Selected Publications

Linda H. AikenMarta SimonettiDouglas M SloaneConsuelo CerónDavid BravoAlejandra GalianoPaz SotoJere R. BehrmanHerbert L SmithMatthew D McHughEileen T Lake

(2021). “Hospital nurse staffing and patient outcomes in Chile: a multilevel cross-sectional study”, The Lancet Global Health, In Press.



Unrest in Chile over inequalities has underscored the need to improve public hospitals. Nursing has been overlooked as a solution to quality and access concerns, and nurse staffing is poor by international standards. Using Chile’s new diagnosis-related groups system and surveys of nurses and patients, we provide information to policy makers on feasibility, net costs, and estimated improved outcomes associated with increasing nursing resources in public hospitals.


For this multilevel cross-sectional study, we used data from surveys of hospital nurses to measure staffing and work environments in public and private Chilean adult high-complexity hospitals, which were linked with patient satisfaction survey and discharge data from the national diagnosis-related groups database for inpatients. All adult patients on medical and surgical units whose conditions permitted and who had been hospitalised for more than 48 h were invited to participate in the patient experience survey until 50 responses were obtained in each hospital. We estimated associations between nurse staffing and work environment quality with inpatient 30-day mortality, 30-day readmission, length of stay (LOS), patient experience, and care quality using multilevel random-effects logistic regression models and zero-truncated negative binomial regression models, with clustering of patients within hospitals.


We collected and analysed surveys of 1652 hospital nurses from 40 hospitals (34 public and six private), satisfaction surveys of 2013 patients, and discharge data for 761 948 inpatients. Nurse staffing was significantly related to all outcomes, including mortality, after adjusting for patient characteristics, and the work environment was related to patient experience and nurses’ quality assessments. Each patient added to nurses’ workloads increased mortality (odds ratio 1·04, 95% CI 1·01–1·07, p<0·01), readmissions (1·02, 1·01–1·03, p<0·01), and LOS (incident rate ratio 1·04, 95% CI 1·01–1·06, p<0·05). Nurse workloads across hospitals varied from six to 24 patients per nurse. Patients in hospitals with 18 patients per nurse, compared with those in hospitals with eight patients per nurse, had 41% higher odds of dying, 20% higher odds of being readmitted, 41% higher odds of staying longer, and 68% lower odds of rating their hospital highly. We estimated that savings from reduced readmissions and shorter stays would exceed the costs of adding nurses by US$1·2 million and $5·4 million if the additional nurses resulted in average workloads of 12 or ten patients per nurse, respectively.


Improved hospital nurse staffing in Chile was associated with lower inpatient mortality, higher patient satisfaction, fewer readmissions, and shorter hospital stays, suggesting that greater investments in nurses could return higher quality of care and greater value.


Sigma Theta Tau International, University of Pennsylvania Global Engagement Fund, University of Pennsylvania School of Nursing’s Center for Health Outcomes, and Policy Research and Population Research Center.
Maureen M BlackJere R. BehrmanBernadette Daelmans
et al (2021). “The principles of Nurturing Care promote human capital and mitigate adversities from preconception through adolescence.”

A comprehensive evidence-based framework is needed to guide policies and programmes that enable children and adolescents to accrue the human capital required to meet the Sustainable Development Goals (SDGs).

This paper proposes a comprehensive, multisectoral, multilevel life-course conceptualization of human capital development by building on the Nurturing Care Framework (NCF), originally developed for the foundational period of growth and development through the age 3 years. Nurturing care (NC) comprises stable environments that promote children’s health and nutrition, protect from threats, and provide opportunities for learning and responsive, emotionally supportive, and developmentally enriching relationships. NC is fostered by families, communities, services, national policies, and beyond.

The principles apply across the life course, endorse equity and human rights, and promote long-term human capital. This paper presents an evidence-based argument for the extension of the NCF from preconception through adolescence (0–20 years), organised into six developmental periods: preconception/prenatal, newborn/birth, infancy/toddlerhood, preschool, middle childhood, and adolescence.

The proposed framework advances human capital within each developmental period by promoting resilience and adaptive developmental trajectories while mitigating the negative consequences of adversities.

Attaining the SDGs depends on strengthening human capital formation, extending throughout childhood and adolescence and supported by NC. Embedded in enabling laws, policies, and services, the dynamic NCF components can mitigate adversities, enhance resilience and promote the well-being of marginalised groups. The life-course extension of the NCF is strategically positioned to enhance human capital, attain the SDGs, and to ensure that children or adolescents are not left behind in reaching their developmental potential.

