Structural Determinants of Child Health in Rural China: The Challenge of Creating Health Equity

Over the past two decades, the literature has shown a clear gradient between child health and wealth. The same health–wealth gradient is also observed among children in China, with a large gap in health between rural and urban children. However, there are still unanswered questions about the main causes of China’s rural–urban child health inequality. This paper aims to review the major factors that have led to the relatively poor levels of health among China’s rural children. In addition to the direct income effect on children’s health, children in rural areas face disadvantages compared with their urban counterparts from the beginning of life: Prenatal care and infant health outcomes are worse in rural areas; rural caregivers have poor health outcomes and lack knowledge and support to provide adequate nurturing care to young children; there are large disparities in access to quality health care between rural and urban areas; and rural families are more likely to lack access to clean water and sanitation. In order to inform policies that improve health outcomes for the poor, there is a critical need for research that identifies the causal drivers of health outcomes among children. Strengthening the pediatric training and workforce in rural areas is essential to delivering quality health care for rural children. Other potential interventions include addressing the health needs of mothers and grandparent caregivers, improving parenting knowledge and nurturing care, improving access to clean water and sanitation for remote families, and most importantly, targeting poverty itself

Depressive and Anxiety Symptoms among Children and Adolescents in Rural China: A Large-Scale Epidemiological Study

Although children living in low- and middle-income countries (LMICs) account for 90% of the global population of children, depression, and anxiety among children in LMICs have been understudied. This study examines the prevalence of depression and anxiety and their associations with biological and psychosocial factors among children across China, with a focus on rural areas. We conducted a large-scale epidemiological study of depression and anxiety among 53,421 elementary and junior high school-aged children across China. The results show that 20% are at risk for depression, 6% are at risk for generalized anxiety, and 68% are at risk for at least one type of anxiety. Girls and junior high school students show a higher risk for both depression and anxiety symptoms, while socioeconomic status has varying associations to depression and anxiety symptoms. Our results also show consistent correlations between depression and anxiety symptoms and standard math test scores. These findings underscore the importance of identification, prevention, and treatment of youth depression and anxiety in underdeveloped areas. As China constitutes 15% of the global population of children under age 18, this study offers valuable information to the field of global mental health

The know-do gap in quality of health for chronic non-communicable diseases in rural China

Proper management of non-communicable diseases (NCDs) is a severe challenge to China's rural health system. This study investigates what influences the poor medical treatment of NCDs (diabetes and angina) by evaluating the “know-do gap” between provider knowledge and practice. To determine whether low levels of provider knowledge low quality of patient care is the primary constraint on the quality of NCDs diagnosis and treatment in rural China. Providers from Village Clinics (VC) and Township Health Centers (THC), and Standardized Patients (SP) were selected by a multi-stage random sampling method. Clinical vignettes were administered to 306 providers from 103 VCs and 50 THCs in rural Sichuan Province. SPs presented diabetes symptoms completed 97 interactions with providers in 46 VCs and 51 THCs; SPs presented angina symptoms completed 100 interactions with providers in 50 VCs and 50 THCs. Process quality, diagnosis quality, and treatment quality were assessed against national standards for diabetes and angina. Two-tailed T-tests and tests of proportions for continuous outcomes and tests of proportions for binary dependent variables were used to compare vignette and SP results. Differences between vignette and SP data calculated the know-do gap. Regression analyses were used to examine the providers/facility characteristics and knowledge/practice associations. THC providers demonstrated significantly more knowledge in vignettes and better practices in SP visits than VC providers. However, levels of knowledge were low overall: 48.2% of THC providers and 28.2% of VC providers properly diagnosed type 2 diabetes, while 23.8% of THC providers and 14.7% of VC providers properly diagnosed angina. With SPs, 2.1% of THC providers and 6.8% of VC providers correctly diagnosed type 2 diabetes; 25.5% of THC providers and 12.8% of VC providers correctly diagnosed angina. There were significant know-do gaps in diagnosis process quality, diagnosis quality, and treatment quality for diabetes (p < 0.01), and in diagnosis process quality (p < 0.05) and treatment quality for angina (p < 0.01). Providers in rural China display low levels of knowledge when treating diabetes and angina. Despite low knowledge, evidence of the know-do gap indicates that low-quality healthcare is the primary constraint on the quality of NCD diagnosis and treatment in rural China. Our research findings provide a new perspective for the evaluation of the medical quality and a technical basis for the development of new standardized cases in the future

Adherence to micronutrient powder for home fortification of foods among infants and toddlers in rural China: a structural equation modeling approach

