For Malnourished Boys, Earliest Days a Critical Window for Cognitive Development

In rural Nicaragua where malnutrition is widespread, improved nutrition and health care during a boy’s first 1,000 days (from the beginning of his mother’s pregnancy to about age 2) has a lasting positive impact on cognitive development and learning, new research finds.

“The timing of the intervention was critical,” said Tania Barham of the University of Colorado-Boulder, who published the study with co-authors Karen Macours, Paris School of Economics and the National Institute for Agricultural Research (France), and John Maluccio, Middlebury College, in the latest issue of the American Economic Review.1

The researchers examined the results of a set of cognitive skills tests given at age 10 to about 400 boys whose households took part in a three-year program to improve diet and health. Boys whose households participated until their second birthday scored significantly higher than boys who received the program between ages 2 and 5. The tests measured skills related to learning, including information processing speed, receptive vocabulary, and memory.


Gestation and the first two years of life offer a crucial “window for cognitive skill formation” for boys, she said. The medical literature shows that from the time they are conceived, boys are at a greater risk of death or damage during early life than girls. The girls likely benefited from the better diet and health care as well, but the research team found no differences based on timing.


Better cognitive skills could have implications for the boys’ future earnings and lifelong well-being, according to the researchers. Other studies have linked low levels of cognitive skills to low school achievement, less schooling, and lower lifetime productivity and income; consequently, early deficits can translate into poor outcomes later and make breaking the cycle of poverty more challenging.2


Conditional Cash Transfers


The researchers evaluated a “conditional cash transfer” (CCT) program run in 42 rural Nicaraguan communities with poverty rates averaging above 80 percent. This social program offered mothers three years of regular cash payments on the condition they participated in health and nutrition education sessions, their children received regular preventive health care, and their elementary school-age children attended school. The payments represented a nearly 20 percent increase in household income.


The program was randomly phased in to allow researchers to measure its impact. Known as a “randomized controlled trial,” the approach is one of the most rigorous ways to evaluate the effectiveness of an intervention. The program was offered to half the communities in the first three years and the other half during the second three years; the differences between the two groups were evaluated five years after the program ended.


One of about 30 CCT programs worldwide, the Nicaraguan program aimed to increase spending on food, improve child nutrition, ensure basic health care, and boost school enrollment.3 Nicaraguan households that received the grants consumed significantly more fruits and vegetables, meat, and fats. Short-term evaluations showed “large and significant improvements in nutrition and health” among children in participating households; longer-term evaluations found evidence of increases in both school attainment and learning.4


Improved Physical Development


The researchers also found improved physical development as a result of the program. In the first years of the intervention, the boys whose households received the grants early were significantly taller than those participating later, but these differences narrowed after the later groups’ mothers began receiving the grants. By age 10 there were no height differences between the two groups, suggesting that in the area of physical development “interventions later in childhood can partly or even fully compensate for earlier deficits,” according to Maluccio.


“We know that early life circumstances shape adulthood—influencing health, education, and earnings,” he noted. Negative events in utero and early childhood—such as food shortages due to war or famines leading to low birth weight—are associated with poor outcomes later in life.


“But the evidence on the longer-run effects of positive interventions designed to improve health and nutrition is sparse and mixed,” he reported. These findings provide new support for nutrition and health programs that target the first 1,000 days.


Paola Scommegna is a senior writer/editor at the Population Reference Bureau.




    1. Tania Barham, Karen Macours, and John A. Maluccio, “Boys’ Cognitive Skill Formation and Physical Growth: Long-Term Experimental Evidence on Critical Ages for Early Childhood Interventions,” American Economic Review: Papers & Proceedings 103, no. 3 (2013): 467-71.


    1. Cesar Victora et al., “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital,” The Lancet 371, no. 9609 (2008): 340–57; and Douglas Almond and Janet Currie, “Human Capital Development Before Age Five,” in Handbook of Labor Economics 4B, ed. Orley Ashenfelter and David Card (Amsterdam: Elsevier Science, 2010).


    1. Ariel Fiszbein and Norbert Schady, Conditional Cash Transfers: Reducing Present and Future Poverty (Washington DC: The World Bank, 2009).


    1. Tania Barham, Karen Macours, and John A. Maluccio, “More Schooling and More Learning? Effects of a 3-Year Conditional Cash Transfer Program in Nicaragua after 10 Years” paper presented at the Population Association of America meetings, New Orleans, May 2013; summarized by the Massachusetts Institute of Technology, Jameel Poverty Action Lab.



