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. Data are aggregated from ten different school-­‐‑level surveys conducted in rural areas of five provinces between 2008 and 2015. In total, 50,361 students were evaluated using a 100-­‐‑item, 9-­‐‑subcategory Mental Health Test (a variation of the Children’s Manifest Anxiety Scale). Seven 21 percent of students were at risk for overall anxiety. However, over half of students were at risk for at least one subcategory of anxiety. Students at higher risk for anxiety included students from poorer counties and families, female students, secondary students, and students with lower levels of academic performance. Many students in rural China are at risk for anxiety, and certain student subpopulations are particularly vulnerable. We suggest that China’s government review and update student mental health programs and policies.

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 a high 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 that grandmothers feed a less diversified diet to children than do mothers. Most (84%) caregivers rely solely on their 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 of reliable information sources.

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

Using individual data collected in rural China and adopting Heckman’s two-step function, we examined the impact of childcare and eldercare on laborers’ off-farm activities. Our study finds that having school-aged children has a negative impact on rural laborers’ migration decisions and a positive impact on their decision to work in the local off-farm employment market. As grandparents can help to take care of young children, the impact of preschoolers is insignificant. Having elderly family to care for decreases the income earned by female members of the family. Although both men and women are actively engaged in off-farm employment today in rural China, this study shows that women are still the primary care providers for both children and the elderly. Therefore, reforming public school enrollment and high school/college entrance examination systems so that migrant children can stay with their parents, this will help rural laborers to migrate to cities. The present study also calls for more public services for preschoolers and the elderly in rural China.

Abstract: Soil-transmitted helminths (STHs) infect over one billion people worldwide. There is concern that chronic infection with STHs among school-aged children may detrimentally affect their development, including their health, cognition, and education. However, two recent Cochrane reviews examining the impact of deworming drugs for STH on nutrition, hemoglobin, and school performance found that randomized controlled trials (RCTs) in the literature provide an insufficient evidence base to draw reliable conclusions. This study uses a cluster-RCT to add to existing evidence by assessing the impact of a deworming intervention on nutrition, cognition, and school performance among schoolchildren in rural China. The intervention, implemented by local health practitioners in a setting with a baseline infection prevalence of 41.9% (95% confidence interval [CI] = 39.8%, 43.9%) and infection intensity of 599.5 eggs per gram of feces among positive-tested schoolchildren (95% CI = 473.2, 725.8), consisted of distributing a 400-mg dose of albendazole accompanied with educational training about STH infection, treatment, and prevention. The intervention was conducted twice over the course of the study—at baseline in May 2013 and later in November 2013. We found that the deworming intervention reduced both infection prevalence and infection intensity, but these declines in infection were not accompanied by an impact on outcomes of nutrition, cognition, or school performance. Our interpretation is that the impact of deworming was attenuated by the light infection intensity in our sample population. Evidence from future RCTs is needed to assess the effect of deworming on key outcomes in areas with moderate and severe worm infections.

Abstract: Social interactions in infancy have implications for long-term outcomes. This study uses data from a sample of 1412 rural Chinese infants aged 6–12 and 24–30 months to examine the relationship between peer interactions and cognitive development. Over 75% of the infants in this sample had less than three peers and around 20% had no peers in both periods. The prevalence of cognitive delays is high within this sample and increases as infants age. Multivariate analysis reveals that peer interaction is significantly associated with cognitive development. Heterogeneous analysis suggests that peer interactions and mental development may be related to the child’s primary caregiver and the distance from the child’s household to the center of their village.

Since economic liberalization in the late 1970s, China's health care providers have grown heavily reliant on revenue from drugs, which they both prescribe and sell. To curb abuse and to promote the availability, safety, and appropriate use of essential drugs, China introduced its national essential drug list in 2009 and implemented a zero markup policy designed to decouple provider compensation from drug prescription and sales. The authors collected and analyzed representative data from China's township health centers and their catchment-area populations both before and after the reform. They found large reductions in drug revenue, as intended by policy makers. However, they also found a doubling of inpatient care that appeared to be driven by supply, instead of demand. Thus, the reform had an important unintended consequence: China's health care providers have sought new, potentially inappropriate, forms of revenue. 

Background: Empty-nest elderly refers to those elderly with no children or whose children have already left home. Few studies have focused on healthcare service use among empty-nest seniors, and no studies have identified the prevalence and profiles of non-use of healthcare services among empty-nest elderly. The purpose of this study is to compare the prevalence of non-use of healthcare services between empty-nest and non-empty-nest elderly and identify risk factors for the non-use of healthcare services among empty-nest seniors.

