Publications by authors named "Linxiu Zhang"

38 Publications

Determinants of smallholder farmers' choice on mulch film thickness in rural China.

Environ Sci Pollut Res Int 2021 Apr 18. Epub 2021 Apr 18.

Key Laboratory of Ecosystem Network Observation and Modeling, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing, 100101, China.

Agricultural mulch film pollution has become a prevailing concern. Studies have shown that the thickness of mulch film is a key factor affecting mulch film recycling, but research about farmers' choice on mulch film thickness is lacking. Based on survey data from 2025 households in five Chinese provinces in 2018, the Heckman two-stage model was used to analyze the influencing factors of farmers' choice on mulch film thicknesses. Mulch film had been used by 21.98% of the sample households, and 41.47% of the used mulch film did not meet the national thickness standard. The econometric results showed that farmers' product cognition and market factors were the two most important factors, and there was a significant negative correlation with the choice of film thickness. In addition, the choice of mulch film with different thicknesses was affected by household characteristics, subjective norms, and farmland property rights. Strengthening and stabilizing farmland property rights is a long-term mechanism to promote farmers to choose thicker mulch film. In addition to strengthening the production and sale of substandard film supervision, farmers' choice of film thickness should be included in village regulations and other rural grass-roots governance systems, especially in the mechanism design between agricultural farmland protective subsidies and the prevention of mulch film pollution, rather than just considering the recycling itself.
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http://dx.doi.org/10.1007/s11356-021-13866-xDOI Listing
April 2021

Anthropomorphic Strategies Promote Wildlife Conservation through Empathy: The Moderation Role of the Public Epidemic Situation.

Int J Environ Res Public Health 2021 03 30;18(7). Epub 2021 Mar 30.

Key Laboratory of Behavioral Science, Institute of Psychology, Chinese Academy of Sciences, Beijing 100101, China.

The global illegal wildlife trade directly threatens biodiversity and leads to disease outbreaks and epidemics. In order to avoid the loss of endangered species and ensure public health security, it is necessary to intervene in illegal wildlife trade and promote public awareness of the need for wildlife conservation. Anthropomorphism is a basic and common psychological process in humans that plays a crucial role in determining how a person interacts with other non-human agents. Previous research indicates that anthropomorphizing nature entities through metaphors could increase individual behavioral intention of wildlife conservation. However, relatively little is known about the mechanism by which anthropomorphism influences behavioral intention and whether social context affects the effect of anthropomorphism. This research investigated the impact of negative emotions associated with a pandemic situation on the effectiveness of anthropomorphic strategies for wildlife conservation across two experimental studies. Experiment 1 recruited 245 college students online and asked them to read a combination of texts and pictures as anthropomorphic materials. The results indicated that anthropomorphic materials could increase participants' empathy and decrease their wildlife product consumption intention. Experiment 2 recruited 140 college students online and they were required to read the same materials as experiment 1 after watching a video related to epidemics. The results showed that the effect of wildlife anthropomorphization vanished if participants' negative emotion was aroused by the video. The present research provides experimental evidence that anthropomorphic strategies would be useful for boosting public support for wildlife conservation. However, policymakers and conservation organizations must be careful about the negative effects of the pandemic context, as the negative emotions produced by it seems to weaken the effectiveness of anthropomorphic strategies.
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http://dx.doi.org/10.3390/ijerph18073565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8037496PMC
March 2021

Climate change vulnerability assessment for smallholder farmers in China: An extended framework.

J Environ Manage 2020 Dec 7;276:111315. Epub 2020 Sep 7.

Key Laboratory of Ecosystem Network Observation and Modeling, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing, 100101, China; International Ecosystem Management Partnership, United Nations Environment Programme, Beijing, 100101, China.

Climate change brings uncertainty and challenges to achieving sustainable development goals. The dually vulnerable regions in terms of the environment and economy are facing substantial threats from climate change; particularly, smallholder farmers who heavily rely on natural ecosystems in these regions are being the most affected. Paying attention to the vulnerability assessment of these regions is conducive to precisely improving the ability of their people to cope with climate change. This study aimed to construct an extended framework of climate change vulnerability assessment at the household level by combining the Intergovernmental Panel on Climate Change vulnerability assessment framework with the sustainable livelihood framework. Four typical regions with different climatic and geographical conditions in China, including the Inner Mongolia Autonomous Region (marked as AOHAN, representing the type of grassland, similarly hereinafter), Qinghai Province (HYMH, plateau), Yunnan Province (YLNL, mountain), and the Guangxi Zhuang Autonomous Region (NNQZ, coastal zone), were selected to apply the framework. In total, 29 villages from these four regions were selected at random, and 360 face-to-face interviews were conducted in selected villages based on a pretested questionnaire. The results show that AOHAN had the greatest vulnerability, as well as the highest exposure level among the four regions, which was also the major source of differences in vulnerability. Further analysis shows that although the sensitivity and adaptive capacity showed relatively small differences, the sources of sensitivity and adaptation strategies were quite different among the four regions. In terms of sensitivity, YLNL had the highest level of sensitivity in housing, water, and livestock, and AOHAN assumed the highest sensitivity in land. The advantages and disadvantages in terms of adaptive capacity also varied widely among the four regions. More specifically, AOHAN had a balanced adaptive capacity; YLNL largely relied on the advantages in social and human capitals to compensate for the disadvantage in physical capital; and the strengths in physical and financial capitals are the main sources of adaptive capacities for NNQZ and HYMH, respectively. In general, the vulnerability assessment framework proposed in this study provides guidelines for vulnerability assessments at the household level in the face of climate change. In addition, heterogeneous measures to cope with the threats of climate change should be put forward precisely, based on the climatic, geographical and socioeconomic characteristics of each region.
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http://dx.doi.org/10.1016/j.jenvman.2020.111315DOI Listing
December 2020

