Health

Doctor taking blood pressure and heart beat of patient.

Health

Working to bring quality health care to rural communities.

Overview

While China has recently made leaps in reforming its health system, major gaps still remain. Due to the sheer size of China’s population and economy, the success or failure of its healthcare system has outsized implications for global health and growth. Underlying issues in China’s health system range from a lack of resources, insufficient expertise, and misaligned incentives for providers. However, unlike many developing countries, China has the wherewithal to deploy novel approaches to improve healthcare outcomes. This unique combination of need and means makes China important for the study of health systems and care for underserved populations.

Featured Projects

doctor examining man

Standardized Patients

Standardized patients (SP) are people recruited from local communities and trained to act as “undercover patients” to evaluate clinicians. They are trained to present symptoms of disease while wearing a wire to assess clinician behavior. REAP has trained hundreds of standardized patients to evaluate the quality of health care in rural clinics.
REAP parenting sign

Community Health Workers

REAP’s community health workers program places trained, village-based health workers in rural communities to bring quality health care and support to the mothers of young children.
girls with glasses

Vision Care: Seeing is Learning

REAP has pioneered new understanding about the vital role of vision care as an educational input. Through multiple randomized controlled trials we found that a nearsighted child learns double if you give them a pair of glasses, but only one in seven rural children in China needing glasses actually has them.

Publications

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Journal Articles

Paths of Social-Emotional Development Before 3 Years Old and Child Development After 5 Years Old: Evidence from Rural China

Lei Wang, Yifei Chen, Siqi Zhang, Scott Rozelle
Early Human Development , 2022

Background: Social-emotional development during the first three years of life is associated with later social-emotional development and cognitive development. In rural China, research has found large shares of children under age three are developmentally delayed, yet little is known about the paths of social-emotional development before age 3 or how developmental paths predict later social-emotional skills and cognitive skills. 

Aims: To investigate the paths of child social-emotional development during ages 0–3 and examine how different paths predict social-emotional development and cognitive development at preschool age. 

Methods: Three waves of longitudinal panel data from 1245 children in rural Western China was collected. Child social-emotional development was measured by the Ages and Stages Questionnaire: Social-Emotional. Child cognitive development was measured by the Bayley Scales of Infant Development and by the Wechsler Preschool and Primary Scale of Intelligence-Fourth Edition. Four paths of child social-emotional development were classified: “never” social-emotionally delayed; “persistently” social-emotionally delayed; “improving,” or “deteriorating.” 

Results: 331 (27%) were never social-emotionally delayed; 373 children (30%) were persistently social-emotionally delayed; 149 children (12%) experienced improving social-emotional development; and 392 children (31%) experienced deteriorating social-emotional development. Children who were never social-emotionally delayed or who were on an “improving” path had higher social-emotional development at preschool age (p < .01). Children who were persistently social-emotionally delayed (p < .5) and on a deteriorating path (p < .01) had lower social-emotional development at preschool age. Children on the persistently delay path also were shown to have lower levels of cognitive development at preschool age (p < .01). 

Conclusions: Different paths of child social-emotional development before age 3 are associated with different social-emotional and cognitive development at preschool age.

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Journal Articles

Examining the Relation between Caregiver Mental Health and Student Outcomes in Rural China

Huan Wang, Claire Cousineau, Yuwei Adeline Hu, Grace Hu, Sunny Qi, Adrian Sun, Helen Wu, Scott Rozelle, Manpreet Singh
International Journal of Environmental Research and Public Health , 2021

Research continues to highlight the central relationship between caregivers’ mental health and their children’s development. This study examined the relation between primary caregivers’ mental health and school-aged children’s outcomes, including student mental health, resilience, and academic performance, in rural China. Using cross-sectional data from economically poor areas in the Gansu province, 2989 students (mean age = 11.51, 53.33% male, 46.67% female) and their primary caregivers (74.2% female) completed the 21-item, self-report Depression Anxiety Stress Scale. Students also completed the 25-item Connor-Davidson Resilience Scale and a standardized math test. The results indicated a high prevalence of caregiver depression (31%), stress (39%), and anxiety (24%). Characteristics that were significantly correlated with caregiver mental health issues included being a grandparent, having a low socioeconomic status and low education level, and living in a household with at least one migrant worker. Apart from caregiver stress and student resilience, caregiver mental health issues were negatively correlated with all student outcomes, including student mental health, resilience, and academic performance. Although additional empirical research is needed to investigate the associations between caregiver mental health and student outcomes, our results suggest that rural communities could benefit greatly from programs focused on improving the mental health of caregivers and this, in turn, may have a positive impact on student outcomes.

