Barerra Curriculum

Early Childhood Interventions:
Issues when planning to spread
S Grantham-McGregor,
University College London and
University of West Indies
 Evidence base and spread of Jamaican
intervention
 Issues that need to be considered when
expanding (based on own experience, may not
have the answers)
The Jamaican home visiting intervention:
weekly home visits with paraprofessional using
home made toys, supporting mothers to promote
child’s development
Evidence base: 15 trials (12 RCTs)
Jamaica (UWI) 8 studies
Bangladesh (icddr,b) 5 studies
Colombia (IFS, IDB) 1 study
India (IFS, Yale, NGO)1 study
Low birth weight, severely or moderately

malnourished, disadvantaged children
Evidence base
 All had concurrent child development

benefits (only Jamaican >0.5SDs)
 Most improved home stimulation, mothers

knowledge and occasionally depression (3)
 4 long term follow ups at 6, 17 and 22

years:
3 had sustained benefits
Benefits at age 22years
• IQ
• Education: Higher scores in reading, maths and
general knowledge; grade level attained; secondary
level examination passes, fewer expelled from school
• Less depression and better social skills

• Reduction in violent behaviour
• Higher wages (25%)
Walker et al Pediat 2011, Gertler et al Science 2014
On-going International Spread
 Zimbabwe, (Open Society Foundation, NGO)
 Brazil (Harvard, Sao Paulo University)
 Guatemala (World bank, Child Fund)
 China (China Development Research Foundation)
 India (IFS, Yale, Pratham,CECED )
 Bangladesh (icddr,b and Ministry of health)
 Peru (IDB) National programme

Reach Up:
Web package of training materials
 Training Videos made in Jamaica, Peru and Bangladesh

 Curriculum, training manuals, guide for cultural adaptation,
toy manual, books etc
 Available free to all
(Collaboration of UWI, icddr,b Bangladesh and IFS and IDB)

S Walker, C. Powell, S Chang, H Baker-Henningham,
S Grantham-McGregor, J Hamadani, M Rubio Codina
Issues when spreading an intervention
1. Encourage spread with free access to everyone / Or
focus on quality with Certified users only?
2. Need for advocacy at the country level: by who?

International agencies, NGOs, professional groups,
local champions and media--------
what role for academics?
3. Integrate into existing services / New service ?

Clinic Intervention
in 3 Caribbean islands
Aim
To use the time mothers wait at routine clinic visits
Methods
 Videos depicting child development messages
 Group discussion about video with demonstration
led by a Community health aide
 Given message card by the nurse (reinforcing video)
 Given 2 books and a puzzle at 9, 12 & 18 months
Chang, Grantham-McGregor, Powell, Vera-Hernández, Lopez-Boo,
Baker-Henningham, Walker. Pediat 2015
Parents watching a video
(5 visits) At 3, 6, 9, 12, 18 months
9 three minute videos repeated frequently
Development Media International

Outcomes post intervention
(Chang et al Pediat 2015)
Control Intervened Rx Effect
Grffiths DQ 94.7 ± 8.3 96.1 ± 9.4 1.1 (−0.5 to 2.7)

Cognition 89.5 ± 10.6 92.7 ± 11.7 3.1 (1.3 to 4.9)**
0.31 Z score
Language 99.9 ± 13.6 99.8 ± 14.0 −0.5 (−2.8 to 1.8)
Fine motor 94.6 ± 9.9 96.0 ± 10.3 0.7 (−0.8 to 2.3)
Maternal 39.6 ± 4.1b 41.35 ± 3.6 1.6 (1.0 to 2.2)***
Knowledge
**p<0.01, *** p<0.001

McArthur language, HOME, maternal depression: all ns
Advantages of Integration
 Same children at high risk for health and
nutrition also at risk for development
 Access already in place (only one)
 Sustainability may be more likely
 Can use their facilities and staff
 More cost effective

Disadvantages of integration
 Lack capacity in space and staff.
 Can be chaotic, not be meeting their own targets
Child development may not be their priority
 Health staff tend to be didactic

 Staff want incentives
 Routine health service contacts too few and
stop too young? (6 contacts to 18 months)
When and how to integrate ?
1. When the service is reasonably well-organised and
assessed to be the best platform available
2. Ministry of Health is enthusiastic and make it one of their

goals and an official part of their program (supervision, staff
training and record keeping)
3. There is at least one champion to lead it in the Ministry and

senior nurses and doctors are on board
4. Caution: Most MOH see child development as screening

Issues for Programme Management
 Fiscal health (short term funding). Changing staff a
major problem
 Leadership (influential, permanent, local, passionate Vs
often distant and just consenting)
 Selection of staff may be for wrong reasons

(employment, political gift, already in job / Most suitable)
 Organisation’s climate: Open to change and

evaluation. In hierarchical (vertical) cultures staff
relations difficult. (special case; caste system)
Relationships are critical
Seniors Supervisors Visitors Mothers
Listen/ ask opinion/ give positive reinforcement/

respect/ not authoritarian/ support and help/ not
checking and correcting/ all valued members of
a team
May need to add special workshop on relations

Adaptation: One size does not fit all
Requires knowledge of local practices and environment
Seize opportunities: massage, platting hair, carrying child etc

Use local games songs and traditional toys.
Pictures and pretend games reflect child's environment
Reinforce or discourage practices and attitudes. Which? (Gender
bias, dirt play, punishment, obedience)
Curriculum Adaptation
Challenges
Loss of control
• Local care patterns and conditions often unknown No

time or funds for preliminary research.
• No time for pilots - want rapid results (Political cycle)

• Usually want to add non-evidence based material. May
increase ownership but what cost?
What is the limit to the number of
messages mothers can assimilate?
Want to address every need. Which ?

