Bio


Alexis Medina has been researching the economics of social issues in China for over ten years. She has extensive experience in international program management, including leading survey teams in rural China, overseeing the design and development of field projects, and coordinating data collection and analysis. Her research interests center on the intersection of health and education in rural China. Alexis speaks fluent Mandarin, and holds a Master’s in East Asian Studies from Yale University.

All Publications


  • Passive parenting and its Association with Early Child Development EARLY CHILD DEVELOPMENT AND CARE Luo, R., Jia, F., Yue, A., Zhang, L., Lyu, Q., Shi, Y., Yang, M., Medina, A., Kotb, S., Rozelle, S. 2019; 189 (10): 1709–23
  • Use of maternal health services among women in the ethnic rural areas of western China. BMC health services research Wu, Y., Zhou, H., Wang, Q., Cao, M., Medina, A., Rozelle, S. 2019; 19 (1): 179

    Abstract

    BACKGROUND: The use of maternal health services can markedly promote the maternal health and safety, but there has been a low utilization rate in the ethnic rural areas of western China. Furthermore, the correlated factors have not been well studied. This study aims to assess factors related to the use of maternal health services among women in these areas.METHODS: A cross-sectional study of 68 villages in China's western Sichuan province was conducted in September 2014. All qualifying women from each sample village were involved. A structured questionnaire was administrated in households through face-to-face interviews by trained enumerators to obtain information of use of maternal health services and related factors. Structural equation modeling (SEM) was used to evaluate the direct and indirect relationships between use of maternal health services and correlated factors.RESULTS: A total of 760 women from 68 villages were enrolled. The proportion of antenatal care (ANC), hospital delivery and postpartum visits were 68.94, 48.29 and 28.42% respectively. The SEM analysis demonstrated that social economic status (SES) (beta=-0.75, beta<0.01), ANC (beta=0.13, beta<0.01), and time from home to the nearest hospital (beta=-0.09, beta<0.05), were positively correlated to hospital delivery and postpartum care visits, while maternal care knowledge and perceived quality of hospital care did not have direct correlation. For ANC, SES (beta=-0.36, beta<0.01), time from home to the nearest hospital (beta=-0.13, beta<0.05), knowledge on maternal care (beta=0.12, beta<0.01) and perceived quality of hospital care (beta=0.10, beta<0.01) were all directly correlated factors. Treating ANC as an intermediate variable showed the indirect relationship that perceived quality of hospital care (beta=0.01, beta<0.01) and maternal care knowledge (beta=0.02, beta<0.01) had with hospital delivery and postpartum care rates.CONCLUSIONS: Use of maternal health services is low among women in ethnic rural areas. ANC has important direct and intermediate effects on subsequent use of hospital delivery and postpartum care. Improving ANC behavior should be a priority of maternal health care reforms. Given the long travel times for these women, reforms must also prioritize breaking down practical barriers that prevent this population from accessing care.

    View details for PubMedID 30890133

  • Structural Equation Modeling (SEM) of Cysticercosis in School-Aged Children in Tibetan Rural Farming Areas of Western China: Implications for Intervention Planning. International journal of environmental research and public health Zhou, H., Wang, Q., Zhou, J., Li, T., Medina, A., Felt, S. A., Rozelle, S., Openshaw, J. J. 2019; 16 (5)

    Abstract

    Neurocysticercosis (NCC) significantly contributes to morbidity in developing countries. We recently published a study of prevalence and risk factors in school-aged children in three mountainous areas in Sichuan province of western China. Using structural equation modeling (SEM) on data from that study to guide intervention planning, here we examine risk factors grouped into three broad interventional categories: sociodemographics, human behavior, and sources of pork and pig husbandry. Because neuroimaging is not easily available, using SEM allows for the use of multiple observed variables (serological tests and symptoms) to represent probable NCC cases. Data collected from 2608 students was included in this analysis. Within this group, seroprevalence of cysticercosis IgG antibodies was 5.4%. SEM results showed that sociodemographic factors (beta = 0.33, p < 0.05), sources of pork and pig husbandry (beta = 0.26, p < 0.001), and behavioral factors (beta = 0.33, p < 0.05) were all directly related to probable NCC in school-aged children. Sociodemographic factors affected probable NCC indirectly via sources of pork and pig husbandry factors (beta = 0.07, p < 0.001) and behavioral variables (beta = 0.07, p < 0.001). Both sociodemographic factors (beta = 0.07, p < 0.05) and sources of pork and pig husbandry factors (beta = 0.10, p < 0.01) affected probable NCC indirectly via behavioral variables. Because behavioral variables not only had a large direct effect but also served as a critical bridge to strengthen the effect of sociodemographics and sources of pork and pig husbandry on probable NCC, our findings suggest that interventions targeting behavioral factors may be the most effective in reducing disease.