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Journal Articles

Postnatal Mental Health, Hand Washing Practices, and Infant Illness in Rural China

Qi Jiang, Nourya Cohen, Mika Ohtori, Jie Gao, Qingzhi Wang, Evelyn Zhang, Sabrina Zhu, Hannah Johnstone, Yian Guo, Sarah-Eve Dill, Huan Zhou, Scott Rozelle
Frontiers in Global Women's Health , 2021

Background: Maternal mental health problems play an important role in infant well-being. Although western countries have extensively studied the associations between maternal mental disorders, hygiene practices and infant health, little is known in developing settings. This study investigates the correlations between postnatal mental health problems, hand washing practices and infant illness in rural western China. Methods: A total of 720 mothers of infants aged 0–6 months from four poor counties in rural western China were included in the survey. Mental health symptoms were assessed using the Depression, Anxiety, and Stress Scale-21 (DASS-21). Questions about infant illness and hand washing practices followed evaluative surveys from prior studies. Adjusted ordinary least squares regressions were used to examine correlations between postnatal mental health (depression, anxiety, and stress) symptoms, hand washing practices, and infant illness outcomes. Results: Maternal depression, anxiety and stress symptoms were significantly associated with reduced hand washing overall and less frequent hand washing after cleaning the infant's bottom. Mental health symptoms were also associated with a higher probability of infants showing two or more illness symptoms and visiting a doctor for illness symptoms. Individual hand washing practices were not significantly associated with infant illness; however, a composite measure of hand washing practices was significantly associated with reduced probability of infant illness. Conclusion: Postnatal mental health problems are prevalent in rural China and significantly associated with infant illness. Policy makers and practitioners should investigate possible interventions to improve maternal and infant well-being.

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Journal Articles

The Prevalence and Correlates of Vision Impairment and Glasses Ownership among Ethnic Minority and Han Schoolchildren in Rural China

Huan Wang, Brandon Barket, Sharon Du, Dimitris Friesen, Ezra Kohrman, Esther Tok, Baixiang Xiao, Wenyong Huang, Ving Fai Chan, Graeme MacKenzie, Nathan Congdon
PLOS ONE , 2021

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.

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Journal Articles

Consultation Length, Process Quality and Diagnosis Quality of Primary Care in Rural China: A Cross-Sectional Standardized Patient Study

Qingzhi Wang, Sasmita Adhikari, Yuju Wu, Thankam Sunil, Yuping Mao, Ruixue Ye, Chang Sun, Yaojiang Shi, Chengchao Zhou, Sean Sylvia, Scott Rozelle, Huan Zhou
Patient Education and Counseling , 2021

Objective: Consultation length, the time spent between patient and health care provider during a visit, is an essential element in measuring quality of health care patients receive from a primary care facility. However, the linkage between consultation length and process quality and diagnosis quality of primary care is still uncertain. This study aims to examine the role consultation length plays in delivering process quality and diagnosis quality, two central components of overall primary care quality, in rural China.

Methods: We recruited unannounced standardized patients (SPs) to present classic symptoms of angina and tuberculosis in selected healthcare facilities in three provinces of China. The consultation length and primary care quality of SPs were measured and compared with both international and national standards of care. Ordinary Least Squares (OLS) regressions for process quality (continuous dependent variable) and Logistic regressions for diagnosis quality (binary dependent variable) were performed to investigate the relationship between consultation length and primary care quality.

Results: The average consultation lengths among patients with classic symptoms of angina and those with symptoms of tuberculosis were approximately 4.33 min and 6.28 min, respectively. Providers who spent more time with patients were significantly more likely to complete higher percentage of recommended checklist items of both questions and examinations for angina (β = 1.39, 95%CI 1.01–1.78) and tuberculosis (β = 0.89, 95%CI 0.69–1.08). Further, providers who spent more time with patients were more likely to make correct diagnosis for angina (marginal effect = 0.014, 95%CI 0.002–0.026) and for tuberculosis (marginal effect = 0.013, 95%CI 0.005–0.021).

Conclusions: The average consultation length is extremely short among primary care providers in rural China. The longer consultation leads to both better process and diagnosis quality of primary care.

