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Economics & Social Science

Sylvia S., Warrinier N., Luo R., Yue A., Attanasio O., Rozelle S. From Quantity to Quality: Delivering a Home-based Parenting Intervention through China’s Family Planning Workers, The Economic Journal. [Video, CCTV News: How will a Million Family Planning Workers Transition?] [BBC News: Re-inventing China’s Abortion Police] Abstract

A key challenge in developing countries interested in providing early childhood development programs at scale is whether these programs can be effectively delivered through existing public service infrastructures. We present the results of a randomized experiment evaluating the effects of a home-based parenting program delivered by cadres in China’s Family Planning Commission (FPC) – the former enforcers of the one-child policy. We find that the program significantly increased infant skill development after six months and that increased investments by caregivers alongside improvements in parenting skills were a major mechanism through which this occurred. Children who lagged behind in their cognitive development and received little parental investment at the onset of the intervention benefited most from the program. Household participation in the program was associated with the degree to which participants had a favorable view of the FPC, which also increased due to the program.

Yue A, Bai Y, Shi Y, Luo R, Rozelle S, Sylvia S. (2020) Parental Migration and Early Childhood Development in Rural China, Demography. Abstract

Nearly one quarter of all children under two in China are left behind in the countryside as parents migrate to urban areas for work. We use a four-wave longitudinal survey following young children from six to 30 months of age to provide first evidence on the effects of parental migration on development, health, and nutritional outcomes in the critical first stages of life. We find that maternal migration has a negative effect on cognitive development, with migration before children reach 12 months of age reducing cognitive development by 0.3 standard deviations at age two. Possible mechanisms include reduced dietary diversity and engagement in stimulating activities, both known to be causally associated with skill development in early life. We find no effects on other dimensions of physical and socio-emotional health.

Nie J, Pang X, Wang L, Rozelle S, Sylvia S. (2020) Seeing is Believing: Experimental Evidence of the Impact of Eyeglasses on Academic Performance, Aspirations and Dropout among Junior High School Students in Rural China, Economic Development and Cultural Change. [Working Paper] Abstract

We present the results of a randomized trial testing the impact of providing free eyeglasses on academic outcomes of junior high school students in a poor rural area of western China. We find that providing free prescription eyeglasses approximately halves dropout rates over a school year among students who did not own eyeglasses at baseline. Effects on dropout are mirrored by improvements in student performance on standardized exams in math and aspirations for further schooling.

Luo R, Emmers D, Warrinnier N, Rozelle S, Sylvia S. (2019) Using Community Health Workers to Deliver a Scalable Integrated Parenting Program in Rural China, Social Science and Medicine. Abstract

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.

Luo R, Miller G, Rozelle S, Sylvia S, Vera-Hernández M. (2019) Can Bureaucrats Really be Paid like CEOs? School Administrator Incentives for Anemia Reduction in Rural China, Journal of the European Economic Association. [Pre-analysis Plan] [Working Paper] Abstract

A large literature examines performance pay for managers in the private sector, but little is known about performance pay for managers in public sector bureaucracies. In this paper, we study performance incentives rewarding school administrators for reducing anemia among their students. Randomly assigning 170 schools to three performance incentive levels and two orthogonal sizes of unconditional grants, we analyze performance pay and its complementarity with discretionary resources. We find that both large incentives and larger unconditional grants reduced anemia substantially, but incentives were more cost-effective. Performance incentives led administrators to innovate by working with parents, mitigating potentially offsetting compensatory behavior among households. Strikingly, we also find that larger unconditional grants completely crowded-out the effect of incentives. Our findings suggest that performance incentives can be effective in bureaucratic environments – but also that discretionary resources can fully crowd-out their effect.

Loyalka P, Sylvia, S, Liu C, Chu J, Shi Y. (2019) Pay by Design: Teacher Performance Pay Design and the Distribution of Student Achievement,  Journal of Labor Economics [Pre-analysis Plan] [Working Paper] [China Education Daily: Can Performance Pay make Dreams Come True? (in Chinese)] Abstract

We present results of a randomized trial testing alternative approaches of mapping student achievement into rewards for teachers. Teachers in 216 schools in western China were assigned to performance pay schemes where teacher performance was assessed by one of three different methods. We find that teachers offered “pay-for-percentile” incentives (Barlevy and Neal 2012) outperform teachers offered simpler schemes based on class average achievement or average gains over a school year. Moreover, pay-for-percentile incentives produced broad-based gains across students within classes. That teachers respond to relatively intricate features of incentive schemes highlights the importance of close attention to performance pay design.

