Inadequate care during early childhood can lead to long-term deficits in skill development. Parenting programs are promising tools for improving parenting practices and opportunities for healthy development. We implemented a non-masked cluster-randomized controlled trial in rural China in order to assess the effectiveness of an integrated home-visitation program that includes both psychosocial stimulation and health promotion at fostering development and health outcomes of infants and toddlers in rural China. All 6-18 month-old children of two rural townships and their main caregiver were enrolled. Villages were stratified by township and randomly assigned to intervention or control. Specifically, in September 2015 we assigned 43 clusters to treatment (21 villages, 222 caregiver-child dyads) or control (22 villages, 227 caregiver-child dyads). In the intervention group, community health workers delivered education and training on how to provide young children with psychosocial stimulation and health care (henceforth psychosocial stimulation and health promotion) during bi-weekly home visits over the period of one year. The control group received no home visits. Primary outcomes include measures of child development (i.e. the Bayley Scales of Infant and Toddler Development, third edition—or Bayley-III) and health (i.e. measures of morbidity, nutrition, and growth). Secondary outcomes are measures of parenting practices. Intention-to-treat (ITT) effects show that the intervention led to an improvement of 0·24 standard deviations (SD) [95% CI 0·04 SD-0·44 SD] in cognitive development and to a reduction of 8·1 [95% CI 3·8–12·4] percentage points in the risk of diarrheal illness. In addition, we find positive effects on parenting practices mirroring these results. We conclude that an integrated psychosocial stimulation and health promotion program improves development and health outcomes of infants and toddlers (6–30 month-old children) in rural China. Because of low incremental costs of adding program components (that is, adding health promotion to psychosocial stimulation programs), integrated programs may be cost-effective.
Choosing a valid and feasible method to measure child developmental outcomes is key to addressing developmental delays, which have been shown to be associated with high levels of unemployment, participation in crime, and teen pregnancies. However, measuring early childhood development (ECD) with multi-dimensional diagnostic tests such as the Bayley Scales of Infant and Toddler Development III (Bayley-III) can be time-consuming and expensive; therefore, parental screening tools such as the Ages and Stages Questionnaire (ASQ-3) are frequently an alternative measure of early childhood development in largescale research. The ASQ is also becoming more frequently used as the first step to identify children at risk for developmental delays before conducting a diagnostic test to confirm. However, the effectiveness of the ASQ-3 is uncertain. In this study, we evaluate the accuracy of the ASQ-3 as a screening measure for children at risk of developmental delay in rural China by age group. To do so, we administered the Bayley-III, widely considered to be the “gold standard” of ECD diagnostic tests, to a sample of 1,831 five to twenty-four monthold children and also administered the ASQ-3 to their caregivers. We then compared the outcomes of the ASQ-3 test to those of the Bayley-III. We find that the ASQ-3 was significantly though weakly correlated with the Bayley-III and that the strength of this correlation increased with child age and was stronger when the mother was the primary caregiver (as compared to the grandmother). We also find that the sensitivity and specificity of ASQ-3 ranged widely. The overall findings suggest that the ASQ-3 may not be a very accurate screening tool for identifying developmentally delayed children, especially for children under 13 months of age or children whose primary caregiver is not the mother.
In China, low levels of early childhood development (ECD) in rural areas may inhibit economic development as the nation attempts to transition from a middle-income manufacturing-based economy to a high-income innovation economy. This paper surveys the recent literature on ECD among children ages 0-3 years in rural China, including rates of developmental delays, causes of delays, and implications for the future of China’s economy. Recent studies have found high rates of developmental delays among young children in rural China and point to poor nutrition and psychosocial stimulation as the primary causes. This review highlights the need for large-scale ECD interventions in rural China to raise human capital and support future economic growth.
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.
Empirical evidence from developed countries supports the idea that parent-teacher interaction is highand improves student outcomes. The evidence from developing countries is, however, decidedly mixed.Using longitudinal data from nearly 6000 students and their 600 teachers in rural China, we show theprevalence of parent-teacher interaction is generally much lower than that of developed countries. Wealso show parent-teacher interaction, when it exists, can have positive effects on raising academicachievement and reducing learning anxiety. We demonstrate that the prevalence and effectiveness ofparent-teacher interaction in a developing country context varies considerably due to both demand-sideand supply-side factors.
Studies suggest that students’ prior performance can shape subsequent teacher evaluations, but the magnitude of reputational effects and their implications for educational inequality remain unclear. Existing scholarship presents two major perspectives that exist in tension: do teachers primarily use reputational information as a temporary signal that is subsequently updated in response to actual student performance? Or do teachers primarily use reputational information as a filter that biases perception of subsequent evidence, thus crystallizing student reputations and keeping previously poor-performing students stuck in place? In a field experiment, we recruited a random sample of 832 junior high school teachers from the second-most populous province of China to grade a sequence of four essays written by the same student, and we randomly assign both the academic reputation of the student and the quality of the essays produced. We find that (1) reputational information influences how teachers grade, (2) teachers rely on negative information more heavily than positive information, and (3) negative reputations are crystallized by a single behavioral confirmation. These results suggest that students can escape their prior reputations, but to do so, they must contradict them immediately, with a single confirmation sufficient to crystallize a negative reputation.
