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Austrian K, Maluccio JA, Soler-Hampejsek E, Muluve E, Aden A, Wado YD, Abuya B, Kangwana B. Long-term impacts of a cash plus program on marriage, fertility, and education after six years in pastoralist Kenya: A cluster randomized trial. SSM Popul Health 2024; 26:101663. [PMID: 38577063 PMCID: PMC10992718 DOI: 10.1016/j.ssmph.2024.101663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/29/2024] [Accepted: 03/18/2024] [Indexed: 04/06/2024] Open
Abstract
Background Preventing early marriage by increasing girls education has shown promise. We assessed the effects of a two-year cash plus program on marriage and fertility in a pastoralist setting in Northeastern Kenya, six years after it began. Methods A prospective 80-cluster randomized trial followed 2,147 girls 11-14 years old starting in 2015, re-interviewing 94.2% in 2021. Interventions included community dialogues (violence prevention), a conditional cash transfer (education), health and life skills training (health), and financial literacy (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) + education (VE); (3) + health (VEH); or (4) + wealth creation (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled (weighted average) study arm combining VE, VEH and VEHW, in reference to V-only, four years after the intervention ended when girls were 17-20 years old. Findings Base specification estimates show reductions in the primary outcomes, though none statistically significant in the full sample. Estimates with extended controls are larger and the pooled study arm had significantly lower marriage and pregnancy. There are considerably larger statistically significant effects for the baseline out-ofschool subsample. Pooled estimates indicate 18.2 percentage point lower marriage compared to V-only and 15.1 percentage point lower pregnancy. For the same group pooled estimates indicate a 27.9 percentage point increase in current enrollment (compared to 7.1% in V-only) and a 1.8 grades increase (compared to 1.2 in V-only). Conclusion This study shows the potential for interventions in early adolescence with an education component to delay marriage and fertility into late adolescence and early adulthood in a marginalized and socially conservative setting with low education and high rates of child marriage.
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Affiliation(s)
- Karen Austrian
- GIRL Center, Population Council, PO Box 17643-00500, Nairobi, Kenya
| | - John A. Maluccio
- Department of Economics, Middlebury College, Middlebury, VT, USA
| | | | - Eva Muluve
- Population Council – Kenya, Nairobi, Kenya
| | | | | | - Benta Abuya
- African Population and Health Research Center, Nairobi, Kenya
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Maluccio JA, Soler-Hampejsek E, Kangwana B, Muluve E, Mbushi F, Austrian K. Effects of a single cash transfer on school re-enrollment during COVID-19 among vulnerable adolescent girls in Kenya: Randomized controlled trial. Econ Educ Rev 2023; 95:102429. [PMID: 37351530 PMCID: PMC10266500 DOI: 10.1016/j.econedurev.2023.102429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 06/11/2023] [Accepted: 06/12/2023] [Indexed: 06/24/2023]
Abstract
COVID-19 related school closures in Kenya were among the longest in Africa, putting older adolescent girls nearing the end of secondary school at risk of permanent dropout. Using a randomized-controlled trial we evaluated a logistically simple cash transfer intervention in urban areas designed to promote their return to school. There were no required conditions for receiving the transfer and the intervention is interpreted as a labeled cash transfer. It had substantial significant effects on re-enrollment of adolescent girls, with greater effectiveness for older girls and even for some not enrolled earlier in the school year. The program effectiveness demonstrates feasibility of the approach and underscores the potential importance of additional resources for schooling during the pandemic, when a large majority of households had suffered income losses.
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Affiliation(s)
- John A Maluccio
- Department of Economics, Middlebury College, Middlebury Vermont 05753 USA
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Noble C, Mooney C, Makasi R, Ntozini R, Majo FD, Church JA, Tavengwa NV, Prendergast AJ, Humphrey JH, Manges A, Mangwadu G, Maluccio JA, Mbuya MNN, Moulton LH, Stoltzfus RJ, Tielsch JM, Smith LE, Chasokela C, Chigumira A, Heylar W, Hwena P, Kembo G, Mutasa B, Mutasa K, Rambanepasi P, Sauramba V, Van Der Keilen F, Zambezi C, Chidhanguro D, Chigodora D, Chipanga JF, Gerema G, Magara T, Mandava M, Mavhudzi T, Mazhanga C, Muzaradope G, Mwapaura MT, Phiri S, Tengende A, Banda C, Chasekwa B, Chidamba L, Chidawanyika T, Chikwindi E, Chingaona LK, Chiorera CK, Dandadzi A, Govha M, Gumbo H, Gwanzura KT, Kasaru S, Matsika AM, Maunze D, Mazarura E, Mpofu E, Mushonga J, Mushore TE, Muzira T, Nembaware N, Nkiwane S, Nyamwino P, Rukobo SD, Runodamoto T, Seremwe S, Simango P, Tome J, Tsenesa B, Amadu U, Bangira B, Chiveza D, Hove P, Jombe HA, Kujenga D, Madhuyu L, Mandina-Makoni P, Maramba N, Maregere B, Marumani E, Masakadze E, Mazula P, Munyanyi C, Musanhu G, Mushanawani RC, Mutsando S, Nazare F, Nyarambi M, Nzuda W, Sigauke T, Solomon M, Tavengwa T, Biri F, Chafanza M, Chaitezvi C, Chauke T, Chidzomba C, Dadirai T, Fundira C, Gambiza AC, Godzongere T, Kuona M, Mafuratidze T, Mapurisa I, Mashedze T, Moyo N, Musariri C, Mushambadope M, Mutsonziwa TR, Muzondo A, Mwareka R, Nyamupfukudza J, Saidi B, Sakuhwehwe T, Sikalima G, Tembe J, Chekera TE, Chihombe O, Chikombingo M, Chirinda T, Chivizhe A, Hove R, Kufa R, Machikopa TF, Mandaza W, Mandongwe L, Manhiyo F, Manyaga E, Mapuranga P, Matimba FS, Matonhodze P, Mhuri S, Mike J, Ncube B, Nderecha WTS, Noah M, Nyamadzawo C, Penda J, Saidi A, Shonhayi S, Simon C, Tichagwa M, Chamakono R, Chauke A, Gatsi AF, Hwena B, Jawi H, Kaisa B, Kamutanho S, Kaswa T, Kayeruza P, Lunga J, Magogo N, Manyeruke D, Mazani P, Mhuriyengwe F, Mlambo F, Moyo S, Mpofu T, Mugava M, Mukungwa Y, Muroyiwa F, Mushonga E, Nyekete S, Rinashe T, Sibanda K, Chemhuru M, Chikunya J, Chikwavaire VF, Chikwiriro C, Chimusoro A, Chinyama J, Gwinji G, Hoko-Sibanda N, Kandawasvika R, Madzimure T, Maponga B, Mapuranga A, Marembo J, Matsunge L, Maunga S, Muchekeza M, Muti M, Nyamana M, Azhuda E, Bhoroma U, Biriyadi A, Chafota E, Chakwizira A, Chamhamiwa A, Champion T, Chazuza S, Chikwira B, Chingozho C, Chitabwa A, Dhurumba A, Furidzirai A, Gandanga A, Gukuta C, Macheche B, Marihwi B, Masike B, Mutangandura E, Mutodza B, Mutsindikwa A, Mwale A, Ndhlovu R, Nduna N, Nyamandi C, Ruvata E, Sithole B, Urayai R, Vengesa B, Zorounye M, Bamule M, Bande M, Chahuruva K, Chidumba L, Chigove Z, Chiguri K, Chikuni S, Chikwanda R, Chimbi T, Chingozho M, Chinhamo O, Chinokuramba R, Chinyoka C, Chipenzi X, Chipute R, Chiribhani G, Chitsinga M, Chiwanga C, Chiza A, Chombe F, Denhere M, Dhamba E, Dhamba M, Dube J, Dzimbanhete F, Dzingai G, Fusira S, Gonese M, Gota J, Gumure K, Gwaidza P, Gwangwava M, Gwara W, Gwauya M, Gwiba M, Hamauswa J, Hlasera S, Hlukani E, Hotera J, Jakwa L, Jangara G, Janyure M, Jari C, Juru D, Kapuma T, Konzai P, Mabhodha M, Maburutse S, Macheka C, Machigaya T, Machingauta F, Machokoto E, Madhumba E, Madziise L, Madziva C, Madzivire M, Mafukise M, Maganga M, Maganga S, Mageja E, Mahanya M, Mahaso E, Mahleka S, Makanhiwa P, Makarudze M, Makeche C, Makopa N, Makumbe R, Mandire M, Mandiyanike E, Mangena E, Mangiro F, Mangwadu A, Mangwengwe T, Manhidza J, Manhovo F, Manono I, Mapako S, Mapfumo E, Mapfumo T, Mapuka J, Masama D, Masenge G, Mashasha M, Mashivire V, Matunhu M, Mavhoro P, Mawuka G, Mazango I, Mazhata N, Mazuva D, Mazuva M, Mbinda F, Mborera J, Mfiri U, Mhandu F, Mhike C, Mhike T, Mhuka A, Midzi J, Moyo S, Mpundu M, Msindo NM, Msindo D, Mtisi C, Muchemwa G, Mujere N, Mukaro E, Muketiwa K, Mungoi S, Munzava E, Muoki R, Mupura H, Murerwa E, Murisi C, Muroyiwa L, Muruvi M, Musemwa N, Mushure C, Mutero J, Mutero P, Mutumbu P, Mutya C, Muzanango L, Muzembi M, Muzungunye D, Mwazha V, Ncube T, Ndava T, Ndlovu N, Nehowa P, Ngara D, Nguruve L, Nhigo P, Nkiwane S, Nyanyai L, Nzombe J, Office E, Paul B, Pavari S, Ranganai S, Ratisai S, Rugara M, Rusere P, Sakala J, Sango P, Shava S, Shekede M, Shizha C, Sibanda T, Tapambwa N, Tembo J, Tinago N, Tinago V, Toindepi T, Tovigepi J, Tuhwe M, Tumbo