Targeting Gender-Based Violence to Reduce HIV Among Women

(September 2010) Women with an abusive sexual partner are at greater risk of HIV infection than other women. Several studies have shown this association between HIV and gender-based violence, but the link has now been further documented and examined in a study that followed a group of nearly 1,100 young South African women for two years.1 The women had an average age of 18 years at the start of the study, and most were enrolled in school.

None of the women were HIV-positive at the start of the study, but those in abusive relationships were more likely to test positive for HIV at 12- or 24-month follow-up exams. Study participants rated as having a low sense of power in their relationships were also more likely to become infected. Their “relationship power equity” was measured through responses to questions such as whether they felt they could refuse their boyfriends’ sexual advances.

In the South Africa study, published in The Lancet, researcher Rachel Jewkes and her colleagues reported the higher risk of HIV infection for women who were in a chronically abusive relationship or were previously exposed to violence or excessively controlling behavior—even in childhood.2 The association between HIV infection and violent or controlling behavior partly results from psychological effects that may affect women for years after the event. Emotional stress and low self-esteem might lead them to engage in riskier sex. “Thus, there is a vicious cycle, with abuse enhancing risks of HIV infection and further abuse.”

South Africa has the greatest number of people infected with HIV/AIDS in the world—estimated at 5.7 million in 2009. Prevalence is highest among women: One in three women ages 25 to 29 is HIV-positive. Although more people living with HIV/AIDS are benefiting from life-prolonging antiretroviral treatment, new infections continue to occur at an alarming rate, especially among young women. This highlights the need to understand the risk factors for young people, such as the group included in this study, and how to address them.

Strategies to Stem the Violence

There is a growing body of evidence that shows that carefully targeted and designed intervention programs can change risky behavior. Intervention programs usually try to enable women to protect themselves from HIV and other sexually transmitted infections by asserting more control in their relationships, and by introducing gender equity concepts to men. Although such programs have had limited success in reducing HIV-infection rates so far, some researchers are optimistic that they can eventually create effective programs based on lessons learned from past attempts.3

Two promising programs mentioned in The Lancet article that address gender-based violence and HIV transmission are Stepping Stones, implemented in countries throughout the developing world, and Somos Diferentes, Somos Iguales (“We’re Different, We’re Equal”), created in Nicaragua and exported to several other Spanish-speaking countries. These programs rely on different approaches, but both have made inroads in promoting gender equity—crucial for reducing HIV transmission.

‘Stepping Stones’ to Gender Equity

Stepping Stones is a widely known participatory intervention program aimed at young men and women. First developed in the 1990s to combat rampant HIV-infection rates in Uganda, it has been translated and adapted for use in many other countries. Stepping Stones is now not only used throughout Africa, but also in Eastern Europe, Latin America and the Caribbean, and in India and Bangladesh.

One-half of the young women in the study reported in the The Lancet had participated in a Stepping Stones program administered in rural South Africa. They, along with young men from the same communities, had 13 three-hour sessions featuring sex education; role playing; self-reflection; and discussion related to HIV, gender roles, gender-based violence, and reproductive health. Men and women met in separate groups, usually on school grounds, and then jointly for a final community meeting. The other half of the young women in the study had received a three-hour course on HIV and safe sex. Twelve months later, and again at 24 months, all participants were tested for the HIV and herpes simplex viruses (HSV-2).

The Stepping Stones program was not linked to lower HIV-infection rates for participants. However, it was associated with significantly lower rates of HSV-2, a risk factor for HIV, suggesting that the program prompted behavior change that reduced sexually transmitted infections.

Another promising finding: The young men completing the program reported significant declines in violence against women, including rape. The changes were even greater after 24 months than at 12 months, illustrating that the program has a long-term effect on men’s attitudes and behavior. This encouraging result adds to evidence provided by previous evaluations of Stepping Stones programs.

Nicaragua Program to Reduce Gender Bias

An intervention program in Nicaragua followed a different model, delivering its messages through the mass media. Although HIV prevalence is much lower in Nicaragua than in South Africa, the risk for transmission among young people is heightened there by unsafe sexual activity among many young people and a tradition of male dominance and irresponsible male sexual behavior. The program, Somos Diferentes, Somos Iguales (SDSI), carried out between 2002 and 2005, aimed to raise awareness among young Nicaraguans of the risks of HIV infection and gender-based violence, lessen the stigma against people with HIV, and encourage responsible sex and more equitable gender norms and behaviors.4 Elements of the program have been introduced in Guatemala and elsewhere.

SDSI messages were conveyed through television and radio programming. A weekly TV drama aimed at young people included HIV-positive characters and explored gender bias in everyday situations. Popular cast members made appearances at high schools to discuss HIV, gender equity, and related topics. An SDSI radio call-in show hosted by young adults encouraged debate about sexuality and gender issues.