Abstract Background The WHO recommends daily use of micronutrient powder for infants and toddlers at risk of micronutrient deficiencies in low-and-middle-income countries. China has established a micronutrient powder distribution program in many rural townships and villages, yet adherence to micronutrient powder remains suboptimal; a little is known about the behavioral inputs that may influence adherence. This study examines direct and indirect behavioral inputs in micronutrient powder adherence among caregivers in rural western China following the Integrated Behavioral Model (IBM) framework. Methods Cross-sectional data were collected from April to May 2019 among 958 caregivers of children aged 6 to 24 months in six counties. Data were collected on micronutrient powder adherence behavior, direct behavioral inputs (knowledge and skills, intention, salience, environmental constraints, and habits), and indirect behavioral inputs (attitudes, perceived social norms, and personal agency). Structural equation modeling (SEM) adjusted for sociodemographic covariates was used to evaluate the IBM framework. Results Mean micronutrient powder adherence in the previous seven days was 53.02%, and only 22.86% of caregivers consistently fed micronutrient powder from the start of micronutrient powder distribution at six months of age. The SEM model revealed small- to medium-sized effects of salience (β = 0.440, P < 0.001), intention (β = 0.374, P < 0.001), knowledge and skills (β = 0.214, P < 0.001), personal agency (st. effect = 0.172, P < 0.001), environmental constraints (β=-0.142, P < 0.001), and caregiver generation (β = 0.119, P < 0.05) on micronutrient powder adherence. Overall, 54.7% of the variance in micronutrient powder adherence was explained by the IBM framework. Salience had the largest impact on micronutrient powder adherence (Cohen’s f 2 = 0.227). Compared to parent caregivers, grandparents had a higher degree of micronutrient powder adherence on average (P < 0.001), and behavioral inputs were consistent among both parent and grandparent caregivers. Conclusion There is a need to improve micronutrient powder adherence among rural caregivers. The IBM framework showed a high degree of explanatory power in predicting micronutrient powder adherence behavior. The findings suggest that increased reminders from doctors regarding micronutrient powder and coaching to improve personal agency in micronutrient powder feeding may increase adherence

The association between micronutrient powder delivery patterns and caregiver feeding behaviors in rural China

Abstract Background High adherence and proper usage of micronutrient powder (MNP) influence child nutritional outcomes, yet few studies explore the role of delivery patterns. This study explores the association between MNP delivery patterns and MNP feeding behaviors among Han and minority caregivers in rural Western China. Methods In August 2019, a total of 1021 caregiver-child pairs were selected through a four-stage cluster sampling process. A cross-sectional survey collected information on caregiver demographics, MNP delivery patterns (channel and frequency), and MNP feeding behaviors (proper usage and adherence). Using logistic regression, we examined which delivery channels and delivery frequencies were associated with proper usage and high adherence. Results The results indicated that minority caregivers had lower levels of proper MNP usage than did Han caregivers (89.2%), with Tibetan caregivers’ reporting the lowest rates of adherence (32.6%). Logistic regression revealed that that township-based channel was significantly correlated with proper usage among Tibetan and Yi caregivers (Odds Ratio, OR = 2.0, p < 0.01; and OR = 3.5, p < 0.001). Overall, the township-based and home-visit channels were significantly correlated with high adherence (OR = 1.7 and OR = 2.3, respectively; p < 0.001); delivery frequency was significantly correlated with high adherence (2 months: OR = 2.2, p < 0.001 and ≤ 1 month: OR = 3.5, p < 0.001) but not correlated with proper usage among the whole sample and individual ethnic groups. Conclusions In conclusion, the study finds evidence of a correlation between MNP delivery channel and both proper usage and high adherence as well as a correlation between MNP delivery frequency and high adherence

Postnatal mental health, breastfeeding beliefs, and breastfeeding practices in rural China.

