VOLUME 8 DISEASE CONTROL PRIORITIES • THIRD EDITION Child and Adolescent Health and Development DISEASE CONTROL PRIORITIES • THIRD EDITION Series Editors Dean T. Jamison Rachel Nugent Hellen Gelband Susan Horton Prabhat Jha Ramanan Laxminarayan Charles N. Mock Volumes in the Series Essential Surgery Reproductive, Maternal, Newborn, and Child Health Cancer Mental, Neurological, and Substance Use Disorders Cardiovascular, Respiratory, and Related Disorders Major Infectious Diseases Injury Prevention and Environmental Health Child and Adolescent Health and Development Disease Control Priorities: Improving Health and Reducing Poverty DISEASE CONTROL PRIORITIES Budgets constrain choices. Policy analysis helps decision makers achieve the greatest value from limited available resources. In 1993, the World Bank published Disease Control Priorities in Developing Countries (DCP1), an attempt to systematically assess the cost-effectiveness (value for money) of interventions that would address the major sources of disease burden in low- and middle-income countries. The World Bank’s 1993 World Development Report on health drew heavily on DCP1’s findings to conclude that specific interventions against noncommunicable diseases were cost-effective, even in environments in which substantial burdens of infection and undernutrition persisted. DCP2, published in 2006, updated and extended DCP1 in several aspects, including explicit consideration of the implications for health systems of expanded intervention cov- erage. One way that health systems expand intervention coverage is through selected plat- forms that deliver interventions that require similar logistics but deliver interventions from different packages of conceptually related interventions, for example, against cardiovascular disease. Platforms often provide a more natural unit for investment than do individual inter- ventions. Analysis of the costs of packages and platforms—and of the health improvements they can generate in given epidemiological environments—can help to guide health system investments and development. DCP3 differs importantly from DCP1 and DCP2 by extending and consolidating the concepts of platforms and packages and by offering explicit consideration of the financial risk protection objective of health systems. In populations lacking access to health insurance or prepaid care, medical expenses that are high relative to income can be impoverishing. Where incomes are low, seemingly inexpensive medical procedures can have catastrophic financial effects. DCP3 offers an approach to explicitly include financial protection as well as the distribution across income groups of financial and health outcomes resulting from policies (for example, public finance) to increase intervention uptake. The task in all of the DCP volumes has been to combine the available science about interventions implemented in very specific locales and under very specific conditions with informed judgment to reach reasonable conclusions about the impact of intervention mixes in diverse environments. DCP3 ’s broad aim is to delineate essential intervention packages and their related delivery platforms to assist decision makers in allocating often tightly constrained budgets so that health system objectives are maximally achieved. DCP3 ’s nine volumes are being published in 2015, 2016, 2017, and 2018 in an environ- ment in which serious discussion continues about quantifying the sustainable development goal (SDG) for health. DCP3 ’s analyses are well-placed to assist in choosing the means to attain the health SDG and assessing the related costs. Only when these volumes, and the analytic efforts on which they are based, are completed will we be able to explore SDG- related and other broad policy conclusions and generalizations. The final DCP3 volume will report those conclusions. Each individual volume will provide valuable, specific policy anal- yses on the full range of interventions, packages, and policies relevant to its health topic. More than 500 individuals and multiple institutions have contributed to DCP3. We convey our acknowledgments elsewhere in this volume. Here we express our particular gratitude to the Bill & Melinda Gates Foundation for its sustained financial support, to the InterAcademy Medical Panel (and its U.S. affiliate, the National Academies of Science, Engineering, and Medicine), and to the External and Corporate Relations Publishing and Knowledge division of the World Bank. Each played a critical role in this effort. Dean T. Jamison Rachel Nugent Hellen Gelband Susan Horton Prabhat Jha Ramanan Laxminarayan Charles N. Mock VOLUME 8 DISEASE CONTROL PRIORITIES • THIRD EDITION Child and Adolescent Health and Development EDITORS Donald A. P. Bundy Nilanthi de Silva Susan Horton Dean T. Jamison George C. Patton © 2017 International Bank for Reconstruction and Development / The World Bank 1818 H Street NW, Washington, DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved 1 2 3 4 20 19 18 17 This work is a product of the staff of The World Bank with external contributions. 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Further permission required for reuse; chapter 30: © Frank Spangler/Worldview Images. Used with the permission of Worldview Images. Further permission required for reuse. Library of Congress Cataloging-in-Publication Data has been requested. Contents Foreword xiii Preface xv Abbreviations xvii 1. Child and Adolescent Health and Development: Realizing Neglected Potential 1 Donald A. P. Bundy, Nilanthi de Silva, Susan Horton, George C. Patton, Linda Schultz, and Dean T. Jamison PART 1 ESTIMATES OF MORTALITY AND MORBIDITY IN CHILDREN (AGES 5–19 YEARS) 2. Mortality at Ages 5 to 19: Levels and Trends, 1990–2010 25 Kenneth Hill, Linnea Zimmerman, and Dean T. Jamison 3. Global Nutrition Outcomes at Ages 5 to 19 37 Rae Galloway 4. Global Variation in Education Outcomes at Ages 5 to 19 47 Kin Bing Wu 5. Global Measures of Health Risks and Disease Burden in Adolescents 57 George C. Patton, Peter Azzopardi, Elissa Kennedy, Carolyn Coffey, and Ali Mokdad PART 2 IMPACT OF INTERVENTIONS DURING THE LIFE COURSE (AGES 5–19 YEARS) 6. Impact of Interventions on Health and Development during Childhood and Adolescence: A Conceptual Framework 73 Donald A. P. Bundy and Susan Horton 7. Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 79 Harold Alderman, Jere R. Behrman, Paul Glewwe, Lia Fernald, and Susan Walker ix 8. Evidence of Impact of Interventions on Health and Development during Middle Childhood and School Age 99 Kristie L. Watkins, Donald A. P. Bundy, Dean T. Jamison, Günther Fink, and Andreas Georgiadis 9. Puberty, Developmental Processes, and Health Interventions 107 Russell M. Viner, Nicholas B. Allen, and George C. Patton 10. Brain Development: The Effect of Interventions on Children and Adolescents 119 Elena L. Grigorenko PART 3 CONDITIONS AND INTERVENTIONS 11. Nutrition in Middle Childhood and Adolescence 133 Zohra Lassi, Anoosh Moin, and Zulfiqar Bhutta 12. School Feeding Programs in Middle Childhood and Adolescence 147 Lesley Drake, Meena Fernandes, Elisabetta Aurino, Josephine Kiamba, Boitshepo Giyose, Carmen Burbano, Harold Alderman, Lu Mai, Arlene Mitchell, and Aulo Gelli 13. Mass Deworming Programs in Middle Childhood and Adolescence 165 Donald A. P. Bundy, Laura J. Appleby, Mark Bradley, Kevin Croke, T. Deirdre Hollingsworth, Rachel Pullan, Hugo C. Turner, and Nilanthi de Silva 14. Malaria in Middle Childhood and Adolescence 183 Simon J. Brooker, Sian Clarke, Deepika Fernando, Caroline W. Gitonga, Joaniter Nankabirwa, David Schellenberg, and Brian Greenwood 15. School-Based Delivery of Vaccines to 5- to 19-Year Olds 199 D. Scott LaMontagne, Tania Cernuschi, Ahmadu Yakubu, Paul Bloem, Deborah Watson-Jones, and Jane J. Kim 16. Promoting Oral Health through Programs in Middle Childhood and Adolescence 211 Habib Benzian, Renu Garg, Bella Monse, Nicole Stauf, and Benoit Varenne 17. Disability in Middle Childhood and Adolescence 221 Natasha Graham, Linda Schultz, Sophie Mitra, and Daniel Mont 18. Health and Disease in Adolescence 239 Nicola Reavley, George C. Patton, Susan M. Sawyer, Elissa Kennedy, and Peter Azzopardi PART 4 PACKAGES AND PLATFORMS TO PROMOTE CHILD AND ADOLESCENT DEVELOPMENT 19. Platforms to Reach Children in Early Childhood 253 Maureen M. Black, Amber Gove, and Katherine A. Merseth x Contents 20. The School as a Platform for Addressing Health in Middle Childhood and Adolescence 269 Donald A. P. Bundy, Linda Schultz, Bachir Sarr, Louise Banham, Peter Colenso, and Lesley Drake 21. Platforms for Delivering Adolescent Health Actions 287 Susan M. Sawyer, Nicola Reavley, Chris Bonell, and George C. Patton 22. Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions 307 Daniel Plaut, Milan Thomas, Tara Hill, Jordan Worthington, Meena Fernandes, and Nicholas Burnett 23. Cash Transfers and Child and Adolescent Development 325 Damien de Walque, Lia Fernald, Paul Gertler, Melissa Hidrobo PART 5 THE ECONOMICS OF CHILD DEVELOPMENT 24. Identifying an Essential Package for Early Child Development: Economic Analysis 343 Susan Horton and Maureen M. Black 25. Identifying an Essential Package for School-Age Child Health: Economic Analysis 355 Meena Fernandes and Elisabetta Aurino 26. Identifying an Essential Package for Adolescent Health: Economic Analysis 369 Susan Horton, Elia De la Cruz Toledo, Jacqueline Mahon, John Santelli, and Jane Waldfogel 27. The Human Capital and Productivity Benefits of Early Childhood Nutritional Interventions 385 Arindam Nandi, Jere R. Behrman, Sonia Bhalotra, Anil B. Deolalikar, and Ramanan Laxminarayan 28. Postponing Adolescent Parity in Developing Countries through Education: An Extended Cost-Effectiveness Analysis 403 Stéphane Verguet, Arindam Nandi, Véronique Filippi, and Donald A. P. Bundy 29. Economics of Mass Deworming Programs 413 Amrita Ahuja, Sarah Baird, Joan Hamory Hicks, Michael Kremer, and Edward Miguel Contents xi 30. The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 423 Elina Pradhan, Elina M. Suzuki, Sebastián Martínez, Marco Schäferhoff, and Dean T. Jamison DCP3 Series Acknowledgments 441 Volume and Series Editors 443 Contributors 447 Advisory Committee to the Editors 451 Reviewers 453 Policy Forum Participants 455 Africa Regional Roundtable Participants 457 Index 459 xii Contents Foreword HEALTH AND EDUCATION DURING THE of UNESCO, set out to make a new investment case 8,000 DAYS OF CHILD AND ADOLESCENT for global education. What resulted was a credible yet DEVELOPMENT: TWO SIDES OF THE ambitious plan capable of ensuring that the Sustainable Development Goal of an inclusive and quality education SAME COIN for all is met by the 2030 deadline. While we continue Today, there is comfort to be found in returning to to work today to ensure our messages become action— the inspired words of others. Until H. G. Wells’ time from increased domestic spending on schooling to an machine is made, words are our emotional anchor International Finance Facility for Education—we sought to the past and, one hopes, our window to a brighter to produce an authoritative, technically strong report future. Speaking before the 18th General Assembly of the that would spend more time being open on desks than United Nations in 1963, it was President John F. Kennedy collecting dust on a shelf. who noted that the “effort to improve the conditions of The Disease Control Priorities (DCP) series estab- man, however, is not a task for the few.” Development lished in 1993 shares this philosophy and acts as a key is a shared, cross-cutting mission I know well. For the resource for Ministers of Health and Finance, guiding breakthroughs we witness—from Borlaug’s wheat to a them toward informed decisions about investing in vaccine for polio—are the products of cooperation, a health. The third edition of DCP rightly recognizes that clean break from siloed thinking, and a courage to work good health is but one facet of human development at the sharp edges of disciplines. and that health and education outcomes are forever Working as a lecturer for five years in the 1970s and intertwined. The Commission report makes clear that early 1980s, I came to see—in a way I never had as a more education equates with better health outcomes. student—that education unlocks talent and unleashes And approaching this reality from the other direction, potential. And as Chancellor, Prime Minister, and most this year’s volume of DCP shows that children who are importantly a parent, education has remained a cen- in good health and appropriately nourished are more terpiece in my life because of the hope it delivers. For likely to participate in school and to learn while there. when we ask ourselves what breaks the weak, it is not the The Commission report raises the concept of progressive Mediterranean wave that submerges the life vest, nor the universalism or giving greatest priority to those children food convoy that does not make it to the besieged Syrian most at risk of being excluded from learning. Here, too, town. Rather, it is the absence of hope, the soul-crushing the alignment with DCP is clear as health strides are certainty that there is nothing ahead to plan or prepare most apparent when directed to the poorest and sickest for—not even a place in school. children, as well as girls. Two years ago, the International Commission on It is fitting that one of the Commission’s back- Financing Global Education Opportunity, composed ground papers appears as a chapter in this volume. The of two dozen global leaders and convened by the Commission showed that education spending, particu- Prime Minister of Norway and the Presidents of Chile, larly for adolescent girls, is a moral imperative and an Indonesia, and Malawi, as well as the Director-General economic necessity. Indeed, girls are the least likely to xiii go to primary school, the least likely to enter or com- Sustainable Development Goals and unlocking the next plete secondary school, highly unlikely to matriculate stage of global growth. to college, and the most likely to be married at a young A key message of this volume is that human devel- age, to be forced into domestic service or trafficked. And opment is a slow process; it takes two decades— with uneducated girls bearing five children against two 8,000 days—for a human to develop physically and men- children for educated girls, the vicious cycle of illiterate tally. We also know a proper education requires time. So girls, high birth rates, low national incomes per head, the world needs to invest widely, deeply, and effec- and migration in search of opportunity will only worsen tively—across education, health, and all development so long as we fail to deliver that most fundamental right sectors—during childhood and adolescence. And while to an education. individuals may have 8,000 days to develop, we must Here is a projection to remember. If current education mobilize our resources today to secure their tomorrow. funding trends hold, by 2030, 800 million children—half Let us not forget that the current generation of young a generation—will lack the basic secondary skills nec- people will transition to adulthood in 2030, and it will be essary to thrive in an unknowable future. In calling for their contribution that will determine whether the world more and better results-based education spending, the achieves the Sustainable Development Goals. Commission estimated that current total annual edu- We have, to again draw on Kennedy’s words, “the cation expenditure is US$1.3 trillion across low- and capacity to control [our] environment, to end thirst and middle-income countries, an anemic sum that must hunger, to conquer poverty and disease, to banish illiter- steadily rise to US$3 trillion by 2030. A rising tide must acy and massive human misery.” We have this capacity, lift all ships, and so as education spending at the domes- but only when we work together. Both the Commission tic and international levels sees an uptick, the same must report and this latest Disease Control Priorities volume be witnessed for health. The numbers may seem large, seek to elevate cross-sector initiatives on the global but the reality is that this relatively inexpensive effort agenda. In human development, health and education would do more than unlock better health and education are two sides of the same coin: only when we speak as outcomes; it would bring us closer to achieving all 17 one will this call be heard. Gordon Brown United Nations Special Envoy for Global Education Chair of the International Commission on Financing Global Education Opportunity Prime Minister of the United Kingdom, 2007–2010 Chancellor of the Exchequer, 1997–2007 xiv Foreword Preface More children born today will survive to adulthood than mortality is presented, with surprising conclusions, at any time in human history. This is true both in terms and morbidity is examined with respect to three of the proportion of live births and of absolute numbers. selected issues: nutrition, education, and health in The current cohort of children who have survived to age adolescence. 5 years will transition to adulthood around 2030 and will • Part 2. Impact of Interventions during the Life be the Sustainable Development Goals (SDGs) genera- Course (Ages 5–19 Years) reviews development tion. The health, nutrition, and education of these young issues at different stages in the life course and presents people as they develop from ages 5 to 19 years will have a conceptual framework for health and development lifelong consequences for the adults they become and for from birth, through middle childhood and adoles- their role in the development of the next generation. Will cence, to young adulthood. the world have prepared them well for this task? • Part 3. Conditions and Interventions describes the Our analyses in this volume show that although evolving age distribution of disease and how new the education of this age group is the primary focus of understanding of interventions and epidemiology public sector investment, their health is a much lower has transformed the ways in which health systems priority. Indeed, middle childhood and adolescence has can contribute to health and development objectives. historically received the least attention of any age group. • Part 4. Packages and Platforms to Promote Child Health and development in middle childhood and ado- and Adolescent Development explores how novel lescence is a new focus of the Disease Control Priorities series, approaches to policy that deliver health and devel- which was first published in conjunction with the World opment interventions to children and adolescents Bank’s World Development Report 1993: Investing in Health, are slowly being implemented in low-income coun- and which has become a key reference for health policy tries. In many cases, the focus is on vertical programs makers in low- and middle-income countries (box 1.1). The as part of underdeveloped primary health care sys- earlier editions touched on human development; this third tems, with a particular emphasis on school-based edition is the first to give a specific focus beyond health to delivery. Current health systems often fail children issues of human development, including the special role and adolescents, especially in the low-income coun- of the education sector, and the first to give prominence tries and communities that most need them. to health in this age group. This volume complements • Part 5. The Economics of Child Development volume 2, Reproductive, Maternal, Newborn, and Child assembles economic data and seeks to prioritize inter- Health, which focuses on health in the under-five age group. ventions within three age classes: early childhood, This volume presents its analyses and conclusions in school-age, and adolescence. Each age group is consid- 30 chapters grouped into five parts: ered in a separate chapter, and each chapter prioritizes interventions on the basis of cost-effectiveness, • Part 1. Estimates of Mortality and Morbidity in extended cost-effectiveness, benefit-costs, and returns Children (Ages 5 to 19 Years) explores mortality and on investment. Part 5 also includes age-specific morbidity in this age group, with a focus on low- and economic analysis of important areas of develop- lower-middle-income countries. A new analysis of ment, including the role of education in delaying xv pregnancy and marriage, as well as public financing development, it cannot serve as a substitute for continu- for mass deworming as an example of school-based ing intervention during three key phases: intervention. • The middle childhood phase of growth and consolida- We would like to acknowledge the many thought- tion (ages 5–9 years), when infection and malnutrition ful people who contributed to the content and conclu- remain key constraints on development, and mortal- sions of this volume. The 110 authors from 19 countries ity rates are much higher than previously realized contributed most directly to the preparation of the • The adolescent growth spurt (ages 10–14 years), 30 chapters presented here; the volume simply could never when the increase in muscle, bone, and organ mass have happened without their substantial investment of approaches rates not seen since age 2 years, and there time and effort in crafting and writing the chapters. We, are commensurate demands for good diet and health and they, thank the more than 60 independent reviewers, • The adolescent phase of growth and consolidation selected and commissioned by the National Academy of (ages 15–19 years), when major restructuring of the Science, Engineering, and Medicine, who provided peer brain is associated with behavioral and social experi- reviews of all of the chapters (see the section entitled mentation that has lifelong consequence. “Reviewers” at the end of the volume for a detailed listing of these individuals). As a further check on the policy implications of the con- We note the asymmetry between the public investment clusions, we sought input from those more directly involved in formal education versus health during the age range of in health policy making. A policy consultation was held in 5–19 years, and the lack of recognition that the develop- Geneva under the leadership of the Regional Director of the mental returns from education are themselves dependent World Health Organization (WHO) Eastern Mediterranean on concurrent good health and diet. We argue that cur- Regional Office, with representation from 10 countries.1 The rent policy on health and development has substantially African Union hosted a regional consultation of Ministry of neglected and underserved children in this age range, and Health representatives from five countries in Sub-Saharan that there is too little research on how to respond to the Africa.2 We also presented the main conclusions at a variety needs of middle childhood and adolescence. We propose of fora, seeking feedback from practitioners—including packages of interventions for these crucial later phases of the annual meeting of the European Society for Paediatric development that are in the same range of cost-effective- Infectious Diseases, in Brighton, United Kingdom; and the ness as interventions in the early years of life but of sub- Bill & Melinda Gates Foundation, in Seattle, Washington, stantially lower cost. We also call for significantly increased United States. We are grateful for the many thoughtful investment in research into the health and development responses that we received. needs during middle childhood and adolescence. We would also like to recognize our debt to all those who contributed to The Lancet Commission on Adolescent Volume Editors Health and Wellbeing. This volume was written in parallel Donald A. P. Bundy with the report of the Commission and shares some com- Nilanthi de Silva mon editors and authors. We support the conclusions of Susan Horton the Commission’s report, published in May 2016 (Patton Dean T. Jamison and others); we extend them in this volume to include George C. Patton further economic analysis, as well as an exploration of the health and development needs of children in middle Volume Coordinator childhood, an age group that may be even more neglected Linda Schultz than adolescents in public health policy and planning. The main conclusion of this volume is that human NOTES development is a process that extends over the first 1. Participants are listed at the end of this volume. two decades of life; for individuals to achieve their 2. Participants are listed at the end of this volume, as well as full potential, there is a need for age- and condition- online: http://www.dcp-3.org/CAHDEthiopia. specific interventions throughout this 20-year period. The current focus on the “first 1,000 days” represents a failure to recognize the critical importance of subse- REFERENCE quent development during middle childhood and ado- Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Afifi, and lescence. Although intervention during the first 1,000 others. 2016. “Our Future: A Lancet Commission on Adolescent days is indeed the essential foundation for subsequent Health and Wellbeing.” The Lancet 387 (10036): 2423–78. xvi Preface Abbreviations AIDS acquired immune deficiency syndrome AQ amodiaquine AS artesunate BCR benefit-cost ratio BMI body mass index CCT conditional cash transfer CHERG Child Health Epidemiology Reference Group CME Child Mortality Estimation CT cash transfer DALY disability-adjusted life year DCP1 Disease Control Priorities in Developing Countries, first edition DCP2 Disease Control Priorities in Developing Countries, second edition DCP3 Disease Control Priorities, third edition DHS Demographic and Health Surveys DMFT decayed, missing, and filled teeth DOHaD Developmental Origins of Health and Disease DP dihydroartemisinin-piperaquine ECD early child development ECE early childhood education EFA Education for All EGRA Early Grade Reading Assessment ESP education sector plan FA fractional anisotropy FRESH Focusing Resources on Effective School Health FRP financial risk protection GBD Global Burden of Disease GDP gross domestic product GHE Global Health Estimates GIZ German Development Cooperation GNI gross national income GYTS Global Youth Tobacco Survey xvii HAZ height-for-age z-scores Hb hemoglobin HBSC Health Behaviour in School-Aged Children HEADSS home, education, activities/employment, drugs, suicidality, sex HICs high-income countries HIV human immunodeficiency virus HIV/AIDS human immunodeficiency virus/acquired immune deficiency syndrome HLM hierarchical linear model HPV human papillomavirus HSV-2 herpes simplex virus-2 ICF International Classification of Functioning, Disability and Health IEA International Association for the Evaluation of Educational Achievement IEC information, education, and communication IHME Institute for Health Metrics and Evaluation INCAP Institute of Nutrition for Central America and Panama IPCs intermittent parasite clearance in schools IPT intermittent preventive treatment IQ intelligence quotient IRS indoor residual spraying IST intermittent screening and treatment ITN insecticide-treated bednet KMC kangaroo mother care LBW low birth weight LICs low-income countries LMICs low- and middle-income countries MDA mass drug administration MDGs Millennium Development Goals m-health mobile health MICs middle-income countries MICS Multiple Indicator Cluster Survey NCDs noncommunicable diseases NTD neglected tropical diseases OECD Organisation for Economic Co-operation and Development OOP out of pocket OTL opportunity to learn PDV present discounted value PIAAC Programme for the International Assessment of Adult Competencies PIRLS Progress in International Reading Literacy Study PISA Programme for International Student Assessment PFC prefrontal cortex PRIMR Primary Mathematics and Reading PT planum temporale QALY quality-adjusted life year RCT randomized controlled trial RDT rapid diagnostic test RMNCH reproductive, maternal, newborn, and child health RoR rate of return RSC Rockefeller Sanitary Commission RTI road traffic injury xviii Abbreviations SABER Systems Approach for Better Education Results SSBs sugar-sweetened beverages SBM school-based management SDGs Sustainable Development Goals SES socioeconomic status SHN school health and nutrition SMC seasonal malaria chemoprevention SP sulphadoxine-pyrimethamine SR self-regulation STHs soil-transmitted helminths STI sexually transmitted infection TFR total fertility rate TIMSS Trends in International Mathematics and Science Study TT tetanus toxoid U5MR under-5 mortality rate UCT unconditional cash transfer UMICs upper-middle-income countries UN United Nations UNESCO United Nations Educational, Scientific and Cultural Organization UNICEF United Nations Children’s Fund VLY value of a life year VSL value of a statistical life VWFA visual word form area WASH water, sanitation, and hygiene WAZ weight-for-age WG Washington Group WHO World Health Organization WHZ weight-for-height WPP World Population Prospects WRA women of reproductive age YLD years lost to disability YOURS Youth for Road Safety Abbreviations xix Chapter 1 Child and Adolescent Health and Development: Realizing Neglected Potential Donald A. P. Bundy, Nilanthi de Silva, Susan Horton, George C. Patton, Linda Schultz, and Dean T. Jamison INTRODUCTION (Patton, Sawyer, and others 2016). Given new evidence on It seems that society and the common legal definition the strong connection between a child’s education and have got it about right: it takes some 21 years for a health, we argue that modest investments in the health of human being to reach adulthood. The evidence shows a this age group are essential to attain the maximum benefit particular need to invest in the crucial development from investments in schooling for this age group, such as period from conception to age two (the first 1,000 days) those proposed by the recent International Commission on and also during critical phases over the next 7,000 days. Financing Global Education Opportunity (2016). This vol- Just as babies are not merely small people—they need ume shares contributors to both commissions and comple- special and different types of care from the rest of us— ments an earlier volume, Reproductive, Maternal, Newborn, so growing children and adolescents are not merely and Child Health, which focuses on health in the group of short adults; they, too, have critical phases of develop- children under age 5 years. ment that need specific interventions. Ensuring that There is a surprising lack of consistency in the life’s journey begins right is essential, but it is now clear language used to describe the phases of childhood, that we also need support to guide our development up perhaps reflecting the historically narrow focus on the to our 21st birthday if everyone is to have the opportu- early years. The neglect of children ages 5 to 9 years in nity to realize their potential. Our thesis is that research particular is reflected in the absence of a commonly and action on child health and development should reflected name for this age group. Figure 1.1 illustrates evolve from a narrow emphasis on the first 1,000 days to the nomenclature used in this volume, which we have holistic concern over the first 8,000 days; from an sought to align with the definitions and use outlined in age-siloed approach to an approach that embraces the the 2016 Lancet Commission on Adolescent Health needs across the life cycle. and Wellbeing. The editors of this volume built upon To begin researching and encouraging action, this the commission’s definitions to include additional volume, Child and Adolescent Health and Development, terms that are relevant to the broader age range con- explores the health and development needs of the 5 to sidered here, including middle childhood to reflect the 21 year age group and presents evidence for a package of age range between 5 and 9 years. The editors also refer investments to address priority health needs, expanding on to children and adolescents between ages 5 and 14 other recent work in this area, such as the Lancet years as “school-age,” since in low- and lower-middle- Commission on Adolescent Health and Wellbeing income countries these are the majority of children in Corresponding author: Donald A. P. Bundy, Bill & Melinda Gates Foundation, Seattle, Washington, United States; donald.bundy@gatesfoundation.org. 1 Box 1.1 Key Messages from Volume 8 1. It takes 21 years (or 8,000 days) for a child to • Adolescent Growth and Consolidation develop into an adult. Throughout this period, Phase (ages 15 to early 20s), bring fur- there are sensitive phases that shape development. ther brain restructuring, linked with explo- Age-appropriate and condition-specific support ration and experimentation, and initiation is required throughout the 8,000 days if a child is of behaviors that are life-long determinants to achieve full potential as an adult. of health. 2. Investment in health during the first 1,000 days is 4. Broadening investment in human development widely recognized as a high priority, but there is to include scalable interventions during the next historical neglect of investments in the next 7,000 7,000 days can be achieved cost-effectively at modest days of middle childhood and adolescence. This cost. Two essential packages were identified: the neglect is also reflected in investment in research first addresses needs in middle childhood and early into these older age-groups. adolescence through a school-based approach; the 3. At least three phases are critical to health and devel- second focuses on older adolescents through a opment during the next 7,000 days, each requiring mixed community and media and health systems a condition-specific and age-specific response: approach. Both offer high cost-effectiveness and • Middle Childhood Growth and Consolidation benefit-cost ratios. Phase (ages 5–9), when infection and mal- 5. Well-designed health interventions in middle nutrition remain key constraints on devel- childhood and adolescence can leverage the opment, and mortality rates are higher than already substantial investment in education, and previously realized better design of educational programs can bring • Adolescent Growth Spurt (ages 10–14), when better health. The potential synergy between there is a major increase in body mass, and sig- health and education is currently undervalued, nificant physiological and behavioral changes and the returns on co-investment are rarely associated with puberty optimized. Box 1.2 Evolution of Disease Control Priorities and Focus of the Third Edition Budgets constrain choices. Policy analysis helps substantial burdens of infection and undernutri- decision makers achieve the greatest value from tion (World Bank 1993). limited resources. In 1993, the World Bank pub- lished Disease Control Priorities in Developing DCP2, published in 2006, updated and extended Countries (DCP1), which sought to assess system- DCP1 in several respects, giving explicit consider- atically the cost-effectiveness (value for money) ation to the implications for health systems of of interventions addressing the major sources of expanded intervention coverage (Jamison and others disease burden in low- and middle-income coun- 2006). One way to expand coverage of health inter- tries (Jamison and others 1993). The World Bank’s ventions is through platforms for interventions that World Development Report 1993 drew heavily on require similar logistics but that address heteroge- DCP1’s findings to conclude that specific inter- neous health problems. Platforms often provide a ventions to combat noncommunicable diseases more natural unit for investment than do individual were cost-effective, even in environments with interventions, but conventional health economics box continues next page 2 Child and Adolescent Health and Development Box 1.2 (continued) has offered little understanding of how to make DCP3’s broad aim is to delineate essential interven- choices across platforms. Analysis of the costs of tion packages—such as those for school-age children packages and platforms—and of the health improve- and adolescents, as outlined in this volume—and ments they can generate in given epidemiological their related delivery platforms. This information is environments—can help guide health system invest- intended to assist decision makers in allocating often ments and development. tightly constrained budgets and achieving health system objectives. DCP3 introduces the notion of packages of interven- tions. Whereas platforms contain logistically related Four of DCP3’s nine volumes were published in sets of interventions, packages contain conceptually 2015 and 2016, and the remaining five will appear related ones. The 21 packages developed in the nine in 2017 or early 2018. The volumes appear in volumes of DCP3 include surgery and cardiovascu- an environment in which serious discussion about lar disease, for example. In addition, DCP3 explicitly quantifying and achieving the Sustainable considers the financial risk–protection objective of Development Goals (SDGs) for health continues health systems. In populations lacking access to (United Nations 2015). DCP3’s analyses are well- health insurance or prepaid care, medical expenses placed to assist in choosing the means to attain the that are high relative to income can be impoverish- health SDGs and assessing the related costs. These ing. Where incomes are low, seemingly inexpensive volumes, and the analytic efforts on which they are medical procedures can have catastrophic financial based, will enable researchers to explore SDG- effects. DCP3 considers financial protection and the related and other broad policy conclusions and distribution across income groups as outcomes generalizations. The final volume will report those resulting from policies (for example, public finance) conclusions. Each individual volume will provide to increase intervention uptake and improve delivery specific policy analyses on the full range of inter- quality. All of the volumes seek to combine the avail- ventions, packages, and policies relevant to its able science about interventions implemented in health topic. specific locales and conditions with informed judg- ment to reach reasonable conclusions about the Source: Dean T. Jamison, Rachel Nugent, Hellen Gelband, Susan Horton, Prabhat effect of intervention mixes in diverse environments. Jha, Ramanan Laxminarayan, and Charles N. Mock. primary school, owing to high levels of grade repetition, Some issues of potential importance to child develop- late entry to school, and drop outs. As income levels rise ment are examined in other volumes of DCP3. For exam- and secondary schooling enrollment increases, chil- ple, environmental issues are examined in some depth in dren attending school will be older than age 14 years. volume 7 (Mock and others 2017), which examines the Figure 1.1 also demonstrates the overlap between impact of pollution on health and human development— many of these terms. For example, the Convention on especially the exceptional prevalence of lead poisoning, the Rights of the Child defines child as every human which affects the intellectual development of children. being younger than age 18 years, whereas this volume A premise of this volume is that human development defines adolescence as beginning at age 10 years and occurs intensively throughout the first two decades of life continuing through age 19 years (United Nations (figure 1.1), and that for a person to achieve his or her full General Assembly 1989). Figure 1.1 also shows the potential, age- and condition-specific interventions are alignment between age groups and four key phases needed throughout this 8,000 days (box 1.3). We use four critical to development. These key phases are used as key tools—cost-effectiveness, extended cost-effectiveness, an organizing principle for intervention throughout benefit-cost, and returns on investment—to identify this volume. Where possible, the editors have extended and prioritize investments at different ages and to pro- the analyses to include children through age 21 years; pose delivery platforms and essential packages that are but standard reporting of age data is in quintiles, so for costed, scalable, and relevant to low-resource settings. convenience the editors have accepted the upper age These analyses suggest that public investment in health range as 15-19 years. and development after age 5 years has been insufficient. Child and Adolescent Health and Development: Realizing Neglected Potential 3 Figure 1.1 Nomenclature Concerning Age and Four Key Phases of Child and Adolescent Development 25 Young adult 8,000 20 Youth Late Adolescent Age (days from conception) adolescence growth and consolidation 5,700 15 Adolescence Age in years Early Adolescent adolescence growth spurt 3,900 10 School age Child Middle Middle childhood childhood growth and consolidation 2,100 5 Preschool 1,000 Under age 5 First 1,000 270 Birth Infant daysa 0 Childhood Adolescence Youth Note: a. The first 1000 days is typically measured from the time of conception, as is the 8,000 days that we discuss as the overall child and adolescent development period; other age-ranges presented here are measured from birth. Box 1.3 Early Childhood Development This volume takes a broad approach by examin- and others 1991) demonstrated that health and ing child and adolescent health and development nutrition interventions alone are insufficient to more generally, rather than focusing only on health. address developmental deficits in young children Therefore, although it focuses primarily on the 5–19 facing multiple deprivations. Combining health and years age group, it also includes a discussion of early nutrition interventions with responsive stimulation childhood development (ECD), which complements was found to have short-term developmental benefits the discussion on early health in volume 2. for growth and cognitive development not only in childhood but also into adulthood (Gertler and oth- The existence of key synergies justifies the inclusion ers 2014), with long-term effects on adult earnings of ECD in a series focused on health. These include and social outcomes. synergies in the outcomes of different investments in children and synergies in the delivery of both sets of Violence against children (child abuse) is an extreme interventions. negative example of the same synergy. Synergies in investments in children. Elsewhere in A systematic review (Norman and others 2012) doc- this chapter, we discuss the synergies between health umented how this extreme form of poor nurturing and education for those ages 5–19 years. These same adversely affects physical and mental health. Child synergies are also important for young children. A maltreatment and neglect are associated with sub- pathbreaking study in Jamaica (Grantham-McGregor stantial medical costs in childhood and adulthood box continues next page 4 Child and Adolescent Health and Development Box 1.3 (continued) (Brown, Fang, and Florence 2011; Fang and others To date, the few published studies that have esti- 2015) and have negative impacts on adult economic mated the marginal additional cost of integrating well-being (CDC 2015; Currie and Widom 2010; programs for responsive stimulation into existing Zielinski 2009). Although most of these studies are health services have found these costs to be modest from high-income countries, similar results have (Horton and Black 2017, chapter 24 in this volume). been found in low- and middle-income countries. However, these additional tasks cannot simply be loaded onto existing health workers without recog- Delivery platforms for early interventions at differ- nition of the need for additional training and super- ent ages. In the first 1,000 days, children’s main vision and for some increase in the ratio of health contact with public sector institutions is with the workers to population. Given the limited number of health system, and it makes sense to use the health studies, it is not possible to estimate the economic system to deliver education to parents about respon- returns to integrated programs. sive stimulation. This education can be delivered through group sessions for parents at the local health An essential package for ECD. Chapter 24 in this facility or through home visits incorporating mes- volume (Horton and Black 2017) develops a basic sages on responsive stimulation, as discussed in ECD package relevant for low-income countries; the chapter 19 in this volume (Black, Gove, and Merseth package focuses on parenting programs and encour- 2017). Once children have received the required ages “responsive stimulation” (the positive interaction immunizations, they have fewer interactions with between a young child and his or her caregiver, with the health system; there are synergies then in using mutual benefit). These programs are estimated to preschools and the school system to deliver health cost US$6 per child and are delivered in the first 1,000 and nutrition interventions to children after age days. As per capita incomes rise, preschool programs three years. for children ages three to five years might be added. Investment lags far behind the potential for return and is severe data shortcomings for these older age groups far below investments in health in the first five years and (World Bank 2006), whereas Hill and others found no in primary education after age 5 years. Table 1.1 com- empirical studies of mortality rates for the age group pares our recommendations for additional spending with 5–14 years in countries without vital statistics, which current spending on education and with spending on include the majority of low- and middle-income coun- health for children under age 5 years. tries (LIMCs) (Hill, Zimmerman, and Jamison 2017). This bias in investment is paralleled by a similar bias The estimates, based on Demographic and Health in research. Approximately 99 percent of publications in Surveys Program data, reported here result in sharp Google Scholar and 95 percent in PubMed on the first upward adjustments in estimated numbers of deaths in 20 years of life focus on children under age 5 (annex 1A that age range (Hill, Zimmerman, and Jamison 2017). shows the number of publications since 2004 that our This strong bias toward early childhood in the health search found that include the terms health, mortality, or literature may have been helpful in the successful United cause of death). The availability of age-specific publica- Nations Millennium Development Goals (MDG) drive tions reflects a lack of research funding for and attention to reduce under-five mortality. But it seems to have to middle childhood and adolescence, resulting in a lack caused us to lose sight of the fact that the subsequent of data. The analysis for the Global Burden of Disease decades of growth and development in the transition to 2013 came to a similar conclusion, pointing out that adulthood involve complex processes and critical peri- most of the unique data sources for risk factors for ado- ods that are sensitive to intervention. lescents ages 15–19 years were from school-based sur- This volume focuses on the scientific evidence, but veys, that children younger than age 5 had the most data local contexts, including culture, beliefs, lifestyles, and available of any age group, and that adolescents ages health systems, as well as other key determinants such as 10–14 years had the fewest data sources (Mokdad and gender, race, ethnicity, sexuality, geography, socioeco- others 2016). The World Development Report 2007: nomic status, and disability, are important for developing Development and the Next Generation similarly found practical policies (Chandra-Mouli, Lane, and Wong 2015). Child and Adolescent Health and Development: Realizing Neglected Potential 5 Table 1.1 Estimates of Public Sector Investment in Human Development in Low- and Lower-Middle- Income Countries US$, billions per year Lower-middle- Total for both low- Low-income income and lower-middle- countries countries income countries Current spending Basic educationa 19 190 210 b First 1,000 days 4.4 24 29 Proposed new package School-age children package (excluding school feeding) 0.13 0.38 0.51 c School-age children package (including school feeding) 0.47 2.8 3.3 Adolescent packagec 0.88 2.7 3.6 Total proposed spending on new packages in middle childhood and 1.4 5.5 6.9 adolescence (including school feeding)c a. These estimates are from The Learning Generation (International Commission on Financing Global Education Opportunity 2016, 37). They estimate current public sector spending on basic (primary-level) education in low- and lower-middle-income countries. The report calls for increases to US$50 billion and US$712 billion, respectively, by 2030. b. These estimates are from DCP3, volume 2 and are for the cost of two packages: (1) maternal and newborn and (2) under-five child health. The editors of volume 2 estimate current spending in low- and lower-middle-income countries. Estimated incremental annual investments of US$7 billion and US$14 billion, respectively, are needed to achieve full coverage. c. These estimates are summarized in table 1.4. They are the estimated total cost of implementing the school-age and adolescent packages in low- and lower-middle-income countries. There are no formal estimates of current coverage, but it is likely in the range of 20 percent to 50 percent of these figures. Some groups that tend to be marginalized and overlooked for boys exceeds—the rate at age two years and growth when planning intervention strategies, such as ethnic begins to occur in quite different ways (Tanner 1990). minorities, LGBT (lesbian, gay, bisexual, or transgender) Furthermore, a review in chapter 8 in this volume (Watkins, youth, persons with disabilities, youth in conflict areas, Bundy, and others 2017) suggests that human growth and refugees, are also likely to have the greatest need for remains relatively plastic throughout much of childhood, health and development support. with potentially important amounts of catch-up growth. We need to be more careful about claiming that early insults are irreversible and recognize that more can be A CONCEPTUAL FRAMEWORK done to help older children catch up, especially in middle FOR UNDERSTANDING CHILD AND childhood. The data signal how unintended research bias and the scarcity of studies of ages 5–19 have had perverse ADOLESCENT HEALTH AND DEVELOPMENT policy consequences. In this volume, we develop a conceptual framework for Evidence from neuroscience over the past 15 years exploring the processes and inputs that determine physical suggests that critical phases of brain development and cognitive growth from birth to adulthood (Bundy and occur beyond the first 1,000 days and in some cases Horton 2017, chapter 6 in this volume). The framework long after. By age six years, the brain has reached recognizes the importance of the first 1,000 days. It further approximately 95 percent of its adult volume, but size is notes that during the first two decades of life, there are at not everything; rather, the connections within the brain least three other critically important development phases: are of growing importance through middle childhood middle childhood (ages 5 to 9 years), the early adolescent and adolescence (Grigorenko 2017, chapter 10 in this growth spurt (ages 10 to 14 years), and the later adolescent volume). Different areas of the brain have different phase of growth and consolidation (ages 15 to 19 years) functions and develop at different rates. Peak develop- when age-specific interventions are necessary. See figure 1.2. ment of the sensorimotor cortex—which is associated Rates of physical growth are indeed at their highest at with vision, hearing, and motor control—occurs rela- ages below age two, emphasizing the importance of the tively early, and development is limited after puberty. first 1,000 days. However, at the peak of the adolescent The parietal and temporal association complex, respon- growth spurt, the growth rate for girls is similar to—and sible for language skills and numeracy, develops 6 Child and Adolescent Health and Development the fastest a little later; thus by about age 14 years, The panel shows the pattern for adolescent boys. although it is possible to learn new languages, it is more The patterns are similar for girls but occur at earlier ages difficult to speak a new language in the same way as a because of different patterns of puberty. The panel shows native speaker (Dahl 2004). The prefrontal cortex that the regions associated with movement (such as the develops later still; this area is associated with higher caudate and globus pallidus) are shrinking in size during brain functions, such as executive control (figure 1.2, early adolescence because these structures become panel b). more efficient as the functions become more mature. There is a sequence of brain development, and the In contrast, regions associated with memory, decision kind of growth in middle childhood and adolescence dif- making, and emotional reactions (amygdala and hippo- fers from the kind of growth in early life. It is possible to campus) are still developing and growing in size during see some of these differential growth rates in brain capa- adolescence. bilities by studying the size of the subcortial regions as Brain development during infancy and early child- shown in figure 1.2, panel c (Goddings and others 2014). hood is marked by the development of primary Figure 1.2 Human Development to Age 20 Years Age in years 5 10 15 20 a. Height gain centimeters per year 20 Height gain, 15 Female Male 10 5 0 b. Change in brain development Gonadal hormones Change in brain Synaptic pruning, development neuromodulators, neurotrophins, cerebral blood flow, and metabolism Myelination Sensorimotor cortex Parietal and temporal association complex Prefrontal cortex Percentage change in volume as a c. Percentage change in volume as a proportion of prepubertal volume for each structure (for males) % of prepubertal volume for each structure (for males) 8 6 4 2 0 –2 –4 –6 Age in years 5 10 15 20 Amygdala Caudate Hippocampus Globus pallidus Sources: Adapted from Tanner 1990; Goddings and others 2014; Grigorenko 2017. Note: Behavioral attributes are paralleled by hormonal and neurobiological changes that target specific brain regions and cell populations (shown in shaded gray to capture the dynamic influences of hormones, various brain processes, and myelination). The vertical axis in panel b shows relative rate of growth of three brain areas from 0 to highest. The progressive shading indicates when the indicated activity is at its most intense (darkest shading). Child and Adolescent Health and Development: Realizing Neglected Potential 7 cognitive and emotional abilities. With the onset of the used to estimate rates for children under age 5 (Hill, hormonal changes of puberty in middle childhood, a Zimmerman, and Jamison 2017, chapter 2). new phase of brain development commences in which The estimates for 2010 suggest that the total annual the individual’s interactions with the social, cultural, mortality in LMICs in the 5 to 19 age group is around 2.3 and educational environment shapes the processes of million. The number of deaths estimated for children myelination and synaptic pruning of centers involved in ages 5 to 9 years are 935,000, which is higher than the emotional processing and higher executive functioning estimates of the United Nations Population Division (Viner, Allen, and Patton 2017). Although primary cog- and the Institute for Health Metrics and Evaluation nitive abilities in stunted children may improve during (IHME) for this age group. Congruence of the new middle childhood (Crookston and others 2013), brain estimates with the UN and IHME data is closer for the 10 development during these years and during adolescence to 14 age group and closer yet for the 15 to 19 age group. is primarily focused on acquiring the higher-level cogni- These results suggest that we need to do more to under- tive, emotional, and social skills essential for function- stand mortality in older children. A natural conclusion for ing in complex social systems. As in earlier childhood, policy would be to extend major national and interna- nutritional as well as social environments shape brain tional programmatic efforts that assess levels and causes development (Andersen and Teicher 2008; Blakemore of mortality in children under age 5 years to include the and Mills 2014). entire age range from birth through age 19 years. The Early intervention is critical for setting human United Nations Inter-agency Group for Child Mortality development on an effective trajectory. However, the Estimation (IGME), which provides child mortality esti- emphasis on the proposition that harm experienced in mates through the Child Mortality Estimation (CME) early life is irreversible is not only weakly supported by database, and the Child Health Epidemiology Reference the evidence but also has led to an unfortunate lack of have historically focused on children under age 5 years, emphasis on exploring interventions later in childhood which helps explain why the data are so poor, and so (Prentice and others 2013). Similarly, the widely cited poorly known, for children in middle childhood and ado- conceptual framework of continuously declining rates lescence. At least in part because of the focus in this vol- of return with age (Heckmann 2011) is at variance ume on mortality levels in older children, IGME is with what is now known about the plasticity of expanding its work to cover this age range (Masquelin brain development (Black, Gove, and Merseth 2017, 2017). Although empirical estimates are still evolving, it is chapter 19 in this volume) and of physical growth dur- to be expected that IGME’s effort will soon provide stable ing much of middle childhood (Watkins, Bundy, and and up-to-date estimates that are country specific. others 2017, chapter 8 in this volume), and it also fails Morbidity is even more poorly documented than to take into account the intergenerational benefits of mortality for children over age five years. The volume actions in later childhood and adolescence. Some explores the evidence for geographical and social differ- interventions make sense only at specific points in ences in four key outcome measures—education, anthro- development; for example, some famous tennis players pometric status, micronutrient deficiency, and adolescent attribute their success to learning to play at age eight health— and describes major geographic variation in all years, but they recognize that no amount of tennis four development outcomes (Galloway 2017; Wu 2017; lessons at age three would have achieved the same Patton and others 2017, chapters 3–5, respectively, in this outcome. Current evidence suggests that there are sub- volume), but there is no systematic collection of morbid- stantial returns on investments made throughout the ity data for this age-group, especially in LMICs. In first two decades of life. exploring morbidity, we have begun to see that health and education are strongly linked in this age group; the education analysis shows that individual differences in THE UNFINISHED AGENDA OF MORTALITY health between students contribute to differences between educational outcomes and that differences in health are REDUCTION amenable to intervention in the short term. During middle childhood and adolescence, the major consequences of ill health are related to morbidity rather ESSENTIAL PACKAGES OF INTERVENTIONS than mortality. This fact does not mean that mortality is FOR SCHOOL-AGE CHILDREN AND unimportant in older children. A new analysis of mortal- ity was specifically conducted for this volume using ADOLESCENTS Demographic and Health Surveys to estimate death rates Appropriate health interventions for the first 1,000 days are for ages 5 to 19 years in the same way that data have been addressed in detail in volume 2, which describes 8 Child and Adolescent Health and Development Table 1.2 Essential Package of Interventions for School-Age Children (Ages 5–14 Years) Health area Population Community Primary health center School Benefit of delivering interventions in schools Physical — Deworming Deworming Deworming In endemic areas, regular deworming (following health WHO guidelines) can be done inexpensively in schools now that the majority of deworming drugs are donated; there are reported benefits in school attendance as a result. Insecticide- Insecticide-treated net Insecticide-treated Education concerning the use of insecticide-treated treated net promotion net promotion nets in endemic areas is important because promotion schoolchildren tend to use nets less often than do mothers and small children. Tetanus toxoid Tetanus toxoid and HPV Tetanus toxoid and Schools can be a good venue for administering and HPV vaccination HPV vaccination tetanus boosters, which benefit not only young people vaccination themselves but also babies born to those young women. Oral health Oral health promotion Oral health Education on oral health is important; poor promotion and treatment promotion households generally cannot afford dental treatment. Vision screening Vision screening Vision screening and provision of inexpensive ready- and provision of glasses and treatment made glasses boost school performance. Nutrition — Micronutrient — Micronutrient — supplementation supplementation Multifortified — Multifortified foods — foods School feeding School meals promote attendance and education outcomes. Source: Fernandes and Aurino 2017 (chapter 25 in this volume). Note: — = not available; HPV = human papillomavirus; WHO = World Health Organization. School-age children do not regularly come in contact with the health system unless they seek treatment. With the remarkable success of the Millennium Development Goals in increasing school enrollment and participation and the continuing focus on universal education with the Sustainable Development Goals, it makes sense to use schools to promote health in this age group and to deliver preventive and curative health interventions. These interventions are affordable and also the highest priority, given their health and educational benefits. Table 1.4 presents the cost of components of the essential package of investments for school-age children. two essential packages of interventions targeted at young addition, each stage provides an opportunity to remedy children: one on maternal and newborn health and the earlier failures in development, at least to some extent. other on child health. In volume 8, we complement these First we discuss a package of interventions aimed at packages with an analysis of early childhood development school-age children (see table 1.2); this package (Alderman and others 2017; Black, Gove, and Merseth addresses both middle childhood growth and consolida- 2017; Horton and Black 2017; Horton and others 2017, tion (ages 5–9 years) and the adolescent growth spurt chapters 7, 19, 24, and 26, respectively, in this volume). Our (ages 10–14 years). We then discuss a package aimed at later analysis suggests that there is significant value in add- adolescence, which addresses adolescent growth and con- ing “responsive stimulation” to these health packages solidation (ages 15–19 years) (table 1.3). In practice, there is (box 1.3). More detailed analysis of the cost and relative considerable overlap between the age groups able to benefit effectiveness of the early child development package is pre- from these two packages, and both packages are required sented in chapter 2 of volume 9 (Watkins, Nugent, and to cover the needs of adolescents from ages 10 to 19 years. others 2018). As illustrated in maps 1.1 and 1.2, school-age children This volume focuses on the three phases of develop- and adolescents (that is, the age group of 5–19 years) ment for those older than age five years: middle childhood together constitute a substantial proportion of the overall growth and consolidation, the adolescent growth spurt, population of all countries, with the proportion greatest and adolescent growth and consolidation (figure 1.1). We in the poorest countries: 17.2 percent of high-income argue that intervention during each of these stages is essen- countries and rising to 37.2 percent of low-income tial to enhanced survival and to effective development; in countries. The essential health and development Child and Adolescent Health and Development: Realizing Neglected Potential 9 Table 1.3 Essential Package of Investments for Adolescents (Ages 10–19 Years, Approximately) Health Benefit of targeting interventions to area Population Community Primary health center School adolescents Physical Healthy lifestyle Adolescent- Adolescent-friendly health Healthy lifestyle National media messages on healthy life choices health messages: friendly services: provision of education, in formats designed to appeal to adolescents, tobacco, alcohol, health condoms to prevent STIs, including accident combined with national policy efforts to support injury, accident services provision of reversible avoidance and healthy choices (limiting access of adolescents to avoidance, and contraception, treatment safety products most harmful to their health) safety of injury in general and abuse in particular, screening and treatment for STIs Sexual health — — Sexual health Additional health education in schools aimed messages education at issues relevant to older ages, intended to supplement messages for younger children in the school-age package Adolescent- Provision of adolescent-friendly health services friendly health within schools or within health care facilities in services ways that respect adolescent needs Nutrition Nutrition — — Nutrition — education education messages Mental Mental health — Mental health treatment Mental health — health messages education and counseling Source: Horton and others 2017 (chapter 26 in this volume). Note: — = not available; STI = sexually transmitted infection. Adolescents are the hardest group to reach because many are no longer in school and feel uncomfortable accessing health services predominantly designed for adults. They may fear lack of confidentiality, and in some cases (such as teen pregnancy) may be stigmatized by health care workers. The total costs of the school-age package are about US$10 per child in the 5–14 years age group and US$9 per adolescent in the 10–19 years age group. Table 1.4 presents the cost of components of the essential package of investments for adolescents. packages for school-age children and adolescents have than half of the target population—are dewormed annu- particular relevance in low- and lower-middle-income ally (Bundy, Appleby, and others 2017, chapter 13 in this countries where the population that can benefit from volume) in nearly all LMICs. These largely public efforts these developmental interventions constitutes approxi- are variable in quality and coverage, but the large scale of mately one-third of the total population. existing programs indicates a willingness by governments to invest in health as well as education for this age group. The school system represents an exceptionally cost- Essential Package of Interventions for effective platform through which to deliver an essential School-Age Children package of health and nutrition services to this age Health and nutrition programs targeted through schools group, as has been well documented in high-income are among the most ubiquitous for school-age children in countries (HICs) (Shackleton and others 2016). It is also LMICs. Since the inclusion of school health programs in increasingly equitable, especially because increases in the launch of Education for All in 2000, it is difficult to primary enrollment and attendance rates, and narrowing find a country that is not attempting to provide of gender gaps, are among the greatest achievements of school health services at some level, although the coverage the Millennium Development Goals (Bundy, Schultz, is often limited (Sarr and others 2017). The World Food and others 2017, chapter 20 in this volume). In LMICs Programme estimates that more than 360 million school- with weak health systems, the education system is children receive school meals every day (Drake and others particularly well-situated to promote health among 2017, chapter 12 in this volume), many of whom live in school-going children and adolescents who may not be LMICs, and the World Health Organization (WHO) esti- reached by health services. There are typically more mates that more than 450 million schoolchildren—more schools than health facilities in all income settings, 10 Child and Adolescent Health and Development Map 1.1 Proportion of Country Population That Comprises Children in Middle Childhood (between Ages 5–9) Percent IBRD 42646 | SEPTEMBER 2017 <7 7–10 >10–13 >13–17 No data Source: United Nations, World Population Prospects: The 2015 Revision, July 2015. and rural and poor areas are significantly more likely to this volume]). Estimates suggest that in areas where have schools than health centers. malaria and worm infections are prevalent, poor stu- In this section, we examine the investment case for dents could gain the equivalent of 0.5 to 2.5 extra years providing an integrated package of essential health services of schooling if given appropriate health interventions, for children attending school in low- and lower-middle- while sustaining benefits across multiple years of income countries (see table 1.2). “School-age” includes schooling could improve cognitive abilities by 0.25 both middle childhood and younger adolescence. standard deviation, on average. Extrapolating the ben- efits of improved accumulation of human capital could Middle Childhood Growth and Consolidation Phase translate to roughly a 5 percent increase in earning An important economic rationale for targeting the capacity over the life course (Ahuja and others 2017, health and development of school-age children is to chapter 29 in this volume). promote learning at an age when they have what may Chapter 8 in this volume (Watkins, Bundy, and oth- be their only opportunity to attend school. Ill health ers 2017) shows that some of these interventions also can be a catalyst for extended absence from or dropping have important roles to play in maintaining and sus- out of school; for example, malaria and worm infec- taining the gains of earlier investments, and children tions can reduce enrollment, and anemia resulting who slip through the early safety net can still achieve from malaria or worm infections can affect cognition, some catch-up growth with interventions in middle attention span, and learning (Benzian and others 2017; childhood. Furthermore, the new mortality analyses Brooker and others 2017; Bundy, Appleby, and others presented in chapter 2 (Hill, Zimmerman, and Jamison 2017; Drake and others 2017; LaMontagne and others 2017) show that, for those ages five to nine years, sur- 2017; Lassi, Moin, and Bhutta 2017 [chapters 11–16 in vival continues to be a significant challenge, largely Child and Adolescent Health and Development: Realizing Neglected Potential 11 Map 1.2 Proportion of Country Population That Comprises Adolescents (between Ages 10–19) Percent IBRD 42647 | SEPTEMBER 2017 <14 14–18 >18–22 >22–26 No data Source: United Nations, World Population Prospects: The 2015 Revision, July 2015. because of the persistently high prevalence of infectious approaches are recommended for the school-age group diseases, including pneumonia, diarrhea, and malaria. and the current policy of testing and treating with The control of infectious diseases therefore remains a Artemisinin-based combination therapy does not critical element of intervention in this age group. appear cost-effective in this age-group (Brooker and In many malaria-endemic areas, successful control others 2017, chapter 14 in this volume; see also programs have reduced the level of transmission sub- Babigumira, Gelband, and Garrison 2017, chapter 15 stantially (Noor and others 2014; O’Meara and others in volume 6). Analyses in this volume (Bundy, Appleby, 2008; WHO 2015). However, since the age pattern of and others 2017, chapter 13) and in volume 6 clinical malaria is determined by the level of transmis- (Fitzpatrick and others 2017, chapter 16) also show sion and the consequent level of acquired immunity that intestinal worm burdens are often greatest in (Carnerio and others 2010; Snow and others 1997), school-age children, and whereas there is broad con- clinical attacks of malaria are becoming more com- sensus on the benefits of treating infected children, mon in older children. In The Gambia, the peak age of there is controversy regarding the most cost-effective hospital admission for severe malaria increased from approach to school-based delivery. In practice, most 3.9 years in 1999–2003 to 5.6 years in 2005–2007 countries use school-based mass treatment—that is, (Ceesay and others 2008); similar changes have been treatment of all children at risk, without prior screen- seen in Kenya (O’Meara and others 2008). This has ing. In 2015, more than 450 million children were created a new challenge for intervention, because treated, and India alone claims to have treated 340 none of the population-based presumptive treatment million children in 2016. 12 Child and Adolescent Health and Development Adolescent Growth Spurt Phase probability of dropping out of school, perhaps leading The pubertal growth spurt is a watershed feature in the to lifelong visual impairment (Graham and others transition from childhood to adolescence, a process that 2017, chapter 17 in this volume). Early adolescence is occurs earlier for girls and that can be modified by also a key phase for promoting lifelong healthy behav- external factors, including diet. The phase may provide iors (World Bank 2006), including oral hygiene and the best opportunity for catch-up growth, with growth good dietary practices. This phase may be particularly velocities reaching equivalence to those of children at sensitive to diet, as it is associated with the emergence age two years. of micronutrient deficiency diseases, such as anemia The growth spurt is a time of rapidly increasing mus- and iodine deficiency. cle, bone, and organ mass, and of high dietary demand. One way of responding to this—providing meals in schools—is arguably the most prevalent publicly funded Essential Package of Interventions for Later resource transfer program worldwide, with some 360 Adolescence million children being fed every school day. A narrow A phase of adolescent growth and consolidation begins focus on health outcomes underestimates the benefits of around 15 years of age, continues into the 20s, and multiple cross-sectoral outcomes, including promoting requires a package of age-specific interventions school participation, especially for girls; providing a (table 1.3). This period has traditionally been viewed productive social safety net in hard-to-reach communi- as socially important but has lacked concerted attention ties; and stimulating rural economies through the pro- as a critical period for health and development. This is an curement of local produce (Drake and others 2017, age when self-agency becomes increasingly important, chapter 12 in this volume). School feeding should be and although the concept of adolescent-friendly health viewed as an option among other transfer programs services has been widely adopted, in reality the quality with multiple outcomes. From a social perspective— and coverage rarely respond to the need, in particular, often taken in economic evaluation—the net cost of a ensuring that adolescents are able to make their own transfer is often close to zero, or the 10 percent to decisions about their health. School-based interventions 15 percent of the total cost that is required for delivery that go beyond the teaching of health education in class- (see discussion of the costs of cash and other transfer rooms and encompass changes to the curriculum and programs from multiple perspectives in chapter 23 in the wider social environment, as well as engagement with this volume, de Walque and others 2017). School feeding families and the community, are more likely to improve can thus be viewed as conditional (because school atten- sexual health, reduce violence, and decrease substance dance triggers the transfer) non-cash transfer programs, abuse (Reavley and others 2017, chapter 18 in this vol- and evaluations suggest that offering school meals typi- ume; Shackelton and others 2016). In the broader popu- cally increases attendance rates by 8 percent (Drake and lation, intersectoral action has been central to public others 2017). From this effect alone, benefit-cost ratios health gains in many countries, including transport sec- of 2 or more can be inferred. tor actions to reduce road traffic injuries and taxes to School-based delivery of vaccination is particularly achieve tobacco control (Elvik and others 2009; Farrelly effective at this age, especially for girls. Tetanus toxoid and others 2013). vaccination lowers the risk of contracting tetanus both With the exception of sexual and reproductive health, for recipients and for the children of adolescent girls, available evidence on preventive interventions derives thus providing an intergenerational benefit. In addition, largely from high-income countries and the United 70 percent coverage of human papillomavirus vaccine States in particular. The social and environmental deter- that is effective over a lifetime could avert more than minants of adolescent health and well-being act at differ- 670,000 cases of cervical cancer in Sub-Saharan Africa ent levels and across different sectors. The most effective over consecutive birth cohorts of girls vaccinated as responses are likely to operate at multiple levels of par- young adolescents (LaMontagne and others 2017, ticular settings (Viner and others 2012). The lives of chapter 15 in this volume). There is evidence that young people are affected by community behavior and school-based vaccination programs can achieve effec- norms as well as by the values of adults and other ado- tive coverage. lescents. Community interventions have commonly Early adolescence is the age when the most com- involved local government, families, youth-focused and mon vision problems—refractive errors—first emerge, religious organizations, and schools. and school-based screening of children in select grades Universal health coverage for adolescents requires is a cost-effective way to detect and correct refractive training health care providers not only to respond to errors of vision that could otherwise increase the specific health problems beyond a focus on sexual and Child and Adolescent Health and Development: Realizing Neglected Potential 13 reproductive health but also to adopt nonjudgmental first 1,000 days, and the two intervention packages for attitudes, to maintain confidentiality, and to engage ages 5–19 years in low- and lower-middle-income with adolescents—while maintaining lines of commu- countries. Table 1.4 summarizes the costs of the essen- nication with families. There needs to be a focus on tial packages to promote health of school-age children addressing the financial barriers that are especially and adolescents. important for adolescents to overcome, such as making Of the three areas, education attracts the largest out-of-pocket payments and finding accessible investment at US$206 billion per year in 2015, much of platforms for health delivery that work for this age which is from the public sector and is intended to provide group. There is growing recognition of the importance pre-primary, primary, and secondary education free at of agency for this age group and of the importance of the point of delivery. The International Commission on identifying approaches to health that enhance decision Financing Global Education Opportunity (2016) calls for making and engagement of adolescents around their governments to increase domestic public expenditures to health and health care. Lack of adolescent agency is support universal provision of primary education in low- particularly common in LMICs. and lower-middle-income countries by 2030, requiring Particularly for girls, the expansion of secondary an increase from 4.0 to 5.8 percent of gross domestic education, which is one of the Sustainable Development product (GDP), which is equivalent to an annual rate of Goals (SDGs) targeted for 2030, offers remarkable growth in public education spending of 7 percent over a opportunities to improve health and well-being. 15-year period. In addition to education interventions, Secondary education is effective in increasing the age at the commission identifies 13 nonteaching interventions marriage and first pregnancy (Verguet and others 2017, as “highly effective practices to increase access and learn- chapter 28 in this volume). Participation in quality sec- ing outcomes,” including three health interventions: ondary education enhances cognitive abilities; improves school feeding, malaria prevention, and micronutrient mental, sexual, and reproductive health; lowers risks for intervention. The achievement of universal secondary later-life noncommunicable diseases; and offers signifi- education by 2030 is a specific Sustainable Development cant intergenerational benefits (Blank and others 2010). Goal and is also cited in the report of the Lancet Secondary schools also provide a platform for health Commission on Adolescent Health and Wellbeing as key promotion that can strengthen self-agency around to adolescent growth and development. health; provide essential health knowledge, including In contrast to these very large public expenditures for comprehensive sexuality education; and help to maintain education, the current annual investment for children lifestyles that minimize health risks. Equally, achieving younger than age five years is an estimated US$28.6 bil- the educational and economic benefits that secondary lion, which includes investments in maternal and new- schools offer requires the avoidance of early pregnancy, born health, as well as child health for children under age infectious diseases, mental disorders, injury-related five years. It is estimated, based on current prices, that the disabilities, and undernutrition. cost of increasing coverage to 80 percent would be an Media messages have particular salience during the additional US$27.3 billion annually (table 1.1). This is adolescent years and provide an essential platform for based on estimates in volume 2 (Black, Walker, and others health action and have proven effective in HICs. 2015) of the cost of the two packages: maternal and new- Adolescents are biologically, emotionally, and develop- born health, and health of children under five. mentally primed for engagement beyond their families, For interventions in the health and development of and the media, particularly social media, offer that children in the age range of 5–19 years in low- and opportunity. Social media may also bring hazards, among lower-middle-income countries, we have no direct the most conspicuous being online grooming, cyberbul- estimate of current expenditure. We present here the lying, and a growing preoccupation with body image, estimated total and incremental costs of providing a and so any intervention has to take these negatives into school-age package and an adolescent package to this account (Durlak, Weissberg, and Dymnicki 2011; age group (table 1.1). We estimate the total cost Farahmand and others 2011; Murray and others 2007). as US$6.9 billion, comprising US$1.4 billion and US$5.5 billion in low- and lower-middle-income countries, respectively (not including HPV vaccina- Economic Analysis of the Essential Packages tion). Assuming that current provision is on the order Table 1.1 summarizes current levels of public invest- of 20 percent to 50 percent of need, this implies an ment in three important areas for child and adolescent incremental need of between US$3.4 billion and health and development in LMICs: basic education US$5.4 billion annually, representing between 0.03 (pre-primary, primary, and secondary), health in the percent and 0.07 percent of GDP, dramatically less 14 Child and Adolescent Health and Development Table 1.4 Cost of Components of Essential Packages to Promote Health of School-Age Children and Adolescents in Low- and Lower-Middle-Income Countries Aggregate Aggregate cost in cost in lower- Approximate cost per low-income middle-income child who benefits (US$) Approximate cost countries countries (US$, in low- and lower-middle- per child (US$) in (US$, millions, millions, per Intervention Mode of delivery income countries relevant age group per year) year) School-age children School feeding programs Meals (fortified with 41 (targeted to 20% of 8.2 per child ages 340 2,400 micronutrients) provided at population in most food- 6–12 years school insecure or poor areas) Health education ITN education delivered only 0.50 per educational message 0.75 per child ages 31 110 (oral health, ITN use) in endemic areas (ITN message delivered only in 6–12 years endemic areas; assumed 50% of children in low- and lower- middle-income countries) Vision screening Prescreening by teachers; 3.6 per child to screen 0.60 per child ages 25 90 vision tests and provision of and provide glasses to the 6–12 years ready-made glasses on site by fraction of the age group eye specialists needing glasses Deworming Medication for soil-transmitted 0.70 per child; 50% of 0.35 per child ages 14 52 helminths or schistosomiasis endemic areas 6–12 years delivered by teachers once a year in endemic areas Tetanus toxoid booster Single-dose booster 2.4 per child 0.40 per child ages 16 59 administered to all children in 6–12 years one grade by nurse or similar health care worker HPV vaccine Part of the cancer essential 10 per fully vaccinated girl 0.83 per child ages 43 74 package (Gavi-eligible countries) 6–12 years Aggregate costs 48 10 430 2,700 without HPV vaccine Aggregate costs without 17 2 130 390 school feeding programs but with HPV vaccine Adolescents Media messages on Messages concerning use of 1 per adolescent 1 per adolescent — — national policy regarding tobacco, alcohol, and illicit ages 10–19 years health drugs; sexual and reproductive health; mental health; healthy eating or physical activity Health education in Education for targeted age 9 per year per adolescent 3 per adolescent 90 450 schools group ages 14–16 years ages 10–19 years Adolescent-friendly Health services offering 5 per adolescent 5 per adolescent 790 2,300 health services respectful and confidential ages 10–19 years access for adolescents Aggregate costs 15 per adolescent ages 9 per adolescent 880 2,700 10–19 years ages 10–19 years Source: Fernandes and Aurino 2017 (chapter 25 in this volume); Horton and others 2017 (chapter 26 in this volume). Note: — = not available; Gavi = Gavi, the Vaccine Alliance; HPV = human papillomavirus; ITN = insecticide-treated bednet. The total cost of the school-age package is about US$10 per child in the 5–14 years age group and about US$9 per adolescent in the 10–19 years age group. Compared with per capita public expenditures on health in 2013 of about US$31, this does not seem unreasonable, but it is high for low-income countries, which spent only US$14 per capita on health in 2013. Child and Adolescent Health and Development: Realizing Neglected Potential 15 than the increments sought for education or for the outcomes and educational attainment (Bundy, Schultz, health programs for children under five years of age. and others 2017, chapter 20 in this volume; Plaut and The single most costly component is school meals, others 2017, chapter 22 in this volume), and between which account for almost half of the additional invest- educational attainment and health outcomes (Pradhan ment required. We have argued earlier that this is a and others 2017). Years of schooling and quality of special case and is neither paid for by the Ministry of schooling (as measured by standardized test scores) Health nor primarily aimed at improving health. It is reduce mortality rates in adults and children. Chapter 30 standard in DCP3 to distinguish between interventions of this volume (Pradhan and others 2017) reports within the health sector and those delivered and research that has recently incorporated both adult mor- financed outside the health sector. School meals, tality outcomes and education quality into the literature. although part of the health package, are intersectoral in If rates of return to educational investments are recalcu- origin. For this reason, table 1.1 shows the costs with lated to take into account reasonable estimates of the and without school meals. See also volume 9 for further value of reducing mortality, the returns to education discussion of this issue (chapter 2 [Watkins, Nugent, increase by about one-third. For example, in and others 2018]). lower-middle-income countries, the estimated internal Taken together, these analyses suggest two important rate of return to one additional year of education conclusions for investing in health in the 5 to 19 age increases from 7.0 percent to 9.3 percent if the effect of group. It is apparent that education investments domi- education on mortality is included. In this volume we nate all other public investments in human development explore both of these directions of influence. during the first two decades of life. Using our estimates of current expenditure, the current costs of providing access in low- and lower-middle-income countries to Health, Education, and Social Outcomes basic education and a health care services package for Exposing young children to drought and social shocks in under-fives (including maternal and newborn health) Zimbabwe was shown to adversely affect height in ado- are US$206 billion and US$28.6 billion, respectively. The lescence, which, in turn, adversely affected schooling cost of the additional essential health and development (Alderman, Hoddinott, and Kinsey 2006). Effect sizes packages for those ages 5–19 years are between US$1.4 were large: if individuals had reached median height for billion and US$3.4 billion, respectively. Given that the age, they would have been 3.4 centimeters taller, started latter two health and development investments underpin school six months earlier, and have achieved an addi- those in education, it seems difficult to justify investing tional 0.85 years of schooling. There are also some trials in education without making the complementary invest- in low- and middle-income countries that indicate ments in health and human development for this age impact: for example, young children with better diets in group, especially given the comparatively low cost of the the Philippines did better in school than their less- health and development packages. The modest cost of advantaged siblings (Glewwe, Jacoby, and King 2001). the two packages suggests that scaling up the health Micronutrient deficiencies (particularly of iodine and packages for those ages 5–19 is therefore a high return iron, both known to affect cognition) have adverse and low-cost investment that addresses the most pressing effects on grade repetition and scores on cognitive tests development needs throughout the first two decades (surveyed by Alderman and Bleakley 2013). In contrast, of life. a recent systematic review, largely in LMICs, provides a more ambiguous picture of the impact of school-based interventions (Snilstveit and others 2015). We now rec- HEALTH AND EDUCATION: TWO SIDES OF ognize that development outcomes are crucially depen- dent upon the age-specific timing of intervention and THE SAME COIN upon the duration of follow-up. This is an area This volume makes a strong case for providing both where longitudinal studies are particularly important education and health services during middle childhood but are currently rare. Chapter 7 of this volume and adolescence. The view that education and health are (Alderman and others 2017) uses the lifecycle approach separate silos in human development reflects an admin- to assess the benefit-cost ratios of interventions in nutri- istrative and bureaucratic reality but does not best serve tion and child development in LMICs where nutrition is the needs of the growing child and adolescent. The com- a risk factor, with a focus on the first five years of life. mon sense view that growing children need both health Chapter 12 (Drake and others 2017) summarizes the and education—mens sana in corpore sano—is supported effects of school feeding programs (which alleviate hun- by the evidence for strong links between health ger) on improved school attendance and test scores. 16 Child and Adolescent Health and Development Chapter 27 (Nandi and others 2017) discusses the long- presence of access to new markets, new seeds, or new term human capital and economic benefits of early-life crops, educated farmers quickly surpass illiterate farm- interventions. ers, but in closed, stagnant economies, formal education Chapter 14 in this volume (Brooker and others confers no advantage (Schultz 1993). 2017) reviews the effect of malaria on education. Rapidly changing knowledge and greater access to Randomized controlled trials found that treatment of powerful drugs and vaccines should have led education malaria reduced absenteeism and that treatment pro- to play an important role in halving the mortality rate for vided in childhood improved schooling attainment adolescents and adults 15–60 years of age around the in adolescence; in two countries, schoolchildren receiv- world in the half century since 1970. But rates of decline ing malaria prophylaxis had better attention spans. varied markedly from country to country. Why such Chapter 13 (Bundy, Appleby, and others 2017) and variation? For child mortality, variation in income growth chapter 29 (Ahuja and others 2017) emphasize the explained a modest amount of cross-country differences importance of deworming for education. (Jamison, Murphy, and Sandbu 2016). The number of Uncertainty about the appropriate metrics is one available medical professionals explained more, and the reason the scale of the contribution of ill health to unre- pace at which some countries were able to adopt power- alized cognitive attainment, and hence learning, is poorly ful and low-cost child survival technologies explained understood. Both the WHO and IHME estimate the even more. About 9 percent of the reduction in child effect of ill health on cognition using a threshold mortality from 1970 to 2000 in LMICs resulted from approach, typically the proportion of the affected popu- increased levels of education, as discussed in chapter 30 lation that scores below some threshold—for example, (Pradhan and others 2017). an intelligence quotient (IQ) of 75, indicative of severe Similarly, strong controls for country-specific effects cognitive disability. A more informative metric would be in both the level and the rate of change of child and adult some population level metric of the extent to which mortality resulted in education effects that were quanti- individuals reach their cognitive potential, analogous to tatively and statistically highly significant (Pradhan and the assessment of anthropometric status. There is also a others 2017, chapter 30 in this volume). This study sug- need for an impact model that takes into account the gests that education’s effects on adult mortality rates are overlapping benefits of multiple interventions. Given about the same as the effects on child mortality (around the secular trend for IQ scores to drift upward (Flynn 2–3 percent reduction per additional year of education 2007), it might be helpful to estimate the extent to which and per one standard deviation improvement in test improved health will contribute to the achievement of scores). If rates of return to educational investments are cognitive potential. recalculated to take into account reasonable estimates of the value of mortality reduction, the returns to educa- tion increase by about one-third. For example, in lower- Education and Health Outcomes middle-income countries, the estimated internal rate of An extensive literature documents the correlation return to one additional year of education increases between higher levels of education and lower levels of from 7.0 to 9.3 percent if the effect of education on mortality, illness, and health risk. The earliest data mortality is included. showed no association: in the late nineteenth century, mortality levels of individuals with high education were no lower than those of individuals with little education. RESEARCH AND DEVELOPMENT PRIORITIES However, by the early twentieth century, U.S. census data revealed a strong association between health and The analyses presented here suggest some priorities for education. This transition has been attributed to the future research, with a focus on longer-term periods of scientific revolution launched by Koch and Pasteur with observation that will capture developmental outcomes, the germ theory of disease, which gave households and assessment of multiple and complementary interven- states practicable means of interrupting the transmis- tions, and, most important, a greater focus on children sion of infectious disease (Preston and Haines 1991). in middle childhood and adolescents. Specifically, future Without such knowledge, an educated person could do research should take into account the following issues. little more than could an illiterate compatriot, but the more educated person learned about and adopted the 1. Collect better data on health and development needs in newly available science from Europe much more quickly. the 5 to 21 age range. As shown in annex 1A, there has This conclusion has close parallels with research on the been a strong research focus on the health and devel- value of education to economic productivity: in the opment of children under five and a concomitant Child and Adolescent Health and Development: Realizing Neglected Potential 17 relative absence of research on the needs of children 8. Estimate the scale of the contribution of disability to in middle childhood and adolescence. There is a par- development. Children with disabilities are less able ticular lack of information on children five to nine to benefit from prosperity, and disability remains years of age. a largely hidden topic. This is particularly true of 2. Pilot and evaluate packages of interventions for middle mental health challenges in low-income countries childhood and adolescence. The packages proposed and LMICs, and even more so of behavioral and in this volume are based on the published literature social challenges, including autism. IHME estimates for the individual interventions. In many cases, the suggest that one in six children ages 5–19 years is evidence is partial and overly reliant on experiences severely or very severely disabled. in high-income countries. This suggests a need to carefully pilot and evaluate the packages under local In reviewing these research issues, two short-term circumstances before going to scale. responses could be quickly implemented if there is to be 3. Conduct more long-term longitudinal studies. Most of a serious effort to understand the health and develop- the available analyses are too short term (typically ment needs of middle childhood and adolescence: less than a year) to provide useful guidance on devel- (1) support existing longitudinal studies to define returns opment, which is inherently a long-term issue. To be on interventions in middle childhood and adolescence, useful, studies need to track outcomes over multiple and (2) extend current mortality surveillance tools to years. A key question concerns the relative impor- include those ages 5–19 years. tance to development outcomes of intervention at In this volume, we propose intervening during ages different phases. that have not traditionally been given policy priority, 4. Measure multiple outcomes of interventions. Studies especially in low-income countries. Developing an generally assess a single or a few outcomes, whereas appropriate response will require stronger investment the focus of development is inherently multisectoral in implementation research that addresses the specific and multifactorial. In particular, more studies are needs of middle childhood and adolescence. A poten- needed that simultaneously assess physical growth tial way to move forward efficiently would be to and cognitive development to assess the mutual expand the age range and interventions explored in benefits for health and education outcomes. current research models designed to assess develop- 5. Track mortality beyond age 5. The new evidence that mental outcomes longitudinally. Examples include the mortality is higher than recognized in those ages 5–14 20-year-old Matlab Health and Socioeconomic Survey indicates a need for more clarity about appropriate in Bangladesh; the 40-year-old Medical Research survival interventions for this age group. A starting Council Keneba study in The Gambia; and the 15-year- point in middle childhood would be to assess the old Young Lives studies in Ethiopia, India, Peru, and applicability of interventions that have proved suc- Vietnam, all of which are still ongoing. One of the key cessful in reducing the mortality of children under questions might be, what intervention is necessary to five; however, the causes of death are likely to be quite achieve remediation for children who slipped through different for older adolescents, in particular. the early safety net? 6. Examine the social dimensions of intervention in The burden of mortality and serious disease in the childhood and adolescence. The social ecology of 5–19 age group is substantially higher than had been children’s lives is poorly understood, especially in realized. During the Millennium Development Goals low- and lower-middle-income countries. There era, there was notable success in reducing under-5 is a specific need for locally relevant research on mortality, and a key contributor was the creation of the importance of families and teachers and of the two new mechanisms for tracking mortality in chil- gender context. dren in this age group: the United Nations Inter- 7. Understand biological differences as a development agency Group for Child Mortality Estimation, which issue. There are sex differences in growth and devel- provides current child mortality estimates through opment. For example, pubertal development differs the Child Mortality Estimation database; and the by sex, so the timing of the growth spurt and the Child Health Epidemiology Reference Group, which accompanying physiological changes also happen on develops improved evidence on the causes of child a different timeline and scale. We now know that large mortality. If the world is to be similarly successful in differences are also apparent in brain development, addressing mortality in older children, there will yet we know little of the implications for behavioral need to be a similarly strong evidence-based approach intervention. to mortality in ages beyond five. This could be 18 Child and Adolescent Health and Development achieved if both of these groups extended the age contributed about 30 percent of the observed decline range up to 21 and engaged with the research and in maternal mortality since 1990. However, the health public health communities working with these older of school-age children and adolescents, especially in age groups. low- and lower-middle-income countries, is an impor- tant determinant of education outcomes, having con- sequences for both education access and learning. The CONCLUSIONS analyses presented here for the first 8,000 days indi- Although the current investment focus on the first 1,000 cate that investments in health leverage education days of human development is necessary, it is not outcomes, and investments in education leverage enough. The narrow focus on investing in health in the health. earliest childhood years underserves our children and The current world view is that education is a high adolescents by failing to support their development at priority and that the MDGs have helped ensure near- other critical phases during the first two decades of life universal access to free primary education that is free and by failing to secure the early gains. This unbalanced at the point of delivery. One of the new Sustainable approach has not only resulted in a neglect of health Development Goals is to achieve the same for service provision after the first 1,000 days but has also secondary education. There is also increasing recogni- deflected research away from middle childhood and tion that the RMNCH (reproductive, maternal, new- adolescence. born and child health) demands of the 1,000 days The issue is not that the first 1,000 days are less should also be viewed as a high priority. Here we important than previously thought, but rather that the argue that, for similar reasons, the incremental costs subsequent 7,000 days before the child reaches age 21 of addressing health and development needs during have much greater importance than has been middle childhood and adolescence should be viewed recognized. Based largely on cost-effectiveness and in the same way. Our calculations suggest that the benefit-cost analyses, we have identified two essential proposed essential packages are a practical and afford- packages of interventions that together can help address able investment, even for LMICs. Based on current these health and development demands in middle expenditures world-wide in LMICs, the annual cost of childhood and adolescence. A school-age package, providing access to health care for children under five largely built around school-based delivery, can address is US$28.6 billion, and the cost of providing primary many of the needs during middle childhood and the education is US$206 billion. For the same countries, adolescent growth spurt. An adolescence package, built the estimated incremental cost of the essential health both around the school and around access to non- and development packages for ages 5 to 19 would add stigmatizing, affordable, and confidential health care, between US$1.4 billion and US$3.4 billion. This is a can help further address the needs during the adolescent small increment to leverage the existing investments growth spurt and the very particular needs of later in early childhood and education and to secure the adolescence. The purposes of the two packages overlap, health and development of the next generation. Given as do the age ranges of the target populations, and so the current levels of development assistance and both packages are required to support development domestic investment in both the first 1,000 days and through middle childhood and adolescence. It is impor- in education, there would seem to be a strong eco- tant to recognize that the school and the education sec- nomic case for leveraging these investments with tor are key participants in these processes, both by critical, but more modest, health investments during providing an infrastructure for delivery and, just as the next 7,000 days, with benefits for equity, for real- important, by providing the learning, understanding, izing individual potential, and for maximizing the and life skills that have contributed, for example, about opportunities for the next generation. 30 percent of the observed decline in maternal mortality The implication is that public policy needs to align since 1990. with parental commitments and to the commitment to There are powerful opportunities for synergy addressing health, development, and education through between health and education that are currently the first two decades of life. More countries already underexploited. The school and the education sector emphasize the social and legal importance of the should be recognized as key participants in promoting 21st birthday, and our analyses suggest that it is neces- health, both by providing an infrastructure for deliv- sary and affordable for all countries to translate that ery and, just as important, by providing the learning, commitment into practical investments in middle child- understanding, and life skills that, for example, have hood and adolescence. Child and Adolescent Health and Development: Realizing Neglected Potential 19 ANNEX and Development, edited by D. A. P. Bundy, N. de Silva, S. Horton, D. T. Jamison, and G. C. Patton. Washington, The annex to this chapter is as follows. It is available at DC: World Bank. http://www.dcp-3.org/CAHD. Black, M., A. Gove, and K. A. Merseth. 2017. “Platforms to Reach Children in Early Childhood.” In Disease Control Priorities • Annex 1A. Analysis of Published Literature Describing (third edition): Volume 8, Child and Adolescent Health Health and Mortality, Ages 0–19 Years and Development, edited by D. A. P. Bundy, N. de Silva, S. Horton, D. T. Jamison, and G. C. Patton. Washington, DC: World Bank. Black, R., R. Laxminarayan, M. Temmerman, and N. Walker, NOTE editors. 2015. Disease Control Priorities (third edition): World Bank Income Classifications as of July 2014 are as Volume 2, Reproductive, Maternal, Newborn, and Child follows, based on estimates of gross national income (GNI) Health. Washington, DC: World Bank. per capita for 2013: Black, R., N. Walker, R. Laxminarayan, and M. Temmerman. 2015. “Reproductive, Maternal, Newborn, and Child • Low-income countries (LICs) = US$1,045 or less Health: Key Messages of This Volume.” In Disease • Middle-income countries (MICs) are subdivided: Control Priorities (third edition): Volume 2, Reproductive, a) lower-middle-income = US$1,046 to US$4,125 Maternal, Newborn, and Child Health, edited by R. Black, b) upper-middle-income (UMICs) = US$4,126 to US$12,745 R. Laxminarayan, M. Temmerman, and N. Walker. • High-income countries (HICs) = US$12,746 or more. Washington, DC: World Bank. Blakemore, S. J., and K. L. Mills. 2014. “Is Adolescence a Sensitive Period for Sociocultural Processing?” Annual Review of Psychology 65 (January): 187–207. REFERENCES Blank, L., S. Baxter, E. Goyder, P. Naylor, L. Guillaume, Ahuja, A., S. Baird, J. Hamory Hicks, M. Kremer, and E. 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Jamison INTRODUCTION summarizes the findings in Hill, Zimmerman, and During the past 15 years, the attention of the Jamison (2015) on gender-specific mortality risks and international community, as reflected in the Millennium numbers of deaths by World Bank geographical region Declaration and its associated Development Goals for ages 5–9 years and 10–14 years for 1990 and 2010, (UN 2000), has focused on the health of children under and on the rates of change in these risks and numbers age five years and of adults. Adolescents and children during the two decades. It then extends these findings older than age five years have been relatively neglected. to ages 15–19 years. The chapter concludes by reporting However, publication of the report of a Lancet the World Health Organization’s (WHO) estimates of Commission on Adolescent Health and Wellbeing percentage of deaths by broad cause of death category. (Patton and others 2016), as well as the essays in this We do not discuss risk factors or potential interven- volume, suggest the beginning of serious concern for tions. Definitions of age groupings and age-specific this neglected age group. terminology used in this volume can be found in Mortality rates provide the most significant single chapter 1 (Bundy and others 2017). indicator of health, but two publications (UN 2014; The age range of 5–19 years encompasses the inflection Wang and others 2012) have arrived at different esti- point of human mortality risks, with infectious disease mates of numbers of deaths in the age 5–19 years range. mortality declining from the high risks of early child- Both the UN and Wang studies use models to generate hood before noncommunicable disease risks start their mortality estimates. This chapter reviews and expands exponential increase in adulthood. Despite being a on a third set of estimates of mortality rates and num- healthy age range relative to all others, the number of bers of deaths in those ages 5–19 years in low- and deaths exceeded an estimated 2 million in 2010. This age middle-income countries (LMICs) for 1990 and 2010 range is also crucial for human development. In most (Hill, Zimmerman, and Jamison 2015). The purpose of societies, it covers the large majority of educational the Hill, Zimmerman, and Jamison (2015) study was to attainment; in many societies, it also covers the start of generate empirical estimates of mortality rates to check family formation (Sawyer and others 2012; UNICEF against the modeled numbers from UN (2014) and 2012). This chapter attempts to ground this volume’s Wang and others (2012). It compares and contrasts the discussion of these larger issues with a reminder that empirical estimates with those from the two previous the mortality reduction agenda remains unfinished and modeling exercises. More specifically, the chapter substantial. Corresponding author: Kenneth Hill, Stanton-Hill Research, Moultonborough, NH, United States; kenneth_hill_1@yahoo.com. 25 MORTALITY AT AGES 5 TO 19 YEARS China is the most notable exception. Given the impor- tance of China for global estimates, we adopted a differ- Methods and Data ent estimation strategy for that country, using census The methodology used by Hill, Zimmerman, and data from 1990 and 2010, adjusted for coverage. Because Jamison (2015) to develop the new estimates is fully the DHS program does not cover all LMICs, and because described in their paper and summarized here. The individual countries are represented in the dataset for empirical basis for their estimates is the full birth histories some years and not others, we adopted a model-based collected by Demographic and Health Surveys (DHS) estimation method. We used the empirical survey-specific (Rutstein and Rojas 2006) in more than 70 LMICs. These dataset to estimate relationships between risks of dying full birth histories—which consist of information on at ages 5–9, 10–14, and 15–19 years to the under-5 dates of birth, survival status, and age at death if relevant mortality rate (U5MR), and then applied those relation- for all live births of a representative sample of women of ships to regional estimates of U5MR in 1990 and 2010, reproductive age—are the primary source of information as produced by the Interagency Group on Mortality on mortality under age five years in LMICs, given that Estimation (UN 2014). most of these countries lack accurate civil registration The empirical dataset is derived from 213 surveys systems (UN 2014). Because the birth histories collect covering 77 countries; the earliest survey is from 1986, data on all births, and deaths to those births at all ages, and the latest is from 2011. Before turning to modeled they provide information, albeit increasingly selected by estimates, it is of interest to examine the empirical obser- age of mother, about the mortality of older children and vations themselves. Table 2.1 reports the mean mortality adolescents. The method used to estimate mortality risks risks for both genders for ages 0–4, 5–9, 10–14, and for ages five years and older is the same as that used for 15–19 years, as calculated for the 10 calendar years before mortality under age five years (Hill 2013). The numbers each survey. Across all observations, which are weighted of deaths are much smaller above age 5 years, and partic- toward Sub-Saharan Africa because of the geographic ularly above age 10 years, than below, however, and esti- distribution of the DHS, the median U5MR is 85.6 per mates have been calculated for the 10 calendar years 1,000 live births; the risk of dying for ages 5–9 years is before each survey. 15.8 per 1,000 survivors to age 5 years; the risk of dying Although the coverage of the DHS program has been for ages 10–14 years is 9.3 per 1,000 survivors to age 10; wide, not all countries have conducted such surveys; and the risk of dying for ages 15–19 years is 11.7 per Table 2.1 Median Conditional Probabilities of Dying per 1,000 at Ages 0–4, 5–9, 10–14, and 15–19 Years, Estimated from DHS by World Bank Region World Bank Low- and Middle-Income Country Regions East Asia Latin America and Pacific, Europe and and the Middle East and Sub-Saharan All excluding China Central Asia Caribbean North Africa South Asia Africa Number of DHS analyzed 213 17 14 40 17 17 108 Age range (years) 0–4 80 42 39 53 44 69 110 (50, 113) (39, 72) (19, 49) (35, 74) (34, 75) (53, 81) (85, 138) 5–9 13 9.4 3.2 5.6 4.3 12 23 (6.6, 23) (7.0, 13) (1.6, 3.7) (3.4, 8.1) (3.2, 8.5) (8.5, 18) (15, 30) 10–14 7.5 5.8 2.4 4.3 4.0 5.7 13 (4.2, 13) (4.5, 6.4) (1.8, 3.3) (2.9, 5.8) (2.5, 5.8) (5.2, 7.7) (9.0, 16.2) 15–19 10 8.1 5.1 8.5 5.6 9.0 14 (7.1, 15) (6.3, 9.5) (2.6, 7.3) (5.6, 10) (4.3, 7.4) (7.1, 11) (11, 20) Note: Numbers in parentheses are the 25th and 75th percentiles. DHS = Demographic and Health Surveys. 26 Child and Adolescent Health and Development 1,000 survivors to age 15. The risks are highest in Sub- regressing survey-specific mortality risks for ages 5–9, Saharan Africa in all age ranges; in this region, these risks 10–14, and 15–19 years on the U5MR, and then esti- are also higher relative to the U5MR. mated regional risks for 1990 and 2010 using regional estimates of U5MR. The models relating mortality at ages 5–9 and 10–14 years are statistically much stronger Results: Mortality Risks than the model for mortality at ages 15–19 years. This Across all regions, the lowest risk is in ages 10–14 years. occurs partly because of smaller numbers of recorded The increase in risk from 10–14 to 15–19 years is sub- deaths at ages 15–19 years, but also partly because the stantially larger in two regions, Latin America and the relationship itself seems to be more variable across Caribbean, and Europe and Central Asia. To bring out countries, so the estimates for ages 15–19 years are the relationships between risks in different age groups, substantially more uncertain. figure 2.1 plots the risk of dying, for both genders com- Given its size and importance in any regional or global bined, at ages 10–14 against 5–9 years, and 15–19 against estimates, we adopted a different approach for China. 10–14 years. The risk at 10–14 years is lower than that at Following the work of Banister and Hill (2004), we used 5–9 years in almost all cases; risk at 15–19 years is gener- information on population and deaths by age from the ally higher than at 10–14 years, although there are Chinese population censuses of 1990 (National Bureau numerous exceptions. The risk at 15–19 years relative to of Statistics 1993) and 2010 (National Bureau of Statistics that at 10–14 years seems to increase at lower mortality 2012), after adjustment for estimated undercoverage of levels and thus presumably at higher levels of economic deaths, and calculated mortality risks directly. development. Table 2.2 shows the regional mortality risks by gender Figure 2.2 shows empirical relationships by gender for ages 5–9, 10–14, and 15–19 years for 1990 and 2010 for all three age ranges. Patterns are less clear than in derived from the regression equations outlined; the table figure 2.1, but further analysis through paired t-tests of also shows the annual average rates of change between the basic observations indicates that male mortality risks 1990 and 2010. For all LMICs, the probabilities of dying are higher than female risks in each age range, by about per 1,000 survivors at the beginning of the age intervals 12 percent for ages 5–9 years, 8 percent for 10–14 years, 5–9, 10–14, and 15–19 years decline from 16 to 8, from and 6 percent for 15–19 years; the first two differences 8.5 to 5.5, and from 11.5 to 8.0, respectively. Overall, and are significant at 1 percent or higher, but the third misses in all geographic areas studied except China, declines significance at the 10 percent level. Once again, there is have been fastest for ages 5–9 years, and slowest for some indication that the pattern changes at low levels of ages 15–19 years. In China, declines were fastest for ages mortality toward larger male disadvantages. 5–9 years but slowest for ages 10–14 years, with a notably To obtain estimates for regions that include some rapid decline of more than 6 percent per year for females countries that have not conducted surveys or have not ages 15–19 years. Across all regions and all age ranges, conducted them consistently, we estimated models by the declines were faster for females than for males. Figure 2.1 Observed Probabilities of Dying at Ages 10–14 versus Ages 5–9 Years, and at Ages 15–19 versus Ages 10–14 Years, Both Genders a. Ages 10–14 years versus 5–9 years b. Ages 15–19 years versus 10–14 years 0.1 0.1 Mortality risk between ages Mortality risk between ages 15 and 19 (log scale) 0.03 0.03 10 and 14 (log scale) 0.01 0.01 0.003 0.003 0.001 0.001 0.0003 0.001 0.003 0.01 0.03 0.1 0.001 0.003 0.01 0.03 0.1 Mortality risk between ages 5 and 9 (log scale) Mortality risk between ages 10 and 14 (log scale) Observed Equivalence Mortality at Ages 5 to 19: Levels and Trends, 1990–2010 27 Figure 2.2 Observed Probabilities of Dying by Gender: Ages 5–9, 10–14, and 15–19 Years a. Ages 5–9 years b. Ages 10–14 years 0.1 0.1 Male probability of dying Male probability of dying ages 10 to 14 (log scale) ages 5 to 9 (log scale) 0.03 0.03 0.01 0.01 0.003 0.003 0.001 0.001 0.0005 0.001 0.003 0.01 0.03 0.001 0.003 0.01 0.03 Female probability of dying ages 5 to 9 (log scale) Female probability of dying ages 10 to 14 (log scale) c. Ages 15–19 years 0.1 Male probability of dying ages 15 to 19 (log scale) 0.03 0.01 0.003 0.001 0.001 0.003 0.01 0.03 0.1 Female probability of dying ages 15 to 19 (log scale) Observed Equivalence Table 2.2 Estimated Conditional Probabilities of Dying at Ages 5–9, 10–14, and 15–19 Years, by Gender: World Bank Regions, Annual Average Rates of Change, 1990 and 2010 Probabilities of Dying per Survivor to Beginning of Age Group Males Females World Bank region Year 5 to 9 10 to 14 15 to 19 5 to 9 10 to 14 15 to 19 East Asia and Pacific 1990 0.011 0.0068 0.0093 0.0098 0.0061 0.0086 (excluding China) 2010 0.0048 0.0039 0.0059 0.0038 0.0033 0.0051 Annual rate of change (percent) −4.3 −2.8 −2.3 −4.7 −3.1 −2.6 Chinaa 1990 0.0043 0.0032 0.0056 0.0035 0.0026 0.0051 2010 0.0020 0.0020 0.0029 0.0014 0.0013 0.0014 Annual rate of change (percent) −4.0 −2.3 −3.3 −4.7 −3.6 −6.3 Europe and Central 1990 0.0085 0.0055 0.0079 0.0069 0.0046 0.0069 Asia (low and middle 2010 0.0037 0.0032 0.0050 0.0028 0.0025 0.0042 income) Annual rate of change (percent) −4.2 −2.8 −2.3 −4.5 −3.0 −2.5 table continues next page 28 Child and Adolescent Health and Development Table 2.2 Estimated Conditional Probabilities of Dying at Ages 5–9, 10–14, and 15–19 Years, by Gender: World Bank Regions, Annual Average Rates of Change, 1990 and 2010 (continued) Probabilities of Dying per Survivor to Beginning of Age Group Males Females World Bank region Year 5 to 9 10 to 14 15 to 19 5 to 9 10 to 14 15 to 19 Latin America and 1990 0.0085 0.0054 0.0078 0.0068 0.0045 0.0069 the Caribbean 2010 0.0031 0.0028 0.0045 0.0024 0.0023 0.0039 Annual rate of change (percent) −5.0 −3.4 −2.8 −5.1 −3.4 −2.8 Middle East and 1990 0.010 0.0064 0.0088 0.0094 0.0059 0.0084 North Africa 2010 0.0038 0.0033 0.0051 0.0032 0.0029 0.0046 Annual rate of change (percent) −4.9 −3.3 −2.7 −5.4 −3.7 −3.0 South Asia 1990 0.022 0.012 0.014 0.023 0.012 0.014 2010 0.0097 0.0068 0.0089 0.010 0.0070 0.0091 Annual rate of change (percent) −4.1 −2.8 −2.3 −4.1 −2.8 −2.3 Sub-Saharan Africa 1990 0.037 0.018 0.019 0.032 0.016 0.018 2010 0.019 0.012 0.013 0.017 0.010 0.012 Annual rate of change (percent) −3.2 −2.1 −1.7 −3.2 −2.2 −1.8 Total, low- and 1990 0.017 0.0095 0.012 0.016 0.0074 0.011 middle-income 2010 0.0088 0.0063 0.0084 0.0081 0.0049 0.0080 countries Annual rate of change (percent) −3.2 −2.0 −1.7 −3.3 −2.1 −1.8 a. Estimates for China are based on populations and numbers of deaths recorded in the 1990 and 2010 Population Censuses, adjusted as described in the text. The rates of decline were slowest in Sub-Saharan Africa 10 calendar years before each survey), using country and generally fastest in Latin America and the Caribbean fixed effects. These regressions confirmed the broad and the Middle East and North Africa, although China patterns of the results in table 2.2. The rates of decline had the fastest declines at ages 15–19 years. were fastest for ages 5–9 years (about 3 percent per The rates of decline for all LMICs are similar to, or year), and slowest for ages 15–19 years (about 1 percent even slower than, the rates of decline for Sub-Saharan per year), although significantly different from zero for Africa, the worst performing region. This statistical odd- all groups except males ages 15–19 years; in each age ity arises because Sub-Saharan Africa had the highest range, rates of decline were faster for females than for risks in both periods, had the slowest rates of decline, males. Not surprisingly, the results are not identical to and sharply increased its proportional representation those in table 2.2; there are likely to be unobserved among all LMICs because of rapid population growth at factors determining the selection of countries into these ages. the set in which at least two DHS have been conducted. To confirm that the regional changes in mortality However, the broad support of the basic observations risks by gender and age range were not merely an arti- for the results in table 2.2 is reassuring. fact of the model, reflecting primarily the Interagency The results of an additional analysis drawing on survey Group on Mortality Estimation changes in U5MR, we data from those 34 countries that conducted two DHS regressed the (logged) original observations derived separated by about 10 years (specifically by between 9 directly from DHS data on the year of the survey and 11 years), the first one in 2000 or earlier, the second (the observations are of average mortality risks for the in 2001 or later, are shown in figure 2.3, which plots Mortality at Ages 5 to 19: Levels and Trends, 1990–2010 29 Figure 2.3 Changes in Probabilities of Dying by Age Group, 1990s and 2000s: Countries with DHS about 10 Years Apart in Each Decade (N = 27) a. Decadal change in risk of dying, ages 5–9 years b. Decadal change in risk of dying, ages 10–14 years 0.1 Risk of dying in 2000s (log scale) Risk of dying in 2000s (log scale) 0.03 0.03 0.01 0.01 0.003 0.003 0.001 0.003 0.01 0.03 0.1 0.001 0.003 0.01 0.03 Risk of dying in 1990s (log scale) Risk of dying in 1990s (log scale) c. Decadal change in risk of dying, ages 15–19 years Risk of dying in 2000s (log scale) 0.03 0.01 0.003 0.001 0.001 0.003 0.01 0.03 Risk of dying in 1990s (log scale) Males Females Equivalence Note: DHS = Demographic and Health Surveys. mortality risk in the later survey against that in the ear- The numbers of deaths were estimated by converting lier, for each age range. For ages 5–9 years, the risks from the probabilities of dying in table 2.2 into age-specific the second survey are almost universally lower than mortality rates using standard demographic methods those from the first; for ages 15–19 years, a large majority (Preston, Heuveline, and Guillot 2001), and then fits the same pattern. For ages 10–14 years, however, applying those rates to regional populations as there is more scatter, and the pattern is less clear; before estimated by the United Nations Population Division over-interpreting this result, it is important to remember (UN 2013). The resulting numbers are simply the that the number of deaths is lowest in this age group and product of population size and risk of dying, and the sampling errors are largest. percentage changes reflect the changes in both of these factors. The total number of deaths in LMICs between ages 5 Results: Number of Deaths and 19 years fell from 3.3 million in 1990 to 2.3 million Table 2.3 repeats the general format of table 2.2 but in 2010; male deaths exceeded female deaths by an esti- reports numbers of deaths in 1990 and 2010 and mated 11 percent in 1990 and 15 percent in 2010. The annual rates of change by gender, age range, and region. largest number of deaths in both 1990 and 2010 was in 30 Child and Adolescent Health and Development Table 2.3 Estimated Numbers of Deaths at Ages 5–9, 10–14, and 15–19 Years by Gender: World Bank Regions, with Annual Average Rates of Change, 1990 and 2010 Annual Numbers of Deaths (Thousands) Males Females World Bank region Year 5 to 9 10 to 14 15 to 19 5 to 9 10 to 14 15 to 19 East Asia and Pacific 1990 69 39 50 58 34 45 (excluding China) 2010 30 24 35 23 19 30 Annual rate of change (percent) −4.2 −2.5 −1.7 −4.7 −2.8 −2.0 Chinaa 1990 45 32 69 33 25 59 2010 15 17 31 9 9 14 Annual rate of change (percent) −5.5 −3.3 −4.0 −6.6 −5.0 −7.2 Europe and Central 1990 31 19 25 24 15 21 Asia (low and 2010 10 8 15 7 6 13 middle income) Annual rate of change (percent) −5.9 −4.1 −2.5 −6.3 −4.4 −2.7 Latin America and the 1990 46 28 36 36 23 31 Caribbean 2010 18 16 25 13 13 21 Annual rate of change (percent) −4.8 −2.8 −1.9 −4.9 −2.9 −2.0 Middle East and 1990 35 19 22 31 17 20 North Africa 2010 13 11 17 10 9 15 Annual rate of change (percent) −5.1 −2.8 −1.1 −5.5 −3.1 −1.3 South Asia 1990 340 160 170 330 160 160 2010 170 120 150 160 110 140 Annual rate of change (percent) −3.4 −1.6 −0.65 −3.5 −1.7 −0.68 Sub-Saharan Africa 1990 280 120 100 240 100 94 2010 250 130 130 210 110 110 Annual rate of change (percent) −0.72 0.42 0.97 −0.85 0.32 0.88 Total, low- and 1990 850 410 470 760 370 430 middle-income 2010 500 320 400 430 280 350 countries Annual rate of change (percent) −2.6 −1.1 −0.89 −2.8 −1.5 −1.1 a. Numbers of deaths for China are based on numbers of deaths recorded in the 1990 and 2010 Population Censuses, adjusted as described in the text. ages 5–9 years, although this age group also experienced deaths in 1990, but it was overtaken by Sub-Saharan the fastest rate of decline between those two years; ages Africa in 2010 except in ages 15–19 years. These two 10–14 years recorded the smallest number of deaths, and regions together accounted for almost 70 percent of all ages 15–19 years showed the slowest rate of decline from deaths in LMICs between ages 5 and 19 years in 1990, 1990 to 2010. South Asia had the highest number of and almost 80 percent in 2010. Mortality at Ages 5 to 19: Levels and Trends, 1990–2010 31 Comparison with Other Studies LMICs for ages 10–14 and 15–19 years, although the Hill, Table 2.4 puts the estimates in this chapter of numbers Zimmerman, and Jamison (2015) numbers are higher of deaths in 2010 in the context of global estimates for LMIC deaths at ages 5–9 years, but lower for Sub- arrived at by the Global Burden of Disease (GBD) Saharan Africa at ages 10–14 and 15–19 years. The WPP exercise (Wang and others 2012) and the United and Hill, Zimmerman, and Jamison (2015) numbers are Nations Population Division (UN 2013). We only higher than the GBD estimates for every age-region compared numbers for the world as a whole, for combination in table 2.4. Hill, Zimmerman, and Jamison LMICs, and for Sub-Saharan Africa because the three (2015) hypothesize that the differences between GBD exercises define regions differently. We arrived at and the other estimates at ages 5–14 years result from the GBD estimates for LMICs by subtracting the sum the model life table system used in constructing the GBD of deaths in ages 5–9, 10–14, and 15–19 years for estimates. high-income Asia and Pacific, Australasia, Central Europe, Western Europe, and high-income North America from global deaths in those age groups; for DEATHS BY CAUSE Sub-Saharan Africa, we summed deaths for Central, We report also in this chapter on deaths by cause. We Eastern, Southern, and Western Sub-Saharan Africa. develop no new estimates but instead rely on the WHO’s The World Population Prospects (WPP) tabulates Global Health Estimates (GHE) for 2012 (WHO 2013). deaths by age group and five-year period only for We report only for the age range 5–14 years because 1995–2000, 2000–05, and 2005–10 (UN 2013). We the GHE does not provide five-year age breakdowns. estimated the numbers of deaths for the single year of A paper (Mokdad and others 2016) prepared in con- 2010 by estimating rates of change from 2000–05 to junction with The Lancet Commission on Adolescent 2005–10, and applying those rates of change to the Health and Wellbeing presents recent GBD estimates for 2005–10 estimate for 2.5 years, and dividing by 5 to get the percentage breakdown of deaths by cause for ages a single-year figure. 10–24 years. Table 2.4 shows differences between the GBD esti- Table 2.5 shows estimates of the percentage distribu- mates and those of the other two exercises for ages 5–9 tion of deaths by cause for LMICs. To provide compari- and 10–14 years. At the global level and for LMICs, the son the table also shows the same results for the age GBD numbers are only about 60 percent of the WPP group 1–59 months. Although diarrheal disease, malaria, numbers; for Sub-Saharan Africa, they are little more and respiratory conditions account for an important than 35 percent; for ages 15–19 years, the agreement is fraction of mortality in both age groups, these condi- closer, although the GBD numbers are still 10 percent tions are substantially more important at younger ages. lower than the WPP numbers globally and for all LMICs, Injury, in contrast, is reported to be more important at and almost 40 percent lower for Sub-Saharan Africa. In older ages. contrast, the Hill, Zimmerman, and Jamison (2015) and Table 2.6 shows the GHE estimates of death by cause WPP (UN 2013) numbers are closer: almost identical for by World Bank region. Table 2.4 Comparison of Numbers of Deaths between Ages 5 and 19 Years, 2010, thousands GBDa WPPb Hill, Zimmerman, and Jamison (2015)c Geography 5–9 10–14 15–19 5–9 10–14 15–19 5–9 10–14 15–19 World 450 360 710 710 630 790 n.a. n.a. n.a. Less developed regions 450 360 680 710 620 750 940 600 740 Sub-Saharan Africa 170 110 190 430 330 310 450 240 240 Note: GBD = Global Burden of Disease; WPP = World Population Prospects; n.a. = not applicable. a. Wang and others 2012. b. Calculated from UN 2013. c. See table 2.3. 32 Child and Adolescent Health and Development Table 2.5 Distribution of Deaths by Cause in Low- and Middle-Income Countries, Ages 1–59 Months and 5–14 Years, 2012 Age Group Cause 1–59 months 5–14 years All causes (thousands)a 3,701 1,446 1. Communicable disease 1.1 Tuberculosis 1.5 0.98 1.2 HIV/AIDS 2.7 6.7 1.3 Diarrheal disease 16 9.8 1.4 Malaria 13 2.2 1.5 Respiratory conditions 23 8.5 2. Noncommunicable disease 2.1 Malignant neoplasms 0.81 3.4 2.2 Cardiovascular diseases 0.88 3.1 2.3 Congenital anomalies 4.8 2.3 2.4 Epilepsy 0.52 2.2 2.5 Neonatal conditions 5.9 0.01 3. Injuries 3.1 Unintentional 8.6 22 3.2 Intentional 0.42 3.4 Percentage of deaths in above categories 78 65 Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. a. Global Health Estimates, “Estimates for 2000–2012: Causes of Death,” WHO 2013. This chapter’s estimates of deaths for ages 5–14 years in 2010 is higher at 1.53 million. Deaths by cause are given in percentages. Table 2.6 Deaths by Cause in Low- and Middle-Income Countries, by World Regional Groups, Ages 5–14, 2012 Regional Groups Low and Latin America Middle East High middle East Asia Europe and and the and North Sub-Saharan Causes income income and Pacific Central Asia Caribbean Africa South Asia Africa All causes (in thousands) 23 1,424 120 18 44 42 342 858 1. Communicable disease 1.1 Tuberculosis 0.10 1.0 0.50 0.05 0.25 0.36 0.42 1.4 1.2 HIV/AIDS 0.70 6.8 0.85 0.70 2.5 0.40 1.4 10 1.3 Diarrheal disease 1.0 10 2.8 1.1 2.8 1.0 12 11 1.4 Malaria 0.10 2.3 1.5 0 0.23 0.34 0.65 3.4 1.5 Respiratory conditions 4.9 8.5 4.9 6.8 6.7 11 9.9 8.5 2. Noncommunicable disease 2.1 Malignant neoplasms 17 3.2 11 13 11 12 3.3 1.2 2.2 Cardiovascular diseases 6.2 3.1 6.6 12 6.1 8.8 2.5 2.2 table continues next page Mortality at Ages 5 to 19: Levels and Trends, 1990–2010 33 Table 2.6 Deaths by Cause in Low- and Middle-Income Countries, by World Regional Groups, Ages 5–14, 2012 (continued) Regional Groups Low- and Latin America Middle East High- middle- East Asia Europe and and the and North Sub-Saharan Causes income income and Pacific Central Asia Caribbean Africa South Asia Africa 2.3 Congenital anomalies 5.8 2.2 5.1 5.8 4.3 3.2 2.5 1.5 2.4 Epilepsy 1.9 2.2 2.5 3.0 1.6 0.89 1.9 2.4 3. Injuries 3.1 Unintentional 32 22 33 26 26 23 28 18 3.2 Intentional 7.0 3.3 2.4 5.4 8.5 20 3.5 2.2 Percentage of deaths in above categories 76 65 71 73 70 81 66 62 Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. Deaths by cause are given in percentages and are from Global Health Estimates, “Estimates for 2000–2012: Causes of Death” (WHO 2013). CONCLUSIONS program (see http://www.mics.unicef.org) provide The principle conclusion from this analysis is that, estimates of mortality for this age range. However, in although mortality reaches its minimum in ages 5–19 many surveys the numbers are small, and the estimates years, the number of deaths in this age group in have high uncertainty; as a result, we only estimated LMICs still represents a substantial burden, approxi- rates for periods of 10 years before each survey. The mately 2.3 million in 2010. The data show that in deaths reported at older ages of childhood are also most LMICs, mortality risks are lowest in ages 10–14 increasingly selected for the young age of mother at years; this finding is in contrast to low-mortality, the time of the relevant births, because the histories high-income countries, where the risks are lowest in are only collected from women under age 50 years. In ages 5–9 years. This difference suggests that much of countries lacking complete and accurate civil registra- the LMIC burden of mortality at ages 5–9 years is tion systems, these limitations will adversely affect the residual mortality from infectious childhood ability to monitor changes or identify differentials diseases. in the mortality of older children and younger In other respects, mortality at ages 5–19 years has adolescents. behaved largely as has mortality under age 5 years. Males A final concern is that we have very little informa- have generally higher risks than females; the risks have tion about the cause-of-death structure for this age fallen since 1990, although not quite as rapidly as for range. Verbal autopsy methods applied to deaths of those under age 5 years. children under age five years occurring shortly before Global estimates of mortality in this age group have a DHS have improved the data availability for cause of shown a discrepancy between the numbers estimated by death of younger children (see, for example, Liu and the United Nations Population Division and the numbers others 2015), but no such efforts have been applied to estimated as part of the GBD exercise. This study provides deaths of older children; in general, sample sizes are empirical support for the numbers estimated by the probably too small for such an exercise to produce United Nations and arrives at numbers that are generally stable results. 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Geneva: WHO. Mortality at Ages 5 to 19: Levels and Trends, 1990–2010 35 Chapter 3 Global Nutrition Outcomes at Ages 5 to 19 Rae Galloway INTRODUCTION age range of 5–19 years, to obtain proxy indicators of malnutrition for school-age children. These indicators Globally, there are 1.8 billion children and adolescents are compared with those for the larger age groups—for ages 5–19 years; nearly 90 percent live in low- and example, all children younger than age five years and all middle-income countries (LMICs) (World Bank 2015). women of reproductive age (WRA)—collected in these The prevalence and consequences of malnutrition and studies. The chapter also discusses what is known about inadequate intake of nutrients leading to increased dietary intake and the consequences of malnutrition risk of morbidity and mortality are well studied for for this age group, as well as what actions are needed children in their first 1,000 days (Black and others globally to address nutritional needs in these age groups. 2013). Little information about the prevalence and Chapter 11 of this volume (Lassi, Moin, and Bhutta consequences of malnutrition is available for children 2017) also looks at nutrition in middle childhood and and adolescents ages 5–19 years, although they consti- adolescence. Definitions of age groupings and age- tute 27 percent of the population in LMICs (World specific terminology used in this volume can be found in Bank 2015). chapter 1 (Bundy and others 2017). This paucity of data makes it difficult to develop policies and strategies on why, if, and how to improve the nutritional situation of children and adolescents PREVALENCE OF MALNUTRITION IN in LMICs. Available evidence from smaller studies CHILDREN AND ADOLESCENTS AGES 5–19 for selected age groups within this cohort suggests that YEARS children ages 5–15 years suffer from high prevalence of nutritional deprivation and its consequences. To obtain information on malnutrition during middle Malnutrition is manifested as underweight (measured childhood and adolescence, the author reviewed the by low weight-for-age or body mass index [BMI]), most recent Demographic and Health Surveys (DHS) overweight/obesity (measured by high weight-for-age from 2000 to 2014. DHS are nationally representative or BMI), and micronutrient deficiencies (essential fatty household surveys in LMICs that routinely collect acids, vitamins, and minerals). Overweight and obesity height and weight measurements and anemia preva- are caused by excessive intake of energy and, in most lence for children ages 0–5 years and WRA ages cases, suboptimal intakes of essential fatty acids, vita- 15–49 years. These data were disaggregated by age mins, and minerals because of a poor-quality diet. group to obtain information on the nutritional status The objective of this chapter is to use available of boys and girls ages 4–5 years (the age group is national surveys, which provide information on the 4.00 years to 4.99 years or 48–59 months, or before the nutritional status at the beginning and end of the entire child’s fifth birthday, which is the approximate age Corresponding author: Rae Galloway, Independent Consultant, Alexandria, Virginia, United States; rae.galloway2@gmail.com. 37 when children enter school) and a subset of girls ages and obesity in children younger than age five years is not 15–19 years.1 Nutritional status information, including shown here because, based on the available DHS, the anemia caused primarily by iron deficiency and para- prevalence is less than 5 percent in all regions. sitic infections, was available for girls and boys ages 15–19 years in a smaller number of countries. Anemia To determine the level of public health significance for anemia, the World Health Organization (WHO) pro- Underweight and Anemia in Children Younger than vides guidance on the severity of anemia by prevalence Age Five Years in LMICs at the population level (table 3.1). Figure 3.1 shows the prevalence of underweight for The prevalence of anemia is higher in children ages children ages 48–59 months, compared with children 6–59 months than in children ages 48–59 months; but ages 0–59 months.2 The figure also shows the prevalence anemia prevalence in children ages 48–59 months is of anemia in children ages 48–59 months, compared still high (20 percent to more than 50 percent of with those ages 6–59 months.3 These data are organized by DHS region.4 Table 3.1 Anemia Prevalence and Public Health Significance Underweight Prevalence of anemia at the Level of public health In all regions, children ages 48–59 months are as vulner- population level (percent) significance able to being underweight as all children ages 0–59 <5.0 None months. In West, Central, and Eastern Africa, approxi- 5.0–19.9 Mild mately 20 percent of children ages 48–59 months are 20.0–39.9 Moderate underweight; the prevalence is highest in South and South-East Asia, where 43 percent of children in this age ≥40.0 Severe group are underweight. The prevalence of overweight Source: WHO 2015. Figure 3.1 Prevalence of Underweight (Low Weight-for-Age) and Anemia (Hb <11 g/dl) in Children Ages 48–59 Months and Children Ages 6–59 Months 80 70 60 50 Percent 40 30 20 10 0 West Africa Central Africa Eastern Africa Southern Africa North Africa and Central Asia SSEA LAC Eastern Europe Region of the world Underweight, ages 48–59 months Underweight, ages 0–59 months Anemia, ages 48–59 months Anemia, ages 6–59 months Sources: Statcompiler; Demographic and Health Surveys 2000–14. Note: g/dl = grams per deciliter; Hb = hemoglobin; LAC = Latin America and the Caribbean; SSEA = South and South-East Asia. If there were two surveys in the country during this period, the most recent survey was used. 38 Child and Adolescent Health and Development children in this age group are anemic in all regions). 47 percent in India. In boys ages 15–19 years, the preva- The highest prevalence of anemia is in children ages lence of underweight ranges from 1 percent in Egypt to 48–59 months in West Africa (63 percent) and South 66 percent in Ethiopia. In most of the Sub-Saharan and South-East Asia (49 percent). Based on the WHO African countries shown, the prevalence of underweight definition, anemia is a severe public health problem in in boys is significantly higher than underweight in girls. children ages 48–59 months in these regions. Data on the prevalence of underweight in males ages 15–49 years were collected in 15 countries.5 In every country, the prevalence of underweight in late adoles- Underweight and Overweight/Obesity in Adolescents cent boys is at least two times higher than the prevalence Ages 15–19 Years of underweight in all males ages 15–49 years (data not shown). The DHS provide prevalence data on underweight (BMI < 18.5 of body weight in kilograms per square Overweight/Obesity of body height in meters [kg/m2]) and overweight At least 10 percent of either late adolescent boys or (BMI ≥ 25 kg/m2) for girls and boys in late adoles- girls are overweight or obese in 13 of 17 countries. cence, that is, ages 15–19 years, in 17 countries Overweight/obesity is higher in girls than boys in (figures 3.2 and 3.3). 13 out of 17 countries; the prevalence in girls is greater than 10 percent in 10 countries, while the prevalence Underweight in boys is greater than 10 percent in just 3 countries The prevalence of underweight in late adolescent girls (figure 3.3). The differential between boys and girls is ages 15–19 years varies from 0.3 percent in the Arab high in Lesotho, Swaziland, Egypt, and the Dominican Republic of Egypt (shown as 0 percent in figure 3.2) to Republic. The prevalence of overweight/obesity in girls Figure 3.2 Prevalence of Underweight (BMI <18.5 kg/m2) in Adolescents Ages 15–19 Years 70 60 50 40 Percent 30 20 10 0 Si 008 cipe 11 1 11 9 13 13 0 3 9 6 14 6 3 09 7 20 ea 01 00 01 01 –0 00 –0 01 –0 20 0– 20 20 20 20 uin ra –09 Et 11 a2 2 n o2 a2 e2 n2 c2 08 05 06 í 01 pia Pr ia bia p. na lG 20 20 20 bli d th nd on ija er Re e2 an ya nd ria hio mi so pu a Le ba Lib nia dia nd Gu Ug Rw bw éa ab Le Na to Re er ila ba n Ar ua ba om Az I er az an Al Eq t, Zim Sw oT nic yp Eg Sã mi Do Girls Boys Source: Statcompiler; Demographic and Health Surveys (DHS) 2000–14. Note: BMI = body mass index. If there were two surveys in the country during this period, the most recent country survey was used. Except in the Arab Republic of Egypt where girls ages 15–19 years are unmarried, girls in late adolescence are included in the DHS sample for women of reproductive age in all countries, with most already having a live birth. Cutoffs for underweight in Egypt use <−2 standard deviations. Global Nutrition Outcomes at Ages 5 to 19 39 Figure 3.3 Prevalence of Overweight/Obesity (BMI ≥25 kg/m2) in Adolescents Ages 15–19 Years 50 45 40 35 30 Percent 25 20 15 10 5 0 Et 201 a 3 11 1 11 6 14 9 13 13 10 9 3 7 9 6 09 e 01 01 00 –0 01 –0 –0 00 –0 uin 20 0– 20 20 20 20 20 hio 1 c2 a2 n2 o2 e2 08 06 08 05 lG 01 pia p. ia bia da na 20 20 20 20 bli d ija th on Re er e2 ria an an ya mi so pu ba Le Lib ipe nd nia ia Ug to Rw Gu bw ab Le Na Ind Re er ila ra ua ínc ba Ar ba Az er az an Eq Al Pr t, Zim Si Sw nic yp nd Eg mi éa Do om oT Sã Girls Boys Source: Statcompiler; Demographic and Health Surveys (DHS) 2000–14. Note: BMI = body mass index. If there were two surveys in the country during this period, the most recent country survey was used. Except in the Arab Republic of Egypt where late adolescent girls ages 15–19 years are unmarried, late adolescent girls are included in the DHS sample for women of reproductive age in all countries, with most already having a live birth. Cutoffs for overweight/obesity in Egypt use >+1 standard deviation.6 is lower than in all WRA. For the countries represented Central Asia, 7 in South and South-East Asia, and 11 in in figures 3.2 and 3.3, except Egypt and Equatorial Latin America and the Caribbean are represented. Guinea, where the nutritional status in men ages 15–49 In every region except Central Asia, late adolescent years was not collected, overweight/obesity was signifi- girls are more vulnerable to being underweight than all cantly higher in men than in late adolescent boys WRA ages 15–49 years. These differences are high in (data not shown). In six countries (Albania, Azerbaijan, Central Africa, North Africa and Eastern Europe, South Guyana, Namibia, São Tomé and Príncipe, and and South-East Asia, and Latin America and the Swaziland), overweight/obesity in men was greater Caribbean, although the prevalence is low in some of than 10 percent (data not shown); the prevalence in these regions. In South and South-East Asia, 43 percent boys is greater than 10 percent in only three countries of adolescent girls are underweight, compared with (figure 3.3). slightly more than 33 percent of all WRA. Overweight and obesity are increasing in late ado- lescent girls in some regions; based on the available Underweight and Overweight/Obesity in Girls Ages data, however, the prevalence is much lower than in all 15–19 Years and Women Ages 15–49 Years WRA. An analysis found that overweight/obesity in Figure 3.4 reviews the prevalence of underweight boys and girls ages 2–19 years in most LMICs was (BMI < 18.5 kg/m2) in girls ages 15–19 years, compared about half of the overweight/obesity in adult men and with all WRA by region; 36 countries in Sub-Saharan women. The study also reported that while overweight Africa, 7 in North Africa and Eastern Europe,7 3 in has been increasing in boys and girls ages 2–19 years in 40 Child and Adolescent Health and Development Figure 3.4 Prevalence of Underweight (BMI <18.5 kg/m2) in Adolescent Girls Ages 15–19 Years and WRA Ages 15–49 Years 50 45 40 35 30 Percent 25 20 15 10 5 0 West Africa Central Africa Eastern Africa Southern Africa North Africa and Central Asia SSEA LAC Eastern Europe Girls Women Source: Statcompiler; Demographic and Health Surveys (DHS) 2000–14. Note: BMI = body mass index; LAC = Latin America and the Caribbean; SSEA = South and South-East Asia; WRA = women of reproductive age. If there were two surveys in the country during this period, the most recent country survey was used. Late adolescent girls ages 15–19 years are included in the DHS sample for WRA in all countries, with most already having a live birth. LMICs, obesity has not increased significantly (Ng and Anemia in Boys Ages 15–19 Years and Men Ages others 2014). 15–49 Years, Selected Countries Figure 3.6 presents available data on the prevalence of anemia in boys and men in selected countries. Anemia in Girls Ages 15–19 Years and Women Ages Compared with men ages 15–49 years, anemia is 15–49 Years higher in late adolescent boys. However, anemia preva- Figure 3.5 compares the prevalence of anemia in girls ages lence is high in all men and late adolescent boys, affect- 15–19 years and WRA ages 15–49 years in 28 countries in ing more than 20 percent of both age groups in 15 of Sub-Saharan Africa, 6 in North Africa and Eastern 22 countries. The prevalence of anemia in late adoles- Europe,8 2 in Central Asia, 5 in South and South-East cent boys (40 percent or higher) is a severe public Asia, and 5 in Latin America and the Caribbean. health problem in eight Sub-Saharan African countries. Within regions, the prevalence of anemia in late ado- Anemia in late adolescent boys is generally lower than lescent girls is similar to the prevalence of anemia in all in girls in the same age range in the same countries WRA. Nearly 50 percent of women in both groups (data not shown). are anemic in West and Central Asia and South and South-East Asia. In other regions, 25 percent to 40 percent of women are anemic. According to the WHO definition, DIETARY INTAKE OF GIRLS AGES 15–19 anemia is a severe public health problem for late adoles- YEARS cent girls and all WRA ages 15–49 years in West Africa, Central Africa, and South and South-East Asia, with An analysis reviews the available studies, most with prevalence of at least 40 percent (see table 3.1 for cutoff small sample sizes, on dietary intake in nonpregnant definitions). Anemia is also a severe public health prob- adolescent girls. These studies are not nationally repre- lem for WRA in Central Asia. sentative surveys, but they provide information on Global Nutrition Outcomes at Ages 5 to 19 41 Figure 3.5 Prevalence of Anemia (Hb <12 g/dl) in Adolescent Girls Ages 15–19 Years and WRA Ages 15–49 Years 60 50 40 Percent 30 20 10 0 West Africa Central Africa Eastern Africa Southern Africa North Africa and Central Asia SSEA LAC Eastern Europe Girls WRA Source: Statcompiler; Demographic and Health Surveys (DHS) 2000–14. Note: g/dl = grams per deciliter; Hb = hemoglobin; LAC = Latin America and the Caribbean; SSEA = South and South-East Asia; WRA = women of reproductive age. If there were two surveys in the country during this period, the most recent country survey was used. Late adolescent girls ages 15–19 years are included in the DHS sample for WRA in all countries, with most already having a live birth. Figure 3.6 Prevalence of Anemia (Hb <13 g/dl) in Adolescent Boys Ages 15–19 Years and Men Ages 15–49 Years 60 50 40 Percent 30 20 10 0 20 aso 11 11 1 0 12 2 09 13 13 06 9 6 4 2 9 09 12 2 9 4 7 –1 01 01 –0 –0 –1 01 00 01 –0 –1 –0 20 0– 1– 8– 20 20 20 20 20 10 F i2 n2 10 a2 2 r2 08 05 13 08 13 06 na 01 01 00 pia bia e da o na iti nd 0 20 20 20 ge 20 20 20 bo on ine th rki l2 e2 e2 r2 Ha an ya hio ru mi so Ni Ga Le nia ia p. ipe go nd Bu ga Gu ca Gu Ug bw Bu oir Na Le Ind Re Et To ila ra ne as ba ínc v ba er d’l az m. ag Se Al Pr Zim Si Sw De ad ˆ te nd Co M o, éa ng om Co oT Sã Boys Men Source: Statcompiler; Demographic and Health Surveys 2000–14. Note: g/dl = grams per deciliter; Hb = hemoglobin. If there were two surveys in the country during this period, the most recent country survey was used. 42 Child and Adolescent Health and Development more vulnerable girls within the entire cohort of adoles- Consequences in Children Ages 5–19 Years cent girls. Energy intake was inadequate and did not Even if stunting in early childhood is not reversible, meet recommended levels in these girls; intakes were further damage to nutritional status and cognitive func- lowest in the Western Pacific and South-East Asia tion needs to be prevented. For children ages five to (Caulfield and Elliot 2015). Micronutrient intake was nine years, malnutrition caused by inadequate food inadequate for iron, calcium, zinc, folate, and vitamin D; intake and helminth infections increases the risk of fewer than 50 percent of girls have adequate intake underweight, anemia, and illness; these conditions (Caulfield and Elliot 2015). Intake of energy-dense, decrease attendance, performance, and years in primary micronutrient-poor, and sugary foods by girls is increas- school (Bundy and others 2009). In HICs, 15 percent of ing in urban areas in LMICs. adult height and 50 percent of adult weight are attained More information is needed on energy and micronu- in adolescence (Heald and Gong 1999). In the United trient intakes during middle childhood and adolescence, States, the period comprising ages 10–14 years is given the relatively high prevalence of underweight and marked by rapid growth and, for girls, the onset of anemia in both genders in this group compared with menses (Sawyer and others 2012). By ages 15–19 years, other age groups, and the increasing prevalence of over- girls attain their adult height, although their pelvis con- weight/obesity, particularly in girls, in some countries. tinues to grow, putting girls at risk of obstructed labor later in life if they are undernourished during pelvic development. Boys continue to gain height and muscle CONSEQUENCES OF MALNUTRITION mass through age 24 years. Requirements for iron are Consequences in Children Younger than Age Five high for girls after the onset of menarche and in boys Years because of muscle mass accretion, increasing their risk of anemia and poor performance in school (Halterman Malnutrition inflicts considerable damage on children in and others 2001). Both iron and iodine deficiencies their first 1,000 days and increases the risk of short stat- compromise IQ by 8–15 percentage points at the popu- ure, ill health, cognitive impairment, and reduced pro- lation level (World Bank 2006). Increasing overweight ductivity and income throughout life (Hoddinott and and poor dietary intake put children at risk for others 2013). As seen from the available data on preva- nutrition-related chronic diseases that are on the rise in lence, malnutrition is significant for children when they adolescents in LMICs; 20 percent to 30 percent of ado- enter school. The ability of children to recover from a lescents live with chronic illnesses, particularly diabetes period of compromised growth later in life—catch-up (Save the Children 2015). growth—has been deemed unlikely (Martorell, Rivera, Adolescent girls are at higher risk of poor birth and Kaplowitz 1990). The inability to reverse stunting outcomes (prematurity, stillbirths, and neonatal may be the result of changes in genetic expression in deaths) and of dying than older WRA (Kozuki and early life caused by inadequate food intake and infec- others 2013). One study in the United States found tions that determine growth in stature later in life that girls younger than age 15 years were at higher risk (Golden 1994). of maternal anemia, preterm delivery, postpartum Emerging evidence, however, suggests that a propor- hemorrhage, and preeclampsia, but they were less likely tion of stunting may be reversible after age two years in to have a cesarean delivery (Kawakita and others Brazil, Ethiopia, India, Peru, and Vietnam (Lundeen, 2015). Becoming pregnant is the main reason why girls Behrman, and others 2014), Guatemala, India, the drop out of school in LMICs (Save the Children 2015), Philippines (Adair 1999), and South Africa (Lundeen, which results in a loss of income of 1 percent to Stein, and others 2014). Chapter 8 in this volume 30 percent of annual GDP (Chaaban and Cunningham (Watkins and others 2017) provides additional infor- 2011). Adolescent pregnancies also may cause higher mation on catch-up growth attributable to immigra- prevalence of stunting in children younger than age tion, adoption, and other changes. However, in two years (Dewey and Huffman 2009). Lundeen, Stein, and others (2014), height deficits related to the reference median also increased, making the interpretation of recovery more complicated. In CONCLUSIONS addition, little is known about how growth and its tim- ing in school-age children in LMICs compares with the Few nationally representative surveys are available on the growth of children in high-income countries (HICs)— nutritional status of boys and girls ages 5–19 years, and for example, are growth spurts comparable, and is the this group continues to be understudied for both preva- timing of puberty experiencing the same secular lence of malnutrition and related outcomes from malnu- changes as in children in HICs? trition. The dearth of information on nutritional status Global Nutrition Outcomes at Ages 5 to 19 43 during middle childhood and early adolescence is partic- NOTES ularly striking. Mining DHS data for what has been col- World Bank Income Classifications as of July 2014 are as fol- lected on children ages 48–59 months and boys and girls lows, based on estimates of gross national income (GNI) per in late adolescence suggests the prevalence of under- capita for 2013: weight and anemia are high and, for the most part, are on par with or higher than the prevalence in children • Low-income countries (LICs) = US$1,045 or less ages zero to five years, WRA, and men. Overweight is an • Middle-income countries (MICs) are subdivided: emerging problem, particularly in girls during late ado- a) lower-middle-income = US$1,046 to US$4,125 lescence, but overweight is lower in girls compared with b) upper-middle-income (UMICs) = US$4,126 to US$12,745 women and in boys compared with men. • High-income countries (HICs) = US$12,746 or more. Malnutrition in children ages 5–19 years has pro- found consequences on education and health outcomes, 1. The girls in the sample are considered WRA by DHS although more studies and analyses could determine the because they have had at least one live birth and do not extent of this impact on national development. represent all girls ages 15–19 years. Global resources need to be made available to study all 2. Indicators are available for low height-for-age (stunting or chronic malnutrition) and low weight-for-height (wasting children during middle childhood and adolescence (ages or acute malnutrition), but because prevalence for these 5–19 years), disaggregating the prevalence of malnutri- indicators peaks at different times in children ages zero to tion to children in middle childhood (5–9 years), early five years, low weight-for-age, often considered a compos- adolescence (10–14 years), and late adolescence (15–19 ite of stunting and wasting, was chosen. years). Such disaggregated data would assist in develop- 3. DHS collects hemoglobin samples from children ages 6–59 ing policies and introducing programs to address the months and does not include children ages 0–5.99 months known and suspected nutrition problems of the entire in the sample. cohort of middle childhood and adolescence to monitor 4. The number of countries for underweight: West Africa their impact on the nutritional status in this group. (13); Central Africa (5); Eastern Africa (13); Southern A better understanding of how to measure malnutri- Africa (3); North Africa and Eastern Europe (7); Central tion in this age group also would be useful, although not Asia (2); South and South-East Asia (7); and Latin America and the Caribbean (8). The number of countries for ane- a prerequisite for action. Knowing more about what mia: West Africa (11); Central Africa (6—one study is a indicators reflect and mean, the timing of growth spurts Malaria Indicators Survey); Eastern Africa (9); Southern in children, and the timing of puberty could help efforts Africa (3); North Africa and Eastern Europe (6); Central better target interventions by age group. We know that Asia (1); South and South-East Asia (5); Latin America and underweight in children younger than age five years is a the Caribbean (5). composite of chronic malnutrition (stunting) and acute 5. Albania 2008–09, Azerbaijan 2006, Bangladesh 2011, malnutrition (wasting). Can we assume this indicator Ethiopia 2011, Guyana 2009, India 2005–06, Lesotho 2009, reflects the same composite of stunting and wasting in Namibia 2013, Rwanda 2010, São Tomé and Príncipe children ages 5–15 years? Information is emerging about 2008–09, Senegal 2010–11, Sierra Leone 2013, Swaziland puberty trends in HICs. For example, Sandhu and oth- 2006–07, Uganda 2011, and Zimbabwe 2010–11. ers (2006) found the onset of puberty in the United 6. Overweight is between +1 standard deviation and ≤+2 standard deviations; obesity is >+2 standard deviations. Kingdom to be earlier in boys with higher BMI, while 7. The Republic of Yemen DHS for 2013 was excluded from height was higher in boys with later puberty. 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A Strategy for Large-Scale Action. Directions others. 2013. “The Association of Parity and Maternal Age in Development Series. Washington, DC: World Bank. with Small-for-Gestational Age, Preterm, and Neonatal and ———. 2015. “Population Estimates and Projections.” Infant Mortality: A Meta-Analysis.” BMC Public Health 13 World Bank, Washington, DC. http://data.worldbank.org (Suppl 3). doi:10.1186/1471-2458-13-S3-S2. /data-catalog/population-projection-tables. Global Nutrition Outcomes at Ages 5 to 19 45 Chapter 4 Global Variation in Education Outcomes at Ages 5 to 19 Kin Bing Wu INTRODUCTION outcomes more, schools are an important source of varia- tion in student achievement in poor countries and can Education produces far-reaching benefits to populations bridge the achievement gap. Definitions of age groupings by improving health, increasing individual productivity and age-specific terminology used in the volume can be and earnings, enhancing civic engagement, and facilitat- found in chapter 1 (Bundy and others 2017). ing economic and social intergenerational mobility (Hannum and Xie 2016; Montenegro and Patrinos 2014; OECD 2013c; Schultz 1961). In the aggregate, it enhances INTERNATIONAL ASSESSMENT OF STUDENT economic growth by contributing to technological ACHIEVEMENT change and innovation (Becker 1964; Mankiw, Romer, and Weil 1992; Mincer 1974; Solow 1956; Pradham and Cross-national studies confirm the positive relationship others 2016, chapter 30 of this volume). between educational attainment, as measured by average Education outcomes are affected by a number of fac- years of schooling, and economic growth (Barro 1991, tors. At the child or student level, nutrition, health, and 1997). However, student achievement can vary widely interactions with parents and other adults affect brain across countries, even across countries with the same aver- development, emotional and psychological well-being, age years of schooling. Education quality is the most criti- and the capacity to learn (Crookston and others 2013). At cal component because the capability to use technology the school level, education quality is enhanced by school and to innovate is contingent on the improvement of leadership, an orderly and safe environment, high expecta- cognitive skills. Hanushek and Woessmann (2015) found a tions, positive reinforcement, regular assessment, con- strong positive relationship between student achievement structive school-home relations, and opportunity to learn and gross domestic product (GDP) per capita growth (OTL) (Sammons, Hillman, and Mortimore 1995). between 1964 and 2003; they also found that cognitive Education, health, and social policies can create an enabling skills explained differences in growth rates between environment and equalize opportunities for all students regions. For example, 10 East Asia and Pacific countries through resource allocation, monitoring and supervision, in their sample experienced growth that was at least curriculum improvement, teacher management, policy 2.5 percentage points per year faster than the typical coun- toward the language of instruction, and interventions tar- try in the world, attributable to their knowledge capital. geted to disadvantaged groups. Chudgar and Luschei’s Although other qualities, such as resilience, collaboration, (2009) study of 25 participating systems in international and entrepreneurship, are very important, cognitive skills studies found that although family background affects lend themselves more easily to international comparison. Corresponding author: Kin Bing Wu, Lead Education Specialist, World Bank (Retired), Menlo Park, California, United States; kbwu_2000@yahoo.com. 47 The International Association for the Evaluation of The IEA organized the first, second, and third math- Educational Achievement (IEA) and the Organisation for ematics, science, and reading tests from the 1960s to the Economic Co-operation and Development’s (OECD’s) 1990s, about once every decade, to study the differences Programme for International Student Assessment (PISA) between education systems and outcomes. The IEA sub- conducted 21 cross-country studies of student sequently conducted the Trends in International achievement in mathematics, science, and reading Mathematics and Science Study (TIMSS) once every between 1964 and 2015 (see annex 4A and table 4.1 for four years and the Progress in International Reading the history of international student assessments). Literacy Study (PIRLS) once every five years. Participating Table 4.1 History of International Assessments of Student Achievement and Adult Skills Studies conducted by the International Association for the Evaluation of Participating Educational Achievement Year Age (years) and grade education systems FIMS 1964 13 and final year 11 FISS 1970–71 10, 14, and final year 14, 16, 16 FIRS 1970–72 13 12 SIMS 1980–82 13 and final year 17, 12 SISS 1983–84 10, 13, and final year 15, 17, 13 SIRS 1990–91 9, 13 26, 30 TIMSS 1994–95 9 (grade 3 or 4), 13 (grade 7 or 8), final year 29, 46, 21 TIMSS-R 1999 13 (grade 8) 38 PIRLS 2001 9 (grade 4) 36 TIMSS 2003 9 (grade 4), 13 (grade 8) 26, 47 PIRLS 2006 9.5 (grade 4) 45 TIMSS 2007 9.5 (grade 4), 13.5 (grade 8) 37, 50 PIRLS 2011 9 (grade 4) 57 TIMSS 2011 9 (grade 4), 13 (grade 8) 50, 42 TIMSS 2015 9 (grade 4), 13 (grade 8) 48, 40 Participating PISA, conducted by the OECD Year Age (years) education systems PISA 2000, 2002 15 31, 10 PISA 2003 15 40 PISA 2006 15 57 PISA 2009 15 65 PISA 2012 15 65 PISA (to be published in late 2016) 2015 15 74 PIAAC, conducted by the OECD Year Age (years) Countries PIAAC 2011 16–65 24 PIAAC 2014 16–65 33 Sources: Hanushek and Woessmann 2015; NCES (National Center for Education Statistics) Trends in International Mathematics and Science Study (TIMSS), http://www.nces.ed .gov/TIMSS//countries.asp; NCES Progress in International Reading Literacy Study (PIRLS), http://www.nces.ed.gov/surveys/pirls/countries.asp; NCES Programme for International Student Assessment (PISA), http://www.nces.ed.gov/surveys/pisa/countries.asp. Note: FIMS = First International Mathematics Study; FIRS = First International Reading Study; FISS = First International Science Study; OECD = Organisation for Economic Co-operation and Development; PIAAC = Programme for the International Assessment of Adult Competencies; PIRLS = Progress in International Reading Literacy Study; PISA = Programme for International Student Assessment; SIMS = Second International Mathematics Study; SIRS = Second International Reading Study; SISS = Second International Science Study; TIMSS = Trends in International Mathematics and Science Study; TIMMS-R = Trends in International Mathematics and Science Study-Repeat. 48 Child and Adolescent Health and Development educational systems increased from the original 11 in systems scored at the top of the international league table 1964 to more than 50 in recent years; they include sys- in eighth-grade mathematics: Singapore; Japan; the tems from Europe, East Asia, the Middle East and North Republic of Korea; Hong Kong SAR, China; Belgium Africa, Latin America and the Caribbean, South Asia, (Flemish); and the Czech Republic. In TIMSS 2011, the and Sub-Saharan Africa. Republic of Korea’s score increased by 32 points, rising to The IEA has historically assessed three student popu- the top spot; Hong Kong SAR, China, increased by lations: upper primary (third or fourth grade), lower 17 points; and Singapore increased by 2 points. Over this secondary (seventh or eighth grade), and the final year of period, Japan’s score decreased by 11 points, Belgium’s upper secondary school. Participating educational sys- (Flemish) by 13 points, and the Czech Republic’s by tems agree on the content to ensure that the test covers 42 points (Loveless 2013). Between PISA 2000 and PISA topics in their curricula. The IEA enforces strict sampling 2012, Peru made the greatest gains among all participating rules and protocols to ensure that an educational system systems (increasing by 76 points in mathematics), albeit under study is representative, whether of a country or of from a very low base, while Brazil and Chile were among a region of a country. A properly drawn sample of several the top 10 countries with the greatest gains during this hundred schools and several thousand students could period (Patrinos 2013). In PISA 2009 and 2012, Shanghai, yield results representative of an education system. China, overtook Finland as the top performer (annex 4B). In 2000, PISA began testing the mathematics, science, Vietnam, a lower-middle-income economy, scored higher and reading competency of 15-year-olds every three than the OECD average (OECD 2013a). These changes in years, irrespective of the grade of enrollment. PISA performance demonstrate that cognitive skills are not assesses students’ acquisition of the knowledge and skills fixed but can be developed. The relationship between edu- that are essential for full participation in modern societ- cation quality and economic development is not linear; ies, with the goal of identifying ways in which students relatively low income countries can make great strides, can learn better, teachers can teach better, and schools thereby changing the trajectory of their development. can operate more effectively (OECD 2010). The reasons for changes in student achievement are Both IEA and PISA provide training to participating complex and country specific, and they may be attribut- education systems in sampling, test administration, and able to a combination of interventions at the student, data cleaning and analysis. They also validate the results school, and policy levels and broader social trends. to ensure comparability across countries. The IEA and Where girls’ performance in mathematics and science PISA scores are highly correlated at the national level lagged behind boys’, programs to improve girls’ profi- (Hanushek and Woessmann 2015). Over 100 countries ciency in these subjects increased the overall national or regions of a country have participated in at least one average, as in the Republic of Korea (Chiu, personal of the IEA or OECD tests (annex 4A).1 Financial con- communication 2016).2 Countries that had previously straints and consideration of the results’ political impact divided their educational systems into general and voca- often are the main deterrents to participation. tional education saw improved academic achievement by postponing tracking and exposing more students to general education, as in Poland (OECD 2011). Germany LESSONS FROM INTERNATIONAL increased its scores and ranking from 2003 to 2012 after ASSESSMENTS it adopted a national educational standard in all federal Education system performance varies tremendously, and states and put significant effort into teacher training and country rankings in the international league table often assessment (Chiu, personal communication 2016). generate headlines. However, in addition to the previ- Teaching math through strong visual presentation and ously mentioned student-level and school-level factors, improving student engagement improved test scores, as student achievement at the system level is affected by size in Singapore (Cavendish 2015). Curriculum change that of the rural population, diversity of terrain, adult literacy unintentionally reduced coherence led to a decline in test rates, income distribution, ethnicity and languages, atti- scores, as in Taiwan, China (Chiu, personal communica- tudes toward gender equality, and history of conflict. It is tion 2016). Linking strong schools with weak schools important to put the results in a broader context when raised teachers’ competency in weaker schools, as in interpreting them. Shanghai (Liang, Kidwai, and Zhang 2016). Using inter- national assessment to guide educational interventions has substantially improved student outcomes, as in Changes in Student Performance and Adult Skills Germany and Peru (Anderson, Chiu, and Yore 2010; Education system performance can improve or decline Patrinos 2013). The opening up, particularly to over time. For example, in TIMSS 1995, six education women, of more nonteaching professions with better Global Variation in Education Outcomes at Ages 5 to 19 49 remuneration and expanded migration opportunities School autonomy has a positive relationship with student with open borders made it harder for the education performance when public accountability measures are in sector to retain capable teachers and recruit new talent, place, when school principals and teachers collaborate in thereby affecting education quality (Chui, personal school management, or when both occur. Schools with communication, 2016). better disciplinary climates, more collaboration among Findings from the OECD’s first survey of adult teachers, and more positive teacher-student relationships skills, the Programme for the International Assessment tend to perform better. Stratification in school systems of Adult Competencies (PIAAC), launched in 2011, into general and vocational streams and grade repetition confirmed that educational systems could shape are negatively related to equity and student achievement. people’s skill profiles (OECD 2013b). The Republic of School systems with higher percentages of students Korea was among the three lowest-performing coun- having attended preprimary education tend to produce tries when comparing the performance of adults ages better results (OECD 2010, 2013b). 55–65 years with other countries, but it followed Japan in skill proficiency among the younger generation of workers ages 16–24 years. The United Kingdom was Variance in Achievement between Schools and among the three highest-performing countries in liter- between Students acy proficiency among adults ages 55–65 years, but it International comparisons of the percentage of variance was among the bottom three in literacy proficiency in achievement attributable to between-school differ- among those ages 16–24 years. High school–educated ences and between-student (within-school) differences adults ages 25–34 years in Japan and the Netherlands can provide direction for policy intervention. Variance outperformed Italian and Spanish university graduates in achievement attributable to between-school differ- of the same age (annex 4C). ences results from education policies, school resources, The PIAAC found that skills have a major impact on teacher characteristics, and instructional strategies. The each person’s life chances. The median hourly wage of smaller the between-school variance, the more equitable workers scoring at the highest two levels in literacy (levels the school system. In Finland, less than 10 percent of the 4 and 5) is more than 60 percent higher than that for work- variance in PISA 2009 was attributable to between- ers scoring at or below level 1. Those with lower skills also school differences, suggesting that student achievement tend to report poorer health and lower civic engagement, was less likely to be affected by which school they and they are less likely to be employed (OECD 2013b). attended. In Hong Kong SAR, China; the Republic of Countries would benefit from using mixed-method case Korea; Shanghai; and Taiwan, China, the variance in studies to examine how decadal changes in education between-school achievement ranged from 30 percent to policy affect generational changes in skill profiles. 35 percent, indicating relatively inequitable schools. In low-performing countries, such as Argentina and Trinidad and Tobago, the variance in student achieve- Characteristics of High-Performing Systems ment between schools in PISA 2009 was 90 percent and Examining the distribution of student achievement at more (OECD 2010). Where between-school variance is different levels of proficiency is important for assessing large, policy interventions could be directed to improv- the depth of skills. For example, PISA has five levels of ing school-related factors to equalize the OTL. proficiency in ascending order, from level 1 to level 5. In Variance in achievement attributable to differences PISA 2012, 55 percent of students in Shanghai, 40 percent between students (within-school) results from students’ in Singapore, and 37 percent in Taiwan, China, scored at family characteristics, innate ability, nutrition and health level 5 in mathematics, compared with 13 percent of status, early childhood education, and learning strate- OECD students. Only 4 percent of students in Shanghai, gies. PISA found that students whose parents read to 8 percent in Singapore, and 13 percent in Taiwan, China, them in their early years and who had attended prepri- performed below level 2, compared with 23 percent in mary school performed better than those without these OECD countries (annex 4B; OECD 2013a). types of support. Policy interventions directed at stu- High-performing education systems tend to have dents and families could improve achievement. However, standards-based external examinations and allocate international student assessments focus on collecting the resources more equitably across all types of schools. characteristics of education systems, schools, teachers, Systems that create more competitive environments in and students; they do not collect data on nutrition and which schools vie for students do not systematically per- health, which could be very important determinants of form better. High teacher salaries relative to national education outcomes, particularly in low-income coun- income are associated with better student performance. tries and disadvantaged communities. 