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The early childhood ecosystem is comprised of individuals, organizations/institutions, and microsystems (health, education, etc.) which support young children (ages 0-5). This ecosystem is path-dependent because of historical and ecological barriers and facilitators. These barriers and facilitators are sustained by social, political, and economic structures that perpetuate patterns of inequality in early childhood outcomes.The purpose of this research is to (1) identify these barriers and facilitators from the perspective of families in Los Angeles in Los Angeles as they seek to access informal and formal early childhood services and resources, and (2) understand the role of the early childhood system—encompassing the individuals, institutions, and microsystems centered on childhood development embedded within the early childhood ecosystem— in helping families. This research used qualitative methods to interview families, service providers, government officials, and community members across Los Angeles County, California (LA). LA was selected given the complexity of its early-childhood ecosystem.This research suggests that barriers and facilitators exist across the macro, meso, and micro-levels of the early childhood ecosystem - and contribute to the perpetuation of inequalities. Some of these barriers include poverty, gentrification, social isolation, language, and complicated bureaucracy. However, there are also facilitators expanding policy interests, increasing financial investments, and building social networks. Furthermore, this study found that while much of the early childhood system (embedded within the early childhood ecosystem) perpetuates patterned inequities, there are some individuals, organizations/institutions, and sub-systems that mitigate these barriers. Some of the characteristics of an effective early childhood system are strong governance and accountability, sustainable financing, strong partnerships, and empathetic and responsive programming.Findings indicate implications for policymakers, practitioners, and academics. For example, policymakers should create policies that accounts for the early childhood ecosystem, practitioners should design relational programming, and academics should seek to understand how the early childhood system can be leveraged to influence the early childhood ecosystem.

Evidence on the role of father involvement in children's development from low-resource settings is very limited and historically has only relied on maternal reports of father's direct engagement activities such as reading to the child. However, fathers can also potentially influence their children's development via greater positive involvement with the mother, such as by offering interpersonal support or sharing decision-making duties. Such positive intrahousehold interactions can benefit maternal mental health and wellbeing, and ultimately children's development. We use data collected from mothers, fathers and children in the context of the cluster randomized controlled trial evaluation of Msingi Bora, a responsive parenting intervention implemented across 60 villages in rural western Kenya, to explore the various pathways through which fathers may influence their children's outcomes. In an endline survey in Fall 2019 among a sample of 681 two-parent households with children aged 16-34 months, fathers reported on measures of their behaviors towards children and with mothers, mothers reported on their wellbeing and behaviors, and interviewers assessed child cognitive and language development with the Bayley Scales. In adjusted multivariate regression analyses we found that greater father interpersonal support to mothers and greater participation in shared household decision-making were positively associated with children's development. These associations were partially mediated through maternal wellbeing and behaviors. We found no association between fathers' direct engagement in stimulation activities with children and children's outcomes. Inviting fathers to the program had no impact on their involvement or on any maternal or child outcomes, and fathers attended sessions at low rates. Overall, our results show the potential promises and challenges of involving fathers in a parenting intervention in a rural low-resource setting. Our findings do highlight the importance of considering intrahousehold pathways of influence in the design of parenting interventions involving fathers.