Conditional cash transfers, uptake of maternal and child health services, and health outcomes in western rural China.

BMC Public Health 2020 Jun 5;20(1):870. Epub 2020 Jun 5.

Freeman Spogli Institute for International Studies, Stanford University, Palo Alto, California, USA.

Background: Empirical evidence suggests that the uptake of maternal and child health (MCH) services is still low in poor rural areas of China. There is concern that this low uptake may detrimentally affect child health outcomes. Previous studies have not yet identified the exact nature of the impact that a conditional cash transfer (CCT) has on the uptake of MCH services and, ultimately, on child health outcomes. The objective of this study is to examine the relationship between CCT, uptake of MCH services, and health outcomes among children in poor rural areas of western China.

Methods: We designated two different sets of villages and households that were used as comparisons against which outcomes of the treated households could be assessed. In 2014, we conducted a large-scale survey of 1522 households in 75 villages (including 25 treatment and 50 comparison) from nine nationally designated poverty counties in two provinces of China. In each village, 21 households were selected based on their eligibility status for the CCT program. Difference-in-difference analyses were used to assess the impact of CCT on outcomes in terms of both intention-to-treat (ITT) and average-treatment-effects-on-the-treated (ATT).

Results: Overall, the uptake of MCH services in the sample households were low, especially in terms of postpartum care visits, early breastfeeding, exclusive breastfeeding, and physical examination of the baby. The uptake of the seven types of MCH services in the CCT treatment villages were significantly higher than that in the comparison villages. The results from both the ITT and ATT analyses showed that the CCT program had a positive, although small, impact on the uptake of MCH services and the knowledge of mothers of MCH health issues. Nonetheless, the CCT program had no noticeable effect on child health outcomes.

Conclusions: The CCT program generated modest improvements in the uptake of MCH services and mothers' knowledge of MCH services in poor rural areas of Western China. These improvements, however, did not translate into substantial improvements in child health outcomes for two potential reasons: poor CCT implementation and the low quality of rural health facilities.
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http://dx.doi.org/10.1186/s12889-020-08996-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275386PMC
June 2020

The Impact of Social Support on the Health of the Rural Elderly in China.

Int J Environ Res Public Health 2020 03 18;17(6). Epub 2020 Mar 18.

Key Laboratory of Ecosystem Network Observation and Modeling, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China.

With the dramatic trend of global aging, the physical and mental health of the rural elderly has attracted significant attention. Social support plays an important role in improving the health of the elderly. However, assessing the impact of social support on the physical and mental health of the elderly is challenging in rural China. This paper analyzes the impact of social support on the physical and mental health of the Chinese rural elderly based on data collected from households and village cadres. Probit, Oprobit, and ordinary least squares (OLS) are used to estimate these effects. The results show that 24.3% of the rural elderly are in bad physical health, and 32.9% of them are depressed. Physical and mental health is worse among the female elderly and among those who are in western provinces. Having pensions, taking care of grandchildren, and communicating with children by telephone are shown to significantly improve the mental health of the rural elderly. The government could promote the mental health of the rural elderly by improving public health services, increasing pensions, providing free mobile phones to elderly people in poverty, and advocating that the younger generation provide emotional support.
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http://dx.doi.org/10.3390/ijerph17062004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7143868PMC
March 2020

Factory employment exposure and human health: Evidence from rural China.

Environ Pollut 2020 Apr 19;259:113619. Epub 2019 Nov 19.

Key Laboratory of Ecosystem Network Observation and Modeling, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China; UN Environment-International Ecosystem Management Partnership (UNEP-IEMP), Beijing 100101, China; University of Chinese Academy of Sciences, Beijing, 100049, China.

Quantitating the health effects of employment history in factories, especially polluting ones, is essential for understanding the benefits or losses of industrialization in rural areas. Using a traced subset of nationwide panel data from 2005 covering five provinces, 101 villages, and 2026 households (collected recently in 2016) and the econometric models, this study estimated the effect of factory employment history on workers' health. The results showed that: the absolute number of factory workers increased from 1998 to 2015, and the proportion of factory workers was 7.68% in 2015; the absolute number and the proportion of farmers decreased from 63.84% in 1998 to 29.06% in 2015. Given that all the respondents live in rural areas, the HlthPlace (the first place the individual went to for their last illness in 2015) was selected as the main dependent variable of interest, and Hlthexp (Healthcare expenditure per person at last illness in 2015) and self-reported health were used as auxiliary dependent variables. The findings revealed that, after controlling the characteristics of individual, household, hospital and area, a one year increase of factory employment history corresponded to a 0.035 level increase in the probability of people choosing high-level hospital (p < 0.01) and a 237.61 yuan increase in healthcare expenditure (p < 0.1). The results also showed the adverse effect of self-reported health on factory employment history (p < 0.01). In addition, the relationship between the farming history and health was evaluated, and the econometric results showed that compared with factory employment history, farming history had opposite impacts on health (p < 0.01). Finally, the robustness check showed that the empirical results were reliable and that the initial results were robust. Generally, this study revealed the effect of overall factory employment on health, which is a useful research supplement to the studies on the health effects of specific pollution exposure.
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http://dx.doi.org/10.1016/j.envpol.2019.113619DOI Listing
April 2020

