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.
Community Health Workers
Vision Care: Seeing is Learning
Improving Learning by Improving Vision: Evidence from Two Randomized Controlled Trials of Providing Vision Care in China
Off the Epicenter: COVID-19 Quarantine Controls and Employment, Education, and Health Impacts in Rural Communities
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
Conditional Cash Transfers, Uptake of Maternal and Child Health Services, and Health Outcomes in Western Rural China
Using Standardised Patients to Assess the Quality of Medical Records: An Application and Evidence from Rural China
Heterogeneous Impacts of Basic Social Health Insurance on Medical Expenditure: Evidence from China's New Cooperative Medical Scheme
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.
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.
Old is Not Always Better: Evidence from Five Randomized Experiments in Rural Primary Schools in China
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.
Structural Equation Modeling (SEM) of Cysticercosis in School-Aged Children in Tibetan Rural Farming Areas of Western China: Implications for Intervention Planning
Neurocysticercosis (NCC) significantly contributes to morbidity in developing countries. We recently published a study of prevalence and risk factors in school-aged children in three mountainous areas in Sichuan province of western China. Using structural equation modeling (SEM) on data from that study to guide intervention planning, here we examine risk factors grouped into three broad interventional categories: sociodemographics, human behavior, and sources of pork and pig husbandry. Because neuroimaging is not easily available, using SEM allows for the use of multiple observed variables (serological tests and symptoms) to represent probable NCC cases. Data collected from 2608 students was included in this analysis. Within this group, seroprevalence of cysticercosis IgG antibodies was 5.4%. SEM results showed that sociodemographic factors (b = 0.33, p < 0.05), sources of pork and pig husbandry (b = 0.26, p < 0.001), and behavioral factors (b = 0.33, p < 0.05) were all directly related to probable NCC in school-aged children. Sociodemographic factors affected probable NCC indirectly via sources of pork and pig husbandry factors (b = 0.07, p < 0.001) and behavioral variables (b = 0.07, p < 0.001). Both sociodemographic factors (b = 0.07, p < 0.05) and sources of pork and pig husbandry factors (b = 0.10, p < 0.01) affected probable NCC indirectly via behavioral variables. Because behavioral variables not only had a large direct effect but also served as a critical bridge to strengthen the effect of sociodemographics and sources of pork and pig husbandry on probable NCC, our findings suggest that interventions targeting behavioral factors may be the most effective in reducing disease.
Parental Migration, Educational Achievement, and Mental Health of Junior High School Students in Rural China
Social Engagement and Elderly Health in China: Evidence from the China Health and Retirement Longitudinal Survey (CHARLS)
This study examines the impact of social engagement on elderly health in China. A two-stage residual inclusion (2SRI) regression approach was used to examine the causal relationship. Our dataset comprises 9253 people aged 60 or above from the China Health and Retirement Longitudinal Survey (CHARLS) conducted in 2011 and 2013. Social engagement significantly improved the self-rated health of the elderly and reduced mental distress, but had no effect on chronic disease status. Compared with the rural areas, social engagement played a more important role in promoting the elderly health status in urban areas. Social engagement could affect the health status of the elderly through health behavior change and access to health resources. To improve the health of the elderly in China and promote healthy aging, the government should not only improve access to effective medical care but also encourage greater social engagement of the elderly.
Poor rural areas in China exhibit the country’s highest rates of child mortality, often stemming from preventable health conditions such as diarrhea and respiratory infection. In this study, we investigate the association between breastfeeding and disease among children aged 6–24 months in poor rural counties in China. To do this, we conducted a longitudinal, quantitative analysis of socioeconomic demographics, health outcomes, and breastfeeding practices for 1802 child–caregiver dyads across 11 nationally designated poverty counties in southern Shaanxi Province in 2013–2014. We found low rates of continued breastfeeding that decreased as children developed: from 58.2% at 6–12 months, to 21.6% at 12–18 months, and finally to 5.2% at 18–24 months. These suboptimal rates are lower than all but one other country in the Asia-Pacific region. We further found that only 18.3% of children 6–12 months old met the World Health Organization (WHO)-recommended threshold for minimum dietary diversity, defined as consuming four or more of seven specific food groups. Breastfeeding was strongly associated with lower rates of both diarrhea and cough in bivariate and multivariate analyses. As the first analysis to use longitudinal data to examine the relationship between continued breastfeeding and child illness in China, our study confirms the need for programmatic interventions that promote continued breastfeeding in order to improve toddler health in the region.