K, Zaranyika T, Zaru T, Zimidzi K, Zindo M, Zindonda M, Zinhumwe N, Zishiri L, Ziyambi E, Zvinowanda J, Bepete E, Chiwira C, Chuma N, Fari A, Gavi S, Gunha V, Hakunandava F, Huku C, Hungwe G, Maduke G, Manyewe E, Mapfumo T, Marufu I, Mashiri C, Mazenge S, Mbinda E, Mhuri A, Muguti C, Munemo L, Musindo L, Ngada L, Nyembe D, Taruvinga R, Tobaiwa E, Banda S, Chaipa J, Chakaza P, Chandigere M, Changunduma A, Chibi C, Chidyagwai O, Chidza E, Chigatse N, Chikoto L, Chingware V, Chinhamo J, Chinhoro M, Chiripamberi A, Chitavati E, Chitiga R, Chivanga N, Chivese T, Chizema F, Dera S, Dhliwayo A, Dhononga P, Dimingo E, Dziyani M, Fambi T, Gambagamba L, Gandiyari S, Gomo C, Gore S, Gundani J, Gundani R, Gwarima L, Gwaringa C, Gwenya S, Hamilton R, Hlabano A, Hofisi E, Hofisi F, Hungwe S, Hwacha S, Hwara A, Jogwe R, Kanikani A, Kuchicha L, Kutsira M, Kuziyamisa K, Kuziyamisa M, Kwangware B, Lozani P, Mabuto J, Mabuto V, Mabvurwa L, Machacha R, Machaya C, Madembo R, Madya S, Madzingira S, Mafa L, Mafuta F, Mafuta J, Mahara A, Mahonye S, Maisva A, Makara A, Makover M, Mambongo E, Mambure M, Mandizvidza E, Mangena G, Manjengwa E, Manomano J, Mapfumo M, Mapfurire A, Maphosa L, Mapundo J, Mare D, Marecha F, Marecha S, Mashiri C, Masiya M, Masuku T, Masvimbo P, Matambo S, Matarise G, Matinanga L, Matizanadzo J, Maunganidze M, Mawere B, Mawire C, Mazvanya Y, Mbasera M, Mbono M, Mhakayakora C, Mhlanga N, Mhosva B, Moyo N, Moyo O, Moyo R, Mpakami C, Mpedzisi R, Mpofu E, Mpofu E, Mtetwa M, Muchakachi J, Mudadada T, Mudzingwa K, Mugwira M, Mukarati T, Munana A, Munazo J, Munyeki O, Mupfeka P, Murangandi G, Muranganwa M, Murenjekwa J, Muringo N, Mushaninga T, Mutaja F, Mutanha D, Mutemeri P, Mutero B, Muteya E, Muvembi S, Muzenda T, Mwenjota A, Ncube S, Ndabambi T, Ndava N, Ndlovu E, Nene E, Ngazimbi E, Ngwalati A, Nyama T, Nzembe A, Pabwaungana E, Phiri S, Pukuta R, Rambanapasi M, Rera T, Samanga V, Shirichena S, Shoko C, Shonhe M, Shuro C, Sibanda J, Sibangani E, Sibangani N, Sibindi N, Sitotombe M, Siwawa P, Tagwirei M, Taruvinga P, Tavagwisa A, Tete E, Tete Y, Thandiwe E, Tibugari A, Timothy S, Tongogara R, Tshuma L, Tsikira M, Tumba C, Watinaye R, Zhiradzango E, Zimunya E, Zinengwa L, Ziupfu M, Ziyambe J. Antenatal and delivery practices and neonatal mortality amongst women with institutional and non-institutional deliveries in rural Zimbabwe: observational data from a cluster randomized trial. BMC Pregnancy Childbirth 2022; 22:981. [PMID: 36585673 PMCID: PMC9805263 DOI: 10.1186/s12884-022-05282-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Despite achieving relatively high rates of antenatal care, institutional delivery, and HIV antiretroviral therapy for women during pregnancy, neonatal mortality has remained stubbornly high in Zimbabwe. Clearer understanding of causal pathways is required to inform effective interventions. METHODS This study was a secondary analysis of data from the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial, a cluster-randomized community-based trial among pregnant women and their infants, to examine care during institutional and non-institutional deliveries in rural Zimbabwe and associated birth outcomes. RESULTS Among 4423 pregnant women, 529 (11.9%) delivered outside a health institution; hygiene practices were poorer and interventions to minimise neonatal hypothermia less commonly utilised for these deliveries compared to institutional deliveries. Among 3441 infants born in institutions, 592 (17.2%) were preterm (< 37 weeks gestation), while 175/462 (37.9%) infants born outside health institutions were preterm (RR: 2.20 (1.92, 2.53). Similarly, rates of stillbirth [1.2% compared to 3.0% (RR:2.38, 1.36, 4.15)] and neonatal mortality [2.4% compared to 4.8% (RR: 2.01 1.31, 3.10)] were higher among infants born outside institutions. Among mothers delivering at home who reported their reason for having a home delivery, 221/293 (75%) reported that precipitous labor was the primary reason for not having an institutional delivery while 32 (11%), 34 (12%), and 9 (3%), respectively, reported distance to the clinic, financial constraints, and religious/personal preference. CONCLUSIONS Preterm birth is common among all infants in rural Zimbabwe, and extremely high among infants born outside health institutions. Our findings indicate that premature onset of labor, rather than maternal choice, may be the reason for many non-institutional deliveries in low-resource settings, initiating a cascade of events resulting in a two-fold higher risk of stillbirth and neonatal mortality amongst children born outside health institutions. Interventions for primary prevention of preterm delivery will be crucial in reducing neonatal mortality in Zimbabwe. TRIAL REGISTRATION The trial is registered with ClinicalTrials.gov, number NCT01824940.
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Affiliation(s)
- Christie Noble
- grid.4868.20000 0001 2171 1133Blizard Institute, Queen Mary University of London, London, UK
| | - Ciaran Mooney
- Northern Ireland Medical and Dental Training Agency (NIMDTA), Beechill House, 42 Beechill Rd, Belfast, BT8 7RL UK
| | - Rachel Makasi
- grid.493148.3Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- grid.493148.3Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Florence D. Majo
- grid.493148.3Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - James A. Church
- grid.4868.20000 0001 2171 1133Blizard Institute, Queen Mary University of London, London, UK ,grid.493148.3Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Naume V. Tavengwa
- grid.493148.3Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Andrew J. Prendergast
- grid.4868.20000 0001 2171 1133Blizard Institute, Queen Mary University of London, London, UK ,grid.493148.3Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe ,grid.21107.350000 0001 2171 9311Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
| | - Jean H. Humphrey
- grid.493148.3Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe ,grid.21107.350000 0001 2171 9311Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD USA
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Chasekwa B, Ntozini R, Church JA, Majo FD, Tavengwa N, Mutasa B, Noble C, Koyratty N, Maluccio JA, Prendergast AJ, Humphrey JH, Smith LE. Prevalence, risk factors and short-term consequences of adverse birth outcomes in Zimbabwean pregnant women: a secondary analysis of a cluster-randomized trial. Int J Epidemiol 2022; 51:1785-1799. [PMID: 34875052 DOI: 10.1093/ije/dyab248] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 11/15/2021] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Globally, 15 million children are born preterm each year and 10.7 million are born at term but with low birthweight (<2500 g). METHODS The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) cluster-randomized trial enrolled 5280 pregnant women between 22 November 2012 and 27 March 2015 to test the impact of improved water supply, sanitation and hygiene, and improved infant feeding, on child growth and anaemia. We conducted a secondary analysis to estimate the prevalence and risk factors of miscarriage, stillbirth, preterm birth, size small for gestational age (SGA), low birthweight (LBW), perinatal mortality, and neonatal mortality, and to estimate the effects of adverse birth outcomes on infant survival and growth. RESULTS The prevalence of adverse birth outcomes was: miscarriage: 5.0% [95% confidence interval (CI), 4.4, 5.7]; stillbirth: 2.3% (95% CI 1.9, 2.7); preterm birth: 18.2% (95% CI 16.9, 19.5); SGA: 16.1% (95% CI 15.0, 17.3); LBW: 9.8% (95% CI 9.0, 10.7); and neonatal mortality: 31.4/1000 live births (95% CI 26.7, 36.5). Modifiable risk factors included maternal HIV infection, anaemia, lack of antenatal care and non-institutional delivery. Preterm infants had higher neonatal mortality [risk ratio (RR): 6.1 (95% CI 4.0, 9.2)], post-neonatal infant mortality [hazard ratio (HR): 2.1 (95% CI 1.1, 4.1)] and stunting at 18 months of age [RR: 1.5 (95% CI 1.4, 1.7)] than term infants; 56% of stillbirths and 57% of neonatal deaths were among preterm births. CONCLUSIONS Neonatal mortality and stillbirth are high in Zimbabwe and appear to be driven by high preterm birth. Interventions for primary prevention of preterm birth and strengthened management of preterm labour and ill and small neonates are required to reduce neonatal mortality in Zimbabwe and other African countries with similar profiles.