Wang L, Li M, Zhang S, Sun Y, Sylvia S, Yang E, Ma G, Zhang L, Mo D, Rozelle S, (2018) Contract Teachers and Student Achievement in Rural China: Evidence from Class Fixed Effects, Australian Journal of Agricultural and Resource EconomicsAbstract

For schooling to play an important role in the development of human capital, the system of education needs to provide quality education, which among other things requires high‐quality teachers. Facing fiscal constraints and growing enrolments, school systems in developing countries often supplement their teaching staff by hiring contract teachers. However, there is limited evidence on how the effectiveness of these teachers compares to that of civil service teachers. We use a dataset from rural primary schools in western China to estimate the causal effect of contract teachers on student achievement and find that gains in student scores on standardised examinations in mathematics and Chinese are less in classes taught by contract teachers than in classes taught by civil service teachers. The results demonstrate that China’s education system needs to focus on producing high‐quality teachers to improve the quality of schooling in its rural education system. The findings imply that educators in developing countries should not only seek to hire increasingly more civil service teachers in rural schools, but they should also identify ways of improving the quality of contract teachers. If efforts to improve teaching can succeed, rural students can learn more, earn higher incomes and contribute more to the productivity of the overall economy.

Yang Y, Wang H, Zhang L, Sylvia S, Luo R, Shi Y, Wang W, Rozelle S. (2015) The Han-Minority Achievement Gap, Language, and Returns to Schools in Rural China. Economic Development and Cultural Change. Abstract

Although access to quality education in rural China has expanded dramatically over the past 3 decades, significant disparities persist between ethnic minorities and the Han majority. This article compares the academic achievement and determinants of achievement of minority and Han students in rural western China. In a survey of nearly 21,000 primary school students, we find that minority students score significantly lower than their Han peers on standardized exams in math and Chinese. This Han-minority achievement gap is largest for minority students whose primary language is not standard Mandarin (putonghua): these students score on average more than 0.6 standard deviations lower than Han students in both subjects. For minority students whose primary language is standard Mandarin, the gap with Han students is almost fully explained by different endowments of student, class peer, teacher, and school characteristics. Endowments of these characteristics, however, explain little of the achievement gap for non-Mandarin minority students. A fixed effects analysis also shows that the returns to Han students of attending individual schools tend to be larger than those to minority students with similar characteristics. Further, these school-specific differential returns to Han and minority students are most strongly associated with the characteristics of teachers. 

Sylvia S, Luo R, Zhang L, Shi Y, Medina A, Rozelle S. (2013) Do You Get What You Pay for with School-based Health Programs? Evidence from a Child Nutrition Experiment in Rural China. Economics of Education ReviewAbstract

This study uses a randomized controlled trial of a school-based anemia reduction program in rural China to examine how increased school emphasis on health promotion affects academic performance. Although education and health promotion are complementary functions of schools, they do compete for finite school resources. We compare the effects of a traditional program that provided only information about anemia and subsidies to an otherwise identical program that included performance incentives for school principals based on school-level anemia prevalence. By the end of the trial, exam scores among students who were anemic at baseline improved under both versions of the program, but scores among students in the incentive group who were healthy at baseline fell relative to healthy students in the control group. Results suggest that performance incentives to improve student health increase the impact of school-based programs on student health outcomes, but may also lead to reallocation of school resources.

Public Health & Medicine

Nie J, Zhang L, Gao J, Li J, Zhou Q, Shi Y, Sean S, Congdon N (2020). Using incognito standardised patients to evaluate quality of eye care in China. British Journal of Ophthalmology. Abstract

Background/aims: Few studies have objectively examined the quality of eye care in China. We assessed refractive care using the incognito standardised patient (SP) approach, a gold standard for evaluating clinical practice.

