REAP Publications

Background
High adherence and proper usage of micronutrient powder (MNP) influence child nutritional outcomes, yet few studies explore the role of delivery patterns. This study explores the association between MNP delivery patterns and MNP feeding behaviors among Han and minority caregivers in rural Western China.

Methods
In August 2019, a total of 1021 caregiver-child pairs were selected through a four-stage cluster sampling process. A cross-sectional survey collected information on caregiver demographics, MNP delivery patterns (channel and frequency), and MNP feeding behaviors (proper usage and adherence). Using logistic regression, we examined which delivery channels and delivery frequencies were associated with proper usage and high adherence.

Results
The results indicated that minority caregivers had lower levels of proper MNP usage than did Han caregivers (89.2%), with Tibetan caregivers’ reporting the lowest rates of adherence (32.6%). Logistic regression revealed that that township-based channel was significantly correlated with proper usage among Tibetan and Yi caregivers (Odds Ratio, OR = 2.0, p < 0.01; and OR = 3.5, p < 0.001). Overall, the township-based and home-visit channels were significantly correlated with high adherence (OR = 1.7 and OR = 2.3, respectively; p < 0.001); delivery frequency was significantly correlated with high adherence (2 months: OR = 2.2, p < 0.001 and ≤ 1 month: OR = 3.5, p < 0.001) but not correlated with proper usage among the whole sample and individual ethnic groups.

Conclusions
In conclusion, the study finds evidence of a correlation between MNP delivery channel and both proper usage and high adherence as well as a correlation between MNP delivery frequency and high adherence.

In many developing countries, low population density may be a major reason for low school participation in rural areas, and the problem is likely to worsen with rapid urbanization. However, few studies have investigated empirically the role of population density in rural education, especially the moderating effect of population density on the outcomes of education policies. This study aims to fill this gap in the literature. From 1999 through the early 2000s, China launched a set of major nationwide policies aimed at universalizing 9-year compulsory education in rural areas. Using differencein- differences and triple difference strategies, we show that the policies significantly increased the probability of junior high school enrollment of rural children and, more importantly, these policies were more effective in densely populated regions. These fi ndings confi rm the importance of population density to rural education.

One out of every three children under age 5 in developing countries lives in conditions that impede human capital development. In this study, we survey the literature on parenting training programs implemented before age 5, with the aim to increase parental investment in human capital accumulation in developing countries. Our review focuses on the implementation and effectiveness of parenting training programs (i.e., training in child psychosocial stimulation and/or training about nutrition). We emphasize the mechanisms that drive treatment-induced change in human capital outcomes and identify the demand- and supply-side behaviors that affect efficacy and effectiveness. Although the literature includes evidence on program features that are associated with successful interventions, further evidence on the dynamics of human capital formation, documentation of medium- to long-term persistence of treatment impacts, and research on the implementation and evaluation of programs at scale are needed to delineate a scalable and inclusive program that provides long-term treatment impacts.

Topic
This systematic review and meta-analysis summarizes existing evidence to establish whether vision impairment, ocular morbidity and their treatment are associated with depression and anxiety in children.

Clinical Relevance
Understanding and quantifying these associations support early detection and management of mental health symptoms in children with vision impairment and ocular morbidity. Additionally, this review provides evidence in favour of insurance coverage for timely strabismus surgery.

Methods
We searched nine electronic databases from inception to February 18, 2021, including observational and interventional studies assessing whether vision impairment and/or ocular morbidity and their treatment are associated with depression and/or anxiety in children. We used narrative synthesis and meta-analysis with the residual maximum likelihood method. A protocol was registered and published on The International Prospective Register of Systematic Reviews (PROSPERO, CRD42021233323).

Results
Among 28,992 studies, 28,956 (99.9%) were excluded as duplicates or unrelated content. Among 36 remaining studies, 21 (58.3%) were observational studies concerning vision impairment, eight (22.2%) were observational studies concerning strabismus, and seven (19.4%) were interventional studies. Vision-impaired children experienced significantly higher scores of depression (Standard Mean Difference [SMD] 0.57, 95% Confidence Interval (CI) 0.26-0.89, 11 studies) and anxiety (SMD 0.61, 95% CI 0.40-0.821, 14 studies) than normally-sighted children. In particular, myopic children experienced higher scores of depression (SMD 0.59, 95% CI 0.36-0.81, six studies) than normally-sighted children. Strabismus surgery significantly improved symptoms of depression (SMD: 0.59 95% CI 0.12-1.06, three studies) and anxiety (SMD: 0.69 95% CI 0.24-1.14, four studies) in children.

Discussion
Among children, vision impairment is associated with greater symptoms of depression and anxiety. Surgical treatment of strabismus improved these symptoms. Further randomized controlled trials exploring the impact of public health measures for myopia correction on mental health in children are needed. Scaling up access to strabismus surgery could improve the mental health of affected children.

