Lia C. H. Fernald

Strategies for reducing inequalities and improving developmental outcomes for young children in low-income and middle-income countries

This report is the second in a Series on early child development in low-income and middle-income countries and assesses the effectiveness of early child development interventions, such as parenting support and preschool enrolment. The evidence reviewed suggests that early child development can be improved through these interventions, with effects greater for programmes of higher quality and for the most vulnerable children. Other promising interventions for the promotion of early child development include childrens educational media, interventions with children at high risk, and combining the promotion of early child development with conditional cash transfer programmes. Effective investments in early child development have the potential to reduce inequalities perpetuated by poverty, poor nutrition, and restricted learning opportunities. A simulation model of the potential long-term economic effects of increasing preschool enrolment to 25% or 50% in every low-income and middle-income country showed a benefit-to-cost ratio ranging from 6·4 to 17·6, depending on preschool enrolment rate and discount rate.

Role of cash in conditional cash transfer programmes for child health, growth, and development: an analysis of Mexico's Oportunidades

BACKGROUND Many governments have implemented conditional cash transfer (CCT) programmes with the goal of improving options for poor families through interventions in health, nutrition, and education. Families enrolled in CCT programmes receive cash in exchange for complying with certain conditions: preventive health requirements and nutrition supplementation, education, and monitoring designed to improve health outcomes and promote positive behaviour change. Our aim was to disaggregate the effects of cash transfer from those of other programme components. METHODS In an intervention that began in 1998 in Mexico, low-income communities (n=506) were randomly assigned to be enrolled in a CCT programme (Oportunidades, formerly Progresa) immediately or 18 months later. In 2003, children (n=2449) aged 24-68 months who had been enrolled in the programme their entire lives were assessed for a wide variety of outcomes. We used linear and logistic regression to determine the effect size for each outcome that is associated with a doubling of cash transfers while controlling for a wide range of covariates, including measures of household socioeconomic status. FINDINGS A doubling of cash transfers was associated with higher height-for-age Z score (beta 0.20, 95% CI 0.09-0.30; p<0.0001), lower prevalence of stunting (-0.10, -0.16 to -0.05; p<0.0001), lower body-mass index for age percentile (-2.85, -5.54 to -0.15; p=0.04), and lower prevalence of being overweight (-0.08, -0.13 to -0.03; p=0.001). A doubling of cash transfers was also associated with children doing better on a scale of motor development, three scales of cognitive development, and with receptive language. INTERPRETATION Our results suggest that the cash transfer component of Oportunidades is associated with better outcomes in child health, growth, and development.

Early childhood development coming of age: science through the life course

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

10-year effect of Oportunidades, Mexico's conditional cash transfer programme, on child growth, cognition, language, and behaviour: a longitudinal follow-up study

BACKGROUND Mexicos conditional cash transfer programme, Oportunidades, was started to improve the lives of poor families through interventions in health, nutrition, and education. We investigated the effect of Oportunidades on children almost 10 years after the programme began. METHODS From April, 1998, to October, 1999, low-income communities were randomly assigned to be enrolled in Oportunidades immediately (early treatment, n=320) or 18 months later (late treatment, n=186). In 2007, when 1093 children receiving early treatment and 700 late treatment in these communities were aged 8-10 years, they were assessed for outcomes including physical growth, cognitive and language development, and socioemotional development. The primary objective was to investigate outcomes associated with an additional 18 months in the programme. We used cluster-adjusted t tests and multivariate regressions to compare effects of programme participation for height-for-age, body-mass index (BMI), and cognitive language and behavioural assessment scores in early versus late treatment groups. FINDINGS Early enrolment reduced behavioural problems for all children in the early versus late treatment group (mean behaviour problem score -0.09 [SD 0.97] vs 0.13 [1.03]; p=0.0024), but we identified no difference between groups for mean height-for-age Z scores (-1.12 [0.96] vs -1.14 [0.97]; p=0.88), BMI-for-age Z scores (0.14 [0.99] vs 0.17 [1.06]; p=0.58), or assessment scores for language (98.8 [13.8] vs 98.4 [14.6] p=0.90) or cognition (98.8 [12.9] vs 100.2 [13.2]; p=0.26). An additional 18 months of the programme before age 3 years for children aged 8-10 years whose mothers had no education resulted in improved child growth of about 1.5 cm assessed as height-for-age [corrected] Z score (beta 0.23 [0.023-0.44] p=0.029), independently of cash received. INTERPRETATION An additional 18 months in the Oportunidades programme has independent beneficial effects other than money, especially for women with no formal education. The money itself also has significant effects on most outcomes, adding to existing evidence for interventions in early childhood. FUNDING Mexican Ministry of Social Development and the National Institutes of Child Health and Human Development.