An analysis of the program in three cities showed that young people were tuning in to the programs and were beginning to change their attitudes and behaviors. For example, compared with others, young people who watched or listened to the SDSI programs were more likely to say that men should share in housework, that a husband never has the right to hit his wife, and that they would be willing to be friends with someone with HIV/AIDS.5

Stepping Stones, SDSI, and similar programs around the world contribute toward efforts to reduce gender-based violence and promote gender equity. If these concepts and behaviors take hold in a society, women will be more empowered to protect themselves against abusive or controlling sexual partners and break the vicious cycle of abuse and HIV infection that plague so many women around the world.

Mary Mederios Kent is senior demographic writer at the Population Reference Bureau.


  1. Rachel K. Jewkes et al., “Intimate Partner Violence, Relationship Power Inequity, and Incidence of HIV Infection in Young Women in South Africa: A Cohort Study,” The Lancet 376, no. 9734 (2010): 41-48; and Jay G. Silverman, “Key to Prevent HIV in Women: Reduce Gender-Based Violence,” The Lancet 376, no. 9734 (2010): 6-7.
  2. Jewkes et al., “Intimate Partner Violence, Relationship Power Inequity, and Incidence of HIV Infection in Young Women in South Africa.”
  3. Rachel K. Jewkes et al., “Impact of Stepping Stones on Incidence of HIV and HSV-2 and Sexual Behaviour in Rural South Africa: Cluster Randomised Controlled Trial,” BMJ 337, no. a506 (2008), accessed at, on Sept. 7, 2010.
  4. Henry Espinoza, “Using Edutainment and Social Activities to Challenge Machismo in Nicaragua: The Example of Somos Diferentes, Somos Iguales,” Sexual Health Exchange 2 (2005): 9-10, accessed at, on Sept. 7, 2010.
  5. Irela Solorzano et al., “Positive Impact of an HIV Prevention Communication for Social Change Program on Youth in Nicaragua” (2006), accessed at, on Sept. 7, 2010.

Domestic Violence in Developing Countries: An Intergenerational Crisis

(September 2004) A new comparative study using nationally representative information on domestic violence in nine developing countries finds that women whose fathers abused their mothers are twice as likely to suffer domestic abuse themselves.

The report, Profiling Domestic Violence: A Multi-Country Study, published by ORC Macro, also finds that domestic violence in these countries is highly correlated with a husband’s drunkenness and controlling behaviors. But the study did not find that a woman’s poverty, lack of education, or lack of decisionmaking control consistently elevate her risk of being abused.1

“Gender-based violence is a gender issue,” explains Kiersten Johnson, a co-author of the study and a researcher at ORC Macro. For example, the study found that women who shared the bulk of household decisions with their male partners were at a lower risk of abuse—regardless of their household’s income levels.

Domestic Violence is a Worldwide Problem

The report is based on data from the Demographic and Health Surveys (DHS) in nine developing countries: Cambodia, Colombia, Dominican Republic, Egypt, Haiti, India, Nicaragua, Peru, and Zambia. These surveys, conducted mostly after 1998, collected comprehensive demographic and health data from women ages 15 to 49. In addition, information was collected on “empowerment” indicators such as education, employment, and participation in household decisionmaking.

Researchers also asked the women about their experience of domestic violence throughout their adult lives, including detailed questions about their experience of physical, sexual, and emotional violence within their current relationships. The percentages of women who said an intimate partner had ever abused them ranged from 48 percent in Zambia and 44 percent in Colombia to 18 percent in Cambodia and 19 percent in India. (A 1998 Commonwealth Fund study put levels of similar violence in the United States at 31 percent.2)

More than one in six married women in each country that was studied reported being pushed, shaken, slapped, or targeted with a thrown object by their male partners. At least one in 10 has been threatened or publicly humiliated by their husbands.

Co-author Sunita Kishor, a senior gender specialist at ORC Macro, cautioned that survey questions differed across some of the countries, making absolute comparisons of domestic-abuse prevalence problematic. But Profiling Domestic Violence makes clear that domestic violence remains a problem in these nine countries—and that in at least several of them, women are socialized into accepting its legitimacy under some circumstances.

“Educated women tend to disagree [with the practice of domestic abuse] more, but it’s not as if you get a zero-level of disagreement even among them,” says Kishor. “In most countries, the gender-role norm violation that woman are most likely to agree with as deserving of a beating is a woman’s neglect of her children. This is very, very telling—there’s a huge buy-in to the care of children being a very fundamental duty of women.”