Methods: A total of 52 SPs were trained to provide standardised responses during eye examinations, and underwent automated and non-cycloplegic, subjective refraction by a senior ophthalmologist from Zhongshan Ophthalmologic Center, a national-level clinical and research centre. SPs subsequently received subjective refraction and eye exams at a randomly selected sample of 40 public hospitals and 93 private optical shops in Shaanxi, Northwestern China. Difference between expert and local refraction in the better-seeing eye was calculated by the vector diopteric method, and completeness of exams assessed against national standards. SP and provider demographic information and provider clinical experience were recorded.

Results: SPs (n=52, mean (range) age, 25.7 (22-31) years, 28.8% male) underwent 133 eye exams (mean total duration 15.0±11.7 min) by 133 local refractionists (24-60 years, 30.3% male). Only 93 (69.9%), 121 (91.0%) and 104 (78.2%) of local refractionists assessed vision, automated and subjective refraction, respectively. The median inaccuracy was -0.25 diopters (D), while 25.6% of results differed by an absolute value of ≥1.0 D and 6.0% by ≥2.0 D. Predictors of inaccurate refraction included spectacle power <-6.0 D (OR=2.66; 95% CI, 1.27 to 5.56), service at a public (vs private) hospital (OR=2.01; 95% CI, 1.11 to 3.63) and provider male sex (OR=2.03; 95% CI, 1.11 to 3.69).

Conclusion: Inaccurate refractions are common in Northwestern China, particularly in public facilities. Important assessments, including subjective refraction, are frequently omitted.

Cai R, Tang J, Deng C, Lv G, Xu X, Sylvia S, Pan J. (2019) Violence against health care workers in China, 2013-2016: Evidence from the national judgment documents. Human Resources for Health. Abstract

Incidents of patient-initiated workplace violence (WPV) against health care workers have been a subject of substantial public attention in China. Patient-initiated violence not only represents a risk of harm to health care providers but is also indicative of general tensions between doctors and patients which pose a challenge to improving health system access and quality. This study aims to provide a systematic, national-level characterization of serious WPV against health care workers in China.

To provide a national-level characterization of serious WPV against health care workers, this study extracted data from the China Judgment Online System (CJOS), a comprehensive database of judgement documents. Three key phrases, “criminal case”, “health care institution”, and “health care worker” were used to search the CJOS for relevant cases between January 1st, 2013 and December 31st, 2016. Data extracted from identified cases was used to document the occurrence, the degree of risk, and the factors associated with serious WPV.

Between January 1st, 2013 and December 31st, 2016, 459 criminal cases (with 680 violence perpetrators in total) involving patient-initiated WPV against health care workers in China were reported and processed. The analysis revealed spatial heterogeneity in the occurrence of serious WPV, with lower incidence in western provinces compared to central and eastern provinces. Primary hospitals experienced the highest rates of serious WPV and emergency departments and doctors were at higher risk compared with other departments and health workers. Perpetrators were primarily male farmers aged 18-44 with low levels of educational attainment. The most frequent reported reasons of serious patient-initiated WPV included perceived medical malpractice by the perpetrator after the death of a patient, death of a patient with no other reason given, failures of the compensation negotiations after the death of a patient, and dissatisfaction with the treatment outcomes.

Serious WPV against providers is common across provinces and health care institutions in China. These data suggest that perceptions of low-quality care are an often-reported reason for violence. In addition to ongoing reforms designed to improve medical quality, efforts should be made to provide patients better service and strengthen the doctors’ communications with the patients.

Wu Y., Zhou H., Ma X., Shi Y., Xue H., Zhou C., Yi H., Medina A., Li J., Sylvia S. Using Standardized Patients to Assess the Quality of Medical Records: An application and evidence from Rural China. Forthcoming, BMJ Quality & Safety. Abstract

Objective: Provide an unbiased assessment of the quality of medical records for outpatient visits to rural facilities in China.

Methods: A sample of 207 township health facilities across three provinces of China were enrolled. Unannounced standardized patients (SPs) presented to providers following standardized scripts. Three weeks later, investigators returned to collect medical records from each facility. Audio recordings of clinical interactions were then used to evaluate completeness and accuracy of available medical records.