50 Child and Adolescent Health and Development STUDENT ACHIEVEMENT IN POOR REGIONS (WHO 2010). India did not have a national curriculum; OF INDIA AND CHINA each state determined its own education structure, cur- riculum, and language of instruction. China has a national The high-performing education systems in TIMSS, curriculum that applies to all public schools irrespective PIRLS, PISA, and PIAAC are relatively small in size and of location. Chinese schools were far better resourced population. Managing an educational system well is than Indian schools. In both countries, local educational much more challenging in countries with more than a authorities were consulted on the appropriateness of billion people and with highly variable geography and applying the test to their students. Stratified random income. For example, top-performing Shanghai is a sampling was used in both countries, but the sampling municipality of 23 million people and has the highest frames were different (and they were different from that per capita income in China. The key question is how of TIMSS-R). As such, the findings are only suggestive, students in the poor regions of populous countries fare, not representative or definitive, of student achievement relative to the more advanced regions of the same coun- in the hinterland of these two large countries and its try and to international averages. This section addresses potential link with TIMSS performance. The results this question by reporting the findings of two surveys should be treated as a test case for further investigation. conducted in poor regions of India and China, using Gansu’s eighth-graders’ average of 72 percent correct selected TIMSS mathematics items. of the 36 items was above the international average of The India survey was part of the World Bank’s study 52 percent; Rajasthan’s and Orissa’s ninth-graders scored on secondary education in India. It was conducted in 34 percent and 37 percent correct on average, respec- 2005, involving 3,418 students in 114 schools in Rajasthan tively. Item by item, the Gansu students scored above the (in the west) and 2,856 students in 109 schools in Orissa international average on 34 of 36 items, while Orissa (in the east) (Wu, Sankar, and Azam 2006). These states students had lower scores on 35 of 36 items, and have a significantly lower per capita GDP than the Rajasthan students performed below on all items. Given national average. The eighth grade was part of elemen- that students in Rajasthan and Orissa had the benefit of tary education in Rajasthan but was part of secondary an additional year of education, their low scores should education in Orissa. The differences in the education be a concern for policy makers. Figure 4.1 illustrates the structure in these two states led to selection of the ninth differences in percentage correct for each item. These grade for testing because it was part of secondary educa- results to some extent foreshadow the relatively weak tion in both states. Thirty-six test items designed for the performance of two of the better-performing Indian eighth grade internationally were selected from pub- states (Tamil Nadu and Himachal Pradesh) on PISA lished items from the TIMSS 1999 (TIMSS-R) and 2009 and the stellar performance of Shanghai, China, on administered to the sampled ninth-graders in both states the same test. Yet, a significant achievement gap between (annex 4D). The survey also administered questionnaires Gansu and Shanghai could be inferred given the latter’s to the sampled students, teachers, and schools to assess top position in PISA 2009 and 2012. factors affecting student performance (annex 4E). A multilevel analysis was performed to explore the The China survey was part of a 2006 World Bank determinants of achievement in Rajasthan, Orissa, and study on compulsory education (Wu, Boscardin, and Gansu (Wu, Boscardin, and Goldschmidt 2011; Wu, Goldschmidt 2011). The same test items from TIMSS-R Sankar, and Azam 2006). The unconditional analytical used in India were used to test a sample of 4,103 eighth- models found that school quality was highly variable in graders in 138 schools in Gansu province in China. the poor regions of both large countries—46 percent Located in arid northwest China, Gansu is the second of the variance in achievement in Rajasthan and poorest province in the country. As in India, the survey 50 percent of the variance in Orissa was attributable to administered questionnaires to the sampled students, differences between schools; in Gansu, 55 percent of the teachers, and schools to assess factors affecting student variance was attributable to between-school differences performance, but a question on breakfast and measure- (annex 4E). The paragraphs that follow and annexes 4F ment of weight and height were added to the student and 4G report only those variables with statistical signif- questionnaire (annex 4F). icance and could inform policy. Major differences existed between the two countries. India’s per capita GDP was less than one-fourth of China’s. Infrastrastructure and the telecommunication India systems were relatively well developed, even in China’s Student Level poor western regions, but much less so in India in 2006. At the student level in Rajasthan and Orissa, the analysis India lagged far behind China in health indicators found a statistically significant association between good Global Variation in Education Outcomes at Ages 5 to 19 51 Figure 4.1 Average Percentage Correct by Item in Gansu, China, and Rajasthan and Orissa, India, Compared with International Average 100 90 80 70 Percent correct 60 50 40 30 20 10 0 33 19 29 4 18 12 5 25 1 26 3 17 20 8 31 15 24 6 11 9 13 10 36 2 35 21 32 27 14 23 16 30 34 7 22 28 Item number on test, ordered from easiest to hardest on international average score Gansu International average Rajasthan Orissa Source: Wu, Boscardin, and Goldschmidt 2011. performance on the one hand, and being male, higher parental expectations, and having had breakfast. On education levels of mothers, higher parental expecta- average, girls performed lower than boys. Increase in age tions, advanced resources at home, and OTL on the and grade repetition were associated with lower perfor- other hand. Boys outperformed girls, on average, in both mance. Students with parents who expected them to states. In Rajasthan, students who belonged to Scheduled complete tertiary education performed better. Students Tribes3 performed below nontribal students. In Orissa, who rarely had breakfast before school performed lower Scheduled Caste students performed lower than the gen- than students who had breakfast. The last variable is par- eral students, on average. The OTL through homework ticularly important because 43 percent of students rarely and examination had positive effects on student achieve- had breakfast. However, there was insufficient variation ment (annex 4F). in weight and height at the ninth-grade level to link those measures with student performance (annex 4G). School Level When students’ family resources were aggregated at the School Level school level, a significant effect on student achievement At the school level, teacher qualification, teacher prepara- in both states was found. School types made a difference tion, and teaching strategy were positively associated in Rajasthan: students enrolled in government-aided with student achievement. Students with teachers who schools and unaided (private) schools performed better had higher levels of education performed much higher. than government schools (annex 4F). An increase of an additional hour of lesson preparation In the full model, student-level variables explained by the teacher was associated with a small but significant only 8 percent of the variance in achievement and increase in student performance. Additional teacher time school-level variables explained 33 percent in Rajasthan. spent during class time discussing questioning strategies Student-level variables explained only 4 percent of the was positively associated with student performance. variance in achievement between students, and school- Schools with more resources and facilities, ranging from level variables explained 19 percent in Orissa (annex 4E). drinking water and electricity to computers, student dor- mitories, and televisions, were positively associated with student performance. Schools with a high percentage of China minority students were negatively associated with stu- Student Level dent performance, although at the individual student In Gansu, significant factors at the student level were as level, minority status was not associated with student follows: gender, age, students’ prior achievement, outcome (annex 4G). 52 Child and Adolescent Health and Development In the full model, the student-level variables only interventions, and enable international donors to target explained 7 percent of the variance in achievement their resources more effectively. between students, and the school-level variables only explained 12 percent of variance between schools (annex 4E). ANNEXES The annexes to this chapter are as follows. They are avail- Discussion able at http://www.dcp-3.org/CAHD. In both the India and China studies, the collected data explained a much smaller portion of the variance in • Annex 4A. Participating Educational Systems in achievement between students than the variance between International Assessment of Student Achievement, schools. This outcome suggests that a singular focus on 1995–2015 education policy without simultaneous interventions at • Annex 4B. Performance of 15-Year-Old Students in 10 the student level is unlikely to improve achievement on Top-Performing Educational Systems in PISA, 2012 a large and sustained scale. Although it is difficult to • Annex 4C. Comparison of Skill Proficiency among change family characteristics, socioeconomic back- Adults, 2011 grounds, and innate abilities, it is entirely possible to • Annex 4D. Average Percentage Correct, by Item, improve students’ nutrition and health, and to provide in Gansu, China, and Rajasthan and Orissa, India, opportunity for early child development. Compared with International Average Longitudinal studies in a number of countries have • Annex 4E. Percentage of Variance in Achievement found significant long-term impacts of nutrition and Explained by Differences between Schools and health on educational outcome (Crookston and others between Students in Rajasthan, Orissa, and Gansu 2013; Hannum, Liu, and Frongillo 2014; Lundeen and • Annex 4F. Factors Associated with Student others 2014). Several randomized controlled trials in Achievement in Grade 9 in Rajasthan and Orissa, elementary schools in western China that took blood India samples from elementary students to use as independent • Annex 4G. Factors Associated with Student variables to predict their test scores confirmed that giv- Achievement in Grade 8 in Gansu ing the treatment group multivitamins, including iron, raised hemoglobin and increased mathematics test scores by 0.2–0.4 standard deviation compared with NOTES those of a control group (Kleiman-Weiner and others World Bank Income Classifications as of July 2014 are as fol- 2013; Luo and others 2012). These studies suggest that lows, based on estimates of gross national income (GNI) per directly measuring nutrition and health through blood capita for 2013: tests can help target interventions at the student level to increase their educational outcomes. • Low-income countries (LICs) = US$1,045 or less • Middle-income countries (MICs) are subdivided: a) lower-middle-income = US$1,046 to US$4,125 CONCLUSIONS b) upper-middle-income (UMICs) = US$4,126 to US$12,745 • High-income countries (HICs) = US$12,746 or more. The evidence from international student assessments supports the overall relationship between knowledge cap- 1. Other regional student assessment programs focus on ital and economic growth, although it is not linear. The Latin America and the Caribbean, as well as on English- PIAAC findings on adult skills suggest that countries with speaking and French-speaking countries in Sub-Saharan low skill levels are at a competitive disadvantage in the Africa. However, this chapter only focuses on the IEA and global knowledge economy. Yet TIMSS and PISA have PISA assessments because of their international scope and shown that education systems can improve student long history. achievement on a large scale. Future international assess- 2. M. H. Chiu was interviewed by the author in Taiwan, China, on June 23, 2016. Dr. Chiu is Professor at the ments could consider including a more detailed question- Graduate Institute of Science Education, National Taiwan naire on nutrition and health and collection of biomarkers Normal University and President, National Association for through blood tests, at least in a subsample. Availability Research in Science Teaching (NARST), United States. of such integrated information on education, nutrition, 3. Scheduled Tribes are indigenous peoples and Scheduled and health on an international scale could explain in Castes are the most disadvantaged social groups in India. greater depth the differences in achievement across coun- They are recognized in India’s constitution as eligible for tries and between students, help countries prioritize their support. Global Variation in Education Outcomes at Ages 5 to 19 53 REFERENCES Elementary Schools: Results of a Randomized Control Trial Anderson, J. O., M. H. Chiu, and L. D. Yore. 2010. “First in Shaanxi Province.” Economic Development and Cultural Cycle of Pisa (2000–2006)—International Perspectives on Change 60 (4): 735–72. Successes and Challenges: Research and Policy Directions.” Mankiw, G., D. Romer, and D. Weil. 1992. “A Contribution to International Journal of Science and Mathematics Education the Empirics of Economic Growth.” Quarterly Journal of 8 (3): 373–88. Economics 107 (2): 407–37. Barro, R. 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This is evident in mortality shifts showing a rise in deaths Adolescents are commonly viewed as healthy in com- that are largely preventable: deaths from intentional and parison with other age groups (Sawyer and others nonintentional injuries; deaths due to human immuno- 2012). Adolescence is an age at which many positive deficiency virus/acquired immune deficiency syndrome attributes of health peak, and these positive attributes (HIV/AIDS), tuberculosis, and other infectious diseases; predict health in later life. Physical fitness peaks about and deaths due to maternal causes (Patton and others age 20 years; it remains high until the early 30s, when 2009). Patterns of nonfatal disease burden also shift it declines steadily to old age (Rockwood, Song, and across these years. The prevalence of mental disorders Mitnitski 2011). Those with the highest fitness levels rises sharply across adolescence (Gore and others 2011). in their 20s are more likely to stay physically healthy Many risk processes leading to chronic noncommunicable throughout life, using less health service as they age diseases (NCDs) in later life, including tobacco use, (Rockwood, Song, and Mitnitski 2011). Adolescent alcohol and illicit substance use, unsafe sex, obesity, and cardiorespiratory fitness, muscular strength, and body lack of physical activity, typically emerge in these years composition are also predictive of lower all-cause mor- (Gore and others 2011). Definitions of age groupings tality and cardiovascular disease in later life (Ruiz and and age-specific terminology used in this volume can be others 2009). Adolescence is similarly central in skeletal found in chapter 1 (Bundy and others 2017). health. Bone mineral density, a primary determinant of later-life osteoporosis and its complications, peaks in the late teens to early 20s (Baxter-Jones and others HEALTH INFORMATION SYSTEMS AND 2011). In the two years of peak skeletal growth, adoles- ADOLESCENCE cents accumulate more than 25 percent of adult bone mass; patterns of physical activity and adolescent Sound information is essential for selecting priori- nutrition are important modifiable influences (Julián- ties in health and social policy and monitoring the Almárcegui and others 2015; Whiting and others 2004). effects of subsequent actions (AbouZahr, Adjei, and Increasingly, adolescence is recognized as a time of Kanchanachitra 2007). Global and national health changing trajectories and health across the life course information systems have paid little attention to the Corresponding author: George C. Patton, Department of Paediatrics, University of Melbourne; and Murdoch Children’s Research Institute, Melbourne, Australia; george.patton@rch.org.au. 57 adolescent age group, in part because of the prevailing governments. The Global Youth Tobacco Survey and the view of young people as healthy. Very few attempts to Global School-Based Student Health Survey (GSHS) systematically measure their health have been made. were both established in the past two decades, primarily Initiatives in adolescent health metrics have more to gain greater information on NCD risks that emerge in commonly arisen from interest in particular aspects adolescence. They are both administered by the World of health, such as sexual and reproductive health or Health Organization (WHO), with support from the adolescent-onset risks for NCDs in later life. The U.S. Centers for Disease Control and Prevention, and Millennium Development Goals (MDGs), for exam- focus on younger adolescents ages 13–15 years in schools ple, proposed indicators on the development of young in LMICs. Although broadly focused on risks for NCDs, people in low- and middle-income countries (LMICs) the GSHS also covers other aspects of adolescent health. but with a health focus predominantly on sexual and The DHS are the most well established of the reproductive health (Beaglehole and Bonita 2008). global household surveys. It is supported by the U.S. Broad conceptual frameworks for reporting adoles- Agency for International Development and operates cent health have been used in only a small number of in LMICs. It has provided some health information high-income countries (HICs) that undertake regular for ages 15–25 years over the past three decades, pre- reports on the health status of young people (AIHW dominantly around sexual and reproductive health. It 2003; Kolbe and others 1997; Office of the Minister for has more recently been complemented by the Multiple Children and Youth Affairs 2008; Ministry of Social Indicator Cluster Surveys (MICS), administered by Development 2008). In these countries reporting has the United Nations Children’s Fund. MICS use meth- moved from a focus on age-disaggregation of routinely odologies similar to those of DHS, with a predomi- collected health and demographic statistics to reporting nant focus on the sexual and reproductive health of behavioral and risk factor data collected directly from married women and girls. young people (UNICEF 2007). Current Data Surveys and Databases for Adolescent HEALTH INDICATORS AND COVERAGE FOR Health ADOLESCENTS Planning responses to adolescent health requires Health indicators are summary measures chosen to data that are timely, developmentally relevant, age- describe particular aspects of health, health risk, or and gender-disaggregated, and defined to a local level. health system performance. They are generally devel- Ideally, these data would allow comparisons over time oped in the context of a specific policy initiative and and tracking of inequalities within and between coun- conceptual framework. Indicators are commonly defined tries. In reality existing global data systems for adoles- within the context of specific disease-related initiatives, cents are uncoordinated, inconsistent in coverage a process that has led to rapid inflation in numbers of and timing, inadequately disaggregated, and missing indicators, presenting a major challenge for global health large groups of adolescents, and they fail to deal with information systems (Murray 2007). Many indicators the spectrum of health problems and their determi- remain poorly measured, leading to calls to define nants. This situation matters because LMICs are, to a smaller numbers of core health indicators focused on large extent, dependent on global surveys, such as mortality, morbidity, service coverage, and risk factors Demographic and Health Surveys (DHS), for data for (Bchir and others 2006). health policy and programming. The MDGs brought a focus to indicators for HIV/ Map 5.1 and annex table 5A outline the available AIDS and maternal health in adolescents. There have surveys and databases that provide data on adolescent been a number of subsequent calls to expand indica- health problems, health risks, and social determinants of tors and data collection systems beyond this focus on health. Adolescent health and well-being is currently sexual and reproductive health to take into account assessed in a patchwork of surveys that include school- rapid transitions in adolescent health in many coun- and household-based surveys. tries (Boerma and Stansfield 2007). More comprehen- Health Behaviour in School-Aged Children (HBSC) sive approaches would consider relevant social is the oldest of the school-based surveys. It is supported determinants of health, as well as the contribution of by an academic network and has, over the past three adolescent-onset risk factors to future disease burden decades, collected data on younger adolescents in schools (Walker, Bryce, and Black 2007). in many HICs and middle-income countries, with inter- Growing evidence suggests the importance of sound mittent, ad hoc support from some national information to promote effective responses to the 58 Child and Adolescent Health and Development Map 5.1 Global Coverage of Adolescent Health by International Data Collections, 2000–12 IBRD 42560 | OCTOBER 2016 GSHS/HBSC DHS only GSHS/HBSC and DHS MDB only GSHS/HBSC and MDB No data Source: Reprinted from The Lancet 379 (9826): Patton, G. C., C. Coffey, C. Cappa, D. Currie, L. Riley, and others, “Health of the World’s Adolescents: A Synthesis of Internationally Comparable Data,” 1665–75, © 2012, with permission from Elsevier. Note: DHS = Demographic and Health Surveys; GSHS = Global School-Based Student Health Survey; HBSC = Health Behaviour in School-Aged Children; MDB = World Health Organization Global Mortality Database. health problems of young people, including prevention Figure 5.1 Conceptual Framework on Adolescent Health of traffic injury (Shope and others 2001); reducing Social, educational, and economic policies and interventions adolescent alcohol abuse (Wagenaar 2003); responding Social to underweight and malnutrition; and promoting the determin- Risk and social, neighborhood, and school engagement back- ants protective of health factors ground for healthy development (Hawkins and others Preconceptual 2009; Patton and others 2006). Despite this growing influences and Early child Puberty and social- Adulthood recognition of the importance of good information for prenatal development role transitions development adolescent health, there is as yet no current interna- tionally agreed-upon set of indicators. The 2012 Lancet Health-related behaviors Adolescent Health Series conceptual framework was and states adopted for the purpose of defining indicators relevant Adolescent to adolescent health (figure 5.1). It incorporates ele- health ments from earlier national reports, including mea- outcomes sures of health and well-being (AIHW 2007), social Health policies Preventive care and health-service delivery role transitions (Department for Children, Schools, Source: Reprinted from The Lancet 379 (9826): Sawyer, S. M., R. A. Afifi, L. H. Bearinger, S. J. Blakemore, and Families 2010), risk and protective factors B. Dick, and others, “Adolescence: A Foundation for Future Health,” 1630–40, © 2012, with permission (Bronfenbrenner 1979), and health service system from Elsevier. Global Measures of Health Risks and Disease Burden in Adolescents 59 responses (Rosen and Levine 2010). The series selected Indicators Needing Better Measures indicators across five areas: Much work needs to be done on indicator development and measurement. Sexual and reproductive health in • Health outcomes reflecting major causes of death and adolescents has had the greatest policy and program- incident disability in ages 10–24 years matic attention, leading to a greater degree of consensus • Health-related behaviors and states that carry risks on definitions of indicators and, in turn, the production for current or later-life disease and typically emerge of data. In other areas, there are difficulties in defining in adolescence and young adulthood and measuring indicators. The lack of investment in, and • Risk and protective factors derived from the imme- agreement around, mental health indicators is one strik- diate social contexts affecting emerging health risks ing gap that is relevant for an age group in which the • Markers of social role transitions that are associated peak onset for mental disorders occurs (Gore and others with altered patterns of health risk 2011). This void reflects a lack of clarity about the defi- • Health service policy interventions provided to ado- nition of an indicator and a lack of agreement about lescents that have the potential to influence current or which standardized and practical measures might be later health status. used widely in health surveys. Potentially useful mea- sures exist, however, in that the K-6 (Kessler-6), PHQ-2 The indicators drew on the four categories of data (Patient Health Questionnaire), and PHQ-9 seem brief outlined in annex 5A including the global mortality data- enough to be useful in the major surveys (Green and base, international household surveys, international others 2010; Richardson and others 2010). school-based surveys, and other United Nations (UN) Indicators of health service delivery to young people sources. The indicators included the most recent data were poorly measured other than an MDG-related available, collected since 2000, even if the data were not focus on HIV/AIDS. In some instances, such as human available for the entire age spectrum or were available papillomavirus (HPV) vaccination, this gap is likely to only at a subnational level. Regional subgroups were reflect the comparatively recent introduction and as yet defined according to the 2010 Global Burden of Disease absence of wide-scale implementation (Goldie and study (Murray and others 2012). others 2008). In other instances, such as health care The Lancet series used indicator definitions with the responses to major mental disorders, it reflects both best comparable data to optimize global coverage. lack of agreement about the indicator and measure- Where available, the series used well-accepted and con- ment problems. In delineating indicators of interven- sistent definitions, although definitions varied consid- tion coverage, there is scant evidence about the erably for many indicators. In these instances, the series effectiveness of interventions such as youth-friendly examined currently available data sources (annex 5A) primary health care and longer-term outcomes of to derive definitions that allowed comparisons to treatment for mental disorders (Tylee and others 2007). be made across a maximum possible number of Such evidence is needed to define indicators of health countries. service coverage and quality. Current international sur- veys, such as those conducted by the Commonwealth Fund, provide data on unmet health care needs but Global Coverage of Adolescent Health focus on a small number of HICs and lack scope for Given the widespread perception of adolescence as a disaggregation by age group. Given that the delivery of healthy life phase, it is not surprising that this picture of high-quality interventions is likely to be the main way young people’s health is patchy, with a range of data gaps. in which health systems may effect change in adoles- Global coverage of the 25 indicators selected for the 2012 cent health, this gap is concerning. Lancet series on adolescent health are outlined in annex 5B. One area that few national or international reports Comparable data coverage was higher for indicators that have addressed well is measurement of risk and protec- have been the focus of the MDGs. However, only a few tive factors related to the social contexts of child and indicators had global coverage greater than 50 percent; adolescent development. In addition to being important coverage was very low for some indicators, particularly determinants of adolescent health, these factors are around mental health, substance use, and health service commonly the areas for which good evidence around delivery. Accurate population data on the major causes of prevention exists (Catalano and others 2012). Positive nonfatal health-related disability in this age group, even for family, school, and community connections are mea- HIV/AIDS, is telling for its absence. This lack of good sured in school health surveys, but much more work health information reflects a number of gaps that can be needs to be done to clarify cross-culturally valid indica- classified into four categories. tors in these areas (McNeely and Barber 2010). 60 Child and Adolescent Health and Development Indicators Needing Agreed-Upon Definitions of indicators will be feasible. Recently introduced sur- Sometimes which indicator and definition is most veys, such as the GSHS, are also limited to younger valid, and whether a single indicator is sufficient, is adolescents in school rather than being population unclear, for example, maternal mortality rate and ratio. based. School-based surveys provide no information on Both the choice and definition of indicators in earlier those outside of school, almost certainly a higher-risk national and international reports have varied greatly, population for many health problems (Bovet and others in part reflecting the available data. Many HICs have 2006). Additionally, because retention rates drop with used the HBSC; this practice has led not only to com- progression through secondary school, the predomi- parable measures but also to the adoption of similar nant focus of school surveys has been early adolescence, definitions (UNICEF 2007). Even so, in areas such arguably too young an age group in which to track as tobacco and substance use, and physical activity, important risk processes related to alcohol abuse and measurement is not a major problem; however, these illicit drug use that tend to emerge at a later age (Patrick areas do have substantial differences in the definitions and Schulenberg 2011). used that limit comparisons between countries and To what extent the measurement of young people’s over time. health best takes place in adolescent school-based sur- International comparability can be optimized where veys or augmentation of existing household surveys similar methods of sampling and measurement are that include older age groups is an important question. used across surveys (Pirkis and others 2003). Such har- School-based surveys are efficient where a high propor- monization of data collection is evident in the major tion of adolescents are in school; for those countries and household surveys (MICS, DHS, Reproductive Health regions where school retention rates are low or absentee- Surveys, AIDS Indicator Surveys), but it is not yet opti- ism high, however, it is unlikely to be a sufficient strategy mal for the major international school-based surveys, without data collection on the higher-risk groups out- even though some comparisons are possible. The GSHS side of school. This situation will be particularly true for complements the more established HBSC in providing girls in countries with lower enrollment rates because new data on adolescents in LMICs. Despite the difficul- girls are less likely to be in school than boys. Furthermore, ties inherent in international comparisons, there appear because of lower school retention in later secondary to be sufficient similarities between these two interna- school, school-based surveys, even in HICs, are likely to tional surveys to suggest that aggregated analyses might provide a better measure of the health of younger rather be feasible in the future (Pirkis and others 2003). This than older adolescents. Yet it is in older adolescence that comparability could be strengthened even further with many health risk behaviors, such as tobacco, alcohol, and alignment of sampling and measurement strategies. other substance use; obesity; and physical activity, and health states become established. The younger adoles- Indicators Needing Extended or Different Data cent age group with the greatest coverage is arguably too Collection young for the extent of these problems to be adequately Some of the difficulties in capturing a complete pic- assessed. ture of young people’s health lie in the limits of inter- Although some programs do capture risk behaviors national data collection. Mortality indicators are one and states in older groups (for example, the European example. Although arguably a poorer guide to health School Survey Project on Alcohol and Other Drugs, status of adolescents than for other age groups with the WHO’s STEPwise approach to Surveillance), the higher death rates, these estimates depend on good range of country coverage globally is limited and depends national registers of death. Those countries with the on high retention rates in upper secondary schools. For highest mortality rates, and therefore where mortality this reason, the extension of household surveys with a is a more important indicator, tend to be those with- broader range of measures is likely to be important. out national registers. These surveys collect fewer data from men and remain The capacity to measure and respond to the health largely restricted to sexual and reproductive health, even risk behaviors that emerge in adolescence and young though the MICS have taken recent steps to extend to adulthood will be central in prevention efforts for other areas of health. There are challenges beyond survey NCDs (Strong and others 2008; WHO 2000). Investment design, respondent burden, and cost. Questions may also has increased since the 2000 World Health Assembly arise about whether an adolescent or a parent is the bet- call for surveillance to track the major risks for chronic ter informant, who can provide consent, and whether NCDs (WHO 2000). Yet many adolescent estimates in confidentiality can be maintained. LMICs are based on only one data point, with little Strategies relevant to socially marginalized young certainty about whether and when serial measurements people, including those out of school, out of home, and Global Measures of Health Risks and Disease Burden in Adolescents 61 in juvenile detention, are needed. These young people better information on infant and child mortality in are unlikely to be included in current data collections pursuit of MDG 4. CHERG subsequently extended its and health profiles, and their access to health services is work to examine the relationship between infant and often very poor. Strategies for health surveillance are maternal mortality; CHERG has produced reports that needed in these groups, such as focused institutional have shaped global policy responses and information surveys or respondent-driven sampling, methods that systems around early childhood mortality and disease. have been used to track HIV prevalence and risk behav- A coordinating entity for the measurement of young iors at a local level (Chopra and others 2009). people’s health might have a work plan that includes Digital technologies potentially offer an alternative conducting research that would lead to better measures path, either in the context of existing surveys or of important and neglected indicators, refining indica- development of new surveys. In countries with con- tor definitions with optimal validity, determining the spicuous acute adolescent health problems—such as best methods of capturing data in this adolescent age intentional and nonintentional injuries, HIV/AIDS, group, and ensuring the full use of available data. and mental disorders—it may be possible to use these Ultimately, this effort could lead to harmonization technologies to tap into data from existing facilities across the different data sources, establishment of where young people are seeking care. Web-based sam- a consensus set of global indicators, development of a pling and assessment methods, the use of mobile global index of adolescent health, and better use of data phones and hand-held devices for data collection, and in policy formation. new data-sharing strategies also have great potential to Outside of HICs, with a few notable exceptions, rela- increase the range and use of data (Lang 2011). So, too, tively few countries have compiled status reports on the digital technologies offer scope for collection of data on health and development of young people. The absence health service encounters, the weakest aspect in current of data on intervention coverage suggests that even in adolescent health data systems (Simmons, Fajans, and the development of policy within the health sector, the Ghiron 2007). Combined with the use of logic models, data currently collected may receive little attention and these technologies might also generate data that are have little capacity to drive health program delivery at a useful at local levels to guide practice responses and country level. Without such bottom-up data collection secure support for data collection by decision makers. capacity that can specify local priorities and document health intervention coverage, securing either political or Indicators for which Data Are Not Fully Utilized donor engagement may be difficult (Boerma and No clear inclusive forum exists for the collection AbouZahr 2005). and collation of global data on young people’s health. As a result, countries such as Australia, Brazil, and New Zealand, despite having sophisticated survey GLOBAL PATTERNS OF ADOLESCENT and health information systems, do not have data that DISEASE AND HEALTH RISK are easily internationally comparable (AIHW 2007). A The 2012 Lancet series illustrated wide international simple solution of incorporating at least some elements variations in almost all areas of young people’s health. of the HBSC into national surveys in these countries, These differences existed both between and within as well as adopting an agreed-upon international core regions, such as those defined by the WHO. The poorest set of indicators, would do much to ensure interna- regional health profiles were generally for young people tional comparability. in Sub-Saharan Africa, where mortality, rates of HIV/ However, more systematic approaches will be AIDS infection, and role transitions such as early child- needed. A range of UN agencies and other groups con- birth linked to health risk were high. There were striking tribute elements to current surveillance, but they do so regional differences that included death rates from vio- without any clear coordinating mechanism (Murray lence in Latin American countries and wide variations in and Lopez 2010). In more targeted areas of global rates of suicide and traffic injury deaths. With regard to health, the development of mechanisms for the coordi- risks for later NCDs, the available data suggest that HICs nation of strategic information has underpinned many had some of the poorest profiles relating to patterns of advances. In HIV/AIDS, malaria control, vaccine- alcohol abuse, mental disorders, and overweight. preventable diseases, and diarrheal diseases monitoring and evaluation groups have been organized and may extend across UN agencies (Stein and others 2007). The Adolescent Health Outcomes Child Health Epidemiology Reference Group (CHERG) HIV seroprevalence based on household surveys was was established in 2001 in response to the need for available from 29 countries representing 29 percent of 62 Child and Adolescent Health and Development the global population. Data were predominantly from use appeared similar in males and females. In most Asian Sub-Saharan Africa and to a lesser extent from central regions and the Caribbean, rates were higher in males. and southern Asia. We have not included estimates from sentinel surveillance sites or women attending antenatal Binge Drinking clinics because these generally overestimate prevalence Data on binge drinking in the past month were available (Wilson and others 2010). In areas where HIV/AIDS is for 51 countries and 17 percent of the global population. endemic, rates are substantially higher in females ages Definitions are not strictly comparable between the 15–24 years than in males. Swaziland had the highest GSHS and HBSC. The former defines binge drinking as estimated rates of HIV/AIDS infection. Countries with the consumption of at least five units of alcohol on any higher rates of HIV/AIDS that have not had country- day in the past month; the latter defines it as getting wide surveys include Angola, Botswana, Eritrea, The drunk at least once in the past month. Rates are substan- Gambia, Guinea-Bissau, Namibia, Nigeria, South Africa, tially higher for age 15 years than for age 13 years. In Somalia, and Sudan. Countries outside of Africa without general, estimates for binge drinking from HICs were seroprevalence data include Pakistan, Papua New substantially higher than derived from LMICs, with the Guinea, the Russian Federation, Thailand, and Ukraine. exception of some Latin American countries. Austria, Axis 1 psychiatric disorder in the past 12 months in Ireland, and the United States had the highest rates, with those ages 18–24 years was only available from 23 coun- close to one-third of 15-year-olds reporting binge drink- tries representing 37 percent of the global population. ing in the past month. In a number of countries with smaller sample sizes (less than 4,000 for all age groups, for example, Belgium, Illicit Substance Use France, Germany, and Lebanon) or with subregional Data on illicit substance use in the past 30 days were avail- samples (for example, Japan), confidence intervals able in 41 countries representing 12 percent of the global around the estimates for those ages 18–24 years were population. The best data available were for the European greater than 5 percent. No comparable data are avail- Region and North America. There were substantial varia- able for those younger than age 18 years. Rates of disor- tions in the rates of use; the highest were in Canada, der tended to be higher in females than males in most France, Spain, the Netherlands, and the United States. countries. There was a threefold difference in rates across countries, with low rates in Bulgaria, India, Italy, Underweight and the Netherlands, and high rates in Brazil, France, Underweight in those ages 13–15 years could be defined New Zealand, Spain, and the United States. Erskine and in 72 countries representing 48 percent of the global others (2016) estimated the coverage of prevalence data population. The greatest availability of body mass for mental disorder in children ages 5–17 years. index (BMI) data was in the European Region. Limited The overall global coverage was very poor; 124 out of data were available for Sub-Saharan Africa and Central 187 countries have no data at all on the prevalence of Asia, regions where the prevalence of underweight mental disorders. The mean global coverage for mental might be expected to be highest. Rates of underweight disorders in this age group was 6.7 percent (Erskine and were generally less than 10 percent in the European others 2016). regions and North America. In regions with higher rates of underweight, males tended to fall into this cat- egory more than females. South-East Asia had high Health Risk Behaviors and States rates of underweight with Indonesia, Myanmar, and Sri Coverage for health risk behaviors ranged between 40 and Lanka particularly high. Limited data exist for other 85 countries. In general, there was good to excellent cov- regions; Djibouti, Fiji, and the Republic of Yemen stood erage of health risk behaviors and states in North America, out for their high rates, particularly in males. the European Region, and southern Latin America. Overweight Tobacco Use Overweight in those ages 13–15 years was available for a Tobacco use in the past 30 days was available in 62 coun- similar range of countries as underweight. In HICs, rates tries representing 45 percent of the global population of overweight were substantially higher in males than of young people. Rates of tobacco use were high in a females. Canada, Greece, Italy, Malta, and the United number of Western European countries, Chile, Jamaica, States stand out for their high rates, particularly in Namibia, Tonga, and in males in Indonesia. In the young males where more than one-third were over- European Region, North America, Latin America, and weight. LMICs demonstrated substantial variation in many Sub-Saharan African countries, rates of tobacco rates of overweight; the lowest rates were in Malawi, Global Measures of Health Risks and Disease Burden in Adolescents 63 Mongolia, Myanmar, Pakistan, and Sri Lanka. It is strik- of physical activity. The rates of physical activity are ing that many LMICs had substantial rates of over- lower in LMICs, particularly for females, in the Middle weight; between one-fifth and one-third of young males East and North Africa, many Sub-Saharan African are overweight in Latin American countries, Oceania, countries, Pakistan, and the Philippines. China, Thailand, and Mauritania. Tonga had the highest rates of overweight, with approximately 60 percent of Sexual and Reproductive Health those ages 13–15 years fulfilling the criteria. Indicators of sexual and reproductive health were gener- ally more available. Map 5.2 provides an illustration of Physical Activity information on sexual health risks available from house- Physical activity data were available for 86 countries hold surveys. The surveys do not collect data on those representing more than 50 percent of the global popu- younger than age 15 years. lation. Boys were generally more likely than girls to ful- fill the recommended level of activity. HICs displayed • Sexual activity by age 15 years was relatively well some tendency to have higher rates of reported activity populated if the data sources extended to school- than LMICs. In most HICs, a majority of those ages 13 based surveys. Theoretically, data were available for and 15 years meet the guidelines of at least 60 minutes 117 countries and almost 50 percent of the global of moderate physical activity on most days of the week; population. Generally, more information was avail- the rates were lower in older females. Among HBSC able for females than males. The household survey countries, Bulgaria, Croatia, France, Greece, Israel, Italy, data derive from retrospective reports in samples Malta, Romania, and Russia stand out for their low rates ages 15–24 years, while available school-based survey Map 5.2 Sexual Health Risks in Adolescents in Countries with Available Household Data IBRD 42561 | OCTOBER 2016 a. Young people 15–24 who report sex before 15, b. 2+ partners in past year and reporting condom use both sexes at last sex, 15–24 year olds Proprotion (%) Proportion (%) 0 20 0 70 c. Females 20–24 who gave birth by age 18 d. Married females 15–24 years with unmet contraception need Proprotion (%) Proportion (%) 0 50 0 30 Source: Reprinted from The Lancet 387 (10036): Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Alifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. 64 Child and Adolescent Health and Development data cover having had sex by the time of report. Rates • Child birth by age 18 years had relatively good cov- from retrospective reports appeared to be lower than erage with data available for 57 percent of the world’s those from concurrent reports in countries where young women in 96 countries across a wide range of both sets of data are available. European countries incomes. Rates of early childbirth closely mirrored surveyed through HBSC showed an almost fourfold rates of early marriage, with high rates in Southern variation in rates for males and females and up to an Asia, Sub-Saharan Africa, and countries in Latin eightfold variation between countries. Coverage was America and the Caribbean. Namibia, South Africa, poorest in the Middle East and North Africa, and and Swaziland stand out for their relatively high coverage was limited in HICs in East Asia and Pacific. early birth rates and lower rates of early marriage. Bulgaria, the Central African Republic, Denmark, Iceland, Mauritania, Mozambique, the United States, and Zambia appeared to have higher rates of early ALTERNATIVES TO HARMONIZATION IN sexual activity in females. • Female marriage before age 18 years had good data DATA COLLECTION coverage for much of Sub-Saharan Africa, and mixed The current low rates of coverage do not allow an adequate coverage in Asia, the Middle East, and Latin America picture to be developed of health and health risks in ado- and the Caribbean. Similar data may be available in lescents in most countries. Recent attempts have been HICs (Stein and others 2007), but they are not col- made to model the use of existing sources of information lated according to this definition to allow international to provide a more comprehensive picture of global health comparability. Rates of early marriage were high in and health risks (Murray and others 2012). Multiple defi- Southern Asia; Bangladesh reported the highest rate nitions from different data sources are modeled in Murray globally, with two-thirds of women marrying before age and others (2012) using ordinary least-squares regression 18 years. Very high rates of early marriage were reported to generate estimates of frequency within particular for most of Sub-Saharan Africa. Rates in Eastern Europe categories. Maps 5.3–5.8 illustrate global patterns of three and Latin America were generally in the intermediate health risks that emerge prominently during the adoles- range but with striking variations among countries. cent years and the changes over the past two decades. Map 5.3 Prevalence of Daily Smoking in Ages 10–24 Years, 2012 Percent IBRD 42562 | DECEMBER 2016 Less than 5 5–10 10–15 15–20 More than 20 No data Source: Reprinted from The Lancet 387 (10036): Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Alifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. Global Measures of Health Risks and Disease Burden in Adolescents 65 Map 5.4 Annual Change in Daily Smoking in Ages 10–24 Years, 1990–2012 Percent IBRD 42632 | OCTOBER 2016 More than 2% decrease 1 to 2% decrease No change 1 to 2% increase More than 2% increase No data Source: Reprinted from The Lancet 387 (10036): Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Alifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. Map 5.5 Ages 15–24 Years Reporting Binge Drinking in the Past 12 Months, Both Genders, 2013 Percent IBRD 42563 | DECEMBER 2016 Less than 5 5–10 10–20 20–30 30–40 40–50 More than 50 No data Source: Reprinted from The Lancet 387 (10036): Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Alifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. 66 Child and Adolescent Health and Development Map 5.6 Annual Change in Ages 15–24 Years Reporting Binge Drinking in the Past 12 Months, Both Genders, 1990–2013 Percent IBRD 42633 | DECEMBER 2016 More than 2% decrease 1–2% decrease No change 1–2% increase More than 2% increase No data Source: Reprinted from The Lancet 387 (10036): Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Alifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. Map 5.7 Prevalence of Overweight and Obesity in Ages 10–24 Years, 2013 IBRD 42564 | DECEMBER 2016 Less than 10 10–20 20–30 30–40 More than 40 No data Source: Reprinted from The Lancet 387 (10036): Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Alifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. Global Measures of Health Risks and Disease Burden in Adolescents 67 Map 5.8 Annual Change in Overweight and Obesity in Ages 10–24 Years, 1990–2013 Percent IBRD 42634 | DECEMBER 2016 No change 0.5–2% increase 2–3.5% increase 3.5–5% increase More than 5% increase No data Source: Reprinted from The Lancet 387 (10036): Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Alifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. The prevalence of smoking was defined as tobacco age of drinking is a particular risk factor (Bonomo, smoking at least once per day. Smoking prevalence data Patton, and Bowes 2006; Viner and Taylor 2007). were available for 186 countries for ages 10–14, 15–19, Alcohol consumption in adulthood is linked to eight and 20–24 years, and for males and females. different cancers, hypertension, hemorrhagic stroke, Tobacco use is a major risk factor for NCDs later atrial fibrillation, and various forms of liver disease in life and overwhelmingly has its onset in adoles- and pancreatitis (Parry, Patra, and Rehm 2011). cence. Maternal smoking during pregnancy is also a Greater use of alcohol in pregnancy has prominent well-established risk factor for poor fetal growth as intergenerational harms in the form of fetal alcohol well as for later-life illness in offspring (Bruin, syndrome (Riley and McGee 2005). Gerstein, and Holloway 2010). Overall, tobacco use Binge drinking was defined as consuming 48 grams has declined since 1990, but progress has been mixed. of alcohol in a single occasion for females and 60 Rates of daily smoking remain greater than 15 percent grams for males in the past year, per Global Burden of in ages 10–24 years across most European countries. Disease definitions. Alcohol prevalence data were In Russia, one in four people ages 10–24 years smokes available for 188 countries for a combined 15–24 age daily. Across all groups of countries, daily smoking is group, and for males, females, and both genders com- more common in males than females. A number of bined. The modeled estimates were for a 15–24 year countries in Sub-Saharan Africa, Eastern Europe, and age band that assumed constant prevalence across all the Middle East have seen increases. Many nonsigna- ages in this group. Data were available for 1990, 1995, tories to the Framework Convention on Tobacco 2000, 2005, 2010, and 2013. Control have not seen any decline in adolescent and Binge drinking was considerably more prevalent in young adult tobacco use. males than in females in every country grouping. Little Alcohol use disorders typically begin during the progress has been made in reducing adolescent and young adult years. As with nicotine addiction, younger young adult binge drinking since 1990. An increasing 68 Child and Adolescent Health and Development trend for binge drinking is clear; both males and females • The capacity to understand health trends has in LMICs are likely to overtake HICs in binge drinking been limited by funding constraints resulting in in the coming years. lack of investment in repeat surveys in many Overweight and obesity increase markedly across countries. adolescence and young adulthood with very high per- sistence, particularly for obesity (Patton and others Moving forward will require responses in multiple 2011). The risks in later life include premature mortal- areas, including the following: ity, chronic disability, type 2 diabetes, ischemic heart disease, hypertension, and cerebrovascular dis- • Improving the harmonization of assessments across ease (Reilly and Kelly 2011). Preconception maternal surveys based on standardized indicators and mea- obesity increases risks for miscarriage, gestational sures. Where harmonization is not possible, studies diabetes, operative delivery, preeclampsia, infant peri- are needed to understand how different survey natal mortality, and macrosomia (Yu, Teoh, and approaches might be complementary. Robinson 2006). • Extending the coverage of current surveys to new and For those ages 19–24 years, overweight was defined emerging problems and health risks, including mental as BMI ≥ 25 to < 30 kilograms per square meter (kg/ disorders and emotional well-being, substance use, and m2) and obesity as BMI ≥ 30 kg/m2. For those ages injury risks. Doing so is likely to require the develop- 10–18 years, classification was based on percentiles ment of new indicators and measures. using the International Obesity Task Force definition. • Extending existing surveys to provide adequate cov- Overweight and obesity prevalence data were avail- erage of younger adolescents, as well as developing able for 188 countries for age groups 10–14, 15–19, systems for assessing structural and social determinants and 20–24 years, and for males, females, and both of health. sexes combined. Data were available for all years from 1990 to 2013. Digital technologies will offer great opportunities for Adolescent overweight and obesity have increased more affordable and more effective data collection sys- in prevalence across almost all countries since 1990, as tems, training, and support of in-country expertise in shown in map 5.8. Notable exceptions are Argentina, data analysis. Bulgaria, the Islamic Republic of Iran, Turkey, and countries in central Sub-Saharan Africa. The annual increase has been about 10 percent in China and Vietnam; there have also been marked increases in ANNEXES other countries across South-East Asia, as well as in The annexes to this chapter are as follows. They are Sub-Saharan Africa. If their recent increases in obesity available at http://www.dcp-3.org/CAHD. continue, middle-income countries will soon outstrip HICs in rates of overweight and obesity. • Annex 5A. Characteristics of Important International Data Sources Used in Adolescent Health Indicators • Annex 5B. Availability of Information from International CONCLUSIONS Data Collections to Populate Indicators of Adolescent Current knowledge of adolescent health reflects many of Health, 2000–12 the broader gaps in global health information systems. Adolescents are further disadvantaged on a number of counts. 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Bundy and Susan Horton This chapter provides a conceptual framework for The focus on the first 1,000 days—from the first day exploring the processes and inputs that determine the of pregnancy until age two years—has caused us to physical, cognitive, and intellectual growth of human lose sight of the fact that child and adolescent growth beings from birth to adulthood. This task is made partic- and development are complex processes with multiple ularly difficult by the absence of a holistic academic periods of sensitivity to intervention. Early interven- discipline that provides an overview of this critical phase tion is undoubtedly critical to human development. in the human life course. It is also complicated by the However, the emphasis on the proposition that harm curiously partial approach to studies in this area; much experienced in early life is irreversible not only is of the literature on child health ends when a child weakly supported by the evidence, but also has led to reaches age two years, while much of the literature on an unfortunate lack of emphasis on exploring impor- child education does not begin until a child reaches age tant and relevant interventions later in childhood. five years. This significant mismatch in the literature Similarly, the declining rate of return on educational reflects a similar lack of connection between the scale of investments posited by Heckmann (2011) may need to public investment in primary education—one of the few be reconsidered following recent neurobiological public goods that attracts near-universal support—and research on brain development and a broader recogni- the scale of investments in health and nutrition during tion of the complexity of intellectual skills, which middle childhood and adolescence. extend well beyond numeracy and literacy. Development during adolescence (ages 10–19 years) has received greater attention than the middle child- INTERVENTIONS DURING MIDDLE hood years (ages 5–9 years; see, for example, Patton and others 2016). The unfortunate tendency to treat adoles- CHILDHOOD AND ADOLESCENCE cence as separate from childhood has impeded efforts Volume 2 of the third edition of Disease Control Priorities, to enhance the understanding of the interrelationships Reproductive, Maternal, Newborn, and Child Health (Black between adolescence and earlier development and of the and others 2016), explores evidence of the importance of contribution of health and nutrition to the development maternal and young child health for subsequent child of the next generation. Definitions of age groupings development. This chapter complements those findings by and age-specific terminology used in this volume can be exploring evidence of the consequences of intervention at found in chapter 1 (Bundy and others 2017). later points throughout the life course. This chapter places Corresponding author: Donald A. P. Bundy, Bill & Melinda Gates Foundation, Seattle, Washington, United States; Donald.bundy@gatesfoundation.org. 73 particular emphasis on giving equivalent weight to the that stunting before age three years can be partially understanding of the role of interventions at all stages, reversed by delayed maturation and a longer period of from early childhood through middle years and adoles- catch-up (Martorell, Khan, and Schroeder 1994), given cence. To provide a conceptual scaffolding, we developed the right circumstances. A review in chapter 8 in this figure 6.1 to assemble evidence of effects along the same volume (Watkins and others 2017) presents evidence for age-specified life course. smaller, but potentially important, amounts of catch-up Figure 6.1 illustrates the value of a perspective that growth in older children before the onset of puberty. extends beyond the first 1,000 days. Rates of physical These data may mean that we need to be more careful growth are indeed the highest at younger than age two about assuming that early insults are irreversible and years, when nutrition is critical. However, the rates at pay more attention to what can be done for children the peak of the adolescent growth spurt for girls are in middle childhood. The scarcity of studies in this similar to—and for boys exceed—the rates at age two age group also may show the influence of unintended years (figure 6.1, panel a). It has long been recognized research bias on policy. Figure 6.1 Human Development to Age 20 Years Age in years 5 10 15 20 a. Height gain centimeters per year 20 Height gain, 15 Female Male 10 5 0 b. Change in brain development Gonadal hormones Change in brain Synaptic pruning, development neuromodulators, neurotrophins, cerebral blood flow, and metabolism Myelination Sensorimotor cortex Parietal and temporal association complex Prefrontal cortex Percentage change in volume as a c. Percentage change in volume as a proportion of prepubertal volume for each structure (for males) % of prepubertal volume for each structure (for males) 8 6 4 2 0 –2 –4 –6 Age in years 5 10 15 20 Amygdala Caudate Hippocampus Globus pallidus Sources: Panel a adapted from Tanner 1990; panel b adapted from Grigorenko 2017; panel c adapted from Goddings and others 2014. Note: The vertical axis in panel b shows relative rate of growth of three brain areas from 0 to highest. The progressive shading indicates when the indicated activity is at its most intense (darkest shading). Behavioral attributes are paralleled by hormonal and neurobiological changes that target specific brain regions and cell populations (shown in shaded gray to capture the dynamic influences of hormones, various brain processes, and myelination). 74 Child and Adolescent Health and Development Although the first 1,000 days are clearly a key period process helps explain why adolescence is a time of strong for brain development, evidence from neuroscience from passions (Dahl 2004), impulsiveness (Casey, Jones, and the past 15 years has given us greater insight into the com- Hare 2008), and risk taking (Casey, Jones, and Hare 2008; plexities of brain development. By age 6 years, the brain Steinberg 2007). The earlier development of brain regions has reached approximately 95 percent of its adult volume; associated with these behaviors outstrips the slower devel- the volume of gray matter peaks about age 12 years in opment of brain areas associated with control of impulses, boys (figure 6.1, panel c) (Goddings and others 2014). For delay of gratification, and regulation of emotions the brain, however, size is not everything. Connections (Steinberg 2007). Accordingly, a focus on readily measur- within the brain are of greater importance to functioning able cognitive function, as in much of the educational lit- than size. The process of myelination speeds up the pro- erature, ignores the more complex and later-developing cessing of signals, and the process of synaptic pruning brain functions that have important consequences for leads to strengthening of particular pathways. White mat- creativity, social functioning, and strategic thinking. ter in the brain, which reflects increased myelin, peaks in Figure 6.2 was developed to guide human development early adulthood. These processes of brain development strategic policy and suggests how key health, nutritional, also depend on individuals’ interactions with their envi- and educational interventions might be timed according ronments, which in turn stimulate their learning. to the different sensitivities at different ages. The figure Different areas of the brain have different functions also indicates the likely levels of school participation at and develop at different rates. Peak development of the different ages for low- and middle-income populations, sensorimotor cortex, which is associated with vision, showing how important the education sector can be for hearing, and motor control, occurs relatively early, and reaching children in middle childhood and adolescence, development is limited after puberty. The parietal and and presaging the discussion of delivery platforms in temporal association complex, responsible for language section 4 of this volume, which in turn underpins the skills and numeracy, develops the fastest a little later; discussion of various age- and stage-specific interven- hence, the observation that by about age 14 years, although tion packages discussed in section 5 of this volume. it is possible to learn new languages, it is more difficult to speak a new language in the same way as a native speaker (Dahl 2004). The prefrontal cortex develops later still; this IMPLICATIONS FOR PHASES OF is the area associated with higher brain functions, such as executive control (figure 6.1, panel b) (Grigorenko 2017). DEVELOPMENT It is possible to see some of these differential growth Our current understanding of human development dur- rates in brain capabilities in the relationship between the ing the first two decades of life suggests that there is a size of subcortical regions in figure 6.1, panel c. The series of phases, each of which is critical to development figure plots size as a function of stage of puberty using and each of which requires a different set of interventions Tanner’s well-known five stages, which can be catego- to support development and sustain the gains of the pre- rized as pre-, early, mid-, late, and postpuberty. The panel vious phases. Table 6.1 attempts to represent this process shows the pattern for adolescent boys; the patterns are by dividing the first 20 years of life into five phases of similar for girls but occur at earlier ages because of dif- physical, behavioral, and emotional development. ferent patterns of puberty. The panel shows that the size The age ranges selected are indicative and simplified; of those regions associated with movement (such as the at the population level the phases will each cover a caudate and globus pallidus) is shrinking during early broader range and they will overlap. Middle childhood adolescence because these functions are more mature. In arguably begins before age five years, but beginning at contrast, regions associated with memory, decision age five years helps alignment with formal education making, and emotional reactions (amygdala and hippo- practice. Middle childhood is also not entirely separa- campus) are still growing in adolescence. ble from adolescence, and for many children incorpo- The development of behaviors and social skills has rates an initial period of juvenility followed by the early long been recognized as age dependent, and it is now rec- beginnings of pubertal processes. Similarly, many of the ognized that this development is closely related to health risks of middle childhood—especially around neurological development. The subcortical regions are not infectious disease—persist into early adolescence, so fully developed at the point at which they reach maximum that during the adolescent growth spurt phase the size; they require additional time to establish rapid pro- school age and the adolescent packages are both rele- cessing and transmission of signals to other parts of the vant. Finally, the end point at age 20 years is a widely brain. The prefrontal cortex develops later still with matu- accepted marker of the transition from adolescence to ration continuing into the third decade. This prolonged adulthood, hence the social and legal importance of the Impact of Interventions on Health and Development during Childhood and Adolescence: A Conceptual Framework 75 Figure 6.2 Indicative Rate of School Enrollment in Low- and Middle-Income Countries Early stimulation Nutrition Immunization Malaria Micronutrients Combat hunger Deworming Hygiene 100 Healthy lifestyle 90 Percentage of school enrollment 80 < Tertiary level, ECD skills training, and 70 (Nutrition, health care, Primary and second chance parental training, ECE) secondary levels 60 education > 50 Age-enrollment profile Preschool 40 enrollment 30 20 Children and youth in school 10 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Age in years Source: Adapted from World Bank 2011. Note: ECD = early childhood development; ECE = early childhood education. Table 6.1 Key Phases of Child and Adolescent Health and Development Phase Period Developmental importance Examples of interventions Packages The First 1,000 Ages 9 months The most rapid growth of body and Maternal, reproductive, RMNCH (volume 2): Packages Days to 2 years brain; underpins all subsequent newborn, child health (see on maternal and newborn development; highest risk of mortality volume 2); responsive health and on child health stimulation Middle Childhood Ages 5 to Steady physical growth of body while Infection control, diet quality, The school-age package Growth and 9 years sensorimotor brain function develops; and promotion of healthy Consolidation nontrivial risk of death; some catch-up behaviors and well-being growth possible Adolescent Ages 10 to Rapid physical growth, attaining Age-appropriate variants The school-age and Growth Spurt 14 years growth velocities not seen since age 2 on above, plus vaccination, adolescent packages years, and rapid growth of centers for structured physical exercise, emotional development; main phase and promotion of healthy for remedial catch-up growth emotional development Adolescent Ages 15 to Consolidation of physical growth More focus on reproductive The adolescent package Growth and 19 years and especially of links in the brain; health, incentives to stay Consolidation risk-taking behavior associated with in school, protection from socioemotional development; last excessive risk taking, and chance for remedial growth in height early identification of mental health issues Note: RMNCH = Reproductive, Maternal, Newborn, and Child Health. 76 Child and Adolescent Health and Development twenty-first birthday, but it is now recognized that sig- Development: Realizing Neglected Potential.” In Disease nificant late-stage adolescent changes continue through Control Priorities (third edition): Volume 8, Child and to the mid-twenties. Adolescent Health and Development, edited by D. A. P. Bundy, Table 6.1 also indicates the packages of interventions N. de Silva, S. Horton, D. T. Jamison, and G. C. Patton. Washington, DC: World Bank. that can be developed to respond to the specific needs of Casey, B. J., R. M. Jones, and T. A. Hare. 2008. “The Adolescent each phase of development. Brain.” Annals of the New York Academy of Sciences 1124: 111–26. Dahl, R. E. 2004. “Adolescent Brain Development: A Period of OVERVIEW OF SECTION 2 OF THIS VOLUME Vulnerabilities and Opportunities.” Keynote Address. Annals The following chapters in this section expand on the of the New York Academy of Sciences 1021: 1–22. this discussion of intervention and the life course and Goddings, A.-L., K. L. Mills, L. S. Clasen, J. N. Giedd, R. M. Viner, and others. 2014. “The Influence of Puberty on Subcortical are based on the conceptual framework illustrated in Brain Development.” NeuroImage 88: 242–51. figure 6.1. Grigorenko, E. L. 2017. “Evidence on Brain Development and Interventions.” In Disease Control Priorities (third edition): • Chapter 7 in this volume (Alderman and others 2017) Volume 8, Child and Adolescent Health and Development, examines in more detail the timing of investments edited by D. A. P. Bundy, N. de Silva, S. Horton, D. T. Jamison, and provides equity arguments for investment in and G. C. Patton. Washington, DC: World Bank. those children who were disadvantaged in the invest- Heckmann, J. J. 2011. “Effective Child Development Strategies.” ments received before age five years. In The Pre-K Debates: Current Controversies and Issues, edited • Chapter 8 in this volume (Watkins and others 2017) by E. Zigler, W. S. Gilliam, and W. S. Barnett. Baltimore, MD: explores the issue of the irreversibility of early insult Paul H. Brookes Publishing. by asking whether catch-up is possible for children Martorell, R., L. K. Khan, and D. G. Schroeder. 1994. “Reversibility of Stunting: Epidemiological Findings in whose physical or cognitive growth has been limited Children from Developing Countries.” European Journal of in the first 1,000 days. Clinical Nutrition 48: S45–57. • Chapter 9 in this volume (Viner, Allen, and Patton Patton, G. C., S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Afifi, 2017) explores age-specific adolescent development. and others. 2016. “Our Future: A Lancet Commission on • Chapter 10 in this volume (Grigorenko 2017) pro- Adolescent Health and Well Being.” The Lancet 387 (10036): vides a more detailed explication regarding brain 2423–78. development. Steinberg, L. 2007. “Risk Taking in Adolescence: New Perspective from Brain and Behavioral Science.” Current Directions in Psychological Science 16: 55–59. Tanner, J. L. 1990. Fetus into Man: Physical Growth from Conception REFERENCES to Maturity. Cambridge, MA: Harvard University Press. Alderman, H., J. R. Behrman, P. Glewwe, L. Fernald, and S. Walker. Viner, R. M., N. B. Allen, and G. C. Patton. 2017. “Puberty, 2017. “Evidence of Impact of Interventions on Growth Developmental Processes, and Health Interventions.” In and Development during Early and Middle Childhood.” In Disease Control Priorities (third edition): Volume 8, Child and Disease Control Priorities (third edition): Volume 8, Child and Adolescent Health and Development, edited by D. A. P. Bundy, Adolescent Health and Development, edited by D. A. P. Bundy, N. de Silva, S. Horton, D. T. Jamison, and G. C. Patton. N. de Silva, S. Horton, D. T. Jamison, and G. C. Patton. Washington, DC: World Bank. Washington, DC: World Bank. Watkins, K., D. A. P. Bundy, D. T. Jamison, G. Fink, and Black, R., R. Laxminarayan, M. Temmerman, and N. Walker. A. Georgiadis. 2017. “Evidence of Impact of Interventions 2016. Reproductive, Maternal, Newborn, and Child Health, on Health and Development during Middle Childhood and volume 2 in Disease Control Priorities (third edition), edited School Age.” In Disease Control Priorities (third edition): by D. T. Jamison, R. Nugent, H. Gelband, S. Horton, Volume 8, Child and Adolescent Health and Development, P. Jha, R. Laxminarayan, and C. N. Mock. Washington, DC: edited by D. A. P. Bundy, N. de Silva, S. Horton, D. T. Jamison, World Bank. and G. C. Patton. Washington, DC: World Bank. Bundy, D. A. P., N. de Silva, S. Horton, G. C. Patton, L. Schultz, World Bank. 2011. World Bank Group Education Strategy 2020. and D. T. Jamison. 2017. “Child and Adolescent Health and Washington, DC: World Bank. Impact of Interventions on Health and Development during Childhood and Adolescence: A Conceptual Framework 77 Chapter 7 Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood Harold Alderman, Jere R. Behrman, Paul Glewwe, Lia Fernald, and Susan Walker INTRODUCTION as well as epigenetics, with social and behavioral models. Worldwide patterns of linear growth faltering, based on The approach in this chapter unites economic theory data from many low- and middle-income countries with health science. (LMICs) (Victora and others 2010), indicate deteriora- We use the lifecycle approach to assess the benefit-cost tion of child nutritional status, on average, from age 0 to ratios of interventions in nutrition and child development 24 months; after this period, nutritional status levels off in LMICs, where undernutrition is a risk factor, with a or slightly reverses (for example, Prentice and others focus on the first five years of life. Definitions of age 2013; Stein and others 2010). Analyses of the five coun- groupings and age-specific terminology used in this vol- tries in the Consortium of Health-Orientated Research ume can be found in chapter 1 (Bundy and others 2017). in Transitioning Societies (COHORTS) study found that Birth weight and linear growth in the first two years low birth weight or undernutrition at age two years (or are associated with many beneficial outcomes later in life both) were associated with shorter adult height, less (Adair and others 2013). The 2013 Lancet nutrition schooling, and lower economic productivity (Victora series also acknowledged the need to address both and others 2008). The 2008 Lancet series on nutrition undernutrition and increased obesity in LMICs (Black argued that height-for-age is the best nutritional predic- and others 2013), recognizing that there is a high preva- tor of adult human capital (Victora and others 2008). lence of both conditions and that the conditions often These results influenced prioritization of global are linked. The 2013 series connected the importance of efforts to combat undernutrition in the first 1,000 days, prenatal nutrition and adolescent girls’ nutrition (Bhutta from conception to age 24 months. More broadly, these and others 2013). Women’s height affects risks for preg- 1,000 days are seen as a critical period for establishing nancy complications (Toh-Adam, Srisupundit, and the physical, cognitive, and socioemotional foundation Tongsong 2012) and low birth weight (Black and others for later life (Walker, Wachs, and others 2011) and are 2013); given associations of birth weight with subsequent viewed as the period of greatest plasticity (Gluckman undernutrition (Christian and others 2013), these find- and others 2009). As reviewed by Halfon and others ings bring the discussion full circle. Thus, the 1,000-day (2014), new approaches to life course development have window could be made much longer—even going back integrated biological systems, drawing from genetics to mothers’ childhoods. Corresponding author: Harold Alderman, International Food Policy Research Institute, Washington, DC, United States; h.alderman@cgiar.org. 79 Children’s early years are critically important for cog- obesity and adult chronic diseases (Monteiro and Victora nitive, language, and socioemotional development, and 2005; Yajnik 2004, 2009). strong evidence indicates that the window of influence As with malnutrition, cognitive delays can occur extends well beyond the first 1,000 days. Protective and throughout infancy, childhood, and adolescence, under- risk factors for undernutrition are often similar to the stood in this volume as birth through age 19 years. factors influencing cognitive and socioemotional devel- Measurable differences in receptive language by socio- opment (Walker, Wachs, and others 2011). For example, economic groups are apparent in preschool children shared risk factors include intrauterine growth retarda- ages three to five years (Paxson and Schady 2007; Schady tion, nutrient deficiencies, and social and economic and others 2015); differences in cognitive ability have conditions. Risks specific to poor cognitive development been observed even in the first two years (Fernald and include inadequate learning opportunities and inade- others 2012). Early life stress—often toxic if extreme— quate quality of caregiver-child interactions. Shared can also have difficult-to-reverse lifetime consequences protective factors include breastfeeding and maternal (Shonkoff and Garner 2012). Individual responsiveness education. to interventions implemented after initial developmen- The overlapping risk factors, timing of peak vulnera- tal insults are widely debated (see chapter 8 in this vol- bilities, and the possibility that early deficits have ume, Watkins and others 2017). long-lasting impacts have motivated interest in interven- More than 3 million children younger than age five tions that integrate nutritional and other approaches to years died in 2011; half of these deaths were associated promote overall child development (Alderman and with fetal growth restriction, suboptimal breastfeeding, others 2014). Ideally, policies and programs must move stunting, wasting, and vitamin A and zinc deficiencies from a focus on single issues to a wider-reaching, more (Black and others 2013). Given that about 75 percent of integrated approach across the life course, which would child deaths before age five years occur in the first year, allow for each child to develop as well as possible and addressing catch-up growth beyond the 1,000-day window mitigate the impact of constraints under which their is driven less by concern for mortality risk and more by development may be occurring (Fine and Kotelchuck concerns relating to later-life consequences for survivors. 2010). Such integration, however, requires clearer under- Some evidence indicates that skill accumulation is standing of individuals’ developmental timing and more plastic than physical growth; skills such as executive age-dependent responses to external factors (Wachs and function—a component of cognitive function—and others 2014). Cognitive functions, receptive and expres- socioemotional development have time paths different sive language, and socioemotional skills develop at from those of conventional cognitive abilities (Borghans different ages (Grantham-McGregor and others 2007). and others 2008). Still, very little is known about time Development in brain structure and function support- paths of effective interventions for addressing nutritional, ing acquisition of cognitive, language, and socioemo- cognitive, and socioemotional development, particularly tional skills is most rapid during early childhood, with in LMICs. Maximum gains relative to costs, particularly continued development in later years for many skills. for cognitive and socioemotional developmental out- The early years, beginning in utero and extending to comes, are likely to require early investment, followed by age 36 months, are the best stage in which to prevent appropriate nutritional and educational investments and stunting. The debate continues as to whether children continued support for effective parent-child interaction who become stunted before age 24 months can catch up over childhood and adolescence. Determining which later in their lives. Population averages from cross- later-life interventions cost-effectively reduce conse- sectional data show some limited catch-up in height-for- quences of early malnutrition or cognitive delay is age z scores, though average height deficits widen important if efforts at prevention fall short, as they beyond age two years into adulthood (Leroy and others already have for hundreds of millions of children. 2014; Lundeen and others 2014). Longitudinal studies report considerable individual movements in both direc- tions between stunted and nonstunted status after age 24 LIFECYCLE FRAMEWORK FOR months that are associated with family and community ASSESSMENT OF BENEFITS AND COSTS characteristics, suggesting potential for catch-up or pre- OF INTERVENTIONS TO SUPPORT CHILD vention of faltering (Crookston and others 2013; Lundeen and others 2013; Mani 2012; Prentice and DEVELOPMENT others 2013; Schott and others 2013). Catch-up may, The lifecycle framework highlights the age dimen- however, have some risks; for example, weight gain on sion for both outcomes and determinants of child small frames has been associated with subsequent and adolescent development. Figure 7.1 presents such a 80 Child and Adolescent Health and Development Figure 7.1 Physical Growth and Other Developmental Outcomes within a Lifecycle Framework Exogenous Proximate Determinants for Lifecycle Stage 1 1. Outcomes in First 1,000 Days from 1. Individual characteristics (genetics) Conception and through Preschool Ages 2. Household characteristics, including income, parental education, a. Physical (health, nutritional status, survival) parental time use, and home environment b. Cognitive (for example, language, executive function) 3. Community characteristics, including health and nutritional c. Socioemotional services, environment, water and sanitation, and markets d. Mortality Exogenous Proximate Determinants for Lifecycle Stage 2 2. Outcomes for School-Age Children 1–3 a–d, plus years of schooling and skills learned in school Exogenous Proximate Determinants for Lifecycle Stage 3 3. Outcomes in Later Adolescence 1–3 a–d, completed education, labor market, partnering, parenting, household production Exogenous Proximate Determinants for Lifecycle Stage 4 4. Outcomes in Adulthood 1–3 a–d, labor market, health, partnering, parenting, grandparenting, household production, chronic diseases framework, with three formative stages extending from The lifecycle could be divided into fewer or more stages, conception through childhood and adolescence, contin- but the pattern by which actions in one stage influence uing to an adult stage.1 both outcomes in that period and in subsequent stages, either directly or indirectly, is generalizable. Moreover, the • Lifecycle Stage 1 from conception through preschool age timing of exit from one stage and entry into the subse- • Lifecycle Stage 2 primary and early secondary school quent one is itself partially dependent on earlier outcomes ages and concurrent decisions; for example, entry into school • Lifecycle Stage 3 late adolescence depends in part on nutritional status (Alderman and oth- • Lifecycle Stage 4 adulthood. ers 2001; Glewwe, Jacoby, and King 2001); entry into the labor force depends on both physical stature and schooling Individuals who survive each stage continue on to achievement (Pitt, Rosenzweig, and Hasan 2012; Yamauchi the next stage, as indicated by the green arrows in the 2008). Even transitions that are biological, such as menar- figure (see also Nandi and others 2017, chapter 27 in this che and the beginning and duration of the adolescent volume). The sections in this chapter and in chapter 8 growth spurt, are partially dependent on earlier health (Watkins and others 2017) present evidence of opportu- outcomes and on behavioral and hormonal responses to nities for interventions in the first three lifecycle stages— cultural and environmental contexts. preschool, school-age, and late adolescence—including Broadly speaking, the outcomes in each lifecycle stage evidence on costs, returns to investments, and implica- can be classified into three categories: physical growth, tions for tradeoffs. cognitive development (including language, executive Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 81 function, mathematics, and reasoning), and socioemo- with worse outcomes in the earlier period. Whether gov- tional development. The relevant outcomes of these ernments or households prefer strategies that reinforce categories vary at the different stages. The risk of early earlier differentials, or whether they prefer to invest to mortality is particularly relevant in the first stage; school compensate for disparities, is also an empirical question. attainment is most relevant in the second and third This framework also helps deepen our understanding stages; and employment is most relevant in the third and of how short-term health shocks may affect future out- fourth stages. Establishing priorities for investment or comes. If dynamic complementarities are strong, then integrating mortality with other outcomes, such as moderate shocks to children’s health in early life may improved development for survivors, is particularly lead to major differences in schooling and other later challenging without a common metric. Most other out- outcomes if nothing is done to compensate for these comes can be assessed by measuring their financial value shocks. Similarly, self-productivity is consistent with relative to their cost, but there is no consensus on how to long-term impacts of early-life nutritional deficits, mor- make such an assessment for mortality. A wide range of bidity, inadequate stimulation, and toxic stress (National estimates of the value of averted mortality have been Scientific Council on the Developing Child 2014). proposed. These, however, range from the cost of the To quantify the links in the framework illustrated in cheapest alternative for averting mortality to what com- figure 7.1, the challenge imposed by the multiple proxi- pensating differentials individuals require to assume mate determinants of the outcomes of interest in each more risk, for example, based on wage tradeoffs lifecycle stage must be addressed. With the rare excep- (Summers 1992; Viscusi and Aldy 2003). tion of randomized controlled trials or transitory natu- ral experiments that alter one of them, these determinants are likely to be highly correlated across different lifecycle Usefulness of the Lifecycle Framework stages. Accordingly, the causal effects of growth in one A particular conceptual value of a lifecycle model is that period on outcomes in subsequent stages may be over- it can illustrate how inputs in one stage influence out- stated because this approach attributes to the previous comes in later stages. For example, higher stocks of stage the effect not only of growth in that stage on sub- health (or health skills) in one stage may create even sequent growth (the green arrow) but also the effects of higher health later. Cunha and Heckman (2007) term correlated determinants across stages (the blue arrows). this process self-productivity. Similarly, the model can Additionally, it is difficult to separate the physical, highlight cross-productivities in which better health in cognitive, and socioemotional dimensions of growth over one stage increases cognitive skills in the same or subse- the lifecycle. For example, to examine the impact of an quent stages. Cross-productivities may also occur if investment in physical growth, either the investment has cognitive skills in one period enhance socioemotional to affect only physical growth, or else other dimensions of skills in another (Helmers and Patnam 2011), or if child development need to be controlled. Randomized dimensions of health in one period influence other controlled trials or natural experiments directed only at developmental dimensions subsequently. The model physical growth with impacts measured over multiple also describes what Cunha and Heckman (2007) call lifecycle phases might permit such an assessment to be dynamic complementarities, by which higher health or made, but such studies are rare. If observational data are skills in one stage lead to greater returns to investments used, and channels for the impacts of investment other in subsequent stages. than physical growth are not controlled for in the analy- Dynamic complementarities have important implica- sis, the impacts of physical growth are likely to be misrep- tions from an economic efficiency perspective: more resented because physical growth will almost certainly be investments should be targeted to those with better ini- positively correlated with impacts of the investment tial health and greater skills, although doing so would through other channels. Since one of those channels is widen disparities as children age. This is not only a pos- cognitive development, for example, identifying the sible outcome of decisions by governments, but may also impacts of physical growth as distinct from the impacts pertain to households’ investments in siblings. Given of cognitive development is challenging. dynamic complementarities, do households invest more in their children who have higher potential, or do they seek more equity and compensate by investing more in Prioritization of Interventions “less productive” children? However, whether dynamic Prioritization of interventions involves an understanding complementarities predominate is an empirical issue— of these causal impacts, as well as the costs of these inter- there may be dynamic substitution if investments in one ventions, in the context of LMICs. The costs of interven- period have a greater return when provided to children tions include the total resource costs of changes in the 82 Child and Adolescent Health and Development boxes on the left-hand side of figure 7.1, where resource costs, even though they may have implications for real costs mean the use of resources for this intervention that resource costs. have value in other uses. Many interventions have In addition, because of the interest in longer-term resource costs for both public sector providers and pri- impacts, it is important to recognize that the timing of vate individuals. If parents have to take their children to both impacts and costs matters if there is an advantage health clinics to receive interventions, resource costs are to obtaining returns earlier rather than later because the incurred in the form of transportation costs and the costs returns can be reinvested to generate further returns. of the parents’ time, in addition to the public resource This is particularly important if early-life interventions costs of the clinic. In addition, there are likely to be dis- have impacts decades later through their effects on adult tortion costs from raising funds to finance public expen- productivity and chronic diseases. In this context, the ditures; these distortion costs have been estimated to be intertemporal discount rate used may make a consider- approximately 25 percent of public expenditures able difference. Hoddinott, Alderman, and others (2013) (Devarajan, Squire, and Suthiwart-Narueput 1997). If provide a scenario in which the benefit-cost ratio for only service provider costs are incorporated into the reducing stunting in Bangladesh is 17.9 with a 3 percent analyses, total resource costs are likely to be understated. discount rate, but this ratio declines to 8.9 with a A further consideration related to costs may be the 5 percent discount rate, and 3.3 with an 8 percent dis- budget envelope, that is, the short-term constraint on count rate. available revenue or line item for a sector. Policy makers Finally, the framework in figure 7.1 is context depen- may perceive that the budget envelope constrains their dent. Resources, environments, policies, cultures, and choices so that, for example, increases to public sector markets are likely to vary considerably, and careful expenditures on one item, such as preschool programs, assessment is needed within the particular context for must come at the expense of other items, such as pri- which an intervention is being considered. mary school teacher salaries, even if the benefit-cost ratios of both options are considerably greater than one. The budgetary process imposes a constraint on their QUANTIFYING THE MODEL: ILLUSTRATIONS choices that, from their perspective, is an additional cost OF BENEFIT-COST RATIOS AND RELATIVE component. The impact of the budget envelope is partic- RATES OF RETURN FOR INTERVENTIONS ularly likely to affect new initiatives because endowment FOR DIFFERENT AGES IN A LIFECYCLE effects and vested interests may make it difficult to reduce public sector expenditures on items purchased in FRAMEWORK the past even if their benefit-cost ratios are smaller than The benefits and costs or, equivalently, internal rates of those of proposed new interventions. Although the bud- return from interventions are needed to guide decisions get envelope does not represent real resource costs, it about choices among different interventions to mitigate may be a real constraint on public sector choices, espe- inadequate child development versus other possi- cially for new initiatives. ble interventions. We illustrate some dimensions of Policy makers who think they are constrained by benefit-cost ratios with an example of interventions to budget envelopes have incentives to offload real program prevent or reduce inadequate physical growth early in costs onto private entities, to the extent possible. For the preschool stage of the lifecycle, and then we discuss a example, if new services are provided and a choice is well-known stylized characterization of relative rates of made between expenditure of public sector funds to return to investments over the lifecycle. improve households’ access to those services and higher private transportation costs to be borne by those house- holds, the constraint imposed by budget envelopes cre- Benefits over the Lifecycle: An Illustration ates incentives to choose the latter even if those costs are On the benefit side, including all the important impacts borne by very poor people. This last point is related to a is critical—which means that different types of benefits more general distortion present in many policy discus- need to be expressed in the same terms—as is accountng sions that wrongly equate public sector expenditures for the fact that some impacts may be realized only years with real resource costs, ignoring the fact that important after the intervention and need to be discounted to the components of real resource costs may be private sector present to obtain present discounted values (PDVs). costs and that components of public sector expenditures Table 7.1 illustrates moving one child out of low– such as transfers may not be real resource costs. birth weight (LBW) status in a low-income country, Considerations such as budget envelopes and endow- based on the best estimates of causal links over the ment effects should not be confused with real resource lifecycle. The major impacts include three from the Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 83 Table 7.1 Estimates of Present Discounted Values of Seven Major Impacts of Moving One Infant Out of Low–Birth Weight Status in a Low-Income Country Present Discounted Value (2004 US$) 3% annual 5% annual 10% annual Impacts discount rate discount rate discount rate Reduced infant mortality 95 99 89 Reduced neonatal care 42 42 42 Reduced costs of infant and child illness 36 35 34 Productivity gain directly from increased adult height 152 85 25 Productivity gain from increased schooling and cognitive ability 367 205 60 Reduced costs of chronic diseases 49 15 1 Intergenerational effects 92 35 6 Total benefits 832 516 257 Source: Based on Alderman and Behrman 2006. preschool lifecycle stage and four from the adult lifecycle discount rate, and 0.4 percent with a 10 percent discount stage. The adult stage includes the productivity impacts rate—because the impacts (assumed equal to a decade of that encompass intermediate effects through channels income) are obtained late in the lifecycle and so are dis- such as schooling without double-counting; for exam- counted considerably to obtain their present values. ple, the productivity gains from increasing adult height The relevant costs include the intervention-provider must be additional to those from increasing cognitive resource costs, the private resource costs, and the distor- skills (Alderman and Sahn 2016). All of the impacts have tion costs of using taxes to fund public expenditures on been put into the same terms (U.S. dollars), with the the program. The total resource costs are not the same as most contestable value being that for averted mortality public budget expenditures, which ignore private and in the preschool stage, for which case the cost of vaccina- distortion costs and tend to underestimate the resource tions, the cheapest alternative means of averting mortal- costs; they also can include considerable transfers, such ity, was used (Summers 1992). The PDVs of total as in-kind transfer or conditional cash transfer programs benefits vary a fair amount with the discount rates and so might overstate resource costs. because of the gains from being able to reinvest returns Benefit-cost ratios are the PDV of benefits divided by that are realized sooner rather than later and are half as the PDV of costs. If the ratio exceeds 1.0, then the large using a 10 percent discount rate than when using a expected PDV of benefits exceeds the PDV of costs, and 5 percent rate, and are 39 percent smaller using a the intervention is warranted. Because both the benefits 5 percent discount rate than when using a 3 percent rate. and the costs tend to vary substantially by context, the The estimated impacts shown in the table are primar- benefit-cost ratios related to the impacts in table 7.1 are ily from productivity gains with 3 percent and 5 percent likely to vary greatly across LMICs. An alternative means discount rates (62 percent and 57 percent of the total of summarizing such information is the internal rate of benefits, respectively). Productivity gains remain a sub- return, which is defined as the discount rate that makes stantial part of the total (33 percent), even with the the benefit-cost ratio exactly equal to one. 10 percent discount rate, because these gains are realized each year during the working lives of surviving adults. If these economic productivity gains were ignored by Relative Rates of Return to Human Capital Investments focusing only on direct health impacts, overall benefits over the Lifecycle would be substantially underestimated. A well-known example of relative rates of return to Finally, even though the early-life origins of chronic investments in skills formation over the lifecycle is diseases have received increasing attention in recent described by Cunha, Lochner, and Masterov (2006), who decades, the estimated PDV of gains from this source are found declining rates of return to age-specific invest- relatively small—5.9 percent of the total benefits with a ments in human capital as a child’s age increases. 3 percent discount rate, 2.9 percent with a 5 percent Accordingly, investments before birth appear to have 84 Child and Adolescent Health and Development higher returns than investments in the first two years of very careful analysis of a few small special samples from life, which appear to have higher returns than preschool Guatemala, Jamaica, and the United States, or on analy- programs directed toward children ages three to five ses of cross-country data such as in Engle and others years. These, in turn, appear to have higher returns than (2011). The available evidence is insufficient to indicate additional years of schooling, which also have higher a wide range of possible heterogeneous investments. returns than postschooling job training. A key implica- This concern pertains to average returns across subpop- tion is that interventions should be concentrated early in ulations as well as any complementarities of inputs and life, when the highest overall returns are obtained, until the possibility that the return to an investment in one reaching a point at which diminishing marginal rates of stage depends on investments in previous stages. return make investments later in life relatively more pro- ductive. Current human capital investment levels may yield declining rates of return, but optimal investments Benefit-Cost Ratios for Investments in Nutrition would yield equal rates of return for all age levels. We document the recent prevalence of nutritional defi- The stylized returns of Cunha, Lochner, and cits to establish that they are major problems and turn to Masterov (2006) and the myriad discussions the returns estimated benefit-cost ratios of interventions designed have engendered raise the question, why do the rates of to reduce some of these deficits. return differ so much by age? If private rates of return Table 7.2 gives the prevalence, by world region, of key are so high for early-life investments, why do families indicators of preschool-age malnutrition based on the not take immediate advantage of such high-return most recent data available from the United Nations opportunities? Is it because of lack of knowledge or Children’s Fund before the February 2014 conference for credit market constraints? Perhaps private rates of the third edition of Disease Control Priorities: low birth return are not as high as social rates of return because weight; whether exclusively breastfed for the first six of positive externalities. If so, then another set of ques- months of life; and, for children younger than age five tions arises: Why does public investment not follow? Is years, moderate and severe underweight, severe under- it lack of knowledge, high discount rates for policy weight, wasting defined as weight-for-height, overweight makers because of political cycles, the combination of or obese, and stunting. Although availability of data on the budget envelope and endowment effects, or a con- these indicators has improved considerably in recent cern that the evidence is too thin or is based on studies decades, substantial data problems remain that are dis- from distant countries? Again, understanding why the cussed in the original sources. For example, China is not age pattern of rates of return exists, as well as clarifying included in the East Asia and Pacific and World aggre- the extent to which they differ from private and social gates for the last five indicators (although we have perspectives, would be very useful for developing effec- included values for China for other indicators when tive policy responses, such as whether emphasis should available), and coverage in some cases is otherwise lim- be placed on enhancing information, improving capital ited. Table 7.3 gives further estimates and projections, markets, subsidizing providers of services relevant to from 1990 to 2020 and by major region, of the early-life development, increasing the direct public pro- prevalence—and number of children affected (in vision of services relevant to early-childhood develop- millions)—of overweight/obesity and stunting among ment, empowering mothers, or other possibilities. children younger than age five years. Many presume that such age patterns of rates of return to investments in human skills prevail in many Low Birth Weight LMICs. There does seem to be some support for rela- Low–birth weight (LBW) babies (less than 2,500 grams) tively high rates of return on investing in nutrition and face a greater risk of dying in their early months and stimulation during the first 1,000 days of life (Gertler years compared with normal birth weight babies; if and others 2014; Hoddinott and others 2008; Hoddinott, LBW babies survive, they have greater risks of cognitive Alderman, and others 2013; Hoddinott, Behrman, and disabilities, impaired immune function, diabetes, and others 2013), as well as for investing in preschool pro- heart disease later in life (UNICEF 2006b, n.d.; UNICEF grams across a number of countries for children ages and WHO 2004). The prevalence of LBW varies consid- three to five years (Engle and others 2011) in some set- erably across regions: South Asia’s rate of 27 percent is tings. Nevertheless, the age pattern of rates of return is almost twice the rate in Sub-Saharan Africa (15 percent), much less well documented for most LMICs than for the which is the region with the second-highest rate. United States. For example, it would be desirable to be Approximately 19.5 million LBW babies are born able to base policy recommendations for other LMICs annually, half of whom are born in only three coun- on more extensive information than on the available tries: India (38.0 percent), Pakistan (7.7 percent), and Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 85 Table 7.2 Children’s Nutritional Status in Major World Regions, Most Recent Available Data Exclusive Children Younger than Age Five Years Low breastfeeding birth weight of children Underweight Wasting Stunting (< 2,500 for first 6 (moderate and Underweight (moderate and Overweight/ (moderate and Region or subregion grams, %) months (%) severe, %)a (severe, %) severe, %)a obese (%)a severe, %)a Sub-Saharan Africa 15 — 21 7 9 7 40 East and Southern 14 41 18 5 7 5 40 Africa West and Central Africa 15 20 23 8 12 9 39 Middle East and North 12 29 8 — 9 12 20 Africa South Asia 27 38 33 14 16 3 39 East Asia and Pacificb 6 43 6 4 4 5 12 China 3 — 4 — 2 7 10 Latin America and the 9 — 3 — 2 7 12 Caribbean Central and Eastern 6 22 2 — 1 16 12 Europe/Commonwealth of Independent States High-income countries 7 — 2 — 2 15 7 Least developed countries 17 — 23 7 10 4 38 b World 14 — 16 10 8 7 26 Sources: For low birth weight, http://www.childinfo.org/low_birthweight_profiles.php; for exclusive breastfeeding, http://www.unicef.org/progressforchildren/2006n4/index_breastfeeding.html; all others, http://www.childinfo.org/malnutrition_nutritional_status.php A1. (All accessed January 11, 2014; all last updated February 2013.) Note: — = not available. a. Regional averages for underweight (moderate and severe), wasting (moderate and severe), overweight/obese, and stunting (moderate and severe) are estimated using statistical modeling of data from the UNICEF and WHO Joint Global Nutrition Database, 2011 revision (completed July 2012). The severe underweight indicator was not included in this exercise; regional averages for this indicator are based on population-weighted averages calculated by UNICEF. “Moderate” (“severe”) is defined as more than 2 (3) standard deviations from the age-gender-specific reference median (below the medians except for overweight/obese). b. Data exclude China for last five columns (children younger than age five years). Nigeria (3.9 percent) (UNICEF 2013). Trend analysis is six months of life. There is a fair amount of variation in complicated by the lack of comparable estimates over the prevalence of breastfeeding, from 20 percent and time, both within and among countries. A population- 22 percent, respectively, in West and Central Africa and weighted average for available surveys shows that the Central and Eastern Europe to 38 percent to 43 percent incidence of LBW remained unchanged from the 1990s in South Asia, East and Southern Africa, and East Asia to 2010 for both Sub-Saharan Africa and Asia and Pacific. (UNICEF 2013). Underweight Breastfeeding Globally, 16 percent of children younger than age five Exclusive breastfeeding in the first six months of life years are moderately or severely underweight. The high stimulates babies’ immune systems, protects them from prevalence of moderate and severe underweight of diarrhea and acute respiratory infections—two of the 33 percent (14 percent for severe) in South Asia stands major causes of infant mortality in LMICs—and out in comparison with other regions; Sub-Saharan improves their responses to vaccination (UNICEF Africa (with West and Central Africa a little higher) is 2006a). Particularly in unhygienic conditions, breast next, with 21 percent. All other regions have prevalence milk substitutes carry high risks of infection that can be of less than 10 percent; the lowest is 2 percent to 3 percent fatal for infants. Yet only slightly more than one-third of for Central and Eastern Europe/Commonwealth of all infants in LMICs are exclusively breastfed for the first Independent States and Latin America and the Caribbean. 86 Child and Adolescent Health and Development Table 7.3 Estimated Prevalence and Number of Children (Millions) Younger than Age Five Years Who Are Overweight/Obese or Stunted in Major Regions, 1990–2020 Overweight/Obese Stunted 1990 2000 2010 2020 1990 2000 2010 2020 Prevalence (%) Africa 4.0 5.7 8.5 12.7 40.3 39.3 38.2 37.1 Asia 3.2 3.7 4.9 6.8 48.6 37.7 27.6 19.0 Southern and Central Asia 2.3 2.9 3.5 4.3 60.7 48.4 36.4 25.9 LAC 6.8 6.8 6.9 7.2 23.7 18.1 13.5 10.0 All developing countries 3.7 4.5 6.1 8.6 44.4 36.1 29.2 23.7 Global 4.2 5.1 6.7 9.1 39.7 32.9 26.7 21.6 Children younger than age five years (millions) Africa 4.5 7.4 13.3 22.0 44.9 51.3 60.0 64.1 Asia 12.4 13.7 17.7 24.3 189.9 138.0 99.5 68.4 Southern and Central Asia 4.2 5.4 6.6 8.0 110.1 90.9 69.0 48.4 LAC 3.8 3.8 3.7 3.5 13.2 10.2 7.2 4.9 All developing countries 20.7 25.0 34.7 49.9 248.4 199.9 167.2 137.9 Global 26.9 31.4 42.8 59.4 253.0 203.8 171.4 142.0 Sources: de Onis, Blössner, and Borghi 2010, 2011. Note: LAC = Latin America and the Caribbean. Overweight/obese is defined as > 2 standard deviations from weight-for-height median. Stunting is defined as more than two standard deviations below the height-for-age median. Wasting and Central Asia has the lowest prevalence, but still has Children who suffer from wasting are at substantially substantial increases from 4.2 million in 1990 to increased risk of severe acute malnutrition and death. 8.0 million projected for 2020. Globally, 8 percent of children suffer from wasting. South Asia has the highest prevalence of wasting (16 percent), Stunting and the highest prevalence of underweight (33 percent). Globally, 26.7 percent of children younger than age five Sub-Saharan Africa has 9 percent prevalence of wasting, years were stunted in 2010, an estimated 171.4 million the second-highest rate. children. Southern and Central Asia and Sub-Saharan Africa have particularly high prevalence rates of between Obesity 36 percent and 38 percent. However, although preva- Increasing trends in child overweight/obesity have lence in these two regions is similar for 2010, the trends occurred in the past two decades in most regions. are different. For Sub-Saharan Africa, the prevalence of Globally, an estimated 42.8 million (7 percent) of chil- 40.3 percent in 1990 (44.9 million children) declined dren younger than age five years were overweight or very slowly to 38.2 percent in 2010, and it is projected to obese in 2010, a 59 percent increase from an estimated be 37.1 percent by 2020 (64.1 million). In contrast, in 26.9 million in 1990. Projections are for a further Southern and Central Asia, the prevalence in 1990 was increase of 39 percent from 2010 to 59.4 million in 2020, much higher at 60.7 percent, an estimated 110.1 million of which 49.9 million are projected to be in LMICs. Latin stunted children, yet the rate dropped to 36.4 percent America and the Caribbean had the highest prevalence (69 million) in 2010; it is projected to be 25.9 percent in 1990, at 6.8 percent, which increased slowly to (48.4 million) in 2020. 6.9 percent in 2010 and is projected to be 7.2 percent in 2020. Other LMIC regions had much more rapid increases in the past two decades; Sub-Saharan Africa Benefit-Cost Estimates for Nutritional Interventions was notable because of the increase from 4.0 percent in Some consensus exists on the benefits of specific nutri- 1990 to 8.5 percent in 2010, projected to be 12.7 percent tional interventions. Often using meta-analyses of con- in 2020. Throughout the period 1990–2020, Southern trolled trials, reviews such as Bhutta and others (2013) Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 87 indicate the expected changes in outcomes of stunting or finding confirms that the body of indirect estimates of anemia for a given intervention. A body of evidence returns to nutrition programs based on changes in exists on the costs for achieving such outcomes (Horton schooling or cognitive ability discussed in the following and others 2010). These costs, as well as the expected sections is in keeping with direct longitudinal evidence. outcomes, can be combined to calculate the relative Table 7.4 lists some estimated benefit-cost ratios for cost-effectiveness of approaches to achieving a desired nutritional interventions for preschool children based on improvement in nutrition. However, to estimate a Behrman, Alderman, and Hoddinott (2004). The benefits benefit-cost ratio, one needs to convert the multiple rel- are calculated along the lines of those in table 7.1. Details, evant outcomes into the same metric as the costs. As including the cost assumptions, are given in the original indicated in the example in table 7.1, doing so usually source, as are some sensitivity analyses (including vary- involves summing over different outcomes. Some of ing the discount rate between 3 percent and 5 percent) these, such as a reduction in resources used to care for that result in a range of estimates. These interventions illness, can be directly assessed in monetary terms. can be divided into three groups according to the aim: Others, such as increased labor productivity, require estimates of the degree to which the change in nutri- • Reduce LBW tional status leads to an increase in earnings, as well as • Directly improve infant and child nutrition assumptions about the productivity of those not in • Reduce micronutrient deficiencies. wage jobs. Most such estimates are based on indirect inference—the changes in schooling or learning attrib- For each group, estimates are provided for three inter- utable to improved nutrition combined with the impact ventions. Some points to note concerning this table are the that such increases in learning will have on earnings, following: the benefit-cost ratios are sensitive to the under- often derived from separate studies. lying assumptions, so some of the ranges are large; the One study, however, has been able to track individuals benefit-cost ratios vary a fair amount within each group, from the time they participated in a community- for example, 0.58–35.20 for reducing LBW; and many of randomized program of supplemental feeding when these benefit-cost estimates are substantially greater than they were infants and toddlers to their adult years about 1.0, suggesting that even if there is some further discount- 35 years later (Hoddinott and others 2008; Hoddinott, ing to account for uncertainty in such estimates, a number Behrman, and others 2013). This study found that men of these interventions merit serious consideration in con- who had received better (protein-enriched, higher texts in which the nutritional deficiencies they are intended energy) supplements before age three years earned, on to address are prevalent. Table 7.5 provides similar results average, 44 percent higher wage rates later in life; this using different discount rates. Table 7.4 Benefit-Cost Estimates for Nutritional Interventions for Preschool Children with Discount Rates of 3 Percent to 5 Percent Benefit-cost ratio 1. Reducing LBW for pregnancies with high probabilities of LBW 1a. Treatments for women with asymptomatic bacterial infections 0.6–5.0 1b. Treatment for women with presumptive STD 1.3–10.7 1c. Drugs for pregnant women with poor obstetric history 4.1–35.2 2. Improving infant and child nutrition in populations with high prevalence of child malnutrition 2a. Breastfeeding promotion in hospitals in which norm has been promotion of use of infant formula 5.6–67.1 2b. Integrated child care programs 9.4–16.2 2c. Intensive preschool program with considerable nutrition for poor families 1.4–2.9 3. Reducing micronutrient deficiencies 3a. Iodine (per woman of childbearing age) 15.0–520.0 3b. Vitamin A (per child younger than age six years) 4.3–43.0 3c. Iron (pregnant women) 6.1–14.0 Source: Based on Behrman, Alderman, and Hoddinott 2004. Note: LBW = low birth weight; STD = sexually transmitted disease. 88 Child and Adolescent Health and Development Table 7.5 Sensitivity of Nutritional Intervention Benefit-Cost Ratios to Different Discount Rates and Values of Disability-Adjusted Life Years Discount rate 3%; Discount rate 6%; Discount rate 3%; Discount rate 6%; DALY value of DALY value of DALY value of DALY value of Intervention US$1,000 US$1,000 US$5,000 US$5,000 Community nutrition education and 12.5 7.5 62.5 37.5 promotion Vitamin A and zinc supplementation 17.3 10.0 86.5 52.0 Salt iodization 30.0 12.0 30.0 12.0 Iron fortification 8.0 7.0 8.0 7.0 Anthelmintics at preschool 6.0 2.4 6.0 2.4 Source: Based on Horton, Alderman, and Rivera 2009. Note: DALY = disability-adjusted life year. Additional estimates of benefit-cost ratios for nutri- to represent private costs and another 25 percent to rep- tion interventions in the first 1,000 days that increase resent distortion costs. The resulting benefit-cost ratios preschool linear growth (height) are provided in make interventions to reduce stunting still appear to be table 7.6. These ratios are based on recent estimates by an attractive investment given that all the estimates are Hoddinott, Alderman, and others (2013). On the cost greater than 1.0, and all except the Democratic Republic side, Hoddinott, Alderman, and others (2013) provide of Congo are greater than 6.0, with a median of 12.4 two sets of estimates of budgetary costs per child—as (the estimate for the median country, Bangladesh). The opposed to costs compiled from ingredients or inputs— range of estimates also is considerable, from 2.4 for the to provide 10 evidence-based interventions to reduce Democratic Republic of Congo to 33.1 for Indonesia, stunting and micronutrient deficiencies in children in suggesting that context is important for evaluating such their first two years of life. On the benefit side, Hoddinott, interventions. Alderman, and others (2013) first multiplied the point A generic concern for these estimates is that the estimate of the increase in per capita permanent income underlying data are often from small-scale studies. Both (consumption) from reducing stunting by 0.20 in recog- benefits and costs are likely to change as programs scale nition of the estimate by Bhutta and others (2013) that up (Alderman, Behrman, and Puett 2017; Menon and this package of interventions will reduce stunting by others 2014); benefits for hard-to-reach subpopula- 20 percent and then assumed that only 90 percent of tions may be higher or lower than for the general pop- these income gains are realized. ulation, but costs are more likely to increase as programs The first data column in the table reproduces the expand coverage. This is a generic concern, but it is resulting benefit-to-budgetary-costs ratios using the more likely to affect more personnel-intensive pro- generally higher cost estimates based on Bhutta and grams, such as counseling, relative to micronutrient others (2013). However, the procedures in this particular fortification or supplementation. This is also a concern approach underestimate benefits because they include for most, although not all, estimates of returns to stim- only income or consumption benefits (and not, for ulation and preschool. example, benefits from averting mortality and resource costs saved as a result of reduced morbidity), and they underestimate resource costs because they do not Benefit-Cost Ratios for Investment in Early Childhood include private costs and market distortion costs, in Cognitive and Socioemotional Development particular, the cost of raising revenue to finance the Overview of Programs and Interventions intervention. They also do not exclude the transfer com- Disparities in children’s development emerge early and ponent of public expenditures and so may overstate are driven by risks associated with poverty that include public sector resource costs; however, for the interven- inadequate nutrition, low maternal education, lack of tions considered, these transfer components probably stimulation, and low levels of maternal well-being. As are relatively small. Therefore, the second data column exposure to risks increases, both in number and dura- includes adjustments to benefits—an increase of tion, low-income children fall further behind more 20 percent to represent social benefits beyond increases advantaged groups. Without appropriate investments in income—as well as an increase in costs of 50 percent from both their families and the state, children do not Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 89 Table 7.6 Benefit-Cost Ratios for Moving Child from Stunting at 24 Months to Not Stunted, in 17 Selected Heavily Burdened Countries Ratio of income benefit to budgetary cost (Hoddinott, Region Country Alderman, and others 2013) Adjusted benefit-cost ratioa Sub-Saharan Africa Congo, Dem. Rep. 3.5 2.4 Madagascar 9.8 6.8 Ethiopia 10.6 7.3 Uganda 13.0 9.0 Tanzania 14.6 10.1 Kenya 15.2 10.5 Sudan 23.0 15.9 Nigeria 24.4 16.9 Middle East and North Africa Yemen, Rep. 28.6 19.8 South Asia Nepal 12.9 8.9 Myanmar 17.2 11.9 Bangladesh 17.9 12.4 Pakistan 28.9 20.0 India 38.6 26.8 East Asia Vietnam 35.3 24.5 Philippines 43.8 30.4 Indonesia 47.7 33.1 Sources: Based on estimates from Hoddinott, Alderman, and others (2013), with cost and intervention data from Bhutta and others (2013). a. Adjustments include increasing benefits by 20 percent to represent nonincome consumption benefits and increasing costs by 50 percent to represent private costs and by 25 percent to represent distortion costs. acquire the skills needed to benefit fully from formal around the age of school entry (Grantham-McGregor and education when they enter primary school. Lower ability others 1997; Walker and others 2010) and adulthood at school entry is associated with lower achievement and (Gertler and others 2014; Walker, Chang, and others increased drop out (Grantham-McGregor and others 2011). Evidence for benefits from other approaches to 2007), leading to continuing and, in some cases, widen- delivering parenting support, such as through community ing inequality, as well as forgone productivity. groups, is also emerging (Singla, Kumbakumba, and The range of programs to improve child cognitive Aboud 2015). Center-based approaches, for example, development in LMICs during the period between birth community day care, have been implemented, particularly and the initiation of primary schooling is reviewed in in Latin America and the Caribbean, with variable bene- Engle and others (2007) and in Engle and others (2011) fits depending on program quality (Grantham-McGregor and includes programs to promote better parenting and and others 2014). There is, however, a lack of information mother-child interaction through home visits by commu- to guide successful scale-up, including resources required, nity health workers or by means of group sessions with and more analysis of the implementation process as mothers. Consistent evidence from several countries indi- promising programs are expanded is particularly urgent. cates that interventions that improve parent-child interac- A subset of interventions that enhance child stimula- tion and stimulation benefit children’s development; the tion also provides nutritional supplements, often tar- most current evidence is from interventions delivered geted to children who were born with low birth weights through home visits by trained community health work- or were stunted. These interventions generally led to ers (Attanasio and others 2014; Hamadani and others improvements in cognitive outcomes and socioemo- 2006; Powell and others 2004; Yousafzai and others 2014). tional development, and sometimes in nutritional out- Some evidence indicates that these early interventions comes. There is, however, little evidence of synergy have sustained benefits for cognitive ability and behavior between stimulation and nutrition interventions in their 90 Child and Adolescent Health and Development outcomes (Grantham-McGregor and others 2014) in the to stimulation was larger than that reported in the few small-scale programs that have been extensively studied, similar interventions from the United States. Although but combining these two types of interventions does not the research design was not set up to assess the relative reduce the expected impact of either intervention when value of cognitive and socioemotional gains, measures on delivered independently. There may be synergies in costs both of these dimensions of development were improved if there are economies of scope because some common in the intervention. In addition to the earnings benefit, infrastructure can support both interventions. the intervention also reduced violent behavior (Walker, Attendance at preschool for children ages three to six Chang, and others 2011) and so provided a social benefit, years increases development and readiness for formal which is not often measured in rates of return. schooling (Engle and others 2011). The proportions of Turkey. Another long-term panel following an early children in the appropriate age range enrolled vary widely, child development intervention in Turkey looked at the with an average of 17 percent of children enrolled in beneficiaries of an intervention in which parents were low-income countries and 54 percent in middle-income provided training to improve the home learning envi- countries (UNESCO 2014). Within regions and countries, ronment for their children (Kaytaz 2005). The lower-income children are less likely to be enrolled (Engle benefit-cost estimates reported in this study when paren- and others 2011). In addition to the need for increased tal training was center based were 4.3 and 6.4, using access is a need for investment in improving quality, with plausible discount rates of 10 percent and 6 percent, improvements in structure (for example, infrastructure, respectively. The benefit-cost estimates for the home- class size) and process (for example, quality of caregiver- based parental training using the same discount rates of child interaction, developmentally appropriate activities); 10 percent and 6 percent were 5.9 and 8.7, respectively. evidence suggests that improvement in process is more These benefits are based on the increase in schooling and critical (Berlinski and Schady 2015). reduced dropout rates and the expected increase of earn- ings that can be inferred from these changes in levels of Rates of Return to Preschool and Early Child schooling; the earnings of the beneficiaries were not Development Programs collected. These estimates do not include any increased Jamaica. An important and influential longitudinal learning per year of school, and, as Kaytaz (2005) indi- study from Kingston, Jamaica, tracked a cohort of 129 cates, the benefits are lower-bound estimates. stunted children since they were ages 9–24 months for Bolivia. Behrman, Cheng, and Todd (2004) analyze more than 20 years; the children were initially randomly the impacts of Bolivia’s Proyecto Integral de Desarrollo assigned to four different groups, three of which involved Infantil. The program, which provided feeding as well as interventions that lasted two years. day care to groups of up to 15 children in the homes of women in low-income neighborhoods, achieved • The first group received weekly one-hour home visits improvements in measures of language and auditory from community health workers, who taught par- development, psychosocial skills, gross motor develop- enting skills and encouraged mothers to interact and ment, and fine motor development, but not in height play with their children in ways that would develop or weight. Using estimates of the expected increase of their children’s cognitive and socioemotional skills. schooling that these improvements are assumed to • The second group received weekly nutritional supple- translate into, as well as estimates of the returns to ments of 1 kilogram of a milk-based formula. schooling of children in the country, the benefit-cost • The third group received both home visits and nutri- ratio ranges between 2.0 and 2.9 for children for whom tional supplements. the increase of schooling would be at the intermediate • The fourth group (the control group) received neither. level through grade 8 for discount rates of 5 percent and 3 percent, respectively, and somewhat lower for children Gertler and others (2014) directly assessed the impact for whom the increase in schooling would be at the sec- of these interventions on young adult earnings. Although ondary level that goes until grade 11. The costs in this the children in the home visit stimulation treatment estimate include the direct program costs, the private arms were stunted at the time of recruitment into the opportunity costs of the time devoted to increased study, they were able to close the wage gap with a schooling, and the expected deadweight cost to the econ- matched nonstunted comparison group. More specifi- omy from raising the revenue to finance the program. cally, the analysis attributed a 25 percent increase in Colombia. Colombia has been running a similar pub- earnings to the stimulation interventions; in contrast, the licly funded day-care program, Hogares Comunitarios nutritional arm of the intervention did not close the de Bienestar (in fact, Proyecto Integral de Desarrollo earnings gap. The authors contend that this increase due Infantil was modeled after this program). Bernal and Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 91 Fernández (2013) reported that children ages three years earnings of wage workers. More specifically, if one and older who spent at least 15 months in the program assumes that the only cost of schooling is forgone showed improvements in both cognitive development wages and that the logarithm of wages is a linear func- and socioemotional skills, although no gains in nutri- tion of schooling and other variables, then the coeffi- tional status were observed. The benefit-cost ratio was cient on schooling from a regression of the log of wages estimated to be between 1.0 and 2.7, using discount rates on schooling and those other variables can be inter- of 8 percent and 5 percent, respectively. preted as the private return to time spent in school (see Both of these studies of day-care centers in Latin Mincer 1974). America reach children up to age six years, but the cen- There are at least two problems with such estimates. ters are not structured preschool programs. Engle and The first is that they estimate only the private returns to others (2011) provided an order of magnitude estimate schooling that result from increased wages, and they of the benefit-cost ratio for such structured preschool exclude both other private returns, such as improved programs at scale. This assessment was based on an esti- health accruing to that person and his or her children, mate of the gap between the completed level of school- and social returns that accrue to other members of soci- ing for the wealthiest quintile in a given country and that ety. These omissions imply that private returns may of the poorest as a function of preschool enrollment in underestimate total returns. Second, overestimation is the previous 8–12 years. This estimate provided the basis also possible because there are other private costs beyond for projecting the expected increase in schooling, and the the time spent in school; there are also social costs, in concomitant increase in earnings, due to an increase in particular, the costs that governments incur by providing preschool participation, controlling for country effects. schooling opportunities at little or no cost to students Using a discount rate of 3 percent, the assessment indi- and their families. The second problem is that these cated that bringing the preschool enrollment rate in all regressions yield private rates of return to investments in LMICs to 25 percent, starting from each country’s base schooling only if the coefficient on schooling measures level, would have a benefit-cost ratio of 14.3; bringing the causal impact of schooling on wages, and there are the enrollment rate to 50 percent would have a several reasons why such estimates may not reflect a benefit-cost ratio of 17.6. Discounting future returns at causal relationship. a higher rate of 6 percent would lead to benefit-cost First, regressions of wages on schooling and other ratios of 6.4 and 7.8, respectively. variables may not lead to accurate estimates of the These estimates have wide ranges and are also sensi- causal impact of schooling on wage income because tive to assumptions about the impact of schooling on random measurement error in schooling could lead to wages as well as estimates of the cost of providing this underestimates of that impact; such measurement errors schooling, but these results are similar to program- are particularly likely to be a problem in data from specific estimates in the literature. For example, Berlinski, LMICs. Moreover, unobserved factors such as ability, Galiani, and Manacorda (2008) presented evidence on motivation, and family connections could determine schooling outcomes measured a decade after the expan- both schooling and earnings, even after controlling for sion of preschool enrollment in Uruguay. Their data wealth and parental schooling, and lead to overestimates indicated that as the supply of preschool services in rates of return to schooling. In addition, such esti- increased between 1989 and 2000, participation in pre- mates from LMICs are almost always for wage earners schools increased by 12 percentage points so that well only, not for the self-employed. Substantial evidence more than 90 percent of all children attended preschool suggests that the return to education among the self- by the end of the period. From their results on the influ- employed is lower than the return to wage earners,2 ence of preschool enrollment on school achievement, as which implies that estimates based only on wage earners well as the cost of construction of classrooms along with are likely to be overestimates in countries with large local salaries for teachers, they estimated a benefit-cost numbers of self-employed workers. Finally, even among ratio of 3.2 using a discount rate of 10 percent. If the wage earners, estimates should, in general, exclude gov- discount of future earnings is 3 percent, the estimated ernment workers if they are to be interpreted as reflect- benefit-cost ratio is 19.1. ing productivity as opposed to private returns; yet in most cases, such workers are included. The pay received by government workers with different levels of educa- Returns to Investments in Schooling tion mainly reflects government salary policies rather Most estimates of the returns to investments in school- than the productivity of different types of workers. ing in LMICs are based on estimates of the association Given these problems, it is not surprising that compi- between grades of schooling attainment and the lations of estimates often yield very different results. 92 Child and Adolescent Health and Development Psacharopoulos and Patrinos (2004) presented compila- of resources call for reforms and improvements in tions indicating that the rate of return to an additional school systems, it may be the case that students, or a year of primary education in Sub-Saharan Africa is subset of them, come to school with huge disadvan- 37.6 percent, but Montenegro and Patrinos (2012) tages that could be offset through interventions in reported a much smaller rate of return of 13.4 percent. early childhood. Two of these problems can be resolved if valid instru- • Third, the impact of specific investments depends, mental variables can be found to predict schooling. A in part, on the ability of students. For example, few studies have attempted to use instrumental variable Glewwe, Kremer, and Moulin (2009) found that an methods to obtain more accurate estimates of the increased supply of books in Kenya benefited the impact of schooling on wages in LMICs. Duflo (2001) stronger students but had no measurable impact used a sharp increase in the construction of primary on the others. A different view of complementarity schools to estimate the impact of schooling on wages in of inputs comes from Grantham-McGregor, Chang, Indonesia. Her estimates indicate that an additional and Walker (1998). This study found that feeding grade of schooling increases wages in that country by schoolchildren improved attention, but the impact 7 percent to 11 percent. She also noted that the instru- on learning depended on the classroom structure, mented results do not differ appreciably from the unin- with stronger results found where the classes were strumented estimation. Behrman and others (2013) more effectively organized. estimated that an additional grade of schooling increases • Finally, education responds to health, not only with wages by 9.8 percent in Guatemala; the main identifying respect to early-life nutrition, but also with respect to instruments were student-teacher ratios, mother’s health investments for school-age children. For exam- height, and mother’s and father’s schooling. While more ple, Miguel and Kremer (2004) found deworming in studies would be useful, these two studies suggest that Kenya to be more cost-effective at increasing school private returns to education are approximately participation3 than supply-side interventions such 10 percent in LMICs. as the provision of textbooks. Bleakley (2007) noted Whatever the impact of additional schooling on adult that hookworm infections in the American South in earnings, there remains the question of what invest- the early 1900s reduced the income in adulthood of ments may lead to an increase in schooling. School infected children by 43 percent and that this negative enrollment or grades of schooling completed can be outcome was effectively eliminated by a concerted increased by demand-side interventions, such as transfer program of hookworm control. Bleakley (2010) esti- programs, or by increases in the supply and quality of mated a similar impact of malaria-control campaigns schooling. The former category includes conditional on incomes in the United States (circa 1920) and in transfers (Behrman, Parker, and Todd 2011) and school Brazil, Colombia, and Mexico (circa 1955). feeding programs (Adelman, Gilligan, and Lehrer 2008). The latter category was reviewed by Glewwe and others The possibility that healthier children will respond (2013), who reported that there are few unambiguous more to schooling inputs is an example of dynamic com- results regarding investments and schooling outcomes. plementarity and is a major component of the returns to A more comprehensive review can be found in Glewwe nutrition (Glewwe, Jacoby, and King 2001). However, the and Muralidharan (2016). Although that literature goes interaction of health and schooling may show some far beyond the issues central to disease control priorities, dynamic substitution rather than complementarity; a few salient points are worth discussing here. there may be educational interventions with higher impacts the lower the initial health conditions. For • First, although ability affects both schooling attain- example, Bobonis, Miguel, and Sharma (2006) studied ment and what is learned in school, the latter is the the provision of iron supplementation and deworming stronger determinant of earnings (Hanushek and medicine to preschool children in India. Overall, chil- Woessmann 2008). dren in the treatment group had less absenteeism, but • Second, despite the regular pattern of increased earn- children who were initially anemic at baseline had a ings with increased schooling, the quality of educa- larger response to the intervention. Similarly, iron sup- tion in many settings is discouraging. For example, plementation costing less than US$5 per child in pri- 52.7 percent of standard 5 (grade 5) students in mary schools in China over a seven-month period led to India could not read a standard 2– (grade 2–) level an improvement in hemoglobin as well as a significant text (ASER Centre 2014). Similar patterns are found improvement in math test scores (Luo and others 2012), in many Demographic and Health Surveys across and the academic improvement was found only for chil- the globe. Although many reasons for this waste dren who were anemic before the program. Evidence of Impact of Interventions on Growth and Development during Early and Middle Childhood 93 CONCLUSIONS that, given the current distribution of investments over the lifecycle, in many contexts the rates of return to Interventions to improve nutrition as well as to enhance some additional investments are likely to be highest cognitive and socioemotional development in each of very early in life. However, there are likely to be dimin- the early lifecycle stages—preschool ages, schooling ages, ishing marginal rates of return to such interventions; and later adolescence—can achieve returns in later even if under present circumstances the rates of return stages that greatly exceed their costs. Yet an empirical were highest to interventions to improve nutrition in question remains: at what lifecycle stage, and in what the womb or very early in a child’s life, it does not fol- context, are the benefit-cost ratios high enough to war- low that all resources should be moved from later to rant investments? The benefit-cost estimates from nutri- earlier in life. As more resources are moved from later tional interventions in the first 1,000 days are based on to earlier life, most likely diminishing marginal rates of extensive data and have been accumulated on a global return will mean that the rates of return to the invest- basis, albeit mostly for small, special samples; there is less ments in early life will fall and those to investments in evidence on benefits and costs for stimulation and early later life will increase. Indeed, it would be socially opti- child development for programs at appreciable scale. mal in an economic sense to move resources directed to Moreover, a review of the cost of programs at scale in human development from older to younger ages until Latin America and the Caribbean indicates a wide—and the social rates of return to the use of resources at all not fully understood—heterogeneity of costs (Araujo ages are equalized. and López-Boo 2013). This knowledge gap hinders any definitive generalizations. Even if estimates of costs were confined to a narrow range over various environments, there is also a general NOTES dearth of results on the heterogeneity of impacts. A few Harold Alderman and Jere R. Behrman acknowledge par- studies show that programs may have greater impacts for tial support for their time working on this chapter from children who enter these programs at an initial disad- Grand Challenges Canada (Grant 0072-03 to the Grantee, vantage (Engle and others 2011). Berlinski, Galiani, and The Trustees of the University of Pennsylvania). Behrman Manacorda (2008) found that the impact of preschool also acknowledges partial support from the Bill & Melinda attendance was largest for those children from house- Gates Foundation (Global Health Grant OPP1032713) and Eunice Kennedy Shriver National Institute of Child Health and holds with parents who have less schooling, and Jung Human Development (Grant R01 HD070993). and Hasan (2014) found that block grants for preschool groups in Indonesia narrowed gaps in language and cog- World Bank Income Classifications as of July 2014 are as fol- nitive development. To the degree that such programs lows, based on estimates of gross national income (GNI) per reduce gaps in children’s development, they have an capita for 2013: additional social value in reducing the intergenerational transmission of poverty with possible gains in efficiency • Low-income countries (LICs) = US$1,045 or less if such programs partially offset capital market failures • Middle-income countries (MICs) are subdivided: that result in underinvestments in children. Although a a) lower-middle-income = US$1,046 to US$4,125 reduction in poverty is usually not translated into bene- b) upper-middle-income (UMICs) = US$4,126 to US$12,745 fits that can be aggregated into benefit-cost ratios, the • High-income countries (HICs) = US$12,746 or more. benefits are likely to be real and positive and could be incorporated by weighting outcomes for children from 1. Halfon and others (2014) propose four phases—generative, poorer families more heavily. acquisition of capacity, maintenance of function, and According to widespread evidence, gradients in cog- managing decline—that differ from the stages discussed nitive ability by socioeconomic status appear early in here, although they are related conceptually. life (Fernald and others 2012; Naudeau and others 2. For example, compare the estimates of van der Sluis, van 2011; Schady and others 2015); therefore, the potential Praag, and Vijverberg (2005) on returns to schooling among the self-employed to the estimate of Psacharopoulos to prevent or reverse gaps suggests that nutrition pro- and Patrinos (2004) on the returns to schooling among grams, the promotion of early stimulation, and pre- wage earners. school education may have social returns that are 3. 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Stimulation and Nutrition Interventions in the Lady Health “The Timing of Integrated Early Interventions: Worker Programme in Pakistan on Child Development, Contributions from Nutritional Neuroscience, Stress Growth, and Health Outcomes: A Cluster-Randomised Neuroscience and Psychological Research.” Annals of the Factorial Effectiveness Trial.” The Lancet 384 (9950): New York Academy of Sciences 1308: 89–106. 1282–93. 98 Child and Adolescent Health and Development Chapter 8 Evidence of Impact of Interventions on Health and Development during Middle Childhood and School Age Kristie L. Watkins, Donald A. P. Bundy, Dean T. Jamison, Günther Fink, and Andreas Georgiadis INTRODUCTION also holds for later life gene-environment interactions. Is it possible for children with positive later childhood experi- A large literature has highlighted the multifaceted and ences to catch up with their peers? If yes, to what extent? negative long-term consequences of poor health in This chapter explores evidence regarding whether early life. The large body of evidence linking adversity interventions in school-age children can affect their later in the first 1,000 days of life to later life outcomes has development. Definitions of age groupings and age- created a major policy shift toward the early years, and specific terminology used in this volume can be found in it has promoted the idea that the consequences of early chapter 1 (Bundy, de Silva, and others 2017). The main insults are irreversible. A longitudinal supplementa- objective of this chapter is to review the evidence for and tion study in Guatemala of children ages 0–7 years is against irreversibility: Can interventions after the early frequently cited in support of this argument (Martorell, years of life help children regain or approach their innate Khan, and Schroeder 1994). The authors concluded capacity for development? Given that the evidence base that stunting is a condition that results from events in for older children is more limited, we do not pursue a early childhood and that, once present, remains for life. systematic review strategy in this chapter, but rather look This view was echoed in The Lancet series on maternal for specific empirical examples supporting or refuting the and child undernutrition: “Poor fetal growth or stunt- idea of lifelong irreversibility; a search for black swans. ing in the first two years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income, and decreased off- CHANGES IN ENVIRONMENT spring birthweight” (Victora and others 2008, 340). The available evidence does indeed support the conten- Changes in environment provide an ideal setting for tion that children with a poor start in life are likely to investigating the irreversibility hypothesis: many chil- remain on that low trajectory if nothing else changes: dren who grow up in poor early life environments move indeed, early investment clearly is important. However, this to better environments as a result of migration, adop- does not mean that children’s experiences in later child- tion, or transfer to different institutional settings. These hood are not important. From a biological perspective, transitions provide a natural starting point for assessing early programming is plausible, but the same obviously the potential for catch-up. Corresponding author: Kristie Lynn Watkins, Imperial College London, London, United Kingdom; kristie.lynn.watkins@gmail.com. 99 Immigration Studies Historical Migration Evidence One study on immigration found that school-age chil- Steckel (1987) examined historical data on children dren who were born in Turkey and then migrated to brought to the United States as slaves and found that Sweden were short at first measurement upon immigra- they were initially stunted but grew rapidly through the tion but then caught up to achieve heights similar to those centiles during adolescence. Similarly, Komlos (1986) of ethnically Turkish children born in Sweden (Mjönes examined historical data on students at Hapsburg 1987). Similarly, a semilongitudinal study assessed chil- military schools following the Napoleonic Wars and dren ages 5–12 years of Chinese, Filipino, Hispanic, and found that boys who were the sons of poor families and Southeast Asian origins who had migrated to San stunted at admission showed sizable catch-up growth, Francisco (Schumacher, Pawson, and Kretchmer 1987). presumably attributable to improved diet and living Upon their arrival, most of the children from the four conditions, once they were admitted to military schools. ethnic groups had mean height and weight between the 5th and 25th percentiles of those of the U.S. population. At follow-up one year later, the median growth rate of SECONDARY STUNTING AND UNDERWEIGHT most cohorts exceeded that of the U.S. reference, with no differences noted between younger and older children. Clinical and physiological conditions, such as frequent exposure to diarrhea or worm infections, can be associ- ated with stunting and underweight that are secondary Adoption Studies to disease. If the initial effects were irreversible, remov- As Golden (1994) highlighted, immigration studies exam- ing the primary risk factors later in life should not have ine the effect of far-reaching changes to the physical envi- an impact on growth. However, successful treatment of ronment of a child, whereas adoption studies examine the several conditions has been shown to result in partial or effect of a change in the quality of the local or home complete catch-up growth for school-age children: celiac environment on growth later in life. In general, most disease (Barr, Schmerling, and Prader 1972; Bodé adoption studies report anthropometric gains for school- and others 1991; Cacciari and others 1991; Damen and age children—for example, Korean orphans adopted by others 1994), growth hormone deficiency (Burns and American families (Lien, Meyer, and Winick 1977; Winick, others 1981; Kemp and others 2005), hypothyroidism Meyer, and Harris 1975), Indian girls adopted by Swedish (Boersma and others 1996; Pantsiotou and others 1991; families (Proos, Hofvander, and Tuvemo 1991a, 1991b), Rivkees, Bode, and Crawford 1988), and corticosteroid and previously abused children taken into foster care or excess (Davies and others 2005; Prader, Tanner, and von adopted in England (King and Taitz 1985). Harnack 1963). Adoption studies offer some of the clearest evidence that improving conditions can reverse the consequences of early childhood deprivation. They also offer evidence that, even if early intervention has been successful, inter- FOOD SUPPLEMENTATION vention later in life may be necessary to sustain the gains Studies of food supplementation in school-age children of early intervention. A study in Peru found that children have reported small but significant gains in growth. who were treated for severe malnutrition early in life and Kristjansson and others (2007), in a meta-analysis of later adopted were significantly taller at age nine years three randomized controlled trials (RCTs) in low-income than were similar children who remained in their original countries and lower-middle-income countries (Du and home environments (Graham and Adrianzen 1972). Also others 2004; Grillenberger and others 2003; Powell and in Peru, a unique study (Graham and Adrianzen 1971) others 1998), reported a small, significant effect of admitted children from very poor families to a convales- school meals on weight gain (0.39 kilogram), approxi- cent unit after birth and maintained them on an optimal mately 0.25 kilogram per year factoring in study dura- diet until an average age of 17.6 months. These children tion. The review also found a small, nonsignificant effect showed initial gains relative to their siblings who did not on height gain (0.38 centimeter). receive this treatment, but within one year of returning More recently, the World Food Programme and the home and through the last measurements at age eight World Bank assessed the impact of school feeding years, there was no significant difference in the heights of programs on anthropometric outcomes in three inde- the two groups (Adrianzen, Baertl, and Graham 1973; pendent studies in Burkina Faso, the Lao People’s Baertl, Adrianzen, and Graham 1976). These findings Democratic Republic, and Uganda. In Uganda, no sig- suggest that environments promoting growth later in life nificant effects were found on body-mass-index-for-age may be needed to consolidate early gains. z-scores or height-for-age z-scores (HAZ) in children 100 Child and Adolescent Health and Development ages 6–13 years (Adelman and others 2008). In Burkina of their infection status, as discussed in chapters 13 and 29 Faso, significant gains were reported in weight-for-age in this volume (Bundy, Appleby, and others 2017; Ahuja (0.21 standard deviation) for children ages 6–10 years, and others 2017, respectively). Here we focus on the obser- especially boys (Kazianga, de Walque, and Alderman vation that effects are generally seen in studies of children 2014). In Lao PDR, significant improvements were who are known to be infected, especially when infec- reported in both height-for-age (0.29 standard devia- tion rates are high. For example, deworming of children tion) and weight-for-age (0.22 standard deviation) with intense trichuriasis—which is associated with among children ages 3–10 years, although the authors Trichuris dysentery syndrome and severe stunting—results suggested that the nutritional findings were inconclusive in dramatic catch-up growth (Cooper and others 1995). because of the complications that arise in stratified anal- Similarly, a Cochrane review of the effect of soil-transmitted yses (Buttenheim, Alderman, and Friedman 2011). helminths on growth in children younger than age 16 Kristjansson and others (2007) conducted a meta- years found that the three studies that followed up with analysis of three controlled before-and-after studies of only those children who had been screened and found to school meals in low-income countries and lower-middle- be infected showed a significant mean increase in weight income countries (Agarwal, Agarwal, and Upadhyay 1989; (0.58 kilogram), with no significant difference in height Bailey 1962; Devadas and others 1979). They found following treatment (Taylor-Robinson and others 2012). greater weight gains of approximately 0.75 kilogram per A meta-analysis of 19 RCTs by Hall and others (2008) year, slightly larger than the impacts found in RCTs (0.71 found that children ages 1–19 years who are treated for kilogram). In contrast to the RCT evidence, meta-analysis intestinal worm infections experience significant improve- of the three controlled before-and-after studies found a ments in height (9 studies, 0.11 centimeter), weight (11 significant effect on height gain (1.43 centimeters), studies, 0.21 kilogram), HAZ (6 studies, 0.09 standard approximately one-third more than in control groups. deviation), weight-for-age z-score (5 studies, 0.06 stan- dard deviation), and weight-for-height z-score (4 studies, 0.38 standard deviation). According to Taylor-Robinson MICRONUTRIENT SUPPLEMENTATION and others (2012), differences in the findings of the two reviews could be due to differences in their protocols. Micronutrient supplementation and fortification have been found to increase growth at school age. A meta-analysis of 33 zinc supplementation studies in prepubertal children conducted by Brown and others IMPACT OF INTERVENTIONS AND CATCH- (2002) found significant effects for both weight UP GROWTH ON COGNITIVE ACHIEVEMENT (0.31 kilogram) and height (0.35 centimeter). In seven of AMONG SCHOOL-AGE CHILDREN the studies, the mean initial age of the children was Growth- and nutrition-promoting interventions in greater than five years. Ramakrishnan and others (2004), school-age children have been found to improve learn- in a meta-analysis of the effects of vitamin A, iron, and ing and cognitive functioning. Although not true for all multiple-micronutrient interventions on the growth of studies (Gertler and others 2014), several studies on the children younger than age 18 years, found significant impact of food supplementation (Cueto, Jacoby, and improvements in height and weight with multiple- Pollitt 1998; Muthayya and others 2007), micronutrient micronutrient interventions, but not with vitamin A or supplementation (Soewondo, Husaini, and Pollitt 1989; iron alone. Five multiple-micronutrient interventions Zimmermann and others 2006), deworming (Nokes and were included, two of which were in school-age children others 1992), and treatment of growth-hormone defi- and reported significant effects on height and weight ciencies (Van Pareren and others 2004) on school-age (Abrams and others 2003; Ash and others 2003). A sys- children found that these interventions led to significant tematic review focusing on multiple-micronutrient for- improvements in learning and cognitive outcomes. tification in school-age children reported mixed effects Evidence from studies using observational data indi- for height and weight gain (Best and others 2011). cates that reversing stunting or achieving catch-up growth among school-age children leads to gains in learning and cognition. Some of these studies used data from the Young DEWORMING Lives child cohort study in Ethiopia, India, Peru, and The ability to detect improved growth as a result of anthel- Vietnam, which follows children from infancy through mintic treatment of children is controversial. Much of this childhood and adolescence. In particular, the studies by controversy is about the interpretation of studies of inter- Crookston and others (2013), Crookston and others ventions that treat all children in a community irrespective (2014), Fink and Rockers (2014), and Georgiadis and Evidence of Impact of Interventions on Health and Development during Middle Childhood and School Age 101 others (2016) found evidence that children who experi- periods as a result of local weather conditions that, in enced higher growth, as measured by the change in turn, led to differential exposure to pathogens related HAZ, in early primary school years and in adolescence to parasitic infection. The methodological approach of performed better in reading comprehension, vocabulary, this study is based on instrumental variables that pro- and mathematics tests and were less likely to be over-age duce valid results as long as local weather conditions for their grade than were children with slower growth affect cognitive achievement only by influencing child across the four countries. growth. Georgiadis (2016) presents a range of tests Although this evidence is suggestive, it is not that support this key assumption and thereby the conclusive regarding whether catch-up growth among validity of his conclusions. His findings suggest that school-age children leads to improvements in learning growth in utero and in infancy and its impact on cog- and cognitive outcomes. nitive development can be reversed through parental Two studies used observational data to address this promotion of nutrition and cognitive development in issue and to identify the causal effect on cognitive school-age years. development of growth during school-age years. The first study is by Glewwe and King (2001), who investi- CONCLUSIONS gated the impact of growth at different periods (from conception to age two years and from ages two to eight The evidence reviewed in this chapter suggests that the years) on the intelligence quotient (IQ) test score of effects of early deprivation do not necessarily persist children from the Philippines. The key finding of this throughout life, especially if environmental circum- study was that only growth in the second year stances change. Consistent with Golden’s (1994) claim after birth had a significant and positive effect on that substantial catch-up growth is possible at school IQ test scores. The second study is by Georgiadis age, we find that trajectories of child growth and cogni- (2016), who investigated the impact of higher growth tive development respond rather strongly to growth-pro- during early primary school years, compared with the moting interventions after age two years, as summarized period from conception to infancy and from infancy by the evidence in table 8.1. Of course, this does not through just before starting primary school, on chil- mean that catch-up growth and improvements in cogni- dren’s achievement in mathematics and vocabulary tive functioning in school-age children always happen; it tests using data from the Young Lives study. In partic- just means that there is very little evidence to support the ular, Georgiadis (2016) compared the test scores of notion that early deficits are irreversible, as concluded in children who experienced different growth in these the original work by Golden (1994). Table 8.1 Findings of Studies on the Possibility of Catch-Up Growth Source of changed Study conditions Description Quantitative findings Schumacher, Pawson, Immigration Immigrant children ages 5–12 years with low HAZ On average, 0.1 standard deviation improvement in and Kretchmer 1987 were studied upon their arrival in the United States HAZ occurred after about one year. and after one year. Mjönes 1987 Immigration The growth of school-age children who were born Immigrant children were short on arrival but caught in Turkey and immigrated to Sweden was compared up to heights of ethnically similar children born in with the growth of Turkish children born in Sweden. Sweden. Steckel 1987 Improved diet and Anthropometric data were analyzed from logs of As children, slaves were about the first or second lower exposure to tens of thousands of American slaves between centile for height; as late adolescents, they exceeded infection (inference) 1820 and 1860. the 25th centile. Komlos 1986 Move to boarding Anthropometric data were analyzed from students The boys, who were stunted at admission, exhibited school who were born between 1775 and 1815 and who sizable catch-up, potentially attributable to improved attended Hapsburg military schools. diet and living conditions. King and Taitz 1985 Foster care and Growth of previously abused children was tracked The children experienced significant improvements adoption following (1) long-term placement in foster care or in both HAZ and WAZ, with the long-term foster care adoption or (2) short-term placement in foster care. group showing the greatest improvement. table continues next page 102 Child and Adolescent Health and Development Table 8.1 Findings of Studies on the Possibility of Catch-Up Growth (continued) Source of changed Study conditions Description Quantitative findings Abrams and others Micronutrient Children ages 6–11 years were administered a The treatment group on average gained 0.17 standard 2003 supplementation beverage fortified with 12 micronutrients for eight deviation in WAZ, significantly different from the 0.08 weeks. standard deviation gain in the control group. Ash and others 2003 Micronutrient Children ages 6–11 years were administered a The treatment group on average gained 3.2 supplementation beverage fortified with 10 micronutrients for six centimeters in height, significantly different from the months. 2.6 centimeter gain in the control group. Cooper and others Deworming Children with intense trichuriasis associated with Six months after deworming, the children exhibited 1995 Trichuris dysentery syndrome and severe stunting growth in mean height and weight that was two were dewormed. standard deviations greater than the growth of British children their age. Stephenson and Deworming Primary school boys in a high-prevalence area were The treatment group exhibited rapid gain in weight, others 1993 given a single dose of deworming treatment and 1.0 kilogram more than the control group, across the followed up with four months later. four months of the study. Note: HAZ = height-for-age z-score; WAZ = weight-for-age z-score. 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Evidence of Impact of Interventions on Health and Development during Middle Childhood and School Age 105 Chapter 9 Puberty, Developmental Processes, and Health Interventions Russell M. Viner, Nicholas B. Allen, and George C. Patton INTRODUCTION (GBD 2013 Risk Factors Collaborators 2015) are largely determined during adolescence. Adolescence is increasingly recognized as a critical Adolescence is also a time when young people may period in the life course, a time when rapid development modify or alter the pathways to adult health or illness of the brain, body, and behaviors opens a window of (Viner and others 2012). Early life experiences may opportunity for interventions that may affect health reinforce both good and poor trajectories. Similarly, throughout life. resilience during adolescence may improve outcomes Puberty results in very rapid somatic growth, brain for young people born into adversity. The transfer from development, sexual maturation, and attainment of primary to secondary school, sexual debut, and entry reproductive capacity. It is accompanied by final matura- into the labor market may be critical points for pre- tion of multiple organ systems and major changes in the venting the accumulation of health risk (Viner and central nervous system and in psychosocial behavior others 2012). (Patton and Viner 2007). The discovery of continued This chapter outlines the key dynamics of adolescent brain development through adolescence is one of the development and examines how they provide opportu- great advances of neuroscience in the past 20 years. nities for intervention. Definitions of age groups and A dramatic spurt in brain development begins during age-specific terminology used in this volume can be adolescence and continues until the mid-20s, with found in chapter 1 (Bundy and others 2017). marked development of both cortical and subcortical structures (Goddings and others 2012). This rapid development in the body and brain inter- PUBERTY AND DEVELOPMENTAL acts with social changes, including increasing individua- PROCESSES tion and new peer groups, to facilitate transitions important for individuals to function as productive Puberty is a time of rapid growth in all body systems and adults (World Bank 2006). A range of social determi- changes in brain function and cognitive development nants of health arise in adolescence, with peers, schools, (Patton and Viner 2007). and eventually the workplace becoming strong determi- nants of health and well-being as the influence of the family wanes (Viner and others 2012). These social Stages of Puberty changes are apparent even in traditional or more socio- The process of puberty begins earlier than most recog- centric cultures. More than half of the top 10 risk factors nize, that is, between the ages of six and eight years with identified in the Global Burden of Disease study the early phase of adrenarche, the turning on of the Corresponding author: Russell M. Viner, UCL Institute of Child Health, University College London, London, United Kingdom; r.viner@ucl.ac.uk. 107 adrenal glands. Adrenarche has few phenotypic signs in beginning of menses. Boys continue growing slowly most children, but increasing evidence indicates that after the end of puberty, achieving final height at about adrenal androgens may contribute to the structural and age 18 years. functional development of the brain and associated The bone, renal, immune, and cardiovascular systems behaviors in adolescence (Whittle and others 2015). are also developing, and liver enzymes and blood lipids The timing of adrenarche affects the risks for mental are maturing. Bone mineral accretion accelerates during health problems (Mundy and others 2015) and a range puberty under the influence of gonadal steroids, with of cardiometabolic issues. Body mass index (BMI) is peak bone mass achieved by the early 20s (Loud and associated with adrenal androgens (Corvalan, Uauy, and Gordon 2006). Cardiovascular and renal development Mericq 2013); children exhibiting premature adrenarche means that blood pressure and heart rate make a transi- have been found to have higher levels of insulin and tion to adult values, in parallel with growth in height insulin resistance and a predisposition to higher BMI and mass. The cardiovascular risk profile differs between (Ibáñez and others 2008). the genders, with more adverse lipid patterns among The second phase of puberty is gonadarche, the pro- boys than girls. Other blood markers, such as hemoglo- cess of sexual maturation and achievement of reproduc- bin levels, similarly change to a sexually dimorphic tive capacity (Marshall and Tanner 1968). The production pattern. of gonadal steroids stimulates the growth and develop- ment of secondary sexual characteristics; it also kindles development across all organ systems, including the Timing of Puberty central nervous system. Other endocrine systems mature The sequence of pubertal events is remarkably consistent during puberty, including the growth hormone/insulin- across countries and ethnic groups, although timing like growth factor and thyroid axes. varies by country. The timing of puberty is influenced Marshall and Tanner (1968) developed a system for partly by genetics, but largely by nutrition and economic identifying stages in the external signs of puberty. The development (Hochberg and Belsky 2013). The mean earliest external changes—breast buds in girls and testic- age at menarche is now 12–13 years in most high-income ular enlargement in boys—typically appear about age countries (HICs); it is usually later in low-income 11 years, but vary among individuals. Despite a similar countries, even in affluent populations (Parent and age of gonadarche in boys, these early changes are more others 2003). visible in girls. Menarche, the onset of menstrual periods The mean age of menarche stopped falling in most (menses), typically occurs in late puberty, approximately HICs after the 1960s, but it is still falling in low-income two years after breast budding. While menses appears to countries. However, data from the United States signal reproductive maturity for girls, it largely signals (Herman-Giddens and others 1997) and, more recently, maturity of the uterus because early menstrual periods Europe (Parent and others 2016) suggest that early are irregular and girls are rarely fertile immediately after pubertal events are occurring at younger ages but that menarche (Hochberg and Belsky 2013). late pubertal events are not. The reasons for this broad- Puberty is generally complete within two to four ening of puberty are unclear, although exposure to years following gonadarche, but other changes including endocrine disrupter chemicals and psychosocial stress fat and muscle patterning continue through adolescence. are possible mechanisms (Parent and others 2016). The timing of puberty is partly genetic (Day and others Recent studies have suggested that earlier pubertal devel- 2016), but intrauterine events, nutrition, family factors, opment is likely a response to changing environmental stress, and socioeconomic conditions also play roles circumstances (Gluckman and Hanson 2006; Hochberg (Hochberg and Belsky 2013). and Belsky 2013). By contrast, the timing of adrenarche Puberty is increasingly recognized as a time of dis- appears to be relatively constant across populations tinct transitional physiology (Rosenfeld and Nicodemus (Hochberg 2009). 2003). The most dramatic change is the pubertal growth spurt, with boys typically growing 30 centime- Effects on Health and Disease ters and girls growing 25–27 centimeters due to syn- In addition to puberty’s direct influences on physiology ergy between the sex steroids and growth hormone and growth, the timing of puberty appears to program (Abbassi 1998). For girls, the growth spurt occurs early, changes in lifelong health. In particular, strong evidence with peak growth typically occurring about the time of indicates that higher BMI accelerates the onset of the start of breast development. For boys, it occurs puberty (Burt Solorzano and McCartney 2010; Frisch later. Girls typically stop growing by the end of 1984; Hochberg and Belsky 2013), but early puberty also puberty, adding only about 2.5 centimeters after the programs individuals for greater fat accumulation 108 Child and Adolescent Health and Development over the life course (Power, Lake, and Cole 1997; Prentice In an evolutionary context, neurodevelopment and Viner 2013). during puberty is likely to optimize reproductive suc- Early puberty is associated with cardiometabolic risk, cess by realigning emotional, social, and metabolic increasing the risk of cardiovascular events and mortal- strategies to the external environment (Hochberg and ity, type 2 diabetes (Prentice and Viner 2013), and high Belsky 2013). blood pressure (Hardy and others 2006). These associa- tions appear to be at least partly independent of child- hood obesity (Prentice and Viner 2013). Mechanisms Brain Development likely relate to stress reactivity, the growth hormone/ In adolescence, brain development involves two key pro- insulin-like growth factor axis (Sandhu and others cesses: significant growth and change in regions of the 2006), and glucose insulin homeostasis (Burt Solorzano prefrontal cortex (Paus, Keshavan, and Giedd 2008; and McCartney 2010). Steinberg 2005) and improved connectivity between Early puberty is linked to cancer in later life through regions of the prefrontal cortex and regions of the limbic several mechanisms. Longer exposure to gonadal steroids system (Casey 2015; Steinberg 2005). These changes are may increase the risk of steroid-dependent cancers such as thought to underpin higher-order cognitive functions, breast and ovarian cancer in females (Ahlgren and others such as reasoning, interpersonal interactions, the 2004; Jordan, Webb, and Green 2005) and possibly pros- perception of both short- and long-term risk and tate cancer in males (Giles and others 2003). Mechanisms reward, and the regulation of behavior and emotion may include longer exposure to sex hormones, increased (Paus, Keshavan, and Giedd 2008; Steinberg 2005). oxidative stress (Vincent and Taylor 2006), or hyperinsu- Normative neurodevelopmental processes prepare linemia (Frezza, Wachtel, and Chiriva-Internati 2006) the brain for responding to the demands of both adoles- related to obesity in early developers or to behavioral risk cence and adult life, but may also make adolescents vul- factors such as substance use (Patton and Viner 2007). nerable to risk behavior and psychopathology (Paus, Keshavan, and Giedd 2008). Dual-system and imbalance Evolutionary Implications models posit that adolescence is a particularly vulnerable The relationship of the timing of puberty to environ- period because of the imbalance between early matura- ment and nutrition has its origins in evolutionary tion of the limbic motivational and emotional systems biology. Severe environmental stress and malnutrition and slower, or later, development of the regulatory may result in delayed puberty, prioritizing the survival regions of the prefrontal cortex (Casey 2015). The dual- of the individual given that reproduction is not possi- systems model emphasizes a developmentally normal ble. Similarly, ideal environmental conditions may mismatch between intense affective and behavioral reac- result in delayed puberty, maximizing the individual’s tions and motivations and limited capacity to regulate later reproductive success. However, environmental them (Steinberg 2005). stress that is not sufficient to threaten survival may Recent studies, however, suggest a more complex pic- accelerate pubertal development, increasing the likeli- ture (Mills and others 2014; Pfeifer and Allen 2012). For hood of reproduction before death (Hochberg and example, brain-imaging studies in adolescents do not Belsky 2013). provide consistent support for the association between In this schema, adrenarche represents a point at which immaturity in the frontal cortex and the emergence the environment can reprogram reproductive strategies of risk behavior and psychopathology (Crone and (Del Giudice 2009). It may also allow children time to Dahl 2012). test their social status in a peer environment free from Recent attempts to quantify brain maturation have reproductive imperatives. used measures of the whole brain, such as network-based Accelerated puberty also increases health risk measurements of resting-state brain function that are behaviors, such as early sexual activity and violence. independent of specific tasks (Dosenbach and others Associations have been found between early pubertal 2010) or structural data from magnetic resonance imag- development in girls and sexual abuse, severe psychoso- ing (Vértes and Bullmore 2015). Some of these measures cial stress, and even absence of the father. For example, may be related to both the emergence of more integrated migrant children arriving in HICs frequently experience self-regulatory abilities and plasticity in response to new onset of puberty earlier than would be expected in either learning experiences (Crone and Dahl 2012; Dosenbach their home or host country. Their transition from a and others 2010). However, the relationship between threatening to an ideal nutritional environment may these neurodevelopmental patterns and cognitive, affec- accelerate their pubertal development (Hochberg and tive, and behavioral changes in adolescence is not fully Belsky 2013). understood. Puberty, Developmental Processes, and Health Interventions 109 Cognitive Development dominance across adolescence of the system responsible Cognitive domains, including learning, reasoning, for valuing future rewards. information processing, and memory, improve as The impact of temporal discounting is consistent adolescents develop. Executive functioning capabilities, with the observed association between adolescence and which facilitate self-regulation of thoughts, actions, risk-taking behaviors, despite adequate knowledge of and emotions, continue to develop in parallel with risks (Steinberg 2005). It also suggests that affective changes in the prefrontal cortex (Kesek, Zelazo, and valuation of immediate versus long-term outcomes Lewis 2008). These increases in self-regulatory control (as opposed to conceptual understanding of them) is are thought to support deductive reasoning; informa- likely to be the main way in which adolescent decision tion processing; efficiency; and the capacity for abstract, making deviates from mature (adult-like) decision planned, hypothetical, and multidimensional thinking making. (Steinberg 2005). Sensitivity to Peer Influence Cognitive and Affective Processing Adolescents assign greater weight than adults to social Recent research has focused on both cognitive and affec- outcomes such as peer acceptance. During the transition tive processing, particularly regarding how these pro- from childhood to adolescence, the amount of time cesses interact and influence each other in the context of spent with peers increases dramatically (Brown 2004) decision making. First, cognitive skills allow improved and peer and family values increasingly diverge (Gardner self-regulation of affect—the capacity to initiate new or and Steinberg 2005; Steinberg 2008). These changes sug- alter ongoing emotional responses—to achieve a goal gest that teenagers are less resistant to peer pressure than (Ochsner and Gross 2005). Second, affective influences either children or adults, although susceptibility to peer on cognitive processing, including decision making, risk influence per se declines over the course of adolescence taking, and judgment, change significantly during ado- (Steinberg and Monahan 2007). lescence (Hartley and Somerville 2015; Steinberg 2005). Neuroscientific research has begun to explore this The social and emotional context for cognitive pro- resistance to peer influence. Grosbras and others (2007) cessing during adolescence may include factors such as studied children age 10 years with high or low resistance the presence of peers or the value of performing a task, to peer influence and found that, while viewing angry which are hypothesized to influence the motivational hand gestures and facial expressions, those with high salience of specific contexts and the extent to which cog- resistance to peer influence showed more coordinated nitive processing is recruited (Johnson, Grossmann, and brain responses across parts of the brain associated with Kadosh 2009). Moreover, some of these changes in cog- processing nonverbal behavior and with planning and nitive and affective processing are linked to the onset of executing movement. The better the brain is at coordi- puberty (Crone and Dahl 2012), with flexibility of the nating its response to other people’s nonverbal emotional frontal cortical network greater in adolescence than in expressions across the emotional and self-regulation adulthood (Jolles and others 2012). networks of the brain, the better the person is at resisting peer influence. Consistent with this, Pfeifer and others Temporal Discounting (2011) found that adolescents who are better at resisting Temporal discounting refers to the inclination to discount peer influence have greater activity in a region of the the value of future rewards as compared with immediate brain involved in reward, positive affect, and emotional ones (Christakou, Brammer, and Rubia 2011). This ten- regulation. dency declines sharply between ages 15 and 16 years (de Water, Cillessen, and Scheres 2014). Moreover, the Executive Control neurobiological basis for temporal discounting is related The literature on the structural and functional changes to developmental changes in dopamine activity (Pine associated with brain maturation suggests a model in and others 2010). Specifically, increases are evident in which some regions are tightly integrated into long- both dopaminergic connectivity to the prefrontal cortex range networks, while other regions are segregated into (Kalsbeek and others 1988; Verney and others 1982) and short-range networks. Fjell and others (2012) demon- the density of dopamine transporters (Spear 2000). strated that developmental changes in cognitive control Dopamine receptors are overproduced in early adoles- were associated with both the surface area of the ante- cence, followed by pruning that is more evident in sub- rior cingulate cortex and the properties of large fiber cortical than in prefrontal regions (Spear 2000). The connections. Crone and Dahl (2012) proposed that net effect is to shift the relative balance between subcor- because these patterns of long-range connectivity are tical and cortical dopaminergic systems, with increasing still maturing, some aspects of executive control may 110 Child and Adolescent Health and Development be less automatic and more flexible during adolescence, Depression resulting in greater vulnerability when performing Considerable evidence demonstrates that early puberty attentional and decision-making tasks under high increases the risk of depression in girls (Hayward demands (because the ability to integrate control is less and others 1997; Kaltiala-Heino, Kosunen, and automatic) and enabling adolescents to respond in Rimpelä 2003; Kaltiala-Heino and others 2003; Mendle, novel and adaptive ways. Thus, specific learning or Turkheimer, and Emery 2007). Angold, Costello, and training experiences during adolescence may guide the Worthman (1998) found that pubertal stage predicts final connectivity patterns in some of these long-range the risk of major depression in adolescents better than cognitive control networks. age. Rates of depression are higher in boys than in girls before puberty, but are higher in adult women than in adult men. Girls begin to surpass boys in depression at ADOLESCENCE AS A TIME OF RISK stage-3 puberty. Puberty may even reduce the preva- lence of depression in males (Angold, Costello, and The developmental changes that occur in adolescence Worthman 1998). create greater vulnerability to emotional and behavioral dysregulation (Steinberg 2005). Although adolescents are relatively physically healthy Anxiety compared with other age groups, adolescence is a key Anxiety disorders increase markedly in both sexes dur- phase of life for the establishment of risk factors for ing adolescence. However, the evidence for an associa- several highly burdensome diseases. The transition into tion with pubertal timing is much less clear for anxiety early adolescence is marked by dramatic increases in than for depression. A recent review of more than 45 morbidity and mortality, often associated with mental empirical studies found only moderate-quality evidence health disorders, substance use, and the consequences that both earlier timing and more advanced pubertal of risk taking and poor decision making (Blum stage increase anxiety or symptoms in girls after adjust- and Nelson-Mmari 2004; Williams, Holmbeck, and ing for age. Findings for boys are even less robust Greenley 2002). The majority of mental health and (Reardon, Leen-Feldner, and Hayward 2009). substance use problems begin before age 21 years There is little evidence regarding anxiety disorders. (Jones 2013), and poor health outcomes during adoles- Hayward and others (1992) found an association cence may have ongoing and negative impacts on adult between panic attacks and pubertal stage, but Graber life (Sawyer and others 2012). For example, major non- and others (1997) found no association between anxiety communicable diseases, such as heart disease and can- disorders and pubertal timing in boys or girls. cer, are acutely sensitive to lifestyle and behavioral risk factors that are often established during adoles- cence, such as nutrition, physical activity, sleep, obesity, Deliberate Self-Harm stress, and substance use (Lowry and others 1996). Deliberate self-harm, a major risk factor for suicide, The dramatic changes occurring in the brain during rises sharply in early adolescence. In young women, it adolescence also make this a time of significant neu- peaks about age 15–16 years and falls thereafter (Hawton roplasticity, suggesting that behavioral patterns can and others 2002; Madge and others 2008). The litera- become strongly encoded in the brain during this time ture on puberty and deliberate self-harm is much (Crone and Dahl 2012). smaller than that on depression or anxiety. In a large population-based study, strong associations between deliberate self-harm and pubertal stage (adjusted for Aggression and Violence age) were attenuated when models were adjusted for Aggression, including bullying and violence, increases depressive symptoms, showing that this association was dramatically and peaks in middle adolescence (Krug and largely or entirely mediated by depression (Patton and others 2002; Patton and Viner 2007). Given the known others 2007). effects of testosterone on aggression in animals and humans (Archer 1991), researchers focused on the rela- tionship between puberty and aggression in males Eating Disorders (Olweus and others 1988). More recently, large-scale There is a strong association between puberty and eating studies have found good evidence that the risk of vio- disorders, at least in girls. A recent systematic review lence and aggression increases with pubertal stage in identified advanced pubertal status or early pubertal boys (Hemphill and others 2010). timing as a risk factor for eating disorders or disordered Puberty, Developmental Processes, and Health Interventions 111 eating in more than 40 studies in girls and more than 20 Young people make five key transitions on the path- studies in boys. Early-maturing girls and boys have way to adulthood (World Bank 2006): higher risk of a range of eating disorders, including anorexia nervosa and bulimia nervosa, as well as symp- • Learning: Transition from primary to secondary toms of eating disorders, including dissatisfaction with schooling and from secondary to higher education body, weight, or shape (Klump 2013). However, some • Work: Transition from education into workforce studies found no association between eating disorders • Health: Transition to responsibility for own health and puberty, particularly in boys, and others reported • Family: Transition from family living to autonomy, an association between early or advanced puberty marriage, and parenthood and improved body image (McCabe, Ricciardelli, and • Citizenship: Transition to responsible citizenship. Banfield 2001). Transitions are accompanied by new behaviors, including the initiation of many health-related behaviors Physical Health that track strongly into adult life. They are a time of great Less recognized are associations between puberty opportunity to tread new paths and embark on new and physical illnesses. Puberty coincides with a rise in trajectories toward health and well-being. prevalence of many autoimmune conditions and a marked shift in gender ratio toward females (Beeson Secondary Education as a Health Intervention 1994). In both genders, type 1 diabetes begins in early puberty, although the peak age of onset occurs approx- Evidence is emerging that secondary education is effica- imately two years earlier in girls than in boys, reflect- cious against a range of health outcomes in adolescents ing differences in pubertal timing (Pundziute-Lycka and young adults, from sexually transmitted infections and others 2002). Early puberty is an independent risk to adolescent fertility, mortality, and mental health factor for the persistence of asthma into adolescence (Patton and others 2016). Education is one of the stron- and severity of asthma in adulthood (Varraso and gest determinants of health and human capital others 2005). Seizures often become more frequent (Commission on Social Determinants of Health 2008), and new types of epilepsy emerge during adolescence and universal primary education is one of the key United (Klein, van Passel-Clark, and Pezzullo 2003). The Nations Millennium Development Goals. In both rich pubertal growth spurt results in new musculoskeletal and poor countries, persons with more education live problems, and puberty is linked with various pain longer lives with less disability and ill health, and the syndromes. The increase in back, facial, and stomach relationship is likely to be causal (Baker and others 2011; pains in early adolescence is associated with pubertal Miyamoto and Chevalier 2010; Pradhan and others status in both sexes (LeResche and others 2005). 