Jere R. Behrman

(2021). “Social Mobility and Human Capital in Low- and Middle-Income Countries,” in Social Mobility in Developing Countries: Concepts, Methods, and Determinants, edited by Vegard Iversen, Anirudh Krishna, and Kunal Sen, Oxford, UK: Oxford University Press, 2021, in Press.

Parental human capital and endowments may affect children’s human capital, which in turn may affect children’s earning and occupations and thus affect social mobility.

This paper focuses on what we know about these possible links in low- and middle-income countries. It starts with definitions of human capital and endowments and simple frameworks for guiding the summary of what we know and do not know about these links in low- and middle-income countries.

It discusses determinants of children’s human capital in the form of cognitive skills, socioemotional skills, and health, which pertain directly to some indicators of social mobility; reviews estimates of the impacts of these forms of human capital, which pertain to some other indicators of social mobility, such as incomes and earnings; and concludes with a summary suggesting some positive impacts of parental human capital and endowments on social mobility in low- and middle-income countries and a discussion of gaps in the literature pertaining to both data and methodology.

Andreas GeorgiadisJere R. BehrmanLiza Benny

(2021). “Maternal Undernutrition in Adolescence and Child Human Capital Formation over the Life-Course: Evidence from an International Cohort Study”, Economica, in press.

Maternal undernutrition and adolescent childbearing are prevalent in low- and middle-income countries and have harmful consequences for children. However, less is known on whether these implications persist throughout the offspring’s life course. Moreover, although adult nutritional status has been suggested to largely reflect conditions during the period from conception to 2 years old (“the first 1,000 days”), others have argued that adolescence is an equally important period for nutrition. This is not well established, however, and there is less evidence on the relative importance of conditions during the first 1,000 days of a girl’s life, versus during adolescence, for her nutritional status during pregnancy.

This working paper addresses these gaps through two interrelated investigations. First, we document associations of mothers’ stunting and adolescent childbearing with their children’s developmental outcomes from infancy through early adolescence, using data on a cohort of children and their mothers from Ethiopia, India, Peru, and Vietnam. Second, in order to infer whether maternal adult undernutrition may reflect undernutrition during adolescence, we use data from another cohort of girls in each of these countries who were surveyed throughout adolescence to estimate the extent of catch-up growth during adolescence.

The results suggest that maternal stunting and adolescent childbearing are both associated with offspring stunting at infancy, that the association between the mother’s and offspring’s stunting persists through the offspring’s early adolescence, and that the two maternal outcomes are not systematically associated with offspring cognitive achievement.

Angela TrudeLinda RichterJere R. BehrmanAryeh D. SteinAna M. B. MenezesMaureen M Black

(2021). “Mitigating effects of responsive caregiving and learning opportunities during preschool ages on the association of early adversities on adolescent IQ: evidence from birth cohorts in two middle-income countries”, The Lancet Child & Adolescent Health 5: 37-46.


Millions of children globally are at risk of not reaching their developmental potential because of early adversities. We hypothesized that responsive caregiving and learning opportunities, components of nurturing care, at pre-school ages might mitigate the effects of adversities.


We analyzed longitudinal birth cohort data from Brazil (1993 Pelotas Birth Cohort, n=632) and South Africa (Birth to Twenty Plus [Bt20+] Birth Cohort, n=1130) to assess whether responsive caregiving and learning opportunities at pre-school ages (2–4 years) modified associations between cumulative early adversities and adolescent human capital. The cumulative adversities score (range 0–9) included household wealth and crowding; mothers’ schooling, height, age, and mental health; and children’s birth weight, gestational age, and length at age 12 months. We extracted data on responsive caregiving and learning opportunities from the Early Childhood Home Observation for Measurement of the Environment Inventory, assessed at age 4 years (1993 Pelotas cohort) and 2 years (Bt20+ cohort). We examined three human capital indicators: intelligence quotient (IQ) assessed at age 18 years (1993 Pelotas cohort) and 16 years (Bt20+ cohort); psychosocial adjustment assessed at age 15 years and 14 years, respectively; and height assessed at age 18 years and 16 years, respectively. We used linear models with interaction terms between cumulative adversities, and responsive caregiving and learning opportunities, to predict adolescent human capital.


