Reductions in perceived stress and increases in perceived control were mediators of programme effects on women. CONCLUSIONS Although Oportunidades did not target maternal mental health directly, we found modest but clinically meaningful effects on depressive symptoms. Our design permits stronger causal inference than observational studies that have linked poverty and depressive symptoms. Our results emphasize that the well-being of individuals is responsive to macro-level economic policies and programmes.

Pathways to health: a framework for health-focused research and practice

Public health research and practice is faced with three problems: 1) a focus on disease instead of health, 2) consideration of risk factor/disease relationships one at a time, and 3) attention to individuals with limited regard for the communities in which they live. We propose a framework for health-focused research and practice. This framework encompasses individual and community pathways to health while incorporating the dynamics of context and overall population vulnerability and resilience. Individual pathways to health may differ, but commonalities will exist. By understanding these commonalities, communities can work to support health-promoting pathways in addition to removing barriers. The perspective afforded by viewing health as a dynamic process instead of as a collection of risk factors and diseases expands the number of approaches to improving health globally. Using this approach, multidisciplinary research teams working with active community participants have the potential to reshape health and intervention sciences.

Performance of a receptive language test among young children in Madagascar.

Language tests developed and validated in one country may lose their desired properties when translated for use in another, possibly resulting in misleading estimates of ability. Using Item Response Theory (IRT) methodology, we assess the performance of a test of receptive vocabulary, the U.S.-validated Peabody Picture Vocabulary Test-Third Edition (PPVT-III), when translated, adapted, and administered to children 3 to 10 years of age in Madagascar (N = 1372), in the local language (Malagasy). Though Malagasy is considered a single language, there are numerous dialects spoken in Madagascar. Our findings were that test scores were positively correlated with age and indicators of socio-economic status. However, over half (57/96) of items evidenced unexpected response variation and/or bias by local dialect spoken. We also encountered measurement error and reduced differentiation among person abilities when we used the publishers’ recommended stopping rules, largely because we lost the original item ordering by difficulty when we translated test items into Malagasy. Our results suggest that bias and testing inefficiency introduced from the translation of the PPVT can be significantly reduced with the use of methods based on IRT at both the pre-testing and analysis stages. We explore and discuss implications for cross-cultural comparisons of internationally recognized tests, such as the PPVT.

Gender disparities in child development in the east Asia-Pacific region: a cross-sectional, population-based, multicountry observational study

BACKGROUND Gender differences in child development have been extensively studied in high-income countries, but few data are available from low-income and middle-income countries. Our objective was to assess gender disparities in child development that might arise from differential investment in child health, nutrition, and education in six countries across the east Asia-Pacific region. METHODS In this cross-sectional, population-based study we quantified the magnitude of gender differences in child development using the East Asia-Pacific Early Child Development Scales (EAP-ECDS) in six countries (Cambodia, China, Mongolia, Papua New Guinea, Timor-Leste, and Vanuatu). We used stratified random sampling (according to age, residence [urban vs rural], and sex) in all countries to recruit eligible children aged 3-5 years from non-ethnic minority populations with no identified or suspected special educational needs for whom EAP-ECDS scores for five or more of seven domains and urban-rural residence information were available. Gender differences in development associated with four national indicators of gender equality (sex ratio at birth, Gender Development Index, Gender Inequality Index, and Gender Parity Index for primary school enrolment) were also examined. We used generalised estimating equation regression to study moderation of differences by family socioeconomic status and wealth, and structural equation models with maximum likelihood to test mediation through health, nutrition, and education. FINDINGS Between June 1, 2013, and Dec 13, 2013, 7582 eligible children were included from Cambodia (n=1189), China (n=1618), Mongolia (n=1230), Papua New Guinea (n=1639), Timor-Leste (n=1176), and Vanuatu (n=730). Girls had significantly higher development scores than boys in Cambodia (difference in composite score: β=1·87 points, 95% CI 0·29 to 3·45; p=0·747), China (2·66 points, 1·20 to 4·13; p=0·0004), Vanuatu (3·10 points, 1·65 to 4·55; p<0·0001), and Mongolia (3·94 points, 2·67 to 5·21; p<0·0001), but not Papua New Guinea (-0·43 points, -1·19 to 0·33; p=0·272) or Timor-Leste (0·09 points, -0·96 to 1·14; p=0·861). Differences in favour of girls were the largest for language skills in Mongolia (5·30 points, 95% CI 4·45 to 6·15); differences in language skills were smallest in the two poorest countries, Timor-Leste (-0·07 points, -1·03 to 0·88) and Papua New Guinea (0·05 points, -1·02 to 1·12). Greater differences in composite scores for girls compared with boys-in favour of girls-were associated with higher national Gender Development Index values (R2=0·790). In Mongolia, smaller gender differences in development were associated with increased household wealth (6·07 points [95% CI 3·22 to 8·92] in the lowest wealth quartile vs 2·27 points [1·38 to 3·15] in the highest wealth quartile), whereas in Timor-Leste, girls only outperformed boys when living in households with higher socioeconomic status (2·87 points [0·27 to 5·47] in the highest wealth quartile and 3·74 points [2·17 to 5·31] in the highest quartile of parental socioeconomic status). Mediating pathways explained up to 37% (in Vanuatu) of the association between gender and development, controlling for family socioeconomic status. INTERPRETATION Girls aged 3-5 years generally outperformed boys on tests of development, and increasing levels of gender equality across six countries in the east Asia-Pacific region were associated with improved performance of young girls relative to boys. Greater opportunities for economic development are anticipated to result from improvements in gender equality and in the development of girls. Further study is warranted to understand family-level processes and societal norms that lead to gender differences in child development in the early years. FUNDING UNICEF, the Asia-Pacific Regional Network for Early Childhood, and the Open Society Foundations.