Practice Implications: We recommend primary care providers to increase the length of their communication with patients. To do so, government should implement healthcare reforms to clarify the requirements of affordable and reliable consultation length in medical care services. Moreover, such an experience can also be extended to other developing countries.

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Journal Articles

Attention Deficit Hyperactivity Disorder (ADHD) among Elementary Students in Rural China: Prevalence, Correlates, and Consequence

Xiaodong Pang, Huan Wang, Sarah-Eve Dill, Matthew Boswell, Xiaopeng Pang, Manpreet Singh, Scott Rozelle
Journal of Affective Disorders , 2021

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.

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Journal Articles

Comparing the Quality of Primary Care between Public and Private Providers in Urban China: A Standardized Patient Study

Min Su, Zhongliang Zhou, Yafei Si, Sean Sylvia, Gang Chen, Yanfang Su, Scott Rozelle, Xiaolin Wei
International Journal of Environmental Research and Public Health , 2021

Previous studies have been limited by not directly comparing the quality of public and private CHCs using a standardized patient method (SP). This study aims to evaluate and compare the quality of the primary care provided by public and private CHCs using a standardized patient method in urban China. We recruited 12 standardized patients from the local community presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi’an, China. We measured the quality of primary care on seven criteria: (1) adherence to checklists, (2) correct diagnosis, (3) correct treatment, (4) number of unnecessary exams and drugs, (5) diagnosis time, (6) expense of visit, (7) patient-centered communication. Significant quality differences were observed between public CHCs and private CHCs. Private CHC physicians performed 4.73 percentage points lower of recommended questions and exams in the checklist. Compared with private CHCs, public CHC providers were more likely to give a higher proportion of correct diagnosis and correct treatment. Private CHCs provided 1.42 fewer items of unnecessary exams and provided 0.32 more items of unnecessary drugs. Private CHC physicians received a 9.31 lower score in patient-centered communication. There is significant quality inequality in different primary care models. Public CHC physicians might provide a higher quality of service. Creating a comprehensive, flexible, and integrated health care system should be considered an effective approach towards optimizing the management of CHC models.

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Journal Articles

Health, Economic, and Social Implications of COVID-19 for China's Rural Population

Huan Wang, Sarah-Eve Dill, Huan Zhou, Yue Ma, Hao Xue, Sean Sylvia, Kumi Smith, Matthew Boswell, Alexis Medina, Prashant Loyalka, Cody Abbey, Dimitris Friesen, Nathan Rose, Yian Guo, Scott Rozelle
Agricultural Economics , 2021

This study examines the effects of local and nationwide COVID‐19 disease control measures on the health and economy of China's rural population. We conducted phone surveys with 726 randomly selected village informants across seven rural Chinese provinces in February 2020. Four villages (0.55%) reported infections, and none reported deaths. Disease control measures had been universally implemented in all sample villages. About 74% of informants reported that villagers with wage‐earning jobs outside the village had stopped working due to workplace closures. A higher percentage of rural individuals could not work due to transportation, housing, and other constraints. Local governments had taken measures to reduce the impact of COVID‐19. Although schools in all surveyed villages were closed, 71% of village informants reported that students were attending classes online. Overall, measures to control COVID‐19 appear to have been successful in limiting disease transmission in rural communities outside the main epidemic area. Rural Chinese citizens, however, have experienced significant economic consequences from the disease control measures.

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Journal Articles

Publishing and Assessing the Research of Economists: Lessons from Public Health

Sean Sylvia, Scott Rozelle
China Economic Review , 2021

We highlight a growing concern in the economics profession that young scholars face incentives that are misaligned with conducting research that furthers knowledge and addresses pressing policy problems. The premium given to publication in top journals leads to an emphasis on exhaustive treatment of narrow questions. Detailed, robustly identified studies of novel questions are of undeniable value; however, the opportunity cost of producing such studies is large in terms of research quantity and policy relevance. For economists who aim to achieve what we view as the ultimate goals of academic research (enhancing understanding of the world, solving social problems, and building foundational knowledge to enable future breakthroughs), we offer some insights from publication philosophy in the field of public health. We discuss how public health has developed norms around publishing that are more successful in meeting these ultimate goals. We then offer thoughts on potential lessons for young economists in China and the economics discipline.