For each additional Z score of total cumulative adversity, adolescent IQ decreased by 5·89 (95% CI −7·29 to −4·50) points in the 1993 Pelotas cohort (p<0·0001) and 2·69 (–4·52 to −0·86) points in the Bt20+ cohort (p=0·0039). After adjusting for total cumulative adversities, adolescent IQ points increased by 5·47 (95% CI 4·20 to 6·74) with each additional Z score of learning opportunities and by 2·26 (0·93 to 3·59) with each additional Z score of responsive caregiving in the 1993 Pelotas cohort, but not in the Bt20+ cohort (0·86 [–0·12 to 1·83] and 0·65 [–0·32 to 1·61], respectively). Associations between early adversities and IQ were modified by learning opportunities in the 1993 Pelotas cohort (beta coefficient for interaction 1·74, 95% CI 0·43 to 3·04; p=0·0092) and by responsive caregiving in the Bt20+ cohort (2·24, 0·94 to 3·54; p=0·0075). A high nurturing environment attenuated the negative effects of early cumulative adversities on IQ.
Xiaoying LiuJere R. BehrmanEmily HannumFan WangQingguo Zhao

(2021). “Same environment, stratified impacts? Air pollution, extreme temperatures, and birth weight in Southeast China,”  SSRN.

Ambient air pollution and extreme temperatures have been associated in a number of settings with adverse birth outcomes. However, some newborns may be more vulnerable than others. First, the pathway from ambient conditions to adverse birth outcomes could vary according to indicators of socioeconomic status such as maternal education. For example, less-educated mothers may be more vulnerable than more-educated mothers if they lack access to living, work, transportation, and leisure spaces with indoor air filtration and temperature regulation, or if they lack knowledge of or resources for mitigation strategies. Second, overall effect modifications associaed with maternal education may mask another source of heterogeneity: babies’ underlying innate health. Protective effects of maternal education may be more pronounced for the most physically vulnerable babies.

Linking 54,828 singleton live birth records from a district in Guangzhou, China to ambient air pollution (PM10 and a composite measure) and extreme temperature data, we test whether, overall, maternal education is an “effect modifier” in the relationships between ambient air pollution, extreme temperature, and birth weight. Via conditional quantile regressions, we then test for effect heterogeneity according to the underlying physical vulnerability of babies–those further to the left in the conditional distribution of birth weight–after conditioning on other confounders. Results show that the protection associated with a college-educated mother with respect to pollution and extreme heat is substantial: up to 0.31 standard deviations of birth weight. Importantly, this protection is amplified under more extreme ambient conditions and for physically vulnerable infants, after conditioning on other confounders.

Karen AustrianErica Soler-HampejsekJere R. BehrmanJean DigitaleMaximillian BweupePaul C. Hewett

(2020). “The impact of the Adolescent Girls Empowerment Program (AGEP) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in Zambia.” BMC Public Health. 20, 349.


Adolescent girls in Zambia face risks and vulnerabilities that challenge their healthy development into young women: early marriage and childbearing, sexual and gender-based violence, unintended pregnancy and HIV. The Adolescent Girls Empowerment Program (AGEP) was designed to address these challenges by building girls’ social, health and economic assets in the short term and improving sexual behavior, early marriage, pregnancy and education in the longer term. The two-year intervention included weekly, mentor-led, girls group meetings on health, life skills and financial education. Additional intervention components included a health voucher redeemable for general wellness and reproductive health services and an adolescent-friendly savings account.


A cluster-randomized-controlled trial with longitudinal observations evaluated the impact of AGEP on key indicators immediately and two years after program end. Baseline data were collected from never-married adolescent girls in 120 intervention clusters (3515 girls) and 40 control clusters (1146 girls) and again two and four years later. An intent-to-treat analysis assessed the impact of AGEP on girls’ social, health and economic assets, sexual behaviors, education and fertility outcomes. A treatment-on-the-treated analysis using two-stage, instrumental variables regression was also conducted to assess program impact for those who participated.


The intervention had modest, positive impacts on sexual and reproductive health knowledge after two and four years, financial literacy after two years, savings behavior after two and four years, self-efficacy after four years and transactional sex after two and four years. There was no effect of AGEP on the primary education or fertility outcomes, nor on norms regarding gender equity, acceptability of intimate partner violence and HIV knowledge.


Although the intervention led to sustained change in a small number of individual outcomes, overall, the intervention did not lead to girls acquiring a comprehensive set of social, health and economic assets, or change their educational and fertility outcomes. It is important to explore additional interventions that may be needed for the most vulnerable girls, particularly those that address household economic conditions. Additional attention should be given to the social and economic environment in which girls are living.