2017, chapter 30 in this volume). The United Nations Adult women have higher rates of migraine and Sustainable Development Goals include a target for tension headaches than adult men; this pattern is evi- countries to provide every child with access to free pri- dent about age 11 years and is linked with puberty mary and secondary education by 2030 (Barro 2013).1 (Wedderkopp and others 2005). Yet the health gains from secondary education have been studied less than those from primary education, despite a dramatic global expansion in the length of education in the past 30 years, with most gains in the late ADOLESCENCE AS A TIME OF OPPORTUNITY primary and early secondary years (IHME 2015). Among Adolescence is a key time for interventions to improve adults in HICs, upper-secondary education is most health. The benefits of intervention in early childhood strongly associated with better health and mental health are well described, and nations have made significant (Miyamoto and Chevalier 2010), although tertiary edu- investments in maternal and child health and primary cation confers additional benefits in U.S. studies (Case education (Commission on Social Determinants of and Deaton 2015). Secondary education is known to Health 2008; Conti and Heckman 2012). Adolescence promote better pregnancy and child health outcomes presents an opportunity to preserve investments made in among adult women internationally (Grépin and childhood and to switch trajectories (Romeo 2010), Bharadwaj 2015; UNESCO 2010), and a small literature while the emergence of new social determinants of from Sub-Saharan African countries suggests that sec- health, such as peers, and connection with school, neigh- ondary schooling may have a stronger and more consis- borhood, and workplace, offer new vehicles and venues tent effect on teenage fertility than primary education for intervention. (Mahy and Gupta 2002). 112 Child and Adolescent Health and Development Nutritional Interventions will recover by the time of posttreatment assessment Adolescence presents an opportunity to reverse earlier (Asarnow, Jaycox, and Tompson 2001; March and others deficits from stunting or wasting in childhood (GBD 2004). Despite these favorable results, the long-term 2013 Risk Factors Collaborators 2015). Nutritional suffi- outcomes of current treatment approaches are unclear. ciency in adolescence is particularly important for preg- One meta-analysis of psychotherapy for depression in nancy. Childbearing during adolescence places an youth found no lasting effects one year following treat- additional nutritional burden on the mother and may ment (Weisz, McCarty, and Valeri 2006). explain some of the additional risk that pregnancy in Mental disorders, once established, are difficult to ame- adolescence poses to the 16 million teenagers who give liorate fully, highlighting the importance of evidence-based birth annually and their offspring (Mundy and others strategies to prevent or slow the onset of disorders in 2015; Whittle and others 2015). Adolescent growth and vulnerable individuals. To achieve this goal, it is necessary development therefore provides an opportunity for pre- to identify developmentally significant, modifiable risk conception interventions to ensure adequate nutrition in factors and to target change in them. adolescent girls. These issues are discussed in greater In recent decades, numerous controlled studies have detail in chapter 11 in this volume (Lassi, Moin, and evaluated the effect of programs to prevent mental ill- Bhutta 2017). ness (Durlak and Wells 1997, 1998) and substance use (Tobler and others 2000); problems at school and depression (Gillham, Shatté, and Freres 2000); and Psychosocial Interventions aggression and behavior problems, especially in children Exposure to an enriching environment during adoles- (Tremblay, LeMarquand, and Vitaro 1999); along with cence may offset many of the negative neurobehavioral many other conditions. These studies have shown that and physiological consequences of early life adversity some programs may strengthen protective factors, such (Romeo 2010). The onset of puberty marks the begin- as social and problem-solving skills, stress management ning of dramatic changes in the processing of rewards skills, prosocial behavior, and social support, and reduce and emotional stimuli and social-cognitive reasoning the consequences of risk factors, symptoms, and sub- (Crone and Dahl 2012). Efforts to sensitize young people stance use. to their social environment and push them to explore However, few studies have examined how to prevent and engage provide opportunities to promote prosocial the onset of case-level mental and substance use disor- motivation and goals in early adolescence. ders, mainly because of the challenges associated with Furthermore, neurodevelopment likely affects a designing and funding studies with enough statistical young person’s ability to engage with or benefit from power to detect such effects (Cuijpers 2003). Such pro- interventions, particularly those that target decision grams have had modest effects (Horowitz and Garber making and risk behaviors in peer and affective contexts. 2006), and there is a need to ascertain which individuals In particular, immaturity in cognitive processes, such are most likely to benefit from specific interventions. as temporal discounting, may necessitate a different In sum, while prevention and intervention approaches approach to intervention in early adolescents than in delivered early in life are promising, there is a clear need middle to late adolescents. Furthermore, adolescents are to understand how to match interventions with individ- uniquely vulnerable to peer influences, both antisocial uals to increase their impact and cost-effectiveness. and prosocial, and this vulnerability can be used to enhance health outcomes. Indeed, resisting negative peer influences is important for self-regulation. Finally, CONCLUSIONS specific experiences may affect neurodevelopment— Adolescence is a time of great developmental plasticity psychosocial interventions may enhance self-regulation and risk for the onset of a range of disorders that can and can have benefits not only during adolescence but carry a high burden of disease throughout the lifespan. also later in life. It offers a critical developmental window of opportunity Research to date has yielded some efficacious early for intervention and prevention. Puberty and brain intervention and prevention approaches to mental dis- development during adolescence are responsible for dra- orders during adolescence. For example, both psychoso- matic shifts in burden of disease, away from childhood cial and pharmacological treatments with established conditions toward injuries and emerging noncommuni- efficacy are available for treating depression (Kazdin cable diseases. Knowledge of the unique developmental 2003). 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World Development Report 2007: Drug Prevention Programs: 1998 Meta-Analysis.” Journal of Development and the Next Generation. Washington, DC: Primary Prevention 20 (4): 275–336. World Bank. Puberty, Developmental Processes, and Health Interventions 117 Chapter 10 Brain Development: The Effect of Interventions on Children and Adolescents Elena L. Grigorenko INTRODUCTION major premises of the DOHaD is that both structural and functional characteristics of brain development are The landscape of the child public health literature in the highly informative predictors of the lifespan ratio of twenty-first century has been strongly influenced by the health and disease. As the brain substantiates behavioral Developmental Origins of Health and Disease (DOHaD) change, understanding its development is key in con- hypothesis (Van den Bergh 2011). This hypothesis pro- structing and disseminating interventions that maximize poses that human complex diseases and disorders, healthy development and minimize the impact of dis- regardless of age of onset, have their roots in childhood abilities and disorders. and adolescence and are products of the dynamics of This chapter briefly outlines aspects of the brain various forces that substantiate human development. literature that pertain to public health interventions, pro- Similar developmentally oriented views have been pro- grams, and policy approaches to protecting, augmenting, posed by other theoretical frameworks (for example, Li and maximizing the healthy development of the brain. 2003), but the DOHaD hypothesis has received the most First, the essential characteristics of brain development traction in the literature and is a driving force behind are outlined. Second, a variety of research on brain devel- studies that connect early development to lifespan health. opment changes associated with public health is briefly The human brain is arguably the most complex bio- discussed. The relevance of this research, conducted logical system, comprising a diversity of functionally predominantly in high-income countries (HICs), is con- distinct regions, structurally distinct neural circuits, and sidered, with a view to its applicability in low- and morphologically distinct cell types. Its lifespan is highly middle-income countries (LMICs). Definitions of age dynamic, encompassing continuity and changes at both groupings and age-specific terminology used in this vol- structural and functional levels. The brain has a unique ume can be found in chapter 1 (Bundy and others 2017). developmental trajectory compared with the rest of the body. Whereas at birth an infant is approximately 6 percent of its adult body weight, the brain is already DEVELOPMENT OF THE HUMAN BRAIN 25 percent of its adult weight; by age two years, these proportions are 20 percent and 77 percent, respectively Anatomical Maturation (Dekaban and Sadowsky 1978). This rapid rate of brain The human brain’s maturation is remarkably pro- growth is accompanied by a slow rate of functional mat- longed and characterized by ongoing dynamic changes uration that extends into early adulthood. One of the throughout the lifespan (Giedd and Rapoport 2010). Corresponding author: Elena L. Grigorenko, University of Houston, Houston, Texas, United States; elena.grigorenko@times.uh.edu. 119 Postnatally, it follows (figure 10.1) an inverted U-shaped determines the color; and relatively few neuronal cell trajectory that peaks about age eight years and then bodies. In general and simplifying terms, the gray declines monotonically (Ducharme and others 2016). matter forms the structures of the brain, and the The brain matures along its two dimensions, gray and white matter ensures that these structures are con- white matter. Gray matter is composed chiefly of neu- nected; both are essential for all functions substanti- ronal cell bodies, which determine the color, as well as ated by the brain. The gray and white matter have dendrites, unmyelinated and relatively few myelinated different developmental trajectories; their relative axons, glial cells including astroglia and oligodendro- proportions and rates of accumulation differ at differ- cytes, synapses, and capillaries. White matter is com- ent developmental stages and in healthy and disor- posed chiefly of myelinated axons; the myelin, which dered brains. Figure 10.1 Developmental Trajectories of Brain Morphometry a. Total brain volume b. Gray matter volume 1,300 800 Gray matter volume (cc) 750 Total brain volume (cc) 1,200 700 1,100 650 1,000 600 8 10 12 14 16 18 8 10 12 14 16 18 Age in years Age in years c. White matter volume 510 White matter volume (cc) 470 430 390 350 8 10 12 14 16 18 Age in years Boys Girls Sources: Adapted from Giedd and Rapoport 2010, adapted from Lenroot and others 2007. Note: cc = cubic centimeters. The data were collected from a sample of males (N = 475 scans) and females (N = 354 scans) ages 6–20 years. The middle lines in each set of three lines represent mean values; the upper and lower lines represent upper and lower 95 percent confidence intervals. All curves differ significantly in height and shape. 120 Child and Adolescent Health and Development By age six years, the brain reaches approximately 95 areas mature later than older ones, and higher-order percent of its adult volume. Its size in boys is approxi- association areas mature after lower-order soma- mately 10 percent bigger than in girls; this gender differ- tosensory areas (Gogtay and others 2004). For ence persists throughout the lifespan, although the example, the developmental imbalance between the bodies of boys do not become larger than bodies of girls earlier-maturing limbic system networks and later- until adolescence, suggesting a decoupling of the matu- maturing frontal systems might explain the psycho- ration trajectories of brain and body size (Giedd and logical and behavioral texture of adolescence, which Rapoport 2010). The developmental trajectory of gray may occur as this imbalance is being resolved (Casey, matter peaks in early childhood, preceding a peak in Duhoux, and Cohen 2010). total brain volume, and then gradually decreases • The maturing brain is characterized by the reshaping unevenly throughout the brain. The amount of gray of its functional properties, particularly its connectiv- matter peaks earliest in the primary sensorimotor areas ity, which peaks during adolescence and is defined by and latest in the higher-order association areas. The vol- the physical links between codeveloping brain areas, ume of white matter increases gradually into early the co-activational patterns between brain areas adulthood. Myelination not only enhances the parame- engaged in specific tasks, and the etiological connec- ters of signal transmission, it also boosts the connectivity tions between brain areas that are co-influenced by and networking properties of the brain. Some evidence the same genetic and environmental factors. indicates that white matter increases are coupled with the emergence of specific psychological functions, such as language (Paus and others 1999). Recent technologi- Functional Development cal advances resulted in the differentiation of cortical The human brain is commonly represented as a system of volume into two underlying components, cortical thick- tiered networks of highly organized neurons, where spa- ness and cortical surface area. Cortical thickness in the tiotemporal biochemical and bioelectrical activity gives majority of brain regions demonstrates linear mono- specialized functionality to structural anatomic compo- tonic decline occurring mostly similarly for boys and nents of the brain (Power and others 2010). The connec- girls between the ages of 4.9 and 22 years, with the peak tion between structure and function is bidirectional, so of cortical thickness manifesting no later than age that specific anatomical characteristics—such as lesions, 8 years (Ducharme and others 2016). synaptic development, and myelination—parameterize Data on the developmental trajectories of the brain in the functionality of a particular network. The functional HICs have accumulated rapidly within several initiatives, dynamics of the network can change physical character- such as the BRAIN Initiative.1 Selected findings from istics of the underlying brain structure. From conception these initiatives include the following: through the lifespan and into senescence, this system’s developmental trajectory is shaped by the continuous • A remarkable amount of variability of individ- co-influence of each individual’s genome and ual brain size occurs, whether across or within environome—the immediate system of environmental groups, making individualized clinical predictions factors that influence human health and behavior. difficult. Understanding the stability and malleability of the sys- • Subtle deviations from normal developmental tra- tem is a fundamental task of modern science and the jectories of the brain anatomy appear to be at focus of a number of large-scale projects, such as the least associated with—if not causal factors of—a Human Connectome Project.2 number of developmental disorders (Giedd and Because the system as a whole and each network Rapoport 2010). emerge developmentally, studies have traditionally • There are different indicators of brain development, engaged research into where in the brain a network may and some of them appear to be more clinically infor- be localized and how it operates. Such research histori- mative than others. For example, cortical thickness cally used methods of anatomical localization, for exam- has a demonstrated association with the manifesta- ple, through brain surgery or autopsy, but these methods tion of developmental disorders (Thormodsen and are of limited value in living humans. More recent meth- others 2013). ods (electroencephalography, positron emission tomog- • Cortical thickness appears to correlate with per- raphy, functional magnetic resonance imaging, and near formance on complex cognitive tasks (Karama and infrared spectroscopy/optimal imaging) based on vari- others 2011). ous technological advances study the brain in living • Different areas of the brain have differential matura- humans, where the focus, along with anatomical struc- tional dynamics. In general, phylogenetically newer ture, is on functional connectivity. These methods, Brain Development: The Effect of Interventions on Children and Adolescents 121 which at first were technology, skill, cost, and safety GENOME-ENVIRONOME DYNAMICS OF demanding, have been evolving to minimize these BRAIN DEVELOPMENT demands and maximize safety (such as applicability to pediatric populations), transportability (such as use in Blueprint of the Genome minimally equipped settings), and utilization (such as The development of the brain is based on the apt expres- usability in low-resource settings). sion of integral gene products (the transcriptome) coded The current view of the developmental trajectory of by sequences of DNA (the genome), specifically, protein the brain’s functional networks and their systems con- and RNA (Tebbenkamp and others 2014). Recent analy- verges on the following: ses of the human brain transcriptome3 have, for the first time, allowed a comprehensive picture of the trajectories • From infancy into young adulthood, properties of of genes associated with specific neurodevelopmental the network change in such a way that initially strong processes to be constructed (figure 10.2). There are correlations between brain activity in closely located strong time-specific correlations between the character- anatomical regions tend to weaken, while initially istics of the transcriptome and the morphological and weak correlations between more distant regions tend functional specialization of brain regions. Alterations to to increase (Power and others 2010), allowing, pre- DNA sequences can result in modifications of gene sumably, for the mental and behavioral functional expression, which can cause changes in the brain and the repertoire of an adult to be substituted for that of a development of brain-based disorders. newborn. Yet, the brain is a highly open and modifiable • This change in the distribution of correlations may system—neuronal circuits, established early in life, be related to anatomical developmental changes in undergo remodeling as they develop their adult func- the brain: synaptic pruning (Huttenlocher 1979), tional properties in response to both genomic and envi- that is, the process of eliminating synapses connect- ronmental cues. This room for varying interpretations of ing different neurons. Synaptic pruning may be the a single genotype—that is, when the same genotype can driving factor substantiating the decrease in prox- exhibit different phenotypes in variable environments— imal correlations, whereas myelination (Paus and is referred to as plasticity. The capacity of the human others 2001)—the process of forming a myelin sheath brain to respond to the environment and its fluctuations around a nerve to allow nerve impulses to move more represents an adaptive system that allows individuals to quickly—may be the driving factor for the increase in better survive and reproduce. In other words, the brain, distal correlations. metaphorically, is the hub connecting the various infor- • Developmental increases in functional connectivity mation streams from the genome and the environome appear to be, at least in part, due to spontaneous that allows for the organism’s interpretations of and or orchestrated co-occurrences of activity (Lewis adaptations to genetic and environmental forces. and others 2009), namely, the co-activation of dif- ferent brain structures in the context of, for exam- ple, implicit or explicit learning, based on which Nutritional Requirements functional connections within the brain might be As the most metabolically active organ, the brain’s ade- established as new skills are acquired. quate balanced nutrition prenatally and postnatally is • Functionally different neural networks are thought to essential for its development and for the proper matu- have differential maturational courses. ration of the neural mechanisms substantiating child • Characteristics of functional networks have been development (Gómez-Pinilla 2008). Overwhelming associated in adulthood with indicators of intel- evidence demonstrates that malnutrition, especially lectual performance (van den Heuvel and others when severe, has significant and lasting implications for 2009) and executive control (Seeley and others development (Laus and others 2011). Malnutrition 2007). Although comparable data for children are slows the brain’s development, thinning the cerebral limited, a careful investigation of the developmental cortex and reducing the numbers of neurons, synapses, trajectories of brain functional networks in con- dendritic arborization, and myelination—all of which junction with other maturing systems—for exam- decrease brain size, which, in turn, challenges the ple, language, cognition, and self-regulation—might brain’s functional properties. Specifically, numerous enhance the understanding of human development cranial imaging studies of the brains of patients with as a systemic transformation of a maturing individ- protein energy malnutrition (for example, Atalabi and ual guided by the brain. others 2010) have demonstrated cerebral atrophy and 122 Child and Adolescent Health and Development ventricular dilation, which may lead to inadequate pat- Figure 10.2 Timeline of Major Human Neurodevelopmental terns of brain activity. Nutritional rehabilitation during Processes Based on Gene Expression Trajectories childhood and adolescence can reverse these effects, at 100 least partially. Gene expression (% of Similarly, adequate specific microelements are essen- 80 tial for developing brains. For example, both severe lack maximum) 60 of iodine and severe exposure to neurotoxins such as lead result in irreversible brain damage (Benton 2010). 40 An adequate concentration of vitamin A is essential for 20 the development of the visual system; levels that are too high or too low prenatally can be teratogenic (Reifen 0 and Ghebremeskel 2001). Moreover, complex dynamics m y y +y W CW 12 0 12 PC –2 20 1– 8P 0– occur among different vitamins; a prenatal imbalance 12 38 0– 8– between folate and vitamin B12 can increase the risk of Age postnatal insulin resistance, which is associated with poorer cognitive development (Yajnik and others 2008). Neocortex The differential developmental trajectories of the brain’s Cell proliferation features mean there are differential sensitive periods Progenitors and immature neurons when the violation of nutritional requirements is most Synapse development detrimental. Because the brain most rapidly develops Dendrite development prenatally and postnatally, these two periods are critical Myelination for subsequent outcomes. Yet, because brain develop- Sources: Adapted from Tebbenkamp and others (2014). The expression levels and trajectories are ment, although not as rapid as at the early stages of adapted from Kang and others (2011). development, does not slow down substantially until Note: m = months; PCW = postconceptional weeks; y = years. Expression trajectories of genes associated with major neurodevelopmental processes reflect the occurrence and progression of individuals reach their early 20s, microelement deficien- these processes in the human neocortex. cies and malnutrition are also important in middle childhood and adolescence. Specific strategies—such as salt iodization to prevent iodine deficiency, home fortification to prevent iron early life experience in general and parenting quality in deficiency, and food and specific micronutrient supple- particular (Kundakovic and Champagne 2015). There is mentation in food-insecure populations—have been a growing field of studies on socioeconomic neurogra- shown to be effective in preventing nutritional deficien- dients, defined as neural differences associated with cies. Yet, the research literature that qualifies and quanti- differences in SES (Schibli and D’Angiul 2013). For fies the impact of these strategies on brain development example, it has been demonstrated that low SES envi- is limited (Prado and Dewey 2014). ronments in general and poverty in particular influence the rate of human brain development (Hanson and others 2013). Specifically, children from lower SES envi- Environmental Experiences ronments differ in their gray matter accumulation in the Substantial evidence indicates that both gray and white frontal and parietal lobes, such that differences widen matter are susceptible to environmental perturbations throughout development as the exposure to impover- (Lupien and others 2009). Although the direction of the ished environments continues (figure 10.3). Of note is causality—from brain to behavior or from behavior to that volumetric brain differences are associated with the brain—is often unclear, it is indisputable that environ- emergence of disruptive behavioral problems (Hanson ment is a critical ingredient of change in the brain’s and others 2013). structure and function. For example, children who expe- Anatomical brain differences have also been associ- rienced severe exposure to air pollution in South Mexico ated with characteristics of prenatal and postnatal envi- City were reported to have prefrontal white matter ronments. For example, prenatal maternal stress is alterations and the precursors of Alzheimer’s disease associated with decreased dendritic spine density in (Calderon-Garciduenas and Torres-Jardon 2012). multiple brain areas (such as the hippocampus and the Two environments that contextualize brain develop- anterior cingulate and orbitofrontal cortex) substantiat- ment are particularly prominent: socioeconomic status ing emotional regulation (Murmu and others 2006). (SES), especially poverty (Hanson and others 2013), and Conversely, early maternal support postnatally is strongly Brain Development: The Effect of Interventions on Children and Adolescents 123 Figure 10.3 Brain Growth Trajectories, by Age and Socioeconomic Status a. Total gray matter b. Frontal gray matter 700,000 Frontal gray matter volume (cm3) 190,000 Total gray matter volume (cm3) 650,000 180,000 600,000 170,000 160,000 550,000 150,000 500,000 140,000 5 10 15 20 25 30 35 5 10 15 20 25 30 35 Age (months) Age (months) c. Parietal gray matter 130,000 Parietal gray matter volume (cm3) 120,000 110,000 100,000 90,000 5 10 15 20 25 30 35 Age (months) High SES Mid SES Low SES Source: Adapted from Hanson and others 2013. Note: SES = socioeconomic status; cm3 = cubic centimeters. predictive at school age of healthy development of the experience, for example, the maturation of binocular hippocampus, a brain region key to memory and stress vision modulation (Luby and others 2012). • Experience-independent. When changes in the brain occur spontaneously and override its initial structure and function, for example, the development of the Neuroplasticity lateral geniculate nucleus in the maturation of the The overriding principle of neuroplasticity is that behav- visual system ioral change is associated with a specific gain or loss of • Experience-dependent. When changes in the brain synapses within neuronal networks (Caroni, Donato, allow the acquisition of new behaviors, for example, and Muller 2012). Multiple factors differentiate the types all types of learning. of neuroplasticity in the typically developing brain (Kolb and Gibb 2014). Neuroplasticity is related to the relevance, frequency, Neuroplasticity can be characterized as follows: intensity, and sequences of experiences. It can be adap- tive, as in the acquisition of a new skill, or maladaptive, • Experience-expectant. When structural or func- as in the formation of a dependency or disorder. Of note tional changes in the brain require specific types of is that changes in the brain that result from the same 124 Child and Adolescent Health and Development environmental impact, such as injury, vary remarkably, family members (Pieterse 2015). In HICs, maltreatment depending on when in the developmental process the has been consistently shown to be detrimental to brain impact occurred. An experience can generate qualita- development (Painter and Scannapieco 2013). Given the tively different changes in different regions within the widespread opportunities for maltreatment in LMICs same brain. In addition, plastic changes themselves (Tomlinson, Cooper, and Murray 2005) due to early change over time; for example, the overproduction of pregnancies, large numbers of children in the same synapses in the early stages of development is reversed by home, high levels of poverty, and low levels of education, pruning in adolescence, which continues well into adult- it is extremely important to identify programs demon- hood. One of the most rapidly developing areas of strated to be effective and efficacious in HICs and trans- research pertains to the dynamics of infant and toddler portable, at least potentially, to LMICs. One such neuroplasticity in response to severe negative environ- program is the Nurse-Family Partnership (Olds and mental impacts, such as maltreatment (Graham and others 1997), which is being introduced to South Africa others 2015), and remediation, such as training of self- (Pieterse 2015). control (Berkman, Graham, and Fisher 2012). Language Development SKILL ACQUISITION AND CHANGES IN THE Language acquisition occurs during a sensitive period of brain development (Knudsen 2004). BRAIN The neural signatures of language acquisition are This section focuses on different behavioral loci associ- detectable at very early stages of development (Rivera- ated with brain changes that have been or can become Gaxiola, Silvia-Pereyra, and Kuhl 2005). These neural targets for specific public health interventions. Only four signatures, although themselves dynamically transform- selected loci are discussed here—early attachment, lan- ing, are highly predictive of numerous other indicators guage development, acquisition of literacy and numer- of child development, both linguistic and nonlinguistic. acy, and self-regulation (SR). However, children require several key elements to progress through the language acquisition process: Early Environment and Attachment • First, children need to be immersed in environments Substantial evidence demonstrates that atypical early in which they have high-frequency exposure to the development in which the presence of the attachment language because the mechanism thought to be most bond between children and significant others— used is statistical learning, which assumes an ongoing mothers, fathers, or primary caregivers—is disrupted exposure to language data so that linguistic mental is extremely detrimental for brain and behavior devel- representations can be inferred and automatized opment. One source of such evidence comes from (Saffran, Aslin, and Newport 1996). Yet, simple expo- research into orphanhood, when children are raised in sure to linguistic stimuli, no matter how intense, is institutions, often characterized by nutritional, physi- not enough. cal, stimulational (that is, cognitive, linguistic, and • Second, the motivation to learn language is social and emotional), and care deficiencies. Institutionally requires the presence of a social context for language reared children tend to be characterized by deviations acquisition (Kuhl 2007). The acquisition of language from typical brain development, in particular, a dis- engages and affects the computational and social tributed network of alterations in the white matter— areas of the brain. To master language, children both limbic and paralimbic pathways, frontostriatal capitalize on and enhance systems of cognitive and circuitry, and sensory processing pathways (for exam- social skills (Meltzoff and others 2009). Thus, the ple, Bick and others 2015). No comparable studies brain-behavior pathways that underlie and follow have been completed in LMICs; yet, the frequency of language acquisition are highly dynamic and future orphaned children in LMICs—given conflict zones, oriented as their properties predict subsequent steps child labor, deadly epidemics, and other maladies—is in child development (Pascoe and Smouse 2012; much higher than in HICs and, therefore, should be a Prathanee, Lorwatanapongsa, Makarabhirom, and priority for research. Wattanawongsawang 2010). Another source of such evidence comes from studies into the prevalence of childhood maltreatment in These conditions—statistical exposure and social LMICs. For example, it has been reported that 25 percent context—form appropriate targets for policies to enhance to 50 percent of young South Africans are maltreated by typical and to remediate atypical brain-behavior Brain Development: The Effect of Interventions on Children and Adolescents 125 development. Such policies, which have been developed remarkable convergence of multiple studies from differ- in HICs and are being introduced to LMICs, include the ent countries, including LMICs, specifying the impact of following: skill acquisition on brain structure and function. • Raising public awareness of atypical development Literacy (Mahmoud, Aljazi, and Alkhamra 2014) Literacy systems appear to involve brain areas substanti- • Promoting professional training of specialists able to ating early vision, script analysis, language analysis, and diagnose, remediate, and support individuals with their mutual associations (Dehaene, Morais, and developmental difficulties (Cheng 2010) Kolinsky 2015). Literate individuals have been reported • Facilitating early identification of developmental dif- to demonstrate numerous advantages, compared with ficulties (Glumbic and Brojcin 2012; Hamadani and illiterate individuals, in the speed and accuracy of pro- others 2010; Sidhu, Malhi, and Jerath 2010) cessing both letter-based and picture-based materials. • Advocating inclusive preschool education The specificity of reading as a skill distinguishing literate • Providing additional support to children with devel- and illiterate individuals is reflected by the fact that read- opmental language delays (Rakap 2015) and imple- ing recruits a specific brain area located in the left ventral menting specialized intervention programs (Amato occipito-temporal cortex to become a visual word form and others 2015; De Cesaro and others 2013; Erasmus area (VWFA)—an area that demonstrates specific, uni- and others 2013; Fernandes, De La Higuera Amato, and versal, and reproducible responses to script. The patterns Molini-Avejonas 2012; Fernandes and others 2014; of activation in the VWFA are correlated with the degree Kotby, El-Sady, and Hegazi 2010; Pascoe and others of mastery of reading. 2010; Prathanee, Lorwatanapongsa, Makarabhirom, It is important that adult plasticity in this area Suphawatjariyakul, and others 2010). underlies the ability to acquire print—the graphic rep- resentation of a spoken language—either in a first or in These systemic changes reflect the emerging emphasis subsequent languages. Also important is that the VWFA on early child care and education in LMICs in general is strongly connected, both structurally and function- and language development in particular because all are ally, to the brain areas that support spoken language. extremely important for brain development. The rele- Because reading assumes a conversion from vision to vant research accumulating in LMICs has replicated language, it requires activation of the language net- findings from HICs and reinforces the crucial signifi- work, or at least its component. Indeed, literate, com- cance of these systemic changes (Cheng 2010; Günhan pared with illiterate, individuals demonstrate increased 2011; Pascoe and Smouse 2012). and modified activation of the language-related cortical and subcortical network (in particular, the planum temporale [PT]—an area of the brain that supports, Literacy and Numeracy along with surrounding areas, the neuronal representa- Numerous studies have been conducted to isolate and tions of the consonants and vowels of spoken language) map the specific brain pathways or functional systems while engaged in specific language- and reading-related that support literacy (Dehaene and Cohen 2007) and tasks. This means that literacy acquisition not only numeracy (Butterworth and Walsh 2011). Clearly, the results in the creation of specific systems supporting acquisition of these skills is based on the use of existing reading, but also changes other systems supporting areas of the brain, which are reorganized structurally related functions, enhancing and automatizing them. and functionally while being recycled and recruited into To illustrate (figure 10.4), literacy enhances the connec- systems of acquisition (Dehaene and Cohen 2007). Large tivity between the ventral temporal lobe (including and growing fields of research are investigating the VWFA) and the inferior parietal and posterior superior impact of literacy and numeracy on brain functioning temporal regions (including PT) via enhanced myelina- by (1) conducting longitudinal tracking of children as tion. This strengthening may enable the automatization they move from preliteracy and prenumeracy stages into of the grapheme-to-phoneme conversion, crystalliza- stages of mastery, (2) comparing groups of literate and tion of reading skills, and subsequent development of numerate and illiterate and innumerate adults, and (3) related higher-order cognitive processes, such as read- comparing individuals with typical and atypical path- ing comprehension. Moreover, reading mastery has ways of acquisition for literacy and numeracy. Each of been shown to increase gray-matter density in several these approaches is associated with its own methodolog- regions of the brain that contribute to the establish- ical challenges, and limitations exist in the interpreta- ment and functioning of the brain system that supports tions of the relevant data and findings. Yet, there is a literacy. 126 Child and Adolescent Health and Development Numeracy Figure 10.4 Impact of Reading Acquisition: Enhanced Connectivity Although this field is considerably smaller than that of between PT and VWFA literacy studies, systemic findings include the following (Butterworth, Varma, and Laurillard 2011): FA of left arcuate posterior segment 0.50 * * * • Groups of multiple-duty neurons that respond to object dimensions such as space, time, object size, 0.48 and number appear to be located in the intraparietal cortex. • These neurons are part of an extensive distrib- 0.46 uted network given that, similar to literacy, numer- acy engages multiple processes such as early vision, 0.44 motor, spatial, and mnemonic functions. • Neuroimaging studies have converged on the intra- Illiterate Ex-illiterate Literate parietal sulcus (novel numeric operations) and the angular gyrus (previously learned numeric opera- Participants tions) as the loci of numeric processing. Source: Adapted from Dehaene, Morais, and Kolinsky 2015. • The intraparietal sulcus is viewed as the founda- Note: FA = fractional anisotropy; PT = planum temporale; VWFA = visual word form area. The structural link between the visual orthographic (VWFA) and the auditory phonological (PT) systems tional structure in the construction of numeric brain is enhanced with literacy: there is an increase in the FA in the posterior branch of the left arcuate networks; it demonstrates structural abnormalities fasciculus in literate and ex-illiterate (that is, individuals who learned to read in adulthood) relative in individuals with the developmental disorder of to illiterate participants. This increase in FA with literacy correlates with activation of the PT in response to spoken sentences. Error bars represent one standard error. mastering numeracy—dyscalculia—and changes in *p < 0.05; **p < 0.001. gray-matter density in expert mathematicians. Figure 10.5 Developmental Course of Brain Maturation The evidence that education in general and the acquisition of literacy and numeracy alter the brain Gonadal hormones structure and function comes primarily from HICs. The Change in brain development Synapses, relevant research in LMICs is focused predominantly on neuromodulators, documenting the manifestation of difficulties in acquir- neurotrophins, ing literacy and numeracy in different languages and cerebral blood flow, and metabolism societies (Pouretemad and others 2011), frequency of Myelination these difficulties (Ashraf and Najam 2014; Hsairi Guidara and others 2013; Jovanovic and others 2013), hs rs s s s 0 ar ar ar ea nt and the development of relevant intervention ye ye ye mo 5y 10 15 20 12 approaches (Lee and Wheldall 2011; Obidoa, Eskay, and Age Onwubolu 2013). Sensorimotor cortex Parietal and temporal association complex Self-Regulation Prefrontal cortex One of the ultimate goals of development is to master the skill of SR—goal planning, inhibition, mental flexi- Source: Adapted from Lee and others 2014. bility, sustained motivation, executive control, and self- Note: Behavioral attributes are paralleled by hormonal and neurobiological changes that target specific brain regions and cell populations (shown in shaded gray to capture the dynamic influences agency. SR is a critical element in the dynamic system of of hormones, various brain processes, and myelination). health and disease and the key to productive adulthood and successful aging. SR is supported by a distributed connectivity with other brain areas as it recruits them to brain system whose main task is to support the adequate substantiate the system of SR. appraisal of the system of demands of all relevant factors Specifically, the following changes peak in the adoles- on individuals and the subsequent formulation of cent brain (Luciana 2013): behavior to satisfy these demands. The executive load is developmentally uniquely intensified in adolescence, • A general thinning of the cortex and pruning in and corresponding changes occur in the brain subcortical structures (gray matter) and an increase (figure 10.5). These changes are related primarily to the in the volume and enhanced organization of brain maturation of the prefrontal cortex (PFC) and its connections (white matter) crescendo. This results in Brain Development: The Effect of Interventions on Children and Adolescents 127 increasingly efficient functioning within and across opportunities available in various environmental contexts, brain networks. including educational systems, public health policies, and • Heightened distinctions occur in regional brain vol- specific intervention programs. As knowledge of the umes, and functional brain responses to reward brain’s developmental trajectories accumulates, the extent intensify. of the brain’s modifiability, especially in response to tar- • Maturation of the PFC and the SR network requires geted interventions, will become clearer. This understand- exposure to key environmental experiences, such ing will help guide the development of intervention as positive incentive and reward. Such exposures approaches suitable for and most effective at the sensitive are particularly important in adolescence because periods of brain development that occur across the they are coupled with age-dependent experience- lifespan. expectant increases in dopaminergic tone (that is, the amount of distribution of the neurotransmitter dopamine) in the brain. NOTES Work on this essay was supported by NIH grants R01 Dopaminergic signaling—the engagement of HD085836 (Elena L. Grigorenko, PI) and P50 HD052120 dopamine-based reward systems, exposure to uncertain (Richard Wagner, PI). Grantees undertaking such projects are and risky environments, behavioral explorations, and encouraged to express freely their professional judgment. This independence seeking—contributes to the maturation chapter, therefore, does not necessarily reflect the position of the PFC and the related distributed system in general or policies of the abovementioned agency, and no official endorsement should be inferred. I am grateful to Eileen Luders and the cross-talk between subcortical (limbic) and cor- and Tuong Vi Nguyen for providing helpful comments on the tical (prefrontal) regions in particular. As consolidation manuscript, to Mei Tan for her editorial assistance, and to Janet through learning occurs, a brain system emerges whose Croog for preparing the figures. role is to support decision making based on calculations World Bank Income Classifications as of July 2014 are as of the probability and magnitude of risk and reward. follows, based on estimates of gross national income (GNI) Our current knowledge of the development of the per capita for 2013: brain systems substantiating SR, although largely empirically based rather than explanatory, suggests sev- • Low-income countries (LICs) = US$1,045 or less eral approaches for intervention. 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It also reflects earlier maternal nutrition because period as early adolescence (ages 10–14 years), late ado- appetite control, energy homeostasis, and the pubertal lescence (ages 15–19 years), youth (ages 15–24 years), axis are being developed in natal and early postnatal life and young adulthood (ages 20–24 years). Definitions (Soliman, De Sanctis, and Elalaily 2014). In childhood, of age groupings and age-specific terminology used in stunting (low height for age) and wasting (low weight this volume can be found in chapter 1 (Bundy and others for height) delay both overall growth and the onset of 2017). Worldwide, there are nearly 1.8 billion people ages puberty. In addition, girls born small for gestational age 10–24 years, constituting one-quarter of the total popu- are at risk for insulin resistance, premature pubarche, lation; 89 percent of young people (ages 10–24 years) live early menarche, and an attenuated growth spurt. Although in low- and middle-income countries (LMICs). increased adiposity is a normal physiologic process that Figure 11.1 shows some of the interactions of nutri- precedes puberty, early weight gains are linked to taller tion and development during the life course. Adolescent stature in childhood, with a probable increase in growth development is complex, with puberty, neurocognitive hormone, insulin-like growth factor, and future obesity, maturity, and social role transitions interacting in com- as well as a possible increase in hyperinsulinemia (Viner, plex ways, all with important consequences for nutrition. Allen, and Patton 2017, chapter 9 in this volume). Physical Growth and Mental Development Importance of Nutrition in Adolescence Growth failure and micronutrient inadequacy during Adolescence is a time of transition when habits are formed childhood and adolescence can delay growth and cre- that persist into adult life. Good habits, such as exercise ate high risk of chronic diseases in adulthood. Puberty and a healthy diet, are likely to bring many benefits, is accompanied by a growth spurt that increases the including improved performance in school (Doku and requirements for both macronutrients and micronu- others 2013). Nutritional habits are important, with high trients. These higher requirements are balanced by a intake of processed, energy-dense foods, high BMI, and more efficient use of protein for development rather iron deficiency among the top 20 risk factors of disability- than energy. For females, pubertal timing is affected by adjusted life years (DALYs) worldwide (WHO 2009). Corresponding author: Zulfiqar Bhutta, Aga Khan University, Karachi, Pakistan; zulfiqar.bhutta@aku.edu. 133 Figure 11.1 Nutrition and Related Risk Factors across the Continuum of Care Wasted or stunted Overweight or obese Fetal exposure to Preconception undernutrition or Eating disorder overnutrition Anxiety or depression Restricted intrauterine related to body image Adulthood growth Increased risk of chronic Poor pregnancy outcomes diseases such as diabetes, Prenatal or perinatal hypertension, and others Adolescence Low birth weight (1.8 billion) people ages 10–24 years Nutrition across the continuum of care Malnourished infant or School age child Infancy or early Overweight or obese childhood Overweight or obese Stunted or wasted Stunted Increased susceptibility to infections Increased susceptibility to Poor cognition, growth, infections and neurodevelopmental Poor school performance outcomes Such factors pose risks for later-life noncommunicable front of and viewing television, and skipping meals diseases, which are responsible for two of every three (especially breakfast). Environmental factors include deaths globally (Sawyer and others 2012). eating or buying food prepared outside the home, Most studies and guidelines on eating behavior are maternal education and employment, and parental diet from high-income countries (HICs). The 2010 U.S. (Moreno and others 2014). dietary guidelines for adolescents (ages 9–18 years), for Gender norms are often more harmful than benefi- example, suggest that girls require 1,400–2,400 calories cial with regard to nutrition and physical activity. Girls per day and boys require 1,600–3,200 because of their are exposed to a culture of overdieting and unhealthy typically larger frames and muscle mass. However, any weight loss more often than boys, and many believe that teenager involved in athletic physical activity can require exercise is unfeminine and that athletic women are mas- up to 5,000 calories per day (Caprio and others 1994). culine. Qualities encouraged in sports, such as strength, The available studies suggest that adolescents are dominance, and competition, are also considered unfem- becoming more independent in their food choices, more inine. Spencer, Rehman, and Kirk (2015) found that girls likely to be influenced by their peers, and less likely to prioritize body image over health. Dror and Allen (2014) pick healthy foods (Seymour, Hoerr, and Huang 1997). reviewed consumption of dairy products in developed Other factors that affect their overall nutrition include countries and found that girls consume less dairy than the kinds of foods available at home, amount of time recommended because they think it causes weight gain, available to make food (Venter and Winterbach 2010), and because their parents either do not consume dairy knowledge of food content (Li and others 2008), and or do not urge their children to do so, among other rea- ability to purchase snacks (Ahmed and others 2006). sons. Although the media, parents, and peers can foster Sociodemographic, behavioral, and environmental fac- negative images, they can also help introduce healthier tors are also linked to different patterns of adolescent approaches to weight control and nutrition (Spencer, nutrition. Sociodemographic factors include socioeco- Rehman, and Kirk 2015). nomic status, age, sex, location, and degree of urbaniza- This chapter discusses the evidence on nutrition for chil- tion. Behavioral factors include patterns of beverage dren ages six to nine years and for adolescents, including intake, portion sizes, dieting, family dinners, eating in undernutrition, overweight and obesity, micronutrient 134 Child and Adolescent Health and Development deficiencies, nutrition for pregnant adolescents, and eating Marshall, Burrows, and Collins (2014) have suggested disorders. Each section discusses the issue and then presents that dietary intake is generally inadequate for children evidence on the effectiveness of interventions to address it. and adolescents in LMICs (table 11.1), and adolescents Chapter 3 of this volume (Galloway 2017) discusses global do not fulfill their daily nutritional requirements. nutrition outcomes at ages 5 to 19. Furthermore, disparity is high among adolescents from lower socioeconomic profiles as compared with their wealthier counterparts. UNDERNUTRITION Statistics on undernutrition—including wasting, stunt- ing, anemia, and vitamin A deficiency—in children Prevalence of Undernutrition younger than age five years are well known, but data on Data on undernutrition in adolescents are underrepre- undernutrition specifically in adolescents are rare. In the sented in global databases, although some smaller studies least developed countries, the prevalence of adolescent report regional data. Among adolescents ages 10–14 underweight is 22 percent (UNICEF 2014) and is associ- years, protein energy malnutrition affects 12 girls per ated with various health risks. Undernutrition is linked 100,000 in Africa and 3 girls per 100,000 in the Eastern to lower gut immunity, decreased protective secretions, Mediterranean (WHO 2014). Matsuzaki and others and low innate and acquired immunity (Seidenfeld, (2015) studied 722 adolescents and young adults in Sosin, and Rickert 2004). India from 2003 to 2005 and found mean BMI of Undernourished adolescents have commonly expe- 16.8 kilograms/square meter in adolescents and rienced stunted growth in childhood. Undernutrition 19.3 kilograms/square meter in young adults. Thomas, in early life can result in fewer pancreatic cells that Srinivasan, and Sudarshan (2013) studied 409 students produce insulin. Although this deficit is compensated in rural India and found that 39 percent were thin (BMI for in adolescence, with stunted adolescents having below the 5th percentile for age) and 59 percent were more peripheral insulin receptors, this compensation stunted. Lopes and others (2013) studied 523 adolescents contributes to increased accumulation of fat (Rytter (ages 12–18 years) in urban Brazil and found that and others 2014). Stunted children, adolescents, and 9 percent were stunted and 24 percent were overweight, adults have higher rates of later arterial hypertension. with 36 percent of families having mild and 24 percent Undernutrition in childhood and adolescence also having moderate to severe food insecurity. Stunting was results in constant physiologic and psychologic stress, associated with low intake of calcium and iron, whereas increasing the production of stress hormones that food insecurity was associated with low intake of protein weaken the body and decreasing the production of and calcium. In a study of 23,496 students (ages 11–17 thyroid hormones and insulin-like growth factor that years) conducted in seven African countries (Benin, regulate growth. Djibouti, the Arab Republic of Egypt, Ghana, Malawi, Table 11.1 Dietary Intake of Children and Adolescents Study Findings Marshall, Burrows, and Most school-age children in LMICs eat plant-based foods, fewer than 50 percent consume dairy, breakfast is the Collins 2014 most often skipped meal, and consumption of processed foods is increasing. Doku and others 2013; In Ghana, 31 percent of those ages 12–18 years ate breakfast fewer than four days a week, 56 percent rarely ate Ochola and Masibo 2014 fruits, 48 percent rarely ate vegetables, and boys were more physically active than girls. Barugahara, Kikafunda, and In Uganda, girls ages 11–14 years achieved the World Health Organization daily requirements in the following Gakenia 2013 proportions: 30 percent for folate, 36 percent for energy, 54 percent for iron and riboflavin, 59 percent for protein, 61 percent for vitamin A, 89 percent for vitamin C, and 92 percent for fiber. Kawade 2012 In India, school-going girls (ages 10–16 years) were deficient in zinc, with 50 percent having cognitive impairments. Nago and others 2010 In Benin, adolescents (ages 13–19 years) received 40 percent of their daily diet from food prepared outside the home, accounting for 75 percent of their daily energy intake. Alam and others 2010 In Bangladesh, consumption of nonstaple good-quality food items within the last week were less frequent and correlated positively with the household asset quintile. Note: LMICs = low- and middle-income countries. Nutrition in Middle Childhood and Adolescence 135 Table 11.2 Summary Estimates of Effectiveness of Interventions for Undernutrition in Adolescence Study Intervention Outcome Creed-Kanashiro and others Nine-month intervention consisting of participatory training Anemia: RR, 0.32; 95% CI, 0.15 to 0.69 2000 with community kitchen leaders, educational materials, Iron deficiency: RR, 0.78; 95% CI, 0.37 to 1.63 increased access to heme iron (chicken liver and blood) in first five months Mann, Kaur, and Bains 2002 Iron (60 milligrams per day) as well as energy Hemoglobin: mean difference, −0.10; 95% CI, supplementation (in the form of pinnies to energy deficient −0.46 to 0.26 group for three months) Pinnies were prepared from whole wheat flour, semolina, whole soy flour, refined oil, sugar, whole milk powder, and crushed groundnut kernels in the rations. A 60 gram pinni provided 325 kilocalories. The subjects were supplemented with 1.5–3 pinnies according to their energy deficiency. Note: CI = confidence interval; RR = relative risk. Mauritania, and Morocco), Manyanga and others (2014) had a 34 percent (male) and 37 percent (female) chance found that almost 16 percent of girls and 25 percent of of being overweight at age 35 years. In Sub-Saharan boys were underweight. The highest prevalence of under- Africa, being overweight as a child has been linked to weight was found in males in Ghana (34 percent), and significant morbidity and mortality as an adult, with the lowest was found in females in Egypt (10 percent). higher BMI associated with type 2 diabetes, hyperten- sion, coronary heart disease (although this effect is not independent of the effect of high adult BMI), Interventions for Undernutrition asthma, polycystic ovary syndrome, and premature Numerous interventions involving food supplementa- mortality (Park and others 2012; Reilly and Kelly 2011). tion have been found to be effective in different age Furthermore, being above or below a healthy weight has groups, particularly in pregnant women to increase birth been linked to genetic and environmental factors such as weight. However, limited evidence is available for chil- maternal height, age, education, household size, and dren older than age five years and adolescents. In a study socioeconomic status (Keino and others 2014). on adolescents (ages 17–19 years) in Peru, Creed- While undernutrition—especially stunting—continues Kanashiro and others (2000) found that a nine-month to be a severe problem, particularly in LMICs, the increas- intervention including participatory training, educa- ing global trend in child overweight and obesity is alarm- tional materials, and increased access to heme iron in the ing because countries have to programmatically deal with first five months reduced anemia. Mann, Kaur, and Bains the double burden of disease. In rapidly developing and (2002) supplemented the diet of anemic girls ages urbanizing societies, diets are becoming more energy 16–20 years in India for three months and found no dense and processed, yet lacking in fiber and multivita- difference in hemoglobin levels between those consum- mins, while lifestyles are becoming more sedentary ing adequate and those consuming inadequate calories (Popkin 1994). In LMICs, the concern is really the expo- (table 11.2). sure to the nutrient mismatch: starting out with poor fetal nutrition or low birth weight and being overweight in early adulthood, in parallel with the nutrition transition OVERWEIGHT AND OBESITY (Adair and Cole 2003; Borja 2013). The role of fetal and Obesity and overweight are consequences of excess food early childhood development in establishing risk for intake, often combined with genetic factors. Childhood noncommunicable disease is discussed in detail in obesity and overweight have been linked to severe obe- Disease Control Priorities, third edition (DCP3), volume 5, sity in adulthood, with a stronger effect on men. Being chapter 6 (Afshin and others 2017), while the policies for overweight as an adolescent is strongly associated with addressing unhealthy diet and obesity as risk factors for obesity as an adult (Ferraro, Thorpe, and Wilkinson disease are discussed in Mozaffarian and others (2011), as 2003). Guo and others (1994) found that white adoles- well as in DCP3 volume 5, chapter 5 (Bull and others cents (age 18 years) with a BMI above the 60th percentile 2017) and chapter 7 (Malik and Hu 2017). 136 Child and Adolescent Health and Development Declining physical activity may also be a factor in to almost 13 percent, sedentary activity increased from increasing childhood overweight and obesity. In 85 coun- 2.2 hours to 3.1 hours per day, and energy intake tries, no more than 50 percent of boys or girls partici- decreased 19 percent (Seo and Niu 2014). Manyanga and pated in 60 minutes or more of physical activity per day, others (2014) studied overweight and obesity in students with the Middle East and North Africa having the lowest ages 11–18 years in seven African countries and found ratios for girls (Patton and others 2012). These changes that 23 percent of girls were overweight and 4.5 percent are accompanied by growth that favors urban over were obese, compared with 18 percent and 3 percent, rural areas, with the result that overweight and stunted respectively, of boys. The highest rates of overweight in populations reside in the same country (Popkin 1994; females were in Mauritania (36 percent) and Djibouti Tzioumis and Adair 2014; Usfar and others 2010). This (9 percent); the lowest rates of overweight in males duality can also be found within the same household or were in Ghana (7 percent) and Benin (0.3 percent). In even the same person: when energy-dense food is being Indonesia, 6 percent of children ages 6–14 years and consumed in a household, an adult could gain weight but 19 percent of those ages 15 years and older were over- be deficient in micronutrients, while a child could lack weight or obese (Usfar and others 2010). Ogden and adequate calories and nutrients and fail to grow appropri- others (2006) found equally high rates in HICs. ately (Tzioumis and Adair 2014). Interventions for Overweight and Obesity Prevalence of Overweight and Obesity Interventions to prevent obesity (lifestyle modification) Worldwide, from 1980 to 2013, the prevalence of over- have been found to yield positive results such as lower weight and obesity combined has risen by 27 percent blood pressure (Cai and others 2014). However, most of for adults and 47 percent for children (ages 2–19 the studies are from HICs. Waters and others (2011) years) to 37 percent and 13 percent, respectively (Ng found that interventions focusing on nutritional aware- and others 2014). Overweight and obesity increased in ness, increased physical activity, and better-quality diets both LMICs and HICs during this period, increasing significantly lowered BMI in children ages 6–12 years. to 23 percent from 16 percent for girls and to 24 The strongest impact was found for interventions percent from 17 percent for boys in HICs, and to 13 focusing on diet and physical activity that were con- percent from 8 percent for girls and boys in LMICs. In ducted in community and school settings (Bleich LMICs, the highest obesity rates are in the Middle East and others 2013). Lobelo and others (2013) reviewed and North Africa, certain Pacific Islands, Caribbean technology-based interventions, such as web-based nations, Chile, Costa Rica, Mexico, and Uruguay (Ng programs, e-learning, and active video games, for and others 2014). healthy weight management and obesity prevention In Latin America and the Caribbean, between 16.5 mil- and found positive effects on diet, physical activity, and lion and 21.1 million adolescents (ages 12–19 years) were psychosocial functioning (table 11.3). overweight or obese from 2008 to 2013 (Rivera and oth- Interventions to manage obesity include methods that ers 2014). In China, from 2004 to 2009, the prevalence of seek to impart awareness about healthy nutrition overweight in boys ages 12–18 years rose from 7.5 percent and physical activity, behavioral therapy, and use of Table 11.3 Summary Estimates of Effectiveness of Interventions for Obesity in High-Income Countries Study Intervention Outcome Obesity prevention: Health promotion and education or counseling on diet, BMI: SMD, −0.05 (−0.11, −0.01); 16 studies, Bhutta and Lassi 2016 physical activity, lifestyle support, and dietary advice N = 14,912 Obesity management: Counseling on diet, physical activity, lifestyle support, and BMI at 6 months follow-up: SMD, −3.02 (−5.08, Bhutta and Lassi 2016 dietary advice −0.22); 4 studies, N = 362 Obesity management: Randomized, parallel-group trial with a low-fat or low- Participants with a low-carbohydrate diet had Bazzano and others 2014 carbohydrate diet, with dietary counseling a −3.5 kg (95% CI, −5.6 to −1.4 kg) decrease in weight compared with a −1.5% (95% CI, −2.6% to −0.4%) decrease among participants with a low-fat diet at 12 months Note: BMI = body mass index; CI = confidence interval; kg = kilogram; SMD = standardized mean difference. Nutrition in Middle Childhood and Adolescence 137 medicine (orlistat, sibutramine, and metformin) or sur- Prevalence of Micronutrient Deficiencies gery. Such interventions have been found to decrease Iron deficiency anemia is one of the top five causes of overweight in children and adolescents. Behavioral inter- years lost to disability (YLDs) and accounts for nearly 50 ventions lasting 12 months had the most effect on percent of total YLDs for adolescents (ages 10–19 years). decreasing BMI, followed by behavioral interventions It is the top cause of YLDs in boys and girls ages 10–14 combined with medicine (Whitlock and others 2010). years in South-East Asia and in boys in the Americas When combined with healthy lifestyle counseling, nutri- (WHO 2009). For 13,113 young people in the Islamic tional interventions were found to improve school per- Republic of Iran, older adolescents (ages 14–17 years) formance, with increased physical activity linked to had lower than recommended intake of vitamin A, cal- improved function, memory, and mathematics achieve- cium, and phosphorus; younger adolescents (ages 11–16 ment (but not to reading, vocabulary, and language years) had lower than recommended intake of zinc, cal- achievement); attention; inhibitory control; or simulta- cium, phosphorus, magnesium, and folate; and young neous processing (Martin and others 2014). For severe adults (ages 18–28 years) had lower than recommended obesity, behavioral and surgical interventions were found intake of folate, iron, and calcium (Akbari and Azadbakht to lower BMI and improve functioning in adolescents, 2014). In China, children younger than age 18 years were but surgery outperformed behavioral therapy for at least found to be deficient in vitamins A, B12, and K, as well two years of follow-up (Ells and others 2015). as in iodine, iron, selenium, zinc, and calcium (Akbari and Azadbakht 2014). Children and women, including adolescent girls in resource-poor conditions, are espe- MICRONUTRIENT DEFICIENCIES cially vulnerable. Wong and others (2014) found lower Adolescents need more nutrients than adults because than recommended intake of vitamins C and A and they gain at least 40 percent of their adult weight riboflavin in Asia, vitamin B6 in Africa, and folic acid in and 15 percent of their adult height during this all regions studied. However, in Latin America and the period. Inadequate intake can lead to delayed sexual Caribbean, the intake of vitamins A, C, B6, and ribofla- development and slower linear growth (Jacob and vin was higher than recommended. Nair 2012). Cognitive growth also depends on micronutrients; B complex vitamins are important in neural communi- Interventions for Micronutrient Deficiencies cation, and their absence leads to depression (Black Many children and adolescents have a micronutrient- 2008). Vitamin B12, folate, and thiamine are important deficient diet, and appropriate nutrient supplements are for neural pathways, and deficiency has been linked to needed. Nutrients can be provided via tablets, powders impaired episodic memory and language issues (Black sprinkled on food or mixed in water, and fortified spreads 2008). Iron is required for oligodendrocyte growth and or snacks. Such foods need to have adequate amounts of neurotransmitter production, and deficiency affects energy and micronutrients, taste good, be clean and cognition, memory, and social and motor development hygienic, and have a long shelf life (Nestel and others (Fretham, Carlson, and Georgeiff 2011). Iodine is 2003). There is some indication that supplementation is involved in structural development, and its absence helpful for healthy children. Multiple-micronutrient sup- causes mental retardation (Kapil 2007). Zinc is found in plementation has been associated with a marginal the forebrain and hippocampus, and its deficiency is increase in fluid intelligence and improved academic linked to impaired attention, learning, and memory, as performance; however, more research is needed (Eilander well as to possible development of neuropsychological and others 2010). diseases (Nyaradi and others 2013). Given the persistence of iron-deficiency anemia, vita- Studies have found inconsistent impact of micronu- min A deficiency, and iodine deficiency, food fortification trient supplementation on children ages 5–15 years in (iron and iodine in salt), diet modification, and public LMICs (Khor and Misra 2012). Iron has been shown to health and disease control measures (deworming and affect weight and mid-arm circumference in children malaria nets) may be needed (Ahluwalia 2002). In older older than age six years (Vucic and others 2013). populations, studies have not supported the use of anti- Vitamin D has been linked to a healthy lipid profile, oxidant vitamins or mineral supplements (Dangour, with higher levels associated with low triglycerides and Sibson, and Fletcher 2004). However, in children, adoles- low total cholesterol, including good ratios of low- to cents, and women, iron supplementation has been found high-density cholesterol (Kelishadi, Farajzadegan, and to increase attention, concentration, and intelligence Bahreynian 2014). (Falkingham and others 2010). In children younger than 138 Child and Adolescent Health and Development Table 11.4 Summary Estimates of the Effectiveness of Micronutrient Interventions Study Intervention Outcome Bhutta and Lassi Daily iron supplementation Anemia: RR, 0.60 (0.42, 0.86); 1 study, N = 238 2016 (adolescents) Weekly iron and folic acid supplementation Anemia: RR, 0.46 (0.23, 0.94); 4 studies, N = 852 Vitamin A supplementation Anemia: RR, 0.73 (0.56, 0.93); 1 study, N = 138 Calcium supplementation BMD change: MD, 1.09 (−0.15, 2.33); 1 study, N = 53 BMD change of hip after one-year supplementation: MD, 1.09 (−0.15, 2.33); 1 study, N = 53 BMD change of hip after one-year supplementation: MD, 1.17 (−0.45, 2.79); 1 study, N = 53 Mean birth weight: SMD, 0.47 [−0.17, 1.10]; 2 studies, N = 307 Vitamin D Serum 25 hydroxy vitamin D (OH)D levels at three years: MD, 8.8 (−2.68, 20.28); 2 studies, N = 588 Zinc supplementation Hemoglobin: SMD, 4.81 (0.47, 8.66); 2 studies, N = 494 Serum zinc: SMD, 4.28 (2.49, 6.06); 3 studies, N = 805 Iodine supplementation Thyroid-stimulating hormone: MD, 0.30 (−0.06, 0.66); 1 study, N = 47 Multiple micronutrients Anemia: RR, 0.95 (0.76, 1.18); 1 study, N = 113 Note: BMD = bone mineral density; MD = mean difference; RR = relative risk; SMD = standardized mean difference. age 18 years, calcium supplementation had a small posi- Overall, stunting is a strong indicator of lower human tive effect on total body and upper-limb bone mineral capital (WHO 2016b). density (Winzenberg and others 2006), but it did not Adolescent girls are vulnerable to malnutrition sec- lower the risk of fracture (Falkingham and others 2010). ondary to the potential for pregnancy and socioeconomic In pubertal girls, calcium supplementation was associ- adversity. Approximately 16 million girls ages 15–19 years ated with increased bone mass during 18 months of give birth each year, accounting for 11 percent of total intervention (Teegarden and Weaver 1994). Iodine sup- births and 23 percent of DALYs attributable to pregnancy plementation via salt was found to decrease the risk of and childbirth worldwide (WHO 2016a). Half of all goiter, cretinism, low intelligence, and low urinary iodine births in this age group occur in seven countries: excretion (Aburto and others 2014). More evidence is Bangladesh, Brazil, the Democratic Republic of Congo, needed on supplementation for adolescents (table 11.4). Ethiopia, India, Nigeria, and the United States. Early preg- nancies have significant health, social, and economic repercussions; 10 percent of all maternal deaths occur in NUTRITION FOR PREGNANT ADOLESCENTS adolescents, and 20 countries with the most adolescent Nutrition for adolescents is important given that risk of maternal deaths account for 82 percent of all maternal preterm birth, low birth weight, asphyxia, stillbirth, and deaths (Verguet and others 2017, chapter 28 in this neonatal death are higher in adolescents than in young volume; WHO 2016a). The risk of maternal mortality is adults (ages 20–24 years) (WHO 2016a). Fall and others higher in adolescents than in young adults ages 20–24 (2015) analyzed five longitudinal studies from Brazil, years, and 14 percent of all unsafe abortions occur in Guatemala, India, the Philippines, and South Africa and adolescents (Nove and others 2014). Pregnant adolescents reported links between maternal and child undernutri- are more likely to leave school; poorer and less educated tion. They also reported adverse health outcomes in adolescents are more likely to become pregnant (Nove adults, including shorter height; less schooling; lower and others 2014), which can result in transgenerational income or assets; lower–birth weight offspring; higher socioeconomic disadvantage (WHO 2007). Maternal BMI; and harmful glucose concentrations, lipid profiles, malnutrition; micronutrient deficiency; obesity; gesta- and blood pressure. Undernutrition and low birth weight tional diabetes mellitus; and use of alcohol, tobacco, and are further linked with some cancers and mental illnesses. psychotropic drugs affect mothers and their babies. Nutrition in Middle Childhood and Adolescence 139 Impaired fetal growth, more common in adolescent preg- Belizan, and von Dadelszen 2014). The WHO recom- nancies, has been linked to adult diabetes (Sawyer and mends iodine intake of 250 micrograms per day for others 2012). pregnant women in iodine-deficient-endemic areas (Zimmermann 2009). Protein energy supplementation has been found to Interventions during Pregnancy affect pregnant women in general, especially if they Interventions for gestational diabetes mellitus in preg- are undernourished. This intervention increases mean nant women have mixed results. Lassi and Bhutta (2015) birth weight and decreases the risk of low birth weight, found that healthy diet, increased physical activity, and small-for-gestational-age births, and stillbirths (Imdad strict glycemic control reduced the risk of gestational and Bhutta 2012). Again, no studies have been con- diabetes, decreased adiposity, and improved pregnancy ducted specifically on adolescent mothers. For the outcomes in adolescents and women. However, Yin and majority of micronutrients, evidence could not be found others (2014) found no significant impact of physical on adolescent populations; therefore, this is an area of activity on the risk of gestational diabetes. Mohd Yusof research for countries where adolescent pregnancy is still and others (2014) found no significant change in the risk common. of gestational diabetes with similar interventions, but they did find an association between earlier initiation of EATING DISORDERS intervention and underweight babies. Behavioral ther- apy added to standard antenatal care can lead to lower The American Psychiatric Association (2013) defines an gestational weight gain—a risk factor for gestational eating disorder as a continuous disturbance of food con- diabetes—in obese women without comorbid condi- sumption that leads to either a different pattern of eating tions (Mohd Yusof and others 2014). These studies or different absorption of food and can cause significant do not provide evidence specifically for adolescent physical or psychological complications. Disorders such mothers. as anorexia nervosa, bulimia nervosa, and binge-eating Many studies have found that micronutrient supple- disorder cause nutritional problems including decreased mentation during pregnancy is beneficial. Daily iron growth, impaired weight gain, and poor oral health supplementation increases mean birth weight and (Gonçalves and others 2013). Eating disorders at younger decreases the risk of low-birth weight babies, and ages (11–17 years) have been linked to eating disorders, preventive iron supplementation decreases the risk of overweight, and depression at later ages (17–23 years) maternal anemia and iron deficiency at term (Pena- (Gonçalves and others 2013). Rosas and others 2012). An intermittent regimen of iron Anorexia is defined as low self-esteem and a fear of and folic acid supplementation has been found to be as gaining weight; anorexic individuals are frequently severely efficacious as a daily regimen, but with fewer side effects underweight and amenorrheic (Seidenfeld, Sosin, and (Fernandez-Gaxiola and De-Regil 2011). No studies Rickert 2004). Anorexia can severely impair bone health, have specifically studied supplementation in pregnant reduce physical and sexual growth, cause hormonal dys- adolescents. function, affect cognitive development, and predict future Folic acid supplementation during pregnancy helps psychological disease (Donaldson and Gordon 2015; prevent neural tube defects (De-Regil and others Seidenfeld, Sosin, and Rickert 2004). Mortality from 2010). It has also been found to decrease the incidence anorexia is 12 times higher than mortality from any other of megaloblastic anemia and increase mean birth cause for American women ages 15–24 years (Herpertz- weight (Lassi and others 2013). The evidence for Dahlmann, Bühren, and Seitz 2011). Bulimia is defined by vitamin A is mixed. Vitamin A decreases the risk of episodes of binge eating followed by purging through anemia, improves hemoglobin levels during preg- forced vomiting or abuse of diet pills or laxatives and by nancy, and improves birth weight for women with compensating through excessive exercise (Seidenfeld, human immunodeficiency virus, but it has no effect on Sosin, and Rickert 2004). Adolescents with bulimia have other outcomes in pregnant women or infants higher suicidal ideation (53 percent of sample) than those (Thorne-Lyman and Fawzi 2012). Zinc fortification with no psychopathology (4 percent) (Sullivan 1995). increases zinc serum levels and may improve growth Although the majority of the evidence is from (Das and others 2013). Vitamin D supplementation HICs, similar patterns have been reported in upper- increases serum levels (Ota and others 2015). Calcium middle-income countries. Girls are exposed to risk supplementation in both high- and low-dose regimens factors beginning in early adolescence. Peer pressure to reduces hypertensive disorders during pregnancy and be thin, thinness as the ideal body image, and dissatis- preterm births and increases birth weight (Hofmeyr, faction with current body type can increase the chances 140 Child and Adolescent Health and Development that adolescents will develop eating disorders (Crow anorexia. Newer or not well-established therapies include and others 2014). Adolescent girls who binge eat have family treatment behavior and supportive individual ther- high functional impairment and comorbid mental apy for bulimia and Internet-delivered cognitive behav- health problems. This behavior, along with weight con- ioral therapy for binge-eating disorder (Dobbins and cerns and other behaviors to control weight, were others 2013). It is impossible to compare effectiveness found to be associated with higher BMI two years later because studies use different methods to measure in teen girls in the United States (Rohde, Stice, and outcomes. Marti 2015). Perhaps partly as a result of peer pressure in early adolescence, eating disorders develop most commonly in middle and late adolescence (Portela and CONCLUSIONS others 2012). Malnutrition in adolescence has been a neglected area of research and programming globally. The evidence for Prevalence of Eating Disorders effective interventions to address nutritional problems in LMICs is particularly weak. In particular, proven In 2010, 193.9 million DALYs were attributable to sub- effective responses for stunting, overweight and obesity, stance abuse and mental disorders (7.4 percent of all and micronutrient deficiencies are not yet available. DALYs). Eating disorders accounted for 1.2 percent of From HICs, there is some evidence on interventions for DALYs attributable to mental and substance abuse. The eating disorders and obesity, although much further highest amount of DALYs were reported in persons ages work is needed in these settings as well. 10–28 years. In the United States, up to 30 million peo- Yet there is an emerging double nutritional threat ple suffer from eating disorders, with 86 percent of suf- to child and adolescent health in LMICs. To reduce ferers reporting onset before age 20 years and 43 percent deficiency-related malnutrition while preventing over- at ages 16–20 years (Whiteford and others 2013). weight and obesity, integrated adolescent health programs Multiple studies from the United States found that eat- are needed that prevent infection, improve diet quality, ing disorders were prevalent in 3.6 percent of adoles- and encourage physical activity. Although the double bur- cents and that 63 percent of these individuals had den of nutrient deficiency, coupled with overweight and comorbid psychiatric disorders as well (Stice, Marti, and obesity, is increasing in LMICs, policies in most countries Rohde 2013); lifetime prevalence was 13 percent (Smink focus almost exclusively on undernutrition in multiple and others 2014). For a Dutch cohort of adolescents forms; only a few countries have implemented national ages 11–19 years, Smink, van Hoeken, and Hoek (2012) policies to prevent obesity. In view of the rapidly growing found that lifetime prevalence was 1.7 percent for number of adolescents who are overweight or obese, the anorexia, 0.8 percent for bulimia, and 2.3 percent for detrimental effects of obesity on health, and the costs to binge-eating disorder in women; these disorders were health care systems, programs to monitor and prevent rare for men. In the Islamic Republic of Iran, the preva- unhealthy weight gain in children and adolescents are lence of diagnosed eating disorders was 0.25 percent. urgently needed (Lassi and others 2015). Boys and girls scored much lower on the eating disorder examination questionnaire when compared with previ- ous studies from Western countries (Nakai and others NOTE 2015). 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Nutrition in Middle Childhood and Adolescence 145 Chapter 12 School Feeding Programs in Middle Childhood and Adolescence Lesley Drake, Meena Fernandes, Elisabetta Aurino, Josephine Kiamba, Boitshepo Giyose, Carmen Burbano, Harold Alderman, Lu Mai, Arlene Mitchell, and Aulo Gelli INTRODUCTION from high-income countries (HICs) is included because Almost every country in the world has a national school of the near universality of school feeding and the insights feeding program to provide daily snacks or meals to that inclusion can provide as economies develop. For school-attending children and adolescents. The interven- example, the design of school feeding in countries under- tions reach an estimated 368 million children and ado- going the nutrition transition1 may provide some lessons lescents globally. The total investment in the intervention on how to shift from providing access to sufficient calo- is projected to be as much as US$75 billion annually ries to promoting healthful diets and dietary behaviors (WFP 2013), largely from government budgets. for children and adolescents (WFP 2013). School feeding may contribute to multiple objectives, Agricultural development has increasingly gained including social safety nets, education, nutrition, health, attention. It is clear that to enable the transition to sus- and local agriculture. Its contribution to education tainable, scalable government-run programs, the inclu- objectives is well recognized and documented, while its sion of the agricultural sector is essential (Bundy and role as a social safety net was underscored following the others 2009; Drake and others 2016). Accounting for food and fuel crises of 2007 and 2008 (Bundy and others the full benefits of school feeding through cost- 2009). In terms of health and nutrition, school feeding effectiveness and benefit-cost analysis is challenging, contributes to the continuum of development by build- similar to other complex interventions, but undertaking ing on investments made earlier in the life course, this accounting is critical for assessing the tradeoffs with including maternal and infant health interventions and competing investments. early child development interventions (see chapter 7 in This chapter reviews the evidence about how school this volume, Alderman and others 2017). School feeding feeding meets these objectives and provides some indi- may also help leverage global efforts to enhance the cation of costs in relation to benefits. The costs of the inclusiveness of education for out-of-school children, intervention are well established; estimates that adolescent girls, and disabled persons, as called for in the encompass all the benefits of school feeding are more Sustainable Development Goals (see chapter 17 in this challenging. The benefits must be quantified and volume, Graham and others 2017). translated to the same unit to allow for aggregation. Although the Disease Control Priorities series focuses Moreover, how school feeding interventions are on low- and middle-income countries (LMICs), evidence designed and implemented varies significantly across Corresponding author: Lesley Drake, Partnership for Child Development, Imperial College London, United Kingdom; lesley.drake@imperial.ac.uk. 147 countries. Given that delivery of school feeding often others 2016). Brazil’s national program, the next largest, involves multiple sectors, common policy frameworks provides daily meals to more than 43 million children and cross-sectoral coordination are required to achieve (Drake and others 2016). China’s National Nutrition maximum benefit (Bundy and others 2009). Improvement Plan provided school meals to 33.5 million Several other chapters in the volume highlight school children ages 7–15 years across China in 2015 (Liu 2016). feeding. These include chapter 11 (Lassi, Moin, and School feeding interventions, most notably imple- Bhutta 2017), chapter 20 (Bundy and others 2017), mentation modalities of delivery, vary across countries. chapter 22 (Plaut and others 2017), and chapter 25 School feeding may include hot meals, biscuits, or (Fernandes and Aurino 2017). snacks provided in school or as take-home rations, where the households of schoolchildren receive a regu- lar commodity ration on meeting conditions, such as regular attendance. School feeding programs vary in THE GLOBAL PICTURE targeting. School meals may be provided free and at Almost all countries practice school feeding (Bundy and reduced, subsidized, or full price. Countries that follow others 2009); about one of three primary and lower- a rights-based approach, such as Brazil and India, pro- secondary schoolchildren benefit, although the number vide free school meals to all children in certain age of children varies markedly across countries (figure 12.1). groups. In most LMICs, however, free school meals are Approximately 18 percent of schoolchildren in low- targeted geographically to areas with high prevalence of income countries (LICs) received school meals in 2012, food insecurity and poverty, or individually, based on compared with 49 percent in upper-middle-income conditions of vulnerability, such as those in orphanages countries (WFP 2013). On the basis of global estimates or disadvantaged households (WFP 2013). of coverage and investment, the authors estimate that an School feeding programs have evolved with levels of additional investment of US$1.7 billion is needed to sup- development. Many HICs, such as the United States, port the increase in program coverage in 23 LICs to the introduced school feeding programs in the first half of levels of upper-middle-income countries—the equiva- the twentieth century as welfare interventions and to lent of 2 percent to 3 percent of total global investment support agricultural markets. More recently, countries in school feeding and a 10 percent increase in total bene- such as Brazil have systematically incorporated school ficiaries.2 India’s Mid-Day Meal Scheme is the largest feeding procurement with agriculture development national school feeding program in the world, serving an interventions. In contrast, national school feeding pro- estimated 113.8 million children each day (Drake and grams in many LMICs were introduced more recently, Figure 12.1 School Feeding Participation Worldwide a. Composition of school-age children, by school b. Composition of school-age children, by school enrollment, school enrollment and school meals receipt meals receipt, and country income group 121 million, 100 11% 90 80 368 million, 70 32% 60 Percent 50 40 30 653 million, 20 57% 10 0 Low Lower middle Upper middle High All income groups Out-of-school children Out-of-school children Enrolled, but receiving no school meals Enrolled, but receiving no school meals Enrolled and receiving school meals Enrolled and receiving school meals Sources: UNESCO 2014; World Bank 2016. Note: Primary and lower-secondary schoolchildren only. 148 Child and Adolescent Health and Development with education as the primary objective (Bundy and a social protection tool that can contribute to educa- others 2009) or as a means of social protection in face of tion, nutrition, health, and agricultural objectives crises, given that experience has shown they are relatively supporting child and adolescent development (Bundy easy to scale up during emergencies (Alderman and and others 2009; Jomaa, McDonnell, and Probart Bundy 2011). From 2000 to 2012, at least eight LICs 2011). Figure 12.2 presents ways school feeding can launched school feeding programs—six in Sub-Saharan affect these outcomes. Homegrown school feeding may Africa—within the broader framework of the Education also contribute to agricultural development, but not for All agenda (WFP 2013). Some of this growth may be enough evidence exists yet to be incorporated in this due to the inclusion of homegrown school feeding, an review, although box 12.1 presents specific examples. approach that sources foods for school meals from local producers or markets, under the food security pillar of the Comprehensive Africa Agriculture Development Design and Implementation Issues Programme of 2003 (NEPAD 2003). The number of Characteristics such as age, gender, and level of disadvan- homegrown school feeding programs has grown steadily tage may modify the strength of some of these pathways in Sub-Saharan Africa since that time (GCNF 2014). (Kristjansson and others 2009). Moreover, external fac- tors, such as the quality of school inputs, may confound the overall impact of school feeding (Adelman, Gilligan, THE EVIDENCE FOR EFFECTIVENESS and Lehrer 2008; Greenhalgh, Kristjansson, and Robinson This section reviews the large evidence base highlight- 2007; Kristjansson and others 2009; chapter 22 in this ing the effectiveness of school feeding for multiple volume, Plaut and others 2017; Watkins and others 2015). outcomes. The evidence suggests that school feeding is Intervention implementation and study design may also Figure 12.2 School Feeding Pathways to Shaping Child and Adolescent Development School feeding School participation Income transfer Energy, macro-, and micronutrient availability Child labor supply Micronutrient intake Dietary Illness and Activity level Attendance and and status behaviors morbidity and type enrollment Household food availability Learning Retention or drop-out Physical growth and health status Educational Cognitive ability attainment Education sector inputs Source: Adapted from Adelman, Gilligan, and Lehrer 2008. School Feeding Programs in Middle Childhood and Adolescence 149 Box 12.1 Homegrown School Feeding: Supporting Local Agriculture The O’Meals program in Nigeria (Osun State Recently, the menu replaced yam with the more- Elementary School Feeding and Health Programme) nutritious cocoyam, and organizers are investigating is viewed as a means to combat hunger, increase pri- the introduction of orange-fleshed sweet potato mary school enrollment, and encourage local and (Drake and others 2016). statewide economic growth. The program provides hot, nutritionally balanced school meals daily to In Ghana, preliminary evidence from an impact more than 252,000 primary schoolchildren. At the evaluation of homegrown school feeding suggests same time, it provides employment and income sizable gains with regard to income from sales of to thousands of local caterers, farmers, and trad- produce and increases in farming households’ agri- ers, which may indirectly improve their health. cultural incomes (Aurino and others 2016). School Meal Planner, Ghana Monday Yam + fish stew + orange Tuesday Rice + beans + stew + chicken + orange Wednesday Bean porridge + bread + whole egg + banana Thursday Rice + egusi garnished with vegetable + chicken + banana Friday Cocoyam porridge + vegetable + beef + slice of paw paw Source: Drake and others 2016. affect the results. The key issues that can be reflected in the Programme (WFP), which may be considerably differ- process indicators include consistency of implementation ent. For example, WFP school feeding rations typically of the intervention over the entire study period, compli- include a basic set of foods, such as multifortified corn- ance of beneficiaries with the intervention, adequacy of soy blend, sugar, and salt, which are internationally pro- energy transferred, duration of the study, and palatabil- cured, in contrast with the rations presented in table 12.1. ity (Greenhalgh, Kristjansson, and Robinson 2007). To illustrate this point, table 12.1 presents a selec- Benchmarking School Feeding Programs across tion of parameters for nationally led school feeding Countries programs in 15 countries (Drake and others 2016). Ration design is key, particularly for assessing the School feeding programs across countries can be bench- quality of the meals and the potential link to local marked using the Systems Assessment for Better Education agriculture. The number of school days may enhance Results (SABER) tool, which is structured around five the nutritional impact of school feeding, as well as the pillars (Bundy and others 2009; Drake and others 2016): educational impact, while also influencing the imple- mentation costs. • Policy frameworks It is important to understand not only whether school • Institutional capacity and coordination feeding is effective but also the causal chain according to • Budget and financing which impact is achieved, which is context specific. This • Design and implementation is an important area for further research (Greenhalgh, • Community participation. Kristjansson, and Robinson 2007). More rigorous design evaluations are also needed on government-led school A national school feeding policy can contribute to feeding programs, given that the bulk of such evidence is sustainability and integration with other policy priorities. based on school feeding implemented by the World Food Capacity and coordination among relevant institutions 150 Child and Adolescent Health and Development Table 12.1 Government-Led School Feeding Interventions in 15 Countries, Selected Parameters Number Net enrollment Gender Income Ration of school rate, overall parity Country levela Timing Ration contents calories days (%) index Botswana Upper middle Daily mid-morning hot Sorghum porridge, stewed canned 572 185 90 0.97 meal; second meal beef, maize, beans, vegetable oil, provided in some districts bread, milk Brazil Upper middle Modality varies across At least 20 percent of daily 335 200 — — states and municipalities nutritional needs provided, including three portions of fruits and vegetables Cabo Verde Lower middle Hot in-school meal; a Cereals (rice or pasta), beans, oil 300 — 98 0.92 glass of milk provided in (vegetable or soya), carrot, fish, some schools Portuguese cabbage Chile Upper middle Modality varies by age Food items vary by vendor but 850 180 94 0.97 group should include meat and fresh fruit and vegetables China Upper middle Hot meal; mid-morning Hot dishes include meat and 810 for 200 100 0.87 snacks vegetables; snacks include biscuits meals; 300 and bread for snacks Côte d’Ivoire Lower middle Hot meal Cereals, flours, and legumes 1,141 52 77 0.87 Ecuador Upper middle Breakfast meal; milk Fortified drink composed of wheat 396 — 95 1.00 snack also provided in flour and soy, granola in flakes, some schools cereal bar, and four types of biscuits Ghana Lower middle Hot midday meal Maize, legumes, rice, fish, yams, 800 195 76 1.00 eggs, groundnuts, vegetables India Lower middle Hot midday meal Cereals, pulses, eggs, and fruits 575 200 94 1.03 Kenyab Lower middle Hot midday meal Cereals, pulses, vegetable oil, and 700 — 82 1.00 salt Mali Lower middle Cooked lunch Staple foods (millet, sorghum, 735 180 70 0.88 maize, and rice) with legumes, oil, pulses (such as cowpeas), and meat, fish, or both Mexico Upper middle Cold or warm breakfast Skim or partially skim milk, 395 — 95 1.00 wholemeal cereals, and fresh or dried fruit Namibia Upper middle Mid-morning meal Fortified maize meal blend porridge 475 200 86 0.97 c Nigeria Lower middle Hot midday meal Includes eggs, fish, and meat 536 — 64 0.92 South Africa Upper middle Mid-morning meal Protein, starch, and a vegetable — 182 90 0.95 or fruit Sources: Drake and others 2016; World Bank 2016, latest year available for each country. Note: — = not available. The net enrollment rate is the ratio of children of official school age who are enrolled in school to the population of the corresponding official school age. The gender parity index for gross enrollment ratio in primary education is the ratio of girls to boys enrolled at the primary level in public and private schools. a. World Bank income level in 2012. b. School feeding details specific to homegrown school feeding program. c. Osun State. See box 12.1 for more information about this program. School Feeding Programs in Middle Childhood and Adolescence 151 at the national, regional, and local levels are needed, par- which poverty and food insecurity are concentrated in ticularly across different ministries. Channels for one or multiple areas, as well as the smallest geographic financing the program and the implementers, for exam- unit at which targeting can be applied. Poor accessibility ple, payments to caterers, need to be defined. Communities to these areas and insufficient infrastructure to deliver must be engaged in the program; their contributions, school feeding may present barriers. An evaluation from such as firewood, condiments, and meal preparation, the Lao People’s Democratic Republic (Lao PDR) indi- may be needed. cated that, because of similar barriers, only one-half to two-thirds of schools eligible for school feeding in select districts actually received school feeding (Buttenheim, Social Protection Alderman, and Friedman 2011). Rising urban poverty School feeding provides a transfer to households in and income inequality may justify individual or the value of food distributed (Alderman and Bundy school-targeting approaches, although care must be 2011). This transfer can reduce a household’s food taken to ensure that food provided in targeted schools needs; when provided regularly over the school year, it does not inadvertently draw students from nearby smooths volatility, thereby increasing disposable schools receiving no food. Moreover, individual target- income to meet other immediate needs or invest- ing may be challenging if some children in a classroom ments. A range of outcomes is possible, including receive food while other children do not. better nutrition. A quasi-experimental design analysis A review of eight social protection programs in Latin found that India’s school feeding program mitigated America and the Caribbean found that school feeding the effects of drought on physical growth, which had focused on the most disadvantaged households in most occurred earlier in the lives of the beneficiaries (Singh, countries. However, in some countries such as Guatemala Park, and Dercon 2014). In response to the food and where the poorest children do not attend school, school fuel price crises of 2007–08, at least 38 LMICs scaled feeding was less well targeted (Lindert, Skoufias, and up school feeding programs, in recognition of its Shapiro 2006). We replicated Lindert, Skoufias, and potential as a social safety net (WFP 2013). A global Shapiro (2006) by using data from Malawi, Tanzania, review of social safety net programs found that school and Uganda. The share of households in the lowest feeding was one of the largest in estimated number of income quintile were more likely to receive school meals, beneficiaries (World Bank 2014; also see chapter 8 in with the largest population share evident in Tanzania this volume, Watkins and others 2017). (figure 12.3). Several factors determine the effectiveness of school In Ghana, the Ministry of Employment and Social feeding as a social protection tool. One factor is targeting Welfare, in a review of targeting in the national school the poorest and most vulnerable households and com- feeding program in 2010, found that higher investment munities (Alderman and Bundy 2011). The efficiency of was not consistently made in districts with greater pov- geographic targeting is conditioned by the degree to erty and food insecurity (WFP 2013). The program was retargeted in 2012. Figure 12.3 Targeting Efficiency of School Feeding in Malawi, Tanzania, and Uganda Education School feeding can promote access to education, as mea- 80 sured by indicators such as enrollment, attendance, and 70 retention (Krishnaratne, White, and Carpenter 2013). Households receiving school feeding (%) 60 Evidence for these links helped identify school feeding 50 as a means for contributing to the Millennium 40 Development Goal 2 of universal enrollment in primary 30 education. Given the links between nutrition status and 20 cognition, school feeding programs, if integrated with 10 interventions to improve education quality, can also 0 contribute to learning and academic achievement Malawi 2010 Tanzania 2008 Uganda 2009 (Adelman, Gilligan, and Lehrer 2008; Krishnaratne, 1st income quintile 2nd income quintile 3rd income quintile White, and Carpenter 2013). Moreover, school feeding 4th income quintile 5th income quintile may directly or indirectly reduce gender disparities in Source: Analysis based on the Atlas of Social Protection: Indicators of Resilience and Equity, education outcomes. The following section reviews the World Bank. evidence, giving greater weight to systematic reviews 152 Child and Adolescent Health and Development and studies with rigorous designs, such as randomized achievement. Although some indications of a positive controlled trials. relationship have been documented, other studies have not found statistically significant results. The mixed Access to Education findings may be due to several factors, including differ- A review of rigorously designed studies indicated a stan- ences in school quality. These differences are consistent dardized effect size of 0.156 for enrollment (p < 0.05, three with other types of schooling interventions, for which studies), 0.449 for drop-out (p < 0.001, two studies), and evidence on what works is inconclusive (Glewwe and 0.690 for progression (p < 0.001, one study) (Krishnaratne, others 2013). White, and Carpenter 2013). The review did not find In Chile, more frequent consumption of dairy prod- statistically significant effects on attendance and learning, ucts improved education outcomes for primary and sec- although the coefficients were positive (Krishnaratne, ondary students (WHO 1998). Preliminary evidence White, and Carpenter 2013). In addition to providing an from Ghana suggests improved learning outcomes for incentive to attend school, evidence indicates that school girls in schools where micronutrients were given in the feeding reduces absenteeism. A review of studies from meals. The improvements related to literacy (14 percent), multiple LMICs found that school feeding was associated mathematics (13 percent), and reasoning ability with an average of four to six more days attendance at (8 percent) (Aurino and others 2016). Other studies, in school per year (Kristjansson and others 2009). contrast, have found minimal to no impact of school The choice of modality may also play an important feeding on academic achievement. Timing of delivery of role. For example, Afridi, Barooah, and Somanathan the feeding and overall learning environments can con- (2014) showed that monthly attendance increases in tribute to explaining the inconsistency of evidence related response to a switch to a cooked meal from snacks, with to school feeding and academic achievement (Powell and modest increases in the state budget in India. Fortified others 1998; Vermeersch and Kremer 2004). For instance, biscuits in Bangladesh improved school enrollment by Vermeersch and Kremer (2004) attribute their negative 14.2 percent, reduced the probability of drop out by finding to the disruptive role of school feeding in the 7.5 percent, and raised attendance by about 1.3 days a school day, whereas the positive outcome from Powell month (Ahmed 2004). Adelman, Gilligan, and Lehrer and others (1998) may be due to the timing of the pro- (2012) in Northern Uganda, and Kazianga, de Walque, gram (just before the school start). In addition, Chang and Alderman (2009) in Burkina Faso found that both and others (1996) found that school feeding was associ- school meals and take-home rations effectively increased ated with improved on-task behaviors in well-organized enrollment. Ahmed and del Ninno (2002) showed that classrooms but not in disorganized classrooms. take-home rations for poor households in rural Bangladesh Table 12.2 presents overall average estimates for the increased school access, with an 8 percent increase in impact of school feeding on educational outcomes school enrollment and 12 percent increase in attendance. Moreover, the evidence suggests that school feeding can mitigate gender disparities in school enrollment Table 12.2 Summary of Educational Impacts of School Feeding where girls face greater barriers (Gelli, Meir, and Espejo 2007). In particular, the provision of take-home rations Overall weighted to girls can represent a significant income transfer to average effect Number of studies households, outweighing the forgone benefits of nonat- Access to schooling tendance (Bundy and others 2009). The WFP experience Enrollment 0.14 7 suggests that making provision of take-home rations Attendance 0.09 6 conditional on attendance rates of more than 80 percent was effective, especially in low-resource communities Drop-out –0.06 3 where child labor is common (WFP 2013). In Burkina Completion 0 2 Faso, the provision of school meals or monthly take- Learning outcomes home rations of 10 kilograms of cereal flour conditional Language arts scores 0.09 8 on a 90 percent attendance rate increased the enrollment of girls ages 6–12 years by about 6 percent (Kazianga, de Math scores 0.10 10 Walque, and Alderman 2014). Composite test score 0.14 3 Source: Snilstveit and others 2015. Learning and Academic Achievement Note: Weighted average effects are based on the Cohen’s index and were estimated based on the standardized mean differences calculated from individual studies. These effects reflect the estimated A smaller but still substantial body of evidence explores change in percentile rank for an average student in the control group had he or she received school the impacts of school feeding on learning and academic feeding. School Feeding Programs in Middle Childhood and Adolescence 153 drawing from a systematic review of studies with rigor- Alderman (2014) have shown that take-home rations ous design undertaken in LMICs between 1990 and 2015 improved weight-for-age by 0.4 standard deviations for (Snilstveit and others 2015). These studies primarily the younger siblings of the beneficiaries compared with included randomized controlled trials, as well as qua- control groups. si-randomized trials, with adjustments for nonrandom selection to groups such as propensity score matching or Nutrient Adequacy regression discontinuity design. Standardized effect sizes Evidence suggests that school feeding can be effective were estimated for individual studies, and meta-analysis in promoting macronutrient and micronutrient ade- was used to obtain overall estimates. quacy in the diet (Jomaa, McDonnell, and Probart 2011). For food supplementation programs, evidence from a randomized controlled trial in Kenya showed Nutrition that the inclusion of meat or milk in the school feeding The World Health Organization recommends that menus improved plasma vitamin B12 concentrations. school feeding programs contribute 30 percent to No other measures of micronutrient status were 45 percent of the recommended daily allowance of affected, however, probably because of concurrent energy and nutrients for half-day schools, and 60 percent incidence of malaria or other infectious diseases to 75 percent for full-day schools (WHO 1998). HICs, (Jomaa, McDonnell, and Probart 2011; Siekmann and including Chile, Mexico, the United Kingdom, and the others 2003). In a quasi-randomized study, Afridi United States, have introduced nutrient-based standards (2010) found that in the state of Andhra Pradesh in in school feeding programs to enhance the contribution India, the Mid-Day Meal Scheme eliminated daily pro- of school meals to recommended dietary intake. tein deficiency and decreased calorie deficiency by Nutrient-based standards are less common in LMICs, almost 30 percent and daily iron deficiency by nearly however, with the exception of India (Drake and others 10 percent (Afridi 2010). Regarding efficacy, Best and 2016). A review of national school feeding programs in others (2011) reported in a review that micronutrient 12 LMICs indicated that many seek to provide more supplementation increased micronutrients and diversified food baskets that include fresh produce, reduced anemia more than supplementation of a single although this objective is often only aspirational (Aliyar, micronutrient or no supplementation. Gelli, and Hamdani 2015). In 8 out of 10 studies reviewed in Best and others School feeding may help children and adoles- (2011), school feeding raised serum concentrations of cents receive sufficient nutrients and grow. The inclu- iron, iodine, vitamin A, and vitamin B, while improv- sion of micronutrient-rich foods or powders may ing hemoglobin levels. Two studies identified increased address anemia and support improved cognition levels of zinc (Nga and others 2009; Winichagoon and (Abizari and others 2012; Abizari and others 2014; others 2006). The impact of school feeding on micro- Finkelstein and others 2015). School meals may also nutrient status may depend on the dose, initial micro- foster understanding of healthy diets and behaviors that nutrient status, and interactions with other can extend beyond school and throughout life, particu- micronutrients supplemented. The iron status of larly if nutrition education is incorporated into the Kenyan schoolchildren was associated with the dosage program (Kubik and others 2003; Story, Neumark- of iron-fortified flour (Andang’o and others 2007), Sztainer, and French 2002). while a randomized controlled trial in Vietnam However, counteracting factors may weaken these showed that only multifortified biscuits reduced ane- relationships. For example, households may allocate mia more than iron supplementation, which suggests food to siblings not receiving the school meals, possibly that other micronutrients affect anemia status (Hieu offsetting the impact of school feeding on the nutritional and others 2012). status of the target child. Studies analyzing this issue Food-based strategies in school feeding programs show, nevertheless, that overall energy intake increases can effectively address micronutrient deficiencies. almost as much as the transfer provided at school—the The introduction of orange-flesh sweet potato in flypaper effect (Afridi 2010; Ahmed 2004; IFPRI 2008; meals, for example, improved vitamin A status in Jacoby 2002). In addition, Jacoby (2002) and Ahmed South Africa (van Jaarsveld and others 2005), while (2004) have shown that children who received snacks consumption of carotene-rich yellow and green leafy shared them with their younger siblings. Few studies vegetables improved vitamin A and hemoglobin con- have tracked the nutritional status of siblings too young centration and decreased anemia rates in Filipino to attend school, however, although Adelman, Gilligan, schoolchildren (Maramag and others 2010). The and Lehrer (2012) and Kazianga, de Walque, and incorporation of locally available, micronutrient-rich 154 Child and Adolescent Health and Development foods may also promote local agriculture. Homegrown others 2002). Nutritional risk in this study was defined school feeding programs follow this approach as less than 50 percent of the recommended daily allow- (box 12.1). A survey of 36 LMICs (mostly Sub- ance of total energy intake or of two or more micronu- Saharan African) indicated that national sourcing trients, or both. A study from Mexico found that (local purchasing) resulted in the inclusion of more children in schools participating in a school breakfast diverse and fresh foods (GCNF 2014). program had higher response speed and memory com- Last, mixed approaches that combine food supple- pared with children from nearby schools that did not mentation and micronutrient supplementation or food participate in the program (Vera Noriega and others fortification can also promote nutrient adequacy. In 2000). A review did not find that the timing of meal Northern Uganda, school meals and take-home rations delivery affects cognition, although one study from were found to reduce anemia prevalence in girls ages Israel did find that children performed better shortly 10–13 years by 17 to 20 percentage points (Adelman, after a meal (Vaisman and others 1996). Gilligan, and Lehrer 2012). In contrast, impacts on ane- mia were not detected in randomized controlled trials Anthropometry and Nutrition from Burkina Faso and Lao PDR, where the rations did A Cochrane review on school feeding (Kristjansson not include multifortified foods (Buttenheim, Alderman, and others 2009) conducted a meta-analysis of three and Friedman 2011; Kazianga, de Walque, and Alderman randomized controlled trials in three LMICs: Jamaica 2014). The success of these approaches critically depends (Powell and others 1998), Kenya (Grillenberger and on the regularity of the supplementation throughout the others 2003), and China (Du and others 2004). The school year. meta-analysis found a small yet significant effect on weight (0.39 kilogram, 95 percent confidence interval Nutrition and Cognition 0.11, 0.67) and a small nonsignificant effect on height A large body of literature shows the links between mal- gain (0.38 centimeters, 95 percent confidence interval nutrition, including micronutrient deficiencies, and –0.32, 1.08). The three school feeding programs dif- poor cognition (Glewwe and Miguel 2008; Grantham- fered greatly in modality of implementation and tar- McGregor and Ani 2001). In this area, studies have get population. In the Jamaica study, 395 children in focused on how school feeding can promote cognitive grades 2–5 were given breakfast for a year (Powell and skills such as better attention and short-term memory others 1998). In Kenya, grade 1 schoolchildren were by reducing deficiencies in iron and other micronutri- given meat, milk, or an energy supplement for 18 ents. One randomized controlled study found that regu- months (Grillenberger and others 2003). In China, lar provision of fortified biscuits improved the the study focused on girls age 10 years who received micronutrient status and cognitive function of children milk supplementation (Du and others 2004). A more (van Stuijvenberg and others 1999). Two randomized recent review (Watkins and others 2015), which controlled studies from Kenya found that the inclusion broadened the inclusion criteria by considering stud- of animal source foods improved cognition and child ies such as controlled before-and-after studies, found learning, although the magnitude of effects were small that school feeding had significant effects on weight (Neumann and others 2003; Whaley and others 2003). and height gain. Afridi, Barooah, and Somanathan (2013) found that the Micronutrient supplementation and fortified foods provision of free meals increased student effort, as mea- delivered through school feeding programs may also sured by their performance in solving puzzles of increas- affect nutrition outcomes of children. Best and others ing difficulty, in India. (2011) reported that 10 studies found that school meals The timing of the meal may be important. Breakfast with micronutrient supplementation had statistically programs may support cognitive function during school significant impacts on micronutrient status even after hours, especially for children who had previously controlling for baseline status. Findings from several skipped breakfast. Findings from two rigorous studies controlled before-and-after studies suggest that micro- suggest that eating breakfast improves on-task time nutrient supplementation may also have statistically (amount of time spent focused on the school activity) significant impacts on height and weight. Table 12.3 and attention (Bro and others 1994; Bro and others summarizes the evidence. 1996). A universal, free breakfast program in Boston public schools in the United States improved school Dietary Behaviors attendance and math achievement, and decreased days Schools and school feeding programs, through nutri- tardy for children at nutritional risk as assessed in a pre- tion education, can serve as a platform for shaping post study during a six-month period (Kleinman and behaviors and food preferences for healthier nutrition School Feeding Programs in Middle Childhood and Adolescence 155 Table 12.3 Summary of Nutrition and Cognitive Impacts of School Feeding Anthropometric Status Micronutrient Status School feeding Height or Weight or Hemoglobin activity stunting underweight Iron or anemia Iodine Vitamin A Zinc B vitamins Cognition In-school meals +++ +++ + ++ n.a. + + + +++ Take-home rations ++ ++ — + n.a. — — — ++ Multiple micronutrient ++ ++ +++ +++ + +++ +++ + ++ fortification Multiple micronutrient ++ ++ ++ ++ + ++ ++ + ++ powder Source: Watkins and others 2015. Note: RCT = randomized controlled trial. n.a. = not assessed by an RCT; + = evidence from one RCT; ++ = evidence from two RCTs; +++ = evidence from more than two RCTs; — = lack of any evidence. (Hawkes and others 2015). The development of tion education is scant, particularly in developing coun- healthy dietary habits during childhood can also help tries, and more research is needed. prevent diet-related diseases later in life, with the evi- dence showing that dietary habits tend to be persis- Agriculture tent from childhood through adulthood (Dunn and Initial evidence has shown that home-grown school others 2000). Dietary diversity may provide an indica- feeding can change the eating preferences of households, tor of better diets among children and adolescents. improve community incomes, support smallholder pro- The inclusion of animal-source foods in school snacks duction, and facilitate better market access. Thereby, it increased dietary diversity in Kenya (Murphy and has an impact on rural economies. The impact on rural others 2003). investments and agricultural development has increas- Encouraging lifelong healthy diet choices has so far ingly gained attention through links to the school feed- received more attention in HICs; however, it is increas- ing market. It is also clear that to enable the transition to ingly relevant in LMICs, where childhood overweight and sustainable, scalable government-run programs, the obesity are increasing (Lobstein and others 2015). Some inclusion of the agricultural sector is critical (Bundy and studies conducted in HICs found a positive association others 2009; Drake and others 2016). between school meals and overweight and obesity Initial evidence has shown that homegrown school (Schanzenbach 2009). Others suggest instead that pro- feeding can not only change eating preferences of house- grams targeted to primary-school-age children most holds, community incomes, and smalholder production effectively reduced obesity, especially when healthy meals and market access, but can also benefit smallholder were accompanied by communication promoting behav- farmers and investments in rural economies. ioral change (Corcoran, Elbel, and Schwartz 2014). Preliminary findings from an impact evaluation in Initiatives at school that combine healthy eating and Ghana show a 33 percent increase in agricultural sales and active living have been introduced in HICs to support a strong increase in household income in interventions in child and adolescent development (De Bourdeaudhuij which homegrown school feeding is implemented and others 2011; Herforth and Ahmed 2015; Story, (Aurino and others 2016). However, it is clear that rigor- Nanney, and Schwartz 2009). Similar action in LMICs ous evidence regarding the impacts that school feeding may be needed to respond to the nutrition transition has on employment and income in the agricultural sector (Faber and others 2014). needs to be reinforced (Aurino and others 2016; Drake Communication materials aimed at changing behav- and others 2016; GCNF 2014; Masset and others 2012). ior, alongside school meals, can help inculcate these The following issues need further exploration: ideas in schoolchildren and influence household diet. For example, radio jingles and posters were developed in • Transparency in price and payment is key for small- Ghana to complement initiatives undertaken in the holder trust. Ghana School Feeding Programme to improve nutrition • Timely access to price, quality, and quantity informa- among children, adolescents, and their communities tion enhances operational efficiencies of aggregators (Gelli and others 2016). Evidence on the impact of nutri- and market systems. 156 Child and Adolescent Health and Development • Adaptation of quantity and quality requirements and sanitation, or deworming (Azomahou, Diallo, and effective communication on them can ease the tran- Raymond 2014). sition to supplying structured markets. Modality is a key determinant of school feeding costs. • The mobile phone platform can allow easier aggre- On average, school meals, biscuits, and take-home gation and management of commodities despite the rations cost US$27, US$11, and US$43, respectively, per short period of aggregation. child per year (Gelli and others 2011). The differences are driven largely by differences in meal size or modality of the transfer; take-home rations cost more because WEIGHING THE COSTS AGAINST BENEFITS: they provide an additional transfer to the household beyond the food delivered in school. AN ECONOMIC ASSESSMENT OF SCHOOL Significant variation in cost is also evident across FEEDING countries. Drawing from a sample of 74 low-, middle-, This section reviews the literature on quantifiable and high-income countries, school feeding costs an costs and benefits for an overall assessment of the average of US$173 per child per year, ranging from economics of school feeding. Three issues are particu- US$54 in LICs to US$82 in middle-income countries larly salient: and US$693 in HICs (Gelli and Daryanani 2013). These estimates are standardized for several parameters to • The heterogeneity in the design and implementa- support cross-country comparability, including the tion of school feeding interventions across countries number of kilocalories in the ration and the number of underscores the need for standardization when pos- days school feeding was provided. Food costs were typ- sible. A comparison of costs with benefits is essen- ically the largest component, accounting for more than tial for any economic assessment of school feeding half of total program costs (Galloway and others 2009; or modification to the intervention. For example, Gelli and others 2011).3 Although the contributions of retargeting school feeding to the most disadvantaged communities are not usually reflected in these esti- areas, or shifting from geographic to individual tar- mates,4 they are estimated to be about 5 percent of total geting, may reach disadvantaged populations more cost in LICs, or about US$2 per year (Galloway and efficiently. others 2009). • Such changes may also entail significant mone- The benchmarking of school feeding costs as a per- tary and other costs, including resistance from local centage of primary school education costs can also government officials whose districts will no longer support comparability across countries. As table 12.4 receive the intervention, or risk of stigma that chil- shows, school feeding costs become a smaller propor- dren and adolescents may experience for receiving tion of primary education costs as the income level of free or reduced-price meals if the program is not the country increases. For LICs, the share is 68 percent, designed to mitigate that risk. compared with 19 percent for MICs and 11 percent • Some important drivers of costs may be outside the for HICs. scope of the intervention, such as global food prices As gross domestic product increases, the per capita or poor road conditions. cost of primary school education increases more rap- idly than the per capita cost of school feeding, which drives this finding (figure 12.4) (Bundy and others Costs of School Feeding Costs of school feeding include costs associated with Table 12.4 School Feeding Costs in 74 Countries procuring food, transportation and storage, and staff time to monitor program implementation. Some pro- Total cost Share of per capita cost of primary grams hire cooks or caterers to prepare meals; others Income level of country (US$) education (%) rely on community volunteers. Communities may pro- Low (n = 22) 54 68 vide other, in-kind contributions, such as fresh fruit or vegetables, fuel, condiments, and utensils. The provi- Middle (n = 40) 82 19 sion of multifortified biscuits and take-home rations High (n = 12) 693 11 entails costs in staffing and delivery. Efficiencies may be Total (n = 74) 173 33 gained through integrating school feeding with other Source: Gelli and Daryanani 2013. school health interventions, such as water, hygiene and Note: n = number of observations. School Feeding Programs in Middle Childhood and Adolescence 157 Figure 12.4 School Feeding and Primary Education Costs per Child per Year 12,000 5 Per capita cost of school feeding/ 10,000 per capita cost of education 4 8,000 Per capita cost Linear fit per capita cost of school feeding/ 3 linear fit per capita cost of education 6,000 2 Linear fit low-income countries 4,000 Linear fit middle-income countries 2,000 1 Linear fit high- and middle-income countries Linear fit high-income countries 0 10,000 20,000 30,000 40,000 50,000 0 10,000 20,000 30,000 40,000 50,000 GDP per capita, PPP (constant 2005 international $) GDP per capita, PPP (constant 2005 international $) Primary education School feeding Sources: Bundy and others 2009; Gelli and Daryanani 2013. Note: GDP = gross domestic product; PPP = purchasing power parity. 2009; Gelli and Daryanani 2013). The high cost of micronutrient powders to school meals may also school feeding relative to education is notable, partic- increase cost efficiency relative to nutrient content. In ularly in LICs. Ghana, the provision of micronutrient powders in school meals costs only an estimated additional US$2.92 per child for the entire school year (Stopford Assessing Costs against Benefits and others, forthcoming). This section reviews the cost of school feeding by output Estimation of the overall cost-effectiveness of school and outcome. For output, figure B12.2.1 presents the feeding is complicated by the multiple benefits of the cost of delivering 30 percent of the recommended daily intervention and the need to transform the units of allowances of key micronutrients in 12 countries based different outcomes into the same unit. To simplify the on school feeding menus (Drake and others 2016). The problem, school feeding can be viewed as increasing composition of school meals varies widely, and diversifi- the quantity and quality of education obtained, with cation may lead to higher costs. Some studies have found improved nutrition outcomes contributing to quality positive effects on anthropometric indicators from meat (Gelli and others 2014). Capturing both education and or milk in the meals (Du and others 2004; Grillenberger nutrition outcomes in such calculations is critical for and others 2003). However, LICs are unlikely to be able comparisons with other interventions, such as condi- to sustain the higher costs of meat, and possibly milk, in tional cash transfers,5 as well as direct schooling invest- meal programs. As economies develop, these food items ment. Compared with conditional cash transfers, school can be gradually introduced and governments might be feeding has high nontransfer costs of approximately able to use schools to encourage the development of 20 percent to 40 percent (Bundy and others 2009). dairy sectors. Bangladesh, Rwanda, and Vietnam are Previous studies (Jamison and Leslie 1990; Schuh encouraging these links through their school feeding 1981) have hypothesized that the benefit-cost of school programs. feeding programs are attractive. A recent systematic For decentralized programs, setting the appropriate review and meta-analysis (Snilstveit and others 2015) reimbursement rate to meet recommended nutrient found that school feeding had significant effects on levels is critical (Parish and Gelli 2015). Tools such as school attendance equivalent to an additional 8 days the School Meals Planner can support the design of attended. There were also effects in the expected costed menus that incorporate nutrient-rich foods direction on improving enrollment, decreasing drop- (box 12.2). The addition of supplements such as out, and improving various measures of attainment 158 Child and Adolescent Health and Development Box 12.2 School Meals Planner The School Meals Planner software and accompany- high-level political engagement. Officials from 42 ing materials were developed in response to demand districts located across the 10 regions of Ghana from governments to support the design of nutri- designed menus using the School Meals Planner. tious, well-balanced meals for homegrown school These menus reached more than 320,000 feeding programs. children. The tool is a user-friendly dashboard that helps A set of handy calibrated measures was provided to planning officials who may not be nutritionists each school caterer to ensure provision of food (figure B12.2.1). It was adapted to Ghana and quantities listed on the menus. A communication tested during the 2014/15 school year. Food com- campaign sensitized schools and communities to the position tables and nutrition recommendations health and broader developmental benefits of locally specific to Ghana were developed through grown, healthy diets. Figure B12.2.1 The School Meals Planner Edit Meal ? Meal RDA ? Meal Name: Ghana rice and beans Targets: 30% RDA Regions: Ghana2 (Default Region) Calcium (27%) Age Group: 6–12 Niacin (77%) Gingerbread Men ? Ribovlavin (66%) Thiamine (115%) Energy (110%) <40% 40–100% >100% Protein (110%) Energy Protein Fat Iron Vitamin A Zinc Fat (45%) Nutrition Overview Table ? Iron (80%) Add New Food Vitamin A (198%) Beta- Zinc (79%) carotene Show Weight Ash equivaler Delete Edit Contribution Name (g) (g) (g) X Rice, white raw 120 0.84 0 X Broad beans, dried raw 40 1.24 12.8 X Plantain, ripe raw 20 0.2 103.6 X Palm oil, red 5 0 3434 Total 185 2.28 3550.4 Source: Fernandes and others 2016. Note: RDA = recommended daily allowance. (cognitive scores, maths scores, and language arts scores), in this volume) estimate the benefit-cost of the effect of although none of these was significant. Higher school attendance as around 3 for low-income countries, and attendance, in turn, has returns in higher wages upon around 7 for lower-middle-income countries. If there graduation, and the returns to education in Sub-Saharan are additional effects of improved cognition, the returns Africa are high. Fernandes and Aurino (2017, chapter 25 could be even higher. School Feeding Programs in Middle Childhood and Adolescence 159 CONCLUSIONS 4. 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Patton. Washington, DC: World Bank. Journal of Nutrition 133 (11): 3950S–56S. Watkins, K., D. A. P. Bundy, D. T. Jamison, F. Guenther, and WHO (World Health Organization). 1998. “Healthy Nutrition: An A. Georgiadis. 2017. “Evidence of Impact of Interventions Essential Element of a Health-Promoting School.” Information on Health and Development during Middle Childhood Series on School Health—Document Four, WHO, Geneva. and School Age.” In Disease Control Priorities (third Winichagoon, P., J. E. McKenzie, V. Chavasit, T. Pongcharoen, edition): Volume 8, Child and Adolescent Health and S. Gowachirapant, and others. 2006. “A Multimicronutrient- Development, edited by D. A. P. Bundy, N. de Silva, Fortified Seasoning Powder Enhances the Hemoglobin, S. Horton, D. T. Jamison, and G. C. Patton. Washington, Zinc, and Iodine Status of Primary School Children in DC: World Bank. North East Thailand: A Randomized Controlled Trial of Watkins, K., A. Gelli, S. Hamdani, E. Masset, C. Mersch, and Efficacy.” Journal of Nutrition 136 (6): 1617–23. others. 2015. “Sensitive to Nutrition? A Literature Review of World Bank. n.d. “Atlas of Social Protection Indicators of School Feeding Effects in the Child Development Lifecycle.” Resilience and Equity (ASPIRE).” http://datatopics Working Paper Series #16, Home Grown School Feeding. .worldbank.org/aspire/. http://www.hgsf-global.org. ———. 2014. The State of Social Safety Nets. Washington, DC: WFP (World Food Programme). 2013. The State of School World Bank. Feeding. Rome: WFP. ———. 2016. World Development Indicators. Washington, Whaley, S., M. Sigman, C. Neumann, N. Bwibo, D. Guthrie, DC: World Bank. Retrieved October 2015. http://data and others. 2003. “The Impact of Dietary Intervention on .worldbank.org/. 164 Child and Adolescent Health and Development Chapter 13 Mass Deworming Programs in Middle Childhood and Adolescence Donald A. P. Bundy, Laura J. Appleby, Mark Bradley, Kevin Croke, T. Deirdre Hollingsworth, Rachel Pullan, Hugo C. Turner, and Nilanthi de Silva INTRODUCTION Definitions of age groupings and age-specific terminol- ogy used in this volume can be found in chapter 1 The current debate on deworming presents an interest- (Bundy, de Silva, and others 2017). ing public health paradox. Self-treatment for intestinal worm infection is among the most common self- administered public health interventions, and the deliv- ESTIMATED NUMBER OF INFECTIONS AND ery of donated drugs through mass drug administration DISEASE BURDEN (MDA) programs for soil-transmitted helminths (STHs) exceeds 1 billion doses annually. The clinical literature, Three types of STH commonly infect humans: round- especially the older historical work, shows significant worm (Ascaris lumbricoides), hookworm (comprising impacts of intense STH infection on health; a burgeon- two species, Ancylostoma duodenale and Necator amer- ing economics literature shows the long-run conse- icanus), and whipworm (Trichuris trichiura). Recent quences for development (see, for example, chapter 29 in use of geographic information systems and interpo- this volume, Ahuja and others 2017; Fitzpatrick and lated climatic data have identified the distributional others 2017). Yet, the literature on clinical trials shows limits of STHs on the basis of temperature and rainfall conflicting results, and the resulting controversy has patterns as well as socioeconomic factors (Pullan and been characterized as the worm wars. Brooker 2012). Globally, in 2010 an estimated 5.3 The two previous editions of Disease Control Priorities billion people, including 1 billion school-age children, contain chapters on STH and deworming programs lived in areas stable for transmission of at least one (Hotez and others 2006; Warren and others 1993). Much STH species; 69 percent of these individuals lived of the biological and clinical understanding reflected in in Asia. those chapters remains largely unchanged. This chapter Map 13.1 is based on clear limiting relationships presents current estimates of the numbers infected and observed between infection and climatic factors for each the disease burden attributable to STH infections to illu- species. For example, experimental and observational minate current program efforts, advances in the under- findings suggest that transmission is implausible in standing of epidemiology and program design, and the extremely hot, arid, or cold environments, particularly in controversy regarding the measurement of impact. Africa and the Middle East (Brooker, Clements, and Corresponding author: Donald A. P. Bundy, Bill & Melinda Gates Foundation; Seattle, Washington, United States; Donald.bundy@gatesfoundation.org. 165 Map 13.1 Distribution of Soil-Transmitted Helminth Infection Risk, Applying Climatic Exclusion Limits IBRD 42565 | DECEMBER 2016 Within stable limits of at least one STH Less stable transmission of at least one STH Beyond transmission limits for all three species GDP > US$20,000 Urban extent Peri-urban extent Source: Adapted from Pullan and Brooker 2012. Note: Analysis includes only regions considered endemic for STHs. GDP = gross domestic product; STH = soil-transmitted helminth. Bundy 2006; Brooker and Michael 2000; Pullan and between infection prevalence, intensity, and potential Brooker 2012). Relationships are less clear in Asia, espe- morbidity originally proposed by Chan and Bundy cially for roundworm, for which positive survey data (1999) for use in the first Global Burden of Disease exist even in extremely hot and arid regions of India and study (Chan 1997). In brief, the age-stratified mean Pakistan, perhaps because resistant transmission stages prevalence was estimated for all endemic regions at allow for seasonal transmission in environments other- subnational scales. The approach used to map the wise hostile for much of the year. mean prevalence of infection within the boundaries of Several attempts have been made to estimate world- transmission differed by region, determined by the wide prevalence of STHs since the first estimates progress in control, environmental associations, and assembled by Norman Stoll in the seminal paper titled data availability considerations. For Asia, Latin “This Wormy World” (Stoll 1947); this section pro- America and the Caribbean, the Middle East and vides revised estimates of the burden of disease for North Africa, and Oceania, empirical estimates were STHs in 2013. The number of persons infected with generated directly from the data. For countries within STHs is generated by applying the revised estimates Sub-Saharan Africa—where detailed data were lack- from 2010 (Pullan and others 2014) to age-stratified ing for several countries but where relationships population estimates for 2013. These estimates build between infection patterns and environmental factors on a modeling framework that exploits relationships were clearer—a geostatistical space-time modeling 166 Child and Adolescent Health and Development framework was used to predict the prevalence of each estimate disability-adjusted life years (DALYs) for 2013 infection across the continent, following the approach (Murray and others 2015). of Hay and others (2009). In 2013, an estimated 0.4 billion children under age For STHs, prevalence alone does not provide a 15 years worldwide were infected with at least one spe- useful measure of potential morbidity because only a cies of intestinal nematode, resulting in 1.46 million small number of infections will be associated with ill DALYs. Although the greatest number of DALYs occur in health. Instead, morbidity is related to the intensity of Sub-Saharan Africa and Latin America (map 13.2), a infection, with the most intense infections occurring in large at-risk population means that the vast majority of only a minority of infected individuals (Bundy and total infections occur in Asia, where at least one-fourth Medley 1992). As prevalence increases, the prevalence of preschool and school-age children are host to at least of high-intensity infections increases at a higher rate, one STH species (table 13.1). The most important STH such that high-prevalence communities experience infection globally for children is roundworm, reflecting disproportionate amounts of morbidity (Chan and the age distribution of infection. Roundworm is of par- others 1994). Heterogeneity between communities ticular concern for preschool-age children in Sub- within subnational areas was therefore approximated Saharan Africa, resulting in 143 DALYs per 100,000 using modeled distributions, and the number of per- population (table 13.2)—mostly attributable to wasting sons with infection intensities greater than age- resulting from high-intensity infections. These figures dependent thresholds was estimated indirectly for each are substantially lower than previous estimates (de Silva species. The frequency distributions of worms, and and others 2003), attributable in part to several method- thus the numbers exceeding these thresholds, were ological improvements: estimated using negative binomial distributions that assumed general species-specific aggregation parame- • Limitation of populations at risk to areas suitable for ters based on data from Brazil, Kenya, and Uganda transmission (Pullan and others 2014). The Institute for Health • Increased availability of contributing survey data Metrics and Evaluation then used these estimates to • Generation of estimates at higher spatial resolutions. Map 13.2 Distribution of DALYs for Soil-Transmitted Helminth Infections, per 100,000 Population IBRD 42566 | OCTOBER 2016 <5 5–50 50–100 100–200 >200 Nonendemic Data not available Sources: IHME (Institute for Health Metrics and Evaluation). 2014. “Global Burden of Disease Study 2013: Age-Specific All-Cause and Cause-Specific Mortality 1990–2013.” IHME, Seattle, Washington. Note: DALY = disability-adjusted life year. Soil-transmitted helminths include hookworm, roundworm, and whipworm. Mass Deworming Programs in Middle Childhood and Adolescence 167 168 Child and Adolescent Health and Development Table 13.1 Total Population, Number of Infected Persons, and Overall Prevalence, 2015 Number of Persons Infected (millions) Overall Prevalence (95% CI) (95% CI) Total population Hookworm Roundworm Whipworm Any STH Indicator (millions) (millions) (millions) (millions) (millions) Hookworm Roundworm Whipworm Any STH Preschool age (younger than age five years) Middle East and 55.6 0.3 1.9 0.6 2.5 0.5 3.4 1.2 4.6 North Africa (0.2–0.3) (1.2–2.8) (0.4–1.0) (1.7–3.7) (0.3–0.6) (2.2–4.9) (0.8–1.7) (3.1–6.6) Latin America and 54.5 1.7 5.3 4.6 10.1 3.2 9.7 8.5 18.4 the Caribbean (1.1–2.6) (3.1–8.4) (2.9–7.1) (6.3–14.8) (2.0–4.8) (5.7–15.4) (5.3–13.0) (11.6–27.2) Sub-Saharan Africa 210.7 12.5 17.8 13.4 37.4 5.9 8.4 6.4 17.7 (7.7–19.1) (10.6–27.8) (7.7–21.5) (23.1–55.3) (3.7–9.1) (5.0–13.2) (3.7–10.2) (11.0–26.3) East Asia and Pacific 151.0 14.6 13.4 12.5 34.1 9.6 8.8 8.1 22.6 (8.9–22.6) (7.0–22.5) (6.8–20.2) (20.2–51.6) (5.9–14.9) (4.7–14.9) (4.5–13.4) (13.4–34.2) South Asia 172.4 7.5 20.0 6.8 30.0 4.4 11.6 4.0 17.3 (4.8–11.1) (11.8–30.6) (4.0–11.0) (18.4–43.6) (2.8–6.4) (6.8–17.8) (2.3–6.4) (10.7–25.3) Total 644.2 36.6 58.4 37.9 114.1 5.7 9.1 5.9 17.8 (22.7–55.7) (33.9–93.0) (21.7–60.8) (70.0–170.0) (3.5–8.7) (5.3–14.4) (3.4–9.4) (10.9–26.4) School age (ages 5–14 years) Middle East and 94.4 0.7 5.0 1.8 6.8 0.7 5.3 1.9 7.2 North Africa (0.4–0.9) (3.4–7.2) (1.2–2.6) (4.6–9.6) (0.5–1.0) (3.6–7.6) (1.2–2.8) (4.9–10.2) Latin America and 107.0 4.5 15.0 13.0 27.3 4.2 14.0 12.2 25.5 the Caribbean (2.9–6.8) (9.4–22.6) (8.5–19.2) (18.1–38.4) (2.7–6.3) (8.8–21.1) (7.9–17.9) (16.9–35.9) Sub-Saharan Africa 354.3 34.0 47.2 36.4 94.8 9.6 13.3 10.3 26.7 (21.6–50.4) (30.0–70.1) (22.2–55.5) (62.7–131.0) (6.1–14.2) (8.4–19.8) (6.3–15.7) (17.7–37.0) East Asia and Pacific 294.0 44.3 34.2 32.0 88.0 15.1 11.6 10.9 30.0 (27.8–63.2) (18.5–55.8) (18.7–50.8) (55.1–127.1) (9.4–21.5) (6.3–19.0) (6.4–17.3) (18.7–43.2) South Asia 343.0 24.7 63.0 21.7 90.5 7.2 18.3 6.3 26.4 (16.3–35.4) (39.1–91.5) (12.8–33.7) (59.5–124.3) (4.7–10.3) (11.4–26.7) (3.7–9.8) (17.3–36.2) Total 1,192.8 108.2 164.4 105.0 307.4 8.9 13.9 8.8 25.9 (68.0–156.6) (100.6–249.2) (63.3–161.9) (200.7–432.4) (5.7–13.1) (8.4–20.9) (5.3–13.6) (16.8–36.2) Source: Adapted from Pullan and others 2014. Note: CI = confidence interval; STH = soil-transmitted helminth. Numbers in parentheses indicate range at 95 percent confidence interval. Table 13.2 DALYs per 100,000 Population, by Region and Type of Soil-Transmitted Helminth DALYs per 100,000 Hookworm Roundworm Whipworm Preschool age (younger than age 5 years) Middle East and North Africa 4.2 (2.4–6.4) 14.3 (9.9–19.7) 0.0 (0.0–0.1) Latin America and the Caribbean 21.8 (13.1–34.1) 34.1 (24.6–46.1) 8.2 (4.3–15.2) Sub-Saharan Africa 39.7 (25.3–59.7) 143.2 (117.6–173.7) 6.5 (3.7–10.6) East Asia and Pacific 21.7 (13.4–34.2) 19.7 (13.3–28.9) 7.3 (3.3–14.0) South Asia 19.3 (11.4–29.8) 43.1 (32.2–58.0) 2.0 (0.9–3.8) School age (ages 5–14 years) Middle East and North Africa 7.3 (4.4–11.0) 4.8 (2.7–8.2) 0.1 (0.0–0.3) Latin America and the Caribbean 73.7 (47.0–107.7) 19.2 (10.7–31.8) 16.9 (8.7–30.2) Sub-Saharan Africa 80.7 (51.8–120.2) 33.7 (22.5–49.6) 18.1 (10.0–30.2) East Asia and Pacific 52.7 (34.0–78.5) 11.6 (6.0–20.9) 14.4 (6.3–28.5) South Asia 38.1 (22.8–58.4) 36.6 (21.4–60.6) 5.2 (2.5–9.5) Source: Institute for Health Metrics and Evaluation, Global Health Data Exchange, http://ghdx.healthdata.org/. Note: CI = confidence interval. Numbers in parentheses indicate range at 95 percent CI. Results are still limited by the paucity of recent data, sanitation programs, especially in poor communities. It especially for much of Asia. These prevalence estimates seems probable that the targeting of more than 1 billion were informed by a comprehensive review of population- deworming treatments a year in poor communities has based surveys conducted between 1980 and 2010. also contributed. More contemporary surveys and However, a number of coordinated efforts have been joined-up databases are needed for reliable estimates, underway recently to scale up and complete the mapping but crude estimates suggest that the number of school- for neglected tropical diseases (NTDs), including STHs. age children living with worm infection was cut in half It will be important to ensure that future revisions of the from 2010 to 2015. Global Burden of Diseases, Injuries, and Risk Factors Study incorporate these new prevalence estimates when producing revised DALYs for STHs. Map 13.3 shows the current distribution of STH SCALE OF DEWORMING PROGRAMS infections. These infections were historically prevalent Deworming programs have long been popular with in many parts of the world where they are now public health teams and the people exposed to infection. uncommon. These areas include parts of Europe; Norman Stoll’s “This Wormy World” provided a clear Japan; the Republic of Korea; Taiwan, China; and the vision of the ubiquity of infection and the scale of Caribbean and North America (Mexico and the United deworming programs in the then-endemic areas, States), where sustained control efforts and economic including the U.S. South (Stoll 1947). Since the begin- development have led to their elimination, at least as a ning of the twentieth century, schools have been viewed public health problem (Hong and others 2006; as the natural base for programs because they provide Kobayashi, Hara, and Kajima 2006; Tikasingh, Chadee, an existing infrastructure to reach the age group for and Rawlins 2011). The distribution of worm species whom infection is often most intense and who might also reflects social and environmental factors, with benefit the most from deworming at a stage when they greater transmission of hookworm infection in rural are still learning and growing (Bundy, Schultz, and areas, and greater prevalence of roundworm and others 2017, chapter 20 in this volume). In Dakar in whipworm in periurban environments (Pullan and 2000, at the World Education Forum that relaunched Brooker 2012). the Education for All program, the role of schools in The distribution of STH infection is declining, par- delivering health programs, including deworming, was tially as a result of global economic development, declin- reinvigorated by the launch of the global partnership ing poverty, and greater access to health services and Focusing Resources on Effective School Health (FRESH). Mass Deworming Programs in Middle Childhood and Adolescence 169 Map 13.3 Distribution of Soil-Transmitted Helminth Infection Prevalence for Children Younger than Age 15 Years, by Species, 2015 a. Hookworm IBRD 42567 | OCTOBER 2016 b. Roundworm map continues next page 170 Child and Adolescent Health and Development Map 13.3 Distribution of Soil-Transmitted Helminth Infection Prevalence for Children Younger than Age 15 Years, by Species, 2015 (continued) c. Whipworm <1 1–10 10–20 20–50 >50 Nonendemic Data not available Source: Adapted from Pullan and others 2014 and updated to 2015. Note: Based on geostatistical models for Sub-Saharan Africa and empirical data for all other regions. FRESH was given greater vitality a year later when the three commonly used anthelmintics, the World Health World Health Assembly endorsed a target of deworming Organization (WHO) reports that approximately 75 percent of schoolchildren in member states with 564 million children (150 million preschool-age chil- endemic STH infections. The FRESH principles con- dren and 416 million school-age children) were tinue to guide school health programs and are still being treated with albendazole or mebendazole for STHs used and cited, for example, in the strategic plan for (WHO 2015a) (table 13.3). While 556.2 million per- national deworming announced in Ethiopia in 2012. sons (including approximately 36 million preschool- From these beginnings, deworming, especially school- age children and 139 million school-age children) based deworming, has become a major public health were treated with albendazole under MDA programs program. In the London Declaration on Neglected targeting elimination of lymphatic filariasis (WHO Tropical Diseases announced in 2012, 14 pharmaceutical 2015b), approximately 113.2 million persons were companies committed to donating medicines for 10 of treated with ivermectin under the onchocerciasis the most prevalent NTDs, including STHs. The specific elimination program in Africa (WHO 2015a). These donations for STHs are targeted at school-age children figures suggest that in 2015, more than 1 billion per- and comprise 400 million treatments of albendazole sons were treated with drugs that are efficacious (GlaxoSmithKline) and 200 million treatments of meb- against STHs during the course of just one year. endazole (Johnson & Johnson). Medicines donated for The official estimates of treatment coverage in school- other purposes, such as ivermectin for onchocerciasis age children continue to show relatively low, albeit rising, and lymphatic filariasis, are also effective against STHs, levels of coverage, estimated to be about 45 percent in 2014 and additional albendazole is donated specifically for (figure 13.1 and table 13.3). These estimates are based on lymphatic filariasis. the donated drugs provided through WHO mechanisms, This progress adds up to a substantial volume of expressed as a proportion of the world’s school-age treatments efficacious against STHs. In 2015, the latest children. Both the supply (that is, the numerator) and date for which treatment data are available for all the demand (that is, the denominator) continue to rise Mass Deworming Programs in Middle Childhood and Adolescence 171 Table 13.3 Total Number of Preschool-Age and School-Age Children Estimated to Require Preventive Chemotherapy for Soil-Transmitted Helminths, by WHO Region, 2009 and 2015 2009 2015 Requiring PC for Receiving PC for Regional Requiring PC for Receiving PC for Regional WHO region STHs (millions) STHs (millions) coverage (%) STHs (millions) STHs (millions) coverage (%) African 283.8 91.0 32 298.0 153.0 51 Americas 45.5 21.1 46 46.9 24.3 52 Eastern Mediterranean 78.0 2.5 3 74.4 17.9 24 European 4.3 0.4 9 2.3 0.5 23 South-East Asia 372.0 144.8 39 354.4 172.1 49 Western Pacific 99.1 14.1 14 75.2 32.4 43 Total 882.7 273.9 31 851.2 400.2 47 Source: WHO 2011, 2016. Note: PC = preventive chemotherapy; STHs = soil-transmitted helminths; WHO = World Health Organization. Figure 13.1 Reported Global Coverage of Preschool- and School-Age self-administered treatments in the unprogrammed cate- Children, 2003–14, with a Projection to the 2020 Target of 75 Percent gory that go unreported. The scale of actual treatment of Coverage schoolchildren in any year could easily be twice that 80 reported in the official statistics. 70 60 HEALTH IMPACT OF WORMS AND 50 DEWORMING Coverage (%) 40 Although the WHO recommends MDA for vulnerable groups, such as children and pregnant women, who live 30 in areas with endemic intestinal worm infection, a series of reviews from both the Cochrane Collaboration (most 20 recently, Taylor-Robinson and others [2015]) and the 10 Campbell Collaboration (Welch and others 2016) argues that there is substantial evidence that mass deworming 0 does not produce health benefits and does not support 2000 2005 2010 2015 2020 2025 the use of MDA. How can these two views be reconciled? Year Preschool-age children School-age children Source: Adapted from figure 1 of Trusscott, Turner, and Anderson 2015. The data on reported Substantial Historical Literature on the Clinical coverage are from the World Health Organization, “Neglected Tropical Diseases: PCT Databank,” Consequences of STH Infection http://www.who.int/neglected_diseases/preventive_chemotherapy/lf/en/. Note: Figure shows the treatment coverage of preschool-age and school-age children up to 2014. The clinical literature, gathered over the early part of The dashed lines are indicative of the change necessary to reach the goal of 75 percent the last century, shows significant impacts of intense treatment by 2020. STH infection on health. Through collation of data from several different studies that described the occur- leading to little change in coverage year over year reported rence of Ascaris-induced intestinal obstruction in spe- by the WHO. These estimates report the number of doses cific regions of endemic countries, and studies on the that are donated specifically for school-based deworming community prevalence of ascariasis in the same regions, (about 379 million tablets in 2015); they do not report the the incidence of Ascaris-induced intestinal obstruction number of other donated drugs that are efficacious against was shown to clearly increase, in a nonlinear fashion, as STHs (an additional 900 million doses in 2014) or the community prevalence of infection increased (de Silva, large number of nongovernmental organization and Guyatt, and Bundy 1997a). Similar data collations 172 Child and Adolescent Health and Development showed patients with acute intestinal obstruction due medium-term consequences for growth and develop- to ascariasis harbored more than 60 worms in most ment. Furthermore, for each of these infections, cura- instances, with a 10-fold higher worm burden in fatal tive treatment leads to alleviation of the immediate cases. Children younger than age five years were shown symptoms as well as to accelerated gains in growth to develop obstruction with much smaller worm bur- and development, indicating that the pathology of dens (de Silva, Guyatt, and Bundy 1997b). A model of worm infection can largely be reversed if treated in a the global numbers at risk of morbidity and death due timely manner. to ascariasis estimated that in 1990, some 11.5 million This literature, now largely historical, on clinical trials children were at risk of clinically overt acute illness and of patients with known and intense infection compared that some 200,000 children developed serious compli- with untreated controls, offers convincing evidence on cations such as intestinal obstruction, biliary or pan- both the effect of infection on patients and the benefits creatic disease, appendicitis, and peritonitis, resulting of treatment. Such trials should no longer be conducted in about 10,000 deaths each year (de Silva, Chan, and because it would be unethical to withhold treatment Bundy 1997). from patients known to be infected. Evidence also points to the effects of Trichuris infec- tion on growth and development of infected children, in particular in those children who have a heavy burden of Impact of Current MDA-Based Trial Design infection. Reports from Jung and Beaver (1951) described The majority of deworming trials today are designed dysentery, diarrhea, and colitis in children with Trichuris quite differently from traditional clinical trials. They are infection; heavily infected children more frequently pre- based on the operational design of deworming pro- sented with the more severe symptom of rectal prolapse. grams, in which MDA covers all of the target popula- This heavy infection can lead to a well-described tion, usually an age class, living in an area where Trichuris dysentery syndrome, characterized by dysen- infection is endemic, with no measure of individual tery, anemia, growth retardation, finger clubbing, rectal infection status or intensity. Because infection intensity prolapse, and a specific trichuriasis colitis (Cooper and is overdispersed, such that most people have lower- Bundy 1988). Furthermore, curative treatment for para- than-average infection and a minority have intense site infection leads to rapid alleviation of these symp- infection (figure 13.2), there will be considerable and toms (Cooper and Bundy 1988; Jung and Beaver 1951). unknown variance in the intensity of individual infec- Studies have recorded significant catch-up growth in tion. Because the intensity is unknown in any individual, middle childhood—especially ages four to eight years— so too is the likelihood of morbidity and the potential following curative treatment, with significant increases scale of benefit from treatment. With the current trial in height and weight as well as improvements in cogni- design, the population outcome can only be measured as tion (Callender and others 1998; Cooper and others some average of individual benefits. Even were there to 1990; Cooper and others 1995; Nokes and others 1992). be considerable benefit for the minority of intensely Anemia is associated with trichuriasis colitis and is infected individuals, if there is little or no benefit for the the defining characteristic of hookworm infection. On majority with light infections then the average effect will maturation and migration to the gut, hookworms attach be small. The underlying situation across the population to the intestinal mucosa and submucosa, rupturing cap- is unknowable with current MDA-based trial designs. illaries mechanically as well as through release of anti- To illustrate what the analyses show in practice, we clotting agents to maintain blood flow (Hotez and compare two comprehensive analyses drawing on the others 2004). The development of anemia is related to same small pool of trials available in this area of research. infection intensity as well as to the duration of infection In the first analysis, Taylor-Robinson and others (2015) and nutritional status of individuals (Crompton and examined both randomized trials of universal deworming Whitehead 1993; Hall and others 2008). A seminal trial programs, which include children both with and without by Stoltzfus and others (1997) showed a significant asso- worms, and studies among groups of infected children ciation between hookworm infection and severe ane- already screened and diagnosed. They then conducted mia, as well as iron deficiency over and above dietary formal meta-analysis for eight outcomes: weight, intake of iron. The authors predicted that eliminating height, middle-upper-arm circumference, triceps skinfold hookworm infections from their study population could thickness, subscapular skinfold thickness, body mass lead to a reduction in anemia of 25 percent and severe index, hemoglobin, and school attendance. They con- anemia by as much as 73 percent. cluded that, while targeted deworming of infected chil- Thus, the pathology for each of these helminth dren may increase weight gain, for mass deworming infections can be severe in both immediate effects and programs that cover children with and without worms, Mass Deworming Programs in Middle Childhood and Adolescence 173 Figure 13.2 Distribution of Worm Burden a. Individual worm burden in a population 0.25 0.20 0.15 Probability 0.10 0.05 0 10 20 30 40 50 60 70 Worm burden b. Average worm burden, by age Roundworm (worm burden) Whipworm (epg) Hookworm (epg) 20 600 50 500 (worms or epg) Mean intensity 15 40 400 30 10 300 20 200 5 10 100 0 0 0 <5 9 9 9 4 + 9 4 4 4 9 + 1 4 <5 9 9 9 4 + 5– –1 –2 –4 45 5– –1 –2 –3 –4 50 0– 2– 5– –1 –2 –4 45 10 20 30 10 15 25 35 10 20 30 Age group (years) Age group (years) Age group (years) c. Example of model fitting to repeat time points 12 10 Mean worm burden 8 6 4 2 0 0–4 5–9 10–19 20–29 30–44 45–70 Age group (years) Data Model Sources: Panel a, adapted from Hollingsworth, Truscott, and Anderson 2013; panel b, adapted from Truscott and others 2014; panel c, adapted from Truscott, Turner, and Anderson 2015. Note: epg = eggs per gram of stool. Worm burden indicates the expected number of worms harbored by an individual. “There is now substantial evidence that [mass treatment In the other analysis, Croke and others (2016) aug- of all children in endemic areas] does not improve average mented Taylor-Robinson and others’ (2015) sample [emphasis added] nutritional status, hemoglobin, cogni- with information from published studies as well as tion, school performance, or survival” Taylor-Robinson several excluded studies and then conducted meta- and others (2015, 2). They included a maximum of 11 analysis on this augmented sample. Focusing on weight estimates from 10 trials for weight gain, with many fewer gain, for which the number of available studies is trials for most of the other outcome measures. greatest, they noted that the appropriate test for the 174 Child and Adolescent Health and Development hypothesis of no treatment effect in all cases is a individual morbidity and infection intensity. One fixed-effect meta-analysis. Using this model, the important point is that the targeted treatment trials are hypothesis of zero weight gain from deworming was also the earlier trials: detecting average effects in popu- rejected at the 10 percent level using the original data lations will only become more difficult as infection from the Taylor-Robinson and others (2015) study. levels continue to decline. Using the augmented sample, they found a 0.111 kilo- gram weight gain (p < 0.001) from deworming in a fixed-effects model and a 0.134 kilogram weight gain OPTIMIZING PROGRAM DESIGN BY (p = 0.01) in a random-effects model. MODELING POPULATION DYNAMICS Noting that including trials from settings with mini- mal STH prevalence and mass deworming is not recom- Both chapters on deworming in the earlier editions of mended because such a policy may minimize the Disease Control Priorities emphasized the importance estimated impact of deworming, they then estimated of understanding population dynamics as a determinant positive and statistically significant impacts in settings in of good program design (Hotez and others 2006; Warren which the WHO recommends multiple doses of mass and others 1993). This section explores how the popula- treatment annually (greater than 50 percent prevalence), tion dynamics modeling is being used to optimize pro- and in settings where the WHO recommends mass gram design and, in particular, what the modeling says deworming at least once per year (greater than 20 percent about the value of MDA versus screen and treat and of prevalence). For high- and medium-prevalence areas school-based deworming versus universal coverage. (greater than 50 percent prevalence of any single STH A common epidemiological feature of STH infec- species), the fixed-effects estimate was 0.157 kilogram, tions is the overdispersed distribution of worms while the random-effects estimate was 0.182 kilogram. (figure 13.2, panel a): while many people have a For trials in settings with greater than 20 percent preva- medium to low burden of infection, a minority of lence, the fixed-effects estimate was 0.142 kilogram, while people have a high burden of infection. Because of the the random-effects estimate was 0.148 kilogram. linear relationship between infection intensity and Accordingly, while Taylor-Robinson and others morbidity, individuals with high burdens are most (2015) highlighted an apparent contradiction between likely to suffer health impacts of STHs, to contribute the evidence on treatment of infected individuals (evi- the largest number of infectious eggs, and to be rein- dence of benefit) and mass treatment (no evidence of fected following mass treatment, raising the possibility benefit), Croke and others (2016) demonstrated that that targeting these individuals would be the most mass deworming also has evidence of benefit, albeit of effective way to control both the health impact and the smaller magnitude than the effects identified in targeted transmission of STHs. However, this approach has studies. Evidence for this benefit is particularly strong in some practical challenges. high- and medium-prevalence settings. The estimated weight gain in these universal treatment studies is nota- • First, commonly used diagnostics—wet smear in bly smaller than in studies of individuals known to be saline or Kato-Katz examination of stool samples to infected—on the order of 0.13 and 0.75 kilogram, count eggs—are poor diagnostics of the underlying respectively—which would be the logical consequence worm burden because of both variations in egg out- of averaging across a population with an overdispersed put and the nonlinear relationship to worm burden distribution of intensity of infection and probability of (Anderson and Schad 1985). morbidity. • Second, selective diagnosis and treatment involves The similar results but very different conclusions of expensive fieldwork, including collecting and ana- these two analyses of the same trial datasets may be lyzing stool samples and finding, reidentifying, and helpful for understanding the paradoxical literature in treating highly infected individuals (see next section the deworming area. Both analyses found effects with on costs). targeted treatment trials, as is well documented in the • Third, the nature of the overdispersed distribution clinical literature. Both analyses found small effects on means that a large proportion of the population weight gain (the measure for which most trials are has to be sampled to detect the few who have to be available for meta-analysis) when exploring the effects treated. across whole populations with unknown distribution of infection intensity—finding these effects significant The few field studies that have been performed have in one analysis and not significant in the other. Resolving found that selective treatment of persons with high par- this debate requires exploring the distribution of asite burden is less effective than mass treatment at Mass Deworming Programs in Middle Childhood and Adolescence 175 reducing population-level prevalence (Asaolu, Holland, adults is likely to be required to break transmission, anal- and Crompton 1991); that mass treatment is more yses have shown that in many settings the higher cost of cost-effective than selective treatment (Holland and oth- coverage is offset by the lower number of rounds ers 1996); and that school-based deworming is a highly required, given that treatment can be stopped when cost-effective way to reduce anemia (Brooker and others transmission has been permanently interrupted (Lo 2008; Guyatt and others 2001) in particular settings, and others 2015; Turner and others 2015; Turner and reflecting the results of modeling studies (Guyatt, Bundy, others 2016). and Evans 1993) and a recent review of costs and cost- This section considers two issues: how treatment can effectiveness (Turner and others 2015). Current evidence bring down intensity and morbidity, and how treatment suggests that the most cost-effective way to reduce might break transmission. Empirical evidence is avail- high-burden infections in children is through school- able for the former, but caution should remain about based deworming rather than selective treatment. the latter. Although MDA has proven to be effective Epidemiological studies have also found indirect with onchocerciasis and lymphatic filariasis, these dis- benefits to mass treatment of children, such as reduc- eases have much slower epidemic growth rates than do tions in prevalence of infection in untreated adults STHs, and both require vectors for transmission rather (Asaolu, Holland, and Crompton 1991; Bundy and than fecal contamination of the environment with others 1990). These indirect effects have been found for infective stages. roundworm and whipworm, but different effects were found in different settings, reflecting local differences in prevalence and distribution of infection. The population-level impact of a school-based deworming ESTIMATED COST OF MDA program and the impact on transmission to other One of the main arguments for deworming, and the members of the community and reinfection after treat- basis of the WHO recommendation for the use of MDA, ment depend on the epidemiology of the parasite, effi- especially school-based deworming, is the cost-effectiveness cacy of the treatments, age distribution of the arising from an exceptionally low-cost intervention population, and coverage of the treatment program. delivered infrequently without the need for costly screen- For roundworm and whipworm, the highest burden of ing. The value for money of this approach for low- infection is usually in children (figure 13.2, panel b); income countries has recently been greatly enhanced by therefore, a school-based program covering preschool- the availability of donated treatments. This section and school-age children could have a large impact on explores the costs in more detail. transmission, particularly in settings with a high pro- MDA offers notable economies of scale (Brooker and portion of school-age population, provided the treat- others 2008; Evans and others 2011) because the cost ment used is effective for whipworm (Chan and others per treatment decreases as the number treated rises 1994; Turner and others 2016) and prevalence is at (figure 13.3, panel a). This effect occurs because some of moderate to low levels. For hookworm, the burden of the most significant costs associated with MDA delivery infection tends to be higher in adults; therefore, a are fixed and do not depend on the number treated: school-based deworming program is likely to be less increasing the number treated therefore reduces the effective at reducing both morbidity (Coffeng and oth- average fixed cost per treatment (Turner and others ers 2015; Truscott, Turner, and Anderson 2015) and 2016). These economies of scale may account for transmission at the population level (Anderson, much of the observed variation in the costs of delivering Truscott, and Hollingsworth 2014; Anderson and oth- NTD treatment (Turner and others 2015). ers 2013; Anderson and others 2015; Chan and others Table 13.4 lists the costs of STHs delivered through 1994). However, systematically excluding a portion of a variety of MDA program designs. Integrating STH the community from treatment can undermine elimi- programs with other NTD programs or indeed other nation programs (Coffeng and others 2015), although control programs, such as child health days, can pro- it also helps slow the emergence of drug resistance. duce economies of scope, by which the average cost Many of these results are from mathematical model- per treatment declines as a result of delivering two or ing studies, which have become more complex in recent more interventions at once (figure 13.3, panel b); for years. An important development has been the valida- example, integrating NTD programs reduces the over- tion of models against repeat time-point data (figure 13.2, all cost between 16 percent and 40 percent (Evans and panel c); these models are being expanded to include others 2011; Leslie and others 2013). Furthermore, the the most recent data (Coffeng and others 2015; Truscott, incremental cost of adding deworming into estab- Turner, and Anderson 2015). Given that coverage of lished immunization campaigns or child health days 176 Child and Adolescent Health and Development Figure 13.3 Observed Economies of Scale and Scope Associated with Preventive Chemotherapy a. Cost per school-age child treated b. Cost per person treated in single drug administration compared with triple drug administration 0.80 0.25 Cost per person treated (US$) Delivery cost per child (US$) 0.20 0.60 0.15 0.40 0.10 0.20 0.05 0 10,000 20,000 30,000 40,000 0 100,000 200,000 300,000 400,000 Number treated Number treated 2003 2004 2005 Stand-alone treatment Integrated control (triple drug administration) Sources: Panel a, data from Brooker and others 2008; panel b, data from Evans and others 2011. Note: Triple drug administration refers to the co-administration of albendazole, ivermectin, and praziquantel on a single delivery platform in communities where multiple neglected tropical diseases are prevalent. Table 13.4 Key Preventive Chemotherapy Costing Studies Using Albendazole and Mebendazole Target of Primary distribution Study Country intervention method Results Brooker and others Uganda STHs and SCH School based The overall economic cost per child treated in the six districts was 2008 (annually) US$0.54, which ranged from US$0.41 to US$0.91 (delivery costs: US$0.19–US$0.69). The overall financial cost per child treated was US$0.39. Costs are in 2005 US$. Goldman and Multicountry LF (and STHs Community based The financial cost per treatment ranged from US$0.06 to US$2.23. others 2007 study indirectly) (annually) Costs are in 2000–03 US$ (base year 2002). Evans and others Nigeria STHs, SCH, Community based In 2008, school-age children in eight local government areas received 2011 LF, and (annually) a single round of ivermectin and albendazole followed at least one onchocerciasis week later by praziquantel. The following year, a single round of triple drug administration was given, reducing the programmatic costs for MDA, not including drug and overhead costs, 41 percent (from US$0.078 to US$0.046 per treatment). Costs are in 2008–09 US$. Goldman and Haiti STHs and LF School based and The cost per treatment was US$0.64, including the value of donated others 2011 community based drugs. The program cost, excluding the value of the donated drugs, (annually) was US$0.42 per person treated. Costs are in 2008–09 US$. Leslie and others Niger STHs and SCH School based and The full economic cost of delivering the school-based and 2011 community based community-based treatment was US$0.76 and US$0.46, (annually) respectively. Including program costs alone, the values were US$0.47 and US$0.41, respectively. Costs are in 2005 US$. Leslie and others Niger STHs, SCH, LF, School based and The average economic cost of integrated preventive chemotherapy 2013 and trachoma community based was US$0.19 per treatment, excluding drug costs. The average (annually) financial cost per treatment of the vertical SCH and STH control program (before the NTD programs were integrated) was US$0.10. Costs in are 2009 US$. table continues next page Mass Deworming Programs in Middle Childhood and Adolescence 177 Table 13.4 Key Preventive Chemotherapy Costing Studies Using Albendazole and Mebendazole (continued) Target of Primary distribution Study Country intervention method Results Boselli and others Lao PDR STHs within a Child health days The incremental cost of adding deworming into the national 2011 child health day (annually) immunization campaign was US$0.03 per treatment (delivery costs: campaign US$0.007). The cost per treatment for the vertical school-based national deworming campaign (targeting school-age children) was US$0.23. Costs are in 2009 US$. Fiedler and Uganda STHs within Child health days (one The average economic cost per child reached by the child health day Semakula 2014 a vitamin A round) program was US$0.22 (per round). Costs are in 2010 US$. supplementation campaign Note: LF = lymphatic filariasis; MDA = mass drug administration; NTD = neglected tropical disease; SCH = schistosomiasis; STHs = soil-transmitted helminths. For a more detailed summary of cost data for preventive chemotherapy, see Keating and others (2014) and Turner and others (2015). with an already developed delivery infrastructure is in previously endemic areas of North America (Mexico very small—approximately US$0.03 per treatment and the United States), Japan, Korea, and upper- (Boselli and others 2011)—and much lower than middle-income countries throughout southern and delivering treatment through vertical national eastern Asia. deworming programs (Turner and others 2015); how- This trend accelerated during the past decade, espe- ever, it may target younger children only and not cially in the poorest countries where infection was previ- access the age group with intense infection. This pos- ously most intense. Estimates are crude, but suggest that sibility highlights the critical need to consider the local infection prevalence in school-age children was halved context of NTD control programs when comparing between 2010 and 2015. Efforts are underway to provide the reported costs of MDA. more extensive and more accurate surveys of infection status, supported by the creation of integrated databases that provide contemporary estimates of infection and treatment coverage. Efforts to monitor the potential CONCLUSIONS emergence of drug resistance in treated populations are STH deworming programs are among the largest pub- also increasing. lic health programs in low- and lower-middle-income Much of the treatment is delivered through schools countries as measured by coverage. The actual scale of and targets school-age children. In 2015, India had the these programs is unknown but is substantial; more largest public health intervention ever conducted in a than 1 billion donated doses of medicines effective single day, deworming 89 million schoolchildren during against STHs are delivered by formal programs and the Annual School Deworming Day. The target for 2016 supplemented by widespread self-treatment and is 270 million schoolchildren. Modeling suggests that unprogrammed activities. Deworming is one of the expanding programs to include other age groups might most common self-administered treatments in low- break transmission, and studies are exploring the utility income countries; there is no question that there is of this approach in practice. Increasingly, countries are strong community demand for this intervention. The combining MDA for lymphatic filariasis and STHs since large majority of formal MDA programs for STHs is both use the same anthelmintics. school based. STH infection has been shown to be associated with STH infection is declining worldwide, likely reflecting clinical and developmental outcomes that are largely the influence of improved hygiene and sanitation associ- reversible by treatment (box 13.1). Both historical and ated with global declines in poverty. The decline also contemporary trials of targeted treatment of individuals reflects control efforts during the twentieth century that known to be infected have also demonstrated benefit have largely eliminated STHs as a public health problem from treatment. 