EARLY STIMULATION AND NUTRITION: THE

IMPACTS OF A SCALABLE INTERVENTION

Orazio Attanasio Helen Baker-Henningham

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Yale, USA; IFS, UK; and FAIR at NHH, Bangor University, UK; and University
Norway of the West Indies, Jamaica
Raquel Bernal Costas Meghir
CEDE, Universidad de los Andes, Yale, USA; JPal, USA; and IFS, UK
Colombia
Diana Pineda Marta Rubio-Codina
Fundación Éxito, Colombia Inter-American Development Bank, USA

Abstract
Early childhood development is becoming the focus of policy worldwide. However, the evidence
on the effectiveness of scalable models is scant, particularly when it comes to infants in developing
countries. In this paper, we describe and evaluate with a cluster-Randomized Controlled Trial an
intervention designed to improve the quality of child stimulation within the context of an existing
parenting program in Colombia, known as FAMI. The intervention improved children’s development
by 0.16 of a standard deviation (SD) and children’s nutritional status, as reflected in a reduction of
5.8 percentage points of children whose height-for-age is below 1 SD. (JEL: J13, I10, I20, H43)

The editor in charge of this paper was Paola Giuliano.

Acknowledgments: This study was funded by Grand Challenges Canada Grant (GCC) 0462-03-10 and
Fundación Éxito (FE). Attanasio was partly funded by an European Research Council Advanced Grant
AdG—695300. Meghir was partly funded by National Institutes of Health grant R01HD7210, the Cowles
Foundation, and Institution for Social and Policy Studies at Yale. Attanasio, Bernal, Meghir and Rubio-
Codina were funded by the Jacobs Foundation Marbach Residence Program in 2017, for a visit that
contributed greatly to this study. This trial is registered at the ISRCTN Registry, trial no. ISRCTN93757590.
The Universidad de los Andes ethics committee (no. 287/2014) and the University College London research
ethics committee (no. 2168/011) approved this study. We thank the Instituto Colombiano de Bienestar
Familiar (ICBF), the ICBF program supervisors, and program coordinators at FE for facilitating the
intervention; the FAMI program providers, children, and families who willingly participated in the study;
all the staff including nine tutors and field manager M. L. Gómez; all research staff: Santiago Lacouture,
Alejandro Sánchez, Sara Ramı́rez, and Diana Pérez; the IQuartil data collection team; and the experts from
GCC. The editor and three anonymous referees provided useful comments. The study presents the authors’
views and not those of the institutions they belong to, including the Inter-American Development Bank, its
board of directors, or the countries they represent. Attanasio is a Research Associate at the NBER. Meghir
is a Research Associate at the NBER and a Research Fellow at the CEPR and IZA.
E-mail: [email protected] (Attanasio); [email protected] (Baker-Henningham);
[email protected] (Bernal); [email protected] (Meghir);
[email protected] (Pineda); [email protected] (Rubio-Codina)

Journal of the European Economic Association 2022 20(4):1395–1432

https://doi.org/10.1093/jeea/jvac005
c The Author(s) 2022. Published by Oxford University Press on behalf of European Economic Association.
This is an Open Access article distributed under the terms of the Creative Commons Attribution
License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and
reproduction in any medium, provided the original work is properly cited.
1396 Journal of the European Economic Association

1. Introduction

Human capital, important as it is for life outcomes (Becker 1994) and economic
development, is undermined by poverty from the very beginning of life. This, in
turn, leads to a vicious cycle: The underachievement of individuals from deprived
backgrounds contributes to the intergenerational persistence of poverty. It is now
widely understood that the early years of brain development, and indeed the first
1,000 days, can be particularly important for adult outcomes, with the experiences
during early childhood having a long-lasting impact.1

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Over the last couple of decades, our understanding of the process of child
development and the evidence on the types of interventions that might improve
outcomes have advanced significantly (Black et al. 2017; Britto et al. 2017). In
particular, the potential of parenting support programs to improve child development,
especially in vulnerable contexts, has been amply demonstrated (Neville, Pakulak, and
Stevens 2015; Britto et al. 2017).
Given the established knowledge, early years interventions should aim at improving
the ability of parents to provide responsive and emotionally supportive environments
and ensure developmentally stimulating opportunities for their children (Bradley and
Putnick 2012; Singla, Kumbakumba, and Aboud 2015; Black et al. 2017), while
at the same time be implementable at realistic cost levels and given the available
implementation infrastructure, including personnel. If well-designed and adequately
targeted to the appropriate age and population subgroups, then these programs may be
crucial in breaking the intergenerational transmission of poverty.
Indeed, governments around the world have recognized the importance of the
early years and have started to introduce services to support children from deprived
backgrounds. Head Start in the United States and Sure Start in the United Kingdom are
prime examples in developed economies, while the Cuna Má s in Peru and the Family,
Women, and Childhood program (FAMI for its acronym in Spanish) in Colombia,
which is our focus in this work, are similar examples in low- or middle-income
countries (LMICs). Indeed, an increasing number of countries now have national early
childhood policies Devercelli, Sayre, and Denboba (2016).
Although at-scale early years programs are becoming widespread, evidence on their
long-term effectiveness, that is, their ability to improve early childhood development
(ECD) outcomes in a manner that translates into improved functioning and well-
being later in life, is limited. Long-run impacts will likely vary depending on the
details of what they actually offer and how they actually offer it. Understanding their
effectiveness in the context of LMICs is even more important than in high-income
countries, as poverty levels are higher, risk factors such as malnutrition are more
prevalent, and resources are more limited.

1. Cunha et al. (2006), Heckman (2006), Engle et al. (2007), Doyle et al. (2009), Almond and Currie
(2011), Pongcharoen et al. (2012), Shonkoff et al. (2012), and Yoshikawa et al. (2013).
Attanasio et al. Early Stimulation and Nutrition 1397

In this paper, we go beyond the standard approach of evaluating an existing

program, such as the work on Head Start (Bitler, Hoynes, and Domina 2014; Kline and
Walters 2016) and Early Head Start (Love et al. 2005). Instead, we design and evaluate
with a clustered Randomized Controlled Trial (c-RCT) a scalable intervention aimed
at improving an existing parenting program run by the government. The intervention
we studied involved the introduction to FAMI, an existing government program, of
(i) a structured early stimulation curriculum, delivered through weekly group sessions
with mothers and children, and monthly individual home visits; (ii) training and
coaching of the personnel delivering the intervention, provided by trained mentors

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(tutors, henceforth); and (iii) an enhanced nutritional supplement for beneficiary
children, alongside with nutrition education.2 By collaborating with the government
and using the existing infrastructure (i.e. program structure and personnel), we place
the intervention within an operating institutional setting, which facilitates reaching
scale.
The main question we are asking is whether offering early stimulation and
appropriate nutrition in poor environments in a manner designed to be scalable by
building on a nationwide program implemented by a government agency can still
improve children’s human capital and ultimately mitigate the effects of poverty. In
our context, the scalability of an intervention depends not only on its cost, but also
on the possibility of running the intervention within an institutional framework that
can handle it effectively. This is a key policy question, as well as one that adds to the
evidence on the importance of early childhood interventions.
FAMI brings together mothers and their infants in a group setting with other
mother-child dyads. Sessions are run by a local woman employed by the government,
the FAMI mother. We developed a program adapted to these circumstances and inspired
by the original Jamaica home visiting intervention (Grantham-McGregor and Smith
2016), now known as Reach Up (RU, see Grantham-McGregor and Walker 2015;
Walker et al. 2018), and its replication in a scalable fashion in Colombia (Attanasio
et al. 2014, 2020; Andrew et al. 2018).
The intervention was randomly allocated to 46 of 87 municipalities located in three
of Colombia’s 32 departments and lasted an average of 10.4 months. Mothers in the
control communities still had the option of attending the existing program (FAMI). In
other words, the counterfactual against which treatment is compared is FAMI running
as usual, and not the complete absence of the program (see Kline and Walters 2016).
On an intention to treat basis, our intervention significantly improved children’s
cognitive development by 0.16 (p-value 0.044) of a standard deviation (SD), with an
implied average treatment on the treated (ToT) effect of 0.3 SD–0.4 SD, depending
on how we define compliance and intensity of treatment. As our end-line data were
collected so that children were exposed to the treatment for at most 10 months, we also

2. Moran et al. (2004) and Nowak and Heinrichs (2008) reported that the most effective parenting
programs included an evidence-based curriculum, systematic training of frontline workers, and
opportunities for parents to learn and practice with children.
1398 Journal of the European Economic Association

perform a dosage analysis, where variations in exposure were due to differences in the
timing of the training of facilitators. Our analysis shows that the impact increases with
increased intervention exposure. We also find some evidence of heterogenous impacts,
with larger impacts for beneficiaries in the poorest households. This is consistent with
the findings from another at-scale early years intervention (Bitler, Hoynes, and Domina
2014), although this study focuses on children older than those we consider.
Children’s nutritional status also improved: The fraction of children whose height-
for-age is below 1 SD declined by 0.058 (p-value 0.10) with a corresponding increase
in those with height-for-age between 1 SD and 1 SD (0.074 increase in height-for-

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age, p-value D 0.036).3 Results on the long-term effects of nutritional interventions
are scarce and generally mixed. While short-term positive impacts were sustained
in Guatemala (Hoddinott et al. 2013), in the Jamaica experiment, powdered milk
supplementation showed important impacts early on which faded out in the longer term
(Walker et al. 2005, 2006, 2011). In both studies children were stunted at baseline. In
Attanasio et al. (2014), micronutrient supplementation to a population of children with
no specific nutritional deficit had no effect.
In addition to the main impacts, we also explore the mechanisms through which
these might have been achieved. After providing evidence that the intervention
significantly increased some potential mediators, such as parental investment in
children, we show that indeed parental investment can explain most of the observed
impact on child development using simple mediation analysis. This finding is confirmed
by the results from a structural model that accounts for the endogeneity of parental
investment in the estimation of a result consistent with that in Attanasio et al. (2020).
In addition to the impacts of the intervention and its implementability, which we
have discussed so far, we need to consider its cost, which is about $322 per year per
child, plus $11 per child for annual pre-service training. The cost of the unenhanced
FAMI program is itself about $327 per child per year; our intervention, therefore,
roughly doubles the cost of the existing program. This might seem high; however, a
comparison of the costs and impacts of several early years interventions promoted by
the Colombia government in the same period (see Table B.1 in Online Appendix B),
suggests that, given cost, interventions improving process quality by introducing a
curriculum and improving child rearing practices,4 have higher impact than those
improving infrastructure quality alone (such as buildings and staffing). In our case, the
impact of the intervention, deployed for 10 months, is 0.162 SD compared to a total
cost of USD 322. Moreover, as we have suggestive evidence that the impacts increase
with additional sessions, the reported impact is likely to be an underestimate of the
total impact. Therefore, the evidence presented in this paper suggests that it is possible
to gradually improve the quality of nationwide programs at scale in a way that is both
impactful and affordable.

