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    Journal Article

    Ai Yue, Yaojiang Shi, Renfu Luo, Boya Wang, Ann Weber, Alexis Medina, Sarah Kotb, Scott Rozelle
    Journal of Developmental and Behavioral Pediatrics, 2019
    ABSTRACT: Objective: To provide an empirical overview of the parenting landscape in rural China, focusing on 18- to 30-month-old children and their caregivers in rural Shaanxi province. Methods: We collected unique data on 1442 caregiver-toddler dyads in rural areas of Shaanxi province and examined caregiver attitudes toward parenting, sources of information about parenting, and interactive parenting practices, and how each of these differed across generations. We measured how parenting attitudes and sources of information informed parenting practices. Finally, we measured levels of child development in our sample and the association between parenting practices and children’s developmental outcomes. Results: Most of the caregivers did not engage with children in a way that encouraged early development. Caregivers rarely told stories, sang, or used toys to play with their children. Grandmothers were more stressed by the children in their care and engaged significantly less than mothers did in the 3 stimulating interactions. Professional sources of information about parenting were underutilized by all caregivers. We found high rates of developmental delay in our sample and showed that these delays were associated with the lack of caregiver engagement. Conclusion: Our findings suggest that the major economic and social shifts occurring in rural China have not led to a widespread prevalence of stimulative parenting practices. Although caregivers report positive attitudes toward child-rearing, reliable sources of scientific information are lacking. Our results show a troubling generational disconnect between the information-seeking behaviors and parenting practices of rural caregivers.
     
    Index terms: caregiver-child interaction, parenting, early child development.
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    Working Paper

    Qiran Zhao, Xiaobing Wang, Scott Rozelle
    China Economic Review, 2019

    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.

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    Journal Article

    Yu Bai, Siqi Zhang, Lei Wang, Ruirui Dang, Cody Abbey, Scott Rozelle
    Journal of Contemporary China, 2019

    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.

     

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    Journal Article

    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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    Journal Article

    Prashant Loyalka, Ou Lydina Liu, Guirong Li, Igor Chirikov, Elena Kardanova, Lin Gu, Guangming Ling, Ningning Yu, Fei Guo, Liping Ma, Shangfeng Hu, Angela Sun Johnson, Ashutosh Bhuradia, Saurabh Khanna, Isak Froumin, Jinghuan Shi, Pradeep Kumar Choudhury, Tara Beteille, Francisco Marmolejo, Namrata Tognatta
    Proceedings of the National Academy of Sciences of the United States of America, 2019

    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.

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    Journal Article

    Huan Zhou, Qingzhi Wang, Junmin Zhou, Tiaoying Li, Alexis Medina, Stephen Felt, Scott Rozelle, John Openshaw
    Environmental Research and Public Health, 2019

    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.

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    Journal Article

    Dong Roman Xu, Mengyao Hu, Wenjun He, Jing Liao, Yiyuan Cai, Sean Sylvia, Kara Hanson, Yaolong Chen, Jay Pan, Zhongliang Zhou, Nan Zhang, Chengxiang Tang, Xiaohui Wang, Scott Rozelle, Hua He, Hong Wang, Gary Chan, Edmundo Roberto Melipillan, Wei Zhou, Wenjie Gong
    BMJ Open, 2019

    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.

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    Journal Article

    Renfu Luo, Grant Miller, Scott Rozelle, Sean Sylvia, Marcos Vera-Hernández
    Journal of the European Economic Association, 2019

    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. 

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    Journal Article

    Lei Wang, Wilson Liang, Cordelia Yu, Mengjie Li, Siqi Zhang, Yonglei Sun, Qingrui Ma, Laura Johnsson, Cody Abbey, Renfu Luo, Ai Yue, Yu Bai, Scott Rozelle
    Journal of Comparative Economics, 2019

    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. 