Arindam NandiJere R. BehrmanRamanan Laxminarayan

(2020). “The Impact of a National Early Childhood Development Program on Future Schooling Attainment: Evidence from ICDS in India”, Economic Development and Cultural Change. 69:1, 291-316.

Evidence on the long-term benefits of early-life interventions remains inadequate in developing countries. In this paper, we evaluate the effect of India’s Integrated Child Development Services (ICDS), a national program of supplementary nutrition and health services, on schooling.

Using national survey data and employing age-state and village or city ward fixed-effect regression, we find that non-migrant 15- to 54-year-old men and 15- to 49-year-old women who were exposed to an ICDS center during the first three years of life completed 0.1–0.3 more grades of schooling than those who were not exposed. The effect is stronger among women than men.

Sally Grantham-McGregorAkanksha AdyaOrazio AttanasioBritta AugsburgJere R. BehrmanBet CaeyersMonimalika DayPamela JervisReema KocharPrerna MakkarCostas MeghirAngus PhimisterMarta Rubio-CodinaKarishma Vats

(2020). “Group Sessions or Home Visits for Early Childhood Development in India: A Cluster RCT”, Pediatrics. 146 (6) e2020002725

OBJECTIVES: Poor early childhood development in low- and middle-income countries is a major public health problem. Efficacy trials have shown the potential of early childhood development interventions but scaling up is costly and challenging. Guidance on effective interventions’ delivery is needed. In an open-label cluster-randomized control trial, we compared the effectiveness of weekly home visits and weekly mother-child group sessions. Both included nutritional education, whose effectiveness was tested separately.

METHODS: In Odisha, India, 192 villages were randomly assigned to control, nutritional education, nutritional education and home visiting, or nutritional education and group sessions. Mothers with children aged 7 to 16 months were enrolled (n = 1449). Trained local women ran the two-year interventions, which comprised demonstrations and interactions and targeted improved play and nutrition. Primary outcomes, measured at baseline, midline (12 months), and endline (24 months), were child cognition, language, motor development, growth and morbidity.

RESULTS: Home visiting and group sessions had similar positive average (intention-to-treat) impacts on cognition (home visiting: 0.324 SD, 95% confidence interval [CI]: 0.152 to 0.496, P = .001; group sessions: 0.281 SD, 95% CI: 0.100 to 0.463, P = .007) and language (home visiting: 0.239 SD, 95% CI: 0.072 to 0.407, P = .009; group sessions: 0.302 SD, 95% CI: 0.136 to 0.468, P = .001). Most benefits occurred in the first year. Nutrition-education had no benefit. There were no consistent effects on any other primary outcomes.

CONCLUSIONS: Group sessions cost $38 per child per year and were as effective on average as home visiting, which cost $135, implying an increase by a factor of 3.5 in the returns to investment with group sessions, offering a more scalable model. Impacts materialize in the first year, having important design implications.

Arindam NandiAnita ShetJere R. BehrmanMaureen M BlackDavid E BloomRamanan Laxminarayan

(July 2020). Anthropometric, Cognitive, and Schooling Benefits of Measles Vaccination: Longitudinal Cohort Analysis in Ethiopia, India, and Vietnam. Vaccine, 37(31), 4336-4343. 


To estimate the associations between measles vaccination and child anthropometry, cognition, and schooling outcomes in Ethiopia, India, and Vietnam.


Longitudinal survey data from Young Lives were used to compare outcomes at ages 7–8 and 11–12 years between children who reported receipt or non-receipt of measles vaccine at 6–18 months-of-life (n = ∼2000/country). Z-scores of height-for-age (HAZ), BMI-for-age (BMIZ), weight-for-age (WAZ), Peabody Picture Vocabulary Test (PPVT), early grade reading assessment (EGRA), language and mathematics tests, and attained schooling grade were examined. Propensity score matching was used to control for systematic differences between measles-vaccinated and measles-unvaccinated children.


Using age- and country-matched measles-unvaccinated children as comparisons, measles-vaccinated children had better anthropometrics, cognition, and schooling. Measles-vaccinated children had 0.1 higher HAZ in India and 0.2 higher BMIZ and WAZ in Vietnam at age 7–8 years, and 0.2 higher BMIZ at age 11–12 years in Vietnam. At ages 7–8 years, they scored 4.5 and 2.9 percentage points (pp) more on PPVT and mathematics, and 2.3 points more on EGRA in Ethiopia, 2.5 points more on EGRA in India, and 2.6 pp, 4 pp, and 2.7 points more respectively on PPVT, mathematics, and EGRA in Vietnam. At ages 11–12 years, they scored 3 pp more on English and PPVT in India, and 1.7 pp more on PPVT in Vietnam. They also attained 0.2–0.3 additional schooling grades across all ages and countries.