Results: Medical records were located for 210 out of 620 SP visits (33.8%). Of those located, more than 80% contained basic patient information and drug treatment when mentioned in visits, but only 57.6% recorded diagnoses. The most incompletely recorded category of information was patient symptoms (74.3% unrecorded), followed by non-drug treatments (65.2% unrecorded). Most recorded was recorded information was accurately, but accuracy fell below 80% for some items. The keeping of any medical records was positively correlated with whether the hospital had protocols for record storage. Providers with bachelor’s degrees or higher were more likely to record completely (β 0.76, 95%CI 0.04 to 1.47) and accurately (β 0.72, 95%CI 0.01 to 1.42). Providers at hospitals with prescription review were less likely to record (β -1.03, 95%CI -1.86 to -0.16) and did so less accurately (β -1.04, 95%CI -1.86 to -0.22).

Conclusion: Despite the importance of medical records for health system functioning, many rural facilities have yet to implement systems for maintaining patient records and records are often incomplete when they exist. Prescription review tied to performance evaluation should be implemented with caution as it may create disincentives for record keeping. Interventions to improve record keeping and management are needed.

Xue H, Shi Y, Huang L, Yi H, Zhou H, Zhou C, Kotb S, Tucker J, Sylvia S. (2018) Diagnostic Ability and Antibiotic Prescriptions: A Quasi-Experimental Study of Primary Care Providers in Rural China, Journal of Antimicrobial Chemotherapy, 74 (1): 256–263.  Abstract

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 inversely 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.

Gao Q, Shi Y, Mo D, Nie J, Yang M, Rozelle S, Sylvia S. (2018) Medical Waste Management in Rural China, PLOS OneAbstract

Objective: The purpose of this paper is to describe current practices of medical waste management, including its generation, investments, collection, storage, segregation, and disposal, and to explore the level of support from upper tiers of the government and health care system for medical waste management in rural China.

Methods: The authors draw on a dataset comprised of 209 randomly selected rural township health centers (THCs) in 21 counties in three provinces of China: Anhui, Shaanxi and Sichuan. Surveys were administered to health center administrators in sample THCs in June 2015.

Results: The results show that the generation rate of medical waste was about 0.18 kg/bed, 0.15 kg/patient, or 0.13 kg/person per day on average. Such per capita levels are significant given China’s large rural population. Although investments of medical waste facilities and personnel in THCs have improved, results show that compliance with national regulations is low. For example, less than half of hazardous medical waste was packed in sealed containers or containers labeled with bio-hazard markings. None of the THCs segregated correctly according to the categories required by formal Chinese regulations. Many THCs reported improper disposal methods of medical waste. Our results also indicate low levels of staff training and low rates of centralized disposal in rural THCs.

Conclusions: Medical waste is a serious environmental issue that is rising on the agenda of policymakers. While a large share of THCs has invested in medical waste facilities and personnel, it appears that actual compliance remains low. Using evidence of low rates of training and centralized disposal, we surmise that a lack of support from upper tiers of management is one contributing factor. Given these findings, we recommend that China’s policymakers should enhance support from upper tiers and improve monitoring as well as incentives in order to improve medical waste management.

Xue H, Hagger J, An Q, Liu K, Zhang J, Auden E, Yang B, Yang J, Liu H, Nie J, Wang A, Zhou C, Shi Y, Sylvia S. (2018) The Quality of Tuberculosis Care in Urban Migrant Clinics in ChinaInternational Journal of Environmental Research and Public Health, 15(9): 2037.  Abstract

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.

Sylvia S, Xue H, Zhou C, Shi Y, Yi H, Zhou H, Rozelle S, Pai M, Das J. (2017) Tuberculosis Detection and the Challenges of Integrated Care in Rural China: A Cross-sectional Standardized Patient Study. PLoS Med, 14(10): e1002405. Abstract

Background: Despite recent reductions in prevalence, China still faces a substantial tuberculosis (TB) burden, with future progress dependent on the ability of rural providers to appropriately detect and refer TB patients for further care. This study (a) provides a baseline assessment of the ability of rural providers to correctly manage presumptive TB cases; (b) measures the gap between provider knowledge and practice and; (c) evaluates how ongoing reforms of China’s health system – characterized by a movement toward ‘integrated care’ and promotion of initial contact with grassroots providers – will affect the care of TB patients.

Methods and Findings: Unannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms were deployed in three provinces of China in July 2015. The SPs successfully completed 274 interactions across all three tiers of China’s rural health system, interacting with providers in 46 village clinics, 207 township health centers and 21 county hospitals.

