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Colombia's national early childhood strategy launched in 2011 aimed at improving the quality of childcare services offered to socio-economically vulnerable children, and included the possibility that children and their childcare providers could transfer from non-parental family daycare units to large childcare centers in urban areas. This study seeks to understand whether the offer to transfer and the actual transfer from one program to the other had an impact on child cognitive and socioemotional development, and nutrition, using a cluster-randomized control trial with a sample of 2767 children between the ages of 6 and 60 months located in 14 cities in Colombia. The results indicate a negative effect of this initiative on cognitive development, a positive effect on nutrition, and no statistically significant effect of the intervention on socioemotional development. We also explored the extent to which these impacts might be explained by differences in the quality of both services during the transition, and report that quality indicators are low in both programs but are significantly worse in centers compared to community nurseries.

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BACKGROUND: Poor early childhood development (ECD) in low- and middle-income countries is a major concern. There are calls to universalise access to ECD interventions through integrating them into existing government services but little evidence on the medium- or long-term effects of such scalable models. We previously showed that a psychosocial stimulation (PS) intervention integrated into a cash transfer programme improved Colombian children's cognition, receptive language, and home stimulation. In this follow-up study, we assessed the medium-term impacts of the intervention, 2 years after it ended, on children's cognition, language, school readiness, executive function, and behaviour. METHODS AND FINDINGS: Study participants were 1,419 children aged 12-24 months at baseline from beneficiary households of the cash transfer programme, living in 96 Colombian towns. The original cluster randomised controlled trial (2009-2011) randomly allocated the towns to control (N = 24, n = 349), PS (N = 24, n = 357), multiple micronutrient (MN) supplementation (N = 24, n = 354), and combined PS and MN (N = 24, n = 359). Interventions lasted 18 months. In this study (26 September 2013 to 11 January 2014), we assessed impacts on cognition, language, school readiness, executive function, and behaviour 2 years after intervention, at ages 4.5-5.5 years. Testers, but not participants, were blinded to treatment allocation. Analysis was on an intent-to-treat basis. We reassessed 88.5% of the children in the original study (n = 1,256). Factor analysis of test scores yielded 2 factors: cognitive (cognition, language, school readiness, executive function) and behavioural. We found no effect of the interventions after 2 years on the cognitive factor (PS: -0.031 SD, 95% CI -0.229-0.167; MN: -0.042 SD, 95% CI -0.249-0.164; PS and MN: -0.111 SD, 95% CI -0.311-0.089), the behavioural factor (PS: 0.013 SD, 95% CI -0.172-0.198; MN: 0.071 SD, 95% CI -0.115-0.258; PS and MN: 0.062 SD, 95% CI -0.115-0.239), or home stimulation. Study limitations include that behavioural development was measured through maternal report and that very small effects may have been missed, despite the large sample size. CONCLUSIONS: We found no evidence that a scalable PS intervention benefited children's development 2 years after it ended. It is possible that the initial effects on child development were too small to be sustained or that the lack of continued impact on home stimulation contributed to fade out. Both are likely related to compromises in implementation when going to scale and suggest one should not extrapolate from medium-term effects of small efficacy trials to scalable interventions. Understanding the salient differences between small efficacy trials and scaled-up versions will be key to making ECD interventions effective tools for policymakers. TRIAL REGISTRATION: ISRCTN18991160.

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The relationship between early adversity and numerous negative outcomes across the lifespan is evident in a wide range of societies and cultures (e.g., Pakulak, Stevens, & Neville, 2018). Among the most affected neural systems are those supporting attention, self-regulation, and stress regulation. As such, these systems represent targets for neurobiologically informed interventions addressing early adversity. In prior work with monolingual native English-speaking families, we showed that a two-generation intervention targeting these systems in families improves outcomes across multiple domains including child brain function for selective attention (for detail, see Neville et al., 2013). Here, we discuss the translation and cultural adaptation (CA) of this intervention in local and international contexts, which required systematic consideration of cultural differences that could affect program acceptability. First, we conducted a translation and CA of our program to serve Latino families in the United States using the Cultural Adaptation Process (CAP), a model that works closely with stakeholders in a systematic, iterative process. Second, to implement the adapted program in Medellín, Colombia, we conducted a subsequent adaptation for Colombian culture using the same CAP. Our experience underscores the importance of consideration of cultural differences and a systematic approach to adaptation before assessing the efficacy of neurobiologically informed interventions in different cultural contexts.

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In this paper we use high quality data from two developing countries, Ethiopia and Peru, to estimate the production functions of human capital from age 1 to age 15. We characterize the nature of persistence and dynamic complementarities between two components of human capital: health and cognition. We also explore the implications of different functional form assumptions for the production functions. We find that more able and higher income parents invest more, particularly at younger ages when investments have the greatest impacts. These differences in investments by parental income lead to large gaps in inequality by age 8 that persist through age 15.