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Affiliation(s)
- Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - James A Church
- Blizard Institute, Queen Mary University of London, London, UK
| | - Florence D Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Naume Tavengwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Batsirai Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Christie Noble
- Blizard Institute, Queen Mary University of London, London, UK
| | - Nadia Koyratty
- Department of Population Medicine and Diagnostics, Cornell University, Ithaca, NY, USA
| | - John A Maluccio
- Department of Economics, Middlebury College, Middlebury, VT, USA
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Blizard Institute, Queen Mary University of London, London, UK.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Jean H Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura E Smith
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.,Department of Population Medicine and Diagnostics, Cornell University, Ithaca, NY, USA
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Maluccio JA, Pandey K. Food Aid and Fertility: Does Under-Two Targeting Influence Short-Term Fertility? Popul Res Policy Rev 2022. [DOI: 10.1007/s11113-022-09728-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
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Austrian K, Soler-Hampejsek E, Kangwana B, Maddox N, Diaw M, Wado YD, Abuya B, Muluve E, Mbushi F, Mohammed H, Aden A, Maluccio JA. Impacts of Multisectoral Cash Plus Programs on Marriage and Fertility After 4 Years in Pastoralist Kenya: A Randomized Trial. J Adolesc Health 2022; 70:885-894. [PMID: 35168885 DOI: 10.1016/j.jadohealth.2021.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 11/12/2021] [Accepted: 12/06/2021] [Indexed: 01/03/2023]
Abstract
PURPOSE Early marriage has multiple drivers including cultural and social norms alongside lack of educational and economic opportunities. This complexity may explain why few programs have demonstrated marriage delays and suggests multisectoral interventions are necessary. This study examined a 2-year multisectoral program designed to delay marriage in a marginalized setting. METHODS The study used a prospective 80-cluster randomized trial following up 2,147 girls aged 11-14 years from 2015 to 2019. Interventions included community dialogs about inequitable gender norms (violence prevention), a conditional cash transfer (education), weekly group meetings with health and life skills training (health), and financial literacy training (wealth creation). Villages were randomized to one of four study arms: (1) violence prevention only (V-only); (2) violence prevention and education (VE); (3) VE and health (VEH); or (4) all four interventions (VEHW). We used analysis of covariance to estimate intent-to-treat impacts of each study arm with an education component, as well as a pooled study arm combining the VE, VEH, and VEHW arms, in reference to V-only, 2 years after the intervention ended, when girls were 15-18 years old. RESULTS There were small but insignificant reductions on primary outcomes in unadjusted analyses that were larger and significant in adjusted analyses. Effects were particularly large for girls not in school at baseline-the pooled study arm reduced marriage by 18.0 and pregnancy by 15.6 percentage points, a relative reduction of 34% and 43%, respectively. DISCUSSION The article demonstrates the potential for multisectoral interventions with education components to delay early marriage in an impoverished, socially conservative, pastoral setting.
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Affiliation(s)
- Karen Austrian
- Poverty, Gender and Youth Program, Population Council - Kenya, Nairobi, Kenya.
| | | | - Beth Kangwana
- Poverty, Gender and Youth Program, Population Council - Kenya, Nairobi, Kenya
| | - Nicole Maddox
- Department of Social and Political Sciences, Bocconi University, Milan, Italy
| | - Maryama Diaw
- Department of Population and Family Health, Mailman School of Public Health, Columbia University, New York, New York
| | - Yohannes D Wado
- African Population and Health Research Center, Nairobi, Kenya
| | - Benta Abuya
- African Population and Health Research Center, Nairobi, Kenya
| | - Eva Muluve
- Poverty, Gender and Youth Program, Population Council - Kenya, Nairobi, Kenya
| | - Faith Mbushi
- Poverty, Gender and Youth Program, Population Council - Kenya, Nairobi, Kenya
| | | | | | - John A Maluccio
- Department of Economics, Middlebury College, Middlebury, Vermont
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Austrian K, Soler-Hampejsek E, Kangwana B, Wado YD, Abuya B, Maluccio JA. Impacts of two-year multisectoral cash plus programs on young adolescent girls' education, health and economic outcomes: Adolescent Girls Initiative-Kenya (AGI-K) randomized trial. BMC Public Health 2021; 21:2159. [PMID: 34819047 PMCID: PMC8613919 DOI: 10.1186/s12889-021-12224-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 11/11/2021] [Indexed: 11/10/2022] Open
Abstract
Background Early adolescence is a critical window for intervention when it is possible to lay a foundation for a safe transition to adulthood, before negative outcomes occur. The Adolescent Girls Initiative–Kenya randomized trial tested the effects of combinations of interventions for young adolescent girls in two sites – the Kibera informal settlement in Nairobi and rural Wajir County in the Northeastern region. Methods The interventions included community dialogues on the role and value of girls (violence prevention), a conditional cash transfer (education), weekly group meetings for girls with health and life skills training (health), and training and incentives for financial literacy and savings activities (wealth creation). Participants were randomized to one of four study arms: 1) violence prevention only, 2) violence prevention and education, 3) violence prevention, education and health or 4) violence prevention, education, health and wealth creation. An intent-to-treat (ITT) analysis was conducted using longitudinal data to estimate the impact of each combination of interventions and various sensitivity analyses conducted addressing potential attrition bias and multiple hypothesis testing concerns. Results In Kibera, the education conditional cash transfer had small effects on grade attainment but larger impacts on completion of primary school and the transition to secondary school in the most comprehensive arm; the health intervention improved sexual and reproductive health knowledge and condom self-efficacy; and the wealth intervention improved financial literacy and savings behavior. In Wajir, the education conditional cash transfer increased school enrollment and grade attainment, and the wealth intervention improved savings behavior. Conclusions The results indicate that when trying to improve a range of outcomes related to adolescent wellbeing for young girls, a multisectoral intervention with components addressing household economic constraints is a promising approach. Trial registration Trial Registry: ISRCTN, ISRCTN77455458. Registered 24/12/2015 - Retrospectively registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12889-021-12224-3.
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Affiliation(s)
- Karen Austrian
- Population Council, Avenue 5, 3rd Floor, Rose Avenue, PO Box 17643-00500, Nairobi, Kenya.
| | | | - Beth Kangwana
- Population Council, Avenue 5, 3rd Floor, Rose Avenue, PO Box 17643-00500, Nairobi, Kenya
| | - Yohannes Dibaba Wado
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya
| | - Benta Abuya
- African Population and Health Research Center, APHRC Campus, 2nd Floor, Manga Close, Off Kirawa Road, P.O. Box 10787-00100, Nairobi, Kenya
| | - John A Maluccio
- Department of Economics, Middlebury College, 14 Old Chapel Road, Middlebury, VT, 05753, USA
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Varghese JS, Maluccio JA, Cunningham SA, Ramirez-Zea M, Stein AD. Development of a temporally harmonized asset index: evidence from across 50 years of follow up of a birth cohort in Guatemala. BMC Med Res Methodol 2021; 21:85. [PMID: 33902451 PMCID: PMC8074514 DOI: 10.1186/s12874-021-01263-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Accepted: 03/30/2021] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Asset-based indices are widely-used proxy measures of wealth in low and middle-income countries (LMIC). The stability of these indices within households over time is not known. METHODS We develop a harmonized household asset index using Principal Component Analysis for the participants (n = 2392) of INCAP Longitudinal Study, Guatemala using data from six waves of follow-up over the period of 1965-2018. We estimate its cross-sectional association with parental schooling (in 1967-75) and attained schooling (in 2015-18) of cohort members. We study how patterns of cross-sectional loadings change over time and between urban-rural settings. We assess its robustness to omission of assets or study waves and alternate specifications of factor extraction procedure (exploratory factor analysis, multiple correspondence analysis). RESULTS The harmonized index constructed using 8 assets and 11 housing characteristics explained 32.4% of the variance. Most households increased in absolute wealth over time with median wealth (25th percentile, 75th percentile; households) increasing from - 3.74 (- 4.42, - 3.07; 547) in 1967 to 2.08 (1.41, 2.67; 1145) in 2017-18. Ownership of television, electricity, quality of flooring and sanitary installation explained the largest proportion of variance. The index is positively associated with measures of schooling (maternal: r = 0.16; paternal: r = 0.10; attained: r = 0.35, all p < 0.001). In 2015-18, house ownership versus housing characteristics and ownership of electronic goods differentiate households in urban and rural areas respectively. The index is robust for omission of assets or study waves, indicator categorization and factor extraction method. CONCLUSION A temporally harmonized asset index constructed from consistently administered surveys in a cohort setting over time may allow study of associations of life-course social mobility with human capital outcomes in LMIC contexts. The approach permits exploration of trends in household wealth of the sample over a follow-up period against repeated cross-sectional surveys which permit the estimation of only the mean trajectory.