(nutrition, hygiene, family planning, maternal depression,
HIV, change cultural practices, domestic violence,
agriculture, work for school leavers or unemployed)
Need explicit and attainable Objectives
Want long and complicated routine records. May get in

the way of intervention and morale. Don’t want supervisor
checking all through the session
Need succinct easy to complete records that can be
acted on quickly.
Not used to working with
non-professionals
 Adequate training (not1to 2 days)

 Need a more structured curriculum with manual
 On-going mentoring with supportive relationship
 Aims for visitors (self esteem, knowledge, career path)
 Careful selection (education, sex, age, children, volunteers,
full time or part time?)
Maintaining quality
a major challenge
 Fidelity to basic concepts often not kept
(work directly with child and ignore mother; too
didactic; never follow child’s interests, or fit
activity to child’s level; not leave toys, use wrong
materials)
 Reduced preparation time and limited, poor quality
training (Use videos, training manuals, structured
curriculum)
 Reduced supervision and frequency or duration of
visits
 Access can be a major problem especially for
supervisors: (use mobiles)
Evaluation
Design: scattered across country to be representative
probably not a good idea when beginning. Keep in
one area where monitoring feasible
When to evaluate impact when going to scale?

Probably only process evaluation at first, emphasis
on confirming it is being done correctly
Must have valid measurements

Is maternal report valid for
outcome measures? Probably not
Some remaining critical questions
 How intense does an intervention have to be?

How Intense? Effects of visiting frequency on
developmental quotients (DQ) in disadvantaged
children(n=125)
110
Weekly
(d= 1.16 SD)
106
DQ Fortnightly
102 (d =0.49SD )
Monthly
98
Control
94
pre-test post-test
Powell et al, Pediat, 1989
Examples of low intensity studies
Study Treatment Intensity Treatment

effect sizes
Valley 2015 Book reading 8 sessions in 8 weeks McArthur +
S Africa 14 – 16 mos Picture vocab ns
Attention +
Singla 2015 Stimulaton, 13 group sessions Cognitive 0.36

Uganda health, nutrition and 2-1 home visit Rec language 0.27
12-36mo over 6 mos Mat depression 0,39
Aboud 2011 Stimulation + 6 group sessions over Language 0.35*

Bangladesh responsive 7 mos more than HOME 0.38**
feeding controls (12)
8-20 mos
Must have longitudinal follow up and RCTs to assess

Remaining critical questions
What age to begin? Is earlier (pregnancy or birth )
the better? If at birth, do we have to continue to
school or preschool entry? Very expensive
What age to stop? Until the next educational

service or assume benefits will last?
Does duration matter? Improvement tends to level

off after 1 to 3 years. But is sustainability
increased.?
Early age of beginning intervention
Study Age Treatment effect

size
Adoption Adopted between birth No deficit
Studies and 6mos
Rutter
Cooper 16 Home Prenatal to 6 mos 6 & 12mos: mother more

2009 visits sensitive* less intrusive*.
Murray
2016 18 mos: secure attachment *
S Africa Bayley MDI ns
Home visits
Kangaroo care for preterm: (Feldman et al 2012 , Bera et al 2014,

Charpack et al 2001)
Post-natal period
 Post-natal period particularly sensitive to

interventions on attachment, maternal responsiveness?
 Maternal hormones high (e.g. oxytocin) associated

with maternal behaviour
 Childs stress response system developing
 Is it a good time to intervene for cognitive

development?
Feldman 2012, Blair et al 2011
Early, intense and long: Abecedarian from
4 months to 8 years (Campbell & Ramsey 1994)
MDI / IQ
115
110
105
100
95
90
85
80
3 12 24 36 48 60 84 96 144
Day Care months Teacher home visits
Enrolment age 9 to 24mos: Developmental
levels of intervened stunted (n=132) children
DQ
110
Both (d=1.45)
105
Stimulated
100 Supplemented
95
Control
90
85
33-48mo of age
80
Baseline 6 mo 12 mo 18 mo 24 mo
Grantham-McGregor et al, Lancet 1991

Significant Benefits in Abecedarian and Jamaican
Studies at 21-22yrs (Campbell 2002, Walker 2011, Gertler 2015)
ABC Jamaica
IQ IQ (points) 4.4 6.4
Academic Reading + +
Maths + +
Completed Grades 1.2 F, 01 M 0.6
College entry + ns
Mental health Depression ns +
Behaviour Serious violence ns +
Teen pregnancy + ns
Economic Wages ns 25%
ns=not significant
Age on enrolment: 3 and 4 years. The Perry
Pre-school Project: 27 year follow up
%
80
Intervened Control
60
40
20
0
earns > females ever on >5 births to
$2,000/mo married welfare arrests unmarried
Schweinhart et al, 1993 mothers
Duration: General cognitive ability by 4 treatment
periods beginning at 43months to -87 months
(McKay , Sinisterra et al 1978)
High SES
General
Cognitive
Ability
(logits)
Age in months
IQ (WISC) at 2 year follow up at 9 years old
High SES
Sinisterra 1987
Conclusions for age on enrolment and duration
 Few additional cognitive benefits from beginning from 4
months compared to 18 months
 Cognitive improvement with stimulation continues from 1 to 3

years, then plateaus or declines; may depend on age of
enrolment
 Effect of intervention on cognition reduced from 60 months

(ABC, Cali)
 Post natal mothers readily affected by responsivity/sensitivity

interventions post-natally
 Too few longitudinal studies in different countries to assess

with any confidence (back to 1977 publications)
Need more research!
Most effective age of beginning and ending,

intensity and duration in relation to sustainability (may
vary by type of intervention and outcome)
Future
Academics cannot do it alone.