3. The p-values we report are adjusted for multiple testing as explained in the main body of the paper.
4. Such as the integration of a structured curriculum and improved interactions between caregivers and
children supported by coaching and mentoring.
Attanasio et al. Early Stimulation and Nutrition 1399

Our findings demonstrate the potential for improving human capital in poor settings
and therefore form the basis for policy in a broader set of contexts across LMICs and
contribute to the limited existing literature on the scalability of ECD interventions.
The evidence on the long-term impacts of parenting interventions is mainly from small
efficacy trials.5 However, the evidence on the short- and medium-term impacts of
scalable or at-scale parent support programs, that is, interventions designed to improve
outcomes for a large number of children, is scarce and inconclusive both in high-income
countries and LMICs.
Relevant studies in high-income countries include Robling et al. (2016) for the

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evaluation of NFP in the United Kingdom, Cattan et al. (2019) for that of Sure Start in
the United Kindom, Love et al. (2005) for Early Head Start in the United States, and
Hjort et al. (2017) in Denmark. In LMICs, most of the few existing studies report on
short-term impacts’such as the evaluation of the nationwide Cuna Mas Program in Peru
(Araujo et al. 2021), the evaluation of a group-based intervention delivered within a
nationwide conditional cash transfer (CCT) program in Mexico (Fernald et al. 2017b),
program integrations within primary health clinics in the Caribbean (Chang et al. 2015)
and Bangladesh (Hamadani et al. 2019), or an evaluation comparing home visits versus
group delivery in India (Grantham-McGregor et al. 2020). Two exceptions, which
investigate impacts approximately two years after the end of intervention activities, are
the studies in Colombia, where early stimulation and supplementation were delivered
within the infrastructure of the country’s CCT (Attanasio et al. 2014; Andrew et al.
2018), and in Pakistan, where these were integrated into an existing community-based
health service (Yousafzai et al. 2014, 2016). Scalability of effective and sustainable
interventions is therefore a major and salient challenge.
The evidence we present also has direct implications for the importance of safety-
net programs, such as Food Stamps in the United States (see Hoynes, Schanzenbach,
and Almond 2016), for child outcomes. These programs can improve nutrition for
children by providing more resources to parents. We show that providing such
nutritional supplementation directly (in combination with child stimulation) can be
an effective way of improving children’s nutritional status, implying that parents do
not appear to crowd out the additional resources provided for the children, even when
they are delivered for use at home, as in our case. The absence of (complete) crowding
out is a key element for understanding whether such programs can work and the extent
to which they do.
The rest of the paper is organized as follows. The next section describes the
context, the existing program, and the add-on intervention we evaluate. In Section 3,
we discuss the evaluation design and sample. Section 4 presents the empirical strategy,

5. Examples from the United States include the Nurse-Family Partnership (NFP) (Olds et al. 1986a,b,
1994; Heckman et al. 2017) and the Promising Practices (Brooks-Gunn et al. 1994; McCormick et al.
2006). In LIMCs, there is the well-known Jamaica home visiting model, which provided early stimulation
(play-based activities) and nutritional supplementation (powdered milk) to stunted children in slums in
Kingston for 24 months and obtained large impacts on ECD outcomes in the short term that translated into
improved IQ and mental health (Walker et al. 2011) and higher wages (Gertler et al. 2014) in adulthood.
1400 Journal of the European Economic Association

and Section 5 the main evaluation results. Section 6 investigates the mechanisms
behind the impacts obtained, and, finally, Section 7 discusses policy implications and
concludes.

2. Background and Intervention

The intervention that we evaluate consists of improving FAMI, an existing program

run by the Colombian Family Welfare Agency (ICBF for its acronym in Spanish), a

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government institution. The fact that the innovation we are considering is grafted on a
pre-existing infrastructure is important both for interpreting the size of its impacts and
to provide a genuinely scalable model. In this section, we first describe the existing
program and then describe the improvements that we test.

2.1. Description of the Existing Parent Support Program, FAMI

The FAMI program is aimed at supporting vulnerable families during pregnancy,

childbirth, early childhood with nutrition, health monitoring, and childrearing.
Beneficiaries are identified by their score in SISBEN, Colombia’s proxy means test
based on household socio-economic characteristics and used for targeting most social
policies. For the child stimulation component, the program is delivered through weekly
group sessions of one hour each and a monthly home visit of about an hour for parents
of children 0–24 months of age. Group meetings take place in community spaces,
such as schools and churches, or the FAMI facilitator’s own home. Based on ICBF’s
nationwide administrative data from 2013, prior to the beginning of this study, the size
of each FAMI unit varies between 10 and 24 beneficiaries with a mean of 13 (SD D
1.4). Approximately 80% of the beneficiaries are parents of children 0–24 months of
age, and 20% are pregnant women. Close to 225,000 families were FAMI beneficiaries
around 2013, when this study started. FAMI mothers, the program facilitators, are
local women and generally have a high school degree but no specific training on ECD.
Similarly, the program has no concrete curriculum, other than some general operational
guidelines and broad learning standards.6 Indeed, during the pilot stage, we observed
a rather diverse set of activities and discussions during the group sessions, with little-
to-no engagement of the children. The monthly home visits were not designed around
stimulation activities for the child but involved general advice for the family. The
program also delivers a nutritional supplement that corresponds to 22%–27% of the
(monthly) recommended calorie intake of children younger than two and pregnant
women. The average cost of the pre-existing FAMI program is $318 US (US dollars
or USD) per child per year (Bernal 2013). Further details on the pre-existing program
and on the nature of the changes we introduced are provided in Online Appendix A.

6. This approach has applied to all public ECD services in the country to date. The Board for Early
Childhood has emphasized the principle of curricular freedom, and national standards are intentionally
broad. Program providers are expected to adapt the learning standards to their own programs.
Attanasio et al. Early Stimulation and Nutrition 1401

2.2. Description of the Intervention

The intervention we evaluate aims to enhance the existing program through three
complementary elements: (i) a structured early stimulation curriculum to improve child
development, accompanied by pedagogical materials such as books, puzzles, and toys;
(ii) training and coaching for the FAMI mothers; and (iii) a larger and higher quality
nutritional supplement than that previously received by FAMI participants, along with
nutrition education during group sessions and home visits, and other materials such as
recipe books and cards with age appropriate nutrition messages.

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The stimulation curriculum was based on RU (Grantham-McGregor and Walker
2015; Walker et al. 2018), adapted, for the most part, to group meetings. FAMI includes,
however, a monthly home visit whose content was, again, adapted from RU. Both
group meetings and home visits, last for about an hour, and aim at improving parenting
practices and at introducing developmentally appropriate activities for children, in
particular, activities that promote language, cognitive, and fine motor development.
Mothers are encouraged to practice stimulation activities on a daily basis. Although
most of the program content was delivered through the weekly group sessions, the
monthly home visits were used to better tailor the activities to the developmental
level of each child and to introduce other, possibly more complex, activities. With
respect to RU, the adapted curriculum added group discussions, more language
activities, activities for children aged from birth to 6 months, and cards with nutrition
information. The program also trained mothers in sensitive and responsive parenting
and appropriate behavior management, promoting positive interactions, discouraging
child mistreatment, and ultimately promoting child socio-emotional development. The
curriculum was designed to be delivered by facilitators without specialized knowledge
of child development. For this reason, it was purposefully quite prescriptive.
Separate group meetings were offered for pregnant and lactating women with
children up to 6 months, mothers with children 6–11 months, and mothers with children
aged 1–2 years. However, as in practice, mothers did not keep to their allocated slots, we
ensured that the session would cater to children of different ages, with age-appropriate
activities for all. An average of five mothers attended each session (min D 1, max D 15,
SD D 2.6). The curriculum involved materials to be used during the sessions, including
age-appropriate books, puzzles, home-made toys, pictures, construction blocks, and
nutrition cards. The intervention also included supplementary sessions to teach mothers
how to construct home-made toys with recyclable materials that could be used to
practice the activities proposed at home. This way, most mothers were able to set up a
toy library for home use. All materials used in the session were taken home for practice
and returned the following week.7

7. While we received authorization from the ICBF to implement and evaluate the intervention, its
deployment was not publicized.
1402 Journal of the European Economic Association

Pregnant women were invited to participate in all sessions and were encouraged to
practice the activities along with the other mothers and their babies. However, in this
study, we focus on the impacts of the intervention on children 0–24 months only.
A team of nine tutors, with college degrees in psychology and social work, trained
and supervised by the research team, trained the FAMI mothers in the intervention
before it started. Training was provided sequentially by the town. All FAMI mothers
in each given town were trained simultaneously for an average of 3.5 weeks and
85 hours.8 The training involved demonstration, practice, and feedback in running the
group sessions and in conducting the play and language activities with mothers and

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children, and in learning how to make the home-made toys. After the initial training was
finalized, the tutors coached the FAMI mothers continuously throughout the duration
of the intervention. In each supervision round, which took place approximately every
6 weeks, tutors observed one group session and one home visit, after which they
provided feedback to the FAMI mother. Each tutor oversaw 5 towns and 19 FAMI
mothers, on average. The tutors were, in turn, supervised by a program supervisor (a
member of the research team) who visited each tutor every 2 months.
In short, the curriculum we introduced was intended to add both structure and
content to the on-going sessions. FAMI mothers in the treatment group found the
intervention to be substantially different to what was going on in the status quo, with
82% reporting they found it differed from their usual practice.9
Lastly, the intervention also included a monthly nutritional supplement that
provided 35% of the daily calorie intake requirements for target children.10 The
nutritional content of the supplement was specifically targeted either for the pregnant
mothers or to each child depending on their age, see Online Appendix A for further
details.11 All supplements were delivered monthly to the FAMI facilitator, who was in
charge of distributing them among program participants during the first group session
of each month. Families would not receive the monthly nutritional supplement if they
did not attend this session. So, in a way, the early stimulation component represented
a conditionality for receiving the supplement.
Clearly, crowding out of other nutrition and sharing within the household is a
central concern. Participants were told that the beneficiary of the supplement was the

8. This was done in two stages: an initial stage of 2 weeks and a second stage of 1.5 weeks about
2 months later, on average. More specifically, towns with less than five FAMI units received 75 hours of
training in 3 weeks, towns with six–nine FAMI units were trained for 100–125 hours in 5–6 weeks, and
towns with more than ten FAMI units received training during 150–175 hours offered during 6–7 weeks.
9. Specific differences with respect to how they had typically worked were: (i) practicing play activities
with mothers and their children; (ii) practicing language activities with babies; (iii) making home-made
toys with mothers; (iv) encouraging parents to play with their children at home; and (v) listening to parents
about their achievements at home. Almost all of them (99%) reported that they would continue to use the
proposed curriculum after the end of the project.
10. In fact, it included more than that as it allowed for a potential consumption of up to 20% of the
supplement’s nutritional content by other household members.
11. The package contained tuna, sardines, canola oil, iron-fortified whole milk (the only micronutrient
included), beans, and lentils.
Attanasio et al. Early Stimulation and Nutrition 1403

TABLE 1. Costs of the original program and its improvement US $ per child per year.