Our findings suggest that measles vaccination may have benefits on cognitive gains and school-grade attainment that can have broad educational and economic consequences that extend beyond early childhood.

Whitney SchottElisabetta AurinoMary PennyJere R. Behrman

(May 2020). Time use and Sexual Maturity−related Indicators Differentially Predict Youth Body Mass Indices, Peruvian Girls Versus Boys. Annals of the New York Academy of Sciences, 1468(1), 55-73. 

Rapid development in Latin America has been accompanied by lifestyle shifts, including changes in time use and social environments. Overweight/obesity has also emerged as a public health challenge. We examined whether lifestyle changes and sexual maturity−related indicators (early pubertal development and having a child) predict increases in adiposity among Peruvian youth.

Using longitudinal data from Young Lives, we examined changes in adiposity between ages 8 and 15 years old for the younger cohort and ages 15 and 22 years old for the older cohort. Boys and girls in both cohorts demonstrated substantial increases in age‐adjusted adiposity measures, but predictors were different for boys versus girls.

For boys, increases in time spent in work and domestic chores predicted increases in adiposity body mass index and BMI‐for‐age Z‐score, and increases in time spent sleeping were associated with decreases in adiposity (waist circumference and waist‐to‐height ratio). For girls, sexual maturity−related indicators (early menarche and childbearing) predicted increases in adiposity, regardless of time use.

Potential mechanisms for these results may include diet, physical activity, wealth, and urban−rural residence. Time use among youth was associated with diet quality and physical activity, but in different ways for boys versus girls. Strategies for dealing with rising overweight and obesity should incorporate sex‐based specificities.

Yuan HuJunsen ZhangJere R. Behrman

(2020). “The Causal Effects of Parents’ Schooling on Children’s Schooling in Urban China”, Journal of Comparative Economics.

Parental schooling is widely thought to improve child outcomes. But most studies on parental-child relations are associative, without control for estimation problems, such as unobserved intergenerationally-correlated endowments, if causality is of interest. The few exceptions are relatively recent studies that focus on high-income countries (HICs), with their much different contexts than the low- and middle-income countries (LMICs) in which the vast majority of children globally are growing up.

This paper estimates the causal (conditional on the assumptions for the model) relationships between parents’ schooling and their children’s schooling in the most populous LMIC, using adult identical (monozygotic, MZ) twins data from urban China. Our ordinary least-squares estimates show that one-year increases in maternal and paternal schooling are associated, respectively, with 0.4 and 0.5 more years of children’s schooling.

However, if we control for genetic and other endowment effects by using within-MZ fixed effects, the results indicate that mothers’ and fathers’ schooling have no significant effects on children’s schooling. Our main results remain with various robustness checks, including controlling for measurement error.

These results suggest that the positive associations between children’s and parents’ schooling in standard cross-sectional estimates in this major LMIC are mainly due to the correlation between parents’ unobserved endowments and their schooling and not the effects of their schooling per se.

Sarah E. WeingartenKirk A. DeardenBenjamin T. CrookstonMary PennyJere R. BehrmanDebbie L. Humphries

(July 2020). Are Household Expenditures on Food Groups Associated with Children’s Future Heights in Ethiopia, India, Peru, and Vietnam? International Journal of Environmental Research and Public Health, 17(13), 4739. 

Household expenditure surveys, routinely conducted in low—and middle-income countries (LMICs), usually include questions pertaining to recent household expenditures on key food groups. When child anthropometrics are also available, such expenditure data can provide insights into household food purchasing patterns that are associated with subsequent child growth measures.

We used data from 6993 children, born around 2001, from Ethiopia, India, Peru, and Vietnam, from the Young Lives younger cohort. We compared associations between two weeks of household food expenditures (in PPP—Purchasing Power Parity adjusted dollars) on food groups and child height-for-age-Z score (HAZ) at subsequent time points to assess longitudinal associations. Total food expenditures, rural/urban residence, maternal and paternal schooling, and child sex were included in our adjusted models because they may affect the relations between household food group expenditures and future child HAZ.