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Affiliation(s)
- Jithin Sam Varghese
- Nutrition and Health Sciences Program, Laney Graduate School, Emory University, Atlanta, GA, USA
| | - John A Maluccio
- Economics Department at Middlebury College, Middlebury College, Middlebury, VT, USA
| | - Solveig A Cunningham
- Hubert Department of Global Health, Emory University, 1518 Clifton Rd NE, #7007, Atlanta, GA, 30322, USA
| | - Manuel Ramirez-Zea
- INCAP Research Centre for the Prevention of Chronic Diseases (CIIPEC), Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala
| | - Aryeh D Stein
- Hubert Department of Global Health, Emory University, 1518 Clifton Rd NE, #7007, Atlanta, GA, 30322, USA.
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Behrman JR, Hoddinott J, Maluccio JA. Nutrition, Adult Cognitive Skills, and Productivity: Results and Influence of the INCAP Longitudinal Study. Food Nutr Bull 2020; 41:S41-S49. [PMID: 32522126 DOI: 10.1177/0379572119898956] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article summarizes research based on the INCAP Longitudinal Study that demonstrates the positive effects of the atole intervention on prime-age adult cognitive skills and productivities. The findings are interpreted in the context of a life-cycle stages model in which various factors and investments at each stage of life influence outcomes not only in that stage but in subsequent ones. The results point to the likely importance of improvements in adult cognitive skills due to better early-life nutrition on adult male labor market outcomes as well as on women's "home productivity" in terms of anthropometrics for the next generation. Possible mechanisms are also explored, including the impacts of early-life exposure to atole on children's height when starting school, on grades of schooling attainment, and on the extent of experience with higher-skilled jobs, as well as the impacts of improved cognitive skills on wages. Not only are investments in early-life nutrition important for immediate welfare but also they have significant productivity payoffs in adulthood.
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Affiliation(s)
- Jere R Behrman
- Department of Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - John Hoddinott
- Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA
| | - John A Maluccio
- Department of Economics, Middlebury College, Middlebury, VT, USA
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Melgar P, Maluccio JA, Arevalo AI, Alvarez A, Alvarez M. Social and Economic Development and Change in 4 Guatemalan Villages Over a Half Century. Food Nutr Bull 2020; 41:S69-S78. [PMID: 32238015 DOI: 10.1177/0379572120912876] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article describes nearly 50 years of social and economic development and changes that have occurred in the 4 villages of the Institute of Nutrition of Central America and Panama (INCAP) Longitudinal Study (1969-1977). In doing so, it contextualizes the changes in health and nutrition for the study population over that period. Since the start of the INCAP Longitudinal Study, the original 4 villages, like their home country, have undergone tremendous demographic, social, and economic change. Originally rather isolated, road and transportation access for the villages has improved steadily and substantially. The population in the villages has more than doubled. Schooling access and outcomes have also improved substantially, with average grades of schooling tripling and literacy doubling, reaching levels currently on par with national averages. Occupations have also changed over the course of a generation. Early on, subsistence farming and agriculture in general were dominant but are now much less common. Much of this change is associated with declining agricultural markets alongside increased access to nonagricultural jobs near the villages and in the capital. With all these changes have come improvements in living standards. It is within this dynamic context that study participants for the INCAP Longitudinal Study were born and raised and where most now live as adults.
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Affiliation(s)
- Paúl Melgar
- INCAP Research Center for the prevention of Chronic Diseases-CIIPEC, Institute of Nutrition of Central America and Panama -INCAP, Guatemala City, Guatemala
| | - John A Maluccio
- Economics Department at Middlebury College, Middlebury College, Middlebury, VT, USA
| | - Aura Isabel Arevalo
- INCAP Research Center for the prevention of Chronic Diseases-CIIPEC, Institute of Nutrition of Central America and Panama -INCAP, Guatemala City, Guatemala
| | - Andrea Alvarez
- INCAP Research Center for the prevention of Chronic Diseases-CIIPEC, Institute of Nutrition of Central America and Panama -INCAP, Guatemala City, Guatemala
| | - Marvin Alvarez
- INCAP Research Center for the prevention of Chronic Diseases-CIIPEC, Institute of Nutrition of Central America and Panama -INCAP, Guatemala City, Guatemala
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Ford ND, Behrman JR, Hoddinott JF, Maluccio JA, Martorell R, Ramirez-Zea M, Stein AD. Correction to: Exposure to improved nutrition from conception to age 2 years and adult cardiometabolic disease risk: misclassification of 31 individuals. Lancet Glob Health 2019; 8:e37. [PMID: 31839139 DOI: 10.1016/s2214-109x(19)30466-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 10/21/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Nicole D Ford
- Hubert Department of Global Health, Rollins School of Public Health Emory University, Atlanta, GA 30322, USA
| | - Jere R Behrman
- Departments of Economics and Sociology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - John F Hoddinott
- Division of Nutritional Sciences and Charles H Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY, USA
| | - John A Maluccio
- Department of Economics, Middlebury College, Middlebury, VT, USA
| | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health Emory University, Atlanta, GA 30322, USA
| | - Manuel Ramirez-Zea
- Institute of Nutrition of Central America and Panama Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Aryeh D Stein
- Hubert Department of Global Health, Rollins School of Public Health Emory University, Atlanta, GA 30322, USA.
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Humphrey JH, Mbuya MNN, Ntozini R, Moulton LH, Stoltzfus RJ, Tavengwa NV, Mutasa K, Majo F, Mutasa B, Mangwadu G, Chasokela CM, Chigumira A, Chasekwa B, Smith LE, Tielsch JM, Jones AD, Manges AR, Maluccio JA, Prendergast AJ. Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial. Lancet Glob Health 2019; 7:e132-e147. [PMID: 30554749 PMCID: PMC6293965 DOI: 10.1016/s2214-109x(18)30374-7] [Citation(s) in RCA: 251] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 07/03/2018] [Accepted: 08/01/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.
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Affiliation(s)
- Jean H Humphrey
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe.
| | - Mduduzi N N Mbuya
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Division of Nutritional Sciences, Cornell University, Ithaca, NY, USA; Global Alliance for Improved Nutrition, Washington, DC, USA
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lawrence H Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA
| | | | - Naume V Tavengwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Kuda Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Florence Majo
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Batsirai Mutasa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | | | | | | | - Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Laura E Smith
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, Buffalo, NY, USA
| | - James M Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA
| | - Andrew D Jones
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Amee R Manges
- University of British Columbia, Vancouver, BC, Canada
| | | | - Andrew J Prendergast
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore MD, USA; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe; Blizard Institute, Queen Mary University of London, London, UK
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Ford ND, Behrman JR, Hoddinott JF, Maluccio JA, Martorell R, Ramirez-Zea M, Stein AD. Exposure to improved nutrition from conception to age 2 years and adult cardiometabolic disease risk: a modelling study. Lancet Glob Health 2018; 6:e875-e884. [PMID: 30012268 PMCID: PMC6138451 DOI: 10.1016/s2214-109x(18)30231-6] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 04/08/2018] [Accepted: 04/16/2018] [Indexed: 01/18/2023]
Abstract
BACKGROUND Low-income and middle-income countries with populations that are chronically undernourished in early life are undergoing a nutrition transition and are experiencing an epidemic of cardiometabolic disease. These dual burdens are thought to be causally related; therefore, the extent to which improvements in early-life nutrition can offset adult-onset disease is important. The aim of this study was to examine whether improvement of protein-energy nutrition from conception to age 2 years can attenuate the risk of cardiometabolic disease. METHODS We followed up a cohort of 2392 individuals born between Jan 1, 1962, and Feb 28, 1977, in four villages in Guatemala who had participated in a cluster-randomised protein-energy nutritional supplementation (Atole) trial. Of 1661 participants available for follow-up from Feb 26, 2015, to April 29, 2017, we studied 684 women and 455 men. We assessed cardiometabolic disease risk at ages 37-54 years using anthropometry, fasting and post-challenge glucose, fasting lipid concentrations, and blood pressure. We used generalised linear and logistic regression modelling to estimate the effect of Atole from conception to age 2 years (the first 1000 days) on cardiometabolic disease risk. FINDINGS Exposure to Atole from conception to age 2 years was associated with increased fatness (body-mass index [1·29 kg/m2, 95% CI 0·08 to 2·50], body fat [1·73%, 0·20 to 3·26], and obesity [odds ratio 1·94, 1·11 to 3·40]), diastolic blood pressure (1·59 mm Hg, -0·74 to 3·92), and blood lipids (total cholesterol [10·10 mg/dL, 0·80 to 19·40] and non-HDL cholesterol [10·41 mg/dL, 1·51 to 19·31]), reduced post-challenge glucose (-5·84 mg/dL, -12·51 to 0·83), and reduced odds of diabetes (odds ratio 0·46, 0·21 to 0·97). We found stratum heterogeneity by sex in pooled models for non-HDL cholesterol (4·34 mg/dL, 95% CI -6·86 to 15·55 for women vs 19·84 mg/dL, 5·86 to 33·82 for men) and post-challenge glucose (-0·19 mg/dL, -8·63 to 8·24 for women vs -13·10 mg/dL, -23·64 to -2·56 for men). p values for interaction of sex and exposure to Atole from conception to age 2 years were 0·09 and 0·04, respectively. INTERPRETATION Improved protein-energy nutrition from conception to the 2nd birthday reduced the odds of diabetes at ages 37-54 years; however, this protein-energy supplementation also increased the risk of obesity and several obesity-related conditions. Our findings suggest a mixed ability of protein-energy nutritional supplementation in early life to prevent adult cardiometabolic disease incidence in the context of high childhood stunting and high adult overweight and obesity. FUNDING National Institutes of Health.