Original program Additional intervention costs

Materials $8 $27
Other administration costs $2 –
Salary FAMI mother $240 –
Mentoring 0 $88
Total without nutrition $250 $115
Nutrition $77 $209
Total with nutrition $327 $322

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FAMI training N.A. $11 one-time cost

child. However, there was no way to guarantee that its content was appropriately used
in the home or the extent to which it was (exclusively) offered to the target child.12 We
can only provide suggestive evidence, based on the program outcomes.
Table 1 presents the running cost of the existing program, in the first column,
alongside the additional cost of the intervention, the improvement we evaluate, in the
second column. Costs are presented by component, showing a total program cost with
and without nutrition. All values in Table 1 are expressed in USD per year per child,
using the exchange rate at the time of the intervention and assuming an average FAMI
size of ten mother-child pairs.13
The cost of the intervention we are evaluating, which is relevant both for its
scalability and cost-effectiveness, should not be the same as the cost of the original
program. As shown in Table 1, a substantial part of the cost of the original program is
the salary of the FAMI mothers, which did not change, as the intervention did not hire
additional FAMI mothers or decrease the number of children served by each FAMI.
However, a substantial component of the cost of improving the existing program is
the monitoring and mentoring that the FAMI mothers now receive. This amounts to
$88 US per year per child, which covers the salaries of the tutors. For comparison, the
FAMI mother’s salary corresponds to $240 US per child per year. Including the $27
US for materials yields a total cost of the coaching component of $115 US. Excluding
the nutritional component in both the original program and this intervention, the FAMI
intervention we are considering increases the cost of the program by about 46%. We
consider the initial facilitator training ($11 US) as a one-off expense to be incurred in
the first year. As it could benefit subsequent cohorts of children, it should be seen as an

12. We could not evaluate the stimulation component alone, that is, without the nutritional component,
because both were part of the original program. Dissociating them for evaluation purposes was not feasible,
both logistically and ethically.
13. This is conservative, given an average of 9.5 children younger than two per FAMI unit in the sample
(plus 2.1 pregnant women); and a nationwide average of 13 (SD D 1.4; range D [10, 24]), as computed
using administrative data for 2013 (before the intervention started).
1404 Journal of the European Economic Association

investment with some durability.14 The largest increase in cost comes from the added
nutritional package, which costs 2.71 times more than what it regularly costs, from $77
US to $209 US per child per year. Overall, the total increase in the cost of the program is
of $322 US (or $333 US adding the one-off initial training), which effectively amounts
to doubling the original cost of $327 US per child per year. Online Appendix A offers
additional details on the cost of each component, and Online Appendix B includes a
more thorough discussion on costs and scalability.

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3. Sampling Design, Descriptive Statistics, and Implementation

The study took place between September 2014 and July 2016. At the start of the project,
we prepared a pre-analysis plan and registered the trial at the ISRCTN registry (Online
Appendix H).15 The intervention was intended to operate for 15 months between the
end of 2014 and March 2016. In practice, the total duration varied by community,
mainly to accommodate the initial training, and lasted an average of 45 weeks
(10.4 months) with a range of 34–58 weeks. The logistics of rolling out the intervention
implied a considerable amount of variation in exposure for the target children, mainly
due to organizational issues.
The study towns were located in three departments in central Colombia
(Cundinamarca, Boyacá, and Santander). They were all chosen to have (i) fewer than
40,000 inhabitants, to avoid large urban centers; (ii) at least two FAMI units;16 and
(iii) no more than one unit of another public parenting program called Modalidad
Familiar (MF) to minimize attrition towards this alternative program. MF is a public
parenting program, similar to FAMI, that was introduced during the first half of 2014.17
The presence of MF is balanced between control and treatment sample towns, so we
are de facto estimating the effect of enhancing the FAMI program in the presence of
some MF. Importantly for interpreting the results of our evaluation, the presence of
MF in the study sample is minimal, with only 7% of the target children leaving FAMI
to join MF. We further discuss this issue below.

14. While a similar argument on durability could be made for the materials, experience has taught us
that their depreciation rate is quite high as they are rotated among families. Hence, it is safe to assume that
they do need to be replaced, approximately, on a yearly basis.
15. The trial registration is at http://www.isrctn.com/ISRCTN93757590.
16. This requirement is associated with the power calculations for the trial and to facilitate the logistics
associated with the training and coaching carried out by the tutors, who had to travel across various towns.
17. MF is similar to FAMI in that it serves beneficiaries through monthly home visits and weekly group
meetings, but (1) it serves children 0–5 years of age, while FAMI serves children aged 0–2; (2) it has a
set-up infrastructure for group meetings (a center), while FAMI uses other community spaces or FAMI’s
own home; (3) it serves, on average, 45 beneficiaries as compared to close to 15 in FAMI; (4) it is led by a
professional and an assistant, as compared to a single person who is not required to have a college degree
in FAMI; (5) it offers a nutritional supplement five times larger than that of FAMI; and (6) it has access to
a group of professionals including a psychologist and a nutritionist who support MF activities.
Attanasio et al. Early Stimulation and Nutrition 1405

Out of a universe of 135 such towns in these departments, we randomly drew 49

for the treatment group and 47 for the control. We assigned the remaining 39 towns
to a randomly ordered waiting list. Towns in this waiting list were used to replace
towns that had completely transitioned to the new MF program (whether in treatment
or control). We could successfully replace 10 of the 19 towns that no longer ran the
FAMI program, which yielded a final sample of 87 towns: 46 in the treatment group
and 41 in the control group.
The average number of children younger than two per FAMI unit in the sample
was 9.5 (SD D 2.9), and the average number of pregnant women was 2.1 (SD D 1.7).

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This implies an average of 11.6 (SD D 2.8) total beneficiaries per FAMI unit. Within
each unit, we enrolled in the study all children under 12 months of age at baseline,
leading to a sample of N D 1,460 children (4.3 children per FAMI and 17 per town, on
average). We chose this subsample of children in order to maximize the potential time
of exposure to our intervention, before children outgrow the FAMI program at age two.
Overall, a total of 702 children in 171 FAMI units in 46 towns received the treatment
(our enhanced version of the FAMI program); and 758 children in 169 FAMI units
in 41 towns were in the control group, and therefore continued to receive the FAMI
program as usual. At follow-up, we tried to reach all children in the study sample,
regardless of whether they were still attending a FAMI or not, and regardless of the
length of their exposure to FAMI.
Online Appendix C provides further details on the study design, including power
calculations, the study flow of participants, and the geographic distribution of treatment
and control towns.

3.1. Data

As described in the pre-analysis plan, reported in Appendix H, we defined

a number of primary outcomes. These included measures of nutritional status,
namely, externally standardized height-for-age Z-scores, constructed following the
World Health Organization (WHO) standards (Bayley 2006); and socio-emotional
development, as measured by the Ages and Stages Questionnaire: Socio-Emotional
(ASQ:SE) (Squires, Bricker, and Twombly 2009). We chose developmental tests that
have been extensively used in evaluations of early care or education and/or have
been recommended for LMICs (Fernald et al. 2017a). These instruments were either
available in Spanish or had been previously translated, as they had been used in
Colombia before among similar populations. Anthropometric measures were collected
in both rounds, whereas developmental measures were only collected at follow-up. At
baseline, children were younger than one year of age. Given the limited resources we
had and how complex and expensive it is to reliably assess the development of such
young children, we decided not to.18

18. Child development assessments and anthropometric measures were collected by testers with degrees
in psychology and health, respectively. The remaining variables in the household survey were collected by
regular enumerators prior to the child assessments.
1406 Journal of the European Economic Association

For the analyses, we used internally age-standardized Bayley-III scores, where raw
scores were standardized using the sample mean and SD calculated from weighted
local smoothing regressions. We also aggregated all Bayley-III subscales using the
factor model described in Online Appendix D, which we interpret to reflect the
child’s “cognitive” development. Children with extreme values for developmental
or nutritional outcomes, according to international standards, were excluded from the
analyses.19
In order to obtain an understanding of the mechanisms at play, we also
estimate impacts on intermediate outcomes that could have mediated the effect of

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the intervention on children’s developmental outcomes. In particular, we collected
by maternal report, both at baseline and at follow-up, information on variables
that measure the quality of the home environment, maternal self-efficacy, maternal
knowledge about child development, and food insecurity.
For the quality of the home environment, we used four variables constructed from
items in UNICEF’s Family Care Indicators (FCI, Kariger et al. 2012): the number of
magazines, books, or newspapers in the home; the number of toy sources; the number
of varieties of play materials in the home; and the number of varieties of play activities
the child engaged in with an adult over the 3 days before the interview, which were
summarized in a single factor, labelled “parental investment” and estimated using the
factor model described in Online Appendix D. We assessed maternal self-efficacy using
the self-efficacy in the nurturing role scale in Porter and Hsu (2003). This scale contains
16 items rated in 7-point scales that pertain to mothers’ perceptions of their competence
on basic skills required in caring for an infant. To measure maternal knowledge about
child development, we used 10 items, some selected from the Knowledge of Infant
Development Inventory (KIDI, MacPhee 1981) and some developed by the research
team.
Food insecurity was collected with the Latin American Scale for the Measurement
of Food Insecurity (ELCSA scale), both at baseline and at follow-up. The ELCSA
had been previously validated in Colombia (Álvarez Uribe and Instituto Colombiano
de Bienestar Familiar 2008) and allows classifying households in four food insecurity
levels: secure, mild insecurity, moderate insecurity, and severe insecurity (Álvarez
Uribe and Instituto Colombiano de Bienestar Familiar 2008). In the analysis, we use
an indicator that equals 1 if the household is food insecure (mild, moderate, or severe)
and 0 otherwise.
Detailed socio-economic household information was also collected, including
maternal vocabulary scores (a proxy for maternal IQ), which was assessed on the
Spanish version of the Peabody Picture Vocabulary Test (PPVT), Test de Vocabulario
en Imagenes Peabody (TVIP) (Padilla, Lugo, and Dunn, 1986).
Finally, background information on FAMI mothers was gathered directly from
them in both rounds. In addition to basic socio-demographic characteristics, we also

19. Specifically, we excluded 12 children who scored more than 3 SD below the mean on the Bayley-III
cognitive scale (possible disability) and 15 children who were 6 SD below the mean and 6 SD above the
mean of height-for-age (extreme observations).
Attanasio et al. Early Stimulation and Nutrition 1407

TABLE 2. Sociodemographic characteristics of children and their families at baseline.