Social disadvantage and the black-white disparity in spontaneous preterm delivery among California births.

We examined the contribution of social disadvantage to the black-white disparity in preterm birth. Analyses included linked vital and hospital discharge records from 127,358 black and 615,721 white singleton California births from 2007–11. Odds ratios (OR) were estimated by 4 logistic regression models for 2 outcomes: early (<32 wks) and moderate (32–36 wks) spontaneous preterm birth (ePTB, mPTB), stratified by 2 race-ethnicity groups (blacks and whites). We then conducted a potential impact analysis. The OR for less than high school education (vs. college degree) was 1.8 (95% confidence interval 1.6, 2.1) for ePTB among whites but smaller for the other 3 outcome groups (ORs 1.3–1.4). For all 4 groups, higher census tract poverty was associated with increased odds (ORs 1.03–1.05 per 9% change in poverty). Associations were less noteworthy for the other variables (payer, and tract percent black and Gini index of income inequality). Setting 3 factors (education, poverty, payer) to ‘favorable’ values was associated with lower predicted probability of ePTB (25% lower among blacks, 31% among whites) but a 9% higher disparity, compared to probabilities based on observed values; for mPTB, respective percentages were 28% and 13% lower probability, and 17% lower disparity. Results suggest that social determinants contribute to preterm delivery and its disparities, and that future studies should focus on ePTB and more specific factors related to social circumstances.

Assumption Trade-Offs When Choosing Identification Strategies for Pre-Post Treatment Effect Estimation: An Illustration of a Community-Based Intervention in Madagascar

Abstract Failure (or success) in finding a statistically significant effect of a large-scale intervention may be due to choices made in the evaluation. To highlight the potential limitations and pitfalls of some common identification strategies used for estimating causal effects of community-level interventions, we apply a roadmap for causal inference to a pre-post evaluation of a national nutrition program in Madagascar. Selection into the program was non-random and strongly associated with the pre-treatment (lagged) outcome. Using structural causal models (SCM), directed acyclic graphs (DAGs) and simulated data, we illustrate that an estimand with the outcome defined as the post-treatment outcome controls for confounding by the lagged outcome but not by possible unmeasured confounders. Two separate differencing estimands (of the pre- and post-treatment outcome) have the potential to adjust for a certain type of unmeasured confounding, but introduce bias if the additional identification assumptions they rely on are not met. In order to illustrate the practical impact of choice between three common identification strategies and their corresponding estimands, we used observational data from the community nutrition program in Madagascar to estimate each of these three estimands. Specifically, we estimated the average treatment effect of the program on the community mean nutritional status of children 5 years and under and found that the estimate based on the post-treatment estimand was about a quarter of the magnitude of either of the differencing estimands (0.066 SD vs. 0.26–0.27 SD increase in mean weight-for-age z-score). Choice of estimand clearly has important implications for the interpretation of the success of the program to improve nutritional status of young children. A careful appraisal of the assumptions underlying the causal model is imperative before committing to a statistical model and progressing to estimation. However, knowledge about the data-generating process must be sufficient in order to choose the identification strategy that gets us closest to the truth.