    View details for PubMedID 30836642

  • Breastfeeding and the Risk of Illness among Young Children in Rural China. International journal of environmental research and public health Li, S., Yue, A., Abbey, C., Medina, A., Shi, Y. 2019; 16 (1)

    Abstract

    Poor rural areas in China exhibit the country's highest rates of child mortality, often stemming from preventable health conditions such as diarrhea and respiratory infection. In this study, we investigate the association between breastfeeding and disease among children aged 6⁻24 months in poor rural counties in China. To do this, we conducted a longitudinal, quantitative analysis of socioeconomic demographics, health outcomes, and breastfeeding practices for 1802 child⁻caregiver dyads across 11 nationally designated poverty counties in southern Shaanxi Province in 2013⁻2014. We found low rates of continued breastfeeding that decreased as children developed: from 58.2% at 6⁻12 months, to 21.6% at 12⁻18 months, and finally to 5.2% at 18⁻24 months. These suboptimal rates are lower than all but one other country in the Asia-Pacific region. We further found that only 18.3% of children 6⁻12 months old met the World Health Organization (WHO)-recommended threshold for minimum dietary diversity, defined as consuming four or more of seven specific food groups. Breastfeeding was strongly associated with lower rates of both diarrhea and cough in bivariate and multivariate analyses. As the first analysis to use longitudinal data to examine the relationship between continued breastfeeding and child illness in China, our study confirms the need for programmatic interventions that promote continued breastfeeding in order to improve toddler health in the region.

    View details for PubMedID 30621049

  • Breastfeeding and the Risk of Illness among Young Children in Rural China INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH Li, S., Yue, A., Abbey, C., Medina, A., Shi, Y. 2019; 16 (1)
  • Stimulation and Early Child Development in China: Caregiving at Arm's Length. Journal of developmental and behavioral pediatrics : JDBP Yue, A., Shi, Y., Luo, R., Wang, B., Weber, A., Medina, A., Kotb, S., Rozelle, S. 2019

    Abstract

    To provide an empirical overview of the parenting landscape in rural China, focusing on 18- to 30-month-old children and their caregivers in rural Shaanxi province.We collected unique data on 1442 caregiver-toddler dyads in rural areas of Shaanxi province and examined caregiver attitudes toward parenting, sources of information about parenting, and interactive parenting practices, and how each of these differed across generations. We measured how parenting attitudes and sources of information informed parenting practices. Finally, we measured levels of child development in our sample and the association between parenting practices and children's developmental outcomes.Most of the caregivers did not engage with children in a way that encouraged early development. Caregivers rarely told stories, sang, or used toys to play with their children. Grandmothers were more stressed by the children in their care and engaged significantly less than mothers did in the 3 stimulating interactions. Professional sources of information about parenting were underutilized by all caregivers. We found high rates of developmental delay in our sample and showed that these delays were associated with the lack of caregiver engagement.Our findings suggest that the major economic and social shifts occurring in rural China have not led to a widespread prevalence of stimulative parenting practices. Although caregivers report positive attitudes toward child-rearing, reliable sources of scientific information are lacking. Our results show a troubling generational disconnect between the information-seeking behaviors and parenting practices of rural caregivers.