Treatment Control p-value RW

Sociodemographic characteristics

Child’s age in months 5.72 5.51 0.353 0.945

(3.39) (3.26)
Child’s birth weight (gr) 3189 3156 0.442 0.956
(572) (500)
Maternal age (number of years) 26.16 26.47 0.421 0.956

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(6.84) (6.70)
Maternal years of schooling 8.85 8.41 0.121 0.688
(3.42) (3.31)
Household Income (COP thousands) 526.1 477.2 0.232 0.883
(388.1) (340.7)
Household size 4.08 4.10 0.932 0.976
(1.47) (1.43)
Maternal PPVT (raw score) 22.32 19.76 0.037 0.386
(8.53) (8.08)
Child’s gender (% male) 51.9 50.9 0.729 0.976
First born (%) 46.6 45.1 0.655 0.976
Teenage mothers (%) 25.4 20.9 0.059 0.508
Father present (%) 69.7 75.1 0.031 0.386
Owns home (%) 37.1 39.6 0.623 0.976
Household in poverty (%)a 58.7 64 0.298 0.920

Intermediate outcomes

Parental Investmentb 0.03 0.03 0.625 0.948

(0.96) (1.02)
Maternal knowledgec 29.26 29.49 0.680 0.948
(3.61) (3.44)
Maternal self-efficacy 26.50 26.49 0.974 0.978
(5.51) (4.67)
Food insecurity (%) 50.4 41.9 0.219 0.631

No. of observations 700 756

Notes. Standard deviations (clustered by town) in parentheses. RW: p-values adjusted for multiple testing using
the Romano–Wolf (Romano and Wolf 2005, 2016) step-down method. In this case all hypotheses in the panel are
included in the RW p-value calculation. Household Income is measured in thousands of Colombian Pesos (COP).
a. % of households with total income below the poverty line in 2014 ($50 US person/month).
b. Factor score of FCI subscales.
c. Only available at follow-up (raw scores presented).

collected their vocabulary scores and knowledge of child development using the same
tests as for mothers.

3.2. Descriptive Statistics

Table 2 shows baseline characteristics by treatment status. At baseline, children were,

on average, for both the treatment and control groups, 5.6 months of age, and in about
27% of the cases, the father was absent from their household. Households had two
1408 Journal of the European Economic Association

children, on average; maternal average schooling was 8.6 years; and 23% of mothers
were teenagers. In 2010, the teenage pregnancy rate was 21% nationwide and 30% for
young girls living in households in the poorest income quintile.
The target population was particularly poor: Average household income was COP
501,000 per month (US 178), which represents 81% of the legal monthly minimum
wage in 2014. Close to 70% of these households had answered the SISBEN survey
for screening of social program eligibility, a good proxy for poverty, and 96% of
those surveyed were deemed eligible for social programs (i.e. they scored in SISBEN
levels 1 and 2). Similarly, 62% of households in the sample had a total income below

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the poverty line adjusted for household size. In 2014, the poverty rate was 42% in
semi-urban and rural areas of Colombia.
The environment in which the sample children grew up is highly deprived: In
terms of the home learning environment (“parental investment”), on average, these
households owned 2.6 books, magazines, or newspapers and 1.4 different varieties
of play materials for young children in the household, and adults were reported to
have engaged in 2.5 different types of play activities with young children over the
past 3 days.20 For comparison, among a representative sample of low-middle-income
households with children aged 6–12 months in Bogota (Colombia’s capital city), we
observed an average of 3.2 different varieties of play materials and 3.4 different types
of play activities. Moreover, the median household in this sample only owned three
books for adults.
In Table 3, we show averages for the baseline nutritional status of children by
treatment status. Specifically, we report weight-for-age, height-for-age, and height-
for-weight Z-scores, in addition to a variety of nutritional indicators by deficit or
excess as identified by international standards. In our sample 12% of the children are
stunted. For comparison, stunting was about 9.3% for children younger than one year
of age in rural areas in Colombia in 2013 and 11.8% in urban areas (as measured
in the Colombian Longitudinal Household Survey, CEDE 2013). Table 3 also shows
that an additional 15% of children were at risk of stunting, that is, children whose
height-for-age was between 2 SD and 1 SD.
In Table 4, we report the mean and standard deviation of the cognitive, language,
and socio-emotional development levels for the control group as measured at follow-up
(ages 17–33 months). These have been standardized with a mean of 100 and a standard
deviation of 15, which is the US reference population (composite scores). Subject to
all the caveats of such comparisons, this allows us to place our population relative
to the expected developmental outcome under favorable conditions. The Bayley-III
composite scores were 0.6 SD below the norming sample mean in both the cognitive
and language scales, and 0.4 SD below in the motor scale. We also observed that 18%
of children score between 1 SD and 2 SD with respect to the norming sample
in cognition, 23% in language, and 15% in motor development. Only about 2%–3%
would be considered at risk of developmental delay given that their composite scores
are below 2 SD.

20. These variables are not shown in Table 1 but correspond to the components of the FCI “parental
investment” factor.
Attanasio et al. Early Stimulation and Nutrition 1409

TABLE 3. Nutritional status of children at baseline by randomization status.

Treatment Control p-value RW

Weight-for-age z-score 0.26 0.27 0.921 0.988

(1.39) (1.42)
Length/height-for-age z-score 0.01 0.21 0.241 0.797
(1.68) (1.74)
Weight-for-length z-score 0.37 0.55 0.167 0.749
(1.59) (1.65)
Underweight (%) 6.4 5.1 0.465 0.918

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Risk of underweight (%) 9.1 10.7 0.415 0.918
Wasting (%) 5.9 6.4 0.775 0.988
Risk of wasting (%) 10.9 8.2 0.179 0.749
Stunting (%) 9.2 13.9 0.081 0.501
Risk of stunting (%) 14.7 15.5 0.793 0.988
Overweight (%) 9.9 9.2 0.707 0.988
Obesity (%) 4.8 7.3 0.174 0.749

Notes. Standard deviations (clustered by town) in parenthesis. Adjusted p-values using the Romano–Wolf
(Romano and Wolf 2005, 2016) procedure (2,000 iterations, clustered by town) are included in the last column.
All variables in the table are considered as one group of hypotheses. Underweight: weight-for-age < 2 SD;
risk of underweight: weight-for-age between 1 SD and 2 SD; wasting: weight-for-height < 2 SD; risk of
wasting: weight-for-height between 1 SD and 2 SD; stunting: height-for-age < 2 SD; risk of stunting:
height-for-age between 1 SD and 2 SD; overweight: weight-for-height between 2 SD and 3 SD; and obesity:
weight-for-height > 3 SD.

TABLE 4. Developmental outcomes of children in the control group at follow-up.

Mean
(standard deviation) N

Bayley
Cognitive composite score 91.98 703
(13.07)
Language composite score 91.59 702
(12.31)
Motor composite score 93.97 701
(12.58)
ASQ:SE
% of children at socio-emotional risk 0.38 705

Notes. Standard errors are clustered by town in parenthesis. Bayley-III composites are computed based on external
standardization provided by test developers. The fraction of children at socio-emotional risk by the ASQ:SE is
computed using the thresholds provided by the test developers (Squires, Bricker, and Twombly 2009).

In terms of socio-emotional development, 38% of the children were at risk of

developmental delay according to thresholds defined by the ASQ:SE using the test
norming sample. For comparison, we know from the CEDE 2013 that 22% of children
younger than two in low-Socioeconomic Status (SES) urban households were at risk
of developmental delay by the same measure, 26% in high-SES urban households, and
19% in rural households in 2013.
Finally, in Online Appendix E, we present the basic characteristics of FAMI
mothers by study group. On average, they were 42 years of age, had completed
1410 Journal of the European Economic Association

13 years of education, and had almost 12 years of work experience in the FAMI
program. They had an average of 2.5 children of their own. There were no jointly
significant differences between FAMI mothers in treatment and control towns.