Synthesis of Sulfur-Selenium Doped Carbon Quantum Dots for Biological Imaging and Scavenging Reactive Oxygen Species.

Sci Rep 2019 12 23;9(1):19651. Epub 2019 Dec 23.

School of Chemistry and Chemical Engineering,Guangdong Pharmaceutical University, Guangdong, China.

The sulfur-selenium doped carbon quantum dots (S,Se-CQDs) were synthesized by one-step through hydrothermal method in this study, which have high fluorescence quantum yield (43%) and advanced ability to scavenge reactive oxygen species (ROS). They were characterized by transmission electron microscope (TEM), nuclear magnetic resonance (NMR), X-ray photoelectron spectroscopy (XPS), fourier transform infrared spectroscopy (FTIR). The results showed that the clearance rate of free radical reached to 40% with 200 μg/mL of S,Se-CQDs. The antioxidant activity of S,Se-CQDs is related to -SH and Se-SH on carbon quantum dots. S,Se-CQDs were able to access to cells which is beneficial to enhance the removal efficiency to ROS. In the biocompatibility experiment, the cell survival rate exceeded 95%, there was little effect on hatching rate, survival rate and heart rate of zebrafish which demonstrated that S,Se-CQDs have an excellent biocompatibility. It prompts that S,Se-CQDs will has proud application prospects in the field of biomedicine.
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http://dx.doi.org/10.1038/s41598-019-55996-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6928214PMC
December 2019

Management principles for heavy metal contaminated farmland based on ecological risk-A case study in the pilot area of Hunan province, China.

Sci Total Environ 2019 Sep 25;684:537-547. Epub 2019 May 25.

Key laboratory of ecosystem network observation and modeling, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China; International Ecosystem Management Partnership, United Nations Environment Programme, Beijing 100101, China.

A pilot project for farmland soil remediation was carried out in the Changsha-Zhuzhou-Xiangtan (CZX) area of Hunan province, China. However, the pilot project focused mainly on the risk of exposure to heavy metals on grain safety, and little attention was paid to the risk to ecosystem quality. The study selected three areas in counties of in the CZX, and focused on five high toxicity heavy metals-Cd (cadmium), Cr (chromium), Pb (lead), As (arsenic), Hg (mercury) to explore the potential ecological risks of the soil. Probabilistic ecological risk assessment (new method) and traditional methods were introduced to quantitatively evaluate the ecological risk. Two target criteria levels (LC/EC/IC and NOEC/LOEC) were employed. Through constructing species sensitivity distribution (SSD) models and joint probability curves (JPC), the predicted no effect concentrations (PNECs) derived from the SSD models were 0.21, 1.57, 3.05, 0.86 and 0.16 mg/kg for Cd, Cr, Pb, As and Hg, respectively. Compared with the ecological risk assessment results of the traditional methods, the new method reached a different conclusion, Cr showed the highest risk, at 84.3%, which signified that there was an 84.3% probability that 5% of the species with their NOEC/LOECs exceeded in County C. Despite differences among the risk assessment approaches, all methods indicated that County C was the most contaminated. The case study signifies that traditional methods underestimated the soil ecological risk of exposure to heavy metals and there should be a strong focus on farmland ecosystem security. At the same time, this study provided a scientific basis for goal-setting in species protection and prioritizing ecosystem protection as a management principle for heavy metal contaminated farmland from the perspective of ecological risk.
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http://dx.doi.org/10.1016/j.scitotenv.2019.05.015DOI Listing
September 2019

The More Educated, the Healthier: Evidence from Rural China.

Int J Environ Res Public Health 2018 12 13;15(12). Epub 2018 Dec 13.

Center for Chinese Agricultural Policy, Institute of Geographic Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing 100101, China.

Education, as an important aspect of human capital, not only affects the economic returns of an individual, but also affects non-economic returns. This paper uses data from the China Family Panel Studies (CFPS) in 2014 and explores the impact of education on the health status of rural residents by using the family fixed-effect model. We find that education can improve the self-reported health status and reduce the possibility of depression of rural residents. We also find that the effect of education on self-reported health status of rural young people more significant than that of middle-aged and old people, but the effect on depression score was weaker than that of middle-aged and old people. Compared with the high-income group, education improved the health of the lowest income group more significantly. Finally, we explore the mechanism of education affecting the health of rural residents from a multi-dimensional perspective.
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http://dx.doi.org/10.3390/ijerph15122848DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6313666PMC
December 2018

Using daily text messages to improve adherence to infant micronutrient powder (MNP) packets in rural western China: A cluster-randomized controlled trial.