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    Journal Article

    Jin Liu, Scott Rozelle, Qing Xu, Ning Yu, Tianshu Zhou
    International Journal of Environmental Research and Public Health, 2019

    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.

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    Journal Article

    Shanshan Li, Ai Yue, Cody Abbey, Alexis Medina, Yaojiang Shi
    International Journal of Environmental Research and Public Health, 2019

    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.

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    Journal Article

    Hongmei Yi, Di Mo, Huan Wang, Qiufeng Gao, Yaojiang Shi, Paiou Wu, Cody Abbey, Scott Rozelle
    Reading Research Quarterly, 2018

    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.

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    Journal Article

    Yang He, Renfu Luo, Tianyi Wang, Jingjing Gao, Chengfang Liu
    International Journal of Environmental Research and Public Health, 2018

    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. 

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    Journal Article

    Ai Yue, Jiaqi Gao, Meredith Yang, Lena Swinnen, Alexis Medina, Scott Rozelle
    Frontiers in Psychology, 2018

    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.

     

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    Journal Article

    Yue Ma, Yujuan Gao, Yue Wang, Haoyang Li, Lina Ma, Jiangchao Jing, Yaojiang Shi , Hongyu Guan , Nathan Congdon
    International Journal of Environmental Research and Public Health, 2018

    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.

     

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    Journal Article

    Hongyu Guan, Huan Wang, Kang Du, Jin Zhao, Matthew Boswell, Yaojiang Shi, Yiwei Qian
    International Journal of Environmental Research and Public Health, 2018
    Abstract: If children with common vision problems receive and use eyeglasses, their educational performance rises. Without proper treatment, visually impaired children may not achieve educational gains and could suffer from poor mental health. We use a randomized controlled trial to study the impact of an eyeglasses promotion program in rural China on the mental health of myopic primary school students. Three measures of mental health are used: learning anxiety, physical anxiety, and scores on the Mental Health Test (MHT). Our empirical analysis showed that on average, the treatment has small and insignificant for learning anxiety and MHT, and a small but significant reduction in physical anxiety. However, subgroup analysis reveals that myopic students who study more intensively see their learning anxiety and physical anxiety reduced after being provided with eyeglasses. In contrast, students with the lower study intensity suffer a rise in learning anxiety after receiving eyeglasses. A potential mechanism for the differing impacts is the increase in teasing reported among low study-intensity students that does not occur for high study-intensity students. Care should be taken to maximize the benefits and minimize the costs of in-school vision programs.
     
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    Journal Article

    Fang Chang, Yaojiang Shi, Amber Shen, Asa Kohrman, Katherine Li, Qinqin Wan, Kaleigh Kenny, Scott Rozelle
    The Developing Economies, 2018

    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. 

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    Working Paper

    Prashant Loyalka, Anna Popova, Guirong Li, Zhaolei Shi
    2018

    Despite massive investments in teacher professional development (PD) programs in developing countries, there is little evidence on their effectiveness. We present results of a large-scale, randomized evaluation of a national PD program in China in which teachers were randomized to receive PD; PD plus follow-up; PD plus evaluation of the command of PD content; or no PD. Precise estimates indicate PD and associated interventions failed to improve teacher and student outcomes after one year. A detailed analysis of the causal chain shows teachers find PD content to be overly theoretical, and PD delivery too rote and passive, to be useful.

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    Journal Article

    Lei Wang, Yonglei Sun, Buyao Liu, Lijuan Zheng, Mengjie Li, Yu Bai, Annie Osborn, Maggie Lee, Scott Rozelle
    International Journal of Environmental Research and Public Health, 2018
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    Journal Article

    Siqi Zhang, Ruirui Dang, Ning Yang, Lei Wang, Cody Abbey, Scott Rozelle
    International Journal of Environmental Research and Public Health, 2018

    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.

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    Journal Article

    Lili Li, Lei Huang, Yaojiang Shi, Renfu Luo, Meredith Yang, Scott Rozelle
    China Economic Review, 2018

    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.