In Ethiopia, India, and Peru every extra PPP$ spent on fats was associated with 0.02–0.07 higher future HAZ. In Vietnam, every extra PPP$ spent on starches, was significantly associated with a 0.01 lower future HAZ. Across countries, different patterns of food expenditure and procurement may be differentially critical for predicting child HAZ. Our results demonstrate how expenditures on specific food groups can be associated with children’s linear growth. This study provides additional evidence of the utility of longitudinal household food expenditure data in understanding child nutritional status.

Paul C. HewettAmanda L. WilligJean DigitaleErica Soler-HampejsekJere R. BehrmanKaren Austrian

(July 2020). Assessment of an adolescent-girl-focused nutritional educational intervention within a girls’ empowerment programme: a cluster randomised evaluation in Zambia. Public Health Nutrition, 1-14. 


Adolescent girls are at risk for both macro- and micronutrient deficiencies affecting growth, maternal and child health. This study assessed the impact of an adolescent-girl-tailored nutritional education curriculum on nutritional outcomes, including knowledge, dietary behaviour, anthropometry and anaemia.


A cluster-randomised evaluation was conducted with two study arms: girls in mentor-led weekly girls’ groups receiving sexual and reproductive health and life-skills training assigned to an age-appropriate nutritional curriculum and control girls in the weekly girls’ groups without the nutritional education. The primary analysis was intent-to-treat (ITT) generalised least squares regression. Secondary analysis using two-stage, instrumental-variables estimation was also conducted.


The intervention and evaluation were conducted in urban and rural areas across four of ten provinces in Zambia.


In total, 2660 girl adolescents aged 10–19 years were interviewed in 2013 (baseline) and annually through 2017.


ITT results indicate that exposure to the nutritional educational programme did not meaningfully change outcomes for adolescents or their children. Intervention adolescents were no more likely to correctly identify healthy foods (P = 0·51) or proper infant-feeding practices (P = 0·92); were no less likely to be stunted (P = 0·30) or underweight (P = 0·87) and no less likely to be anaemic (P = 0·38). Outcomes for children of intervention participants were not improved, including being breastfed (P = 0·42), stunted (P = 0·21), wasted (P = 0·77) or anaemic (P = 0·51).


Even a high-quality nutritional educational intervention tailored to adolescents within an empowerment programme does not assure improved nutritional outcomes; adolescent preferences, resource control and household dynamics require consideration in the context of nutritional educational programmes.

Jere R. BehrmanJohn HoddinottJohn Maluccio

(June 2020). Nutrition, Adult Cognitive Skills, and Productivity: Results and Influence of the INCAP Longitudinal Study. Food and Nutrition Bulletin, 41(1), S41-S49. 

This article summarizes research based on the INCAP Longitudinal Study that demonstrates the positive effects of the atole intervention on prime-age adult cognitive skills and productivities.

The findings are interpreted in the context of a life-cycle stage model in which various factors and investments at each stage of life influence outcomes not only in that stage but in subsequent ones. The results point to the likely importance of improvements in adult cognitive skills due to better early-life nutrition on adult male labor market outcomes as well as on women’s “home productivity” in terms of anthropometrics for the next generation.

Possible mechanisms are also explored, including the impacts of early-life exposure to atole on children’s height when starting school, on grades of schooling attainment, and on the extent of experience with higher-skilled jobs, as well as the impacts of improved cognitive skills on wages. Not only are investments in early-life nutrition important for immediate welfare but also they have significant productivity payoffs in adulthood.

Subha ManiJere R. BehrmanSheikh GalabPrudhvikar Reddy

(May 2020). Impact of the NREGS on Children’s Intellectual Human Capital. The Journal of Development Studies, 56(5), 929-945. 

This paper uses panel data from the Young Lives Survey to examine the effect of the world’s largest public works program and India’s flagship social protection program, the National Rural Employment Guarantee Scheme (NREGS), on children’s learning outcomes such as grade progression, reading comprehension test scores, writing test scores, math test scores, and Peabody Picture Vocabulary Test (PPVT) scores.

We find that the program has strong positive effects on these outcomes in both the short-and-medium run. Finally, the impact estimates reported here are robust to a number of econometric concerns such as – program placement, selective attrition, and type I error.

Arindam NandiJere R. BehrmanMaureen M BlackSanjay KinraRamanan Laxminarayan

(2020). “Relationship between Early-Life Nutrition and Ages at Menarche and First Pregnancy, and Childbirth Rates of Young Adults: Evidence from Apcaps in India.” Maternal & Child Nutrition. 16(1) e12854.