3.3. Attrition, Compliance, and Dosage

In both treatment and control towns, children in the sample might be “lost” in the
follow-up survey and/or might drop out of FAMI. The first is an attrition problem,
while the latter is a compliance one. At follow-up, we attempted to reassess all children,

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including those who dropped out of FAMI, to avoid non-random selection.
We report figures on attrition in Online Appendix F (Table F.1). The attrition
rate, at 8.6%, was slightly higher in the treatment group (10.6%) than in the control
group (6.7%), although the difference is significant only at the 10% level. Children
lost at follow-up were older, less likely to have a resident father at home, and more
likely to have mothers with lower vocabulary (PPVT) scores. Moreover, as shown
by the interactions of the treatment indicator with observables, attrition affected
slightly the composition of the treatment and control samples (third column of Online
Appendix Table F.1). While the attrition differential between treatment and control
towns was not very large, in Online Appendix G, we discuss how we deal with the
potential bias that it could introduce to our impact estimates. Furthermore, there we
show that attrition does not bias our main findings.
Children who dropped out of the FAMI program between baseline and follow-up,
if found, were interviewed at follow-up and their families were asked for the reason
to leave FAMI. A total of 47% reported that they outgrew the program eligibility age,
40% that they started attending a different ECD public program (12% a parenting
program and 28% a childcare program), and 13% reported to have moved to another
municipality. In Tables F.2 and F.3 in Online Appendix F, we show that the treatment
slightly reduces the probability of dropping out of FAMI for an alternative program
and is not related to the probability of attending MF.
If age-eligible, a family could have attended a maximum of 44 weekly group
sessions and received 11 monthly home visits during the study period. In terms of
effective attendance, 77.5% of all children in the treatment group assessed at follow-
up participated in at least one FAMI pedagogical activity (group session or home
visit), while the rest did not attend any at all. Information on participation in specific
activities was collected as part of the supervision protocol of the enhanced intervention
and therefore is only available for the intervention group. In Figure F.1 in Appendix F
(graphs (a) and (b)), we show the distribution of children in the intervention group by
total exposure to the pedagogical component of the program. Conditional on having
attended at least one session, the median number of pedagogical activities attended
was 28 out of a total of 55.21

21. Some other children in the treatment group might have dropped out of the FAMI program between
baseline and the beginning of the intervention due to the time elapsed to complete the training of the FAMI
mother (up to 4 months). These children, therefore, would not have attended any of the enhanced sessions.
Attanasio et al. Early Stimulation and Nutrition 1411

On the main reasons why parents found it difficult to attend group sessions or
receive home visits, close to 38% reported child illness, 15% reported maternal illness,
and 19% reported conflict with other commitments. An additional 12% reported
difficulties in finding or being able to afford transportation to the meetings, and 10%
reported bad weather. The remainder reported other reasons. Children with lower
program attendance were older, less likely to live with their fathers, and had younger
and more educated mothers. While they exhibited better learning environments at
home, they were exposed to higher verbal or physical punishment (Table F.4 in Online
Appendix F).

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Regarding, the nutritional component of the intervention, close to 29% of children
in the treatment group did not receive any nutritional supplements, and those who
received at least one, received 9.8 supplements on average (SD D 3.6) out of a
maximum of 14 (Online Appendix F, Figure F.1, graph (c)). As the supplements were
delivered by the FAMI mother during the first group meeting of each month, non-
attendance implied that a beneficiary might not receive the supplement. We cannot
verify if and how the nutritional supplement was used at home or the extent to which
it was shared within the family.
Compliance with both components of the program largely overlapped with the
same subsamples of children. In particular, 66% of children in the treatment group
received at least one nutritional supplement and attended at least one session, 21%
did not receive any nutritional supplements nor attend any sessions, 9% attended at
least one session but did not receive any nutritional supplements, and 5% received
at least one supplement but never attended sessions (Figure F.1, graph (d) in Online
Appendix F).

4. Estimating Average Impacts

For each outcome of interest, we estimate Intent to Treat (ITT) effects on children’s
development using the regression
yi sl;1 D ˇ0 C ˇ1 Tsl C ı 0 Xi sl;0 C Fl;0  C D0  C Zi sl;1  C "i sl;1 ; (1)
where Yi sl;1 is an outcome of interest for child i in FAMI unit s in town l at follow-up
(t D 1); Tsl is a dummy equal to 1 if the FAMI unit s in town l was in the treatment
sample. Xi sl;0 is a set of baseline child and household characteristics, including child’s
age, gender, weight-for-age and height-for-age z-scores, the household’s wealth index,
maternal PPVT scores (to proxy for maternal IQ), and an indicator for the mother being
an adolescent. These are included to improve efficiency and to correct for any minor
baseline imbalances caused by attrition.22 Finally, D0 represents a set of department

22. Item non-response in baseline covariates is not correlated with treatment status. Thus, we imputed
missing covariate values with the average of the non-missing observations and accounted for this imputation
with a dummy variable in equation (1). The exact fraction of imputed observations varies by covariate up
to a maximum of 6.8%.
1412 Journal of the European Economic Association

fixed effects, which control for regional differences, Zi sl;1 is the vector of tester or
interviewer dummies, and "i sl;1 is the residual term. We cluster standard errors of the
estimates at the town level, which is the unit of randomization.
The presence of the MF program in the town does not bias our impact estimates. MF
was in place before randomization, and our sample of children was drawn from those
attending the FAMI center at baseline before randomization. Moreover, as documented
in Online Appendix F, treatment did not affect the probability of switching to MF, and
it only affected that of switching to other alternatives marginally.
In addition to average impacts, we look at impacts across the distribution of

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outcomes and also analyze the possibility of heterogeneous impacts in two ways. First,
we consider the entire distribution of the outcomes of interest in the treatment and
control samples and test for differences in these distributions using the Anderson–
Darling statistics (Anderson and Darling 1952).23 Second, we re-estimate equation (1)
for subgroups in the evaluation sample. In particular, we divide the sample by wealth,
as measured by a household wealth index, by the mother’s education, and by the child’s
gender.

5. The Impact of the Improved FAMI

For most outcomes, we measure impacts in terms of SD units of the variable of interest
in the control group. We also include the 95% confidence interval, the standard p-value
for two-tailed null hypotheses, and the Romano–Wolf stepdown p-values adjusted for
multiple hypotheses testing for the specific group of hypotheses presented in each
table. The Romano–Wolf procedure was performed using 2,500 bootstrap replications
and clustering by town.

5.1. Main Impacts

In Table 5, we report the average impacts of the intervention on the Bayley-III factor
for a summary measure of overall development; the ASQ:SE for socio-emotional
development; and the height-for-age Z-score for nutritional status. In subsequent tables,
we present results for more disaggregated measures of these outcomes. Impacts are
computed regardless of whether children actually attended the program or how many
times they attended, that is, these are Ordinary Least Squares (OLS) estimates of
equation (1) or ITT.
The effect of the program on the Bayley-III factor was 0.163 SD, and it is
statistically significant at the 5%, after adjusting for multiple hypotheses testing for
the three primary outcomes in the table. We find no significant average impact of the
program on socio-emotional development or height-for-age Z-scores. Socio-emotional
development is part of the set of potential outcome variables, as the program also aimed

23. Such a test is considered more powerful to detect differences in the tails of the distribution than the
Kolmogorov–Smirnoff test (Engmann and Cousineau 2011).
Attanasio et al. Early Stimulation and Nutrition 1413

TABLE 5. Impact on children’s outcomes.

Impact
(95% CI) p-value RW p-value

Bayley-III factor 0.163 0.015 0.047

(0.035, 0.290)
ASQ:SE total score 0.021 0.722 0.704
(0.096, 0.139)
Height for age Z-score 0.078 0.190 0.317
(0.038, 0.195)

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Notes. 95% confidence interval in parenthesis for two-tailed tests. Standard errors clustered by town. Covariates
included: child’s gender, an indicator of high household wealth index, maternal PPVT score, teenage mother, an
indicator of high municipality population, previous attendance to a childcare center, department and interviewer
fixed effects, and baseline weight-for-age and height-for-age Z-scores. Bayley-III factor is a factor score of the
five age-standardized Bayley-III scales. ASQ:SE total score is the age-standardized ASQ:SE score.

p < 0.05 based on Romano–Wolf adjusted p-values (RW, Romano and Wolf 2005, 2016), as we consider three
simultaneous hypotheses for children’s outcomes.

at training mothers in sensitive and responsive parenting and appropriate behavior

management. However, the curriculum had a stronger focus on cognition and language
through the demonstration and practice of specific activities, which might explain the
lack of effect on socio-emotional development.24 We discuss further the results on
nutritional status below.
As mentioned, the impacts in Table 5 are measured in terms of SD of the outcome
of interest in the control group. An alternative meaningful metric would be the fraction
of the gap in the outcome of interest that the estimated impact represents in a reference
population. To perform such an exercise, we use a subsample of children analyzed by
Rubio-Codina et al. (2015). The authors considered a sample of about 1,400 children
aged 6–36 months living in families representative of the bottom 85% of the wealth
distribution in Bogota and estimated a difference in the Bayley-III cognitive scale of
about 0.8 SD between those in the top and the bottom 25% of such a wealth distribution,
which corresponds roughly to the 17th and the 68th percentile of the entire population
in the city. To make the Bogota and the FAMI samples comparable, we estimated a
factor model using both samples simultaneously, but limiting the Bogota sample to
children of the same age as the FAMI children. We used the Bayley-III cognitive scale,
available in both samples, as an anchor and imposed a loading factor normalized to
one. We find that the developmental levels of FAMI children are similar to those of
children in the bottom 10% of the Bogota sample, and the impact of the intervention
is equivalent to closing the gap between children in the top and bottom wealth decile
by 23%.
The size of these effects is not negligible, especially if we take into account that the
intervention lasted on average no more than 45 weeks and attendance was incomplete
(77.5% attended at least one session). It also compares favorably to the impact of

24. Note also that the measures used to capture socio-emotional development might not be very precise.
1414 Journal of the European Economic Association

nearly 0.26 SD obtained in Attanasio et al. (2014), which was a one-on-one weekly
home visiting program that lasted for 18 months with very high compliance rates.

The Role of Attrition. As discussed earlier, there has been some attrition, which is a
differential between the treatment and control groups, even conditional on observables.
To assess the possible bias caused by this, we estimate a selection model where attrition
is a function of baseline characteristics as well as indicators for the identity of the
interviewers assigned to households at baseline and follow-up. The identity of the
interviewers explains attrition, presumably because of differing quality among them.

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Furthermore, as interviewers were allocated randomly across towns, making their
identity orthogonal to individual characteristics, their identity is a valid instrument.
We also need to assume that the identity of the interviewers is unrelated to children’s
outcomes, which is reasonable since those administering the Bayley-III test were
different people from the interviewers collecting the household survey. The attrition
equation is estimated jointly with the outcome equation. The results are reported in
Table G.1 in Online Appendix G and show that our conclusions are not sensitive to
correcting for such non-random attrition.