178 Child and Adolescent Health and Development Box 13.1 WHO Recommendations for the Control of Morbidity Attributable to Soil-Transmitted Helminths Present recommendations exceeds 50 percent. The PC strategy is being imple- Since 2001, the World Health Organization (WHO) mented worldwide; in 2015, more than 50 percent of has recommended, for the prevention and control preschool children and more than 63 percent of school- of the morbidity due soil-transmitted helminth age children in areas endemic for STHs were treated (STH) infection, the implementation of preventive with anthelmintics. chemotherapy (PC) in the form of periodical, large- scale administration of anthelmintics to population Updating the recommendations groups at risk of morbidity due to infection. A WHO Guideline Review Committee (GRC) com- Children and women of childbearing age are consid- prising independent experts met in Geneva in April ered the population groups with the highest risk of 2016 to reassess the WHO recommendations on morbidity from STH infection, because they are in a STHs control in light of scientific and programmatic period of life in which they are particularly vul- evidence cumulated during the last 15 years of PC nerable to nutrient deficiencies associated with interventions. The conclusions of the GRC are pres- infection. ently being finalized and are expected to be published The current recommendation is for treatment once a in early 2017. year when the prevalence of STH infection is more than 20 percent and twice a year when prevalence Source: WHO 2001. The findings of a small group of more recent clinical The controversy in this area has extended from the trials based on MDA have been controversial. These tri- results themselves to their policy implications. There is als measure average change in health metrics for the general agreement that STH infection can affect health, whole population treated, irrespective of the infection but disagreement regarding the circumstances that status of individuals. Since morbidity is related to inten- would justify an MDA program. While this debate con- sity, and intensity has an overdispersed distribution in tinues, demand for MDA is continuing in the endemic populations, the average change in health metrics likely countries and self-treatment is continuing on a massive reflects the outcomes for a majority of people who are scale. The debate would benefit from quantitative pol- lightly infected and may derive limited benefit from icy analysis setting out the population parameters that treatment and for a minority who are more intensely would and would not justify an MDA approach (see infected and may derive greater benefit. The actual dis- chapter 29 in this volume, Ahuja and others 2017, for tribution of intensity and infection in these trial popula- an example of how this analysis has been approached tions is unknown because individual screening is not from an economic perspective). The trend toward inte- necessary for MDA. The controversy arises because the grated MDA programs that target both lymphatic filar- change when averaged across the whole population is iasis and STHs would also change the policy question typically small, and there are insufficient data to deter- being asked. mine with confidence whether the small size of the Looking to the future, we can expect infection levels change reflects the underlying population distribution to continue to decline as a result of the combination of or the scale of benefit. An additional factor is that these high levels of treatment and continuing economic devel- more recent trials are conducted against the background opment trends in poor communities. We can also hope of successful control efforts and the correspondingly low for a resolution of the worm wars as methods for assess- intensity of infection in most of the study populations. ing impact improve to reflect epidemiological realities, Studies are now being designed that aim to separate but this goal may be compromised if levels of impact these factors. continue to fall with sustained control. Mass Deworming Programs in Middle Childhood and Adolescence 179 NOTE Helminth Control in Uganda: Intra-Country Variation and Effects of Scaling-Up.” Health Policy and Planning 23 (1): 24–35. World Bank Income Classifications as of July 2014 are as fol- Brooker, S., and E. 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Filariasis: Progress Report, 2014.” Weekly Epidemiological 2014.“Can Chemotherapy Alone Eliminate the Transmission Record 90 (38): 489–504. of Soil Transmitted Helminths?” Parasites and Vectors 7: 266. ———. 2016. “Summary of Global Update on Preventative Truscott, J. E., H. C. Turner, and R. M. Anderson. 2015. “What Chemotherapy Implementation in 2015.” Weekly Impact Will the Achievement of the Current World Health Epidemiological Record 91 (39): 456–60. 182 Child and Adolescent Health and Development Chapter 14 Malaria in Middle Childhood and Adolescence Simon J. Brooker, Sian Clarke, Deepika Fernando, Caroline W. Gitonga, Joaniter Nankabirwa, David Schellenberg, and Brian Greenwood INTRODUCTION will increase the incidence of clinical attacks of malaria, including severe attacks, in school-age children (ages The age distribution of cases of malaria is influenced by 5–14 years). However, the epidemiology and manage- the intensity of transmission. In areas where the popu- ment of malaria in school-age children has, until recently, lation has low exposure to infection, malaria occurs in received little attention. This chapter reviews the current all age groups. In high transmission areas, in contrast, burden of malaria in school-age children, its clinical the main burden of malaria, including nearly all malar- consequences, and approaches to controlling the disease ia-related deaths, is borne by young children (figure in this increasingly vulnerable group. The review focuses 14.1). These different age patterns are seen because largely on Sub-Saharan Africa, in part because this exposure to repeated malaria infections induces some region has the greatest burden of malaria in school-age protection against subsequent attacks; but protection is children, but also because of the lack of information on rarely complete. the impact of malaria in school-age children in other The age pattern of clinical malaria is determined by parts of the world, including those where Plasmodium the level of transmission and the consequent level of vivax is the dominant malaria parasite. An earlier version acquired immunity, so it is sensitive to changes in the level of the review has been published (Nankabirwa, Brooker, of transmission (Carneiro and others 2010; Snow and and others 2014). Definitions of age groupings and others 1997). In many malaria-endemic areas, successful age-specific terminology used in this volume can be control programs have reduced the level of transmission found in chapter 1 (Bundy, de Silva, and others 2017). substantially (Noor and others 2014; O’Meara and others 2010; WHO 2015). Consequently, in such communities, the peak age of clinical attacks of malaria is shifting from PREVALENCE OF MALARIA PARASITEMIA IN very young to older children. In The Gambia, the peak age SCHOOL-AGE CHILDREN of hospital admission for severe malaria increased from 3.9 years in 1999–2003 to 5.6 years in 2005–07 (Ceesay The burden of malaria in school-age children is poorly and others 2008); similar changes have been seen in defined because this age group is not routinely included Kenya (O’Meara and others 2008). in household-based cluster surveys. Information on If the financial support for malaria control continues, the prevalence of malaria in this group is derived further decreases in the intensity of transmission can be mainly from school-based surveys and from World anticipated in many highly endemic areas; these decreases Health Organization (WHO) estimates (WHO 2015). Corresponding author: Brian Greenwood, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, United Kingdom; brian.greenwood@lshtm.ac.uk. 183 Figure 14.1 Age Distribution of Cases of Severe Malaria by Intensity of Malaria Marked seasonality No marked seasonality 5 Low transmission intensity 5 Low transmission intensity 4 4 3 3 2 2 1 1 0 0 Percentage of cases per month of age 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 5 Medium transmission intensity 5 Medium transmission intensity 4 4 3 3 2 2 1 1 0 0 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 5 High transmission intensity 5 High transmission intensity 4 4 3 3 2 2 1 1 0 0 0 1 2 3 4 5 6 7 8 9 10 0 1 2 3 4 5 6 7 8 9 10 Age in years Cerebral malaria Severe malarial anemia Respiratory disease Source: Roca-Feltrer and others 2010. Note: The figure shows the percentage distribution of each severe malaria syndrome by age for children under age 10 years according to seasonality and transmission intensity, such that the integral of the curve is equal to 100 percent of expected cases. Understanding the burden of malaria among school-age studies have been undertaken in older school-age children is essential to justify investment in school- children in Sub-Saharan Africa, and many of those are based malaria control interventions (Bundy and others out of date following improvements in malaria con- 2000) and to identify delivery mechanisms to help trol. In general, higher prevalence rates have been control malaria in this underserved population. observed in West and Central Africa than in East More than 500 million school-age children worldwide Africa, but a great deal of heterogeneity has been are at risk of malaria infection; 200 million of those at observed with rates ranging from less than 5 percent risk live in Sub-Saharan Africa (table 14.1) (Gething and to greater than 50 percent in different surveys. Recent others 2011). Annex 14A, table 14.1 summarizes the studies in Malawi have emphasized the burden of results of studies on the prevalence of asymptomatic malaria in school-age children and the role that those malaria parasitemia in this population. Map 14.1 shows children play in acting as a reservoir of infection the frequency with which malaria surveys have been (Mathanga and others 2015; Walldorf and others undertaken in school-age children, with an increase in 2015). recent years in East Africa. Map 14.2 shows the prevalence Few reports on the prevalence of asymptomatic observed in school-age children by geographical area. malaria in school-age children outside of Sub-Saharan The majority of malariometric surveys are con- Africa are available (annex 14A, table 14.1). In the ducted in children ages 2–10 years. Relatively few Republic of Yemen, Bin Mohanna, Bin Ghouth, and 184 Child and Adolescent Health and Development Table 14.1 Estimated School-Age (5–14 Years) Population at Risk of Plasmodium falciparum Malaria in Millions by Region,a 2010 Region Unstable risk Stable risk Total Andean Latin America 1.0 0.6 1.7 Caribbean 2.4 1.8 4.2 Central Asia 0.2 – 0.2 Central Latin America 3.9 2.3 6.2 Central Sub-Saharan Africa <0.1 26.1 26.1 East Asia 1.6 0.6 2.2 Eastern Sub-Saharan Africa 3.3 80.7 84.0 Middle East and North Africa 4.0 2.5 6.5 Oceania <0.1 1.4 1.4 South Asia 165.6 98.6 264.3 South-East Asia 37.8 31.6 69.4 Southern Sub-Saharan Africa 2.3 4.8 7.1 Tropical Latin America 4.6 1.7 6.3 Western Sub-Saharan Africa 1.6 86.8 88.4 World 228.5 339.5 568.0 Source: Adapted from Gething and others 2011; data provided by the Malaria Atlas Project (www.map.ox.ac.uk), with thanks to Pete Gething and Zhi Huang, University of Oxford. Note: – = not applicable. Rows may not add precisely due to rounding. a. Based on the Global Burden of Disease study, http://www.healthdata.org/sites/default/files/files/GBD_GBD2010_Regions_countries.pdf. Rajaa (2007) find a prevalence of 13 percent in children Mortality ages 6–11 years in the Hajr valley. In Latin America, The WHO estimates that there were approximately 438,000 malaria transmission is restricted to Amazonian areas (range 236,000–635,000) deaths from malaria in 2015; and is uniformly low. In Brazil, Vitor-Silva and others 90 percent of those deaths occurred in Sub-Saharan Africa (2009) find that P. vivax was more common than (WHO 2015). A comprehensive review of malaria-related P. falciparum among schoolchildren. On the Thai- deaths between 1980 and 2010 (Murray and others 2012) Burma border, Luxemburger and others (1994) find that reports many more deaths than the WHO; the review esti- 10 percent of school-age children were infected, mainly mates that 6 percent to 9 percent of malaria deaths occur with P. falciparum. in children ages 5–14 years, corresponding to an annual figure in the range of 70,000–110,000 deaths. A lower malaria mortality rate was found in school-age children IMPACT OF MALARIA ON THE HEALTH AND compared with younger children in Bangladesh and Sub- Saharan Africa (Adjuik and others 2006). A similar age DEVELOPMENT OF SCHOOL-AGE CHILDREN pattern was found in India, with an estimated malaria- Most school-age children with malaria parasitemia do related death rate of 29 per 1,000 in children ages 5–14 not have any symptoms because they have acquired years, compared with 55 per 1,000 in children under age 5 some immunity. However, asymptomatic infections years in 2005 (Dhingra and others 2010). can contribute to anemia and impairment of cognitive development. School-age children may be infected with a malaria parasite that expresses antigens to Incidence of Clinical Malaria in School-Age Children which they have not been exposed and to which they An estimated 214 million (range 149 million to 303 have little or no immunity; the result is the develop- million) cases of malaria occurred worldwide in 2015; ment of symptoms such as fever and, more rarely, more than 80 percent were in Sub-Saharan Africa (WHO severe diseases such as cerebral malaria, life- 2015). However, data on the incidence of clinical malaria threatening anemia, and death. in school-age children are scarce. Review of the limited Malaria in Middle Childhood and Adolescence 185 Map 14.1 Location of Malaria Parasite Surveys in School-Age Children, 1985–2013 IBRD 42568 | DECEMBER 2016 1985–1989 1990–1994 1995–1999 2000–2004 2005–2009 2010–2013 Source: Malaria Atlas Project (MAP), http://www.map.ox.ac.uk. information published indicates that annual incidence association between the prevalence of anemia and para- can vary from 0.03 to 2.7 cases per child per year, depend- sitemia, but these studies were conducted mainly among ing on the transmission setting (annex 14A, table 14.2). preschool-age children. The limited data available suggest that it is not unusual The strongest evidence for the role of malaria as a for school-age children to experience one clinical attack cause of anemia in school-age children comes from the of malaria severe enough to warrant treatment once results of intervention studies with trials of intermittent every one to two years (Barger and others 2009; Clarke preventive treatment (IPT) in school-age children show- and others 2004; Nankabirwa and others 2010; Rohner ing improvement in hemoglobin concentration in both and others 2010). East Africa (Clarke and others 2008; Nankabirwa and others 2010) and West Africa (Barger and others 2009; Clarke and others 2013; Tine and others 2011). Malaria as a Cause of Anemia in School-Age Children Overall, differentiating the effect of malaria on ane- Anemia is a common problem among school-age mia in school-age children from other confounding children in the tropics. Its etiology is usually multifacto- factors is difficult; the limited evidence available suggests rial, and the relative importance of different causes var- that it has a significant role. Although administration of ies from area to area. It is difficult to separate malaria as supplementary iron can increase the incidence of clinical a causative agent from other factors, such as nutritional attacks of malaria in some circumstances, most studies deficiencies, helminth infections, and HIV/AIDS, which have shown only a modest effect (Ojukwu and others often coexist in the same communities (Stephenson and 2009). The WHO and other health authorities (Raiten, others 1985). Many other cross-sectional surveys carried Namasté, and Brabin 2011) recommend that iron out in highly endemic areas have found a significant supplementation is indicated in areas in which iron 186 Child and Adolescent Health and Development Map 14.2 Prevalence of Malaria Parasitemia in School-Age Children in Sub-Saharan Africa Percent IBRD 42568 | DECEMBER 2016 0.0 0.1–4.9 5.0–19.9 20.0–39.9 40.0–100.0 Malaria transmission extent Transmission Transmission fringe No transmission No data Source: Malaria Atlas Project (MAP), http://www.map.ox.ac.uk. deficiency is a major problem, even if these areas are achieving their full academic potential and causing a loss endemic for malaria, provided that malaria control mea- to the state with respect to its investment in education. sures, such as distribution of insecticide-treated bednets (ITNs), are put in place at the same time. Impact of Malaria on Cognitive Function Studies in Africa and Asia provide strong evidence that Malaria as a Cause of School Absenteeism malaria can impair the cognitive function of school-age The estimated annual loss of school time in Kenya attrib- children (Fernando, Rodrigo, and Rajapakse 2010; utable to malaria in 2000 was 4 million to 10 million school Kihara, Carter, and Newton 2006). Descriptive studies days (Brooker and others 2000). Because malaria is an have evaluated the impact of severe malaria, uncompli- important cause of school absenteeism, preventive efforts cated malaria, and asymptomatic parasitemia on various should significantly improve school attendance. In a ran- aspects of cognition. domized clinical trial in Sri Lanka, Fernando and others In Kenya, a retrospective assessment of children ages (2006) report a 55 percent reduction in malaria incidence six to nine years who had had an episode of cerebral and a 62.5 percent reduction in school absenteeism among malaria found significant differences in speech and lan- children who received chloroquine prophylaxis. guage and cognition, compared with the healthy control Despite the limited number of studies, the available group (Carter, Mung’ala-Odera, and others 2005; Carter, evidence suggests that the cumulative effect of school Ross, and others 2005; Carter and others 2006); in absenteeism attributable to malaria for children in Uganda, cerebral malaria was associated with persistent endemic areas is considerable, preventing children from impairment of one or more cognitive domains Malaria in Middle Childhood and Adolescence 187 188 Child and Adolescent Health and Development Table 14.2 Summary of the Results of Recent Trials of Chemoprevention in School-Age Children Protective efficacy Clinical malaria Malaria Study Study Percent parasitemia Anemia setting Population Type Treatment regimen drug (95% CI) Percent (95% CI) Percent (95% CI) Source Year-round transmission Western 6,735 children ages 5–18 IPCs Treatment once every school term SP + AQ Not examined 89 (73–95) 48 (8–71) Clarke and others 2008 Kenya years; 30 schools (3 treatments per year) Sierra Leone 591 children ages IPCs Treatment at month 0 and month 3 SP Not examined No impact No impact Rohner and others 2010 6–14 years; 1 school (2 treatments per year) Uganda 780 children; 3 schools IPCs Single course of treatment; protective SP Not examined No impact No impact Nankabirwa and others efficacy measured after 42 days SP + AQ Not examined 48.0 (38.4–51.2) Mean change Hb +0.37 2010 (0.18–0.56) DP Not examined 86.1 (79.5–90.6) Mean change Hb +0.34 (0.15–0.53) Uganda 740 children; 1 school IPCs Treatment once a school term DP No impact 54 (47–60) No impact Nankabirwa, Wandera, (4 treatments per year) and others 2014 IPCs Treatment once every month DP 96 (88–99) 94 (92–98) 40 (19–56) (12 treatments per year) Highly seasonal transmission Mali 262 children ages SMC Two treatments 8 weeks apart during SP 36 (12–53) Not examined Not examined Dicko and others 2008 5–10 years; 1 village the malaria season (2 treatments per year) Mali 296 children ages SMC Two treatments 8 weeks apart during SP + AS 66.6 80.7 59.8 Barger and others 2009 6–13 years; 1 village the malaria season (2 treatments AQ + AS 46.5 75.5 54.1 per year) Mali 1,815 children ages 6–14 IPCs Single treatment at end of the malaria SP + AS Not examined 99 (98–100) 38 (9–58) Clarke and others 2013 years; 38 schools season (1 treatment per year) Senegal 1,000 children under age SMC Two treatments given monthly toward SP + AQ 79 (10–96) 57 (5–81) 41 (18–58) Tine and others 2011 10 years; 8 villages end of malaria season (2 treatments per year) Note: AQ = amodiaquine; AS = artesunate; CI = confidence interval; DP = dihydroartemisinin-piperaquine; Hb = hemoglobin; IPCs = intermittent parasite clearance in schools; IST = intermittent screening and treatment; SMC = seasonal malaria chemoprevention; SP = sulphadoxine-pyrimethamine. (John and others 2008). Similar findings were recorded attention are also reported from a trial in schools in in Malawian children with retinopathy-positive cerebral southern Mali (Clarke and others 2013). malaria (Boivin and others 2011). Overall, these studies strongly suggest that both clin- Cerebral malaria is not a prerequisite for cognitive ical malaria and asymptomatic parasitemia can adversely impairment as a consequence of malaria infection; stud- affect the cognitive skills of school-age children, but the ies have suggested that uncomplicated episodes of malaria mechanism by which this occurs remains uncertain. can adversely affect cognition. Studies in Sri Lanka show that school-age children scored significantly lower on tests of mathematics and language during an episode of APPROACHES TO THE CONTROL OF clinical malaria than children in the control group MALARIA IN SCHOOL-AGE CHILDREN (Fernando, de Silva, and Wickremasinghe 2003). In a study in Sri Lanka, Fernando and others (2003) find a A range of strategies is available for the control of malaria negative correlation between mathematical and language in this age group, delivered through schools or communi- skills and a past history of repeated attacks of malaria ties. The optimal approach to delivering interventions, during the preceding six years among children ages 6–14 including frequency and timing, and their ultimate years, even after correcting for socioeconomic factors. A effectiveness will vary according to the local intensity of history of one or more malaria attacks was associated malaria transmission. Malaria interventions are best deliv- with poor performance in mathematics and language in ered as part of an integrated package, for example, as part a cohort of 198 schoolchildren studied in Brazil (Vitor- of a school health program that also delivers deworming Silva and others 2009). A study of school-age children in (see chapter 13, Bundy, Appleby, and others [2017]) or Mali, where P. falciparum malaria predominates, reaches school feeding (chapter 12, Drake and others [2017]). similar conclusions (Thuilliez and others 2010). Many of the studies considered were primarily descriptive, and their results are open to potential con- Treatment of Clinical Attacks founding by social or economic factors not included in Ease of access of school-age children to effective treat- the analysis. Accordingly, the strongest evidence to sup- ment for clinical attacks of malaria is an essential port the view that malaria impairs cognitive function component of any effective national malaria control comes from intervention trials. In Sri Lanka, a random- program. However, in many parts of Sub-Saharan Africa, ized, placebo-controlled, double-blind trial of chloro- geographic and financial barriers prevent children from quine prophylaxis in children ages 6–12 years showed obtaining rapid access to diagnosis and treatment (see that educational attainment improved and that school volume 6, chapter 14, Babigumira and others 2017). absenteeism was reduced significantly (p < 0.0001) in Schools can play a vital role in ensuring that their pupils children who took chloroquine prophylaxis (Fernando obtain rapid access to diagnosis and treatment by provid- and others 2006). Children in The Gambia ages 3–59 ing appropriate health education activities in school, but months who were randomized to receive malaria pro- information about the treatment of malaria is rarely part phylaxis with dapsone-pyrimethamine or placebo during of the curriculum. A content analysis of school textbooks the malaria transmission season for three successive years in nine endemic countries found that most included infor- (Greenwood and others 1988) were reassessed when mation on modes of transmission, mosquitoes, and signs their mean age was 17 years (Jukes and others 2006). and symptoms of malaria, but little about ITNs or the Educational attainment was better in children who had need for prompt and appropriate treatment (Nonaka and received prophylactic treatment than in the placebo others 2012). These findings suggest that improving text- group, but the scores for the cognitive tests were not sig- book content in accordance with the national malaria nificantly different between groups. Prophylaxis substan- control strategy should become a priority. tially increased the school enrollment of girls. The Access to prompt treatment can be improved by pro- intervention also reduced school drop out for students in viding antimalarials to schools and by training teachers government schools (Zuilkowski and Jukes 2014). to administer antimalarial treatments correctly. In the In a large, stratified, cluster-randomized, double- past, when first-line treatment was either chloroquine blind, placebo-controlled trial conducted in schools in or SP given presumptively, training teachers to provide Kenya, IPT with sulphadoxine-pyrimethamine plus treatment was shown to be feasible and to reduce school amodiaquine (SP + AQ) significantly improved sus- absenteeism and malaria deaths (Afenyadu and oth- tained attention of schoolchildren ages 10–12 years ers 2005; Pasha and others 2003). However, the WHO (Clarke and others 2008). Significant effects on sustained now recommends diagnosis before any antimalarial Malaria in Middle Childhood and Adolescence 189 treatment is given (WHO 2015). Building on recent Figure 14.2 Age Patterns in the Prevalence of Malaria efforts to expand diagnosis and treatment of malaria Parasitemia and of Reported Use of a Bednet on the outside of the formal health sector (Ansah and others Previous Night in Uganda. 2015), an ongoing study in Malawi is evaluating the a. Females impact on school attendance and health outcomes of 70 training teachers to use rapid diagnostic tests (RDTs) (Witek-McManus and others 2015). If this approach is 60 effective, operational issues, including supply chains, 50 Percentage blood safety, and teacher attrition, will require careful 40 consideration before the strategy is scaled up. 30 20 Vector Control 10 The main methods of vector control of malaria are 0 0 20 40 60 80 ITNs, indoor residual spraying (IRS), and reduction of mosquito breeding sites. Age (years) b. Males Insecticide-Treated Nets 70 Strong evidence indicates that regular use of ITNs sub- 60 stantially lowers the risks of clinical malaria and all-cause 50 mortality in children under age five years and reduces the Percentage 40 burden of malaria among pregnant women (Lengeler 2004; Lim and others 2011). For these reasons, large-scale 30 ITN distribution programs initially focused on these two 20 vulnerable groups. However, following appreciation of 10 the indirect herd effect of a high level of ITN coverage in 0 a community, the development of long-lasting ITNs, and 0 20 40 60 80 an increase in the financial and political support for ITN Age (years) programs, there has been a shift from prioritizing vulner- = Reported use of a bednet the previous night able populations to protecting everyone with an ITN, = Malaria parasitemia including school-age children. However, an analysis of household surveys undertaken between 2005 and 2009 in Source: Pullan and others 2010. 18 African countries found that school-age children were the group least likely to sleep under an ITN the previous round of effective antimalarial treatment reduced the night; between 38 percent and 42 percent of school-age incidence of clinical malaria by 97 percent, but it did children were unprotected (Noor and others 2009). not reduce anemia (Nevill and others 1988). A reduc- Similar low ITN usage has been observed among school- tion in the incidence of malaria was shown in a ran- age children in Cameroon (Tchinda and others 2012), domized trial of children ages 4–15 years in an area of Kenya (Atieli and others 2011), and Uganda (Pullan and low and unstable transmission on the Thai-Burmese others 2010) (figure 14.2). Substantial progress in popu- border (Luxemburger and others 1994). In a rural area lation coverage with ITNs has been made since 2000, of western Kenya, where malaria transmission is peren- with more than 50 percent of the population of nial and high, a community-based trial showed that Sub-Saharan Africa sleeping under ITNs in 2015; never- ITNs halved the prevalence of anemia in girls ages theless, ITN use among those ages 5–19 years remains 12–13 years; ITNs were less effective in preventing lower than among the population as a whole (WHO anemia among girls ages 6–10 years (Leenstra and 2015). Thus, even in countries with existing national others 2003). Additional evidence provided by cross- policies of universal access to ITNs, school-based distri- sectional survey data suggests that net use among bution of nets could have a complementary short-term school-age children is associated with a 71 percent and role in addressing this gap. 43 percent lower risk of P. falciparum infection in Few studies have investigated the efficacy of ITNs in Somalia (Noor and others 2008) and Uganda (Pullan school-age children. An early trial among children in a and others 2010), respectively. An analysis of country- rural boarding school in central Kenya showed that wide data from school surveys in Kenya (Gitonga and sleeping under an untreated mosquito net following a others 2012) shows that ITN use was associated with a 190 Child and Adolescent Health and Development reduction in the odds of malaria infection and anemia Malaria Chemoprevention in coastal areas, where malaria transmission is low to The two main approaches to the use of antimalarial moderate, and among boys in western lakeshore Kenya, drugs to prevent malaria infection are chemoprophylaxis where transmission is high. In addition, ITN use and IPT. reduced the risk of parasitemia in the western highland epidemic zones and the risk of anemia in coastal areas where transmission is low. Chemoprophylaxis As children become more independent with increas- Chemoprophylaxis involves the regular administration ing age, parents have less control over their bedtimes, of antimalarial drugs to those at risk over a sustained where they sleep, and whether they use nets. Education period to provide persistent, protective blood levels. targeted directly to older children, for example, through Compelling evidence indicates the benefits of chemo- malaria education in schools, could increase regular use prophylaxis in school-age children. A review of trials of ITNs among teenage children. of malaria chemoprophylaxis in the population of malaria-endemic areas reports significant health impacts Indoor Residual Spraying in nearly all studies (Prinsens Geerligs, Brabin, and IRS, the application of long-acting insecticides to the Eggelete 2003). Most of these studies focus on young walls and roofs of houses and, in some cases, public children, but in 30 of the 36 trials that examined infec- buildings and domestic animal shelters, is an effective tion rates in children over age five years, reductions in method of malaria control. IRS implemented as a malaria parasitemia ranged from 21 percent to 100 community-wide campaign can achieve substantial percent (Prinsens Geerligs, Brabin, and Eggelete 2003). A reductions in the incidence and prevalence of malaria 2008 review confirms these findings (Meremikwu, infection in all age groups (Pluess and others 2010). Donegan, and Esu 2008). Chemoprophylaxis with Repeated IRS campaigns conducted between 1955 and chloroquine not only reduced the incidence of clinical 1959 in the Pare-Taveta area of Tanzania were associ- malaria and absenteeism in Sri Lankan schoolchildren, it ated with a reduction in malaria parasitemia from also significantly improved educational attainment 73 percent to 7 percent in children ages 5–9 years, and (Fernando and others 2006). from 62 percent to 4 percent in children ages 10–14 years (Draper 1960). Targeted IRS conducted over Intermittent Preventive Treatment 12 months in the epidemic-prone Kenyan highlands An alternative to chemoprophylaxis is IPT, the periodic halved the monthly prevalence of asymptomatic infec- administration of a full therapeutic dose of an antima- tion in school-age children and reduced the incidence larial or antimalarial combination to groups at increased of clinical disease (Zhou and others 2010). Studies risk of malaria. IPT clears existing asymptomatic infec- that have investigated the impact of combining vector tions and prevents new infections during the period control with ITNs and IRS have produced mixed immediately after treatment when protective blood lev- results, with some showing a benefit and others no els are present. IPT is being evaluated in schoolchildren added effect. in two ways: intermittent parasite clearance in schools (IPCs) and seasonal malaria chemoprevention (SMC). Reduction of Breeding Sites IPCs involves the administration of IPT on a periodic Breeding sites of malaria anopheline vector mosquitoes basis to schoolchildren, with the aim of clearing asymp- can be controlled in some epidemiological situations tomatic malaria infections and aiding hematologic through application of larvicides, introduction of pred- recovery during the ensuing malaria-free period. Studies ator species, and habitat destruction and drainage that have evaluated IPCs in school-age children are sum- (Tusting and others 2013). However, achieving a sig- marized in table 14.2. The first study of IPCs (called IPT nificant reduction in malaria transmission in many in that study), conducted in schools in western Kenya, parts of Sub-Saharan Africa is difficult because of the shows that IPCs with SP + AQ given once a term signifi- multiplicity and changing nature of breeding sites of cantly reduced malaria parasitemia and anemia and sig- the main vector species, such as Anopheles gambiae nificantly improved sustained attention (Clarke and (Fillinger and Lindsay 2011). It is unlikely that encour- others 2008). However, the spread of parasites resistant aging schoolchildren to destroy potential breeding sites to SP, and the consequent withdrawal of SP and AQ in of An. gambiae in school grounds will have any impact many East African countries, precluded further investi- on the prevalence of malaria, although it could help gation of IPCs using these drugs in this area. Studies reduce the numbers of other mosquito species, includ- using alternative drugs, including dihydroartemisinin- ing those that transmit dengue. piperaquine, conducted in a range of settings, show Malaria in Middle Childhood and Adolescence 191 effects on parasitemia, anemia, and clinical malaria sim- in which these studies were done. The potential of this ilar to those obtained with SP + AQ, with a protective approach to control malaria in school-age children needs efficacy ranging between 54 percent and 99 percent further investigation. reduction in malaria infection, and 38 percent to 60 percent reduction in anemia (Barger and others 2009; Vaccination Clarke and others 2013; Nankabirwa and others 2010). Development of an effective malaria vaccine has proved Several conclusions can be drawn from these studies. to be a major challenge, despite the exploration of many innovative approaches. One vaccine (RTS,S/AS01) has • First, IPCs is highly effective in reducing the burden shown partial efficacy in a large-scale Phase 3 clinical of malaria among school-age children. trial and was given a positive opinion by the European • Second, the medication used for IPCs, and the tim- Medicines Agency in July 2015 (RTS,S Clinical Trials ing of treatments, needs to be adapted to the local Partnership 2015). However, the duration of protection epidemiology. provided by RTS,S/AS01 is relatively short, and vaccina- • Third, IPCs is likely to be most effective in settings tion in early life is unlikely to provide protection that where a high proportion of children harbor asymp- lasts into school age. Only very limited data are available tomatic infections, where malaria is a major cause of on the safety and immunogenicity of RTS,S/AS01 in anemia, or both. school-age children (Bojang and others 2005). RTS,S/ AS01 is the most advanced malaria vaccine, but several Seasonal Malaria Chemoprevention other vaccines are making steady progress (Schwartz and SMC involves administration of treatment on a monthly others 2012); in the longer term, vaccination may have basis to coincide with the annual peak in malaria trans- an important role in the prevention of malaria in school- mission. This intervention is highly effective in reducing age children. the incidence of clinical malaria and anemia in young children (Wilson 2011). In 2012, the WHO recom- mended implementation of SMC for children under age five years in areas of the Sahel subregion of Africa with ECONOMICS OF MALARIA CONTROL IN highly seasonal transmission. This recommendation is SCHOOLS being implemented increasingly widely in countries of Few economic analyses have evaluated malaria control the Sahel. Although less extensively researched, and not among school-age children. A 2011 systematic review yet recommended by the WHO, evidence suggests that identified 48 studies that evaluated the cost-effectiveness SMC is as effective in school-age children as in children of malaria interventions (White and others 2011), of under age five years (Barger and others 2009; Dicko and which only two were conducted among school-age others 2008; Tine and others 2011, 2014), and Senegal populations. The first study evaluated the cost- provides SMC to children up to age 10 years. effectiveness of community-wide IRS programs among children ages 2–15 years in southern Mozambique Intermittent Screening and Treatment (Conteh and others 2004). The financial costs per person An alternative to IPCs or SMC is intermittent screening covered in the rural area and peri-urban areas were and treatment (IST), an intervention in which individu- US$3.86 and US$2.41, respectively. Using health facility als are screened periodically for malaria infection using records to estimate the number of infections averted, the an RDT, and those infected (whether symptomatic or economic cost per case of malaria parasitemia averted not) are treated with a full course of an effective antima- among those ages 2–15 years was US$21.23. larial agent or combination of agents. A population-based The second study evaluated the cost-effectiveness of study of IST in Burkina Faso shows no impact on the IPCs (Temperley and others 2008). The study estimated incidence of clinical malaria in children under age five that the cost of IPCs delivered by teachers was US$1.88 years or on malaria transmission (Tiono and others per child per year, with drug and teacher training consti- 2013); a cluster randomized trial in schools on the coast tuting the largest cost components. The estimated cost of Kenya, where transmission is low to moderate, finds per anemia case averted through IPCs was US$29.84, and no impact on health or cognition (Halliday and others the estimated cost per case of malaria parasitemia averted 2014). Possible reasons for the absence of an impact in was US$5.36 (Temperley and others 2008). Another these studies are the inability of some of the currently study investigates the cost of IST delivered through available RDTs to detect low-density parasitemia, and the schools and estimates the cost of IST per child screened rapid rate of reinfection following treatment in the areas to be US$6.61 (Drake and others 2011). These estimates 192 Child and Adolescent Health and Development of cost and cost-effectiveness fall within the range of per capita costs of other malaria control strategies Box 14.1 (White and others 2011), but they are more expensive than school-based deworming programs. However, the Policy Recommendations for the Control of Malaria simultaneous delivery by teachers of both IPCs and deworming as part of an integrated school health in School-Age Children package may yield economies of scope and increase National malaria control programs need to pay increas- cost-effectiveness. More studies are required on the ing attention to the problem of malaria in school-age cost-effectiveness of malaria control in schoolchildren. children, as the proportion of cases of malaria in older It is also important to consider the effect of other children increases. Education about causes of malaria; its ongoing malaria control measures because they will clinical features; and ways of diagnosing, treating, and reduce malaria transmission in the wider community. preventing the infection should be an integral part of the In this situation, mathematical models of malaria can curriculum of all schools in areas where the school-age provide insight because they can simultaneously model population is at risk of malaria infection. All school- multiple interventions and take into account the dynam- age children in high-transmission areas need to sleep ics of malaria transmission, especially the mass effects of under insecticide-treated bednets. School-age children community interventions. For example, modeling of the who develop clinical malaria need to be able to recognize cost-effectiveness of community-wide IST highlighted the nature of their illness and have easy and rapid access its value in medium-high transmission settings among to reliable diagnosis and effective treatment, either in their school-age children, but only if it was continued indefi- schools or at nearby health facilities. nitely (Crowell and others 2013). The combined use of mathematical modeling and economic evaluation can help identify which interventions should be targeted specifically toward school-age children and which inter- • Local and individual levels: Families that include ventions should be delivered as part of community-wide schoolchildren would be better able to take the malaria control. necessary steps to prevent and treat malaria. Operational research is needed to determine how best to raise awareness of the importance of malaria, how to CONCLUSIONS manage it, and how to improve the use of established con- trol measures in this group. Improving the malaria- On the basis of the available data, some recommendations relevant content of school curricula will help children help can be made about the management of malaria in school- themselves and equip them with the understanding age children (box 14.1), but much more needs to be learned needed to accept new approaches to the control of malaria, about the effectiveness of different approaches (box 14.2). such as the value of blood testing for parasitological diag- Better data are needed on the burden of malaria in nosis to guide appropriate treatment. School-age children school-age children. A standardized approach to data can become an important route for disseminating infor- collection would improve the ability to monitor progress mation on malaria control to the rest of the family. in this at-risk group. Systems to capture episodes of clin- Further studies are needed to understand the poten- ical and fatal malaria in school-age children do not need tial role of medications in preventing malaria in to be school based, but they should summarize data for school-age children. Chemoprophylaxis, SMC, IPCs, this specific risk group. and IST may all be beneficial, but it is not clear yet in The potential of serological tests to help in evaluating which settings each might be most effective or cost- the burden of malaria in school-age children needs to be effective. Some chemoprevention is likely to be useful studied further. Improved information on the extent of in high transmission settings. The cost-effectiveness of the burden of malaria and on the socioeconomic conse- chemoprevention is likely to be lower in low transmis- quences of malaria in this age group would enhance sion settings, where most recipients are unlikely to awareness at multiple levels. have malaria. However, the transmission threshold at which to introduce, or withdraw, chemoprevention • Global level: Policy makers and multilateral funding will only become clear through the modeling of organizations would pay more attention to this issue. empirical data. The optimal characteristics of drugs • National level: Interactions among education, health, for SMC, IPCs, and IST are likely to include low cost, a and potentially other sectors would be catalyzed. very good safety profile, exceptional tolerability, long Malaria in Middle Childhood and Adolescence 193 Box 14.2 Key Research Priorities for Malaria in School-Age Children Epidemiology Prevention • Acquisition of better knowledge of the mag- • Exploration of ways to improve coverage with nitude and features of malaria in school-age insecticide-treated bednets among school-age children, especially in areas in which the overall children incidence of malaria is declining • Investigation of the comparative advantages and cost-effectiveness of screening and treatment Pathogenesis programs and of intermittent preventive treat- • Investigation both of the importance of malaria ment in the prevention of malaria in school-age as a cause of anemia in school-age children and children in high-risk areas, and investigation of of how anemia is caused by the malaria parasite the circumstances that favor either approach • Investigation of the mechanisms by which severe, • Exploration of the potential for vaccination to uncomplicated, and asymptomatic malaria prevent malaria in school-age children impair cognition Economic and social consequences Treatment • Acquisition of better knowledge of the socioeco- • Investigation of how malaria can be diagnosed nomic consequences of malaria in school-age using a rapid diagnostic test and treated effec- children, and the costs and benefits of individual tively by school staff in different settings malaria control measures in this age group half-life, and single-dose treatment. The development “Malaria in school-age children in Africa: an increasing of a rigorous target product profile would help guide important challenge.” Trop med Int Health, 19:1294-1309. the development of drugs suitable for use in the pre- © COPYRIGHT OWNER The Authors. Licensed under vention of malaria in school-age children. The poten- Creative Commons Attribution (CC BY 4.0) available at: https://creativecommons.org/licenses/by/4.0/. tial of IST programs to identify and help not only individuals but also communities at elevated risk of World Bank Income Classifications as of July 2014 are as malaria warrants further exploration. follows, based on estimates of gross national income (GNI) More effective control of malaria is only one part of per capita for 2013: the drive to improve the health and potential of school- age children. More work is needed to determine how and • Low-income countries (LICs) = US$1,045 or less when to integrate malaria control strategies with other • Middle-income countries (MICs) are subdivided: school-based programs at the local and national levels. a) lower-middle-income = US$1,046–US$4,125 b) upper-middle-income (UMICs) = US$4,126–US$12,745 • High-income countries (HICs) = US$12,746 or more ANNEX The annex to this chapter is as follows. It is available at http://www.dcp-3.org/CAHD. REFERENCES Adjuik, M., T. Smith, S. Clark, J. Todd, A. Garrib, and oth- • Annex 14A. Estimates of Parasitemia and Clinical ers. 2006. “Cause-Specific Mortality Rates in Sub-Saharan Disease among School-Aged Children in Africa Africa and Bangladesh.” Bulletin of the World Health Organization 84 (3): 181–88. NOTES Afenyadu, G. Y., I. A. Agyepong, G. Barnish, and S. 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P. Mathanga, M. Verney, A. Mtali, Zhou, G., A. K. Githeko, N. Minakawa, and G. Yan. 2010. D. Ali, and others. 2015. “Design and Implementation “Community-Wide Benefits of Targeted Indoor Residual of a Training Programme for School Teachers in the Spray for Malaria Control in the Western Kenya Highland.” Use of Malaria Rapid Diagnostic Tests as Part of a Basic Malaria Journal 9: 67. First Aid Kit in Southern Malawi.” BMC Public Health Zuilkowski, S. S., and M. C. H. Jukes. 2014. “Early Childhood 15: 904. Malaria Prevention and Children’s Patterns of School WHO (World Health Organization) 2015. Guidelines for the Leaving in The Gambia.” British Journal of Educational Treatment of Malaria. 3rd ed. Geneva: WHO. Psychology 84: 483–501. 198 Child and Adolescent Health and Development Chapter 15 School-Based Delivery of Vaccines to 5- to 19-Year Olds D. Scott LaMontagne, Tania Cernuschi, Ahmadu Yakubu, Paul Bloem, Deborah Watson-Jones, and Jane J. Kim INTRODUCTION encountered—can provide salient lessons for other countries, irrespective of income status. This chapter Significant progress has been achieved in the social, highlights the promise of school-based delivery of economic, educational, and health status of many vaccines in LMICs, using the experience of TT and HPV populations. Compared with previous generations, the vaccine delivery as examples. Definitions of age group- educational status of those born after 1990 has improved, ings and age-specific terminology used in this volume as reflected in higher rates of school enrollment, can be found in chapter 1 (Bundy and others 2017). especially in low- and middle-income countries (LMICs) (UNESCO 2014). Countries have started to expand their immunization programs beyond infants to young TETANUS AND HPV EPIDEMIOLOGY AND children, adolescents, and adults, with the goal of pre- PREVENTION venting, controlling, and where possible, eliminating vaccine-preventable diseases (WHO 2013a). Tetanus The combination of increased school attendance and Tetanus is caused by the bacterium Clostridium tetani, expanded target populations for vaccines has created a the spores of which are widespread in the environment rich opportunity for exploring vaccine delivery in schools (Black, Huber, and Curlin 1980). The bacterium is (annex 15A, figure 15A.1). Meningitis, measles, hepatitis B, introduced into umbilical stump tissue during unclean tetanus toxoid (TT), and human papillomavirus (HPV) delivery or unclean cord care practices, or occasionally are examples of vaccines offered in schools, either as at the site of traditional surgery and deep penetrating routine primary or booster vaccinations or through wounds. The disease is caused by the action of a neuro- campaigns for catch-up strategies or disease control toxin produced by the bacteria when they grow in the (Grabowsky and others 2005; Mackroth and others 2010; absence of oxygen. Tetanus is characterized by muscle WHO 2012a). These vaccines have demonstrated efficacy spasms, initially in the jaw. As the disease progresses, in preventing significant morbidity and mortality among mild stimuli may trigger generalized tetanic seizure-like school-age children, adolescents, and adults (Mehlhorn, activity, which contributes to serious complications and Balcer, and Sucher 2006; WHO 2009). Understanding eventually to death unless supportive treatment is given country experiences with the operational and logistical (Black, Huber, and Curlin 1980). factors that have enabled successful delivery of vaccines Vaccines containing TT are the primary prevention through school-based programs—and the challenges strategy against infection and have been in use Corresponding author: D. Scott LaMontagne, PATH, Seattle, WA, United States; slamontagne@path.org. 199 for decades. Both the efficacy and the effectiveness of Prevention the TT vaccine are well documented (Newell and others Both TT and HPV vaccinations have been demonstrated 1971). TT vaccines, particularly the widespread expan- to be cost-effective in schools (Goldie and others 2008; sion of maternal tetanus immunization services, have Griffiths and others 2004). Targeting children at the been largely responsible for the marked reduction in beginning and end of primary school for booster doses of neonatal tetanus deaths, from 787,000 deaths in 1988 to TT vaccines and targeting young adolescents before com- 49,000 by 2013 (Liu and others 2015; Vandelaer and pleting primary school for HPV vaccines have been two others 2003). successful delivery strategies (LaMontagne and others According to the World Health Organization (WHO), 2011; Steinglass 1998). Young adolescents ages 9–11 years effective and full immunization against the tetanus infec- produce higher levels of antibodies to HPV vaccines, tion requires five doses between infancy and adolescence which are maintained at higher levels over time, com- (WHO 2006). An additional dose during the first preg- pared with older adolescents (Block and others 2006). nancy will protect a woman and her fetus throughout Additionally, delivering HPV vaccines at this young age this and future pregnancies, provided that she has generally ensures that girls receive the vaccine before received all previous recommended doses (Rahman and sexual exposure to HPV (Moscicki 2007; WHO 2014b). others 1982). Countries have been using TT vaccines, Since adolescents do not regularly attend health including school-based vaccination, as a main strategy to facilities, schools may offer advantages for reaching this eliminate maternal and neonatal tetanus and to maintain population (Mackroth and others 2010). Increasingly elimination status. The success of such strategies has high levels of primary school enrollment and attendance been demonstrated in Tanzania (WHO 2013c). throughout LMICs have created an opportunity to identify and efficiently reach a large proportion of the population eligible for school-based vaccination Cervical Cancer (Grabowsky and others 2005; UNESCO 2014). Schools Cervical cancer is caused by several types of HPV can also be used to leverage additional services or inter- (zur Hausen 1977). Two types, 16 and 18, account for ventions (Broutet and others 2013) that might be needed approximately 70 percent of all cases (Denny and by the age groups receiving TT or HPV vaccine, such as others 2015; Ferlay and others 2010). This virus is sex- antihelmintics for deworming, vision screening, and ually transmitted, and most people are exposed within bednet distribution (Broutet and others 2013). the first few years of engaging in sexual relations (Moscicki 2007). If the infection persists long term, women can develop precancerous lesions; if left PROGRAM DESIGN FOR SCHOOL-BASED untreated, these lesions can develop into cervical cancer VACCINE DELIVERY OF TT AND HPV (zur Hausen 1977). The progression from infection to VACCINES disease takes, on average, 20 years. Globally, there are more than 528,000 new cases of cervical cancer and TT Vaccine Delivery Strategies more than 266,000 deaths each year among women; The childhood tetanus immunization schedule recom- more than 85 percent of the disease burden occurs in mended by the WHO includes five doses: LMICs (Ferlay and others 2010). Cervical cancer can be prevented through either • Primary series of three doses of DTP (diphtheria/ primary prevention (vaccination) or secondary preven- tetanus/pertussis) or other tetanus-containing vaccine, tion (screening and treatment) (Denny and others such as DTwP (diphtheria/tetanus/whole pertussis) or 2015). Vaccines against HPV are effective when adminis- DTaP/TDaP (diphtheria/tetanus/acellular pertussis) tered to individuals not yet exposed to HPV vaccine given before age one year types, which for most people is before sexual debut • Booster dose of a TT vaccine at ages four to seven (Denny and others 2015). Screening through cervical years smears (Papanicolaou or Pap smears), visual inspection • Second booster dose between ages 12 and 15 years with acetic acid, or HPV DNA (deoxyribonucleic acid)- (WHO 2006). based testing is effective in detecting precancerous lesions that can be treated. Accordingly, HPV vaccina- Resources available through existing school health tion is recommended for girls ages 9–13 years (WHO services are used to give the TT booster doses in adoles- 2014b), and screening is recommended for adult women cence while ensuring that out-of-school children are also generally beginning at age 25 or 30 years to age 49 years served through routine activities of national immuniza- (Denny and others 2015). tion programs (WHO 2008b). 200 Child and Adolescent Health and Development Many low- and lower-middle-income countries HPV Vaccine Delivery Strategies implement some school-based vaccination (annex 15A, The WHO recommends that the HPV vaccine be given to table 15A.1), targeting the school grades where the larg- girls between ages 9 and 13 years, including immuno- est proportion of children are found. Several countries compromised individuals (WHO 2014b). As of early 2016, have conducted household and school-based surveys to three HPV vaccines are available—a quadrivalent vaccine tabulate age-by-grade distributions to determine which (Gardasil, Merck & Co.), a bivalent vaccine (Cervarix, grade is most appropriate for capturing the largest pro- GlaxoSmithKline), and a nonavalent vaccine (Gardasil9, portion of children—ages 4–7 years or ages 12–15 years. Merck & Co.). Licensure recommendations vary by Indonesia found that most children ages 6–9 years are country; in general, Gardasil and Gardasil9 are registered enrolled in grades one to three (Kim-Farley and others for use in females ages 9–26 years in 130 and 39 countries, 1987). Nepal and Tunisia determined that entry in pri- respectively. In some countries, these two HPV vaccines are mary school was the optimal time to provide TT vacci- also registered for use in males of the same age for the pre- nation (Vandelaer, Partridge, and Suvedi 2009; vention of genital warts. Cervarix is generally registered for WHO 2008c). use in females ages 9–44 years in more than 120 countries; An email survey was sent to all 192 WHO member it is not registered for males because no clinical trial of the countries in 2008 (WHO-UNICEF 2009). Of the efficacy of this vaccine in males has been conducted. 143 countries responding, 61 countries (43 percent) Although all HPV vaccines were licensed for reported conducting some school-based immuniza- a three-dose schedule, the European Medicines Agency tion. Among these 61 countries, the TT-containing (EMA) (EMA 2013, 2014) and the WHO Strategic vaccine was one of the interventions given; 41 coun- Advisory Group of Experts on Immunization recently tries (67 percent) start from primary school grade 1, concluded there was sufficient evidence for the biva- and 54 percent target ages 9–13 years. Data from the lent and quadrivalent HPV vaccines to recommend a 2012 WHO-UNICEF Expanded Programme on two-dose schedule for young immunocompetent ado- Immunization Joint Reporting Form indicate that, lescent girls up to age 14 years, with a minimum inter- among 86 low- and lower-middle-income countries, val of six months between doses (WHO 2014c). As of 21 countries (24 percent) administer TT-containing early 2016, 46 countries had adopted the revised two- vaccines; 10 of these countries deliver the vaccine in dose schedule, or schedules with two initial doses and grade 1, and 16 deliver TT vaccines through grade 6 a delayed third-dose booster after five years, for young (on average, capturing children ages 12–15 years) immunocompetent adolescent girls in their national (WHO-UNICEF 2013). The relatively low levels of immunization programs (Brotherton and Bloem 2015; school vaccination in these countries, combined with Institute of Social and Preventive Medicine 2014). increasing school enrollment, particularly among girls, As of early 2016, HPV vaccination is part of the suggests an untapped opportunity to increase vaccina- recommended national schedule in nearly 80 countries tion coverage through school-based programs. or territories, of which approximately 25 percent are Information, education, and communication com- low- or middle-income (comprising both lower-middle ponents are essential in ensuring the success of school- and upper-middle income) countries. As of June 2016, based TT vaccination in LMICs. Parents and community 89 countries and territories have HPV vaccination on a leaders need to know why the children are being vacci- national schedule (map 15.1; annex 15A, table 15A.2). nated; have resources for further information, as well as However, an additional 37 LMICs have piloted the know when the vaccination activities will take place; introduction of the vaccine in one or more urban and and understand what to do if their children miss the rural districts, 20 of which are in Sub-Saharan Africa vaccine. To prevent rumors that TT vaccination is con- (annex 15A, table 15A.3). nected to fertility control and to address the immunity Based on experiences with pilot demonstration gap that results in lack of a second opportunity for TT programs, school-based vaccination is most often used as vaccination in adolescent boys and adult men, both the primary delivery strategy, usually accompanied by a boys and girls are often vaccinated. Information on the secondary strategy based in health centers to reach out-of- protection conferred by the vaccine against tetanus school and underserved girls (Ladner and others 2012; caused by injuries during sports, planting, and LaMontagne and others 2011; Paul and Fabio 2014; other activities helps achieve community acceptance Watson-Jones and others 2012). Countries introducing (Steinglass 1998). The active engagement, collabora- HPV vaccines through schools seem to use grade- and tion, and training of the ministries of health and edu- age-based eligibility equally (Gallagher and others cation on the requirements of the school-based TT 2016; LaMontagne and others 2011; Paul and Fabio 2014). vaccination are crucial (WHO 2008c). School-Based Delivery of Vaccines to 5- to 19-Year Olds 201 Map 15.1 HPV National Vaccine Introduction Globally, June 2016 IBRD 42570 | OCTOBER 2016 With the HPV vaccine in their national vaccination schedules Without the HPV vaccine in their national vaccination schedules Note: HPV = human papillomavirus. Several elements make HPV vaccine delivery unique. 2015; Watson-Jones and others 2016). Some countries These considerations may create operational challenges also use the opportunity to sensitize girls and women to for implementation (WHO 2014a). the importance of adhering to the screening guidelines, the delivery of cervical cancer screening of adult women, • There is often lack of awareness of cervical cancer or other child health programs (Wamai and others 2012). and of HPV infection as a causal agent (Rama and HPV vaccination requires special attention to social others 2010). mobilization and communication efforts to ensure • Unlike other immunization programs that target acceptability and high coverage (Bingham, Drake, and infants of both genders, HPV vaccination is tar- LaMontagne 2009). In most low- and lower-middle- geted to girls ages 9–13 years (before sexual debut) income countries, messages were disseminated through (WHO 2014b). meetings in schools and communities, during home • Because the recommended age group for HPV vacci- visits, and through written materials and radio nation may not routinely attend health facilities, and announcements (Kabakama and others 2016; visits by health workers to schools for vaccination may LaMontagne and others 2011). In Rwanda, Uganda, be one-time events, such as vaccination campaigns, and Vietnam, teachers play an important role in delivery platforms and strategies used for HPV vaccine communication efforts (Binagwaho and others 2012; delivery may be new for LMICs (WHO 2012b). Galagan and others 2013). The WHO encourages all • Consent procedures for HPV vaccines are not stan- countries to develop communication strategies with dardized; both opt-in and opt-out are used (Cover and multisectoral stakeholders and engage communities at others 2012; Moodley and others 2013; WHO 2014a). the start of planning the program (WHO 2013b). Among LMICs that have completed pilot delivery of HPV vaccination can be integrated with other health HPV vaccine, all have chosen to focus messages on cer- services for this underserved age group, which may vical cancer prevention and the importance of vaccina- enhance the efficiency and sustainability of vaccination tion rather than to stress the sexual transmission of programs (Broutet and others 2013; Mugisha and others HPV because these messages have been proven to be 202 Child and Adolescent Health and Development the most important for parental acceptability (Bingham, this intervention. A summary of facilitators and barriers Drake, and LaMontagne 2009; Kabakama and others to TT-containing vaccine delivery in schools is provided 2016; LaMontagne and others 2011). in annex 15A, table 15A.4). Some pilot programs followed extensive informed con- sent processes (Moodley and others 2013). In others, the government used the same consenting procedures applied HPV Vaccine to other vaccines, including those delivered to children up Schools have been a primary delivery strategy for HPV to age 17 years, principally through an opt-out or implied vaccine in a number of LMICs (Gallagher and oth- consent approach (LaMontagne and others 2011). Pending ers 2016; Ladner and others 2012; LaMontagne and developments that could facilitate easier delivery of HPV others 2011; Raesima and others 2015). The rising levels vaccines to young adolescent populations include expanded of primary school attendance in many LMICs has in-country licensure for delivery to boys (Markowitz and enhanced this delivery approach (UNESCO 2014). The others 2012), alternative dosing schedules for three-dose vaccine is usually offered at specific times during the regimens (Esposito and others 2011; LaMontagne and school year, and school-based delivery may be combined others 2013), and the recent approval of two-dose sched- with outreach or health facility vaccine delivery. High ules for immunocompetent adolescent girls younger than three-dose coverage (75 percent to 100 percent) has been age 15 years (WHO 2014c). Moreover, opportunities for achieved in pilot studies and demonstration programs reduced procurement prices through Gavi, the Vaccine using school-based delivery strategies, which is similar to Alliance and the Pan American Health Organization the coverage levels achieved in national programs that Revolving Fund, as well as potential cost reductions also used school-based delivery (Brotherton and Bloem through the pooled purchase for middle-income countries 2015; Markowitz and others 2012; Sinka and others by the United Nations Children’s Fund, are likely to 2013). A systematic review of HPV vaccine delivery increase the number of countries that will introduce HPV experiences in 47 LMICs reported coverage levels of vaccines by 2020 (Gavi, the Vaccine Alliance 2016). 70 percent or greater in the vast majority of programs that used a school-based delivery component (Gallagher and others 2016). Differences in coverage between the EVIDENCE OF EFFECTIVE SCHOOL-BASED previously recommended three-dose schedule and the DELIVERY OF HPV AND TT VACCINES revised two-dose schedule were not observed; however, only 10 countries had reported coverage data from two- TT Vaccine dose delivery. Further information about the possible Although some country programs have added delivery impact of fewer doses on feasibility of school-based HPV of TT vaccines to those as young as age 10 years, docu- vaccine delivery will be available in future years as this mentation of the implementation method, successes, schedule becomes established. and challenges has been largely absent in the literature. Countries implementing school-based programs need Among the 27 low- and lower-middle-income countries to decide whether to establish age- or grade-based eligi- administering TT-containing vaccines in schools, bility. A demonstration project in Tanzania found signifi- 19 have reported coverage data (WHO-UNICEF 2013). cantly higher coverage with grade-based vaccination, In Indonesia, consistently high coverage of more than 95 compared with age-based vaccination, at slightly lower percent of children enrolled in schools has been reported cost (Watson-Jones and others 2012). Bhutan has reported (Kim-Farley and others 1987; WHO-UNICEF 2013). Sri national coverage of more than 90 percent through Lanka monitors the proportion of schools reached for school-based delivery (Dorji and others 2015). A sum- immunization in each province, and 92 percent of all mary of facilitators and barriers to HPV vaccine delivery schools were covered by 2005 (WHO 2008b). Data from in schools can be found in annex 15A, table 15A.5. the 2014 WHO-UNICEF Joint Reporting Form show nine additional countries (Afghanistan, the Arab Republic of Egypt, Honduras, Mongolia, Mozambique, COSTS AND COST-EFFECTIVENESS OF Nepal, Sierra Leone, Tonga, and Vanuatu) reported cov- SCHOOL-BASED TT AND HPV VACCINE erage levels for TT-containing vaccines of more than 80 percent for the population targeted in schools between DELIVERY 2011 and 2013 (WHO-UNICEF 2014). However, the Consideration of the costs and cost-effectiveness of lack of adequate documentation of TT-containing vac- school-based vaccination programs are instrumental in cines in schools continues to be a major obstacle to decisions for national introduction and scale-up meaningful conclusions about school-based delivery for (WHO 2006, 2014b). Given the shortage of routine School-Based Delivery of Vaccines to 5- to 19-Year Olds 203 health services for adolescents (UNICEF 2007), the financial cost ranged from US$1.65 to US$2.25 per dose opportunities to leverage existing programs are limited and US$4.96 to US$7.49 per fully immunized girl for (Broutet and others 2013; WHO 2008a). Accordingly, a three-dose vaccination schedule. The economic costs the incremental costs associated with implementation were higher, ranging from US$2.11 to US$4.62 per dose and delivery of TT and HPV vaccinations, both targeted and US$6.37 to US$16.10 per fully immunized girl. to adolescents, are expected to be high relative to new A two-dose vaccine schedule would reduce both finan- childhood interventions. School-based delivery of vac- cial and economic costs per fully immunized girl, but cines provides an opportunity to access young adoles- start-up costs are expected to be similar. As hypothe- cent populations who may not attend regular health sized, these costs are higher than the delivery costs of services. To date, the empirical data on the added costs of other routine immunizations reported in LMICs, which school-based vaccination programs have been limited, have ranged between US$0.75 and US$1.40 per dose, with little to no coverage of TT vaccination (Griffiths depending upon vaccine, country, and year of imple- and others 2004). However, several demonstration stud- mentation (Brenzel and others 2006). ies have emerged on the financial and economic costs of Specific findings from the studies also suggested inter- school-based HPV vaccination (Levin and others 2013; esting trends in the cost of HPV vaccine delivery mecha- Levin and others 2014; Levin and others 2015). nisms. For example, Quentin and others (2012) found that HPV vaccine delivery in urban schools was cheaper than delivery in rural schools, mainly due to higher costs Costs of HPV Vaccine Delivery of procurement and transport to rural areas. Irrespective Several published studies have estimated the incremental of location, grade-based delivery was less costly by costs of school-based HPV vaccine delivery in Bhutan, roughly 30 percent than age-based delivery in schools India, Peru, Tanzania, Uganda, and Vietnam, which are because of higher coverage and number of eligible girls. all LMICs (Levin and others 2015). Each of the analyses Hutubessy and others (2012) found that the recurrent distinguished financial costs, reflecting actual expendi- costs for delivering HPV vaccines in schools were higher tures, from economic costs, including the value of than delivery in health facilities by US$1.65 for three donated and shared resources, to more fully assess the doses per eligible girl (US$0.55 per dose). Similarly, opportunity costs of the HPV vaccination program. Levin and others (2013) found that school-based deliv- Results from three studies largely resulted in consistent ery had higher economic costs than an integrated (school estimates for economic and financial costs per HPV vac- and health center) approach or delivery solely in a health cine dose and per fully immunized girl (table 15.1; Levin center, mainly due to the additional personnel and trans- and others 2013). In these studies, the incremental portation costs required to reach the schools. Table 15.1 Financial and Economic Costs for School-Based HPV Vaccine Delivery Using a Three-Dose Schedule (Excluding Vaccine Cost), 2013 U.S. dollars Tanzania (Hutubessy Tanzania (Quentin Peru (Levin Uganda (Levin and Vietnam (Levin and others 2012) and others 2012) and others 2013) others 2013) and others 2013) Program scale Scaled-up national Scaled-up regional Demonstration Demonstration Demonstration program program project project project Method of Projected (using WHO Projected Microcosting Microcosting Microcosting estimation C4P tool) approach approach approach Financial cost, per dose 2.2 2.3 2.2 2.2 1.7 Financial cost, per FIG 7.5 7.1 6.5 6.9 5.0 Economic cost, per dose 4.6 4.0 4.1 3.2 2.1 Economic cost, per FIG 16.1 12.7 12.4 10.4 6.4 Note: FIG = fully immunized girl for recommended three-dose schedules at the time of study; HPV = human papillomavirus; WHO C4P tool = World Health Organization Cervical Cancer Prevention and Control Costing tool. Methods for estimating costs differed across studies, except in Peru, Uganda, and Vietnam. 204 Child and Adolescent Health and Development Main Contributors to Costs are more reflective of the subsidized price of HPV Head-to-head comparison of the main cost contributors vaccines for countries eligible through Gavi, the Vaccine across all settings was precluded by differences in catego- Alliance (for example, US$0.55–US$2.00 per dose), HPV rizations of costs across studies. The cost of procure- vaccination was found to be cost-saving or had attractive ment, including receiving and transporting vaccines to cost-effectiveness ratios well below per capita GDP the appropriate locations, was the largest cost component (Goldie and others 2008; Kim and others 2013; Levin and of scaled-up delivery of HPV vaccination in schools others 2015). In these analyses, the most influential driv- (46 percent to 70 percent of financial costs) (Hutubessy ers of cost-effectiveness were the cost per vaccinated girl and others 2012; Quentin and others 2012). Of the (including vaccine price and delivery costs), vaccine remaining costs, service delivery, comprising health coverage and efficacy, overall cancer and genital warts worker salary and allowances; social mobilization, com- disease burden, and assumptions about the discount rate. prising information, education, and communication With the recent change in the recommended schedule for (IEC); and supervision of vaccinations were important HPV vaccine among young immunocompetent adoles- contributors to the total delivery costs (LSHTM and cent girls from three doses to two and increased flexibility PATH, forthcoming). in the interval between doses, adjustments to the cost and In one study, costs were broadly categorized as start-up cost-effectiveness assumptions and analyses are likely to costs (for example, social mobilization and IEC, training, result in an increasingly favorable cost scenario for and microplanning) and recurrent (for example, school-based delivery in a wider range of LMICs. personnel) costs (Levin and others 2013). Start-up costs The question of male HPV vaccination has been of school-based vaccination programs were a large evaluated in several high-income countries, but only a share of the total financial cost per dose (69 percent in few cost-effectiveness analyses have addressed this ques- Peru, 41 percent in Uganda, and 72 percent in Vietnam). tion in LMICs, and the conclusions have been mixed. When shared and donated resources were taken into In Brazil (Kim, Andres-Beck, and Goldie 2007) and account, start-up costs were far lower at 36 percent, Vietnam (Sharma, Sy, and Kim 2015), including males in 27 percent, and 56 percent of the total economic cost the HPV vaccination program yielded marginal health per dose, respectively. gains relative to vaccinating girls only. While the analysis The cost estimates may not be widely generalizable in Vietnam found that at a low vaccine cost, vaccinating to other countries because the unit costs were setting boys had a cost-effectiveness ratio below per capita GDP, specific. Accordingly, the experience of school-based both studies concluded that increasing coverage in girls delivery of HPV vaccines may not be generalizable to was more cost-effective than extending coverage to boys. other adolescent vaccines such as TT, although the same In contrast, in Mexico (Insinga and others 2007), the principles may well apply. Furthermore, simultaneous quadrivalent HPV vaccine in both girls and boys was delivery of TT and HPV vaccines in schools—to the found to be very cost-effective when including genital same or different age cohorts or grades—may allow for warts and cervical cancer benefits. As in analyses from the sharing of cost drivers, such as transport, which can high-income countries, the cost-effectiveness of male reduce delivery costs. HPV vaccination depends heavily on the achievable HPV vaccine uptake in females, vaccine price, and health conditions (such as male and female cancers) included Cost-Effectiveness of HPV Vaccination in the analysis. According to several cost-effectiveness analyses in LMICs, Overall, these findings imply that at the estimated HPV vaccination of preadolescent girls is likely to be total cost of delivering HPV vaccination in schools, HPV good value for money, even at the higher cost of school- vaccination of preadolescent girls is good value for based delivery (Levin and others 2015). Several studies money, but that vaccination of boys is less certain. have estimated that the economic cost per fully vacci- nated girl for a three-dose vaccination schedule was I$25 (25 international dollars) when the vaccine cost was Summary of Cost-Effectiveness Analyses US$5 per dose (Goldie and others 2008). At this vaccine Although the evidence on the cost of HPV vaccine deliv- cost, under assumptions of lifelong high vaccine efficacy ery in LMICs is emerging, findings from a number of against HPV-16/18 cervical cancers, the analyses found studies in selected settings affirm that the cost of school- that HPV vaccination was very cost-effective in most based delivery of HPV vaccination is slightly higher LMICs, according to a cost-effectiveness threshold of relative to other traditional and new infant immuniza- per capita gross domestic product (GDP) (Fesenfeld, tions. Reaching a target group not routinely served by Hutubessy, and Jit 2013). At lower vaccine costs that national immunization programs may require new or School-Based Delivery of Vaccines to 5- to 19-Year Olds 205 modified delivery strategies (LaMontagne and others LMICs, especially using two-dose schedules, can be 2011; WHO 2014b); more intensive IEC activities implemented and reach high coverage. And a strong case (Galagan and others 2013; WHO 2013b); and additional for the cost-effectiveness of using schools as a location logistics and staff time, resulting in higher start-up and for adolescent vaccinations has been documented. recurrent costs. An analysis from Tanzania concluded Government ownership, endorsement, and financial that the financial cost of introducing HPV vaccination support; active and sustained involvement and leadership for a three-dose schedule to 26 regions over a five-year from ministries of health and education; and broad- period (2011–15) was an estimated US$11.9 million, based community support from health workers, teachers, excluding vaccine cost; or US$40.9 million with vaccine community leaders, civil society, parents, and adolescents at an unsubsidized price of US$5 per dose (Hutubessy are critical elements in the success and sustainability and others 2012). To the extent that scaling up a program of any vaccine delivery program, but especially those to the national level would result in economies of scale; using schools. or that the vaccination program could be integrated Delivery of TT-containing and HPV vaccines is as part of an existing, efficient program; or that the an opportunity to regalvanize school health programs vaccination schedule would be reduced from three doses and build a stronger foundation for the delivery to two, both financial and economic costs of HPV vac- of other important health interventions. A holistic cine delivery may be lower than what has been estimated approach combining vaccine delivery with other inter- in these smaller-scale studies. Countries will need to ventions may help sustain both and has the potential to commit substantial resources to initiate, scale up, and lead to improvements in the overall health of children sustain HPV vaccination programs. and adolescents. Based on the start-up and recurrent cost estimates of school-based delivery from published studies, the majority of cost-effectiveness analyses have found HPV ANNEX vaccination to be good value for money, even in the poor- The annex to this chapter is as follows. It is available at est countries. Securing a low vaccine cost and achieving http://www.dcp-3.org/CAHD. high vaccine uptake and adherence in adolescent girls will maximize the return on investment of school-based • Annex 15A. Supplemental Figures and Tables for HPV vaccination in any setting. School-Based Vaccinations CONCLUSIONS NOTES School-based delivery of vaccines is a viable approach Tania Cernuschi, MSc, MPH, represented Gavi, the Vaccine for the control of infections and diseases that cause Alliance Secretariat, Geneva, Switzerland, at the time this work significant morbidity and mortality. Increasing school was performed. enrollment and attendance by children and adolescents, World Bank Income Classifications as of July 2014 are as particularly girls, has changed the landscape for health follows, based on estimates of gross national income (GNI) service delivery, providing an excellent opportunity to per capita for 2013: capture large proportions of populations eligible for TT-containing, HPV, and other vaccines. To ensure equi- • Low-income countries (LICs) = US$1,045 or less table access for the most vulnerable populations, school- • Middle-income countries (MICs) are subdivided: based delivery of vaccines must be complemented by a) lower-middle-income = US$1,046 to US$4,125 strategies to reach those not attending school, such b) upper-middle-income (UMICs) = US$4,126 to US$12,745 • High-income countries (HICs) = US$12,746 or more. as mobile teams, outreach, and provision of vaccines at health facilities. 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School-Based Delivery of Vaccines to 5- to 19-Year Olds 209 Chapter 16 Promoting Oral Health through Programs in Middle Childhood and Adolescence Habib Benzian, Renu Garg, Bella Monse, Nicole Stauf, and Benoit Varenne INTRODUCTION gangrene affecting orofacial soft and hard tissues with high mortality), as significant but neglected oral condi- Oral diseases are among the most common diseases tions. Other oral diseases, which are partly discussed in worldwide, particularly for school-age children and ado- other volumes, include simple gingivitis and periodonti- lescents. They pose significant public health problems tis, congenital malformations, fluorosis of teeth in areas for all countries and entail substantial health, social, and of high fluoride concentrations in drinking water, oral economic impacts. Simple and effective interventions mucosa lesions that are often symptoms of other systemic exist to prevent most oral diseases. The school setting, diseases, and simple malocclusions. among others, plays an important role. This chapter describes oral disease control priorities for school-age children and adolescents ages 5–19 years. Tooth Decay Oral diseases and effective population-based interven- Tooth decay affects about 3.1 billion people. The preva- tions are highlighted in two other chapters in the Disease lence of tooth decay in permanent teeth ranked 1st and in Control Priorities (third edition) series: chapter 10 in deciduous teeth ranked 10th among 291 diseases ana- volume 1 (Niederman, Feres, and Ogunbodede 2015) lyzed in the Global Burden of Disease study (Marcenes and chapter 5 in volume 3 (Sankaranarayanan and oth- and others 2013). The highest burden of tooth decay is in ers 2015). Definitions of age groupings and age-specific upper-middle-income countries, and the lowest is in terminology used in this volume can be found in low-income countries (LICs) (figure 16.1), although chapter 1 (Bundy and others 2017). these averages mask large variations among countries within each income category. Between 40 percent and ORAL DISEASES AND CONDITIONS 90 percent of 12-year-old children in low- and middle- income countries (LMICs) suffer from tooth decay (FDI AFFECTING CHILDREN AND ADOLESCENTS World Dental Federation 2015); tooth decay is also a School-age children and adolescents are affected by a problem in high-income countries (HICs). In the United range of oral diseases and conditions. This chapter focuses States, tooth decay in children is four times more com- on tooth decay (dental caries) as it is the most common mon than asthma (CDC 2004). Across all country income disease with the highest global burden. It also includes groups, the majority of decay remains untreated, ranging oral injuries and trauma, as well as noma (a destructive from 52 percent in HICs to almost 100 percent in LICs. Corresponding author: Habib Benzian, Department of Epidemiology and Health Promotion, College of Dentistry, New York University, New York, United States; habib.benzian@mac.com. 211 Figure 16.1 Average Number of Teeth Affected by Tooth Decay hours of school were lost because of oral health prob- in 12-Year-Olds, by Country Income Group, Latest Data Available, lems in 1989 in the United States, confirming such 2000–14 impacts in high-income settings (U.S. DHHS 2000). Growing evidence suggests that severe tooth decay and malnutrition are associated. Children with severe High income dental caries are at increased risk for undernutrition and failure to thrive because pain, chronic infection, and abscesses from decayed teeth impair their appetite, abil- Upper-middle ity to chew, diet, and sleep (Sheiham 2006). Conversely, income prevention and treatment can contribute to reduced malnutrition and undernutrition; underweight children with severe tooth decay show rapid weight gain once Lower-middle destroyed teeth are extracted (Benzian, Monse, and oth- income ers 2011; Duijster and others 2013; Sheiham 2006). The association between dental caries and obesity is more complex. Both diseases share common risk factors, Low income such as overconsumption of sugar-laden foods and bever- ages. Studies confirm an association between obesity and caries for the permanent dentition, but the causal direc- 0 0.5 1.0 1.5 2.0 2.5 tion of the association requires more examination (Hayden Decayed Missing Filled and others 2013). Evolving evidence suggests that food- related preventive interventions addressing dental caries Source: FDI World Dental Federation 2015. Note: The data are based on the WHO Oral Health Country/Area Profile Project (http://www.mah.se also provide benefits for reducing obesity and vice versa. /capp/), which is the only authoritative source of international data on tooth decay. The DMFT index is generally used to report tooth decay in epidemiological studies. The index records the number of decayed (D), missing (M), and filled (F) teeth (T). A DMFT score of 1.0 means that 1 of the 32 permanent Oral Injuries and Trauma teeth is decayed, missing, or filled. Oral injuries and trauma include fractures of facial bones, as well as fractures, dislocations, and loss of Tooth decay can develop once the first teeth erupt. teeth. Orofacial injuries may be a result of traffic acci- Toothache as the main symptom is highly prevalent dents, sport injuries, abuse, or violence. They account among all age groups, ranging between 15 percent and for 5 percent of injuries among all age groups, even 45 percent in different studies (Boeira and others 2012; though oral structures represent only 1 percent of body Hayes and others 2013; Kassebaum and others 2015; surface. Oral injuries are more frequent in the first 10 Miotto, Barcellos, and Lopes 2013; Noro and others years of life, with more boys affected than girls. The 2014). The decay process may progress to total tooth likelihood of oral injuries decreases with age, but the destruction and exposure of the pulp—causing severe incidence of trauma to the head and neck increases pain, infection, and systemic reactions—which may be (Andersson 2013). Estimates indicate that 30 percent of fatal as a result of septicemia (Kawashita, Kitamura, and children show signs of trauma to their deciduous teeth; Saito 2011). 20 percent are affected by trauma to their permanent, Severe tooth decay may also affect child growth and mostly anterior, teeth. Oral injuries and trauma have nutrition, with significant impacts on psychosocial significant physical, psychosocial, and economic well-being, contributing to reduced quality of life and impacts and are major public health problems. Dental educational opportunities (Espinoza and others 2013; treatment is necessary in about half of all trauma cases Leal and others 2012; Ramos-Jorge and others 2014; involving permanent teeth. The annual direct costs Sheiham 2006). Studies from LMICs such as Brazil, the of dental trauma are between US$3.6 million and Islamic Republic of Iran, the Philippines, South Africa, US$9.0 million in 2012 dollars per 1 million inhabitants and Thailand, show that tooth decay negatively affects per year (Borum and Andreasen 2001). social interactions and the self-esteem of children and adolescents (Kakoei and others 2013; Miotto, Barcello, and Lopes 2013; Naidoo, Chikte, and Sheiham 2001). It Noma is also among the most frequent reasons for school and Noma is a disease characterized by severe gangrenous work absenteeism (Department of Education 2008; destruction of soft and hard tissues of the mouth and Krisdapong and others 2013). An estimated 59 million face. It predominantly affects children under age six years 212 Child and Adolescent Health and Development in Sub-Saharan Africa. Noma progresses rapidly from a naturally present in honey, syrups, and fruit juices. small lesion to major destruction. The disease is rare but High sugar consumption is often combined with an has significant impacts on the lives of those affected; unhealthy diet characterized by, for example, low fruit mortality is between 70 percent and 90 percent. Survivors and vegetable intake and overconsumption of foods suffer lifelong impairments to speaking or eating because with high fat and salt content (Alzahrani and others of significant tissue destruction. Victims and their fami- 2014); it is thus closely linked to the leading causes of lies are often stigmatized, with increased risk of poverty major NCDs, such as diabetes and obesity. To reduce for affected households (Marck 2013; Ogbureke and the likelihood of dental caries, obesity, and diabetes, the Ogbureke 2010). World Health Organization (WHO) Guideline on Noma is most prevalent in Burkina Faso, Ethiopia, Sugars Intake (WHO 2015) recommends that less than Mali, Niger, Nigeria, and Senegal; however, because of 10 percent of the daily energy intake come from sugar. unreliable documentation, there are no accurate epi- Further benefits may be achieved by reducing consumption demiologic data. The etiology of noma is associated to less than 5 percent (five teaspoons per day) of total with malnutrition, insufficient access to improved daily energy intake (Moynihan and Kelly 2014). sanitation, cohabitation with animals, and compro- mised immune systems. This confluence of etiologic factors can be disrupted; if diagnosed at early Alcohol and Tobacco Use stages, simple and effective treatment, consisting of Children and adolescents are increasingly exposed to disinfection and hygiene measures combined with other risk factors that may lead to oral diseases later in antibiotics, is possible. However, by the time patients life, particularly oral cancer. Tobacco use in all its forms receive care, noma is often in advanced stages. Surviving is the main risk factor for oral cancer, and harmful alco- children usually require costly and complex surgery, hol consumption further amplifies the risk. Although which is either unavailable or unaffordable. Informing exposure in HICs is decreasing as a result of effective at-risk population groups, especially mothers, about regulations, the challenges in LMICs are increasing. The simple oral and other hygiene improvements, balanced average age of smoking initiation has dropped from nutrition, and early detection of potential lesions can 15–17 years to 13–14 years; high rates of tobacco and help prevent noma. alcohol use are increasingly common. Up to 20 percent of 15-year-olds in LMICs use tobacco, and more than 50 percent of 13-year-olds in the United States have tried RISK FACTORS, SOCIAL DETERMINANTS, alcohol. In the Philippines, 30 percent of those ages INEQUALITIES, AND DISEASE TRENDS 11–16 years reported alcohol use in the past month. The many factors that influence oral health include indi- These habits may persist and deepen during adulthood vidual, environmental, family, community, and broader (Ahlström and Österberg 2004; Bach 2015; Lillard and societal factors. For children and adolescents, high sugar Christopoulou 2015; Peltzer and Pengpid 2015). intake and insufficient oral hygiene are the leading risk Electronic nicotine delivery systems have grown in pop- factors for poor oral health, while behavioral and envi- ularity. Although the evaluation of their health effects is ronmental influences affect the likelihood of oral inju- still ongoing, indications of their harm include the ries and trauma. induction of children and adolescents to smoking and The risk factors for oral diseases and major noncom- nicotine addiction, with its negative impact on adoles- municable diseases (NCDs) overlap; these include, for cent brain development. example, unhealthy diet and the consumption of tobacco and alcohol. This overlap provides the basis for inte- Changing Consumption Patterns grated prevention strategies through the common risk factor approach (Sheiham and Watt 2000), one of the Moreover, global demographic changes, rapid urbaniza- cornerstones of oral health promotion. tion, the economic transition from low-income status to lower-middle-income status, and migration streams within and between countries are influencing consump- High Sugar Consumption tion patterns for many populations. In recent decades, A diet characterized by frequent and high intake of the proportion of the population living in middle- sugary food or sugar-sweetened beverages (SSBs) income countries has grown from 26.7 percent in 1990 to increases the risk of developing tooth decay. Free sug- 72 percent in 2012. During the same period, the propor- ars include all sugars added to foods and drinks by tion of people living in LICs decreased from 57.7 percent manufacturers, cooks, or consumers, as well as sugars to 11.7 percent. Although these shifts have brought Promoting Oral Health through Programs in Middle Childhood and Adolescence 213 major advances in general development (Jamison and PREVENTION AND HEALTH PROMOTION TO others 2013), they have also modified population expo- IMPROVE ORAL HEALTH sure to risk factors for diseases. In particular, these changes have increased the consumption of sugar, fat, The development of effective prevention and oral health and salt. Accordingly, the disease burden in LMICs has promotion strategies, in conjunction with pain relief and shifted from a focus on infectious diseases to a predomi- emergency services, may be the most realistic strategy for nance of NCDs (Popkin, Adair, and Ng 2012). LMICs based on available resources and ethical consid- Oral diseases are part of this global transition erations (Frencken, Holmgren, and van Palenstein (figure 16.1), as exemplified by changes in disability- Helderman 2002). This section discusses oral health adjusted life years (DALYs1) caused by tooth decay in Sub- promotion in school settings, including related support- Saharan Africa. From 1990 to 2012, the global average ive policies, as a cost-effective area for government and increase in disease burden of dental caries, as measured in public health intervention. DALYs, was 34.5 percent; for most countries in this region, however, it was between 42 percent and 78 percent (Dye and others 2013; Kassebaum and others 2015). Making Schools Healthy Places Children and adolescents spend significant time in school, which is a key setting for promoting oral and CHALLENGES TO EFFECTIVE ORAL HEALTH general health. Net primary school enrollment rates PROMOTION IN LMICs worldwide for both genders have increased steadily for decades and averaged 89 percent in 2013 (UNESCO Countries that have traditionally emphasized prevention 2015). Reaching a majority of children through pri- and control of oral diseases, particularly in schools (such mary schools may be possible without requiring com- as Hong Kong SAR, China; Scandinavian countries; and plex additional health structures. Oral health Switzerland) have been able to achieve substantial interventions can be used as entry points for wider improvements in oral health status with high rates of integration with other health activities, including the caries-free children. In LMICs, however, despite the potential to address broader determinants of health growing oral disease burden, designing and implement- (Macnab and Kasangaki 2012). Building skills and pro- ing effective oral health promotion strategies has proved viding services, together with improving the condi- challenging for several reasons: tions of the school environment, have the potential to influence lifelong knowledge, attitudes, health status, • Communicable diseases and diseases with high and behaviors of children.2 mortality receive priority over NCDs and oral dis- Schools are also influential model institutions in eases (Benzian, Hobdell, and others 2011; Piva and their communities and may facilitate participatory Dodd 2009). approaches that involve parents and the wider com- • There is reluctance to view oral health in the con- munity in health promotion. Creating health- text of systemic health care and to include it as part promoting schools requires school-level commitment of comprehensive health care services and related as well as policy guidance to encourage risk-reduction infrastructure. measures, such as banning smoking or foods with high • Reliable information on the oral disease burden, sugar content on the premises (Bundy 2011), or pro- which is often not integrated into national health viding clean and healthy environments that include surveillance, is lacking, resulting in the unavailabil- sustained access to safe water, sanitation, and hygiene ity of up-to-date epidemiological data, even though (Emory University Center for Global Safe Water and standardized survey tools exist (FDI World Dental UNICEF 2013). Federation 2015; Petersen and others 2005) Research on the effects of oral health promotion in • Evidence-based and population-wide preventive schools comes primarily from HICs, but evidence from strategies that take into account the broader determi- LMICs is growing (Haleem and others 2016; Macnab nants of health are absent (Watt 2007). 2015; Monse and others 2013; Petersen and others • Priority is given to curative clinical approaches, 2015). Several supportive policy frameworks exist to which are generally costly and associated with access guide countries in developing school health strategies. barriers. Oral diseases are considered the fourth most The Focusing Resources on Effective School Health expensive health condition and result in high out-of- approach provides a conceptual framework and guides pocket payments, particularly in LMICs (Kandelman national policies; its principles also apply to oral health and others 2012). promotion in schools (World Education Forum 2000). 214 Child and Adolescent Health and Development The WHO Health Promoting Schools framework includes technical guidance for oral health programs Box 16.1 (Macnab 2015), although a recent Cochrane review revealed limited evidence for sustained impact and Integrated School Health: The Fit for School called for better implementation and research (Langford and others 2014). Building on both concepts, the Fit for Programme School Action Framework provides practical implemen- The Fit for School Programme is implemented by the tation guidance and integrates daily, skills-based oral Ministries of Education in Cambodia, Indonesia, the Lao health activities with other school-based priority inter- People’s Democratic Republic, and the Philippines, with ventions (box 16.1) (Benzian and others 2012). support from Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) GmbH. As the recipient of an Reducing Risk Exposure award from the World Health Organization, the World Reducing Sugar Consumption. Public institutions, Bank, and the United Nations Development Programme especially schools, should not only raise awareness of but for innovation in global health, the model integrates an oral also provide healthy food and beverage options. Some health intervention into a school health program address- 370 million children worldwide receive school meals ing prevalent diseases in school-age children. Students each day, providing opportunities to offer healthy choices brush their teeth with fluoride toothpaste as a daily group low in free sugars, fat, and salt, thereby reducing the risk activity, combined with group handwashing with soap. for tooth decay, obesity, and related chronic conditions (Vandevijvere and others 2015). This approach helps familiarize children with healthy hab- Canteens or vendors on or near school premises typ- its and reduces other hygiene-related diseases (Monse and ically offer snacks and SSBs. Schools may consider limit- Benzian 2011). Research in participating schools has shown ing or prohibiting the sale of sugary foods and SSBs on that daily group toothbrushing with fluoride toothpaste school premises, along with providing healthy alterna- has prevented 17.3 percent of new caries lesions (Monse tives. Advertisements for and sponsorship of unhealthy and others 2013). However, results depend on implementa- foods and drinks may also be banned from schools (New tion quality. Under controlled conditions, reviews show a Zealand Beverage Guidance Panel 2014; Patel and preventive power of up to 25 percent for toothbrushing Hampton 2011; Wilder and others 2015). with fluoride toothpaste (Marinho and others 2009). The On a policy level, the introduction of taxes on Fit for School Programme costs US$0.60 per child per year unhealthy products such as SSBs, regulations for trans- in supplies and reduces absentee rates due to illness. parent food labeling, and restrictions on marketing to Source: Marinho and others 2003. children and adolescents may contribute to reducing risk exposure (Rayner, Scarborough, and Briggs 2015). Banning Tobacco and Alcohol Products. A review of for cycling and use of motorbikes or similar vehicles are school-based tobacco prevention initiatives in 40 LMICs measures to reduce the frequency and severity of dental confirmed that only bans reduced smoking rates; edu- and craniofacial trauma. cational interventions alone had no significant effect (Agaku and others 2015). Accordingly, an appropriate Strategies to Promote Oral Health policy would be to ban the sale, marketing, and spon- Skills-Based Oral Health Promotion. Oral health pro- sorship of tobacco and alcohol products for children motion in schools has traditionally focused on educa- and adolescents in general and on school premises in tional approaches that transfer knowledge about disease particular (Saraf and others 2012). or healthy behavior. However, evidence suggests that these approaches alone have limited long-term effects. Improving Safety and Protection. Although it is Instead, a focus on activities that develop children’s impossible to prevent all oral injuries and trauma, skills, hygiene practices, and habits is more successful in certain measures can make schools safer. For example, improving individual oral health behaviors (Cooper and avoiding injury-prone installations, such as sharp edges others 2013; Hopkins and others 2007; Kay and Locker or places for high climbing, can help prevent falls, oral 1998; Peters and others 2009). injuries, and trauma (Glendor 2009). Wearing mouth Skills-based oral health education includes daily group protection can reduce the risk of trauma from contact toothbrushing with fluoride toothpaste at school. Group sports, but it requires sufficient resources. Road safety activities are fun for children and enforce healthy social on the way to school and enforced use of proper helmets norms, which are effective drivers of oral hygiene behavior Promoting Oral Health through Programs in Middle Childhood and Adolescence 215 (Claessen and others 2008). Toothbrushing in a group fluoride may include brushing with high-fluoride- while using appropriate washing facilities is a practical containing gel once a week or application of fluoride var- way to facilitate implementation with little extra workload nish by trained health workers in schools. In HICs, the for supervising teachers. Because these activities do not application of fissure sealants may be considered. These require the involvement of health professionals, they can procedures require adequate infrastructure, staff, and be readily integrated into the daily school schedule. resources, which are beyond the means of most LMICs. Moreover, as with many health interventions, robust Promoting Access and Use of Appropriate Fluorides. cost-effectiveness data from large-scale implementation Ample evidence demonstrates that use of fluorides is are lacking (Isman 2010; Marinho and others 2013). the most effective method for preventing dental caries in The institutionalization of such activities requires sup- populations. The WHO, the FDI World Dental Federation, portive structures on several levels (Benzian and others and the International Association for Dental Research, and 2012). On a policy level, improving access to and use of the Chinese Stomatological Association (2007) strongly appropriate fluorides requires reducing taxation of fluoride recommend twice-daily toothbrushing with fluoride toothpaste, increasing taxation of toothpaste without fluo- toothpaste (box 16.2) for the following reasons: ride to discourage its use, and strengthening national regu- lations for the quality and labeling of fluoride toothpaste. • Prevention of tooth decay by using fluoride is the most realistic way to reduce the burden of tooth Oral Health Care Services. Generally, provision of health decay in populations. services at schools is costly and challenging to sustain. • Fluoride toothpaste remains the most widespread, Referral systems are often deficient, even in HICs (Pine significant, and rigorously evaluated form of fluoride 2007); primary oral health care in LMICs is generally used globally. challenged by low numbers of oral health professionals, • Fluoride toothpaste is generally safe to use. lack of infrastructure and supplies, or high access barriers posed by costs and transportation (Petersen 2014). The most efficient and effective way to improve use of Depending on available resources, schools may offer oral fluoride in schools is integrating toothbrushing with fluo- health care services in the form of an attached dental clinic ride toothpaste as a routine activity into the daily school or regular visits of oral health professionals or trained com- schedule (Petersen and others 2015). Other sources of munity health workers. Basic treatment, such as pain relief and emergency care, may be provided on site or through referral to nearby health facilities. Teachers may preselect Box 16.2 children with dental problems. Screening without provision of basic care to children in need is considered unethical. A study using data from 1999 estimated that, for Principles of Toothbrushing with Fluoride 1 billion children in LMICs (ages 6–18 years), restorative Toothpaste oral care would cost more than US$860 billion (Yee and Sheiham 2002), an amount exceeding the capacities of • Brush teeth at least twice a day for two minutes with any health care system. The direct treatment costs of oral fluoridated toothpaste (1,200–1,500 parts per million disease in 2010 (all age groups and countries combined) fluoride concentration). Children up to age six years were estimated to be US$300 billion, with HICs spend- should use only a pea-sized amount of toothpaste. ing US$244 billion and the United States and Canada • Brush preferably after meals, especially breakfast, and alone spending US$120 billion (Listl and others 2015). before going to bed. These findings highlight dramatic inequalities in oral • Do not swallow toothpaste; spit out the slurry after health care expenditure, reflecting low service availability brushing, without rinsing with water. in LMICs. They also show that a focus on costly clinical • Parents and teachers should supervise toothbrushing so oral health care is not a realistic option in these settings. that children do not swallow toothpaste. Delivery of dental procedures is discussed in chapter 1 of • Rinse toothbrush after use, store it in an upright position, volume 1 in this series (Mock and others 2015). allow it to air dry, and ensure that it does not touch other toothbrushes or surfaces to avoid cross-contamination. • Visit a dental or health professional for routine check- Strengthening Surveillance and Research ups and in cases of discomfort, pain, or discoloration Oral disease surveillance in LMICs should be strength- of the teeth. ened and integrated with national surveillance systems to improve epidemiological information on the disease 216 Child and Adolescent Health and Development burden for better advocacy and effective action (Varenne well-being and quality of life, general health, school per- 2015). A number of opportunities exist for integrating formance, and social interactions. Preventing oral dis- oral health data into ongoing international collaborative eases with simple and cost-effective population-wide surveys such as the Global School-Based Student Health interventions is possible, even in resource-constrained Survey, the Global Youth Tobacco Survey, and the WHO LMICs (Geneau and others 2010), and schools are ideal STEPs surveys for NCDs. Oral health–specific modules platforms for reaching children. Recommended exist for each of these surveys, but they are not regularly approaches require action at the school, community, and applied or reported. policy levels, and include the following: More evidence is also needed to better understand what interventions are effective and under what condi- • Prioritization of schools as health-promoting settings tions. Applied research and rigorous evaluation of where skills-based and high-impact interventions, approaches, projects, and programs may help identify such as daily toothbrushing with fluoride toothpaste, effective and appropriate strategies. Furthermore, research can be implemented as part of integrated school results need to be accessible and presented in a format health that can inform policy decisions, particularly for effective • Increased advocacy to emphasize the burden and school health interventions (Benzian and others 2012). consequences of oral diseases to prioritize interven- tions for prevention and control in LMICs • Development of concepts, practical implementation Supportive Policies for Oral Health models, evaluation tools, and related national capac- Advocacy at the global and national levels to highlight ity for cost-effective best-buy interventions to address the burden and consequences of oral diseases among caries and other priority oral diseases in LMICs. children and adolescents may help prioritize interven- tions for prevention and control. Approaches with good The disease and risk factor trends indicate that evidence and cost-effectiveness, as well as skills-based inaction is likely to increase the challenges. Although oral health education, may strengthen healthy lifelong most evidence is from HICs, further research may behaviors. Strategies addressing the social determinants strengthen the links between concept, policy, and and common risk factors of oral diseases require policies action. Such an agenda needs consensus from stake- promoting oral health as part of the general health sec- holders and organizations active in the prevention and tor, as well as other sectors such as education, agricul- control of oral diseases to better prioritize oral dis- ture, transportation, commerce and trade, housing, and eases in LMICs. Only then can advocacy, science, water and sanitation, to establish health-conducive envi- strengthening of capacities, and technical assistance ronments and healthy nutrition. The emerging regional go hand in hand to have a significant effect on the and national action plans addressing NCDs may provide global burden of oral diseases (Benzian, Hobdell, and opportunities for integration of simple, sustainable, and others 2011). scalable oral health interventions. Strengthening Intersectoral Collaboration DISCLAIMER School-based health promotion is an intersectoral chal- Renu Garg and Benoit Varenne are staff members of the lenge, with stakeholders mainly from the education; health; World Health Organization (WHO), and Bella Monse is and water, sanitation, and hygiene sectors; but also from a staff member of the Gesellschaft für Internationale other sectors that jointly address key determinants of Zusammenarbeit (GIZ) GmbH. The authors alone are health. Task-sharing and leveraging the existing workforce responsible for the views expressed in this publication, may reduce costs and facilitate implementation. Defining since they do not necessarily represent the decisions, clear roles and responsibilities for all involved stakehold- policies, or views of the WHO or of GIZ. ers, including parents and the community, is crucial to ensuring successful and sustainable implementation. NOTES CONCLUSIONS World Bank Income Classifications as of July 2014 are as fol- lows, based on estimates of gross national income (GNI) per Worldwide, children and adolescents suffer from a sig- capita for 2013: nificant and largely preventable burden of oral diseases, particularly dental caries. The consequences affect • Low-income countries (LICs) = US$1,045 or less Promoting Oral Health through Programs in Middle Childhood and Adolescence 217 • Middle-income countries (MICs) are subdivided: Control Priorities (third edition): Volume 8, Child and a) lower-middle-income = US$1,046 to US$4,125 Adolescent Health and Development, edited by Bundy, b) upper-middle-income (UMICs) = US$4,126 to D. A. P., N. de Silva, S. Horton, D. T. Jamison, and G. C. US$12,745 Patton. Washington, DC: World Bank. • High-income countries (HICs) = US$12,746 or more. Bundy, D. A. P. 2011. Rethinking School Health: A Key Component of Education for All. Directions in Development 1. The DALY is a measure of overall disease burden, expressed Series. Washington, DC: World Bank. as the number of years lost due to ill-health, disability, or CDC (Centers for Disease Control and Prevention). 2004. early death. “Children’s Oral Health.” Factsheet. Division of Oral 2. The measures described for the school context are equally Health, CDC, Atlanta, GA. relevant for the kindergarten and preschool contexts, even Claessen, J.-P., S. Bates, K. Sherlock, F. Seearsand, and R. Wright. if these settings are not explicitly mentioned. 2008. “Design Interventions to Improve Tooth Brushing.” International Dentistry Journal 58 (S5): 307–20. Cooper, A. M., L. A. O’Malley, S. N. Elison, R. Armstrong, G. 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Sheiham. 2002. “The Burden of Restorative and others. 2012. “A Systematic Review of School-Based Dental Treatment for Children in Third World Countries.” Interventions to Prevent Risk Factors Associated with International Dental Journal 52 (1): 1–9. 220 Child and Adolescent Health and Development Chapter 17 Disability in Middle Childhood and Adolescence Natasha Graham, Linda Schultz, Sophie Mitra, and Daniel Mont INTRODUCTION In particular, we have focused on the relationship with Worldwide, people with disabilities have difficulty education—the gateway to participating fully in society, accessing education, health services, and employment. securing a livelihood, and capitalizing on the opportu- Disability is an economic development issue because it is nities that society offers. Children with disabilities are linked to poverty: disability may increase the risk of pov- less likely to attend school; when they do attend school, erty, and poverty may increase the risk of disability (Sen they are less likely to stay in school and be promoted 2009). A growing body of evidence indicates that chil- (Filmer 2005; Mizunoya, Mitra, and Yamasaki 2016; dren with disabilities and their families are more likely WHO and World Bank 2011). They account for a large than their peers to experience economic disadvantage, proportion of children who do not complete a primary especially in low- and middle-income countries (LMICs). education, reducing their employment opportunities Approximately 15 percent of the world’s adult popula- and productivity in adulthood (Burchardt 2005; Filmer tion lives with some form of disability (WHO and World 2008; Mete 2008). Bank 2011). Children ages 0–14 years account for slightly The literature has focused on advocacy, reflecting the less than 6 percent of persons with disabilities globally, relative neglect of this important area. This focus is begin- but the number of disabled children is grossly underesti- ning to change, at least with regard to the availability of mated in LMICs (UNICEF 2008). The estimates for prev- information, and efforts to provide more quantitatively alence of disability among children fall in a wide range rigorous information are increasing (see, for example, because the methods for identifying them in surveys have WHO and World Bank 2011). However, information for varied (Cappa, Petrowski, and Njelesani 2015). This vari- children and adolescents ages 5–19 years is notably lack- ation results from the complexity of identifying child- ing, especially from LMICs. In this age group, the focus hood disability (Meltzer 2010, 2016). However, new has been on schoolchildren and the development conse- international standards offer hope for good quality, inter- quences of excluding children from education. In the nationally comparable data moving forward. absence of a comprehensive economic analysis or review This chapter expands on a central theme of this vol- of disability and development in children and adoles- ume: the need for a multisectoral approach to address- cents, this chapter makes extensive use of case studies, ing the complex interactions between child and which document real-world efforts in LMICs to address adolescent development and physical and mental health. disability in this age group in poor communities. Corresponding author: Daniel Mont, Center for Inclusive Policy, Washington, DC, United States; danielmont01@gmail.com. 221 Through the use of these case studies, this chapter the Rights of Persons with Disabilities uses a concept of provides examples of how deprivations can become disability consistent with the social model.1 disability if children are excluded from school in The differing nuances of the word disability and the LMICs. The case studies emphasize interventions to differing cultural contexts within which people operate ensure that children with disabilities gain access to edu- have made internationally comparable data on the cation, and they examine the design of supportive incidence, distribution, and trends difficult to obtain. education systems and the use of school health pro- Where children are involved, fur ther complexities grams to address the needs of children with impair- arise. For example, survey questions developed for ments. Most assessments have focused on physical adults but used for children may skew the results disability, especially mobility, and they provide this (WHO and World Bank 2011), and caregivers who specific perspective on barriers to education. Little is complete surveys may not accurately portray children’s known about these common forms of disability in experiences (Chamie 1994). The setting for data collec- LMICs; even less is known about the impact of socio- tion can also affect the prevalence estimates for chil- behavioral constraints, such as those associated with dren. For example, HICs often identify disability in autism, which we know to be prevalent and important medical or educational settings, but many LMICs do constraints in high-income countries (HICs). This not have formal services for identifying children with chapter explores this issue in a case study of a rare pro- disabilities (Cappa, Petrowski, and Njelesani 2015). gram in a lower-middle-income country in Sub-Saharan Progress is being made with respect to measuring Africa. Definitions of age groupings and age-specific disability in an internationally comparable manner, and terminology used in this volume can be found in the United Nations Children’s Fund (UNICEF) and the chapter 1 (Bundy, de Silva, and others 2017). Washington Group on Disability Statistics (WG) have developed a survey for identifying children with disabil- ities. Data using the child functioning module, or child DISABILITY DEFINITIONS AND questionnaire have been finalized and ready for use. The WG has also developed questions for adults that MEASUREMENTS have already been adopted in censuses, general surveys, Disability can be defined and measured in several ways. and disability-specific surveys, creating a growing evidence Traditionally, disability was considered a medical issue to base for work on disability and development (Altman prevent or cure (medical model). Later, disability came 2016). Both the WG’s adult and the child measures define to be considered a social construct that required societal people with disabilities as those with functional and basic changes (social model). More recently, interactional activity limitations that put them at risk of social exclusion models of disability have been developed that combine due to barriers in the environment (Altman 2016). both medical and social determinants and courses of Various ethical considerations arise when collecting action. In this bio-psychosocial model, disability is seen data on children with disabilities. Data on children come as emerging from the interaction between impairments from surveys of mothers or primary caretakers. Caretakers and the environment; environment is understood as who have responded to questions about children’s diffi- going beyond the physical environment to include the culties functioning might expect that the questions will cultural and institutional environments. Several inter- be followed by services, and a second-stage assessment actional models are available (Mitra 2006; Shakespeare needs to be linked to service delivery. Another concern is 2006); the most influential is the one underlying the the issue of labeling a child as having a disability. This International Classification of Functioning, Disability labeling can cause shame to families in some cultures and and Health (ICF) (WHO 2002). In the ICF, disability can create expectations that limit children. Fortunately, refers to the negative aspects of the interaction between the newer approach to disability identification in surveys, the individual with a health condition and the context of as in the UNICEF/WG instrument, lessens the impact of the person (such as physical and attitudinal). Under the this issue significantly. The word disability is never used, ICF, disability is used as an umbrella term for impair- and children are never labeled as having a disability. ments, activity limitations, and participation restric- Children are identified only anonymously in statistical tions. In addition to theoretical definitions for these analyses, rather than on a case-by-case basis in person. models, various definitions of disability are used by This chapter defines disability by a person’s func- statistical agencies that collect information on censuses tional, activity, and participation limitations based on and surveys, as well as by legislative and political bodies his or her physical, cultural, and policy environments. to determine eligibility for disability programs or cover- The concept of disability is not solely equated with a age under disability rights laws. The UN Convention on medical diagnosis; it encompasses an environment that 222 Child and Adolescent Health and Development restricts a person’s activity and participation. A lack of much higher in 3 countries (2.9 percent in Uganda; assistive devices, an inaccessible physical environment, 4.5 percent in South Africa, and 5.0 percent in Maldives). negative attitudes, and stereotypes all prevent people Disability prevalence rates in secondary-school-age from participating in society on an equal basis. Because children do not exceed about 2.0 percent in 13 of 15 this chapter is a literature review, it also uses the defini- countries. None of these disability prevalence estimates tions underlying the studies under review, which may be for children is satisfactory, and more research and data different from the above definition. collection are needed in this area. The GBD estimates are inferred from data on health conditions and impairments alone, using available data PREVALENCE BY AGE AND on distributions of limitations that may result from health conditions and impairments. Mizunoya, Mitra, TYPE OF DISABILITY and Yamasaki (2016) used a questionnaire developed for The estimated prevalence of childhood disability varies adults, which is known to be unable to identify certain substantially across and within countries, depending on disabilities that prevail among children, such as develop- questionnaires and study designs under use. The preva- mental disabilities. lence estimates in this chapter are not definitive but There are many types of disability, with varying rather a reflection of available data. A literature review by degrees of severity. A disability can be physical, cognitive, Cappa, Petrowski, and Njelesani (2015) found that the psychosocial, communicative, or sensory. The nature of prevalence of childhood disability in LMICs ranged from the causes of the impairments associated with these dis- less than 1 percent to almost 50 percent. Unfortunately, abilities can vary significantly by country context, as can census data are not good sources of data on disability the types of barriers that children with those disabilities among children because census questions—even the face. Attention to the type of disability can add a good short set of WG questions recommended for use in cen- deal of depth to the analyses of disability data and the suses by the United Nations Statistical Commission—are development and implementation of disability policies. not effective in identifying children with developmental Disease Control Priorities in Developing Countries, second disabilities. A special child-functioning survey module is edition, discusses discuss loss of vision and hearing needed to accurately assess disability status, and this (Frick and others 2006) as well as learning and develop- module would be too long for use in censuses. mental disabilities (Durkin and others 2006). Despite the shortcomings of the measures used to Unfortunately, good-quality data on the type of date, there are a number of estimates of disability preva- disability—especially data that are internationally lence among children. Based on the latest Global Burden comparable—are difficult to obtain (Cappa, Petrowski, and of Disease (GBD) data (IHME 2016), on average, a greater Njelesani 2015; Maulik and Darmstadt 2007). That is one percentage of children ages 0–14 years in LMICs are esti- reason that UNICEF and the WG have developed a module mated to have a disability compared with children of the on childhood disability. Even data using the Ten Question same age group in HICs (table 17.1). The IHME statistics Screening Instrument adopted in UNICEF’s Multiple define disability in a particular way because it is used as Indicator Cluster Survey are of limited use in this regard for the basis for the estimation of disability-adjusted life several reasons. First, the instrument was not designed for years. Disability in this context includes the acute, often complete disaggregation by type of disability. Second, it was temporary, and typically reversible disability that arises designed as part of a two-stage process. The first stage was from, for example, an episode of influenza, a bout of to cast a wide net to capture all children who might possi- malaria, or a broken limb, as well as the chronic, often bly be identified as having a disability, to be followed by permanent, and typically irreversible conditions within more detailed assessment. The second stage, however, is the more usual definitions of disability. As a result, the rarely done, which presumably creates false positives for IHME definition leads to estimates that suggest a much studies using only the Ten Question Screening Instrument. larger proportion of the population is affected. There is no reason to believe that the false positives in the UNICEF (2005) estimates that 150 million children dataset have the same distribution by type of disability as and adolescents younger than age 18 years live with dis- the true positives. Where follow-up assessments have been ability. Mizunoya, Mitra, and Yamasaki (2016), using the used (for example, the 2013 Two-Stage Child Disability WG questions for adults, found that the median preva- Study in Bhutan undertaken by the Bhutan National lence stands at 0.8 percent and 1 percent for primary- and Statistics Bureau), however, there have been questions secondary-school-age children, respectively, in 15 LMICs. about their quality because they require personnel with Disability prevalence in primary-school-age children did specific training. The Bhutan report notes that some level not surpass 1.5 percent in 12 of 15 countries, but it was of issues arose with the cognitive follow-up assessments. Disability in Middle Childhood and Adolescence 223 Table 17.1 Estimated Point Prevalence of Disability and Severity among Children and Adolescents Ages 0–14 across WHO Regions percent Low- and Middle-Income Countries, WHO Region High- Sex and age group income Eastern South- Western (years) World countries Africa Americas Mediterranean Europe East Asia Pacific No disability Male 0–14 30 37 22 31 35 36 30 32 Female 0–14 30 37 22 30 33 36 30 31 Very mild disability Male 0–14 12 11 13 11 11 13 12 11 Female 0–14 11 12 13 11 11 13 11 11 Mild disability Male 0–14 18 15 20 19 18 17 21 19 Female 0–14 20 17 22 21 20 19 23 20 Moderate disability Male 0–14 22 23 23 21 19 20 21 21 Female 0–14 22 22 23 21 20 20 20 21 Severe disability Male 0–14 15 12 18 15 14 12 15 14 Female 0–14 14 10 17 14 14 11 14 13 Very severe disability Male 0–14 2 2 3 2 2 2 2 2 Female 0–14 2 2 3 3 2 2 2 2 Source: IHME 2016. Note: High-income countries includes Asia Pacific and North America. Western Pacific includes East Asia, South Asia, Central Asia, Oceania, Australasia, and the Western Pacific. Comparison problems arise in HICs as well. As The surveys revealed important trends in disability table 17.2 shows, data on disability among children and risk among children. For example, children in ethnic adolescents from Australia and the United States are not minority groups, from poorer households, and with comparable; the age categories are different as are the limited early childhood education were more likely categories of types of disabilities assessed. One common than their peers to screen positive for disability result, even with these differences, is that boys have a (UNICEF 2008). Weight and nutrition are risk factors higher rate of disability. This is a common finding as well (Groce and others 2013). Low birth weight and across almost all child disability surveys. a lack of essential dietary nutrients, such as iodine or Using its 10-question Multiple Indicator Cluster folic acid, are associated with incidence and preva- Survey, UNICEF screened more than 200,000 children lence of disability (Hack, Klein, and Taylor 1995; ages two to nine years in 20 countries for risk of disabil- UNICEF 2008; Wang and others 1997). The propor- ity (UNICEF 2008). Between 14 percent and 35 percent tion of children at risk for disability increases among of children screened positive for risk of disability in most children with severe stunting and nutrient depriva- countries (UN Statistics Division 2010). However, this tion (UNICEF 2008). An estimated 200 million chil- finding is an overestimate because the questions were dren younger than age five years do not reach their designed to be a first-stage screen to be followed by a full cognitive, social, and emotional development more detailed assessment that was not conducted. potential (Grantham-McGregor and others 2007). 224 Child and Adolescent Health and Development Table 17.2 Prevalence of Disability by Type of Disability, Australia and the United States percent Australia United States Ages 0–14 years Ages 5–17 years Boys Girls All Boys Girls All Intellectual or learning 5.2 2.0 3.7 — — — Remembering — — — 5.3 2.8 4.1 Psychiatric 1.5 0.7 1.1 — — — Sensory or speech 4.0 2.1 3.1 — — — Hearing — — — 0.6 0.6 0.6 Vision — — — 0.9 0.8 0.8 Physical 4.2 3.1 3.7 0.7 0.6 0.6 Acquired brain injury 0.5 0.2 0.3 — — — Going outside the home — — — 2.2 1.8 2.0 Dressing — — — 1.2 0.7 0.9 Total 9.6 5.4 7.6 6.5 4.0 5.3 Sources: AIHW 2004; American Community Survey 2014, https://www.census.gov/people/disability. Note: — = not available. The columns sum to more than the total because some children have multiple disabilities and so are included in more than one row. DISABILITY AND SOCIOECONOMIC household assets, and expenditures (Mitra, Posarac, and INEQUALITIES: DETERMINANTS, Vick 2013; Mizunoya and Mitra 2013). However, several studies have provided growing evidence that disability CONSEQUENCES, AND CORRELATION is associated with a higher likelihood of experiencing Disability is both a determinant and a consequence of multiple deprivations simultaneously (Mitra, Posarac, socioeconomic inequalities. Children in poor families or and Vick 2013; Trani and Canning 2013; Trani and others communities, in LMICs especially, are exposed to 2015; Trani and others 2016). Although the nature of poverty-related risk factors that may contribute to the deprivations may vary across countries, they may include onset of health conditions associated with disability. employment, health, educational attainment, household Low birth weight and cumulative deprivations from material well-being, social participation, or psychological malnutrition (Black and others 2008; UNICEF 2008), well-being. lack of clean water, and inadequate sanitation can man- Even with the same levels of income, people with ifest in developmental disabilities (Rauh, Landrigan, disabilities and their households are likely to be effec- and Claudio 2008). In addition, lack of access to health tively poorer than people without disabilities and their services may convert a health condition into a disability. households. This trend is in part due to the direct costs Finally, a child with a disability might experience further of disability, for example, higher health and transpor- issues that exacerbate the severity of his or her disability tation costs (Braithwaite and Mont 2009; Cullinan, (Krahn, Hammond, and Turner 2006). First, certain Gannon, and Lyons 2011; Zaidi and Burchardt 2005). resources, such as clean water and sanitation or health Researchers have attempted to quantify the extra cost clinics, may be inaccessible. Second, individuals with of living with a disability, but the findings vary consid- disabilities may be subjected to discrimination within erably. The costs of disability accounted for an esti- their families and receive a disproportionately low share mated 9 percent of income in Vietnam, 14 percent in of familial resources (Rosales-Rueda 2014). Bosnia and Herzegovina, and 11 percent to 69 percent Growing evidence suggests a correlation between pov- in the United Kingdom (Braithwaite and Mont 2009; erty and disability among children and adults with dis- Zaidi and Burchardt 2005). ability (WHO and World Bank 2011). Overall, in LMICs The direct and indirect costs related to disability can the evidence points to individuals with disability often worsen social and economic well-being through many being economically worse off in educational attainment; channels, including the costs associated with medical the evidence is more mixed with regard to employment, care, assistive devices, personal support, and exclusion Disability in Middle Childhood and Adolescence 225 from employment (Jenkins and Rigg 2003). People with Zambia (Trani and Loeb 2012); Morocco and Tunisia disabilities can be poorer because of the loss of work (Trani and others 2015); India (World Bank 2007); 51 productivity resulting from various factors including LMICs and HICs (WHO and World Bank 2011). their exclusion from the workforce, as well as from the This association, consistently found among adults, more limited labor participation of their family mem- may result from lower school attendance among chil- bers who might have care-giving responsibilities (Buckup dren with disabilities, or it may be due to more frequent 2009; Palmer and others 2015). The estimated cost of onsets of disability among adults with limited educa- lost productivity due to exclusion from employment tional attainment, for example, via malnutrition, lack of among individuals with disabilities is as high as 7 percent access to health care, and risky working conditions. of gross domestic product (Buckup 2009). Many of the There is a small but growing literature on school direct and indirect costs could be reduced if inaccessible attendance and disability in LMICs. Much of this litera- environments were more inclusive (WHO and World ture is descriptive and documents the extent of the Bank 2011). This two-way causality between disability gap in school attendance across disability status (Filmer and socioeconomic deprivations may also combine with 2008; Trani and Canning 2013). Filmer (2008) docu- other factors, such as violence and conflict, that may lead ments gaps in school attendance across disability status to both disability and poverty simultaneously. in 13 LMICs from 1992 to 2005, ranging from 10 percent Educational opportunities may mitigate some of the to 60 percent in middle childhood (ages 6–11 years), associations between disability and poverty. In a and 15 percent to 58 percent in adolescence (ages cross-country study of 13 LMICs, disability was associ- 12–17 years), although the measures of disability vary ated with a higher probability of being poor, but this substantially. Studies in Malawi, Namibia, Zambia, and correlation was no longer statistically significant once Zimbabwe found that, while only 9 percent to 18 percent educational attainment was controlled for, suggesting that of nondisabled children older than age five years had education could mediate this association (Filmer 2008). never attended school, 24 percent to 39 percent of disabled children had never done so (Eide and Loeb 2006; Eide, van Rooy, and Loeb 2003; Eide and others DISABILITY AND EDUCATION 2003; Loeb and Eide 2004). In India, close to 40 percent Many children with disabilities have been excluded from of disabled children were not enrolled in school, com- mainstream educational opportunities in many parts of pared with 8 percent to 10 percent of children in the world. Education is particularly important for dis- Scheduled Tribes or Castes (World Bank 2007). abled children, who are often stigmatized or excluded. Mizunoya, Mitra, and Yamasaki (2016) explored School attendance helps dispel the misconceptions the gap in enrollment in primary and secondary edu- about disability that serve as barriers to inclusion in cation between children with and without disabilities other spheres (Bundy 2011). Education bolsters human using the WG measure for adults. Using nationally capital, minimizes barriers to entering the workforce, representative datasets from 15 LMICs, they found and improves economic earning potential. consistent and statistically significant disability gaps Inclusive education is based on the belief that all chil- in both primary and secondary education in all coun- dren can learn and should have access to a curriculum tries. A household fixed effects model shows that dis- and necessary adaptations to ensure meaningful educa- ability reduces the probability of school attendance by tional attainment. Support for inclusive education is a median of 30.9 percentage points, and that neither gaining momentum in LMICs, with a few countries the individual characteristics nor their socioeconomic adapting strategies to fit the local context. Durkin and and unobserved household characteristics explain the others (2006) examine interventions likely to improve disability gap. This finding indicates that general pov- child development and educational outcomes for chil- erty reduction policies through social transfers to the dren in LMICs. At present, no country has a fully inclu- poor will not contribute to closing the disability gap sive system (WHO and World Bank 2011). in schooling. Finally, Mizunoya, Mitra, and Yamasaki (2016) found that the disability gaps for primary- school-age children follow an inverted U-shape rela- School Attendance tionship with gross national income (GNI) per capita. A large body of evidence shows that adults with disabilities This result suggests that, as GNI per capita rises and in LMICs have lower educational attainment than adults more resources become available for improving access without disabilities: Bulgaria, Georgia, Moldava, Romania to education, children without disabilities increas- (Mete 2008); 15 countries (Mitra, Posarac, and Vick 2013); ingly attend school, whereas the situation of children Vietnam (Mont and Cuong 2011); Afghanistan and with disabilities may improve only slowly. 226 Child and Adolescent Health and Development Among children with disabilities, enrollment rates 2005). Curricula in many countries are not adapted differ according to type of impairment. In Burkina to the learning needs, challenges, and strengths of Faso, disabled children were more than twice as individual children. Inclusive education policies can likely not to attend school as other children, but only benefit all children because such policies are intended 10 percent of deaf children were in school, compared to respond to individual differences and abilities. with 40 percent of children with other physical disabil- • Environmental barriers outside the school system. ities (UNESCO 2010). In India, more than 50 percent Schools exist within an environmental context, and of children with mental disabilities were enrolled, exclusion may result from barriers not within the compared with 70 percent of children with poor school’s purview. These barriers can include, for vision, presumably because both physical access and example, inaccessible transportation, poor provision their ability to communicate with teachers is higher of assistive devices, and inaccessible health clinics that for the latter group (Mont 2014). make the health of children with disabilities more fragile. Exclusion can also result from parents being less willing to send their children to school because Barriers to Education of low expectations of the utility of that education or Beyond enrollment and regular attendance, studies show from feelings of shame. that children with disabilities are more successful in schools that are accessible for all learners (Dessemontent, Addressing these issues requires both policy- and Bless, and Morin 2012; Kalambouka and others 2007; school-level changes, as well as an action plan (McGregor Lindsay 2007; Ruijs and Peetsma 2009). Common and Vogelsberg 1998; Bundy 2011). Perhaps the most barriers to education include gaps in policy regarding important requirement is school- and policy-level lead- inclusive education, including limited resources, insuffi- ership committed to educating all children. cient number of trained teachers, lack of adaptive learn- Several avenues are available for financing special ing materials, and inaccessible facilities: needs education. Brazil used the national budget to establish a special national fund; Pakistan allocated • Accessible facilities. Building accessible schools is vital funding from its national budget to finance a special to making the transition to inclusive education. education network of schools. Nicaragua and Panama Children who use wheelchairs need ramps to enter dedicate a fixed amount of the overall education budget, the school, elevators to attend classes on upper floors, 0.92 percent and 2.3 percent, respectively, to special and accessible toilets. Building an accessible school needs education. Chile and Mexico cover the financial costs barely 1 percent more than building an inac- costs of special needs institutions, including materials, cessible school (Steinfeld 2005), but retrofitting an training, and teaching aids. Denmark, Finland, Hungary, inaccessible school is considerably more expensive. and New Zealand help individuals offset the additional Incorporating universal design in the floor plan costs of educating a child with special needs. Switzerland enables schools to include disabled children and min- and the United States have implemented combined imizes the need for separate schools. approaches (Hartman 1992; Parrish 1994). • Teacher capacity. Many LMICs educate children with disabilities in separate classrooms or mainstream them into regular classrooms but provide little sup- MEASURING ECONOMIC RETURNS OF port. Teacher training and access to specialists are at the core of full inclusion, but very few receive INCLUSIVE INTERVENTIONS training in inclusive education through either pre- or Measuring the economic returns to inclusive educa- in-service training (Ferguson 2008; Odom, Buysse, tion is complex because the costs are incurred in the and Soukakou 2011). Children also have limited short term, but the benefits accrue in the long term. access to specialists and teaching assistants. Effective Rigorous evaluations and economic analyses of how to programs often include training in inclusive educa- invest in inclusive education programs or the returns tion for administrators at the school, district, and generated by inclusive education are not yet available. national levels and have the resources, personnel, and As a result, the return on investment, children’s income discretion to implement changes suitable to the local potential, and the increase in caretaker productivity context. are not well known. • Curriculum design. A hallmark of inclusive education In Nepal, education has a bigger impact on the future is having a child-centered curriculum (McLeskey, earnings of children with disabilities than on those of Waldron, and Redd 2014; Rose, Meyer, and Hitchcock other children (Lamichhane and Sawada 2013). Gains in Disability in Middle Childhood and Adolescence 227 functional capacity can be largest when interventions vision lowered students’ academic performance 0.2–0.3 occur early in children’s development. Early detection of standard deviation, equivalent to a loss of 0.3 year of developmental delays can improve development and schooling (Glewwe, Park, and Zhao 2016). In high- school readiness (WHO and UNICEF 2011). Removing poverty counties in the United States, students with poor barriers early can minimize the compounding effects of vision who received free screening and eyeglasses had a multiple barriers. One approach is to use education as an 3.4 and 5.0 percentage point higher probability of pass- equalizing platform, especially in the formative years. ing standardized tests in reading and math, respectively, The returns to inclusive education, rehabilitation ser- than similar students in control schools. vices, or any other intervention depend on future barriers Skilled eye care personnel and infrastructure are lack- that individuals with disabilities will face as adults. If ing in LMICs, and schools have become a platform for significant barriers to employment are coupled with dis- delivering eye care services in various contexts (Limburg, crimination, transportation difficulties, and weak labor Kansara, and d’Souza 1999; Sharma and others 2008; laws, the return on childhood interventions may be small. Wedner and others 2000; Zhang and others 2011). In Following this line of reasoning, countries with fewer Cambodia, teachers were trained to assess whether chil- barriers to adult activities will gain higher returns from dren and adolescents needed an eye examination child services. One sectoral reform by itself may not have (Ormsby and others 2012). Within four weeks, fewer a substantial return, but improving inclusion in multiple than 100 teachers screened 13,175 students and referred sectors creates synergies that will increase those returns 44 to a team of refractionists, who provided ready-made in the future. or customized glasses. The costs per child were minimal, including opera- tional costs (travel, per diems, training), vision screen- CASE STUDIES ing kits, and glasses (about US$2–US$3 for ready-made These six case studies provide a nuanced look at both and US$3–US$7 for custom-made glasses). Teachers’ the progress in and the barriers to improving educa- time was covered by their salaries, while equipment tional provision and participation for children with was borrowed. The cost of eyeglasses can vary by the disabilities. They illustrate how the first steps to inclusive type of glasses and the region or country. In eight education have been taken in different settings. delivery models, eyeglasses cost between US$2.59 and Observing the positive effects of inclusive education in US$7.06 per pair (Wilson 2011). Costs were similar in schools and in communities can spur the development Zanzibar (Laviers and others 2010). In China, costs of equitable policies in other sectors. ranged between US$2 and US$15 (Glewwe, Park, and Zhao 2016). In the United States, screenings cost about Case Study 1. Vision, Learning, and Free Eyeglasses US$2, and examinations and glasses cost about US$100 (Glewwe, West, and Lee 2015). Elisabetta Aurino, Lesley Drake, Paul Glewwe, Imran Baltussen, Naus, and Limburg (2009) modeled the Khan, and Kristine West contributed this case study. cost-effectiveness of interventions to determine the Poor vision can affect the development of children and prevalence of visual impairment by age and enrollment adolescents and the economic prosperity of a country, in Africa, America, Asia, and Europe. They also evaluated costing the world more than US$200 billion a year (Fricke cost-effectiveness for 10 years and found that annual and others 2012).2 However, data on the prevalence of screening was more cost-effective for adolescents (ages visual impairments in school-age children and adolescents 11–15 years) than for children (ages 5–10 years) because are limited and varied. In one 2004 study, 1 percent of of differences in prevalence and enrollment. Screening at school-age children ages 5–15 years (almost 13 million) broad age intervals was more cost-effective than screen- were visually impaired (Resnikoff and others 2008). ing at single age intervals. Country-specific estimates range from 1 percent in Malawi Sustainability and other constraints can be challeng- (Lee 2016), to 13 percent in China (Glewwe, Park, and ing. Eyeglasses need to be replaced regularly, especially in Zhao 2016), and 31 percent in high-poverty school dis- children. Supply constraints relate to lack of trained tricts in the United States (Glewwe, West, and Lee 2015). personnel and poor eye care infrastructure. Demand Poor vision may lead to poor educational outcomes constraints include lack of awareness of need and socie- (Bundy and others 2003). Primary schoolchildren in tal views that eyewear is unattractive (Kodjebacheva, Northeast Brazil with poor vision had a 10 percentage Maliski, and Coleman 2015). In China, take-up was point higher probability of dropping out and an 18 per- 65 percent, while in the United States it was 75 percent. centage point higher probability of repeating a grade The main impediment in all studies was failure to gain (Gomes-Neto and others 1997). In rural China, poor parental permission for the exam. 228 Child and Adolescent Health and Development In summary, school-based approaches provide an school for older children and adolescents regardless of economically attractive intervention to correct visual the definition of disability or type of school. Having a impediments that hinder child development. childhood disability also lowered the level of completed education. Moreover, having a parent with a disability reduced the chances that children without disabilities Case Study 2. Childhood Disability, Education, and would attend school (Mont and Nguyen 2013a). Poverty in Vietnam Including the WG questions on both the census and Daniel Mont contributed this case study. household survey allowed for small-area estimation of the relationship between poverty and disability. The The WG is the international standard setter for mea- poverty gap between households with and without a suring disability at the national level. It identifies the disabled member varied significantly and was lower in likelihood of disability using the ICF. The question- areas with better infrastructure and health care services naire identifies difficulties that people have in under- (Mont and Nguyen 2013b). taking basic activities (box 17.1). It is also useful for This dataset from Vietnam adds weight to the rela- disaggregating socioeconomic indicators by disability tionship between disability and poverty. As the question- status (Loeb 2016). naires are administered more widely, policy makers can In 2006, Vietnam based disability questions on the better determine where the link between disability and WG questionnaire and included them in the Vietnam poverty is strongest and what the most promising and Household Living Standards Survey, which was adminis- appropriate avenues are for designing interventions to tered to a nationally representative sample of house- weaken that link. holds. The result was a high-quality dataset on both disability and socioeconomic indicators (Mont and Nguyen 2013b). Case Study 3. Disability-Inclusive School Health and The poverty rate in Vietnam was 22 percent for peo- Nutrition Programs ple with disabilities and 15 percent for people without Sergio Meresman and Cai Heath contributed this case study. disabilities (Mont and Cuong 2011). The poverty gap was even higher for younger people. Poverty was nearly School health and nutrition programs have increas- twice as high for children with disabilities, after adjusting ingly been recognized for their educational impact on for the extra costs of living with a disability, as for other the most vulnerable learners (PCD 2015). Inclusive children (table 17.3). education encompasses children who have difficulty Having a childhood disability was also associated seeing or hearing, limited mobility, or difficulty learn- with having less education. Children with disabilities ing in classrooms designed for children without dis- were 41 percent less likely to attend school; excluding abilities. Disability-inclusive school health and children with mild disabilities, that figure rose to 47 nutrition refers to educational approaches designed to percent. Overall, having a disability in childhood was meet the needs of all children who are vulnerable to found to significantly reduce the chances of completing dropping out or being excluded from education, Box 17.1 Washington Group Short Set of Questions on Disability The next questions ask about difficulties you may 5. Do you have difficulty (with self-care such as) have doing certain activities because of a HEALTH washing all over or dressing? PROBLEM. 6. Using your usual (customary) language, do you have difficulty communicating, for example, 1. Do you have difficulty seeing, even if wearing glasses? understanding or being understood? 2. Do you have difficulty hearing, even if using a hearing aid? 3. Do you have difficulty walking or climbing steps? Possible responses for all questions are no diffi- 4. Do you have difficulty remembering or culty, some difficulty, a lot of difficulty, and cannot concentrating? do at all. Disability in Middle Childhood and Adolescence 229 Table 17.3 Poverty Rates for People in Vietnam, with and without Disabilities, 2006 percent People with disabilities after accounting Current age (years) People without disabilities People with disabilities for extra costs of living with a disability 5–18 19.3 31.1 36.2 19–40 15.1 24.7 31.4 41–62 9.2 11.9 15.3 Older than 62 14.5 17.0 22.8 Source: Mont and Cuong 2011. Table 17.4 Pillars of the FRESH Framework FRESH pillar Key concepts for inclusion Practical implications Equitable school health Inclusive development; universal design Gather and disaggregate data on children with disabilities; policies require adequate and sustainable funding; make policy makers aware and trained A safe learning environment Physical access; stigma-free environment Follow accessibility standards; promote human rights, equity, and diversity to remove attitudinal barriers Skills-based health Curriculum adaptations; information, education, Adapt methodologies and content to the learning needs of all education and communication materials in accessible children; provide accessible learning materials formats (Braille, sign language, easy reading) School-based health and Inclusive delivery of health and nutrition Train teachers and health workers in inclusive school health nutrition services services; cross-sector collaboration; integrated and nutrition; provide health screening and appropriate approaches to programming assistive devices; conduct high-quality context analysis; support inclusive homegrown school feeding programs; provide inclusive water, sanitation, and hygiene programming; engage families and organizations to support outreach and delivery of services Source: Meresman and others 2015. Note: FRESH = Focusing Resources on Effective School Health. including children with disabilities, orphans, Although a disability-inclusive approach to school migrants, those affected by human immunodeficiency health and nutrition programming is a recent concept, virus/acquired immune deficiency syndrome (HIV/ the need for these strategies in education sector plan- AIDS), those who do not speak the language used in ning has long been apparent. Kenya’s 2005–10 Education the classroom or who belong to a different religion or Sector Plan identified two key gaps: a lack of clear caste, and those who are sick, hungry, or not excelling guidelines on the implementation of an all-inclusive academically. education policy and a lack of reliable data on children In 2000, the Education for All goals and Focusing with special needs (Republic of Kenya 2005). Zanzibar’s Resources on Effective School Health (FRESH) frame- 2008–16 Education Sector Plan noted, “Enrollment of work were launched at the World Education Forum in children with special needs is low [and] this results in Dakar (FRESH Initiative 2000). The framework outlines insufficient support to people with special needs.” Key approaches that support effective school health pro- strategies included designing all education interven- gramming (table 17.4). tions in a disability-inclusive manner, collecting more The FRESH framework is helpful for designing and accurate data, and improving training for teachers implementing disability-inclusive school programs (Government of Zanzibar 2007). because it addresses the needs of the learners from mul- School health and nutrition programs are becoming tiple angles. For more information on FRESH, see chap- more disability inclusive. In Kenya the government’s ter 20 in this volume on school as a platform for homegrown school feeding program (discussed in chap- addressing health (Bundy, Schultz, and others 2017). ter 12 in this volume, Drake and others 2017) sought to 230 Child and Adolescent Health and Development improve targeting and data collection for all vulnerable estimated 1 in 68 children in the United States has children, sensitize teachers and parents, and provide autism (CDC 2014), and estimated prevalence is com- vocational training to improve economic outcomes parable in other regions (Elsabbagh and others 2012). (PCD 2013). Autism is typically a lifelong condition characterized by impaired social interaction and communication and the presence of restrictive or repetitive behavior. Case Study 4. Early Childhood Monitoring to Screen Children with autism are significantly more likely to for Disability in the Lao People’s Democratic Republic have intellectual disabilities and other mental and phys- Sally Brinkman contributed this case study. ical conditions than other children. Autism can severely affect the quality of life of autistic persons and their The Lao People’s Democratic Republic is a predomi- caregivers. nantly rural low-income country. More than two-thirds In the United States, autism was estimated to cost of the country’s 6.5 million people live in rural areas, US$1.4 million for individuals over a lifetime and where the poverty rate is almost 30 percent (Lao US$137 billion for society per year (Buescher and Population and Housing Census 2015; Lao Statistics others 2014). Less is known about the costs of autism Bureau 2014). Most rural children have never seen a in LMICs (Wang and others 2012; Xiong and others doctor, and less than one-fifth of the population lives in 2011). villages with health centers; three in four villages have In Kenya, inclusive education has been a major gov- primary schools (Lao Population and Housing Census ernment policy for many years, but most children with 2015). Little is known about the situation of children with disabilities continue to receive their education in special disabilities (Evans and others 2014). schools and units (Adoyo 2007; Kenya Ministry of In April 2014, the Early Childhood Education Education 2009). To investigate some of the factors that Program received funding to improve child develop- have hindered the success of inclusive education, Autism ment and school readiness and establish a monitoring Speaks conducted a small qualitative survey of stake- system to measure child development. The program holders, including teachers, placement officers, and rep- includes a two-phase process. First-phase screening is resentatives of a community-based organization, in part of a population-wide system for monitoring child- Kilifi, Kenya. The discussions centered on the challenges hood development. Second-phase screening is provided facing the mainstreaming agenda and the steps that to children who were identified in the first phase as hav- could be taken to facilitate inclusive education. Questions ing a disability or impairment (World Bank 2014). were asked about children with autism, although the The project is collecting baseline data using the WG interview also touched on other forms of disability. short set of questions on disability, with data to be col- The survey revealed that inclusive education in Kilifi lected on an estimated 6,500 children across five prov- faces four principal challenges: teacher-related problems inces. The results will demonstrate the questionnaire’s (lack of training; poor attitude toward inclusion), family effectiveness in Lao PDR and determine the prevalence obstacles (preference for separate education; tendency to of childhood disability—both important steps in filling delay the start of school for children with disability), the current knowledge gap regarding children with inadequate resources (inadequate facilities; large class disabilities. sizes), and government policies (motivation allowances The most likely impediment to scale-up of the pro- for teachers in special units but not for teachers with gram will be the expense and service capacity needs disabled students in regular schools; former practice of associated with second-phase screening, which must be basing school resources on test results). Teachers in covered by the health care system, nongovernment agen- mainstream schools identified lack of adequate training cies, or families. Analyzing the results of first-phase for handling children with disabilities as the major hin- screening against the diagnostic tests to assess the costs drance to inclusive education. of scaling up to the national level will be important. What needs to be done to facilitate inclusive educa- tion in Kenya and other low-resource settings? Case Study 5. Autism Spectrum Disorders: Providing Participants from the study highlighted four areas that Inclusive Education in Kilifi, Kenya have the potential to be scaled up in Kenya and other countries: Amina Abubakar, Andy Shih, Joseph Gona, and Amy Daniels contributed this case study. • Train and provide teachers in mainstream schools The prevalence of autism spectrum disorders has with the skills required to handle students with spe- grown considerably in recent decades. Today an cial needs Disability in Middle Childhood and Adolescence 231 • Ensure that children with limited mobility can move HIV/AIDS education. In Uruguay, a country with around the school comfortably more than 30,000 people who have severe hearing • Initiate parent-based interventions aimed at raising impairments or are deaf (MIDES 2011), most children awareness and encouraging them to time school and adolescents with disabilities attend school but are matriculation properly, reinforce skill-building tech- not involved in health and sexuality education pro- niques at home, and become engaged in inclusive grams (Meresman and others 2015). In Brazil, a coun- education efforts try with more than 5 million people who have impaired • Make special needs education mandatory for all hearing (CONADIS 2010), HIV/AIDS education has teacher trainees and critically evaluate the current involved marginalized communities for many years, teacher education curriculum in colleges and univer- but materials in sign language and inclusive program- sities to ensure an all-inclusive curriculum. ming have yet to be developed. Since 2010, the Inter-American Institute on Disability Taking steps to implement the policy and provide and Inclusive Development, the Center for Health adequate infrastructural support for learners with spe- Promotion, and the Partnership for Child Development cial needs will contribute toward a more inclusive educa- have been working with deaf organizations in Brazil and tional setting in Kilifi, Kenya, specifically, and in other Uruguay to promote inclusive approaches to HIV/AIDS low-resource settings more generally. education and information on reproductive health. This partnership established the Everyone’s School (Escola de Todos) Program, which is administered in collaboration Case Study 6. Targeting HIV Prevention and Sexual with the national education and health authorities and Health Education for Young People with Hearing Loss the national HIV/AIDS programs in both countries. in Brazil and Uruguay Everyone’s School provides access to reproductive health and HIV/AIDS education in sign language for deaf Sergio Meresman contributed this case study. youth. Educational resources were prepared by deaf Persons with disabilities are at high risk of HIV/AIDS participants and distributed throughout the deaf com- exposure and are disproportionately affected by the epi- munity in Brazil and Uruguay. The set included posters, demic in communities worldwide (World Bank 2003). postcards, and quick response (QR) code messages—a The main drivers of the epidemic are strongly associated digital media platform that is increasingly being used in with disability, including a high prevalence of poverty inclusive school health and nutrition projects—aimed at (Inclusion International 2006; Watermeyer 2006), lack of deaf people. Two workshops were conducted. In each, education (Helander 1999; Muthukrishna 2006; World about 20 participants adapted and translated key mes- Bank 2003), and lack of access to sexual and reproductive sages on health, prevention, and effective condom use health education or services (DenBoer 2008; Katoda into Brazilian and Uruguayan sign language. 1993; WHO and UNFPA 2009). Once persons with dis- As a result of the positive outcomes of the Everyone’s abilities become infected, many structural and social School Program, task forces were created with the goal of factors linked with disability significantly decrease the improving accessibility to programs and services. Such likelihood that they will receive the treatment, care, and interest spawned new initiatives, including an inclusive support available to other people living with HIV/AIDS prevention grant made available by the National (World Bank 2004). Prevention Program of Uruguay to support training and Because of the misconception that individuals with to design accessible campaigns around sexually trans- disability are not exposed to sexual violence and abuse mitted diseases and unwanted pregnancies. A group of and not at risk of contracting sexually transmitted infec- deaf youth trained in the initial program is preparing to tions (Berman Bieler and Meresman 2010), prevention implement the new initiative. campaigns and educational programs frequently over- look this population, making it more vulnerable to the risks of transmission (Groce 2003). A long chain of barri- CONCLUSIONS ers and taboos—combined with the poverty and exclu- The definition of disability has changed over the years sion that disproportionately affect persons with disabilities and is now commonly used to describe the interaction and their families—deprives disabled persons of access to between impairments and the physical, cultural, and sexuality education suited to their age and needs, to HIV/ institutional environments. Progress on defining disabil- AIDS programs, and to health services in general. ity has not been matched by efforts to provide standard- In South America, the deaf and hard-of-hearing ized estimates of the prevalence of disability. The population is one of the largest groups omitted from differing nuances used by statistical agencies, legislative, 232 Child and Adolescent Health and Development and political bodies has made it difficult to collect com- • Collect high-quality data about disability and the parable data on prevalence and severity of disability in school environment via administrative data systems both LMICs and in HICs, alike. consistent with international standards to fill gaps Education is the gateway into society, but that gate- and monitor progress on the education of children way is not fully open to children with disabilities. with disabilities. Developing polices that equalize the opportunity to • Analyze sector-wide strategies, programs, and bud- receive a quality education requires a deeper under- gets to determine whether they include concrete standing of the scope and nature of children with dis- actions to support children with disabilities and their abilities’ exclusion and the barriers they face. Recent families development in how we conceptualize and measure dis- • Develop, implement, and monitor a comprehensive ability are beginning to make a difference in our ability multisector national strategy and plan of action to do that. for children with disabilities that addresses family Introducing inclusive education is the start of a pro- support, community awareness and mobilization, cess to increase the ability of individuals with disabilities human resources capacity, coordination, and service to participate in their communities. The path to imple- provision menting and achieving inclusive education is complex • Establish clear lines of responsibility and mechanisms and is likely to be country specific. However, meaningful for coordination, monitoring, and reporting across steps can be taken at all stages of development. sectors Establishing inclusive education may be slow, but • Ensure that an inclusive education strategy and cross-sectoral collaborations will be critical to achieving action plan are part of the education sector plan, progress and to documenting and disseminating suc- including building or retrofitting schools that are cesses. The impacts of disability are cross-sectoral, and accessible for children with disabilities; creating an approach that focuses on a single sector will be less accessible curricula and learning materials, pro- successful than an approach that takes into account the cesses, and assessments; and training teachers to full range of challenges facing a disabled child. Policies foster a commitment to inclusion in schools and that promote access to education will be more fruitful if communities school-to-work transition programs are in place to pro- • Evaluate and identify gaps in service delivery, mote employment and inclusion for people with advocate for and seek sustainable financial and disabilities. technical support to address the gaps identified, Several publications and reports have outlined key and link the collection of disability data with ser- actions that governments can take to support children vice provision with disabilities (Thomas and Burnett 2013; UNICEF 2013, 2015). The following actions, which are in line with the recommendations of these publications and those NOTES outlined in the World Report on Disability (WHO and World Bank 2011) and in the State of the World’s Children World Bank Income Classifications as of July 2014 are as follows, based on estimates of gross national income (GNI) 2013 (UNICEF 2013), should form part of a successful per capita for 2013: platform designed to meet the needs of all learners: • Low-income countries (LICs) = US$1,045 or less • Undertake situational analyses to better understand • Middle-income countries (MICs) are subdivided: the nature and scope of the barriers children with a) lower-middle-income = US$1,046 to US$4,125 disabilities face when it comes to attending school. b) upper-middle-income (UMICs) = US$4,126 to US$12,745 These studies should rely on the bio-psychosocial • High-income countries (HICs) = US$12,746 or more. model of disability that conceptualizes disability as arising from the interaction between a children’s impairments and the environmental barriers they 1. In the Convention on the Rights of Persons with Disabilities, “Persons with disabilities include those who face. have long-term physical, mental, intellectual or sensory • Promote inclusive education for children with disabil- impairments which in interaction with various barriers ities at all levels, including early childhood education, may hinder their full and effective participation in society and review national policies in relevant sectors— on an equal basis with others.” health, education, and social—to ensure that they are 2. The authors wish to thank Hasan Minto, Vilay Pillay, and aligned with international conventions and commit- David Wilson of the Brien Holden Vision Institute for ments and inclusive of children with disabilities information regarding the cost of glasses. Disability in Middle Childhood and Adolescence 233 REFERENCES Available Data Collection Instruments.” ALTER—European Journal of Disability Research 9 (4): 317–30. Adoyo, P. 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Li, and others. 