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Affiliation(s)
- Nicole D Ford
- Hubert Department of Global Health, Rollins School of Public Health Emory University, Atlanta, GA, USA
| | - Jere R Behrman
- Departments of Economics and Sociology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA, USA
| | - John F Hoddinott
- Division of Nutritional Sciences and Charles H Dyson School of Applied Economics and Management, Cornell University, Ithaca, NY, USA
| | - John A Maluccio
- Department of Economics, Middlebury College, Middlebury, VT, USA
| | - Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health Emory University, Atlanta, GA, USA
| | - Manuel Ramirez-Zea
- Institute of Nutrition of Central America and Panama Research Center for the Prevention of Chronic Diseases, Institute of Nutrition of Central America and Panama, Guatemala City, Guatemala
| | - Aryeh D Stein
- Hubert Department of Global Health, Rollins School of Public Health Emory University, Atlanta, GA, USA.
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Chasekwa B, Maluccio JA, Ntozini R, Moulton LH, Wu F, Smith LE, Matare CR, Stoltzfus RJ, Mbuya MNN, Tielsch JM, Martin SL, Jones AD, Humphrey JH, Fielding K. Measuring wealth in rural communities: Lessons from the Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial. PLoS One 2018; 13:e0199393. [PMID: 29953495 PMCID: PMC6023145 DOI: 10.1371/journal.pone.0199393] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 05/25/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Poverty and human capital development are inextricably linked and therefore research on human capital typically incorporates measures of economic well-being. In the context of randomized trials of health interventions, for example, such measures are used to: 1) assess baseline balance; 2) estimate covariate-adjusted analyses; and 3) conduct subgroup analyses. Many factors characterize economic well-being, however, and analysts often generate summary measures such as indices of household socio-economic status or wealth. In this paper, a household wealth index is developed and tested for participants in the cluster-randomized Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe. METHODS Building on the approach used in the Zimbabwe Demographic and Health Survey (ZDHS), we combined a set of housing characteristics, ownership of assets and agricultural resources into a wealth index using principal component analysis (PCA) on binary variables. The index was assessed for internal and external validity. Its sensitivity was examined considering an expanded set of variables and an alternative statistical approach of polychoric PCA. Correlation between indices was determined using the Spearman's rank correlation coefficient and agreement between quintiles using a linear weighted Kappa statistic. Using the 2015 ZDHS data, we constructed a separate index and applied the loadings resulting from that analysis to the SHINE study population, to compare the wealth distribution in the SHINE study with rural Zimbabwe. RESULTS The derived indices using the different methods were highly correlated (r>0.9), and the wealth quintiles derived from the different indices had substantial to near perfect agreement (linear weighted Kappa>0.7). The indices were strongly associated with a range of assets and other wealth measures, indicating both internal and external validity. Households in SHINE were modestly wealthier than the overall population of households in rural Zimbabwe. CONCLUSION The SHINE wealth index developed here is a valid and robust measure of wealth in the sample.
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Affiliation(s)
- Bernard Chasekwa
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - John A. Maluccio
- Department of Economics, Middlebury College, Middlebury, VT, United States of America
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Lawrence H. Moulton
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Fan Wu
- Department of Economics, Middlebury College, Middlebury, VT, United States of America
| | - Laura E. Smith
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, University at Buffalo, State University of New York, Buffalo, NY, United States of America
| | - Cynthia R. Matare
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, United States of America
| | - Rebecca J. Stoltzfus
- Program in International Nutrition, Division of Nutritional Sciences, Cornell University, Ithaca, NY, United States of America
| | - Mduduzi N. N. Mbuya
- Global Alliance for Improved Nutrition (GAIN), Washington, DC, United States of America
| | - James M. Tielsch
- Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, United States of America
| | - Stephanie L. Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina Chapel Hill, Chapel Hill, NC, United States of America
| | - Andrew D. Jones
- Department of Nutritional Sciences, School of Public Health, University of Michigan, Ann Arbor, MI, United States of America
| | - Jean H. Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, United States of America
| | - Katherine Fielding
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Maluccio JA, Wu F, Rokon RB, Rawat R, Kadiyala S. Assessing the Impact of Food Assistance on Stigma Among People Living with HIV in Uganda Using the HIV/AIDS Stigma Instrument-PLWA (HASI-P). AIDS Behav 2017; 21:766-782. [PMID: 27372803 DOI: 10.1007/s10461-016-1476-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
HIV-related stigma among persons living with HIV/AIDS (PLHIV) is prevalent throughout sub-Saharan Africa. There is limited evidence, however, on which interventions are effective in reducing it. We used data from a prospective impact evaluation of a 12-month food assistance intervention among 904 antiretroviral therapy (ART)- naïve PLHIV in Uganda to examine the program impact on stigma. Stigma was measured using the comprehensive HASI-P scale, which demonstrated good internal consistency (Cronbach's alpha = 0.87) and was correlated with several related constructs including physical and mental health-related quality of life, disclosure, and physical health symptoms in the sample. Using quasi-experimental difference-in-difference matching methods to better infer causality, we tested whether the intervention improved the overall stigma scale and its subscales. The food assistance intervention had a significant effect on reported internalized (but not external) stigma of approximately 0.2 SD (p < 0.01). The HASI-P stigma scale is a useful tool for measuring and tracking stigma. Food assistance interventions, embedded in an HIV care program, can reduce internalized stigma.
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Affiliation(s)
- John A Maluccio
- Department of Economics, Middlebury College, 14 Old Chapel Road, Middlebury, VT, 05753, USA.
| | - Fan Wu
- Department of Economics, Middlebury College, 14 Old Chapel Road, Middlebury, VT, 05753, USA
| | - Redwan B Rokon
- Department of Economics, Middlebury College, 14 Old Chapel Road, Middlebury, VT, 05753, USA
| | - Rahul Rawat
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute (IFPRI), Dakar, Senegal
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
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Maluccio JA, Melgar P, Méndez H, Murphy A, Yount KM. Social and Economic Development and Change in four Guatemalan Villages: Demographics, Schooling, Occupation, and Assets. Food Nutr Bull 2016; 26:S25-45. [PMID: 16060210 DOI: 10.1177/15648265050262s104] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This article uses census data and village histories to examine changes over the last 35 years in the four villages where the Institute of Nutrition of Central America and Panama (INCAP) Longitudinal Study (1969–77) was conducted and offers a rare picture of development and change in rural localities over a long period of time. In addition, by characterizing the environment in which the subjects of this study were raised, we provide context for and inputs into quantitative analyses of data collected at various points in time on these subjects. The villages have undergone massive demographic, social, and economic change. Initial differences have conditioned many of these changes, especially differences associated with agricultural potential and location. Originally these villages were rather isolated, but road and transportation access has improved substantially. The populations in the villages have more than doubled and also have aged. While marriage patterns have held steady, religious practice has changed a great deal. After many years of steady out-migration, three of the four villages are more recently experiencing net in-migration, a pattern associated with ease of access. Schooling access and outcomes also have improved, with average grades of schooling nearly tripling and literacy doubling to levels currently above national averages. Although agriculture remains an important component of individual livelihood strategies, non-agricultural sources of employment have become more important. Much of this change is associated with declining agricultural markets and increased access to non-agricultural jobs near the villages and in the capital. Accompanying these changes has been an improvement in living standards as measured by a number of indicators of household living conditions and consumer durable goods.
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Affiliation(s)
- John A Maluccio
- Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 20006, USA.
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Abstract
In this note, we calculate and describe proxy measures that account for variation in standard of living across subjects in the Institute of Nutrition of Central America and Panama (INCAP) Longitudinal Study (1969–77), at the time of the original intervention. Using principal components analysis, we construct two linear indices from an array of household consumer durable goods and housing characteristics, measured at the nuclear family level in the 1975 cross-sectional census. The two indices perform well on three dimensions. First, they are internally coherent in that average ownership and quality of housing characteristics increase with the principal component score. Second, they are robust in that the different approaches yield similar results, for example, in classifying nuclear families into tertiles. And third, they are consistent in that they yield results similar to scores constructed by previous researchers. The indices can be used as background controls in analyses of the INCAP Longitudinal Study (1969–77) data and subsequent follow-up studies, including the Human Capital Study 2002–04. Several articles presented in this supplement to the Food and Nutrition Bulletin used the 1975 index.