Interactions between providers and standardized patients were assessed against international and national standards of TB care. Using a lenient definition of correct management as at least a referral, Chest X-ray or sputum test, 41% (111 of 274) SPs were correctly managed. Although there were no cases of empirical anti-TB treatment, antibiotics unrelated to the treatment of TB were prescribed in 168 of 274 interactions or 61.3% (95% CI: 55%—67%). Correct management proportions significantly higher at county hospitals compared to township health centers (OR 0.06, 95% CI: 0.01–0.25, p < 0.001) and village clinics (OR 0.02, 95% CI: 0.0–0.17, p < 0.001). Correct management in tests of knowledge administered to the same 274 physicians for the same case was 45 percentage points (95% CI: 37%—53%) higher with 24 percentage points (95% CI: -33%—-15%) fewer antibiotic prescriptions.

Relative to the current system, were patients can choose to bypass any level of care, simulations suggest that a system of managed referral with gatekeeping at the level of village clinics would reduce proportions of correct management from 41% to 16%, while gatekeeping at the level of the township hospital would retain correct management close to current levels at 37%.

The main limitations of the study are two-fold. First, we evaluate the management of a one-time new patient presenting with presumptive TB, which may not reflect how providers manage repeat patients or more complicated TB presentations. Second, simulations under alternate policies require behavioral and statistical assumptions that should be addressed in future applications of this method.

Conclusions: There were significant quality deficits among village clinics and township health centers in the management of a classic case of presumptive TB, with higher proportions of correct case management in county hospitals. Poor clinical performance does not arise only from a lack of knowledge, a phenomenon known as the “know-do” gap. Given significant deficits in quality of care, reforms encouraging first contact with lower tiers of the health system can improve efficiency only with concomitant improvements in appropriate management of presumptive TB patients in village clinics and township health centers. 

Luo R, Yue A, Zhou H, Shi Y, Zhang L, Martorell R, Medina A, Rozelle S, Sylvia S. (2017) The Effect of a Micronutrient Powder Home Fortification Program on Anemia and Cognitive Outcomes Among Infants in Rural China: A Cluster Randomized Trial. BMC Public Health, 17, 738. Abstract

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.

Liu C, Lu L, Zhang L, Luo R, Sylvia S, Medina A, Rozelle S, Smith DS, Chen Y, Zhu T. (2017) Effect of Deworming on Indices of Health, Cognition and Education Among School Children in Rural China: A Cluster-Randomized Controlled Trial. American Journal of Tropical Medicine & Hygiene, 96(6), 1478–1489. 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.

Zhou H, Sun S, Luo R, Sylvia S, Yue A, Shi Y, Zhang L, Medina A, Rozelle S. (2016) Impact of Text Message Reminders on Caregivers’ Adherence to a Home Fortification Program in Rural Western China: A Cluster Randomized Controlled Trial. American Journal of Public Health, 106(7), 1256-1262. Abstract

Objectives. To test whether text message reminders sent to caregivers improve the effectiveness of a home micronutrient fortification program in western China.

Methods. We carried out a cluster-randomized controlled trial in 351 villages (clusters) in Shaanxi Province in 2013 and 2014, enrolling children aged 6 to 12 months. We randomly assigned each village to 1 of 3 groups: free delivery group, text messaging group, or control group. We collected information on compliance with treatments and hemoglobin concentrations from all children at baseline and 6-month follow-up. We estimated the intent-to-treat effects on compliance and child anemia using a logistic regression model.

Results. There were 1393 eligible children. We found that assignment to the text messaging group led to an increase in full compliance (marginal effect = 0.10; 95% confidence interval [CI] = 0.03, 0.16) compared with the free delivery group and decrease in the rate of anemia at end line relative to the control group (marginal effect = −0.07; 95% CI = −0.12, −0.01), but not relative to the free delivery group (marginal effect = −0.03; 95% CI = −0.09, 0.03).

Conclusions. Text messages improved compliance of caregivers to a home fortification program and children’s nutrition.