Benefits of wildlife consumption to child nutrition in a biodiversity hotspot

Terrestrial wildlife is the primary source of meat for hundreds of millions of people throughout the developing world. Despite widespread human reliance on wildlife for food, the impact of wildlife depletion on human health remains poorly understood. Here we studied a prospective longitudinal cohort of 77 preadolescent children (under 12 y of age) in rural northeastern Madagascar and show that consuming more wildlife was associated with significantly higher hemoglobin concentrations. Our empirical models demonstrate that removing access to wildlife would induce a 29% increase in the numbers of children suffering from anemia and a tripling of anemia cases among children in the poorest households. The well-known progression from anemia to future disease demonstrates the powerful and far-reaching effects of lost wildlife access on a variety of human health outcomes, including cognitive, motor, and physical deficits. Loss of access to wildlife could arise either from the diligent enforcement of existing conservation policy or from unbridled unsustainable harvest, leading to depletion. Conservation enforcement would enact a more rapid restriction of resources, but self-depletion would potentially lead, albeit more slowly, both to irrevocable local wildlife extinctions and loss of the harvested resource. Our research quantifies costs of reduced access to wildlife for a rural community in Madagascar and illuminates pathways that may broadly link reduced natural resource access to declines in childhood health.

Nurturing care: promoting early childhood development.

The UN Sustainable Development Goals provide a historic opportunity to implement interventions, at scale, to promote early childhood development. Although the evidence base for the importance of early childhood development has grown, the research is distributed across sectors, populations, and settings, with diversity noted in both scope and focus. We provide a comprehensive updated analysis of early childhood development interventions across the five sectors of health, nutrition, education, child protection, and social protection. Our review concludes that to make interventions successful, smart, and sustainable, they need to be implemented as multi-sectoral intervention packages anchored in nurturing care. The recommendations emphasise that intervention packages should be applied at developmentally appropriate times during the life course, target multiple risks, and build on existing delivery platforms for feasibility of scale-up. While interventions will continue to improve with the growth of developmental science, the evidence now strongly suggests that parents, caregivers, and families need to be supported in providing nurturing care and protection in order for young children to achieve their developmental potential.

Social and economic correlates of depressive symptoms and perceived stress in South African adults

Objectives: Adults in South Africa demonstrate rates of mental illness at or above levels elsewhere in the developing world. Yet there is a research gap regarding the social context surrounding mental health in this region. The objective of this analysis was to characterize the prevalence and correlates of depressive symptoms and perceived stress among a heterogeneous South African population. Methods: Low-income adults (n  =  257) in Capetown, Port Elizabeth and Durban were interviewed regarding demographics, income, subjective social status, life events and decision-making. The Center for Epidemiologic Studies Depression Scale (CES-D) and Cohen’s Perceived Stress Scale (PSS) were used. Results: CES-D scores were 18.8 (SD 11.7), with 50.4% of men and 64.5% of women exceeding the cut-off at which professional care is recommended (p = 0.03). PSS scores were 18.6 (SD 6.7), with a mean of 17.5 among men and 19.6 among women (p = 0.02). In multivariate regressions, increased CES-D scores were associated with more household members (p<0.1), lower educational attainment (p = 0.07), less income stability (p<0.07), lower subjective social status (p<0.01) and independent decision-making (p = 0.04). Increased PSS scores were associated with female gender (p<0.05), multiracial race (p<0.02), more household members (p<0.1), lower subjective social status (p<0.02) and recent birth or catastrophe (p<0.01). Conclusions: Depressive symptoms and perceived stress are public health concerns in this sample, with more symptoms among those with fewer resources. The prevention of mental illness is critical, especially in vulnerable populations.

Effects of health and nutrition on cognitive and behavioural development in children in the first three years of life. Part 1: low birthweight, breastfeeding, and protein-energy malnutrition.