5.2. ToT and Dosage Effects

ToT Effects. Since non-compliance with the program is one sided, we can use
instrumental variables to identify the effect of ToT, using the random assignment
to treatment as an instrument. There are, however, many different ways of thinking of
the intensity of the program. If we measure effective participation as the fraction of
children who attended at least one of the pedagogical activities of the program (i.e. a
group session or a home visit), which is 77.5%, then the ToT on the Bayley-III factor
is 0.21 SD. If, instead, we measure effective participation as the fraction of children in
the treatment group who attended at least the unconditional median number of sessions
(i.e. 21 out of 55 total), which is 53.2%, the ToT on the Bayley-III factor is 0.30 SD.
Finally, if we define effective participation as the fraction of children who attended
the median number of pedagogical activities conditional on having attended at least
one (i.e. 28 sessions), which is 38.6%, then the ToT effect is 0.42 SD.25 Thus, the
potential effects are large even for a reasonably short intervention, delivered in groups.
To realize such potential compliance, we would need to improve our understanding
of the factors that drive attendance and whether parents misperceive the returns of the
program in terms of child development. This is a key area of further research.

25. There is an additional complication in estimating ToT effects from the ITT impacts we report. As
we mentioned above, our estimate represents the impact of the improved FAMI relative to the standard
FAMI (status quo), which is attended by the children in the control group. Presumably, there are also
compliance problems in the control program on which, unfortunately, we do not have data. The ToT
estimate we have discussed should be interpreted as the impact of a fully compliant improved FAMI over
the business-as-usual FAMI in which compliance does not change.
Attanasio et al. Early Stimulation and Nutrition 1415

TABLE 6. Effects of potential dosage on Bayley-III factor.

Potential dosage Effect of average potential dosage

(standard error) (p-value)

Bayley-III factor 0.209 0.169

(0.079) (0.010)

Notes. Standard errors clustered by town. Covariates included: child’s gender, an indicator of high household
wealth index, maternal PPVT score, teenage mother, an indicator of high municipality population, previous
attendance to a childcare center, department and interviewer fixed effects, baseline weight-for-age and height-

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for-age Z-scores, the difference in days between baseline, and follow-up data collections. In the treatment group
the potential dose varies from 34–58 weeks.

p < 0:05.

Dosage Effects. By the time follow-up data were collected, the FAMI intervention
had been running for about 10 months. This short interval was dictated by budgetary
considerations. As discussed in Section 2, the intervention involved training the FAMI
mothers for about 3.5 weeks. The trainers, divided into several groups, covered all
the treatment towns in about 2 months. The end-line data collection itself extended
for about 2 months. The combination of these two factors meant that by the time
the outcomes were measured the potential intervention dosage that children could
be exposed to in the various treatment communities varied considerably, between 34
and 58 weeks. We define the potential dosage of the intervention as the number of
sessions that could have been attended during the period comprised between the date
in which the children were assessed at end-line and the date on which the training had
been completed, divided by 100. For the control sample, dosage is fixed at 0. As this
measure of dosage was determined by logistical considerations, it is very likely to be
uncorrelated with child development outcomes, and thus, we assumed it is exogenous.
To corroborate this assumption, we test whether dosage correlates with a number
of village variables within the treatment group. The results do not show any discernible
correlation (see Table F.4 in Online Appendix F). Furthermore, we add to the observable
controls in equation (1) a variable that measures the difference in days between follow-
up and baseline data collection rounds. This difference was also driven by similar
logistic considerations but does not correlate with our measure of dosage.
Given this evidence, we modify equation (1) in the following fashion:
Yi sl;1 D ˇ0 C ˇ1 Dos sl C ı 0 Xi sl;0 C Fl;0  C D0  C Zi sl;1  C "i sl;1 ; (2)
where Dos sl is dosage as defined as above. We report the results on the Bayley-III
factor as the outcome of interest in Table 6.
The estimates show a positive and significant effect (with a p-value of 0.010)
of dosage equivalent to an increase of 0.209 SD in cognitive development for every
100 additional sessions. In the last column of the table, we report the impact implied
by these results for the average dosage received by children in the treatment group,
which is estimated at 0.169. This result is consistent with the impact reported in
Table 5. We also experimented with a quadratic specification for dosage. We do
not find any significant non-linearity. This result is perhaps not surprising given the
1416 Journal of the European Economic Association

relatively short amount of time the intervention had been implemented at the time we
collected follow-up data.

5.3. Heterogeneous Impacts

In this subsection, we look at heterogeneity in impacts. As mentioned in Section 4,

we consider both unobserved heterogeneity and heterogenous impacts of observable
variables, such as wealth and maternal education.

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Unobserved Heterogeneity. Figure 1 reports the distribution of the Bayley-III factor
and the ASQ:SE (socio-emotional skills) by treatment and control. To obtain each
figure, we first regress the respective outcome on the control variables included in
equation (1), and then we plot the distribution of the residuals of this regression for the
treatment and the control groups separately. In the graph, we also report the p-value
of the Anderson–Darling (AD) and the Kolmogorov–Smirnov (KS) tests for the null
hypothesis of identical distributions by groups.26
What is apparent from the graphs and the results of these tests is that the program
had a significant impact on the Bayley-III factor (p-values D 0.010 and 0.012 for the
AD and KS tests, respectively) and affected the distribution over most of its support.
The results for the ASQ:SE are less strong; nevertheless, the p-value for the AD test is
0.067, showing some impact.
As we saw in the descriptive analysis, 12% of the children in our sample are stunted
(height-for-age < 2 SD) and 15% are at the risk of stunting (2 SD < height-for-
age < 1 SD). It is well-established that stunting at this age is a good indicator
of long-term malnutrition and can have long-run negative impacts on human capital
development (Hoddinott et al. 2013). The program included a significant nutritional
component, which given the nature of our sample, could have both a short- and a
long-term impact. While Table 5 did not show significant impacts on height-for-age,
the third graph in Figure 1 shows a more nuanced picture and significant impacts on
the distribution of height for age (p-values D 0.050 and 0.075).
We pursue this in Table 7, where we assess the impacts on different parts of the
distribution of height-for-age. The results indicate that the fraction of children whose
height-for-age was below 1 SD decreased by 6.8 percentage points or 0.15 SD, while
the number of children with normal height-for-age increased by a similar fraction
(7.6 percentage points). Both results are statistically significant at the 5% level, even
after adjusting the p-values for multiple testing, and point to the value of considering
the entire distribution. This result is of importance because it has often been proven
difficult to impact height-for-age through less intensive interventions (Bernal 2015).

26. The Anderson–Darling test focuses more on the tails of the distribution and has been shown to have
greater power than alternative tests, such as the Kolmogorov–Smirnov test (Bennett 2008), which focuses
on first-order dominance.
Attanasio et al. Early Stimulation and Nutrition 1417

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F IGURE 1. Distribution of conditional outcomes by treatment status. Plot of the distribution of

the residuals resulting from a regression of outcomes on observed characteristics described in
equation (1), for the treatment and the control samples separately.
1418 Journal of the European Economic Association

TABLE 7. Impacts on height-for-age by ranges of the distribution.

Impacts
(95% CI) p-value RW p-value

Pr(Height-for-age between –5 SD and –1 SD) 0:068 0.024 0.044

(0:126; 0.010)
Pr(Height-for-age between –1 SD and 1 SD) 0.076 0.013 0.033
(0.017, 0.134)
Pr(Height-for-age between 1 SD and 5 SD) 0.001 0.950 0.955
(0.025, 0.023)

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Observations Treatment 559 Control 632
559 632

Notes. Impacts measure the change in the probabilities considered in each row in a linear probability model.
Standard errors clustered by town. Covariates: child’s gender, an indicator of high household wealth index,
maternal PPVT score, teenage mother, an indicator of high municipality population, previous attendance at
a childcare center, department and interviewer fixed effects, and baseline weight-for-age and height-for-age
Z-scores.

p < 0:05 based on Romano–Wolf adjusted p-values (RW, Romano and Wolf 2005, 2016), considering all three
hypotheses jointly.

Observed Heterogeneity. We now consider how average impacts differed across key
groups. This exercise can help us understand whether the intervention helped the most
vulnerable and from a policy perspective it helps improve targeting. We investigate
whether the effects of the intervention on children’s development, as measured by the
Bayley-III factor, varied by maternal education, child gender, and household wealth at
baseline.
For each of these three baseline variables, we divided the sample into two groups:
less than high school versus more for maternal education; boy versus girl for child’s
gender; and household wealth above or below the sample median.27 The results are
reported in Table 8. Impacts do not seem to substantially vary by the level of maternal
education. Although the point estimates are larger for mothers with complete high
school (0.176 SD vs. 0.142 SD), this difference is not significant. Turning to gender, the
point estimates suggest that the intervention worked better for boys, but the differences
are, again, not significantly different from zero. However, we do find significant effects
of wealth on the impacts, even after correcting for multiple testing, across all the six
hypotheses considered jointly. The effects, at 0.24 SD, are estimated to be much
stronger for children living in poorer households. Moreover, the difference between
the impact on children from poorer households and that on children from the higher
wealth group is significant, with a RW p-value of 0.060.
This result is key and contains both a positive and a negative message: The
intervention can indeed improve the outcomes of the most deprived group in this
already poor population. However, the better-off children from this group are in

27. The wealth index is computed as the first principal component of a number of dwelling characteristics
(such as the material of walls, floors, and roofs, the number of bathrooms and rooms, access to utilities,
etc.), and durable goods ownership.
Attanasio et al. Early Stimulation and Nutrition 1419

TABLE 8. Heterogeneous impacts on the Bayley-III factor by child and household characteristics at
baseline.

Impacts Estimated difference

Group (N) (RW-p-value) (RW-p-value)

Maternal education  complete high school (N D 660) 0.176 0.034

(0.072)

Maternal education < complete high school (N D 632) 0.142 (0.757)

(0.234)

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Male (N D 673) 0.198 0.074
(0.077)
Female (N D 619) 0.125 (0.717)
(0.231)

Wealth index above the median (N D 657) 0.042  0.243

(0.592)
Wealth index below the median (N D 635) 0.285 (0.060)
(0.008)

Notes. Heterogeneous effects estimated by subsamples: Difference is a cross-model test for ITT associated
parameter. Covariates: child’s gender, an indicator of high household wealth index, maternal PPVT score, teenage
mother, an indicator of high municipality population, previous attendance to a childcare center, department
and interviewer fixed effects, and baseline weight-for-age and height-for-age Z-scores. Romano–Wolf stepdown
p-values for the six multiple hypotheses for the impact and three hypotheses for the differences in the last column.

p < 0.10,  p < 0.01 based on Romano–Wolf adjusted p-values (RW, Romano and Wolf 2005, 2016).

no way “well-off” or middle class, and neither do they measure up well in their
development against, say, even the Bogota middle class, never mind the international
standards. Hence, the intervention would need to improve for this group. These results
generally highlight the difficulty with improving ECD programs for broad populations,
so targeting interventions to the needs of separate groups is likely to be important.
No significant heterogeneous effects were found in the case of socio-emotional or
nutritional outcomes.
Lastly, we investigate whether intervention impacts varied by quality of
implementation and FAMI mother characteristics. We do not find any significant
differences in impacts by any of the measures of implementation fidelity available,
nor by FAMI mother’s age or education. The only variable for which we find
some marginally significant differences in impact is a measure of FAMI mother’s
“motivation”, as assessed by the tutors: Children who attended centers by a FAMI
mother reported to be more “motivated” than the median, registered a higher impact
(0.22SD vs. 0.07). This 0.15 difference is significant with a p-value of 0.099.