    View details for DOI 10.1097/DBP.0000000000000678

    View details for PubMedID 31107768

  • Concurrent validity of the Ages and Stages Questionnaire and the Bayley Scales of Infant Development III in China. PloS one Yue, A., Jiang, Q., Wang, B., Abbey, C., Medina, A., Shi, Y., Rozelle, S. 2019; 14 (9): e0221675

    Abstract

    Choosing a valid and feasible method to measure child developmental outcomes is key to addressing developmental delays, which have been shown to be associated with high levels of unemployment, participation in crime, and teen pregnancies. However, measuring early childhood development (ECD) with multi-dimensional diagnostic tests such as the Bayley Scales of Infant and Toddler Development III (Bayley-III) can be time-consuming and expensive; therefore, parental screening tools such as the Ages and Stages Questionnaire (ASQ-3) are frequently an alternative measure of early childhood development in large-scale research. The ASQ is also becoming more frequently used as the first step to identify children at risk for developmental delays before conducting a diagnostic test to confirm. However, the effectiveness of the ASQ-3 is uncertain. In this study, we evaluate the accuracy of the ASQ-3 as a screening measure for children at risk of developmental delay in rural China by age group. To do so, we administered the Bayley-III, widely considered to be the "gold standard" of ECD diagnostic tests, to a sample of 1,831 five to twenty-four month-old children and also administered the ASQ-3 to their caregivers. We then compared the outcomes of the ASQ-3 test to those of the Bayley-III. We find that the ASQ-3 was significantly though weakly correlated with the Bayley-III and that the strength of this correlation increased with child age and was stronger when the mother was the primary caregiver (as compared to the grandmother). We also find that the sensitivity and specificity of ASQ-3 ranged widely. The overall findings suggest that the ASQ-3 may not be a very accurate screening tool for identifying developmentally delayed children, especially for children under 13 months of age or children whose primary caregiver is not the mother.

    View details for DOI 10.1371/journal.pone.0221675

    View details for PubMedID 31487302

  • Do Infant Feeding Practices Differ Between Grandmothers and Mothers in Rural China? Evidence From Rural Shaanxi Province. Family & community health Yue, A., Zhang, N., Liu, X., Tang, L., Luo, R., Yang, M., Rozelle, S., Medina, A. 2018; 41 (4): 233–43

    Abstract

    The overall goal of this study is to examine whether infant feeding practices differ between mothers and grandmothers in rural China. We randomly sampled 1383 caregivers of infants aged 18 to 30 months living in 351 villages across 174 townships in nationally designated poverty counties in rural areas. Results show that a high fraction of caregivers of 18- to 30-month-old children living in low-income areas of rural China do not regularly engage in positive infant feeding practices. Only 30% of children in our sample achieved adequate dietary diversity. Only 49% of children in our sample were fed meat in the day prior to survey administration. Few caregivers reported giving any vitamin supplements (such as calcium or iron supplements) to their children. We find that 33% of the children were cared for by grandmothers rather than mothers, and that grandmothers feed a less diversified diet to children than do mothers. Most (84%) caregivers rely solely on their own experiences, friends, and family members in shaping their feeding behaviors. Overall infant feeding practices are poor in rural China. Grandmothers engage in poorer feeding practices than do mothers. Grandmothers have improved their feeding practices compared to when their own children were young. Our results suggest shortcomings in the quality of infant feeding practices, at least in part due to an absence of reliable information sources.

    View details for PubMedID 30134338

  • Effect of a Local Vision Care Center on Eyeglasses Use and School Performance in Rural China A Cluster Randomized Clinical Trial JAMA OPHTHALMOLOGY Ma, Y., Congdon, N., Shi, Y., Hogg, R., Medina, A., Boswell, M., Rozelle, S., Iyer, M. 2018; 136 (7): 731–37