PLoS One 2018 19;13(1):e0191549. Epub 2018 Jan 19.

Freeman Spogli Institute for International Studies, Stanford University, Stanford, United States of America.

Objective: To evaluate the effectiveness of daily text messages as a means to improve caregivers' adherence to infant micronutrient powder (MNP) in rural Shaanxi Province of China.

Methodology: 638 infants aged 6-11 months in 234 villages were involved in a cluster-randomized controlled trial (RCT). All caregivers were given free infant MNP packets at baseline in April 2013 and the follow-up survey was in July 2013. We randomly assigned 318 infants in 117 villages to treatment group (receiving daily text message) and 320 infants in the other 117 villages as control group.

Results: On average, daily text messages increased the number of MNP packets fed (marginal effect = 4.63; 95% confidence interval (CI) = 0.16, 9.10). The text message is more likely to increase the consumption of MNP packets if the primary caregiver was the mother (marginal effect = 12.19; 95% CI = 0.69, 23.68). Receiving the text message appears to significantly increase the likelihood of full adherence when the primary caregiver can either check (odds ratio = 2.93; 95% CI = 1.34, 6.40) or knows how to send (odds ratio = 3.26; 95% CI = 1.53, 6.97) text messages.

Conclusion: Daily text messages improved the consumption of infant MNP packets. However, the impact was not large enough to increase the probability of caregivers being fully adherent to the feeding instruction, which is to feed 5-7 packets per week as recommended. In addition, when the mother is the caregiver and when the caregiver can check or knows how to send text messages there is greater adherence by the primary caregivers.

Trial Registration: http://www.isrctn.com/ISRCTN44149146.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0191549PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5774801PMC
February 2018

The effect of a micronutrient powder home fortification program on anemia and cognitive outcomes among young children in rural China: a cluster randomized trial.

BMC Public Health 2017 09 25;17(1):738. Epub 2017 Sep 25.

Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, USA.

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

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

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

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

Trial Registration: ISRCTN44149146 ; prospectively registered on 15th April 2013.
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http://dx.doi.org/10.1186/s12889-017-4755-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613507PMC
September 2017

More Poop, More Precision: Improving Epidemiologic Surveillance of Soil-Transmitted Helminths with Multiple Fecal Sampling using the Kato-Katz Technique.

Am J Trop Med Hyg 2017 Sep 19;97(3):870-875. Epub 2017 Jul 19.

National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China.

Soil-transmitted helminths, or parasitic intestinal worms, are among the most prevalent and geographically widespread parasitic infections in the world. Accurate diagnosis and quantification of helminth infection are critical for informing and assessing deworming interventions. The Kato-Katz thick smear technique, the most widely used laboratory method to quantitatively assess infection prevalence and infection intensity of helminths, has often been compared with other methods. Only a few small-scale studies, however, have considered ways to improve its diagnostic sensitivity. This study, conducted among 4,985 school-age children in an area of rural China with moderate prevalence of helminth infection, examines the effect on diagnostic sensitivity of the Kato-Katz technique when two fecal samples collected over consecutive days are examined and compared with a single sample. A secondary aim was to consider cost-effectiveness by calculating an estimate of the marginal costs of obtaining an additional fecal sample. Our findings show that analysis of an additional fecal sample led to increases of 23%, 26%, and 100% for , and hookworm prevalence, respectively. The cost of collecting a second fecal sample for our study population was approximately USD4.60 per fecal sample. Overall, the findings suggest that investing 31% more capital in fecal sample collection prevents an underestimation of prevalence by about 21%, and hence improves the diagnostic sensitivity of the Kato-Katz method. Especially in areas with light-intensity infections of soil-transmitted helminths and limited public health resources, more accurate epidemiological surveillance using multiple fecal samples will critically inform decisions regarding infection control and prevention.
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http://dx.doi.org/10.4269/ajtmh.16-0728DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590569PMC
September 2017

Effect of Deworming on Indices of Health, Cognition, and Education Among Schoolchildren in Rural China: A Cluster-Randomized Controlled Trial.

Am J Trop Med Hyg 2017 Jun;96(6):1478-1489

National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China.

AbstractSoil-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.
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http://dx.doi.org/10.4269/ajtmh.16-0354DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5462590PMC
June 2017

The gender gap among school children in poor rural areas of western China: evidence from a multi-province dataset.

Int J Equity Health 2016 Sep 29;15(1):162. Epub 2016 Sep 29.

Freeman Spogli Institute for International Studies, Stanford University, Stanford, USA.

Background: The gender gap remains a major impediment in the path towards equality and it is especially wide in low-income countries. Up to the early 2000s, many studies documented extensive inequalities in China: girls had poorer health, less nutrition and less education than their male counterparts. The goal of this study is to examine whether the gender gap persists, given that China is now making the transition into the ranks of upper-middle income countries. We consider educational outcomes, mental and physical health status, as well as non-cognitive outcomes.