2011. “A Ten-Year Review of the Iodine Deficiency Disorders “Self Correction of Refractive Error among Young People Program of the People’s Republic of China.” Journal of in Rural China: Results of Cross-Sectional Investigation.” Public Health Policy 18 (2): 219–41. BMJ 343: d4767. Disability in Middle Childhood and Adolescence 237 Chapter 18 Health and Disease in Adolescence Nicola Reavley, George C. Patton, Susan M. Sawyer, Elissa Kennedy, and Peter Azzopardi INTRODUCTION When reading this chapter, it is important to remember that nearly all of the data and evidence Rising adolescent health problems, such as road traffic come from studies of programs in high-income coun- injuries (RTIs), mental disorders, and substance use tries (HICs). We cannot say with any certainty the disorders, are an increasing cause for concern in coun- extent to which the results presented here apply to tries that have otherwise reduced maternal mortality low- and middle-income countries (LMICs). This lack and boosted child survival (Patton and others 2009). of research is a particular challenge in planning and Moreover, with aging populations and a convergence to selecting interventions for this age group and helps to a disease burden dominated by noncommunicable dis- emphasize the need for much more research into the eases (NCDs) in later life, adolescent health risks, such health of adolescents in LMICs. as tobacco use, physical inactivity, obesity, substance use, and poor diet, assume greater significance (Jamison and others 2013). Adolescence is defined as ages 10–19 MATCHING INTERVENTIONS TO HEALTH years. Definitions of age groupings and age-specific PROFILES terminology used in this volume can be found in chapter 1 (Bundy and others 2017). Matching interventions to health profiles is critical to Better adolescent health requires matching interven- achieving a significant improvement in adolescent health. tions to health profiles, focusing on the important social Health profiles vary among and within countries, largely determinants of health during the adolescent years, reflecting progress through the epidemiological transition considering adolescent development and neurodevelop- that follows economic development and the demographic ment, and addressing gender and equity. transition. In multiburden countries that have yet to The Sustainable Development Goals will put a greater pass through this transition, diseases of poverty predom- focus on adolescents as recipients of interventions and as inate, including undernutrition, major sexual and repro- decision makers and implementation partners in health- ductive health problems, and infectious diseases (see also related issues. Although the Millennium Development chapter 21, figure 21.1, Sawyer and others 2017). In Goals increased the focus on sexual and reproductive injury-excess countries, high levels of unintentional health among adolescents and young adults ages injury or violence and high adolescent birth rates are 15–24 years, other areas of health risks and problems recorded, while NCD-predominant countries have received far less attention, and health gains have been high rates of mental and substance use disorders weaker among adolescents than among other age groups. and chronic physical illness. Chapter 5 in this volume Corresponding author: Nicola Reavley, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia; nreavley@unimelb.edu.au. 239 (Patton, Azzopardi, and others 2017) provides further girls may be less effective for boys, and vice versa. In details on the categorization of disease burdens and addition, considering the impact of interventions on methods used to derive the three categories of countries. equity is critical. For example, school-based interven- tions may increase inequity, as they do not reach adoles- cents who are not in school. Addressing gender disparities Addressing the Social Determinants of in access and targeting more resources to disadvantaged Adolescent Health adolescents (including ethnic minorities; lesbian, gay, As in any age group, economic and social conditions bisexual, or transsexual youth; persons with disabilities; influence adolescent health. Social determinants that and persons who are homeless or in juvenile detention) improve adolescent health include policies and environ- are critical to closing equity gaps. ments that support access to education and employ- ment, delay marriage and childbearing, provide universal health coverage, and create opportunities to enhance METHODS youth autonomy, decision-making capacity, and human We conducted a series of systematic reviews to assess rights (Sawyer and others 2012). These determinants lie current knowledge on the effectiveness of prevention largely outside of health services, as do the interventions interventions outside formal health care settings across necessary to address them. Accordingly, the settings for nine areas of health1 (see figure 21.1 in chapter 21 by health actions extend from health services, schools, and Sawyer and others 2017). We included both specific education to families and communities, places of health outcomes and health risks. Some responses (for employment, road transportation, the media, and struc- example, policy measures such as taxation, or legislation tural, legal, and policy environments. Chapter 21 in this such as gun control) are not directly targeted at young volume describes these platforms in more detail (Sawyer people but may have particular benefits for them and others 2017). compared with other age groups. Other actions target adolescents directly. Considering Adolescent Development and From March 15 to March 30, 2015, we searched the Neurodevelopment peer-reviewed literature and websites of key organizations. Annex 18A offers further details on the inclusion and Adolescent development and our understanding of it exclusion criteria, classification of levels of evidence, are changing. The age of onset of puberty is decreasing, appraisal of quality, and synthesis methods. yet the age at which mature social roles are achieved is increasing, and adolescence is lasting longer (NRC and IOM 2005). Interventions for adolescent health need to SEXUAL AND REPRODUCTIVE HEALTH, consider this developmental trajectory; strategies suited to younger adolescents may be inappropriate or ineffec- INCLUDING HIV/AIDS tive with older adolescents or young adults (Viner and More than any other area of health, a country’s cultural, others 2012). Moreover, neuroscience has revealed ado- religious, legal, political, and economic contexts affect lescent neurodevelopment to be particularly dynamic the sexual and reproductive health of adolescents, and and strongly influenced by social and nutritional envi- actions for sexual and reproductive health need to take ronments as well as by exposures to behaviors such as these contexts into account. The evidence suggests that substance use (Blakemore and Mills 2014). The deci- implementing multicomponent interventions that act in sion making of adolescents, including that affecting two or more settings improves sexual and reproductive health, differs from that of adults. Adolescents are more health and reduces the impact of human immunodefi- influenced by peers and often seek out and are more ciency virus/acquired immune deficiency syndrome influenced by exciting, arousing, and stressful situations (HIV/AIDS): structural or policy settings, community (Steinberg 2008). To maximize effectiveness, interven- settings (including schools), and health services (annex tions for adolescent health need to consider such 18B, table 18B.1). For example, high-quality, compre- decision-making processes and provide opportunities hensive sex education is more likely to prevent preg- for adolescents to exercise self-determination. nancy and reduce the prevalence of sexually transmitted infections (STIs) or HIV/AIDS if it is combined with the provision of contraceptives (Chin and others 2012; Focusing on Gender and Equity Oringanje and others 2009). Legislation to protect ado- Better adolescent health also requires focusing on gen- lescents from early marriage and pregnancy is more der, since strategies that are effective and appropriate for likely to be effective if accompanied by actions to 240 Child and Adolescent Health and Development encourage favorable community and professional atti- individual preventive interventions, such as insecticide tudes (Gottschalk and Ortayli 2014). Although evidence treated bednets. A study from Nigeria, where an estimated exists to show the impact on safe-sex behaviors of inter- 50 percent of the community experiences an episode of ventions to promote universal health coverage, relatively malaria each year, showed that only 8.5 percent of stu- little exists to show their impact on STI or HIV/AIDS dents ages 13–18 years reported sleeping under insecticide prevalence (Denno, Hoopes, and Chandra-Mouli 2015). treated bednets (Udonwa, Gyuse, and Etokidem 2010). The quality of training for providers is likely to be an important factor in the success of such interventions, and studies targeting marginalized or vulnerable adoles- UNDERNUTRITION cents, including those not in school, are needed (Chandra-Mouli and others 2015). No adolescent-specific evidence exists of the benefit of interventions for the prevention of undernutrition. Interventions do not typically target adolescents INFECTIOUS AND VACCINE-PREVENTABLE alone or report age-disaggregated outcomes. However, good evidence exists about interventions targeting DISEASES nutrition-related risks that commonly affect adoles- Vaccination against infectious diseases has received far cents. These risks include iron-deficiency anemia, less attention in adolescents than in children. Yet adoles- protein-energy malnutrition, and other micronutri- cents are also important for ensuring completion of ent deficiencies. Energy and iron requirements immunization schedules (such as measles-rubella and increase during puberty and are required for optimal hepatitis B vaccine), administering booster doses (such growth (Haider 2006). as diphtheria-tetanus), and ensuring primary immuni- Interventions to reduce protein-energy malnutrition, zation (such as for human papillomavirus). Rubella including balanced protein-energy supplementation vaccination is important for adolescent girls given inter- (Bhutta and others 2013), cash transfers (DFID 2012), generational risks, although hepatitis B vaccine is and improved household food storage systems (Masset important for both genders, given its adult burden. and others 2011), may be particularly beneficial in ado- Other vaccines to consider according to local prevalence lescents (Prentice and others 2013). As adolescence is a of disease and cost are tuberculosis, influenza, and men- period of rapid growth, it is plausible that interventions ingitis vaccines. that support catch-up growth in young children might Lack of basic knowledge has hindered responses to also promote catch-up growth in stunted adolescents, common infectious diseases in adolescents. In contrast although further research is required to confirm this to diarrheal disease in children, the etiological agents, (Reinhardt and Fanzo 2014). proportion of vaccine-preventable morbidity and mor- The additional iron necessary to meet menstruation- tality, and comorbidities are largely unknown in adoles- related needs places adolescent girls at increased risk of cents. Similarly, adolescent tuberculosis has received iron-deficiency anemia. Iron fortification of staple foods, little attention, even though it is the leading contributor such as flour, can reduce iron deficiency anemia at a to the burden of infectious disease in young adults in population level by up to 63 percent and has been shown multiburden countries (Snow and others 2015). to be cost-effective (DFID 2012). Interventions address- Adolescents in Sub-Saharan Africa also carry a sub- ing food insecurity may also improve iron levels (Bhutta stantial burden of malaria. In high-transmission areas, and others 2013). rates are higher in adolescent girls than in boys, with pregnant girls experiencing additional risks (Desai and others 2007). In endemic regions, people are exposed to Adolescent Pregnancy malaria earlier in life and more frequently. In these set- Adolescent pregnancy places girls at increased risk of tings, partial immunity develops relatively early, and the undernutrition; children born to adolescent girls are risk of severe malaria in adolescence declines. However, in more likely to have low birth weight, independent of areas of lower transmission, clinical disease is more com- socioeconomic or maternal preconception nutritional mon in adolescents and young adults. As infection in status (Gibbs and others 2012). Preconception interven- endemic areas is controlled and the development of child- tions, such as multiple-micronutrient supplementation hood immunity becomes less likely, the risk of malaria in or iron and folic acid supplementation continuing into adolescents and young adults increases (Lalloo, Olukoya, pregnancy, deworming to reduce nutrient loss, and ante- and Olliaro 2006). In low-transmission regions, the inci- natal nutrition counseling and education, can play a role dence of malaria among adolescents reflects their use of in preventing undernutrition and poor health outcomes Health and Disease in Adolescence 241 in offspring (Bhutta and others 2013). Delaying first and vehicles (Retting, Ferguson, and McCartt 2003), pregnancies, spacing subsequent births, and increasing and increased visibility of pedestrians (Porchia and young women’s access to education and health care or others 2014). control over household resources are likely to be central in preventing adversity (Bushamuka and others 2005; Although education programs have shown some ben- Chandra-Mouli, Camacho, and Michaud 2013). Delaying efits (Williams 2006), school-age driver education pro- the first pregnancy is essential in stunted adolescent girls grams that focus on selecting driving instructors and (King 2003). offering theory and practical tests should be avoided, as they may encourage earlier driving and lead to greater risk of accident (Roberts and Kwan 2001). UNINTENTIONAL INJURY Intersectoral coordination, underpinned by strong information systems, clear governance, civil society Much of the disease burden of adolescent unintentional advocacy, and a capacity to implement effectively within injury is related to RTIs. Adolescents and young adults, different sectors, is central to achieving reductions in particularly those in LMICs, are at high risk; they are RTIs. more likely to be vulnerable road users, such as pedes- trians, cyclists, and motorcyclists (Peden and others 2004). Moreover, in young men in particular, develop- mental immaturity, risky behavior, and poor decision VIOLENCE making increase the risks (Toroyan and Peden 2007). Violent behavior in adolescents and young adults devel- In HICs, improvements in road design, equipment ops because of complex interactions among individual, and maintenance, traffic control, vehicle design and relationship, community, and societal factors (Krug and protective devices, driver training and regulation, others 2002). Individual risk factors include substance police enforcement and sanctions, public education use, impulsivity, low educational attainment, and child- and information, and postcrash care have signifi- hood aggression. Relationship risk factors include peer cantly reduced the burden of injury, including in involvement in problem behavior, family conflict, poor adolescents (WHO and ExpandNet 2013). Chapter 3 family management, child abuse, and pro-violent paren- in volume 7 discusses RTIs in more detail (Bachani tal attitudes and behavior. Communities with poor and others 2017). More targeted actions include the social cohesion, low socioeconomic status, high residen- following: tial mobility, drug trafficking, and unemployment also increase the risk of violence. Societal risk factors include • Graduated licensing systems that extend the learning inequality, availability of weapons, and laws and cultural period, increase low-risk supervised driving, and norms that support violence. regulate exposure to high-risk settings, such as driv- Adolescent-specific violence prevention strategies are ing at night without supervision, driving with other implemented in three principal settings: schools, commu- young passengers, or using alcohol during an initial nities, and families, and policy interventions are most licensing period (Simpson 2003). Robust testing of often targeted to the broader community (WHO 2010a) competence before issuing licenses is generally an (annex 18B, table 18B.2). Universal school-based interven- essential element. tions have shown some evidence of effectiveness in reduc- • Legislation and enforcement of mandatory helmet ing violent or aggressive behavior (Fagan and Catalano wearing for motorcyclists in countries where a high 2013; Hahn and others 2007), with similar impacts in proportion of adolescents and young adults ride schools in areas characterized by lower socioeconomic motorcycles (Norton and others 2006). status and high crime rates (Hahn and others 2007). • Investment in pedestrian safety in regions where School-based interventions are likely to be more pedestrian injuries are common, such as Sub-Saharan effective in at-risk adolescents, with beneficial effects Africa. Effective actions include the imposition of in mixed groups and boys-only groups (Limbos and lower speed limits on lengths of road where pedes- others 2007; Mytton and others 2006; Park-Higgerson trians mix with other traffic and enforcement of and others 2008). Family-focused interventions seek to these limits (Afukaar 2003), regulation including promote parent-child communication and improve police enforcement of the behavior of drivers and parenting skills, such as providing children with infor- riders at pedestrian crossings (Elvik and Vaa 2009), mation about the positive and negative consequences of improved pedestrian facilities such as footpaths and their behavior (Fagan and Catalano 2013; Woolfenden, crossings (Forjuoh 2003), separation of pedestrians Williams, and Peat 2002). Some interventions use a 242 Child and Adolescent Health and Development combined family and school approach (Fagan and include families where appropriate, target persons at Catalano 2013). Although good evidence exists of the high risk, and be subject to rigorous evaluation (Ellsberg impact of parenting interventions targeted to younger and others 2015; Whitaker and others 2006). Legislative children (Furlong and others 2012), less research has and judicial responses are important, but they are been conducted among adolescents. However, family- unlikely to reduce intimate-partner and sexual violence focused and family- and school-based interventions in isolation (Ellsberg and others 2015). have shown beneficial effects (Fagan and Catalano 2013). Limited evidence exists on the effectiveness of community-based social development interventions MENTAL DISORDERS that target risk factors for violence (Fagan and Catalano 2013; Sethi and others 2010). Most mental disorders begin before age 25 years, most Most evidence of the effectiveness of policy interven- often at ages 11–18 years (Kessler and others 2005). tions comes from studies conducted in the broader Although not all adolescent mental health problems population. Reducing the availability and harmful use of persist into adulthood, particularly if the episodes are alcohol and reducing the access to weapons (for exam- brief, those that do often have lifelong impacts (Copeland ple, laws against owning and carrying weapons, fines for and others 2011; Patton and others 2014). This has led carrying weapons, policies on school-based weapons) to increased emphasis on early intervention, either in have been shown to reduce violence in adolescents and primary health care or, in some countries, through young adults (Krug and others 2002; WHO 2010a). adolescent-focused mental health services (McGorry, Reducing the violence-related burden of disease in Bates, and Birchwood 2013). Although access to health young people is likely to require a multifaceted approach services has increased in some places, evidence that these that is integrated with policies directed at social and increases have led to detectable improvements in adoles- political risk factors, such as inequality, lack of access to cent mental health is largely lacking (Jorm 2015). education, unemployment, availability of weapons and Although prevention of mental disorders is increas- laws, and cultural norms that support violence (WHO ingly seen as a public health priority, evaluation studies 2010a). This is likely to be particularly important in have focused mainly on taking effective clinical treat- countries in which many adolescents are not in school. ments, such as cognitive-behavioral therapies, and Early adolescence is a period in which gender role applying them to the general population of adolescents differences intensify and boys and girls begin to explore or to at-risk subgroups to test if they prevent the devel- intimate relationships. Interventions at this stage offer opment of disorders. A systematic meta-review and opportunities to promote attitudes and behaviors that meta-analysis of randomized controlled trials of pre- reduce the risk of interpersonal and sexual violence. vention interventions for depression or anxiety in chil- Evidence for the prevention of intimate-partner and dren and adolescents showed that these interventions sexual violence in adolescents and young adults is produced a minimal to moderate reduction in symp- largely lacking. In many cases, particularly in LMICs, toms in the short term, but no effect beyond 12 months studies are of poor quality, with small sample sizes, var- of follow-up (Stockings and others 2016). ied outcome measures, and short follow-up periods. Innovative approaches are needed, including those The most common types of interventions targeted to that focus on developmental mental health risks such as this age group are educational and skills-based interven- bullying and interpersonal violence. Exploration is also tions, which can be effective in changing attitudes but needed into the role of digital and social media as risk which appear to have little impact on violent behavior factors and as potential avenues for preventive interven- (Fellmeth and others 2013). Moreover, most of these tions (Nesi and Prinstein 2015). interventions have been implemented in schools and tertiary institutions in HICs, particularly the United States. Community-based programs to promote gen- SUICIDE der-equitable norms are the most common interven- tions in LMICs, but the evidence for their effectiveness The risk factors for suicide in adolescents include sui- is mixed (Lundgren and Amin 2015). cidal behavior in families, depression, alcohol abuse, use Programs are needed that more fully address the risk of hard drugs, mental health problems, suicidal behavior factors for intimate-partner and sexual violence, alcohol of friends, family discord (especially for females), poor misuse, family-derived attitudes to violence, and social peer relationships, living apart from parents, antisocial norms, such as those that condone violence and gender behavior (especially in females), sexual abuse, physical inequality. They need to be tailored to local contexts, abuse, and unsupportive parents (Evans, Hawton, Health and Disease in Adolescence 243 and Rodham 2004). Contagion—when a suicidal act (Klimes-Dougan, Klingbeil, and Meller 2013). Chapter 9 increases the likelihood of other suicides in a in volume 4 addresses this issue in more depth community—is a further factor in up to 60 percent of (Vijayakumar and others 2015). suicides in adolescents and young adults (Hazell 1993). Deliberate self-harm is also common in adolescents, particularly in females, and heightens the risks for subse- PHYSICAL HEALTH AND HEALTH RISKS quent suicide (Hawton, Zahl, and Weatherall 2003). Adolescent suicide prevention strategies typically Prevention of Overweight and Obesity include one or more of the following goals: increased The prevalence of overweight and obesity in a population help-seeking for suicidal thoughts and behaviors; identi- commonly increases in mid-adolescence and continues fication and referral of at-risk young people by health into early adulthood (Ng and others 2014). Because ado- professionals, teachers, parents, or peers; reduction of lescent obesity strongly predicts adult obesity and associ- risk factors for suicide; and promotion of mental health ated morbidity, preventing obesity in adolescence is (Gould and others 2003). School-based interventions essential (Whitaker and others 1997), particularly when are the most commonly evaluated interventions in the considering the maternal and intergenerational health adolescent age group; although some evidence shows risks of obesity in young women (Ruager-Martin, Hyde, that universal interventions improve attitudes toward and Modi 2010). suicide (Cusimano and Sameem 2011; Katz and others Modifiable risks for obesity also change rapidly across 2013; Klimes-Dougan, Klingbeil, and Meller 2013; adolescence. Physical activity commonly decreases, and Robinson and others 2013), these gains are unlikely to be sedentary behavior increases (Dumith and others 2011); maintained at follow-up, and iatrogenic effects remain adolescents have greater autonomy in their choice of largely untested (Robinson and others 2013). Gatekeeper food and are more likely to eat outside of the home, training, which teaches specific groups of people to increasing the likelihood that they will choose less identify people at high risk of suicide and refer them for healthy food (Niemeier and others 2006). Exposure to treatment, also improves knowledge and attitudes media influences and susceptibility to the marketing of toward suicide and builds confidence in providing help processed foods also intensify (Jordan, Kramer- (Katz and others 2013; Klimes-Dougan, Klingbeil, and Golinkoff, and Strasburger 2008). Meller 2013; Miller, Eckert, and Mazza 2009; Robinson In summary, although the evidence for interventions and others 2013). to reduce body mass index and increase physical activity Evidence is mixed on the effectiveness of universal in adolescents is mixed, multicomponent interventions school-based interventions, gatekeeper training, public incorporating support for increased physical activity education and mass media interventions, screening or and education about the importance of a healthy diet intervention-after-suicide programs (Andriessen 2014), and physical activity are more likely to be effective and clinical treatments (Robinson, Hetrick, and Martin (Clemmens and Hayman 2004; Crutzen 2010; De 2011) on help-seeking behavior, help-giving behavior, Bourdeaudhuij and others 2011; Murillo Pardo and oth- suicidal ideation, or suicide attempts in adolescents. ers 2013; Pearson, Braithwaite, and Biddle 2015; Seo and Evidence from studies among the broader population Sa 2010) (annex 18B, table 18B.3). Further research is suggests that training health practitioners to recognize needed to explore obesity prevention interventions that depression and evaluate suicide risks and restricting capitalize on other aspects of adolescence, including access to lethal methods show some benefits for prevent- peer and social network influences. Further research is ing suicide (Mann and others 2005). also needed to explore the impact of gender on the Many studies of suicide prevention interventions are response to obesity prevention interventions, since it is of poor quality, and evidence for effective interventions likely that gender becomes increasingly important dur- to prevent suicide in young people is largely lacking, ing adolescence (Rees and others 2006). Barriers to particularly in LMICs. Reducing the suicide-related participation may be greater for girls than for boys and burden of disease in young people is likely to require a may include sensitivity regarding body image, a focus on multifaceted approach that focuses on restricting access competitive sports, and inadequate facilities in schools, to means and training health practitioners, particularly such as changing rooms and showers (Camacho- in depression and substance use (Burns and Patton Miñano, LaVoi, and Barr-Anderson 2011; Pearson, 2000; Gould and others 2003; Robinson, Hetrick, and Braithwaite, and Biddle 2015; Rees and others 2006). Martin 2011). Help-seeking behavior is likely to differ Further research is also needed into interventions between males and females, and future evaluations of targeting adolescents and young adults who are not in preventive actions should address gender differences educational settings, are from minority groups, or 244 Child and Adolescent Health and Development are disadvantaged (De Meester and others 2009; Rees and family-based (Kumpfer, Alvarado, and Whiteside 2003), others 2006; Stice, Shaw, and Marti 2006; van Sluijs, community-level (Gates and others 2006; Strang and McMinn, and Griffin 2008). However, policy approaches others 2012), and online (Champion and others 2013; such as taxing unhealthy foods and beverages, reducing fast- Wood and others 2014) interventions, and some evidence food advertising, and front-of-pack, traffic-light nutrition supports using screening and motivational interven- labeling are more likely to work best and be cost-effective tions in health care settings (Barnett and others 2012; (Gortmaker and others 2011; Laska and others 2012). Jensen and others 2011). Further studies are needed, particularly in LMICs. However, since the effects of such programs are small, they should form part of Alcohol, Illicit Drugs, and Tobacco more comprehensive strategies for preventing drug use. Alcohol Mass media interventions are unlikely to be effective Consumption of alcohol often begins and then (Ferri and others 2013). increases during adolescence, with some evidence sug- Treatment and rehabilitation services and strategies gesting that adolescents are starting at increasingly to minimize harm have been the main focus in reducing early ages (Francis and others 2014). Early initiation of the consequences of illicit drug use. Harm minimization alcohol use is linked to binge drinking, heavy drinking, strategies are essential in preventing the transmission of and alcohol-related problems in adolescence and adult- blood-borne viruses, including HIV/AIDS and hepatitis, hood (Bonomo and others 2004). Evidence suggests and may include needle and syringe exchange programs, that early consumption may impair neurological devel- drug substitution programs that switch users from black opment (Ewing, Sakhardande, and Blakemore 2014). market drugs to legal drugs dispensed by health profes- Although evidence suggests that interventions in sionals, HIV/AIDS testing and counseling, prevention schools and family settings have achieved small but sig- and services for the management of STIs, overdose pre- nificant impacts on alcohol consumption and vention, and education relating to wound and vein care alcohol-related harm (Foxcroft and Tsertsvadze 2011a, (WHO and ExpandNet 2011). Strategies need to be tai- 2011b; Smit and others 2008), regulatory or statutory lored to the local context, including patterns of use and enforcement interventions are likely to show the greatest levels of harm. benefit in preventing harmful use (Martineau and others 2013), as shown in annex 18B, table 18B.4. Regulating access to alcohol through age restrictions on purchases is Tobacco Use particularly effective for preventing alcohol-related harm As most adult smokers began smoking in adolescence, in adolescents and young adults. However, most of this regular tobacco use in adolescence increases the likeli- evidence is from HICs; interventions should be tailored hood of associated adult and intergenerational health to the local context, taking into consideration the level of risks. Whether or not an adolescent initiates tobacco use alcohol consumption, age- and gender-related drinking depends on diverse factors, such as gender; concerns patterns, and level of harm (WHO 2010b). Chapter 7 in with body weight; attitudes to smoking; parental, peer, volume 4 provides more detail on this issue (Medina- and community smoking; socioeconomic status; and Mora and others 2015). level of education (Warren and others 2009). School- (Thomas, McLellan, and Perera 2013), family- (Thomas Illicit Drugs and others 2015), community- (Carson and others As with alcohol, adolescence is a time when most peo- 2011), and media-based (Brinn and others 2010) inter- ple are first exposed to drugs and start using them. ventions can be beneficial, but the effects are small School-based interventions aim to prevent drug use, (annex 18B, table 18B.6). There is good evidence that delay initiation, or prevent regular use (see annex 18B, policies to control tobacco are associated with lower table 18B.5). However, interventions that provide infor- prevalence of smoking in young people. These policies mation alone are not likely to be effective in reducing include age restrictions on purchase, taxation and pric- use, although evidence shows that programs with a ing, smoke-free-air laws, and funding for tobacco con- social competence approach have significant but mini- trol programs (Farrelly and others 2013; Wakefield and mal benefits (Carney and others 2014; Faggiano and Chaloupka 2000). The Framework Convention on others 2014). Evidence also shows that brief interven- Tobacco Control provides clear guidance on the mini- tions have small but significant effects on substance use, mum standards governing the production, sale, distri- with greater benefits if delivered in an individual for- bution, advertisement, and taxation of tobacco that are mat and over multiple sessions (Barnett and others needed to protect adolescents and young adults from the 2012). Evidence is mixed about the effectiveness of harms of smoking. Health and Disease in Adolescence 245 CONCLUSIONS disabilities; and youth who are homeless or in juvenile detention have the greatest health needs, scant evidence Major gaps in the evidence base for effective actions in exists to suggest the effectiveness of interventions across many health areas reflect the relative lack of investment the spectrum of disadvantage. Some interventions may in adolescent health programs, especially in LMICs. For not reach vulnerable groups and may actually worsen example, for health areas such as undernutrition and inequities. Interventions should therefore be designed RTIs, no adolescent-specific evidence has been gathered and implemented with an equity lens to ensure that ben- through systematic reviews. Even in the area of sexual efits extend to the most hard-to-reach adolescents and and reproductive health, the evidence from systematic young adults (O’Neill and others 2014). Scaling up reviews is limited on what might need to be done differ- should also give careful consideration to gender, race, ently to allow adolescents to access interventions that are ethnicity, sexuality, geography, socioeconomic status, and effective in adults (Mavedzenge, Luecke, and Ross 2014). disability (Chandra-Mouli, Lane, and Wong 2015). However, because the social and environmental deter- Finally, nearly all of the data and evidence come from minants of health among adolescents and young adults studies of programs in HICs. We cannot say with any vary widely, intersectoral and multicomponent interven- certainty the extent to which the results presented here tions offer the best opportunity to improve adolescent apply to LMICs. This lack of research is a particular chal- health. For example, school- and health-service-based lenge in planning and selecting interventions for adoles- interventions to prevent early marriage and pregnancy cents and emphasizes the need for much more research are more likely to succeed if accompanied by interven- into the health of adolescents in LMICs. tions that generate community support, such as public hearings, meetings, and fairs (Gottschalk and Ortayli 2014). School-based interventions that go beyond teach- ANNEXES ing health education in classrooms to encompass changes The annexes to this chapter are as follows. They are available at to the curriculum and the wider social environment, as http://www.dcp-3.org/CAHD. well as engagement with families and the community, are more likely to improve sexual health, reduce violence, • Annex 18A. Methods and decrease smoking-related outcomes (Blank and oth- • Annex 18B. Evidence of Effectiveness and Cost-Effectiveness ers 2010; Harden and others 2009; Langford and others of Sexual and Reproductive Health Interventions, includ- 2014). In the broader population, intersectoral action has ing HIV been central to public health gains in HICs, including reducing RTIs and helping to control tobacco use (Elvik and Vaa 2009; Farrelly and others 2013). NOTES With the exception of sexual and reproductive health, World Bank Income Classifications as of July 2014 are as fol- available evidence is mostly from HICs, particularly the lows, based on estimates of gross national income (GNI) per United States. Implementation in other countries, in par- capita for 2013: ticular in LMICs, is uncertain. As effective interventions will only have benefits if widely implemented, consider- • Low-income countries (LICs) = US$1,045 or less ation must be given to local contexts, including culture, • Middle-income countries (MICs) are subdivided: beliefs, knowledge, lifestyles, and health systems. Effective a) lower-middle-income = US$1,046 to US$4,125 implementation and scale up require a systematic b) upper-middle-income (UMICs) = US$4,126 to US$12,745 • High-income countries (HICs) = US$12,746 or more. approach to addressing these factors and to achieving a balance between desired outcomes and implementation 1. The nine areas of health included in this chapter are infec- constraints. 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Peat. 2002. “Family “Computer-Based Programmes for the Prevention and and Parenting Interventions for Conduct Disorder Management of Illicit Recreational Drug Use: A Systematic and Delinquency: A Meta-Analysis of Randomised Review.” Addictive Behaviors 39 (1): 30–38. doi:10.1016/j Controlled Trials.” Archives of Disease in Childhood .addbeh.2013.09.010. 86 (4): 251–56. 252 Child and Adolescent Health and Development Chapter 19 Platforms to Reach Children in Early Childhood Maureen M. Black, Amber Gove, and Katherine A. Merseth INTRODUCTION development is rapid—have focused attention on the This chapter reports on platforms that promote early need to ensure that children receive the interventions child development. The economics of early child devel- necessary to achieve their developmental potential. opment programs and packages are covered in chapter 24 Finally, global economic growth in the 1990s and the in this volume (Horton and Black 2017). Early child success of the Millennium Development Goals in reduc- development research, programs, and policies have ing poverty and stunting and in increasing child survival advanced significantly in low- and middle-income coun- have brought optimism to efforts to promote child tries (LMICs) during the past two decades (Black, Walker, health and development. The evidence that interven- and others 2016), spearheaded by three prominent tions early in life are effective in promoting early child advances. development (Engle and others 2007; Engle and others The first advance is the recognition that the foundations 2011; Nores and Barnett 2010) supports the implemen- of adult health and well-being are based on prenatal and tation of such programs at scale. early-life genetic-environmental interactions that affect Calls from global leaders have emphasized increased brain development. This recognition has created a strong investment, programs, and policies for early child devel- emphasis on strategies to ensure that young children reach opment (Lake and Chan 2015) and have brought about their developmental potential (Shonkoff and others 2012). the inclusion of early child development in the The second advance is the urgent call for strategies to United Nations’ Sustainable Development Goals (SDGs) promote early child development, following estimates (UN 2015). This chapter reviews the definition of early that more than 200 million children younger than age child development; risks and protective factors related five years in LMICs are at risk of not reaching their to early child development; early child development developmental potential (Grantham-McGregor and systems (rights and equity, integrated interventions and others 2007), largely due to nutritional deficiencies and multisectoral coordination, governance, and quality a lack of responsive caregiving. Recent estimates report improvement and accountability); and platforms that although the prevalence of at-risk children has needed to implement early child development programs declined, more than 43 percent of children in LMICs are that address children’s changing developmental skills at risk for poor development (Lu, Black, and Richter across the continuum from infancy through early pri- 2016). Initiatives during the first 1,000 days of life—the mary school. Definitions of age groupings and age- period from conception through age 24 months, specific terminology used in this volume can be found when nutritional requirements are high and brain in chapter 1 (Bundy and others 2017). Corresponding author: Maureen M. Black, Distinguished Fellow, RTI International; and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States; maureenblack@rti.org. 253 EARLY CHILD DEVELOPMENT Walker, and others 2016), include a home environment that is sensitive to children’s health and nutritional Early child development refers to the developmental needs, responsive, emotionally supportive, and develop- progression of perceptual, motor, cognitive, language, mentally stimulating and appropriate, with opportuni- socioemotional, and self-regulation skills through the ties for play and early learning, and protection from first eight years of life. Within the grounding of social adversities (Black and Aboud 2011; Bradley and Putnick ecological theory (Bronfenbrenner and Morris 2007), 2012). Nurturing care occurs through caregiver-child children’s early development is influenced by family, interactions and promotes children’s developmental community, and environmental interactions. Families potential in multiple areas, including health, nutrition, and caregivers provide proximal care for children and security and safety, responsive caregiving, and early mediate distal influences from neighborhoods, commu- learning (figure 19.1). nities, and the larger environments, including legal, Research into interventions has shown that in keeping safety, and cultural factors. Because children influence with theories of early child development (Bronfenbrenner caregivers’ interactions through their characteristics and and Morris 2007), nurturing care extends beyond fami- behavior, and in turn, are influenced by caregivers lies to include community child care providers, teachers (Bergmeier and others 2014), children participate in in early education, and community support to families their own development through a transactional process. (Farnsworth and others 2014). A family’s capacity to As children grow older, their direct interactions outside provide nurturing care is enabled proximally by house- their family increase, through contact with friends, care hold characteristics and resources, and distally by com- providers, teachers, and other community members. munity resources and exposures, policies, laws, and Children reach their developmental potential with cultural variations. Recent evidence has shown that the acquisition of competencies in academic, behavioral, nurturing care during early childhood attenuates the socioemotional, and economic areas. Theories of child detrimental effects of various risks on brain develop- development take a life-course perspective, emphasizing ment (Hanson and others 2015; Noble, Houston, and that the skills acquired throughout childhood, adoles- others 2015) and on early growth (Black, Tilton, and cence, and adulthood build on the capacities established others 2016) and helps children build healthy habits that prenatally and early in life. Criteria for the proximal promote development. home environment, referred to as nurturing care (Black, Figure 19.1 Domains of Nurturing Care Necessary for Children to Reach RISK AND PROTECTIVE FACTORS FOR EARLY Their Developmental Potential CHILD DEVELOPMENT Risks to children’s development begin before conception and are often associated with poverty, nutritional defi- ciencies, and maternal stress; they can result in lifelong physical and mental health consequences that are thought to operate through epigenetic processes Nutrition (Boersma and others 2014; Hanson and others 2012). Health The concept of biological embedding theorizes that the burden of many adult diseases is partially caused by early adversity, particularly socioeconomic stress factors, Domains of through a combination of latent effects, pathway effects, nurturing and accumulation of disadvantage (Hertzman 1999, care 2013). Associations have been documented between Security adverse childhood experiences and later health out- Early and safety comes (Brown and others 2010), including epigenetic learning signatures of the human genome (Bick and others 2012). These findings have led to the conclusion that the origins of adult disease are often found among developmental Responsive and biological disruptions occurring early in life caregiving (Shonkoff, Boyce, and McEwen 2009). Although there is increasing recognition that the early years serve as an entry point for reducing the burden of disease and 254 Child and Adolescent Health and Development improving population health, policies and programs Brazil (Victoria and others 1992); an inverse association that promote early development are only beginning to between zinc deficiency, preschooler stress, and maternal emerge (Hertzman 2013). education has been found in Vancouver (Vaghri and Children in LMICs face multiple threats from infectious others 2011). diseases, such as HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome), diarrhea, malaria, and pneumonia, which can negatively affect their Nutritional Deficiencies development, particularly when they occur in the context Children have specific nutritional requirements early in of malnutrition. In addition, diagnostic and treatment life to support their rapid physical growth and brain services for children with developmental disabilities are development. Many aspects of brain development are limited in these settings (Engle and others 2011). activated either prenatally or in the first months of life (Fox, Levitt, and Nelson 2010). Stunting (length-for- age greater than two standard deviations below the Poverty median) and micronutrient deficiencies during this Early life poverty is a well-documented risk to children’s period increase the risk of subsequent cognitive, motor, early development. Not only can poverty contribute to and academic problems (Black 2003; Sudfeld and oth- caregiver stress, but the effects are evident in children’s ers 2015). Although the first 1,000 days are sensitive brain development. Children raised in low-income fam- for nutritional adequacy, the timing of early brain ilies are at risk for smaller hippocampal gray matter development—with regions developing and maturing volume (Hanson and others 2015; Noble, Engelhardt, at different points—and the plasticity of early brain and others 2015) and low frontal and temporal lobe development suggest that the window of opportunity volume—brain areas associated with cognitive and aca- for early child development interventions extends demic performance (Hair and others 2015). The impact through the second 1,000 days, up to age five years of poverty is evident in children’s growth and develop- (Wachs and others 2014). ment in the first year of life (Black, Tilton, and others 2016; Hamadani and others 2014) and in language processing and vocabulary by age 18 months (Fernald, Maternal Stress Marchman, and Weisleder 2013). Disparities increase Stress, depression, and anxiety during pregnancy can throughout childhood; the effects of being raised in pov- affect fetal development, leading to low birth weight and erty extend to adulthood and result in low task-related increased risk of anxiety and metabolic dysregulation activation of the brain regions that support language, (Wachs and others 2014). Postnatal stress can interfere cognitive control, and memory skills, and high activa- with parenting and early caregiver-child interactions, tion of regions associated with emotional reactivity with long-term effects on child brain structure and func- (Liberzon and others 2015; Pavlakis and others 2015). tion (Glover 2011). Recent evidence has also shown Maternal education is one pathway out of the poverty associations between maternal-reported stress and chil- trap. Maternal education has been positively related to dren’s neuroendocrine-immune functioning (measured children’s health and development in LMICs (Black, through saliva), suggesting that children of stressed Tilton, and others 2016; Walker, Wachs, and others 2011). mothers may be desensitized to inflammatory immune Better-educated mothers are able to manage household processes and therefore at risk for inflammatory diseases resources and provide the protection, nurturance, and (Riis and others 2016). These findings occurred regard- early learning opportunities that promote children’s less of socioeconomic status in a sample of children age healthy growth and development (Bornstein and Putnick five years whose families were of high and low socio- 2012). An increase in maternal education has been cred- economic status, and suggest that interventions to reduce ited with the significant reduction in mortality in chil- maternal stress may have additional benefits for chil- dren under age five years in 175 countries from 1970 to dren’s health and development. 1990 (controlling for per capita income) (Gakidou and others 2010). This finding has been replicated in other cross-national studies as well as national studies in both Accumulated Risks low-income and high-income countries (HICs). For Risks often co-occur, with accumulated risks more likely to example, an inverse association between infant mortality undermine children’s developmental potential than single and maternal education within families of equal poverty risks, particularly when they co-occur early in life (Wachs levels has been shown in Nicaragua (Peña, Wall, and and others 2014). The focus on risks to child development Persson 2000), replicating findings from an early study in has often led to a harm-reduction perspective, with Platforms to Reach Children in Early Childhood 255 delivery strategies targeting children at greatest risk. 2010). The limitations of the traditional universal and Although programs to alleviate single risks may be effec- selective approaches have led program personnel to seek tive, evidence suggests that programs addressing multiple an alternative that reaches all children by addressing the risks, such as both nutrition and early child development, barriers that prevent children most in need from access- have greater likelihood of producing sustainable results ing services. The concept of proportionate universality, (Nores and Barnett 2010; Rao and others 2014). The a universal service with scale and intensity proportion- co-occurrence of multiple risks has spurred recommenda- ate to the level of disadvantage, is a promising approach tions for integrated interventions that address multiple to reducing inequity in areas with a social gradient in risks (Black and Dewey 2014). child development (Marmot and others 2010). EARLY CHILD DEVELOPMENT SYSTEMS Integrated Interventions and Multisectoral Coordination Successful early child development programs are The concept of integrated interventions refers to ser- grounded in solid policy frameworks and systems. vices that address multiple issues with shared messages, Vargas-Barón (2013) has identified eight domains that the use of shared or existing platforms, and opportuni- characterize strong and sustainable early child devel- ties for synergy (Black, Perez-Escamilla, and Fernandez opment systems. Five domains are particularly rele- Rao 2015). Multisectoral coordination refers to coordi- vant to this chapter: equity and rights, integration and nated services across sectors, with either sector-specific coordination, governance, quality improvement, and or unifying policies (Vargas-Barón 2013). Although accountability. multiple calls for integrated services have been made on theoretical and practical grounds (Black and Dewey 2014), few evaluations have been conducted (Grantham- Equity and Rights McGregor and others 2014). The international commu- Equity and rights can refer to the availability of early nity and development agencies have incorporated early child development services. Delivery strategies for early child development into high-profile documents such as child development programs are categorized as follows: the World Health Organization’s (WHO) Report of the World Health Organization Commission on Social • Universal, when they are available to all Determinants of Health (WHO 2009), the World Bank’s • Selective, when targeted to subpopulations at risk World Declaration on Education for All (UNESCO • Indicated, when available to children identified by 1990), and the United Nations Educational, Scientific screening (Gordon 1983). and Cultural Organization’s Dakar Framework for Action (UNESCO 2000), and the SDGs. A critical role Public educational programs are universal and incor- of these agencies is to support the governments of porated into the governance structure of the education LMICs in the establishment of national early child sector. Making early child development programs uni- development policies and structures, such as a national versal can improve equity by ensuring that all children commission to coordinate early child development are able to acquire the skills to reach their developmen- programs across ministries and sectors. Successful inte- tal potential (Irwin, Siddiqi, and Hertzman 2007). grated programs and coordinated multisectoral pro- However, universal approaches may not reach all chil- cesses can be sustainable and scaled up when they stand dren in low socioeconomic status households because on solid policy ground (Vargas-Barón 2013). Very few of barriers to access, such as inability to pay fees, lack LMICs have well-defined national early child develop- of transportation, and multiple languages (Carey, ment frameworks or policies. An early child develop- Crammond, and De Leeuw 2015). Early child develop- ment agenda within LMICs can benefit greatly from ment programs are often selective and available in policies that are strong and comprehensive and result regions or areas where large segments of the population in enforceable mandates (Shonkoff and others 2012). experience extreme poverty, malnutrition, or other Table 19.1 lists considerations regarding integrated conditions that put them at risk of not reaching their programs and multisectoral coordination related to early developmental potential. The drawback of selective child development, highlighting both benefits and cau- approaches is that they may be inequitable because they tions. Integrated programs address the interdependen- miss children in the middle socioeconomic status range, cies among young children’s basic needs, often building where most vulnerable children are found (Carey, strength and learning through play (Woodhead and Crammond, and De Leeuw 2015; Marmot and others others 2014). 256 Child and Adolescent Health and Development Table 19.1 Integrated Programs and Multisectoral Coordination for Nutrition and Child Development Interventions Issue Benefit Cautionary note Scientific basis Children require support for health, nutrition, security Avoid overwhelming or confusing caregivers with and safety, responsive caregiving, and early learning. multiple messages across domains. Single components are not sufficient. Impact of integrated Impact of nutrition intervention is strongest in the first Impact of child development interventions continues intervention may be stronger 1,000 days. beyond the first 1,000 days. than single-sector models Economy of effort One community worker may be able to deliver multiple Additional time per visit may be required to deliver messages. multiple messages. Financial support Sharing community workers across sectors may be Clarity is needed in balancing financial investment and economical. administrative coordination across sectors. Comprehensive approach Integrated nutrition and child development intervention Avoid overwhelming caregivers with multiple can address children’s needs and may result in synergy. messages. Promotion of integrated Strong policies may result in more and better-quality Policy support from international agencies requires multisectoral policies by programs that address the comprehensive needs of program, training, and evaluation support. international organizations children. Existing delivery platform Delivery platforms may vary across sectors, providing Limited data exist on the impact of varying platforms additional opportunities to reach participants. (such as individual versus group). Evaluation Conducting evaluation across multiple domains may Evaluation demands from two sectors may occur. be efficient. Governance Governance structure may facilitate cross-sector Sectors have separate budgets, priorities, and coordination. management targets. Training and supervision Training and supervision could be coordinated Specialized training and supervision may be necessary across sectors to develop comprehensive, integrated to adequately meet the needs of differing domain and messages. sector priorities. Feasibility Information on feasibility and lessons learned could Additional costs may be incurred to evaluate enhance program development. feasibility across two sectors. Costing Cost analyses can be helpful to evaluate cost-benefit Additional expenses may be incurred to build costing ratio of services. into services across two sectors. Implementation science Principles of implementation science, including Additional costs may be incurred to apply principles of stakeholder involvement, can assist with program implementation science across two sectors. sustainability and scaling. A meta-analysis of the impact of preschool pro- Women and Child Development, and includes pre- grams concluded that integrated programs, which schools (Anganwadi Centers) in local communities typically are government funded, had the largest throughout the country. Evaluations of the centers have effect on children’s cognitive development (Rao and demonstrated that they increase children’s nutrition and others 2014). The analysis, which included 115 inter- development, although also showing variability in the ventions from 70 studies in 30 LMICs, also found quality of staff training and implementation and in the that the most effective programs were provided by benefits to children (Chudasama and others 2014; well-qualified personnel working with both parents Malik and others 2015; Rao 2010). With support from and children. the World Bank and other organizations, the Indian In 1975, India established the Integrated Child government has launched the Integrated Child Development Services, a government-sponsored nutri- Development Services Systems Strengthening and tion and child development program for pregnant Nutrition Improvement Program to promote children’s women and for children up to age six years (Rao 2005). nutrition and to raise the quality of the program The program is administered through the Ministry of by strengthening the policy framework, facilitating Platforms to Reach Children in Early Childhood 257 community engagement, and increasing the focus on emerging, with indications of benefits to children’s children under age three years. motor and socioemotional development (Ramakrishnan, Goldenberg, and Allen 2011). The timing imperative of children’s early health and nutrition is often addressed Governance by the health sector through close involvement with Implementation of early child development programs is women before delivery and with children through the often fragmented, particularly for children under age first 24 months. After age 24 months, fewer routine five years, with limited regulatory systems or govern- health visits take place, and health sector services are ment oversight. Indicated approaches are generally dominated by acute care. The health sector plays an reserved for children with specialized needs. The gover- important role in providing anticipatory guidance, nance structure needs to be considered in making deci- screening for developmental delays, and referring sions regarding integrated services and coordination children for services, but there are few links with the across sectors. Integrated services require governance education sector. structures that support integrated policies and program- ming, with attention to training, supervision, and Education Sector monitoring. Early child development interventions have focused Services that are incorporated into governance struc- strongly on primary school education, with estimates tures benefit from being able to call on infrastructure, from 2015 that 91 percent of eligible children are public financing, and planning and coordination with enrolled in primary school (UNESCO 2015). Historically, other government services. Health and education are governments in LMICs provided a basic cycle of primary well-established government sectors, and both relate to school beginning with grade 1 (usually from age six early child development. However, the locus of early years, with some variation across countries), with no child development services varies widely across gover- public educational services available before that. nance systems and often operates through nongovern- Early child development was included in the initial mental organizations with limited state oversight (Britto Education for All documents of the United Nations and others 2014). (UNESCO 1990, 2000). Although preprimary educa- tion has since been incorporated into the educational Health Sector sector in many LMICs, its structure and quality are Young children with adequate health and nutrition from variable. Primary school performance is enhanced by conception through age 24 months have the best chance preprimary attendance (Berlinski, Galiani, and Gertler of thriving and reaching their developmental potential 2009), especially when the quality of preprimary edu- (Black and others 2013). Growth during this sensitive cation is high and the transition to primary school is period is associated with subsequent cognition and well coordinated. High-quality preprimary education school attainment (Martorell and others 2010); associa- refers to both structural characteristics, such as envi- tions between growth and cognition or school attain- ronmental safety and hygiene, and teaching and learn- ment after 24 months are less strong (Hoddinott and ing characteristics, such as staff-child interaction others 2008). The timing of adequate nutrition is critical and opportunities for play, exploration, and early in health and nutritional interventions (Wachs and oth- learning. ers 2014). For example, stunting before age 24 months is Although healthy development depends on the related to poor child development; increases in length- complex and carefully timed interplay of nutritional, for-age before age 24 months are associated with health, and educational inputs throughout children’s increases in school-age cognitive performance (Sudfeld first eight years, there is extremely limited coordina- and others 2015). Although increases in height-for-age tion between the health and education sectors and a after 24 months have been associated with subsequent notable lack of purposeful investment. As a result, cognitive performance, the findings are relatively modest there is a gap between the end of regular health (Black, Perez-Escamilla, and Fernandez Rao 2015; services at approximately age two years and the initi- Crookston and others 2013). ation of formal education at age five or six years Similarly, micronutrient deficiencies are prevalent (figure 19.2). This gap occurs at a very sensitive time among young children, particularly during the first in children’s physical, cognitive, and socioemotional 1,000 days when rates of growth are high and children development. The impact of missed opportunities to are moving from a milk-based to a food-based diet. intervene in support of healthy development for the Evidence on the impact of micronutrient supplementa- most vulnerable may have lasting consequences for tion among children younger than age 24 months is children and societies. 258 Child and Adolescent Health and Development Figure 19.2 Age Gap in Early Child Development Services Preconception and Pregnancy between Health and Education Sectors Recent evidence has shown that adequate health, nutritional status, and psychological well-being before conception provide the best chance of a healthy pregnancy and healthy fetal and infant development Services provided Health Education (Boersma and others 2014). Although few systematic preparation programs for childbearing have been Gap in services established, recent calls focus on ensuring that adoles- cents are prepared for pregnancy, particularly in areas where there are nutritional deficiencies among women Conception Birth 1 2 3 4 5 6 7 8 of childbearing age (Thurnham 2013). Both the health Age (years) and the education sectors could be engaged in precon- ception preparation for adolescents that includes reproductive health education to avoid unplanned Quality Improvement and Accountability early pregnancies and that also includes empower- Quality assurance is a critical component of early child ment, stress alleviation strategies, and preparation for development programs, guided by strong monitoring and adulthood and parenting. evaluation procedures (Berlinski and Schady 2015). A major challenge to early child development has been the Birth to Age 24 Months: Clinic Services, Home lack of population-level indicators, such as stunting is for Visiting, and Community Services nutrition. Individual-level assessments provide informa- tion on the development of individual children, but Although significant advances in maternal, newborn, require too much time and technical expertise to evaluate and child health have been made, evidenced by declines programs administered at scale. Population-level indica- in neonatal, under-five, and maternal mortality, rates tors are needed that are easy to administer and interpret; of mortality remain high, especially in LMICs (Lassi, are reactive to program changes; and have strong psycho- Kumar, and Bhutta 2016). In addition to poverty, metric properties, including reliability and validity mortality is associated with low maternal education, (McCoy and others 2016; Raikes, Dua, and Britto 2015). poor nutrition, comorbid health conditions, and lack of access to skilled care. Interventions to alleviate many of the causes of mortality are available through PLATFORMS TO IMPLEMENT EARLY CHILD community-based care. Platforms to promote child DEVELOPMENT ACROSS A DEVELOPMENTAL development during infancy are also available through community-based care and include individual or group CONTINUUM sessions in health clinics, home visiting, and commu- The fragmentation in early child development services nity groups. is partially associated with the rapidly changing socie- Care for Child Development is a comprehensive pro- tal and economic structure surrounding families. gram developed by the World Health Organization Historically, families have cared for young children with (WHO) and United Nations Children’s Fund (UNICEF) support from the health sector, through services such as to promote early growth and development in the context monitoring growth and development, preventing infec- of health care contacts, either in clinics or homes (WHO tious diseases with vaccines, treating childhood illnesses, and UNICEF 2012). The program is delivered through and promoting breastfeeding and complementary feed- health care providers in Turkey, where there were bene- ing. Although families have succeeded in promoting fits in the home environment (Ertem and others 2006), their children’s growth and development, particularly and through community home visitors in China and when mothers are well educated (Walker, Wachs, and Pakistan (Jin and others 2007; Yousafzai and others others 2011), changes in social and economic structures 2014), with benefits to children’s development. In a in which mothers are employed, either inside or outside follow-up of children at age four years who participated of the home, have led to heightened demand for alterna- in a randomized trial of home intervention from birth tive sources of care. Based on children’s changing devel- through two years, the children who received responsive opmental needs, government and nongovernment caregiving had sustained effects in IQ, executive func- platforms have emerged to provide care (table 19.2), tioning, preacademic skills, and prosocial behaviors, and although they vary in how well they enable children to the mothers had benefits in responsive caregiving behav- meet their developmental potential. iors (Yousafzai and others 2016). Platforms to Reach Children in Early Childhood 259 Table 19.2 Early Child Development Platforms by Age of Child Age of Child Preconception Ages Ages Age Ages Sector Platform and prenatal 0–24 months 2–4 years 5 years 6–8 years Health sector Clinic: individual or group X X sessions Home visiting X X Nongovernmental Home visiting X X X organization, health Community groups X X X and education sectors Media X X X Child care X X Education sector Preprimary school X Primary school X Home visiting programs are often conducted by com- With support from the Saving Brains program of Grand munity health workers linked to health or social sectors Challenges Canada and the Inter-American Development and deliver interventions related to health and nutrition Bank, the Jamaican program is being scaled up to other (Yousafzai and others 2014), maternal mental health LMICs, as Reach Up and Learn.1 Reviews of other home (Rahman, Patel, and Maselko 2008), and child develop- visiting programs have also demonstrated success in pro- ment (Walker, Chang, and others 2011). The long-term moting developmental skills (Aboud and Yousafzai 2015), effects of early home visits can be seen in the Jamaica although there have been few long-term follow-ups. trial, a two-year randomized controlled assessment of Community programs to promote early child devel- home-based intervention promoting opportunities for opment are often organized by nonprofit organizations play and early learning through homemade toys and and provide general information on strategies to pro- materials, delivered to low-income families of stunted mote early child development. In a recent example from toddlers (Grantham-McGregor and others 1991). By age Uganda sponsored by Plan International, trained male two years, no differences in performance were seen and female community volunteers provided 12 family- in standardized developmental assessments between oriented sessions that addressed child care (play, talk, stunted children who received the home visiting inter- diet, hygiene, and love and respect) and maternal vention and a comparison sample of healthy nonstunted well-being (for example, increasing father involvement) children. The children received no further intervention among families with children ages 12–36 months (Singla, and entered the Jamaican educational system. At ages Kumbakumba, and Aboud 2015). Most sessions were 17–18 years, the stunted children in the early home visit- directed to both parents, with two exclusively for moth- ing group did better in 11 of 12 measures of cognitive ers and two for fathers. Sessions based on principles of and educational performance, and they had better men- social cognitive learning theory included messages, tal health indicators (lower rates of depression and anxi- games, role plays, parent-child interaction, group prob- ety, and higher self-esteem) and fewer attentional lem solving, homework, and activity booklets with activ- problems than stunted children in the control group ities that parents were encouraged to practice with their (Walker and others 2005; Walker and others 2006). child at home. The impact of the program on the home In early adulthood, those who had been randomized to environment, maternal mental health symptoms, and the intervention group were less likely to exhibit serious children’s development suggests that the group sessions violent behavior, and they had higher IQ scores, higher were effective in altering the behavior of families and in educational attainment, fewer symptoms of depression promoting child development. (Walker, Chang, and others 2011), and earnings of 25 percent more than young adults in the control group (Gertler and others 2014). Jamaica has a strong history of Ages Two to Four Years: Child Care universal preschool education, suggesting that the conti- The period that encompasses ages two to four years nuity of home visiting with preschool and primary presents a major gap (figure 19.2) in LMICs; neither school may have contributed to the long-term success. the health sector nor the educational sector is 260 Child and Adolescent Health and Development sufficiently responding to the needs of this group. to understand the impact of child care on children’s Few government-supported programs are available, health and development. and child care is often provided by private, nongovern- mental organizations with little regulation or oversight. Age Five Years: Preprimary School The number of child care programs has increased Access to preprimary education has been a central objec- globally, often in response to the need for mothers of tive of the Education for All initiative. Preschool has young children to work. However, there is little evidence benefits for subsequent performance in primary school regarding the impact on children. Cochrane reviews of (Berlinski and Schady 2015), especially when programs the effects of child care programs on children’s develop- include education (UNESCO 2015) and nutrition ment and well-being were conducted in LMICs (Brown (Nores and Barnett 2010). Global preprimary enroll- and others 2014) and in HICs (van Urk and others ment increased by nearly two-thirds from 1999 to 2012, 2014). Both reviews yielded only a single controlled especially in Latin America and the Caribbean (UNESCO study. Child care enrollment has increased substantially, 2015). Despite that impressive increase, preprimary cov- especially in Latin America (Berlinski and Schady 2015). erage ranges from 19 percent for low-income countries A recent review of programs in LMICs, all from Latin to 86 percent for HICs; the largest enrollment is among America, reported large positive effects on children’s children from the highest wealth quintiles and in urban development, with no evidence of either positive or centers (UNESCO 2015). These trends are consistent negative effects on children’s health and nutrition (Leroy, with caregiver reports of early childhood care attendance Gadsden, and Guijarro 2012). Regulatory guidelines for from UNICEF’s Multiple Indicator Cluster Survey. child care are emerging, but their quality varies substan- Based on data from 164,900 children across 58 LMICs, tially. The effects of child care on development vary 31.4 percent of all children ages 36–59 months in the by quality of child care, with stronger effects among sample had access to early education programs; prepri- programs that deliver opportunities for play and explo- mary enrollment rates were nearly twice as high among ration along with safety and hygiene (Berlinski and children from the top wealth quintile (47.3 percent) than Schady 2015). from the lowest quintile (19.7 percent). Child care programs range from custodial care, Preprimary access and coverage are variable; 40 of the often tied to maternal employment, to the provision of 58 LMICs in the Multiple Indicator Cluster Survey pro- developmentally oriented, early learning opportunities. vide compulsory preprimary education. The recently Much of the research into child care has been con- adopted SDG pledge to ensure “all girls and boys have ducted in HICs. One of the most striking studies of the access to quality early childhood development, care, and impact of a developmentally oriented, early learning preprimary education so that they are ready for primary program is the Abecedarian Project, a randomized con- education” marks the first time the global goal regime trolled trial of a high-quality program for disadvan- has made explicit the link between early childhood taged children from North Carolina, with long-term development and primary school readiness. adult follow-up (Campbell and others 2012; Campbell The body of rigorous evaluation of preprimary pro- and others 2014). The program, initiated in the 1970s, grams in LMICs in general, and in Sub-Saharan Africa in included all-day care from shortly after birth through particular, is growing. Several recent studies serve as exam- age five years, with planned opportunities for learning, ples for the examination of the effect of preprimary atten- activities that promote social-emotional development, dance on children’s cognitive development. A study of 423 healthy nutrition, and access to health care. Follow-up preprimary-age children in Kenya; Zanzibar, Tanzania; when participants were in their thirties found the inter- and Uganda found that children who attended pre- vention produced beneficial effects on years of school- primary programs performed better on measures of cogni- ing (Campbell and others 2012) and on the risk factors tive development 18 months after enrollment, compared for cardiovascular and metabolic diseases (Campbell with children who did not attend (Mwaura, Sylva, and and others 2014); effects on economic indicators were Malmberg 2008). A follow-up cross-sequential study mixed, and few differences on social adjustment were found a positive curvilinear effect of preprimary programs observed. on children’s cognitive development (Malmberg, Mwaura, The Abecedarian study, together with the Jamaican and Sylva 2011). Similar cognitive gains, as well as study (Gertler and others 2014), provide evidence that improvement in other developmental domains, have been early intervention can have long-term effects on documented in Mozambique in a randomized controlled many aspects of children’s health and development. trial of a community preprimary program sponsored by Additional long-term systematic studies are needed Save the Children (Martinez, Naudeau, and Pereira 2012). Platforms to Reach Children in Early Childhood 261 Children who attended this program demonstrated By 2008, the average LMIC was enrolling students in improved cognitive, fine motor, and socioemotional skills, primary school at nearly the same rate as the average as well as increased primary school enrollment at the HIC (Gove and Cvelich 2011). However, access to pri- appropriate age. The preprimary program also produced mary school continues to be a global concern. The 2015 positive impacts on the primary school enrollment of Global Monitoring Report estimates that 58 million chil- older siblings and increased the labor supply of primary dren of primary school age were out of school in 2015. caregivers, suggesting that the benefits of preprimary The main contributors to persistently large numbers of attendance extend beyond the enrolled children to their out-of-school children include crisis and conflict, chal- families. The researchers estimated the cost of the pro- lenging economic conditions, distance to school, and gram to be US$2.17 per student per month. denial of access for girls and for children with disabilities Evaluations of preprimary education elsewhere have (UNESCO 2015). also concluded that preprimary attendance is associated Although substantial gains in primary school enroll- with better academic and preacademic performance. ment have been achieved, by the 2015 Education for All An assessment of 880 Cambodian children age five years deadline, one in six children in LMICs—more than 100 showed children who had attended any type of prepri- million—did not complete primary school (UNESCO mary school performed better than those who had not, 2015). Not only are children in LMICs less likely to com- although children in state-supported preprimary schools plete primary education than children in HICs, they are had significantly higher scores than children in commu- learning less while in school. Estimates from large-scale nity or home-based schools (Rao and others 2012). international assessments of literacy and numeracy con- Other efforts are underway to reach young children ducted in fourth grade show that the average student in with educational content through media. Radio, televi- low-income countries is performing at the third per- sion, and other media can increase home access to early centile of students in HICs (Crouch and Gove 2011). child development programming aimed at either chil- Although raising the quality of learning is central to dren or parents. Local versions of Sesame Street reach global goals, much of government and donor efforts have children in more than 150 countries (Cole, Richman, focused on expanding access to education. The goals of and McCann Brown 2001). In Bangladesh, almost universal primary enrollment and completion are clear 50 percent of a sample of preschoolers watched televi- and reasonably easy to measure, and can readily be sion daily (Khan and others 2007); among television compared across countries with common methods watchers, 83 percent of urban and 58 percent of developed and publicized by the UNESCO Institute rural children watched Sesame Street. A meta-analysis for Statistics. In contrast, systematic approaches to stu- representing more than 10,000 young children from dent learning measurements that can be reported at the 15 countries found significant benefits from Sesame global level are lacking. While international large-scale Street in literacy and numeracy, in health and safety, assessments—such as the Progress in International and in social reasoning and attitudes toward others Reading Literacy Study and the Trends in International (Mares and Pan 2013). Mathematics and Science Study—contribute to As children approach school age, limited attention is cross-country learning comparisons, their coverage is often paid to the impact of health and nutrition on largely restricted to the global north. The few LMIC par- learning and well-being. However, nutritional deficien- ticipants scored quite poorly on these assessments, with cies, infection, and inflammation are major contributors the overall results deemed to be unreliable in some cases. to impaired child neurodevelopment during early and Regional assessments, such as the Second Regional middle childhood and can adversely affect children’s Comparative and Explanatory Study from Latin America academic performance and social-emotional develop- and the Caribbean, the Southern and Eastern Africa ment (John, Black, and Nelson 2016). Consortium for Monitoring Educational Quality, and the CONFEMEN Programme for the Analysis of Education Systems in West Africa, have been slow to Ages Six to Eight Years: Primary School expand, and LMICs continue to struggle with how to The past 25 years have seen an enormous expansion of conduct and use student assessment results to improve access to primary school, with the largest growth in learning in their classrooms (Gove and others 2015). LMICs (UNESCO 2015). The enrollment gap between The U.S. Agency for International Development HICs and LMICs has closed considerably, driven in part (USAID) commissioned development of the Early by the commitments to Education for All that were made Grade Reading Assessment (EGRA) to help LMICs in Jomtien, Thailand, in 1990 (UNESCO 1990) and rapidly diagnose and improve learning outcomes while affirmed in Dakar, Senegal, in 2000 (UNESCO 2000). also informing the global community. The EGRA was 262 Child and Adolescent Health and Development formulated in 2006, guided by research on the develop- more likely to read and comprehend than control ment of early reading skills, and relies on individual students (Piper, Zuilkowski, and Mugenda 2014). oral assessment of children to understand the reading Based on the success of PRIMR, the Kenyan govern- process in achieving and struggling readers. The EGRA ment extended the collaboration to develop the Tusome has been adapted for use in more than 75 countries and Early Grade Reading Activity. Tusome means “let’s in more than 120 languages. Open-source versions are read” in Kiswahili and is designed to promote early available, with guidance for adaptation based on literacy in English and Kiswahili through the provision the characteristics of a given language and country of structured teaching and learning materials and extra (RTI International 2016). Its widespread use has deliv- training for grade 1 and 2 teachers through tutors and ered a shared language for describing results and mon- coaching. Tusome has been scaled up into more than itoring educational system changes, while enabling 23,500 public and alternative education institutions countries to incorporate their unique contexts and nationwide, and by 2018 it will reach 5.4 million cultures (Dubeck and Gove 2015). Kenyan children in grades 1 and 2 (USAID 2016). More than a dozen countries have used the EGRA Kenya’s experience and similar efforts supported by data to develop benchmarks and standards for achieve- USAID and other donors have highlighted the need for ment across different grades. The EGRA has been used additional evidence on how to take pilot programs to for program monitoring and evaluation and for devel- scale. While there have been several reviews of evalua- opment of reports reflecting educational systems within tions of learning improvement efforts in LMICs (Evans countries and at the country-level2 and consolidated and Popova 2015; McEwan 2015), few programs have information across contexts (Gove and Cvelich 2011). been able to scale up and sustain the level of improve- Using these benchmarks, countries can estimate the pro- ment observed in the pilot. portion of children in grades 2–3 meeting minimum proficiency in reading, an indicator that could be reported globally, as required by the SDGs (specifically CONCLUSIONS SDG 4.1). Enabling LMICs to monitor and improve learning outcomes in the early grades is likely to pro- The field of global early child development is emerging, mote attendance and academic success and to improve stimulated by promising findings from the impact of the quality of the education system. ensuring adequate development early in life and by The expansion of primary schools and the elimina- encouragement from international leaders through tion or reduction of school fees have boosted primary the SDGs. Significant gaps exist in programming and school enrollment. However, quality in many primary investment that may interfere with future success, par- schools in LMICs is low, particularly in Sub-Saharan ticularly for children under age five years. Limited Africa (UNESCO 2012). Assessment strategies, such as attention to workforce development and support, pro- the EGRA, India’s Annual Status of Education Report, gram standards and materials, best practices, and qual- and East Africa’s Uwezo initiative, have helped focus ity are concerns (Yousafzai and Aboud 2014). Although attention on the low learning levels in many primary initial efforts to estimate cost-effectiveness suggest that schools in LMICs (UNESCO Institute for Statistics interventions that include responsive stimulation are 2016). Children who do not acquire basic literacy and more cost-effective than nutrition interventions alone numeracy skills early in their academic careers have dif- in promoting children’s early development (Gowani ficulty with subsequent subjects and are at risk of drop- and others 2014), there have been few attempts to esti- ping out, which would limit their economic opportunities mate costs (Horton and Black 2017). Population-based and those of entire societies. indicators are needed for early child development, Early academic success depends on strong teacher along with national databases to enable countries to training and a curriculum and materials that support plan and evaluate intervention programs for young learning. With the global shift in focus from access to children. learning, governments and donors are experimenting These actions are meant to continue the advances with classroom-level interventions, such as the Primary that have been made in early child development policies, Mathematics and Reading Initiative (PRIMR) (Piper, programs, and research in recent decades. Government Zuilkowski, and Mugenda 2014). A randomized con- commitments through education ministries to provide trolled trial of the approach in more than 400 schools in schools, teacher training, learning materials, and supple- Kenya found that the intervention significantly improved mentary support to enable young children to attend oral reading fluency in grades 1 and 2 for both English primary school—such as the elimination of school fees and Kiswahili, with PRIMR students two to three times and the provision of school meals—have helped increase Platforms to Reach Children in Early Childhood 263 primary school access. LMICs, with the support of inter- NOTES national donors, have developed and evaluated curricula World Bank Income Classifications as of July 2014 are as fol- designed to promote early grade reading and mathemat- lows, based on estimates of gross national income (GNI) per ics, as well as systematic methods to measure progress. capita for 2013: Children who acquire these skills in the first years of primary school are likely to remain in school, to • Low-income countries (LICs) = US$1,045 or less learn, and to acquire the skills needed for sustainable • Middle-income countries (MICs) are subdivided: development. a) lower-middle-income = US$1,046 to US$4,125 Policies and programs for children up to age five b) upper-middle-income (UMICs) = US$4,126 to US$12,745 years are less well developed than those for primary • High-income countries (HICs) = US$12,746 or more. schools. From a positive perspective, preprimary educa- tion has been endorsed globally by Education for All 1. 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Since the inclusion of Schools are a cost-effective platform for providing sim- school health and nutrition (SHN) in the launch of the ple, safe, and effective health interventions to school-age call for Education for All (EFA) in 2000, it has been dif- children and adolescents (Horton and others 2017). Many ficult to find a country that is not attempting at some of the health conditions that are most prevalent among level to provide SHN services (Sarr and others 2017). It poor students have important effects on education— is estimated that more than 368 million schoolchildren causing absenteeism, leading to grade repetition or drop- are provided with school meals every day (World Food out, and adversely affecting student achievement—and Programme 2016), and according to the World Health yet are easily preventable or treatable. With gains in enroll- Organization (WHO) statistics (WHO 2015), 416 mil- ment achieved by the Millennium Development Goals, lion school-age children were dewormed in 2015, which SHN interventions are important cross-sectoral collabo- equals 63.2 percent of the target population of children rations between Ministries of Health and Education to in endemic areas; see chapter 29 in this volume (Ahuja promote health, cognition, and physical growth across the and others 2017). These largely public efforts are vari- life course. able in quality, and coverage is greatest in the richer The education system is particularly well situated to countries, but the scale indicates public recognition of promoting health among children and adolescents in the willingness to invest in middle childhood and poor communities without effective health systems adolescence. who otherwise might not receive health interventions. Health status affects cognitive ability, educational There are typically more schools than health facilities attainment, quality of life, and the ability to contribute to in all income settings, and rural and poor areas are society. Some of the most common health conditions of significantly more likely to have schools than health childhood have consequences for education. SHN inter- centers. The economies of scale, coupled with the effi- ventions can support vulnerable children throughout ciencies of using existing infrastructure and the poten- key stages of their development in middle childhood and tial to administer additional interventions through the adolescence. A set of priority school-based interventions, same delivery mechanism, make SHN interventions Corresponding authors: Linda Schultz, World Bank, Washington, DC, United States; lschultz@worldbank.org. 269 particularly cost-effective. As a result, schools can reach These programs have a long history. At the turn of the an unprecedented number of children and adolescents twentieth century, school feeding1 initiatives were among and play a key role in national development efforts by the first social welfare programs to emerge in high- improving both child health and education. Because income countries (Atkins 2007). Recognition that SHN schools are at the heart of all communities, we have an benefits learning had been clear from the 1920s, when opportunity to use the school as a sustainable, scalable school-based deworming programs were instituted option for simple health service delivery. across the southern United States specifically to promote This chapter explores the developmental rationale for education and reduce poverty (Ettling 1981). By the improving the health of school-age children and the 1980s, SHN programs had become ubiquitous in economic rationale for administering health interven- upper-middle-income countries and high-income coun- tions to school-age children (typically from ages 5 to 14 tries. Change also began in the 1980s in low- and years) through existing educational systems as compared middle-income countries (LMICs) with a shift away with the health system. Definitions of age groupings and from the traditional complex, medical-based approach, age-specific terminology used in this volume can be usually targeted to elite urban or boarding schools, and found in chapter 1 (Bundy, de Silva, and others 2017). toward interventions targeted to the poorest schools. Both the health and education communities have championed SHN in LMICs. The WHO’s Ottawa Charter SCHOOL HEALTH AND NUTRITION for Health Promotion, launched in 1986, provided SHN describes a wide range of interventions delivered momentum for global recognition of the importance of through schools to improve education and health out- addressing health in the educational context (WHO comes by enhancing nutrition, alleviating hunger, and 1986). This recognition was further propelled by the preventing disease. SHN interventions can target the work of the WHO Expert Committee on Comprehensive most common local health conditions that affect school- School Health and Nutrition Education and Promotion age children and can be delivered by teachers and other in the mid-1990s. The WHO’s Information Series on proxies for the health system. Delivery of health interven- School Health and Nutrition, together with the United tions through schools enables children to take advantage Nations Educational, Scientific and Cultural Organization of investments made in the education sector and improves (UNESCO) and Education Development Center, com- country competitiveness, given that each increased year menced in the late 1990s (WHO 1997). There was also of schooling is associated with greater earning capacity an attempt to promote thinking around SHN at the 1990 and lower levels of mortality, illness, and health risks. As World Education Forum in Jomtien, Thailand, but it was more children survive and thrive (figure 20.1), the role of not until 10 years later that the concept gained traction schools becomes increasingly important. in the global commitment to achieve EFA launched at the World Education Forum in Dakar, Senegal, in 2000. To strengthen the focus on SHN, several organizations, including UNESCO, the United Nations Children’s Fund (UNICEF), the WHO, and the World Bank, used the Figure 20.1 Rate of Survival beyond Age Five Years Dakar Forum to launch an organizing framework enti- 1,000 tled Focusing Resources on Effective School Health and Probability per 1,000 that newborn Nutrition (FRESH). Since then, an increasing number of reaches at least age five years 950 low- and lower-middle-income countries have adopted 900 more comprehensive SHN policies with the specific aims 850 of achieving EFA along with the education-specific 800 Millennium Development Goals of universal basic edu- 750 cation and gender equality in educational access (Bundy 700 2011). In Sub-Saharan Africa, the percentage of coun- 650 tries implementing programs that meet the minimum WHO Health Promoting School criteria of equity and 600 1966 1971 1976 1981 1986 1991 1996 2001 2006 2011 effectiveness rose from 10 percent in 2000 to more than World Sub-Saharan Africa 80 percent in 2014 (Drake, Maier, and de Lind van Wijngaarden 2007) (figure 20.2). In Sub-Saharan Africa, Source: World Bank 2016. the percentage of reproductive health service–supported Note: Survival rate is the inverse of the under-five year mortality rate, which is the probability per 1,000 that a newborn will die before reaching age five years, subject to age-specific mortality rates programs rose from 10 percent to more than 70 percent, for the specified year. with an estimate of 80 percent in 2014. 270 Child and Adolescent Health and Development Figure 20.2 Expansion of School Health and Nutrition in greater extent in high-income countries, especially in the Sub-Saharan Africa United States (Durlak, Weissberg, and Dymnicki 2011; Murray and others 2007; Shackleton and others 2016). 100 90 Some of the most prevalent health conditions of school- Percentage of countries 80 age children affect children’s education participation and 70 learning outcomes significantly (table 20.1). Typical 60 interventions and their target conditions include the fol- 50 40 lowing: deworming and worm infection; bednets and 30 malaria; handwashing and bacterial infections; tooth- 20 brushing and dental caries; spectacles and refractive error; 10 0 micronutrients and micronutrient deficiency; and food 2001 2007 2014 and hunger. Research has shown that the average IQ loss Year for children with these conditions can range from 3.7 IQ School meals points per child with untreated worm infections to 6.0 IQ National school health and nutrition policy points for children with anemia. Together, these prevalent National policy for safe water in schools conditions are estimated to translate into the equivalent of Reproductive health services between 200 million and 500 million years of school lost due to ill health in LMICs each year (Bundy 2011). Source: Adapted from Drake, Maier, and de Lind van Wijngaarden 2007. Interventions for these common health conditions can have long-term economic benefits. Estimates show that poor students in areas where these conditions are prevalent would gain the equivalent of 0.5–2.5 extra years of school- HEALTHY CHILDREN, BETTER LEARNING ing if their health benefited from appropriate interventions. SHN programming is increasingly recognized as a critical Sustaining the benefits across multiple years of schooling element for achieving universal access to education. could improve cognitive abilities by 0.25 standard devia- Access to a school, provision of quality teaching and tions, on average; extrapolating the benefits of improved learning materials, and availability of trained teachers are accumulation in human capital could translate to roughly necessary, but insufficient, to achieve good learning out- a 5 percent increase in earning capacity over the life course; comes. Children also need to be healthy and regularly see chapter 29 in this volume (Ahuja and others 2017). attending school to be able to benefit fully from the SHN interventions can enhance equity by supporting learning opportunities. Ill health can be the catalyst for student participation and contributing to a reduction in the extended absence or dropping out of school completely; education achievement gap between well-performing and malaria and worm infections can reduce enrollment; underperforming students. A study in South Africa found anemia can affect cognition, attention span, and learning; that children who score 0.25 standard deviations above the and the pain associated with tooth decay can affect both mean on grade 2 examinations were significantly more attendance and learning (chapters 11–16 of this volume; likely to complete grade 7 (figure 20.3). If schools that deliv- Benzian and others 2017; Brooker and others 2017; ered health and nutrition interventions could raise exami- Bundy, Appleby, and others 2017; Drake, Fernandes, and nation scores, they may experience higher student retention, others 2017; LaMontagne and others 2017; Lassi, Moin, compared with schools without health programs. and Bhutta 2017). The potential for school health inter- Although better health alone cannot compensate ventions to shape physical and psychosocial health as well for missed learning opportunities, it can provide chil- as education outcomes for youth has been explored to a dren with the potential to take advantage of learning Table 20.1 Estimates of the Global Cognitive Impact of Common Diseases of School-Age Children in LMICs Additional cases of Lost years of Common diseases Prevalence (%) Total cases (millions) IQ points lost per child IQ <70 (millions) schooling (millions) Worms 30 169 3.75 15.8 201 Stunting 52 292 3 21.6 284 Anemia 53 298 6 45.6 524 Source: Bundy 2011. Note: IQ = intelligence quotient; LMICs = low- and middle-income countries. The School as a Platform for Addressing Health in Middle Childhood and Adolescence 271 Figure 20.3 Estimated School Dropout Rates, with and without School opportunities (Grigorenko and others 2006). Children Health and Nutrition Interventions, in South Africa are more ready to learn after treatment; they may be able to catch up with better-off peers if their improved learn- 160 ing potential can be used effectively in the classroom. 140 The education sector is responsible for the quality of 120 education delivered and for leveraging the investment it Number of pupils has already made. 100 A key message of this volume is that different types of 80 health interventions are required at different stages in 60 child and adolescent development. The accumulating 40 evidence on the benefits of targeted interventions from 20 middle childhood to late adolescence is summarized in chapter 6 in this volume (Bundy and Horton 2017); the 0 2 4 6 8 potential impact of targeted intervention in school-age School grade children is discussed in chapter 8 of this volume (Watkins and others 2017). Mean +0.25 SD Mean SHN and school feeding interventions build on the foundation of early child development interventions and Source: Liddell and Rae 2001. Note: SD = standard deviation. Students who score 0.25 SD higher on exams in grade 2 are more exploit the accessibility of children in schools. Figure 20.4 likely to complete grade 7. If schools that delivered health and nutrition interventions could raise demonstrates how the World Bank characterized the var- examination scores, they may experience higher student retention compared with schools without ied opportunities for health interventions at different life health programs. Figure 20.4 Learning as a Lifelong Process Early stimulation Nutrition Immunization Malaria Micronutrients Combat hunger Deworming 100 Hygiene Healthy lifestyle 90 (Tertiary level, 80 ECD skills training, and (Nutrition, health care, Primary and second chance School enrollment, percent 70 education) parental training, ECE) secondary levels 60 50 Age-enrollment profile Preschool 40 enrollment 30 20 Children and youth in school 10 0 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Age in years Source: Adapted from World Bank 2011, updated to include preschool enrollment; World Bank 2016. Note: ECD = early child development; ECE = early childhood education. Rates of preschool enrollment by country group: 18.05 (low income), 49.56 (lower-middle income; reflects reported rate from 2012), 58.39 (middle income). The rates indicate the total enrollment in preprimary education, regardless of age, expressed as a percentage of the total population of official preprimary education age. 272 Child and Adolescent Health and Development stages as part of an education strategy. The figure indi- Figure 20.5 Percentage of Population Enrolled in Primary School and cates schematically when interventions might be particu- Who Move on to Secondary School in South Asia and Sub-Saharan larly helpful. For example, early stimulation can help Africa, 1970 and 2015 ensure school readiness; malaria prevention and educa- 120 tion on bednet use, school feeding, and deworming treat- ments can help keep children in school by enhancing 100 attendance and reducing dropout rates; and vision correc- 80 Percent tion and skills-based health education, along with school 60 feeding, might help improve learning by enhancing cog- 40 nition and educational achievement (World Bank 2012). 20 0 1970 2015 1970 2015 SCHOOLS AS ENTRY POINTS FOR HEALTH South Asia Sub-Saharan Africa INTERVENTIONS Enrolled in primary school (gross) Schools are one of the few institutions in poor commu- Completed primary school Enrolled in secondary school (gross) nities that provide access to trained human resources. In contrast, the health systems in many LMICs experience Source: World Bank 2016. multiple barriers, especially in costs and human Note: Total enrollment, regardless of age, expressed as a percentage of the population of official resources, that limit their ability to reach beyond health primary or secondary education age. Gross enrollment rate can exceed 100 percent as a result of the inclusion of over-age and under-age students because of early or late school entrance and facilities. Schools cannot replace health systems, which grade repetition. remain the formal avenue for health delivery, but educa- tion systems can complement health delivery mecha- nisms by providing outreach opportunities through Figure 20.6 Ratio of Primary School Teachers to Community Health schools. Even in LMICs, school-based interventions can Workers in 13 Low- and Lower-Middle-Income Countries, by GDP be widely implemented by the education sector, with the per Capita health sector ensuring proper oversight and training of 100 school staff (Bundy 2011). 90 Ratio of primary school teachers to School-based health programs have the potential to community health workers 80 reach an estimated 575 million school-age children in 70 low-income countries (UNESCO 2008). This opportu- India 60 nity is particularly relevant to Sub-Saharan Africa. Central African Republic Young people constitute the greatest proportion of the 50 Burundi Pakistan population, and this is the only region in which the 40 Burkina Faso 30 Ghana number of young people continues to grow substantially Nigeria (UNFPA 2012). It is also important that this is now a 20 Ethiopia Nepal Bhutan region in which most children attend school. As shown 10 Bangladesh Swaziland in figure 20.5, the percentage of the population that has Rwanda enrolled in school, completed primary education, and 0 500 1,000 1,500 2,000 2,500 3,000 moved on to secondary school has increased consider- GDP per capita (2012) ably during the past four decades, so that the proportion Sources: Data on the number of primary school teachers are from UNESCO Institute for Statistics of school-going children and adolescents in Sub-Saharan (http://stats.uis.unesco.org); data on the number of community health workers are from the WHO Africa today approaches that of South Asia. Despite the Global Health Observatory Data Repository (http://apps.who.int/ghodata/); and GDP data are from increasing number of children in school, Sub-Saharan World Bank 2016. Note: GDP = gross domestic product. Africa has low enrollment rates compared with the rest of the world. Looking ahead, an unprecedented number of children are anticipated to be in school in this region responsibilities that accompany SHN programming. as enrollment rates improve. Because most countries Preservice sensitization and training can help educators have SHN programs, opportunities exist to scale up the recognize that healthy children learn better. scope of services and tailor specific types of programs to SHN systems build on existing infrastructure, curric- local contexts. It is important to note that the high ulum opportunities, and teacher networks to accelerate pupil-to-teacher ratio in many schools may discourage implementation and reduce costs. There are more teach- educators and the education sector from adding extra ers than nurses and more schools than clinics, often by The School as a Platform for Addressing Health in Middle Childhood and Adolescence 273 an order of magnitude. Figure 20.6 shows that the ratio Girls and young women benefit particularly from of primary teachers to community health workers in SHN and school feeding programs because some of the several countries is in the range of 20:1 to 65:1; this rela- most common health conditions affecting education tionship is only loosely related to gross domestic product are more prevalent in girls, and because gender-based (GDP). Including teachers—as the largest segment of vulnerability and exclusion can place girls at greater risk the workforce and often community leaders—in public of ill health, neglect, and hunger (Bundy 2011). health activities can also broaden awareness of, and com- Deworming and iron supplementation offer particular munity commitment to, public health interventions. benefits to girls because women and girls are, for phys- iological reasons, more likely to experience high rates of anemia. SHN programs draw children—especially SCHOOL HEALTH AND NUTRITION girls—into schools and encourage them to stay (Gelli, PROGRAMS: PRO-POOR AND PRO-GIRL Meir, and Espejo 2007). This dynamic is particularly relevant to achieving EFA; marginalized children, INTERVENTIONS among whom girls are overrepresented, account for the SHN programs can help level the playing field for the majority of out-of-school children (UNESCO 2011). most vulnerable students: the poor, the sick, and Moreover, improved health and increased educational the malnourished. These are the children who require attainment for young women can help delay age at first the greatest support throughout their schooling to min- birth, which is associated with improved financial risk imize the risk of absenteeism and dropping out, but who protection and enhanced intergenerational health out- generally have the least access to care and support comes; see chapter 28 in this volume (Verguet and (World Bank 2012). SHN and nutrition programs are others 2017). pro-poor because the greatest benefits accrue to those Girls can benefit greatly from health promotion and children who are most affected at the outset (Bundy life-skills lessons offered in schools. This benefit is 2011). This pro-poor focus has also been increasingly exemplified with human immunodeficiency virus/ emphasized in WHO SHN policies and practices (Tang acquired immune deficiency syndrome (HIV/AIDS) and others 2009). education, particularly because young women in Sub- Poverty is a key consideration in the design of SHN Saharan Africa are estimated to be two to seven times and school feeding programs. The negative correlations more likely to be infected with HIV than young men between ill health, malnutrition, and income level are (MacPhail, Williams, and Campbell 2002). Health clearly demonstrated in both cross-country comparisons responses are more sustainable and have a greater and individual country analyses (de Silva and others reach when integrated into an existing framework, 2003), partly because low income and poverty promote such as through a wider curriculum of health promo- disease and inadequate diets. Paradoxically, SHN pro- tion (Jukes, Simmons, and Bundy 2008). Research grams are often most equitable when they are universal; shows that the most trusted source for young people to mass delivery can help ensure that the interventions learn about HIV/AIDS is through schools and teachers reach those poorest children who are more often system- (Boler 2003). A wide range of life skills and health pro- atically overlooked, especially by intervention programs motion curriculum design, content, and implementa- that operate through diagnoses at health facilities. tion is available (Hargreaves and Boler 2006). Relatively However, the equity value of universal access within simple lessons on skills-based health education can schools does not imply that there is no value in targeting usefully address stigma and discrimination, and an poor communities. With few exceptions, the diseases integrated curriculum at a higher level of complexity that affect children and their education are most preva- can usefully influence protective health behaviors. lent in poor countries, particularly in the poorest com- Data show that for every extra year children remain in munities within those countries. As a result, targeting school HIV/AIDS rates are reduced (World Bank interventions to those communities most likely to bene- 2002). The years of school attended may not equate to fit is cost-effective and a common characteristic of greater attainment of skills-based health education strong SHN programs. The benefits of targeting school because curriculum quality and extent of integration feeding interventions is discussed in depth in chapter 12 into the larger school framework vary widely in this volume (Drake, Fernandes, and others 2017). (Hargreaves and others 2008; Jukes, Simmons, and Lessons gleaned from country case studies can illustrate Bundy 2008). the strengths of different school feeding approaches in SHN programs may also work synergistically with both program design and service delivery (Drake, conditional and unconditional social transfer pro- Woolnough, and others 2016). grams; see chapter 7 in this volume (Alderman and 274 Child and Adolescent Health and Development others 2017) and chapter 12 in this volume (Drake, Figure 20.7 Global Out-of-School Children of Primary School Age, Fernandes, and others 2017). Take-home rations and by Gender, 1970–2010 conditional cash transfers can encourage girls to go to 90 school; bursaries, which give rations directly to girl 80 students, can encourage girls to stay in school 70 Children (millions) (Chapman 2006). The broader value of these pro- 60 grams is discussed in chapter 23 in this volume (de 50 Walque and others 2017). 40 Schools are an increasingly attractive and effective 30 20 platform for reaching girls given that the gender gap in 10 enrollment is closing in most countries. Figure 20.7 0 illustrates decreasing out-of-school rates between 1970 1970 1975 1980 1985 1990 1995 2000 2005 2010 and 2010. The trend for girls is especially clear: Girls Boys between 1970 and 2010 the significant gap in enroll- Source: World Bank 2016. ment of boys and girls was dramatically reduced, Note: The total number of boys and girls of primary school age who are not enrolled in either although a substantial number of children—more or primary or secondary schools. less equally boys and girls—never enroll in school. Figures 20.8 and 20.9 provide a more nuanced look at the narrowing gender disparities in out-of-school chil- Figure 20.8 Out-of-School Children of Primary School Age in dren in South Asia and Sub-Saharan Africa, showing South Asia, 1975–2013 that greater change in enrollment among girls has occurred in South Asia. 35 Significant cross-country differences exist in gender 30 disparities in enrollment rates based on historical expe- Children (millions) 25 rience and government policies. Data from five Sub- 20 Saharan African countries are presented in figure 20.10. 15 In Mozambique, the number of out-of-school children decreased significantly from 2000 to 2014, while gender 10 gaps remained substantial. In contrast, the gender gap 5 remained small in Ghana, while the trend was down- 0 1975 1980 1985 1990 1995 2000 2005 2010 ward; in Niger, the number of out-of-school children Girls Boys remained relatively constant over the period, while the gender gap widened. Source: World Bank 2016. In some Sub-Saharan African countries, the num- Note: The total number of boys and girls of primary school age who are not enrolled in either primary or secondary schools. bers of out-of-school children have proved difficult to reduce; as a result, the observation that SHN programs can benefit out-of-school children becomes increas- ingly important. As documented in Guinea and Figure 20.9 Out-of-School Children of Primary School Age in Madagascar, many out-of-school children will take Sub-Saharan Africa, 1975–2013 advantage of simple health services provided in 30 schools, for example, deworming and micronutrient supplements; school feeding programs, especially take- 25 Children (millions) home rations, have been shown to benefit siblings at 20 home (Adelman and others 2008; Bundy and others 15 2009; Del Rosso and Marek 1996). Deworming pro- grams in schools have been found to reach out-of- 10 school children at scale (Drake and others 2015) and 5 reduce disease transmission in the community as a 0 whole (Bundy and others 1990; Miguel and Kremer 1975 1980 1985 1990 1995 2000 2005 2010 2004). Although the benefits of SHN programs can Girls Boys extend beyond those who attend school, SHN pro- Source: World Bank 2016. grams are best considered in conjunction with other Note: The total number of boys and girls of primary school age who are not enrolled in either approaches to encouraging enrollment and attendance. primary or secondary schools. The School as a Platform for Addressing Health in Middle Childhood and Adolescence 275 Figure 20.10 Out-of-School Children of Primary School Age, in Five mechanisms, and working cultures between different Countries, by Gender, 2000–14 line ministries. Each sector needs to identify its respec- tive role and responsibilities and present a coordinated 1,200,000 plan of action to improve the health and education 1,000,000 outcomes of children. Beyond the education and 800,000 health ministries and nonstate actors, intersectoral Number 600,000 collaboration is more complex. The starting point is usually the establishment of cross-sectoral working 400,000 groups or steering committees at national, district, and 200,000 local levels to coordinate actions and decision making 0 (FRESH 2014). The understanding and recognition by 2000 2002 2004 2006 2008 2010 2012 2014 the education and health sectors of each other’s core Boys Girls business and priorities are also essential; the stronger Burkina Faso Burkina Faso Ghana Ghana and more explicit focus that the WHO places on Kenya Kenya achieving both health and education outcomes can Mozambique Mozambique Niger Niger facilitate collaboration between health promotion practitioners and teachers. Source: World Bank 2016. Successful multisector school-based health service Note: Out-of-school children of primary school age for specific countries. Figure shows the total number of boys and girls of primary school age who are not enrolled in primary or secondary delivery includes referral and treatment opportunities schools. Gaps in the graphs are due to lack of data for those years. that extend beyond the school platform. School-based responses to the various diseases affecting school-age children vary depending on the nature of the treat- It is important that out-of-school children have access ment required. For example, there is a clear policy to skills-based health education and life-skills develop- context for integrating the identification and referral ment to prevent illnesses such as HIV/AIDS (Hargreaves of refractive error into wider SHN programs. It is and others 2008). essential that school-based vision screening programs include screening and referral at the primary level; refraction and optical dispensing at the district level; DEFINING SECTOR ROLES and supported advanced care, including pediatric and The implementation, funding, and oversight of SHN contact lens services, at the tertiary health care level, programs do not fall squarely within either the educa- although the costs increase and feasibility decreases tion or the health sector. Rather, many approaches, with each step away from the primary level (World stakeholders, and collaborations are involved in the Bank 2012). See chapter 17 in this volume (Graham delivery of health and nutrition services in schools. and others 2017) for a more detailed look at school- Diverse experiences suggest that existing programs high- based vision programming. light certain consistent roles played by government and SHN programs offer a compelling case for public nongovernmental agencies and other partners and sector investment and interventions. First, these stakeholders. It is clear that program success depends on interventions may create externalities whereby exter- the effective participation and support of strategic part- nal benefits accrue to people other than treated indi- nerships, especially with the beneficiaries and their par- viduals. For example, deworming programs reduce ents or guardians (table 20.2). the intensity of infection in untreated children in In nearly every national SHN program, the Ministry schools, in neighboring schools, and in siblings of of Education is the lead implementing agency, reflect- those treated at schools (Miguel and Kremer 2004). ing both the goal of SHN programs to improve educa- Second, some health interventions are pure public tional achievement and the fact that the education goods—all school-age children are eligible to access system often provides the most complete existing these services and there is typically little private infrastructure to reach school-age children. In success- demand for general preventive measures. Accordingly, ful programs this responsibility has been shared the private sector is unlikely to compete to deliver between the Ministry of Education and the Ministry of these goods and services. SHN programs are most Health, particularly since the latter has the ultimate likely to achieve universal coverage and be sustainable responsibility for the health of all children. However, when they are under the jurisdiction of the public collaboration across sectors is not easy, particularly sector and integrated into national education sector given different institutional structures, operational plans (ESPs). 276 Child and Adolescent Health and Development Table 20.2 Comparison of Roles Played by Government Agencies, Partners, and Stakeholders in School Health and Nutrition Programs Partner Roles Comments Ministry of Education • Lead implementing agency • Health and nutrition of schoolchildren is a priority for EFA. • Lead financial resource • Education policy defines school environment, curriculum, duties • Education sector policy of teachers. • Education system has a pervasive infrastructure for reaching teachers and school-age children. Ministry of Health • Lead technical agency • Health of school-age children has lower priority than clinical • Health sector policy services and infant health. • Health policy defines role of teachers in service delivery and how health materials are procured. Other public sector agencies (for • Support education and health systems • Ministries of local government are often fund holders for teachers example, ministries of welfare, social • Fund holders and schools, as well as for clinics and health agents. affairs, local government, agriculture) • Ministries of welfare and social affairs provide mechanisms for the provision of social funds. Private sector (for example, health • Specialist service delivery • Major role in drug procurement and production of training services, pharmaceuticals, publications) • Materials provision materials. • Specialist roles in health diagnostics. Civil society (for example, NGOs, FBOs, • Training and supervision • At the local level, serve as gatekeepers and fund holders; may PTAs) • Local resource provision also target implementation. • Offer additional resource streams, particularly through INGOs. Teachers associations, local community • Define teachers’ roles • School health programs demand an expanded role for teachers. (for example, children, teachers, • Partners in implementation • Gatekeepers for both the content of health education (especially parents) moral and sexual content) and the role of nonhealth agents • Define acceptability of curriculum (especially teachers) in health service delivery. Pupils are active • Supplement resources participants in all aspects of the process at the school level. • Communities supplement program finances at the margins. Source: Jukes, Drake, and Bundy 2008. Note: EFA = Education for All; FBO = faith-based organization; INGO = international nongovernmental organization; NGO = nongovernmental organization; PTA = parent-teacher association. ECONOMIC RATIONALE FOR SCHOOL-BASED provide a preexisting mechanism, so costs are marginal; they also provide a system that as part of its primary HEALTH INTERVENTIONS educational purpose aims to be sustainable and perva- In the complex set of conditions required for children to sive, reach disadvantaged children, and promote social learn well, improved health can be one of the simplest equity. Tailoring and targeting the types of interventions and cheapest conditions to achieve (World Bank 2012). to local contexts lies at the heart of practical success. The focus of this economic rationale is on conditions for Targeting reduces costs and facilitates management; it which there are existing interventions that are suffi- may optimize outcomes. ciently safe, simple, and well evaluated to be appropriate Education sector spending exceeds public health for education sector implementation through schools, spending in most LMICs. In Ghana, Mozambique, and typically with health sector supervision. Niger, for example, public expenditures for education are Several factors support the economic rationale for more than double those for public health (figure 20.11). schools as a platform for the delivery of health interven- The higher investment in the education sector relative to tions. One of the main factors is the potential savings the health sector is reflected in the greater number of offered by school systems, rather than health systems, as schools and teachers versus health centers and health the delivery mechanism. From this perspective, schools workers in communities (see figure 20.6). The School as a Platform for Addressing Health in Middle Childhood and Adolescence 277 Figure 20.11 Expenditures on Education versus Health as a through schools (Fernandes and Aurino 2017). The Proportion of GDP, 2013 analysis suggests that the economic benefits as measured 9 by the returns to health and education outweigh the costs, while remaining affordable within government 8 budget constraints. The essential package includes tar- Share of GDP (percent) 7 geted school meals with micronutrient fortification, 6 education on malaria prevention and oral hygiene, 5 deworming treatment, screening for refractive error, and 4 appropriate immunization. 3 The cost savings of delivering simple and safe inter- 2 ventions through schools can be illustrated in deworming 1 and screening for refractive error. For example, delivery 0 of mass administration of deworming treatment through Ghana Mozambique Niger schools (not including the cost of treatment because it Genaral government expenditure on education is currently donated for schoolchildren) is estimated to Public health expenditures cost US$0.03–US$0.04 per child per year, compared with Private health expenditures US$0.21–US$0.51 through mobile health teams coordi- nated by primary health centers (Guyatt 2003). Screening Source: World Bank 2016. Note: GDP = gross domestic product. Total health expenditure is the sum of public and private costs for refractive error and provision of glasses through health expenditure. It covers the provision of preventive and curative health services, family area hospitals were estimated to be US$8.17, but the planning activities, nutrition activities, and emergency aid designated for health; it does not include cost drops to US$2–US$3 if the screening is provided by provision of water and sanitation. General government expenditure on education (current, capital, and transfers) is expressed as a percentage of GDP. It includes expenditure funded by transfers mobile teams dispatched to schools following screening from international sources to government. General government usually refers to local, regional, by teachers (Baltussen, Naus, and Limburg 2009; Graham and central governments. Data are more readily available (as are world and regional estimates) and others 2017) (table 20.3). With minimal training for health than for education. combined with access to periodic supervision and sup- port, school teachers can safely administer pills or screen The large share of the population that school-age children for health conditions of interest, limiting the time children represent and the high percentage of children requirement and cost of access to skilled health personnel. that attend school imply significant economies of scale in The presence of children at school obviates the need the cost of delivering school-based health interventions. to draw children to another point of service at regular The economies of scale can be expected to be larger for intervals or for mobile health teams to travel to reach interventions with small variable or marginal costs, that them. Furthermore, the implementation of multiple is, the cost of treating an additional child. School-based interventions through the same delivery system allows health interventions may also have fixed costs for estab- for shared costs and efficiencies, for example, for teacher lishing infrastructure, staffing, government capacity, training. The effectiveness of primary health centers is intersectoral policies, and monitoring systems. contingent on the target population coming to clinics to The rationale for school-based health interventions is receive the interventions, which can be a significant time also stronger for interventions that address prevalent conditions in populations (see table 20.1). In this case, the expected benefits are higher per dollar invested. Targeting Table 20.3 Essential Package of School-Based Health school-based health interventions to children at greater Interventions, 2012 U.S. dollars risk may lead to greater benefits, but it may also lead to Annual cost per child per year ($) higher costs, depending on how the targeting is achieved. School meals 44 MNP supplementation 3 COMPARATIVE COST-EFFECTIVENESS OF Malaria 2–3 DELIVERING HEALTH INTERVENTIONS Refractive error screening 2–3 THROUGH SCHOOLS Toothbrush provision 0.50 Schools offer advantages over community and primary HPV vaccine 2 health center platforms. Chapter 25 in this volume Tetanus toxoid vaccine 0.40 presents an essential package of low-cost health inter- Source: Fernandes and Aurino 2017. ventions that can be delivered effectively in LMICs Note: HPV = human papillomavirus; MNP = micronutrient powder. 278 Child and Adolescent Health and Development and cost burden on poorer families and especially chal- nondiscriminatory, protective, inclusive, and gender lenging for interventions with multiple dosages, such as sensitive to promote the physical and psychosocial the human papillomavirus (HPV) vaccine, and for the health of children, teachers, and school staff school-age population; see chapter 15 in this volume • Pillar 2: Safe learning environment. Access to safe (LaMontagne and others 2017). The economic analysis water and provision of separate sanitation facilities of the effect of health interventions on improved educa- for girls, boys, and teachers; a safe, healthy, clean, tion attainment is discussed in chapter 22 in this volume and emotionally supportive environment that fosters (Plaut and others 2017). children’s ability to attend school, pay attention, and learn • Pillar 3: Skill-based health education. Life-skills edu- CONTEXT FRAMING AND POLICY cation that addresses health, nutrition, and hygiene FRAMEWORK issues with knowledge, attitudes, and skills to pro- Creating and refining an SHN program involves a series mote positive behaviors of policy decisions, especially how to work effectively • Pillar 4: School-based health and nutrition services. across sectors and how to select interventions to include. Simple, safe, and familiar health and nutrition ser- Fortunately, two policy tools track some of the decisions vices that can be delivered cost-effectively in schools, that countries made in developing their SHN programs. and increased access to youth-friendly clinics • The FRESH framework was introduced at the begin- All four of these components are necessary for a suc- ning of LMIC programming in this area and is still cessful program. They can be implemented effectively widely used. Its primary purpose was to provide a only if they are supported by strategic partnerships policy framework to support the start-up of new between (1) the health and education sectors, especially programs or the strengthening of existing programs. teachers and health workers; (2) schools and their • The Systems Approach for Better Education Results respective communities; and (3) pupils’ awareness (SABER) was introduced more than a decade later as and participation. Figure 20.12 provides an illustrative a mechanism for refining the policy environment of example of the mutually reinforcing nature of the four existing programs. The emergence of this tool reflects FRESH pillars. the need created by the remarkable proliferation of Governments that sought EFA outcomes also sought new school health and school feeding programs in to mainstream programs based on these pillars into LMICs. their national ESPs. Typically, ESPs reflect both expected budgetary and capacity needs, and are developed in consultation with key external and national stakehold- FRESH ers and partners. Analysis of the country ESPs provides The use of schools as a platform for delivering SHN insight into the relevance and prioritization of specific interventions was accelerated by the launch of the SHN issues by national governments. A comparison FRESH framework at the World Education Forum in between the content of ESPs that were developed 2000, by a multi-agency partnership that included immediately following the launch of FRESH and those UNESCO, UNICEF, the WHO, the World Food developed 15 years later provides an indication of how Programme, and the World Bank (Sarr and others SHN programs have been mainstreamed into education 2017). systems. Figure 20.13 illustrates the proportion of FRESH is a comprehensive, evidence-based frame- countries seeking financing for each of the four pillars work that promotes better education through health of FRESH at the two time points for a set of 25 coun- interventions delivered by schools and is supported by tries in Sub-Saharan Africa. Countries include Benin, an international consensus among partners and stake- Burkina Faso, Burundi, Cameroon, the Central African holders. The FRESH framework offers strategic guidance Republic, Chad, Eritrea, Ethiopia, The Gambia, Ghana, to ensure that program implementation is standardized Guinea, Guinea Bissau, Kenya, Liberia, Madagascar, and evidence based (World Bank 2012). It lays the foun- Mali, Mauritania, Mozambique, the Democratic dation for effective and equitable SHN programs and Republic of Congo, Rwanda, Senegal, Togo, Uganda, consists conceptually of four mutually reinforcing pillars Zambia, and Zimbabwe. (FRESH 2014): The share of ESPs seeking financing for policy pillar 1 is low at both times, reflecting the long-term nature of • Pillar 1: Health-related school policies. Health- the policy planning cycle and the typically fixed, and nutrition-related school policies that are nonrecurrent cost of implementing policy change. The School as a Platform for Addressing Health in Middle Childhood and Adolescence 279 Figure 20.12 FRESH Components Supported by the Strategic Partnerships Health center ls rra fe Re Me ssa ges Community contribution ty ss ibili A cce Source: © Partnership for Child Development. Used with the permission of Partnership for Child Development. Further permission required for reuse. Figure 20.13 Reflection of Funding Prioritized for FRESH Pillars in In contrast, infrastructure and service costs, reflected Education Sector Plans from 25 Countries in Sub-Saharan Africa, under pillars 2 and 4, respectively, have a substantial 2001–15 recurrent component, which is reflected in the large proportion of countries seeking financing for these 100 90 pillars at both times. Pillar 2 also reflects the focus on building new schools to support EFA, hence its Countries (percent) 80 70 inclusion in the ESPs for all countries in the earlier 60 50 period and to a lesser degree in the later period, perhaps 40 reflecting investment in additional water and sanitation 30 facilities and a new focus on menstrual hygiene manage- 20 10 ment. Pillar 3 in the 2000s in Sub-Saharan Africa was 0 focused on HIV/AIDS prevention education. In the Pillar 1: Health- Pillar 2: Safe Pillar 3: Skills- Pillar 4: School- early period, this intervention was given special empha- related school learning based health based health sis by the regional Accelerate initiative, in which policies environment education and nutrition services most countries participated. As the HIV/AIDS epi- FRESH pillars demic waned, financing for pillar 3 declined (Sarr and 2001 to 2007 2010 to 2015 others 2017). Perhaps the most important consequence of FRESH Source: Sarr and others 2017. has been to offer a common point of entry for new Note: FRESH = Focusing Resources on Effective School Health; UNESCO = United Nations Educational, Scientific and Cultural Organization. The dates for each period correspond to the date when the efforts to improve health in schools. This is important education sector plan (ESP) was published. ESPs set country priorities for the sector and typically because over time SHN programs can address issues reflect funding needs for 5 to 10 years. They are developed by governments in consultation with that both the education and health sectors are unfa- relevant stakeholders. ESPs from the earlier period were obtained from the UNESCO Planipolis portal, while ESPs from the later period were obtained from the Global Partnership for Education website. miliar with and that are intrinsically multisectoral. 280 Child and Adolescent Health and Development The FRESH framework remains a driver of new SHN Figure 20.14 Reflection of FRESH Pillars in School Health and programming and has provided a common platform Nutrition Practices in 16 Countries upon which to build agency-specific programs. Pillar 1 Chapter 17 in this volume (Graham and others 2017) National policy discusses how countries have used the FRESH frame- work to guide education that is inclusive for children Structure standards with disabilities. Handwashing standards Pillar 2 SABER Sanitation standards The degree to which SHN in practice is embedded in the Water standards education sector can be benchmarked with the SABER tool. The SABER tool was developed by a partnership led Participatory approaches Pillar 3 by the World Bank (2012) and was based on the FRESH framework. The tool consists of a structured question- SHN in curriculum naire whose responses are determined based on consul- tation with representatives from relevant ministries, Scale up of services Pillar 4 including Ministries of Education, Health, and Social Protection. One of the domains developed for SABER is Services implemented SHN programming, with a large subcomponent for 0 10 20 30 40 50 60 70 80 90 100 analysis of school feeding programs. Percentage of countries surveyed The SABER School Health and Nutrition and School Feeding diagnostic tools provide a snapshot of the Source: Sarr and others 2017. Note: FRESH = Focusing Resources on Effective School Health; SABER = Systems Approach for development status of their related policies in coun- Better Education Results; SHN = school health and nutrition. Indicators from SABER School Health tries. Specifically, SABER assists governments in assess- and Nutrition report from 16 countries conducted between 2011 and 2013. Countries comprise ing the quality of their SHN and school feeding Benin, Cape Verde, Côte d’Ivoire, Ethiopia, Ghana, Kenya, Madagascar, Malawi, Mali, Niger, Nigeria, Rwanda, Senegal, Tanzania, Uganda, and Zanzibar. programs and progress in implementing each indica- tor, and it benchmarks them against other programs and education domains. As such, SABER inspires and supports policy dialogue and reform, and lays the made—SABER helps identify common policy and insti- groundwork for a deeper analysis of the implementa- tutional threads that run through most of the more tion of these frameworks. The SABER School Health successful experiences, such as the following: and Nutrition and School Feeding rubric frameworks help ensure that when possible, schools can serve as • Focus on education outcomes entry points for health care for school-age children • Multisectoral policy and a memorandum of under- (World Bank 2012). standing between health and education sectors, Figure 20.14 presents findings from an analysis of backed by strong senior leadership from politicians select indicators from SABER SHN reports from 16 and senior officials LMICs published between 2011 and 2013, using the four • Information dissemination and consultation with pillars of FRESH as the guiding principle. local communities (World Bank 2012) The results indicate that 13 of the 16 countries have national SHN policies; more than 50 percent have water, sanitation, and handwashing standards in place; 12 of the 16 countries implementing SHN services had spe- Other School Health and Nutrition Policy Tools cific recurrent budget lines to support delivery. In addi- Other tools for policy making on SHN programs are tion, gender-responsive policies, skills, and services were available, in addition to FRESH and SABER. The School highlighted in SABER reports from 10 of the 16 Health Policies and Practices Survey, the Global School- countries. based Student Health Survey (GSHS), and the Health Approaches to school feeding and SHN, as well as Behavior in School-aged Children Survey (HBSC) are different routes to educational success, can be very three such tools. diverse. No single set of policy options will be relevant to The School Health Policies and Practices Survey was all countries. In developing national and subnational developed by the WHO in collaboration with the U.S. policies—and there are always trade-offs in the choices Centers for Disease Control and Prevention (WHO and The School as a Platform for Addressing Health in Middle Childhood and Adolescence 281 CDC, n.d.). The survey aims to assess the status of identify policy gaps and opportunities, improve imple- school health policies and practices in primary and sec- mentation, and scale up. HSBC and GSHS provide ondary schools. It is administered through a question- similar tools for guiding the school health policy deci- naire for school principals or head teachers. There are sions of the health sector. 150 questions divided into six content areas: general This approach is most effective if the health sector school information, healthy and safe school environ- retains responsibility for the health of children and the ment, health services, nutrition services, health educa- education sector retains responsibility for implementa- tion, and physical education. tion. By working together, Ministries of Education and The self-administered GSHS, similarly developed by Health can promote better health and education through the WHO and the U.S. CDC, is designed to help coun- multisector SHN interventions. tries measure and assess the behavioral risk and protec- tive factors among students ages 13–15 years. The data collected through the survey help set priorities, establish ACKNOWLEDGMENTS programs, advocate for resources, and allow for compar- ison across countries. It is a school-based questionnaire The author team would like to recognize Kwok-Cho survey, managed by a survey coordinator who is Tang, formerly with the World Health Organization, appointed through the Ministries of Health and and Meena Fernandes, Partnership for Child Education. Ten key topics covered include alcohol Development, for their important contributions to the use, dietary behaviors, drug use, hygiene, mental chapter. health, physical activity, protective factors, sexual behav- iors, tobacco use, and violence and unintended injury. To date, some 110 countries in all six WHO regions have NOTES either implemented the GSHS or are in the process of World Bank Income Classifications as of July 2014 are as fol- doing so (WHO 2016a). Of the 110 countries, only 3 are lows, based on estimates of gross national income (GNI) per in Europe. capita for 2013: The HBSC is the primary behavioral survey adminis- tered in the WHO European Region for this target pop- • Low-income countries (LICs) = US$1,045 or less ulation. HBSC collects data every four years on the • Middle-income countries (MICs) are subdivided: health and well-being, social environments, and health a) lower-middle-income = US$1,046 to US$4,125 b) upper-middle-income (UMICs) = US$4,126 to US$12,745 behaviors of boys and girls ages 11, 13, and 15 years • High-income countries (HICs) = US$12,746 or more. through self-administered questionnaires in classrooms. The key content areas covered by the GSHS and HBSC 1. When an intervention involves the provision of food, the surveys are similar, while the HBSC survey also includes term school feeding is used. The term includes at least two a focus on social and economic determinants. To date, 44 modalities: in-school feeding, where children are fed in countries and regions across Europe and North America school; and take-home rations, where families are given have been involved in the HBSC survey (WHO 2016b). food if their children attend school regularly. 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WHO and CDC (U.S. Centers for Disease Control and ———. 2016. “World Development Indicators.” Education Prevention). Not dated. “Global School Health Policies Statistics. World Bank, Washington, DC. http://databank and Practices Surveys: Survey Implementation Workshop.” . worldbank .org / data/reports .aspx?source=education WHO, Geneva, and CDC, Washington, DC. http://www -statistics-~-all-indicators. .searo.who.int/entity/noncommunicable _diseases/events World Food Programme. 2016. “School Meals.” World Food /global-shpps-survey-implementation-slides.pdf. Programme, Rome. https://www.wfp.org/school-meals. The School as a Platform for Addressing Health in Middle Childhood and Adolescence 285 Chapter 21 Platforms for Delivering Adolescent Health Actions Susan M. Sawyer, Nicola Reavley, Chris Bonell, and George C. Patton INTRODUCTION settings in which adolescents learn, participate, and Adolescent health has been gaining attention in the past engage. Actions to improve adolescent health are most decade (Levine and others 2008; UNICEF 2011; WHO effective when embedded in contemporary understand- 2014; World Bank 2007). As described by the Lancet ing of adolescent development and prevention science Commission on Adolescent Health and Wellbeing (Catalano and others 2012), which underscores the (Patton, Sawyer, and others 2016), the adolescent years importance of engaging with young people themselves are crucial for the development of human capital. as they become more active agents in their own lives During adolescence, neurocognitive and pubertal matu- (Patton, Sawyer, and others 2016). ration interact with the social determinants of health, Patterns of disease burden and health risk vary widely creating a highly dynamic profile of health as individuals between countries as they progress through the epidemi- pass from childhood through adolescence and into ological transition. As undernutrition, infectious and adulthood (Sawyer and others 2012). vaccine-preventable diseases, HIV/AIDS, and reproduc- During these years, the burden of disease rises, tive health needs are brought under control, the burden including the burden of human immunodeficiency of road traffic injuries, violence, chronic physical disor- virus/acquired immune deficiency syndrome (HIV/ ders, mental disorders, and substance use becomes more AIDS), mental disorders, and injuries. At the same prominent (Patton, Sawyer, and others 2016). Actions to time, new health risks emerge in response to biological improve health in adolescence need to include a wider maturation (sexual behaviors); marketing of unhealthy range of health concerns in addition to sexual and repro- products (tobacco; alcohol; foods high in sugar, salt, and ductive health, and they also need to extend beyond treat- fats); and community attitudes, traditions, and values ing disorders to addressing their root causes, including (female genital mutilation, lack of access to secondary poverty and homelessness, lack of education, disability, education, support for too early marriage, unsafe work minority sexual identity, indigenous status, and other practices). Due to the extent of neurocognitive matura- causes of social marginalization in adolescents. tion, increasing participation in education and changing Following a brief review of the developmental context social contexts, adolescence is also a time when inter- of adolescent health, this chapter categorizes countries ventions to improve adolescent health outcomes can according to their excess burden of disease and then expand beyond families or health services to the wider describes six platforms that can be used to deliver health Corresponding author: Susan M. Sawyer, Department of Paediatrics, the University of Melbourne, Parkville, Victoria, Australia; susan.sawyer@rch.org.au. 287 actions to adolescents (ages 10–19 years): health services, and teachers become important adult figures in addition schools, media and social marketing, community, mobile to parents and other family members. Social media health (m-health), and structural actions. The chapter becomes an important space for peer relationships, discusses the rationale of these platforms for delivering which also shape identity, health, and well-being. health treatments for established health issues, for Poverty and homelessness contribute to social mar- responding to emerging needs, and for preventing future ginalization and poor health at all ages, but pose addi- health problems. It also emphasizes the importance of tional risks in the context of adolescent development. matching actions to health needs, responding to differ- The biological amplification of sexual attraction during ences between and within countries, and aligning actions adolescence increases the risk of too early pregnancy and across platforms spanning different sectors, including sexually transmitted infections (STIs). For girls, too early health and education. pregnancy, whether within or outside of marriage, A key message relates to how knowledge of adoles- results in premature completion of education, which cent development promotes understanding of why dif- compromises their future employment and financial ferent platforms are needed to deliver actions for independence, with accompanying risks to their health adolescent health. While the term “action” is used inter- and that of their children. For persons who are lesbian, changeably with the term “intervention,” action is pre- gay, bisexual, or transgender, minority sexual status ferred when describing the need for multicomponent increases the risk of social marginalization, which makes interventions that require more than one platform and them vulnerable to violence and stigma. Health out- interventions that are more distal to the individual. The comes in adolescence (for example, HIV/AIDS, mental term “platform” is used to describe the mechanism or disorders, disability) can themselves be a risk for social infrastructure that is required to deliver actions or inter- exclusion and a source of inequality. ventions (health services, schools, laws). In reading the As a consequence of age and development, young text, it is important to remember that nearly all of the people lack life experience, have poor health literacy data and evidence come from studies of programs in (Manganello and others 2015), are sensitive to stigma high-income countries (HICs). We cannot say with any and shame, have a strong desire for confidentiality (Ford certainty the extent to which the results presented here and others 1997), have poorly developed organizational apply to low- and middle-income countries (LMICs). skills, and lack financial resources. They often depend on This limitation is a particular challenge in planning and their parents or caregivers to transport them to, consent selecting interventions for this age group and empha- to, and pay for health care. They can have difficulty sizes the need for much more research into the health understanding and regulating their emotional states, of adolescents in LMICs. Definitions of age groupings which affects their decision making. For example, they and age-specific terminology used in this volume can be may know how to prevent unplanned pregnancies and found in chapter 1 (Bundy, de Silva, and others 2017). STIs, but may not use such measures when they are in the midst of powerful emotions or “hot cognitions.” Young people tend to be less influenced than adults by THE DEVELOPMENTAL CONTEXT OF concerns about long-term risks, but are more vulnerable than adults to advertising and marketing of unhealthy ADOLESCENT HEALTH products that provide social status. All of these attributes During adolescence, neurodevelopment drives adoles- make young people vulnerable to unhealthy behaviors cents to engage with and challenge their social environ- and make it difficult for them to seek and access health ments and requires parents to balance their protective care and sustain healthy behaviors. role with one that enables adolescents to engage safely However, just as the developmental context of adoles- with their communities and the wider world. Beyond cence informs the pattern of health risks and outcomes family, the social context in which young people mature experienced at this time, it also creates opportunities for profoundly influences their health and well-being. At this improving future health and well-being. For example, time, adolescents become more sensitive to social stand- children who do not smoke during adolescence are ing and engagement with their peers (Crone and Dahl unlikely to smoke as adults. Thus, primary prevention 2012). Bullying and peer victimization become more (actions to keep adolescents from starting to smoke) is common in adolescence, increasing the feeling of social far better at improving health across the life course than exclusion and the odds of mental disorders, especially in secondary prevention (actions to encourage older adults girls (Bond and others 2007). Indeed, adolescents are to stop smoking), at less cost. at heightened risk for the onset of mental disorders. Some actions are universally applicable to a popula- Schools become the main context of peer relationships, tion but are adolescent-sensitive. For example, tobacco 288 Child and Adolescent Health and Development taxation is a universal action that is adolescent-sensitive, immunization clinics) or older adults (for example, pop- as adolescents are more sensitive to price than adults ulation approaches to HIV/AIDS prevention) do not (Jha and Peto 2014). Other actions are adolescent- gain the same traction in adolescents. Legal barriers may specific. For example, school-based actions to raise prevent unmarried girls from accessing contraception, awareness of the harmful effects of tobacco are financial barriers may make it difficult for adolescents to adolescent-specific because they only target students. pay for health care without the consent of their parent or Certain sexual and reproductive health laws are also spouse, and community immunization clinics may not adolescent-sensitive due to their disproportionate be convenient for adolescents at school. Adolescent- impact on adolescents. Thus, while access to legal abor- sensitive and adolescent-specific interventions are most tion is universally relevant for sexually active women, it effective when they build on a solid understanding of disproportionately affects adolescents due to their higher adolescent development, including how adolescents unmet need for contraception, the relative impact of engage with and pay for health care, and when they unplanned pregnancy on girls’ education, and their dis- empower adolescents to become active protagonists in proportionate use of unsafe abortion services (Woog their own lives. and others 2015). Other sexual and reproductive health laws are adolescent-specific (for example, laws that restrict the access of unmarried adolescents to contra- MATCHING HEALTH ACTIONS TO ception, laws about the age of legal majority, and the minimum legal age for sexual intercourse). HEALTH NEEDS With the exception of schools, platforms to deliver To begin to understand how needs change as countries adolescent health actions are universal platforms that can pass through the epidemiological transition, the Lancet be used to deliver adolescent-specific actions. For exam- Commission on Adolescent Health and Wellbeing ple, the universal platform of health services includes grouped 236 causes of disability-adjusted life years adolescent-specific components such as adolescent sexual (DALYs) and deaths into nine categories of disease and reproductive health clinics and school-based clinics. (Patton, Sawyer, and others 2016) and classified coun- Many actions and interventions that are effective tries into three broad categories according to their in younger children (for example, community-based excess burden of disease (figure 21.1). Within this Figure 21.1 Country Categorization Based on Adolescent Burden of Disease Diseases of poverty Injuries NCDs Infectious and vaccine preventable diseases Physical disorders Unintentional Undernutrition injuries Mental disorders HIV/AIDS Violence Substance use disorders Sexual and reproductive health Multiburden Injury excess NCD predominant Source: Reprinted from The Lancet 387 (10036): G. C. Patton, S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Afifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome; NCD = noncommunicable disease. Countries are categorized according to adolescent burden of disease (per 100,000 people), reflecting their passage through the epidemiological transition. Multiburden countries are defined as having 2,500 or more disability-adjusted life years (DALYs) per 100,000 population per year due to diseases of poverty. Injury-excess countries are defined as having 2,500 or more DALYs per 100,000 population per year due to injury and less than 2,500 due to diseases of poverty. NCD-predominant countries are defined as having less than 2,500 DALYs per 100,000 population due to injury and less than 2,500 due to diseases of poverty. Platforms for Delivering Adolescent Health Actions 289 Figure 21.2 Patterns of Disease Burden by Age and Gender (Ages 10–24) a. Males 20K DALYs per 100,000 population 15K 10K 5K 0K 10–14 15–19 20–24 10–14 15–19 20–24 10–14 15–19 20–24 NCD predominant Injury excess Multiburden Age (years) b. Females 20K DALYs per 100,000 population 15K 10K 5K 0K 10–14 15–19 20–24 10–14 15–19 20–24 10–14 15–19 20–24 NCD predominant Injury excess Multiburden Age (years) HIV/AIDS Infectious Sexual and reproductive health Nutrition Violence Injury Alcohol/drugs Mental disorders Chronic physical Source: Reprinted from The Lancet 387 (10036): G. C. Patton, S. M. Sawyer, J. S. Santelli, D. A. Ross, R. Afifi, and others, “Our Future: A Lancet Commission on Adolescent Health and Wellbeing,” 2423–78, © 2016, with permission from Elsevier. Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome; NCD = noncommunicable disease; DALY = disability-adjusted life year. 290 Child and Adolescent Health and Development framework, HIV/AIDS is in its own category because road traffic accidents (Patton, Sawyer, and others addressing this condition requires distinct health pol- 2016). Thus, in injury-excess countries, the platform icy and programmatic responses. The burden of sui- of structural actions provides the bedrock for cide is included within mental disorders. A more improved road safety (improved roads, traffic control, detailed description of this framework is provided in car safety, drunk-driving legislation, reductions in the chapter 5 in this volume (Patton, Azzopardi, and others speed limit) that will disproportionately benefit ado- 2017). Because it is based on DALYs, this framework lescents (WHO 2013). Another example is mental does not consider behaviors that, while commencing health. Across the life course, adolescence is the time in adolescence, do not influence health until some of greatest incidence of mental disorders, especially in years later (for example, tobacco use). girls (Kessler and others 2005). Social marginaliza- Multiburden countries have a high burden of tion, poor school connectedness in early secondary all nine health conditions, including diseases of pov- school, and school-based bullying and victimization erty (HIV/AIDS and other infectious and vaccine- increase the likelihood of common mental disorders preventable diseases, undernutrition, and poor sexual such as depression and anxiety (Bond and others and reproductive health, including high maternal 2007). These conditions also confer risks for health mortality), injuries and violence, and noncommunica- problems such as substance use (Bond and others ble diseases (NCDs). These countries also have high 2007) and wider developmental outcomes such as adolescent fertility. Injury-excess countries have a high early school leaving (Stein and Kean 2000). Not only burden of unintentional injuries and violence and a are preventive actions required to address upstream high rate of adolescent fertility, together with NCDs. social determinants, but these interventions also have NCD-predominant countries have a high burden of multiplier effects due to their influence on more than chronic physical, mental (including suicide), and sub- one outcome (Catalano and others 2012). stance use disorders. Marked variation is also seen within countries, reflecting, among other factors, inequities in the social SIGNIFICANCE OF CHANGING PATTERNS OF determinants of health and access to preventive inter- HEALTH FOR DELIVERY PLATFORMS ventions, education, and health services. The extent of variation in the profile of adolescent A country’s pattern of disease burden has implications health and health risks between countries (Gore and for the priority given to different health actions and use others 2011; Mokdad and others 2016; Patton and oth- of health platforms. ers 2009; Patton, Sawyer, and others 2016) reinforces the opportunities and scope for preventive actions and indicates priority targets. For example, in multiburden Multiburden Countries countries, health actions need to target the diseases of In multiburden countries, the priority is to reduce the poverty, while avoiding further rises in injuries, vio- excess burden from infectious disease, undernutrition, lence, and NCDs. In these countries, addressing the and sexual and reproductive health, including HIV/ unmet need for contraception should be a priority. AIDS. Health services need to have the human capacity Injury-excess countries need to prioritize actions that and resources to treat acute and chronic infectious dis- address their high rates of injury and violence as well eases in adolescents. They also have to manage adoles- as high birth rates among adolescents. NCD- cent pregnancies and respond to high unmet needs predominant countries need to prioritize actions that regarding contraception for adolescent girls, both mar- address the impact of chronic mental health condi- ried and unmarried. tions, substance use disorders, and chronic physical Efforts to promote continued education, especially conditions, including obesity. for girls, are important, as longer participation in It is important to understand how the burden of schooling reduces the burden of infectious diseases in disease increases with age and varies by gender across adolescents (Ngimuh and others 2016) and the risk for the life course and during adolescence (figure 21.2), as too early pregnancy in the context of marriage. To this this has implications for health platforms. For exam- end, the excess burden from infectious diseases requires ple, boys and girls are more vulnerable road users structural actions to guarantee fresh water and sanita- than adults due to their pattern of road use as pedes- tion, including clean toilets, at schools. Actions are also trians, cyclists, and motorcyclists (Peden and others needed to guarantee the physical and emotional safety 2004). Boys are more likely to die from unintentional of students while at school and en route. Schools pro- injury and violence than girls, much of it related to vide opportunities to deliver important preventive Platforms for Delivering Adolescent Health Actions 291 actions regarding sexual and reproductive health, such marketing platforms can each be used to change social as comprehensive sexuality education, and better norms regarding too-early pregnancy and the role of growth through improved nutrition from school meals. contraception. Greater participation in secondary education also expands the opportunities to deliver health services directly through schools, including clinical interven- NCD-Predominant Countries tions such as vaccination, antiworming, and iron and In NCD-predominant countries, health services need to folate supplementation. prioritize interventions for chronic physical conditions, Beyond schools, social media and community plat- mental disorders, and substance abuse disorders. forms can also be used to promote knowledge of and Enabling clinicians, including nurses, to identify and access to preventive resources for sexual and reproduc- manage common mental disorders requires shifting the tive health (modern contraception), infectious diseases focus of medical education and reorienting health ser- (insecticide treated bednets), HIV/AIDS (circumcision), vices toward NCDs. Most health services require greater and healthy growth and nutrition (nutritional supple- clinical capacity to respond to mental health conditions. ments). Opportunities exist to use media and social In addition to human capacity, opportunities exist for marketing to explicitly target adolescents in health inter- mobile health, with m-health applications offering ventions that increase health literacy, which contributes opportunities for well-being (for example, mindfulness to adolescent health. apps) and treatment (for example, cognitive behavioral Cash transfers to promote vaccination, school therapy apps, and crisis-support telephone and text attendance, and HIV/AIDS-free status are also possible. services). Chapter 18 in this volume (Reavley and others 2017) Schools in NCD-predominant countries can promote provides evidence underpinning the strength of evidence physical activity. Schools, communities, and social media for actions in this area. can also help to change social norms regarding tobacco, Given the many barriers that adolescents face access- alcohol, and other drug use, body image, and the stigma ing health services, multiburden countries need to focus of mental disorders. on guaranteeing universal health coverage. Countries Most NCD-predominant countries have implemented that currently provide free health care to children under laws that have greatly reduced adolescents’ access to five should consider extending it to adolescents. tobacco. Less progress has been made in introducing legislation to reduce adolescents’ access to alcohol. As with structural actions to curb substance use among Injury-Excess Countries adolescents, there is precedence to use taxation of food In injury-excess countries, health services need to and beverages with added salt, sugar, or fats, given early develop accessible trauma services in addition to pri- evidence of effect (Colchero and others 2016). mary care. Actions across the structural platform need to include legislation regarding driving under the influence of alcohol, graduated driver’s licenses, and mandatory PLATFORMS TO DELIVER ACTIONS use of motorbike helmets. Schools, communities, media, and social marketing can support these actions by deliv- FOR HEALTH ering messages that seek to change social norms, as have The health care system is the sum of the people, institu- been progressively implemented in many HICs (Sauber- tions, and resources that maintain and improve the Schatz and others 2016). health of the people they serve (WHO 2007). Health To address high adolescent birth rates, schools services are just one of the platforms that can deliver should provide comprehensive sexuality education to actions and interventions for adolescent health. Indeed, all adolescents and, ideally, link education to the pro- major actions for adolescent health occur outside health vision of contraception. Health services need to be services, suggesting that an integrated system of delivery able to make contraception legally available to adoles- platforms would improve the response to conspicuous cents. In some countries, this will require legislation. and emerging health needs and efforts to prevent other Other structural actions relate to laws enabling health issues from developing. clinicians to provide legal abortions and cash transfers The Lancet Commission on Adolescent Health and promoting school attendance and discouraging preg- Wellbeing (Patton, Sawyer, and others 2016) described nancy in childhood. Once again, aligning actions the opportunities for health actions delivered across across sectors is important; schools, media, and social six platforms: health services, schools, communities, 292 Child and Adolescent Health and Development m-health, media and social marketing, and structural with adolescents (WHO 2015a), summarized in actions. These platforms are not mutually exclusive. For figure 21.3. Adolescents in high-, middle-, and low- example, direct clinical care is delivered mostly by tradi- income countries alike value patient- and family- tional health services such as community clinics and centered care with an emphasis on respect, quality hospitals. However, direct clinical care can also be deliv- communication including confidentiality, appropriate ered via school-based clinics and mobile clinics that visit provision of information, involvement in decisions schools and workplaces. M-health approaches can also about their care, and coordination of care (Ambresin deliver direct clinical care, as an adjunct to clinical care, and others 2013). Routine psychosocial assessment, and for a wide variety of educational and health- such as the HEADSS (home, education, activities/ promoting activities. employment, drugs, suicidality, sex) approach These platforms are interdependent. For example, the (Goldenring and Rosen 2004), has been shown to ability of clinicians to prescribe contraception to unmar- improve the identification of emerging risks (Sanci and ried girls depends on a nation’s legal framework, reli- others 2000; Sanci and others 2015) and to provide a gious dictates, and community expectations. And, as context for anticipatory guidance and preventive inter- described in chapter 18 in this volume (Reavley and ventions. Adolescents desire privacy and confidential- others 2017), health benefits occur in the context of mul- ity regarding their health care. They are quick to feel ticomponent actions. Thus, for any single area of health embarrassment and shame and are often afraid of need, aligning actions across different platforms will being judged, all of which are barriers to seeking health bring added benefits. care. Health care for adolescents often takes place in the context of families, including parents or extended family members, other caregivers and guardians, or Health Services partners. A unique feature for adolescents is concern Health services manage adolescents’ conspicuous that their parents and families will be informed about health needs, identify and respond to emerging health sensitive issues such as sexual behaviors, substance use, issues (for example, contraception for new-onset sex- and mental disorders (Ford and others 1997). Not only ual activity or interventions to address suicidal ide- do health care providers need to be nonjudgmental, ation), and deliver preventive interventions that reduce willing to maintain confidentiality, and able to engage the likelihood of the onset of a particular health risk with adolescents and young adults, but they also need (for example, obesity). This requires access to primary to do this while remaining appropriately engaged with care, specialist, and hospital services. Until recently, families. Health care providers need to understand the there has been little focus on health services for ado- legal and ethical challenges of providing health care to lescents or what is needed to guarantee universal legal minors while delivering health care that is consis- health coverage for this age group. Such a focus is tent with the United Nations Convention on the Rights predicated on a robust knowledge of adolescent devel- of the Child, which requires young people to become opment, as this influences how adolescents engage increasingly involved in their health care as they with health services and the particular barriers they mature (United Nations General Assembly 1989). experience. More than a decade ago, the World Health Organization Barriers to access reside within the health care system, developed a framework for delivering quality primary within health care providers, within families and com- health care to adolescents. The framework emphasized munities, and within adolescents themselves. The major the importance of adolescent- or youth-friendly health health system barriers—lack of geographically accessible care that has equity of access; is effective, accessible, and services and lack of clinicians—are not unique to adoles- acceptable to young people; and is appropriate to their cent health care. In contrast, the direct and indirect costs needs (WHO 2002). The principles of what is increas- of health care are significant barriers for adolescents ingly referred to as adolescent-responsive health care who, for developmental reasons, do not place the same apply to all levels (clinic, hospital) and all types (mental value on current or future health as older adults. Most health) of health services (Sawyer, Proimos, and Towns adolescents rely on family for transportation and pay- 2010). More recently, the World Health Organization ment of health care, making free health care particularly developed policy guidelines for delivering quality valuable for them. health care to adolescents from the perspective of both Regardless of country grouping, health services and individual providers (WHO 2015a) and health services clinicians need to have the same competencies (atti- (WHO 2015b). Governments in LMICs are using these tudes, knowledge, skills) if they are to work effectively guidelines to improve the quality of health care they Platforms for Delivering Adolescent Health Actions 293 Figure 21.3 Domains That Require Special Attention in Health Consultations with Adolescents Uses developmentally Integrates treatment of the appropriate language presenting complaint with Builds rapport, promotes broader assessment engagement and empowerment Provides confidential time alone Contextualizes health care to Communication Structure of the with the adolescent normalize confidential assessment style consultation Undertakes psychosocial of health-related assessment behaviors Assesses capacity for Involves the adolescent in autonomous decision decision making making Parent or guardian Policies and involvement in procedures the process of care Ensures privacy Supports adolescents’ rights to Supports parent (or confidential health care guardian) involvement as Promotes adolescent assent and appropriate consent Builds parent (or guardian) Reduces financial burden of health understanding of care on adolescents appropriate health consultations with Links to community services and adolescents agencies Source: © Springer. Used with the permission of Springer. Further permission required for reuse. provide to adolescents, with some evidence of benefit although hospital services are inconsistently colocated. (Chandra-Mouli, Chatterjee, and Bose 2016). The age criteria for adolescent mental health services In HICs, there has been a move toward large primary also vary by country. care clinics that include doctors, nurses, and allied health Specialist adolescent medicine first emerged in the staff. In LMICs, there is growing interest in using non- United States more than 50 years ago. An increasing physician clinicians to supplement health personnel number of countries now support specialist train- (Mullen and Frehywot 2007). This model is suitable for ing (Argentina, Canada), while other countries have providing a range of resources, including nurses who embedded adolescent health competencies within may have fewer communication barriers with adoles- generalist pediatric, family medicine, and obstetric cents than doctors (AlBuhairan and Olsson 2014). and gynecology specialties. Specialist pediatric ser- Historically, specialist pediatric services ceased vices should be linked with adult services to prevent around the time of puberty, resulting in adolescents adolescents from dropping out of health care at key from the age of 12–13 years being managed by adult transitions, such as when specialist services end. In providers in adult settings. Extending specialist pedi- HICs, the risk of dropping out of care or poor engage- atric services to a higher upper age is more consistent ment with adult services is best appreciated for chronic with adolescent development. In many HICs, the prac- physical health conditions. In LMICs, the issue has tice of pediatrics now extends up to age 19 years. arisen especially in the context of HIV/AIDS (Lee and This practice is starting in LMICs. For example, the others 2015). Indian Academy of Pediatrics raised the upper age of Table 21.1 summarizes the effective and promising pediatrics to 19 in 1999. However, adolescents requir- actions that can be delivered by health services, catego- ing inpatient care in Saudia Arabia continue to be rized by health group. Interventions were deemed to be nursed with adults from the age of 14 years (AlBuhairan effective when at least 50 percent of review studies and Olsson 2014). reported positive outcomes. Interventions with some Specialist mental health services are usually separate positive evidence not reaching this threshold were from specialist pediatric and other health services, deemed as promising and in need of further research. 294 Child and Adolescent Health and Development Table 21.1 Effective and Promising Health Service Actions and Adolescent Health Health condition Action Sexual and reproductive health, including HIV/AIDS • Condoms and affordable modern contraception, including long-acting reversible contraception • Early diagnosis and treatment of HIV/AIDS and sexually transmitted infections • Male circumcision • Antenatal, delivery, and postnatal care • Transition to adult care for HIV/AIDS Undernutrition • Screening and micronutrient supplementation Vaccine-preventable and infectious diseases • Early identification and treatment • Adolescent vaccinations (human papillomavirus, childhood catch-up) • Deworming • Bednet distribution • Seasonal malaria chemoprevention Injury and violence • Trauma care, including first responders (ambulances) Tobacco, alcohol, and illicit drugs • Risk screening • Motivational interviewing to promote cessation Mental disorders, including suicide • Management of condition • Practitioner training in recognizing and treating depression • Routine assessment of mental health, including suicide risk Chronic physical disorders • Management of condition • Promotion of self-management • Promotion of transition to adult health care Obesity • Management of comorbidities Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. Actions in italics are promising but lack a strong evidence base in adolescents and young adults. Training to improve clinician competency is needed on universal primary education, and primary school in all areas. It is especially important for recognizing and enrollment has expanded rapidly in LMICs (IHME treating depression. 2015); between 2000 and 2012, the number of out-of- school children of primary school age fell 42 percent (UNESCO 2015). In 2015, at least lower-secondary edu- Schools cation (8–10 years of education) was the norm in 34 Schools offer three distinct benefits for adolescent percent of countries for young men and in 18 percent of health (chapter 20 in this volume, Bundy, Schultz, and countries for young women. Upper-secondary or beyond others 2017). First, participation in education is ben- (10+ years of education) was the norm in 44 percent of eficial for an individual’s current and future health countries for young men and 56 percent of countries for and well-being. Second, schools provide a setting for young women (IHME 2015). delivering preventive actions. Third, schools provide Participation in secondary education has significant a setting for managing emerging and conspicuous potential to improve adolescent health, yet the health health problems. benefits of secondary education for adolescents have Education is a powerful determinant of adolescent been poorly studied in LMICs. In HICs, there may be a health and human capital as well as a driver of socioeco- threshold effect of upper-secondary education for nomic progress (Cutler and Lleras-Muney 2012; Plaut self-reported health, mental health, and alcohol use, with and others 2017, chapter 22 in this volume). The little additional benefit from tertiary education Millennium Development Goals have focused attention (Miyamoto and Chevalier 2010). In countries with high Platforms for Delivering Adolescent Health Actions 295 participation in secondary education, using schools to Greater participation in secondary education is promote health explicitly can bring benefits above and associated with reductions in all-cause injury and beyond the health benefits of educational participation mortality for ages 15–19, adolescent fertility, and alone. maternal mortality (Patton, Sawyer, and others 2016). The benefits of expanding secondary education for The quality of the school environment, or school health and well-being accrue through various mecha- ethos, also has a profound influence on health (Villa- nisms, including healthier behaviors, greater cognitive Torres and Svanemyr 2015). A school’s ethos reflects capacity, and longer productive lives (NRC and IOM many factors, including the school’s management and 2005). While most attention has focused on direct health organization, social and physical environment (includ- actions that can be delivered through schools, such as ing physical and emotional safety, clean toilets, and comprehensive sexuality education or school-based adequate sanitation), quality of teaching, perceived health services, indirect actions are just as, if not more, fairness of discipline, availability of pastoral care, powerful (figure 21.4). access to health services, whole-of-school health pro- motion, and access to extracurricular activities, such as sports, art, and music. Figure 21.4 Indirect and Direct Actions for Health That Can Be As summarized in table 21.2, the most effective Delivered in Schools actions delivered through schools are multicomponent interventions that involve whole-school activities, Indirect actions for health Direct actions for health changes in the school’s policies, curriculum, and social School attendance Access to health promotion (for example, and physical environment, together with family and comprehensive sexuality education) community engagement (Bonell and others 2013; School ethos Access to health services Fletcher, Bonell, and Hargreaves 2008). These types of actions show consistently positive outcomes for Table 21.2 Effective and Promising School-Based Actions and Adolescent Health Health condition Action Sexual and reproductive health, including • Quality secondary education HIV/AIDS • Comprehensive sexuality education • Safe schools with clean toilets and facilities for menstrual care • School-based health services with condoms and modern contraceptives • Peer-led interventions Undernutrition • Micronutrient supplements • Healthy school meals Vaccine-preventable and infectious diseases • Human papillomavirus vaccination • Deworming Injury and violence • Multicomponent interventions targeting violent behavior and substance use Tobacco, alcohol, and illicit drugs • Alcohol-free policies • Smoke-free policies • Multicomponent Mental disorders, including suicide • Educational interventions • Gatekeeper training • School-based mental health services Chronic physical disorders • School-based health services Obesity • Multicomponent interventions involving education about healthy diet and increasing opportunities for physical education Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. Actions in italics are promising but lack a strong evidence base in adolescents and young adults. 296 Child and Adolescent Health and Development adolescent sexual health, violence, and tobacco smoking child marriage and actions to engage communities and and may also be beneficial for other health risks enable them to appreciate the benefits of schooling, (Shackleton and others 2016). especially for girls. Providing comprehensive sexuality education through schools, especially when coupled with the pro- vision of contraception and condoms, is increasingly Community efficient as a site of health promotion as more girls par- Young people are deeply embedded in their communi- ticipate in secondary education (Blank and others 2010; ties and are affected by the behavior, norms, and values Blank and others 2012; Chin and others 2012). of adults, as well as other adolescents. Communities can Comprehensive sexuality education has been shown to influence adolescent health in various ways. They can do be effective in LMICs as well as HICs. Abstinence-only so directly, by reducing access to harmful substances, education has not been found to prevent HIV/AIDS, preventing violence, or providing safe environments, other STIs, or adolescent pregnancy (Chin and others including transportation to and from school. They can 2012; DiCenso and others 2002). also do so indirectly by encouraging healthy behaviors Most interventions to increase access to and reten- through community attitudes and norms. Communities tion in education have targeted younger adolescents, provide formal and informal opportunities for young largely in primary schools. Scholarships, school fee people to engage, participate, and learn, which are bene- reductions, cash transfers conditional on remaining in ficial for adolescent health and well-being. Beyond these school, efforts to reduce grade repetition, school prox- roles, communities are also places to deliver preventive imity, and mother tongue education are cost-effective actions and treatment services. actions (Glewwe and Kremer 2006; UNESCO 2015). In Community-based youth-focused activities (sports, some circumstances, providing free school uniforms, mentorship, leadership activities) can have multiple ben- abolishing school fees, and offering deworming pro- efits. Positive youth development programs seek to pro- grams are among the most cost-effective interventions mote self-confidence and empowerment, social and (chapter 29 in this volume, Ahuja and others 2017), emotional skills, and problem solving. Using a variety of while in others providing school meals for students and strategies (theater, music, and the arts; sports and out- financial support for parent-teacher associations is less door education; leadership training and mentorship), cost-effective (chapter 12 in this volume, Drake and these programs also provide opportunities to address others 2017; chapter 22 in this volume, Plaut and others and challenge harmful attitudes toward gender, violence, 2017). Building schools close to students has high up- mental health, and disability. Some of these benefits can front costs, but is considered cost-effective, as one accrue through informal community programs. For school can serve children for many years (UNESCO example, the promotion of sports for girls can improve 2015). Addressing gender disparities in access and tar- physical fitness, challenge harmful gender norms, and geting more resources to the poorest regions and to empower girls (Shaw and others 2014). However, it can disadvantaged students (notably children affected by be challenging to promote access for the most disadvan- armed conflict, children whose home language is not taged adolescents who have the most to gain from these used at school, and children with disabilities) are criti- programs. cal to closing equity gaps (UNESCO and UNICEF Health services can also be delivered in community 2015). Also needed are informal and flexible approaches settings, distinct from primary care clinics. Community- to reaching children outside of mainstream education, based health care workers are likely to be most effective such as child laborers and married adolescents who in places with low levels of trained health workers and have left school (Yasunaga 2014). few formal health clinics. Unlike the large workforce Many forces operate to exclude or divert adoles- trained to offer community-based maternal and child cents from secondary education. Prominent among health services, in most countries, no equivalent work- these are the costs of education and the opportunity force is trained to address adolescents’ particular health costs to families of the loss of adolescent labor, espe- needs. Adolescents, especially girls who are not in cially in rural areas. In many LMICs, poor adolescents school, can access community-based sexual and repro- are less likely to attend secondary school (UNESCO ductive health education. While this will be of bene- 2015). Early marriage accounts for higher dropout fit, the extent to which community-based sexuality rates among girls in many LMICs (chapter 28 in education meets their needs and how well it compares this volume, Verguet and others 2017). Hence actions to school-based comprehensive sexuality education is to promote continued education in secondary educa- not known. Poor quality is a likely challenge in both tion need to be supported by legislation that prevents contexts. Ethiopia (Health Extension Worker Program), Platforms for Delivering Adolescent Health Actions 297 India (Accredited Social Health Activist Program), and communities who are particularly concerned about Pakistan (Lady Health Worker Program) have estab- confidentiality. lished community-based health worker programs in an Few programs have been well evaluated or taken to effort to overcome critical deficiencies in human scale. The best examples of community platforms have resources; if targeted to adolescents and supported by generally incorporated elements that build on available training, these programs could offer important benefits community structures, use good information on health to adolescents, especially girls (Bhutta and others 2010; needs and risks, adopt a multicomponent strategy, and Liu and others 2011). monitor progress (table 21.3). For example, the In socially and geographically disadvantaged areas, Communities That Care framework, which has been mobile clinics that visit different communities may also piloted in several U.S. sites, has been found to have clear provide health services to adolescents. Mobile clinics benefits for health outcomes such as substance use and that are located close to secondary schools, staffed by violence and to be cost-effective (Catalano and others clinicians who have been trained to work with adoles- 2012). cents, and adequately resourced (especially with contra- Community-based interactions have particular ception) could provide services efficiently to smaller opportunities to benefit adolescents who are out of populations. The relative anonymity of mobile health school or from marginalized groups. This platform is workers may be advantageous for adolescents from small particularly relevant in LMIC areas with the lowest Table 21.3 Effective and Promising Community Actions and Adolescent Health Health condition Action Sexual and reproductive health, including • Cash transfer programs, with payments tied to staying in school HIV/AIDS • Positive youth development • Peer education Undernutrition • Micronutrient supplements (particularly in pregnancy) • Protein-energy supplementation • Deworming • Cash transfer programs • Nutrition education Vaccine-preventable and infectious diseases • Deworming • Bednet distribution Injury and violence • Promotion of parental skills and parent-child communication • Positive youth development • Promotion of gender equality • Economic empowerment • Group training for awareness, knowledge, and skills • Police enforcement of traffic injury control Tobacco, alcohol, and illicit drugs • Promotion of parent-child communication and parenting skills • Needle-syringe exchange access • Mentoring • Interventions to promote parental skills and parent-child communication Mental disorders, including suicide • Gatekeeper training Chronic physical disorders • Peer support initiatives Obesity • Opportunities for maintaining physical activity in daily life Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. Actions in italics are promising but lack a strong evidence base in adolescents and young adults. 