Consortium of child development experts, economists
and policy makers including LMICs
Develop effective ways of advocacy, going to scale,

integrating with other services, maintaining quality.
Natural experiment on change in poverty
(Costello et al 2003)
Increase of income at age 13 to 17 years :
Improvement in conduct disorder and oppositional

behaviour not anxiety or depression
School achievement and crime

Adaptation questions
Want middle class materials

.
 Home made / bought toys / specially manufactured ?

 Pictures reflect child's environments or as they should be?
 Books with or without words?
Answers vary by maternal education and economic status

and availability of bought toys (need a series of small studies)
Text Messages, Behavioral Changes and
Negative Spillovers in Early Childhood
Work in progress
Oscar Barrera (Paris School of Economics)

Karen Macours (Paris School of Economics)
Patrick Premand (WB)
Renos Vakis (WB)
Outline
•  Motivation
–  Insights from earlier work & policy question
•  The text message pilot
–  Design of the intervention
–  Evaluation design
–  Measurement
•  Results
–  Parenting practices
–  Early childhood development outcomes
–  Social interactions
Motivation
•  Growing evidence that well-designed early childhood
interventions can lead to large gains in ECD outcomes &
later life
–  Grantham-McGregor et al (1991), Walker et al (2011), Attanasio
et al (2014, 2015), Engle et al (2011)
•  Yet scalable design that works not straightforward
–  Berlinski and Schady (2015); papers in this conference
–  Issues of compliance, implementation, etc.
–  Behavioral response not easy to predict in world with many
constraints
•  hard lessons from preschool scale-up in Cambodia (Bouguen
et al, 2016)
–  Behavioral change might require shift in social norms
•  Role of social interaction, opinion leaders, …
Policy question
•  Large delays among poor rural population in Nicaragua
–  Several risk factors:
•  Non-diversified diets
•  Lack of hygiene, poor preventive practices
•  Lack of stimulation -poor communication within the household
•  Home environment
•  Sustainable impact of 2 CCT programs + impact parenting
intervention on early childhood cognition through parental
behavioral change
•  Macours, Schady, Vakis (2012); Barham, Macours and Maluccio (2013) Macours,
et al (2012);
•  Interest by the government of Nicaragua for scalable
interventions
–  Complement existing home-visit program by government workers
–  How to reach more parents more regularly?
–  Text messages? (~ increasingly popular internationally)
Role of social interactions for
behavioral change
•  Importance of leadership in the performance of groups
–  Jones and Olken (2005), Kosfeld and Rustagi (2015)
•  Very large multiplier effects of empowering/motivating
local female leaders on education& nutrition investment of
CCT in closeby region
•  Macours and Vakis (2014)
•  Female leaders also found elsewhere to lead to higher
investment in human capital
•  Clots-Figueras (2012), Beaman et al (2012), Pathak and Macours
(2016)
•  Many interventions targeting parental investment in ECD
through local facilitators
–  Attanasio et al (2014), Fitzsimons et al (2014)
Text message pilot: design
•  Distribute simple mobile phones + help households register in
program
•  Households received simple daily text message for 11 months
on good parenting practices
–  Health and nutrition
–  Stimulation and home environment
•  Messages are age-specific and personalized
•  Content: based on government ECD curriculum + design
earlier parenting intervention
–  Qualitative pilot in study population to assure understanding
•  Target: Households with children younger than 6 years old
•  Incentive to read messages: weekly quiz for air time
•  Liaison person in each community to help with technical
issues
Some example messages
•  Nutrition
–  Give MARIA papaya, mango, oranges; those fruits are very good
–  Do not give coffee to PEDRO; coffee makes him sleep badly
•  Health
–  Wash the hands of MARIA various times a day
–  Don’t smoke close to PEDRO, it is bad for his health
•  Stimulation
–  Show MARIA the colors and shapes of the plants in the patio
–  Ask PEDRO to tell a story, it will bolster his creativity
•  Home environment
–  Be patient with the questions of PEDRO
–  Congratulate MARIA when she lets other children play with her
toys
Evaluation design
•  3012 households with children < 7 years in 97 villages (census)
•  Household-level randomization
•  75% treated; 25% control (control gets phone but no messages)
•  Different variations of treatment
•  Content: Health and nutrition; Stimulation and home environment; mix
•  Target: sending texts to the mother; to the father; to both.
•  Style: Information; motivation/aspirations; social norms.
•  Stratification
–  Household has a leader
•  health promotor, preschool or primary school teacher, village leader
–  Education level
•  27% Caregivers <4 years of education; 34% finished primary
–  Father in the household
•  Powered to detect 0.08 sd itt effects
Design for leader effects
•  400 households with leaders in 92 villages
–  Control: leaders don’t get message
•  23 villages
–  Treatment: leader households get message for their child
•  23 villages men
•  23 villages women
•  23 villages men&women
–  Note: 5 villages with no leader with small child
•  At baseline: Knowledge and practices leaders higher
than non-leaders
•  Leaders not given any role nor special training– just
receive text message and basic explanation like
everybody else
Internal Validity
•  Balance in baseline characteristics
•  Attrition (10%) is balanced
•  Compliance with experimental design
–  High take-up rate: > 90% of targeted households received phones
and enrolled
•  Personal delivery and basic explanation in village meeting
•  Follow-up meeting and some at home delivery
–  But : share of households responding to quiz much less and
gradually declines over time (from 70 to 10%)
–  Text message platform with some glitches but generally
messages sent daily (& quizes weekly)
•  Monitoring system in place
–  Concerns with phone signal, damaging of phones, and battery
Data and timeline
•  Baseline: 2013
•  Phone messages start end of 2014
•  Follow-up data collection: 2015
–  9-11 months of text messages
•  Separate Instruments/questions for:
–  Children
–  Mothers (and/or female caregiver)
–  Fathers (or father figure)
Observed Final outcomes
1. Denver Developmental Screening Test: Four subscales
(a) Social-personal: social interactions, ability of child to dress and eat on
her own, imitate others
(b) Language: use of sounds, words, sentences
(c) Fine motor skills: manual tasks such as drawing, playing with cubes,
reaching for objects
(d) Gross motor skills: crawling, walking, jumping, throwing
•  Test scaled based on number of tasks for which child is in the bottom
quartile of the reference population distribution (or in the bottom decile)
•  Applied to children 0-83 months of age
Additional tests applied to children 36-83 months of age