Zhou C, Sylvia S, Zhang L, Luo R, Yi H, Liu C, Shi Y, Loyalka P, Chu J, Medina A, Rozelle S. (2015) China’s Left Behind Children: Impact of Parental Migration on Health, Nutrition, and Educational Outcomes. Health Affairs, 34(11), 1964–1971. Abstract

China’s rapid development and urbanization have induced large numbers of rural residents to migrate from their homes to urban areas in search of better job opportunities. Parents typically leave their children behind with a caregiver, creating a new, potentially vulnerable subpopulation of left-behind children in rural areas. A growing number of policies and nongovernmental organization efforts target these children. The primary objective of this study was to examine whether left-behind children are really the most vulnerable and in need of special programs. Pulling data from a comprehensive data set covering 141,000 children in ten provinces (from twenty-seven surveys conducted between 2009 and 2013), we analyzed nine indicators of health, nutrition, and education. We found that for all nine indicators, left-behind children performed as well as or better than children living with both parents. However, both groups of children performed poorly on most of these indicators. Based on these findings, we recommend that special programs designed to improve health, nutrition, and education among left-behind children be expanded to cover all children in rural China. 

Luo R, Shi Y, Zhou H, Yue A, Zhang L, Sylvia S, Medina A, Rozelle S. (2015) Micronutrient Deficiencies and Developmental Delays in Infants: Evidence from a Cross-sectional Survey in Rural China. BMJ Open, 5(10). Abstract

Objectives Research increasingly indicates the importance of the nutritional programming that occurs in the first 2–3 years of life. Quality nutrition during this brief window has been shown to have large and significant effects on health and development throughout childhood and even into adulthood. Despite the widespread understanding of this critical window, and the long-term consequences of leaving nutritional deficiencies unaddressed, little is known about the status of infant nutrition in rural China, or about the relationship between infant nutrition and cognitive development in rural China.

Design, setting and participants In April 2013 and October 2013, we conducted a survey of 1808 infants aged 6–12 months living in 351 villages across 174 townships in nationally designated poverty counties in rural areas of southern Shaanxi Province, China.

Main outcome measures Infants were administered a finger prick blood test for haemoglobin and assessed according to the Bayley Scales of Infant Development. They were also measured for length and weight. Caregivers were administered a survey of demographic characteristics and feeding practices.

Results We found that 48.8% of sample infants were anaemic, 3.7% were stunted, 1.2% were underweight and 1.6% were wasted. Approximately 20.0% of the sample infants were significantly delayed in their cognitive development, while just over 32.3% of the sample infants were significantly delayed in their psychomotor development. After controlling for potential confounders, infants with lower haemoglobin counts were significantly more likely to be delayed in both their cognitive (p<0.01) and psychomotor development (p<0.01).

Conclusions The anaemia rates that we identify in this study classify anaemia as a ‘severe’ public health problem according to the WHO. In contrast, there is virtually no linear growth failure among this population. We find that low haemoglobin levels among our sample population are associated with significant cognitive and psychomotor delays that could eventually affect children’s schooling performance and labour force outcomes.

Trial registration number ISRCTN44149146.

Li L, Luo R, Sylvia S, Medina A, Rozelle S. (2015) The Prevalence of Anemia in Central and Eastern China: Evidence from the China Health and Nutrition Survey. Southeast Asian Journal of Tropical Medicine and Public Health, 46(2), 306–321. Abstract

Although China has experienced rapid economic growth over the past few decades, significant health and nutritional problems remain. Unfortunately, because little work has been done to track basic diseases, such as iron-deficiency anemia, the exact prevalence of these health problems is often unknown. The goals of this paper are to (1) assess the prevalence of anemia in China and (2) to identify individual-, household- and community-based factors that correlate with anemia. We use data from the 2009 wave of the China Health and Nutrition Survey (CHNS), including hemoglobin measurements on 7261 individuals from 170 communities and 7 provinces in Central and Eastern China. Our baseline data show that the overall anemia rate is 13.4% using the WHO’s blood hemoglobin thresholds (1968). This rate implies that in China’s more developed Central and Eastern regions up to 180 million people are anemic. Moreover, certain vulnerable subgroups are disproportionately affected by anemia. Seniors (aged 60 and above) are more likely to be anemic than individuals in younger age cohorts, and females have higher rates of anemia across all age groups (except among children, aged 7 to 14 years). We find a negative correlation between household wealth and anemia status, suggesting that anemia rates might decline as China’s economy continues to grow. On the other hand, we find that anemia rates are slightly higher in migrant households, which by their very nature should be experiencing improved economic status.