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Policy Briefs

Tracking China's Economic Path

Hongbin Li, Scott Rozelle
2021

Stanford scholars are setting and expanding research agendas to analyze China’s economic development and its impact on the world. The newly launched Stanford Center on China’s Economy and Institutions — co-directed by SIEPR senior fellows Hongbin Li and Scott Rozelle — is supporting their work. In this SIEPR Policy Brief, Li and Rozelle outline the research underway by the new center's affiliates.

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Journal Articles

Improving Learning by Improving Vision: Evidence from Two Randomized Controlled Trials of Providing Vision Care in China

Xiaochen Ma, Huan Wang, Yaojiang Shi, Sean Sylvia, Lei Wang, Yiwei Qian, Scott Rozelle
Journal of Development Effectiveness , 2021

This paper examines the external validity of health intervention by comparing the impacts of providing free eyeglasses on the educational performance of nearsighted children in two settings: rural public schools in Western China and urban private migrant schools in Eastern China. The intervention significantly improves educational outcomes by 0.14 standard deviations in math in rural public schools but not in private migrant schools. The difference in measured impacts is due in part to lower quality schooling in migrant schools in Eastern China. Our findings show that only when school is providing a quality education, health interventions might increase student learnings.

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Journal Articles

Tracking the Effects of COVID-19 in Rural China Over Time

Huan Wang, Markus Zhang, Robin Li, Oliver Zhong, Hannah Johnstone, Huan Zhou, Hao Xue, Sean Sylvia, Matthew Boswell, Prashant Loyalka, Scott Rozelle
International Journal for Equity in Health , 2021
Background: China issued strict nationwide guidelines to combat the COVID-19 outbreak in January 2020 and gradually loosened the restrictions on movement in early March. Little is known about how these disease control measures affected the 600 million people who live in rural China. The goal of this paper is to document the quarantine measures implemented in rural China outside the epicenter of Hubei Province and to assess the socioeconomic effect of the measures on rural communities over time. Methods: We conducted three rounds of interviews with informants from 726 villages in seven provinces, accounting for over 25% of China’s overall rural population. The survey collected data on rural quarantine implementation; COVID-19 infections and deaths in the survey villages; and effects of the quarantine on employment, income, education, health care, and government policies to address any negative impacts. The empirical findings of the work established that strict quarantine measures were implemented in rural villages throughout China in February. Results: There was little spread of COVID-19 in rural communities: an infection rate of 0.001% and zero deaths reported in our sample. However, there were negative social and economic outcomes, including high rates of unemployment, falling household income, rising prices, and disrupted student learning. Health care was generally accessible, but many delayed their non-COVID-19 health care due to the quarantine measures. Only 20% of villagers received any form of local government aid, and only 11% of villages received financial subsidies. There were no reports of national government aid programs that targeted rural villagers in the sample areas. Conclusions: By examining the economic and social effects of the COVID-19 restrictions in rural communities, this study will help to guide other middle- and low-income countries in their containment and restorative processes. Without consideration for economically vulnerable populations, economic hardships and poverty will likely continue to have a negative impact on the most susceptible communities.
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Journal Articles

Maternal Health Behaviors During Pregnancy in Rural Northwestern China

Yue Ma, Yujuan Gao, Jason Li, Andrew Sun, Baozhu Wang, Jun Zhang, Sarah-Eve Dill, Alexis Medina, Scott Rozelle
BMC Pregnancy and Childbirth , 2020

Background: Maternal health during pregnancy is a key input in fetal health and child development. This study
aims to systematically describe the health behaviors of pregnant women in rural China and identify which
subgroups of women are more likely to engage in unhealthy behaviors during pregnancy.

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Journal Articles

Effects of Baby-Friendly Practices on Breastfeeding Duration in China: A Case-Control Study