Methods: We draw on a dataset containing 69,565 observations constructed by combining data from 7 different school-level surveys spanning 5 provinces. The surveys were all conducted by the authors between 2008 and 2013 using uniform survey instruments and data collection protocols in randomly selected schools across western provinces in rural China. The sample children range in age from 9 to 14 years (with 79 % of the sample being aged 10 to 12). Our analysis compares rural girls with rural boys in terms of 13 different indicators.

Results: With the exception of anemia rates, the health outcomes of girls are equal to those of boys. Girls and boys are statistically identical in terms of weight-for-age, height-for-age, and prevalence of intestinal worm infections. Girls performed better than boys on five of six cognitive and educational performance indicators. Girls performed worse than boys on all mental health indicators. All estimates are robust to the inclusion of different age ranges, controlling for the level of household assets, ethnic minority status, as well as the addition of provincial dummies.

Conclusions: Our findings suggest that with the exception of non-cognitive outcomes, anemia and standardized math test scores, the gender gap in our study areas in China appears to be diminishing.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5041561PMC
http://dx.doi.org/10.1186/s12939-016-0442-5DOI Listing
September 2016

Impact of Text Message Reminders on Caregivers' Adherence to a Home Fortification Program Against Child Anemia in Rural Western China: A Cluster-Randomized Controlled Trial.

Am J Public Health 2016 07 14;106(7):1256-62. Epub 2016 Apr 14.

Huan Zhou and Shuai Sun are with the Department of Health and Social Behavior, West China School of Public Health, Sichuan University, Chengdu, Sichuan, China. Renfu Luo is with the Center for Chinese Agricultural Policy, School of Advanced Agricultural Sciences, Peking University, Beijing, China. Sean Sylvia is with the School of Economics, Renmin University of China, Beijing. Ai Yue and Yaojiang Shi are with the Center for Experimental Economics in Education (CEEE), Shaanxi Normal University, Shaanxi, China. Linxiu Zhang is with the Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing. Alexis Medina and Scott Rozelle are with the Freeman Spogli Institute for International Studies, Stanford University, Stanford, CA.

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.
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http://dx.doi.org/10.2105/AJPH.2016.303140DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4984765PMC
July 2016

Nutritional Deficiencies, the Absence of Information and Caregiver Shortcomings: A Qualitative Analysis of Infant Feeding Practices in Rural China.

PLoS One 2016 13;11(4):e0153385. Epub 2016 Apr 13.

Rural Education Action Program, Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, 94305, United States of America.

Background And Objectives: Development during the first two years of life is critical and has a lasting impact on a child's health. Poor infant and child nutrition can lead to deficiencies in essential micronutrients, which may cause a weakened immune system and lasting effects on children's growth and development. Recent studies in rural Shaanxi Province found an anemia prevalence of 54.3% among rural children aged six to twelve months. While new large-scale, quantitative research has begun to catalogue the extent of child malnutrition and anemia, no effort has yet been made to look more closely at the potential reasons for rural children's nutritional deficiencies through qualitative analysis. This study aims to elucidate some of the fundamental causes of poor complementary feeding practices that may lead to anemia among children in rural Shaanxi Province, China.

Methodology: We interviewed sixty caregivers participating in a large survey on child health and nutrition. We conducted three waves of interviews with children's primary caregivers in seventeen rural villages within four nationally-designated poverty counties in the southern part of Shaanxi Province.

Results: The qualitative analysis reveals that poor complementary feeding practices are common across our sample. Information gathered from our interviews suggests that complementary feeding practices are impeded by two constraints: absence of understanding topics related to infant health and nutrition under caregivers, as well as inadequate sources of information on these topics. Poverty does not appear to constrain child feeding practices.

Conclusion: Our results uncover lack of proper knowledge on infant and child nutrition among rural caregivers in China. This situation causes them to fail incorporating micronutrient rich foods in their children's diet. Age-appropriate complementary feeding can stimulate children's physical and cognitive development, but in its absence it leads to iron-deficiency anemia. We suggest that steps be taken to educate caregivers to improve complementary feeding of their infants and children.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0153385PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4830571PMC
September 2016

China's Left-Behind Children: Impact Of Parental Migration On Health, Nutrition, And Educational Outcomes.

Health Aff (Millwood) 2015 Nov;34(11):1964-71

Scott Rozelle is a professor of economics at the Freeman Spogli Institute for International Studies, Stanford University.

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.
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http://dx.doi.org/10.1377/hlthaff.2015.0150DOI Listing
November 2015

Correlation Between New Cooperative Medical Scheme Policy Design and Catastrophic Medical Payment: Evidence From 25 Counties in Rural China.

Asia Pac J Public Health 2016 Jan 28;28(1):26-38. Epub 2015 Oct 28.

School of Governance, Nanjing University, Nanjing, China National Health and Family Planning Commission, Beijing, China.