    Abstract

    Visual impairment is common among children in rural China, but fewer than one-third of children with poor vision own and wear eyeglasses.To study the effect of hospital-based vision centers on academic performance, ownership of eyeglasses, and eyeglasses-wearing behavior in rural Chinese children.Cluster randomized, investigator-masked, clinical trial from September 2014 through June 2015. A vision center capable of providing refractive services was established in the Hospital of Yongshou County, a nationally designated poor county in rural Shaanxi Province, western China. All 31 rural primary schools in Yongshou County participated; participants were all children in grades 4 through 6 (aged approximately 10-12 years) with uncorrected visual acuity of Snellen 6/12 or worse in either eye (2613 children). Data analysis was conducted March through May 2016, and data were analyzed by the intention-to-treat principle.After teacher-led vision screening early in the school year (September-October 2014), schools were randomly assigned to either early referral (December 2014-February 2015) to the vision center for refraction and free eyeglasses if needed or late referral (March-June 2015) for the identical intervention.The primary outcome was score on a study-administered mathematics test (June 2015) adjusted for baseline score. Secondary outcomes were self-reported eyeglasses ownership and wear at final examination (June 2015).All 2613 children evaluated were of Han Chinese race/ethnicity, and 1209 (46.3%) were female. Twelve hundred children (45.9%) met the vision criteria. Among these, 543 (45.3%) were randomized to early screening and 657 (54.7%) to late screening; 433 (79.7%) of the early screening group and 516 (78.5%) of the late screening group completed the study. Of eligible children, 120 (27.7%) owned eyeglasses at baseline. The adjusted effect on test scores comparing early and late groups was 0.25 SD (95% CI, 0.01-0.48; 1-sided P = .04), with the point estimate equivalent to half a semester of additional learning. At the end of the study, 347 of the 433 participants in the early group (80%) reported owning eyeglasses and 326 (75%) reported wearing eyeglasses; among the 516 participants in the late group, 371 (61%) reported owning and 286 (55%) reported wearing eyeglasses.In this study, early provision of free eyeglasses was seen to improve children's academic performance and wearing of spectacles. These findings suggest that a county hospital-based vision center may be an effective way to improve children's educational opportunities in rural China.isrctn.org Identifier: ISRCTN03252665.

    View details for PubMedID 29801081

  • Using daily text messages to improve adherence to infant micronutrient powder (MNP) packets in rural western China: A cluster-randomized controlled trial PLOS ONE Wang, X., Luo, R., Liu, C., Zhang, L., Yue, A., Medina, A., Rozelle, S. 2018; 13 (1): e0191549

    Abstract

    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.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.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.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.http://www.isrctn.com/ISRCTN44149146.

    View details for PubMedID 29352304

  • Prevalence and risk factors for Taenia solium cysticercosis in school-aged children: A school based study in western Sichuan, People's Republic of China. PLoS neglected tropical diseases Openshaw, J. J., Medina, A., Felt, S. A., Li, T., Huan, Z., Rozelle, S., Luby, S. P. 2018; 12 (5): e0006465

    Abstract

    Taenia solium cysticercosis affects millions of impoverished people worldwide and can cause neurocysticercosis, an infection of the central nervous system which is potentially fatal. Children may represent an especially vulnerable population to neurocysticercosis, due to the risk of cognitive impairment during formative school years. While previous epidemiologic studies have suggested high prevalence in rural China, the prevalence in children as well as risk factors and impact of disease in low-resource areas remain poorly characterized.Utilizing school based sampling, we conducted a cross-sectional study, administering a questionnaire and collecting blood for T. solium cysticercosis antibodies in 2867 fifth and sixth grade students across 27 schools in west Sichuan. We used mixed-effects logistic regression models controlling for school-level clustering to study associations between risk factors and to characterize factors influencing the administration of deworming medication. Overall prevalence of cysticercosis antibodies was 6%, but prevalence was significantly higher in three schools which all had prevalences of 15% or higher. Students from households owning pigs (adjusted odds ratio [OR] 1.81, 95% CI 1.08-3.03), from households reporting feeding their pigs human feces (adjusted OR 1.49, 95% CI 1.03-2.16), and self-reporting worms in their feces (adjusted OR 1.85, 95% CI 1.18-2.91) were more likely to have cysticercosis IgG antibodies. Students attending high prevalence schools were more likely to come from households allowing pigs to freely forage for food (OR 2.26, 95% CI 1.72-2.98) and lacking a toilet (OR 1.84, 95% CI 1.38-2.46). Children who were boarding at school were less likely to have received treatment for gastrointestinal worms (adjusted OR 0.58, 95% CI 0.42-0.80).Our study indicates high prevalences of cysticercosis antibodies in young school aged children in rural China. While further studies to assess potential for school-based transmission are needed, school-based disease control may be an important intervention to ensure the health of vulnerable pediatric populations in T. solium endemic areas.