2. TVIP: Test of receptive language
3. Digit span: forwards and backwards
4. Self-control test (~ adaption of Marshmallow Test)
•  All tests similar to previous studies in same region
•  All tests conducted specifically trained team of test-administrators
Empirical specification ITT
•  Sample: children 12-83 months at follow-up
•  All test results converted to within-sample z-scores
•  Controls for age, gender, stratification variables, village FE
•  Test-administrator FE (after random assignment)
•  Final outcomes, accounting for multiple hypotheses testing
–  average intent-to-treat effect across all outcomes
–  first factor (after factor analysis)
•  Intermediate outcomes
–  Knowledge test scores
–  Reported practices
•  family of outcomes by risk factor
–  Observed hygiene
•  8-point scale of hygiene of child/home observed by test administrator
Results for average effects
•  Intermediary outcomes: Positive and significant effect
on:
–  Knowledge corresponding to text message content
–  Reported practices
•  Nutrition (eating fruit and vegetables, animal proteins, …)
•  Preventive health (vitamins, doctor visits, …)
•  Stimulation (reading, playing, presence of books/toys, ..)
–  Better observed hygiene
–  in line with the randomized variation in content of messages
•  Impact home environment less clear
•  Final outcomes: No average significant effects

Empirical specification:
Social interactions
•  Consider separate impact of leaders in one’s village
being randomly exposed to messages
•  Sample: households without leaders
•  Controls for age, gender, stratification variables, test
administrator
•  Cluster at village level
•  Final and intermediate outcomes
Leader effects on final
outcomes non-leaders
All children Children older than 36
ALL TESTS ALL TESTS Denver TVIP,
memory,
control
average first factor average first factor first factor first factor
ITT -‐0.006 0.017 0.006 -‐0.004 0.040 -‐0.038
(0.02) (0.04) (0.02) (0.04) (0.05) (0.04)
leader with messages -‐0.060*** -‐0.089** -‐0.078*** -‐0.133** -‐0.108** -‐0.107**
(0.02) (0.04) (0.02) (0.05) (0.05) (0.04)
ObservaPons 2154 2154 1485 1485 1508 1486
Age, gender, administrator & straPficaPon controls. Robust standard errors in parentheses; *** p<0.01, **
p<0.05, * p<0.1
Leader effects on intermediate
outcomes
Knowledge Prac.ces Hygiene

All Health& SPmulaPon
nutriPon &environm
ent
ITT 0.078*** 0.049*** 0.070*** 0.027 0.084*
(0.03) (0.02) (0.02) (0.02) (0.04)
leader with messages 0.027 -‐0.054* -‐0.099** -‐0.008 -‐0.034
(0.04) (0.03) (0.04) (0.03) (0.09)
ObservaPons 2086 2168 2168 2190 2186
Age, gender, administrator & straPficaPon controls. Robust standard errors in parentheses; ***
p<0.01, ** p<0.05, * p<0.1
Impacts of messages to leaders
•  Negative spillovers of messages to leaders on
–  Intermediate outcomes
•  Health and nutrition practices
•  But not on knowledge
–  Final outcomes
•  In particular language (TVIP, Denver) and self-control
•  Larger for low-educated households
•  Negative leaders spillover decrease as the distance from
leaders house increases
Potential mechanisms
•  Confusion:
–  Leaders may have received a different text from
neigbouring households, could confuse others
•  Larger negative effects for less educated parents
•  Sabotage:
–  Leaders have preconceived notions, and tell people
not to act on messages if they go against their notions
(~ opinion leaders)
•  Impacts on leaders themselves
–  Positive impact knowledge, no significant impact on practices
nor outcomes
•  Note: negative spillovers on both treatment and control
households
Conclusions
•  Receiving daily text message on parenting
–  Can shift parental knowledge and reported investment in early
childhood
–  Potential of text message to complement other
interventions : information and/or nudge
–  But no observed impacts on final outcomes after 9 months
•  Opinion leaders also receiving messages not necessarily