BACKGROUND: The importance of breastfeeding in low- and middle- income countries is well recognized, yet the importance of postnatal mental health on breastfeeding practices and beliefs in these settings has been understudied. This study investigates the associations between maternal mental health problems, breastfeeding beliefs and breastfeeding practices in rural China. METHODS: Cross-sectional data were collected in November and December 2019 from 742 mothers of infants under 6 months old in rural Sichuan Province, China. Maternal mental health (depression, anxiety, and stress symptoms) was assessed using the Depression, Anxiety, and Stress Scale (short form). Breastfeeding beliefs were assessed using the Iowa Infant Feeding Attitude Scale and Breastfeeding Self-Efficacy Scale (short form). Breastfeeding practices were assessed through a 24-h dietary recall questionnaire. Ordinary least squares regression, multiple logistic regression and heterogeneous effects analyses were used to identify associations between symptoms of mental health problems and breastfeeding outcomes. RESULTS: The average age of sample infants was 2.7 months. Among mothers, 13% showed symptoms of depression, 16% anxiety, and 9% stress. The prevalence of exclusive breastfeeding in the previous 24 h was 38.0%. Depression symptoms were significantly associated with breastfeeding attitude (?= - 1.11, 95% CI: - 2.07, - 0.14) and breastfeeding self-efficacy (?= - 3.19, 95% CI: - 4.93, - 1.45). Anxiety and stress symptoms were significantly associated with breastfeeding self-efficacy (?= - 1.81, 95% CI: - 3.43, - 0.18 and ? = - 2.88, 95% CI: - 4.98, - 0.78, respectively). There were no significant associations between symptoms of mental health problems and exclusive breastfeeding. The heterogeneous effects analyses revealed that less educated mothers with symptoms of stress had lower odds of exclusive breastfeeding than educated mothers without symptoms of stress (OR: 0.53, 95% CI: 0.25,1.10). Mothers of younger infants had higher odds of exclusive breastfeeding than the mother of older infants, regardless of depression, anxiety, or stress symptoms. CONCLUSION: Symptoms of maternal mental health problems are significantly associated with breastfeeding attitude and self-efficacy; however, these symptoms are not associated with breastfeeding practices. Maternal educational level and infant age may play a role in mothers breastfeeding practices. To improve breastfeeding practices, interventions should employ a multi-dimensional approach that focuses on improving maternal mental well-being and considers demographic characteristics

Early Childhood Reading in Rural China and Obstacles to Caregiver Investment in Young Children: A Mixed-Methods Analysis

Studies have shown that nearly half of rural toddlers in China have cognitive delays due to an absence of stimulating parenting practices, such as early childhood reading, during the critical first three years of life. However, few studies have examined the reasons behind these low levels of stimulating parenting, and no studies have sought to identify the factors that limit caregivers from providing effective early childhood reading practices (EECRP). This mixed-methods study investigates the perceptions, prevalence, and correlates of EECRP in rural China, as well as associations with child cognitive development. We use quantitative survey results from 1748 caregiver–child dyads across 100 rural villages/townships in northwestern China and field observation and interview data with 60 caregivers from these same sites. The quantitative results show significantly low rates of EECRP despite positive perceptions of early reading and positive associations between EECRP and cognitive development. The qualitative results suggest that low rates of EECRP in rural China are not due to the inability to access books, financial or time constraints, or the absence of aspirations. Rather, the low rate of book ownership and absence of reading to young children is driven by the insufficient and inaccurate knowledge of EECRP among caregivers, which leads to their delayed, misinformed reading decisions with their young children, ultimately contributing to developmental delays

Variations in the Home Language Environment and Early Language Development in Rural China

The home language environment is critical to early language development and subsequent skills. However, few studies have quantitatively measured the home language environment in low-income, developing settings. This study explores variations in the home language environment and child language skills among households in poor rural villages in northwestern China. Audio recordings were collected for 38 children aged 20–28 months and analyzed using Language Environment Analysis (LENA) software; language skills were measured using the MacArthur–Bates Mandarin Communicative Developmental Inventories expressive vocabulary scale. The results revealed large variability in both child language skills and home language environment measures (adult words, conversational turns, and child vocalizations) with 5- to 6-fold differences between the highest and lowest scores. Despite variation, however, the average number of adult words and conversational turns were lower than found among urban Chinese children. Correlation analyses did not identify significant correlations between demographic characteristics and the home language environment. However, the results do indicate significant correlations between the home language environment and child language skills, with conversational turns showing the strongest correlation. The results point to a need for further research on language engagement and ways to increase parent–child interactions to improve early language development among young children in rural China

Health, economic, and social implications of COVID‐19 for China's rural population

This study examines the effects of local and nationwide COVID‐19 disease control measures on the health and economy of China's rural population. We conducted phone surveys with 726 randomly selected village informants across seven rural Chinese provinces in February 2020. Four villages (0.55%) reported infections, and none reported deaths. Disease control measures had been universally implemented in all sample villages. About 74% of informants reported that villagers with wage‐earning jobs outside the village had stopped working due to workplace closures. A higher percentage of rural individuals could not work due to transportation, housing, and other constraints. Local governments had taken measures to reduce the impact of COVID‐19. Although schools in all surveyed villages were closed, 71% of village informants reported that students were attending classes online. Overall, measures to control COVID‐19 appear to have been successful in limiting disease transmission in rural communities outside the main epidemic area. Rural Chinese citizens, however, have experienced significant economic consequences from the disease control measures