Few studies have examined the association between the New Cooperative Medical Scheme (NCMS) policy design and its achievement of providing financial protection to rural residents. This study collected data on NCMS policy design and health care spending from 25 counties and rural households in their catchment areas. It shows that on average, NCMS has a growing but small effect on the reduction of catastrophic medical payment (CMP) incidence. If outpatient spending can be reimbursed from an NCMS pooled account, the incidence of CMP before a reimbursement and that after a reimbursement will be reduced. Higher nominal reimbursement rate for inpatient spending at provincial hospitals is correlated with higher incidence of CMP before a reimbursement. Higher ceiling for annual reimbursement from NCMS is associated with lower incidence of CMP after a reimbursement. Thus, NCMS policy design can be improved to strengthen its effects on the reduction of CMP incidence.
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http://dx.doi.org/10.1177/1010539515612907DOI Listing
January 2016

AN INVESTIGATION OF VISION PROBLEMS AND THE VISION CARE SYSTEM IN RURAL CHINA.

Southeast Asian J Trop Med Public Health 2014 Nov;45(6):1464-73

This paper examines the prevalence of vision problems and the accessibility to and quality of vision care in rural China. We obtained data from 4 sources: 1) the National Rural Vision Care Survey; 2) the Private Optometrists Survey; 3) the County Hospital Eye Care Survey; and 4) the Rural School Vision Care Survey. The data from each of the surveys were collected by the authors during 2012. Thirty-three percent of the rural population surveyed self-reported vision problems. Twenty-two percent of subjects surveyed had ever had a vision exam. Among those who self-reported having vision problems, 34% did not wear eyeglasses. Fifty-four percent of those with vision problems who had eyeglasses did not have a vision exam prior to receiving glasses. However, having a vision exam did not always guarantee access to quality vision care. Four channels of vision care service were assessed. The school vision examination program did not increase the usage rate of eyeglasses. Each county-hospital was staffed with three eye-doctors having one year of education beyond high school, serving more than 400,000 residents. Private optometrists often had low levels of education and professional certification. In conclusion, our findings shows that the vision care system in rural China is inadequate and ineffective in meeting the needs of the rural population sampled.
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November 2014

Micronutrient deficiencies and developmental delays among infants: evidence from a cross-sectional survey in rural China.

BMJ Open 2015 Oct 5;5(10):e008400. Epub 2015 Oct 5.

Rural Education Action Program, Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, USA.

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.
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http://dx.doi.org/10.1136/bmjopen-2015-008400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4611485PMC
October 2015

Population Prevalence of Need for Spectacles and Spectacle Ownership Among Urban Migrant Children in Eastern China.

JAMA Ophthalmol 2015 Dec;133(12):1399-406

Zhongshan Ophthalmic Center, State Key Laboratory of Ophthalmology, Division of Preventive Ophthalmology, Sun Yat-sen University, Guangzhou, China11Translational Research for Equitable Eyecare, Queen's University Belfast, Belfast, Northern Ireland12Orbis.

Importance: The number of urban migrants in China is 300 million and is increasing rapidly in response to government policies. Urban migrants have poor access to health care, but little is known about rates of correction of refractive error among migrant children. This is of particular significance in light of recent evidence demonstrating the educational impact of providing children with spectacles.

Objective: To measure prevalence of spectacle need and ownership among Chinese migrant children.

Design, Setting, And Participants: Population-based, cross-sectional study among children who failed vision testing (uncorrected visual acuity ≤6/12 in either eye) between September 15 and 30, 2013, at 94 randomly selected primary schools in predominantly migrant communities in Shanghai, Suzhou, and Wuxi, China.

Main Outcomes And Measures: Refractive error by cycloplegic refraction; spectacle ownership, defined as producing glasses at school, having been told to bring them; and needing glasses, defined as uncorrected visual acuity of 6/12 or less correctable to greater than 6/12 in either eye, with myopia of -0.5 diopters (D) or less, hyperopia of +2.0 D or greater, or astigmatism of 0.75 D or greater in both eyes.

Results: Among 4409 children, 4376 (99.3%) completed vision screening (mean [SD] age, 11.0 [0.81] years; 55.3% boys; 4225 [96.5%] migrant and 151 [3.5%] local). Among 1204 children failing vision testing (total, 27.5%; 1147 migrant children [27.1%] vs 57 local children [37.7%]; P = .003), 850 (70.6%) completed refraction. Spectacle ownership in migrant children needing glasses (147 of 640 children [23.0%]) was less than among local children (12 of 34 children [35.3%]) (odds ratio = 0.55; 95% CI, 0.32-0.95; P = .03). Having uncorrected visual acuity less than 6/18 in both eyes was associated positively with baseline spectacle ownership (odds ratio = 5.73; 95% CI, 3.81-8.62; P < .001), but parental education and family wealth were not.

Conclusions And Relevance: Among urban migrant children, there was a high prevalence of need for spectacles and a very low rate of spectacle ownership. Spectacle distribution programs are needed specifically targeting migrant children.
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http://dx.doi.org/10.1001/jamaophthalmol.2015.3513DOI Listing
December 2015

Impact of Free Glasses and a Teacher Incentive on Children's Use of Eyeglasses: A Cluster-Randomized Controlled Trial.

Am J Ophthalmol 2015 Nov 12;160(5):889-896.e1. Epub 2015 Aug 12.

State Key Laboratory of Ophthalmology and Division of Preventive Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangzhou, China; ORBIS International, New York, New York; Queen's University Belfast, Belfast, United Kingdom. Electronic address:

Purpose: To study the effect of free glasses combined with teacher incentives on in-school glasses wear among Chinese urban migrant children.