positive
–  Small but significant negative spillovers on
intermediate and final outcomes
Implications for design effective
interventions
•  Shifting parental investment in part about shifting norms and pre-
conceived notions shared by all households
•  Key to recognize role of social interactions for shifting norms
•  But social interactions with positive multiplier effects don’t
happen automatically
–  Understanding social dynamics and existing opinions prior to
design
•  potential challenge for scale-up
•  Local adaptation in design
–  Role of training and empowerment of local opinion leaders?
–  Design that facilitates interactions with well-informed and
motivated leaders?
•  In group and/or individual
Thank you
Nutrition, Parenting and
Development Among Infants
and Toddlers in Rural China
Scott Rozelle
Stanford University
Sean Sylvia
Renmin University
Nele Warrinnier
KU Leuven
Huge Inequalities in Educational Outcomes in
China …
… Between Urban and Rural …

… in College
Probability of a child from a poor rural area going
to college (relative to child from the city)
Times (x)
25
Urban
20 21x
15 Urban
10 13x
Urban
5
Poor 8x Poor Poor
Rural Rural Rural
0
Any college Four Year College Elite College
… In High School
2010 Census
data
Total labor force
Today’s Labor Force
Upper Secondary Attainment

= 24%
________________________________________________________________________________
Total Labor Force

Share of Labor Force that Attained Upper
Secondary Education
Country Share
in 2010
• Turkey 31
• Brazil 41
• Argentina 42
• Mexico 36
• South Africa 28
• China 24
OECD 74
Middle income grads: 72
Low Level of High School Education
in China Today is a Rural Problem!
China in the 2013 Mexico in the 198
100
Percent of ≈90%
students 80
that go to
60
any High
37%
School 40
20
0
Large cities Poor rural
in China areas
… in Junior High School (grades 7 to 9) …
China’s rural students are not even getting through

junior high school
Drop out rate 11% 23% 31%

Over 30 percent
8% of students from
+? poor rural areas
12% 12% are dropping out
+ + of JUNIOR
11% 11% 11% HIGH
SCHOOL!
Grade 7 Grade 8 Grade 9

Summary
Huge Inequalities in Educational Outcomes in
China …
… Between Urban and Rural …
… in College
… in High School
… in Junior High School
What is the source of the
inequality?
• Absence of investments in facilities?

• Poor teachers / absent teachers?
• Poor curriculum?
• Absence of demand?
inequality?
• Absence of investments in facilities? NO

• Poor teachers / absent teachers? NO
• Poor curriculum? NO
• Absence of demand? NO
inequality?
• Absence of investments in facilities? NO

• Poor teachers / absent teachers? NO
• Poor curriculum? NO
• Absence of demand? NO
What about systematically low cognition

of rural children?
Both genes and environment are important
for the infant development
Epigenetics shows that infant nutrition

and nurturing can change the expression
of Gene, maybe we need pay more
attention on nurturing or parenting
Empirical Studies on Cognition in China (using
Bayles MDI scales)
Share of Sample with BSID scores < -SD
• Urban:
– Shanghai Jiaotong University School of
Medicine 14%
– Beijing Union Hospital (Xiehe) 12%
– Hefei Provincial Hospital 16%
– Guangzhou City Hospital 13%
[source; Gates Foundation 2015 Grand
Challenges Conference, Beijing, October 2015]
Empirical Studies on Cognition in China (using
Bayles MDI scales)
Share of Sample with BSID scores < -SD
• Urban:
– Shanghai Jiaotong University School of
Medicine 14%
– Beijing Union Hospital (Xiehe) 12%
– Hefei Provincial Hospital 16%
– Guangzhou City Hospital 13%
[source; Gates Foundation 2015 Grand
Challenges Conference, Beijing, October 2015]
• Rural:  no published studies

Rest of the Presentation
• Sampling and Project Design
• Nutrition and ECD
• Parenting and ECD
• Conclusion
351 Villages in 174 Townships;
≈1800 caregiver-baby pairs
Enrolled all babies in village

between 6 to 12 months
• Control Villages: No intervention, just
regular observation
• “Free Villages”: Caregivers trained about
baby nutrition and given free NurtureMate
packets
• Arm 3: Parenting / stimulation Group
3 prefectures (collection of
counties)
• Shangluo Prefecture
• Ankang Prefecture
• Hanzhong Prefecture
Columbia Trial: Southern Shaanxi:
197, 028 sq km; 70,333 sq km;
76,077 sq mi 27,182 sq mi
11 Nationally-
Designated
Poverty Counties
of 185 towns in the 11
ies …
drop the “county seat

” we have about 60
ers per treatment arm
4 sample towns
Not
County
seat
Sample County
In each town we then randomly chose 1
administrative village (from a comprehensive list of
all villages in the town) … if there were less than
10 babies in the cohort age, we chose another
village until we reached 10 babies
Not
County
seat
Sample Town Sample County
… and repeat for all