Yue Zhang, Jinliuxing Yang, Wenhao Li, Nianrong Wang, Ya Ye, Shuangqin Yan, Sumei Wang, Ting Zeng, Zijuan Huang, Fenghua Zhang, Yin Li, Shiyi Yao, Haijun Wang, Scott Rozelle, Tao Xu, Xi Jin
International Breastfeeding Journal , 2020
Background:  The Baby-Friendly Hospital Initiative is generally considered an effective way to promote breastfeeding. Although China has the largest number of baby-friendly hospitals in the world, research on baby-friendly practices in China is limited, and the rate of exclusive breastfeeding (EBF) at 6 months, 20.7%, compared to the 2025 global goal of 50% is low. It is, therefore, important to determine the factors that remain significant barriers to EBF in China. To explore how the key baby-friendly practices affect EBF duration in China, we used a case-control study to compare the effects of baby-friendly-related practices on both EBF and non-breastfeeding (NBF) mothers at 3 months and to investigate the effects of both single and comprehensive baby-friendly practices in promoting EBF duration at 3 months, which is one step toward EBF at 6 months. Methods:  Participants were recruited from four maternal and child health hospitals in western (Chongqing), eastern (Qingdao), southern (Liuzhou), and central China (Maanshan). A total of 421 mothers (245 in the EBF group, 176 in the NBF group) of infants aged 3 months were surveyed through a self-reported questionnaire from April 2018 to March 2019. The experience of baby-friendly practices and breastfeeding during hospitalization were assessed with yes/no questions. Socio-demographic factors that influenced breastfeeding at 3 months were analyzed using bivariate and multivariate logistic regression analyses. Results:  Of mothers in the EBF group, 65.57% reported engaging in at least seven baby-friendly practices compared to 47.72% of mothers in the NBF group. Significantly more mothers in the EBF group engaged in baby-friendly practices than in the NBF group. These practices included “breastfeeding within one hour after birth” (74.29% vs. 59.09%), “breastfeeding on demand” (86.48% vs. 75.00%), and “never use a pacifier” (46.53% vs. 31.25%). After adjusting for confounding variables, we found that the mothers who engaged in fewer than seven baby-friendly practices were about 1.7 times less likely to breastfeed than were those who engaged in seven or more baby-friendly practices (odds ratio [OR] 1.720, 95% confidence interval [CI] 1.106, 2.667). Further, the mothers who did not breastfeed on demand were as likely to not breastfeed up to 3 months (OR 2.263, 95% CI 1.265, 4.049), as were mothers who did not breastfeed during hospitalization (OR 4.379, 95% CI 1.815, 10.563). Conclusions:  These data from hospitals in China suggest that higher compliance with baby-friendly practices may have a positive impact on EBF at 3 months, particularly in terms of promoting the implementation of breastfeeding on demand and breastfeeding during hospitalization in China.
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Journal Articles

Early Child Development and Caregiver Subjective Well-Being in Rural China

Renfu Luo, Qijia Lyu, Scott Rozelle, Shun Wang
China Agricultural Economic Review , 2020

Purpose: This study aims to bridge the gaps in the existing literature by studying the links between children's development and the subjective well-being of the caregivers using first-hand data collected in rural China. Design/methodology/approach: Although the broad array of literature has examined the effects of child development on the subjective well-being of caregivers, the relationship between early childhood development and caregiver subjective well-being has not been well-studied using sample families with potential developmental delay in rural China. Also, existing research has relied on maternal reports to evaluate the developmental status of children. The study used data collected from 32 townships in seven nationally designated poverty counties in the Qinling mountainous area in 2016. The authors measure child development using the social-emotional module of the Ages & Stages Questionnaire and Bayley Scales of Infant and Toddler Development–Third Edition. Findings: The authors find that child development indicators are correlated with caregiver subjective well-being. In particular, social-emotional skills are positively associated with life evaluations and positive emotion. However, we do not find any significant correlation between child development and negative emotion or depression, anxiety and stress scores. Originality/value: The value of this study is to report the indicators of child development in rural China and examines the correlation between child development and caregivers' subjective well-being.

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Working Papers

Off the Epicenter: COVID-19 Quarantine Controls and Employment, Education, and Health Impacts in Rural Communities

Huan Wang, Sarah-Eve Dill, Huan Zhou, Yue Ma, Hao Xue, Prashant Loyalka, Sean Sylvia, Matthew Boswell, Jason Lin, Scott Rozelle
2020

In late January 2020, China’s government initiated its first aggressive measures to combat COVID-19 by forbidding individuals from leaving their homes, radically limiting public transportation, cancelling or postponing large public events, and closing schools across the country. The rollout of these measures coincided with China’s Lunar New Year holiday, during which more than 280 million people had returned from their places of work to their home villages in rural areas. The disease control policies remained in place until late February and early March, when they were gradually loosened to

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Journal Articles

Conditional Cash Transfers, Uptake of Maternal and Child Health Services, and Health Outcomes in Western Rural China