There is a significant gap in academic achievement between rural and urban students in China. Policymakers have sought to close this gap by improving the quality of teaching in rural areas through teacher professional development (PD) programs. However, there is limited evidence on the effectiveness of such programs. In this paper, we evaluate the impact of a PD program-National Teacher Training Program (NTTP) and find that the NTTP has no effect on math achievement. We also find that while the program has a positive effect on math teaching knowledge of teachers, it has no significant effect on teaching practices in the classroom. Taken together, these results indicate that teachers may have improved their knowledge for teaching from NTTP, but did not apply what they learned to improve teaching practices or student learning.
Although students in rural and migrant schools in China generally have not performed well, a share of each cohort has been able to thrive in school and to test into academic high school and college. To understand the origins of persistence, specifically, why some students learn more than do others, researchers have identified certain sources of the problem. Few studies, however, have paid attention to the role that low levels of cognitive development of students play in their academic performance.
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.
This paper describes the current level of human capital in China and seeks to identify a number of education-related challenges that may slow down the nation’s economy from transitioning to high-income status. Relying on recent census-based data from OECD for the rest of the world and using data from the 2015 Micro-Census for China, the authors show that the low levels of education of China’s labour force is really a problem that has its roots in the past (in the 1970s, 1980s, and 1990s). In recent years (since 2000), China has been investing heavily in education as shown by the increasing the share of youth, including rural youth, attending high school. Despite this recent effort to raise the nation’s human capital, the education system still faces several challenges in trying to provide high-quality education for all youth. First, the government must figure out a way to overcome the relatively low rates of participation in high school by rural students. Second, there is concern that many vocational schools, especially those in rural areas, cannot deliver quality education. Finally, the paper will show that many rural students may be unprepared due to poor early childhood development outcomes.
We assess and compare computer science skills among final-year computer science undergraduates (seniors) in four major economic and political powers that produce approximately half of the science, technology, engineering, and mathematics graduates in the world. We find that seniors in the United States substantially outperform seniors in China, India, and Russia by 0.76–0.88 SDs and score comparably with seniors in elite institutions in these countries. Seniors in elite institutions in the United States further outperform seniors in elite institutions in China, India, and Russia by ∼0.85 SDs. The skills advantage of the United States is not because it has a large proportion of high-scoring international students. Finally, males score consistently but only moderately higher (0.16–0.41 SDs) than females within all four countries.
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.
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.
Using the Bayley Scales of Infant and Toddler Development-III (BSID-III), we examine the rates of developmental delays among children aged 0–3 years in four major subpopulations of rural China, which, altogether, account for 69% of China's rural children and 49% of children nationwide. The results indicate that 85% of the 3,353 rural children in our sample suffer from at least one kind of developmental delay. Specifically, 49% of the children have cognitive delays, 52% have language delays, 53% have social emotional delays, and 30% have motor delays. The results suggest that these high rates are due to two main factors in the parenting environment. The first is micronutrient deficiencies, which are reflected in a high prevalence of anemia (42%). The second is an absence of interactive parenting inputs, such as storytelling, reading, singing, and playing. Although we find these inputs to be significantly and positively associated with better developmental outcomes, only a small share of caregivers engage in them. With this large and broad sample, we show that, if China hopes to build up enough human capital to transition to a high-income economy, early childhood development in rural areas urgently requires more attention.
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.
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.
Background: There is a substantial body of evidence supporting the association between maternal active smoking during pregnancy and child development, but the association between prenatal exposure to environmental tobaccos smoke (ETS) and early child development has not been well documented. This cross-sectional study examines the association between prenatal exposure to ETS and the development of children in their first two years of life.
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.
Abstract: Visual impairment is common among rural Chinese children, but fewer than a quarter of children who need glasses actually own and use them. To study the effect of rural county hospital vision centers (VC) on self-reported glasses ownership and wearing behavior (primary outcome) among rural children in China, we conducted a cluster-randomized controlled trial at a VC in the government hospital of Qinan County, a nationally-designated poor county. All rural primary schools (n = 164) in the county were invited to participate. Schools were randomly assigned to either the treatment group to receive free vision care and eyeglasses, if needed, or control group, who received glasses only at the end of the study. Among 2806 eligible children with visiual impairment (visual acuity ≤ 6/12 in either eye), 93 (3.31%) were lost to follow-up, leaving 2713 students (45.0% boys). Among these, glasses ownership at the end of the school year was 68.6% among 1252 treatment group students (82 schools), and 26.4% (p < 0.01) among 1461 controls (82 schools). The rate of wearing glasses was 55.2% in the treatment group and 23.4% (p < 0.01) among the control group. In logistic regression models, treatment group membership was significantly associated with spectacle ownership (Odds Ratio [OR] = 11.9, p < 0.001) and wearing behavior (OR = 7.2, p < 0.001). County hospital-based vision centers appear effective in delivering childrens’ glasses in rural China.