Randomization
• Randomly assign each sample town to one of
three arms:
– Nutrition
– Parenting
– Control
• In order to avoid “spillovers” among villages

within same town, all villages within a town
were assigned to the same intervention arm
• Parenting and Development Outcomes
• Conclusion
351 Villages in 174 Townships;
≈1800 caregiver-baby pairs
Enrolled all babies in village

between 6 to 12 months
• Control Villages: No intervention, just
regular observation (n≈600)
• “Free Villages”: Caregivers trained about
baby nutrition and given free NurtureMate
packets (n≈600)
• Arm 3: Parenting / stimulation Group
The intervention (to half the babies)
In our study we use a Heinz

micronutrient packet called
“NurtureMate”.
– Tasteless powder that can be
mixed in with baby’s porridge or
other food
– Good for babies aged 6-36 months
– Approved by the Chinese
government for distribution in
China
– One packet per day … RDA: 5 – 7
packets per week
REAP’s Three “Action Platforms”
Do tests for micronutrient

deficiencies
Share of infants/toddlers with
anemia (malnutrition)
@ 6-12 months
Share of toddlers
with Hb levels under 49% 61% 73%
110 g/L
Shaanxi Hebei Yunnan

anemia (malnutrition)
@ 6-12 months / 6-18 months
Share of toddlers
with Hb levels under 49% 61% 73%
110 g/L

MDI and PDI: Bayley Scales of
Infant Development (BSID)
Like an IQ test for
babies
“low cognition/motor skills” @ 6-
12 months
Share of toddlers
with MDI Bayles 29% 49% 62% Bad
scores that are less
than 85 (less than -1
SD)
Good

“low cognition/motor skills” @ 6-
12 months / 6-18 months
Share of toddlers
with MDI Bayles 29% 38% 42%
SD)

What do the babies/toddlers
from 6 to 30 months look like
over time in the absence of
the nutritional supplement
treatment?
Evidence from control group…

Infants in control group see decline in anemia
prevalence over the 4 rounds, but still high
60%
50%
40%
30%
0.49
20%
0.34
10% 0.2 0.23
0%
6-11 months 12-17 months 18-23 months 24-30 months
6-12 12-18 18-24 24-30
months
“low cognition/motor skills”
Share of toddlers
with MDI Bayles 29% 32% 41% 53%
SD)
6-12 12-18 18-24 24 to 30

months months
Can nutritional supplement improve the
infant health? (ITT results)
Hemoglobin Anemia status
concentration (g/L) (1=anemic,0=not anemic)
Nutritional supplement group
(1=yes, 0=no)* First follow-up
1.76** -0.06*
survey (1=yes, 0=no) (0.88) (0.03)
(1=yes, 0=no)* Second follow-
-0.06 0.03
up survey (1=yes, 0=no) (1.06) (0.04)
(1=yes, 0=no)* Third follow-up
0.18 -0.001
survey (1=yes, 0=no) (1.01) (0.04)
Control variables yes yes
Observation 6,120 6,120
R-squared 0.16 0.11
The ITT analysis shows that nutritional supplement increase the Hemoglobin
concentration (0.14 SD) and reduce anemia rate significantly in the short term
(six months of intervention), but we cannot see any mid-term effect after six
months (adjusted for other confound factors).
Can nutritional supplement promote the
mental development (MDI)? (ITT results)
MDI test score (g/L) MDI test score <70
(1=yes,0=no)
1.89* -0.02
survey (1=yes, 0=no) (1.10) (0.02)
0.32 -0.02
up survey (1=yes, 0=no) (1.31) (0.02)
0.84 -0.01
survey (1=yes, 0=no) (1.35) (0.03)
R-squared 0.27 0.19
We found that nutritional supplement can increase the MDI test score
in the short term (six months of intervention) in the ITT analysis (0.11
SD), but no any effect after six months of intervention (adjusted for
other confound factors).
Can nutritional supplement improve the
infant health? (ATT results)
Hemoglobin Anemia status
concentration (g/L) (1=anemic,0=not anemic)
5.62** -0.18*
survey (1=yes, 0=no) (2.81) (0.11)
-0.09 0.08
up survey (1=yes, 0=no) (3.01) (0.10)
0.75 -0.01
survey (1=yes, 0=no) (3.16) (0.11)
R-squared 0.16 0.11
The effect will be much higher if caregivers comply with the nutritional
supplement treatment (ATT analysis), the Hemoglobin concentration will
increase about 6 g/L (0.44 SD), the anemia rate will decrease significantly by
18 percentage point in the short term (six months of intervention).
Can nutritional supplement promote the
mental development (MDI)? (ATT results)
MDI test score (g/L) MDI test score <70
(1=yes,0=no)
5.84* -0.06
survey (1=yes, 0=no) (3.52) (0.06)
0.27 -0.04
up survey (1=yes, 0=no) (3.66) (0.07)
5.15 -0.002
survey (1=yes, 0=no) (4.12) (0.08)
R-squared 0.20 0.17
If the caregivers comply with the nutritional supplement treatment,