6. Understanding the Impacts

In this section, we study possible mechanisms that could have generated the
documented impacts on final outcomes. We start by estimating the impact of the
intervention on a number of inputs that are relevant for child development, following
Heckman, Pinto, and Savelyev (2013). We then take a structural approach to estimate
1420 Journal of the European Economic Association

the causal link between the relevant inputs we consider and child development, taking
into account the possible endogeneity of the former, through a production function
framework similar to that in Cunha and Heckman (2008), Cunha, Heckman, and
Schennach (2010), and Attanasio et al. (2020).

6.1. Effects on Intermediate Outcomes and Mediation Analysis

The intervention we are studying is a transfer in kind of early education and nutritional
supplementation. As with other transfers in kind, the intervention can induce parents

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to change their contributions to their child’s development in other dimensions. The
food supplement delivered by the intervention we are evaluating could be clawed back
by reducing other food inputs to the target child, or perhaps sharing it in the family
and even selling it; and the additional stimulation received by the target children could
cause parents to switch attention to other children or to themselves, therefore mitigating
the intervention’s impact. On the other hand, it is also possible that low-income parents
are not fully aware of the returns to investing in their children (Cunha, Elo, and Culhane
2013; Attanasio, Cunha, and Jervis 2019), so that the effects of the intervention may
have been generated by an increase in investment induced by a change in these beliefs.
Therefore, there are also good reasons to believe that, instead of crowding out, the
intervention could have led to a crowding in of resources. In this case, adding to the
transfer from the intervention may have particularly high returns. Indeed, Attanasio
et al. (2020) evaluates another early years stimulation intervention in Colombia and
shows that, in response to it, parents crowd-in resources by increasing investments.
Exploring the mediating factors and the mechanisms underlying intervention impacts
is a way of obtaining answers to some of these questions. Moreover, understanding
these is critical to improve the design and targeting of public policies.
We start by presenting, in Table 9, the effects of the program on the intermediate
outcomes described in Section 3.1. The first row reports the impact of the intervention
on parental investment, estimated from the FCI index, which captures the quality of
the home environment, combines books, magazines and newspapers, play activities,
and play materials in the home (see Online Appendix D). The following rows assess
impacts on maternal knowledge about child development, maternal self-efficacy, and
food insecurity. Maternal knowledge and self-efficacy as potential mediators capture
the idea that, through the intervention, parents (mothers, in particular) might become
more effective in their childrearing practices.
The impact on the quality of the home environment was 0.34 of a SD in the
control group and statistically significant, with a p-value of zero. This is a strong result
and indicates that the intervention induces parents to invest more in their children.
However, we do not find any statistically significant program effects on maternal
knowledge about child development, maternal self-efficacy, or food insecurity.28

28. The effect we found is not as strong as that reported in Attanasio et al. (2014) of 0.5 SD on play
materials and play activities with adults at home and resulting from a home visiting intervention in
Colombia. We return to this issue in the Discussion section.
Attanasio et al. Early Stimulation and Nutrition 1421

TABLE 9. Program impacts on intermediate outcomes.

Impact as fraction of
SD in control group
(95% CI) p-value RW p-value

Parental investment 0.340 0.000 0.000

(0.207, 0.472)
Maternal knowledge (raw score) 0.016 0.831 0.828
(0.160, 0.128)
Maternal self-efficacy (raw score) 0.039 0.604 0.828

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(0.108, 0.186)
ELCSA food insecurity status 0.089 0.220 0.496
(0.231, 0.052)

Notes:  p < 0:10,  p < 0:05,  p < 0:01 based on Romano-Wolf adjusted p-values (RW, Romano and Wolf
2005, 2016), considering all four hypotheses jointly. 95% confidence interval in parenthesis for two-tailed tests.
OLS estimation; standard errors clustered by town. Impacts are measured in terms of SD of the control group.
Covariates: child’s gender, an indicator of high household wealth index, maternal PPVT score, teenage mother,
an indicator of high municipality population, previous attendance to a childcare center, and department and
interviewer fixed effects. Parental investment is measured by a factor model estimated using the subscales of FCI
Home Environment Quality, as discussed in Online Appendix D.

6.2. A Structural Interpretation of the Impacts: Production Function Estimates

Given the results on intermediate outcomes, we proceed to estimate a model where

child development is determined by a production function, which depends on parental
investment and other background variables. Both child development and parental
inputs are represented by latent variables, which are not observed directly but for
which we have informative markers that allow us to estimate them by factor analysis.
Given the evidence in Table 10, the sole mediator we consider for child development is
parental investment. This approach is a similar to that of Heckman, Pinto, and Savelyev
(2013). However, here, following Attanasio et al. (2020), we also consider the possible
endogeneity of parental investments.
We estimate a production function for human capital development, which we
assume to be a function of parental investment, several other environmental factors,
and, potentially, the intervention itself. In particular, we assume that child development
can be expressed by the Cobb–Douglas production function:
ln.CDi sl / D 0 C 1 ln.PIi sl / C 2 Tsl C ı 0 Xi sl C Fl  C D C Zi sl  C ui sl ;
(3)
where CDi sl is the child development latent variable and PIi sl represents the
parental investments latent variable, both estimated by the factor model described
in Online Appendix D and used to estimate the reduced form impacts in Tables 5
and 10. In equation (3), the treatment allocation Tsl can affect child development
both directly and through its impact on parental investments (PI). The covariates
Xi sl include the child’s gender, household wealth, maternal PPVT score, a dummy
variable for teenage mothers, and distance to the municipality’s Town Hall to capture
unobserved differences in household socio-economic condition. We also control for
1422 Journal of the European Economic Association

TABLE 10. IV estimation of the production function for Bayley-III factor.

OLS First stage IV

Bayley-III factor Parental investment Bayley-III factor

(1) (2) (3) (4) (5)

Treatment (T) 0.135 0.079 0.294 0.006

(0.065) (0.065) (0.068) (0.110)
Parental investment (PI) 0.185 0.467 0.454

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(0.036) (0.249) (0.171)
Time to town hall 0.099 0.079 0.040 0.048 0.049
(0.027) (0.028) (0.030) (0.043) (0.037)
Time to FAMI 0.143
(0.035)

First stage F-statistics

IV: time to FAMI 16.86
IV: time to FAMI and treatment 19.15
Overidentification p-value 0.956
N 1,292 1,292 1,292 1,292 1,292

Notes. Standard errors are clustered by town in parenthesis. Covariates: child’s gender, an indicator of high
household wealth index, maternal PPVT score, teenage mother, an indicator of high municipality population,
previous attendance at a childcare center, department and interviewer fixed effects, and baseline weight-for-age
and height-for-age Z-scores.

p < 0:10,  p < 0:05,  p < 0:01.

baseline childcare attendance and municipal population. Earlier studies also controlled
for lagged child development. However, as explained, we did not collect baseline
developmental outcomes since the children were too young to obtain a precise measure
with the resources we had available. Instead, we control for the child’s nutritional
status at baseline’namely, height-for-age and weight-for-age. As before, D represents
department fixed effects, and Zi sl is the vector of tester fixed effects. Finally, ui sl
represents unobservable factors determining child development, including shocks
experienced by the child and additional inputs not observed by the researchers but
possibly chosen by parents. The Cobb–Douglas assumption is consistent with the
evidence in Cunha, Heckman, and Schennach (2010) and in Attanasio et al. (2020),
who performed a similar analysis on another early stimulation intervention in Colombia
delivered through home visits rather than group sessions.
The main challenge in estimating the parameters in equation (3) is the fact that
parental investment PIi sl is likely to be endogenous, as the parents might be reacting to
shocks experienced by the child or might choose investment jointly with other inputs.
While the treatment is exogenous by construction, since it is assigned randomly across
communities, it is not necessarily a valid exclusion restriction because it can have
an independent effect on the outcome. Indeed, a question we pose is whether the
treatment affects child development directly or whether its impact is mediated by
parental investment. To answer this question, we need to establish the causal link
Attanasio et al. Early Stimulation and Nutrition 1423

between investment and child development. We therefore need an instrument, Wi sl ,

that affects parental investment while not affecting child development directly. For this
purpose, we use the travel time from the household residence to the FAMI center. To
control for differences between households that are centrally located versus households
that live in more outlying areas (that could differ in unobservable dimensions), we
control for distance to the Town Hall when estimating equation (3) by instrumental
variables (IV). Therefore, we estimate a first-stage investment equation of the
form:

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ln.PIi sl / D 0 C 1 Ts C 2 Wi sl C  0 Xi s C vi s ; (4)

where the covariates Xi s are the same as those in the production function in
equation (3).
In the first column of Table 10, we report the treatment effect on the Bayley-III
factor, estimated by OLS, and in the second column, we introduce parental investment,
also using OLS. The coefficient on treatment is reduced in size, and it is no longer
statistically different from zero, demonstrating that if the OLS assumption is valid, then
the impact is mediated by parental investments (although we cannot necessarily ignore
the coefficient on treatment because it is quite large, albeit imprecisely estimated).
In the third column of Table 10, we report the estimates of the investment
equation coefficients 1 associated with treatment allocation and 2 associated with
travel time to FAMI, which serves as an instrument when we estimate the production
function shown in the subsequent columns. This is strongly significant, even conditional
on distance to the Town Hall, which is intended to capture how centrally the household
is located. Importantly the F-statistic is large enough to rule out a weak instrument
problem, whether treatment is used an additional exclusion restriction or not (see
bottom of column (3)).
In the fourth column of Table 10, we re-estimate the production function, as in
column (2) but using IV. These estimates show a much higher impact of investments
and a zero direct effect of treatment: The point estimates imply that the entire effect of
treatment is driven by an increase in parental investments through the intervention. The
difference between the investment coefficients in columns (2) and (4) from 0.185 to
0.467 is significant at the 10% level and consistent with the results reported in Attanasio
et al. (2020), where the coefficient in the production function of child development also
increased considerably after accounting for the endogeneity of parental investment.
This suggests that parents are compensating for negative shocks when choosing an
investment.
Given this last consideration, in the fifth column of Table 10, we remove the
intervention from the production function (3). Now the coefficient on investment
is 0.454, and it is significant at the 1% level. We notice that the model is now
overidentified, as we now have two instruments for the single endogenous variable,
PIi s . When testing the implied overidentifying restriction, we do not reject the null of
the correct specification.
1424 Journal of the European Economic Association