298 Child and Adolescent Health and Development enrollment in secondary education. However, these areas The same benefits pertain to health services them- also have the least access to community programs. The selves, especially in remote regions, where m-health is more that adolescents participate in quality upper- used to report the quality of medical investigations (for secondary education, the less need there is for parallel example, medical imaging, electrocardiograms). Benefits community-based interactions. are similarly available for training remotely based pro- fessionals, where interactive Webinars and more exten- sive online courses (for example, massive open online Mobile Health courses) are now common aspects of professional devel- Young people are the earliest adopters of information opment in many parts of the world. and communication technologies such as mobile phones, These new tools provide a platform for delivering the Internet, instant messaging, and social networking. health services to all populations. Adolescents may be Rapid uptake of these technologies, even in the most more comfortable accessing m-health services than older remote communities, means that online interventions adults, especially if confidentiality can be assured. For have the potential to be a powerful platform for adoles- example, mobile apps could be used to offer treatment for cent health. These technologies offer a strategy for deliv- conditions such as mental disorders, where stigma func- ering health care, preventive interventions, and education tions as a barrier to accessing treatment. Such interven- and health information. Digital media have the potential tions would offer particular benefits for adolescents living to reach diverse groups, including geographically and in countries without an effective mental health workforce. socially marginalized adolescents, while low costs offer However, adolescents will need adult supervision of their the potential to sustain interventions over long periods engagement with m-health services, at least initially. (Puccio and others 2006). Ready access to free, health-related information and Using m-health approaches, adolescents can directly interactive games is a particular feature of new media engage with clinicians from a distance (for example, by (for example, PlayForward). While relevant for all telehealth). Other direct clinical approaches include cog- adolescent health issues, the benefits are likely to be nitive behavior therapy or texting with trained counselors greater for more sensitive and stigmatized topics that (for example, Crisis Text Line) and online prescription might not otherwise be raised with peers, family, or and payment of medication. During consultations, clini- community-based professionals, such as sexuality, abuse, cians can access online diagrams, videos, or other materi- interpersonal violence, and mental health. Web access is als that are likely to educate adolescents more powerfully likely to be most important for adolescents whose cul- than traditional means. In time, virtual reality games are tures or religions are most controlling of their access to likely to be used to deliver health education and promote information, including comprehensive sexuality educa- adolescent health literacy. As adjuncts to clinical care, cli- tion (Latifnejad Roudsari and others 2013). Some web- nicians can recommend mindfulness or adherence apps sites in the United States focus sensitively on adolescent for adolescents to use following consultations. M-health sexual and reproductive health (sexetc.org, bedsider approaches can promote efficiency during consultations .org). As with all health actions, engaging young people by facilitating clinically required information before the in the development of m-health resources would help to consultation (for example, online psychosocial assess- ensure that this approach meets their needs. ment). After consultations, m-health can provide oppor- At this stage, notwithstanding the enthusiasm for tunities to improve quality or evaluate services, such as m-health actions, current evidence of effectiveness is using text feedback to assess patient-reported experiences very limited regarding the longer-term benefits for of care or patient-reported outcomes, and to monitor health. This means that only promising, rather than outbreaks of disease (for example, UNICEF’s U-Report). effective, interventions are shown in table 21.4. Table 21.4 Promising Mobile Health Actions and Adolescent Health Health condition Action Sexual and reproductive health, including HIV/AIDS • Targeting of knowledge, attitudes, and risk behaviors Tobacco, alcohol, and illicit drugs • Targeting of knowledge, attitudes, and risk behaviors • Text messaging to encourage quitting Obesity • Interactive and personalized feedback Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. Actions in italics are promising but lack a strong evidence base in adolescents and young adults. Platforms for Delivering Adolescent Health Actions 299 Once evidence has been gained, a particular chal- Media and Social Marketing lenge will be finding ways to bring effective interven- Media and social marketing have the potential to target tions to the attention of young people and those who the health-related attitudes and values of adolescents as work with them, including families, teachers, and health well as those of their families and the broader commu- professionals. nity. While previously considered distinct, the line Reflecting their neurodevelopment and life experi- between mass media and social marketing is increasingly ences, younger adolescents are less adept at judging the blurred. Both can be used to shape community and reliability and accuracy of online information, which adolescent attitudes, which is one component of setting may render them vulnerable to extreme views (Coiro expectations that support the implementation of other and others 2015). actions, whatever the platform. The reach of platforms for m-health has greatly Media include traditional approaches (radio, televi- expanded (ITU 2015). For example, in Bangladesh, sion, newspapers) as well as social and mass media. more than 70 percent of women of reproductive age Social media and marketing have greater capacity than have access to a mobile phone within the household traditional media to target actions according to adoles- (Labrique and others 2012). So, while access to the cents’ interests. Actions range from the provision of Internet is still challenging in many parts of the world, health information, including embedding health mes- it is changing rapidly, even in remote parts of Sub- sages within traditional media, as well as more focused Saharan Africa: strategies targeting behavior change. Partnerships with civil society and media professionals are powerful in • By the end of 2015, there were more than 7 billion exploiting the potential of these platforms. Here again, mobile cellular subscriptions, corresponding to a partnerships with young people themselves are an penetration rate of 97 percent, up from 738 million important aspect of meaningful and influential social in 2000. marketing that targets young people. One example is • Between 2000 and 2015, global Internet penetration Youth for Road Safety (YOURS), a global youth-led grew sevenfold from 6.5 to 43.0 percent. organization and a member of the UN Road Safety • Mobile broadband penetration reached 47 percent in Collaboration. Beyond social media, YOURS uses youth 2015, a twelvefold increase since 2007. ambassadors to empower young people to develop • The proportion of houses with Internet access at evidence-based road safety actions that make sense to home increased from 18 percent in 2005 to 46 percent them. Schools and communities could facilitate access to in 2015. this platform, creating opportunities to leverage and integrate resources for wider learning. However, there is still global inequality of access: The strongest evidence of effect pertains to advertis- ing restrictions and multimedia campaigns to reduce • Two-thirds of people from LMICs remained offline tobacco use (table 21.5). These efforts are most effective in 2015. when linked with structural interventions (taxation and • Only 9.5 percent of people in the poorest countries legislation to reduce access). As with m-health, there is currently use the Internet. remarkably little evidence of health benefits for specific Table 21.5 Effective and Promising Media and Social Marketing Actions and Adolescent Health Health condition Action Sexual and reproductive health, including HIV/AIDS • Promotion of community support for sexual and reproductive health and HIV/AIDS health access for adolescents Injury and violence • Promotion of knowledge of the effects of violence and available services • Promotion of knowledge of risks Tobacco, alcohol, and illicit drugs • Advertising restrictions • Campaigns to build community awareness Mental disorders, including suicide • Promotion of adolescent mental health literacy Obesity • Promotion of physical activity Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. Actions in italics are promising but lack a strong evidence base in adolescents and young adults. 300 Child and Adolescent Health and Development social media interventions. However, the benefits of Internet advertising and Internet gambling (Patton, using social media to change attitudes and behaviors Sawyer, and others 2016; Sawyer and others 2012). related to the purchase of commercial products suggests Knowledge of adolescent neurodevelopment pro- that, in time, these approaches will be able to change vides a framework for thinking about how adolescents health-related behaviors, especially in the young. require both protective and empowering structural actions. Most laws have developed historically without attention to adolescent development. More rational legal Structural Actions frameworks would take greater account of adolescents’ Legislation, taxation, and implementation of policies evolving cognitive and emotional capacities. With access are essential structural actions to improve adolescent to knowledge, adolescents demonstrate similar or even health. Indeed, for many health risks, such as tobacco and greater cognitive capacity than adults to make good alcohol, road traffic injuries, violence, unsafe work, judgments in calm and emotionally neutral situations. and obesity, structural actions are the most effective inter- However, emotions are more likely to drive their deci- ventions for adolescent health (table 21.6). In addition to sion making in emotionally charged situations of stress protecting adolescents from hazards, laws are equally or excitement, especially with peers. In addition to pro- important in guaranteeing that adolescents have access to tecting adolescents from harm, legal frameworks should resources for health, such as effective contraception. Other ensure age-appropriate autonomy, freedoms, and rights laws function to address social determinants, such as age (United Nations General Assembly 1989). Most adoles- of marriage, legal driving age, legal working age, and pro- cents are capable of voting at age 16, and doing so both tection from hazards. International agreements are also empowers adolescents and promotes civic engagement. important for tackling transnational influences such as This is an example where there are few risks but many Table 21.6 Effective and Promising Structural Actions and Adolescent Health Health condition Action Sexual and reproductive health, including • Legislation making 18 years the minimum age of marriage HIV/AIDS • Legislation legalizing the provision of contraception to minors • Legislation legalizing abortion Undernutrition • Fortification of foods with nutrients such as iron and folate Injury and violence • Gun control legislation • Legislation legalizing homosexuality and using legislation to protect women from violence and sexual coercion • Youth justice reform to promote second chances and diversions from custody • Legislation making 16 the minimum age for criminal responsibility • Graduated drivers’ licensing • Mandatory wearing of motorcycle helmets • Multicomponent traffic injury control Tobacco, alcohol, and illicit drugs • Restrictions on alcohol sales to minors • Taxes on alcohol • Drunk-driving legislation • Restrictions on illicit drugs • Interventions in licensed premises Mental disorders, including suicide • Restricted access (gun control, safe containers) Obesity • Tax on foods high in sugar, salt, and fat • Front-of-package nutrition labels • Restrictions on fast-food advertising Note: HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome. Actions in italics are promising but lack a strong evidence base in adolescents and young adults. Platforms for Delivering Adolescent Health Actions 301 benefits from a law that enables younger participation of There are obvious priorities to address in all coun- adolescents. Yet adolescents need laws, policy safeguards, tries if health actions are to match needs. First, as ado- and support for decisions made in contexts where lescents have significant need for, but poor access to, heightened emotion affects the choices they might make health services, efforts to orient the health service plat- (Patton, Sawyer, and others 2016). The notion of gradu- form toward adolescents are urgently required. Such ated laws and policies is one approach to balancing efforts include improving the competencies of the protection with empowerment. For example, graduated health workforce and considering different financing driving licenses support young people to acquire appro- models. Innovative approaches need to include schools priate driving skills and experience before they can and community-based health care, social media, and obtain a full license (Lyon, Pan, and Li 2012). m-health actions. Structural actions depend on sound governance, Second, the health benefits from participation in implementation capacity, and good information systems secondary education are clear, especially for girls. to monitor implementation and health outcomes. Thus, Education is one of the smartest investments for adoles- legal reforms are unlikely to be successful without cent health. Schools also provide a scalable platform for addressing the values, knowledge, attitudes, and behav- evidence-based actions, including comprehensive sexu- ior of the judiciary and police responsible for their ality education, condoms and contraception, meals and implementation. They are more likely to succeed when nutritional supplements, and routine immunization. broader community engagement and education lead to Third, as the major determinants of adolescent health, wider support. In fragile states, structural actions are growth, and development lie beyond the health and edu- difficult, as the governmental systems for implementa- cation sectors, actions for health must also include legis- tion are generally weak. In many other countries, infor- lative and financial reforms to limit adolescents’ access to mation systems to support structural actions are also hazardous commodities and environments and to pro- weak. Yet, structural actions are the bedrock of any mote their access to multisectoral resources for health. country’s capacity to improve adolescent health. Attention needs to be paid to the family and community sectors (cash transfers to reduce poverty and keep ado- lescent girls in school). Notwithstanding these clear directions, the evidence CONCLUSIONS base for adolescent health actions is relatively weak, with As children mature through adolescence, the platforms the predominant evidence from HICs and the focus on available to deliver health actions need to expand from a sexual and reproductive health. The lack of evidence sole reliance on families to the inclusion of schools, from LMICs is a particular challenge in planning and communities, media, health services, and wider struc- selecting interventions for adolescents; more research on tural actions that shape behaviors through legislative the health of adolescents in LMICs is clearly needed, and financial means. Actions are needed that match especially regarding efforts to adapt effective interven- conspicuous health needs, address emerging health tions from HICs to LMICs. The lack of benefit-cost issues, and are oriented toward prevention. Beyond ratios limits the capacity of governments to be as confi- health services, other platforms are critically important dent as they would like in taking programs to scale. in shaping adolescent health. The most effective actions Better understanding of the costs of implementation and for adolescents are multisectoral and span different plat- the benefits of interventions is expected to provide more forms. Alignment across sectors provides potent oppor- compelling evidence for actions that support adolescent tunities for amplification of effect. Thus, the relatively health. However, there are high priority actions to be modest effect of school-based sexuality education pro- implemented in every country. grams on reducing pregnancy is enhanced when aligned Beyond financial resources, the extent to which these with school-based health services that provide ready platforms can deliver necessary actions for adolescent access to contraception. Without alignment across plat- health is more often the sum of a country’s political and forms, certain actions cannot be implemented. For community support and technical capacity, including a example, health services cannot confidentially provide trained workforce. Effective interventions will only contraception to adolescents if this contravenes national achieve health outcomes if widely implemented. For this, or customary laws. Given the extent to which these plat- attention needs to be paid to local communities and forms span different government ministries, funding, cultures, which will entail the involvement of all stake- and programming silos, the development of national holders. As much as possible, it will mean using existing adolescent health policies would help to advance the system capacities, but additional investments will, with- delivery of multisectoral actions. out doubt, also be required. 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Patton, Yasunaga, M. 2014. “Non-Formal Education as a Means to and others. 2016. “School-Based Interventions Going Meet Learning Needs of Out-of-School Children and beyond Health Education to Promote Adolescent Adolescents.” UNESCO Insitute of Statistics, Montreal. Platforms for Delivering Adolescent Health Actions 305 Chapter 22 Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions Daniel Plaut, Milan Thomas, Tara Hill, Jordan Worthington, Meena Fernandes, and Nicholas Burnett INTRODUCTION skills, values, and attitudes that lead to healthy lives. Explicit recognition of the role of health in promoting Over the past several decades, efforts to fight infectious education is less common. As a complement to the global diseases and malnutrition have increased alongside state of education, as detailed in chapter 4 of this volume attempts to enroll children in basic education, demon- (Wu 2017), this chapter outlines the theoretical role of strating a global commitment to equity and quality in health interventions in increasing education access and child health and education. Health and education quality. It then surveys evidence from LMICs on the interventions can be complementary, as discussed in extent to which common education interventions and chapter 30 of this volume (Pradhan and others 2017). school-based health interventions improve education out- Improvements in access to quality education have comes. It considers the potential of primary and second- contributed to preventing disease—for example, an ary schools to serve as platforms for health interventions, encouraging drop in infant mortality rates is attributed focusing on interventions targeting middle childhood not only to health services but also to worldwide through adolescence, understood to be the range compris- improvements in education. Work commissioned by ing ages 5–19 years. This focus precludes a discussion of the International Commission on Financing Global the high returns to investment in early childhood, but the Education Opportunity found that about 7.3 million studies included are particularly relevant to policy makers lives were saved between 2010 and 2015 in low- and in countries where participation rates in early childhood middle-income countries (LMICs) because of increases education are still very low. Definitions of age groupings in educational attainment since 1990 (Pradhan and and age-specific terminology used in this volume can be others 2017). Poor health is linked to poor student found in chapter 1 (Bundy, de Silva, and others 2017). outcomes. Disease and malnutrition reduce children’s capacity to attend school and their ability to learn, partic- ularly in poor communities lacking quality education EDUCATION: PROGRESS AND GAPS services (Jukes, Drake, and Bundy 2008). Indeed, some development strategies have explicitly Enormous progress has been made in global education in pursued cross-sector synergies. For example, the 2015 the past few decades, especially with respect to achieving Incheon Declaration states that quality education instills universal primary education and reducing gender Corresponding author: Daniel Plaut, Results for Development, Washington, DC, United States; dplaut@r4d.org. 307 disparity (UNESCO 2015). However, several of the grade 2 level (ASER Centre 2014). Major quality- Millennium Development Goals (MDGs) for education related challenges in education clearly persist in LMICs. were not met by 2015. This brief summary of the state of global education provides the background for the ensuing CONCEPTUAL FRAMEWORK discussion of school-based education and health interventions. To understand how health interventions might be critical Since the 1990 Jomtien Conference on Education for to achieving global education goals, it is important to All, international support for education has focused on understand how they fit conceptually alongside educa- improving access and quality (UNESCO 2013). Partly tion interventions. As illustrated in figure 22.1, health reflecting the MDG focus on primary enrollment and interventions should play a key role in improving educa- gender parity in primary and secondary school, access tion outcomes along with education interventions that has taken overwhelming priority. Quality, initially inter- seek to improve access to education and student learning. preted mainly as educational inputs (teachers, text- For the purposes of this chapter, health interventions are books), has, since the mid-2000s, come to be interpreted narrowly defined as programs designed to enhance the as not just inputs but also as outcomes—that is, learning. physical well-being of students. They can improve edu- Indeed, the Sustainable Development Goals emphasize cation outcomes by preventing and treating health defi- both access and learning at all levels of education. ciencies that might otherwise deter children from Access to primary education has expanded signifi- attending school. By enabling children to attend school cantly with widespread enrollment efforts. Nearly more often and in better health, these interventions 60 million additional children enrolled in school between affect access to education and the ability to learn. 1999 and 2013 (ISS 2014). Equally impressive has been Health interventions may also affect education the progress made in primary school gender parity, illus- outcomes by improving children’s cognitive skills. As trated by a female-to-male pupil ratio of 0.94 in demonstrated by Jukes, Drake, and Bundy (2008), mal- low-income countries in 2011 (World Bank 2013). nutrition and infectious disease are linked to poor cogni- Although this progress is unprecedented, major gaps tive skills among school-age children (children ages 5 to persist in access to education worldwide. Growth in 14 years). Conversely, interventions addressing health enrollment has slowed significantly since 2008, and conditions, particularly malnutrition and malaria, may more than 59 million children were still not enrolled in improve indicators of cognitive skills (Conn 2014). primary school in 2013 (ISS 2014). This figure not only Although the conceptual link between health inter- has significant moral implications, but also costs LMIC ventions and improved education outcomes is clear, economies up to 10 percent of gross domestic product there is little consensus regarding the extent of their (Thomas and Burnett 2013). At the secondary school impact or how it compares with the impact of education level, growth in enrollment began from a relatively low interventions. To fill this gap, several meta-analyses have base. Secondary enrollment stood at only 65 percent in evaluated interventions in LMICs (Banerjee and others 2012 (World Bank 2013), and only 63 percent of coun- 2013; Conn 2014; Evans and Popova 2015; Krishnaratne, tries achieved gender parity in secondary education White, and Carpenter 2013; McEwan 2015; Petrosino enrollment (UNESCO 2015). and others 2012). This chapter draws largely from studies Gaps in global education are even larger when it that satisfy the inclusion criteria of those meta-analyses comes to learning outcomes. About 250 million of the to understand the impacts of selected health interven- world’s 650 million primary schoolchildren are not tions on education outcomes. As the following sections acquiring basic skills in literacy and mathematics show, evidence of the impact of these health interven- (UNESCO 2014). The Global Partnership for tions on increasing access to education (including Education’s LMIC partners face a learning crisis, with increasing attendance) is mixed, but generally positive. only 44 percent of their 180 million children reaching Their impact on learning is less clear. grade 4 and learning the basic literacy and numeracy skills appropriate for that grade (Global Partnership for Education 2013). Citizen-led assessments of learn- SURVEY OF EDUCATION INTERVENTIONS ing in East Africa and India show similarly daunting numbers. In East Africa, Uwezo (2013) found that less To address education challenges, governments and non- than a third of standard three children in 2013 were governmental organizations have implemented a range passing their grade 2 tests on basic numeracy (29 of education interventions to improve access and percent) and literacy (25 percent). In India, only learning. This section provides an overview of common 48 percent of grade 5 children are able to read at a education interventions and evidence on their impact. 308 Child and Adolescent Health and Development Figure 22.1 Example of a Conceptual Framework for the Impact of Health and Education Interventions on Education Outcomes Health interventions Reduced health deficiencies Improved cognitive development and ability Fewer sick days Increased engagement Education outcomes Regular attendance Access Learning Quality teaching Higher enrollment Effective management Improved education Reducing barriers to access curriculum delivery Incentives-based Instructional interventions interventions Education interventions McEwan (2015) distinguishes between incentives-based Incentives-Based Interventions and instruction-based education interventions: Cost-Reduction Interventions Among the principal demand-side barriers to education • Incentives-based interventions improve learning by for the poor are household costs: tuition and related changing incentives for teachers, parents, students, expenses, such as textbooks, uniforms, transportation costs, and administrators. Interventions include reducing and the opportunity cost of forgone labor by parents and tuition costs (for example, scholarships, subsidies), children. Cost-based interventions reduce the price of introducing performance-based pay for teachers, education for students and households, stimulating changing school management structures, and provid- demand for education services. The abolition of primary ing families with information about the importance school fees in many countries since the early 2000s has of education. contributed to a rise in enrollment, but rarely to an • Instruction-based interventions expand access and increase in learning outcomes (UNESCO 2014). Abolishing improve learning by providing materials and services school fees does not always translate into higher public to schools. They include building physical infra- school enrollment, particularly in countries where house- structure, providing textbooks and technology, and holds shoulder the burden of costs other than tuition training teachers. (Foko, Tiyab, and Husson 2012). Furthermore, as demon- strated by Bold and others (2011), free primary education The impact of these interventions is measured by a can exacerbate concerns about the low quality of educa- variety of indicators. Enrollment, attendance, progres- tion provided by public schools in LMICs. sion, and dropout rates are used to indicate access. Conditional cash transfers (CCTs) are promising Literacy and numeracy test scores are typically used to cost-reduction interventions for increasing enrollment indicate learning. Evidence about the impact of these and attendance rates (chapter 23 in this volume, de interventions is discussed next. Walque and others 2017). Cash transfers are direct and Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions 309 regular cash payments that supplement the income of performance and hire and fire teachers (Duflo, Dupas, poor and vulnerable households (Arnold, Conway, and Kremer 2009; Kim, Alderman, and Orazem 1999). and Greenslade 2011). In education, CCTs have been Although SBM interventions have demonstrated a applied to bolster school enrollment, with payments positive impact on learning outcomes, McEwan (2015) contingent on children’s school attendance. CCTs pro- found the average effects of management and supervi- vide incentives for attendance, make education more sion interventions to be small and not robust. According accessible to the poor, and offset the opportunity costs to that review, interventions in The Gambia, Indonesia, of enrolling children in school. Although Krishnaratne, and Madagascar showed few effects of SBM and super- White, and Carpenter (2013) claim that CCTs have vision reforms (Blimpo and Evans 2011; Glewwe and had a significant impact on access (figure 22.2), their Maïga 2011; Pradhan and others 2011). Thus, while the impact on learning is less clear. limited evidence base suggests that SBM could posi- tively improve learning outcomes, not enough is known School-Based Management about the mechanisms through which this process School-based management (SBM) refers to interventions occurs (Krishnaratne, White, and Carpenter 2013). that improve the management and supervision of schools through authority and accountability at the school level (McEwan 2015). SBM is premised on the notion that local Information-Based Interventions communities and parents are most motivated to ensure Information asymmetries can affect access to and quality quality school performance (Banerjee and others 2010). of education (box 22.1). Providing information about SBM interventions can support existing education man- the education system has been shown to have an impact agement structures, such as the Pratham Initiative in India, on indicators of both access and quality (Murnane and which sought to bring about renewed engagement among Ganimian 2014). village education committees (Banerjee and others 2010), Several interventions have sought to increase the as well as new management structures, such as in Pakistan perceived value parents and students assign to education, where new committees were established under a commu- often by providing information on the economic benefits nity support process (Kim, Alderman, and Orazem 1999). of staying in school. Two studies suggest that providing One category of SBM interventions is the allocation information on the returns to education can change per- of funds for school improvement through school man- ceptions, exerting a positive impact on school access and agement committees. For example, the Quality Schools learning outcomes at relatively low cost. Program in Mexico allowed parents and teachers to Jensen (2010) targeted grade 8 students in the develop school improvement plans and provided cash Dominican Republic with information about the eco- grants over five years to implement them (Skoufias and nomic returns of continuing to secondary education. Shapiro 2006). SBM interventions can also provide com- Results showed that participating students perceived munity members with the authority to monitor teacher significantly higher returns to education when they were interviewed several months later. Moreover, dropout rates fell 3.9 percentage points, or 7 percent, the follow- Figure 22.2 Impact of Conditional Cash Transfers on Improving ing year; four years later the average years of education Access to Education was 0.20 year higher. These results were concentrated among students from households above the median Progression income level, and there was little or no effect on school- ing for the poorest students. Given that both socioeco- Dropout nomic groups increased their perception of returns to schooling, financial constraints may have prevented the poorest households from continuing their education Attendance (Banerjee and others 2013). Nguyen (2008) similarly found that providing students Enrollment and parents in Madagascar with statistics about increased earnings from higher levels of education boosted average 0 0.05 0.10 0.15 0.20 0.25 school attendance by 3.5 percentage points. The informa- Standard deviation tion also had a positive effect on language and math test scores, raising scores by 0.20 standard deviation after Note: Figure reflects a weighted sum of Cohen’s d (differences in mean between control and treatment groups, normalized by the study’s standard deviation) from the individual studies. The three months, but only for students who had underesti- weighted sum is calculated using random effects estimation. mated the returns to education at baseline. 310 Child and Adolescent Health and Development Box 22.1 Information Interventions Regarding Learning Outcomes Several studies have explored the ability of ranking compared with other students; the second targeted information campaigns about poor included each school’s average score and ranking learning outcomes to bring about improvements against other schools. This intervention reduced in education quality and school accountability. schools’ ability to operate in the context of According to Bruns, Filmer, and Patrinos (2011), information asymmetries and applied competitive providing information on students’ educational pressure on schools to improve their quality or attainment may have a positive impact on reduce their price. Andrabi, Das, and Khwaja (2015) learning outcomes by empowering parents to concluded that the intervention improved learning choose higher-performing schools, encouraging outcomes by 0.10 standard deviation and reduced parents and students to monitor school resource private school fees 21 percent. allocations and learning outcomes, and pressuring Banerjee and others (2006) analyzed three types of governments and education providers to improve information interventions to encourage local partic- learning outcomes. ipation in improving education outcomes. While the Many interventions providing information on first two were passive, the third involved a targeted children’s educational attainment have improved intervention to facilitate community action for learning outcomes. The Learning and Education improving learning. The targeted intervention was Achievement in Pakistan Schools Project provided found to have the largest impact on parental engage- two report cards to parents in randomly selected ment. Results suggest that the provision of informa- villages on the basis of results from learning tion alone may be insufficient to affect learning assessments in English, mathematics, and Urdu outcomes and that additional interventions are (Andrabi, Das, and Khwaja 2015). The first report likely needed to generate and sustain impact on card included each child’s individual test scores and students’ learning. Instructional Interventions 21 percent with the provision of nearby community- Infrastructure based schools. Overall, community-based schools in Proximity of schools has been shown to increase rural Afghanistan increased formal school enrollment participation dramatically, especially for children who 47 percent and raised test scores by 0.59 standard live in remote regions or who face cultural barriers to deviation. enrollment and participation. A randomized study by Kazianga, de Walque, and Alderman (2009) found Burde and Linden (2009) assessing the impact of similar results in their evaluation of the Burkinabé the Partnership for Advancing Community-Based Response to Improve Girls’ Chances to Succeed Program Education in Afghanistan demonstrated the impor- in Burkina Faso, which placed well-equipped schools in tance of school proximity in providing incentives for 132 villages where the potential for primary-school-age school participation. They found that enrollment rates girls to attend school was particularly high. The were greater than 70 percent in areas where schools initiative led to a significant improvement in enroll- were within a mile of home. Enrollment declined sig- ment (19 percent), with the enrollment of girls increas- nificantly as distance from school increased, reaching ing more than that of boys. Improvement was also seen about 30 percent for children living more than two in test scores, which rose by 0.41 standard deviation miles away. These results illustrate the importance of (figure 22.3). The study found that “girl-friendly” local infrastructure and have significant implications amenities, including separate latrines for boys and girls, for understanding gender disparity in education. contributed to the improvement in enrollment, demon- Enrollment of girls in rural Afghanistan proved to be strating the potential role of specialized infrastructure particularly sensitive to school proximity, improving in targeting previously neglected populations. Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions 311 Figure 22.3 Impact of Infrastructure Interventions on Access and teaching resources and support materials (Lai, Zhang, Learning Qu, and others 2012). Such interventions improve learning outcomes by improving the quality of teaching, Literacy reducing class sizes, providing incentives to teachers to do their jobs, and equipping teachers with the neces- sary resources to teach effectively (box 22.2). Although Math generally targeted to improving learning outcomes, these interventions can also improve attendance and Attendance enrollment because parents are more likely to send their children to school if they trust that teachers Enrollment are present and believe that children are learning (Krishnaratne, White, and Carpenter 2013). 0 0.10 0.20 0.30 0.40 0.50 0.60 In general, interventions providing additional Standard deviation teaching resources demonstrate a significant impact on the full range of access and learning education outcomes Source: Krishnaratne, White, and Carpenter 2013. (Krishnaratne, White, and Carpenter 2013). Although Note: Figure reflects a weighted sum of Cohen’s d (differences in mean between control and treatment groups, normalized by the study’s standard deviation) from the individual studies. promising, such interventions need to be designed care- The weighted sum is calculated using random effects estimation. fully to avoid distorting incentives. For example, while providing financial incentives to teachers on the basis of student performance (test scores) may push teachers to Box 22.2 raise the quality of their instruction, it may also adversely provide teachers with incentives to maintain artificially Impact of Pedagogical Interventions on Learning high average exam scores by pressuring poorly perform- ing students to drop out or repeat grades (Glewwe, Ilias, Outcomes and Kremer 2003). In a meta-analysis of interventions seeking to improve learning outcomes, Conn (2014) found that the types of Materials and Technology learning interventions with the most impact are “those that A key category of instructional interventions to improve alter instructional techniques.” Two pedagogical interven- education outcomes is the provision of additional tions have proved effective: materials and technology for both students and teach- ers. Such interventions can include textbooks (Glewwe, Kremer, and Moulin 2009), writing materials and • Adaptive instruction that caters to children’s particular chalkboards (Krishnaratne, White, and Carpenter learning levels 2013), flipcharts (Glewwe and others 2004), lesson • Teacher coaching that provides long-term teacher plans or curriculum guides (Banerjee and others 2007), mentoring or coaching, rather than one-off in-service as well as technology or computer-based learning in the training events. classroom (Barrera-Osorio and Linden 2009; Cristia and others 2012; Lai, Zhang, Hu, and others 2012; Lai, These sorts of interventions have the largest significant impact Zhang, Qu, and others 2012). Overall, such interven- on learning outcomes, but differences in categorization tions have had some positive impact on math test illustrate some of the limitations of meta-analysis in providing scores, but no effect on attendance, enrollment, or pro- conclusive and comparable findings regarding intervention gression (Krishnaratne, White, and Carpenter 2013). types and their impact (Evans and Popova 2015). The context and manner in which materials are pro- vided are important in determining impact. Although the provision of materials alone is often ineffective Teacher Resources (Glewwe and others 2004; Glewwe, Kremer, and Moulin Because teaching quality is a key determinant of educa- 2009; Kremer, Moulin, and Namanyu 2003), combining tion outcomes, interventions have sought to improve materials with training and a well-defined teaching the quality of teaching through various means. These model augments the efficacy of materials (Friedman, measures include the provision of extra teachers Gerard, and Ralaingita 2010; Lucas and others 2014). (García-Huidobro 2000), financial rewards for According to McEwan (2015), computers and instruc- improved student performance (Muralidharan and tional technology interventions have shown the largest Sundararaman 2008), and additional and improved effect on learning outcomes. 312 Child and Adolescent Health and Development Summary of the Impacts of Selected Education Although these findings reveal several interventions Interventions with large and significant effects, Conn (2014) and Evans The education interventions described in this section are and Popova (2015) caution against drawing inferences some of the more promising approaches currently in about many of those interventions because of the small practice. Each type of intervention has merits, and number of studies. Findings of the impact of CCTs on meta-analyses have explored their impacts relative to access and the impact of teacher resources and materials each other, with mixed results. Table 22.1 summarizes on learning are based on more studies, so their effect the education interventions with randomized controlled sizes are particularly meaningful (box 22.3). trials (RCTs) that have shown statistically significant effects on education outcomes in one meta-analysis by THE CASE FOR HEALTH INTERVENTIONS Krishnaratne, White, and Carpenter (2013). Incentives-based interventions such as CCTs and While education interventions are crucial for improving school fees have demonstrated a greater impact on access and learning, health interventions can also play an improving access to education (increasing enrollment, important role. The role of health in education is partic- attendance, and progression and decreasing dropout), ularly important in LMICs, which are burdened with a while instruction-based interventions have proved to be disproportionate share of morbidity and mortality caused more effective at improving learning. The provision of by widespread malnutrition, parasites, and other infec- infrastructure and teacher resources shows promise tious diseases. Many children in South Asia and Sub- across both access and learning indicators, with peda- Saharan Africa are unable to access school because of gogical interventions demonstrating the largest and acute and chronic illnesses. For example, a national sur- most significant effect on improving learning outcomes. vey in the Democratic Republic of Congo (ISSP 2012) Instruction-based interventions clearly are promising showed that health issues kept 7 percent of the country’s for improving learning outcomes. 4 million out-of-school children from enrolling. Table 22.1 Impact of Incentives-Based and Instructional Education Interventions on Access and Learning Access to Schooling Learning Outcomes Type of education intervention Enrollment Attendance Dropout Progression Math Language Global Incentives-based interventions Cost-reduction interventions CCTs 0.22* 0.20* 0.11* 0.17* −0.02 −0.03 0.05 (16) (8) (4) (4) (2) (1) (3) School fees 0.02 0.63* — — 0.13* — — (2) (1) (1) Provision of 0.40* 0.38* 0.42 0.20 0.51* 0.38* — infrastructure (4) (3) (2) (1) (2) (2) Information-based 0.03 −0.10 −0.01 — 0.40 0.05* 0.03 interventions (2) (3) (2) (2) (2) (2) Instructional interventions Teacher resources 0.23* 0.09* 0.09* — 0.29* 0.28* −0.02 (2) (4) (3) (5) (5) (3) Materials — 0.05 0.22 0.00 0.16* 0.20 0.11 (8) (2) (1) (10) (9) (2) School-based 0.08 −0.02 0.02 0.06* 0.23* 0.12 0.20* management (3) (3) (3) (3) (3) (2) (1) Source: Krishnaratne, White, and Carpenter 2013. Note: Numbers in parentheses indicate the number of studies; — = not available; CCTs = conditional cash transfers. Table reflects a weighted sum of Cohen’s d (differences in mean between control and treatment groups, normalized by the study’s standard deviation) from the individual studies. The weighted sum is calculated using random effects estimation. *p < 0.05. Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions 313 Box 22.3 International Commission on Financing Global Education Opportunity In 2016, the International Commission on Financing in low-income countries, often from preventable Global Education Opportunity was set up to conditions, and recommends that decision makers reinvigorate the case for investing in education. invest in joint education-health initiatives. Early Chaired by Gordon Brown, former prime minister childhood development and services for adolescent of the United Kingdom, the commission released girls are recommended in particular as investments its report entitled, “The Learning Generation: that can deliver strong complementary health and Investing in Education for a Changing World,” education benefits. Chapter 30 of this volume at the United Nations in September 2016. The (Pradhan and others 2017) was prepared as a report provides a series of 12 recommendations background paper for the Brown Commission. to ensure all children are learning (International The chapter estimates the effects of education on Commission on Financing Global Education under-five mortality, adult mortality, and fertility. Opportunity 2016). A key set of recommendations In addition, it calculates the economic returns to focuses on promoting inclusion, within which education resulting from declines in under-five the commission emphasizes the importance of mortality and adult mortality, while also taking into countries investing beyond education to address account the effects of education investments on other barriers that prevent learning. The report income. Estimates of the internal rate of return to draws attention to the fact that up to 500 million education are about 50 percent higher if the impact school days are lost because of ill health each year of mortality is included in the analysis. Poor health is a major barrier to educational achieve- complicated by the myriad assessments measuring the ment (Glewwe and Miguel 2008). Addressing chronic two main dimensions of cognitive skills: (1) general health conditions is essential for increasing school intelligence and reasoning and (2) memory and atten- enrollment, while preventing and treating acute illness tion. Tests of cognitive skills vary by study, and the are critical for reducing absenteeism. Even if they are choice of tests is determined by budgetary consider- healthy enough to attend school, children in poor health ations, adaptability to local contexts, and ease of imple- are less able to learn. For example, children with insuffi- mentation. A related complication is that cognitive skills cient calories and micronutrients may lack the energy to and learning are cumulative processes, and detectable focus in class, limiting their ability to learn (Gomes-Neto improvements may require more time to manifest than and others 1997). is typical for health trials. Health interventions could improve cognitive devel- Effectiveness of health interventions depends on opment and education outcomes by ensuring that context, specifically disease burden and the education enrolled children are present, ready, and able to learn system. For example, the effectiveness of deworming (Bundy, Schultz, and others 2017). Even where the con- may be greater if delivered regularly to high-risk areas or ditions of access and instruction are ideal, cognitive if delivered at the beginning rather than the end of the function may constrain learning and achievement. For school term. The provision of school feeding to children example, Holding and Snow (2001) examined the last- with untreated helminth infection may not lead ing, adverse impact of malaria infection on cognition to improved attendance or learning. The relationship and behavior, and Black (2003) reviewed the effects of between anemia and cognition is well established, but micronutrient deficiencies on children’s cognitive the condition may be due to nutritional deficiencies, functioning. helminth infection, HIV/AIDS, or a combination of Given the physiological importance of children’s factors (Stephenson, Latham, and Kurz 1985). Integrated health status in determining their readiness to learn, a health interventions are likely to be more effective and growing literature has emerged on the impact of health cost-effective. interventions on cognitive skills. However, identifying Taking into account these caveats on heterogeneity a relationship between cognition and learning is and the difficulty of measuring the effects of health 314 Child and Adolescent Health and Development interventions, this section reviews recent evidence on the cognitive tests. Meta-analyses of quasi-experimental effectiveness of deworming, malaria control, school results show no clear impact of deworming on learning feeding, and nutrition in promoting education out- (Evans and Popova 2015; McEwan 2015). Over the long comes. These health interventions were chosen because term, persistent infections are associated with impaired they address some of the most prevalent threats to child cognitive development and lower educational achieve- health in LMICs and because schools have been used as ment (Mendez and Adair 1999), and worm infections are a delivery platform to support their scalability and estimated to lead to an intelligence quotient (IQ) loss of enhance their cost-effectiveness, as discussed in chapters 3.75 points per child infected, on average, and 200 20 (Bundy, Schultz, and others 2017) and 25 (Fernandes million years of lost schooling (Jukes, Drake, and Bundy and Aurino 2017) in this volume. 2008). Ozier (2014) found that, because of externalities, a mass school-based deworming program in Kenya was associated with improved cognitive performance for Deworming Treatment nontreated infants 10 years after the program. However, More than 600 million school-age children are in need of just as for learning, conclusive evidence from recent treatment for intestinal worm infection (WHO 2016). empirical studies with quasi-experimental design is lack- Infected children suffer from listlessness, diarrhea, ing for cognition (Taylor-Robinson and others 2015). abdominal pain, wasting, stunting, anemia, cognitive The mixed evidence on learning and cognitive impact impairment, lower productivity, and lower earning may be in part due to measurement issues, as discussed capacity (Guyatt 2000). in chapter 13 in this volume (Bundy, Appleby, and School-age children are more likely than adults to others 2017). spread worm infection because they are frequently in contact with other students, less likely to use latrines, and more likely to have poor hygienic practices. School- Malaria Control based interventions have tremendous potential for posi- More than 500 million school-age children worldwide tive externalities—if a critical mass of students is are at risk of malaria infection, which can be pre- dewormed in a school, students who do not receive vented through a variety of interventions, including deworming treatment are less likely to be infected by insecticide-treated bednets and prophylactic antimalarial their classmates (Anderson and May 1991). School- drugs, as discussed in chapter 14 in this volume (Brooker based deworming programs distribute oral deworming and others 2017). Although malaria is most severe and medicine every 6–12 months to prevent infection. They common in early childhood, it has serious consequences sometimes also include teacher training on preventive during the school-age years, accounting for up behaviors. to 20 percent of mortality in schoolchildren in Many studies indicate that deworming has strong malaria-ridden countries (World Bank 2015). A range of impacts on enrollment and attendance, as reviewed by malaria prevention strategies is typically delivered Petrosino and others (2012) and discussed in chapters through schools or communities. 13 (Bundy, Appleby, and others 2017) and 29 (Ahuja The effect of malaria reduction on educational and others 2017) in this volume. A study of hookworm attainment is indeterminate because of the prevalence of eradication in the American South found that mass child labor in most malaria-ridden countries (Bleakley deworming increased enrollment, attention, and liter- 2007). Reducing malaria increases the benefits of educa- acy (Bleakley 2007). Miguel and Kremer (2004) found tion because healthy children are more able to capitalize that low-cost, single-dose therapies reduced hook- on opportunities generated by schooling. Conversely, worm, roundworm, and schistosomiasis infections reducing malaria increases the opportunity costs of by 99 percent and improved school participation education because healthy children are more able to by 7 percentage points in a large study (30,000 school- supplement household income. The effect on educa- children) in Kenya. These estimates mask heterogeneity tional attainment of reducing malaria thus requires given that children who are worse off have the most to empirical investigation. gain. Simeon and others (1995) discerned no average Studies of school-based delivery provide strong impact, but did find significant impacts on attendance evidence that malaria prevention improves attendance for the subset of children who had heavy Trichuris and cognition among children in endemic areas. infection or were stunted. Repeated provision can ensure better results, especially Alderman and others (2006) found no impact of for the most vulnerable. Studies demonstrate that albendazole on test scores, while Grigorenko and others malaria is a significant contributor to absenteeism, (2006) found that praziquantel improved scores on some accounting for 13 percent to 50 percent of medical Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions 315 absences from school (Nankabirwa and others 2014). have traditionally focused on boosting enrollment In Kenya alone, an estimated 4 million to 10 million and attendance, although the emphasis is shifting to school days were lost because of malaria in 2000 assessing their impact on academic achievement, as has (Brooker and others 2000). been done in high-income countries. School health education programs that promote School feeding could affect education outcomes antimalarial practices were found to reduce absenteeism through several channels. First, school feeding can pro- 25 percent among Kenyan schoolchildren (Ogutu and vide incentives for enrollment by lowering the opportu- others 1992). Malaria prevention combined with chloro- nity cost of attendance. On average, school feeding quine prophylaxis in Sri Lanka was linked to a 62 percent represents an income transfer of US$60 per child per reduction in school absenteeism and a 26 percent year, as discussed in chapter 12 in this volume (Drake increase in mathematics and language test scores and others 2017). Second, school feeding alleviates (Fernando and others 2006). hunger, which improves attention span and increases a Some debate surrounds the impact of malaria on student’s capacity for performance. Third, school feed- school performance. Bangirana and others (2011) ing provides the nutritional inputs to boost cognitive found a minimal impact of malaria on test scores in development, especially in early childhood (Martorell Uganda, but suggested that the effect of malaria on 1996), which could improve performance. Finally, nutri- cognition in schoolchildren may develop too gradually tion promotes health by improving resistance to disease, to be observed during the short periods common in which enables children to stay healthy and maintain controlled studies. Similarly, Clarke and others (2008) better attendance (Buttenheim and others 2011). Thus, found that intermittent preventive treatment of school- school feeding could, in theory, affect education access, children in Kenya had no effect on achievement, but cognition, and learning outcomes. did positively affect performance on attention and Although the impact of improved nutrition is memory tests. undisputed, its logistical implementation through Indeed, such results do not preclude an impact of school feeding has an ambiguous impact on education malaria prevention on students’ cognitive skills. A outcomes. Several issues associated with the implemen- strong body of evidence demonstrates that cerebral and tation of school feeding could counteract the positive uncomplicated malaria can impair cognitive function influence of improved nutrition. School feeding could (Fernando, Rodrigo, and Rajapakse 2010; Kihara, Carter, provide food that is insufficiently nutritious. School and Newton 2006; Thuilliez and others 2010), while a feeding could also reduce teaching time or overcrowd consistent association has not been found for asymp- schools if enrollment increases rapidly, both of which tomatic parasitemia (Halliday and others 2012). These could cause a drop in education quality (Conn 2014). studies suggest that school-based malaria programs Furthermore, in resource-constrained settings, there offering diagnostic services, treatment, and prevention could be a substitution effect whereby children who may improve education outcomes by promoting receive school feeding are given less to eat at home, readiness to learn. negating any possible gains. In addition, by increasing attendance, school feeding programs could induce a reduction in child labor, which reduces household School Feeding income and the availability of food at home (Adelman, More than 165 million children worldwide face chronic Gilligan, and Lehrer 2008). It is thus critical to look malnutrition (UNICEF 2013), which can be alleviated to the evidence to judge whether the merits of school to some degree by school feeding—the regular provi- feeding hold up empirically. sion of food to children attending schools, discussed in Several reviews have highlighted the positive effects chapter 12 in this volume (Drake and others 2017). of school feeding on enrollment, attendance, and reten- Although malaria and deworming treatments are typi- tion (Jomaa, McDonnell, and Probart 2011). However, cally limited to low-income countries, school feeding is the impact of school feeding on cognition and learning implemented in almost every country in the world is more nuanced and dependent on the quality of (WFP 2013). The recognition of its potential impacts schooling. Studies suggest that school feeding can on education outcomes is also widespread. School feed- influence the two domains of cognition by reducing ing programs can help get children into school and keep micronutrient deficiencies, although the impacts are them there. They can contribute to learning once chil- less than for micronutrient supplementation (Conn dren are in school, given the well-established link 2014). Breakfast programs may be especially important between nutrition and cognition (Adelman, Gilligan, for cognitive function, especially in contexts where and Lehrer 2008). In LMICs, school feeding programs breakfast is rarely consumed at home, as discussed in 316 Child and Adolescent Health and Development chapter 12 in this volume (Drake and others 2017). achievement, suggesting the need for complementary Learning effects are stronger for arithmetic tests than education interventions. for reading, writing, and spelling (Jomaa, McDonnell, and Probart 2011). Summary of the Impacts of Selected Health Interventions Nutrition Table 22.2, which is based on a meta-analysis by Nutrition interventions are also commonly distributed Krishnaratne, White, and Carpenter (2013), combines through schools, separately or in conjunction with effect sizes from disparate, context-specific studies to school meals. These interventions include the provision arrive at a general conclusion. It is based on just one of supplement tablets as well as micronutrient pow- meta-analysis of school-based health interventions, so it ders, which can be sprinkled on meals to enhance their should only be taken as suggestive, rather than the final nutrient content. By tackling micronutrient deficien- word on these interventions. Similarly, online annexes cies associated with health status and cognition, nutri- 22A and 22B combine both health and education inter- tion interventions can promote learning and academic vention effect sizes from Krishnaratne, White, and achievement. Carpenter (2013) to illustrate their effect sizes relative to Nutrition interventions may seek to address one or each other. Both demonstrate that, in some cases, health more micronutrient deficiencies, with one of the most interventions can have as large an effect size on access common being iron deficiency. In a review of the liter- and learning outcomes as education interventions. ature, Best and others (2011) found positive effects of While the size of some of the effects are large and supplementation of multiple micronutrients on micro- appear to be statistically significant, making these infer- nutrient and anemia status as compared with supple- ences about statistical significance at the 95 percent mentation of a single micronutrient. Impact can also confidence level hinges on assuming that normal approx- depend on the dose, initial micronutrient status, and imation is valid for a very small number of studies. No interactions with other micronutrient supplements. result for an individual intervention is based on more For instance, the inclusion of iron-fortified flour than four studies. Tipton (2015) highlights the danger enhanced the iron status of Kenyan schoolchildren of making inferences from small samples. Evans and (Andang’o and others 2007). However, in Vietnam, iron Popova (2015) considered the results from Krishnaratne, supplementation alone did not affect anemia status, White, and Carpenter (2013) and five other meta-analyses although the provision of multiple-fortified biscuits and concluded that they largely agree that school-based did, suggesting that the presence of other nutrients may health interventions have a significant impact on access affect iron absorption and anemia status (Hieu and indicators (consistent with results in the table), but are others 2012). In a review of the literature, Conn (2014) not effective in improving test scores. found that nutrition interventions had significant However, these findings cannot necessarily be taken impacts on cognitive function, but not academic as evidence that improvements in health are not essential Table 22.2 Impact of Health Interventions on Access and Learning Access to schooling Learning outcomes Type of health intervention Enrollment Attendance Dropout Progression Math Language Global School feeding 0.24* 0.26* — 0.69* 0.40 0.19 0.02 (4) (4) (1) (1) (2) (1) Nutrition 0.04* 0.27* 0.33 — 0.65* 0.66* — (1) (2) (1) (2) (2) Malaria — 0.59* 0.24* 0.38* 0.62* 0.56* — prevention (1) (1) (1) (1) (1) Deworming 0.29 0.09 — — 0.04 0.02 −0.03 (1) (1) (1) (1) (1) Source: Based on data from Krishnaratne, White, and Carpenter 2013. Note: Numbers in parentheses indicate the number of studies; — = not available. Table reflects a weighted sum of Cohen’s d (differences in mean between control and treatment groups, normalized by the study’s standard deviation) from the individual studies. The weighted sum is calculated using random effects estimation. *p < 0.05. Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions 317 for improving learning outcomes. Analyzing impact significantly better on attention tests than untreated evaluations from Sub-Saharan Africa, Conn (2014) students. Both studies were placebo controlled and dou- found that, although deworming had no discernible ble blind. More should be done to rigorously assess the impact on test scores, it did significantly improve cogni- impact of these and other interventions in other contexts tive skills (as measured by tests like Raven’s Progressive and to link them to learning. Matrices). This result suggests that the improvements in In summary, evidence on the impacts of health inter- health yielded by health interventions may be necessary, ventions is inconclusive, particularly for learning but not sufficient, for promoting learning. outcomes. More research using cluster-randomized Although most experimental studies focus on approaches, larger sample sizes, and longer timeframes is measuring changes in access and achievement indica- needed to assess the impacts of health interventions on tors, RCT studies that measure cognitive function also learning outcomes. show encouraging results. High-quality evidence is Evidence on the importance of health in determining available for nutritional supplements and malaria pre- readiness to learn and the lack of clear evidence on the vention interventions in particular. For example, impact of health interventions on learning outcomes do Sungthong and others (2004) found that Thai primary not necessarily contradict each other. Rather, other nec- schoolchildren receiving iron supplements performed essary conditions (such as adequate educational moderately better than the control group on a standard- resources) may be lacking in the settings where these ized test of cognitive function (TONI II), while Clarke studies took place, preventing health interventions from and others (2008) showed that Kenya schoolchildren improving education outcomes. Cunha and Heckman treated with a preventive malaria program performed (2007) discussed a theoretical model involving such Box 22.4 Assessing Cost and Cost-Effectiveness On the basis of a systematic review of studies volume provide more details on the costs of these by the Disease Control Priorities (third edition) health interventions. Economics Team (which calculated costs per stu- dent per year in 2012 U.S. dollars), deworming The comparative cost-effectiveness of interventions treatment costs, on average, US$0.93. Programs for education outcomes has been analyzed. Jensen for malaria control cost US$3.67, and programs (2010) found that information-based interventions, for school feeding cost US$75.90, on average. which cost as little as US$0.08 per student (Nguyen Although these studies cover interventions that 2008), may be a highly cost-effective way to promote varied considerably in scope, the averages provide school access for marginal students. These findings a sense of the resources required to fund such are in sharp contrast to conditional cash transfers like programs. Although the review did not include Mexico’s Progresa, which costs US$500 per person. studies on nutritional supplements, such interven- Dhaliwal and others (2012) cite examples suggesting tions have been recognized elsewhere as generally that information-based interventions, deworming, cost-effective (Dhaliwal and others 2012), and and nutritional supplements are highly cost-effective. on the basis of an observational study of Filipino Kremer, Brannen, and Glennerster (2013) note that schoolchildren, Glewwe, Jacoby, and King (2001) pedagogical interventions matching teaching to suggest that in developing countries, a dollar students’ learning levels and providing information invested in an early childhood nutrition program might be the most cost-effective interventions for returns at least three dollars worth of gains in aca- learning. McEwan (2015) found that computer- demic achievement. Chapters 12 (Drake and oth- assisted teaching and textbook distribution are among ers 2017), 20 (Bundy, Schultz, and others 2017), 24 the least cost-effective learning interventions. Further (Horton and Black 2017), 26 (Horton and others research and cost-effectiveness analysis of both 2017), and 14 (Brooker and others 2017) in this education and health interventions are needed. 318 Child and Adolescent Health and Development dynamic complementarities in inputs to education. universal conclusions about the effects of both health Moreover, conclusions drawn from meta-analyses can be and education interventions is not surprising, given how incomplete or misleading because of heterogeneous education and health outcomes are interdependent. effects (the impact of interventions could vary by bene- In some contexts, education interventions may fail to ficiary gender or socioeconomic status), temporal effects improve education outcomes because poor health is the (the size of impacts at the endline of a study does not binding constraint on educational achievement. In necessarily indicate lasting effects), and differences in age others, health interventions may fail to improve educa- at exposure (the impacts are age dependent for some tion outcomes because school infrastructure is so poor health interventions, such as the wealth of evidence on that improving children’s individual abilities to excel in the heightened importance of adequate nutrition in a school does not improve actual outcomes. Health inter- child’s first 1,000 days). ventions alone do not guarantee improved learning Reviewing the cost and cost-effectiveness of school- outcomes and vice versa; quality education and health based interventions falls outside the remit of this chapter. services must be provided contemporaneously to Furthermore, the vast majority of cost-effectiveness maximize the impact of each. studies measure cost over a single outcome (disability- For this reason, focusing on integrated implementa- adjusted life years averted), not taking into account the tion is important. Studies such as Banerjee and others multisectoral benefits of an intervention. However, (2006) and Piper and Korda (2010) have shown that because cost-effectiveness has central implications for incentives-based interventions can have a greater the feasibility of interventions in resource-constrained impact when implemented alongside instruction-based settings, box 22.4 briefly notes some cost evidence interventions. Scant evidence on integrated health and specific to school-based delivery. education interventions is available for LMICs. An intervention in Jamaica that combined early stimula- CONCLUSIONS: THE EMERGING NEXUS OF tion with nutritional supplements for stunted children illustrates the potential impact of integrated interven- HEALTH AND EDUCATION tions: more than two decades after its implementation, Our understanding of the interaction between children’s the impact on IQ and learning outcomes was still health status and education outcomes has progressed significant (Grantham-McGregor and others 2014). considerably. Indeed, a wealth of evidence on a range of Although the timing of this intervention, which tar- health interventions has been generated from nonex- geted children younger than age four years, was likely a perimental studies and RCTs during the past two factor in its impact, this promising intervention pro- decades, including for some health interventions not vides an example of how a more holistic approach to discussed in this chapter (such as HIV/AIDS prevention interventions seeking to improve education outcomes and treatment, provision of eyeglasses, disability access, by improving cognitive skills could provide significant and sanitation). long-term gains. Overall, the data suggest that health interventions However, in more developed settings, even the can have a significant impact on education outcomes. distinction between health and education outcomes has Health interventions have been widely shown to started to blur as policy makers measure development improve indicators of access, such as attendance and using more comprehensive measures of well-being. This enrollment. The impact of these interventions on learn- is evident in theoretical frameworks in which education ing and cognitive skills is mixed and uncertain. Despite is recognized as a causal factor for health (Braveman and years of opportunity for definitive research the very Gottlieb 2014), as well as in practice. In the United plausible hypothesis that sick, malnourished, and States, programs such as Fast Track and Communities hungry children learn less in school remains to be That Care provide comprehensive services for children adequately tested. The limited research on interventions and their families. The Centers for Disease Control ini- to address these problems has so far been inconclusive. tiative Healthy People 2020 uses high school graduation This point is but one example of an important theme of as a leading indicator of social determinants of health. this volume as a whole: research on child health and This merging of education and health in policy and nutrition has been dominated by studies of children practice may provide guidance for designing programs younger than age five years, leaving an important gap that integrate education with critical interventions for concerning school-age children. malnutrition and diseases that are no longer pervasive in As discussed in the previous section, the lack of high-income countries. consensus on some interventions is likely due in part to Many chapters in this volume make the economic methodological challenges. Furthermore, the lack of and social case for investing in health. This chapter has Getting to Education Outcomes: Reviewing Evidence from Health and Education Interventions 319 shown that these cases become even stronger when Arnold, C., T. Conway, and M. Greenslade. 2011. Cash Transfers: policy makers bear in mind the importance of health Literature Review. London: Department for International interventions for promoting education. Development. ASER Centre. 2014. “ASER 2014: Main Findings.” ASER Centre, New Delhi. ANNEXES Banerjee, A., R. Banerji, E. Duflo, R. Glennerster, and S. Khemani. 2006. “Can Information Campaigns Spark Local The annexes to this chapter are as follows. They are avail- Participation and Improve Outcomes?” Policy Research able at http://www.dcp-3.org/CAHD. Working Paper 3967, World Bank, Washington, DC. Banerjee, A., R. Banerji, R. Glennerster, and S. Khemani. 2010. • Annex 22A. Impact of Interventions on Education “Pitfalls of Participatory Programs: Evidence from a Outcomes Randomized Evaluation of Education in India.” American Economic Journal: Economic Policy 2 (1): 1–30. • Annex 22B. Median Significant Effect Sizes on Banerjee, A., S. Cole, E. Duflo, and L. Linden. 2007. “Remedying Education Outcomes Education: Evidence from Two Randomized Experiments in India.” Quarterly Journal of Economics 122 (3): 1235–64. Banerjee, A., P. Glewwe, S. Powers, and M. Wasserman. 2013. NOTE “Expanding Access and Increasing Student Learning in World Bank Income Classifications as of July 2014 are as Post-Primary Education in Developing Countries: A follows, based on estimates of gross national income (GNI) Review of the Evidence.” Post-Primary Education Initiative per capita for 2013: Review Paper, Abdul Latif Jameel Poverty Action Lab, Massachusetts Institute of Technology, Cambridge, MA. • Low-income countries (LICs) = US$1,045 or less Bangirana, P., S. Musisi, M. J. 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Programs and policies around the world have attempted Unconditional cash transfer (UCT) programs are those to address poverty to improve outcomes for children and in which families receive cash benefits because the house- adolescents, and one popular approach is to use cash hold falls below a certain income cutoff or lives within a transfer (CT) programs (Engle and others 2011). CT geographically targeted region; however, no conditions are programs support vulnerable populations by distribut- tied to the transfer (Barrientos and DeJong 2006). Given ing transfers to low-income households to prevent that UCTs do not monitor the behavior of households or shocks; protect the chronically poor; promote capabili- require visits to health clinics, these programs are opera- ties and opportunities for vulnerable households; and tionally less complex and easier for governments to imple- transform systems of power that exclude certain margin- ment because they do not require a well-functioning alized groups, such as women or children (Devereux and health care sector. Thus, administrative costs are often Sabates-Wheeler 2004). The economic rationale for CT substantially lower for UCTs than for CCTs. School feed- programs is that they can be an equitable and efficient ing is an example of a noncash transfer and is discussed in way to address market failures and reach the most vul- chapter 12 of this volume (Drake and others 2017). nerable populations (Fiszbein and others 2009). Both CCTs and UCTs assume that parents are income When the provision of CTs is tied to mandatory constrained, and thus do not have the money to spend behavioral requirements, they are conditional cash to meet the most pressing needs of their families (for transfer (CCT) programs, which operate by giving cash example, nutritious food, medical treatment). Providing payments to families only if they comply with a set of greater purchasing power allows parents to choose what requirements (the “conditions” of the cash transfer), goods to buy and in what quantity and of what quality. usually related to health and education (de Janvry and The economic rationale for conditioning transfers on Sadoulet 2006). For example, many CCT programs dis- certain behaviors is that individuals or households do tribute benefits conditional on the use of preventive not always behave rationally because they have imperfect health care services, attendance at health and nutrition information, they behave myopically, or there are con- education sessions designed to promote positive behav- flicts of interest between parents and children (Fiszbein ioral changes, or school attendance for school-age chil- and others 2009). In addition, conditioning transfers on dren (Barrientos and DeJong 2006; Lagarde, Haines, and human capital creates positive externalities and usually Corresponding author: Damien de Walque, Development Research Group, World Bank, Washington, DC, United States; ddewalque@worldbank.org. 325 has more political support. However, many argue that according to which families have more money to spend conditioning transfers is paternalistic and costly to mon- on inputs (Guo and Harris 2000; Yeung, Linver, and itor and that the neediest households might find it too Brooks-Gunn 2002) or more time to spend with chil- costly to comply (Grimes and Wängnerud 2010; Handa dren (Del Boca, Flinn, and Wiswall 2014), and the family and Davis 2006; Popay and others 2008; Shibuya 2008). stress model, according to which maternal depression Mexico’s Prospera (previously Progresa and and stress are lower because household resources are Oportunidades) and Brazil’s Bolsa Familia were among higher (Mistry and others 2004). the first CCTs to be designed in the late 1990s and have CCT and UCT programs can vary widely in their been models for programs throughout Africa, Latin objectives, design, and context. While many programs America, and the United States (Aber and Rawlings 2011; have the broad goals of reducing poverty and improving Fiszbein and others 2009). By 2011, CT programs cov- human capital, some are more focused on decreasing ered an estimated 750 million to 1 billion people world- poverty, some on improving education outcomes, some wide; India (48 million households), China (22 million on improving health outcomes, and some on improving households), Brazil (12 million households), and Mexico nutrition outcomes. Program designs reflect these differ- (5 million households) were among the countries with ences in objectives with differences in conditions, target- the largest programs (DFID 2011). In spite of the com- ing, transfer size, beneficiaries, and complementary mon features of many CTs, there is a large degree of het- components. Consequently, although CCT and UCT erogeneity across countries and programs with regard to programs have the potential to effect multiple outcomes program benefits, conditions, requirements, payments, by lessening a household’s budget constraints, some pro- and targets. For example, in Ecuador and Peru, the trans- grams and contexts may be better suited to improving fer is a fixed payment per family per month that does not child and adolescent health and education outcomes. For vary by household size, whereas in Brazil, Malawi, and example, programs in a handful of countries are begin- Mexico the benefits depend on the number, age, and ning to experiment with the integration of parenting gender of children in the household. In some programs support or nutritional support—a direct intervention to (for example, Prospera in Mexico and Familias en Acción promote child development—within CT programs (for in Colombia), the payment is greater for secondary- example, in Colombia, see Attanasio and others 2014; in school-age children than for primary-school-age chil- Mexico, see Fernald and others 2016). dren. Similarly, the average transfer amount varies greatly, The literature review proceeded as follows. We began ranging from 6 percent in Brazil to 22 percent to by examining the conclusions in the 2011 Lancet series 29 percent in Mexico and Nicaragua to 200 percent of on early child development in LMICs (Engle and others pretransfer consumption in Malawi (Fiszbein and others 2011; Walker and others 2011) and in five systematic 2009; Miller, Tsoka, and Reichert 2010). The size of the reviews addressing CCTs published since 2011 (Bassani transfer reflects the goal of the program, which can be to and others 2013; Fernald, Gertler, and Hidrobo 2012; move households to a minimum level of consumption Glassman, Duran, and Koblinsky 2013; Manley, Gitter, (Colombia, Jamaica, Mexico) or to base the size of the and Slavchevska 2013; Ruel, Alderman, and Maternal and transfer on the opportunity cost of health care (Honduras) Child Nutrition Study Group 2013). We then conducted or on the transportation costs to the public health facility a literature search to find papers that had been published (Nepal) (Gaarder, Glassman, and Todd 2010). since those systematic reviews. The search used Google This chapter first reviews the evidence from CT pro- Scholar, JSTOR, and PubMed for peer-reviewed articles grams, both conditional and unconditional, throughout and websites of the International Food Policy Research low- and middle-income countries (LMICs), focusing spe- Institute, United Nations Children’s Fund, and the World cifically on the direct effects on child and adolescent health Bank for gray papers. The search was restricted to studies and education outcomes. It then discusses the design of CT that used experimental or quasi-experimental techniques programs and why and how they could theoretically affect such as randomization, regression discontinuity, propen- outcomes for young children and adolescents. Although sity score matching, or difference-in-differences. there are other types of social safety net programs, such as We found evidence from studies examining the effects voucher schemes, food transfers, and user fee removals, we of CTs on birth weight (3 studies); infant mortality focus on CTs because many countries are switching to such (6 studies); height-for-age (or stunting) (23 studies); programs given that they are easier to distribute. In addi- weight-for-age (or underweight) (12 studies); weight-for- tion, the evidence for many other types of programs is too height (or wasting) (10 studies); hemoglobin (or sparse for them to be included in the analysis. anemia) (10 studies); morbidity (16 studies); cognitive, CT programs are hypothesized to improve child and language, and behavioral development (11 studies); and adolescent outcomes via the family investment model, sexual and reproductive health (9 studies) (table 23.1). 326 Child and Adolescent Health and Development Table 23.1 Summary of Cash Transfer Effects Significant effects of CT only in Indicator Significant effects of CT on outcome subgroups or some measures No effects or adverse effect of CT Birth and neonatal outcomes Birth weight Mexico (Barber and Gertler 2010) Colombia, urban areas (Attanasio and Uruguay (Amarante and others 2012) others 2005) Perinatal, neonatal, Brazil (Shei 2013) Mexico, infant mortality, but not neonatal Indonesia (World Bank 2011) or infant mortality Brazil (Rasella and others 2013) (Barham 2011) Nepal (Powell-Jackson and others 2009) India (Lim and others 2010) Anthropometric measures Height, height-for- Mexico (Gertler 2004) Burkina Faso, one-year impact (Akresh, de Bangladesh (Ahmed and others 2009) age, stunting (HAZ) Mexico, rural (Neufeld and others 2005) Walque, and Kazianga 2016) Brazil (Morris, Olinto, and others 2004) Mexico (Behrman and Hoddinott 2005) Colombia, children < age 24 months Ecuador (Paxson and Schady 2010) (Attanasio and others 2005) Mexico (Fernald, Gertler, and Ecuador (Fernald and Hidrobo 2011) Neufeld 2008) Malawi, children ages 5–18 years (Miller, Tsoka, and Reichert 2010) Indonesia (World Bank 2011) Sri Lanka (Himaz 2008) Mexico, urban (Neufeld 2005) Mexico, rural, children < age 6 months (Rivera and others 2004) Peru (Perova and Vakis 2009) Mexico, urban, children < age 6 months Tanzania (Evans, Holtemeyer, and (Leroy and others 2008) Kosec 2015) Mexico, rural, less-educated mothers Zambia (Seidenfeld and others 2014) (Fernald, Gertler, and Neufeld 2009) Nicaragua, stunting (Maluccio and Flores 2005) Nicaragua, one-year impact (Macours, Schady, and Vakis 2012) South Africa, exposed at age 0–35 months (Agüero, Carter, and Woolard 2009) Weight-for-age, Increased weight or decreased Mexico, children < age 6 months (Leroy Bangladesh (Ahmed and others 2009) underweight (WAZ) underweight: and others 2008) Burkina Faso (Akresh, de Walque, and Nicaragua (Maluccio and Flores 2005) Mexico, rural, children ages 48–71 months Kazianga 2016) Decreased weight: (Neufeld and others 2005) Malawi (Miller, Tsoka, and Reichert 2010) Brazil (Morris, Olinto, and others 2004) Zambia, WAZ (Seidenfeld and others 2014) Nicaragua (Macours, Schady, and Indonesia (World Bank 2011) Vakis 2012) Peru (Perova and Vakis 2009) Tanzania (Evans, Holtemeyer, and Kosec 2015) Weight-for-height Decreased BMI or overweight: Mexico, children < age 6 months (Leroy Bangladesh (Ahmed and others 2009) (wasting, WHZ), BMI Mexico (Fernald, Gertler, and Neufeld 2008) and others 2008) Indonesia (World Bank 2011) Sri Lanka, children, ages 36–60 months Mexico, urban (Neufeld 2005) (Himaz 2008) Mexico (Fernald, Gertler, and Zambia, WHZ (Seidenfeld and others 2014) Neufeld 2009) Nicaragua (Maluccio and Flores 2005) Tanzania (Evans, Holtemeyer, and Kosec 2015) table continues next page Cash Transfers and Child and Adolescent Development 327 Table 23.1 Summary of Cash Transfer Effects (continued) Significant effects of CT only in Indicator Significant effects of CT on outcome subgroups or some measures No effects or adverse effect of CT Measures of morbidity and anemia Illness or sick days Brazil (Reis 2010) Mexico, rural areas (Gutiérrez and Ghana (Handa, Park, and others 2014) Burkina Faso (Akresh, de Walque, and others 2004) Jamaica (Levy and Ohls 2007) Kazianga 2016) Tanzania, two-year evaluation (Evans, Mexico (Fernald, Gertler, and Malawi (Miller, Tsoka, and Reichert 2010) Holtemeyer, and Kosec 2015) Neufeld 2008) Mexico (Gertler 2000) Peru (Perova and Vakis 2012) Mexico (Gertler 2004) Mexico (Gutiérrez and others 2006) Peru (Perova and Vakis 2009) Specific illnesses Uganda (Gilligan and Roy 2014) Colombia, rural areas, < age 48 months Brazil (Reis 2010) (Attanasio and others 2005) Indonesia (World Bank 2011) Hemoglobin, anemia Mexico (Gertler 2004) Ecuador, poorest quintile, rural (Paxson Mexico (Neufeld and others 2005) Uganda (Gilligan and Roy 2014) and Schady 2010) Mexico (Fernald, Gertler, and Mexico, urban, ages 6–23 months Neufeld 2008) (Neufeld 2005) Ecuador (Fernald and Hidrobo 2011) Mexico, rural, at one-year, not two-year Nicaragua (Maluccio and Flores 2005) evaluation (Rivera and others 2004) Peru (Perova and Vakis 2009) Developmental outcomes Cognition and Mexico (Fernald, Gertler, and Ecuador, poorest quintile of rural Mexico (Fernald, Gertler, and language Neufeld 2008) population (Paxson and Schady 2010) Neufeld 2009) Nicaragua (Macours, Schady, and Ecuador, children of rural mothers with no Peru (Andersen and others 2015) Vakis 2008, 2012) education (Fernald and Hidrobo 2011) Zambia (Seidenfeld and others 2014) Nicaragua (Barham, Macours, and Maluccio 2013) Uganda (Gilligan and Roy 2014) Behavior Mexico (Ozer and others 2009) Mexico (Fernald, Gertler, and Neufeld 2009) Indirect effects of cash transfer programs Antenatal care Bangladesh (Nguyen and others 2012) Mexico, prenatal care quality (Barber and El Salvador (De Brauw and Honduras (Morris, Flores, and others 2004) Gertler 2010) Peterman 2011) India (Lim and others 2010) Mexico, urban and rural in 2000 Nepal (Powell-Jackson and others 2009) (Hernández Prado and others 2004) Peru (Perova and Vakis 2009) Indonesia (World Bank 2011) Mexico, certain specifications only (Sosa- Zambia (Handa, Peterman, Seidenfeld, Uruguay (Amarante and others 2012) Rubí and others 2011) and others 2015) Presence of skilled Bangladesh (Nguyen and others 2012) Indonesia, certain specifications only Mexico (Urquieta and others 2009) birth attendant at El Salvador (De Brauw and (World Bank 2011) Uruguay (Amarante and others 2012) birth, in-facility birth Peterman 2011) Mexico, rural (Hernández Prado and Zambia (Handa, Peterman, Seidenfeld, India (Lim and others 2010) others 2004) and others 2015) Nepal (Powell-Jackson and others 2009) Peru, certain specifications only (Perova and Vakis 2009) Nepal (Powell-Jackson and Hanson 2012) table continues next page 328 Child and Adolescent Health and Development Table 23.1 Summary of Cash Transfer Effects (continued) Significant effects of CT only in Indicator Significant effects of CT on outcome subgroups or some measures No effects or adverse effect of CT Growth monitoring Colombia (Attanasio and others 2005) Burkina Faso, CCT not UCT (Akresh, de Ecuador (Paxson and Schady 2010) Honduras (Morris, Flores, and others 2004) Walque, and Kazianga 2012) Ecuador (Fernald and Hidrobo 2011) Jamaica (Levy and Ohls 2007) Nicaragua, one-year evaluation (Maluccio Ghana (Handa, Park, and others 2014) and Flores 2005) Mexico (Gertler 2000) Tanzania, one-year evaluation (Evans, Mexico (Gutiérrez and others 2004, 2006) Holtemeyer, and Kosec 2015) Nicaragua (Macours, Schady, and Vakis 2012) Peru (Perova and Vakis 2009) Peru (Perova and Vakis 2012) Child food Colombia (Attanasio and Mesnard 2006) Bangladesh (Ahmed and others 2009) consumption Nicaragua (Macours, Schady, and Ecuador (Fernald and Hidrobo 2011) Vakis 2008) Uganda (Gilligan and Roy 2014) Sexual and reproductive health HIV/AIDS Malawi, UCT and CCT for education (Baird South Africa, CCT for education (Pettifor and others 2012) and others 2015) Lesotho, lottery incentives if STI-negative South Africa (Abdool Karim and (Björkman Nyqvist and others 2015) others 2015) Malawi, CCT if HIV-negative (Kohler and Thornton 2012) Sexually transmitted Malawi, UCT and CCT for education (Baird Tanzania, CCT if STI-negative (de Walque infections and others 2012) and others 2012; de Walque, Dow, and Kenya, education subsidy combined with Nathan 2014) HIV/AIDS education, but not without (Duflo, Dupas, and Kremer 2015) South Africa, CCT for education (Abdool Karim and others 2015) Lesotho, lottery incentives if STI-negative (Björkman Nyqvist and others 2015) Sexual behaviors Malawi, UCT and CCT for education (Baird Malawi, CCT if HIV-negative and others 2012) (Kohler and Thornton 2012) Kenya, UCT (Handa, Halpern, and others 2014) Kenya, education subsidy combined with HIV/AIDS education, but not without (Duflo, Dupas, and Kremer 2015) South Africa, UCT (Cluver and others 2013) South Africa, CCT for education (Pettifor and others 2015) Tanzania, CCT if STI negative (de Walque and others 2012; de Walque, Dow, and Nathan 2014) Lesotho, lottery incentives if STI-negative (Björkman Nyqvist and others 2015) Note: BMI = body mass index; CT = cash transfer; CCT = conditional cash transfer; HAZ = height-for-age z score; HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome; STI = sexually transmitted infection; UCT = unconditional cash transfer; WAZ = weight-for-age z score; WHZ = weight-for-height. Cash Transfers and Child and Adolescent Development 329 IMPACT OF CASH TRANSFERS ON HEALTH that CTs significantly decreased the number of reported OUTCOMES illnesses or sick days. In contrast, program participation had no significant effect on reported illness in Jamaica Birth Weight (Levy and Ohls 2007) and was associated with an Low birth weight is a major determinant of health out- increase in reported illness among children ages zero to comes in childhood and later life. In Latin America, five years in Ghana (Handa, Park, and others 2014). In CCTs and UCTs have been found to increase birth weight Mexico, three evaluations reported a significant decrease (Amarante and others 2012; Attanasio and others 2005; in illness rates in the treatment groups (Gertler 2000, Barber and Gertler 2010). In Colombia and Mexico, 2004; Gutiérrez and others 2006); one evaluation the effect of CCTs on birth weight was between 0.13 and (Gutiérrez and others 2004) found a significant decrease 0.58 kilograms, although in Colombia, the effect was in reported sick days in rural areas, but not urban; and only significant in urban areas. CTs also decreased one evaluation (Fernald, Gertler, and Neufeld 2008) the incidence of low birth weight (defined as less than found no significant association between the size of the 2,500 grams) by 5 percent in Mexico and 15 percent to CT received by the family and self-reported sick days of 17 percent in Uruguay. Neither the Mexico nor the the child. In Peru, results were similarly mixed: a two- Uruguay study found any changes in the use of antenatal year evaluation reported that children in Juntos were less care associated with participation in the CT programs. likely to be ill (Perova and Vakis 2009), but a five-year However, in Mexico, improvements in birth weight were evaluation found no impact on self-reported illness attributed to improvements in quality of care. In (Perova and Vakis 2012). Uruguay, improvements in birth weight were attributed Studies in Brazil (Reis 2010), Colombia (Attanasio to improvements in mothers’ nutrition and a fall in and others 2005), Indonesia (World Bank 2011), and mothers’ labor supply and smoking. Uganda (Gilligan and Roy 2014) analyzed the effect of CCTs on specific reported illnesses, such as diarrhea, Perinatal, Neonatal, or Infant Mortality fever, respiratory conditions, and vomiting. In Uganda (Gilligan and Roy 2014), there was a significant decrease Three studies from the review in Fernald, Gertler, and in reported diarrhea rates, while in Colombia, there was Neufeld (2012) and three more-recent studies investi- a significant decrease in reported diarrhea for rural chil- gated the effect of CTs on perinatal mortality (stillbirth dren, but not for urban children, and there was no after 28 weeks of pregnancy or death of a child within impact on respiratory conditions for children in rural or the first week of birth), neonatal mortality (death of a urban areas. In Brazil, although the CT program signifi- child within the first month of birth), infant mortality cantly improved children’s morbidity, it had no signifi- (death of a child within the first year of birth), or under- cant impact on reported vomiting, diarrhea, respiratory five mortality. Four of the six studies found significant conditions, and bed days. Contrary to expectations, in decreases in mortality rates in Brazil, India, and Mexico Indonesia, the program significantly increased reports of (Barham 2011; Lim and others 2010; Rasella and others fever and diarrhea. 2013; Shei 2013). More than half of the decline in infant mortality in Mexico resulted from reductions in respira- tory and intestinal infections and nutritional deficien- Anthropometric Measures cies (Barham 2011). However, studies in Indonesia Anthropometric indicators are widely used to assess (World Bank 2011) and Nepal (Powell-Jackson and children’s nutritional status. Persistent or severe poor others 2009) found no significant impact on neonatal or nutrition has direct effects on linear growth and the abil- infant mortality. ity to accumulate muscle mass and fat (Hoddinott and Bassett 2008). Height-for-age z score (HAZ) is a measure Self-Reported Child Health: Illness or Morbidity of chronic malnutrition, with stunting (HAZ lower than Of the studies reviewed, 16 investigated the effects of CTs −2 standard deviations) representing an internation- on reported illness or morbidity. Most programs found ally recognized cutoff (WHO 1986). Weight-for-height significant positive effects on measures of illness and z score (WHZ) is a measure of acute malnutrition, morbidity, such as sick days, reported diarrhea, or with wasting (WHZ lower than −2 standard deviations) reported respiratory problems. Studies in Brazil (Reis reflecting a deficit in tissue and fat mass. Weight-for-age 2010), Burkina Faso (Akresh, de Walque, and Kazianga z score (WAZ) is a composite indicator of HAZ and 2016), Malawi (Miller, Tsoka, and Reichert 2010), and WHZ and thus captures both transitory and chronic Tanzania (Evans, Holtemeyer, and Kosec 2015) found aspects of malnutrition (Hoddinott and Bassett 2008). 330 Child and Adolescent Health and Development Height-for-Age was due to small sample sizes, to children being older The evidence linking CCTs to improvements in child and thus less sensitive to nutritional inputs (Victora and height was mixed, both across and within countries. In others 2010), to a lack of improvement in children’s Mexico alone, four studies found a significant effect of the nutritional intake, or to delays and errors in program program on height (Behrman and Hoddinott 2005; implementation. Although many studies show improve- Fernald, Gertler, and Neufeld 2008; Gertler 2004; Neufeld ments in food consumption and health service use, and others 2005), three found significant improvements many factors could limit the effectiveness of CTs in only for specific subpopulations such as children ages zero improving nutritional status, such as the quality of chil- to six months (Leroy and others 2008; Rivera and others dren’s diet and health services, knowledge of adequate 2004) or children of mothers with no education (Fernald, feeding practices, and environmental risks such as con- Gertler, and Neufeld 2009), and one study found no sig- taminated water and malaria (Bassett 2008; Manley, nificant effects in urban areas (Neufeld 2005). Gitter, and Slavchevska 2013). Evaluations of other CCT programs were also incon- clusive: in Bangladesh (Ahmed and others 2009), Brazil Weight-for-Height (Morris, Olinto, and others 2004), Indonesia (World Bank The evidence of the impact of CTs on WHZ or wasting 2011), Peru (Perova and Vakis 2009), and Tanzania in general reveals little to no impact. Studies of CTs in (Evans, Holtemeyer, and Kosec 2015), there were no sig- Bangladesh (Ahmed and others 2009), Indonesia (World nificant effects on children’s height. In Nicaragua, a study Bank 2011), Nicaragua (Maluccio and Flores 2005), and of the Red de Protección Social Program (Maluccio and Tanzania (Evans, Holtemeyer, and Kosec 2015) found no Flores 2005) found no impact on HAZ, but a significant impact on wasting or WHZ. However, a study of a UCT decrease in stunting, while a study of the Atención a in Zambia (Seidenfeld and others 2014) found an Crisis Program (Macours, Schady, and Vakis 2012) increase in WHZ, but no impact on wasting, and a study found a significant improvement in HAZ after adding of a UCT in Sri Lanka (Himaz 2008) found a significant extended controls, but these impacts had faded two years increase in WHZ, but only among children ages 36–60 after the program ended. Similarly, in Burkina Faso, months. In Mexico, Neufeld and others (2005) found no CCTs led to significant improvements in HAZ after one effect of the program on WHZ, while Leroy and others year, but no significant impacts were detected after (2008) found a significant increase in WHZ, but only for two years (Akresh, de Walque, and Kazianga 2016). children younger than age 6 months. Also in Mexico, In Colombia, there was a significant improvement in Fernald, Gertler, and Neufeld (2008) found that receiv- children’s HAZ, but only for children younger than age ing a greater amount of cash from Oportunidades was 24 months (Attanasio and others 2005). associated with lower body mass index– (BMI-) for-age The evidence for UCTs was also inconclusive. There in children ages 3–5 years and a lower prevalence of was a significant improvement in children’s HAZ in Sri overweight, but the effect on BMI had disappeared after Lanka (Himaz 2008), but no effect on young children’s 10 years (Fernald, Gertler, and Neufeld 2009). HAZ in Ecuador and Zambia (Fernald and Hidrobo 2011; Paxson and Schady 2010; Seidenfeld and others Weight-for-Age 2014). In South Africa, there was a significant improve- The effects of CCT and UCT programs on WAZ or the ment in height for children who had been exposed to prevalence of underweight are mixed, although the the CT program more than 50 percent of the time when majority of studies found no significant effects or only they were age 0–35 months (Agüero, Carter, and found effects in subgroups. CCT studies in Bangladesh Woolard 2009). In Malawi, there was a significant (Ahmed and others 2009), Nicaragua (Macours, Schady, improvement in height for children ages 5–18 years, but and Vakis 2012), Peru (Perova and Vakis 2009), and no significant effect on the prevalence of stunting for Tanzania (Evans, Holtemeyer, and Kosec 2015) found no children younger than age 5 years, although the sample impact on WAZ or underweight; a different study in size for this subpopulation was quite small (Miller, Nicaragua (Maluccio and Flores 2005) found a signifi- Tsoka, and Reichert 2010). cant reduction in the prevalence of underweight. CCT These mixed findings are consistent with a meta- studies in Brazil (Morris, Olinto, and others 2004) and analysis showing small and nonsignificant impacts of Indonesia (World Bank 2011) found a decrease in CTs on child HAZ across 17 programs (Manley, Gitter, weight. Findings regarding the impacts of UCTs on and Slavchevska 2013). Because of limitations in the weight are also inconclusive; a study in Malawi (Miller, study designs, it is not possible to determine whether Tsoka, and Reichert 2010) found no impact on weight or the lack of significant effects on height in some studies the prevalence of underweight, and a study in Zambia Cash Transfers and Child and Adolescent Development 331 (Seidenfeld and others 2014) found an increase in WAZ childbirth, while programs in El Salvador, Honduras, but no impact on the prevalence of underweight. In Indonesia, Mexico, and Peru were broader in their out- Burkina Faso, neither CCTs nor UCTs had an impact on reach, but still required pregnant women to seek prenatal WAZ (Akresh, de Walque, and Kazianga 2016). care. UCT programs in Uruguay and Zambia had no In Mexico, results for the effect of Oportunidades on antenatal care requirements. A systematic review showed weight outcomes were also mixed. Neufeld and others that CCTs increased antenatal care, skilled attendance at (2005) found that the prevalence of underweight in rural birth, and births at clinics (Glassman, Duran, and areas increased in response to the program for children Koblinsky 2013). However, the results were mixed, gener- age 48 months and older, but not for younger children ally depending on the focus of the program. and that the program had no significant impact on the There was no significant impact on the number of prevalence of overweight or on WAZ. A study by Leroy antenatal visits in El Salvador (De Brauw and Peterman and others (2008), however, found a significant increase 2011), Nepal (Powell-Jackson and others 2009), or in weight for children younger than age six months. Zambia (Handa, Peterman, Seidenfeld, and others 2015). However, the programs in Bangladesh, Honduras, India, Indonesia, and Uruguay significantly increased either the Hemoglobin probability or the number of antenatal visits (Amarante Of the nine studies reviewed in Fernald, Gertler, and and others 2012; Lim and others 2010; Morris, Flores, Hidrobo (2012) and one more-recent study, five found and others 2004; Nguyen and others 2012; World Bank no effects of CT programs on hemoglobin levels or 2011), while the CCT in Peru decreased the probability anemia (Fernald, Gertler, and Neufeld 2008; Fernald and of prenatal visits (Perova and Vakis 2009). In Mexico, Hidrobo 2011; Maluccio and Flores 2005; Neufeld and prenatal care increased approximately 6 percent in urban others 2005; Perova and Vakis 2009). Two studies (one in areas, but the results for rural areas were mixed and Ecuador and one in Mexico) found improvements in depended on the evaluation method used (Barber and hemoglobin levels, but only for subgroups (Neufeld Gertler 2010; Hernández Prado and others 2004; Sosa- 2005; Paxson and Schady 2010). Two studies (one in Rubí and others 2011). Even though the study by Barber Mexico and one in Uganda) found that CTs led to sig- and Gertler (2010) did not find a significant impact on nificant improvements in hemoglobin or anemia rates the use of prenatal care, it did find a significant impact (Gertler 2004; Gilligan and Roy 2014); one study (Rivera on the quality of prenatal care, with beneficiary women and others 2004) found significant improvements only receiving, on average, more of the recommended proce- in the one-year evaluation, but not in the two-year eval- dures during their prenatal appointments. uation, when the late intervention group began receiving The CCT programs in Bangladesh, India, and Nepal the CCT. had a specific goal of increasing professional care at childbirth, and indeed these programs significantly increased both the probability of having an in-facility Intermediate Pathways birth and the probability of having a skilled birth atten- CT programs could affect children’s development dant (Lim and others 2010; Nguyen and others 2012; through several intermediate pathways, such as increased Powell-Jackson and Hanson 2012; Powell-Jackson and use of health services by pregnant mothers and young others 2009). CCT programs in El Salvador, Indonesia, children, increased parasite treatments and vitamin and Peru also led to an increase in the probability of supplements, increased food consumption, and having a skilled attendant at birth (De Brauw and improved physical and psychological well-being of Peterman 2011; Perova and Vakis 2012; Triyana 2014; mothers. Given space limitations, this chapter provides World Bank 2011); however, the impacts in Indonesia an overview only of the findings related to the condi- and Peru depended on the empirical specification tions present in many CT programs—health service use (Perova and Vakis 2009; World Bank 2011). UCT pro- for pregnant women and young children and food con- grams in Uruguay and Zambia had no impact on having sumption of individual children. a skilled attendant present at birth (Amarante and others 2012; Handa, Peterman, Seidenfeld, and others 2015). In Health Service Use: Pregnant Women Mexico, Hernández Prado and others (2004) found that The programs reviewed varied widely in scope. Programs Oportunidades increased the probability of having a in Bangladesh, India (Janani Suraksha Yojana doctor present at birth in rural areas, but decreased the Program), and Nepal (Nepal’s Safe Delivery Incentive probability in urban areas, while Urquieta and others Program) focused on pregnant women with the aim of (2009) found no significant impact on the probability of encouraging antenatal care and professional care at having a skilled attendant present at birth. 332 Child and Adolescent Health and Development Health Service Use: Young Children where the human immunodeficiency virus/acquired Although a large majority of the studies reviewed found immune deficiency syndrome (HIV/AIDS) epidemic significantly positive effects of CTs on the probability makes this issue highly relevant. Baird and others (2012) that a child had received growth monitoring or health evaluated an intervention targeting human capital for- checkups, the impact depended on whether the transfer mation as an alternative HIV/AIDS prevention strategy was conditional. Of the studies reviewed, 11 (10 from in Malawi. They found that a CT, both conditional and Latin America and the Caribbean and 1 from Africa) unconditional, of, on average, US$10 per household per examined transfer programs that were conditional on month (US$40 every four months) had various impacts parents taking their children to health visits (Attanasio on the prevalence of HIV/AIDS and herpes simplex and others 2005; Evans, Holtemeyer, and Kosec 2015; virus-2 (HSV-2) together with pregnancies and sexual Gertler 2000; Gutiérrez and others 2004, 2006; Levy and relations of girls with men older than age 25 years. They Ohls 2007; Macours, Schady, and Vakis 2012; Maluccio further documented that CTs improved the mental and Flores 2005; Morris, Flores, and others 2004; Perova health of the girls, unless the cash was given condition- and Vakis 2009, 2012), 3 examined UCTs either in ally to the parents (Baird, de Hoop, and Özler 2013). Ecuador (Fernald and Hidrobo 2011; Paxson and Schady However, an evaluation of the medium-term impacts of 2010) or in Ghana (Handa, Park, and others 2014), and 1 this intervention, two years after it stopped, indicated experimentally varied whether the transfer was condi- that most of the impacts were no longer present (Baird tional on preventive health care of children in Burkina and others 2015). Faso (Akresh, de Walque, and Kazianga 2012). Whereas In Kenya, a national CT program for orphans and the studies on conditional programs revealed a signifi- vulnerable children reduced the risk of sexual debut cant increase in the percentage of children being taken to among young people ages 15–25 years and also health facilities for growth monitoring or preventive care, reduced the likelihood of pregnancy among women the studies on UCTs did not find a significant increase. ages 12–24 years by 5 percentage points (Handa, Halpern, and others 2014; Handa, Peterman, Huang, Food Consumption and others 2015). Schooling and peer influences have Given that CTs increase a household’s purchasing power, been found to be the main mediators for the reduc- CT programs could be expected to increase a house- tion in sexual debut (Brugh and others 2014). Also in hold’s food consumption. Indeed, review studies showed Kenya, Duflo, Dupas, and Kremer (2015) found that that both UCTs and CCTs had a large positive impact on an education subsidy program had no impact (includ- the quality and quantity of households’ food consump- ing in the longer term) on the HSV-2 infection rate. tion (Fernald, Gertler, and Hidrobo 2012; Hidrobo, However, an education subsidy combined with HIV/ Hoddinott, Kumar, and others 2014; Hidrobo, Hoddinott, AIDS prevention education focusing on abstinence Peterman, and others 2014). Although households’ food until marriage resulted in a significant reduction in consumption improved, these improvements did not the HSV-2 infection rate in the intervention com- necessarily translate into improved nutrition for chil- pared with the control group. dren. A potential reason for the weak impacts on nutri- In a propensity-score-matched case-control study, a tion may be the intrahousehold allocation of food, such child-focused state CT in South Africa was shown to that children did not benefit from the household’s reduce transactional sex and age-disparate sex (Cluver increased food consumption, with regard to either quan- and others 2013). Results from two South African ran- tity or quality. Studies investigating the impacts on food domized controlled trials suggest that CTs conditional consumption at the level of the individual child found no on schooling have mixed results. An individually ran- impacts on children’s food consumption in Bangladesh domized study of young women conditioned on (Ahmed and others 2009) and Ecuador (Fernald and school attendance with an HIV/AIDS incidence end- Hidrobo 2011). However, in Colombia (Attanasio and point found no impact on HIV/AIDS incidence, even others 2005), Nicaragua (Macours, Schady, and Vakis though the young women who received CTs reported 2008), and Uganda (Gilligan and Roy 2014), CTs signifi- engaging in significantly fewer risk behaviors (Pettifor cantly increased the number of days children consumed and others 2015). Another study found that cash foods rich in protein and other micronutrients. incentives conditional on schooling led to a 30 percent reduction in HSV-2 incidence, but could not establish the impact of cash incentives on HIV/AIDS incidence Sexual and Reproductive Health (Abdool Karim and others 2015). Both studies might The impact of UCTs on sexual and reproductive health not have had enough statistical power to detect impacts has been assessed, in particular in Sub-Saharan Africa, on HIV/AIDS incidence. Cash Transfers and Child and Adolescent Development 333 A few randomized field trials have explored the use of (Gilligan and Roy 2014). In Zambia, the UCT had no financial incentives to encourage safe sexual behavior by impact on a highly abbreviated language and cognition making payments contingent on, for example, testing for scale (Seidenfeld and others 2014). Evidence from Peru HIV/AIDS, sexually transmitted infection (STI) status, or showed no effects of the Juntos CCT on language out- school enrollment. These experiments have focused comes in children (Andersen and others 2015), but two mainly on young adults ages 18–29 years; however, the studies in Nicaragua showed benefits to cognitive results are also relevant for adolescents’ sexual and repro- development from participation in two different CT ductive health outcomes. Kohler and Thornton (2012) programs (Barham, Macours, and Maluccio 2013; assessed an experiment in Malawi that offered a single Macours, Schady, and Vakis 2012). cash reward after one year to individuals who remained Two Latin American countries have tried to improve HIV-negative. The intervention had no measurable effect child development outcomes using the existing structure on HIV/AIDS status. De Walque and others (2012) and of CCTs to deliver parenting support, including stimula- de Walque, Dow, and Nathan (2014) evaluated a condi- tion and nutrition supplementation. In Colombia, the tional cash grant program in Tanzania in which the cash home-visiting program included as part of a CCT had awards of US$10 or US$20 every four months were con- positive effects on child development (Attanasio and oth- ditional on receiving negative test results for a set of cur- ers 2014), as did the integration of Mexico’s CCT Prospera able STIs. After one year, the group eligible to receive the with Educación Inicial, a large-scale, group-based, US$20 CTs showed a significant reduction in STI preva- parenting-support program (Fernald and others 2016). lence, while the group eligible for the US$10 CT showed no measurable effect. The study was not powered to mea- sure impact on HIV/AIDS incidence. Education Outcomes Björkman Nyqvist and others (2015) assessed the Beyond health, CT programs can have broad impacts on effect on HIV/AIDS incidence of a lottery program in the overall development of children and adolescents and Lesotho with low expected payments but a chance to win their households (Handa, Seidenfeld, and others 2014). a high prize conditional on receiving negative test results In their systematic review, Baird and others (2014) used for STIs (the expected payment per testing round was data from 75 reports covering 35 studies to complement about three times lower than in the Tanzania trial dis- the evidence on the effectiveness of CT programs in cussed above). The intervention resulted in a 21.4 percent improving schooling outcomes and to inform the debate reduction in HIV/AIDS incidence over two years. Lottery surrounding the design of such programs. They found incentives appear to be particularly effective for individ- that both CCTs and UCTs improve the odds of being uals willing to take risks. In both the Lesotho and enrolled in and attending school compared with no CT Tanzania studies, the effects were shown to be sustained program. in one-year postintervention follow-up studies. While the positive impact of CTs on human capital accumulation suggests that those improvements would also translate into better labor market outcomes, such as IMPACT OF CASH TRANSFERS ON CHILD employment and wages, such long-term impacts have DEVELOPMENT AND EDUCATION not yet been documented, probably because of the length of the study period required to make such assess- Early Child Development Outcomes ments. However, CTs have been shown to improve Evidence from studies examining the effects of CCTs household productivity by being invested in agricultural and UCTs on cognitive, language, motor, or socioemo- assets, reducing participation in low-skilled labor, and tional development was also reviewed (six studies limiting child labor outside the home (Covarrubias, reviewed in Fernald, Gertler, and Hidrobo 2012 and five Davis, and Winters 2012). more-recent studies). The majority of studies from the 2012 review reported small, but significant, positive effects of CCTs on developmental outcomes in children COMPARING CASH TRANSFER (Fernald, Gertler, and Neufeld 2008, 2009; Fernald and DESIGNS, INCLUDING COST AND COST- Hidrobo 2011; Macours, Schady, and Vakis 2008; Ozer EFFECTIVENESS and others 2009; Paxson and Schady 2010). The studies published since the 2012 review showed mixed results. Conditional versus Unconditional In Uganda, food and CTs were linked directly to pre- An important question is whether and how the condi- school participation, and cash, but not food, was found tions attached to CCTs affect the outcomes they seek to to increase children’s cognitive scores significantly improve. CCT programs represent a top-down approach 334 Child and Adolescent Health and Development in which individuals or organizations decide what is best They substantially increased school enrollment, uncon- for poor children and provide incentives to their parents ditional attendance, and grade progression, but they to achieve these objectives. In contrast, UCT programs had a more limited impact on learning outcomes as assume that, once a budget constraint is relaxed, parents measured by standardized tests. They also improved the are in a better position to make appropriate decisions health outcomes of children ages zero to five years, regarding their child’s human capital. CCT programs are leading to more preventive visits to health clinics, fewer more costly per recipient to administer than UCT pro- illnesses (both as reported by parents and as measured grams because of the costs associated with monitoring by a biomarker for inflammation), and better nutri- conditions. tional outcomes (as indicated by anthropometric In their systematic review, Baird and others (2014) measurements). However, the conditionality led to dif- specifically examined the role of conditions. They found ferentiated impacts. For school enrollment and several that the effects for enrollment and attendance are always health outcomes, CCTs outperformed UCTs. larger for CCTs than for UCTs, but the difference is not The results from Burkina Faso further indicated that statistically significant. When programs are categorized CCTs were more effective than UCTs in improving the as having no schooling conditions, having some condi- enrollment of “marginal” children—those who were not tions with minimal monitoring and enforcement, and enrolled in school or were less likely to go to school, having explicit conditions that are monitored and including girls, younger children, and lower-ability chil- enforced, a much clearer pattern emerges: programs that dren (Akresh, de Walque, and Kazianga 2013). These are explicitly conditional, monitor compliance, and results shed new light on the role of conditionality in CT penalize noncompliance have substantively larger effects programs. In resource-poor settings, both UCTs and (60 percent improvement in odds of enrollment). Unlike CCTs relax the budget constraint and allow households enrollment and attendance, the effectiveness of CT pro- to enroll more children than they would traditionally grams for improving test scores is small at best. prioritize for human capital investments. But the condi- Few studies have explicitly compared CCTs and UCTs tions attached to CCTs play a critical role in improving in the same context. One experiment (Baird, McIntosh, the outcomes of children in whom parents are less likely and Özler 2011) examined the impact of CCTs and UCTs to invest. on adolescent girls’ schooling and health outcomes in Malawi, concluding that CCTs outperformed UCTs for schooling outcomes, but UCTs outperformed CCTs for Role of the CT Recipient several other outcomes—for example, delaying marriage Another important question is whether the gender of the and childbearing. Benhassine and others (2015) used a CT recipient matters. Numerous intrahousehold bargain- randomized experiment in Morocco to estimate the ing research papers indicate that resources under the impact of a labeled CT program: a small cash transfer mother’s control have a stronger positive impact on a made to fathers of school-age children in poor rural child’s health and schooling than resources controlled by communities, not conditional on school attendance but the father (Lundberg, Pollak, and Wales 1997; Schultz explicitly labeled as an education support program. They 1990; Thomas 1990, 1993). However, almost all current documented large gains in school participation and con- CT programs give resources to the mother, so it is not cluded that adding conditionality and targeting mothers possible to disentangle how much of any impact is due to made almost no difference in that context. the recipient’s gender, how much is due to the income effect, A pilot program in rural Burkina Faso incorporated and how much is due to the change in relative prices asso- a random experimental design to evaluate the relative ciated with the conditionality. Furthermore, the recipient’s effectiveness of four social protection programs target- gender might affect outcomes differently for conditional ing poor households: CCTs given to fathers, CCTs given as opposed to unconditional CTs. While Benhassine and to mothers, UCTs given to fathers, and UCTs given to others (2015) and Haushofer and Shapiro (2016) found mothers (Akresh, de Walque, and Kazianga 2016). In no important differences in measured impacts depending the same context, this study also investigated the role of on the recipient’s gender, Akresh, de Walque, and Kazianga conditionality and the gender of the recipient in a CT (2016) found more contrasting results when they explic- program targeting all children—boys and girls up to age itly investigated the gender of the transfer recipient in 15 years—and the impact of different CT modalities on Burkina Faso. a broad range of education, health, and household wel- While giving cash to mothers seems slightly, but not fare outcomes. The results indicated that CTs improved significantly, better for education outcomes, giving cash the education and health of children as well as the to fathers leads to significantly better nutritional out- socioeconomic conditions of households and adults. comes during years when the harvest has been poor. Cash Transfers and Child and Adolescent Development 335 In the context of a CCT program, another interesting underweight, WHZ or wasting, and hemoglobin or ane- question is the role of parental and child returns to mia. With regard to indirect effects of CTs, results were schooling or health decisions regarding school atten- strong and significant for participation in prenatal care, dance or safe sexual behaviors, especially with adoles- presence of a skilled birth attendant, and growth cents who can more easily make their own decisions. monitoring. Parents and children may have different views about CTs may not show clear and consistent effects on when it is optimal for a child to invest in human capital. anthropometric results or anemia for several reasons. CT In addition, the actions of children are unlikely to be programs try to address many issues at multiple levels perfectly observed by their parents, which potentially (parental, community) that influence child develop- leads to a moral hazard problem that may prevent ment, but they do not directly work to change the investments in schooling or health even when such broader factors that have previously been linked with investments would be optimal from the point of view of improving nutrition and decreasing stunting and ane- the parent-child pair under perfect information mia, such as safe water and sanitation, infant and young (Bursztyn and Coffman 2012). child feeding practices, and country-level food availabil- Bursztyn and Coffman (2012) found that parents ity (Smith and Haddad 2014). Similarly, programs pro- attach a value to the monitoring of attendance provided moting child development that have an educational or by CCTs in Brazil. However, Baird, McIntosh, and Özler stimulation component have shown larger cognitive (2011) obtained inconclusive results when comparing effects than cash-only or nutrition-only programs, both the effectiveness of giving one extra dollar to children in the United States (Nores and Barnett 2010) and in with the effectiveness of giving one extra dollar to par- Latin America (Attanasio and others 2014; Fernald and ents in the context of joint transfers to parents and chil- others 2016). In spite of this evidence, there are clear cost dren in Malawi. constraints—for example, the estimated annual unit cost of an early child development or child care intervention including nutrition supplementation has been estimated CONCLUSIONS to be three to four times the cost of a conditional CT This chapter reviews the evidence from CT programs program (Shekar, Heaver, and Lee 2006). throughout LMICs and their direct effects on the health Strong evidence indicates that CT programs keep and education outcomes of children and adolescents. It adolescent students enrolled in school longer. Some of also discusses the design of CT programs and why and these programs, but not all, have also been effective in how they could theoretically affect the outcomes of controlling the spread of HIV/AIDS among adolescents, young children and adolescents. It is very difficult to primarily by keeping them in school. Some experiments compare results across countries and contexts, because, with direct incentives to stay free of STIs have also been as illustrated in table 23.1, UCTs and CCTs have hetero- promising. However, further experiments with CCT geneous objectives, targeting, conditions applied to the programs and their implementation on a larger scale are transfer, amount of the transfer, and complementary needed before it can be concluded that they offer an services. CCT programs also differ because of country- efficient, scalable, and sustainable HIV/AIDS-prevention level differences in the supply of health services. For strategy. example, even if households comply with the specified In our review, CCTs generally showed greater effects conditions, increased use of health services may not than UCTs, although there were still far fewer UCTs than result in improved health outcomes if health services CCTs, so it is difficult to generalize. Moreover, UCTs are have poor infrastructure, high absenteeism, or inade- more common in Sub-Saharan Africa, while CCTs are quate supplies. Policy makers should not assume that CT more common in Latin America, so it is difficult to dis- programs will be the most efficient intervention for entangle the conditionalities from regional differences. improving the health outcomes of children and adoles- In a large review of studies examining CCTs versus cents. The specific context, design, and objectives of each UCTs, the largest effects on education outcomes were successful experience should be carefully considered found for programs that were explicitly conditional, had before it is replicated and implemented in other settings. a clear system for monitoring compliance, and had pen- Our review shows mostly positive effects of CT programs alties for noncompliance (Baird and others 2014). Thus, on some child outcomes, including birth weight; infant CT programs appear to be most effective when the mortality; illness or morbidity; and cognitive, language, receipt of cash is linked with a specific intervention that and behavioral development. Outcomes with large can maximize the potential impact of the transfer. mixed or subgroup effects included HAZ or stunting. However, there may be a limit to the number of condi- Outcomes with large null results included WAZ or tions that households can handle because of the 336 Child and Adolescent Health and Development possibilities for misunderstanding (Gaarder, Glassman, World Bank, Washington, DC. http://ejournal.narotama and Todd 2010). Moreover, programs with multiple .ac.id/files/North-South%20knowledge%20sharing%20 objectives may find that conditionality leads to greater on%20incentive-based%20conditional%20cash%20 improvements in some outcomes than in others. transfer%20programs.pdf. Agüero, J. M., M. R. Carter, and I. Woolard. 2009. “The Impact CCTs and UCTs attempt to break the cycle of pov- of Unconditional Cash Transfers on Nutrition: The South erty, but there are still many questions relating to how African Child Support Grant.” Paper prepared for the CCTs and UCTs function, how CCTs and UCTs differ North American Summer Meetings, Econometric Society, in effectiveness, what can be done to improve the Boston, MA, June 4–7. effectiveness of CT programs in general, and whether Ahmed, A. U., A. R. Quisumbing, M. Nasreen, J. Hoddinott, and the CCT model can be used throughout the world. E. Bryan. 2009. Comparing Food and Cash Transfers to the Future research relating to CTs could focus on a wide Ultra Poor in Bangladesh. Washington, DC: International range of topics: for example, examining the CT “black Food Policy Research Institute. box” to understand mechanisms and pathways linking Akresh, R., D. de Walque, and H. Kazianga. 2012. “Alternative program participation to child development out- Cash Transfer Delivery Mechanisms: Impacts on Routine comes; testing potential additions to CT programs Preventative Health Clinic Visits in Burkina Faso.” Working Paper 17785, National Bureau of Economic Research, (intensive parenting education, child care availability) Cambridge, MA. that could make the programs more effective, particu- ———. 2013. “Cash Transfers and Child Schooling: larly for child development; varying the CT amount or Evidence from a Randomized Evaluation of the Role program requirements to understand and identify of Conditionality.” Policy Research Working Paper 6340, potential threshold effects; understanding the contex- World Bank, Washington, DC. tual factors (community or household characteristics) ———. 2016. “Evidence from a Randomized Evaluation that could maximize the effectiveness of CTs; and of the Household Welfare Impacts of Conditional and modifying existing CT programs to have a greater Unconditional Cash Transfers Given to Mothers or focus on obesity and chronic disease prevention in Fathers.” Policy Research Working Paper 7730, World Bank, countries experiencing the nutrition transition, such Washington, DC. as many Latin America countries. With a greater Amarante, V., M. Manacorda, E. Miguel, and A. Vigorito. 2012. “Do Cash Transfers Improve Birth Outcomes? Evidence understanding of how and why CTs function, their from Matched Vital Statistics, Program, and Social Security effectiveness can be improved for children and adoles- Data.” Working Paper 17690, National Bureau of Economic cents throughout the world. Research, Cambridge, MA. Andersen, C. T., S. A. Reynolds, J. R. Behrman, B. T. Crookston, K. A. Dearden, and others. 2015. “Participation in the NOTE Juntos Conditional Cash Transfer Program in Peru Is World Bank Income Classifications as of July 2014 are as fol- Associated with Changes in Child Anthropometric Status lows, based on estimates of gross national income (GNI) per but Not Language Development or School Achievement.” capita for 2013: Journal of Nutrition 145 (10): 2396–405. Attanasio, O. P., E. Battistin, E. Fitzsimons, A. Mesnard, and • Low-income countries (LICs) = US$1,045 or less M. Vera-Hernández. 2005. “How Effective Are Conditional • Middle-income countries (MICs) are subdivided: Cash Transfers? Evidence from Colombia.” Briefing Note a) lower-middle-income = US$1,046 to US$4,125 54, Institute for Fiscal Studies, London. http://www.ifs.org b) upper-middle-income (UMICs) = US$4,126 to US$12,745 .uk/bns/bn54.pdf. • High-income countries (HICs) = US$12,746 or more. Attanasio, O. P., C. Fernandez, E. O. A. Fitzsimons, S. M. Grantham-McGregor, C. Meghir, and others. 2014. “Using the Infrastructure of a Conditional Cash Transfer Program to Deliver a Scalable Integrated Early REFERENCES Child Development Program in Colombia: Cluster Abdool Karim, Q., K. Leask, A. Kharsany, H. Humphries, Randomized Controlled Trial.” BMJ 349 (September 29): F. Ntombela, and others. 2015. “Impact of Conditional Cash g5785. Incentives on HSV-2 and HIV Prevention in Rural South Attanasio, O. P., and A. 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Cash Transfers and Child and Adolescent Development 341 Chapter 24 Identifying an Essential Package for Early Child Development: Economic Analysis Susan Horton and Maureen M. Black INTRODUCTION We use the term responsive stimulation when discuss- The eight other volumes in this third edition of Disease ing ECD interventions that highlight the importance of Control Priorities focus on health; this volume comple- positive interactions between children and caregivers. ments their focus by examining the synergies between Other terms are used in the literature, including parent- health and education outcomes. Most of the chapters in ing, caregiving, and psychosocial stimulation; these terms this volume focus on children ages five years and older imply a unidirectional concept, rather than the bidirec- and on adolescents. This chapter deals with children tional concept that underlies many theories of child younger than age five years, serving as a counterpart to development. the detailed analysis of young child health in volume 2 The most appropriate interventions vary according to (Black and others 2016). children’s ages. Children younger than age three years The importance and effectiveness of interventions to spend much of their time with parents, family members, enrich early child development (ECD) are discussed in or caregivers. Infants and young children need care and chapter 19 of this volume (Black, Gove, and Merseth 2017). adult attention, and the ratio of children per adult needs Surveys of the literature for low- and middle-income to be low, making group settings less feasible and more countries (LMICs) include Engle and others (2007), Engle costly. Between age three years and the age of school and others (2011), and Nores and Barnett (2010). entry, children are more likely to be in a group setting Recent literature has begun to consider the synergies in outside of the home for at least part of the day; delivering interventions focusing on nutrition or health 54 percent of this age group worldwide is enrolled in in conjunction with child development. Surveys have preschool (UNESCO 2015). This practice is dictated in examined whether codelivery enhances outcomes, reduces part by economics—the ratio of children per adult costs, and increases cost-effectiveness or benefit-cost supervisor can be higher—and by children’s develop- ratios (Batura and others 2014; Grantham-McGregor and mental needs as they begin to interact more with peers. others 2014). The main public services with which children younger This chapter examines the costs and benefit-cost than age three years interact are those for health, ratios of interventions that incorporate responsive stim- nutrition, and social protection. Young children can ulation to achieve better child outcomes. The purpose is benefit from community-based interventions (Singla, to develop and cost an essential package of ECD inter- Kumbakumba, and Aboud 2015), but these interven- ventions appropriate across LMICs that will comple- tions do not generally have national coverage. Delivering ment health and nutritional interventions. interventions for responsive stimulation in coordination Corresponding author: Susan Horton, University of Waterloo, Ontario, Canada; sehorton@uwaterloo.ca. 343 with health and nutrition services for these younger A second, more specific, search was undertaken in July children may be an effective approach in this age group. 2015 with additional search terms (annex 24A) that After age three years, it is more appropriate to inte- yielded three relevant articles, two of which contained grate health and nutrition interventions into preschools benefit-cost or unit cost information. Other articles were and schools because children have few regularly sched- obtained through consultation with experts, searches of uled health visits unless they are ill. Accordingly, our bibliographies of relevant articles, and searches of gray discussion of the economics of ECD is divided into the literature. two age groups: children younger than age three years In all, 11 articles that provide economic estimates and children ages three to five years. were identified. One contained information on Factors other than age also affect the best way to benefit-cost ratios only, three on unit cost only, and deliver interventions. The likelihood that children par- seven on both. These articles cover a broad range of ticipate in preschool depends on income. Enrollment in LMICs, although coverage of Latin America and preschool is lower in poorer countries and higher the Caribbean was the most in-depth (five studies). One in richer ones; within countries, enrollment is higher in study was found for multiple countries in the Middle families in the highest wealth quintile compared with East, two for Turkey, one for Mozambique, and one for other quintiles (UNESCO 2015). Enrollment in group Pakistan, and one covers a broad range of LMICs. settings is likely to be higher in urban areas than in areas Although South-East Asia has large preschool programs of lower population density. This means that program and center-based care programs, no articles providing design has potential impacts on equity—urban and economic estimates were found for that region. rural areas and countries at different income levels may The 11 identified studies of the economics of ECD need different services. cover regions similar to those addressed in the larger This chapter focuses on responsive stimulation inter- literature on effectiveness of ECD discussed in chapter ventions delivered through health and nutrition services 19 in this volume (Black, Gove, and Merseth 2017). A for young children when they are usually accompanied survey and meta-analysis of the effectiveness literature by family members and preschool experiences for chil- outside Canada and the United States was undertaken dren ages three to five or six years. We do not discuss day by Nores and Barnett (2010). They restricted their care arrangements for younger children at length because coverage to experimental studies and to quasi-experi- they tend to be more informal and not necessarily of mental studies with stronger designs, identifying 28 high quality, at least for Latin America and the Caribbean studies in 13 countries (4 in Latin America and the (Berlinski and Schady 2015). Because of the degree of Caribbean, 4 in Asia, 3 in Western Europe, and 1 each in dispersion, high required staff-to-child ratios, and Mauritius and Turkey). Four of the programs identified problems in monitoring (Leroy, Gadsden, and Guijarro in Nores and Barnett’s (2010) survey are also covered in 2012), day care is not an easy modality by which to the economic literature—the interventions in Bolivia, deliver interventions to improve responsive stimulation. Jamaica, Turkey, and Uruguay that are discussed in the We also do not cover interventions specifically intended next two sections. It is a noticeable omission that no to address the mental health of caregivers; mental health effectiveness and benefit-cost studies are available for is the subject of volume 4 (Patel and others 2015). Sub-Saharan Africa. We first briefly discuss the methods used for the liter- Our survey of cost and benefit-cost is therefore likely ature search and the results on costs per child and to be fairly representative of the larger literature on effec- benefit-cost ratios of interventions. We use this informa- tiveness, and there is overlap of actual programs covered. tion to develop and cost an essential package and to We know quite a lot about the few programs that have derive some brief conclusions. Definitions of age-specific been the subject of well-designed research studies. These groupings and age-specific terminology used in this vol- programs may be more effective than the average, but ume can be found in chapter 1 (Bundy and others 2017). because they are more intensive, they may cost more. The same would be true for the United States, where the Perry Preschool Project, Head Start, and the Abecedarian METHODS Project were intensively studied, with long-term fol- We began with a systematic search of the published liter- low-up. Other programs that have not been studied may ature. The original searches of the literature for this be less costly, but they may also be less effective and less volume undertaken in July 2014 and January 2015 did cost-effective. However, the objective should be to try to not yield any cost-effectiveness or benefit-cost studies replicate good-quality, effective programs. for preschool children (Horton and Wu 2016), most The literature on both effectiveness and economic likely because the search terms were not specific enough. aspects also has a regional bias. Studies focus more on 344 Child and Adolescent Health and Development middle-income countries; in particular, we know very showed them to parents waiting in health centers, fol- little about cost and effectiveness in Sub-Saharan Africa, lowed by group discussion, was 5.3 (Walker and others where coverage is lowest and expansion of coverage is 2015). In Pakistan, a randomized controlled trial com- most needed. pared nutrition alone, responsive stimulation alone, and the two combined against a control receiving usual care (Gowani and others 2014). The combined option BENEFIT-COST RATIOS OF EARLY CHILD had the best outcome and cost less than the other two DEVELOPMENT INTERVENTIONS interventions. The lower costs were unrepresentative of an intervention at scale because they were due to two Children Younger than Age Three Years vacant supervisor positions, and the research study may Recent studies have examined the effectiveness of com- have helped compensate for the absence of usual levels bined health, nutrition, and early childhood interven- of supervision. tions in LMICs for children, typically younger than age López Boo, Palloni, and Urzua (2014) estimated a three years (Grantham-McGregor and others 2014; benefit-cost ratio of 1.5 for an intervention in Nicaragua Nores and Barnett 2010). Table 24.1 presents our benefit- that combined responsive stimulation and a nutrition cost findings based on our literature search. intervention of multiple micronutrient powders for chil- Two randomized controlled trials for Pakistan and dren younger than age three years. However, the entire the Caribbean had positive economic evaluations. The benefit is based on reduction of anemia, which is likely benefit-cost ratio for an intervention in Antigua, to be predominantly due to the nutrition intervention; Jamaica, and St. Lucia that developed videos and it does not take into account any cognitive benefits Table 24.1 Benefit-Cost Ratios of Early Child Development Interventions Benefit-cost ratio Study Country or region Comments (d = discount rate) Ages zero to two years Berlinski and Schady 2015 Latin America Home visits; modeled costs and returns, using 3 percent 3.6 (Guatemala) discount rate. Outcomes: child cognitive skills; mother’s 2.6 (Colombia) employment. 3.5 (Chile) Walker and others 2015 Jamaica, St. Lucia, Antigua Details not yet published; summary results cited in 5.3 Berlinski and Schady 2015.a Gowani and others 2014 Pakistan Parenting intervention took advantage of spare capacity Not calculated, but (home visits without intervention were “too short”); combined nutrition and combined intervention was less costly because two parenting very favorable regular supervisory posts vacant; likely not replicable in nonresearch setting.a López Boo, Palloni, and Nicaragua Benefit-cost ratio is for combined effect of Sprinklesb 1.5 Urzua 2014 and early child development, but effect calculated on the basis of anemia (likely to be primarily effect of Sprinkles).a Ages three to five years: Preschool programs Behrman, Cheng, and Todd Bolivia Range depends on assumptions about gain in earnings 2.28–3.66 (d = 3%) 2004 from increased educational attainment, and cost of 1.37–2.48 (d = 5%) education.a Berlinski and Schady 2015 Latin America Modeled benefits (child cognitive skills hence future 5.1 (Guatemala) earnings, and mother’s employment) compared to 3.4 (Colombia) preschool costs. 4.3 (Chile) Berlinski, Galiani, and Uruguay Modeled benefits of increased school grade completion, 19.1 (d = 3%) Manacorda 2008 net of cost of preschool and additional school cost. 3.2 (d = 10%) table continues next page Identifying an Essential Package for Early Child Development: Economic Analysis 345 Table 24.1 Benefit-Cost Ratios of Early Child Development Interventions (continued) Benefit-cost ratio Study Country or region Comments (d = discount rate) Engle and others 2011 73 low- and middle-income Modeled change in wages due to increased school 14.3–17.6 (d = 3%) countries attainment, associated with increased preschool 6.4–7.8 (d = 6%) participation. Includes additional preschool cost but not school cost. Kaytaz 2004 Turkey Considers cost of preschool education plus forgone 2.18–3.43 (d = 6%) earnings of students staying longer in school. Range 1.12–1.69 (d = 10%) depends on assumptions on share continuing to tertiary education.a Note: For details of interventions, see table 24.2. Berlinski and Schady (2015) also model the benefit-cost ratio of day care provision to children ages zero to five years as 1.2 (Guatemala), 1.1 (Colombia), and 1.5 (Chile), also using a modeling exercise and discount rate of 3 percent. Psacharopoulos (2015) provides benefit-cost estimates of 3:1 for preschool in the Philippines citing Patrinos (2007), and 77:1 in Kenya, citing Orazem, Glewwe, and Patrinos (2009). Patrinos (2007) cites Glewwe, Jacoby, and King (2001), which is a study of the return to nutrition interventions in preschools in the Philippines; and Orazem, Glewwe, and Patrinos (2009) cite Vermeersch and Kremer (2004), which is a study of the return to school meals in Kenya. We have not included these estimates. a. Measured outcomes are described in table 24.2. b. Sprinkles is a brand of multiple micronutrient powders. resulting from responsive stimulation. Finally, one study and it is not clear that Psacharopoulos (2015) accounted for Latin America and the Caribbean models the effect for the cost of the breakfast in the calculations. of a home visiting program that educates mothers in The benefit-cost ratios estimated for LMICs are child development (Berlinski and Schady 2015); how- slightly lower than those estimated for well-known pre- ever, this program is not combined with a nutrition or school studies in the United States, which ranged from health intervention. Benefit-cost ratios for the three 2.7 to 7.2 for three programs (Temple and Reynolds countries ranged from 2.6 to 3.6. There may be other 2007). One difference is that the type of longitudinal benefit-cost studies of home visiting programs in LMICs studies available in the United States has not been con- that we did not survey given that our search focused on ducted in LMICs; Gertler and others (2014), one of the combined programs that included health interventions. first, is a 20-year follow-up to a seminal intervention in More economic studies of combined interventions Jamaica. For LMICs, there are estimates of the benefits in would be helpful. cognitive achievement, school attainment, and wages. There are few data, however, on some of the substantial costs avoided by quality preschool programs in the Children Ages Three to Five Years United States, such as the costs of crime. LMIC estimates There is a larger literature on preschool programs than probably underestimate the benefits of ECD interven- on programs for younger children (table 24.1). Benefit- tions; Gertler and others (2014) found large effects on cost ratios of preschool for five countries—Bolivia, wages for Jamaica that were associated with increases in Chile, Colombia, Turkey, and Uruguay—generally international migration for the treated group. exceeded 3 (using a discount rate of 3 percent or higher); Comparing across all programs irrespective of child in Uruguay, the benefit-cost ratio was 19.1, using a dis- age, the benefit-cost ratio of integrated programs tends count rate of 3 percent. Benefit-cost ratios for preschool to be higher than that of stand-alone programs. This ages remained generally greater than 1 for discount rates outcome may be due in part to lower marginal costs of up to 10 percent. A cross-country study generated a the intervention, as well as possible synergies in out- benefit-cost ratio of 14.3–17.6, but it did not incorporate comes. This inference relies on four studies (Gowani and the requisite additional costs of greater school enroll- others 2014; López Boo, Palloni, and Urzua 2014; Walker ment (Engle and others 2011). and others 2015; and a subsequent interpretation by A nutritional add-on to preschool—a breakfast of Psacharopoulos 2015 of Vermeersch and Kremer 2004). porridge—generated an extraordinarily high benefit-cost Because two of these are not or not yet published ratio of 77 in Kenya (Psacharopoulos 2015, citing (Walker and others 2015; Vermeersch and Kremer 2004), Orazem, Glewwe, and Patrinos 2009, who in turn use and the study designs of the other two have unique Vermeersch and Kramer 2004). However, the underlying features, additional studies are needed to confirm this empirical study does not appear to have been published, tendency. 346 Child and Adolescent Health and Development somewhat more standardized, but preschool programs UNIT COST OF INTERVENTIONS also vary in intensity, for example, hours per week and Unit cost data are presented in table 24.2. There are some ratio of children to teachers. inconsistencies in the data, for example, Araujo, López Costs are updated to 2012 U.S. dollars to permit com- Boo, and Puyana (2013) reported financial costs that do parisons, and comparing costs as a percentage of per not take account of volunteers, donations, and parental capita gross national income (GNI) is also useful. contributions. Programs for younger children are more Berlinski and Schady (2015) and van Ravens and Aggio heterogeneous in structure. They vary from day care (2008) model costs, arguing that the salary of an ECD (Araujo, López Boo, and Puyana 2013; Behrman, Cheng, educator has approximately a constant relation to the and Todd 2004), to programs to educate mothers of salary of a primary teacher; that primary teachers’ sala- children ages five and six years in groups (Chang and ries have a predictable relationship to GNI; and that the others 2015; Sirali, Bernal, and Naudeau 2015), to home educator-to-child ratio is fairly predictable, depending visits (Gowani and others 2014; van Ravens and Aggio on child age (very high for day care, lower for preschool, 2008). What is covered in the costs for preschool and lower still for group education programs for parents programs is more uniform because the programs are and caregivers). Table 24.2 Unit Costs of Early Child Development Interventions Annual cost Annual per child cost per as share Country or Cost in Currency child in of GNI Study region Intervention and outcomes measured study Unit (year) 2012 US$ (percent) Ages zero to two years Araujo, López Latin Financial costs for four parenting programs 188 Child per US$ 220 2.2 for Boo, and America across Latin America and the Caribbean, (median) year median Puyana 2013 and the ranging from US$13 to US$599 per child; countries Caribbean median = Mexico and Ecuador. No outcome measured. Walker and Antigua, Parents were shown a video on responsive 100 Child over 2012 US$ 100a 2.0 others 2015 Jamaica, stimulation at routine health visits, engaged in 15-month and St. Lucia group discussion, and received small books and period puzzles to use at home. Outcome: parenting scale, Griffith Mental Development Scale, Communicative Development Index. Gowani and Pakistan Lady Health Workers (who provide health and 4 Child per 2012 US$ 48 3.8 others 2014 nutrition advice in home visits) were trained month, to also give responsive stimulation; also birth to 24 monthly group meetings held with mothers; 2x2 months factorial design. Outcomes: cognition, motor, language scores. López Boo, Nicaragua PAININ program provided three-hour care 37 Child per 2012 US$ 37 2.1 Palloni, and per day in centers (with ECD and Sprinklesb) year Urzua 2014 in urban areas; home parenting visits twice a week in rural areas by volunteer mothers. Outcomes: anemia, hemoglobin, verbal and numeric memory. van Ravens and Middle East Home visiting: develop formula that cost per 85 in Child per 2006 US$ 117 2.3 Aggio 2008 child is 16/(total fertility rate), as % of per median year capita GDP; range of costs US$13–US$1,393 country for 19 countries. No outcomes. (Jordan) table continues next page Identifying an Essential Package for Early Child Development: Economic Analysis 347 Table 24.2 Unit Costs of Early Child Development Interventions (continued) Annual cost Annual per child cost per as share Country or Cost in Currency child in of GNI Study region Intervention and outcomes measured study Unit (year) 2012 US$ (percent) Ages three to five years Araujo, López Latin Financial costs from 28 child care programs, 836 median Child per 2010 US$ 977 10 for Boo, and America ranging from US$257 to US$3,264 per child; year median Puyana 2013 and the median = Mexico and Ecuador. No outcomes countries Caribbean measured. Behrman, Bolivia PIDI: provides day care to children ages 6–72 43 Child per 1996 US$ 600 26.0 Cheng, and months in poor, largely urban areas; 40 percent month Todd 2004 of cost is food. Outcomes: motor, language, psychosocial skills; nutritional status. Berlinski, Uruguay Government-provided preschool for ages four 1,164.80 Child per 1997 198 1.4 Galiani, and to five years. Outcomes: subsequent school (US$129.10) year Uruguayan Manacorda attainment. pesos 2008 Kaytaz 2004 Turkey Preschool. Outcomes: subsequent school 886,424,000 Child per 2002 Turkish 1,245 11.5 attainment. (US$552) year liras Martinez, Mozambique Preschool for three and a quarter hours per day; 25 (pilot); 50 Child per 2010c US$ 50 (at 9.4 Naudeau, and cost in pilot phase (Martinez, Naudeau, and scale up year c 2012 US$ scale-up) Pereira 2012; Pereira 2012) was only half of cost in scale up Sirali, Bernal, (Sirali, Bernal, and Naudeau 2015). Outcomes: and Naudeau subsequent enrollment in primary school; 2015 scores on various development tests; spillover to older sibling school enrollment and parents’ work time. Sirali, Bernal, Turkey MOCEP 25-week training program for mothers 40 Participant 2010 US$ 90a 0.8 and Naudeau and children ages five to six years; lectures (25 weeks) 2015 and discussions once per week, kits for use at home, home visits by trainers. No outcomes discussed. van Ravens and Middle East Preschool: develop formula that cost per child 239 median Child per 2006 US$ 330 6.5 for Aggio 2008 is 12.5 percent of per capita GDP; range of country year median costs US$54–US$3,482 for 19 countries. No Jordan country outcomes discussed. Note: ECD = early child development; GDP = gross domestic product; GNI = gross national income; MOCEP = Mother and Child Education Program; PAININ = Comprehensive Childcare Program; PIDI = Programa de Atención Integral a la Niñez Nicaragüense, Proyecto Integral de Desarollo Infantil. a. Cost is for duration of program per child; duration is not exactly one year. b. Sprinkles are a brand of multiple micronutrient powders. c. Original authors do not specify dates; these are estimated by current authors. Berlinski and Schady (2015) explained that the cost structural quality programs, although Berlinski and of preschool programs varies systematically with process Schady (2015) argued that the benefit-cost ratio of quality. More intensive supervision adds about enhancing process quality is likely higher than that of 10 percent to the cost of preschool programs, while enhancing structural quality. This is, however, a con- structural quality—quality of buildings, higher pay for tested literature, because trained teachers who can teachers, smaller class sizes—can add up to 300 percent improve process quality may not stay long in low-quality to the basic cost of preschool programs. The data are school environments, such as those with dilapidated insufficient to examine the benefit-cost ratio variations buildings. Vermeer and others (2016) undertook an of basic, improved process quality, and improved international meta-analysis and commented on how 348 Child and Adolescent Health and Development different factors affect a measure of program quality that children ages three to five years provides group parental can be measured by observers, and in turn is known to education for mothers of older children (Sirali, Bernal, correlate with longer-term outcomes. and Naudeau 2015), the Mother and Child Education Program in Turkey. This program has been widely dis- seminated to other countries. Children Younger than Age Three Years The cost of integrating a component on responsive stim- ulation with regular visits for nutrition and health is THE ESSENTIAL PACKAGE AND ITS COST more modest than that of establishing either a day care or a preschool program. Table 24.2 provides unit cost Assumptions data for five programs for younger children that primar- Parenting programs are more likely to be oriented to ily seek to benefit mothers and children in their homes or children younger than age three years and to entail the in community-based day care with volunteer mothers. participation of mothers. The Mother and Child Programs for younger children vary considerably in Education Program delivered to mothers of older chil- their format, and annual costs per child range from dren is somewhat unusual in this respect (Sirali, Bernal, about 0.8 percent of per capita GNI for financial costs of and Naudeau 2015). Some parenting programs are deliv- day care and home visit programs in Latin America and ered to groups of mothers (see table 24.2 for examples the Caribbean, as well as a mother-child education pro- for the Caribbean and Turkey); others are delivered pri- gram in Turkey, to 3.8 percent of per capita GNI for a marily through home visits (see table 24.2 for examples home visit program in Pakistan. The median share of per from the Middle East and Latin America and the capita GNI is 2.2 percent. Programs tend to cost more Caribbean); and hybrid programs use both group and per child in absolute amount as country income increases home visit components (see table 24.2 for one program because salaries increase, and where the educators are in Pakistan). Preschool programs typically focus on ages paid rather than serve as volunteers. Home visit pro- three to five years, although they may include younger grams cost more than programs in which groups of children. mothers attend centers for parenting education. The cost of ECD programs is driven primarily by However, center-based programs may simply transfer salary costs. Costs depend on several factors, including the costs of attendance to families rather than trainers, the ratio of educators to children, country GNI because and these programs may reduce participation by those in salaries tend to increase with country income, and the poorer households or those living in more remote specific design of individual programs. locations. Program type has a substantial impact on cost because there are systematic differences in the ratio of staff to children and families. Parenting programs provided to Children Ages Three to Five Years groups can have higher child-to-staff ratios than those Preschool programs are more costly than programs involving home visiting; the lowest ratios observed are involving educating mothers or caregivers. The annual for preschool programs, where teachers educate children costs per child range from 1.4 percent of per capita GNI rather than parents. The ratios might be approximately in Uruguay to 26 percent in Bolivia. However, the very 50 to 1, 25 to 1, and 12 to 1, respectively (estimate based lowest and highest costs are probably outliers. The on Araujo, López Boo, and Puyana 2013; Gowani and Uruguay program is in an upper-middle-income coun- others 2014; and van Ravens and Aggio 2008). Based on try and provides a half-day program, which may reduce these staffing ratios, we estimate that home visiting pro- costs, while the program cost in Bolivia is 16 percent of grams might cost about twice as much per child as group per capita GNI if cost of food is excluded. The median parenting programs, while preschool programs might cost is approximately 10 percent of per capita GNI. This cost about four times as much per child as group parent- amount is roughly consistent with a formula developed ing programs. All three types of programs—parenting by van Ravens and Aggio (2008), who used salaries and programs, home visiting programs, and preschool staff-to-child ratios and estimated the cost to be programs—may vary in effectiveness. 12.5 percent of gross domestic product (GDP). Preschool Similarly, we can estimate that the per capita income of programs are consistently more costly than group par- lower-middle-income countries is about three times that of enting education because of the higher staff-to-child low-income countries, and that of upper-middle-income ratio that is necessary. countries is about nine times that of low-income countries, Parenting programs are less common in this age using the World Bank definitions. Table 24.2 includes group, but one program summarized in the table for information from one low-income country, Mozambique. Identifying an Essential Package for Early Child Development: Economic Analysis 349 We developed the following estimates for costs per services. This program could be conventional (in person) child per year in 2012 U.S. dollars, based on table 24.2, or could take advantage of innovative methods, such as also using the ratios discussed: videos combined with facilitated group discussion. Parenting programs could be integrated into existing • Group parenting programs: US$30–US$35 per home visiting programs that provide health services, in child in lower-middle-income countries and US$90– which case the program could be offered instead of or in US$100 per child in upper-middle-income countries combination with group delivery. The programs should be • Home visiting programs: US$60–US$70 per child provided in one year of the child’s first three years, prefer- in lower-middle-income countries and US$200 per ably as early as possible to have the greatest impact. child in upper-middle-income countries Countries might also choose to implement the pro- • Preschool programs: US$300 per child in lower- gram differently in different regions, providing group middle-income countries and US$600 per child in sessions in more densely populated areas and home visits upper-middle-income countries. to more remote households and to poorer households. Costs will increase as the proportion receiving home We have no data for low-income countries in Sub- visits increases, but equity and impact will also increase. Saharan Africa, other than one preschool program that Programs must have a certain intensity to have an cost US$50 per child per year for a three hour per day impact. In the Caribbean pilot (Walker and others 2015), program once the program moved beyond the pilot mothers participated in group discussions five times phase. over approximately 15 months; each session took about These estimates are roughly consistent with the coun- 25 minutes of the mother’s time (a combination of view- try data (table 24.2) and the staffing ratios presented. ing a video and participating in a group discussion, with Costs for individual countries will vary with per capita one-on-one reinforcement during the visit with the GNI and program design. It is always possible to make nurse). In Pakistan, mothers received home visits of programs cheaper by, for example, reducing intensity or approximately 30 minutes about once a month, and the using volunteers, but doing so can be detrimental to pilot program followed children in their first two years effectiveness. We assume that programs delivered to of life (Gowani and others 2014). In Latin American mothers need to be delivered once per lifetime of chil- programs, parents generally met with community work- dren, whereas children may participate in preschool ers for slightly more than an hour a week for 10 months programs for two or three years until they begin formal of the year over a two-year period (Araujo, López Boo, schooling. The cost of US$30–US$35 for a group parent- and Puyana 2013). A group program in Uganda for both ing program per child born is modest compared with the parents that entailed 12 sessions is discussed in chapter larger investment in health per child born. Routine 19 in this volume (Black, Gove, and Merseth 2017); the immunization alone with six or more vaccines now costs content of the parenting programs is also important. US$46.50 per fully immunized child (Brenzel, Young, Programs that do not have sufficient quality and inten- and Walker 2015; see Black and others 2016). sity will not be effective. Evidence from programs (table 24.1) suggests that the benefit-cost ratio of a well-designed and well- Preschool Programs implemented program is in the range of 2–5, using a Evidence suggests that children are more ready for modest 3 percent to 5 percent social discount rate. school cognitively, socially, and emotionally if they have Although some benefit-cost estimates are higher than preschool education; this is particularly important for these, they may be from studies that underestimate the children from more vulnerable households. The esti- full program cost. mated cost per child is US$300 per child per year in lower-middle-income countries and US$600 per child per year in upper-middle-income countries. We assume Recommendations for an Essential Package that governments would subsidize or pay the full cost of Based on considerations of cost, our subjective assess- this education for vulnerable households but require ment of feasibility, and benefit-cost, we recommend the parental contribution or full payment for more affluent following. households. This approach is more common in upper-middle-income countries. Essential Package When estimating preschool costs, van Ravens and Countries should aim to cover all first-time parents (at a Aggio (2008) assume a half-day program and use a ratio minimum) and all births (preferably) with a group parent- of 20 children per teacher. UNICEF (2008) recommends ing program that is integrated into the provision of health 15 hours per week and a 15:1 maximum ratio, but even 350 Child and Adolescent Health and Development many countries in Europe do not achieve this goal, and are critical. If ECD is seen as a low-cost add-on to exist- this objective would certainly imply higher costs than ing health and nutrition programs, and current staff is provided here. overburdened by yet more tasks, the outcomes are likely to be of low quality. Well-designed and well-supervised interventions can affordably improve the likelihood that vulnerable children will be better able to reach their full CONCLUSIONS potential. Codelivery of health, nutrition, and responsive stimula- tion programs can benefit child development and be cost-effective. For children younger than age three years, ANNEX codelivery is best achieved by integrating responsive The annex to this chapter is as follows. It is available at stimulation elements into existing health and nutrition http://www.dcp-3.org/CAHD. programs. For children ages three to five years, codeliv- ery can be achieved by integrating health and nutrition • Annex 24A. Literature Search Terms and Methods interventions into preschool programs. For children younger than age three years, group par- enting programs cost about US$30–US$35 per year in ACKNOWLEDGMENT lower-middle-income countries, and about twice that if home visiting is included. Some home visiting is likely to The authors would like to thank Vittoria Lutje for run- be required to reach some populations and improve equity. ning the systematic searches, Florencia López Boo for The benefit-cost ratio for existing programs ranges from providing helpful references, and Daphne Wu for pro- about 2:1 to about 5:1. Group parenting programs need viding excellent research assistance. facilitators but can also incorporate media, such as videos. Preschool programs cost about US$300 per child in lower-middle-income countries, and the benefit-cost NOTE estimates for existing programs similarly range from World Bank Income Classifications as of July 2014 are as fol- about 2:1 to 5:1 (higher benefit-cost ratios have been lows, based on estimates of gross national income (GNI) per obtained, but typically where costs are underestimated). capita for 2013: Countries can usually afford to subsidize preschool for only selected groups, such as poor households and mar- • Low-income countries (LICs) = US$1,045 or less ginalized groups. • Middle-income countries (MICs) are subdivided: Programs for individual children and families need to a) lower-middle-income = US$1,046 to US$4,125 be complemented by appropriate national policies for b) upper-middle-income (UMICs) = US$4,126 to US$12,745 child development. 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Identifying an Essential Package for Early Child Development: Economic Analysis 353 Chapter 25 Identifying an Essential Package for School-Age Child Health: Economic Analysis Meena Fernandes and Elisabetta Aurino INTRODUCTION As chapter 20 notes, health services for school-age This chapter presents the investment case for providing an children can promote educational outcomes, including integrated package of essential health services for children access, attendance, and academic achievement, by mitigat- attending primary schools in low- and middle-income ing earlier nutrition and health deprivations and by countries (LMICs). In doing so, it builds on chapter 20 in addressing current infections and nutritional deficiencies this volume (Bundy, Schultz, and others 2017), which (Bundy, Schultz, and others 2017). This age group is partic- presents a range of relevant health services for the school- ularly at risk for parasitic helminth infections (Jukes, Drake, age population and the economic rationale for adminis- and Bundy 2008), and malaria has become prevalent in tering them through educational systems. This chapter school-age populations as control for younger children identifies a package of essential health services that low- delays the acquisition of immunity from early childhood to and middle-income countries (LMICs) can aspire to school age (Brooker and others 2017). Furthermore, school implement through the primary and secondary school health services are commonly viewed as a means for build- platforms. In addition, the chapter considers the design ing and reinforcing healthy habits to lower the risk of non- of such programs, including targeting strategies. Upper- communicable disease later in life (Bundy 2011). middle-income countries and high-income countries This chapter focuses on packages and programs to reach (HICs) typically aim to implement such interventions on school-age children, while the previous chapter, chapter 24 a larger scale and to include and promote additional health (Horton and Black 2017), focuses on early childhood inter- services relevant to their populations. Studies have docu- ventions, and the next chapter, chapter 26 (Horton and mented the contribution of school health interventions to others 2017), focuses on adolescent interventions. These a range of child health and educational outcomes, partic- packages are all part of the same continuum of care from ularly in the United States (Durlak and others 2011; Murray age 5 years to early adulthood, as discussed in chapter 1 and others 2007; Shackleton and others 2016). Health (Bundy, de Silva, and others 2017). A particular emphasis services selected for the essential package are those that of the economic rationale for targeting school-age children have demonstrated benefits and relevance for children in is to promote their health and education while they are in LMICs. The estimated costs of implementation are drawn the process of learning; many of the interventions that are from the academic literature. The concept of a package of part of the package have been shown to yield substantial essential school health interventions and its justification benefits in educational outcomes (Bundy 2011; Jukes, through a cost-benefit perspective was pioneered by Drake, and Bundy 2008). They might be viewed as health Jamison and Leslie (1990). interventions that leverage the investment in education. Corresponding author: Meena Fernandes, Partnership for Child Development, Imperial College, London, United Kingdom; meenaf@gmail.com. 355 Schools are an effective platform through which to overview of low-cost interventions in each domain and the deliver the essential package of health and nutrition ser- possible delivery platforms identified in the literature. vices (Bundy, Schultz, and others 2017). Primary enroll- Although interventions promoting psychosocial ment and attendance rates increased substantially during health may be beneficial for primary-school-age the Millennium Development Goals era, making schools children, most studies focus on secondary school a delivery platform with the potential to reach large num- and adolescents. Interventions delivered through bers of children equitably. Furthermore, unlike health population-based mechanisms, such as the media, are centers, almost every community has a primary school, likely targeted to decision makers and to adolescents and teachers can be trained to deliver simple health inter- rather than children. For some conditions, such as oral ventions, resulting in the potential for high returns for health, identification and prevention may be through relatively low costs by using the existing infrastructure. one platform (schools or communities), and remedial This chapter identifies a core set of interventions for treatment may be through another (primary children ages 5–14 years that can be delivered effectively health centers). through schools. It then simulates the returns to health and Most of the interventions have potential impacts on education and benchmarks them against the costs of the education as a consequence of improvements in health, intervention, drawing on published estimates. The invest- although the specific pathways vary. Providing meals in ment returns illustrate the scale of returns provided by schools may help mitigate the energy intake gap for chil- school-based health interventions, highlighting the value dren experiencing low to moderate undernutrition, of integrated health services and the parameters driving thereby promoting overall health status and school costs, benefits, and value for money (the ratio of benefits to participation. The regular provision of iron-folate pills costs). Countries seeking to introduce such a package need or meals fortified with micronutrient powders may to undertake context-specific analyses of critical needs to reduce the prevalence of anemia and so improve cogni- ensure that the package responds to the specific local needs. tive ability, thereby improving school attendance and learning. Correcting refractive error may have a direct CONDITIONS AND POSSIBLE impact on future economic productivity by improving learning and academic achievement. INTERVENTIONS The benefits of interventions such as oral hygiene and Possible interventions for the essential package were con- vaccines are related primarily to health. Although most sidered from the perspective of four domains of child vaccines are delivered in early childhood, primary development. Three of which (physical, nutrition, and schools can be optimal delivery platforms for primary psychosocial) pertain primarily to health, and one (cogni- doses of the human papillomavirus (HPV) vaccine tion) primarily to education. Table 25.1 presents an and booster doses of tetanus vaccine (LaMontagne and Table 25.1 Platforms for Delivering School-Based Health Interventions Platform Domain Population level Community School Primary health center Physical health Education Refractive error Deworming; insecticide- Deworming; insecticide- treated bednets; malaria treated bednets; chemoprevention; tetanus toxoid tetanus toxoid and HPV and HPV vaccination; oral vaccination; oral health health prevention; sex education and dentistry messages; refractive error Nutrition Nutrition education Micronutrient Micronutrient supplementation; Micronutrient messages supplementation; multifortified foods; school supplementation multifortified foods feeding; nutrition education messages Psychosocial Mental health n.a. Mental health education and Mental health counseling messages counseling Cognition Conditional cash School promotion Vision screening Vision screening transfers Note: HPV = human papillomavirus; n.a. = not applicable. Interventions in bold are covered in this chapter. 