ATT analysis shows the MDI test score can increase 5.84 point
(0.35 SD) in the short term (six months of intervention), but still no
any mid-term effect after six months of intervention.
Summary: Nutrition and Development
• Many of infants in poor rural China suffer from
malnutrition and development impairment
• As the infants get older (before 30 months old),

while micronutrient deficiencies fall, their mental
and social emotion development will be worse
without any intervention
• Nutritional supplement can promote the nutrition,

and cognition … BUT:
– Impacts are relatively small
– Impacts mostly occur between 6-12 to 12 to 18
months
• Parenting and Development Outcomes
• Conclusion
What is baseline parenting like
… in Rural China?
Baseline Characteristics
Control Treatment p-
Group Group value
Households characteristic
(1) first born 0.669 0.609 0.507
(0.472) (0.491)
social security support
(2) recipient 0.280 0.237 0.703
(0.451) (0.427)
Caregiver characteristics
(3) mother is primary caregiver 0.614 0.624 0.825
(0.489) (0.487)
(4) maternal education ≥ 9 years 0.720 0.742 0.673
(0.451) (0.440)
Parents / caregivers love their children
Intervention
Control Group P
Group
value
Baseline Endline Baseline Endline
I really enjoyed being
with my child.
83.8 89.9 91.5 91.0 P=0.09
Playing with my child

was fun and 80.2 85.8 86.4 77.3 P<0.01
interesting.
IWould
know how to readmoney on your baby, if you could help
you spend  everyone = YES
with my child.
46.4 58.9 47.63 44.1 P=0.01
make their future better?
P-value shows difference in difference for unadjusted analysis.

Share of caregivers that played with
their children yesterday
baseline endline baseline endline
Treatment Group Control Group

(receive parenting training)
Share of caregivers that told stories to

Share of caregivers that read a book to
baseline baseline

Share of caregivers that sang a song to

Over 70 % of HH has < 2 books
Number of Books in Household at Baseline
80
.8
60
.6
40
.4
20
.2
0
0
< 2 Less 3-10

than 2 books
10 or more books
>10
between 3-10 books
Number of books at home

Summary: Chinese
families love their
children but do not
know much about
parenting
The intervention
• Once-per-week, in-home, one-on-one
parenting class
• Trainers: Township family planning cadres

(of course, this is a HUGE shift in their
responsibilities
==> before: sterilization / abortions / fining
==> now: bring toys and books for children
teach caregivers about parenting
Provide them with 2 sets of materials
• Curriculum:
– Stage-based
– 6 months to 42 months (156 lessons  52 x 3)
– Fully “scripted” (although Parenting Trainers
almost all went to at least community colleges,
but, have NO background in child development
or psychology)
• Toys, books and supporting materials
(2 per week / one of four activity areas)
– Cognitive skills … language acquisition… socio-
emotional … physical/motor skills
Loosely based in Jamaica
curriculum (same as used in
Columbia study  Our team
with help from Child
Psychologists from SX Normal
University adapted the
curriculum to China
curriculum to China
Toys
and
books
+ Toys packages: two tubs/trainer
• 添加玩具照片。
• 添加玩具照片。
curriculum to China
Delivered
by Family
Toys Planning
and Cadres
books from each
Sample
Town
The intervention
• Once-per-week, in-home, one-on-one
parenting class
• Trainers: Township family planning cadres

(of course, this is a HUGE shift in their
responsibilities
==> before: sterilization / abortions / fining
==> now: bring toys and books for children
teach caregivers about parenting
Training Family Planning Cadres
Parenting trainers
•Family planning cadres become “Parenting
Warriors”
Impacts:
Parenting practices
&
Child development
- MDI (cognition)
Impacts:
Parenting practices
&
Child development
- MDI (cognition)
Share of caregivers that played with
Positive and statistically

significant impact of
parenting intervention on
play

Share of caregivers that told stories to

telling stories

Share of caregivers that read a book to

reading to child

Share of caregivers that sang a song to
singing to child

Impacts:
Parenting practices
&
Child development
- MDI (cognition)
Intention to Treat
Bayley Mental
Development
Dependent Variable: MDI MDI MDI<80 MDI<80
(1) (2) (3) (4)
treatment 0.220* 0.220* -0.152** -0.151**

(0.119) (0.117) (0.061) (0.062)
additional
controls x x
* Significant at the10 percent level
Intention to Treat
Bayley Motor
Development
Dependent Variable: PDI PDI PDI<80 PDI<80
(1) (2) (3) (4)
treatment 0.008 0.008 -0.035 -0.039

(0.116) (0.116) (0.040) (0.039)
additional controls x x
* Significant at the10 percent level
Treatment on Treated
Bayley Mental
Development
Dependent Variable: MDI MDI MDI<80 MDI<80
(1) (2) (3) (4)
number of visits 0.027* 0.027** -0.019** -0.019**

(0.014) (0.014) (0.008) (0.008)
additional
controls x x
Comparing Impact Estimates
Parenting on Bayley Mental Development
1
0.8
0.6
0.4
0.2
0 1
ITT ATT at2 Mean 3
ATT at Full
Number of Visits Compliance
Heterogeneous Treatment
Effects
(1) (2) (3) (4)
MDI MDI MDI MDI
treatment 0.268 0.106 0.447*** -0.030
(0.185) (0.187) (0.167) (0.216)
male 0.017
(0.159)
male * treatment -0.066
No Impact on Boys
(0.280) vs. Girls …
firstborn -0.110
(0.155)
firstborn * treatment 0.230 No Impact on First
(0.232) vs. Second Born
bad health -0.012
(0.170)
bad health * treatment -0.521*
(0.290)
mom main carer -0.217
(0.172)
mom main carer * treatment 0.471*
(0.275)
Observations 222 220 223 223
Heterogeneous Treatment
Effects
(1) (2) (3) (4)
MDI MDI MDI MDI
treatment 0.268 0.106 0.447*** -0.030
(0.185) (0.187) (0.167) (0.216)
male 0.017
(0.159)
male * treatment -0.066
(0.280)
firstborn -0.110
(0.155)
firstborn * treatment 0.230
(0.232)
bad health -0.012
Large Het Effect (0.170)
of
bad health * treatment Mother vs. -0.521*
(0.290)
mom main carer Grandmother -0.217
(0.172)
mom main carer * treatment 0.471*
(0.275)
Observations 222 220 223 223
Comparing Impact Estimates
Parenting on Bayley Mental Development
1
0.8
0.22 0.47 0
0.6
0.4
0.2
0
ITT
1
Mom is
2
Main Grandma
3
is Main
Caregiver Caregiver
What happens when mother outmigrates (they go
back to work in the city and move away from home
and leave her child in the care of grandmother?
100
80 Mother
60
40
20
Grandmother
0
The effect of mother’s outmigration on
development outcomes
Determinants of migration
Who outmigrates?
-Moms of older babies
-Moms of only children
-Younger Moms
-Higher educated Moms / Dads
The plan for rest of the
presentation
• Sampling
• Experiment one: Nutrition and Child