Culture of Violence ‘Akin to Second-Hand Smoke’

The wealth of data collected by DHS also enabled Kishor and Johnson to identify common global risk factors for domestic violence—all of which, they stress, are largely beyond a woman’s control.

“Often there’s this belief that you see in public discourse that women who are beaten are in some way to blame—they’re too fat or unattractive, for example,” says Johnson. “But it’s not any one characteristic or aspect of your life. Instead, there are multiple factors at the individual, husband, and family level—including your ‘inheritance’—that are dynamically interacting.”

By “inheritance,” Johnson means a woman’s experience as a child of her mother’s abuse. Such experience, Kishor says, has “tremendous intergenerational implications.”

“I don’t think enough attention is being paid to these matters,” says Kishor. “The data shows that even exposure to a mother’s experience of abuse, not just firsthand violence, almost doubles your risk [of being abused yourself]. It’s akin to the literature about secondhand smoke—even exposure to it can have ill-effects” (see Table 1).

Table 1
Percentages of ever-married women age 15-49 who experienced spousal violence ever and in the past 12 months, by whether their mother was ever beaten by their father

Family History Cambodia Colombia Dominican
Haiti Nicaragua Peru
Ever Experienced Spousal Violence
Father beat mother
No 15.2 36.1 20.0 27.0 27.4 35.8
Yes 29.7 55.4 36.3 37.8 36.6 50.0
Don’t know 20.7 46.5 27.9 32.1 35.4 46.3
Experienced Violence in the Past 12 Months
Father beat mother
No 13.1 u 9.2 20.5 11.4 u
Yes 28.1 u 21.6 33.2 17.2 u
Don’t know 17.7 u 18.2 22.8 15.5 u

u = Unknown (not available)
Note: Data not available for remaining three countries studied in report.

Profiling Domestic Violence also found that other common correlates of domestic abuse—besides having husbands who frequently get drunk or exhibit controlling behaviors (such as limiting her outside contact or repeatedly accusing her of infidelity)—include:

  • Being married more than once;
  • Being married young;
  • Having multiple children; or
  • Being older than your husband.

In addition, Kishor and Johnson found that many abused women in developing countries do not seek help, ranging from 41 percent in Nicaragua to 78 percent in Cambodia. And those who do reach out often contact people they know rather than health professionals.

Disempowerment and Violence: No Clear Connection

Surprisingly, several measures of female empowerment—employment, education, or attitudes related to gender equity, such as believing that women have the right to refuse sex to their husbands—did not directly correlate in the study with a reduced risk of abuse. And women who make most of their household’s decisions alone—such as whether to make large purchases or to have another child—were victims of domestic violence at the same rate as those with little say in the allocation of their family’s resources. Instead, the study found that women who made decisions jointly with their male partners suffered far less abuse.

“The causality is not clear from these data between increased risk of abuse for women who make most of the decisions alone,” Kishor says. “Is it because she is in such a dysfunctional relationship that she is forced into taking charge? Or is it because she’s taking the decisions alone that she’s actually being beaten?” This uncertainty, she adds, raises questions about conventional indices of empowerment.

“We need to be looking closely at a lot of these indicators and asking what they’re really telling us in different contexts,” Kishor says. “While empowerment usually implies that you are in control of your life, the data suggest that, within a marital context, ‘dominating’ [these] decisions may not equate to empowerment.”

The Health Consequences of Abuse

The study found clearer connections between abuse and degraded health for victimized women and their children. For instance, women in almost all the surveyed countries who had experienced abuse from their intimate partners had higher rates of unwanted births and nonlive births (by 33 percent to 72 percent) than those who had never been abused.

Women who experienced violence were also more likely to have had sexually transmitted infections, their pregnancies were substantially less likely to have received first-trimester antenatal care, and their children between the ages of 12 months and 35 months were less likely to have been fully vaccinated. The children of abused women were also more likely to die before age 5.

Both authors stress that including national domestic violence statistics alongside health and demographic information is a large step forward in addressing the roots of abuse.

“Up until recently, there wasn’t the kind of impetus or interest in this kind of data, or even the recognition of domestic violence as an issue of public health and development,” Johnson says. “It’s important to know that there are multiple factors involved, and thus multiple arenas in which interventions can occur.”

Robert Lalasz is a senior editor at PRB.


  1. Sunita Kishor and Kiersten Johnson, Profiling Domestic Violence: A Multi-Country Study (Columbia, MD: ORC Macro, 2004).
  2. Karen Scott Collins et al., Health Concerns Across a Woman’s Lifespan: The Commonwealth Fund 1998 Survey of Women’s Health, accessed at, on Sept. 14, 2004.

For More Information

Profiling Domestic Violence: A Multi-Country Study is available at