Academic achievement in middle schools in rural China remains poor for many students. This study examines whether programmes and interventions can improve academic achievement by reviewing rigorous experimental evaluations of nine programmes (11 interventions) on 47,480 rural middle school students in China. The results find none of the interventions improved academic achievement. Moreover, we find no evidence for heterogeneous treatment effects by student gender, age or previous academic achievement. These results may be due in part to the academically-demanding nature of the middle school curriculum, which is applied universally to students with varying levels of cognitive ability.

Extant research continues to establish the importance of teacher job satisfaction to student performance, yet teacher job satisfaction remains under-investigated in rural China. In this paper, we examine the prevalence and correlates of teacher job satisfaction. Using data from 634 teachers across 120 schools in rural China, we find an alarmingly high prevalence of teacher job dissatisfaction: roughly 21% of rural teachers were less than satisfied with their jobs. In addition, we find that several individual- and school-level characteristics, including being a male teacher, being a homeroom teacher, not having a management role in school, being a middle-aged teacher, and a school’s boarding status, are correlated with teacher job dissatisfaction. In sum, the results demonstrate a need for further research and policy interventions to improve teacher job satisfaction in rural schools.

The cost-effectiveness of policies providing subsidized health goods is often compromised by limited use of the goods provided. Through a randomized trial involving 251 primary schools in western China, we tested two approaches to improve the cost-effectiveness of a program distributing free eyeglasses to myopic children. Relative to delivery of free eyeglasses to schools, we find that providing vouchers redeemable in local optical shops modestly improved the targeting of eyeglasses to those who would use them without reducing effective coverage. Information provided through a health education campaign increased eyeglass use when eyeglasses were delivered to schools, but had no effect when requiring voucher redemption or when families were only given a prescription for eyeglasses to be purchased on the market. Though most expensive, free delivery to schools with a health education campaign was the most socially cost-effective approach tested and increased effective coverage of eyeglasses by 18.5 percentage points after seven months.

Background

Despite rising incomes and rapid economic growth, there remains a significant gender gap in health outcomes among rural children in China. This study examines whether the gender gap in child health is related to the behavior of caregivers when seeking healthcare, and whether healthcare subsidies help to bridge the gender gap in rural health outcomes.

Methods

Focusing on vision care specifically, we draw on data from a randomized controlled trial of 13,100 children in Gansu and Shaanxi provinces in China that provided subsidized eyeglasses to myopic children in one set of schools (henceforth, referred to as the treatment schools) and provided prescription information but not subsidized eyeglasses to myopic children in another set of schools (control schools).

Results

The baseline results reveal that while female students generally have worse vision than male students, they are significantly less likely than male students to be taken by their caregivers to a vision exam. The experimental results indicate, however, that caregivers respond positively to both health information and subsidized healthcare, regardless of the gender of their children. When prescription information is paired with a subsidy voucher for healthcare (a free pair of eyeglasses), the uptake rate rises dramatically.

Conclusions

The gender gap in healthcare can be minimized by implementing subsidized healthcare policies.

Rural China has seen an increase in its migrant workers returning home. As a result, many of these workers’ children, who had previously boarded at school, needed to return home as well. While the existing research indicates that boarding affects the development of disadvantaged children, the effect of the switch to nonboarding on the growth of vulnerable boarding children remains unknown. Using two-stage data from 20,594 fourth- and fifth-grade students in rural Shaanxi and Gansu provinces as well as the difference-in-differences method, this study estimates the impact of switching to nonboarding on the academic performance and mental health of vulnerable boarding students. The results suggest that the shift toward nonboarding significantly reduces boarding students’ academic performance, and further testing shows that these results are robust. Additionally, the switch to nonboarding insignificantly increased the standardized mental health scores of rural primary school students but significantly increased their standardized impulsive tendency scores. Heterogeneity analysis found that boarding students whose mothers had lower educational achievement or whose families belonged to lower economic levels had poorer academic performance after switching, while boarding students whose parents had higher education achievement or myopia possessed better mental health after switching. This study offers novel, policy-relevant insights into potential strategies that would improve the academic performance and mental health of students who transition to nonboarding, especially those with low-educated parents and those belonging to poor families.

Purpose

To study the factors determining spectacle-wear compliance and reasons for non-wear among students in rural China.

Methods

This study was based on a spectacle intervention trial among 162 schools in rural China. Students with refractive errors were randomly assigned to either a free or voucher group to receive spectacles at baseline. Spectacle-wear compliance was assessed through an unannounced follow-up 7 months after spectacles were distributed. Students not wearing spectacles were also asked their reasons for non-wear. The collected data underwent descriptive, bivariate, and logistic regression analyses.

Results

A total of 1904 students received spectacles at baseline, 1826 (95.9%) of whom were present at the 7-month follow-up. Among those students, 41.7% wore their spectacles. There was no significant difference in compliance rates between the free and voucher groups. Predictors of wearing spectacles at follow-up included older age (Odds ratio = 1.56, 95% CI: 1.12–2.19), the severity of refractive error (3.68, 2.23–6.07), wearing spectacles before baseline (3.91, 2.53–6.04) and having friends who wore spectacles (1.87, 1.32–2.63). When students could see the blackboard from their seats (0.68, 0.51–0.89) and thought that wearing spectacles was bad looking (0.76, 0.57–1.00), they were reluctant to wear spectacles. The two main reasons for non-wear were the widespread perception that wearing spectacles would weaken eyesight (32.8%) and the inconvenience of wearing spectacles during activities (23.6%).