7. Discussion and Conclusions

Interventions that promote ECD, starting from birth, may well be the key to successful
human capital policies, particularly in poor environments. However, the characteristics
and effectiveness of such programs at scale are not well understood yet. In recent years,
many early years interventions have been implemented worldwide, but effective and
sustainable programs at scale are rare. Furthermore, many institutionalized initiatives
are of low quality (Lo, Das, and Horton 2016). Scaling up is not only a question of
funds, but also of the available human resources in a variety of different contexts. A

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possible approach to deploying early years intervention at scale is to determine whether
existing large-scale programs (and their infrastructure) can be successfully improved,
so to guarantee the quality required for them to have significant impacts on children.
In this study, we present results from an experiment where we designed and
implemented a scalable intervention that was added to an existing government group-
based parenting support intervention, combined with nutritional supplementation.
Effectively, the intervention we study is an improvement of an existing national
program, consisting of incorporating structured content (curriculum of activities) and
training and coaching for program facilitators, as well as nutrition education and a
larger and higher quality nutritional supplement. As we have discussed, this design
offers a directly scalable policy, both in terms of its costs and in its implementability,
given the existing infrastructure and human resources. We should stress that we are
not evaluating the impact of FAMI as it exists or of our intervention compared to a
situation with no program. As we have mentioned, FAMI has existed for many years,
and a direct evaluation of it does not exist and would be difficult, if not impossible,
to perform. On the other hand, we think that our exercise is useful and relevant for
the current policy debate, which is considering improvements and not the abolition of
FAMI.
Our curriculum is an adaptation of RU, a home visitation program shown to
be effective in altering the long-run cognitive trajectory of children from deprived
environments in its original implementation in Jamaica (Walker et al. 2011; Gertler
et al. 2014). Adaptations of the curriculum to a variety of contexts and countries have
also had positive impacts on developmental outcomes (see Grantham-McGregor and
Smith (2016) for a review).
Evaluation of group-based adaptations of RU and other parenting programs is,
however, more limited. Yet, they represent a promising and natural low-cost approach to
improving outcomes in vulnerable populations in a more efficient manner as delivery is
less intensive in human resources. Furthermore, while the delivery of the RU curriculum
in groups might imply a reduced focus on the specific needs of an individual child,
well-run groups might induce positive effects by improving existing networks and
acquaintances and provide role models for some mothers.
The fact that we find reasonably-sized positive impacts in the short time span
covered by our data collections is important, in practice, the intervention would last
longer, and children would hopefully graduate into pre-schools where they could
gradually build up their abilities and school readiness, thus addressing one key cause
Attanasio et al. Early Stimulation and Nutrition 1425

of poverty persistence. The evidence we present also points to potentially large gains
where they are most needed, namely, among the poorest. The importance of these
results is even more apparent if we consider the fact that compliance with the number
of sessions actually attended by children and their caregivers was relatively low and
the intervention was relatively short, at least in comparison with the most successful
efficacy trials referred to in this study. And yet our intervention had an ITT effect of
16% of a SD and a ToT effect of up to 42% of a SD in development. Moreover, there
was a reduction in the fraction of children whose height-for-age was below 1 SD of
5.8 percentage points.

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Some features of this particular study make us believe that these estimates are
lower bounds of the potential of this intervention. First, the control group had access
to the basic program, without the improved intervention, unlike similar studies in
the literature in which the control group did not receive any intervention. Second,
as stressed, the average impact reflects larger impacts for the children most in need
and a small or null impact for the better-off children. Third, and most importantly,
it was not possible to fully control and enforce the many relevant implementation
aspects that might be needed to ensure fidelity of the intervention and impact
development.29 In fact, the implementation of the intervention was far from smooth
and faced various challenges. Examples of the problems encountered include the
low duration of participant exposure to the program, logistical difficulties for the
delivery of pedagogical materials and the nutritional supplements in complicated
rural geographies, heterogeneity in the fidelity of program implementation, and initial
resistance of program providers to change their behavior. The implementation problems
we document in our context are common to many programs implemented at scale.
The focus on the scalability is one of the most salient aspects of this study and
reflects the difficulties policy makers face when moving from small trials to larger
studies with reduced control over what actually happens in the field. As we suggest
above, when an intervention is scaled-up, one needs to consider not only financial costs
but also the possibility of sustaining the quality of implementation given the existing
service infrastructure. On the latter, we notice that our intervention was implemented on
top an existing program, with a minimal involvement on the part of the researcher team.
Our results indicate that despite a number of implementation problems, which were
in part present because we wanted to work with a model that could be reproduced at
scale, the enhancement we evaluated had a sizeable effect on the children most in need.
However, we do recognize that it is not obvious that a scaled-up intervention could
maintain the level and quality of training and mentoring that were achieved during
the study, although we stress that the evaluation did not use personnel with special
qualifications. In any case, it is clear that proper mentoring should be developed with
care.

29. FAMI providers continued to be paid and supervised by the government with no legal obligation or
additional monetary incentive to participate in our program. They were strongly encouraged to do so, but
they could choose not to without any practical consequence.
1426 Journal of the European Economic Association

Regarding the financial cost of the intervention, we notice that the cost of the
pedagogical component of the intervention was $115 US per child per year ($27
US for pedagogical materials and $88 US for coaching) plus a $11 US one-off
cost per child for FAMI pre-service training. At scale, there could be important
economies of scale in the mentoring system, by far the largest component of the
total pedagogical cost, which could reduce these figures substantially. The cost of
the additional nutritional supplementation was $209 US per child per year. By the
end of this study, the Colombian government adopted the nutritional supplementation
evaluated herein nationwide, with an investment of $10 US million. The pedagogical

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component corresponds to 40% of the operational cost of the unenhanced version of the
FAMI program, equivalent to 1.7 monthly minimum wages per year. In contrast, center-
based childcare services cost $1,100 US per child per year. Or the transition to large
childcare centers, which has been one of the center pieces of recent government policy,
costs $780 US per child per year, more than twice the intervention we are studying.
Therefore, the cost of our intervention is moderate, especially, in comparison to other
ECD programs in the country, and financially sustainable.
As we stressed above, the impacts of the intervention we evaluated are relative to
a status quo where children of the same age were receiving an unimproved program.
To interpret these results, it is useful to put them in the context of the quality of
other public early-years services in Colombia. Bernal (2013) presents a diagnostic of
public childcare quality by modality, using standard measures. Quality levels are low
for all modalities, close to minimum standards. This pattern is also found in other
Latin-American countries. Part of the problem is precisely the lack of a structured
curriculum and supervision/mentoring strategies, which is what the improvement we
evaluate introduces to FAMI. What we show is that scaling up services with quality is
possible within an existing institutional infrastructure that allows for such coaching and
mentoring strategies. The evidence we presented suggests that it is possible to gradually
improve the quality of nationwide programs at scale in a way that is affordable. Ours
is an enhancement of an existing program that leverages on local low-skilled human
resources. Critically, the intervention specifically aims at improving process quality
(such as the integration of a structured curriculum and improved interactions between
caregivers and children supported by coaching and mentoring), which the literature
has shown to be critically associated with child developmental outcomes (Yoshikawa,
Weiland, and Brooks-Gunn 2016).
A key question is whether these short-term impacts sustain over time. Andrew
et al. (2018) reports that the effects on child development and parental investment
documented in Attanasio et al. (2014) disappear two years after the end of the
intervention. The authors mention that this result might be due to a small initial effect
(similar to ours) and/or the lack of continued family support for early stimulation. The
impact fade-out observed for the intervention studied by Attanasio et al. (2014) is not
unique. Several studies have found that medium-term program impacts might vanish
but reappear later in the child’s life-cycle (Lawrence et al. 2005).
In Attanasio et al. (2014), intervention activities ended as soon as the study ended.
In our case, however, the intervention effectively kept running since an important
Attanasio et al. Early Stimulation and Nutrition 1427

part of it consisted of the training of the facilitators in the pre-existing program. In

particular, most treated FAMI providers continued to use the curriculum even though
they were no longer being coached. In addition, participants in public programs are
more likely to continue to be enrolled in similar public programs as children grow. For
example, children could have moved on to home-based childcare, provided through
the Hogares Comunitarios program (Bernal and Fernández 2013), which could help
reinforce or maintain these effects over time.
The total number of FAMI beneficiaries has decreased since 2013. However, close
to 150,000 children are still part of this program. Crucially, the toolkit developed for

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this intervention is flexible and easily adaptable to any ECD programs facilitated by
paraprofessional personnel, as many are in Colombia, as well as in other developing
countries. As we discuss in detail in Online Appendix B, it would be straightforward to
replicate at scale the training and coaching strategy proposed in this study by leveraging
on the already existing monitoring and supervision infrastructure for community-based
programs, including FAMI. Training professional staff in local ICBF offices would be
feasible, and they could easily implement both training and coaching of FAMI and
similar programs run by paraprofessional personnel.
While the pre-existing program is present everywhere in Colombia, we
implemented and evaluated the improvement in Central Colombia. This choice was
motivated by the fact that this region tends to be more culturally and ethnically
homogeneous with respect to other parts of Colombia, such as the coastal regions
(both Pacific and Atlantic) where Afro-Colombians and indigenous) are more likely to
reside. Scale up in these regions would likely require additional piloting and adaptation.
To conclude, we show that a scalable program can have substantial effects on child
development in highly deprived populations at a low cost and based on government
infrastructure. Improving the quality of large-scale programs in developing countries
can form a key element of the policy toolkit for fighting poverty.

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Supplementary data

Supplementary data are available at JEEA online