356 Child and Adolescent Health and Development others 2017), while health centers can target out-of- primary school, with the selected grade containing the school children and marginalized girls. In a global sur- largest share of the target age group. vey, 95 of 174 countries used schools to deliver some The package includes hygiene education, but not vaccines, but the prevalence was much lower among the water and sanitation components of WASH. This LMICs than HICs, 28 percent and 64 percent, respec- decision reflects the high cost of intervention, espe- tively (Vandelaer and Olaniran 2015). Effective immuni- cially the construction of water supply infrastructure zation from tetanus requires several doses in infancy and school facility infrastructure and maintenance through early childhood, with boosters in middle child- (Snilstveit and others 2015)-the costs of which would hood (around ages 4–7 years) and adolescence (ages exceed the costs of all other candidate interventions for 12–15 years). The World Health Organization (WHO) the essential package. recommends delivering tetanus-diphtheria toxoid com- Table 25.2 estimates the burden of conditions treat- bination immunizations rather than a single antigen able by interventions in the essential package in LMICs, tetanus toxoid (WHO 2006). At least 80 countries underscoring the potential global impact of school- include the tetanus toxoid and booster immunizations in based health services. school-based programs, making it the vaccine most commonly delivered through schools (Vandelaer and Olaniran 2015) and part of the essential package. An estimated 80 percent of the global burden of cer- ESTIMATING THE COSTS vical cancer is concentrated in LMICs, underscoring the Table 25.3 summarizes the evidence on the costs and relevance of the HPV vaccine as a preventive measure. outcomes of interventions in the essential package. The The essential package promotes the administration of estimates typically focus on average annual costs two doses of the HPV vaccine to girls in a given grade in incurred in delivering the intervention; they exclude Table 25.2 Burden of Conditions Affecting the Health and Development of School-Age Children Domain and condition or infection Estimated school-age population at risk Possible interventions Physical health Schistosoma and STHs, including Schistosomiasis: 207 million cases globally Deworming treatment hookworm, roundworm, whipworm STHs: 870 million cases in 2014 a Malaria 568 million at risk globally; more than 200 million ITNs, intermittent preventive screening and cases of Plasmodium falciparum in ages 5–14 years administration of malaria chemoprevention, indoor in 2010 in Sub-Saharan Africa alone residual spraying Tetanus All school-age children Tetanus toxoid vaccine HPV All girls ages 9–14 years HPV vaccine Tooth decay 40 percent to 90 percent of children age 12 years Provision of toothbrushes, promotion of oral care, in LMICsb dental screening and referrals Nutrition Micronutrient deficiencies Anemia: 304.6 millionc Micronutrient powders, food fortification, micronutrient-rich foods Underweight Girls: 16 percent; boys: 25 percentd School feeding Cognition Uncorrected refractive error 13 millione Vision screening and provision of inexpensive eyeglasses Note: HPV = human papillomavirus; ITNs = insecticide-treated bednets; LMICs = low- and middle-income countries; STHs = soil-transmitted helminths. a. Fenwick 2012. b. Bagramian, Garcia-Godoy, and Volpe 2009. c. McLean and others 2009. d. Manyanga and others 2014. Seven African countries (Benin, Djibouti, the Arab Republic of Egypt, Ghana, Malawi, Mauritania, and Morocco) reported prevalence for students ages 11–17 years. e. Resnikoff and others 2008. Identifying an Essential Package for School-Age Child Health: Economic Analysis 357 Table 25.3 Costs of Potential Interventions Costs per year (2012 US$ unless otherwise noted) Cost per death Cost per DALY Domain Intervention Cost per child Cost per case averted averted averted Nutrition School mealsa 41 (2008) 100 kilocalorie gain: — n.a. 10.22 Micronutrient powder 2.92 (2014) Anemia: 8.59 — n.a. supplementationb Infectious disease Deworming: Mass drug 0.35 Helminth infection: n.a. 3.36–6.92 administrationc 0.93–5.28 Malaria: Intermittent parasite 1.88–4.03 (2009) (White Infection: 5.36–9 110–4,961 (2009) 24 (2009) clearanced and others 2011) (Horton and Wu 2015); 1.45–33 (2009) (White and others 2011); anemia: 29.84–50 (Horton and Wu 2015) Malaria: Insecticide treated 0.40 Infection: 10–48 950–2,500 (2009) 20–48 (2009) bednetsd Vision screening Refractive error screening and Ready-made glasses: 2–3; Poor vision: 0.71–1.07 — 84 provision of corrective glassese Screening kit: 9 each Oral health Toothbrush provision and 0.60 Caries reduction: 40 — n.a. educationf percent, 1.25 per child Vaccines Tetanus toxoid vaccineg 0.40 (2003) — 117 (2003) 3.61 (2003) HPV bivalent vaccineh Vaccine cost: 0.55–2.00 2,161–2,608 QALY gained for per dose for Gavi-eligible reduced cervical cancer countries; Delivery: risk: 4,500–8,890 (2011 4.88–6.73 per fully international $) vaccinated girl (2009) Note: — = not available; n.a. = not applicable; DALY = disability-adjusted life year; HPV = human papillomavirus; LMICs = low- and middle-income countries; QALY = quality-adjusted life year. a. Standardized cost of school meals in LMICs in 2008 US$ (Kristjanssen and others 2015). Cost is standardized to 401 kilocalories. School meals should contribute at least 30 percent to international recommendations, or 555 kilocalories. b. Cost estimate from Stopford and others, forthcoming. Cost per case averted was calculated assuming that micronutrient powders reduce anemia by 34 percent, based on a review of the evidence (Salam and others 2013). c. Cost per case averted from Horton and Wu 2015. d. Cost per death and DALY averted from Horton and Wu 2015; White and others 2011. e. Cost per DALY for ages 5–10 years from Baltussen, Naus, and Limburg 2009. Cost per case averted assumes that eyeglasses have a useful lifespan of four years, one teacher has one kit for 165 schoolchildren, and compliance is 70 percent, similar to Baltussen, Naus, and Limburg 2009. f. Monse and others 2013. g. Griffiths and others 2004. h. Change in recommendation from a three-dose to a two-dose schedule is likely to improve cost-effectiveness. Gavi eligibility is based on average gross national income. At least 54 LMICs qualify for support (http://www.gavi.org/support/apply/countries-eligible-for-support/). Estimate of cost per death averted from Levin and others 2015. teacher training, policy development, and monitoring integrated with other teacher training courses. Refresher and evaluation. The estimates are drawn from existing courses are particularly critical in contexts with high studies; therefore the components of each cost estimate teacher turnover. Appropriate monitoring and evaluation are not presented or standardized. are also strongly recommended to ensure appropriate implementation. Training Costs Regular training and refresher courses are needed Nutrition Costs for teachers delivering the interventions. Training could School meals can contribute to the recommended cover all interventions in the essential package and be energy intake for undernourished children (Drake and 358 Child and Adolescent Health and Development others 2017). The three possible modalities include effective way to promote use of ITNs (Nankabirwa, meals, biscuits or snacks, and take-home rations. Wandera, and others 2014). Almost every country in the world offers school feed- ing in some form, and meals are the most common modality. The essential package includes the provision Vision and the Correction of Refractive Error of meals or alternatively of snacks in contexts where Refractive error can be detected through basic screen- meals are not possible. Snacks such as packaged bis- ing and can be corrected by the provision of inexpen- cuits or milk may be more appropriate in emergency sive corrective lenses (Graham and others 2017). contexts or where schools do not have the infrastruc- Schools are important in this context as a focus for ture to prepare or serve meals. The inclusion of micro- identifying children with poor vision: children are nutrients may increase costs, but also benefits. Various typically unaware of their impairment and health sys- studies assess the value of iron-folate pills for girls, tems in LMICs rarely have community outreach. The especially those entering adolescence. The interven- prevalence of refractive error is low, and the costs of tion in the essential package focuses on addressing corrective lenses can be spread across the target popu- micronutrient deficiencies. lation, reducing the cost per child and increasing the affordability of the intervention. Studies suggest that uncorrected refractive error affects 2.34 per 1,000 peo- Infectious Disease Treatment Costs ple in Africa and 6.59 per 1,000 people in South-East The cost-effectiveness estimates for infectious diseases— Asia (Baltussen, Naus, and Limburg 2009); however, the in particular, malaria and helminth infection—may vary proportion in Africa will likely rise as more children with the transmission setting and level of treatment have access to schools and books. Studies suggest that coverage. Deworming treatment is included in the the corrective lenses affordable in LMICs are likely to essential package, given the prevalence of soil-transmitted be ready-made. helminths (STHs) and Schistosoma infection in this age group (Bundy, Appleby, and others 2017). The pills are free to public health systems because they are donated Oral Health Costs by the global pharmaceutical industry via the WHO, and Two options for oral health are dental services and pre- costs are related primarily to delivery. In some contexts, vention through skills-based oral health education one oral treatment provided to each child annually is (Benzian and others 2017). In LMICs, oral health ser- sufficient; in contexts with higher prevalence, two vices are typically provided in clinics and hospitals, and treatments may be needed. The cost of delivering are limited by the availability of qualified personnel; the schistosomiasis treatment in addition to STH treatment ratio of dentists to population is roughly 1 to 2,000 in is marginal and assumed to be absorbed almost fully in HICs, compared with 1 to 150,000 in Sub-Saharan the modeling of costs. The alternative of screening for Africa. Oral disease is an expensive condition to treat worm infections, for example by using the Kato-Katz and is poorly integrated in primary health systems in test, and treating only those who are infected is signifi- LMICs (Kandelman and others 2012). cantly more expensive and is not included in the pack- Dental screening at schools and referrals to mobile age (Speich and others 2010). health teams with dental expertise may be possible in For malaria, three school-based interventions were some settings but was not considered affordable and considered for inclusion in the essential package. The generalizable to be included in the essential package. In alternative of intermittent preventive treatment (Stuckey contrast, oral health promotion through schools is low and others 2014)—that is, the distribution of antimalar- cost and has the potential to shape long-term oral ials to all children at specific times, for example, when hygiene behaviors and is included. Oral health promo- malaria is seasonally epidemic—was also ruled out tion can take place through information provided in because there is no affordable treatment available that is health education classes regarding the benefits of using recommended by the WHO for this use in school-age a toothbrush and fluorination; it may involve daily children. group brushing with fluoride toothpaste at school. The The evidence clearly demonstrates the cost- essential package proposes the inclusion of the Fit for effectiveness of ITNs to lower the risk of malaria (Lim School integrated oral health intervention, which has and others 2011), as well as the low usage rate among been tested in Cambodia, Indonesia, the Lao People’s school-age children (Noor and others 2009). The essen- Democratic Republic, and the Philippines. The pro- tial package includes malaria education in schools for gram, which cost US$0.60 per child per year for endemic countries because it is deemed to be the most supplies in the Philippines, reduced school absences Identifying an Essential Package for School-Age Child Health: Economic Analysis 359 as well as caries by one-third after one year (Monse and the benefits of school feeding are based on evidence on others 2013). specific pathways leading to health and educational outcomes. Vaccine Costs Evidence on the costs of administering the tetanus Nutrition and Food toxoid vaccine in schools is lacking for LMICs, hence School feeding has at least three objectives: social protec- the estimates are based on studies of the cost of ante- tion, education, and health (Drake and others 2017). natal vaccination in primary health clinics. The share School meals transfer a significant amount of noncash of children reached through schools is likely to be income to households, which can cushion shocks such as higher, depending on attendance rates. School-based high food prices. School meals can draw children to delivery is unlikely to have significant economies of school, support learning, and support physical growth scale compared with interventions such as school by reducing energy deficits. Meals enhanced with micro- feeding that reach all children on a daily basis. The nutrients can also support child nutrition and enhance tetanus toxoid booster vaccine is typically adminis- cognition. Iron-deficiency anemia is one of the top five tered once a year to all children at the beginning and causes of years lost to disability, contributing nearly 50 end of primary school, in accordance with the national percent of the total for ages 10–19 years (Murray and immunization schedule. others 2013). While these multiple benefits support the Vaccination to prevent HPV includes two doses case for school feeding, they are difficult to quantify and administered to girls between ages 9 and 13 years. The aggregate (see chapter 12 in this volume, Drake and costing exercise reflects the administration of two others 2017 for more discussion on school feeding). doses to girls in one grade in primary school. The cost A recent systematic review (Snilstveit and others of the vaccine is highly dependent on the price of the 2015) synthesizes the findings from 16 studies (15 unique vaccine itself, which may be subsidized through programs) published in 21 papers, of the effects of school GAVI, the Vaccine Alliance. On average, the cost of feeding (where feeding occurs in school, that is, does not administering HPV immunizations in LMICS is include take-home rations). The review examines three greater than for other routine immunizations, which access outcomes (enrollment, drop-out, and attendance), range from US$0.75 to US$1.40 per dose. However, as well as four measures of schooling outcomes (cogni- the cost has dropped in recent years, enabling HPV tive scores, math scores, language arts scores, and com- vaccination to be delivered in low-resource settings. posite achievement scores). A meta-analysis indicated Some studies have found that delivering HPV vac- that although in many cases the point estimate of the cines through schools costs more than delivering effect of school feeding was in the expected direction them through health facilities and integrated school- (improving enrollment, reducing drop-out, and improv- health centers (Hutubessy and others 2012; Levin and ing scores), none of the effects was statistically significant, others 2014), but coverage may also be higher. School- other than an increase in attendance. based delivery is likely to reach a larger share of the We use the effect on enrollment (a 9 percent increase, population, including children from disadvantaged equivalent to 8 extra days in school [Snilstveit and others households. 2015]), the cost per school meal of $41 per child (table 25.4), and mean per capita GDP in 2015 of $620 in low-income countries and $2035 in lower-middle income countries in 2015 (World Bank 2016a). We assume that ESTIMATING THE BENEFITS the average child eating school meals for one year is Each intervention in the essential package is justified by 10 years old, enters the labor force at age 15, and contin- its low costs of delivery and high ratio of benefits to ues working until age 55. Annual wage income per person costs, making it a sound and affordable investment for of working age was therefore about $574 in low-income LMIC governments. Improved education and health countries and about $1,489 in lower-middle-income outcomes translate into improved productivity and countries in 2015 (based on the proportion of the popu- higher national gross domestic product (GDP). To per- lation of working age, 15–64 years, being 54 percent in mit comparisons with costs, these benefits must be low-income countries and 64 percent in lower-middle- quantified in financial terms. income countries [World Bank 2016b], and labor income This section summarizes the economic benefits of being approximately half of GDP). The returns to an each intervention and the pathways through which extra year of education are 12 percent per annum in they are achieved, based on the literature. Estimates for Sub-Saharan Africa (Montenegro and Patrinos 2014; 360 Child and Adolescent Health and Development Figure 25.1 Estimated Cumulative Per-Child Benefits from attendance for children who had heavy Trichuris infection Receipt of One Year of School Feeding in LICs and lower- or were stunted. Two studies have calculated the economic middle-income countries and social returns to deworming in the United States and 400 Kenya, respectively, through long-term follow-ups (Baird and others 2015; Bleakley 2007). In the United States, 350 Cumulative per-child benefits hookworm eradication led to gains in income and returns 300 to schooling. In Kenya, deworming increased labor and educational outcomes among men and women, (USD, 2015) 250 200 respectively. The authors estimated a conservative internal 150 rate of return to deworming of 32 percent. Schools can provide significant economies of scale for 100 deworming treatment. The cost for delivery through 50 schools was US$0.03 (Tanzania) and US$0.04 (Ghana) 0 per child per year, compared with delivery through 10 15 20 25 30 35 40 45 50 55 mobile health teams coordinated by primary health cen- Age (years) ters of US$0.21 in Tanzania and US$0.51 in Montserrat LICs (Guyatt 2003). See also chapters 13 (Bundy, Appleby, and Lower-middle-income countries others 2017) and 29 (Ahuja and others 2017) in this Note: LICs = low-income countries. volume for discussion of these issues. Malaria places a significant burden on health care Pradhan and others 2017, chapter 30, estimate somewhat systems and productivity in endemic countries. In Sub- lower but still substantial returns to education across low- Saharan Africa, malaria is responsible for at least 15 and middle-income countries). percent of disability-adjusted life years (DALYs) (WHO With these assumptions, we can calculate that eight 2001). Furthermore, mortality from malaria is concen- days of increased attendance increases future wages by trated among the poor. An estimated 60 percent of 1.08 percent (12 percent multiplied by 0.09). A stream of malaria-related deaths occur in the poorest 20 percent of future wages of $W per year (starting 5 years in the the global population, a higher share than other common future and continuing for 40 years) is worth about 20W infectious diseases and conditions. Various studies have currently, when discounted at 3 percent. Figure 25.1 estimated the impact of malaria with regard to nutri- presents the estimated trajectory of benefits that accrue tional, cognitive and educational impairments among due to the delivery of school feeding for one year based school-age children, such as anemia, diminished cogni- on the calculation described. tive function and motor and language skills, and school Combining these assumptions implies that the benefit- absenteeism (Boivin and others 2007; Clarke and others cost of school meals is around 3 in low-income countries 2004; John and others 2008; Nankabirwa, Brooker, and and exceeds 7 for lower-middle income countries. With others 2014; Nankabirwa, Wandera, and others 2014). more optimistic assumptions (for example, that there are Malaria is associated with GDP losses of 1 percent to additional benefits from improved cognitive scores), the 20 percent, averaging 10 percent in Sub-Saharan Africa benefit-cost ratio would be even higher. (Gallup and Sachs 2001). The regional loss in economic output is about US$12 billion a year (WHO 2001). Several strategies are in place to control and eradicate Infectious Disease malaria. Ultimately, effectiveness varies with the intensity Children infected with intestinal worms are often too sick of transmission and other factors contributing to anemia, or tired to attend school or to concentrate in school when such as undernutrition and helminth infection. Global they do attend. Persistent worm infections are associated policy efforts have focused on pregnant women and chil- with impaired cognitive development and lower educa- dren younger than age five years because of strong evi- tional achievement (Mendez and Adair 1999; Simeon, dence on the effectiveness of interventions such as ITNs Grantham-McGregor, and Wong 1995). A study from (White and others 2011). Recent efforts have shifted to Kenya found that after a deworming program, enrollment providing ITNs to everyone, not only the most vulnerable. increased 7 percent and school absenteeism decreased Less attention has been given to school-age children, 25 percent (Miguel and Kremer 2004). However, these although the prevalence of malaria in the school-age effects mask heterogeneity; children who are worse off to population is often high and can explain approximately begin with are likely to gain more. Simeon, Grantham- one-half of mortality occurring in this age group McGregor, and Wong (1995) found significant impacts on (Nankabirwa, Brooker, and others 2014). Identifying an Essential Package for School-Age Child Health: Economic Analysis 361 For the school-age population, strategies to control skilled eye care personnel (Limburg, Kansara, and and eradicate malaria can provide benefits, such as averted d’Souza 1999; Sharma and others 2008; Wedner and cases of malaria and anemia; reduced absenteeism; others 2000). Training teachers to assess whether chil- enhanced attention span and cognitive function; and low- dren should be examined and potentially receive glasses ered risk of cerebral malaria, which may alter speech, lan- has been tested in various contexts; in a rural region in guage, and motor skills. Cambodia, fewer than 100 teachers in less than four ITNs are a cost-effective intervention for reducing weeks screened 13,175 students and referred 44 to a malaria and anemia among asymptomatic cases (White team of refractionists to be assessed for eyeglasses and others 2011). School-age children are the least likely (Keeffe 2012). to use ITNs, although studies generally find positive The essential package recommends periodic screen- evidence that they face a lower risk when they do ing of children in a specific grade for refractive error and (chapter 14 in this volume, Brooker and others 2017). provision of glasses, with the aim of screening all chil- Based on data from 18 Sub-Saharan African countries, dren at risk over time (Baltussen and Smith 2012). about 40 percent of school-age children are not pro- tected (Noor and others 2009). As demonstrated in studies from Ghana, Kenya, Lao Oral Health PDR, and Thailand, skills-based health education in The burden of poor oral health and hygiene is concen- schools can increase knowledge about malaria and the trated in upper-middle-income countries and HICs, correct use of ITNs and decrease parasite prevalence (Ayi although the share of the population that is untreated and others 2010; Nonaka and others 2008; Okabayashi is highest in LMICs. Tooth decay can affect psycho- and others 2006; Onyango-Ouma, Aagaard-Hansen, and social well-being and lead to school absenteeism Jensen 2005). In Ghana, school-based education regard- (Kakoei and others 2013; Krisdapong and others 2013; ing ITN use was associated with a decline in malaria Naidoo, Chikte, and Sheiham 2001). Prevention of cav- prevalence to 10 percent from 30 percent over the course ities may also reduce undernutrition because of the of one year (Ayi and others 2010). Averting even a single pain associated with severe tooth decay (Benzian and episode of malaria may bring substantial benefits, such as others 2011). The risk of poor oral health is expected to increased participation in higher education and improved rise as diets in LMICs shift to greater consumption of cognitive development over the life of the child. processed foods and sugars (Viswanath and others 2014). Between 1990 and 2012, the average increase in DALYs due to dental caries was between 42 percent and Vision and the Correction of Refractive Error 78 percent in most countries in Sub-Saharan Africa The benefits of correcting poor vision are related pri- (Dye and others 2013; Kassebaum and others 2015). marily to education pathways and gains in labor market Building healthy habits in childhood may provide ben- outcomes. An estimated 153 million people globally efits over the life course. Group activities in school may suffer from poor vision, including 13 million school-age be an effective means for establishing these norms children (Resnikoff and others 2008; Smith and others (Claessen and others 2008). 2009). Economic losses due to impaired vision exceed an estimated US$200 billion a year globally (Fricke and others 2012). Although little is known about the preva- Vaccines lence of uncorrected refractive error among school-age Although the HPV vaccine is substantially more expen- children, an estimated 9 percent of children in Ethiopia sive than the tetanus toxoid vaccine, both are cost- (Yared and others 2012) and 13 percent in China effective. At the global level, cervical cancer caused 6.9 (Glewwe, Park, and Zhao 2012) have undiagnosed or million DALYs in 2013, with more than 80 percent of untreated vision problems. In Brazil, poor vision resulted cases occurring in LMICs (Fitzmaurice and others in a 10 percentage point higher probability of dropping 2015). Country- and region-specific studies have been out and an 18 percentage point higher probability of conducted on the benefits of HPV vaccination, with a repeating a grade (Gomes-Neto and others 1997). In focus on health benefits. The overwhelming majority of China, poor vision decreased students’ academic perfor- these studies indicate that HPV vaccination of preado- mance, as measured by test scores, by 0.2–0.3 standard lescent girls (usually ages 8–14 years, depending on the deviations, equivalent to a loss of 0.3 years of schooling specific country) has the potential to substantially reduce (Glewwe, Park, and Zhao 2012). the morbidity and mortality associated with cervical Providing eye care screening and free glasses in cancer. Assuming coverage of 70 percent, effective over a schools can overcome the barriers of cost and lack of lifetime, HPV vaccination could avert more than 670,000 362 Child and Adolescent Health and Development cervical cancer cases in Sub-Saharan Africa over five child of each intervention draws on the cost per treated consecutive birth cohorts of girls vaccinated as young child in table 25.3. For targeted interventions, the cost adolescents (Kim and others 2013). per treated child exceeds the average cost per child. Some The HPV vaccination is now part of the recom- efficiencies can be expected. In this exercise, a 20 percent mended national schedule in more than 60 countries or reduction in costs for the integrated delivery of malaria territories, but only 8 of these are LMICs (WHO and and oral health education was assumed (figure 25.3). UNICEF 2013). However, more than 25 LMICs, about The delivery of some interventions is recommended one-third in Africa, have piloted the vaccine in one or for all children (oral hygiene). For other interventions, more urban and rural districts. Recommendations to screening of all children and treatment for an identified replace the three-dose schedule with a two-dose schedule, subset of children is recommended (eyeglass screening). with a minimum interval of six months between doses, For some interventions, the economic returns are greater would increase the benefits in relation to the costs (WHO when targeted to a subset of the population, such as 2014). More information on the HPV vaccine can be school feeding for food-insecure areas or for children at found in volume 3, chapter 4 (Denny and others 2015). risk of dropping out. Delivery of the tetanus toxoid vaccine lowers the risk These estimates exclude start-up costs, which could of contracting tetanus, both for recipients and for their include the costs of establishing policies or guidelines children who have not yet been vaccinated, providing an or undertaking mapping exercises. For example, a intergenerational benefit. In Africa, tetanus has caused national mapping exercise of helminth worms would 3 million DALYs (Ehreth 2003). For the essential package, indicate where deworming treatment is needed, and countries need to administer the tetanus toxoid vaccine to mapping of poverty and food security would support children in the grade that captures the largest proportion of children ages 4–7 or 12–15 years. Figure 25.2 Indicative Mapping of Benefits and Costs of Essential Package Interventions Benefit COMPARING COSTS AND BENEFITS OF THE ESSENTIAL PACKAGE Figure 25.2 provides an illustrative mapping of the ben- Deworming treatment Malaria prevention Vision screening efits and costs for all of the interventions in the essential School feeding package. Some interventions should be delivered to all Tetanus toxoid vaccine HPV vaccine children, while others should be targeted geographically Oral health promotion or by age to limit overall costs. Table 25.4 presents the essential package of school Targeted by age or geographically Not targeted Cost health interventions for LMICs, based on costs and bene- fits. Differences between LICs and lower-middle-income Note: HPV = human papillomavirus. countries are due to differences in resources. Upper- middle-income countries can augment the essential pack- Figure 25.3 Cost Shares of the Essential Package, by Country age with additional interventions or expand coverage of Income Level targeted interventions to a wider age group or to more U.S. dollars schools. All countries may tailor the package to the context a. Low-income countries b. Lower-middle-income and add additional components. $0.40 countries The essential package addresses a variety of health $0.75 risks facing school-age children. Some are tackled $0.35 directly; others seek to change behaviors associated with $5.40 poor health outcomes, including the use of ITNs and $0.60 $0.75 promotion of oral health. The frequency of delivery is $0.35 also noteworthy. Some interventions are delivered just $8.20 $17.33 $0.60 once over the course of primary school (HPV vaccina- tion), while others recur daily (school feeding) or annu- ally (deworming and vision screening). All costs are standardized to one calendar year. School feeding Vision screening Deworming In total, the essential package costs an estimated Health education Vaccines US$10.30 per child per year in LICs. The average cost per Identifying an Essential Package for School-Age Child Health: Economic Analysis 363 Table 25.4 Costs of the Essential Package of Health Interventions for School-Age Children Low-Income Countries Lower-Middle-Income Countries Average Average annual annual cost per cost per Domain Intervention Target child (US$) Intervention Target child (US$) School feeding Daily snacks All children in at least 20% 8.20 Daily meals with All children in at least 16.40 or meals with of schools in regions with the micronutrient 40% of schools in regions micronutrient highest levels of poverty and fortification with the highest level of fortification food insecurity poverty and food insecurity Deworming Deworming All children attending schools 0.35 Deworming All children attending 0.35 treatment in areas endemic for STHs and treatment schools in areas schistosomiasisa endemic for STHs and schistosomiasisa Vision screening Screening and All children in a select grade 0.60 Screening and All children in a select 0.60 provision of ready- provision of custom grade made glasses or ready-made glasses Oral health and Health education All children for oral health 0.75 Health education All children for oral 0.75 malaria about prevention promotion and all children about prevention health promotion and of tooth decay and attending schools in endemic of tooth decay and all children attending usage of ITNs areas for malariaa usage of ITNs schools in endemic areas for malariaa Vaccines Tetanus toxoid Children in a select grade in 0.40 Tetanus toxoid Children in a select grade 0.40 vaccine all schools vaccine in all schools HPV vaccine HPV vaccine Girls from a select grade 5 in all schools (two doses) Note: HPV = human papillomavirus; ITNs = insecticide-treated bednets; STHs = soil transmitted helminths. a. Assuming 50 percent of child population at risk. the targeting of school feeding to the most disadvan- costs and potential benefits. The interventions can taged households. Costs of the total package are aggre- improve the quality and the quantity of schooling, gen- gated by size of population in low-income and erating a high benefit-cost ratio. The returns to educa- lower-middle income countries in chapter 1 (Bundy, tion are highest in LICs, but this finding is due, in part, de Silva, and others 2017). to higher per capita income in lower-middle-income countries. More research is needed on how to support countries in financing the essential package as well as evaluating the benefits over the life course. CONCLUSIONS Interventions for school-age children can have signifi- Several low-cost health interventions to support the cant impacts on schooling, earnings, health status, and development of children can be delivered through productivity in LMICs. The estimated benefit-cost ratios schools. The health and education benefits for each for such interventions consistently exceed one, suggest- intervention are significant, but there is comparatively ing that the discounted value of gains exceeds the costs. less evidence on the combined benefits of providing These results support the case for placing school health several interventions jointly. The provision of a set of high on the policy agenda and for promoting coherence integrated basic interventions may create cost efficien- with early childhood health intervention programs to cies and increase the benefit-cost ratio. For example, maximize benefit gains. Causal estimates of the impacts health education classes can include material on both of interventions stem mostly from small-scale local inter- oral hygiene and malaria prevention. ventions and are likely to be sensitive to population het- This chapter defines an affordable package of school- erogeneity (social, economic, and cultural differences), based health interventions for LMICs and estimates the differences in program implementation (administrative 364 Child and Adolescent Health and Development capacity and trust), and differences in the wider political Baird, S., J. H. Hicks, M. Kremer, and E. Miguel. 2015. “Worms economy of reform. As a result, available impact esti- at Work: Long-Run Impacts of a Child Health Investment.” mates may have limited external validity. In addition, Working Paper 21428, National Bureau of Economic benefit-cost ratios based on these impact estimates are Research, Cambridge, MA. Baltussen, R., J. Naus, and H. Limburg. 2009. “Cost-Effectiveness sensitive to the choice of rates of return and discount of Screening and Correcting Refractive Errors in School rates applied in evaluating future impacts against costs. Children in Africa, Asia, America and Europe.” Health Policy If benefit-cost ratios associated with interventions for 89 (2): 201–15. the school-age child are so attractive, why have govern- Baltussen, R., and A. Smith. 2012. “Cost Effectiveness of Strategies ments not implemented them at scale? Benefits may not to Combat Vision and Hearing Loss in sub-Saharan Africa scale up, despite scale economies, and the benefit-cost and South East Asia: Mathematical Modelling Study.” BMJ ratio for nationwide implementation may be lower. 344: e615. doi:10.1136/bmj.e615. Moreover, governments may not be sufficiently aware of Benzian, H., M. Hobdell, C. Holmgren, R. Yee, B. Monse, and the benefits of the interventions; indeed, the documents others. 2011. “Political Priority of Global Oral Health: An guiding national and international policy tend to evalu- Analysis of Reasons for International Neglect.” International ate immediate reductions in clinical morbidity and Dental Journal 61 (3): 124–30. Benzian, H., B. Varenne, N. Stauf, R. Garg, and B. Monse. 2017. mortality and to give low priority to the long-term “Promoting Oral Health through Programs in Middle socioeconomic benefits. Furthermore, the health and Childhood and Adolescence.” In Disease Control Priorities development of school-age children has historically been (third edition): Volume 8, Child and Adolescent Health given low priority in health system planning, so even and Development, edited by D. A. P. Bundy, N. de Silva, where governments recognize the net benefits of inter- S. Horton, D. T. Jamison, and G. C. Patton. 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Forthcoming. “A Cost Analysis of the among School Children in Gondar Town, Northwest Inclusion of Micronutrient Powders in the Ghana School Ethiopia.” Middle East African Journal of Ophthalmology Feeding Programme.” 19 (4): 372. 368 Child and Adolescent Health and Development Chapter 26 Identifying an Essential Package for Adolescent Health: Economic Analysis Susan Horton, Elia De la Cruz Toledo, Jacqueline Mahon, John Santelli, and Jane Waldfogel INTRODUCTION (Reproductive, Maternal, Newborn, and Child Health) to Adolescents form a large proportion of the population RMNCAH to include adolescents. The Every Woman Every in many low- and middle-income countries (LMICs)— Child (2015) strategy is titled “The Global Strategy for more than 20 percent in the countries with the Women’s, Children’s and Adolescents’ Health 2016–2030” fastest-growing populations (WHO 2014). The adolescent and signals a positive change. It highlights research indicat- period, defined as ages 10 through 19 years, is key to future ing that the health of women, children, and adolescents is health because it is during these years that health decisions central to the Sustainable Development Goals for 2030. and habits are formed that have long-term impacts. The term youth is mentioned 10 times in the Outcome Adolescents who are enabled to make healthy eating and Declaration of the Sustainable Development Agenda exercise choices, to adopt healthy sexual behaviors, and to (UN 2015), and the term adolescent is mentioned once in avoid addictive substances and excessive risks have the reference to adolescent girls. best opportunities for health in later life. Equally impor- This chapter provides an overview of methods and tant, some mental health issues are manifested in late examines the economic case for investment in adolescent adolescence, and early detection is important. health by surveying what is known on cost, cost- Despite the pivotal nature of this age, adolescents effectiveness, and cost-benefit ratios of interventions. We until recently have been relatively neglected in interna- then use these economic data to examine the cost of an tional donor strategies for maternal, newborn, and child essential package of health and behavioral interventions health. Specific areas where funding is lacking include that all countries need to provide. The essential package preventing unsafe abortion and coerced sex, and provid- draws on packages developed elsewhere (Every Woman ing antenatal, childbirth, and postnatal care (iERG 2013). Every Child 2015; Patton and others 2016; WHO 2013). Many adolescents are entitled to appropriate health care Useful information also comes from costing studies of under the Convention on the Rights of the Child, but related packages (Deogan, Ferguson, and Stenberg 2012; those ages 18 and 19 years are not specifically included. Temin and Levine 2009). Countries can modify this pack- Recent reports and studies seek to bring greater attention age depending on their specific needs and resource to adolescent health needs (Gorna and others 2015; Laski availability. Finally, we estimate what such a package might and others 2015; Patton and others 2016; UNICEF 2011, cost in 2012 U.S. dollars and provide brief conclusions. 2012; WHO 2014). Groups such as the International Health Definitions of age groupings and age-specific terminology Partnership (http://www.internationalhealthpartnership.net) used in this volume can be found in chapter 1 (Bundy, de have begun to modify the well-known term RMNCH Silva, and others 2017). Corresponding author: Susan Horton, University of Waterloo, Ontario, Canada; sehorton@uwaterloo.ca. 369 METHODS • Interventions covered in the chapter on school-age children (chapter 25 in this volume, Fernandes and Our focus is on the costs and cost-effectiveness of certain Aurino 2017) are more appropriate with younger areas of health of particular concern in adolescence. age groups, although some overlap occurs between Topics we do not address are discussed in other volumes school age and adolescence. Table 26.1 shows how in this series: the discussion is divided between this chapter and the preceding chapter on school-age children. • Human papillomavirus (HPV) (volume 3, Gelband and others 2015; volume 6, Holmes and others 2017) We searched the literature on the economics of • Reproductive health more generally (volume 2, Black interventions that were aimed specifically at adoles- and others 2016) cents or that would primarily benefit adolescents. The • Interventions in nonhealth areas, such as education main areas where we anticipated finding studies and child marriage, that have strong impacts on included nutrition, sexual and reproductive health, health mental health, alcohol, injury, and smoking and other • Conditional cash transfers (chapter 23 in this volume, addictive substances. de Walque and others 2017) There are relatively few cost and cost-effectiveness • Cost-effectiveness results from the second edition of studies on these topics in the peer-reviewed literature in Disease Control Priorities (DCP2), which included English for LMICs. We drew first on systematic reviews substantial modeling of interventions for smoking of cost and cost-effectiveness for high-income countries (Jha and others 2006), alcohol (Rehm and others (HICs), which were identified using a search in PubMed 2006), obesity (Willett and others 2006), injury (see details in annex 26A). We identified seven such (Norton and others 2006), and mental health (Hyman systematic reviews published since 2000. and others 2006); these are all health issues for which We then undertook a systematic review of the adolescence is a particularly vulnerable age. DCP2 literature in English for LMICs (see annex 26A for included a chapter on adolescent health (Lule and details) to identify individual studies since 2000. others 2006) that reviewed the economic literature We augmented this review with an expert search and before 2000. identified seven studies. Table 26.1 Platforms for Delivering Different Interventions for Adolescents, Compared with School-Age Children Health area Population level Community School Primary health center Physical health Healthy lifestyle Deworming Deworming Deworming messages: tobacco, Malaria prevention and Malaria prevention and treatment Malaria prevention and treatment alcohol, injury treatment Tetanus toxoid and HPV vaccination Tetanus toxoid and HPV vaccination Sexual health Tetanus toxoid and HPV messages Oral health promotion Oral health promotion and treatment vaccination Sexual health education Oral health promotion Healthy lifestyle education Adolescent-friendly Adolescent-friendly health services Adolescent-friendly health services health services Nutrition Nutrition education Micronutrient Micronutrient supplementation messages supplementation Multifortified foods Multifortified foods School feeding Nutrition education Mental health Mental health Mental health education and Mental health treatment messages counseling Cognitive School promotion Vision screening Vision screening development Note: HPV = human papillomavirus. Blue colored interventions are covered in chapter 25 in this volume, Fernandes and Aurino 2017, on school-age children. 370 Child and Adolescent Health and Development Costs and cost-effectiveness are expressed in the orig- Table 26.1 categorizes interventions by the type of inal currency units; for LMICs they are also converted to delivery platform, as well as the broad program out- 2012 U.S. dollars, first by adjusting using the consumer come; the four groupings are physical health, nutrition, price index in the currency of the studied country, and mental health, and cognitive development. Many pro- then using the 2012 market exchange rate to the U.S. grams delivered in person need to be supplemented by dollar. The WHO (2001) benchmark for cost-effectiveness national-level policy changes as well as by supportive is the point at which an intervention’s cost per disability- messages in the media. Most programming for adoles- adjusted life year (DALY) averted is less than three times cents will be delivered either in the community or in a country’s per capita gross national income (GNI), and school (for those in school). an intervention is very cost-effective if the cost per DALY Neuroscience has given us new insights into the averted is less than per capita GNI. difficulties in effecting behavior change in adolescents. We did not convert the cost-effectiveness numbers for In this age range, the brain develops in ways that stim- HICs. The benchmark for acceptability for public financ- ulate innovation and risk-taking. Peer influence ing would be about US$50,000 per quality-adjusted life becomes increasingly important, and input from par- year (QALY) saved in the United States or £30,000 per ents and adults less salient (see discussion in chapter 6 QALY saved in the United Kingdom; we simply specify in this volume, Bundy and Horton 2017, and chapter in the text whether the interventions are or are not 10 in this volume, Grigorenko 2017). Risk-taking may cost-effective. All figures refer to 2012 U.S. dollars, unless have evolutionary benefits, in that this is the period in otherwise noted. which adolescents have traditionally been expected to Cost and cost-effectiveness studies do not cover leave the parental home and set up a new, independent all the areas of interest for adolescent health interventions. household. Risk-taking also has a downside, in that It is particularly difficult to find costs and cost- executive control functions are still developing and can effectiveness of interventions at the national level (for be overridden in the heat of the moment, particularly example, for policy change or mass media campaigns), in the company of peers. Steinberg (2007) suggests given that there is no easy way to identify the effective- that interventions limiting the scope of potential ness of interventions in the absence of a control group. damage may work better than education alone. For Clearly, however, interventions at the national level can example, graduated driving licenses may more success- be important. We also did not find studies of the cost fully reduce automobile injuries than educational and cost-effectiveness of social media, which may be an programs about safe driving behavior. At the same effective way to reach adolescents. These interventions time, adolescence is such a crucial time for establishing are relatively new, and the literature may not yet have habits and behaviors with lifelong consequences that it caught up. would seem impossible not to include educational interventions. Two methodological issues affect the economic UNIT COST, COST-EFFECTIVENESS, AND evaluation of school-based interventions. First, the same intervention can vary substantially in quality BENEFIT-COST RATIOS OF INTERVENTIONS depending on the context in which it is implemented, Given the relative neglect of adolescent health in LMICs, and hence also in effectiveness. Second, very few the paucity of economic analysis is not surprising. Even school-based programs track outcomes longitudinally. evidence of effectiveness of interventions is scanty. More This shortcoming is particularly an issue for the pilot programs using innovative methods are needed, myriad studies of obesity; short-term weight gain and existing successful pilot interventions need to be outcomes may be a very poor guide to long-term brought to scale. outcomes. Lack of longitudinal studies may be less of Adolescents are also a diverse group, and interven- an issue in the areas of smoking and early pregnancy. tions that succeed in some contexts may not do so in In both cases, avoiding the risky behavior for three or others. Some adolescents are in school, but others are four years may suffice to avoid the undesired out- not, and there are generally fewer cost-effective ways to comes. Adolescents who reach early adulthood with- reach those not in school. Some adolescents are married out becoming smokers are substantially less likely to and face very different health challenges from those who become lifelong smokers. Similarly, postponing first are not. Adolescents living in rural areas face different pregnancy until the end of the teenage years can have circumstances than those in cities; there are also big dif- a significant effect on schooling attainment for young ferences across world regions, for example, in the experi- women as well as health benefits for both the young ence of violence by adolescents. women and their babies. Identifying an Essential Package for Adolescent Health: Economic Analysis 371 Findings for High-Income Countries Obesity Our literature search identified six systematic reviews For HICs, we identified two systematic reviews of for HICs (Guo and others 2010; Korber 2014; Romeo, cost-effectiveness of physical activity as a way to address Byford, and Knapp 2005; Shepherd and others 2010; Vos obesity (see table 26.2) (Korber 2014; Wu and others and others 2010; Wu and others 2011). We also draw on 2011); McDaid and others (2014) also reference studies nonsystematic reviews by De la Cruz and others (2015) on obesity. These three reviews identify some interven- and McDaid and others (2014). Given the amount that tions that are cost-effective and others that are not. In is spent on, for example, educational programs, it is some cases, interventions that are cost-effective are surprising that the cost-effectiveness literature is rela- costly and may not be affordable (Wu and others 2011). tively spotty. De la Cruz and others (2015) surveyed individual studies Table 26.2 Summary of Reviews of Cost-Benefit and Cost-Effectiveness of Interventions for Adolescent Health, High-Income Countries Study Scope of review or study Study findings Guo and others 2010 Study of school-based • School-based health care could have saved Medicare US$35 per student per year; cost of health care in four school intervention US$180 per student per year for children and adolescents ages 5–14 years. districts in the United States • School-based care also narrowed gap between disadvantaged groups (African American) and other students. Korber 2014 Systematic review of 5 studies of United States, 4 Australia, 2 Germany, 1 United Kingdom, 1 New Zealand 13 economic evaluations • Cost per DALY averted for Australia ranged from $A 20,227 to $A 760,000 per DALY (Walking of interventions to promote School Bus). physical activity • Cost per QALY saved for United States ranged from US$900 to US$4,305. • Cost per QALY saved for United Kingdom was £94–£103. McDaid and others 2014 Alcohol: Review of • Education sessions with 11–12-year-olds and parents (one study) have a benefit-cost ratio of 2 studies 9:1; various interventions (other study) have benefit-cost ratios ranging from 5:1 to 100:1 in United States. McDaid and others 2014 Smoking: Review of • The Netherlands: Cost US$25,174 per QALY saved 7 studies, largely school • Germany: 3.6:1 benefit-cost ratio based (2 include mass media as well) • United States: (4 studies) US$5,860–US$405,277 per QALY saved; US$7,333–US$24,271 per QALY saved; highly cost-effective; and cost-effective or cost saving, respectively • Canada: Results similar to United States McDaid and others 2014 Sexual health: 1 study • Net savings for a program to prevent early pregnancy among adolescents in low-income areas in United States is US$11,262 per participant. McDaid and others 2014 Mental well-being: • US$3,500 per DALY for program to screen Australian teenagers with depressive symptoms 5 studies and treat with psychiatrist • US$9,725 per DALY for program in United States to offer 15 sessions of CBT to at-risk teens ages 13–18 years with one parent with depressive disorder • Three interventions to promote well-being in schools in United States had benefits of 28:1, 5:1–10:1, and 25:1 for reduced drug dependency, smoking, and delinquency, respectively. McDaid and others 2014 Obesity prevention: • Various programs in Australia were cost saving over lifetime; others (Walking School Bus, 3 studies gastric banding, and drug therapy) were not. • Program in United States to reduce TV watching, improve physical activity, and improve diet effective in girls at cost of US$5,076 per QALY saved. • Study in United Kingdom found lifestyle interventions effective at cost of US$20,589 per QALY saved. table continues next page 372 Child and Adolescent Health and Development Table 26.2 Summary of Reviews of Cost-Benefit and Cost-Effectiveness of Interventions for Adolescent Health, High-Income Countries (continued) Study Scope of review or study Study findings Romeo, Byford, and Knapp Systematic review of mental 21 studies: 10 United States, 4 United Kingdom, 3 Canada, 1 Australia, 1 Sweden, 1 Norway, 2005 health interventions for and 1 the Netherlands children and adolescents • Programs heterogeneous in design and in outcome measures, not readily converted to a common health outcome metric. Shepherd and others 2010 Systematic review of school- • Examined 15 RCTs: 13 for United States, 2 for United Kingdom based interventions for • Review found significant changes in knowledge and in some measures of self-efficacy but prevention of transmission few significant differences in behavior (only short follow-up). of sexually transmitted infections; modeled for • Estimated cost of teacher-led programs at £4.30/pupil; peer-led £15/pupil; incremental economic cost-effectiveness cost-effectiveness ratio £20,223 per QALY saved for teacher led; £80,782 per QALY saved for peer led Vos and others 2010 Modeling of cost- • School-based program for illicit drug education cost $A 59,000 per DALY averted. effectiveness of broad range • Screen and treat with a psychologist in school for child and adolescent depression cost of interventions for Australia $A 5,400 per DALY averted. (costs in $A); drugs and mental well-being • Screen and treat with bibliotherapy in school for child and adolescent depression cost $A 180 per DALY averted, but evidence of effectiveness limited. Wu and others 2011 Systematic review and cost- 91 studies (141 interventions) of which 48 RCTs; predominantly for United States, almost all for effectiveness of programs to HICs. Of these, the cost per MET per person per year varied considerably: promote physical activity • Point-of-decision prompts had the lowest cost per MET but very small effect on overall physical activity levels. • School and community-based programs had middle cost per MET and middle effect on physical activity levels. • Individually adapted behavior change and social support programs had highest cost per MET but highest effect on physical activity levels. Source: Horton 2015. Note: Costs are in year of original study. CBT = cognitive behavioral therapy; DALY = disability-adjusted life year; HICs = high-income countries; MET = Metabolic Equivalent of Task; QALY = quality-adjusted life year; RCTs = randomized controlled trials. for HICs and identified two studies for obesity: Haynes subsidies for quitting aids has attractive cost-effectiveness and others (2010) suggesting that reducing consump- ratios in the Netherlands (Over and others 2014). tion of carbonated drinks can be very cost-effective; and Vos and others (2010) survey examples of programs to Carter and others (2009), indicating that physical activ- prevent or reduce use of illicit substances, some of which ity promotion is cost-effective, although barely. are cost-effective. Smoking, Alcohol Use, and Illicit Drug Use Reproductive and Sexual Health No systematic reviews were identified for smoking, alco- Two systematic reviews (Guo and others 2010; hol use, or illicit drug use. Individual studies may not Shepherd and others 2010) cover school-based health include keywords related to adolescence, although it is care, which often has a focus on sexual and reproduc- well understood that adolescence is a key period for tive health, and at times, on mental health. Some experimentation with (and in some cases becoming school-based programs are cost-effective in prevent- addicted to) these substances. For the United States, ing sexually transmitted infections (Shepherd and there are examples of cost-effective, as well as others 2010). Some school-based interventions on cost-ineffective, smoking prevention interventions for reproductive health are even cost saving (Guo and adolescents (surveyed in McDaid and others 2014). De la others 2010), as was one program aimed at prevent- Cruz and others (2015) highlight one study for smoking, ing early pregnancy among adolescents living in a in which increased cigarette taxation combined with low-income area (McDaid and others 2014). Identifying an Essential Package for Adolescent Health: Economic Analysis 373 Mental Health population; although only marginally cost-effective over School-based programs can also be effective for mental a 20-year horizon, these restrictions become cost saving health (Romeo, Byford, and Knapp 2005), although cost or cost-effective or very cost-effective in all the countries may make them difficult to afford. De la Cruz and others over a 50-year horizon. Cecchini and others (2010) also (2015) identify a study combining cognitive behavioral model five other interventions aimed at adults that are therapy with a change in medication that improves men- not discussed here. tal health, but this intervention is not quite cost-effective A large trial of school-based interventions in China (Lynch and others 2011). (Meng and others 2013) finds that nutritional or physi- cal activity interventions alone are not effective, but a Overall Findings combined program is effective, albeit not significantly In each of the reviewed health areas in HICs, it is possi- so. This observation that comprehensive interventions ble to find some interventions for adolescents that are are required is consistent with the general literature on cost-effective, using the country’s own threshold, and obesity prevention that is not restricted to children and others that are not. Lack of cost-effectiveness has several adolescents or to LMICs. Meng and others (2013) do not causes, among them, poor implementation, poor moni- calculate cost-effectiveness per DALY or QALY. toring, and poor design. Monitoring behavior change Accordingly, it is not possible to infer whether the inter- interventions is more challenging than, for example, vention is cost-effective; however, it is not inexpensive at monitoring vaccinations. Poor design may arise when US$4.41 per participant over two years, and at US$31.10 modeling or communicating behavior changes in ways if teachers’ time is included. In comparison, per capita that do not appeal to adolescents. Some interventions annual health expenditure from the public budget in may be effective but relatively high cost, so that even if 2013 was, on average, US$15.36 for low-income coun- they are cost-effective, they are not affordable. tries, US$30.67 for lower-middle-income countries, The lessons from HICs are that schools are an appro- and US$260.96 for upper-middle-income countries priate venue for interventions since adolescence is a key (World Bank 2016). age at which interventions should occur; however, it is crucial to have programs that are well conceptualized, Smoking well targeted, and well implemented. Programs need to Findings from a study of a school-based intervention be evidence based. In the United States, the Department for smoking in India (Brown and others 2012) are sim- of Health and Human Services (2014) funds evaluations ilar. Although the program is cost-effective per QALY for pilot programs and lists the types of evidence saved, the cost of US$45.81 per student is not inexpen- required for a program to be eligible for evaluation. As sive; removing the cost of teachers’ time reduces the cost outlined in the methodology section, implications have of this particular intervention by only 5 percent. This to be drawn cautiously. The context of HICs differs from was a large-scale pilot; it is possible that costs could be that of LMICs; and even in HICs, the number of studies reduced by embedding the training involved into the with long-term follow-up is limited. regular teacher training curriculum rather than deliver- ing it via special workshops that require travel and per diem expenses. Findings for Low- and Middle-Income Countries We identified seven studies in LMICs, most of a single Reproductive and Sexual Health country, but one has results for six middle-income coun- Of the four studies of interventions for sexual and repro- tries (MICs). Two are of obesity; four are of sexual and ductive health, only one (Duflo and others 2006) provides reproductive health; and one is of smoking prevention cost-effectiveness estimates. Their findings suggest that (table 26.3). Most of the studies were conducted in providing adolescent girls with information they can use MICs. to make more informed decisions (advising them of the age profile of human immunodeficiency virus/acquired Obesity immune deficiency syndrome [HIV/AIDS] status in For MICs, school-based interventions to reduce obesity men) is the most cost-effective at US$253 per DALY are affordable at less than US$1 or US$1.50 per person averted. More general educational interventions regard- in the overall population; however, they are not cost- ing HIV/AIDS, and subsidies designed to help girls stay effective, according to Cecchini and others’ (2010) com- in school also fall into the very cost-effective zone for prehensive modeling study of interventions in MICs. In Kenya at less than one times per capita GNI (WHO comparison, restrictions on the advertising of food to 2001). Unit costs are modest; Duflo and others (2006) do children cost about one-tenth as much per person in the not present unit costs for the curriculum-based 374 Child and Adolescent Health and Development Table 26.3 Cost And Cost-Effectiveness of Interventions Relevant for Adolescent Health in Low- and Middle-Income Countries, from Systematic Review Cost per unit as Cost per unit in Study Country/region Intervention/condition presented in article Unit Currency (year) 2012 US$ Obesity Cecchini and others Brazil, China, India, Modeling effects of two interventions aimed 2010 Mexico, Russian at obesity at school age, and five others Federation, South Africa aimed at adults: • School-based interventions 0.82 (Brazil) Per head of 2005 US$ 1.44 0.53 (China) population 0.86 0.73 (India) 1.09 1.22 (Mexico) 1.35 0.51 (Russian Federation) 0.87 0.99 (South Africa) 1.19 • Food advertising regulations for children 0.04 (Brazil) Per head of 2005 US$ 0.07 0 (China) population 0 0 (India) 0 0.09 (Mexico) 0.10 Identifying an Essential Package for Adolescent Health: Economic Analysis 0.13 (Russian Federation) 0.22 0.08 (South Africa) 0.10 • School-based interventions (20-year > 1 million (except Russian Per DALY 2005 US$ > 1 million in all horizon) Federation) averted countries 830,177 (Russian Federation) • Food advertising regulations for children CS (Brazil) Per DALY 2005 US$ CS (20-year horizon) 556 (China) averted 902 3,186 (India) 4,753 11,151 (Mexico) 12,340 5,718 (Russian Federation) 9,725 13,241 (South Africa) 15,892 table continues next page 375 376 Child and Adolescent Health and Development Table 26.3 Cost And Cost-Effectiveness of Interventions Relevant for Adolescent Health in Low- and Middle-Income Countries, from Systematic Review (continued) Cost per unit as Cost per unit in Study Country/region Intervention/condition presented in article Unit Currency (year) 2012 US$ • School-based interventions (50-year 93,350 (Brazil) Per DALY 2005 US$ 174,918 horizon) 35,174 (China) averted 57,031 59,665 (India) 89,009 235,957 (Mexico) 261,123 261,114 (Russian Federation) 444,098 153,233 (South Africa) 183,911 • Food advertising regulations for children CS (Brazil) Per DALY averted 2005 US$ CS (50-year horizon) CS (China) CS 752 (India) 1,122 658 (Mexico) 728 4,823 (Russian Federation) 8,209 3,352 (South Africa) 4,023 Meng and others China Combined nutrition and physical education 26.80 Per student US$ (year not given; 31.10 2013 intervention in schools (also reports nutrition 3.80 excluding cost of time likely 2009–10) 4.41 excluding cost alone, physical education alone; no significant of teachers of time of teachers effect) 1,308.90 Per case of US$ (year not given; 1,519 overweight or likely 2009–10) obesity averted Sexual and reproductive health Duflo and others Kenya • Education of school students on HIV/AIDS 575 Per pregnancy US$ (year not given; 1,600 2006 (cost $9 per student in a specific grade averted (proxy for likely 2003) in 2003, estimated by authors of this unprotected sex) chapter) • Informing girls in school of age profile of 91 Per pregnancy US$ (year not given; 253 HIV in men averted likely 2003) • Free school uniforms once in each of two 749 (full cost) Per pregnancy US$ (year not given; 2,084 years for grade 6 students (uniform cost averted likely 2003) $6 in 2003) table continues next page Table 26.3 Cost And Cost-Effectiveness of Interventions Relevant for Adolescent Health in Low- and Middle-Income Countries, from Systematic Review (continued) Cost per unit as Cost per unit in Study Country/region Intervention/condition presented in article Unit Currency (year) 2012 US$ Kempers, Ketting, Moldova Adolescent-friendly sexual and reproductive 2.55 Per person in 2011 US$ 2.59 and Lesco 2014 health services population covered 12.10 Per user 12.58 Kivela, Ketting, and Nigeria School-based intervention for sexuality 7 (Nigeria) Per student 2009 US$ 9.40 Baltussen 2013 education (costs for pilot programs also for India, Indonesia, and Kenya) Terris-Prestholt and Tanzania An adolescent sexual health program, with 13.46 Per student 2001 US$ 17.92 others 2006 school-based education component plus 1.54 Per condom 2.05 condom distribution distributed Smoking Brown and others India School-based education intervention against 31.73 per student for Per student 2006 US$ 45.81 2012 smoking (MYTRI) 2-year program 2,492 Per QALY 2006 US$ 3,598 (2,769 if students’ (3,998 if students’ Identifying an Essential Package for Adolescent Health: Economic Analysis time included) time included) Note: CS = cost saving; HIV/AIDS = human immunodeficiency virus/acquired immune deficiency syndrome; MYTRI = Mobilizing Youth for Tobacco-Related Initiatives in India. 377 interventions, but calculations using their data suggest pregnancies averted, and cases of HIV/AIDS averted, these cost approximately US$25 per student in one grade. funding the services was difficult. A little more than Duflo and others (2006) present figures for a subsidy to 50 percent of the cost came from the National Health keep students in school of 2012 US$16.69 per student Insurance Company; services also relied on contribu- (cost of a uniform) per year, and US$33.38 for the inter- tions from donors, nongovernmental organizations, vention that provided uniforms in two different years. and local authorities, as well as substantial amounts of Two other studies provide costs per student for educa- volunteer time. tional interventions on sexual and reproductive health. Kivela, Ketting, and Baltussen (2013) examine costs in four LMICs; for a program at scale in Nigeria; and pilot Implications for Program Development programs in India, Indonesia, and Kenya. The two extra- This review of evidence from HICs and LMICs provides curricular programs in Indonesia and Kenya cost signifi- some guidance for the economics of an essential package cantly more than the intracurricular ones. Costs were of interventions. At the same time, we must recognize US$85 and US$205 per student, respectively, compared that evidence on what works is still being amassed. with US$9.40 in Nigeria, and US$16.30 in India. The First, data are simply insufficient in a number of budgetary outlays were a quarter or less of the total cost areas, including national media campaigns, national for the three countries with intracurricular programs policy making, and social media, which are likely all because governments are already paying teachers’ salaries. important ways to support any intervention delivered to International standards recommend that there should be individual adolescents. The modeling results on restric- 12–20 lessons of 45–60 minutes each, spread over more tions on food advertising to young people (Cecchini and than one year, for such interventions to be effective. others 2010) are promising, but the estimated effective- Kivela, Ketting, and Baltussen (2013) point out some ness of advertising interventions relies on very limited of the issues of including sexuality education in the cur- evidence. riculum. Their study notes that opposition to the pro- Second, programs delivered through schools are a grams in India and Nigeria caused implementation mainstay (Bundy, Schultz, and others 2017). Their unit delays of several years, with attendant increased costs. costs are not inexpensive, but school-based programs may A study for Tanzania (Terris-Prestholt and others be less costly than community-based ones. Costs of edu- 2006) estimated that an adolescent sexual health inter- cational programs in schools can be reduced by provid- vention cost US$17.92 for the school-based education ing intracurricular programs at scale and incorporating component. Other components included adolescent- training into the teacher education curriculum. Teacher friendly health services, peer distribution of condoms, involvement in educational interventions is crucial, and and community mobilization efforts; the educational effective training can reduce costs and improve afford- component accounted for 70 percent of the costs. ability in the long term. At the same time, neuroscience Information about the net budgetary cost was not pre- suggests that education programs alone are insufficient sented, including how much of the educational program in areas in which adolescents make “hot” decisions. cost was allotted to teacher’s salaries when presenting the Education may need to be complemented with risk program, as opposed to the additional costs for teacher reduction efforts based on behavioral theory and skill training. development. The likelihood of success for simply pre- The last study of sexual and reproductive health venting an undesirable outcome for a few years may be (Kempers, Ketting, and Lesco 2014) presents the cost of higher than that for establishing lifelong healthy habits. an adolescent-friendly sexual and reproductive health One limitation of the evidence is that education service in Moldova. Four well-performing centers were programs are very heterogeneous. Program design, picked for study out of 38. The centers provide services context, and intensity of effort in implementation for sexually transmitted infection, early pregnancy and all matter. Another limitation is that the duration contraception, and HIV/AIDS. Costs were US$6.14 per of follow-up studies of school-based interventions is visit; assuming each participant required on average two usually short. Thus, evidence on long-term impact is visits, the cost was US$12.58 per user per year. Slightly lacking. This differs from the literature on early child- less than 20 percent of the covered youth population hood development and preschool interventions, where used the services, such that the cost per young person in there are a modest number of high-quality research the population covered was US$2.59. studies with long-term follow-up, both for HICs and Although the youth-friendly health services in LMICs (see chapter 19 in this volume, Black and Moldova were potentially cost saving for potential num- others 2017, and chapter 24 in this volume, Horton bers of sexually transmitted infections averted, unwanted and Black 2017). 378 Child and Adolescent Health and Development Finally, youth-friendly health services may be impor- • Female genital mutilation tant and cost-effective, but they are time intensive to • Too early, unwanted, and rapid-succession pregnancies deliver, and issues of affordability in LMICs may arise. • Sexually transmitted infections • HIV/AIDS • Interpersonal violence COSTING AN ESSENTIAL PACKAGE • Mental health Promoting adolescent health requires a broad range of • Psychoactive substance use actions across several sectors. Education is key and • Tobacco use. affects skills and employment opportunities; for girls, education helps delay marriage and early childbearing. Nutritional conditions and vaccine-preventable dis- Policies and laws that allow flexibility in adolescents’ eases are discussed in the package for school-age chil- access to health services without necessarily requiring dren (Fernandes and Aurino 2017); others are consistent parental authorization are vital, as are policies and laws with topics discussed in this chapter. controlling their exposure to unhealthy products and Priority actions for adolescent health in the Global activities (Laski and others 2015). Empowerment and Strategy for Women’s, Children’s and Adolescents’ involvement of adolescents in decision making concern- Health are summarized by Laski and others (2015) as ing their well-being is essential. Although ministries of follows: health will be involved in promoting adolescent health in all of these areas, they will not necessarily lead the efforts. • Health education, including comprehensive sexuality The focus of this chapter is on the more narrowly education defined interventions to promote adolescent health in • Access to and use of integrated health services which ministries of health have the primary responsibil- • Immunization ity. The adolescent package costed here draws on several • Nutrition, including healthy eating and exercise, and other sources. The WHO (2013) provides policy advice supplementation of key micronutrients on programs for preconception care, which overlaps • Psychosocial support for detection and management substantially with the initiatives discussed in the previ- of mental health problems. ous section. Patton and others (2016) include recom- mendations for adolescent health as well as other Start with a Girl is an ambitious agenda with eight supportive nonhealth services. The Global Strategy for components recommended for adolescent girls in Women’s, Children’s and Adolescents’ Health (Every LMICs (Temin and Levine 2009). The total package is Woman Every Child 2015) includes recommendations US$359.31 per girl per year. (We have not updated their in five priority areas for adolescent health interventions cost estimates to 2012 since doing so is not straightfor- (Laski and others 2015). ward for a multicountry estimate). The eight compo- Two other studies provide cost estimates. The Centre nents specific to girls, with associated costs per girl per for Global Development’s Start with a Girl discusses an year, are youth-friendly health services (US$8.50), iron agenda for adolescent girl health that was also costed supplements (US$2.00), HPV vaccination (US$17.50), (Temin and Levine 2009). Deogan, Ferguson, and reducing harmful traditional practices (US$80.85), Stenberg (2012) provide estimates for a package of ado- male engagement (US$113.85), obesity reduction lescent-friendly health services, as well as the cost of (US$0.11), edutainment programs (US$0.57), safe providing this package in 74 LMICs. These services are spaces (US$130.51), and comprehensive sexuality edu- one component of a desirable package for promoting cation (US$6.02). The edutainment intervention, which adolescent health. combines computer games with educational elements, The WHO’s (2013) guidelines on preconception care is directed at issues of sexual and reproductive health, recommend interventions in 13 areas. These areas are gender-based violence, and other health challenges fac- primarily directed at women but apply to older adoles- ing girls. The ninth component is male engagement for cent girls, given the younger age at first birth in many young men ages 15–24 years living on less than US$2 per LMICs. The areas comprise the following: day (US$113.25). Smoking reduction is not costed because it is expected that revenue from higher taxation • Nutritional conditions would more than cover interventions. This package is • Vaccine-preventable diseases somewhat different from what is costed in this chapter. • Genetic conditions It is, on the one hand, much more comprehensive; on • Environmental health the other hand, it does not consider the health of male • Infertility and subfertility adolescents. Identifying an Essential Package for Adolescent Health: Economic Analysis 379 Deogan, Ferguson, and Stenberg (2012) have Finally, we use estimates from the previous section undertaken a comprehensive costing of adolescent- for the costs of school-based education programs. friendly health services for 74 countries. The package Three programs (table 26.3) cost US$9, US$18, and includes contraception; maternity care; management of US$25, approximately. The Indian antismoking sexually transmitted infections; HIV/AIDS testing and program (Brown and others 2012), at almost US$46, counseling, harm reduction, and care and treatment; safe relies heavily on per diem and travel costs as a start-up, abortion services; and care of injuries due to intimate and it is unrepresentative of what a mature program partner violence and sexual violence. It also includes costs might cost. We include a cost of US$18 per adoles- of activities to improve quality of care and increase cent per year and assume that adolescents would par- uptake of services by adolescents. Once full coverage is ticipate in such a program each year for three years achieved, the cost is estimated to be US$4.70 per adoles- (ages 14–16 years). Of this cost, 25 percent represents cent, or US$0.82 averaged over the whole population. additional budget costs to the government of develop- There is some degree of overlap between costs for ing the program, training the trainers, and refreshing adolescent-friendly health services; estimates of expand- the curriculum periodically; the balance is the cost of ing contraceptive services are discussed in volume 9, teachers’ time. We specifically exclude obesity from chapter 3 (Watkins and others 2018). The overall cost of the educational package. The evidence base is weak, US$4.3 billion in aggregate covers 74 countries. We have and current programs are not unequivocally effective. not converted these figures to 2012 U.S. dollars because This is an area where more pilot programs and their projections are in current U.S. dollars for 2011–15 evaluations are required. and the conversion would not be straightforward. The cost of the recommended package is as follows: The essential package costed in this chapter draws on the economic assessment of existing interventions and • US$4.70 per adolescent ages 10–19 years for the key interventions outlined in recent strategy docu- adolescent-friendly health services ments where ministries of health have a leading or major • US$1.16 per adolescent ages 10–19 years for national role. The package that we cost includes the following media campaigns and national policy efforts components: • US$9.00 per adolescent ages 14–16 years for the net budget cost of a school-based education program, • Adolescent-friendly health services excluding cost of teachers’ time; this amount is equiv- • School-based educational programming covering alent to US$3.00 per adolescent ages 10–19 years. such topics as sexual and reproductive health, mental health, smoking, alcohol, and illicit drugs The total package, therefore, costs roughly • National media and policy efforts to support a US$8.90 per year for each adolescent ages 10–19 years. healthy lifestyle program to complement school- Deogan, Ferguson, and Stenberg’s (2012) estimate for based programming adolescent-friendly health services is carefully con- structed using detailed data; the other two items are These interventions correlate fairly well with the bur- simply rough estimates and require further refinement. den of disease in adolescence: the top five causes of death Costs of the total package are aggregated by size of pop- are road injury, HIV/AIDS, suicide, lower respiratory ulation in low-income and lower-middle income coun- infections, and interpersonal violence; and the top five tries in chapter 1 (Bundy, de Silva, and others 2017). causes of years lived with disability are depression, road injuries, anemia, HIV, and suicide (WHO 2014). Because road traffic injuries are an important topic in volume 7 CONCLUSIONS of this series (Mock and others 2017), they are not dis- cussed in the present chapter. Adolescent health, overlooked for years, is now achieving We use Deogan, Ferguson, and Stenberg’s (2012) esti- much-needed prominence in the international health mates for adolescent-friendly health services. We use agenda. Adolescence is a key point in the life course, a Ebbeler’s (2009) estimates for the national media cost point at which important health behaviors are estab- for a sexuality education campaign of US$0.58 per girl lished that determine the path of chronic disease at older or boy reached, and we assume that double this amount ages. It is a key time at which to invest in and benefit the could incorporate a more comprehensive campaign health of the working-age population, older adults, and against various harms. Ebbeler’s (2009) estimates pro- through new mothers and their babies, the next genera- vide the detailed assumptions underpinning the costing tion. The relative neglect of adolescents in research and in Temin and Levine’s (2009) Start with a Girl. programming means that knowledge of how to design 380 Child and Adolescent Health and Development cost-effective programs is inadequate relative to needs. undertaken for promising pilot programs before they are This is an area in which there may be a payoff to trying scaled up. It is not too difficult to collect cost informa- innovative approaches and in which pilot programs tion retrospectively to calculate cost-effectiveness or the require rigorous evaluation. benefit-cost ratio if a program proves to be effective. Economic evaluations for HICs suggest that a number Another priority is for longitudinal studies, particularly of health interventions for adolescents can be cost-effective for the rapidly growing problem of obesity, but there is or very cost-effective, including screening and treating for considerable uncertainty about whether school-based selected mental health conditions as well as school-based programs have any lasting effect. A third knowledge gap programs on education regarding smoking, alcohol, and is how to reach adolescents who are not in school. It is sexual health. Whether interventions aimed at obesity are possible that social media and mass media can be used cost-effective is uncertain because data on long-term innovatively to reach this group, and perhaps the health outcomes are lacking. sector can learn how to design appealing health messages For LMICs, we were able to find only two cost- from advertisers of commercial products. effectiveness studies using QALYs or DALYs as outcomes. One concluded that restrictions on advertising of unhealthy foods was cost-effective (or even cost saving) in preventing ANNEX obesity across a range of countries, while school-based interventions were not. The other study concluded that a This annex to this chapter is as follows. It is available at school-based antismoking pilot program in India was http://www.dcp-3.org/CAHD. cost-effective, although not very cost-effective; it is likely that if it became part of the routine curriculum it could • Annex 26A. Methodology and Results of Systematic become less costly and therefore likely more cost-effective. Search, Cost-Effectiveness Analysis An essential package for adolescent health should include at least three elements: national-level policy combined with communication of social norms, acces- NOTE sible and respectful services, and targeted education. World Bank Income Classifications as of July 2014 are as fol- National and subnational governments need to create lows, based on estimates of gross national income (GNI) per an appropriate environment through legislation and capita for 2013: through social marketing of key messages. Access to services that recognize adolescents’ desires for confi- • Low-income countries (LICs) = US$1,045 or less dentiality and treat them respectfully will facilitate • Middle-income countries (MICs) are subdivided: uptake. Education in health and wellness will provide a) lower-middle-income = US$1,046 to US$4,125 this group with the means to be active participants in b) upper-middle-income (UMICs) = US$4,126 to US$12,745 their own health and improve outcomes. This educa- • High-income countries (HICs) = US$12,746 or more. tion can be provided in schools as well as in other venues where it is cost-effective to reach those who are no longer in school. These elements need to be comple- REFERENCES mented with broader social policy and initiatives out- Black, R., R. Laxminarayan, M. Temmerman, and N. Walker. side the health area that affect adolescent well-being. 2016. Reproductive, Maternal, Newborn and Child Health. The essential package in this chapter costs approxi- Volume 2 in Disease Control Priorities (third edition), edited by mately US$8.90 per adolescent in lower-middle-income D. T. Jamison, H. Gelband, S. Horton, P. Jha, R. Laxminarayan, countries (in 2012 U.S. dollars). 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Familial and public investments INTRODUCTION enter during all lifecycle stages, often induced by the initial By 2012, child mortality had fallen to almost half its level intervention. Later investments may in principle comple- in 1990.1 The next major challenge is to improve ment or substitute for those early in the lifecycle, but some early-life conditions to harness developmental potential. evidence suggests they may be reinforcing (Almond and An estimated 200 million children under age five years in Mazumder 2013; Bhalotra and Venkataramani 2011, low- and middle-income countries (LMICs) are unlikely 2013), consistent with recent models that describe human to reach their developmental potential because of capital production as involving dynamic complementari- inadequate health, nutritional, and other investments in ties across types of investment (for example, health and early life (Grantham-McGregor and others 2007).2 This schooling) and across ages, such that investments early in inability to achieve full potential implies substantial life increase rates of return to investments later in life losses of welfare and future economic productivity (Cunha and Heckman 2007; see also Alderman and others for these children and for their societies (Akresh and 2017, chapter 7 in this volume). others 2012; Behrman, Alderman, and Hoddinott 2004; In the first section, we provide a selected review of Bhalotra and Venkataramani 2011; Bhutta and others evidence of long-term human capital and economic 2008; Currie and Vogl 2013; Hoddinott and others 2008; benefits from early-life interventions and then some Horton, Alderman, and Rivera 2009) and increases the illustrative calculations of benefit-cost ratios for these risk of adult morbidities and lower life expectancy interventions. We focus on interventions affecting (Bhalotra, Karlsson, and Nilsson 2015; Hjort, Solvesten, maternal and early childhood health, including micro- and Wust 2014). This chapter supplements previous nutrient supplementation and breastfeeding, and work focusing on estimates of economic benefits from maternal survival. We then present evidence of effects early-life nutritional interventions in LMICs.3 of early interventions on low birth weight (LBW), Figure 27.1 shows the pathways through which early-life stunting, and cognitive development in the second sec- interventions can affect later-life economic outcomes. tion. The third section discusses issues in the estima- Prenatal and early childhood interventions affect out- tion of benefit-cost ratios of early-life interventions comes at every stage of the lifecycle. These impacts accu- and presents simulations, illustrating sensitivity of mulate, making it important to study long-term dynamic estimates to alternative parameters. The fourth section Corresponding author: Arindam Nandi, Tata Centre for Development, University of Chicago, Chicago, Illinois, United States; anandi@uchicago.edu. 385 Figure 27.1 Lifecycle Approach to Early Childhood Interventions Risks in first 1,000 days after 1. Outcomes in first 1,000 days after conception conception Physical (health, nutritional status) 1. Malnutrition Cognitive 2. Infection Socioemotional 3. Pregnancy and birth complications Executive function 4. Inadequate stimulation 2. Outcomes in preschool ages (Outcomes from box 1) Familial and public 3. Outcomes in late childhood investments within given (Outcomes from box 1 plus school context with related costs attainment) 4. Outcomes in adolescence and young adulthood (Outcomes from box 1 plus labor market, partnering, parenting, household production) 5. Outcomes in mature adulthood (Outcomes from box 1 plus labor market, health, partnering, parenting, household production) 6. Outcomes in old age (Outcomes from box 1 plus labor market exits, grandparenting, household production, chronic diseases, mortality) Source: Adapted from Hoddinott, Alderman, and others 2013. discusses issues of designing policy based on the grow- cognitive development during the first thousand days ing body of estimates from randomized trials in LMICs. after conception (figure 27.1, top right box) has gained Definitions of age groupings and age-specific terminol- increasing recognition. Maternal stress and nutritional ogy used in this volume can be found in chapter 1 deprivation tend to stimulate permanent changes in tis- (Bundy and others 2017). sue structure and function that help the fetus survive but that are associated with abnormal structure, function, and disease in adult life. Almond and Currie (2011, 167) MATERNAL AND CHILDHOOD summarize the implications of the fetal origins hypoth- esis: “One can best help children (throughout their life INTERVENTIONS course) by helping their mothers. That is, we need to Since Barker’s (1990) pioneering “fetal origins” hypoth- focus on pregnant women or perhaps women of esis linking the prenatal environment to indicators of child-bearing age if the key period turns out to be so adult health, including diabetes and heart disease risk, early in pregnancy that many women are unaware of the the importance of in utero influences on physical and pregnancy. Such preemptive targeting would constitute 386 Child and Adolescent Health and Development a radical departure from current policies that steer young children, mothers’ deaths are likely to have larger nearly all healthcare resources to the sick.” impacts on children’s skill development. Mothers’ deaths Maternal health could improve later-life child out- may have gender-specific impacts on children if daugh- comes through at least two avenues. First, improved ters substitute for mothers in home production. Higher maternal health can lead to better delivery outcomes, maternal mortality risks also may lower human capital such as avoidance of premature birth and reduced likeli- investments in girls relative to boys because they shorten hood of LBW, which are associated with negative expected horizons over which returns to investments in economic consequences in later life (Alderman and girls flow. Male mortality risks, higher on average than Behrman 2006).4 Bhalotra and Rawlings (2011) show female mortality risks, for the same reason lower the that, by numerous indicators, poor maternal health is incentives for human capital investments in boys. significantly associated with risks of LBW, infant mortal- The rest of this section reviews some empirical evi- ity, and growth faltering. A one standard deviation dence on impacts of maternal and reproductive health decrease in a mother’s height is associated with increased interventions on later-life outcomes of children. LBW risks of 7.4 percent of the sample mean rate and with increased neonatal mortality risk of 9.3 percent of the sample rate. A one standard deviation decrease in Prenatal Interventions body mass index is associated with higher LBW risks by Field, Robles, and Torero (2009) evaluate the effects of 10.8 percent of the mean and with higher neonatal mor- iodine supplementation during pregnancy in Tanzania. tality risks by 13.1 percent of the mean. LBW and neona- Iodine deficiency is widespread in many developing tal mortality risks are lower by 5.7 percent and 16.9 percent countries. Compelling evidence indicates that iodine of their mean rates, respectively, among nonanemic matters most during fetal brain development, and iodine mothers relative to anemic mothers. These tendencies are deficiencies have adverse effects on children’s cognitive widespread. Many current interventions focus on improv- abilities. In the early 1970s, 40 percent of the Tanzanian ing mothers’ health during pregnancy and tend to influ- population lived in iodine-deficient areas and 25 percent ence mothers’ body mass index and anemia status. had iodine-deficiency disorders. Tanzania subsequently However, the estimated associations of maternal height launched a large and intensive early iodine supplementa- with birth and early childhood outcomes underscore that tion program, which ultimately reached nearly a quarter mothers’ health stocks when they give birth, in the accu- of the population for an average of four years. Field, mulation of which nutritional investments in mothers’ Robles, and Torero (2009) assess whether children who childhoods count, are also important for reproductive and benefited from supplements in utero exhibited higher next-generation outcomes. In addition to maternal health grade progression rates 10–15 years later. They also com- indicators, evidence suggests that maternal behaviors, such pare those exposed to the sporadic iodization efforts as smoking and drinking during pregnancy, compromise with unexposed siblings, thereby controlling for selective fetal development (Almond and Currie 2011; Currie and uptake by families. Vogl 2013; Gilman, Gardener, and Buka 2008; Nilsson They find large and robust impacts. Children pro- 2008; Stratton, Howe, and Battaglia 1996; Victora and tected from iodine deficiency during their first trimester others 2008; Weitzman, Gortmaker, and Sobol 1992). in utero attain an average of 0.3 schooling grades more Second, maternal health can affect later-life economic than siblings and older and younger children in their outcomes conditional on birth outcomes. For instance, district who were not protected, confirming that first breastfeeding and stimulation are associated with trimesters are critical for cognitive development. The children’s cognitive and socioemotional skills, and effects are substantially larger for girls, indicating poten- maternal mental health tends to influence breastfeeding, tially important roles of micronutrient deficiencies in stimulation, and mother-child bonding (Attanasio explaining gender differences in schooling attainment. and others 2014; Bennett and others 2014; Krutikova To verify their findings, Field, Robles, and Torero and others 2015; Maselko and others 2015; Rahman and (2009) present cross-country regressions of school par- others 2008; Rees and Sabia 2009). ticipation on baseline iodine-deficiency disorders and The limiting case of poor maternal health, of course, fractions of populations consuming adequately iodized is maternal death. Deaths of mothers who contribute to salt. The results show a negative correlation between household resources reduce such resources and thereby baseline iodine-deficiency disorders and female second- investments in children. Fathers’ deaths tend to reduce ary schooling and a positive correlation between early household resources more, but mothers’ deaths may salt iodization and female primary schooling attain- reduce the share of resources going to children more. ment. Given the low cost of iodine supplementation and However, because mothers tend to spend more time with the persistence of iodine deficiency in poor countries, The Human Capital and Productivity Benefits of Early Childhood Nutritional Interventions 387 Field, Robles, and Torero (2009) conclude that prenatal cost-effective solutions for addressing the world’s 10 supplementation offers an efficient, cost-effective means biggest challenges, according to the Copenhagen Consensus of improving human capital. Studies of introduction of Expert Panel (2008), were micronutrient-related early iodized salt in Sweden and the United States similarly childhood interventions (table 27.1). The 2012 Copenhagen show that it raised schooling attainment (especially for Consensus Expert Panel also ranked micronutrient sup- women) and cognitive performance, respectively (Feyrer, plementation and fortification as the top priority, but the Politi, and Weil 2013; Politi 2011). micronutrient-related interventions were combined as Recent studies estimate substantial economic benefits “Bundled Interventions to Reduce Undernutrition in of micronutrient supplementation. Five of the top 10 most PreSchoolers” (Lomborg 2014). Updating the estimates in Table 27.1 Top Priorities for Addressing the World’s 10 Biggest Challenges, Ranked by the Expert Panel of the Copenhagen Consensus, 2008 Solution Challenge 1 Micronutrient supplements for children (vitamin A and zinc) Malnutrition 2 The Doha Development Agenda Trade 3 Micronutrient fortification (iron and salt iodization) Malnutrition 4 Expanded immunization coverage for children Diseases 5 Biofortification Malnutrition 6 Deworming and other nutrition programs at school Malnutrition and education 7 Lowering the price of schooling Education 8 Increase and improve girls’ schooling Women 9 Community-based nutrition promotion Malnutrition 10 Provide support for women’s reproductive role Women 11 Heart attack acute management Diseases 12 Malaria prevention and treatment Diseases 13 Tuberculosis case finding and treatment Diseases 14 R&D in low-carbon energy technologies Global warming 15 Bio-sand filters for household water treatment Water 16 Rural water supply Water 17 Conditional cash transfers Education 18 Peacekeeping in postconflict situations Conflicts 19 HIV combination prevention Diseases 20 Total sanitation campaign Water 21 Improving surgical capacity at district hospital level Diseases 22 Microfinance Women 23 Improved stove intervention Air pollution 24 Large, multipurpose dam in Africa Water 25 Inspection and maintenance of diesel vehicles Air pollution 26 Low sulfur diesel for urban road vehicles Air pollution 27 Diesel vehicle particulate control technology Air pollution 28 Tobacco tax Diseases 29 R&D and mitigation Global warming 30 Mitigation only Global warming Source: Copenhagen Consensus Expert Panel 2008. Note: HIV = human immunodeficiency virus; R&D = research and development. 388 Child and Adolescent Health and Development Behrman, Alderman, and Hoddinott (2004) and Horton, one-fourth of children had died by the year of follow up, Alderman, and Rivera (2009), Hoddinott, Rosegrant, and arguing that the relevant parameter for policy purposes Torero (2013) report benefit-cost ratios (BCRs) for iodized is the impact of maternal tetanus on child education salt (BCR=81), iron supplements for mothers and children conditional on survival. Driessen and others (2011) ages 6–24 months (BCR=24), vitamin A supplementation show that an intensive measles vaccination program in (BCR=13), and zinc supplements for children (BCR=3). Bangladesh was associated with an increase in the prob- The evidence thus suggests that micronutrient supple- ability that a boy has enrolled in school of 9.5 percentage mentation and fortification have very high economic points, while having no effect on girls’ enrollment. returns relative to costs. Horton and Ross (2003, 51) review evidence for causal relationships between iron deficiency and a vari- Breastfeeding Interventions ety of “functional consequences with economic implica- Numerous studies indicate positive short- and long-term tions (motor and mental impairment in children and associations of breastfeeding of newborn babies, in partic- low work productivity in adults).” Using plausible impact ular exclusive breastfeeding, with desirable outcomes estimates, they simulate annual physical and cognitive (Horta and Victora 2013; Ip and others 2007; Kramer and productivity losses due to iron deficiency for 10 develop- Kakuma 2012; Victora 2000). The relationship is especially ing countries and obtain a median value of 4 percent of pronounced in LMICs. Anderson, Johnstone, and Remley GDP, with a range of 2.4 percent (Arab Republic of (1999); Horta and Victora (2013); and Victora and others Egypt) to 7.9 percent (Bangladesh). (2015) conclude that breastfeeding may significantly A few studies have examined the association between improve children’s cognitive performance and reduce interventions that address acute undernutrition and future risk factors and cardiovascular disease incidence. future health, educational, and economic outcomes. There is a growing literature on breastfeeding promo- A study by the Institute of Nutrition of Central America tion across the world. Renfrew and others (2009) provide and Panama (INCAP) provided a protein-rich nutritional a systematic review of nine types of breastfeeding promo- supplement to 2,392 children under age seven years start- tion interventions in 48 studies, 65 percent of which are ing in 1969. The intervention was later found to be asso- randomized controlled trials: increased mother and baby ciated with higher schooling grades of women, improved contact (kangaroo mother care [KMC], advocated by the cognitive outcomes of men and women, and higher male World Health Organization [2003] and Conde-Agudelo, wages (Hoddinott, Behrman, and others 2013; Maluccio Diaz-Rossello, and Belizan [2003]), variation in feeding and others 2006, 2009). The Andhra Pradesh Children methods (cup feeding, gavage feeding, bottle feeding), and Parents Study is a similar trial of nutritional supple- methods of expressing breastmilk (use of pumps), increas- mentation provided to pregnant women and young ing breastmilk production (use of galactagogues and children in 29 villages of southern India from 1987 relaxation techniques), supporting optimal nutritional through 1990. Adolescent children born during the trial intake from breastmilk, breastfeeding education and peer period in intervention areas were taller and had better support, training of health care staff, early hospital dis- cardiovascular health and educational outcomes (Kinra charge with home support, and better organization of and others 2008; Nandi and others 2016). care. They conclude that KMC and breastfeeding educa- Canning and others (2011) analyze effects of antena- tion and peer support are the two most effective methods tal maternal vaccination against tetanus, which is of increasing breastfeeding uptake and adherence rates. expected to prevent children from acquiring tetanus at Home-based education and peer support for breastfeed- birth through blood infection and to thereby reduce ing for mothers of LBW babies is estimated to more than infant mortality. They follow up a randomized con- double breastfeeding rates up to 24 weeks and increase trolled trial of maternal tetanus toxoid immunization exclusive breastfeeding rates by even more in low-income conducted in 1974 in Bangladesh, looking at schooling settings. Support programs that are jointly based at home outcomes for children born in 1975–79. They find, in and in facilities also have similar effectiveness in increas- cases in which parents had no schooling, that tetanus ing breastfeeding rates up to 12 weeks. Renfrew and others toxoid vaccination of mothers reduced the probability of (2009) report evidence that short periods of KMC skin- no schooling for children by 4.5 percent and increased to-skin contact significantly increase the duration of any the probability of children completing one to seven breastfeeding at up to one month after hospital discharge grades of schooling by 1.5 percent and of children com- in developed country settings and that daily contact pleting eight or more schooling grades by 3 percent. On between mothers and babies, which results in increased average, schooling attainment increases by about 0.25 breastfeeding rates, is estimated to improve child health grades. They do not correct for the fact that about outcomes at two months and six months across the world. The Human Capital and Productivity Benefits of Early Childhood Nutritional Interventions 389 Jolly and others (2012) conduct a systematic review generated by whether births occur on weekends when and meta-regression analysis of peer-support breast- hospital staffing is more limited or on weekdays, feeding programs. They find that peer support reduces Fitzsimons and Vera-Hernandez (2014) estimate large risks of no breastfeeding by 30 percent in LMICs and impacts of breastfeeding on cognitive development but 7 percent in high-income countries. Peer support no effects on noncognitive development or health in a also reduces risks of nonexclusive breastfeeding by sample of less-educated mothers in the United Kingdom. 37 percent in developing countries. Some methodological concerns about the causal rela- tionship between breastfeeding and future outcomes Maternal Survival need to be mentioned. Most available studies generally Mothers’ deaths can profoundly affect their children’s are associative and do not control for selection into emotional and educational well-being, thereby affect- breastfeeding on the basis of child characteristics such as ing their future schooling attainment and labor innate health or expected survival chances or family productivity. Ainsworth and Semali (2000) analyze characteristics such as socioeconomic status (Colen and effects that maternal deaths (from AIDS) have on Ramey 2014; Drane and Logemann 2000; Jain, Concato, Tanzanian children’s schooling. They find that female and Leventhal 2002). adult deaths—irrespective of whether they were Some studies attempt to mitigate such biases. Doyle parents—are associated with delayed school enroll- and Denny (2010) compare ordinary least squares and ment among children ages 7–11 years and early drop- instrumental variables estimates and conclude that there out among children ages 15–19 years. In contrast, is no significant selection into breastfeeding in their prime-age male deaths do not have significant effects sample of British children. In view of evidence in other on children’s school enrollment. This finding is consis- studies that less-educated women are less likely to breast- tent with teenage children substituting for adult wom- feed, this finding suggests context specificity in selection. en’s time in home-production activities. Impacts of Using sibling comparisons, Der, Batty, and Deary (2006) adult deaths on child schooling are largest among poor argue that cross-sectional relationships between breast- households. feeding and child cognitive outcomes are overestimates Ainsworth and Semali (2000) also find that children of causal effects and that family background explains ages zero to five years who lost their mothers are much most of the positive associations. Colen and Ramey more likely to be stunted than children who lost their (2014) find that perceived positive effects of breastfeed- fathers or children with both parents living. The chil- ing on a series of child health, cognitive, and behavioral dren whose nutritional status is most affected by moth- outcomes in the United States are completely nullified in ers’ deaths are those whose mothers had no schooling sibling comparisons. However, Rees and Sabia (2009), (and who were therefore likely to be from poor house- using sibling fixed effects estimators, find positive breast- holds). Similarly, Case and Ardington (2006), using feeding effects on children’s high school test scores and longitudinal data from KwaZulu-Natal, South Africa, college attendance, and Rothstein (2013) and Belfield and find that maternal orphans are significantly less likely Kelly (2012) use propensity score matching and find pos- to be enrolled in school and complete significantly itive effects of breastfeeding on young American chil- fewer schooling grades than children whose mothers dren’s health and cognitive outcomes. Borra, Iacovou, are alive, but no significant effects are observed for and Sevilla (2012) also use propensity score matching paternal orphans. and find that breastfeeding for four weeks improves cog- Using a large Indonesian panel dataset, Gertler, nitive test scores among British children. Kramer and Levine, and Ames (2004) observe that recent parental others (2008), based on a large randomized controlled death lowered children’s school enrollment, with the trial, find that longer and exclusive breastfeeding improves largest effects for youth at transitions between primary Belarussian children’s IQs. Using hospital-level variation and junior secondary and between junior secondary in coverage of the Baby-Friendly Hospital Initiative, a and secondary. Their results suggest that children in breastfeeding support program initiated in 1991 and led bereaved families drop out of school at roughly 50 by the World Health Organization and the United Nations percent higher rates than their classmates. They find no Children’s Fund, Del Bono and Rabe (2012) find signifi- significant difference between effects on child schooling cantly positive impacts of breastfeeding on children’s of maternal versus paternal deaths. The impact on cognitive and emotional development but not on any human capital investment in girls of improvements in indicators of their physical health. In addition, they find women’s life expectancies from large concentrated that breastfeeding has significantly positive effects on reductions in Sri Lankan maternal mortality is analyzed mothers’ mental health. Using variation in breastfeeding in Jayachandran and Lleras-Muney (2009). They study 390 Child and Adolescent Health and Development district-level data for 1946–53, a period in which mater- estimates for different discount rates (table 27.2). Their nal mortality rates fell by 70 percent. The “treatment” results suggest that the largest economic gains come from group was individuals who were ages 2–11 years in productivity increases due to increased cognitive ability 1946, just before the maternal mortality decline; the (about 40 percent of the total with a 5 percent discount “control” group was individuals ages 18–37 years in rate), followed by productivity increases from reduced 1946 whose schooling preceded the maternal mortality stunting (17 percent) and reduced infant mortality (16 decline. Their results suggest that the maternal mortal- percent). The present discounted value of moving an ity rate decline increased female literacy by 2.5 percent, infant from LBW to non-LBW status ranges from US$832 a 1 percentage point increase (relative to changes in with a discount rate of 3 percent to US$257 at a discount male literacy), and raised completed schooling by about rate of 10 percent. The implication of these results is that 0.2 grades or 4 percent. any intervention that costs less than these amounts per child moved from LBW to non-LBW status is worthwhile to undertake purely on the grounds of saving resources or ANTHROPOMETRIC AND COGNITIVE increasing productivity. OUTCOMES OF EARLY-LIFE INTERVENTIONS Interventions That Reduce Low Birth Weight Nutritional Interventions That Reduce Stunting Alderman and Behrman (2006) estimate the economic Stunting reflects cumulative effects of chronic poverty, benefits of reducing LBW in LMICs through seven path- poor maternal health, inadequate nutrient consumption, ways: reduced infant mortality, reduced neonatal care, and infections, among others (Bhalotra and Rawlings reduced costs of infant and child illness, productivity gains 2011, 2013; Martorell, Khan, and Schroeder 1994; from reduced stunting, productivity gains from increased Victora and others 2008). It has been claimed that cognitive ability, reductions in prevalence (and thereby growth faltering up to age two years is irreversible in its costs) of chronic disease, and intergenerational benefits. effects on an important set of adult outcomes, including Based on their review of relevant empirical studies, they not only stature but also education, health, and produc- estimate that economic benefits from reducing LBW in tivity (Bhutta and others 2008; Victora and others 2008; LMICs are fairly substantial, with a present discounted Victora and others 2010). Alderman, Hoddinott, and value of US$510 (using a 5 percent discount rate) for each Kinsey (2006); Hoddinott, Alderman, and others (2013); infant moved from the LBW to the non-LBW category. Hoddinott, Behrman, and others (2013); and Hoddinott, They decompose the economic benefits of reducing LBW Rosegrant, and Torero (2013) discuss the pathways status into the seven individual components and calculate through which stunting generates economic losses—loss Table 27.2 Estimates of Present Discounted Value of Seven Major Classes of Benefits of Shifting One LBW Infant to Non-LBW Status US dollars, except as noted Annual discount rate 1% 2% 3% 5% 10% 20% 1. Reduced infant mortality 97 96 95 93 89 81 2. Reduced neonatal care 42 42 42 42 42 42 3. Reduced costs of infant and child illness 40 40 39 38 36 33 4. Productivity gain from reduced stunting 350 250 180 100 29 4 5. Productivity gain from increased ability 850 600 434 240 70 10 6. Reduction in costs of chronic diseases 240 133 74 23 1.5 0 7. Intergenerational benefits 422 220 122 45 8 1 Sum of PDV of seven benefits 2,041 1,381 986 581 275.5 171 Sum as percentage of that for 5% 351% 238% 170% 100% 47% 30% Source: Alderman and Behrman 2006. Note: LBW = low birth weight; PDV = present discounted value. The Human Capital and Productivity Benefits of Early Childhood Nutritional Interventions 391 of physical growth potential (and physical strength that Hoddinott, Alderman, and others 2013) calculate average is often needed to be productive in manual occupations), benefit-cost ratios for interventions that reduce stunting delayed enrollment in school, cognitive impairment, and in 14 selected LMICs in Asia and Africa (figure 27.2). increased risk of chronic diseases. Among the interventions considered are universal salt Recent studies, however, suggest the following: iodization, iron fortification of staples, iron–folic acid supplementation, community-based nutrition programs, • Although early-life nutritional status predicts sig- vitamin A supplementation, deworming, and therapeutic nificantly later child nutritional status, about half zinc supplementation. Figure 27.2 shows that the median the variance in later child nutritional status is not benefit-cost ratio is 18.7 (Kenya), with a range from 3.8 predicted by early-life nutritional status. (Democratic Republic of Congo) to 34.1 (India). • The unpredicted component of later child nutri- The benefit-cost ratios for most countries, moreover, tional status is associated with parental and commu- appear to be significantly greater than 1.0 under a range nity characteristics and appears to be malleable and of more conservative assumptions than in the base responsive to some possible interventions. simulations. • The unpredicted growth in nutritional status between Hoddinott, Behrman, and others (2013) use data early and late childhood is significantly associated from a randomized controlled trial in Guatemala to with late childhood cognitive skills (Crookston and examine adult consequences at ages 25–42 years of others 2010; Crookston and others 2011; Crookston growth faltering by age two years. The adults were partic- and others 2013; Prentice and others 2013; Schott and ipants in an INCAP food-supplementation trial in four others 2013). Guatemalan villages when they were under age seven years in 1969–77. The trial was designed to test effects on This revisionist literature raises questions about physical and cognitive development of a nutritious pro- whether the conventional wisdom overemphasizes the first tein-rich supplement, atole. The study uses instrumental thousand days of life, at least with regard to irreversibility variable methods to correct for estimation bias and con- (though whether cost considerations may still imply that trol for potentially confounding factors. The authors early-life interventions have relatively high rates of return find that growth failure had large significant effects on remains a question). A bigger threat to conventional wis- numerous adult outcomes, including schooling attain- dom may be studies in process that find no evidence of ment, family formation, reproduction, cognitive skills, significant causal impacts on late childhood schooling and men’s wage rates, and poverty avoidance. However, no cognitive skills if early-life household resources and the impact was observed on female wage rates, possibly endogenous choices that lead to early-life nutritional because most adult women were engaged in low- status are controlled for (Georgiadis 2015). productivity activities such as agricultural production Building on the work of three studies (Bhutta and and processing. Also, no significant associations were others 2008; Hoddinott and others 2011; Horton and observed between growth failure and several measures of others 2010), two studies (Bhutta and others 2013; adult health, including metabolic syndrome and cardio- vascular disease risk factors. This paper suggests that interventions that improve childhood nutrition and Figure 27.2 Average Benefit-Cost Ratios for Interventions to Reduce promote linear growth from conception to age two years Stunting in Selected High-Burden Countries confer lifelong benefits to individuals as well as to their 40 families. Indeed, Behrman and others (2009) provide evidence, using the same data, of intergenerational ben- 30 efits in that women, but not men, in atole-supplied com- munities during their childhood, though not just up to 20 age two years, three to four decades later had children with significantly greater birth weights and long-term 10 nutritional status. 0 ad ep. . R m Et r pia da ia a n me a Ba mar Pa h n ia p. l pa ca ny da Ye geri es ta De Nutritional Interventions That Improve an Ind Re an as hio Ne kis Ke lad Su n nz o, Ug Ni n, ya ag Ta ng ng M Cognitive Development Co M Sub-Saharan Africa MENA South Asia Early childhood is critical for cognitive skill formation Source: Hoddinott, Alderman, and others 2013. (Cunha and Heckman 2007; Grantham-McGregor and Note: MENA = Middle East and North Africa. others 2007; Heckman, Stixrud, and Urzua 2006), 392 Child and Adolescent Health and Development as illustrated by analysis of how the preschool environ- viability of specific investments in maternal and early ment, for example, the U.S. Perry Preschool Program, child health that compete with one another and with influences adult test scores and other attainments other interventions. Estimating benefit-cost ratios is chal- (Schweinhart and others 2005). In fact, the early child- lenging because of the paucity of information on lon- hood health and nutritional environment also influences ger-term benefits that can be causally associated with cognitive performance because nutritional deficiency or specific interventions and on relevant costs, all of which infection (which reduces net nutrition by consuming tend to vary by context. We provide illustrative estimates metabolic resources) may impair neurological develop- (table 27.3) based on evidence available from interna- ment (Eppig, Fincher, and Thornhill 2010; Fischer tional experience and explore how sensitive our estimates Walker and others 2013). If investments in human capi- are to key assumptions. tal through childhood and adolescence reinforce cogni- tive investments in early life, then the longer-term cognitive gains from early-life nutritional interventions Benefits may be even larger than might appear from short-term We assume that the primary economic benefit for chil- cognitive gains. dren treated by the intervention arises from increasing Numerous studies using quasi-experimental or lifetime productivity and therefore earnings through experimental design provide evidence of the positive increasing schooling, health, or both (Almond 2006; impacts on cognitive function or test scores. Almond, Behrman, Alderman, and Hoddinott 2004; Bhalotra and Mazumder, and Van Ewijk (2015) show that Muslim Venkataramani 2011; Engle and others 2011; Hoddinott, British children who are in utero during Ramadan have Alderman, and others 2013; Hoddinott, Rosegrant, and lower test scores. Majid (2015) shows that Muslim Torero 2013). The estimates we use to obtain the benefits Indonesian children who are in utero during Ramadan depend on (1) the relationship between interventions have lower birth weights; study fewer hours during ele- and human capital (schooling attainment, health) and mentary school; do more child labor; score lower on (2) the relationship between human capital and earnings cognitive and math tests; and as adults, work fewer or productivity. Some recent studies combine (1) and hours and are more likely to be self-employed. Maluccio (2) by estimating direct effects of early-life interventions and others (2009) and Stein and others (2005) show on adult earnings using approaches that also incorporate that the INCAP early-life nutritional supplement any externalities and general equilibrium effects (for resulted in higher cognitive attainments. Barham (2012) example, Baird and others 2016; Bhalotra and shows impacts from a health and family planning pro- Venkataramani 2011; Bleakley 2007). The illustrative gram in the Matlab area of Bangladesh. Venkataramani simulations presented here isolate earnings impacts that (2012) shows impacts from malaria eradication in flow from schooling increases generated by an early-life Mexico. Almond, Edlund, and Palme (2009) identify health intervention. cognitive deficits associated with exposure to radioac- For the base case simulations in table 27.3, we use 0.5 tive fallout. Bhalotra and Venkataramani (2013) show additional schooling grades, as estimated in Field, Robles, that a Mexican clean water reform that led to sharp and Torero (2009). For simulation, as shown in column 2 drops in diarrhea led to better cognitive performance. in table 27.3, we assume that schooling rates of return in Bharadwaj, Loken, and Neilson (2013) show that the labor markets equal schooling rates of return in other assignment of neonatal care facilities to babies who fall activities (for example, household production), as implied just below the LBW threshold resulted in their having by models in which people allocate their time between better test scores relative to babies who fall just above wage activities and other activities so that at the margin, the LBW threshold. rates of return are equalized among all activities. This is a more plausible assumption for many developing econo- mies where most of the working population is engaged in small- and medium-scale agricultural and other informal BENEFIT-COST RATIOS activities with less rigidities in work and pay schedules than Most studies that evaluate interventions provide esti- those that dominate in, say, Western Europe. We assume mates of impacts of early-life nutritional interventions workers live through age 64 years (but see later discussion on later-life education, health, and earnings. In this sec- on survival rates). We use as our base estimates for rates of tion, we construct somewhat generic benefit-cost esti- return to schooling attainment in developing countries mates incorporating both immediate and longer-term those summarized by Orazem, Glewwe, and Patrinos impacts and costs of early-life nutritional interventions. (2009): 7.5 percent for rural areas. Given the dominance of However crude, such estimates are useful in assessing the rural areas in South Asia and Sub-Saharan Africa, where The Human Capital and Productivity Benefits of Early Childhood Nutritional Interventions 393 Table 27.3 Illustrative Simulations of Benefit-Cost Ratios of Early-Life Nutritional Interventions Base case except Higher discount rate Base Case in Higher Higher rate case with Base case column intervention of return to Higher changes except (6) except Base impact on schooling Lower positive in columns discount discount case schooling attainment costs externalities (2)–(5) rate = 6% rate = 6% Assumptions (1) (2) (3) (4) (5) (6) (7) (8) Impact of intervention on schooling attainment (Grades) 0.5 1 0.5 0.5 0.5 1 0.5 1 Rate of return to increased schooling attainment (%) 7.5 7.5 11.5 7.5 7.5 11.5 7.5 11.5 Direct cost of intervention (% of annual basic wage) 4.0 4.0 4.0 2.0 4.0 2.0 4.0 4.0 Direct cost of additional grade of school (% of basic wage) 15.0 15.0 15.0 10.0 15.0 10.0 15.0 10.0 Opportunity cost of additional year of school (% of basic wage) 75.0 75.0 75.0 50.0 75.0 50.0 75.0 50.0 Discount rate (%) 3.0 3.0 3.0 3.0 3.0 3.0 6.0 6.0 Externality as percentage of labor market rate of return 10.0 10.0 10.0 10.0 25.0 25.0 10.0 25.0 Benefit-cost ratio 2.3 2.4 3.5 3.6 2.6 6.9 1.4 4.2 PDV of benefits (US$) 1,000 2,100 1,600 1,000 1,000 3,800 640 2,350 PDV of costs (US$) 450 870 450 300 450 550 440 560 Annual basic wage (US$) 1,000 1,000 1,000 1,000 1,000 1,000 1,000 1,000 Note: PDV = present discounted value. undernutrition prevalence is highest, we assume 7.5 percent paid more than beneficiaries, the benefit-cost ratios in for our base case. We explore the robustness of our results table 27.3 would be smaller. to increasing this rate of return to 11.5 percent in simula- We consider three components of resource costs: tion, as shown in column 3 of table 27.3. • Direct costs per child of interventions. The primary emphasis in the literature is on supplier costs of Costs providing interventions, which include time of indi- In many relevant interventions, one primary cost is the viduals engaged in the interventions, costs of micro- time cost of program implementers and, for interven- nutrients and other materials that may vary with tions that extend schooling, opportunity costs of time program scale, and fixed costs such as program- of school-age students and school teachers. We charac- related infrastructure. There may also be important terize time costs relative to wages of adults with basic private costs, such as the financial and time costs schooling levels, which we label “basic wages.” We that families (usually mothers) incur to ensure that assume a basic wage of US$1,000 per year, roughly the their children benefit from interventions. In addi- threshold per capita income used by the World Bank to tion, there may be distortion costs of raising funds define low-income countries. Changing this basic wage for public sector expenditures on interventions that would not change the benefit-cost ratios presented in have been estimated to be a quarter or more of public table 27.3 if beneficiaries and service providers receive expenditures (Harberger 1997). For our basic simula- comparable wages because it would change benefits and tions, we assume that all these costs for interventions costs in the same proportions. If service providers are for an additional child, such as in Field, Robles, and 394 Child and Adolescent Health and Development Torero (2009), total 4 percent of the basic wage (that Other Central Assumptions is, US$40 if the basic wage is US$1,000). We explore Discount Rates the sensitivity of our estimates to reducing this to Most benefits of preschool programs accrue, and some 2 percent in simulation (4). costs are incurred, years after the interventions. For • Direct costs of one additional year of schooling for one instance, if maternal health programs increase the adult child. We assume that early-life nutritional inter- productivity of the children of the targeted women ventions raise children’s final schooling attainment. attaining higher schooling, these benefits may flow one The added direct cost of extending schooling again to six decades after the interventions. To account for this includes time costs of additional teachers, but also delay, future costs and benefits are discounted to the variable costs such as books and other materials and present. Evaluations of commercial projects often involve fixed costs related to school buildings. Private costs discount rates of 10 percent or 12 percent, but discount include families’ costs for transportation and school rates of 3 percent and 6 percent are often used in social materials. There may be distortion costs associated sectors (Engle and others 2011). We therefore produce with taxation. For our basic simulations, we assume estimates using 3 percent and 6 percent. that all these costs for an additional child per school year total 15 percent of the basic wage, but we explore Survival Rates the sensitivity to a reduction to 10 percent in simu- Another reason that timing may be important is that lation (4). We assume that these costs are incurred not all children will survive to be productive adults when children are about age 14 years, the margin through age 64 years. Therefore, our estimates of future of completing basic schooling in most low-income benefits and costs (but primarily benefits given that they countries. may flow for long periods or only be realized many • Opportunity costs of time of extending schooling for years after interventions) are adjusted for survival children. If schooling attainment is extended because probabilities based on World Health Organization of interventions, not only are there additional direct Life Tables for Uganda for 2009 (as representative of a schooling costs, there are also opportunity costs of Sub-Saharan African country).5 This adjustment children being in school instead of engaged in other reduces benefits from earnings for intervention-treated activities, including work. For our basic simulations, children at ages 45–49 years by about 10 percent and at we assume that these costs for an additional child per ages 55–59 years by about 15 percent. For countries with school year are 75 percent of the basic wage, but we longer life expectancies, these adjustments will be explore the sensitivity of our estimates to 50 percent smaller, and vice versa. in simulation (4). Again, we assume that these costs are incurred when children are about age 14 years. Externalities Often relatively little attention is paid to costs, partic- Schooling is perceived to have positive externalities— ularly private costs, even though private and public benefits to others in society beyond the person resource costs are as important as impacts in assessing schooled—by, for example, reducing crime or increasing the priority of particular interventions. There is often political participation, though systematic empirical confusion between budgetary costs of suppliers, such as evidence on such externalities remains fairly limited. To governmental entities, and real resource costs, private illustrate impacts of possible externalities, we assume and public. Although policy makers need to be cognizant that social rates of return to schooling increases induced of budgetary constraints, allocation of public resources by interventions are 10 percent higher than private rates should be based on the present discounted value of ben- of return (we also investigate the sensitivity of our esti- efits (perhaps weighted to reflect desired distributional mates to an assumed 25 percent higher rate). goals, such as poverty alleviation) relative to the present discounted value of real resource costs. Those real General Equilibrium Effects resource costs include opportunity costs of alternative If the programs we consider were scaled up, resulting uses of public and private resources and any distortion schooling expansions may be substantial, and this out- costs of raising public funds. Public transfers should not ward shift in supply of educated adults may, all else equal, be included in real resource costs although they are part reduce schooling rates of return. This tendency may, of governmental outlays, a matter that has caused some however, be limited by outward shifts in demand for confusion in assessing, for example, benefit-cost ratios of more-schooled adults because of productivity increases conditional and unconditional transfer programs. or, for instance, because more-schooled consumers The Human Capital and Productivity Benefits of Early Childhood Nutritional Interventions 395 consume more schooling-intensive goods and services. The last column makes all the assumptions in column 6 Because the outcome is ambiguous, we do not directly except that the discount rate is assumed to be 6 percent adjust for it, but it is effectively allowed for when we vary instead of 3 percent. This change reduces the estimated rates of return to schooling. benefit-cost ratio to 4.2. The substantial reduction reflects the importance of the appropriate discount rate. Even with this reduction, the benefit-cost ratio implies Benefit-Cost Estimates that benefits are more than four times as large as costs. Table 27.3 summarizes benefit-cost ratios for interven- These estimates are based on a number of assump- tions such as iodine provision in pregnancy studied in tions and illustrate substantial sensitivity to some Field, Robles, and Torero (2009) under the assumptions assumptions, such as the appropriate discount rate. just discussed. Because the ratios attempt to include all But all in all, they suggest the possibility of fairly large benefits and costs, including externalities, these are social potential gains in children’s lifetime productivity from benefit-cost ratios. Private benefits are assumed to be interventions that improve maternal health, as in Field, smaller because they do not include externalities, but Robles, and Torero (2009), with possibly very satisfac- private costs also may be smaller if any of the costs are tory benefit-cost ratios. covered by public subsidies, as is likely. Therefore, private We must note that our analysis of iodine supplemen- benefit-cost ratios may be larger or smaller than the tation is an illustrative example and we are not advocat- public benefit-cost ratios in the table. ing it over any other nutritional intervention. There is a The first column presents base estimates, with large body of knowledge on the benefits of other micro- somewhat conservative assumptions regarding key nutrient interventions including food fortification. In parameters. The base-case social benefit-cost ratio is 2.3, two clinical trials, Andersson and others (2008) and Haas implying that benefits are 130 percent greater than costs. and others (2014) find that double fortification of salt is The next four columns vary the assumed parameters associated with higher levels of hemoglobin and other underlying the base case by making them less conserva- body iron measures among Indian children and women. tive and, as expected, benefit-cost ratios increase. The Horton, Wesley, and Mannar (2011) evaluate the effect increase is relatively small, to 2.4, for simulation (2), of double fortification of salt using iron and iodine on which allows larger impacts of the intervention on hemoglobin levels in India to find a benefit-cost ratio schooling attainment. This is because the increase of ranging from 2.4 to 5.0. There are several systematic 100 percent in impacts of interventions on schooling reviews and meta-analyses of the relationship between attainment not only increases benefits due to greater fortification and child health outcomes across the world schooling attainment, but also increases costs, raising (Aaron, Dror, and Yang 2015; Das and others 2013; both direct and opportunity costs of schooling. For the De-Regil and others 2011; Ojukwu and others 2009; next two cases, the benefit-cost ratios rise to 3.5–3.6, Pachón and others 2015). Farebrother and others (2015) which implies that benefits are more than triple the costs. provide a summary of these systematic reviews. These two variations highlight different channels through which benefit-cost ratios might be higher: higher pro- gram impacts (in the second case perhaps through POLICY DESIGN: MECHANISMS AND improved school quality) and reduced costs. The increase in simulation (5), for which assumed positive externali- SCALE UP ties cause social rates of return to schooling to be Rapid growth in randomized controlled trials and other 25 percent rather than 10 percent greater than private systematic studies has expanded the evidence base, docu- rates of return, is to 2.6, about the same as for simulation menting the way in which cost-effective local or small- (2). Simulation (6) gives benefit-cost ratios that would be scale childhood interventions have led to improvements obtained if all of the changes from the base simulation in health and educational capital and later-life productiv- were implemented together and if their impacts were ity. However, two major challenges arise in using this additive. Under this combined set of more optimistic evidence as the basis for policy. First, although there are assumptions, the benefit-cost ratio is 6.9, suggesting that notable exceptions, many trials identify intervention early-life nutritional investments are definitely attractive. impacts without identifying the mechanisms driving the The estimates, however, are sensitive to discount impact, and, in many cases, multiple mechanisms are rates. The penultimate column makes the base-case plausible (Deaton 2010). This is important because assumptions but uses the more conservative assumption external validity or transferability of interventions may of a 6 percent discount rate. The estimated benefit-cost depend upon understanding the mechanisms and rele- ratio is 1.4, that is, benefits are slightly greater than costs. vant contextual dimensions (Cartwright and Hardie 2012). 396 Child and Adolescent Health and Development The second, related, issue is that an intervention that is CONCLUSIONS scaled up may not have the same impact as it does on a small scale, for instance, because of general equilibrium Evidence is accumulating that early-life health and effects, endogenous political reactions, or heterogeneity nutritional interventions, including those that act to across beneficiaries and implementers (Allcott and improve the health and nutritional status of potential Mullainathan 2012). A vivid illustration is Bold and oth- mothers and pregnant women and those that directly ers (2013), who analyze provision of contract teachers to treat children in early life, have significant impacts on Kenyan schools. They find that pupils in schools in which schooling, earnings, and productivity over the lifecycle a nongovernmental organization managed interventions in LMICs. Our estimates of benefit-cost ratios for such experienced test score improvements, but there were no interventions, obtained under a range of plausible test score gains when the same interventions were imple- parameters, consistently exceed one, suggesting that the mented by the Ministry of Education. Their findings present discounted value of gains exceeds costs. These caution against assuming that the evidence gathered results motivate the case for placing early-life health and from good field trials can be used to guide policy as sug- nutrition high on the policy agenda. Causal estimates of gested, for instance, by Banerjee and He (2008). impacts of early-life nutritional interventions mostly Probably the most-studied social program with stem from small-scale local interventions; therefore, an important health and nutritional component in these estimates are likely to be sensitive to population the developing world is the Mexican Oportunidades heterogeneity (social, economic, and cultural differ- (originally PROGRESA) conditional cash transfer pro- ences), differences in program implementation (admin- gram, introduced in 1997 (Behrman 2007, 2010; Levy istrative capacity and trust), and differences in the wider 2006; Levy and Rodriguez 2004). This program provided political economy of reform. As a result, available impact transfers conditional on various behaviors, including estimates may have limited external validity. In addition, attending health clinics regularly and, among oth- estimation of benefit-cost ratios using these impact esti- ers, obtaining micronutrients for infants and young chil- mates is, as we have illustrated, sensitive to choices of dren. An important program component was the rates of return and discount rates applied in evaluating establishment of an evaluation strategy from the very estimated future impacts against costs. start, with baseline data and periodic household surveys If, in fact, benefit-cost ratios associated with collected from about 25,000 families (both program eli- early-life health interventions are as attractive as some gible and noneligible) with about 125,000 individuals estimates in the literature and our simulations indi- living in 508 small, poor, rural communities (population cate, then it is natural to ask why governments have less than 2,500) to which the initial program was directed, not implemented them at scale. Benefits may not scale 320 of which were randomly selected to receive the pro- up, and even if there are scale economies in costs, the gram initially with the remainder enrolled after about benefit-cost ratio for nationwide implementation may 18 months. The initial program results were instrumen- be lower. Other possibilities are that governments are tal in evaluations that resulted not only in program not sufficiently aware of the benefits of the studied modifications but also in ensuring the political support interventions and, indeed, perusal of documents that necessary for scaling up the program to cover about guide national and international policy suggests that 30 million Mexicans and to continue the program with the tendency is to evaluate immediate reductions in changes in the government, including the first change in morbidity, growth retardation, or mortality, and that the governing party in more than seven decades. the dynamic socioeconomic benefits of health inter- With respect to impacts of the child nutrition com- ventions are often ignored. A third possibility is that ponent of the program, Behrman and Hoddinott’s even where governments recognize the net benefits of (2005) preferred estimates (child fixed effects estimates early-life interventions, they face budgetary constraints that control for unobserved heterogeneity correlated or conflicting political priorities in policy choices that with access to the supplement) indicate significantly are difficult to adjust given strong vested interests in positive and fairly substantial program effects on chil- existing programs. dren ages 12–36 months. The findings imply an increase of about one-sixth in mean growth per year for these children and a lower probability of stunting. The authors ACKNOWLEDGMENTS estimate that the long-term consequences of these The authors thank Grand Challenges Canada Grant improvements are nontrivial; the impact working 0072-03 for partial support for undertaking this through adult height alone could result in a 2.9 percent study. 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Furthermore, among girls younger Millennium Development Goal 5 to reduce the maternal than age 16 years, the relative risk of pregnancy-related mortality ratio—the number of maternal deaths per mortality is up to five times higher compared with 100,000 live births—by two-thirds between 2000 and women ages 20–24 years (Huang 2011; Mayor 2004). 2015, substantial inequalities remain in maternal mor- Although the education of girls has been expanded tality across countries worldwide (Kassebaum and oth- worldwide (Gakidou and others 2010), early marriages ers 2014; UN 2013; UN MME 2015; Verguet and others remain common; up to 65 percent and 76 percent of 2014). Maternal mortality ratios remain unacceptably women are married by age 18 years in Bangladesh and high in South Asia and Sub-Saharan Africa, particularly Niger, respectively (UNICEF 2016). As a result, the rates West Africa (Kassebaum and others 2014; UN MME of adolescent pregnancies remain very high in many 2015). Together, South Asia and Sub-Saharan Africa LMICs (Bates, Maselko, and Schuler 2007; Beguy, account for 86 percent of the world’s maternal deaths Ndugwa, and Kabiru 2013; Chloe, Thapa, and (WHO and others 2014). Mishra 2004; Dixon-Mueller 2008). Building on the momentum gathered by the Maternal and adolescent health need to be examined Millennium Development Goals, the post-2015 agenda through a wider perspective beyond mortality— and its Sustainable Development Goals set the ambi- notably, morbidity outcomes, such as long-term seque- tious target of further reducing the maternal mortality lae for both mothers and their children, and the ratio, currently about 200 deaths per 100,000 live births financial vulnerability of women and adolescents globally (UNICEF 2016), to 70 per 100,000 by 2030 (Ashford 2002; Dale, Stoll, and Lucas 2003; Filippi and (UNW 2016). others 2006; Langer and others 2015). Pregnant young Women ages 15–19 years face elevated risks of women present higher chances of school dropout pregnancy-related mortality and morbidity. In low- (Lloyd and Mensch 2008; Marteleto, Lam, and Ranchhod and middle-income countries (LMICs), these risks are 2008; Meekers and Ahmed 1999), and they could face disproportionately higher (IHME 2013; WHO and high risks of pregnancy-related impoverishment and Corresponding author: Stéphane Verguet, Department of Global Health and Population, Harvard T. H. Chan School of Public Health, Boston, MA, United States, verguet@hsph.harvard.edu. 403 negative economic consequences (Arsenault and others our analysis to one specific underlying factor of fertility— 2013; Ilboudo, Russell, and D’Exelle 2013; Powell- female educational attainment—and examine its impact Jackson and Hoque 2012) if they choose to carry their on adolescent maternal mortality and medical impover- pregnancy to term. Out-of-pocket (OOP) medical pay- ishment associated with complicated delivery in facility. ments in LMICs can lead to impoverishment and For this purpose, this chapter uses ECEA to measure the related coping strategies, such as borrowing money or potential mortality, FRP, and equity benefits that could selling assets, to pay for health care (Kruk, Goldmann, be gained through public financing of increased educa- and Galea 2009; Xu and others 2003). tion of adolescent girls in two illustrative country exam- In the absence of other financing mechanisms, ples: Niger and India. such as private health insurance or fee exemptions, household medical expenditures can be catastrophic (Wagstaff 2010), exceeding a specified percentage of METHODS total household expenditures. For example, with This chapter examines the potential impact on maternal increased incidence of complicated deliveries owing to mortality and impoverishment of the increase in the pregnancies at young ages, the OOP costs associated level of female education by one school year for a cohort with maternal delivery in facilities are likely to be of adolescent women. Definitions of age groupings and higher and may subsequently put pregnant adolescents age-specific terminology used in this volume can be at increased risk of medical impoverishment. In partic- found in chapter 1 (Bundy and others 2017). ular, this increased likelihood of financial risk would be We consider the population of adolescent women, expected to be greater among poorer socioeconomic ages 15–19 years, in Niger and India. Niger has the groups; these groups have less disposable income and highest total fertility rate globally (7.6 children per higher rates of adolescent pregnancies (IIPS 2010; INS woman of reproductive age) and a high maternal and ICF International 2013). This hypothesis is one of mortality ratio (553 deaths per 100,000 live births), several that this chapter examines. leading to 5,400 maternal deaths annually. India has Protection from health care financial risks has become the largest population in South Asia (1.3 billion), the a critical component of national strategies in many largest number of maternal deaths worldwide (45,000 countries (Boerma and others 2014; WHO 2010, 2013). deaths), and a high maternal mortality ratio Reduction of these financial risks is one objective of (174 deaths per 100,000 live births) (Alkima and oth- public sector policies. For example, public investment in ers 2016; UN DESA 2013; UN MME 2015). education to increase girls’ educational levels could reduce adolescent pregnancies and subsequent risks of both mortality and impoverishment, especially among General Approach the poorest women. First, we examine the hypothetical impact of a one- Health economic evaluations (cost-effectiveness year increase in the education level of adolescent girls. analyses) have traditionally focused on estimating an We study the linear relationship between the mean intervention’s cost per health gain (Jamison and oth- number of years of education among women ages ers 2006). Extended cost-effectiveness analysis (ECEA) 15–44 years (IHME 2010) and the adolescent preg- (Verguet, Gauvreau, and others 2015; Verguet, Kim, nancy rate (percentage of women ages 15–19 years and Jamison 2016; Verguet, Laxminarayan, and Jamison who have had children or are currently pregnant) in 2015; Verguet and others 2013; Verguet, Olson, and LMICs with populations greater than 1 million (World others 2015) supplements traditional economic evalu- Bank 2015). Annex 28A, section 1 provides further ation by incorporating evaluation of financial risk details. This approach enables the estimation of the protection (FRP)—prevention of medical impover- hypothetical impact of increasing education of girls on ishment. ECEA quantifies how much FRP, equity, and reducing adolescent pregnancy rates. In these two health can be purchased for a given expenditure. countries, we assume that the cohort of adolescent ECEA can provide answers to help policy makers women who complete one more year of education select the optimal policies for increasing FRP and would experience a reduction in pregnancy rates in the equity and for improving the distribution of health short term, that is, over the subsequent five years (ages benefits (WHO 2010, 2013). 15, 16, 17, 18, and 19 years). Many determinants of adolescent pregnancy and Second, using this estimated impact of increased fertility have long been reported in the scientific litera- education on adolescent pregnancy rates, we use the ture, notably by John Bongaarts (Bongaarts 1978; ECEA framework to estimate the potential reduction Bongaarts and Potter 1983). In this chapter, we restrict in adolescent maternal mortality and impoverishment. 404 Child and Adolescent Health and Development We calculate the number of maternal deaths averted by • Percentage of women ages 15–19 years who are a decrease in adolescent pregnancies, the amount of pregnant out-of-pocket (OOP) costs averted by the prevention of • Incidence of complicated deliveries complicated deliveries, and the corresponding number • Skilled birth attendance coverage per income quintile, of cases of catastrophic health expenditures averted. based on Niger’s Demographic and Health Survey The counterfactual scenario corresponds to the case in and India’s District Level Household and Facility which female education is maintained at the same level; Survey, as a proxy for health care utilization hence, there would be no change in adolescent preg- nancy rates. We rely on an estimated increased relative risk of ECEA provides a tool for gaining a more complete maternal mortality among adolescent women (Huang understanding of the health and financial benefits asso- 2011). In addition, we use data on OOP costs for com- ciated with different health policies and interventions. plicated maternal deliveries and associated transporta- ECEA combines the traditional health system perspec- tion costs extracted from the literature for West Africa tive from cost-effectiveness analysis with the patient (Arsenault and others 2013; Storeng and others 2008) perspective, notably by quantifying the benefits associ- and from India’s National Sample Survey (NSSO 2004). ated with avoiding medical impoverishment and assess- Finally, we extract adolescent women’s incomes from a ing the distributional consequences, such as equity, of country income distribution proxied by a gamma dis- policies (Verguet, Kim, and Jamison 2016; Verguet, tribution supplemented by gross domestic product Laxminarayan, and Jamison 2015). This tool helps pol- (GDP) per capita and Gini coefficient (Salem and icy makers make decisions based on the joint benefits Mount 1974; World Bank 2015). All of the parameters and tradeoffs associated with different policies and used in the analysis are shown in table 28.1. interventions, specifically in both health gains and FRP and equity benefits. In addition to health benefits, ECEA estimates the impact of policies along three ECEA Outcomes dimensions: First, we estimate the number of maternal deaths averted per income quintile owing to a decrease in the • Household OOP private expenditures averted by the adolescent pregnancy rate through increased educa- policy tion. The magnitude of maternal mortality averted • Financial protection benefits provided depends on the existing burden, the excess relative risk • Distributional consequences, for example, as applied of maternal mortality among adolescent women, the to socioeconomic status or geographical setting distribution of adolescent pregnancies per income quintile, and the impact of education on reducing ado- Third, we tentatively assess the costs associated with lescent pregnancy rates. raising the education level of adolescent girls by one year. Second, we estimate the amount of OOP expendi- To do so, we multiply the entering female adolescent tures averted related to complicated adolescent maternal cohort (estimated as the population of women ages deliveries and associated transportation costs. This 15–19 years divided by five, or about 204,000 per wealth amount depends on the incidence of complicated mater- quintile in Niger, for example) by the annual cost of pri- nal deliveries, the relative risk of maternal mortality mary education per pupil as estimated by the United among adolescent women, the distribution of adolescent Nations Educational, Scientific and Cultural Organization pregnancies per income quintile, health care utilization (UNESCO 2015). This approach enables us to quantify per income quintile, and the impact of education on the financial resources that may be needed to achieve reducing adolescent pregnancy rates. such an increase in female education. We do not dis- Third, we measure FRP by the number of cases of count the costs and benefits of increased education catastrophic health expenditures averted, per income because the pregnancy events would occur only a few quintile, which depends on individual income, OOP years into the future (annex 28A, section 2). expenditures, and the educational impact. A catastrophic We rely on secondary data extracted from survey health expenditure for an adolescent woman is defined sources, published literature, and estimates from as OOP expenses higher than 10 percent of income, a United Nations (UN) agencies. Specifically, we use the commonly used threshold (Pradhan and Rescott 2002; following: Ranson 2002; Wagstaff and van Doorslaer 2003). Specifically, among adolescent women no longer facing • Country maternal mortality ratios and population pregnancies, we estimate the number of individuals, per estimates from the UN income quintile, for whom the size of OOP expenses Postponing Adolescent Parity in Developing Countries through Education 405 Table 28.1 Parameters Used for the Analysis of Adolescent Maternal Mortality and Impoverishment Averted by Increased Education in India and Niger Parameter India Niger Sources Total population (millions) 1,311 20 UN DESA 2015 Population of women ages 15–19 years 58,400,000 1,021,000 UN DESA 2015 Maternal mortality ratio per 100,000 live births 174 553 Alkima and others 2016 Occurrence of complicated maternal delivery among 15 15 Authors’ assumption based on all deliveries (%) Prual and others 2000 Relative risk of maternal mortality for women ages 4.6, 1.0, 1.0, 1.0, 1.0 4.6, 1.0, 1.0, 1.0, 1.0 Based on Huang 2011 15, 16, 17, 18, and 19 years Percentage of women ages 15–19 years who are 19; 17; 13; 8; 3 41; 43; 37; 32; 19 INS and ICF International 2013 pregnant, from poorest to richest (income quintiles 1–5) IIPS 2010 Percentage of women ages 15, 16, 17, 18, and 19 1; 3; 5; 9; 12 3; 12; 16; 19; 18 INS and ICF International 2013 years who are pregnant IIPS 2010 Health care utilization (percentage of skilled birth 24; 34; 48; 64; 85 13; 19; 22; 30; 71 INS and ICF International 2013 attendance coverage), from poorest to richest IIPS 2007 (income quintiles 1–5) Out-of-pocket direct medical cost (2014 U.S. dollars) 58; 62; 70; 81; 108 97; 127; 140; 124; 152 Based on Arsenault and others of complicated delivery, from poorest to richest 2013; NSSO 2004; Storeng and (income quintiles 1–5) others 2008 Out-of-pocket transportation cost (2014 U.S. dollars), 8; 8; 8; 8; 6 4 for all income Based on NSSO 2004; Perkins and from poorest to richest (income quintiles 1–5) quintiles others 2009 Gross domestic product per capita (2014 U.S. dollars) 1,596 427 World Bank 2015 Gini index 0.34 0.32 World Bank 2015 Impact of female education on adolescent 1 additional year of 1 additional year of Annex 28A, section 1 and table S1 pregnancy rate education leads to an education leads to an 18 percent relative 18 percent relative reduction (SE = 2 reduction (SE = 2 percent) in adolescent percent) in adolescent pregnancy rate pregnancy rate Cost of primary education, per pupil per year (2014 258 72 Based on UNESCO 2015 U.S. dollars) Note: SE = standard error. (sum of direct medical costs and transportation costs) • A poverty headcount, estimating the number of indi- would have exceeded 10 percent of their income. viduals falling below the country poverty line because The counterfactual scenario corresponds to the situa- of OOP costs, in lieu of cases of catastrophic health tion in which primary education of girls remains at the expenditures same level. All costs are expressed in 2014 U.S. dollars. • A smaller effect, 11 percent relative reduction (instead Complete details of the mathematical derivations used of 18 percent) (annex 28A, section 1, table S1), for the for the analysis are given in annex 28A, section 3. impact of a one-year increase in female education on the adolescent pregnancy rate Sensitivity Analysis Three univariate sensitivity analyses are performed: RESULTS • Different thresholds (20 percent and 40 percent Costs of individual income) for the catastrophic health The total costs of increasing education of adolescent girls expenditures by one school year would be approximately US$15 406 Child and Adolescent Health and Development million in Niger and US$3 billion in India. The number of total OOP expenditures would be averted in the top of adolescent women in the two countries, about 1 mil- two quintiles, in contrast to 27 percent in the bottom lion in Niger and 58 million in India (table 28.1), is two quintiles (table 28.2). This finding occurs largely responsible for the large difference in the estimated cost. because richer individuals use more health care than We observe different orders of magnitude for the size of do poorer individuals; it is also partly because richer the maternal deaths averted (160 for Niger and 1,250 for individuals spend more out of pocket than do poorer India), OOP payments averted (US$150,000 and US$3 individuals (table 28.1). million, respectively), and cases of catastrophic health In India, the OOP expenditures averted are more expenditures averted (1,110 and 5,160, respectively) evenly distributed among the different income groups. (tables 28.2 and 28.3). About 42 percent of total OOP expenditures averted accrue in the top two quintiles, in contrast to 34 percent Adolescent Maternal Deaths Averted in the bottom two quintiles (table 28.3). In each country, the extent of adolescent deaths averted, OOP payments averted, and cases of catastrophic health Catastrophic Health Expenditures Averted expenditures averted vary significantly across different Catastrophic health expenditures results (FRP) reflect income quintiles (tables 28.2 and 28.3). In both coun- a combination of key drivers, including (1) the distri- tries, more adolescent women’s lives would be saved in butions of health care utilization and OOP costs the bottom two quintiles (49 percent in Niger and 61 among income quintiles and (2) individual income. percent in India), compared with the top two quintiles For example, in Niger a larger number of cases of cat- (30 percent and 20 percent, respectively). astrophic health expenditures are averted among the richer (52 percent in the top two quintiles) than among Out-of-Pocket Expenditures Averted the poorer (30 percent in the bottom two quintiles). The OOP expenditures averted display a different pat- Large inequalities exist in health care utilization (71 tern. In Niger, more OOP expenditures would be percent in the richest quintiles, compared with 13 averted in the richer income groups; about 54 percent percent in the poorest). Moreover, Nigerians’ income is Table 28.2 Impact of Increasing Mean Years of Female Education by One Year in Niger Income Income Income Income Income Outcome Total quintile I quintile II quintile III quintile IV quintile V Adolescent maternal deaths averted 164 40 40 34 30 20 (24%) (25%) (22%) (19%) (11%) Adolescent OOP expenditures 152,000 13,000 27,000 29,000 31,000 52,000 averted (2014 U.S. dollars) (9%) (18%) (19%) (20%) (34%) Adolescent cases of catastrophic 1,100 130 200 200 240 330 health expenditures averteda (12%) (18%) (18%) (22%) (30%) Note: OOP = out-of-pocket. a. Cases of catastrophic health expenditures are defined as OOP expenses greater than 10 percent of income. Table 28.3 Impact of Increasing Mean Years of Female Education by One Year in India Income Income Income Income Income Outcome Total quintile I quintile II quintile III quintile IV quintile V Adolescent maternal deaths averted 1,260 400 360 260 170 70 (32%) (29%) (21%) (14%) (6%) Adolescent OOP expenditures 3,050,000 430,000 610,000 730,000 740,000 540,000 averted (2014 U.S. dollars) (14%) (20%) (24%) (24%) (18%) Adolescent cases of catastrophic 5,160 5,160 0 0 0 0 health expenditures averteda (100%) Note: OOP = out-of-pocket. a. Cases of catastrophic health expenditures are defined as OOP expenses greater than 10 percent of income. Postponing Adolescent Parity in Developing Countries through Education 407 very low, even in the richer socioeconomic groups; do poorer ones. Finally, individual income and broader GDP per capita is US$427 (table 28.1). country wealth—low income versus middle income— In contrast, in India all the cases of catastrophic also affect the distribution of the FRP benefits. health expenditures that are averted are in the poorer quintiles (100 percent in the bottom income quintile); in spite of large inequalities in health care utilization Advantages of Analysis (85 percent in the richest, compared with 24 percent Our approach permits FRP to be incorporated into the in the poorest), substantial income inequalities remain. economic evaluation of public policies. This enables GDP per capita is approximately US$1,596, and richer interventions to be selected on the basis of how much individuals face little risk of catastrophic health expen- FRP and equity can be bought, in addition to how much ditures (table 28.1). The difference between India and health can be bought, per dollar expenditure. This meth- Niger occurs because the cost of a complicated deliv- odology helps policy makers consider all of these dimen- ery is higher relative to average income in Niger than sions when making financing decisions. It facilitates in India. comparison across sectors, which is essential for minis- tries of finance and development. We show how the FRP Sensitivity Analyses and equity benefits of public policies can be substantial When the threshold for estimation of cases of cata- and should be taken into account, critically underscor- strophic health expenditures is raised (to 20 percent or ing the multifaceted nature of maternal and adolescent 40 percent), as expected the magnitude of the cases health. incurred decreases in India and Niger, with a slight alteration of the distribution across quintiles in Niger. Alternatively, when the poverty headcount metric is Limitation of Analysis used, the distribution of induced poverty across quin- Our analysis presents several limitations. tiles is significantly altered (annex 28A, tables S3 and First, we have limited data and rely on secondary S4). Finally, when the impact of female education on data and published literature to estimate impact and the adolescent pregnancy rate is reduced (to 11 percent costs (table 28.1). Accordingly, this analysis is illustra- instead of 18 percent), maternal deaths, OOP costs, and tive. A more comprehensive accounting of incurred induced cases of impoverishment averted were all expenditures for adolescent women could be included, reduced by 39 percent (annex 28A, tables S5 and S6). with detailed accounting of medical costs, transporta- tion and housing costs, and time and wages lost. For simplicity, we use average OOP expenses linked to DISCUSSION AND CONCLUSIONS complicated deliveries, even though OOP expenses The use of the ECEA methodology enables the impact of might significantly rise with the degree of complica- public policies on distributional consequences and their tion and emergency. In particular, we do not include benefits in protecting against impoverishment to be broader pregnancy-related OOP costs or other poten- assessed, in addition to the traditional dimension of tial expenditures incurred by adolescent women. health benefits. This type of analysis provides critical While we attempt to examine the impact of ill health additional metrics to policy makers inside and outside on impoverishment, we do not study the impact of the health sector when allocating financial resources. We poverty on health, that is, the potential increased conclude that increased educational attainment for ado- maternal mortality and morbidity consequences asso- lescent girls could bring large poverty reduction benefits ciated with lower socioeconomic status. Similarly, we in addition to significant health benefits by avoiding do not include the potential lifetime economic conse- early pregnancies and maternal deaths. This finding quences of adolescent pregnancy, such as its short- underscores the great economic vulnerability of adoles- term impact on school attendance and its long-term cent women in such settings (Filippi and others 2006; impact on earnings losses, because of the lack of Langer and others 2015). empirical data. We also do not consider the costs to Our findings align well with a number of expecta- induce girls to stay in school another year beyond the tions. Beyond the large health and financial benefits, the costs of an additional school year to the public sector. extent of these gains varies significantly across socioeco- Second, our analysis focuses on only the mortality nomic groups. More lives would be saved in the poorer consequences of adolescent pregnancy, and we do not groups because they face higher rates of early pregnancy. account for the potential sequelae to the mothers and However, more OOP expenditures would be averted in their children following complicated delivery; neither do the richer groups because they use more health care than we consider abortion. Delaying childbirth is modeled as 408 Child and Adolescent Health and Development a risk displacement to older women; the elevated risk NOTES might be a first pregnancy effect or due to an unstable Portions of this chapter were previously published: relationship and abortion. Such elevated risk is particu- larly high at ages younger than 15 years; hence, the • Verguet, S., A. Nandi, V. Filippi, and D. A. P. Bundy. 2016. deaths averted could be even higher if that age group “Maternal-Related Deaths and Impoverishment among were considered in the analysis. Adolescent Girls in India and Niger: Findings from a Third, we do not pursue a full uncertainty analysis Modelling Study.” BMJ Open 6: e011586. doi:10.1136 because our purpose is to expose a framework for policy /bmjopen-2016-011586. © COPYRIGHT OWNER Verguet makers, rather than to provide definitive estimates. and others. Licensed under Creative Commons Attribution Similarly, we choose to represent FRP as measured by (CC BY 4.0) available at: https://creativecommons.org cases of catastrophic health expenditures averted. /licenses/by/4.0/. Alternatives include a money-metric value of insurance (McClellan and Skinner 2006; Verguet, Laxminarayan, World Bank Income Classifications as of July 2014 are as and Jamison 2015), poverty cases averted (Verguet, follows, based on estimates of gross national income (GNI) per capita for 2013: Olson, and others 2015), and avoided cases of forced borrowing and asset sales. We choose the number of • Low-income countries (LICs) = US$1,045 or less cases of catastrophic expenditures averted metric because • Middle-income countries (MICs) are subdivided: of its simplicity. Yet, issues pertain to its use, notably, the a) lower-middle-income = US$1,046 to US$4,125 choice of a specific threshold—for example, 5 percent, b) upper-middle-income (UMICs) = US$4,126 to US$12,745 20 percent, or 40 percent of the capacity to pay (Xu and • High-income countries (HICs) = US$12,746 or more. others 2003)—and the fact that certain individuals may not always be counted in the analysis (Saksena, Hsu, and Evans 2014; Wagstaff 2010). REFERENCES Fourth, our analysis is narrowly restricted to the Alkima, L., D. Chou, D. Hogan, S. Zhang, A.-B. 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Zeramdini, J. Klavus, and Effectiveness Analysis for Health Policy Assessment: A Tutorial. others. 2003. “Household Catastrophic Health Expenditure: PharmacoEconomics 34 (9): 913-23. A Multicountry Analysis.” The Lancet 362 (9378): 111–17. Postponing Adolescent Parity in Developing Countries through Education 411 Chapter 29 Economics of Mass Deworming Programs Amrita Ahuja, Sarah Baird, Joan Hamory Hicks, Michael Kremer, and Edward Miguel INTRODUCTION • Welfare economics or public finance approach. Individuals are presumed to make decisions that Soil-transmitted helminth (STH) and schistosomiasis maximize their own welfare, but government infections affect more than 1 billion people, mainly in intervention may be justified in cases in which indi- low- and middle-income countries, particularly vidual actions create externalities for others. These school-age children. Although light infections can be externalities could include health externalities from fairly asymptomatic, severe infections can have reductions in the transmission of infectious disease, significant health effects, such as malnutrition, list- as well as fiscal externalities if treatment increases lessness, organ damage, and internal bleeding (Bundy, long-term earnings and tax payments. Evidence on Appleby, and others 2017).1 epidemiological and fiscal externalities from deworm- Low-cost drugs are available and are the standard ing will be important for informing decisions under of medical care for diagnosed infections. Because this perspective. diagnosis is relatively expensive, and treatment is • Expected cost-effectiveness approach. Policy makers inexpensive and safe, the World Health Organization should pursue a policy if the statistical expectation of (WHO) recommends periodic mass treatments in the value of benefits exceeds the cost. Future mone- areas where worm infections are greater than certain tary benefits should be discounted back to the present. thresholds (WHO 2015). A number of organizations, Policy makers may also value nonfinancial goals, such including the Copenhagen Consensus, GiveWell, and as weight gain or school participation; they should the Abdul Latif Jameel Poverty Action Lab, which pursue a policy if the statistical expectation of the have reviewed the evidence for, and comparative benefit achieved per unit of expenditure exceeds that cost-effectiveness of, a wide range of development of other policies that policy makers are considering. interventions, have consistently ranked deworming as a priority for investment.2 However, Taylor-Robinson Under either framework, the case for government and others (2015) challenge this policy, accepting that subsidies will be stronger if demand for deworming is those known to be infected should be treated but sensitive to price. If everyone would buy deworming arguing that there is substantial evidence that mass medicine on their own, without subsidies, then subsidies drug administration (MDA) has no impact on a range would yield no benefits; they would generate a dead- of outcomes.3 weight loss of taxation. This chapter discusses the economics of policy choices The first perspective focuses on individual goals and surrounding public investments in deworming and con- assumes that consumers will maximize their own wel- siders policy choices under two frameworks: fare. It treats them as rational and informed, and it Corresponding author: Joan Hamory Hicks, Senior Researcher, Center for Effective Global Action, University of California, Berkeley, jrhamory@berkeley.edu. 413 abstracts from intrahousehold conflicts. The second schools received albendazole twice a year; in addition, perspective does not make these assumptions and seeks some schools received praziquantel for schistosomiasis simply to inform policy makers about expected infections annually. The authors found large reductions in benefit-cost ratios or cost-effectiveness metrics, rather worm infections among treated individuals, untreated than making welfare statements. individuals attending treatment schools, and individuals This chapter summarizes the public finance case for in schools located near treatment schools. The authors deworming subsidies, given the evidence on epidemiologi- estimated an 18 percentage point reduction after one year cal externalities4 and high responsiveness of household in the proportion of moderate-to-heavy infections among deworming to price. It reviews the evidence on the cost-ef- untreated individuals attending treatment schools, and a fectiveness of mass school-based deworming and associated 22 percentage point reduction among individuals attend- fiscal externalities. It argues that the expected benefits of ing a school within 3 kilometers of a treatment school.6 following the WHO’s recommendation of mass presump- Ozier (2014) studied this same randomized program tive deworming of children in endemic regions exceed the in Kenya but focused on children who were ages zero to costs, even given uncertainty about the magnitude and two years and living in catchment areas of participating likelihood of impacts in given contexts.5 This benefit is real- schools at the time of program launch. These children ized even when only the educational and economic benefits were not treated, but they could have benefited from of deworming are considered. Finally, the chapter maintains positive within-community externalities generated by that between the two leading policy options for treatment the mass school-based deworming. Indeed, 10 years after in endemic areas—mass treatment versus screening and the program, Ozier estimated average test score gains of treatment of those found to be infected—the former is 0.2 standard deviation units for these individuals. preferred under both public finance and cost-effectiveness Consistent with the hypothesis that these children bene- approaches. Definitions of age groupings and age-specific fited primarily through the reduced transmission of terminology used in this volume can be found in chapter 1 worm infections, the effects were twice as large among (Bundy, de Silva, and others 2017). children with an older sibling in one of the schools that participated in the program. Bobonis, Miguel, and Puri-Sharma (2006), in EPIDEMIOLOGICAL EXTERNALITIES contrast, found small and statistically insignificant cross- STHs—including hookworm, roundworm, and school externalities of deworming and iron supplemen- whipworm—are transmitted via eggs in feces deposited in tation on nutritional status and school participation of the local environment, typically through open defecation children in India. The authors noted that this finding is or lack of proper hygiene after defecating. Schistosomiasis is unsurprising in this context, given both the lower spread through contact with infected fresh water. School- prevalence and intensity of worm infections and the age children are particularly vulnerable to such infections small fraction of treated individuals. and prone to transmitting infection (Bundy, Appleby, and Together, these studies provide strong evidence for the others 2017). Treating infected individuals kills the para- existence of large, positive epidemiological externality ben- sites in their bodies and prevents further transmission. efits to mass treatment in endemic areas, especially in areas Three studies provide evidence on such epidemiological with higher infection loads.7 Such externality benefits are externalities from deworming school-age children and important to consider in both the public finance and suggest these externalities can be substantial. cost-effectiveness decision-making frameworks. Under the Bundy and others (1990) studied a program in the first perspective, such benefits cannot be fully internalized island of Montserrat, West Indies, where all children by household decision makers and thus provide a potential between ages 2 and 15 years were treated with alben- rationale for government subsidies. Under the second per- dazole, four times over 16 months, to eliminate STH spective, externalities increase the cost-effectiveness of the infections. The authors found substantial reductions in intervention by increasing the total benefit achieved for a infection rates for the targeted individuals (more than given amount of expenditure. 90 percent of whom received treatment), as well as for young adults ages 16–25 years (fewer than 4 percent of whom were treated). These findings suggest large posi- IMPACTS OF THE PRICE OF DEWORMING ON tive epidemiological externalities, although only one geographic unit was examined. TAKE-UP Miguel and Kremer (2004) studied a randomized Assuming that a behavior generates positive externalities— school-based deworming program in rural western Kenya or that under a cost-effectiveness approach, it is valued from 1998 through 1999, where students in treatment by policy makers—public finance theory emphasizes that 414 Child and Adolescent Health and Development the attractiveness of a subsidy depends on the ratio of Figure 29.1 Response of Consumer Demand to Increase in the Price marginal consumers (those who will change their behav- of Health Products ior in response to a subsidy) to inframarginal consumers 100 (those who would have engaged in the behavior even in the absence of a subsidy). The higher this ratio, the more 90 attractive the subsidy. Kremer and Miguel (2007) studied the behavioral 80 response to a change in the price of deworming treat- 70 ment in the Kenyan deworming program. Starting in 2001, a random subset of participating schools was 60 Percent chosen to pay user fees for treatment, with the average 50 cost of deworming per child set at US$0.30, which was about 20 percent of the cost of drug purchase and 40 delivery through this program. This cost-sharing 30 reduced take-up (the fraction of individuals who received treatment) by 80 percent, to 19 percent from 20 75 percent. 