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In low- and middle-income countries (LIMCs), measuring early childhood development (ECD) with standard tests in large scale surveys and evaluations of interventions is difficult and expensive. Multi-dimensional screeners and single-domain tests ('short tests') are frequently used as alternatives. However, their validity in these circumstances is unknown. We examined the feasibility, reliability, and concurrent validity of three multi-dimensional screeners (Ages and Stages Questionnaires (ASQ-3), Denver Developmental Screening Test (Denver-II), Battelle Developmental Inventory screener (BDI-2)) and two single-domain tests (MacArthur-Bates Short-Forms (SFI and SFII), WHO Motor Milestones (WHO-Motor)) in 1,311 children 6-42 months in Bogota, Colombia. The scores were compared with those on the Bayley Scales of Infant and Toddler Development (Bayley-III), taken as the 'gold standard'. The Bayley-III was given at a center by psychologists; whereas the short tests were administered in the home by interviewers, as in a survey setting. Findings indicated good internal validity of all short tests except the ASQ-3. The BDI-2 took long to administer and was expensive, while the single-domain tests were quickest and cheapest and the Denver-II and ASQ-3 were intermediate. Concurrent validity of the multi-dimensional tests' cognitive, language, and fine motor scales with the corresponding Bayley-III scale was low below 19 months. However, it increased with age, becoming moderate-to-high over 30 months. In contrast, gross motor scales' concurrence was high under 19 months and then decreased. Of the single-domain tests, the WHO-Motor had high validity with gross motor under 16 months, and the SFI and SFII expressive scales showed moderate correlations with language under 30 months. Overall, the Denver-II was the most feasible and valid multi-dimensional test and the ASQ-3 performed poorly under 31 months. By domain, gross motor development had the highest concurrence below 19 months, and language above. Predictive validity investigation is needed to further guide the choice of instruments for large scale studies.

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In Colombia's bottom socio-economic strata, 46.6% of children under two are anaemic. A prevalence of above 20% falls within the WHO guidelines for daily supplementation with multiple micronutrient powder (MNP). To evaluate the effect of daily MNP supplementation on anaemia amongst Colombian children aged 12-24 months we ran a cluster RCT (n=1440). In previous work, we found the intervention had no impact on haemoglobin or anaemia in this population. In this current paper, we investigate this null result and find it cannot be explained by an underpowered study design, inaccurate measurements, low adoption of and compliance with the intervention, or crowding out through dietary substitution. We conclude that our intervention was ineffective at reducing rates of childhood anaemia because MNP itself was inefficacious in our population, rather than poor implementation of or adherence to the planned intervention. Further analysis of our data and secondary data suggests that the evolution with age of childhood anaemia in Colombia, and its causes, appear different from those in settings where MNP has been effective. Firstly, rates of anaemia peak at much earlier ages and then fall rapidly. Secondly, anaemia that remains after the first year of life is relatively, and increasingly as children get older, unrelated to iron deficiency. We suggest that factors during gestation, birth, breastfeeding and early weaning may be important in explaining very high rates of anaemia in early infancy. However, the adverse effects of these factors appear to be largely mitigated by the introduction of solid foods that often include meat. This renders population wide MNP supplementation, provided after a diet of solid foods has become established, an ineffective instrument with which to target Colombia's childhood anaemia problem.

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OBJECTIVE: To assess the effectiveness of an integrated early child development intervention, combining stimulation and micronutrient supplementation and delivered on a large scale in Colombia, for children's development, growth, and hemoglobin levels. DESIGN: Cluster randomized controlled trial, using a 2 × 2 factorial design, with municipalities assigned to one of four groups: psychosocial stimulation, micronutrient supplementation, combined intervention, or control. SETTING: 96 municipalities in Colombia, located across eight of its 32 departments. PARTICIPANTS: 1420 children aged 12-24 months and their primary carers. INTERVENTION: Psychosocial stimulation (weekly home visits with play demonstrations), micronutrient sprinkles given daily, and both combined. All delivered by female community leaders for 18 months. MAIN OUTCOME MEASURES: Cognitive, receptive and expressive language, and fine and gross motor scores on the Bayley scales of infant development-III; height, weight, and hemoglobin levels measured at the baseline and end of intervention. RESULTS: Stimulation improved cognitive scores (adjusted for age, sex, testers, and baseline levels of outcomes) by 0.26 of a standard deviation (P=0.002). Stimulation also increased receptive language by 0.22 of a standard deviation (P=0.032). Micronutrient supplementation had no significant effect on any outcome and there was no interaction between the interventions. No intervention affected height, weight, or hemoglobin levels. CONCLUSIONS: Using the infrastructure of a national welfare program we implemented the integrated early child development intervention on a large scale and showed its potential for improving children's cognitive development. We found no effect of supplementation on developmental or health outcomes. Moreover, supplementation did not interact with stimulation. The implementation model for delivering stimulation suggests that it may serve as a promising blueprint for future policy on early childhood development.Trial registration Current Controlled trials ISRCTN18991160.

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We study the determinants of child anthropometrics on a sample of poor Colombian children living in small municipalities. We focus on the influence of household consumption, and public infrastructure, taking into account the endogeneity of household consumption using two different sets of instruments: household assets and municipality average wage. We find that both household consumption and public infrastructure are important determinants of child health. We have also found that the coverage of the piped water network positively influenced child health if the parents have some education.

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