Huan Zhou, Yuju Wu, Chengfang Liu, Chang Sun, Yaojiang Shi, Linxiu Zhang, Alexis Medina, Scott Rozelle
BMC Public Health , 2020
Background: Empirical evidence suggests that the uptake of maternal and child health (MCH) services is still low in poor rural areas of China. There is concern that this low uptake may detrimentally affect child health outcomes. Previous studies have not yet identified the exact nature of the impact that a conditional cash transfer (CCT) has on the uptake of MCH services and, ultimately, on child health outcomes. The objective of this study is to examine the relationship between CCT, uptake of MCH services, and health outcomes among children in poor rural areas of western China. Methods: We designated two different sets of villages and households that were used as comparisons against which outcomes of the treated households could be assessed. In 2014, we conducted a large-scale survey of 1522 households in 75 villages (including 25 treatment and 50 comparison) from nine nationally designated poverty counties in two provinces of China. In each village, 21 households were selected based on their eligibility status for the CCT program. Difference-in-difference analyses were used to assess the impact of CCT on outcomes in terms of both intention-to-treat (ITT) and average-treatment-effects-on-the-treated (ATT). Results: Overall, the uptake of MCH services in the sample households were low, especially in terms of postpartum care visits, early breastfeeding, exclusive breastfeeding, and physical examination of the baby. The uptake of the seven types of MCH services in the CCT treatment villages were significantly higher than that in the comparison villages. The results from both the ITT and ATT analyses showed that the CCT program had a positive, although small, impact on the uptake of MCH services and the knowledge of mothers of MCH health issues. Nonetheless, the CCT program had no noticeable effect on child health outcomes. Conclusions: The CCT program generated modest improvements in the uptake of MCH services and mothers’ knowledge of MCH services in poor rural areas of Western China. These improvements, however, did not translate into substantial improvements in child health outcomes for two potential reasons: poor CCT implementation and the low quality of rural health facilities.
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Journal Articles

Depressive Symptoms and the Link with Academic Performance among Rural Taiwanese Children

Yujuan Gao, Derek Hu, Evan Peng, Cody Abbey, Yue Ma, Chyi-In Wu, Chia-Yuan Chang, Wei-Ting Hung, Scott Rozelle
International Journal of Environmental Research and Public Health , 2020
Previous studies reflect a high prevalence of depressive symptoms among Taiwanese adolescents (ages 13–18), but there is an absence of literature related to the risk of depression of children in Taiwan (ages 6–12), particularly among potentially vulnerable subgroups. To provide insight into the distribution of depressive symptoms among children in rural Taiwan and measure the correlation between academic performance, we conducted a survey of 1655 randomly selected fourth and fifth-grade students at 92 sample schools in four relatively low-income counties or municipalities. Using the Center for Epidemiological Studies-Depression Scale (CES-D) we assessed the prevalence of depressive symptoms in this sample, in addition to collecting other data, such as performance on a standardized math test as well as information on a number of individual and household characteristics. We demonstrate that the share of children with clinically significant symptoms is high: 38% of the students were at risk of general depression (depression score ≥ 16) and 8% of the students were at risk of major depression (depression score > 28). The results of the multivariate regression and heterogeneous analysis suggest that poor academic performance is closely associated with a high prevalence of depressive symptoms. Among low-performing students, certain groups were disproportionately affected, including girls and students whose parents have migrated away for work. Results also suggest that, overall, students who had a parent who was an immigrant from another country were at greater risk of depression. These findings highlight the need for greater resource allocation toward mental health services for elementary school students in rural Taiwan, particularly for at-risk groups. 
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Journal Articles

Using Standardised Patients to Assess the Quality of Medical Records: An Application and Evidence from Rural China

Yuju Wu, Huan Zhou, Yaojiang Shi, Hao Xue, Chengchao Zhou, Hongmei Yi, Alexis Medina, Jason Li, Sean Sylvia
BMJ , 2019
Background: Medical records play a fundamental role in healthcare delivery, quality assessment and improvement. However, there is little objective evidence on the quality of medical records in low and middle-income countries. Objective: To provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China. Methods: A sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardised patients (SPs) presented to providers following standardised scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records. Results: Medical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most of the recorded information was accurate, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with the provider’s income (β 0.05, 95% CI 0.01 to 0.09). Providers at hospitals with prescription review were less likely to record completely (β −0.87, 95% CI −1.68 to 0.06). Significant variation by disease type was also found in keeping of any medical record and completeness. Conclusion: Despite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records, and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed. 
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Journal Articles

Can School Feeding Programs Reduce Malnutrition in Rural China?