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Affiliation(s)
- John A Maluccio
- Food Consumption and Nutrition Division, International Food Policy Research Institute, 2033 K Street, NW, Washington, DC 20006, USA.
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Mbuya MNN, Jones AD, Ntozini R, Humphrey JH, Moulton LH, Stoltzfus RJ, Maluccio JA. Theory-Driven Process Evaluation of the SHINE Trial Using a Program Impact Pathway Approach. Clin Infect Dis 2016; 61 Suppl 7:S752-8. [PMID: 26602304 PMCID: PMC4657588 DOI: 10.1093/cid/civ716] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Two reasons for the lack of success of programs or interventions are poor alignment of interventions with the causes of the problem targeted by the intervention, leading to poor efficacy (theory failure), and failure to implement interventions as designed (program failure). These failures are important for both public health programs and randomized trials. In the Sanitation Hygiene and Infant Nutrition Efficacy (SHINE) Trial, we utilize the program impact pathway (PIP) approach to track intervention implementation and behavior uptake. In this article, we present the SHINE PIP including definitions and measurements of key mediating domains, and discuss the implications of this approach for randomized trials. Operationally, the PIP can be used for monitoring and strengthening intervention delivery, facilitating course-correction at various stages of implementation. Analytically, the PIP can facilitate a richer understanding of the mediating and modifying determinants of intervention impact than would be possible from an intention-to-treat analysis alone.
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Affiliation(s)
- Mduduzi N N Mbuya
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe Division of Nutritional Sciences, Cornell University, Ithaca, New York Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Andrew D Jones
- School of Public Health, University of Michigan, Ann Arbor
| | - Robert Ntozini
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
| | - Jean H Humphrey
- Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Lawrence H Moulton
- Department of International Health, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Humphrey JH, Jones AD, Manges A, Mangwadu G, Maluccio JA, Mbuya MNN, Moulton LH, Ntozini R, Prendergast AJ, Stoltzfus RJ, Tielsch JM. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) Trial: Rationale, Design, and Methods. Clin Infect Dis 2016; 61 Suppl 7:S685-702. [PMID: 26602296 PMCID: PMC4657589 DOI: 10.1093/cid/civ844] [Citation(s) in RCA: 104] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
UNLABELLED Child stunting and anemia are intractable public health problems in developing countries and have profound short- and long-term consequences. The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial is motivated by the premise that environmental enteric dysfunction (EED) is a major underlying cause of both stunting and anemia, that chronic inflammation is the central characteristic of EED mediating these adverse effects, and that EED is primarily caused by high fecal ingestion due to living in conditions of poor water, sanitation, and hygiene (WASH). SHINE is a proof-of-concept, 2 × 2 factorial, cluster-randomized, community-based trial in 2 rural districts of Zimbabwe that will test the independent and combined effects of protecting babies from fecal ingestion (factor 1, operationalized through a WASH intervention) and optimizing nutritional adequacy of infant diet (factor 2, operationalized through an infant and young child feeding [IYCF] intervention) on length and hemoglobin at 18 months of age. Within SHINE we will measure 2 causal pathways. The program impact pathway comprises the series of processes and behaviors linking implementation of the interventions with the 2 child health primary outcomes; it will be modeled using measures of fidelity of intervention delivery and household uptake of promoted behaviors and practices. We will also measure a range of household and individual characteristics, social interactions, and maternal capabilities for childcare, which we hypothesize will explain heterogeneity along these pathways. The biomedical pathway comprises the infant biologic responses to the WASH and IYCF interventions that ultimately result in attained stature and hemoglobin concentration at 18 months of age; it will be elucidated by measuring biomarkers of intestinal structure and function (inflammation, regeneration, absorption, and permeability); microbial translocation; systemic inflammation; and hormonal determinants of growth and anemia among a subgroup of infants enrolled in an EED substudy. This article describes the rationale, design, and methods underlying the SHINE trial. CLINICAL TRIALS REGISTRATION NCT01824940.
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Puentes E, Wang F, Behrman JR, Cunha F, Hoddinott J, Maluccio JA, Adair LS, Borja JB, Martorell R, Stein AD. Early life height and weight production functions with endogenous energy and protein inputs. Econ Hum Biol 2016; 22:65-81. [PMID: 27026217 PMCID: PMC5001437 DOI: 10.1016/j.ehb.2016.03.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2015] [Revised: 02/21/2016] [Accepted: 03/01/2016] [Indexed: 05/03/2023]
Abstract
We examine effects of protein and energy intakes on height and weight growth for children between 6 and 24 months old in Guatemala and the Philippines. Using instrumental variables to control for endogeneity and estimating multiple specifications, we find that protein intake plays an important and positive role in height and weight growth in the 6-24 month period. Energy from other macronutrients, however, does not have a robust relation with these two anthropometric measures. Our estimates indicate that in contexts with substantial child undernutrition, increases in protein-rich food intake in the first 24 months can have important growth effects, which previous studies indicate are related significantly to a range of outcomes over the life cycle.
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Affiliation(s)
| | - Fan Wang
- Department of Economics, University of Houston, United States
| | - Jere R Behrman
- Departments of Economics and Sociology and Population Studies Center, University of Pennsylvania, United States
| | - Flavio Cunha
- Department of Economics, Rice University, United States
| | - John Hoddinott
- Division of Nutritional Sciences and the Charles H. Dyson School of Applied Economics and Management, Cornell University and International Food Policy Research Institute, United States
| | | | - Linda S Adair
- Department of Nutrition, University of North Carolina, United States
| | - Judith B Borja
- USC-Office of Population Studies Foundation, Inc and Department of Nutrition and Dietetics, University of San Carlos, Cebu, Philippines
| | | | - Aryeh D Stein
- Rollins School of Public Health, Emory University, United States
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Austrian K, Muthengi E, Mumah J, Soler-Hampejsek E, Kabiru CW, Abuya B, Maluccio JA. The Adolescent Girls Initiative-Kenya (AGI-K): study protocol. BMC Public Health 2016; 16:210. [PMID: 26931572 PMCID: PMC4774031 DOI: 10.1186/s12889-016-2888-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 02/17/2016] [Indexed: 11/16/2022] Open
Abstract
Background Many adolescent girls in Kenya and elsewhere face considerable risks and vulnerabilities that affect their well-being and hinder a safe, healthy, and productive transition into early adulthood. Early adolescence provides a critical window of opportunity to intervene at a time when girls are experiencing many challenges, but before those challenges have resulted in deleterious outcomes that may be irreversible. The Adolescent Girls Initiative-Kenya (AGI-K) is built on these insights and designed to address these risks for young adolescent girls. The long-term goal of AGI-K is to delay childbearing for adolescent girls by improving their well-being. Intervention AGI-K comprises nested combinations of different single-sector interventions (violence prevention, education, health, and wealth creation). It will deliver interventions to over 6000 girls between the ages of 11 and 14 years in two marginalized areas of Kenya: 1) Kibera in Nairobi and 2) Wajir County in Northeastern Kenya. The program will use a combination of girl-, household- and community-level interventions. The violence prevention intervention will use community conversations and planning focused on enhancing the value of girls in the community. The educational intervention includes a cash transfer to the household conditioned on school enrollment and attendance. The health intervention is culturally relevant, age-appropriate sexual and reproductive health education delivered in a group setting once a week over the course of 2 years. Lastly, the wealth creation intervention provides savings and financial education, as well as start-up savings. Methods/Design A randomized trial will be used to compare the impact of four different packages of interventions, in order to assess if and how intervening in early adolescence improves girls’ lives after four years. The project will be evaluated using data from behavioural surveys conducted before the start of the program (baseline in 2015), at the end of the 2-year intervention (endline in 2017), and 2 years post-intervention (follow-up in 2019). Monitoring data will also be collected to track program attendance and participation. Primary analyses will be on an intent-to-treat basis. Qualitative research including semi-structured interviews of beneficiaries and key adult stakeholders in 2016 and 2018 will supplement and complement the quantitative survey results. In addition, the cost-effectiveness of the interventions will be assessed. Discussion AGI-K will provide critical evidence for policy-makers, donors and other stakeholders on the most effective ways to combine interventions for marginalized adolescent girls across sectors, and which packages of interventions are most cost-effective. Trial registration ISRCTN77455458, December 24, 2015 Electronic supplementary material The online version of this article (doi:10.1186/s12889-016-2888-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Karen Austrian
- Population Council, P.O. Box 17643-00500, Nairobi, Kenya.
| | | | - Joyce Mumah
- African Population and Health Research Center, P.O. Box 10787-00100, Nairobi, Kenya.
| | | | - Caroline W Kabiru
- African Population and Health Research Center, P.O. Box 10787-00100, Nairobi, Kenya.
| | - Benta Abuya
- African Population and Health Research Center, P.O. Box 10787-00100, Nairobi, Kenya.
| | - John A Maluccio
- Middlebury College, 14 Old Chapel Rd, Middlebury, VT, 05753, USA.