India’s Integrated Child Development Services (ICDS) provides daily supplementary nutrition and other public health services to women and children. We estimated associations between exposure to early-childhood ICDS nutrition and adult reproductive outcomes.

During 1987-1990, a balanced protein-calorie supplement called “upma”-made from locally available corn-soya ingredients-was rolled out by subdistricts near Hyderabad and offered to pregnant women and children under age 6 years. In a controlled trial, 15 villages received the supplement and 14 did not. We used data from a 2010-2012 resurvey of adults born during the trial (n = 715 in intervention and n = 645 in control arms). We used propensity score matching methods to estimate the associations between birth in an intervention village and menarcheal age, age at first pregnancy, and fertility of adults.

We found that women born in the intervention group during the trial, as compared with the control group, had menarche 0.45 (95% confidence interval [CI: 0.22, 0.68]; p < .001) years later and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later. Married women from the intervention group had menarche 0.36 (95% CI [0.09, 0.64]; p < .01) years later, first cohabitation with partner 0.8 (95% CI [0.27, 1.33]; p < .01) years later, and first pregnancy 0.53 (95% CI [0.04, 1.02]; p < .05) years later than married women in the control group.

There was no significant difference between intervention and control group women regarding whether they had at least one childbirth or the total number of children born. The findings were similar when we employed inverse propensity score weighted regression models.

Alan SánchezGuido MeléndezJere R. Behrman

 (April 2020). Impact of the Juntos Conditional Cash Transfer Program on Nutritional and Cognitive Outcomes in Peru: Comparison between Younger and Older Initial Exposure. Economic Development and Cultural Change, 68(3), 865-897. 

We evaluate whether the Juntos conditional cash transfer program in Peru has a larger effect on children who benefited initially from the program during the first 4 years of life compared with those children who benefited initially between ages 5 and 8. The former group was exposed during early-life sensitive periods, received the program for a longer period, and received more growth monitoring sessions and vaccinations.

We find that exposure to Juntos led to an improvement in nutritional status and in cognitive achievement, both of which were greater, but only the latter was significant for those initially exposed during the first 4 years of life.

Luca Maria PesandoSharon WolfJere R. BehrmanEdward Tsinigo

 (February 2020). Are Private Kindergartens really Better? Examining Preschool Choices, Parental Resources, and Children’s School Readiness in Ghana. Comparative Education Review, 64(1), 107-136. 

Low-cost private schools are expanding across sub-Saharan Africa and are often perceived by parents to be of better quality than public schools. This article assesses the interplay between kindergarten (or preschool) choice, household resources, and children’s school readiness in Ghana. We examine how child, household, and school characteristics predict private versus public kindergarten attendance and whether household characteristics are associated with school readiness beyond preschool selection.

Using a geospatial-identification strategy to account for observed and unobserved determinants of preschool choice, we find that parental investments—including the number of books at home and caregiver help with homework—predict both private-preschool selection and start-of-year child outcomes beyond their influence on preschool choice. We take this evidence as suggesting that investments in children support learning beyond simply selecting the presumed best preschool type.

We also find independent associations between attending private preschool and one-year changes in early literacy scores. The findings contribute knowledge to the literature on the recent expansion of preschool education in sub-Saharan Africa and globally and shed new light on the role of private-preschool attendance in early academic skill development.

Elisabetta AurinoWhitney SchottJere R. BehrmanMary Penny

(2020).”Nutritional Status from 1 to 15 and Adolescent Learning for Boys and Girls in Ethiopia, India, Peru and Vietnam,” Population Research and Policy Review. 38, pages 899–931.

There has been little examination of (1) associations of early-life nutrition and adolescent cognitive skills, (2) if they vary by gender, (3) if they differ by diverse contexts, and (4) contributions of post-infancy growth to adolescent cognitive attainment. We use Young Lives data on 7687 children from Ethiopia, India, Peru, and Vietnam to undertake ordinary least squares estimates of associations between age-1 height-for-age z-score (HAZ) and age-15 cognitive outcomes (math, reading, vocabulary), controlling for child and household factors. Age-1 HAZ is positively associated with cognitive scores in all countries.

Child gender-specific estimates for these coefficients either do not differ (math, reading) or favor girls (vocabulary). Augmenting models to include growth in HAZ between ages 1 and 15 years that was not predicted by HAZ at age 1 reveals that such improvements are associated with higher cognitive scores, but that sex-specific coefficients for this predictor favor boys in India and Peru.

