Introduction Primary healthcare (PHC) serves as the cornerstone for the attainment of universal health coverage (UHC). Efforts to promote UHC should focus on the expansion of access and on healthcare quality. However, robust quality evidence has remained scarce in China. Common quality assessment methods such as chart abstraction, patient rating and clinical vignette use indirect information that may not represent real practice. This study will send standardised patients (SP or healthy person trained to consistently simulate the medical history, physical symptoms and emotional characteristics of a real patient) unannounced to PHC providers to collect quality information and represent real practice.

Methods and analysis 1981 SP–clinician visits will be made to a random sample of PHC providers across seven provinces in China. SP cases will be developed for 10 tracer conditions in PHC. Each case will include a standard script for the SP to use and a quality checklist that the SP will complete after the clinical visit to indicate diagnostic and treatment activities performed by the clinician. Patient-centredness will be assessed according to the Patient Perception of Patient-Centeredness Rating Scale by the SP. SP cases and the checklist will be developed through a standard protocol and assessed for content, face and criterion validity, and test–retest and inter-rater reliability before its full use. Various descriptive analyses will be performed for the survey results, such as a tabulation of quality scores across geographies and provider types.

Ethics and dissemination This study has been reviewed and approved by the Institutional Review Board of the School of Public Health of Sun Yat-sen University (#SYSU 2017-011). Results will be actively disseminated through print and social media, and SP tools will be made available for other researchers.

Unlike performance incentives for private sector managers, little is known about performance incentives for managers in public sector bureaucracies. Through a randomized trial in rural China, we study performance incentives rewarding school administrators for reducing student anemia -- as well as complementarity between incentives and orthogonally assigned discretionary resources. Large (but not small) incentives and unrestricted grants both reduced anemia, but incentives were more cost-effective. Although unrestricted grants and small incentives do not interact, grants fully crowd-out the effect of larger incentives. Our findings suggest that performance incentives can be effective in bureaucratic environments, but they are not complementary to discretionary resources. 

This research uses a mixed-methods analysis to examine how being left behind impacts the cognition/education,  nutrition,  and  mental  health  outcomes  of  children  in  rural  China.  We find  that  parental  migration  increases  household  income  and  decreases  care,  and  these impacts  vary  based  on location,  socioeconomic  status,  and  age.  We  also  find  that  families generally recognize these impacts. Our findings offer a more general view of the effects of being  left  behind  on  childhood  outcomes  than  previous  research,  which  often  used  small sample sizes from limited geographic areas or age ranges. Although our research focuses on China, the findings are relevant to other developing nations where working-age individuals often  migrate  domestically  or  internationally  in  search  of  work,  such  as  Mexico  and  the Philippines. 

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.

Importance:Uncorrected refractive error causes 90% of poor vision among Chinese children.

Background:Little is known about teachers' influence on children's glasses wear.

Design:Cohort study.

Participants:Children at 138 randomly selected primary schools in Guangdong and Yunnan provinces, China, with uncorrected visual acuity (VA)≤6/12 in either eye correctable to >6/12 in both eyes, and their teachers.

Methods:Teachers and children underwent VA testing and completed questionnaires about spectacles use and attitudes towards children's vision.

Main Outcome Measures:Children's acceptance of free glasses, spectacle purchase and wear.

Results: A total of 882 children (mean age 10.6 years, 45.5% boys) and276 teachers (mean age 37.9 years, 67.8% female) participated. Among teachers,20.4% (56/275) believed glasses worsened children's vision, 68.4% (188/275) felt eye exercises prevented myopia, 55.0% (151/275) thought children with modest myopia should not wear glasses and 93.1% (256/275) encouraged children to obtain glasses.Teacher factors associated with children's glasses-related behaviour included believing glasses harm children's vision (decreased purchase, univariate model: relative risk [RR] 0.65, 95% CI 0.43, 0.98,P< 0.05); supporting children's classroom glasses wear (increased glasses wear, univariate model: RR 2.20, 95% CI 1.23,3.95,P< 0.01); and advising children to obtain glasses (increased free glasses acceptance, multivariate model: RR 2.74, 95% CI 1.29, 5.84,P< 0.01; increased wear, univariate model: RR 2.93, 95% CI 1.45, 5.90,P< 0.01), but not teacher's ownership/wear of glasses.

Conclusions and Relevance:Though teachers had limited knowledge about children's vision, they influenced children's glasses acceptance.

Background: Offering free glasses can be important to increase children's wear. We sought to assess whether ªUpgrade glassesº could avoid reduced glasses sales when offering free glasses to children in China.

Methods: In this cluster-randomized, controlled trial, children with uncorrected visual acuity (VA)< = 6/ 12 in either eye correctable to >6/12 in both eyes at 138 randomly-selected primary schools in 9 counties in Guangdong and Yunnan provinces, China, were randomized by school to one of four groups: glasses prescription only (Control); Free Glasses; Free Glasses + offer of $15 Upgrade Glasses; Free Glasses + offer of $30 Upgrade Glasses. Spectacle purchase (main outcome) was assessed 6 months after randomization.

Results: Among 10,234 children screened, 882 (8.62%, mean age 10.6 years, 45.5% boys) were eligibleand randomized: 257 (29.1%) at 37 schools to Control; 253 (28.7%) at 32 schools to Free Glasses; 187 (21.2%) at 31 schools to Free Glasses + $15 Upgrade; and 185 (21.0%) at 27 schools to Free Glasses +$30 Upgrade. Baseline ownership among these children needing glasses was 11.8% (104/882), and 867 (98.3%) children completed follow-up. Glasses purchase was significantly less likely when free glasses were given: Control: 59/250 = 23.6%; Free glasses: 32/252 = 12.7%, P = 0.010. Offering Upgrade Glasses eliminated this difference: Free + $15 Upgrade: 39/183 = 21.3%, multiple regression relative risk (RR) 0.90 (0.56±1.43), P = 0.65; Free + $30 Upgrade: 38/182 = 20.9%, RR 0.91 (0.59, 1.42), P = 0.69.

Conclusions: Upgrade glasses can prevent reductions in glasses purchase when free spectacles are provided, providing important program income.

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.

It is commonly believed that reading challenges should be addressed early to reduce the likelihood that developmental delays will impact students over the long term. However, students in developing countries often have limited access to reading resources. In this study, the authors used a randomized controlled trial of 11,083 fourth‐ and fifth‐grade students in 120 primary schools in rural China to examine the causal effect of an in‐class library program on student reading outcomes and academic achievement in schools with poor reading resources over an eight‐month period. An in‐class library was installed in each of the selected classes in the 40 treatment schools. The authors found that the program significantly improved student affinity toward reading and student reading habits, and in these regards, it narrowed the gap between male and female students, between low‐ and high‐performing students, and between left‐behind children and children living with parents. However, the authors found no overall effect of the program on reading and academic achievement and a negative effect on student confidence in reading. There was also no effect on student, teacher, and primary caregiver perceptions toward the effect of independent reading on academic achievement, nor any effect on whether teachers and primary caregivers provided reading instructions to students. The authors propose three possible explanations for these findings: a lack of reading instruction from teachers and caregivers, a lack of reading materials specifically tailored to local needs and interests, and the relatively short duration of the intervention.