Huan Wang, Qiran Zhao, Matthew Boswell, Scott Rozelle
Journal of School Health , 2019
BACKGROUND
Childhood malnutrition is commonplace among poor rural communities in China. In 2012, China launched its first nationwide school‐feeding program (SFP) to address this problem. This study examines the prevalence of malnutrition before and after the SFP and identifies possible reasons for the trends observed.
 
METHODS
Ordinary least squares regression and propensity score matching were used to analyze data from 2 cross‐sectional surveys of 100 rural primary schools in northwestern China. Participants were fourth‐and fifth‐grade students. Outcome measures include anemia rates, hemoglobin levels, body mass index, and height for age Z scores.
 
RESULTS
Three years after implementation of the SFP, malnutrition rates among sample students had not fallen. The SFP had no statistically significant effect on either anemia rates or BMI, but was linked to an increase in the proportion of students with below normal height for age Z scores. Meals provided to students fell far short of national recommendations that the SPF should provide 40% of the recommended daily allowance of micronutrients.
 
CONCLUSIONS
Despite significant budgetary outlays between 2012 and 2015, China's SFP has not reduced the prevalence of malnutrition among sample students. To make the SFP more effective, funding and human resources both need to be increased.
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Journal Articles

Academic Achievement and Mental Health of Left-behind Children in Rural China

Lei Wang, Yaojia Zheng, Guirong Li, Yanyan Li, Zhenni Fang, Cody Abbey, Scott Rozelle
China Agricultural Economic Review , 2019
Purpose – China’s rapid pace of urbanization has resulted in millions of rural residents migrating from rural areas to urban areas for better job opportunities. Due to economic pressures and the nature of China’s demographic policies, many of these migrants have been forced to leave their children with relatives – typically paternal grandparents – at home in the countryside. Thus, while income for most migrant families has risen, a major unintended consequence of this labor movement has been the emergence of a potentially vulnerable sub-population of left-behind children (LBCs). The purpose of this paper is to examine the impacts of parental migration on both the academic performance and mental health of LBCs. Design/methodology/approach – Longitudinal data were drawn from three waves of a panel survey that . followed the same students and their families – including their migration behavior (i.e. whether both parents, one parent, no parent migrated) – between 2015 and 2016. The survey covers more than 33,000 students in one province of central China. The authors apply a student fixed-effects model that controls for both observable and unobservable confounding variables to explicate the causal effects of parental migration on the academic and mental health outcomes for LBC. The authors also employ these methods to test whether these effects differ by the type of migration or by gender of the child.
Findings – The authors found no overall impact of parental migration on either academic performance or mental health of LBCs, regardless of the type of migration behavior. The authors did find, however, that when the authors examined heterogeneous effects by gender (which was possible due to the large sample size), parental migration resulted in significantly higher anxiety levels for left-behind girls. The results suggest that parental migration affects left-behind boys and girls differently and that policymakers should take a more tailored approach to addressing the problems faced by LBCs.
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Journal Articles

Heterogeneous Impacts of Basic Social Health Insurance on Medical Expenditure: Evidence from China's New Cooperative Medical Scheme

Conglong Fang, Chaofei He, Scott Rozelle, Qinghua Shi, Jiayin Sun, Ning Yu
Healthcare , 2019

This paper examines the effects of China’s New Cooperative Medical Scheme (NCMS) on medical expenditure. Utilizing the quasi-random rollout of the NCMS for a difference-in-difference analysis, we find that the NCMS increased medical expenditure by 12.3%. Most significantly, the good-health group witnessed a 22.1% rise in medical expenditure, and the high-income group saw a rise of 20.6%. The effects, however, were not significant among the poor-health or low-income groups. The findings are suggestive of the need for more help for the very poor and less healthy.

