Marcos Vera-Hernandez

Early Childhood Stimulation Benefits Adult Competence and Reduces Violent Behavior

OBJECTIVE: An estimated 178 million children younger than 5 years in developing countries experience linear growth retardation and are unlikely to attain their developmental potential. We aimed to evaluate adult benefits from early childhood stimulation and/or nutritional supplementation in growth-retarded children. METHODS: In Kingston, Jamaica, 129 growth-retarded children aged 9 to 24 months took part in a 2-year trial of nutritional supplementation (1 kg milk-based formula per week) and/or psychosocial stimulation (weekly play sessions to improve mother-child interaction). We assessed IQ, educational attainment, and behavior at 22 years old in 105 participants. We used multivariate regressions, weighted to adjust for loss to follow-up, to determine treatment benefits. RESULTS: We found no significant benefits from supplementation. Participants who received stimulation reported less involvement in fights (odds ratio: 0.36 [95% confidence interval (CI) 0.12–1.06]) and in serious violent behavior (odds ratio: 0.33 [95% CI: 0.11–0.93]) than did participants with no stimulation. They also had higher adult IQ (coefficient: 6.3 [95% CI: 2.2–10.4]), higher educational attainment (achievement, grade level attained, and secondary examinations), better general knowledge, and fewer symptoms of depression and social inhibition. CONCLUSIONS: Early psychosocial intervention had wide-ranging benefits in adulthood that are likely to facilitate functioning in everyday life. The reductions in violent behavior are extremely important given the high levels of violence in many developing countries. The study provides critical evidence that early intervention can lead to gains in adult functioning.

Pre- and postnatal arsenic exposure and child development at 18 months of age: a cohort study in rural Bangladesh

BACKGROUND Exposure to arsenic through drinking water has been associated with impaired cognitive function in school-aged children in cross-sectional studies; however, there are few longitudinal studies and little information on effects of exposure in early life when the brain is generally most vulnerable. METHODS A longitudinal cohort study beginning in early pregnancy was conducted in rural Bangladesh, where arsenic concentrations in well water vary considerably. We assessed the effects of pre- and postnatal arsenic exposure on development of 2112 children at 18 months of age with Bayley Scales of Infant Development-II (mental and psychomotor development indices), Wolkes Behavior Rating Scale and maternal report of language. We related the measures of child development to arsenic concentrations in maternal urine in gestational weeks 9 and 30 and childs urinary arsenic at 18 months of age. Details of socio-economic background, home stimulation and anthropometric measurements of mothers and children were also available. RESULTS Median maternal urinary arsenic concentration averaged over early and late gestation was 96 µg/l, whereas childrens urine contained 35 µg/l of arsenic. There was no significant effect of any of the arsenic exposure measures on any of the child development measures after controlling for social and economic confounders, childs age and sex. CONCLUSION Contrary to expectations, we found no indications of adverse effects of pre- or postnatal arsenic exposure on child development at 18 months. It remains possible that duration of exposure is critical and that effects will become apparent later in childhood.

Structural estimation of a principal-agent model: moral hazard in medical insurance

Despite the importance of principal-agent models in the development of modern economic theory, there are few estimations of these models. I recover the estimates of a principal-agent model and obtain an approximation to the optimal contract. The results show that out-of-pocket payments follow a concave profile with respect to costs of treatment. I estimate the welfare loss due to moral hazard, taking into account income effects. I also propose a new measure of moral hazard based on the conditional correlation between contractible and noncontractible variables.

Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial.

OBJECTIVE: More than 200 million children globally do not attain their developmental potential. We hypothesized that a parent training program could be integrated into primary health center visits and benefit child development. METHODS: We conducted a cluster randomized trial in the Caribbean (Jamaica, Antigua, and St Lucia). Fifteen centers were randomly assigned to the control (n = 250 mother-child pairs) and 14 to the intervention (n = 251 mother-child pairs) groups. Participants were recruited at the 6- to 8-week child health visit. The intervention used group delivery at 5 routine visits from age 3 to 18 months and comprised short films of child development messages, which were shown in the waiting area; discussion and demonstration led by community health workers; and mothers’ practice of activities. Nurses distributed message cards and a few play materials. Primary outcomes were child cognition, language, and hand-eye coordination and secondary outcomes were caregiver knowledge, practices, maternal depression, and child growth, measured after the 18-month visit. RESULTS: Eight-five percent of enrolled children were tested (control = 210, intervention = 216). Loss did not differ by group. Multilevel analyses showed significant benefits for cognitive development (3.09 points; 95% confidence interval: 1.31 to 4.87 points; effect size: 0.3 SDs). There were no other child benefits. There was a significant benefit to parenting knowledge (treatment effect: 1.59; 95% confidence interval: 1.01 to 2.17; effect size: 0.4). CONCLUSIONS: An innovative parenting intervention, requiring no additional clinic staff or mothers’ time, was integrated into health services, with benefits to child cognitive development and parent knowledge. This is a promising strategy that merits further evaluation at scale.