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Maluccio JA, Palermo T, Kadiyala S, Rawat R. Improving Health-Related Quality of Life among People Living with HIV: Results from an Impact Evaluation of a Food Assistance Program in Uganda. PLoS One 2015; 10:e0135879. [PMID: 26313908 PMCID: PMC4552093 DOI: 10.1371/journal.pone.0135879] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/27/2015] [Indexed: 12/13/2022] Open
Abstract
Introduction Widespread food insecurity in Africa continues to compromise an effective response to the AIDS epidemic. Health-related quality of life (HRQoL) is a comprehensive indicator of physical, mental, and social well-being that is associated with food insecurity and increasingly used to assess the well-being of people living with HIV/AIDS (PLHIV). We examined the impact of a food assistance intervention, previously shown to have reduced household food insecurity and improved nutritional status, on HRQoL of PLHIV. Methods We capitalized on an existing intervention targeting antiretroviral therapy (ART)- naïve PLHIV in Uganda, and conducted a prospective impact evaluation including a treatment and a comparison group. Data analyzed included 640 participants from two districts (318 in the intervention district) interviewed in both clinic and household settings at baseline and again approximately one year later. The main outcomes considered were physical and mental health dimensions of HRQoL, and other outcomes included self- and healthcare provider-reported symptoms. We utilized difference-in-difference propensity score matching methodologies to infer causality and examine program impacts. Results Over 12 months, food assistance significantly increased physical health scores (PHS) by 2.85 (P < .01) or approximately 0.35 SD, and reduced substantially the number of self- and healthcare provider-reported HIV-related symptoms by 3.83 and 2.68, respectively (P < .01). There was no significant impact, however, on mental health scores (MHS). Conclusions This study demonstrates the potential importance for HRQoL of including food assistance programming as part of the standard of care for PLHIV in areas of widespread food insecurity.
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Affiliation(s)
- John A. Maluccio
- Department of Economics, Middlebury College, Middlebury, Vermont, United States of America
- * E-mail:
| | - Tia Palermo
- Program in Public Health, Stony Brook University (SUNY), Stony Brook, New York, United States of America
| | - Suneetha Kadiyala
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Rahul Rawat
- Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Dakar, Senegal
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Behrman JR, Hoddinott J, Maluccio JA, Soler-Hampejsek E, Behrman EL, Martorell R, Ramírez-Zea M, Stein AD. What determines adult cognitive skills? Influences of pre-school, school, and post-school experiences in Guatemala. Lat Am Econ Rev 2014; 23:4. [PMID: 26550556 PMCID: PMC4631444 DOI: 10.1007/s40503-014-0004-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Most empirical investigations of the effects of cognitive skills assume that they are produced by schooling. Drawing on longitudinal data to estimate production functions for adult verbal and nonverbal cognitive skills, we find that: (1) School attainment has a significant and substantial effect on adult verbal cognitive skills but not on adult nonverbal cognitive skills; and (2) Pre-school and post-school experiences also have substantial positive significant effects on adult cognitive skills. Pre-school experiences captured by height for age at 6 years substantially and significantly increase adult nonverbal cognitive skills, even after controlling for school attainment. Post-school tenure in skilled jobs has significant positive effects on both types of cognitive skills. The findings (1) reinforce the importance of early life investments; (2) support the importance of childhood nutrition ("Flynn effect") and work complexity in explaining increases in nonverbal cognitive skills; (3) call into question interpretations of studies reporting productivity impacts of cognitive skills that do not control for endogeneity; and (4) point to limitations in using adult school attainment alone to represent human capital.
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Affiliation(s)
- Jere R. Behrman
- Department of Economics, Sociology and Demography, University of Pennsylvania, Philadelphia, PA, USA
| | - John Hoddinott
- Department of Poverty, Health, and Nutrition Division, International Food Policy Research Institute, Washington, DC, USA
| | - John A. Maluccio
- Department of Economics, Middlebury College, Middlebury, VT, USA
| | | | | | | | - Manuel Ramírez-Zea
- Institute of Nutrition for Central America and Panama (INCAP), Guatemala City, Guatemala
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Hoddinott J, Behrman JR, Maluccio JA, Melgar P, Quisumbing AR, Ramirez-Zea M, Stein AD, Yount KM, Martorell R. Adult consequences of growth failure in early childhood. Am J Clin Nutr 2013; 98:1170-8. [PMID: 24004889 PMCID: PMC3798075 DOI: 10.3945/ajcn.113.064584] [Citation(s) in RCA: 212] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Growth failure is associated with adverse consequences, but studies need to control adequately for confounding. OBJECTIVE We related height-for-age z scores (HAZs) and stunting at age 24 mo to adult human capital, marriage, fertility, health, and economic outcomes. DESIGN In 2002-2004, we collected data from 1338 Guatemalan adults (aged 25-42 y) who were studied as children in 1969-1977. We used instrumental variable regression to correct for estimation bias and adjusted for potentially confounding factors. RESULTS A 1-SD increase in HAZ was associated with more schooling (0.78 grades) and higher test scores for reading and nonverbal cognitive skills (0.28 and 0.25 SDs, respectively), characteristics of marriage partners (1.39 y older, 1.02 grade more schooling, and 1.01 cm taller) and, for women, a higher age at first birth (0.77 y) and fewer number of pregnancies and children (0.63 and 0.43, respectively). A 1-SD increase in HAZ was associated with increased household per capita expenditure (21%) and a lower probability of living in poverty (10 percentage points). Conversely, being stunted at 2 y was associated with less schooling, a lower test performance, a lower household per capita expenditure, and an increased probability of living in poverty. For women, stunting was associated with a lower age at first birth and higher number of pregnancies and children. There was little relation between either HAZ or stunting and adult health. CONCLUSION Growth failure in early life has profound adverse consequences over the life course on human, social, and economic capital.
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Affiliation(s)
- John Hoddinott
- Poverty, Health and Nutrition Division, International Food Policy Research Institute, Washington, DC (JH and ARQ); the Departments of Economics and Sociology, University of Pennsylvania, Philadelphia, PA (JRB); the Department of Economics, Middlebury College, Middlebury, VT (JAM); The Institute of Nutrition of Central America and Panama, Guatemala City, Republic of Guatemala (PM and MR-Z); and the Hubert Department of Global Health, Rollins School of Public Health (ADS, KMY, and RM), and the Department of Sociology (KMY), Emory University, Atlanta, GA
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Yount KM, Maluccio JA, Behrman JR, Hoddinott J, Murphy A, Ramakrishnan U. Parental Resources, Schooling Achievements, and Gender Schooling Gaps: Evidence of Change over 25 years in Rural Guatemala. Popul Res Policy Rev 2013; 32:495-528. [PMID: 23888089 DOI: 10.1007/s11113-013-9270-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We use village census data and linear regression models to examine changes between 1975 and 2002 in the associations of parental resources with boys' and girls' schooling in four rural Guatemalan villages. Levels of schooling in 1975 were universally low for children 7-17 years. Large increases in schooling achievements occurred between 1975 and 2002. By 2002, schooling levels were comparable for younger boys and girls (7-12 years, N = 3,525) and favored older boys compared to older girls (13-17 years, N = 2,440) by about 0.5 grades. The associations of household standard of living and maternal schooling with schooling among girls diminished over time and became more comparable with these associations among boys, and the associations of household standard of living with schooling among older boys declined and became more comparable with these associations among girls. Thus, as increased social investments reduce the costs of schooling or increase the supply and quality of schooling to families, the magnitudes of the associations between parental resources and children's schooling decline and become more gender equitable at all ages. However, our results show that older boys may benefit more than older girls from social investments in schooling. These changes suggest potential needs to monitor gender gaps in schooling retention among older children, to insure gender equitable access to social investments in schooling, and to encourage parents to invest in schooling as joint measures to achieve greater schooling achievements of girls and boys.
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Affiliation(s)
- Kathryn M Yount
- Hubert Department of Global Health, Emory University, 1518 Clifton Road, NE, Atlanta, GA 30322, USA, Department of Sociology, Emory University, 1555 Dickey Drive, Atlanta, GA 30322, USA
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Donegan S, Maluccio JA, Myers CK, Menon P, Ruel MT, Habicht JP. Two food-assisted maternal and child health nutrition programs helped mitigate the impact of economic hardship on child stunting in Haiti. J Nutr 2010; 140:1139-45. [PMID: 20392883 DOI: 10.3945/jn.109.114272] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Rigorous evaluations of food-assisted maternal and child health and nutrition programs are stymied by the ethics of randomizing recipients to a control treatment. Using nonexperimental matching methods, we evaluated the effect of 2 such programs on child linear growth in Haiti. The 2 well-implemented programs offered the same services (food assistance, behavior change communication, and preventive health services) to pregnant and lactating women and young children. They differed in that one (the preventive program) used blanket targeting of all children 6-23 mo, whereas the other (the recuperative program) targeted underweight (weight-for-age Z score < -2) children 6-59 mo, as traditionally done. We estimated program effects on height-for-age Z scores (HAZ) and stunting (HAZ < -2) by comparing outcomes of children in program areas with matched children from comparable populations in the Haiti Demographic and Health Survey. Children 12-41 mo in the preventive and recuperative program areas had lower prevalence of stunting than those in the matched control group [16 percentage points (pp) lower in preventive and 11 pp in recuperative]. Children in the 2 program areas also were more likely than those in the matched control group to be breast-fed up to 24 mo (25 pp higher in preventive, 22 in recuperative) and children 12 mo and older were more likely to have received the recommended full schedule of vaccinations (32 pp higher in preventive, 31 in recuperative). Both programs improved targeted behaviors and protected child growth in a time of deteriorating economic circumstances.