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Journal Articles

Dynamic Anemia Status from Infancy to Preschool-Age: Evidence from Rural China

Lei Wang, Mengjie Li, Sarah-Eve Dill, Yiwei Hu, Scott Rozelle
International Journal of Environmental Research and Public Health , 2019

Anemia is a serious nutritional deficiency among infants and toddlers in rural China. However, it is unclear how the anemia status changes among China’s rural children as they age. This study investigates the prevalence of anemia as children grow from infancy to preschool-age, as well as the dynamic anemia status of children over time. We conducted longitudinal surveys of 1170 children in the Qinba Mountain Area of China in 2013, 2015 and 2017. The results show that 51% of children were anemic in infancy (6–12 months), 24% in toddlerhood (22–30 months) and 19% at preschool-age (49–65 months). An even larger share of children (67%) suered from anemia at some point over the course of study. The data also show that although only 4% of children were persistently anemic from infancy to preschool-age, 8% of children saw their anemia status deteriorate. We further found that children may be at greater risk for developing anemia, or for having persistent anemia, during the period between toddlerhood and preschool-age. Combined with the finding that children with improving anemia status showed higher cognition than persistently anemic children, there is an urgent need for eective nutritional interventions to combat anemia as children grow, especially between toddlerhood and preschool age.

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Journal Articles

Old is Not Always Better: Evidence from Five Randomized Experiments in Rural Primary Schools in China

Lili Li, Fang Chang, Yaojiang Shi, Scott Rozelle
Journal of Development Effectiveness , 2019

In recent years, researchers have begun to focus attention on trying to identify systematic factors that cause interventions to have different impacts in different contexts. In this paper, we seek to understand whether the age of principals at schools implementing nutrition-based interventions has an impact on program outcomes. To explore the relative effectiveness of younger and older school principals, we use data from five large-scale, nutrition-related randomized controlled trials (RCTs) involving 12,595 primary school students in 336 schools in rural China. Our results, using two age cut-offs for distinguishing young principals from old ones, indicate that improvements in the health and nutrition outcomes of students were significantly higher in schools with younger principals than in schools run by older principals (when using a cutoff of 40 years old). When using a cut-off of 45 years old, the point estimates of the impacts similarly suggest that young principals are more effective, although the results are not significantly significant. The results are similar when we look at the impact of disaggregated interventions in schools managed by young and old principals. The findings are clear that the interventions implemented by older principals are not more effective than those implemented by younger principals.

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Journal Articles

Use of maternal health services among women in the ethnic rural areas of western China

Yuju Wu, Huan Zhou, Qingzhi Wang, Min Cao, Alexis Medina, Scott Rozelle
BMC Health Services Research , 2019
Background: The use of maternal health services can markedly promote the maternal health and safety, but there has been a low utilization rate in the ethnic rural areas of western China. Furthermore, the correlated factors have not been well studied. This study aims to assess factors related to the use of maternal health services among women in these areas.
Methods: A cross-sectional study of 68 villages in China’s western Sichuan province was conducted in September 2014. All qualifying women from each sample village were involved. A structured questionnaire was administrated in households through face-to-face interviews by trained enumerators to obtain information of use of maternal health services and related factors. Structural equation modeling (SEM) was used to evaluate the direct and indirect relationships between use of maternal health services and correlated factors.
Results: A total of 760 women from 68 villages were enrolled. The proportion of antenatal care (ANC), hospital delivery and postpartum visits were 68.94, 48.29 and 28.42% respectively. The SEM analysis demonstrated that social economic status (SES) (β= − 0.75, β< 0.01), ANC (β=0.13, β< 0.01), and time from home to the nearest hospital (β= − 0.09, β< 0.05), were positively correlated to hospital delivery and postpartum care visits, while maternal care knowledge and perceived quality of hospital care did not have direct correlation. For ANC, SES (β= − 0.36, β< 0.01), time from home to the nearest hospital (β= − 0.13, β< 0.05), knowledge on maternal care (β=0.12, β< 0.01) and perceived quality of hospital care (β=0.10, β< 0.01) were all directly correlated factors. Treating ANC as an intermediate variable showed the indirect relationship that perceived quality of hospital care (β=0.01, β< 0.01) and maternal care knowledge (β=0.02, β< 0.01) had with hospital delivery and postpartum care rates.
Conclusions: Use of maternal health services is low among women in ethnic rural areas. ANC has important direct and intermediate effects on subsequent use of hospital delivery and postpartum care. Improving ANC behavior should be a priority of maternal health care reforms. Given the long travel times for these women, reforms must also prioritize breaking down practical barriers that prevent this population from accessing care.
Keywords: Maternal health services, Antenatal care, Ethnic areas, Western China
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