Methods: Four thousand four hundred sixty nine seniors (60 years and above) were draw from a cross-sectional study conducted in three urban districts and three rural counties of Shandong Province in China. Non-visiting within the past 2 weeks and non-hospitalization in previous year are used to measure non-use of healthcare services. Chi-square test is used to compare the prevalence of non-use between empty-nesters and non-empty-nesters. Multivariate logistic regression analysis is employed to identify the risk factors of non-use among empty-nest seniors.

Results: Of 4469 respondents, 2667(59.7 %) are empty-nesters. Overall, 35.5 % of the participants had non-visiting and 34.5 % had non-hospitalization. Non-visiting rate among empty-nest elderly (37.7 %) is significantly higher than that among non-empty-nest ones (32.7 %) (P = 0.008). Non-hospitalization rate among empty-nesters (36.1 %) is slightly higher than that among non-empty-nesters (31.6 %) (P = 0.166). Financial difficulty is the leading cause for both non-visiting and non-hospitalization of the participants, and it exerts a larger negative effect on access to healthcare for empty-nest elderly than non-empty-nest ones. Both non-visiting and non-hospitalization among empty-nest seniors are independently associated with low-income households, health insurance status and non-communicable chronic diseases. The nonvisiting rate is also found to be higher among the empty-nesters with lower education and those from rural areas.

Conclusions: Our findings indicate that empty-nest seniors have higher non-use rate of healthcare services than non-empty-nest ones. Financial difficulty is the leading cause of non-use of health services. Healthcare policies should be developed or modified to make them more pro-poor and also pro-empty-nested.

Background: Anemia early in life has been associated with delayed cognitive and motor development. The WHO recommends home fortification using multiple micronutrient powders (MNPs) containing iron as a strategy to address anemia in children under two. We evaluated the effects of a program freely distributing MNP sachets to caregivers of infants in rural China.

Methods: We conducted a cluster-randomized controlled trial in Shaanxi province, enrolling all children aged 6–11 months in target villages. Following a baseline survey, investigators randomly assigned each village/ cluster to a control or treatment group. In the treatment group, caregivers were instructed to give MNPs daily. Follow-up was after 6, 12, and 18 months of intervention. Primary outcomes were hemoglobin concentrations and scores on the Bayley Scales of Infant Development.

Results: One thousand, eight hundred and-two eligible children and their caregivers were enrolled. At baseline 48% (870) of children were anemic and 29% (529) were developmentally delayed. Six hundred and-ten children (117 villages) were assigned to the control group and 1192 children (234 villages) were assigned to the treatment group. Assignment to the treatment group was associated with an improvement in hemoglobin levels (marginal effect 1.77 g/L, 95% CI 0.017–3.520, p-value = 0.048) and cognitive development (marginal effect 2.23 points, 95% CI 0.061–4.399, p-value = 0.044) after 6 months but not thereafter. There were no significant effects on motor development. Zero effects after the first 6 months were not due to low compliance, low statistical power, or changes in feeding behavior. Hemoglobin concentrations improved in both the treatment and control groups over the course of the study; however, 22% (325) of children remained anemic at endline, and 48% (721) were cognitively delayed.

Conclusions: Providing caregivers with MNP sachets modestly hastened improvement in hemoglobin levels that was occurring absent intervention; however, this improvement did not translate into improved developmental outcomes at endline.

Trial registration: ISRCTN44149146; prospectively registered on 15th April 2013.

Keywords: Micronutrient supplementation, Anemia, Cognition, Early childhood

Abstract: More than 60 million children in rural China are “left-behind”—both parents live and work far from their rural homes and leave their children behind. This paper explores differences in how left-behind and non-left-behind children seek health remediation in China’s vast but understudied rural areas. This study examines this question in the context of a program to provide vision health care to myopic rural students. The data come from a randomized controlled trial of 13,100 students in Gansu and Shaanxi provinces in China. The results show that without a subsidy, uptake of health care services is low, even if individuals are provided with evidence of a potential problem (an eyeglasses prescription). Uptake rises two to three times when this information is paired with a subsidy voucher redeemable for a free pair of prescription eyeglasses. In fact, left-behind children who receive an eyeglasses voucher are not only more likely to redeem it, but also more likely to use the eyeglasses both in the short term and long term. In other words, in terms of uptake of care and compliance with treatment, the voucher program benefitted left-behind students more than non-left-behind students. The results provide a scientific understanding of differential impacts for guiding effective implementation of health policy to all groups in need in developing countries.

Keywords: randomized controlled trial; rural China; left-behind children; healthcare