Sylvia S, Shi Y, Xue H, Tian X, Wang H, Liu Q, Medina A, Rozelle S. (2015) Survey using Incognito Standardized Patients Shows Poor Quality Care in China’s Rural Clinics. Health Policy and Planning, 30(3), 322–333. Abstract

Over the past decade, China has implemented reforms designed to expand access to health care in rural areas. Little objective evidence exists, however, on the quality of that care. This study reports results from a standardized patient study designed to assess the quality of care delivered by village clinicians in rural China. To measure quality, we recruited individuals from the local community to serve as undercover patients and trained them to present consistent symptoms of two common illnesses (dysentery and angina). Based on 82 covert interactions between the standardized patients and local clinicians, we find that the quality of care is low as measured by adherence to clinical checklists and the rates of correct diagnoses and treatments. Further analysis suggests that quality is most strongly correlated with provider qualifications. Our results highlight the need for policy action to address the low quality of care delivered by grassroots providers. 

Luo R, Shi Y, Zhou H, Yue A, Zhang L, Sylvia S, Medina A, Rozelle S. (2014) Anemia and Feeding Practices among Infants in Rural Shaanxi Province in China. Nutrients, 6, 5975–5991. Abstract

Anemia is one of the most prevalent public health problems among infants and iron deficiency anemia has been related to many adverse consequences. The overall goal of this study is to examine the prevalence of anemia among infants in poor rural China and to identify correlates of anemia. In April 2013, we randomly sampled 948 infants aged 6–11 months living in 351 villages across 174 townships in nationally-designated poverty counties in rural areas of southern Shaanxi Province, China. Infants were administered a finger prick blood test for hemoglobin (Hb). Anthropometric measurement and household survey of demographic characteristics and feeding practices were conducted in the survey. We found that 54.3% of 6–11 month old infants in poor rural China are anemic, and 24.3% of sample infants suffer from moderate or severe anemia. We find that children still breastfed over 6 months of age had lower Hb concentrations and higher anemia prevalence than their non-breastfeeding counterparts (p < 0.01), and that children who had ever been formula-fed had significantly higher Hb concentrations and lower anemia prevalence than their non-formula-fed counterparts (p < 0.01). The results suggest the importance of iron supplementation or home fortification while breastfeeding. 

Miller G, Luo R, Zhang L, Sylvia S, Shi Y, Foo P, Zhao Q, Martorell R, Medina A, Rozelle S. (2012) Effectiveness of Provider Incentives for Anaemia Reduction in Rural China: a Cluster Randomised Trial. BMJ, 345. Abstract

Objectives To test the impact of provider performance pay for anaemia reduction in rural China.

Design A cluster randomised trial of information, subsidies, and incentives for school principals to reduce anaemia among their students. Enumerators and study participants were not informed of study arm assignment.

Setting 72 randomly selected rural primary schools across northwest China.

Participants 3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study.

Interventions Sample schools were randomly assigned to a control group, with no intervention, or one of three treatment arms: (a) an information arm, in which principals received information about anaemia; (b) a subsidy arm, in which principals received information and unconditional subsidies; and (c) an incentive arm, in which principals received information, subsidies, and financial incentives for reducing anaemia among students. Twenty seven schools were assigned to the control arm (1816 students at baseline, 1623 at end point), 15 were assigned to the information arm (659 students at baseline, 596 at end point), 15 to the subsidy arm (726 students at baseline, 667 at end point), and 15 to the incentive arm (743 students at baseline, 667 at end point).

Main outcome measures Student haemoglobin concentrations.

Results Mean student haemoglobin concentration rose by 1.5 g/L (95% CI –1.1 to 4.1) in information schools, 0.8 g/L (–1.8 to 3.3) in subsidy schools, and 2.4 g/L (0 to 4.9) in incentive schools compared with the control group. This increase in haemoglobin corresponded to a reduction in prevalence of anaemia (Hb <115 g/L) of 24% in incentive schools. Interactions with pre-existing incentives for principals to achieve good academic performance led to substantially larger gains in the information and incentive arms: when combined with incentives for good academic performance, associated effects on student haemoglobin concentration were 9.8 g/L (4.1 to 15.5) larger in information schools and 8.6 g/L (2.1 to 15.1) larger in incentive schools.

Conclusions Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical.

Trial registration number ISRCTN76158086.