Development
• Experiment two: Parenting intervention

and Child Development
• Policy Implications
So what does this mean?
Share of toddlers
with Bayles scores
53%
that are less than 85 28%
(= IQ less than 90)
6 to 12 24 to 30
months months
Important assumption: We believe these
are representative of three year olds in
poor rural areas
• Poor rural areas are cities

homes to nearly ½ poor
rural
of all of China’s
other
three year olds
rural
Calculated from the 2010 Census

What does this mean?
1. if 53% of ½ of China’s three year

olds have low cognition
2. if 15% of the other half of
China’s three year olds have low
cognition
THEN: > 33 percent of China’s future
population (100s of millions of people) are
in danger of becoming PERMANENTLY
physically and mentally HANDICAPPED
If a person has an IQ of 90, what
does this mean?
Maybe this explains the gap in education
They can not learn math, science, language  not

only can’t go to college, can’t go to high school
If difficult to go to high school, then why go to junior
high school (does this explain junior high drop out?)
Ultimately, if China becomes a high wage, high

income society … large share of these children will
be unemployable / and remember, children being
born now are likely to be alive in 2100 …
Final word
Why aren’t (rural) Chinese children

learning the skills and being educated to
levels that are needed to become a
developed, high-wage, high-skill
economy? College / high school / jr. hi
-Poor cognition due to poor nutrition (a

little bit) and poor parenting (important) as
infants and toddlers
Thank You!
http://reap.stanford.edu
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Early Childhood Interventions:

Issues when planning to spread

Low birth weight, severely or moderately

 All had concurrent child development

 Most improved home stimulation, mothers

 4 long term follow ups at 6, 17 and 22

• Less depression and better social skills

 Brazil (Harvard, Sao Paulo University)

 Guatemala (World bank, Child Fund)

 China (China Development Research Foundation)

 India (IFS, Yale, Pratham,CECED )

 Bangladesh (icddr,b and Ministry of health)

 Peru (IDB) National programme

 Training Videos made in Jamaica, Peru and Bangladesh

(Collaboration of UWI, icddr,b Bangladesh and IFS and IDB)

2. Need for advocacy at the country level: by who?

3. Integrate into existing services / New service ?

Development Media International

Grffiths DQ 94.7 ± 8.3 96.1 ± 9.4 1.1 (−0.5 to 2.7)

**p<0.01, *** p<0.001

nutrition also at risk for development

 Access already in place (only one)

 Sustainability may be more likely

 Can use their facilities and staff

 More cost effective

 Can be chaotic, not be meeting their own targets

Child development may not be their priority

 Health staff tend to be didactic

2. Ministry of Health is enthusiastic and make it one of their

3. There is at least one champion to lead it in the Ministry and

4. Caution: Most MOH see child development as screening

 Leadership (influential, permanent, local, passionate Vs

often distant and just consenting)

 Selection of staff may be for wrong reasons

 Organisation’s climate: Open to change and

Seniors Supervisors Visitors Mothers

Listen/ ask opinion/ give positive reinforcement/

May need to add special workshop on relations

Seize opportunities: massage, platting hair, carrying child etc

• Local care patterns and conditions often unknown No

• No time for pilots - want rapid results (Political cycle)

Want to address every need. Which ?

Want long and complicated routine records. May get in

 Adequate training (not1to 2 days)

When to evaluate impact when going to scale?

Must have valid measurements

 How intense does an intervention have to be?

Study Treatment Intensity Treatment

Singla 2015 Stimulaton, 13 group sessions Cognitive 0.36

Aboud 2011 Stimulation + 6 group sessions over Language 0.35*

Must have longitudinal follow up and RCTs to assess

What age to stop? Until the next educational

Does duration matter? Improvement tends to level

Study Age Treatment effect

Cooper 16 Home Prenatal to 6 mos 6 & 12mos: mother more

Kangaroo care for preterm: (Feldman et al 2012 , Bera et al 2014,

 Post-natal period particularly sensitive to

 Maternal hormones high (e.g. oxytocin) associated

 Childs stress response system developing

 Is it a good time to intervene for cognitive

Grantham-McGregor et al, Lancet 1991

 Cognitive improvement with stimulation continues from 1 to 3

p<0.01, * p<0.001

•  Final outcomes: No average significant effects

•  Opinion leaders also receiving messages not necessarily