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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

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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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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Working Paper

Lei Wang, Wilson Liang, Cordelia Yu, Mengjie Li, Siqi Zhang, Yonglei Sun, Qingrui Ma, Cody Abbey, Renfu Luo, Ai Yue
Working Paper, 2018

Using the Bayley Scales of Infant and Toddler Development III (BSID III), we examine the rates of developmental delays among infants/toddlers aged 0-3 years old in four major subpopulations of rural China, which altogether account for 69% of China’s rural infants/toddlers and 49% of infants/toddlers nationwide. The data demonstrates that 85% of the 3,353 rural infants/toddlers in our sample suffer from at least one kind of developmental delay. Specifically, 49% of the toddlers have cognitive delays; 52% have language delays, 53% have social-emotional delays, and 30% have motor delays.

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Journal Article

Xiuqin Wang, Yue Ma, Mi Hu, Ling Jin, Baixiang Xiao, Ming Ni, Hongmei Yi , Xiaochen Ma, Congyao Wang, Beatrice Varga, Yiwen Huang, Scott Rozelle , Nathan Congdon
Clinical & Experimental Ophthalmology, 2018

Importance:Uncorrected refractive error causes 90% of poor vision among Chi-nese 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 Guangdongand Yunnan provinces, China, with uncorrected visual acuity (VA)≤6/12 in eithereye correctable to >6/12 in both eyes, and their teachers.

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

Main Outcome Measures:Children's acceptance of free glasses, spectacle pur-chase 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) felteye exercises prevented myopia, 55.0% (151/275) thought children with modestmyopia should not wear glasses and 93.1% (256/275) encouraged children toobtain glasses.Teacher factors associated with children's glasses-related behaviour includedbelieving glasses harm children's vision (decreased purchase, univariate model: rel-ative risk [RR] 0.65, 95% CI 0.43, 0.98,P< 0.05); supporting children's classroomglasses 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 glassesacceptance, multivariate model: RR 2.74, 95% CI 1.29, 5.84,P< 0.01; increasedwear, univariate model: RR 2.93, 95% CI 1.45, 5.90,P< 0.01), but not teacher'sownership/wear of glasses.

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

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Journal Article

Qiufeng Gao, Huan Wang, Di Mo, Yaojiang Shi, Kaleigh Kenny, Scott Rozelle
China Economic Review, 2018

In this paper, we attempt to evaluate the effectiveness of reading programs at improving the reading skills and academic achievement of primary school students in rural China.

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Working Paper

Bin Tang, Boya Wang, Di Mo, Linxiu Zhang, Scott Rozelle, Emma Auden, Blake Mandell
Working Paper, 2018

Education of poor and disadvantaged populations has been a long-standing challenge for education systems in both developed and developing countries. In China, millions of students in rural areas and migrant communities lag far behind their urban counterparts in terms of academic achievement. When they fall behind, they often have no way to catch up. Many of their parents have neither the skills nor the money to provide remedial tutoring; rural teachers often do not have time to give students the individual attention they need.

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Journal Article

Lei Wang, Mengjie Li, Cody Abbey, Scott Rozelle
The Developing Economies, 2018

The objective of this paper is to assess the nature of China’s human capital. To achieve our objective, we both measure the share of the labor force that has attained upper secondary schooling levels (high school) as well as examine recent trends of 15–17 year olds who are attending high school. Using two sets of national representative data, we are able to show that, while the human capital of China’s labor force is still low (30%), between 2005 and 2015 the share of rural youth who attended high school rose sharply. According to Ministry of Education–reported statistics, in 2015 87% of 15–17 year olds were attending high school, up from around 50% in 2005. Given the recent pronouncements of the government to make high school universal by 2020, the challenges for the education system are to increase the attendance of rural as well as vocational education and training students.

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Journal Article

Nobuhiko Fuwa, Yuya Kudo, Keijiro Otsuka, Jacques-Francois Thisse, Scott Rozelle
The Developing Economies, 2018

This special issue is based on a seminar held at the Institute of Developing Economies, Japan External Trade Organization (IDE-JETRO) in 2017, focusing on human capital. In a panel discussion at the seminar, the audience and speakers posed questions and offered comments. Below are the interactions summarized according to three major topics covered in this discussion, that is, China’s human capital, clusterbased industrial development, and urban development.

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Journal Article

Fan Li, Prashant Loyalka, Hongmei Yi, Yaojiang Shi, Natalie Johnson, Scott Rozelle
School Effectiveness and School Improvement, 2018

The goal of this paper is to describe and analyze the relationship between ability tracking and student social trust, in the context of low-income students in developing countries. Drawing on the results from a longitudinal study among 1,436 low-income students across 132 schools in rural China, we found a significant lack of interpersonal trust and confidence in public institutions among poor rural young adults. We also found that slow-tracked students have a significantly lower level of social trust, comprised of interpersonal trust and confidence in public institutions, relative to their fast-tracked peers. This disparity might further widen the gap between relatively privileged students who stay in school and less privileged students who drop out of school. These results suggest that making high school accessible to more students may improve social trust among rural low-income young adults.

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Journal Article

Ai Yue, Yaojiang Shi, Renfu Luo, Jamie Chen, James Garth, Jimmy Zhang, Sarah Kotb, Alexis Medina, Scott Rozelle
2018

This article explores the problem of cognitive delays among toddlers in rural China and the role of their caregivers in producing low levels of cognition (i.e., low IQ). According to the results of a well-tested international scale of child development, the Bayley Scales of Infant Development (BSID), cognitive delays are alarmingly common, and nearly half the toddlers in our sample score an IQ of less than 84 on the BSID test (more than one standard deviation below the mean).

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Journal Article

Mi Zhou, Xiaotong Sun, Li Huang, Guangsheng Zhang, Kaleigh Kenny, Hao Xue, Emma Auden, Scott Rozelle
International Journal of Environmental Research and Public Health, 2018

China’s rapid urbanization in the past several decades have been accompanied by rural labor migration. An important question that has emerged is whether rural labor migration has a positive or negative impact on the depressive symptoms of children left behind in the countryside by their migrating parents. This paper uses a nationally representative panel dataset to investigate whether parental migration impacts the prevalence of depressive symptoms among left-behind children in China.

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