Environmental risk factors can play an important and immediate role in limiting early childhood development in low- and middle-income countries (LMICs). Forty-three percent of children under five years in LMICs are at risk of not meeting their developmental potential, with children in sub-Saharan Africa being at greatest risk. Children under age three years are particularly vulnerable due to their rapid brain development and sensitivity to nutrient effects on growth, cognition, and school attainment. Climate and weather shifts can also drive disease patterns, like the spread of malaria. Environmentally-driven food security, dietary patterns, and malaria are understudied in relation to early childhood development. However, these factors may be associated with developmental outcomes among children before the age of five years due to their hypothesized impacts on nutrition, brain growth, and overall health with lifelong and intergenerational implications. Kenya has a large rural population facing challenges adapting to climate change and coping with food insecurity. While the country has a national early childhood development policy, much of the curriculum focuses on preschool-aged children and measures of early childhood development in Kenya are limited and vary by region, measure or domain assessed, and cultural differences. About one-quarter of Kenya’s population is chronically food insecure and levels of stunting and underweight in rural areas, western Kenya, and around Lake Victoria are high. Malaria is also endemic in Kenya and a leading cause of child morbidity and mortality. Kenya therefore serves as an optimal place to study associations between food insecurity, children’s fatty acid and fish intake, malaria, and early childhood development. The association between three dimensions of food insecurity (timing, intensity, and duration) and three domains of early childhood development (gross motor, communication, and personal social) were examined. Longitudinal data were collected from 303 households (including 309 children under age two years at baseline) visited nine times over two years in a community around Lake Victoria in rural Kenya. Children in households experiencing more severe food insecurity three months prior (timing) had significantly lower gross motor, communication, and personal social developmental scores using lagged models controlling for current food insecurity. Children in households that experienced greater aggregate food insecurity over the past two years (intensity) had significantly lower gross motor, communication, and personal social developmental scores. Amount of time exposed to food insecurity (duration) was associated with lower gross motor, communication, and personal social developmental scores. All results were attenuated with the addition of maternal education, household wealth, and child anthropometry to models. Fatty acid and fish consumption among children around Lake Victoria in the same population in rural Kenya was evaluated in relation to gross motor, communication, and personal social development. The majority of fatty acids, including long-chain polyunsaturated fatty acids that are important for early childhood development, in this population’s diets came from fish. Nile perch and dagaa were the most common fish species consumed. Lagged longitudinal analyses over a two year period show that greater amounts of fish consumed three months ago were associated with higher current gross motor, communication, and personal social developmental scores among children under 13.5 months, controlling for current fish consumption, child characteristics, and household demographics. Larger amounts of fatty acids (total omega 3 fatty acids, AA, EPA, and DHA) consumed three months ago were associated with higher current communication developmental scores, controlling for current fatty acid intake, child characteristics, and household demographics. Higher intake of EPA and AA three months ago was associated with greater current personal social developmental scores among children under 13.5 months. In this highly food insecure population, fishery resources can help mitigate nutrient deficiencies, especially of fatty acids, which can be particularly threatening during the complementary feeding stage. Fish may serve as a nutritional safety net where access to nutrient-dense foods is often limited. Findings provide evidence supporting the conservation of natural resources in LMICs and around Lake Victoria by enforcing resource use regulations and implementing market systems to benefit local communities and children’s development. The association between malaria and gross motor, communication, and personal social development was analyzed among 652 children 24 months of age in rural western Kenya. Eighteen percent of children had malaria and 20% of children were at risk for gross motor delay, 21% were at risk for communication delay, and 23% were at risk for personal social delay. Having a positive malaria test was significantly associated with increased odds of a child being at risk for gross motor, communication, and personal social delay adjusting for child characteristics, household demographics, study cluster, and intervention treatment arm. Mediation analyses suggest that anemia was a significant mediator in the pathway between malaria infection and being at risk for gross motor, communication, and personal social development delays. The proportions of the total effect of malaria on being at risk for developmental delay that is mediated by anemia across subscales was small (ranging from 9% of the effect on gross motor development to 16% of the effect on communication development mediated by anemia). Overall, malaria may be associated with short-term child development delays during a vulnerable period in early life. Therefore, preventative malaria measures and immediate treatment are imperative for children’s optimal development, particularly in light of projections of continued high malaria transmission in Kenya and Africa.

Chapter one examines the long-term impact of the state prohibitions of alcohol in the United States. Between 1851 and 1920, thirty-four states enacted statewide prohibitions of alcohol at different times. Making use of the variation in state prohibition as a natural experiment, the long-term labor market outcomes of cohorts exposed to state prohibition during the critical early development period is examined. Female cohorts exposed to alcohol-reduced environments during the critical interval from the prenatal period and up to three years of age are shown to have increased labor force participation and increased income in 1960. The results are mainly driven by exposure in the prenatal period. No results were found for male cohorts, which might be explained by the selective prenatal mortality of the frailest male cohort members unexposed to state prohibition. Chapter two provides an impact evaluation of the Brazilian National Land Credit Program. Making use of a panel dataset and a pipeline control group, the chapter evaluates the impact of the program on the outcome variables of agricultural production and earned income, using both difference in differences and individual fixed effects models. Because beneficiaries acquired land at different times, the heterogeneous effect of additional years of land ownership is investigated. The findings suggest that the program is successful in increasing beneficiaries' agricultural production and earned income, but only after four years of land ownership. Once the repayment of the loan is taken into consideration, however, the benefits of the program largely go to making debt payments and improving the net worth of the beneficiaries rather than to raising current household expenditures. Chapter three evaluates the impact of the Brazilian National Land Credit Program on the heights of beneficiary children. Making use of a family fixed effects model, the program is shown to significantly increase the height for age z-scores of beneficiary children exposed to parents' land ownership in the second, third or fourth year of life. The increases in height for age z-scores are likely attained through the mechanism of increased nutritional security with the acquisition of land through the program.