     

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    Journal Article

    Hongyan Liu, Yaojiang Shi, Emma Auden, Scott Rozelle
    Environmental Health and Research, 2018

    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.

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    Journal Article

    Hao Xue, Jennifer Hager, Qi An, Kai Liu, Jing Zhang, Emma Auden, Bingyan Yang, Jie Yang, Hongyan Liu, Jingchun Nie, Aiqin Wang, Chengchao Zhou, Yaojiang Shi, Sean Sylvia
    International Journal of Environmental Research and Public Health, 2018

    Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14–46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28–72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants

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    Journal Article

    Hao Xue, Yaojiang Shi, Lei Huang, Hongmei Yi, Huan Zhou, Chengchao Zhou, Sarah Kotb, Joseph D. Tucker, Sean Y. Sylvia
    Journal of Antimicrobial Chemotherapy, 2018

    Background: China has one of the highest rates of antibiotic resistance. Existing studies document high rates of antibiotic prescription by primary care providers but there is little direct evidence on clinically inappropriate use of antibiotics or the drivers of antibiotic prescription.

    Methods: To assess clinically inappropriate antibiotic prescriptions among rural primary care providers, we employed unannounced standardized patients (SPs) who presented three fixed disease cases, none of which indicated antibiotics. We compared antibiotic prescriptions of the same providers in interactions with SPs and matching vignettes assessing knowledge of diagnosis and treatment to assess overprescription attributable to deficits in diagnostic knowledge, therapeutic knowledge and factors that lead providers to deviate from their knowledge of best practice.

    Results: Overall, antibiotics were inappropriately prescribed in 221/526 (42%) SP cases. Compared with SP inter- actions, prescription rates were 29% lower in matching clinical vignettes (42% versus 30%, P,0.0001). Compared with vignettes assessing diagnostic and therapeutic knowledge jointly, rates were 67% lower in vignettes with the diagnosis revealed (30% versus 10%, P , 0.0001). Antibiotic prescription in vignettes was in- versely related to measures of diagnostic process quality (completion of checklists).

    Conclusions: Clinically inappropriate antibiotic prescription is common among primary care providers in rural China. While a large proportion of overprescription may be due to factors such as financial incentives tied to drug sales and perceived patient demand, our findings suggest that deficits in diagnostic knowledge are a major driver of unnecessary antibiotic prescriptions. Interventions to improve diagnostic capacity among providers in rural China are needed.

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    Journal Article

    Ai Yue, Nianrui Zhang, Xueyang Liu, Lei Tang, Renfu Luo, Meredith Yang, Scott Rozelle, Alexis Medina
    Family & Community Health, 2018

    The overall goal of this study is to examine whether infant feeding practices differ between mothers and grandmothers in rural China. We randomly sampled 1383 caregivers of infants aged 18 to 30 months living in 351 villages across 174 townships in nationally designated poverty counties in rural areas. Results show that ahigh fraction of caregivers of 18- to 30-month-old children living in low-income areas of rural China do not regularly engage in positive infant feeding practices. Only 30% of children in our sample achieved adequate dietary diversity. Only 49% of children in our sample were fed meat in the day prior to survey administration. Few caregivers reported giving any vitamin supplements (such as calcium or iron supplements) to their children. We find that 33% of the children were cared for by grandmothers rather than mothers, and thatgrandmothers feed a less diversified diet to children than do mothers. Most (84%) caregivers rely solely ontheir own experiences, friends, and family members in shaping their feeding behaviors. Overall infant feeding practices are poor in rural China. Grandmothers engage in poorer feeding practices than do mothers. Grandmothers have improved their feeding practices compared to when their own children were young. Our results suggest shortcomings in the quality of infant feeding practices, at least in part due to an absence ofreliable information sources.

    Key words: child development, feeding practices, information sources, rural China

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