Community Nurseries and the Nutritional Status of Poor Children: Evidence from Colombia

We use two different data sets and three different instruments to estimate the impact of a long‐established pre‐school nursery programme on childrens nutritional status. We use variables related to cost (fee, distance to the nursery) and programme availability (capacity of the programme in the town) as instruments. One of our data sets is representative of very poor individuals living in rural areas of Colombia, while the other focuses in urban areas and includes individuals relatively less poor. We find that programme participation increases childrens height, with the size of the effect being consistent across the three instruments and the two data sets.

Are tax subsidies for private medical insurance self-financing? Evidence from a microsimulation model

This paper develops an empirical strategy to estimate whether subsidies to private medical insurance are self-financing in countries where public and private insurance coexist and the latter covers the same treatments as the former. We construct a simulation routine based on a micro-econometric discrete choice model that allows us to evaluate the impact of premium changes on the utilization of outpatient and inpatient health care services. As an application, we estimate the budgetary effects of scrapping a subsidy from the purchase of individual private policies, using micro-data from Catalonia. Our results suggest that the subsidy is not self-financing. This result is driven by the fact that private medical insurance holders make concurrent use of public and private services, and by the price inelasticity of the demand for private policies.

Quality externalities among hotel establishments: what is the impact of tour operators?

This paper is about quality decisions in a vertical structure, in which competitive producers sell to ‘powerful retailers’. Specifically, the analysis focuses on the role played by the tour operator (TO) in quality investments when distributing the capacity of a given tourism destination. The authors emphasize the presence of quality externalities among hotel establishments, and find that TO distribution can sometimes provide a solution to the ‘tragedy of the commons’ in quality provision. Thus they assess the implications of vertical relationships for quality in the hotel industry and derive appropriate policy recommendations.

Testing for Asymmetric Information in Private Health Insurance

We develop a test for adverse selection and use it to examine private health insurance markets. In contrast to earlier papers that consider a purely private system or a system in which private insurance supplements a public system, we focus our attention on a system where privately funded health care is substitutive of the publicly funded one. Using a model of competition among insurers, we generate predictions about the correlation between risk and the probability of taking private insurance under both symmetric information and adverse selection. These predictions constitute the basis for our adverse selection test. The theoretical model is also useful to conclude that the setting that we focus on is especially attractive to test for adverse selection. Using the British Household Panel Survey, we find evidence that adverse selection is present in this market.

Evaluation of a social franchising and telemedicine programme and the care provided for childhood diarrhoea and pneumonia, Bihar, India.

Abstract Objective To evaluate the impact on the quality of the care provided for childhood diarrhoea and pneumonia in Bihar, India, of a large-scale, social franchising and telemedicine programme – the World Health Partners’ Sky Program. Methods We investigated changes associated with the programme in the knowledge and performance of health-care providers by carrying out 810 assessments in a representative sample of providers in areas where the programme was and was not implemented. Providers were assessed using hypothetical patient vignettes and the standardized patient method both before and after programme implementation, in 2011 and 2014, respectively. Differences in providers’ performance between implementation and nonimplementation areas were assessed using multivariate difference-in-difference linear regression models. Findings The programme did not significantly improve health-care providers’ knowledge or performance with regard to childhood diarrhoea or pneumonia in Bihar. There was a persistent large gap between knowledge of appropriate care and the care actually delivered. Conclusion Social franchising has received attention globally as a model for delivering high-quality care in rural areas in the developing world but supporting data are scarce. Our findings emphasize the need for sound empirical evidence before social franchising programmes are scaled up.

Irie Classroom Toolbox: a study protocol for a cluster-randomised trial of a universal violence prevention programme in Jamaican preschools

Introduction We aim to determine the effectiveness of a school-based violence prevention programme implemented in Jamaican preschools, on reducing the levels of aggression among children at school, and violence against children by teachers. Methods and analysis This is a 2-arm, single-blind, cluster-randomised controlled trial with parallel assignment. Clusters are 76 preschools in Kingston, and all teachers and classrooms in the selected schools are included in the study. In addition, a random sample of up to 12 children in the 4-year-old classes have been selected for evaluation of child-level outcomes. The intervention involves training teachers in classroom behaviour management and in strategies to promote childrens social-emotional competence. Training is delivered through five full-day workshops, monthly in-class coaching over 2 school terms, and weekly text messages. The primary outcome measures are: (1) observed levels of child aggression and (2) observed violence against children by teachers. Secondary outcomes include observations of the levels of childrens prosocial behaviour and the quality of the classroom environment, teachers’ reports of their mental health, teacher-reported child mental health, direct tests of childrens self-regulation and child attendance. Ethics and dissemination If this intervention were effective at improving the caregiving environment of young children in school, this would have significant implications for the prevention of child mental health problems, and prevention of violence against children in low and middle-income countries where services are often limited. The intervention is integrated into the school system and involves training existing staff, and thus, represents an appropriate strategy for large-scale implementation and benefits at the population level. Ethical consent for the study was given by the School of Psychology Ethics and Research Committee, Bangor University (ref: 2014-14167), and by the University of the West Indies Ethics Committee (ref: ECP 50,14/15). Trial registration number ISRCTN11968472; Pre-results.