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Affiliation(s)
- Shannon Donegan
- Department of Economics, Middlebury College, Middlebury, VT 05753, USA
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Martorell R, Melgar P, Maluccio JA, Stein AD, Rivera JA. The nutrition intervention improved adult human capital and economic productivity. J Nutr 2010; 140:411-4. [PMID: 20032473 PMCID: PMC6497421 DOI: 10.3945/jn.109.114504] [Citation(s) in RCA: 91] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
This article reviews key findings about the long-term impact of a nutrition intervention carried out by the Institute of Nutrition of Central America and Panama from 1969 to 1977. Results from follow-up studies in 1988-89 and 2002-04 show substantial impact on adult human capital and economic productivity. The 1988-89 study showed that adult body size and work capacity increased for those provided improved nutrition through age 3 y, whereas the 2002-04 follow-up showed that schooling was increased for women and reading comprehension and intelligence increased in both men and women. Participants were 26-42 y of age at the time of the 2002-04 follow-up, facilitating the assessment of economic productivity. Wages of men increased by 46% in those provided with improved nutrition through age 2 y. Findings for cardiovascular disease risk factors were heterogeneous; however, they suggest that improved nutrition in early life is unlikely to increase cardiovascular disease risk later in life and may indeed lower risk. In conclusion, the substantial improvement in adult human capital and economic productivity resulting from the nutrition intervention provides a powerful argument for promoting improvements in nutrition in pregnant women and young children.
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Affiliation(s)
- Reynaldo Martorell
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA.
| | - Paul Melgar
- Institute of Nutrition of Central America and Panama, Guatemala City Zona 11, Guatemala
| | - John A. Maluccio
- Department of Economics, Middlebury College, Middlebury, VT 05753
| | - Aryeh D. Stein
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA 30322
| | - Juan A. Rivera
- Instituto Nacional de Salud Pública, Cuernavaca, Morelos CP 62508, Mexico
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Barham T, Maluccio JA. Eradicating diseases: The effect of conditional cash transfers on vaccination coverage in rural Nicaragua. J Health Econ 2009; 28:611-621. [PMID: 19233495 DOI: 10.1016/j.jhealeco.2008.12.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Revised: 12/12/2008] [Accepted: 12/22/2008] [Indexed: 05/27/2023]
Abstract
Despite significant global efforts to improve vaccination coverage against major childhood diseases, vaccination rates are below 90%. To eradicate diseases such as measles, however, vaccination rates close to 95% are needed. We use a randomized experiment to investigate the effect of a demand incentive, a conditional cash transfer program, in improving vaccination coverage in rural Nicaragua. Double-difference estimates show the program led to large increases in vaccination coverage, and these resulted in vaccination levels greater than 95% for some vaccines. Effects were especially large for children who are typically harder to reach with traditional supply-side interventions.
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Affiliation(s)
- Tania Barham
- University of Colorado at Boulder, Department of Economics and Institute of Behavioral Science, 483 UCB, Boulder, CO 80304-0483, USA.
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Abstract
BACKGROUND Substantial, but indirect, evidence suggests that improving nutrition in early childhood in developing countries is a long-term economic investment. We investigated the direct effect of a nutrition intervention in early childhood on adult economic productivity. METHODS We obtained economic data from 1424 Guatemalan individuals (aged 25-42 years) between 2002 and 2004. They accounted for 60% of the 2392 children (aged 0-7 years) who had been enrolled in a nutrition intervention study during 1969-77. In this initial study, two villages were randomly assigned a nutritious supplement (atole) for all children and two villages a less nutritious one (fresco). We estimated annual income, hours worked, and average hourly wages from all economic activities. We used linear regression models, adjusting for potentially confounding factors, to assess the relation between economic variables and exposure to atole or fresco at specific ages between birth and 7 years. FINDINGS Exposure to atole before, but not after, age 3 years was associated with higher hourly wages, but only for men. For exposure to atole from 0 to 2 years, the increase was US$0.67 per hour (95% CI 0.16-1.17), which meant a 46% increase in average wages. There was a non-significant tendency for hours worked to be reduced and for annual incomes to be greater for those exposed to atole from 0 to 2 years. INTERPRETATION Improving nutrition in early childhood led to substantial increases in wage rates for men, which suggests that investments in early childhood nutrition can be long-term drivers of economic growth.
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Affiliation(s)
- John Hoddinott
- International Food Policy Research Institute, Washington, DC, USA
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Grajeda R, Behrman JR, Flores R, Maluccio JA, Martorell R, Stein AD. The human capital study 2002-04: tracking, data collection, coverage, and attrition. Food Nutr Bull 2005; 26:S15-24. [PMID: 16060209 PMCID: PMC1978414 DOI: 10.1177/15648265050262s103] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Between 2002 and 2004, the Institute of Nutrition of Central America and Panama (INCAP), in collaboration with Emory University, the International Food Policy Research Institute (IFPRI), and the University of Pennsylvania, re-surveyed young Guatemalan adults who had, as children, been participants in a nutrition supplementation trial conducted by INCAP between 1969 and 1977. This "Human Capital Study 2002-04" complements and extends data obtained in previous studies by collecting new information on measures of physical health and well-being, schooling and cognitive ability, wealth, consumption and economic productivity, and marriage and fertility histories. This paper describes the study domains and data collection procedures. Among 2,393 members of the original sample, 1,856 (77%) were targets for enrollment. Response rates varied by gender, current place of residence, and domain of data collection, with 80% of males and 89% of females completing at least one data collection instrument. Attrition was not random and appears to be associated with a number of initial characteristics of individuals and their households that should be controlled for in future analyses. We conclude that data collection was successful and data quality is high, facilitating the successful undertaking of our planned investigation of important study hypotheses.
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Affiliation(s)
- Rubén Grajeda
- Institute of Nutrition of Central America and Panama, INCAP, P.O. Box 1188, Guatemala, Carretera Roosevelt, Zona 11 Guatemala, Central America.
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Abstract
In this article, we describe expenditure and wealth patterns, indicators of long-run economic well-being, for a sample of young Guatemalan adults interviewed for the Human Capital Study 2002-04, finding a number of differences across subgroups of the sample. The main difference across birth-year cohorts is that younger subjects tend to live in smaller households, with lower total annual household expenditures (and fewer durable goods), though per capita measures are similar across cohorts. This appears to be related to life-cycle fertility patterns. There is a clear positive association between parental socioeconomic status (SES) and current levels of expenditure and durable goods ownership. This association does not hold for all households, however, as there is both upward and downward "mobility" in the sample. Those living in the capital have the highest overall wealth levels, consistent with typical rural-urban patterns. Where there are expenditure differences across groups, they tend to be driven by differences in nonfood rather than food expenditures. Lastly, the study sample is relatively well off compared with their compatriots, with a poverty rate of 35% and an extreme poverty rate of only 3%, against national averages of 56% and 15%, respectively.
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Affiliation(s)
- John A Maluccio
- Food Consumption and Nutrition Division, International Food Policy Research Institute, 2033 K Street, NW, Washington, DC 20006, USA.
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Quisumbing AR, Behrman JR, Maluccio JA, Murphy A, Yount KM. Levels, correlates, and differences in human, physical, and financial assets brought into marriages by young Guatemalan adults. Food Nutr Bull 2005; 26:S55-67. [PMID: 16060212 DOI: 10.1177/15648265050262s106] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article examines marriage patterns among individuals who participated as children in a nutrition supplementation trial in Guatemala and were followed up in 2002-04, at ages 25-42 years. Of all 1,062 known and alive couples, 735, or 69%, responded fully to the marriage assets questionnaire. Focus of the analysis is on the birth cohorts born prior to 1974, a total of 1,058 intervention participants, among whom four-fifths of men (82%) and of women (78%) were married at the time of the 2002-04 survey. Basic patterns are examined in current marital status, age at first marriage and related milestones, human capital assets brought to marriage (e.g., schooling attainment, cognitive ability, literacy, and pre-marital work experience), and physical assets and savings accounts brought to marriage. Measures of husbands' human capital at marriage are positively correlated with wives' human capital, but are consistently higher. Husbands also bring substantially more physical and financial assets than wives. A number of interesting patterns emerge, including (1) changes in the composition of assets that women bring to marriage from physical to human assets, (2) declining gaps in age and premarital work experience between husbands and wives, and (3) increasing gaps in schooling attainment and cognitive ability between husbands and wives. Given conflicting directions of change in spousal gaps in human, physical and financial assets, their net effect on changes over time in the bargaining power of husbands and wives is uncertain and deserves further investigation.
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Affiliation(s)
- Agnes R Quisumbing
- Food Consumption and Nutrition Division, International Food Policy Research Institute, 2033 K Street, NW, Washington, DC 20006, USA.
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