10 This result is consistent with findings observed for other products for disease prevention and treatment 0 of non-acute conditions, such as bednets for malaria 0 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 1.00 and water treatment. Figure 29.1 displays how the US dollars demand for a range of health care products decreases Deworming, Kenya Bednets in clinics, Kenya as price increases.8 Moreover, Kremer and Miguel Bednet vouchers, Kenya Water disinfectant, Zambia (2007) found that user fees did not help target treat- Water disinfectant, Kenya Soap, India ment to the sickest students; students with moder- ate-to-heavy worm infections were not more likely to Source: Abdul Latif Jameel Poverty Action Lab 2011. pay for the medications. These results suggest low costs and large benefits from deworming subsidies, important for both the cost-effectiveness and welfare with two treatments per year costs US$0.60 per person economics perspectives. (Givewell 2016), Croke and others (2016) estimated that the cost of deworming MDA per kilogram of weight gain is US$4.48. For comparison with another policy option, IMPACTS OF DEWORMING ON CHILD a review of school feeding programs by Galloway and WEIGHT others (2009) found that the average of the range associ- ated with a 1 kilogram weight increase for school feeding In this and subsequent sections we examine the cost- from evidence from randomized controlled trials is effectiveness of mass deworming in affecting various US$182. This finding implies that per dollar of expendi- outcomes potentially valued by policy makers. We focus ture, mass deworming produces a weight increase 40.62 primarily on economic outcomes rather than health times that of school feeding. This finding on weight gain outcomes because the impact of deworming on health is suggests that evidence of education and economic covered in chapter 13 in this volume (Bundy, Appleby, impact should not be rejected out of hand based on and others 2017). However, we would like to briefly concern for lack of evidence about mechanisms by expand upon that discussion to address the cost- which such impacts could be achieved. effectiveness of deworming in improving child weight. Bundy, Appleby, and others (2017) discuss recent work of Croke and others (2016), who reviewed the literature IMPACTS OF DEWORMING ON EDUCATION on the impact of multiple-dose deworming on child weight. Overall, they estimated that MDA increases AND LABOR MARKETS weight by an average of 0.13 kilograms, with somewhat Evidence on the impact of deworming on education and larger point estimates among populations in which prev- labor market outcomes directly informs the cost- alence is greater than the WHO’s 20 percent prevalence effectiveness perspective, while the fiscal externalities threshold for MDA, or the 50 percent threshold for resulting from labor market impacts are important from multiple-dose MDA.9 Assuming that an MDA program a welfare economics perspective. Economics of Mass Deworming Programs 415 We review publicly available studies of the impact of School Participation mass deworming that do the following: Using a difference-in-difference methodology in his study • Use experimental or quasi-experimental methods to of the RSC program, Bleakley (2007) compared changes demonstrate causal relationships in counties with high baseline worm prevalence to changes • Incorporate a cluster design to take into account the in low baseline prevalence counties over the same period. potential for infectious disease externalities Findings indicate that from 1910 through 1920, counties • Minimize attrition that could lead to bias. with higher worm prevalence before the deworming cam- paign saw substantial increases in school enrollment, both Most existing studies on deworming randomize at the in absolute terms and relative to areas with lower infection individual level; they fail to consider the potential for rates. A child infected with hookworm was an estimated treatment externalities (Bundy and others 2009) and 20 percentage points less likely to be enrolled in school likely underestimate the impact of treatment. We review than a noninfected child and 13 percentage points less evidence from three deworming campaigns in different likely to be literate. Bleakley’s estimates suggest that times and contexts—one in the United States in the early because of the deworming campaign, a county with a twentieth century and two in East Africa at the turn of 1910 infection rate of 50 percent would experience an the twenty-first century.10 increase in school enrollment of 3 to 5 percentage points The first program was launched by the Rockefeller and an increase in attendance of 6 to 8 percentage points, Sanitary Commission (RSC) in 1910 to eradicate relative to a county with no infection problem. This hookworm infections in the U.S. South. With baseline finding remains significant when controlling for a num- hookworm infection rates at 40 percent among school- ber of potentially confounding factors, such as state-level age children, traveling dispensaries administered policy changes and the demographic composition of treatment to infected individuals in endemic areas and high- and low-worm load areas. In addition, the author educated local physicians and the public about preven- found no significant effects on adult outcomes, which, tion. The RSC reported a 30 percentage point decrease in given the significantly lower infection rates of adults, bol- infection rates across affected areas 10 or more years sters the case that deworming was driving these findings. after launch of the program (Bleakley 2007).11 Miguel and Kremer (2004) provide evidence on the The second program was a school-based treatment impact of deworming on school participation through program sponsored by a nongovernmental organization their cluster randomized evaluation of the Kenyan that was phased into 75 schools in a rural district of school-based deworming program. The authors found western Kenya from 1998 through 2001. Baseline hel- substantially greater school participation in schools minth infection rates were greater than 90 percent assigned to receive deworming than in those that had among school children in this area. The nongovernmen- not yet been phased in to the program. Participation tal organization provided deworming drugs to treat STHs increased not only among treated children but also twice per year and schistosomiasis once per year, as well among untreated children in treatment schools and as educational materials on worm prevention. Schools among pupils in schools located near treatment were phased into the program in three groups over four schools. The total increase in school participation, years; each school was assigned to a group through including these externality benefits, was 8.5 percentage list-randomization, resulting in a cluster randomized points.13 These results imply that deworming is one of stepped-wedge research design. the most cost-effective ways of increasing school par- The third program was delivered by community- ticipation (Dhaliwal and others 2012). Figure 29.2 -based organizations during 2000–03 across 48 parishes shows the cost-effectiveness of deworming in increas- in five districts of eastern Uganda.12 Baseline infection ing school attendance across a range of development rates were greater than 60 percent in children ages 5–10 interventions.14 years (Kabatereine and others 2001). Treatment was pro- vided during child health days, in which parents were offered multiple health and nutrition interventions for Academic Test Scores children ages one to seven years. Using a cluster random- In their study of the Kenyan deworming program, ization approach, parishes were randomly assigned to Miguel and Kremer (2004) did not find short-term receive either the standard intervention of vitamin A effects on academic test scores.15 However, the long-term supplementation, vaccines, growth monitoring, and follow-up evaluation of the same intervention (Baird feeding demonstrations, or to deworming treatment in and others 2016) found that among girls, deworming addition to the standard package (Alderman and others increased the rate of passing the national primary school 2006; Croke 2014). exit exam by almost 25 percent (9.6 percentage points on 416 Child and Adolescent Health and Development Figure 29.2 Cost-Effectiveness of Development Interventions in Increasing School Attendance 40 34.3 35 Additional years of student participation per US$100 30 25 20 17.8 15 10 5 3.1 2.7 0.7 0.3 0.0 0.0 0.0 No significant impact 0 r b to ms s ce lum s s t. an r C oo nd nd fo irl er irl ex T- an fo rns or lg te eg ch a s ce te rs cu s oy ng km nd nif es ion ler lun at sfe oo ion tu rri ag i te lu rm at re ch pr at –3 cu vo ol an en at o of fic wo uc on rs +0 ho tr ing by te o rs’ i ch fo t sc sh De ed ion or ing for ing rn he C es ips ca sf T- lea t ac or rm on ma Fre up sh ing al te ut wo Ir ed on or lar lc lt rm of Inf ist iti ua dia ho wo ing nd ss str sc me -a De Co or en it de er Re nit er M ut M mo mp ra Co me Ca Sources: Hicks, Kremer, and Miguel 2015 based on data from Abdul Latif Jameel Poverty Action Lab. Note: T−C = the difference between outcomes for those allocated to the deworming treatment group and those allocated to the deworming comparison group; km = kilometers; ext. = externality benefits. Some values are adjusted for inflation but the deworming costs are not. Deworming is costed at US$0.49 per child in Kenya. Some of these programs create benefits beyond school attendance. For example, conditional cash transfers provide income to poor households. The Jameel Poverty Action Lab cost-effectiveness calculations for school participation include conditional cash transfers as program costs. a base of 41 percent). Ozier (2014) found test-score gains Children who were treated for worms in Kenya also for children younger than age two years at the time of the had better labor market outcomes later in life. Baird and program. others (2016) considered women and men separately, In the long-term follow-up of the cluster random- given the different set of family and labor market choices ized Uganda deworming program, Croke (2014) they face. They found that Kenyan women who received analyzed English literacy, numeracy, and combined test more deworming treatment are more likely to grow cash scores, comparing treatment and control. The study crops and reallocate labor time from agriculture to non- found that children in treatment villages have signifi- agricultural self-employment. Treated men work cantly higher numeracy and combined test scores com- 17 percent more hours per week, spend more time in pared with those in control villages; effect sizes across all entrepreneurial activities, and are more likely to work in three outcomes range from 0.16 to 0.36 standard devia- higher-wage manufacturing jobs. tions. The effects were significantly larger for children Baird and others (2016) estimated the net present who were exposed to the program for multiple years.16 value of the long-term educational and economic bene- fits to be more than 100 times the cost, implying that even policy makers who assume a small subjective probability Labor Market Effects of realizing these benefits would conclude that the Bleakley (2007) used data from the 1940 U.S. census to expected benefits of MDA exceed their cost. compare adult outcomes among birth cohorts who Based on these increased earnings, the authors entered the labor force before and after the deworming computed an annualized internal rate of return to campaign in the U.S. South. Adults who had more expo- deworming of 32 percent to 51 percent, depending on sure to deworming as children were significantly more whether health spillovers are included. This finding is likely to be literate and had higher earnings as adults. high relative to other investments, implying that The author found a 43 percent increase in adult wages deworming is cost-effective on economic grounds, even among those exposed to the campaign as children. Given without considering health, nutritional, and educa- initial infection rates of 30 percent to 40 percent, hook- tional benefits. worm eradication would imply a long-term income gain Furthermore, because deworming increases the labor of 17 percent (Bleakley 2010).17 supply, it creates a fiscal externality though its impact on Economics of Mass Deworming Programs 417 tax revenue. Baird and others (2016) estimated that the benefits of the program (relative to not implementing net present value of increases in tax revenues likely exceeds the program) in their circumstances. For simplicity, the cost of the program. The fiscal externalities are suffi- consider an example in which they believe that the total ciently strong that a government could potentially reduce benefits may be B1 with probability P1, B2 with probabil- tax rates by instituting free mass deworming. ity P2, or B3 with probability P3. This framework encom- passes the case in which policy makers believe that there is some chance of zero impact because B3 could equal zero. A risk-neutral policy maker will undertake the EVIDENCE AND POLICY DECISION RULES program if 18 This section argues that available evidence is sufficient to support deworming subsidies in endemic regions, even P1 × B1 + P2 × B2 + P3 × B3 – C > 0. if the magnitude and likelihood of program impacts realized in a given context are uncertain. With this framework in mind, from a cost- When assessing evidence, there will always be some effectiveness perspective, deworming would still be uncertainty about whether an intervention will have warranted in many settings on educational and eco- benefits in a given context. First, any body of research nomic grounds alone, even if its benefits were only a risks two types of errors: identifying an impact that fraction of those estimated in the studies discussed. does not exist (type 1 error), and missing an impact Policy makers would be warranted in moving ahead that does exist (type 2). The risk of making a type 1 with deworming, even if they thought benefits were error is captured by the confidence level (P-value) on likely to be smaller in their own context or had some estimates of impact. The risk of making a type 2 error uncertainty about whether benefits would be realized is captured by the power of the study. Second, questions at all. In particular, even if the policy maker believes about the extent to which a body of research applies to the impact of deworming on school participation is the specific context of interest to policy makers will only 10 percent of that estimated in Miguel and always arise. Kremer (2004), or equivalently, if the policy maker Some (for example, Taylor-Robinson and others believes there is a 10 percent chance of an impact of 2015) contend that the evidence does not support invest- the magnitude estimated by Miguel and Kremer ments in mass deworming. One area of disagreement is (2004), and a 90 percent chance of zero impact, it the decision rule used. The decision rule the Cochrane would still be among the most highly cost-effective Review seems to implicitly apply is that programs should ways of boosting school participation (Ahuja and oth- not be implemented unless a meta-analysis (with all its ers 2015). If the impact on weight is even 3 percent of associated assumptions) of randomized controlled trials that estimated by Croke and others (2016), then shows benefits and indicates that the risk of a type 1 deworming is cost-effective relative to school feeding error is less than 5 percent. This approach is inconsistent in increasing weight. If the labor market impact were with policy making from both a cost-effectiveness and a even 1 percent of that found by Baird and others public finance perspective. (2016), then the financial benefits of deworming This decision rule puts no weight on the risk of mak- would exceed the cost. Of course, to the extent that ing a type 2 error, which may be quite important for deworming may affect multiple outcomes, deworming policy makers who do not want to deny a potentially will be even more cost-effective. highly beneficial program to their constituents. Given An analogous expected-value approach would be the statistical tradeoff between type 1 and type 2 errors, natural in a welfare economics framework. Labor market the desire to avoid withholding treatment with poten- effects half as large as those estimated in Baird and oth- tially very high benefits will necessitate being comfort- ers (2016) would be sufficient for deworming to generate able with less-than-definitive proof about program enough tax revenue to fully cover its costs.19 Standard impact. Note that Taylor-Robinson and others (2015) welfare economics criteria for programs being welfare did not report power, but that Croke and others (2016) improving are much weaker than for the tax revenue found that Taylor-Robinson and others (2015) did not fully covering costs. have adequate power to rule out effects that would make From either a cost-benefit or a welfare economics deworming cost-effective. perspective, a sophisticated analysis would be explicitly A more reasonable policy rule under uncertainty Bayesian, taking into account policy makers’ previous would be to compare expected costs with expected ben- assumptions and their best current assessment of their efits. Suppose that the costs of the program are known to specific context. Under a Bayesian analysis that places be C. Suppose policy makers are uncertain about the even modest weight on evidence discussed here, mass 418 Child and Adolescent Health and Development school-based deworming would be justified in areas with Tropical Diseases 2014) could be treated each year via worm prevalence greater than the WHO thresholds. mass deworming programs at a cost of less than It is worth noting that a Bayesian policy maker will US$300 million dollars a year, which is feasible given make current policy decisions based on current infor- current health budgets. The cost of treating them via mation. However, the policy maker would also continue screened programs would likely be US$2 billion annually, research if the expected benefits outweigh its costs; as if not higher, and fewer infections would be treated. new evidence becomes available, it would be systemati- This chapter considers the cost of school-based mass cally combined with the existing best information when deworming programs, which are particularly inexpensive making decisions about continuing or modifying the per person reached. We do not consider the cost- program. effectiveness of more expensive community-based programs that would include extensive outreach efforts beyond schools. One reasonable hypothesis might be COST OF MASS TREATMENT PROGRAMS that these more intensive efforts may be most warranted in areas with either high prevalence, and thus likely high VERSUS SCREENED TREATMENT intensity, of STHs, or where multiple diseases, such as The WHO recommends mass treatment once or twice a lymphatic filariasis, onchocerciasis, trachoma, and schis- year in regions where worm prevalence is greater than tosomiasis, that can be addressed by MDA are endemic certain thresholds (WHO 2015). Screening, followed by (Hotez and others 2007). treatment of those testing positive for worms, is far less practical and more costly than mass treatment without diagnostic testing. CONCLUSIONS School-based mass treatment costs approximately US$0.30 per child per treatment, including delivery costs Recent estimates suggest that nearly one-third of children (GiveWell 2016).20 Diagnosis of worm infections, in in low- and middle-income countries are treated for contrast, is far more expensive and complicated. Speich worms, many via school- or community-based pro- and others (2010) estimate that the cost per child of the grams (Uniting to Combat Neglected Tropical Diseases Kato-Katz test, the most widely used field test for worm 2014). The most commonly used deworming drugs— infections, is US$1.88 in 2013 dollars. If the test works albendazole, mebendazole, and praziquantel—have been perfectly, costs would be more than seven times higher approved for use by the appropriate regulatory bodies in with treatment following screening, compared with multiple countries, have been shown to be efficacious mass treatment without screening. Even proponents of against a variety of worm infections, and have minimal the test-and-treat approach acknowledge this huge dif- side effects (Bundy, Appleby, and others 2017). ferential; Taylor-Robinson and others (2015) stated that The impact of deworming will vary with the local screening is not recommended by the WHO because context—including circumstances such as type of worm, screening costs 4–10 times the cost of treatment. Mass worm prevalence and intensity, comorbidity, the extent treatment is clearly preferred on cost-effectiveness and of school participation in the community, and labor public finance grounds. market factors. The decision to expend resources on These figures ultimately underestimate the cost of deworming should be based on a comparison of expected screening, however.21 First, tests for worms do not iden- benefits and costs, given the available evidence. Our tify all infections. Estimates of the specificity for the analysis of evidence from several contexts on the nutri- Kato-Katz method range from approximately 52 percent tional, educational, and economic impact suggests that to 91 percent (Assefa and others 2014; Barda and others the WHO recommendations for mass treatment are 2013). With a specificity of 52 percent, the cost per justified on both welfare economics and cost-effectiveness infection treated would be much higher for screened grounds. Additional studies will generate further treatment compared with mass treatment. Second, a evidence to inform future decisions. large number of infections would remain untreated. With low specificity, many existing infections would be missed; additionally, screened treatment programs need DISCLAIMERS to reach infected children a second time to treat them, USAID and the Douglas B. Marshall, Jr. Family and it is unlikely they can reach each child who was Foundation support deworming. Michael Kremer is a tested—making screening even less cost-effective. former board member of Deworm the World and is In sum, the majority of the 870 million children at currently Scientific Director of Development Innovation risk of worm infections (Uniting to Combat Neglected Ventures at USAID. Also, Amrita Ahuja is a board Economics of Mass Deworming Programs 419 member of Evidence Action, a nonprofit organization 11. This measure includes the direct impact on the treated, that supports governments in scaling mass school-based as well as indirect impacts accruing to the untreated, deworming programs; this is a voluntary position with population. no associated remuneration. None of these organiza- 12. A parish is an administrative division in Uganda comprising several villages. tions had any influence on this chapter. 13. A two-part reanalysis (Aiken and others 2015; Davey and others 2015) questioned some aspects of this study. However, NOTES several independent analysts have cast doubt on the meth- ods and conclusions of the reanalyses, and concluded that This chapter draws significantly on Ahuja and others (2015). the studies leave the case for deworming fundamentally World Bank Income Classifications as of July 2014 are as unchanged (see, for instance, Berger 2015; Clemens and follows, based on estimates of gross national income (GNI) Sandefur 2015; Healthcare Triage 2015; and Ozler 2015). per capita for 2014: 14. Several early studies assessed the impacts of deworming on school attendance, using individually randomized eval- • Low-income countries (LICs) = US$1,045 or less uations. For example, Simeon and others (1995) studied • Middle-income countries (MICs) are subdivided: treatment among Jamaican children ages 6–12 years; a) lower-middle-income = US$1,046 to US$4,125 Watkins, Cruz, and Pollitt (1996) studied treatment of b) upper-middle-income (UMICs) = US$4,126 to US$12,745 children ages 7–12 years in rural Guatemala; and Kruger • High-income countries (HICs) = US$12,746 or more. and others (1996) studied treatment of children ages 6–8 years in South Africa. None of these studies found an 1. For further discussion of biological differences across impact on school attendance. However, any gains are likely worms, as well as a broader discussion of deworming, to be underestimated since these are individually random- please refer to Bundy, Appleby, and others (2017). ized studies that do not consider treatment externalities. 2. See, for example, Hall and Horton (2008), GiveWell In addition, attendance in the Watkins, Cruz, and Pollitt (2013), and Abdul Latif Jameel Poverty Action Lab (2012). (1996) study was measured through the use of school 3. Bundy, Appleby, and others (2017) provide a discussion of register data, which is unreliable in many low-income Taylor-Robinson and others (2015). countries and which excluded any students who dropped 4. Epidemiological externalities are benefits that accrue to out during the study. Since dropping out is very likely cor- individuals who did not necessarily receive the treatment, related with treatment status, there is a high risk that this for instance, a drug that cures treated individuals, thereby gives a biased picture of school participation over time. reducing transmission of the disease to others. There is also the potential for school officials to overstate 5. We do not address the optimality of the WHO prevalence attendance because of their awareness of the program and thresholds for MDA. the data collection. 6. Miguel and Kremer (2014) provide an updated analysis of 15. Hall and others (2006) similarly found no impact on test the data in Miguel and Kremer (2004), correcting some scores of deworming in Vietnam. As noted previously, errors in the original paper. Throughout this chapter, there is no publicly available version of this paper, so we we cite Miguel and Kremer (2004) but use the updated do not discuss this study further. numbers, where appropriate. 16. The original deworming trial was conducted in 48 com- 7. Although they do not explicitly explore externality impacts, munities in five districts in Eastern Uganda. Croke (2014) several medical studies also show decreases in infection rates used educational data collected by the Uwezo project. among untreated individuals (Miguel and Kremer 2004). The Uwezo survey randomly sampled communities and 8. See Dupas (2014), Kremer and Glennerster (2011), Kremer households from all five of these districts, creating in effect and Holla (2009), and Abdul Latif Jameel Poverty Action a random subsample of communities from the original Lab (2011) for reviews of the literature on the impact of trial. Croke (2014) provided evidence that the sampling prices on adoption of health interventions. of communities by Uwezo was effectively a random 9. As discussed in more detail in Bundy, Appleby, and others sample of the original trial clusters by showing that the (2017), Croke and others (2016) argued that an influential communities have no statistically significant differences earlier study (Taylor-Robinson and others 2015) was under- across a wide range of variables related to adult outcomes. powered to reject the hypothesis that MDA is cost-effective To further support his econometric identification strategy, in increasing weight. Croke and others (2016) doubled the Croke (2014) explored the pattern of test scores of all chil- sample of 11 estimates of the effect of multiple-dose MDA dren tested in these parishes. The youngest children would for worms on weight and updated some of the estimates in have been too young to receive more than two rounds Taylor-Robinson and others (2015), for example, by using of deworming, while the oldest children, at age 16 years, micro-data provided by the original trial authors. would have never received the program. One would expect 10. Hall and others (2006) conducted a cluster randomized that if effects are truly from the deworming intervention, study of the impact of deworming on health and test score the impacts would be lower at the two extremes and higher outcomes in Vietnam. Because there is no publicly available for children in the middle age group, which is what the version of this paper, we do not discuss this study in detail. study found. 420 Child and Adolescent Health and Development 17. Two earlier studies looked at the relationship between Baird, S., J. Hamory Hicks, M. Kremer, and E. Miguel. 2016. deworming and labor market outcomes using “Worms at Work: Long-Run Impacts of a Child Health nonrandomized methods. Using a first-difference research Investment.” Quarterly Journal of Economics. doi: 10.1093/ design, Schapiro (1919) found wage gains of 15 percent to qje/qjw022. Working Paper No. 21428, National Bureau of 27 percent on Costa Rican plantations after deworming. Economic Research, Cambridge, MA. http://qje.oxfordjournals Weisbrod and others (1973) observed little contempo- .org/content/early/2016/07/14/qje.qjw022.abstract. raneous correlation in the cross-section between worm Barda, B., H. Zepherine, L. Rinaldi, G. Cringoli, R. Burioni, infections and labor productivity in St. Lucia. and others. 2013. “Mini-FLOTAC and Kato-Katz: Helminth 18. This abstracts from curvature of the utility function. Eggs Watching on the Shore of Lake Victoria.” Parasites and Because deworming is inexpensive, and there is no evi- Vectors 6: 220. dence that deworming has serious side effects; because Berger, A. 2015. “New Deworming Reanalyses and Cochrane there is evidence for large effects in some cases; and Review.” The GiveWell Blog, July 24. because those with the highest-intensity infections are Bleakley, H. 2007. “Disease and Development: Evidence from likely to be poorer than average, risk-averse policy makers Hookworm Eradication in the American South.” Quarterly or those concerned with equity would be more willing to Journal of Economics 122 (1): 73–117. institute mass deworming than this equation implies. ———. 2010. “Health, Human Capital, and Development.” 19. 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Combat the Health and Nutritional Impact of Helminth Kruger, M., C. J. Badenhorst, E.P.G. Mansvelt, J.A. Laubscher, Infections.” e-Library of Evidence for Nutrition Actions and A.J.S. Benade. 1996. “The Effect of Iron Fortification (eLENA), WHO, Geneva. http://www.who.int/elena/titles in a School Feeding Scheme and Anthelminthic Therapy /deworming/en. 422 Child and Adolescent Health and Development Chapter 30 The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value Elina Pradhan, Elina M. Suzuki, Sebastián Martínez, Marco Schäferhoff, and Dean T. Jamison INTRODUCTION (Baird and others 2012; Behrman 2015; De Neve This chapter analyzes the economic returns to education and others 2015). Early child development has a lifelong investments from a health perspective.1 It estimates the impact on the mental and physical health of individuals.2 effects of education on under-five mortality, adult mor- Other studies have demonstrated that progress in edu- tality, and fertility. It calculates the economic returns to cation can increase positive health-seeking behaviors education resulting from declines in under-five mortal- (such as accessing preventive care) and reduce overall ity and adult mortality, while considering the effects of dependency on the health system (Cutler and Lleras- education investments on income. It also develops Muney 2010; Feinstein and others 2006; Kenkel 1991; policy-relevant recommendations to help guide educa- Sabates and Feinstein 2006). tion investments. Previous literature on education, health, and eco- Our study adds to the evidence that education is a nomic productivity suggests that the impact of educa- crucial mechanism for enhancing the health and tion is more significant in times of rapid technological well-being of individuals. The relationship between progress (Preston and Haines 1991; Schultz 1993). The education and health is bidirectional, because poor morbidity and mortality differentials across levels of health could affect educational attainment (Behrman schooling are significant in the presence of increasing 1996; Case, Fertig, and Paxson 2005; Currie and Hyson scientific knowledge about diseases and behaviors, as 1999; Ding and others 2009). Historical findings in the well as access to medicines and vaccines. Additionally, education and health literature have highlighted analysis by Jamison, Murphy, and Sandbu (2016) shows the strong association between education and health. that most variation in under-five mortality can be Recent literature has exploited natural experiments to explained by heterogeneities in the speed at which coun- provide causal evidence of the impact of education on tries adopt low-cost health technologies to increase health. Studies show that education plays a critical role child survival. in reducing the transmission of human immunodefi- Different studies that have assessed the effects of edu- ciency virus/acquired immune deficiency syndrome cation on mortality and fertility show an association (HIV/AIDS) in women by improving prevention and between educational attainment and reductions in both treatment. Keeping adolescent girls in secondary school outcomes.3 This chapter goes beyond previous work by significantly attenuates the risk of HIV/AIDS infection using improved and updated data, and by controlling Corresponding author: Elina Pradhan, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, United States; epradhan@mail.harvard.edu. 423 tightly for country-specific effects in both levels and with its mortality-related health effects. We also esti- rates of change of mortality. Although several studies mate the BCR of education from earnings-only and have examined the effects of female schooling on child health-inclusive perspectives, and address the ques- mortality, we are aware of only one other cross-national tion: What would be the returns to investing US$1 study (Wang and Jamison 1998) that estimated the in education in low-, lower-middle-, and upper-mid- macro effects of schooling on adult mortality. Other dle-income countries? studies have focused on the relationship between school- • Finally, we discuss our findings, present recommenda- ing and adult health, but they primarily do so for a single tions, and consider the next steps the global education country or small set of countries.4 Some key findings community might take to ensure that all countries make from our study are highlighted in box 30.1. substantial progress toward global education targets. Our study comes at a critical juncture for education and health, as the global community moves forward in the context of the Sustainable Development Goals, MODELING THE EFFECTS OF EDUCATIONAL which stress the importance of taking into account the ATTAINMENT ON HEALTH cross-sectoral nature of global development challenges. This chapter is organized into three broad sections: Data and Methods We estimated the effects of educational attainment over • The first section presents the results of our regression time, measured in mean years of schooling for ages 25 analysis, which examines the effects of increases in years and older. This age group was selected to ensure that mean years of schooling, as well as schooling quality, the data were unlikely to contain censored observations.5 on under-five mortality, adult female mortality, adult Data on mean years of schooling were obtained through male mortality, and fertility. We also decompose the the Barro and Lee (2013) dataset, which includes 92 low- changes in mortality between 1970 and 2010, and and middle-income countries (LMICs), each of which estimate the mortality impact of education gains in included observations at five-year intervals between 1970 the Millennium Development Goal (MDG) period. and 2010. Mortality rates were defined as the probability The findings from our regression inform the subse- of dying between age 0 and age 5 years for under-five quent sections, which use the estimated effect size mortality, and the probability of dying between age 15 to determine the rates of return to and benefit-cost and age 60 years for adult mortality. The United Nations ratios (BCRs) of education. (UN) World Population Prospects (2015 revision) was • The second section explores the effects of augmenting used for all fertility and mortality estimates (table 30.1). the traditional rates of return analysis for education Annex 30A contains a full list of countries included in Box 30.1 Key Findings Of the impressive reductions in mortality seen estimated 7.3 million lives in LMICs between 2010 in low- and middle-income countries (LMICs) and 2015. between 1970 and 2010, we estimate that The health benefits of additional schooling are 14 percent of the reductions in under-five mor- higher for earlier years of schooling. The mar- tality, 30 percent of the reductions in adult female ginal impact of schooling at the primary level is mortality, and 31 percent of the reductions in higher compared with the impact at the second- adult male mortality can be attributed to gains ary level. in female schooling. Quality (as measured by stan- dardized test scores) also has a substantial effect on Every dollar invested in schooling would return health outcomes. US$10 in low-income and US$3.8 in lower-middle- income countries. These values reflect increased Gains in educational attainment during the earnings plus the value of reductions in under-five Millennium Development Goals period saved an and adult mortality. 424 Child and Adolescent Health and Development Table 30.1 Sources of Data in the Study Variable Description Data sources Educational attainment Mean years of total schooling among the population Barro and Lee (2013) dataset, version 2.0 (mean years of schooling) ages 25 years and older. Both overall and gender-specific estimates were used. Standardized achievement test scores Aggregate standardized test scores, developed by Angrist, World Bank EdStats Global Achievement Patrinos, and Schlotter (2013) on the basis of global and database regional achievement tests. Under-five mortality Probability of dying between birth and exact age five UN World Population Prospects 2015 years, expressed as deaths per 1,000 live births. Adult mortality Expressed as deaths under age 60 years per 1,000 alive at UN World Population Prospects 2015 age 15 years, calculated at current age-specific mortality rates. Both overall and sex-specific estimates were used. Male and female deaths, by broad Number of male/female deaths by five-year age groups. UN World Population Prospects 2015 age group Fertility Total fertility rate (children per woman). UN World Population Prospects 2015 GDP per capita Per capita expenditure-side real GDP (PPP-adjusted). Penn World Tables, version 8.1 (April 2015) (Feenstra, Inklaar, and Timmer 2015) Note: GDP = gross domestic product; PPP = purchasing power parity; UN = United Nations. the analysis. Definitions of age groupings and age-specific five-year increments from 1970 to 2010, and is a proxy terminology used in this volume can be found in chapter 1 variable for measuring technological progress over the (Bundy and others 2017). study period. Annex 30B contains descriptive statistics for countries included in the regression, including means Regression Models and standard deviations for mortality and fertility rates, We modeled the effects of educational attainment years of schooling, and test scores. (female schooling, male schooling, and overall school- Preston (1975, 2007) shows that national income ing) on under-five mortality, adult female mortality, and plays a critical role in improving health outcomes. He adult male mortality controlling for time and income further argues that factors exogenous to income have (gross domestic product [GDP] per capita) using hierar- played a crucial role in improving mortality. An influ- chical linear models (HLMs) as in equation (30.1). ential paper by Pritchett and Summers (1996) pointed Jamison, Murphy, and Sandbu (2016) provide a range of to education as well as income as being among comparative models on under-five mortality and assess the important factors influencing mortality decline. their statistical properties. They concluded that the HLM As highlighted by Jamison, Murphy, and Sandbu structure has the best fit to macro-level data to deter- (2016), technological progress, which includes mine the macro-level impact of education on mortality, research, development and implementation advances and we therefore develop their modeling approach here. in vaccines, sanitation, clinical care, and disease con- trol, has played a driving role in improving health yit = β0 + β1educ it + ∑ a t =1 β 2 a time t outcomes in recent years. In line with these authors, (30.1) +β3 Log (GDPPC )+ β 2i timet + u i + ∈it we also loosened the assumption of homogeneity of technical advancements across countries. By allowing The under-five mortality model estimates the impact the impact of time or technological progress to vary of adult education (education of those ages 25 years and every five years, and by allowing for a country- older) on the mortality of those under age 5 at each time specific impact of technological progress on mortality period t, while the adult mortality models estimate the in addition to controlling for GDP, we provide con- impact of adult education on aggregate adult mortality servative estimates of the impact of education on or self and peer mortality, adjusting for income, any mortality and fertility. Annex 30C provides additional technological advancements, and secular time trends. details on the model, and annex 30D tabulates all Time is specified as a categorical variable that indicates regression results in detail. The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 425 Decomposition Analysis occurred had educational attainment stayed at the 1990 Results from the regressions were then used to decom- levels. In this analysis, we model the counterfactual sce- pose the changes in under-five, adult male, and female nario of the number of additional deaths during 2010–15 mortality between 1970 and 2010. In this analysis, we had education stagnated at 1990 levels, where we apply first calculate the difference in mean covariates in the increases in education in low-income countries the sample in 2010 compared with 1970. Then, we calcu- (LICs) and lower-middle-income countries to the coeffi- late the overall reduction in mortality when education cient from our HLM results to calculate the excess increases by the difference in mean from 2010 to 1970, deaths. Annex table 30C.2 provides estimation details. which is the impact estimate from the HLM model mul- tiplied by the difference in the mean of that covariate. Results The fraction attributable to any particular covariate is Effects of Schooling on Adult and Under-Five then the overall reduction in mortality attributable to the Mortality and Fertility changes in that particular covariate, divided by the over- We modeled the effects of education based on three all change in mortality over the period. For example, different schooling variables: mean years of schooling equation (30.2) illustrates the estimation process for for girls, boys, and both genders. The results of our the fraction attributable to education, ΔMorted, where analysis, which examined female and male adult mor- ΔEduc = Educ 2010 − Educ1970 and bed = the estimate of tality separately, make an important contribution to impact of education on mortality from the HLM model. the existing evidence base. Very few studies have focused on any potential impacts that educational βed × ΔEduc attainment may have on adult mortality at the macro ΔMorted = βed × ΔEduc + β gdp × ΔGDP + β 2010 × Δ T level. To the best of our knowledge, the most recent (30.2) cross-country study that specifically assessed the macro effects of schooling on adult mortality is from 1998 Estimating the Mortality Impact of Education Gains (Wang and Jamison 1998). in the MDG Period Table 30.2 shows the results of our hierarchical mod- To understand the impact of education gains during the els; each column represents the results for the five depen- MDG period on under-five and adult mortality, we also dent variables—overall adult mortality, adult male estimate the number of excess deaths that could have mortality, adult female mortality, under-five mortality, Table 30.2 Impact of Schooling on Health Outcomes: Results from Hierarchical Linear Models Dependent Variables Ln[Adult mortality Ln[Adult mortality Ln[Adult mortality Ln[Under-five Ln[Total rate], both sexes rate], male rate], female mortality rate] fertility rate] Independent variables Panel A: Mean years of schooling, both sexes −0.030*** −0.025** −0.031*** −0.033** −0.024*** Ln[GDP per capita] −0.057*** −0.040** −0.083*** −0.13*** −0.047*** Panel B: Mean years of schooling (female) −0.030*** −0.022** −0.037*** −0.042*** −0.024*** Schooling ratio (male:female) 0.016 0.019* 0.010 −0.009 −0.011 Ln[GDP per capita] −0.052** −0.034* −0.079*** −0.13*** −0.047*** Panel C: Mean years of schooling (male) −0.015 −0.014 −0.010 −0.015 −0.015* Schooling ratio (male:female) 0.018* 0.020** 0.013 −0.008 −0.011 Ln[GDP per capita] −0.058*** −0.039** −0.084*** −0.13*** −0.047*** Note: GDP = gross domestic product. Ln[x ] denotes natural log of variable x. Period: 1970–2010. Countries: 80. Observations: 688. Standard errors and goodness of fit measures reported in annex 30D. *p < .10; **p < .05; ***p < .01. 426 Child and Adolescent Health and Development and fertility. Panel A shows results for models in which adult female mortality were particularly substantial, we consider the impact of average male and female declining by 43 percent over the 40-year period. schooling on the five health outcomes. Panels B and C Our decomposition analysis suggests that of the show the impact of female and male schooling, respec- reductions in mortality seen in LICs and middle-income tively, while controlling for the ratio of male to female countries (MICs) between 1970 and 2010, 14 percent of years of schooling. The schooling ratio is included to reductions in under-five mortality, 30 percent of reduc- control for any differential impact of male and female tions in adult female mortality, and 31 percent of reduc- schooling in panels B and C, respectively. tions in adult male mortality can be attributed to gains Table 30.2 demonstrates that improvements in female in female schooling (figure 30.1, panel A). This panel educational attainment drove declines in mortality and shows that technological progress, and to a much lesser fertility in LMICs between 1970 and 2010: A one-year extent income, affected mortality over this period, a increase in a country’s mean years of schooling (both finding in line with other studies (Jamison, Murphy, and sexes) is associated with a 2.5 percent reduction in male Sandbu 2016). adult mortality and 3.1 percent reduction in female adult mortality, a 3.3 percent reduction in under-five mortality, Mortality Impact of Increases in Educational and a 2.4 percent reduction in the total fertility rate Attainment during the MDG Period (TFR), in LMICs (panel A of table). The effect of male A complementary way of assessing the magnitude of schooling on adult and under-five mortality and TFR is education’s impact on mortality is to look at the small and often not significant. In contrast, improve- reduction in the number of deaths resulting from a ments in female schooling are associated with large given increase in education levels. We take as an exam- declines in both female and male adult mortality, ple the increase in female education in LMICs during accounting for much of the observed effects of education the MDG period from 1990 to 2015. This increase was on health. A one-year increase in mean years of schooling 1.5 years in LICs and 2.4 years in MICs. We ask the for girls (panel B of table) is associated with reductions in question: Based on the results of our model female and male adult mortality of 3.7 percent and 2.2 (table 30.2), how many more deaths would have percent, respectively; under-five mortality declines by 4.2 occurred in children under age 5 years and in adults percent, and the TFR by 2.4 percent. The comparison of ages 15–59 years if education levels had remained at the effect of male (panel C of table) and female schooling their 1990 levels? Panel B of figure 30.1 shows the (large effect) on adult mortality, under-five mortality, results. We estimate that a total of 7.3 million under- and fertility clearly shows that the education-related five and adult deaths were averted between 2010 and declines in mortality between 1970 and 2010 in LMICs 2015 because of increases in educational attainment are strongly linked to increases in female schooling.6 since 1990. Total deaths averted in MICs were sub- stantially higher than in LICs because the population Decomposition Analysis: Reductions in Adult and exposed to mortality risk is about six times larger in Under-Five Mortality Rates from Gains in Female MICs compared with LICs, and MICs saw a greater Schooling, 1970–2010 increase in average years of female schooling during Based on the results of our HLM, we developed estimates the MDG period than did LICs. of the proportion of mortality reductions between 1970 and 2010 that can be attributed to improvements in Effects of Different Levels of Schooling on Mortality female schooling. Adult female, adult male, and under-five and Fertility mortality all saw impressive reductions over this period, In addition to analyzing the overall impact of increas- with particularly dramatic improvements seen in under- ing average schooling by one year in a country, we five mortality. Between 1970 and 2010, the global under- considered whether differential effects accrue at dif- five mortality rate declined by 64 percent, from 139 deaths ferent levels of schooling (table 30.3). We conducted a under age five years per 1,000 live births to 50 in 2010. In quadratic analysis that relaxes the assumption that LICs, gains have been particularly strong since 1990: each additional year of schooling has the same impact under-five mortality declined by more than 50 percent, on health, hence allowing the relative change in mor- from 186 deaths per 1,000 live births to 91, during this tality with changing years of attainment to be evalu- 20-year span. The adult mortality rate, that is, the proba- ated.7 Our analysis indicates that additional years of bility that a person dies (expressed per thousand persons) schooling have sustained effects on all the health between age 15 and age 60 at prevailing mortality rates, outcomes we examined. The coefficient on the squared also recorded a notable decline between 1970 and 2010, years of female schooling term is positive and signifi- falling 38 percent globally, from 247 to 153. Reductions in cant for all health outcomes, indicating that the The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 427 Figure 30.1 Education’s Contribution to Mortality Decline relative effect of education on health outcomes declines with increasing years of educational attain- a. Decline in mortality attributable to increases in ment. This result means that the marginal impact of female schooling, 1970–2010 schooling at the primary level is higher compared 140 with the impact at the secondary level. 120 Decline in mortality rates 14% Effects of Educational Quality 100 30% In addition to the effect of years of schooling on 1970–2010 80 31% health, we evaluated the effects of educational quality 60 on health outcomes. This analysis proved challenging for a variety of reasons. Most fundamentally, 40 cross-country data on educational quality are extremely 20 limited, particularly for LICs and lower-middle- 0 income countries. Researchers have used results from Under five Adult female Adult male global or regional achievement tests (such as PISA, (per 1,000 live births) (per 1,000 (per 1,000 TIMSS, SACMEQ, PASEC, and LLECE8) to standard- population) population) ize estimates of educational quality, based on country Decline from female schooling performance on such exams. However, significant gaps Decline from income growth remain in both longitudinal and country coverage, and Decline from technological change concerns have been raised about the validity of using results from a limited set of tests as a proxy for educa- b. Deaths averted by increases in educational attainment tional quality. during the MDG period, 2010–15 Because of the limited number of LMICs with longi- 4.0 3.7 tudinal data on quality, we expanded our analysis to 3.5 include high-income countries (HICs) with data on Deaths averted (millions) 3.0 2.6 quality in the Barro and Lee (2013) dataset. Annex 30A 2.5 provides a full list of countries used in the HLM regres- 2.0 sions on quality. 1.5 To evaluate the impact of education quality on 1.0 0.6 health, we ran an augmented version of the HLM in 0.5 0.4 table 30.2, panel B, to which we added a variable mea- 0 suring schooling quality (standardized achievement Under-five deaths Adult (ages 15–59 years) test scores). deaths Our findings largely underscore the robustness of Middle-income countries Low-income countries the impact of years of schooling on health outcomes, and further suggest that quality can have an additive Note: MDG = Millennium Development Goal. and substantial impact on health outcomes (table 30.4). Table 30.3 Impact of Schooling Levels on Health Outcomes Dependent Variables Ln[Adult mortality Ln[Adult mortality Ln[Adult mortality Ln[Under-five Ln[Total fertility rate], both sexes rate], male rate], female mortality rate] rate] Independent variables Mean years of female −0.081*** −0.071*** −0.089*** −0.14*** −0.10*** schooling (linear) Mean years of female 0.005*** 0.005*** 0.005*** 0.010*** 0.008*** schooling (quadratic) Ln[GDP per capita] −0.043** −0.026 −0.070*** −0.11*** −0.032** Note: GDP = gross domestic product. Ln[x] denotes natural log of variable x. Period: 1970–2010. Countries: 80. Observations: 688. Standard errors and goodness of fit measures reported in annex 30D. *p < .10; **p < .05; ***p < .01. 428 Child and Adolescent Health and Development Table 30.4 Impact of School Quality on Health Outcomes: Results from Hierarchical Linear Models Dependent variables Ln[Adult mortality rate], both sexes Ln[Under-five mortality rate] Ln[Total fertility rate] (A) (B) (A) (B) (A) (B) Independent variables Mean years of schooling (female) −0.017* −0.016* −0.057*** −0.058*** −0.031*** −0.031*** Schooling ratio (male:female) −0.013 −0.019 0.19*** 0.18*** 0.20*** 0.20*** Ln[GDP per capita] −0.020*** −0.20*** −0.45*** −0.46*** −0.16*** −0.16*** Test scores −0.0025** −0.0035** −0.00024 Note: GDP = gross domestic product. Ln[x] denotes natural log of variable x. Period: 1970–2010. Countries: 103. Observations: 362. Standard errors and goodness of fit measures reported in annex 30D. *p < .10; **p < .05; ***p < .01. Table 30.5 Impact on Health Outcomes of a One Standard Deviation Change in Education Quantity and Quality Dependent Variables Ln[Adult mortality Ln[Adult mortality Ln[Adult mortality Ln[Under-five Ln[Total fertility rate], both sexes rate], male rate], female mortality rate] rate] Independent variables Test scores −0.024** −0.02* −0.023** −0.034** −0.002 Mean years of schooling (female) −0.048* −0.033 −0.072** −0.18*** −0.093*** Ratio (years:test scores) 2.0 1.7 3.1 5.2 40 Note: Appendix 30B, table 30B.5 tabulates the mean and standard deviation of the test scores and years of schooling used in this analysis. Ln[x ] denotes natural log of variable x . Period: 1970–2010. Countries: 103. Observations: 362. *p < .10; **p < .05; ***p < .01. Column (B) under each dependent variable shows the associated with a 2.4 percent decline in the overall results of the HLM model with education quality prox- adult mortality rate, a 2.3 percent decrease in adult ied by the composite test scores. Comparison of the female mortality, and a 3.4 percent decrease in under- returns to mean years of schooling in column (B) as five mortality. In all cases, however, the impact of compared to column (A), where the HLM model does female educational attainment remains larger than not control for quality, shows that the impact of returns the impact of educational quality. For the three health to schooling is about the same with or without control- outcomes for which both years of schooling and test ling for test scores. In fact, improvements in test scores are significant—overall adult mortality, female scores are predicted to reduce mortality and fertility mortality, and under-five mortality—the impact of further, above and beyond the improvements in years female years of schooling ranges from 2 to 5.2 times of schooling. the impact of quality. Given the substantial difference in a one-unit Our estimates of the magnitude of the effect of change between educational attainment (one year of education quality on under-five mortality substan- schooling) and test scores (a one-point increase in tially exceed those of Jamison, Jamison, and Hanushek scores), we also present the results of both quantity (2007), perhaps because (1) we estimate the impact and quality by using a one standard deviation change on under-five mortality rather than on infant mortal- above their mean values to enable better comparabil- ity, and (2) we have more observations from LMICs ity between the two (table 30.5). The results of this than these authors. However, our sample would still analysis suggest that the impact of quality is substantial. benefit from additional observations for LICs, lower- A one standard deviation change in educational qual- middle-income countries, and upper-middle-income ity, measured by standardized achievement scores, is countries (UMICs). The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 429 Our findings show that the impact of school quality and strengthens the investment case for education by on health outcomes is considerable and merits further quantifying health returns in addition to earnings returns. scrutiny. It also highlights the limitations of the data, a challenge that should be considered when interpret- ing these results. Of the 103 countries included in the Methods analysis, 59 countries have fewer than four years of The empirical work conducted as a first step in this observations. Of those with four or more observa- analysis generated coefficients for the effect of one tions, 35—or 80 percent of the sample—are HICs. additional year of female education on under-five Further work is needed to develop robust measures of mortality, adult female mortality, and adult male education quality that are comparable across coun- mortality. In this section, we use these coefficients to tries and tracked over time. generate the valuation of these changes in monetary terms. Earlier research by our team, funded by the Norwegian government, reviewed available evidence CALCULATING HEALTH-INCLUSIVE RATES OF on the effects of education and then estimated the RETURN TO EDUCATION AND BENEFIT-COST economic returns resulting from the reduction in under-five mortality attributable to increases in RATIOS female education (Schäferhoff and others 2015). Our Previous analyses have estimated the returns to edu- analysis follows the general approach used in this pre- cation. Using household and labor market survey vious study, but improves the methodology and data, Montenegro and Patrinos (2013, 2014) have expands it to incorporate the monetary value of both estimated the private returns accruing from increased under-five and adult mortality reductions.10 schooling. They note that three major findings have The literature in economics of education typically held across analyses: reports its benefit-cost analyses as internal rates of return, namely, the value of the discount rate that makes • Private returns to schooling tend to remain in the equal the present values of the cost and benefit streams. range of 10 percent per year of schooling. We calculate both the rate of return and more standard • Returns are, on average, higher in LMICs. benefit to cost ratios. • Returns to primary schooling are higher than returns Estimating both internal rates of return and BCRs to secondary schooling. involved the following four broad steps: First, we used the effects of education on under-five When estimating private returns to education, mortality, adult male mortality, and adult female mortal- researchers assume that costs of schooling are ity from our cross-country regressions as the basis for our absorbed by the government and that the only costs to health-inclusive rate-of-return (RoR) and BCR analysis. students are the opportunity costs of forgone earn- From the regressions, we obtained the level of mortality ings; any gains reflect the income differential between reductions resulting from one more year of female the earnings earned by students with different levels schooling for each income group. For example, the aver- of educational attainment. The term social rates of age years of schooling in lower-middle-income countries return refers to the rate of return to education when is six years; our RoR and BCR calculations for these coun- the full cost of schooling is incorporated. In an analy- tries then estimated the rate of return to increasing female sis of 15 LMICs, Psacharopoulos, Montenegro, and schooling from six years, on average, to seven years. Patrinos (2017) further considered the full cost of Second, applying methods similar to Global Health schooling. They found that the social rates of return 2035 (Jamison and others 2013a, 2013b) and our to primary education were higher than those to sec- Norwegian Agency for Development Cooperation ondary and tertiary education for both LICs and (Norad) study, we placed dollar values on these mortal- lower-middle-income countries.9 ity reductions. We calculated the expected health value at Our analysis makes an important contribution to age a, expressed in dollars, associated with the assumed existing research on the rates of return to education by one-year increase in education level using the informa- expanding the traditional focus on earnings returns to tion on dollar value of mortality reductions combined consider some health-related (nonmarket) externalities with status quo mortality rates and fertility rates. The associated with increased educational attainment value-of-a-life-year (VLY) methodology used here (Lochner 2011; Oreopoulos and Salvanes 2011). By cap- underestimates the VLY in LICs compared with UMICs. turing reductions in mortality, our analysis provides a While there is some evidence in the literature to support more comprehensive evaluation of returns to schooling this assumption because the economic component of 430 Child and Adolescent Health and Development the VLY is dependent on the economic productivity of a Estimating Internal Rate of Return country, there is limited reason to assume that the social Equation (30.3) expresses the net present value of costs VLY would differ by a country’s economic productivity and benefits (ePVNR[rs]), in a standard RoR (rs) (Stenberg and others 2016). We applied a conservative analysis: value of a statistical life (VSL) estimate in our study, and provide upper and lower bounds of RoR estimates and ev(a) − c1 (a) − c 2 (a) ePVNR(rs ) = ∑ a = A 65 BCRs in annex 30D to illustrate the uncertainty around . (30.3) (1 + rs )a − A life year valuations. Third, we calculated the earnings value for an incre- ment in education. We received smoothed age-earnings The standard RoR (rs) is simply the value of rs such profiles for LICs, lower-middle-income countries, and that the net present value of earnings (ePVNR[rs]) is UMICs from Psacharopoulos, Montenegro, and Patrinos zero. Standard RoRs calculated are then compared with (2017) for different levels of schooling. We then estimated the health-inclusive RoRs, which we label hRoRs. the marginal increase in earnings at each age across each Equation (30.4) gives the present value of net benefits schooling level (as in our example, where we estimated when the benefit stream is augmented by the value of the expected level of mortality reductions resulting from education’s health effect: one additional year of schooling for individuals with a ev(a) + hv(a) − c1 (a) − c 2 (a) hPVNB(rh ) = ∑ a = A 65 starting level of six years). The earnings value of this . (30.4) (1 + rh )a − A increment in education for a person of age a is simply the difference between the age-earnings profiles of a second- The health-inclusive RoR (rh), hRoR, is simply that ary school graduate and a primary school graduate value of rh such that the health-inclusive net present divided by the number of years of secondary schooling. value (hPVNR(rh)) is zero. Fourth, we drew on cost data from the International Commission on Financing Global Education Opportunity, Estimating Benefit-Cost Ratios which provides estimates of the direct cost (c1) for school- To calculate the health-inclusive BCRs, we simply ing at the respective grade levels in each income group apply the annual discount rate of 3 percent to all costs (table 30.6). The direct cost is the cost of teacher time, and benefits. The health-inclusive BCR at discount rate implicit rent on facilities, and consumables such as text- (r), hBCR(r), is listed below in equation (30.5), and the books. We assumed that if children are in school, they earnings-only BCR, eBCR(r) in equation (30.6). forgo earnings, so the earning value of a person of age a will be negative at the age of entry for the additional year ∑ 65 A−a A−a a= A ⎣ev(a)(1 + r ) + hv(a)(1 + r ) ⎤ ⎡ ⎦ of schooling (A). The direct cost of schooling at ages hBCR(r ) = ∑ 65 A−a A−a greater than A is assumed to be zero. Similarly, the oppor- a= A ⎣c1 (a)(1 + r ) + c 2 (a)(1 + r ) ⎤ ⎡ ⎦ tunity cost (c2) of attending one more year of school was (30.5) calculated as the earnings forgone by attending one more year of school. Similar to direct costs, the opportunity ∑ 65 [ev(a)(1 + r )A − a ] costs of schooling at ages greater than A is also zero. eBCR ( r ) = a= A ∑ 65 Annex 30Eß∑ discusses our approach in estimating the a= A [c1 (a)(1 + r )A − a + c 2 (a)(1 + r )A − a ] direct and opportunity costs of schooling in detail, and it (30.6) tabulates the costs used in our analysis. Annex 30D provides the detailed methods used for RoR and BCR calculations, and an example of how ben- Table 30.6 Direct per-pupil annual costs of schooling (unweighted), in 2012 US$ efits to reductions in under-five and adult male and female mortalities are valued. Low Lower middle Upper middle income income income Results Primary $68 $230 $1,300 Lower secondary $140 $300 $1,400 Health-Inclusive Rate of Return from Investments in Education Upper secondary $300 $430 $1,300 The standard social rate of return or earnings return is Note: The table includes the estimated average (unweighted) per pupil costs by income the rate of return to schooling considering direct costs, group (YR2012, in 2012 US$). These cost estimates were provided by the International Commission on Financing Global Education Opportunity and were also used by opportunity costs, and earnings benefits from schooling. Psacharopoulos, Patrinos, and Montenegro (2017). Our initial calculations suggest that the earnings return The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 431 of investing in an additional year of schooling in LICs is In addition to calculating rates of return for LICs and 11 percent (table 30.7). These standard social rates of lower-middle-income countries, we estimate that the return, however, do not consider other social benefits standard social rate of return of increasing schooling by of schooling. Here, we consider the added benefit of a year in UMICs is 3.0 percent (table 30.7 and figure 30.4). schooling on potential reductions in under-five mortal- The health-inclusive RoR is 4.7 percent (4.1 percent to ity, adult male mortality, and adult female mortality. 5.3 percent), which is approximately 55 percent Including the health benefits due to an additional (36 percent to 74 percent) of the returns from earnings. year of schooling, the rate of return to investing in an The results tabulated in the chapter consider the VSL additional year of schooling in LICs increases to 16 to be 130 times GDP per capita, which is a conservative percent (14 percent to 18 percent).11 This means that the estimate compared with the Global Health 2035 series and rate of return to education increases significantly when our previous Norad report. The estimated health-inclusive the returns to education resulting from reductions in rates of return are sensitive to the VSL assigned to mortal- adult mortality and under-five mortality are added to ity reductions. In annex figure 30F.1, we also present the the standard rate of return. estimated internal rates of return at VSLs of 80 to 180 Figure 30.2 demonstrates that the health benefits times GDP per capita. At 14 percent and 8.5 percent rates accruing from education are comparable to and at of return, the health-inclusive returns to education are certain ages even exceed earnings benefits in LICs. high in LICs and lower-middle-income countries, respec- This is particularly true during early adulthood (ages tively, even with the lowest VSL multiplier used. 20–40 years), when the benefits of reduced adult and The health-inclusive rates of return are relatively larger under-five mortality are 20 percent larger than the in lower-middle-income countries, compared with UMICs, earnings benefits. The protective benefit of education because of higher mortality in lower-middle-income coun- for reducing under-five mortality is particularly tries. In particular, the returns to reductions in under-five impressive in these settings, where under-five mortality mortality are higher in lower-middle-income countries rates remain high. than in UMICs, where under-five mortality rates are less The health-inclusive social rate of return calculations than half those in lower-middle-income countries. As shown that consider health benefits show that the returns in figure 30.4, the earnings benefits of schooling are consis- resulting from lower mortality are high in lower-middle- tently higher than the health benefits across all ages in income countries, where the updated social returns with UMICs. In addition, compared with lower-middle-income health, at 9.3 percent (8.4 percent to 10 percent) are 34 countries, the absolute value of health benefits and earn- percent (21 percent to 46 percent) of the standard social ings benefits are higher in UMICs because of differences in rate of return (see table 30.7 and figure 30.3). GDP and VSL valuations across these two income groups. Table 30.7 Rate of Return of One Additional Year of Schooling in LICs, Lower-Middle-Income Countries, and UMICs percent Without health benefits Standard private rate (standard social rate of Health-inclusive social of return return) rate of return IRR LICs 16 11 16 Lower-middle-income countries 9.0 7.0 9.3 UMICs 5.0 3.0 4.7 Benefits and costs included Health benefits No No Yes Earnings benefits Yes Yes Yes Direct cost of an additional year of schooling No Yes Yes Opportunity cost of attending an additional year Yes Yes Yes of schooling Note: IRR = internal rate of return; LICs = low-income countries; UMICs = upper-middle-income countries. 432 Child and Adolescent Health and Development Benefit-Cost Analysis Figure 30.2 Benefit Stream for LICs from One Additional Year of In addition to the internal rate of return, the returns to Schooling education can alternatively be conceptualized in the 100 form of a benefit-cost analysis. Our results suggest that US$ per person per year there is an enormous payoff to investing in education 80 when investments are assessed from a health perspective. 60 Every dollar invested in female schooling in LICs and lower-middle-income countries would return US$10 40 and US$3.8, respectively, in earnings and reductions in 20 under-five and adult mortality. For our analysis, we assumed a discount rate of 0 3.0 percent, which is consistent with the discount rate used 11 16 21 26 31 36 41 46 51 56 61 in other benefit-cost calculations in public health, includ- Age (years) ing the 2013 Lancet Commission on Investing in Health. Under-five mortality benefit Adult mortality benefit Although benefits exceed costs for all income groups even Wage benefit when taking into account only the earnings effects of edu- cation, the additional benefits from health are significant, Note: LICs = low-income countries. The benefit streams are per person with one additional year of particularly in LICs and lower-middle-income countries. schooling. Our models assume that the health benefits accrue only to female schooling but that the wage benefits accrue to both males and females. Hence, the estimates of the dollar value of health As with RoR estimates, the BCRs are also estimated benefits is a weighted average with the weight depending on the fraction of the educated cohort with some uncertainty. We present sensitivity analyses of that is female. The calculations assume the cohort is 50 percent female. the ratios in annex figure 30F.1 where we estimate BCRs for a VSL ranging from 80 to 180 times GDP per capita. In annex figure 30F.2 we present the range of BCR esti- Figure 30.3 Benefit Stream for Lower-Middle-Income Countries from mates for discount rates from 1.0 percent to 5.0 percent. One Additional Year of Schooling Similar to internal rate of return results, we find that the 300 health-inclusive benefit of an additional year of schooling US$ per person per year 250 is substantial for LICs and lower-middle-income coun- tries even at the lowest VSL multiplier used, with returns 200 of US$8.3 and US$3.3, respectively, for every dollar spent. 150 In LICs, the health benefits of education represent an 100 impressive 92 percent increase over the earnings-only 50 BCR; in lower-middle-income countries, health aug- ments the traditional BCR by 44 percent. Put in other 0 terms, 48 percent (US$4.7) of returns would come from 14 19 24 29 34 39 44 49 54 59 64 the effect of schooling on mortality in LICs, while 31 Age (years) percent (US$1.1) of the returns to education in Under-five mortality benefit Adult mortality benefit lower-middle-income countries result from the effect on Wage benefit adult and under-five mortality. Even in UMICs, where lower mortality rates and higher educational attainment Note: The benefit streams are per person with one additional year of schooling. Our models assume that the health benefits accrue only to female schooling but that the wage benefits accrue to both might suggest smaller gains, the BCR increases by 47 males and females. Hence, the estimates of the dollar value of health benefits is a weighted percent when health is taken into account, with health average with the weight depending on the fraction of the educated cohort that is female. The gains representing 32 percent (US$0.47) of the health- calculations assume the cohort is 50 percent female. inclusive BCR (table 30.8). controlled studies like Jamison, Murphy, and Sandbu (2016), yield estimates of education’s effects on under- DISCUSSION five mortality that fall well below what is often reported Our results on under-five mortality are broadly consis- in the literature. tent with previous robust analyses of the effect of school- Our previous analyses have also established a clear ing on under-five mortality, including that of Jamison, link between schooling and improved under-five Murphy, and Sandbu (2016), who found that a one-year health. A meta-analysis, conducted as part of our pre- increase in female education was associated with a 3.6 vious study for the Oslo Summit on Education, found percent decline in under-five mortality among 95 LMICs that one additional year of female schooling was asso- between 1970 and 2004. Our study, and other tightly ciated with a decrease in under-five mortality of The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 433 between 3.6 percent and 9.9 percent (Schäferhoff and well-being. Schools are frequently used as channels for others 2015). This finding shows that our estimate on health information, notably, education on sexual and under-five mortality, while still substantial, is at the reproductive health. More-educated people have bet- bottom end of the range of previous studies. Even this ter access to and understanding of healthy behavior lower estimate of effect size yields a quantitatively and practices. Moreover, the impact of education important effect on mortality and, as we have shown, is on women’s empowerment and decision-making a significant addition to the estimated economic rate of power is well documented (International Center return to education. Additionally, our results show that for Research on Women 2005; World Bank 2014). educational quality affects health above and beyond Hence, educated women not only have increased years of schooling, but better data and further research access to health services and information, but they are are needed to better understand the relationship, par- better able to make healthier choices because of their ticularly in LMICs. increased bargaining and decision-making power The strong impact that education has on female within their households. mortality is striking and contributes further evidence Gains in female educational attainment have been on the beneficial impacts of education to women’s impressive over the past 40 years. The mean years of schooling attained by girls in low- and middle-income countries have increased from about 2 in 1970 to more Figure 30.4 Benefit Stream for UMICs from One Additional Year of than 6 in 2010; the ratio of male-to-female educational Schooling attainment has increased from 67 percent to 86 percent. As our analysis shows, these gains in female schooling 600 were pivotal in reducing under-five mortality and adult US$ per person per year 500 mortality. However, women’s educational attainment 400 continues to lag behind men’s. In the LICs included in 300 our analysis, mean educational attainment for women remained only 2.8 years in 2010, suggesting that many 200 girls either do not attend or at least fail to complete pri- 100 mary school. Further reductions in mortality can be 0 achieved with health-focused policies, as well as educa- 16 21 26 31 36 41 46 51 56 61 tion policies that address out-of-school children, espe- Age (years) cially out-of-school girls. Under-five mortality benefit Adult mortality benefit Our analysis is limited by the paucity of data. The Wage benefit VLY estimates used in the health-inclusive rate of return and BCR analysis are based on evidence mostly from Note: UMICs = upper-middle-income countries. The benefit streams are per person with one developed economies. Given the range of literature from additional year of schooling. Our models assume that the health benefits accrue only to female LMICs, UMICs, and HICs and the uncertainty around schooling but that the wage benefits accrue to both males and females. Hence, the estimates of the dollar value of health benefits is a weighted average with the weight depending on the fraction VLY, the results presented in this chapter are based on a of the educated cohort that is female. The calculations assume the cohort is 50 percent female. conservative estimate. Further sensitivity analysis using a Table 30.8 Benefit-Cost Ratios of One Additional Year of Schooling in LICs, Lower-Middle-Income Countries, and UMICs % difference (health-inclusive Income group Earnings-only BCR Health-inclusive BCR versus earnings-only) LICs 5.3 10 92 Lower-middle-income countries 2.6 3.8 44 UMICs 1.0 1.5 47 Benefits and costs included Health benefits No Yes Earnings benefits Yes Yes Direct cost Yes Yes Opportunity cost Yes Yes Note: BCR = benefit-cost ratio; LICs = low-income countries; UMICs = upper-middle-income countries. 434 Child and Adolescent Health and Development range of VLY estimates is presented in annex 30F. have already begun to strengthen the links between the Additionally, the rate of return analyses use modeled two sectors. The Global Fund to Fight AIDS, costs of schooling given the lack of comprehensive coun- Tuberculosis and Malaria has begun to finance educa- try data on private and public expenditures on school- tion by supporting conditional cash transfers to keep ing. While estimating the impact of schooling on health girls in school in four Sub-Saharan African countries outcomes, we recognize that the bidirectionality of the with high HIV/AIDS prevalence and incidence, with relationship between education and health could bias the objective of reducing HIV transmission. The gov- our estimates. Our models on adult mortality estimate ernment of Norway has strengthened cross-sectoral the relationship between education and self and peer links through its global health and education Vision mortality—poor health especially during school years 2030 initiative. Other donors could rethink their strat- could limit schooling, which in turn could affect health egies, which in many cases still reflect separate in adult years. It would be important to continue empir- approaches to education and health. ical research to precisely quantify this relationship. Based on our results, we conclude the following: Investments in data are also needed to understand edu- cation quality—our analyses on education quality were • Returns to education are substantially higher than severely restricted by the lack of data on education qual- generally understood, and it is important for ity for LICs and lower-middle-income countries. donors and countries to reflect this in their invest- This study shows that the existing estimates of the rate ment decisions. of return to education are quantitatively important • The results strongly indicate that female education underestimates. This finding results from the systematic matters more than male education in achieving inclusion of the dollar value of education’s favorable effect health outcomes. Investments targeted to girls’ edu- on health. Although investments in education are not cation yield a substantial return on health. Increased undertaken specifically to improve health, they produce efforts are needed to close remaining gender gaps. substantial health returns. In fact, returns to education • It is important to get children into school because investments on health are likely to be larger than reported of the substantial health effects resulting from in this study. To the best of our knowledge, our study is school attendance, even while awaiting further the most comprehensive assessment of the monetized improvements in quality, which our analysis also health benefits resulting from education, but it underesti- show to be important. mates the full effects of education on health. This is the • The highly positive BCR that takes into account the case because it is focused on the impact of education on health impact of education provides a compelling adult mortality and under-five mortality. Other health rationale for much stronger cross-sectoral collabora- outcomes—most important, the effects of education on tion between the education and health sectors. morbidity—are not considered in our study. • Despite the recent shift in the global dialogue Nevertheless, a BCR that takes into account the health on quality of education in LMICs, substantial impact of increases in education provides a forceful gaps remain in the availability of data on the rationale for a much stronger cross-sectoral collabora- quality of education and learning, among other tion between the education and health sectors. data and knowledge gaps. These gaps are largely the result of limited donor investments in global public goods for education. Increased donor sup- port would facilitate better research and progress CONCLUSIONS measurement. This study shows that although investments in educa- tion are not undertaken specifically to improve health, ANNEXES they produce substantial health returns. Returns are particularly high in LICs and lower-middle-income The online annexes to this chapter are as follows. They countries. Our evidence also exemplifies the important are available at http://www.dcp-3.org/CAHD. determinants of health that lie outside the health sector. Addressing these determinants requires cross-sectoral • Annex 30A. Countries Included in the Regression collaboration and links between education and health. Analysis Other research has shown that improved health is also • Annex 30B. Descriptive Statistics linked to better education. • Annex 30C. Technical Annex: Hierarchical Linear Model The need for cross-sectoral work is captured in the • Annex 30D. Incorporating Education’s Effect on Sustainable Development Goals, and certain funders Mortality into Internal Rates of Return The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 435 • Annex 30E. Cost of Education, by Level 3. For a systematic meta-analysis, see Schäferhoff and others • Annex 30F. Sensitivity Analysis of Benefit-Cost Ratios (2015). See also, for example, Caldwell (1980); Wagstaff and Internal Rate of Return (1993); Filmer and Pritchett (1999); Grossman (2006); Gakidou and others (2010); Gupta and Mahy (2003); Kuruvilla and others (2014); Jamison and others (2013); Jamison, Murphy, and Sandbu (2016); Wang and others DISCLAIMER (2014). This paper was initially prepared for the International 4. Matsumura and Gubhaju (2001) on Nepal; Shkolnikov Commission on Financing Global Education Opportunity as and others (1998) on the Russian Federation; Hurt, a background paper for the report, “The Learning Generation: Ronsmans, and Saha (2004) on Bangladesh; Yamano and Investing in Education for a Changing World.” The views and Jayne (2005) on Kenya; de Walque and others (2005) on opinions in this background paper are those of the author(s) Uganda; Lleras-Muney (2005) on the United States; Rowe and are not endorsed by the Education Commission or its and others (2005) on Nepal. members. For more information about the Commission’s 5. For example, years of schooling for students age 15 years report, please visit http://report.educationcommission.org. would underestimate their full educational attainment because they are still in school. 6. Our results on the effects of schooling on fertility are in ACKNOWLEDGMENTS line with other cross-country studies that show declines in TFR as women’s educational level rises (Bongaarts 2010; We would like to thank George Psacharopoulos and Susan Martin and Juarez 1995; Mboup and Saha 1998; Muhuri, Horton for their helpful feedback, and Austen Peter Davis, Blanc, and Rutstein 1994). Desmond Bermingham, and Tore Godal for directions on an 7. Conducting a categorical levels analysis would have earlier analysis. We are grateful to Harry Patrinos, Claudio required data on the length of each level of schooling for Montenegro, and George Psacharopoulos for sharing data on each country in each time period (year). For example, one age-earnings profiles aggregated by income groups. country may define primary school as having a five-year We thank the International Commission on Financing duration, while another may define it as seven years; Global Education Opportunity, which funded this study. furthermore, country definitions of levels of schooling We also thank Norad for supporting an initial study of the change over time. Because we lacked accurate data on lev- economic returns of education resulting from reductions in els over time, it was not possible to run such an analysis. under-five mortality, which was prepared for the Oslo Summit 8. Program for International Student Assessment (PISA) on Education for Development (July 2015). (OECD 2012); Trends in International Mathematics and Science Study (TIMSS) (Mullis and Martin 2013); Southern and Eastern Africa Consortium for Monitoring NOTES Educational Quality (SACMEQ) (Hungi 2011); Program for the Analysis of CONFEMEN Education Systems (PASEC) World Bank Income Classifications as of July 2015 are as (PASEC 2015); Latin American Laboratory for Assessment follows, based on estimates of gross national income (GNI) of the Quality of Education: Regional Comparative and per capita for 2014: Explanatory Study (LLECE) (UNESCO 2015). 9. The authors noted that this characterization of rates of • Low-income countries (LICs) = US$1,045 or less return overlooks many of the important returns that might • Middle-income countries (MICs) are subdivided: also be associated with improved educational attainment. a) lower-middle-income = US$1,046 to US$4,125 Furthermore, the social rates of return were highest for b) upper-middle-income (UMICs) = US$4,126 to US$12,735 tertiary education in UMICs. The authors note that given • High-income countries (HICs) = US$12,736 or more. almost universal primary completion rates in UMICs, there is an unsatisfactory control group of noncompleters Since the chapter was written, the income classifications of to compare with, likely understating returns at the primary some countries have changed. As of July 2016, Cambodia level (Psacharopoulos, Montenegro, and Patrinos 2017). is a lower-middle-income country; Senegal is a low-income 10. Our methods build on those used by The Lancet country; Tonga is a lower-middle-income country, and Commission on Investing in Health, which used existing República Bolivariana de Venezuela is an upper-middle- literature to propose a standardized approach to placing income country. dollar values on mortality change. See Cropper, Hammitt, and Robinson (2011); Jamison and others (2013a, 2013b); 1. See Schäferhoff and others (2015) for an initial study of Viscusi (2015). the economic results of education from reductions in 11. All figures were calculated using a VSL of 130 times GDP under-five mortality commissioned by Norad. per capita. We conducted additional analyses using a VSL 2. The foundations of lifelong health are built in early of 80 times GDP per capita (lower bound) and 180 times childhood. Center on the Developing Child at Harvard GDP per capita (upper bound). 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The Effects of Education Quantity and Quality on Child and Adult Mortality: Their Magnitude and Their Value 439 DCP3 Series Acknowledgments Disease Control Priorities, third edition (DCP3) com- We thank the many contractors and consultants who piles the global health knowledge of institutions and provided support to specific volumes in the form of experts from around the world, a task that required the economic analytical work, volume coordination, chapter efforts of over 500 individuals, including volume edi- drafting, and meeting organization: the Center for tors, chapter authors, peer reviewers, advisory commit- Disease Dynamics, Economics & Policy; Center for tee members, and research and staff assistants. For each Chronic Disease Control; Centre for Global Health of these contributions we convey our acknowledg- Research; Emory University; Evidence to Policy Initiative; ment and appreciation. First and foremost, we would Public Health Foundation of India; QURE Healthcare; like to thank our 32 volume editors who provided the University of California, San Francisco; University of intellectual vision for their volumes based on years of Waterloo; University of Queensland; and the World professional work in their respective fields, and then Health Organization. dedicated long hours to reviewing each chapter, pro- We are tremendously grateful for the wisdom and viding leadership and guidance to authors, and framing guidance provided by our advisory committee to the and writing the summary chapters. We also thank our editors. Steered by Chair Anne Mills, the advisory com- chapter authors who collectively volunteered their mittee ensures quality and intellectual rigor of the high- time and expertise to writing over 170 comprehensive, est order for DCP3. evidence-based chapters. The National Academies of Sciences, Engineering, We owe immense gratitude to the institutional spon- and Medicine, in collaboration with the Interacademy sor of this effort: The Bill & Melinda Gates Foundation. Medical Panel, coordinated the peer-review process for The Foundation provided sole financial support of all DCP3 chapters. Patrick Kelley, Gillian Buckley, the Disease Control Priorities Network (DCPN). Many Megan Ginivan, Rachel Pittluck, and Tara Mainero thanks to Program Officers Kathy Cahill, Philip Setel, managed this effort and provided critical and substan- Carol Medlin, and (currently) Damian Walker for their tive input. thoughtful interactions, guidance, and encouragement World Bank Publishing provided exceptional guid- over the life of the project. We also wish to thank Jaime ance and support throughout the demanding produc- Sepúlveda for his longstanding support, including tion and design process. We would particularly like to chairing the Advisory Committee for the second edi- thank Carlos Rossel, Mary Fisk, Nancy Lammers, tion and, more recently, demonstrating his vision for Rumit Pancholi, Deborah Naylor, and Sherrie Brown DCP3 while he was a special advisor to the Gates for their diligence and expertise. Additionally, we Foundation. We are also grateful to the University of thank Jose de Buerba, Mario Trubiano, Yulia Ivanova, Washington’s Department of Global Health and succes- and Chiamaka Osuagwu of the World Bank for pro- sive chairs King Holmes and Judy Wasserheit for pro- viding professional counsel on communications and viding a home base for the DCP3 Secretariat, which marketing strategies. included intellectual collaboration, logistical coordina- Several U.S. and international institutions contrib- tion, and administrative support. uted to the organization and execution of meetings that 441 supported the preparation and dissemination of DCP3. • Union for International Cancer Control, cancer We would like to express our appreciation to the follow- consultation (November 2013, December 2014) ing institutions: • Harvard T. H. Chan School of Public Health, economic evaluation consultation (September 2015) • University of Bergen, consultation on equity (June 2011) • University of California, Berkeley School of Public • University of California, San Francisco, surgery Health, and Stanford Medical School, occupational and volume consultations (April 2012, October 2013, environmental health consultations (December 2015). February 2014) • Institute of Medicine, first meeting of the Advisory Carol Levin provided outstanding governance for Committee to the Editors (March 2013) cost and cost-effectiveness analysis. Stéphane Verguet • Harvard Global Health Institute, consultation on added valuable guidance in applying and improving the policy measures to reduce incidence of noncommu- extended cost-effectiveness analysis method. Elizabeth nicable diseases (July 2013) Brouwer, Kristen Danforth, Nazila Dabestani, Shane • National Academy of Medicine, systems strengthen- Murphy, Zachary Olson, Jinyuan Qi, and David Watkins ing meeting (September 2013) provided exceptional research assistance and analytic • Center for Disease Dynamics, Economics & Policy assistance. Brianne Adderley ably managed the budget (Quality and Uptake meeting, September 2013; and project processes, while Jennifer Nguyen, Shamelle reproductive and maternal health volume consulta- Richards, and Jennifer Grasso contributed exceptional tion, November 2013) project coordination support. The efforts of these indi- • National Cancer Institute, cancer consultation viduals were absolutely critical to producing this series, (November 2013) and we are thankful for their commitment. 442 DCP3 Series Acknowledgments Volume and Series Editors VOLUME EDITORS Essential Medicines for Neglected Tropical Diseases. Over the past decade, she has also served as a member of a Donald A. P. Bundy WHO reference group on food-borne diseases epidemiol- Donald A. P. Bundy contributed to the seminal World ogy, and on advisory boards for Children Without Worms Development Report 1993: Investing in Health and to the and the Partnership for Child Development. three subsequent editions of Disease Control Priorities (1993, 2006, and 2017) that followed from it. After two decades pursuing academic studies of how to control the Susan Horton impact of infectious disease on child development in Susan Horton is Professor at the University of Waterloo poor populations, he left the University of Oxford to join and holds the Centre for International Governance the Human Development team at the World Bank. He Innovation (CIGI) Chair in Global Health Economics in achieved leadership roles in both the health and the the Balsillie School of International Affairs there. She has education sectors and their interaction, supporting consulted for the World Bank, the Asian Development governments in 77 low- and middle-income countries to Bank, several United Nations agencies, and the apply scientific rigor to the design, implementation, and International Development Research Centre, among evaluation of their national programs. His focus on others, in work carried out in over 20 low- and middle- alleviating poverty and inequity led to coordinating the income countries. She led the work on nutrition for the World Bank’s response to neglected tropical diseases Copenhagen Consensus in 2008, when micronutrients (NTDs), including managing support for the African were ranked as the top development priority. She has Programme for Onchocerciasis Control (APOC), which served as associate provost of graduate studies at the treated more than 100 million people annually in University of Waterloo, vice-president academic at 31 countries. He now leads the Bill & Melinda Gates Wilfrid Laurier University in Waterloo, and interim dean Foundation’s global strategy to eliminate NTDs. He has at the University of Toronto at Scarborough. published more than 350 books and scientific articles and produced several documentary films, including a series broadcast on PBS. Dean T. Jamison Dean T. Jamison is Emeritus Professor in Global Health Sciences at the University of California, San Francisco, and Nilanthi de Silva the University of Washington. He previously held aca- Nilanthi de Silva holds the Chair in Parasitology in demic appointments at Harvard University and the the Faculty of Medicine at the University of Kelaniya, Sri University of California, Los Angeles. Prior to his aca- Lanka, where she has lectured since 1993 and presently demic career, he was an economist on the staff of the serves as the Dean. She is the Chair of the World Health World Bank, where he was lead author of the World Organization (WHO) Strategic and Technical Advisory Bank’s World Development Report 1993: Investing in Health. Group on Neglected Tropical Diseases, as well as the Chair He serves as lead editor for DCP3 and was lead editor for of the WHO Working Group on Access to Assured Quality, the previous two editions. He holds a PhD in economics 443 from Harvard University and is an elected member of the for the Future, the Center for Disease Dynamics, Institute of Medicine of the U.S. National Academies. He Economics & Policy, the (former) Congressional Office recently served as Co-Chair and Study Director of The of Technology Assessment, the Institute of Medicine of Lancet’s Commission on Investing in Health. the U.S. National Academies, and a number of interna- tional organizations. George C. Patton George C. Patton is a Professorial Fellow in Adolescent Susan Horton Health Research at the University of Melbourne and a See the list of volume editors. Senior Principal Research Fellow with Australia’s National Health and Medical Research Council. He has Prabhat Jha led long-term longitudinal studies dealing with health and social development from childhood into adulthood Prabhat Jha is the founding director of the Centre for and into the next generation. He has also led large-scale Global Health Research at St. Michael’s Hospital and prevention trials promoting the health, well-being, and holds Endowed and Canada Research Chairs in Global social development of adolescents in community and Health in the Dalla Lana School of Public Health at school settings. Globally, he has led two special series the University of Toronto. He is lead investigator of the in adolescent health for The Lancet and was the Chair of Million Death Study in India, which quantifies the a Lancet Commission on Adolescent Health and causes of death and key risk factors in over two million Wellbeing. homes over a 14-year period. He is also Scientific Director of the Statistical Alliance for Vital Events, which aims to expand reliable measurement of causes of death SERIES EDITORS worldwide. His research includes the epidemiology and economics of tobacco control worldwide. Dean T. Jamison See the list of volume editors. Ramanan Laxminarayan Ramanan Laxminarayan is Director of the Center for Rachel Nugent Disease Dynamics, Economics & Policy in Washington, Rachel Nugent is Vice President for Global DC. His research deals with the integration of epidemi- Noncommunicable Diseases at RTI International. She ological models of infectious diseases and drug resis- was formerly a Research Associate Professor and tance into the economic analysis of public health Principal Investigator of the DCPN in the Department problems. He was one of the key architects of the of Global Health at the University of Washington. Affordable Medicines Facility–malaria, a novel financing Previously, she served as Deputy Director of Global mechanism to improve access and delay resistance to Health at the Center for Global Development, Director antimalarial drugs. In 2012, he created the Immunization of Health and Economics at the Population Reference Technical Support Unit in India, which has been credited Bureau, Program Director of Health and Economics with improving immunization coverage in the country. Programs at the Fogarty International Center of the He teaches at Princeton University. National Institutes of Health, and senior economist at the Food and Agriculture Organization of the United Nations. From 1991 to 1997, she was associate professor Charles N. Mock and department chair in economics at Pacific Lutheran Charles N. Mock, MD, PhD, FACS, has training as University. both a trauma surgeon and an epidemiologist. He worked as a surgeon in Ghana for four years, including at a rural hospital (Berekum) and at the Kwame Hellen Gelband Nkrumah University of Science and Technology Hellen Gelband is an independent global health policy (Kumasi). In 2005−07, he served as Director of the expert. Her work spans infectious disease, particularly University of Washington’s Harborview Injury malaria and antibiotic resistance, and noncommunica- Prevention and Research Center. In 2007−10, he ble disease policy, mainly in low- and middle-income worked at the WHO headquarters in Geneva, where he countries. She has conducted policy studies at Resources was responsible for developing the WHO’s trauma 444 Volume and Series Editors care activities. In 2010, he returned to his position as especially as it pertains to low- and middle-income Professor of Surgery (with joint appointments as countries: surveillance, injury prevention, prehospital Professor of Epidemiology and Professor of Global care, and hospital-based trauma care. He was President Health) at the University of Washington. His main (2013−15) of the International Association for Trauma interests include the spectrum of injury control, Surgery and Intensive Care. Volume and Series Editors 445 Contributors Amina Abubakar Habib Benzian Centre for Geographic Medicine Research–Coast, KEMRI/ College of Dentistry, New York University, New York, Wellcome Trust Research Programme, Kilifi, Kenya New York, United States Amrita Ahuja Sonia Bhalotra Douglas B. Marshall, Jr., Family Foundation, Houston, Department of Economics, University of Essex, Texas, United States Colchester, United Kingdom Harold Alderman Zulfiqar Bhutta International Food Policy Research Institute, Division of Women and Child Health, Aga Khan Washington, DC, United States University Hospital, Karachi, Pakistan Nicholas Allen Maureen M. Black Department of Psychology, University of Oregon, RTI International, Washington, DC, United States Eugene, Oregon, United States Paul Bloem Laura Appleby World Health Organization, Geneva, Switzerland Partnership for Child Development, London, United Kingdom Chris Bonell Department of Social & Environmental Health Elisabetta Aurino Research, London School of Hygiene & Tropical Partnership for Child Development, London, Medicine, London, United Kingdom United Kingdom Mark Bradley Peter Azzopardi GlaxoSmithKline, London, United Kingdom Senior Health Specialist, Center for Adolescent Health, University of Melbourne, Melbourne, Victoria, Australia Sally Brinkman Telethon Kids Institute, West Perth, Western Australia, Sarah Baird Australia Department of Global Health, George Washington University, Washington, DC, United States Jere Behrman University of Pennsylvania, Pennsylvania, United States Louise Banham Global Partnership for Education, Washington, DC, Simon Brooker United States Bill & Melinda Gates Foundation, Seattle, Washington, United States Jere Behrman Department of Economics, University of Pennsylvania, Carmen Burbano Philadelphia, Pennsylvania, United States World Food Programme, Rome, Italy 447 Nicholas Burnett Renu Garg Results for Development, Washington, DC, United States World Health Organization, New Delhi, India Tania Cernuschi Aulo Gelli World Health Organization, Geneva, Switzerland International Food Policy Research Institute, Washington, DC, United States Sian Clarke Department of Disease Control, London School of Andreas Georgiadis Hygiene & Tropical Medicine, London, United Kingdom Oxford Department for International Development, University of Oxford, Oxford, United Kingdom Carolyn Coffey Murdoch Childrens Research Institute, Melbourne, Paul Gertler Victoria, Australia Haas School of Business, University of California, Berkeley, Berkeley, California, United States Peter Colenso Caroline Gitonga Independent consultant, Brighton, United Kingdom Measure Evaluation, Nairobi, Kenya Kevin Croke Boitshepo Giyose World Bank, Washington, DC, United States Food and Agriculture Organization of the Amy Daniels United Nations, Rome, Italy Simons Foundation, New York, New York, United States Paul Glewwe Elia de la Cruz Toledo Department of Applied Economics, University of School of Social Work, Columbia University, New York, Minnesota, St. Paul, Minnesota, United States New York, United States Joseph Gona Nzovu Anil Deolalikar KEMRI-Wellcome Trust Research Programme, Department of Economics, University of California, Kilifi, Kenya Riverside, Riverside, California, United States Amber Gove Damien de Walque RTI International, Washington, DC, United States World Bank, Washington, DC, United States Natasha Graham United Nations Children’s Fund, New York, New York, Lesley Drake United States Partnership for Child Development, London, United Kingdom Brian Greenwood Faculty of Infectious and Tropical Diseases, London Lia Fernald School of Hygiene and Tropical Medicine, London, School of Public Health, University of California, United Kingdom Berkeley, Berkeley, California, United States Elena Grigorenko Meena Fernandes Department of Psychology, University of Houston, Partnership for Child Development, Brussels, Belgium Houston, Texas, United States Deepika Fernando Cai Heath Department of Parasitology, Faculty of Medicine, Partnership for Child Development, London, University of Colombo, Colombo, Sri Lanka United Kingdom Veronique Filippi Joan Hamory Hicks Department of Infectious Disease Epidemiology, Center for Effective Global Action, University of London School of Hygiene & Tropical Medicine, California, Berkeley, Berkeley, California, United States London, United Kingdom Melissa Hidrobo Günther Fink International Food Policy Research Institute, Department of Global Health and Population, Harvard Washington, DC, United States University, Boston, Massachusetts, United States Kenneth Hill Rae Galloway Stanton-Hill Research, Moultonborough, New Independent consultant, Washington, DC, United States Hampshire, United States 448 Contributors Tara Hill Sophie Mitra Results for Development, Washington, DC, United States Department of Economics, Fordham University, New York, New York, T. Deirdre Hollingsworth Mathematics Institute, University of Warwick, Anoosh Moin Coventry, United Kingdom Department of Paediatrics, Aga Khan University, Elissa Kennedy Karachi, Pakistan Burnett Institute, Melbourne, Victoria, Australia Ali Mokdad Imran Khan Institute for Health Metrics and Evaluation, University Sightsavers, Washington, DC, United States of Washington, Washington, United States Josephine Kiamba Bella Monse Partnership for Child Development, Johannesburg, GIZ German Development Cooperation, Manila, the South Africa Philippines Jane Kim Daniel Mont T. H. Chan School of Public Health, Harvard University, Center for Inclusive Policy, Washington, DC, Boston, Massachusetts, United States United States Michael Kremer Arindam Nandi Department of Economics, Harvard University, Tata Centre for Development, University of Chicago, Cambridge, Massachusetts, United States Chicago, Illinois, United States D. Scott LaMontagne Joaniter Nankabirwa PATH, Seattle, Washington, United States Department of Medicine, Makerere University College Zohra Lassi of Health Sciences, Kampala, Uganda School of Medicine, University of Adelaide, Adelaide, Daniel Plaut South Australia, Australia Results for Development, Washington, DC, Ramanan Laxminarayan United States Center for Disease Dynamics, Economics & Policy, Elina Pradhan Washington, DC, United States T. H. Chan School of Public Health, Harvard University, Boston, Massachusetts Jacqueline Mahon United Nations Population Fund, New York, New York, Rachel Pullan United States Department of Disease Control, London School of Lu Mai Hygiene & Tropical Medicine, London, United Kingdom Development Research Foundation, Beijing, China Nicola Reavley Sebastián Martínez Department of Population and Global Health, SEEK Development, Berlin, Germany University of Melbourne, Melbourne, Victoria Australia Sergio Meresman Inter American Institute on Disability and Inclusive John Santelli Development, Montevideo, Uruguay Mailman School of Public Health, University of Columbia, New York, New York Katherine A. Merseth RTI International, Washington, DC, United States Bachir Sarr Partnership for Child Development, Ottawa, Canada Edward Miguel Department of Economics, University of California, Susan M. Sawyer Berkeley, Berkeley, California Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia Arlene Mitchell Global Child Nutrition Foundation, Seattle, Marco Schaferhöff Washington, DC SEEK Development, Berlin, Germany Contributors 449 David Schellenberg Jane Waldfogel Department of Disease Control, London School of School of Social Work, Columbia University, New York, Hygiene & Tropical Medicine, London, New York, United States United Kingdom Susan Walker Linda Schultz Tropical Medical Research Institute, University of the World Bank, Washington, DC, United States West Indies, Mona, Kingston, Jamaica Andy Shih Kristie Watkins Autism Speaks, New York, New York, United States Department of Infectious Disease Epidemiology, Imperial College London, London, United Kingdom Elina Suzuki Deborah Watson-Jones Organisation for Economic Co-operation and Faculty of Infectious and Tropical Diseases, London Development, Paris, France School of Hygiene & Tropical Medicine, London, Nicole Stauf United Kingdom The Health Bureau Ltd., Buckingham, United Kingdom Kristine West Department of Economics, St. Catherine’s University, Milan Thomas St. Paul, Minnesota, United States Results for Development, Washington, DC, United States Jordan Worthington Hugo C. Turner Results for Development, Washington, DC, School of Public Health, Imperial College London, United States London, United Kingdom Kin Bing Wu Benoit Varenne World Bank (retired), Menlo Park, California, World Health Organization, Brazzaville, Republic of Congo United States Stéphane Verguet Ahmadu Yakubu T. H. Chan School of Public Health, Harvard University, World Health Organization, Geneva, Switzerland Boston, Massachusetts, United States Linnea Zimmerman Russell Viner Department of Population, Family and Reproductive Institute of Child Health, University College London, Health, Johns Hopkins University, Baltimore, Maryland, London, United Kingdom United States 450 Contributors Advisory Committee to the Editors Anne Mills, Chair Amanda Glassman Professor, London School of Hygiene & Tropical Chief Operating Officer and Senior Fellow, Center for Medicine, London, United Kingdom Global Development, Washington, DC, United States Olusoji Adeyi Glenda Gray Director, Health, Nutrition and Population Global Executive Director, Perinatal HIV Research Unit, Chris Practice, World Bank, Washington, DC, United States Hani Baragwanath Hospital, Johannesburg, South Africa Kesetebirhan Admasu Demissie Habte Former Minister of Health, Addis Ababa, Ethiopia Chair of Board of Trustees, International Clinical George Alleyne Epidemiological Network, Addis Ababa, Ethiopia Director Emeritus, Pan American Health Organization, Richard Horton Washington, DC, United States Editor, The Lancet, London, United Kingdom Ala Alwan Edward Kirumira Regional Director Emeritus, World Health Dean, Faculty of Social Sciences, Makerere University, Organization, Regional Office for the Eastern Kampala, Uganda Mediterranean, Cairo, Arab Republic of Egypt Peter Lachmann Rifat Atun Professor, University of Cambridge, Cambridge, Professor, Global Health Systems, Harvard T. H. Chan United Kingdom School of Public Health, Boston, Massachusetts, United States Lai Meng Looi Zulfiqar Bhutta Professor, University of Malaya, Kuala Lumpur, Chair, Division of Women and Child Health, Aga Khan Malaysia University Hospital, Karachi, Pakistan Adel Mahmoud Agnes Binagwaho Senior Molecular Biologist, Princeton University, Former Minister of Health, Kigali, Rwanda Princeton, New Jersey, United States Mark Blecher Anthony Measham Senior Health Advisor, South Africa Treasury World Bank (retired) Department, Cape Town, South Africa Carol Medlin Patricia Garcia Independent Consultant, Washington, DC, Minister of Health, Lima, Peru United States Roger Glass Alvaro Moncayo Director, Fogarty International Center, National Researcher, Universidad de los Andes, Bogotá, Institutes of Health, Bethesda, Maryland, United States Colombia 451 Jaime Montoya Richard Skolnik Executive Director, Philippine Council for Health Yale University School of Public Health (retired) Research and Development, Taguig City, the Philippines Stephen Tollman Ole Norheim Professor, University of Witwatersrand, Johannesburg, Professor, Department of Global Public Health and South Africa Primary Care, University of Bergen, Bergen, Norway Jürgen Unutzer Folashade Omokhodion Professor, Department of Psychiatry, University of Professor, University College Hospital, Ibadan, Nigeria Washington, Seattle, Washington, United States Damian Walker Toby Ord Deputy Director of Data and Analytics, Bill & Melinda President, Giving What We Can, Oxford, United Kingdom Gates Foundation, Seattle, Washington, United States K. Srinath Reddy Ngaire Woods President, Public Health Foundation of India, New Director, Global Economic Governance Program, Delhi, India Oxford University, Oxford, United Kingdom Sevket Ruacan Nopadol Wora-Urai Dean, Koç University School of Medicine, Istanbul, Turkey Professor, Department of Surgery, Phramongkutklao Hospital, Bangkok, Thailand Jaime Sepúlveda Executive Director, Global Health Sciences, University Kun Zhao of California, San Francisco, San Francisco, California, Researcher, China National Health Development United States Research Center, Beijing, China 452 Advisory Committee to the Editors Reviewers Yoko Akachi Lois K. Cohen United Nations University World Institute for National Institute of Dental and Craniofacial Research, Development Economics Research, Helsinki, Finland National Institutes of Health, Bethesda, Maryland, United States Harold Alderman International Food Policy Research Institute, Phaedra S. Corso Washington, DC, United States College of Public Health, University of Georgia, Athens, Georgia, United States Sarah Baird Department of Global Health, George Washington Joy Miller Del Rosso University, Washington, DC, United States Save the Children, Fairfield, Connecticut, United States W. Stephen Barnett Angela Diaz National Institute for Early Education Research, Rutgers Departments of Pediatrics and Preventive Medicine University, New Brunswick, New Jersey, United States Icahn School of Medicine, Mount Sinai, New York, Samuel Berlinski New York, United States Inter-American Development Bank, Washington, DC, Dolores Dickson United States Camfed Ghana, Accra, Ghana Michael J. Boivin Le Thuc Duc College of Osteopathic Medicine, Michigan State Vietnam Academy of Social Sciences, Hanoi, Vietnam University, Ann Arbor, Michigan, United States Judith Rafaelita B. Borja Maureen Durkin Office of Population Studies Foundation, University of School of Medicine and Public Health, University of San Carlos, Cebu City, the Philippines Wisconsin, Madison, Wisconsin, United States Cecilia Breinbauer Aulo Gelli Department of Global Health, University of International Food Policy Research Institute, Washington, Seattle, Washington, United States Washington, DC, United States Claire Brindis Amanda Glassman Philip R. Lee Institute for Health Policy Studies, Center for Global Development, Washington, DC, University of California, San Francisco, San Francisco, United States California, United States Rachel Glennerster V. Chandra-Mouli Abdul Latif Jameel Poverty Action Lab, Massachusetts Department of Reproductive Health and Research, Institute of Technology, Boston, Massachusetts, World Health Organization, Geneva, Switzerland United States 453 Monica Grant Omotade Olayemi Olufemi-Julius Department of Sociology, University of Wisconsin- Institute of Child Health College of Medicine, Madison, Madison, Wisconsin, United States University of Ibadan, Ibadan, Nigeria Rukhsana Haider Ndola Prata Training and Assistance for Health and Nutrition School of Public Health, University of California, Foundation, Dhaka, Bangladesh Berkeley, Berkeley, California, United States Helen Henningham George Psacharopoulos School of Psychology, University of Bangor, Bangor, School of Foreign Service, Georgetown University, United Kingdom Washington, DC, United States Peter Hotez Arthur J. Reynolds Baylor College of Medicine, Sabin Vaccine Institute, Institute of Child Development, University of Houston, Texas, United States Minnesota, Minneapolis, Minnesota, United States Venita Kaul Ambedkar University Delhi, New Delhi, India Meera Shekar Health, Nutrition, and Population Global Practice, Gwang-Jo Kim World Bank, Washington, DC, United States UNESCO Asia, and Pacific Regional Bureau of Education, Bangkok, Thailand Ross A. Thompson Social and Emotional Development Lab, University of Elizabeth Kristjansson California, Davis, Davis, California, United States Centre for Research on Educational and Community Services, University of Ottawa, Ottawa, Canada Ziba Vaghri School of Public Health and Social Policy, Vesna Kutlesic University of Victoria, Victoria, British Columbia, Eunice Kennedy Shriver National Institute of Child Canada Health and Human Development, National Institutes of Health, Bethesda, Maryland, United States Meera Venkatesan Seung Lee President’s Malaria Initiative, United States Agency for Save the Children, Washington, DC, United States International Development, Washington, DC, United States Orin Levine Bill & Melinda Gates Foundation, Seattle, Washington, Henry Wamani Untied States School of Public Health, Makerere University, Kampala, Uganda Ruth Levine Global Development and Population Program, The Howard White William and Flora Hewlett Foundation, Menlo Park, Campbell Collaboration, Oslo, Norway California, United States Hirokazu Yoshikawa Leenu Raju Maimanuku Global TIES for Children, New York University, New Fiji National University, Suva, Fiji Islands York, New York, United States Kofi Marfo Mary Young Institute for Human Development, Aga Khan China Development Research Foundation, Beijing, University, Nairobi, Kenya China Milagros Nores Aisha K. Yousafzai National Institute for Early Education Research, Rutgers Department of Paediatrics and Child Health, Aga Khan University, New Brunswick, New Jersey, United States University, Karachi, Pakistan 454 Reviewers Policy Forum Participants The following individuals provided valuable insights to improve this volume’s key findings through participation in the Disease Control Priorities-World Health Organization, Eastern Mediterranean Regional Office policy forum on Child and Adolescent Health and Development, in Geneva, Switzerland, on May 20, 2016. The forum was organized by Dr. Ala Alwan, Regional Director, World Health Organization, and member of the DCP3 Advisory Committee to the Editors. Simon Abiramia Sheikh Mohammed Hamad J. Al-Thani Member of the Lebanese Parliament; President of the Director, Public Health Department, Supreme Council Parliamentary Committee of Youth and Sports; of Health, Doha, Qatar President of the Board of Directors, OKO; General Ala Alwan Manager, LIFRA and NVMD Beirut, Lebanon Regional Director Emeritus, World Health Organization, Hala Abou-Ali Regional Office for the Eastern Mediterranean, Cairo, Secretary General, National Council for Childhood Arab Republic of Egypt and Motherhood; Member of House of Representatives, Assad Hafeez Cairo, Arab Republic of Egypt Director General, Ministry of National Health Services, Regulation, and Coordination Islamabad, Pakistan Nawal Al Hamad Deputy Director, Public Authority for Food and Moushira Mahmoud Khattab Nutrition, Ministry of Health, Safat, Kuwait Ambassador; Former Minister of Family and Population, Cairo, Arab Republic of Egypt Ahmed bin Mohamed bin Obaid Al-Saidi Elizabeth Mason Minister of Health, Muscat, Oman Honorary Fellow; Institute of Global Health, University College London, London, United Kingdom Suleiman Nasser Al Shehri Consultant, Public Health and Pediatrics; Director Samira Merai General, School Health Ministry of Health, Riyadh, Minister for Women, Family, and Childhood, Ministry Saudi Arabia of Women, Family, and Children Tunis, Tunisia 455 Africa Regional Roundtable Participants The following individuals provided valuable feedback on the volume’s essential packages through participation in the Africa Regional Roundtable on Child and Adolescent Health and Development, held at the African Union in Addis Ababa, Ethiopia, March 7–8, 2016. The forum was organized by Dr. Lesley Drake, Executive Director of Partnership for Child Development and contributor to DCP3 Child and Adolescent Health and Development Volume 8. Oluyemisi Omobolanle Ayoola Ahma Kebede Assistant Director, Federal Ministry of Health, Nigeria Director General, Ethiopia Public Health Institute, Ethiopia Berhanu Moreda Birbissa Adviser, State Minister of General Education, Judith Ongaji Kimiywe Ministry of Education, Ethiopia Professor, Kenyatta University, Kenya Nana-Kwadwo Amanikwaa Duku Biritwum Laila Lokosang Project Manager, NTDs, Ghana Health Service, Ghana Senior CAADP Adviser, Food and Nutrition, Joseph Jide Dada Directorate of Rural Economy and Agriculture, Assistant Director and Desk Officer, School Health, African Union Commission, Ethiopia Federal Ministry of Education, Federal Secretariat, Catherine Gakii Murungi Nigeria Senior Lecturer, Kenyatta University, Kenya Tina Eyaru Kate Beverly Quarshie Deputy Director, Technical Education and Nutrition, Deputy Chief Nutrition Officer, Nutrition Department, Federal Ministry of Education, Federal Secretariat, Ghana Health Service, Ghana Nigeria Kokou Sename Markos Tigist Fekadu Project Officer, Department of Human Resources, Lecturer, Hawassa University, Ethiopia Science and Technology, African Union, Ethiopia Amaya Gillespie Matilda Steiner-Asiedu Coordinator, UNICEF, United States Dean, School of Biological Sciences, University of Abdi Sheikh Abdullahi Habat Ghana, Department of Nutrition and Food Science, Director, Ministry of Education, Kenya Ghana 457 Anta Tal–Dia Esiet Uwemedimo Uko Head of the Health and Development Institute, Director, Action Health Incorporated, Nigeria Universite Cheikh Anta Diop, Senegal Bain Worku Alemayehu Tekelemariam Girl Effect, Ethiopia Associate Professor, Addis Ababa University, Thomas Yanga Ethiopia Director, World Food Program, Ethiopia Askale Teklu Team Leader, World Food Program, Ethiopia 458 Africa Regional Roundtable Participants Index Boxes, figures, maps, notes, and tables are indicated by b, f, m, n, and t following the page number. A mental health, 374 Abecedarian Project, 261 methodology, 370–371 Abubakar, Amina, 231 overweight/obesity, 372–373, 374 Adelman, S., 153, 154 platforms, 370t adolescence sexual and reproductive health, 373, 374, 378 aggression, 111 tobacco use, 373, 374 alcohol use, 245, 373 education interventions, 403–411 anemia in, 41, 42f, 241–242 essential package of interventions, 9, 10t, 13–14, anxiety, 111 379–380 benefit-cost ratios, 277–279, 278f, 278t, 371–379, FRESH framework, 279–281, 280–281f 372–373t, 375–377t gender equity, 240, 274–276, 275–276f binge drinking, 63, 66–67m growth spurt phase, 13 brain development, 240 health indicators and coverage, 58–62, 59m burden of disease, 57–71, 289–291, 289–290f health information systems and, 57–58 community programs, 297–299, 298t health risk behaviors and states, 63–65, 64–67m conceptual framework for, 73–75 health services, 293–295, 294f, 295t defined, 3, 4f in high-income countries, 372–373t, 372–374 depression, 111 HIV/AIDS, 240–241 developmental context, 288–289 illicit substance use, 63, 245, 373 deworming programs, 165–182. infectious diseases, 241 See also deworming programs injury-excess countries, 292 dietary intake, 41, 43 interventions, 107–117 disability, 221–237. See also disability aggression and, 111 eating disorders, 111–112, 140–141 anxiety, 111 economic analysis of interventions, 369–384 depression, 111 alcohol use, 373 eating disorders, 111–112 benefit-cost ratios, 371–379, 372–373t, 375–377t nutrition interventions, 113, 241–242 cost-effectiveness, 371–379, 372–373t, 375–377t physical health, 112 education interventions, 403–411 psychosocial interventions, 113 essential package, 9, 10t, 13–14, 379–380 puberty and developmental processes, 107–111 high-income countries, 372–373t, 372–374 risk factors, 111–112 illicit substance use, 373 secondary education as health intervention, 112 low- and middle-income countries, 374–378, self-harm, 111 375–377t violence and, 111 459 learning outcomes, 271–273, 271t, 272–273f puberty and developmental processes, 107–111 malaria, 183–198. See also malaria risk factors, 111–112 malnutrition/undernutrition, 43, 241–242 SABER tool, 281 media and social marketing, 300–301, 300t school feeding programs, 147–164. See also school mental disorders, 243 feeding programs mental health, 374 school health and nutrition, 270–271, 270–271f, micronutrient deficiencies, 138–139, 139t 295–297, 296f, 296t mobile health programs, 299–300, 299t schools as entry point for interventions, 273–274 multiburden countries, 291–292 secondary education as health intervention, 112 NCD-predominant countries, 292 sector roles, 276, 277t neurodevelopment, 240 self-harm, 111 nutrition, 133–145 sexual and reproductive health, 64–65, 64m, anemia, 41, 42f 240–241, 373, 374, 378 eating disorders, 140–141 social determinants of health, 240 importance of, 133–135, 134f suicide, 243–244 malnutrition/undernutrition, 43, 241–242 tobacco use, 63, 65–66m, 245, 373, 374 micronutrient deficiencies, 138–139, 139t undernutrition, 43, 135–136, 135–136t overweight/obesity, 39–41, 40–41f, 136–138, 137t underweight, 39, 39f, 40–41, 41f, 63, 241–242 physical growth and, 133 unintentional injuries, 242 pregnancy and, 139–140 vaccinations, 241 undernutrition, 43, 135–136, 135–136t violence and, 111, 242–243 underweight, 39, 39f, 40–41, 41f affective processing, 110 nutrition interventions, 113, 241–242 Afghanistan oral health, 211–220. See also oral health disability in, 226 overweight/obesity, 39–41, 40–41f, 63–64, 67–68m, education in, 311 136–138, 137t, 244–245, 372–373, 374 vaccinations in, 203 physical health and activity, 64, 112 Africa. See also specific countries platforms, 269–305, 370t burden of disease in, 63 benefit-cost ratios, 277–279, 278f, 278t cash transfers programs in, 326, 333 burden of disease, 289–290f, 289–291 deworming programs in, 165, 171 community programs, 297–299, 298t disability in, 224, 228 developmental context, 288–289 early childhood interventions in, 87 FRESH framework, 279–281, 280–281f malaria in, 187, 192 gender equity, 274–276, 275–276f middle childhood interventions in, 87, 359, 363 health services, 293–295, 294f, 295t nutrition in, 135, 138, 388, 392 injury-excess countries, 292 underweight children in, 38 learning outcomes, 271–273, 271t, 272–273f Afridi, F., 153, 154, 155 media and social marketing, 300–301, 300t aggression in adolescence, 111. See also violence mobile health programs, 299–300, 299t agriculture, 150b, 156–157 multiburden countries, 291–292 Ahmed, A., 153 NCD-predominant countries, 292 Ahuja, Amrita, 413 policy framework, 279–282, 301–302, 301t AIDS. See HIV/AIDS poverty reduction, 274–276, 275–276f Albania, overweight/obesity prevalence in, 40 SABER tool, 281 alcohol use school health and nutrition, 270–271, 270–271f, in adolescence, 63, 66–67m, 245, 373 295–297, 296f, 296t oral health and, 213, 215 schools as entry point for interventions, Alderman, Harold, 79, 83, 88, 89, 147, 153, 154 273–274 Allen, L. H., 134 sector roles, 276, 277t Allen, Nicholas B., 107 policy framework, 279–282, 301–302, 301t American Psychiatric Association, 140 poverty reduction, 274–276, 275–276f anemia pregnancy, nutrition interventions during, 241–242 in adolescence, 41, 42f, 241–242 psychosocial interventions, 113 cash transfers and, 330–332 460 Index in early childhood, 38–39, 38f, 38t malaria interventions, 192–193 malaria and, 186–187 middle childhood interventions, 83–84, 84t, 88–89, in men (15–49 years), 41, 42f 91–92, 277–279, 278f, 278t, 361 prevalence, 330–332 nutrition interventions, 87–89, 88–89t, 385, 389, soil-transmitted helminth infections and, 173 392–397, 394t in women (15–49 years), 41, 42f oral health interventions, 359–360, 362 Angold, A., 111 school feeding programs, 157–158, 157t, 158f anorexia, 140–141 tetanus vaccinations, 203–204 anxiety, 111 Benin Appleby, Laura J., 165 adolescence interventions in, 279, 281 Aurino, Elisabetta, 147, 228, 355 middle childhood interventions in, 279, 281, 357 Australia nutrition in, 135, 137 adolescent health interventions in, 372–373 Benzian, Habib, 211 burden of disease in, 57, 62 Berlinski, S., 92, 94 disability prevalence in, 224, 225t Bernal, R., 91–92 Austria, binge drinking in, 63 Best, C., 154 autism spectrum disorders, 231–232 Bhalotra, Sonia, 385 Azerbaijan, overweight/obesity prevalence in, 40 Bhutan, 203–204, 223, 273 Azzopardi, Peter, 57, 239 Bhutta, Zulfiqar, 87, 89, 133, 140 binge drinking, 63, 66–67m. See also alcohol use B Bin Ghouth, S., 184–185 Bains, K., 136 Bin Mohanna, M. A., 184–185 Baird, Sarah, 413 Black, Maureen M., 253, 343 Baltussen, Naus and Limburg, 228 Bleakley, H., 93 Bangladesh Bloem, Paul, 199 adolescent pregnancy in, 139 BMI. See body mass index cash transfers programs in, 331, 332, 333 Bobonis, G. J., 93 early marriage in, 65 body mass index (BMI). See also overweight/obesity; mobile health in, 300 underweight nutrition in, 389 in adolescence, 63, 69, 108, 133, 135–137, 244 preprimary school education in, 262 cash transfers programs and, 327, 329, 331 school feeding programs in, 139, 158 deworming programs and, 173 stunting in, 83 in early childhood, 387 Banham, Louise, 269 in middle childhood, 133, 135–137 Banister, J., 27 nutrition outcomes and, 37, 39–41 Barooah, B., 153, 155 Bolivia, early childhood development in, 91, 344–346, BCRs. See benefit-cost ratios 348–349 Beaver, P. C., 173 Bonell, Chris, 287 Behrman, Jere R., 79, 88, 91, 93, 385 Botswana, burden of disease in, 63 Belgium Bradley, Mark, 165 burden of disease in, 63 brain development, 6–7, 119–131 education in, 49 in adolescence, 75, 109, 240 benefit-cost ratios (BCRs) anatomical maturation, 119–121, 120f adolescence interventions, 277–279, 278f, 278t, early environment and attachment, 125 371–379, 372–373t, 375–377t environmental experiences and, 123–124 cash transfers, 334–335 functional development, 121–122 defined, 13 genome-environome dynamics, 122–125, disability interventions, 227–228 123–124f early childhood interventions, 83–84, 84t, 88–89, language development, 125–126 91–92, 343–346, 345–346t, 348 literacy skills, 126, 127f education interventions, 318b, 424, 430–433, neuroplasticity, 124–125 431–432t, 433–434f, 434t numeracy skills, 126–127 HPV vaccinations, 204–206, 204t nutritional requirements, 122–123 Index 461 self-regulation, 127–128 C skill acquisition, 125–128, 127f Cambodia BRAIN Initiative, 121 disability in, 228 Brazil middle childhood interventions in, 359, 362 adolescence interventions in, 375–376 oral health in, 215 Bolsa Familia, 326 Cameroon burden of disease in, 62–63 adolescence interventions in, 279 cash transfers programs in, 326–328, malaria in, 190 330–331, 336 middle childhood interventions in, 279 deworming programs in, 167 Canada disability interventions in, 227 adolescence interventions in, 294, 369, 372–373 early childhood interventions in, 93, 255 early childhood interventions in, 343–344 education in, 49 education in, 63 hearing loss in, 232 illicit substance use in, 63 malaria in, 185, 189 oral health in, 216 middle childhood interventions in, 93, 362 overweight/obesity prevalence in, 63 nutrition in, 43, 135, 139, 148, 151 Cappa, C., 223 oral health in, 212 cash transfers, 325–341, 327–329t school feeding programs in, 148, 151 anemia prevalence and, 330–332 vaccinations in, 205 anthropometric measures and, 330–332 breastfeeding, 86, 389–390 child development outcomes and, 334 Brinkman, Sally, 231 cost-effectiveness of, 334–335 Brooker, Simon J., 183 early childhood and, 333 Bulgaria education outcomes and, 334 burden of disease in, 63–65, 69 health outcomes and, 330–334 disability interventions in, 226 impact on health outcomes, 330–334 sexual and reproductive health in, 65 infant mortality and, 330 bulimia, 140–141 low birth weight and, 330 Bundy, Donald A. P., 1, 73, 99, 165, 269, 403 morbidity rates and, 330 Burbano, Carmen, 147 mortality rates and, 330 burden of disease. See also specific countries neonatal mortality and, 330 and regions nutrition and, 333 in adolescence, 57–71, 289–291, 289–290f perinatal mortality and, 330 deworming programs, 165–169, 167m, 169t, 174f pregnancy and, 332 in high-income countries (HICs), 58, 60–65, 69 recipient role in, 335–336 in low and middle-income countries (LMICs), 58, sexual and reproductive health and, 333–334 61, 63–64 catch-up growth, 80, 101–102, 102–103t in low-income countries (LICs), 69 celiac disease, 100 in middle childhood, 356–357, 357t Cemuschi, Tania, 199 in middle-income countries (MICs), 58, 61, 69 Center for Health Promotion, 232 Burkina Faso Centers for Disease Control and Prevention (U.S.), adolescence interventions in, 276, 279 58, 281 cash transfers programs in, 327–333, 335 Central African Republic disability interventions in, 227 FRESH framework in, 65 education in, 311 sexual and reproductive health in, 65 malaria in, 192 Central Asia. See Europe and Central Asia middle childhood interventions in, 100–101, cervical cancer, 60, 200, 201–206, 202m, 204t 276, 279 Chang, S. M., 93, 153 nutrition in, 42, 153, 155 chemoprevention of malaria, 191–192 oral health in, 213 Cheng, Y., 91 school feeding programs in, 153, 155 child care services, 260–261, 260t Burnett, Nicholas, 307 Child Health Epidemiology Reference Group, 18, 62 Burrows, T., 135 Child Mortality Estimation (CME), 8, 18 462 Index Chile for nutrition interventions, 388 burden of disease in, 63 for school feeding programs, 158, 160n5, 275 disability in, 227 Congo. See Democratic Republic of Congo early childhood interventions in, 345–346 Consortium of Health-Orientated Research in education in, 49 Transitioning Societies (COHORTS), 79 nutrition in, 137, 151, 153–154 Convention on the Rights of Persons with Disabilities, school feeding programs in, 151, 153–154 222, 233n1 tobacco use in, 63 Convention on the Rights of the Child, 3 China corticosteroid excess, 100 adolescence interventions in, 374–376 cost burden of disease in, 64, 69 adolescence interventions, 277–279, 278f, 278t, cash transfers programs in, 326 371–379, 372–373t, 375–377t deworming programs in, 169 cash transfers, 334–335 disability in, 228 deworming programs, 176–177, 177–178t, 177f, early childhood interventions in, 85–86, 93, 259 414–415, 415f, 419 education in, 49–51, 52–53 disability interventions, 227–228 middle childhood interventions in, 85–86, early childhood interventions, 83–84, 84t, 88–89, 93, 362 91–92, 343–349, 345–346t, 347–348t mortality rates in, 26–29, 31 education interventions, 318b, 424, 430–433, nutrition in, 137–138, 148, 155 431–432t, 433–434f, 434t oral health in, 214 HPV vaccinations, 204–206, 204t overweight/obesity prevalence in, 64 malaria interventions, 192–193 school feeding program in, 148, 155 middle childhood interventions, 83–84, 84t, 88–89, Chinese Stomatological Association, 216 91–92, 277–279, 278f, 278t, 361 Chiu, M. H., 53n2 nutrition interventions, 87–89, 88–89t, 385, 389, Chudgar, A., 47 392–397, 394t Clarke, Sian, 183 oral health interventions, 359–360, 362 clinic services, 259–260, 260t school feeding programs, 157–158, 157t, 158f CME. See Child Mortality Estimation tetanus vaccinations, 203–204 Coffey, Carolyn, 57 cost-benefit analysis. See benefit-cost ratios (BCRs) cognitive development, 7–8 Costello, E. J., 111 early childhood, 89–93 Creed-Kanashiro, H. M., 136 malaria and, 187, 189 Croke, Kevin, 165, 174, 175 middle childhood, 89–93, 101–102, 102–103t Crone, E. A., 110 nutrition and, 122–123, 392–393 Crookston, B. T., 101 during puberty, 110–111 Cunha, F., 82, 84, 85 school feeding programs and, 155, 156t Czech Republic, education in, 49 Colenso, Peter, 269 Collins, C. E., 135 D Colombia Dahl, R. E., 110 cash transfers programs in, 326–331, 333–334 DALYs (disability-adjusted life years) early childhood interventions in, 91–92, 93, adolescence interventions and, 289–291, 371–376 345–346 brain development and, 133 middle childhood interventions in, 93 deworming programs and, 167, 169 community services, 259–260, 260t early childhood interventions and, 89 Comprehensive Africa Agriculture Development education and, 319 Programme, 149 middle childhood interventions and, 89, 358, conditional cash transfers (CCTs), 325–340 361–363 for adolescence interventions, 370 nutrition interventions and, 139, 141 for deworming programs, 417 oral health and, 214 for education interventions, 309–310, 313, Daniels, Amy, 231 318, 435 Daryanani, R., 160n4 for middle childhood interventions, 356 De la Cruz Toledo, Elia, 369 Index 463 delivery platforms. See platforms for intervention Brazil, 232 delivery hearing loss, 232 Del Ninno, C., 153 Kenya, 231–232 Democratic Republic of Congo Lao PDR, 231 adolescence interventions in, 279 school health and nutrition programs, early childhood interventions in, 89–90 229–231, 230t education in, 313 Uruguay, 232 middle childhood interventions in, 89–90, 279 Vietnam, 229, 230t nutrition in, 42, 139, 392 vision, learning, and free eyeglasses, 228–229 Demographic and Health Surveys (DHS), 8, 26, 29–30, definitions, 222–223 34, 37–42, 58–59, 61, 93 education and, 226–227 Denmark measurements of, 222–223 disability in, 227 prevalence, 223–224, 224–225t sexual and reproductive health in, 65 school attendance and, 226–227 Deolalikar, Anil B., 385 socioeconomic inequalities and, 225–226 depression, 111 Djibouti De Silva, Nilanthi, 1, 165 burden of disease in, 63 Deutsche Gesellschaft für Internationale middle childhood interventions in, 357 Zusammenarbeit GmbH, 215b nutrition in, 135, 137 Developmental Origins of Health and Disease underweight prevalence in, 63 (DOHaD), 119, 128 DNA, 122 De Walque, Damien, 153, 154, 325 Dominican Republic deworming programs, 165–182 education in, 310 burden of disease, 165–169, 167m, 169t, 174f overweight/obesity prevalence in, 40 cost of, 176–177, 177–178t, 177f dopaminergic signaling, 128 costs, 414–415, 415f, 419 Drake, Lesley, 147, 228, 269 design optimization, 175–176 Dror, D. K., 134 economic analysis of interventions, 413–422 Duflo, E., 93 costs, 414–415, 415f, 419 dynamic complementarities, 82 education outcomes and, 415–417, 417f epidemiological externalities, 414 E health impacts of, 415 early childhood labor market effects of, 417–418 accumulated risks, 255–256 policy framework, 418–419 anemia, 38–39, 38f, 38t screened vs. mass treatment, 419 benefit-cost ratios of interventions, 83–84, 84t, education outcomes and, 415–417, 417f 345–346, 345–346t epidemiological externalities, 414 breastfeeding and, 86 health impact of, 172–175 cash transfers and, 333 health impacts of, 415 child care, 260–261, 260t infection prevalence, 165–169, 166m, 168t, clinic services, 259–260, 260t 170–171m, 172f, 172t cognitive and socioemotional development, 89–93 labor market effects of, 417–418 community services, 259–260, 260t policy framework, 418–419 cost of interventions, 347–348t, 347–349 scale of, 169–172 developmental progression, 254 screened vs. mass treatment, 419 early child development programs, 91–92 DHS. See Demographic and Health Surveys economic analysis of interventions, 343–353 dietary intake in adolescence, 41, 43. benefit-cost ratios, 345–346, 345–346t See also nutrition essential package, 349–351 disability, 221–237 methodology, 344–345 barriers to education, 226–227 unit cost of interventions, 347–348t, 347–349 benefit-cost ratios for interventions, 227–228 education case studies, 228–232, 230t returns to investments in, 92–93 autism spectrum disorders, 231–232 sector governance, 258 464 Index equity and rights, 256 quality improvement and accountability, 259 essential package of interventions, 4–5b, 349–351 relative rates of return, 84–85 governance, 258–259 risk factors, 254–256 health sector governance, 258 stunting, 87, 87t, 90t home visits, 259–260, 260t underweight, 38, 38f, 86 integrated interventions, 256–258, 257t wasting, 87 interventions, 79–98 Early Grade Reading Assessment (EGRA), 262–263 benefit-cost ratios, 83–84, 84t East Asia and Pacific. See also specific countries breastfeeding, 86 burden of disease in, 65 cognitive and socioemotional development, deworming programs in, 168–169 89–93 early childhood interventions in, 86 early child development programs, 91–92 middle childhood interventions in, 86 education, returns to investments in, 92–93 mortality rates in, 26, 28, 31, 33–34 lifecycle framework for assessment of, eating disorders, 111–112, 140–141 80–83, 81f economic analysis of interventions, 14–16, 16t. See also low birth weight, 85–86 benefit-cost ratios (BCRs) nutrition interventions, 85–89, 86–90t adolescence, 369–384 overweight/obesity, 87, 87t alcohol use, 373 relative rates of return, 84–85 benefit-cost ratios, 371–379, 372–373t, 375–377t stunting, 87, 87t, 90t cost-effectiveness, 371–379, 372–373t, 375–377t underweight, 86 education interventions, 403–411 wasting, 87 essential package, 9, 10t, 13–14, 379–380 lifecycle framework for assessment of, 80–83, 81f high-income countries, 372–373t, 372–374 low birth weight, 85–86 illicit substance use, 373 malnutrition/undernutrition, 43 low- and middle-income countries, 374–378, maternal stress, 255 375–377t multisectoral coordination, 256–258, 257t mental health, 374 nutritional deficiencies, 255 methodology, 370–371 nutrition interventions, 85–89, 86–90t overweight/obesity, 372–373, 374 overweight/obesity, 87, 87t platforms, 370t platforms, 253–268 sexual and reproductive health, 373, 374, 378 accumulated risks, 255–256 tobacco use, 373, 374 child care, 260–261, 260t deworming programs, 413–422 clinic services, 259–260, 260t costs, 414–415, 415f, 419 community services, 259–260, 260t education outcomes and, 415–417, 417f developmental progression, 254 epidemiological externalities, 414 education sector governance, 258 health impacts of, 415 equity and rights, 256 labor market effects of, 417–418 governance, 258–259 policy framework, 418–419 health sector governance, 258 screened vs. mass treatment, 419 home visits, 259–260, 260t early childhood, 343–353 integrated interventions, 256–258, 257t benefit-cost ratios, 345–346, 345–346t maternal stress, 255 essential package, 349–351 multisectoral coordination, 256–258, 257t methodology, 344–345 nutritional deficiencies, 255 unit cost of interventions, 347–348t, 347–349 poverty, 255 education interventions, 423–439 preprimary school, 260t, 261–262 benefit-cost ratios, 430–433, 431–432t, primary school, 260t, 262–263 433–434f, 434t quality improvement and accountability, 259 modeling health effects, 424–430, 425–426t risk factors, 254–256 mortality rates and, 426–428, 428f, 428t poverty, 255 nutrition interventions, 385–402 preprimary school, 260t, 261–262 benefit-cost ratios, 393–396, 394t primary school, 260t, 262–263 breastfeeding, 389–390 Index 465 cognitive development, 392–393 information-based interventions, 310, 311b lifecycle approach, 385, 386f infrastructure, 311–312, 312f low birth weight, 391 instructional interventions, 311–312, 312b, maternal health and, 386–387 312f, 313t maternal mortality and, 390–391 international assessment of student achievement, policy framework, 396–397 47–49, 48t prenatal health and, 387–389 interventions, 308–319 stunting, 391–392, 392f literacy and brain development, 126, 127f school-age child health, 355–368 malaria and, 187, 315–316, 317t benefit-cost ratios, 363–364, 363f, 364t materials and technology, 312 benefits, 360–363 middle childhood learning outcomes, 271–273, burden of disease, 356–357, 357t 271t, 272–273f costs, 357–360, 358t, 364t modeling health effects, 424–430, 425–426t essential package, 9t, 10–11, 363–364, mortality rates and, 426–428, 428f, 428t 363f, 364t numeracy and brain development, 126–127 infectious disease treatment benefits and nutrition interventions, 316–317, 317t costs, 359, 361–362 oral health intervention programs, nutrition benefits and costs, 358–359, 360–361 214–215, 215b oral health benefits and costs, 359–360, 362 platforms, 307–324 platforms, 356–357, 356t benefit-cost ratios, 318b training costs, 358 conceptual framework, 308, 309f vaccination benefits and costs, 360, 362 cost-reduction interventions, 309–310, 310f vision correction benefits and costs, 359, 362 deworming programs, 315, 317t Ecuador health interventions, 313–319, 314b, 317t cash transfers programs in, 326–329, 331–333 incentives-based interventions, early childhood interventions in, 347–348 309–310, 310f, 313t education, 16–17, 47–55 information-based interventions, 310, 311b absenteeism and, 187 infrastructure, 311–312, 312f access to, 153 instructional interventions, 311–312, 312b, adolescence 312f, 313t economic analysis of interventions, 403–411 interventions, 308–319 learning outcomes, 271–273, 271t, 272–273f malaria interventions, 315–316, 317t school health and nutrition, 270–271, materials and technology, 312 270–271f, 295–297, 296f, 296t nutrition interventions, 316–317, 317t barriers to, 226–227 school-based management (SBM), 310 benefit-cost ratios, 318b, 430–433, 431–432t, teacher resources, 312 433–434f, 434t poverty and, 255 cash transfers and, 334 preprimary school, 260t, 261–262 in China, 52–53 primary school, 260t, 262–263 cost-reduction interventions, 309–310, 310f returns to investments in, 92–93 deworming programs and, 315, 317t, school-based management (SBM), 310 415–417, 417f school feeding programs and, 152–154, 153t disability and, 226–227, 229–231, 230t secondary education as health economic analysis of interventions, 423–439 intervention, 112 benefit-cost ratios, 430–433, 431–432t, sector governance, 258 433–434f, 434t teacher resources, 312 modeling health effects, 424–430, 425–426t trends in, 49–50 mortality rates and, 426–428, 428f, 428t variance between schools, 50 health interventions, 313–319, 314b, 317t variance between students, 50 high-performing system characteristics, 50 Education for All (EFA), 10, 149, 169, 230, 256, 258, incentives-based interventions, 309–310, 261–262, 269–270, 274, 277, 308 310f, 313t education sector plans (ESPs), 276, 279–280 in India, 51–52, 52f EGRA. See Early Grade Reading Assessment 466 Index Egypt Framework Convention on Tobacco Control, 245 middle childhood interventions in, 357 France, illicit substance use in, 63 nutrition in, 135–136, 389 FRESH. See Focusing Resources on Effective School overweight/obesity prevalence in, 40 Health underweight prevalence in, 39 FRP (financial risk protection), 404–405 vaccinations in, 203 El Salvador, cash transfers programs in, 328, 332 G EMA (European Medicines Agency), 192, 201 Galiani, S., 92, 94 Engle, P. L., 85, 90, 92 Galloway, Rae, 37 ESPs. See education sector plans The Gambia Ethiopia adolescence interventions in, 279 adolescence interventions in, 101, 273, burden of disease in, 63 279, 281, 297 education in, 310 deworming programs in, 171 malaria in, 12, 183 early childhood interventions in, 90 middle childhood interventions in, 279 middle childhood interventions in, 90, 101, Garg, Renu, 211 273, 279, 281, 362 GBD. See Global Burden of Disease study nutrition in, 39–40, 42–43, 139, 392 Gelli, Aulo, 147, 160n4 oral health in, 213 gender equity underweight prevalence in, 40 in adolescence, 240, 274–276, 275–276f Europe and Central Asia. See also specific countries in early childhood, 256 adolescence interventions in, 108 in middle childhood, 274–276, 275–276f burden of disease in, 63 genome-environome dynamics of brain development, deworming programs in, 169 122–125, 123–124f disability in, 224, 228 Georgiadis, Andreas, 99, 101, 102 early childhood interventions in, 87 Germany education in, 49 adolescence interventions in, 372 malaria in, 185 burden of disease in, 63 middle childhood interventions in, 87 education in, 49 mortality rates in, 26–28, 31, 33–34 Gertler, Paul, 91, 325 nutrition in, 40–41 Ghana European Medicines Agency (EMA), 192, 201 adolescence interventions in, 275, European School Survey Project on Alcohol and 277–279, 281 Other Drugs, 61 cash transfers programs in, 328–330, 333 executive control, 110–111 middle childhood interventions in, 275, 277–279, 281, 357, 361–362 F nutrition in, 135–137, 150–153, 156, 158–159 Fall, C. H. D., 139 school feeding programs in, 150–153, 156, 158–159 Fernald, Lia, 79, 325 Gilligan, D., 153, 154 Fernandes, Meena, 147, 307, 355 Gitonga, Caroline W., 183 Fernández, C., 91–92 Giyose, Boitshepo, 147 Fernando, Deepika, 183, 187, 189 Glewwe, Paul, 79, 93, 102, 228 Fiji, underweight prevalence in, 63 Global Burden of Disease (GBD) study, 32, 60, 107. Filippi, Véronique, 403 See also burden of disease Filmer, D., 226 Global School-Based Student Health financial risk protection (FRP), 404–405 Survey, 58, 217 Fink, Günther, 99, 101 Global Youth Tobacco Survey, 58, 217 Fit for School Action Framework, 215, 215b Golden, M. H. N., 100, 102 Fjell, A. M., 110 Gona, Joseph, 231 fluoride interventions, 216, 216b Gove, Amber, 253 Focusing Resources on Effective School Health governance, 258–259 (FRESH), 169, 171, 214, 230, 270, 276, Graber, J. A., 111 279–281, 280–281f Graham, Natasha, 221 Index 467 Grantham-McGregor, S. M., 93 HIV/AIDS Greece, overweight/obesity prevalence in, 63 in adolescence, 240–241 Greenwood, Brian, 183 adolescence prevalence rates, 62–63, 287 Grigorenko, Elena L., 119 Millennium Development Goals for, 58 Grosbras, M. H., 110 Hoddinott, J., 83, 88, 89 growth hormone deficiency, 100 Hoek, H. W., 141 Guatemala, middle childhood interventions in, 99 Hogares Comunitarios de Bienestar (Colombia), Guo, S. S., 136 91–92 Guyana, nutrition in, 39–40, 42 Hollingsworth, T. Deirdre, 165 home visits, 259–260, 260t H Honduras, 203, 326, 328–329, 332 Halfon, N., 94n1 Hong Kong SAR Hall, A., 101 education in, 49–50 Hanushek, E. A., 47 oral health in, 214 Hasan, A., 94 hookworm, 165–166. See also deworming programs Hayward, C., 111 Horton, Susan, 1, 73, 343, 369 Health Behaviour in School-Aged HPV vaccinations Children (HBSC), 58 benefit-cost ratios, 204–206, 204t health information systems, 57–58 delivery strategies, 201–203, 202m health risks effectiveness of, 60, 203 in adolescence, 57–71 Hutubessy, R., 204 binge drinking, 63, 66–67m hypothyroidism, 100 illicit substance use, 63 overweight/obesity, 63–64, 67–68m I physical activity, 64 Iceland, sexual and reproductive health in, 65 sexual and reproductive health, 64–65, 64m IHME. See Institute for Health Metrics and Evaluation tobacco use, 63, 65–66m illicit substance use, 63, 245, 373 underweight, 63 immunizations. See vaccinations health sector governance, 258 India health services, 293–295, 294f, 295t adolescence interventions in, 273, 374–378 hearing loss, 232 Annual Status of Education Report, 263 Heckman, J., 73, 82 cash transfers programs in, 326–328, 330, 332 hepatitis vaccinations, 241 deworming programs in, 166, 178, 414–415 Hicks, Joan Hamory, 413 disability in, 226–227 Hidrobo, Melissa, 325 early childhood interventions in, 85, 90, 93 high-income countries (HICs) education in, 51–52, 52f, 53n3, 308, 310, 404–409, adolescence interventions in, 108–109, 239, 406–407t 242–243, 270–271, 288, 294–295, malaria in, 185 370–374, 372–373t, 378 maternal mortality in, 404–409, 406–407t brain development in, 119, 125–128 middle childhood interventions in, 85, 90, 93, burden of disease in, 58, 60–65, 69 101, 273 disability in, 222–224 nutrition in, 39–40, 42–43, 135–136, 139, 148, early childhood interventions in, 255, 153–155, 392, 396 261–262 school feeding program, 152 education in, 428 underweight prevalence in, 40 middle childhood interventions in, Indonesia 270–271, 355 adolescence interventions in, 377–378 mortality rates in, 34 burden of disease in, 63 nutrition in, 134, 137, 140–141, 147–148, cash transfers programs in, 327–328, 330–332 156–158 early childhood interventions in, 89–90, 93 oral health in, 211, 213–214, 216–218 education in, 310 Hill, Kenneth, 5, 25, 26, 27, 32 middle childhood interventions in, 89–90, 93, 359 Hill, Tara, 307 nutrition in, 137 468 Index oral health in, 215 environmental experiences, 123–124 tobacco use in, 63 functional development, 121–122 underweight prevalence in, 63 genome-environome dynamics, 122–125, vaccinations in, 201, 203 123–124f indoor residual spraying for malaria, 191 language development, 125–126 infant mortality, 5, 62, 330 literacy, 126, 127f injuries neuroplasticity, 124–125 in adolescence, 242, 292 numeracy, 126–127 oral injuries and trauma, 212 nutritional requirements, 122–123 self-harm, 111 self-regulation, 127–128 insecticide-treated nets (ITNs), 190–191, 190f, 241 skill acquisition, 125–128, 127f Institute for Health Metrics and Evaluation (IHME), conceptual framework, 73–77, 74f 8, 112, 167, 169, 223–224, 295, 403–404 adolescence, 73–75 intelligence quotient (IQ) implications for phases of development, 75–77, early childhood interventions and, 259, 260 76f, 76t global trends in, 17 middle childhood, 73–75 nutrition and, 43, 102, 271, 319, 390 early childhood, 79–98 worm infections and, 315 benefit-cost ratios, 83–84, 84t Inter-agency Group for Child Mortality Estimation breastfeeding, 86 (IGME), 8, 18 cognitive and socioemotional development, Interagency Group on Mortality Estimation, 27 89–93 Inter-American Development Bank, 260 early child development programs, 91–92 Inter-American Institute on Disability and Inclusive education, returns to investments in, 92–93 Development, 232 integrated interventions, 256–258, 257t intermittent preventive treatment (IPT) for malaria, lifecycle framework for assessment of, 80–83, 81f 186, 189, 191–192, 316, 359 low birth weight, 85–86 International Assessment of Adult Competencies nutrition interventions, 85–89, 86–90t (PIAAC), 50 overweight/obesity, 87, 87t International Association for Dental Research, 216 relative rates of return, 84–85 International Association for the Evaluation of stunting, 87, 87t, 90t Educational Achievement, 48–49 underweight, 86 International Classification of Functioning, Disability wasting, 87 and Health, 222 education, 308–319 International Commission on Financing Global cost-reduction interventions, 309–310, 310f Education Opportunity, 1, 314b incentives-based interventions, 309–310, interventions, 73–131. See also economic analysis of 310f, 313t interventions information-based interventions, 310, 311b adolescence, 107–117 instructional interventions, 311–312, 312b, aggression and, 111 312f, 313t anxiety, 111 incentives-based interventions, 309–310, depression, 111 310f, 313t eating disorders, 111–112 information-based interventions, 310, 311b nutrition interventions, 113 instructional interventions, 311–312, 312b, physical health, 112 312f, 313t psychosocial interventions, 113 integrated, 256–258, 257t puberty and developmental processes, 107–111 malaria, 188t, 189–192, 190f risk factors, 111–112 malnutrition/undernutrition, 136, 136t secondary education as health intervention, 112 micronutrient deficiencies, 138–139, 139t self-harm, 111 middle childhood, 79–105 violence and, 111 adoption studies, 100 brain development, 119–131 benefit-cost ratios, 83–84, 84t anatomical maturation, 119–121, 120f breastfeeding, 86 early environment and attachment, 125 catch-up growth, 101–102, 102–103t Index 469 cognitive and socioemotional development, cash transfers programs in, 326, 328–330 89–93, 101–102, 102–103t early childhood interventions in, 4b, 91, 260, deworming, 101 344–347 early child development programs, 91–92 education in, 319 education, returns to investments in, 92–93 middle childhood interventions in, 85 environmental changes, 99–100 nutrition in, 155 food supplementation, 100–101 tobacco use in, 63 historical migration evidence, 100 Jamison, Dean T., 1, 25, 26, 32, 99, 423 immigration studies, 100 Janani Suraksha Yojana Program (India), 332 lifecycle framework for assessment of, 80–83, 81f Japan low birth weight, 85–86 burden of disease in, 63 micronutrient supplementation, 101 deworming programs in, 169, 178 nutrition interventions, 85–89, 86–90t education in, 49–50 overweight/obesity, 87, 87t Jung, H., 94 relative rates of return, 84–85 Jung, R. C., 173 stunting, 87, 87t, 90t, 100 underweight, 86 K wasting, 87 Kaur, S., 136 nutrition Kaytaz, M., 91 adolescence, 113, 241–242 Kazianga, H., 153, 154 benefit-cost ratios, 87–89, 88–89t, Kennedy, Elissa, 57, 239 393–396, 394t Kenya breastfeeding, 389–390 adolescence interventions in, 279, 281, 374, cognitive development, 392–393 376–378 early childhood, 85–89, 86–90t autism spectrum disorders in, 231–232 eating disorders, 141 cash transfers programs in, 329, 333 economic analysis, 385–402 deworming programs in, 167, 414–417 lifecycle approach, 385, 386f disability in, 230 low birth weight, 391 early childhood interventions in, 90, 93, 261, malnutrition/undernutrition, 136, 136t 263, 346 maternal health and, 386–387 education in, 315–316, 318 maternal mortality and, 390–391 malaria in, 12, 183, 187–192 micronutrient deficiencies, 138–139, 139t middle childhood interventions in, 90, 93, 279, middle childhood, 85–89, 86–90t, 100–101 281, 361–362 overweight/obesity, 137–138, 137t nutrition in, 154–156, 392 policy framework, 396–397 Khan, Imran, 228 prenatal health and, 387–389 Kiamba, Josephine, 147 school feeding programs, 147–164 Kim, Jane J., 199 stunting, 391–392, 392f King, E., 102 oral health, 214–217, 216b Kirk, S. F. L., 134 overweight/obesity, 137–138, 137t Komlos, J., 100 IPT. See intermittent preventive treatment Korea, Republic of, education in, 49 Iran Kremer, Michael, 93, 153, 413 burden of disease in, 69 Kristjansson, B., 100, 101 nutrition in, 138, 141 oral health in, 212 L Ireland, binge drinking in, 63 labor market impact of deworming programs, Italy, overweight/obesity prevalence in, 63 417–418 LaMontagne, D. Scott, 199 J Lancet Adolescent Health Series, 59–60, 62 Jamaica Lancet Commission on Adolescent Health and adolescence interventions in, 85 Wellbeing, 1, 25, 287, 289, 292 burden of disease in, 63 language development, 125–126 470 Index Lao PDR middle childhood interventions in, 79–80, 84–87, disability in, 231 92–93, 270–271, 277–279, 355, 357–364 middle childhood interventions in, 100, 101, mortality rates in, 8, 25–27, 29–32, 34 359, 362 nutrition in, 37–38, 40–41, 135–138, 141, 147–148, nutrition in, 152, 155 154–156, 385–386, 389–391 oral health in, 215 oral health in, 211–217 Lassi, Z. S., 140 vaccination programs in, 199–206 Lassi, Zohra, 133 low birth weight (LBW), 83–88, 330, 385–387, 391 Latin America and Caribbean low-income countries (LICs) burden of disease in, 63, 65 adolescence interventions in, 108 cash transfers programs in, 326, 330, 333 burden of disease in, 69 deworming programs in, 166–169 defined, 5 early childhood interventions in, 86–87, 90, 92, early childhood interventions in, 261–262 261–262, 344–349 education in, 50, 314, 316, 426–435 education in, 49 middle childhood interventions in, 100–101, malaria in, 185 360–361, 363 middle childhood interventions in, 86–87, 90, 92 nutrition in, 141, 148–149, 157–160, 394–395 mortality rates in, 26–27, 29, 31, 33–34 oral health in, 211, 213, 217 nutrition in, 38, 40–42, 137–138, 152 Lundeen, E. A., 43 Laxminarayan, Ramanan, 385 Luschei, T. F., 47 LBW. See low birth weight Luxemburger, C., 185 Lehrer, K., 153, 154 Lesotho M cash transfers programs in, 329, 334 Madagascar nutrition in, 42 adolescence interventions in, 275, 279, 281 overweight/obesity prevalence in, 40 early childhood interventions in, 90 Levin, A., 204 education in, 310 Liberia middle childhood interventions in, 90, 275, adolescence interventions in, 279 279, 281 middle childhood interventions in, 279 nutrition in, 42, 392 nutrition in, 39–40 Mahon, Jacqueline, 369 LICs. See low-income countries Mai, Lu, 147 lifecycle approach, 385, 386f malaria, 183–198 lifecycle framework for assessment, 80–83, 81f absenteeism from school and, 187 literacy and brain development, 126, 127f anemia and, 186–187 LMICs. See lowand middle-income countries benefit-cost ratios, 192–193 Lobelo, F., 137 chemoprevention, 191–192 local agriculture, 150b, 156–157 cognitive function and, 187, 189 Lochner, L., 84, 85 education interventions, 315–316, 317t London Declaration on Neglected Tropical Diseases impact on child health and development, 185–189 (2012), 171 indoor residual spraying, 191 Lopes, T. S., 135 insecticide-treated nets (ITNs), 190–191, low and middle-income countries (LMICs) 190f, 241 adolescence interventions in, 270–271, 277–279, intermittent preventive treatment (IPT), 191–192 293–295, 297, 302, 369–371, 374–379, interventions, 188t, 189–192, 190f 375–377t mortality rates, 185 brain development in, 125–128 policy recommendation, 193b burden of disease in, 58, 61, 63–64 prevalence, 183–185, 184f, 185t, 186–187m disability in, 221–223, 225–228 research priorities, 194b early childhood interventions in, 79–80, 84–87, screening, 192 92–93, 253, 343–346 seasonal malaria chemoprevention (SMC), 192 education in, 307–309, 403–404, 424, 427–430, vaccine development, 192, 241 432–435 vector control and, 190–191 Index 471 Malawi cash transfers programs in, 326–332 adolescence interventions in, 281 deworming programs in, 169, 178 cash transfers programs in, 326–331 disability in, 227 disability in, 226, 228 early childhood interventions in, 93, 347–348 malaria in, 184, 190 education in, 310 middle childhood interventions in, 281, 357 middle childhood interventions in, 93 nutrition in, 135, 152 nutrition in, 137, 151, 154–155, 393 overweight/obesity prevalence in, 63 vaccinations in, 205 school feeding program in, 152, 152f micronutrient deficiencies, 16, 101, 138–139, 139t Mali micronutrient powders (MNP), 158, 278, 317, 345–346, adolescence interventions in, 279, 281 348, 356–358 malaria in, 188–189 MICs. See middle-income countries middle childhood interventions in, 279, 281 middle childhood oral health in, 213 adoption studies, 100 malnutrition/undernutrition benefit-cost ratios, 277–279, 278f, 278t, 363–364, in adolescence, 43, 241–242 363f, 364t consequences of, 43 benefit-cost ratios of interventions, 83–84, 84t in early childhood, 43 breastfeeding, 86 interventions, 136, 136t burden of disease, 356–357, 357t in middle childhood, 43, 135–136, 135–136t catch-up growth, 101–102, 102–103t nutrition interventions, 136, 136t cognitive and socioemotional development, 89–93, oral health and, 212 101–102, 102–103t prevalence of, 37–41, 38–41f, 38t, 135–136 conceptual framework for, 73–75 Malta defined, 1, 3, 4f burden of disease in, 63–64 deworming programs, 101, 165–182. See also overweight/obesity prevalence in, 63 deworming programs Manacorda, M., 92, 94 disability, 221–237. See also disability Mann, S. K., 136 early childhood interventions and, 91–92 Manyanga, T., 136 eating disorders, 140–141 Marshall, S., 135 economic analysis of interventions, 355–368 Marshall, W. A., 108 benefit-cost ratios, 363–364, 363f, 364t Martínez, Sebastián, 423 benefits, 360–363 Masterov, D., 84, 85 burden of disease, 356–357, 357t maternal health and mortality costs, 357–360, 358t, 364t education interventions and, 403–411, essential package, 9t, 10–11, 363–364, 363f, 364t 406–407t infectious disease treatment benefits and costs, nutrition interventions and, 386–387, 390–391 359, 361–362 Matlab Health and Socioeconomic Survey, 16, 17 nutrition benefits and costs, 358–359, 360–361 Matsuzaki, M., 135 oral health benefits and costs, 359–360, 362 Mauritania platforms, 356–357, 356t adolescence interventions in, 279 training costs, 358 middle childhood interventions in, 279, 357 vaccination benefits and costs, 360, 362 nutrition in, 136–137 vision correction benefits and costs, 359, 362 overweight/obesity prevalence in, 64 education returns to investments, 92–93 sexual and reproductive health in, 65 environmental changes, 99–100 MDGs. See Millennium Development Goals FRESH framework, 279–281, 280–281f media and social marketing, 243, 292, 300–301, 300t gender equity, 274–276, 275–276f Medical Research Council, 16 historical migration evidence, 100 mental health and disorders, 243, 374 immigration studies, 100 Meresman, Sergio, 232 infectious disease treatment benefits and costs, 359, Merseth, Katherine A., 253 361–362 Mexico interventions, 79–105 adolescence interventions in, 375–376 adoption studies, 100 472 Index benefit-cost ratios, 83–84, 84t, 363–364, learning outcomes, 271–273, 271t, 272–273f 363f, 364t policy framework, 279–282 breastfeeding, 86 poverty reduction, 274–276, 275–276f catch-up growth, 101–102, 102–103t SABER tool, 281 cognitive and socioemotional development, school health and nutrition, 270–271, 270–271f 89–93, 101–102, 102–103t schools as entry point for interventions, 273–274 costs, 357–360, 358t, 364t sector roles, 276, 277t deworming, 101 policy framework, 279–282 early childhood, 91–92 poverty reduction, 274–276, 275–276f education, returns to investments in, 92–93 relative rates of return, 84–85 environmental changes, 99–100 SABER tool, 281 essential package, 9t, 10–11, 363–364, 363f, 364t school feeding programs, 147–164. See also school food supplementation, 100–101 feeding programs historical migration evidence, 100 school health and nutrition, 270–271, 270–271f immigration studies, 100 schools as entry point for interventions, 273–274 lifecycle framework for assessment of, 80–83, 81f sector roles, 276, 277t low birth weight, 85–86 stunting, 87, 87t, 90t, 100 micronutrient supplementation, 101 underweight, 86 nutrition interventions, 85–89, 86–90t vaccination benefits and costs, 360, 362 overweight/obesity, 87, 87t vision correction benefits and costs, 359, 362 relative rates of return, 84–85 wasting, 87 stunting, 87, 87t, 90t, 100 Middle East and North Africa. See also specific countries underweight, 86 burden of disease in, 64–65 wasting, 87 deworming programs in, 166, 168–169 learning outcomes, 271–273, 271t, 272–273f early childhood interventions in, 86, 90 lifecycle framework for assessment of, 80–83, 81f education in, 49 low birth weight, 85–86 malaria in, 185 malaria, 183–198. See also malaria middle childhood interventions in, 86, 90 malnutrition/undernutrition, 43, 135–136, mortality rates in, 26, 29, 31, 33–34 135–136t nutrition in, 137, 392 micronutrient deficiencies, 138–139, 139t middle-income countries (MICs) micronutrient supplementation, 101 adolescence interventions in, 270–271, 374–377 nutrition interventions, 85–89, 86–90t, 100–101, burden of disease in, 58, 61, 69 133–145 defined, 5 benefits and costs, 358–359, 360–361 deworming programs in, 178 eating disorders, 140–141 early childhood interventions in, 345–346 importance of, 133–135, 134f education in, 424 malnutrition/undernutrition, 43, 135–136, middle childhood interventions in, 100–101, 135–136t 270–271, 355, 357–358 micronutrient deficiencies, 138–139, 139t mortality rates in, 25, 33–34 overweight/obesity, 87, 87t, 136–138, 137t nutrition in, 140–141, 147–148, 157–160 physical growth and, 133 vaccinations in, 201, 203 stunting, 87, 87t, 90t Miguel, Edward, 93, 413 underweight, 86 Millennium Development Goals (MDGs) wasting, 87 on adolescence interventions, 269, 295 oral health, 211–220. See also oral health on early childhood interventions, 253 benefits and costs, 359–360, 362 on education, 18–19, 308, 356, 403, 424, 428 overweight/obesity, 87, 87t, 136–138, 137t on HIV/AIDS, 58, 60 physical growth and nutrition, 133 on infant and child mortality, 5, 62 platforms, 269–285, 356–357, 356t Mitchell, Arlene, 147 benefit-cost ratios, 277–279, 278f, 278t Mitra, Sophie, 221, 223, 226 FRESH framework, 279–281, 280–281f Mizunoya, S., 223, 226 gender equity, 274–276, 275–276f MNP. See micronutrient powders Index 473 mobile health programs, 299–300, 299t overweight/obesity prevalence in, 40 Moin, Anoosh, 133 tobacco use in, 63 Mokdad, Ali, 57 Nandi, Arindam, 385, 403 Moldova, adolescence interventions in, 377–378 Nankabirwa, Joaniter, 183 Mongolia, overweight/obesity prevalence in, 64 neglected tropical diseases (NTDs), 169, 171–172, Monse, Bella, 211 177–178, 419 Mont, Daniel, 221, 229 neonatal mortality, 330 morbidity rates Nepal adolescence, 8 adolescence interventions in, 273 cash transfers and, 330 cash transfers programs in, 326–328, 330, 332 middle childhood, 8 disability in, 227 soil-transmitted helminth (STH) infections, 167 early childhood interventions in, 90 Morocco middle childhood interventions in, 273 cash transfers programs in, 335 nutrition in, 392 disability in, 226 vaccinations in, 201, 203 middle childhood interventions in, 357 Netherlands nutrition in, 136 adolescence interventions in, 372–373 mortality rates, 25–35 education in, 50 cash transfers and, 330 illicit substance use in, 63 by cause, 32, 33–34t neurodevelopment, 240 education and, 426–428, 428f, 428t neuroplasticity, 122, 124–125 infant mortality, 5, 62, 330 New Zealand in low and middle-income countries (LMICs), 8 adolescence interventions in, 372 malaria, 185 burden of disease in, 62–63 methodology and data, 26–27 disability in, 227 neonatal mortality, 330 Nicaragua number of deaths, 30–31, 31–32t cash transfers programs in, 326–329, 331, nutrition interventions and, 390–391 333–334 perinatal mortality, 330 disability in, 227 risks, 26t, 27–28f, 27–30, 28–29t, 30f early childhood interventions in, 255, 345 Moulin, S., 93 Niger Mozaffarian, D., 136 adolescence interventions in, 275–278, 281 Mozambique Demographic and Health Survey and, 405 adolescence interventions in, 275–279 deworming programs in, 177 early childhood interventions in, 261, 344, education and maternal mortality in, 404–409, 348–349 406–407t middle childhood interventions in, 275–279 middle childhood interventions in, 275–278, 281 sexual and reproductive health in, 65 nutrition in, 42 vaccinations in, 203 oral health in, 213 Multiple Indicator Cluster Surveys (MICS), 58 Nigeria multisectoral coordination, 256–258, 257t adolescence interventions in, 241, 273, 281, Muralidharan, K., 93 377–378 Myanmar burden of disease in, 63 early childhood interventions in, 90 early childhood interventions in, 86, 90 nutrition in, 392 middle childhood interventions in, 273, 281 overweight/obesity prevalence in, 64 nutrition in, 139, 150, 392 underweight prevalence in, 63 oral health in, 213 Njelesani, J., 223 N noma, 211, 212–213 Namibia Norway disability in, 226 adolescence interventions in, 373 early childbirth rates in, 65 education in, 435 nutrition in, 39–40, 42 numeracy and brain development, 126–127 474 Index Nurse-Family Partnership (South Africa), 125 malnutrition/undernutrition nurturing care, 254 adolescence, 43 nutrition, 37–45 consequences of, 43 adolescence, 133–145 early childhood, 43 anemia, 41, 42f interventions, 136, 136t eating disorders, 140–141 middle childhood, 43, 135–136, 135–136t importance of, 133–135, 134f prevalence of, 37–41, 38–41f, 38t, 135–136 malnutrition/undernutrition, 43 micronutrient deficiencies, 16, 138–139, 139t micronutrient deficiencies, 138–139, 139t interventions, 138–139, 139t overweight/obesity, 39–41, 40–41f, 136–138, 137t prevalence, 138 physical growth and, 133 middle childhood, 133–145 pregnancy and, 139–140 eating disorders, 140–141 undernutrition, 135–136, 135–136t importance of, 133–135, 134f underweight, 39, 39f, 40–41, 41f malnutrition/undernutrition, 43, 135–136, anemia 135–136t in adolescence, 41, 42f micronutrient deficiencies, 138–139, 139t in early childhood, 38–39, 38f, 38t overweight/obesity, 87, 87t, 136–138, 137t in men (15–49 years), 41, 42f physical growth and, 133 in women (15–49 years), 41, 42f stunting, 87, 87t, 90t brain development and, 122–123 underweight, 86 cash transfers and, 333 wasting, 87 early childhood, 255 overweight/obesity anemia, 38–39, 38f, 38t adolescence, 39–41, 40–41f breastfeeding, 86 interventions, 137–138, 137t low birth weight, 85–86 middle childhood, 87, 87t, 136–138, 137t malnutrition/undernutrition, 43 prevalence of, 136–137 overweight/obesity, 87, 87t in women (15–49 years), 40–41, 41f stunting, 87, 87t, 90t physical growth, 133 underweight, 38, 38f, 86 pregnant adolescents, 139–140 wasting, 87 stunting, 87, 87t, 90t eating disorders, 140–141 underweight education interventions, 316–317, 317t adolescence, 39, 39f, 40–41, 41f interventions early childhood, 38, 38f adolescence, 113, 241–242 middle childhood, 86 benefit-cost ratios, 87–89, 88–89t, 393–396, 394t in women (15–49 years), 40–41, 41f breastfeeding, 389–390 wasting, 87 cognitive development, 392–393 early childhood, 85–89, 86–90t O eating disorders, 141 obesity. See overweight/obesity economic analysis, 385–402 Ogden, C. L., 137 lifecycle approach, 385, 386f oral health, 13, 211–220 low birth weight, 391 alcohol use and, 213, 215 malnutrition/undernutrition, 136, 136t benefits and costs, 359–360, 362 maternal health and, 386–387 consumption patterns and, 213–214 maternal mortality and, 390–391 fluoride and, 216, 216b micronutrient deficiencies, 138–139, 139t intersectoral collaboration, 217 middle childhood, 85–89, 86–90t, 100–101 interventions, 214–217, 216b overweight/obesity, 137–138, 137t in LMICs, 214 policy framework, 396–397 malnutrition/undernutrition and, 212 prenatal health and, 387–389 noma, 212–213 school feeding programs, 147–164. See also oral injuries and trauma, 212 school feeding programs policy implications, 217 stunting, 391–392, 392f risk factors, 213–214 Index 475 school intervention programs, 214–215, 215b adolescence, 269–305 sugar consumption and, 213, 215 benefit-cost ratios, 277–279, 278f, 278t surveillance, 216–217 burden of disease, 289–290f, 289–291 tobacco use and, 213, 215 community programs, 297–299, 298t tooth decay, 211–212, 212f developmental context, 288–289 overweight/obesity FRESH framework, 279–281, 280–281f adolescence, 39–41, 40–41f, 63–64, 67–68m, gender equity, 274–276, 275–276f 136–138, 137t, 244–245, 372–373, 374 health services, 293–295, 294f, 295t early childhood, 87, 87t injury-excess countries, 292 interventions, 137–138, 137t learning outcomes, 271–273, 271t, 272–273f middle childhood, 87, 87t, 136–138, 137t media and social marketing, 300–301, 300t prevalence of, 136–137 mobile health programs, 299–300, 299t in women (15–49 years), 40–41, 41f multiburden countries, 291–292 NCD-predominant countries, 292 P policy framework, 279–282, 301–302, 301t Pakistan poverty reduction, 274–276, 275–276f adolescence interventions in, 298 SABER tool, 281 burden of disease in, 63–64 school health and nutrition, 270–271, 270–271f, deworming programs in, 166 295–297, 296f, 296t disability in, 227 schools as entry point for interventions, 273–274 early childhood interventions in, 85, 90, 259, sector roles, 276, 277t 344–345, 349–350 cash transfers, 325–341, 327–329t education in, 310 anemia prevalence and, 330–332 nutrition in, 133, 392 anthropometric measures and, 330–332 overweight/obesity prevalence in, 64 child development outcomes and, 334 Pan American Health Organization, 203 cost-effectiveness of, 334–335 Partnership for Child Development, 232 early childhood and, 333 Patrinos, H. A., 93, 94n2 education outcomes and, 334 Patton, George C., 1, 57, 107, 133, 239, 287 health outcomes and, 330–334 peer influence, sensitivity to, 110, 140–141 infant mortality and, 330 perinatal mortality, 330 low birth weight and, 330 Peru morbidity rates and, 330 cash transfers programs in, 326–332, 334 mortality rates and, 330 education in, 49 neonatal mortality and, 330 middle childhood interventions in, 100–101 nutrition and, 333 nutrition in, 43, 136 perinatal mortality and, 330 vaccinations in, 204–205 pregnancy and, 332 Petrowski, N., 223 recipient role in, 335–336 Pfeifer, J. H., 110 sexual and reproductive health and, 333–334 Philippines early childhood, 253–268 burden of disease in, 64 accumulated risks, 255–256 early childhood interventions in, 90, 346 child care, 260–261, 260t health and education outcomes in, 16 clinic services, 259–260, 260t middle childhood interventions in, 102, 359 community services, 259–260, 260t nutrition in, 43, 139 developmental progression, 254 oral health in, 212–213, 215 education sector governance, 258 physical activity in adolescence, 64 equity and rights, 256 PIRLS (Progress in International Reading governance, 258–259 Literacy Study), 48 health sector governance, 258 PISA (Programme for International Student home visits, 259–260, 260t Assessment), 48–51, 428 integrated interventions, 256–258, 257t Plan International, 260 maternal stress, 255 platforms for intervention delivery, 4–5b multisectoral coordination, 256–258, 257t 476 Index nutritional deficiencies, 255 disability, 223–224, 224–225t poverty, 255 malaria, 183–185, 184f, 185t, 186–187m preprimary school, 260t, 261–262 malnutrition/undernutrition, 37–41, 38–41f, 38t, primary school, 260t, 262–263 135–136 quality improvement and accountability, 259 micronutrient deficiencies, 138 risk factors, 254–256 overweight/obesity, 136–137 education, 307–324 soil-transmitted helminths, 165–169, 166m, 168t, benefit-cost ratios, 318b 170–171m, 172f, 172t conceptual framework, 308, 309f primary school, 260t, 262–263 cost-reduction interventions, 309–310, 310f Programme for International Student Assessment deworming programs, 315, 317t (PISA), 48–51, 428 health interventions, 313–319, 314b, 317t Progress in International Reading Literacy Study incentives-based interventions, 309–310, (PIRLS), 48 310f, 313t Proyector Integral de Desarrollo Infantil (Bolivia), 91 information-based interventions, 310, 311b Psacharopoulos, G., 93, 94n2 infrastructure, 311–312, 312f psychosocial interventions, 113 instructional interventions, 311–312, 312b, puberty. See also adolescence 312f, 313t affective processing and, 110 interventions, 308–319 brain development during, 109 malaria interventions, 315–316, 317t cognitive development during, 110–111 materials and technology, 312 developmental processes, 107–111 nutrition interventions, 316–317, 317t effects on health and disease, 108–109 school-based management (SBM), 310 evolutionary implications, 109 teacher resources, 312 executive control and, 110–111 middle childhood, 269–285 peer influence, sensitivity to, 110 benefit-cost ratios, 277–279, 278f, 278t stages of, 107–108 FRESH framework, 279–281, 280–281f temporal discounting and, 110 gender equity, 274–276, 275–276f timing of, 108–109 learning outcomes, 271–273, 271t, 272–273f Pullan, Rachel, 165 policy framework, 279–282 poverty reduction, 274–276, 275–276f Q SABER tool, 281 quality-adjusted life year (QALY), 358, 371–374 school health and nutrition, 270–271, 270–271f Quentin, W., 204 schools as entry point for interventions, 273–274 R sector roles, 276, 277t Rajaa, Y. A., 184–185 Plaut, Daniel, 307 Ramakrishnan, U., 101 poverty reduction Reavley, Nicola, 239, 287 early childhood, 255 Rehman, L., 134 education and, 255 reproductive health. See sexual and middle childhood, 274–276, 275–276f reproductive health Pradhan, Elina, 423 Republic of Korea. See Korea, Republic of pregnancy and prenatal health risk factors. See also health risks cash transfers and, 332 adolescence, 63–65, 64–67m, 111–112 education interventions and, 403–411, early childhood, 254–256 406–407t oral health, 213–214 maternal health and mortality, 386–387, road safety, 242, 292, 300 390–391, 403–411, 406–407t Rockers, P. C., 101 nutrition interventions during, 139–140, roundworm, 165–166. See also deworming programs 241–242, 386–389, 390–391 rubella vaccinations, 241 preprimary school, 260t, 261–262 Russian Federation prevalence rates adolescence interventions in, 375–376 anemia, 330–332 burden of disease in, 63 Index 477 Rwanda oral health in, 213 adolescence interventions in, 273, 279, 281 Sesame Street (television program), 262 middle childhood interventions in, 273, 279, 281 sexual and reproductive health nutrition in, 39–40, 158 in adolescence, 64–65, 64m, 240–241, 373, 374, 378 vaccinations in, 202 cash transfers and, 333–334 Sharma, C. P., 93 S Shih, Andy, 231 St. Lucia, early childhood interventions in, Sierra Leone 345, 347 malaria in, 188 Sandhu, J., 44 nutrition in, 39–40, 42 Santelli, John, 369 vaccinations in, 203 São Tomé and Príncipe Singapore, education in, 49–50 nutrition in, 42 SMC. See seasonal malaria chemoprevention overweight/obesity prevalence in, 39–40 Smink, F. R., 141 Sarr, Bachir, 269 smoking. See tobacco use Sawyer, Susan M., 239, 287 social determinants of health, 240 Schäferhoff, Marco, 423 social marketing. See media and social marketing Schellenberg, David, 183 social protection, 152 school attendance. See also education socioemotional development disability and, 226–227 early childhood, 89–93 malaria and, 187 middle childhood, 89–93, 101–102, school-based management (SBM), 310 102–103t school feeding programs, 147–164. soil-transmitted helminth (STH) infections, 179b. See also nutrition See also deworming programs access to education and, 153 Somanathan, R., 153, 155 benchmarking, 150–152, 151t, 152f South Africa benefit-cost ratios, 157–158, 157t, 158f adolescence interventions in, 271–272, cognitive development and, 155, 156t 375–376 defined, 282n1 burden of disease in, 63, 65 design and implementation of, 149–150 cash transfers programs in, 327, 329, 331, 333 educational outcomes and, 152–154, 153t disability in, 223 effectiveness of, 149–157 early childbirth rates in, 65 global trends, 148–149, 148f middle childhood interventions in, 271–272 local agriculture and, 150b, 156–157 nutrition in, 43, 139, 154, 390 nutrition and, 154–157 oral health in, 212 School Meals Planner software, 159b South Asia. See also specific countries social protection and, 152 adolescence interventions in, 273, 275 School Meals Planner software, 159b anemia in, 39 Schultz, Linda, 1, 221, 269 deworming programs in, 168–169 SDGs. See Sustainable Development Goals disability in, 224 seasonal malaria chemoprevention (SMC), 188, early childhood interventions in, 86–87, 90 191–193, 295 education in, 49, 313, 403, 404 secondary education as health intervention, malaria in, 185 112, 296 middle childhood interventions in, 273, 275 self-harm, 111 mortality rates in, 26, 29, 31, 33–34 self-productivity, 82 nutrition in, 38–42, 392, 393 self-regulation, 122, 127–128 underweight children in, 38 Senegal South-East Asia. See also specific countries adolescence interventions in, 270, 279, 281 anemia in, 39 early childhood interventions in, 262 burden of disease in, 63, 69 malaria in, 188, 192 deworming programs in, 172 middle childhood interventions in, 270, 279, 281 disability in, 224 nutrition in, 42 early childhood interventions in, 344 478 Index malaria in, 185 middle childhood interventions in, 273 middle childhood interventions in, 359 nutrition in, 42 nutrition in, 38–43, 138 overweight/obesity prevalence in, 39–40 underweight children in, 38, 63 Sweden Spain, illicit substance use in, 63 adolescence interventions in, 373 Spencer, R. A., 134 middle childhood interventions in, 100, 102 Sri Lanka nutrition in, 388 cash transfers programs in, 327, 331 Switzerland education in, 316 disability in, 227 malaria in, 187, 189 oral health in, 214 overweight/obesity prevalence in, 64 Synaptic pruning, 122 underweight prevalence in, 63 Systems Assessment fof Better Education Results vaccinations in, 203 (SABER), 150, 281 Srinivasan, R., 135 Stauf, Nicole, 211 T Steckel, R. H., 100 Taiwan, China Stein, A. D., 43 deworming programs in, 169 Stoll, Norman, 169 education in, 49–50 Stoltzfus, R. J., 173 Tanner, J. M., 108 stunting Tanzania early childhood, 87, 87t, 90t adolescence interventions in, 281, 377–378 middle childhood, 87, 87t, 90t, 100 cash transfers programs in, 327–331, 334 nutrition interventions, 391–392, 392f early childhood interventions in, 90, 261 Sub-Saharan Africa. See also specific countries malaria in, 191 adolescence interventions in, 112, 241–242, middle childhood interventions in, 270–271, 273–275, 279–280 281, 361 burden of disease in, 62–65, 68–69 nutrition in, 152, 387, 392 cash transfers programs in, 333, 336 school feeding program in, 152, 152f deworming programs in, 166–169, 171 vaccinations in, 200, 203–204 early childhood interventions in, 85–87, 90, Taylor-Robinson, D. C., 101, 173, 175 93, 261, 263, 344–345 TDA. See Triple Drug Administration education in, 49, 313, 318, 403, 435 temporal discounting, 110 malaria in, 183–185, 187, 189–191 tetanus vaccinations middle childhood interventions in, 270–271, benefit-cost ratios, 203–204 273–275, 279–280, 357, 359–363 delivery strategies, 200–201 mortality rates in, 26–27, 29, 31–34 effectiveness of, 13, 203 nutrition in, 39–41, 149, 155, 159, 392–393 history of, 199–200 oral health in, 213–214 Thailand underweight prevalence in, 40 adolescence interventions in, 270 Sudarshan, H., 135 burden of disease in, 63–64 sugar consumption and oral health, early childhood interventions in, 262 213, 215 education in, 318 suicide, 243–244 middle childhood interventions in, Sustainable Development Goals (SDGs) 270, 362 on adolescence interventions, 239, 369 oral health in, 212 on early childhood interventions, overweight/obesity prevalence in, 64 253, 256 Thomas, Milan, 307 on education, 14, 112, 147, 308, 424, 435 Thomas, R., 135 Suzuki, Elina M., 423 TIMSS. See Trends in International Mathematics Swaziland and Science Study adolescence interventions in, 273 tobacco use burden of disease in, 63, 65 in adolescence, 63, 65–66m, 245, 373, 374 early childbirth rates in, 65 oral health and, 213, 215 Index 479 Todd, P., 91 United States Tonga adolescence interventions in, 243, 269, 271, overweight/obesity prevalence in, 64 371–374 tobacco use in, 63 binge drinking in, 63 tooth decay, 211–212, 212f. See also oral health cash transfers programs in, 325–326 Trends in International Mathematics and Science deworming programs in, 165, 169 Study (TIMSS), 48–49, 51, 262, 428 disability in, 221, 224, 225t, 227–228, 231 Triple Drug Administration (TDA), 177 early childhood interventions in, 85, 91, 93, Tunisia 344, 346 disability in, 226 education in, 47, 307, 403 vaccinations in, 201 illicit substance use in, 63 Turkey middle childhood interventions in, 100, 102, burden of disease in, 69 269, 271, 361 early childhood interventions in, 91, 259, 344, 346, nutrition in, 37, 43, 139, 141, 148, 154–155, 385, 348–349 388, 390 middle childhood interventions in, 100, 102 oral health in, 211–213, 216 Turner, Hugo C., 165 overweight/obesity prevalence in, 63 sexual and reproductive health in, 65 U upper-middle-income countries UCTs. See unconditional cash transfers adolescence interventions in, 374 Uganda early childhood interventions in, 349–350 adolescence interventions in, 279 education in, 424, 432, 434 cash transfers programs in, 328–330, 332–334 middle childhood interventions in, 355, 362–363 deworming programs in, 167, 178, 416 oral health in, 211 disability in, 223 Uruguay early childhood interventions in, 90, 260–261, 350 cash transfers programs in, 327–328, 330, 332 education in, 316 early childhood interventions in, 92, 344–346, malaria in, 187–188, 190 348–349 middle childhood interventions in, 100, 279 hearing loss in, 232 nutrition in, 39–40, 42, 135, 152–153, 155, nutrition in, 137 392, 395 U.S. Agency for International Development (USAID), school feeding program in, 152, 152f 58, 262–263, 419 vaccinations in, 202, 204–205 Ukraine, burden of disease in, 63 V unconditional cash transfers (UCTs), 325, 329–337, vaccinations, 199–209 339, 341 in adolescence, 241 undernutrition. See malnutrition/undernutrition hepatitis, 241 underweight HPV, 60, 200 adolescence, 39, 39f, 40–41, 41f, 63, 241–242 benefit-cost ratios, 204–206, 204t early childhood, 38, 38f, 86 delivery strategies, 201–203, 202m middle childhood, 86 effectiveness, 203 women (15–49 years), 40–41, 41f malaria vaccine development, 192, 241 UNESCO Institute for Statistics, 262–263, 273 middle childhood, 360, 362 United Kingdom program design for school-based delivery, adolescence interventions in, 107, 371–373 200–203 disability in, 225 rubella, 241 education in, 50, 314 tetanus, 13, 199–200 malaria in, 183 benefit-cost ratios, 203–204 middle childhood interventions in, 99, 355 delivery strategies, 200–201 nutrition in, 147, 154, 390 effectiveness, 203 United Nations Development Programme, 215 Vaccine Alliance, 203 United Nations Population Division, 8, 30, Van der Sluis, J., 94n2 32, 34 Van Hoeken, D., 141 480 Index Van Praag, M., 94n2 on anemia prevalence, 38, 38t Varenne, Benoit, 211 on deworming programs, 171–172, 413–415, 419 Vargas-Barón, E., 256 on early childhood interventions, 256, 259 vector control for malaria, 190–191 Global Health Estimates (GHE), 32, 33–34t Verguet, Stéphane, 403 on malaria, 185–186, 189–190 Vermeersch, C., 153 on middle childhood interventions, 10, 357 Vietnam on mortality causes, 25 burden of disease in, 69 on nutrition, 135, 153–154 disability in, 225–226, 229, 230t on oral health, 213 early childhood interventions in, 90 on soil-transmitted helminth (STH) education in, 49, 317 infections, 179b middle childhood interventions in, 101 World Population Prospects (WPP), 32 nutrition in, 43, 154, 158 Worthington, Jordan, 307 vaccinations in, 202, 204–205 Worthman, C. M., 111 Vijverberg, W., 94n2 Wu, Kin Bing, 47 Viner, Russell M., 107 violence Y adolescence and, 111, 242–243 Yakubu, Ahmadu, 199 early child development and, 4b Yamasaki, I., 223, 226 vision correction, 13, 228–229 Yemen Vitor-Silva, S., 185 early childhood interventions in, 90 malaria in, 184 W nutrition in, 392 Waldfogel, Jane, 369 underweight prevalence in, 63 Walker, Susan, 79, 93 Yin, Y. N., 140 Wang, H., 25 Youth for Road Safety (YOURS), 300 Washington Group on Disability Statistics, 222, 229b Z wasting, 87 Zambia Watkins, Kristie L., 99 adolescence interventions in, 279 Watson-Jones, Deborah, 199 cash transfers programs in, 327–328, West, Kristine, 228 331–332, 334 whipworm, 165–166. See also deworming programs disability in, 226 WHO. See World Health Organization middle childhood interventions in, 279 WHO and World Bank, 221–222, 225–226 sexual and reproductive health in, 65 Woessmann, L., 47 Zanzibar women. See also gender equity adolescence interventions in, 281 anemia in, 41, 42f disability in, 228, 230 overweight/obesity in, 40–41, 41f early childhood interventions in, 261 underweight in, 40–41, 41f middle childhood interventions in, 281 World Development Report 2007: Development and Zimbabwe the Next Generation (World Bank), 5 adolescence interventions in, 279 World Education Forum, 169, 214, 230, 270, 279 disability in, 226 World Health Assembly, 61, 171 health and education outcomes in, 16 World Health Organization (WHO) middle childhood interventions in, 279 on adolescence interventions, 61–62, 242–243, nutrition in, 39–40, 42 291–293, 379–380 Zimmerman, Linnea, 25, 26, 32 Index 481 ECO-AUDIT Environmental Benefits Statement The World Bank Group is committed to reducing its environmental footprint. In support of this commitment, we leverage electronic publishing options and print- on-demand technology, which is located in regional hubs worldwide. 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