The results suggest that nutritional indicators at age 1 have gender-neutral associations with math and reading and favor girls for vocabulary achievement at age 15, but unpredicted improvements in HAZ by adolescence are associated with higher cognitive scores for boys than for girls. This evidence enriches our understanding of relationships between children’s nutritional trajectories during childhood and adolescent cognitive development, and how these associations vary by gender in some contexts to the possible disadvantage of girls.

M. Farhan MajidJere R. Behrman

(2020). “Early Life Health and Economic Success in Adulthood” in Klaus F. Zimmermann, ed., Handbook of Labor, Human Resources and Population Economics, New York, New York: Springer Publishing Co.

This handbook provides an integrated picture of knowledge about the economic and social behaviors and interactions of human beings on markets, in households, in companies and in societies. With a core basis in labor economics, human resources, demography and econometrics, it contains a large and complete summary and evaluation of the scientific state of the art.

It relates to relevant fields in law, behavioral science, psychology, health, biology, sociology and political science, among others, where basic human processes are considered. Long survey chapters on core knowledge are combined with shorter frontier research chapters and those with a clear policy perspective.

Elisabetta AurinoWhitney SchottJere R. BehrmanMary Penny

(October 2019). Nutritional Status from 1 to 15 Years and Adolescent Learning for Boys and Girls in Ethiopia, India, Peru, and Vietnam. Population Research and Policy Review, 38(6), 899-931. 

There has been little examination of (1) associations of early-life nutrition and adolescent cognitive skills, (2) if they vary by gender, (3) if they differ by diverse contexts, and (4) contributions of post-infancy growth to adolescent cognitive attainment. We use Young Lives data on 7687 children from Ethiopia, India, Peru, and Vietnam to undertake ordinary least squares estimates of associations between age-1 height-for-age z-score (HAZ) and age-15 cognitive outcomes (math, reading, vocabulary), controlling for child and household factors. Age-1 HAZ is positively associated with cognitive scores in all countries.

Child gender-specific estimates for these coefficients either do not differ (math, reading) or favor girls (vocabulary). Augmenting models to include growth in HAZ between ages 1 and 15 years that was not predicted by HAZ at age 1 reveals that such improvements are associated with higher cognitive scores, but that sex-specific coefficients for this predictor favor boys in India and Peru.

The results suggest that nutritional indicators at age 1 have gender-neutral associations with math and reading and favor girls for vocabulary achievement at age 15, but unpredicted improvements in HAZ by adolescence are associated with higher cognitive scores for boys than for girls. This evidence enriches our understanding of relationships between children’s nutritional trajectories during childhood and adolescent cognitive development, and how these associations vary by gender in some contexts to the possible disadvantage of girls.

Alison ButtenheimMichael Z. LevyRicardo Castillo-NeyraMolly McGuireAmparo M. Toledo VizcarraLina M. Mollesaca RiverosJulio MezaKatty Borrini-MayoriCesar NaquiraJere R. BehrmanValerie A. Paz-Soldan

(September 2019). A behavioral design approach to improving a Chagas disease vector control campaign in Peru. BMC Public Health. 19(1272).


Individual behavior change is a critical ingredient in efforts to improve global health. Central to the focus on behavior has been a growing understanding of how the human brain makes decisions, from motivations and mindsets to unconscious biases and cognitive shortcuts. Recent work in the field of behavioral economics and related fields has contributed to a rich menu of insights and principles that can be engineered into global health programs to increase impact and reach. However, there is little research on the process of designing and testing interventions informed by behavioral insights.


In a study focused on increasing household participation in a Chagas disease vector control campaign in Arequipa, Peru, we applied Datta and Mullainathan’s “behavioral design” approach to formulate and test specific interventions. In this Technical Advance article we describe the behavioral design approach in detail, including the Define, Diagnosis, Design, and Test phases. We also show how the interventions designed through the behavioral design process were adapted for a pragmatic randomized controlled field trial.


The behavioral design framework provided a systematic methodology for defining the behavior of interest, diagnosing reasons for household reluctance or refusal to participate, designing interventions to address actionable bottlenecks, and then testing those interventions in a rigorous counterfactual context. The behavioral design offered us a broader range of strategies and approaches that are typically used in vector control campaigns.


Careful attention to how behavioral design may affect the internal and external validity of evaluations and the scalability of interventions is needed going forward. We recommend behavioral design as a useful complement to other intervention design and evaluation approaches in global health programs.