The following paper and its accompanying paper (Grantham-McGregor SM, et al. Effects of health and nutrition on cognitive and behavioural development in children in the first three years of life. Part 2: Infections and micronutrient deficiencies: iodine, iron, and zinc. Food Nutr Bull 1999;20:76–99) review the literature on the conditions that are prevalent and considered to be likely to affect child development and are therefore of public health importance. the reviews are selective, and we have generally focused on recent work, particularly in areas that remain controversial. the reviews are restricted to nutritional and health insults that are important in the first three years of life. Where possible, we have discussed the better studies. This paper considers the effects of low birthweight (focusing on small-for-gestational-age babies) and early childhood protein-energy malnutrition on mental, motor, and behavioural development. We have also included a section on breastfeeding because of its importance to child health and nutrition programmes.

Poverty-alleviation program participation and salivary cortisol in very low-income children

Correlational studies have shown associations between social class and salivary cortisol suggestive of a causal link between childhood poverty and activity of the stress-sensitive hypothalamic-pituitary-adrenocortical (HPA) system. Using a quasi-experimental design, we evaluated the associations between a familys participation in a large-scale, conditional cash transfer program in Mexico (Oportunidades, formerly Progresa) during the childs early years of life and childrens salivary cortisol (baseline and responsivity). We also examined whether maternal depressive symptoms moderated the effect of program participation. Low-income households (income <20th percentile nationally) from rural Mexico were enrolled in a large-scale poverty-alleviation program between 1998 and 1999. A comparison group of households from demographically similar communities was recruited in 2003. Following 3.5 years of participation in the Oportunidades program, three saliva samples were obtained from children aged 2-6 years from intervention and comparison households (n=1197). Maternal depressive symptoms were obtained using the Center for Epidemiologic Studies-Depression Scale (CES-D). Results were that children who had been in the Oportunidades program had lower salivary cortisol levels when compared with those who had not participated in the program, while controlling for a wide range of individual-, household- and community-level variables. Reactivity patterns of salivary cortisol did not differ between intervention and comparison children. Maternal depression moderated the association between Oportunidades program participation and baseline salivary cortisol in children. Specifically, there was a large and significant Oportunidades program effect of lowering cortisol in children of mothers with high depressive symptoms but not in children of mothers with low depressive symptomatology. These findings provide the strongest evidence to date that the economic circumstances of a family can influence a childs developing stress system and provide a mechanism through which poverty early in life could alter life-course risk for physical and mental health disorders.

Cluster-randomised controlled trials of individual and combined water, sanitation, hygiene and nutritional interventions in rural Bangladesh and Kenya: the WASH Benefits study design and rationale.

Introduction Enteric infections are common during the first years of life in low-income countries and contribute to growth faltering with long-term impairment of health and development. Water quality, sanitation, handwashing and nutritional interventions can independently reduce enteric infections and growth faltering. There is little evidence that directly compares the effects of these individual and combined interventions on diarrhoea and growth when delivered to infants and young children. The objective of the WASH Benefits study is to help fill this knowledge gap. Methods and analysis WASH Benefits includes two cluster-randomised trials to assess improvements in water quality, sanitation, handwashing and child nutrition—alone and in combination—to rural households with pregnant women in Kenya and Bangladesh. Geographically matched clusters (groups of household compounds in Bangladesh and villages in Kenya) will be randomised to one of six intervention arms or control. Intervention arms include water quality, sanitation, handwashing, nutrition, combined water+sanitation+handwashing (WSH) and WSH+nutrition. The studies will enrol newborn children (N=5760 in Bangladesh and N=8000 in Kenya) and measure outcomes at 12 and 24 months after intervention delivery. Primary outcomes include child length-for-age Z-scores and caregiver-reported diarrhoea. Secondary outcomes include stunting prevalence, markers of environmental enteropathy and child development scores (verbal, motor and personal/social). We will estimate unadjusted and adjusted intention-to-treat effects using semiparametric estimators and permutation tests. Ethics and dissemination Study protocols have been reviewed and approved by human subjects review boards at the University of California, Berkeley, Stanford University, the International Centre for Diarrheal Disease Research, Bangladesh, the Kenya Medical Research Institute, and Innovations for Poverty Action. Independent data safety monitoring boards in each country oversee the trials. This study is funded by a grant from the Bill & Melinda Gates Foundation to the University of California, Berkeley. Registration Trial registration identifiers (http://www.clinicaltrials.gov): NCT01590095 (Bangladesh), NCT01704105 (Kenya).