Half of rural toddlers aged 0–3 years in China’s Qinling Mountainous region are cognitively delayed. While recent studies have linked poor child development measures to the absence of positive parenting behaviors, much less is known about the role that caregiver depression might play in shaping child development. In this paper, a mixed methods analysis is used to explore the prevalence of depression; measure the association between caregiver depression and children’s developmental delays, correlates of depression, and the potential reasons for caregiver depression among women in rural China. The analysis brings together results from a large-scale survey of 1,787 caregivers across 118 villages in one northwestern province, as well as information from in-depth interviews with 55 female caregivers from these same study sites. Participants were asked to respond to the Depression, Anxiety and Stress Scale-21 (DASS-21) as well as a scale to measure children’s social-emotional development, the Ages and Stages Questionnaire: Social-Emotional (ASQ-SE). We also administered a test of early childhood development, the Bayley Scales of Infant and Toddler Development (BSID-III), to all of the study household’s infants and toddlers. The results show that the prevalence of depression may be as high as 23.5 percent among all female caregivers (defined as scoring in the mild or higher category of the DASS-21). Grandmothers have higher prevalence of depression than mother caregivers (p < 0.01). Caregiver depression also is significantly associated with a 0.53 SD worsening of children’s social-emotional development (p < 0.01) and a 0.12 SD decrease in children’s language development (p < 0.05). Our qualitative findings reveal six predominant reasons for caregiver depression: lack of social support from family and friends; the burden of caregiving; lack of control and agency within the household; within-family conflict; poverty; the perception of material wealth as a measure of self-worth. Our findings show a serious lack of understanding of mental health issues among rural women, and suggest that rural communities could benefit greatly from an educational program concerning mental health and its influence on child development. Our findings confirm the need for a comprehensive approach toward rural health, with particular attention paid to mental health awareness and support to elderly caregivers.
Effect of Caregiver's mental Health on Early Childhood Development across Different Rural Communities in China
Previous research has found that there are high rates of developmental delays among infants and toddlers in rural areas of China. Caregiver mental health problems might be one significant predictor of developmental delays among infants and toddlers, as has been found in other areas of the world. One way that the mental health of caregivers could affect early childhood development is through its effect on parenting practices. In this study, we used data from four major subpopulations of rural China to measure the correlation of caregiver mental health problems with the developmental outcomes of infants and toddlers. To do so, the study used the Bayley Scales of Infant Development III (BSID III) to examine the rates of developmental delays among 2514 rural infants/toddlers aged 6–30 months old. The results of the testing demonstrate that 48% of the sample’s infants/toddlers have cognitive delays; 52% have language delays; 53% have social-emotional delays; and 30% have motor delays. The data collection team also assessed caregiver mental health by using the Depression Anxiety Stress Scales (DASS-21) questionnaire. According to the findings, 39% of caregivers in the sample have symptoms of at least one kind of mental health problem (depression, anxiety, or stress). We also found that most caregivers do not engage in positive parenting practices, while a significant share of caregivers engage in negative parenting practices. The statistical analysis found that showing signs of mental health problems is significantly and negatively associated with infant/toddler developmental outcomes. The study also found that caregivers who show signs of mental health problems are significantly less likely to engage in interactive parenting practices. The study confirms that society needs to pay more attention to caregiver mental health problems in order to improve infant/toddler developmental outcomes in rural China and increase human capital accumulation in China as a whole.
Anemia and Student's Educational Performance in Rural Central China: Prevalence, Correlates, and Impacts.
Anemia in children impairs physical growth and cognitive development, reducing their overall human capital accumulation. While much research has been conducted on anemia prevalence in the primarily poor and rural western provinces in China, little is known about anemia in the more developed provinces of central China. The overall goal of this study is to assess the extent of anemia in central China and determine the effect of anemia on the academic performance of students. Using data collected from fourth grade students in 25 primary schools, we find that 16–27% of sample children are anemic. Female students and students with mothers who have not migrated for work are more likely to be anemic. Importantly, using both regression analysis and matching methods, we find that students with anemia (and those with low hemoglobin levels) are more likely to perform poorly on standardized mathematics exams. These findings suggest that, over the long term, untreated anemia will perpetuate poverty by restricting the human capital development of affected children.
Anxiety in Rural Chinese Children and Adolescents: 3 Comparisons across Provinces and among Subgroups
China’s competitive education system has produced notably high learning outcomes, but they may be costly. One potential cost is high levels of anxiety. China has launched several initiatives aimed at improving student mental health. However, little is known about how effective these programs and policies are. The goal of this paper is to examine anxiety levels among children and adolescents in rural China, and to identify which subpopulations are particularly vulnerable to anxiety.