Design: Cluster-randomized controlled trial.

Methods: Children with visual acuity (VA) ≤6/12 in either eye owing to refractive error in 94 randomly chosen primary schools underwent randomization by school to receive free glasses, education on their use, and a teacher incentive (Intervention), or glasses prescriptions only (Control). Intervention group teachers received a tablet computer if ≥80% of children given glasses wore them during unannounced visits 6 weeks and 6 months (main outcome) after intervention.

Results: Among 4376 children, 728 (16.7%, mean age 10.9 years, 51.0% boys) met enrollment criteria and were randomly allocated, 358 (49.2%, 47 schools) to Intervention and 370 (50.8%, 47 schools) to Control. Among these, 693 children (95.2%) completed the study and underwent analysis. Spectacle wear was significantly higher at 6 months among Intervention children (Observed [main outcome]: 68.3% vs 23.9%, adjusted odds ratio [OR] = 11.5, 95% confidence interval [CI] 5.91-22.5, P < .001; Self-reported: 90.6% vs 32.1%, OR = 43.7, 95% CI = 21.7-88.5, P < .001). Other predictors of observed wear at 6 months included baseline spectacle wear (P < .001), uncorrected VA <6/18 (P = .01), and parental spectacle wear (P = .02). The 6-month observed wear rate was only 41% among similar-aged children provided free glasses in our previous trial without teacher incentives.

Conclusions: Free spectacles and teacher incentives maintain classroom wear in the large majority of children needing glasses over a school year. Low wear among Control children demonstrates the need for interventions.
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http://dx.doi.org/10.1016/j.ajo.2015.08.006DOI Listing
November 2015

Intended and unintended consequences of China's zero markup drug policy.

Health Aff (Millwood) 2015 Aug;34(8):1391-8

Scott Rozelle is the Helen F. Farnsworth Senior Research Fellow at the Freeman Spogli Institute for International Studies and codirector of the Rural Education Action Program, both at Stanford University.

Since economic liberalization in the late 1970s, China's health care providers have grown heavily reliant on revenue from drugs, which they both prescribe and sell. To curb abuse and to promote the availability, safety, and appropriate use of essential drugs, China introduced its national essential drug list in 2009 and implemented a zero markup policy designed to decouple provider compensation from drug prescription and sales. We collected and analyzed representative data from China's township health centers and their catchment-area populations both before and after the reform. We found large reductions in drug revenue, as intended by policy makers. However, we also found a doubling of inpatient care that appeared to be driven by supply, instead of demand. Thus, the reform had an important unintended consequence: China's health care providers have sought new, potentially inappropriate, forms of revenue.
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http://dx.doi.org/10.1377/hlthaff.2014.1114DOI Listing
August 2015

Soil-Transmitted Helminths in Southwestern China: A Cross-Sectional Study of Links to Cognitive Ability, Nutrition, and School Performance among Children.

PLoS Negl Trop Dis 2015 25;9(6):e0003877. Epub 2015 Jun 25.

National Institute of Parasitic Diseases, Chinese Center for Disease Control and Prevention, Shanghai, China.

Background: Empirical evidence suggests that the prevalence of soil-transmitted helminth (STH) infections in remote and poor rural areas is still high among children, the most vulnerable to infection. There is concern that STH infections may detrimentally affect children's healthy development, including their cognitive ability, nutritional status, and school performance. Medical studies have not yet identified the exact nature of the impact STH infections have on children. The objective of this study is to examine the relationship between STH infections and developmental outcomes among a primary school-aged population in rural China.

Methodology/principal Findings: We conducted a large-scale survey in Guizhou province in southwest China in May 2013. A total of 2,179 children aged 9-11 years living in seven nationally-designated poverty counties in rural China served as our study sample. Overall, 42 percent of the sample's elementary school-aged children were infected with one or more of the three types of STH--Ascaris lumbricoides (ascaris), Trichuris trichuria (whipworm) and the hookworms Ancylostoma duodenale or Necator americanus. After controlling for socioeconomic status, we observed that infection with one or more STHs is associated with worse cognitive ability, worse nutritional status, and worse school performance than no infection. This study also presents evidence that children with Trichuris infection, either infection with Trichuris only or co-infected with Trichuris and Ascaris, experience worse cognitive, nutritional and schooling outcomes than their uninfected peers or children infected with only Ascaris.

Conclusions/significance: We find that STH infection still poses a significant health challenge among children living in poor, rural, ethnic areas of southwest China. Given the important linkages we find between STH infection and a number of important child health and educational outcomes, we believe that our results will contribute positively to the debate surrounding the recent Cochrane report.
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http://dx.doi.org/10.1371/journal.pntd.0003877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4481344PMC
May 2016

Gut instincts: knowledge, attitudes, and practices regarding soil-transmitted helminths in rural China.

PLoS Negl Trop Dis 2015 Mar 25;9(3):e0003643. Epub 2015 Mar 25.

Rural Education Action Program, Freeman Spogli Institute for International Studies, Stanford University, Stanford, California, United States of America.