Conclusions

The main reason that accounts for the low compliance of spectacle wear was misconceptions around spectacle. School-based spectacle programs should consider enhancing the compliance rates to maximize the benefits of spectacle wear.

Purpose: To determine the prevalence of visual impairment and glasses ownership among Han Chinese and Hui minority junior high school children in Ningxia Hui Autonomous Region, China. 

Design: Population-based cross-sectional study. 

Methods: Vision screening was conducted on 20,376 children (age 12–15 years) in all 124 rural junior high schools in Ningxia. Personal and family characteristics, glasses ownership, and academic performance were assessed through a survey questionnaire and standardized mathematics test, respectively. 

Results: The prevalence of visual acuity (VA) ≤6/12 in either eye was significantly higher among Han (54.5%) than Hui (45.2%) children (P<0.001), and was significantly positively associated with age, female sex, Han ethnicity, parental outmigration for work, shorter time spent outside during recess, shorter time spent watching television and higher time spent studying. Among children with VA≤6/12 in both eyes, only 56.8% of Han and 41.5% of Hui children had glasses (P<0.001). Glasses ownership was significantly associated with worse vision, greater family wealth, female sex, higher test scores, age, parental outmigration for work, understanding of myopia and glasses, higher time spent studying and Han ethnicity. 

Conclusion: One of the first of its kind, this report on Han and Hui ethnic schoolchildren confirms a high prevalence of visual impairment among both populations, but slightly higher among the Han. Both groups, especially the Hui, have low rates of glasses ownership. Future interventions and policies designed to improve glasses usage should focus on populations with lower incomes and seek to correct erroneous beliefs about the safety of glasses and efficacy of traditional eye exercises.

Background: Attention deficit hyperactivity disorder (ADHD) is a widely recognized mental health problem in developed countries but remains under-investigated in developing settings. This study examines the prevalence, correlates, and consequences of ADHD symptoms among elementary school students in rural China. Methods: Cross-sectional data were collected from 6,719 students across 120 rural primary schools in China on ADHD symptoms, demographic characteristics, and academic performance in reading and math. ADHD symptoms were evaluated using the caregiver-reported ADHD Rating Scale-IV. Results: The prevalence of ADHD symptoms was 7.5% in our sample. Male students, students in lower grade levels, and students with lower cognitive ability showed a significantly higher prevalence of ADHD symptoms (ORs = 2.56, 2.06, and 1.84, respectively; p<0.05). Left-behind children showed a significantly lower prevalence of ADHD symptoms than did children who were living with their parents (OR = 0.74, p < 0.05). Adjusted regressions show that students with ADHD symptoms scored 0.12 standardized deviations lower in reading (p < 0.05) and 0.19 standardized deviations lower in math (p < 0.01). Limitations: The ADHD Rating Scale-IV is a screening scale rather than a diagnostic test. Caregiver self-report measures also may underestimate ADHD symptoms for our sample. Conclusions: ADHD is a common disorder among rural students in China and appears to be contributing to poor academic outcomes. The higher prevalence of ADHD among students with low cognitive ability also suggests that many rural children in China face multifactorial learning challenges. Taken together, the findings indicate a need for educators and policymakers in rural China to develop programs to reduce risk and support students with ADHD symptoms.

Background

In rural China, children’s vision problems are very common, with many who would benefit from refractive correction not getting the care they need. This study examines whether a health information campaign that involves vision health education and a free trial of health product with free eyeglasses is effective at raising students’ awareness of myopia and promoting students’ eyeglasses usage.

Methods

We conducted an in-the-field randomized controlled experiment of a program providing vision health education and subsidized free eyeglasses to myopic children from 168 primary schools in rural Northwestern China in 2012.

Results

A total of 2189 students, mean age 10.5 years (49.3% male), participated in the baseline survey. At the baseline, the average correct response rate for visual knowledge among the sample students was 30.1%, and only 15% who needed eyeglasses used them. Seven months after intervention, the average correct response rate for vision knowledge were 48.5% and 48.3% in the education group and the education plus free eyeglasses group respectively, significantly higher than that of the control group. The rate of eyeglasses usage was 36% and 43% in the free eyeglasses group and the education plus free eyeglasses group respectively, significantly higher than that of the control group. The rate of eyeglasses compliance in the free eyeglasses group and the education plus free eyeglasses group was 19% and 26%, which also were significantly higher than the control group.

Conclusion

The information campaign combined with subsidized eyeglasses had a better effect both on vision knowledge and eyeglasses usage. The information campaign improved knowledge by providing the right information, and free eyeglasses changed the perceived utility and experience by the students using the product and getting benefits. Information and the free eyeglasses (subsidized) are complements.