This dissertation is composed of two essays focusing on some key emerging issues of health economics in developing countries. In the first chapter, I examine the role of the largest public works program in the world- the National Rural Employment Guarantee Scheme (NREGS) - in buffering the negative effects of early childhood exposure to rainfall shocks on long-term health outcomes. Collecting very detailed administrative records of rainfall shocks and policy coverage, I integrate it with a rich household level panel data from the Young Lives Survey, that follows children from year 2002 to 2010. Using three waves of the panel data spanning over eight years, the study employs individual-fixed effects estimation to analyze the extent of catch-up in height for age for the rural sample exploiting the phase wise variation in roll out of the policy across households. We find while the program does not help correct long term past health deficiencies, it is useful in buffering recent drought shocks. Interestingly, we find the extent of this mitigation varies by policy relevant subgroups, where we find it benefits significantly the poor households from lower caste and lower educational background. We find early drought exposure decreases the height for age score by .4 standard deviations and increases average stunting rate by 8%. For individuals exposed to drought, we find an increase in one standard deviation in average program days increases height-for-age by around .26 standard deviations, which is about half the rural-urban gap in terms of magnitude. The findings indicate while there is long-run impact of early-life conditions on health several years later, access to the program helps to partially mitigate recent shocks but not correct for longer-term past deficiencies. Since there is little scope of remediation in correcting past deficiencies, the study highlights the key role that a social protection policy can play in safe-guarding households against such negative shocks. The second chapter examines the extent of reporting biases in self-reported health response across demographic sub-groups using the unique nationally representative data collected by the World Health Survey-SAGE survey from India, that has self-reported assessments of health linked to anchoring vignettes as well as objective measures like body mass index and performance tests on a range of different domains of health. Analysis of the vignettes responses reveals a systematic under-reporting of worse health among the individuals from less developed states in India, which is statistically significant across various health domains. While males and urban residents were found to systematically under-report ill-health, individuals over 60 years were found to over-report ill health. Utilizing a battery of objective health measures, we introduce a methodology to implicitly test the assumption of `response consistency' in vignettes and confirm its validity by identifying similar systematic bias in self-reported health responses across covariates. Further examination of reporting bias by exploiting the individual fixed effects reveals that substantial variation in self-reported health remains unexplained even after controlling for the usual covariates. The results seem to suggest that systematic differences in self-reported health response, even within a country, needs to be accounted for while making inter group comparisons valid and lends support to the use of the vignette technique for identifying this bias.

Forty-three percent of children under five in low and middle-income countries (LMICs) experience compromised cognitive and psychosocial development. Early childhood development (ECD) interventions that promote parent-child psychosocial stimulation and nutrition activities can help remediate early disadvantages in child development and health outcomes, but are difficult to scale. Key questions are: 1) how to maximize the reach and cost-effectiveness of ECD interventions; 2) what pathways connect interventions to parental behavioral changes and child outcomes; and 3) how to sustain impacts long-term. Msingi Bora (“good foundation” in Swahili) is a multi-arm cluster randomized controlled trial across 60 villages and 1200 households in rural Western Kenya that tests different, potentially cost-effective and scalable models to deliver an ECD intervention in biweekly sessions lasting 7 months. The curriculum integrates child psychosocial stimulation with hygiene and nutrition education. The multi-arm study will test the cost-effectiveness of two models of delivery: a group-based model versus a mixed model combining group sessions with personalized home visits. Households in a third study arm will serve as a control group. Each arm will have 20 villages and 400 households with a child aged 6–24 months at baseline. Primary outcomes are child cognitive and socioemotional development and home stimulation practices. In a 2 × 2 design among the 40 treatment villages, we will also test the role of including fathers in the intervention. We will estimate intention-to-treat and local average treatment effects, and examine mediating pathways using Mediation Analysis. One treatment arm will receive quarterly booster visits for 6 months following the end of the sessions. A follow-up survey 2 years after the end of the main intervention period will examine sustainability of outcomes and any spillover impacts onto younger siblings. Study protocols have been approved by the Maseno Ethics Review Committee (MUERC) in Kenya (00539/18) and by RAND’s institutional review board. This study is funded by the National Institute for Child Health and Human Development (R01HD090045). Results can provide policymakers with rigorous evidence of how best to design ECD interventions in low-resource rural settings. Clinical Trial NCT03548558 registered June 7, 2018 at clinicaltrials.gov; AEA-RCT registry AEARCTR-0002913.

Nonhuman research has implicated developmental processes within the hippocampus in the emergence and early development of episodic memory, but methodological challenges have hindered assessments of this possibility in humans. Here, we delivered a previously learned song and a novel song to 2-year-old toddlers during natural nocturnal sleep and, using functional magnetic resonance imaging, found that hippocampal activation was stronger for the learned song compared with the novel song. This was true regardless of whether the song was presented intact or backwards. Toddlers who remembered where and in the presence of which toy character they heard the song exhibited stronger hippocampal activation for the song. The results establish that hippocampal activation in toddlers reflects past experiences, persists despite some alteration of the stimulus, and is associated with behavior. This research sheds light on early hippocampal and memory functioning and offers an approach to interrogate the neural substrates of early memory.