Background: Soil-transmitted helminth (STH) infections affect more than two out of every five schoolchildren in the poorest regions of rural China, an alarmingly high prevalence rate given the low cost and wide availability of safe and effective deworming treatment. Understanding of local knowledge, attitudes, and practices regarding STH infection in rural China has until now, been sparse, although such information is critical for prevention and control initiatives.

Methodology/principal Findings: This study aims to elucidate the structural and sociocultural factors that underlie high STH infection rates as well as explain why deworming treatment is rarely sought for children. In-depth, qualitative interviews were conducted in six rural villages in Guizhou Province; participants included schoolchildren, children's parents and grandparents, and village doctors. Data analysis exposed three predominant reasons for high STH prevalence: (1) lack of awareness and skepticism about the high prevalence of STH infection, (2) local myths about STH infection and deworming treatment, and (3) poor quality of village health care.

Conclusions/significance: The findings from this study reveal reasons for why deworming treatment is not sought, and inform specific recommendations for a deworming intervention that can more effectively address underlying barriers to deworming in areas of persistently high STH infection rates. The main barrier to seeking STH treatment is not availability or cost of the drugs, but rather the lack of impetus to seek the drugs. A comprehensive nationwide deworming program in China should involve annual provision of free deworming treatment in village clinics or schools, distribution of culturally appropriate educational materials to inform children and families about STH infection, and improvement of the quality of health care delivered by village clinicians.
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http://dx.doi.org/10.1371/journal.pntd.0003643DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4373855PMC
March 2015

Anemia and feeding practices among infants in rural Shaanxi Province in China.

Nutrients 2014 Dec 22;6(12):5975-91. Epub 2014 Dec 22.

Freeman Spogli Institute for International Studies, Stanford University, 616 Serra Street, Stanford, CA 94305, USA.

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.
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http://dx.doi.org/10.3390/nu6125975DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4277010PMC
December 2014

Multiple micronutrient supplementation reduces anemia and anxiety in rural China's elementary school children.

J Nutr 2013 May 20;143(5):640-7. Epub 2013 Mar 20.

Center for Chinese Agricultural Policy, Institute of Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing, China.

Despite growing wealth and a strengthening government commitment to improve livelihoods and welfare, many students across rural China have inadequate access to micronutrient-rich diets. Poor diets can lead to nutritional problems, such as iron-deficiency anemia, that can adversely affect health, attention, learning, and mental health. The overall goal of this paper is to assess the impact of multiple micronutrient supplementation (MMS) on anemia and anxiety among students in poor areas of rural China. To achieve this goal, we conducted a randomized controlled trial in 54 randomly chosen elementary schools in 8 of the poorest counties in Shaanxi Province in Northwest China. Study participants were 2730 fourth-grade students, mostly aged 10-12 y. Schools were randomly assigned to 1 of 2 groups: a control group that received no intervention and an intervention group that received a daily MMS with 5 mg of iron (ferrous sulfate) for 5 mo. Our primary outcome measures were hemoglobin (Hb) concentrations (assessed by HemoCue 201+ technology), anemia prevalence (defined as Hb) concentrations ≤120 g/L), and anxiety (using a written mental health test). The results showed that 42.4% of students were anemic at baseline. The Hb concentration was 121.7 ± 10.7 g/L in the treatment group and 123.4 ± 11.4 g/L in the control group. MMS increased Hb concentrations by 1.7 g/L ± 0.15 and reduced anemia rates by 7.0 percentage points (P < 0.05). Anxiety was reduced by 0.30 SDs (P < 0.01). MMS reduced both anemia and anxiety. Our results should encourage further research on the linkages between nutrition and mental health in a development context.
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http://dx.doi.org/10.3945/jn.112.171959DOI Listing
May 2013

Soil-transmitted helminth infections and correlated risk factors in preschool and school-aged children in rural Southwest China.

PLoS One 2012 27;7(9):e45939. Epub 2012 Sep 27.

Center for Chinese Agricultural Policy, Institute for Geographical Sciences and Natural Resources Research, Chinese Academy of Sciences, Beijing, China.

We conducted a survey of 1707 children in 141 impoverished rural areas of Guizhou and Sichuan Provinces in Southwest China. Kato-Katz smear testing of stool samples elucidated the prevalence of ascariasis, trichuriasis and hookworm infections in pre-school and school aged children. Demographic, hygiene, household and anthropometric data were collected to better understand risks for infection in this population. 21.2 percent of pre-school children and 22.9 percent of school aged children were infected with at least one of the three types of STH. In Guizhou, 33.9 percent of pre-school children were infected, as were 40.1 percent of school aged children. In Sichuan, these numbers were 9.7 percent and 6.6 percent, respectively. Number of siblings, maternal education, consumption of uncooked meat, consumption of unboiled water, and livestock ownership all correlated significantly with STH infection. Through decomposition analysis, we determined that these correlates made up 26.7 percent of the difference in STH infection between the two provinces. Multivariate analysis showed that STH infection is associated with significantly lower weight-for-age and height-for-age z-scores; moreover, older children infected with STHs lag further behind on the international growth scales than younger children.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0045939PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3459941PMC
March 2013