    View details for PubMedID 29738570

    View details for PubMedCentralID PMC5959190

  • Caregiver Depression and Early Child Development: A Mixed-Methods Study From Rural China. Frontiers in psychology Yue, A., Gao, J., Yang, M., Swinnen, L., Medina, A., Rozelle, S. 2018; 9: 2500

    Abstract

    Half of rural toddlers aged 0-3 years in China's Qinling Mountainous region are cognitively delayed. While recent studies have linked poor child development measures to the absence of positive parenting behaviors, much less is known about the role that caregiver depression might play in shaping child development. In this paper, a mixed methods analysis is used to explore the prevalence of depression; measure the association between caregiver depression and children's developmental delays, correlates of depression, and the potential reasons for caregiver depression among women in rural China. The analysis brings together results from a large-scale survey of 1,787 caregivers across 118 villages in one northwestern province, as well as information from in-depth interviews with 55 female caregivers from these same study sites. Participants were asked to respond to the Depression, Anxiety and Stress Scale-21 (DASS-21) as well as a scale to measure children's social-emotional development, the Ages and Stages Questionnaire: Social-Emotional (ASQ-SE). We also administered a test of early childhood development, the Bayley Scales of Infant and Toddler Development (BSID-III), to all of the study household's infants and toddlers. The results show that the prevalence of depression may be as high as 23.5 percent among all female caregivers (defined as scoring in the mild or higher category of the DASS-21). Grandmothers have higher prevalence of depression than mother caregivers (p < 0.01). Caregiver depression also is significantly associated with a 0.53 SD worsening of children's social-emotional development (p < 0.01) and a 0.12 SD decrease in children's language development (p < 0.05). Our qualitative findings reveal six predominant reasons for caregiver depression: lack of social support from family and friends; the burden of caregiving; lack of control and agency within the household; within-family conflict; poverty; the perception of material wealth as a measure of self-worth. Our findings show a serious lack of understanding of mental health issues among rural women, and suggest that rural communities could benefit greatly from an educational program concerning mental health and its influence on child development. Our findings confirm the need for a comprehensive approach toward rural health, with particular attention paid to mental health awareness and support to elderly caregivers.

    View details for PubMedID 30618931

    View details for PubMedCentralID PMC6295552

  • Rural education across China's 40 years of reform: past successes and future challenges CHINA AGRICULTURAL ECONOMIC REVIEW Yue, A., Tang, B., Shi, Y., Tang, J., Shang, G., Medina, A., Rozelle, S. 2018; 10 (1): 93–118
  • EVIDENCE CONSISTENT WITH SCHOOL BASED TRANSMISSION OF <it>TAENIA SOLIUM</it> CYSTICERCOSIS IN PRIMARY SCHOOLS, SOUTHWEST CHINA Openshaw, J., Chedid, C., Medina, A., Felt, S., Li, T., Huan, Z., Rozelle, S., Luby, S. AMER SOC TROP MED & HYGIENE. 2018: 7
  • High prevalence of Taenia solium taeniasis and cysticercosis in Tibetan schoolchildren in western Sichuan, China: a cross-sectional study Li, T., Openshaw, J. J., Chen, X., Medina, A. C., Felt, S. A., Zhou, H., Rozelle, S. D., Luby, S. P. ELSEVIER SCIENCE INC. 2017: S89
  • The quality of primary care and correlates among grassroots providers in rural China: a cross-sectional standardised patient study Shi, Y., Yi, H., Zhou, H., Zhou, C., Xue, H., Rozelle, S., Medina, A., Sylvia, S. ELSEVIER SCIENCE INC. 2017: S16
  • 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 Luo, R., Yue, A., Zhou, H., Shi, Y., Zhang, L., Martorell, R., Medina, A., Rozelle, S., Sylvia, S. 2017; 17: 738

    Abstract

    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.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.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.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.ISRCTN44149146 ; prospectively registered on 15th April 2013.

    View details for PubMedID 28946866

  • Effect of Deworming on Indices of Health, Cognition, and Education among Schoolchildren in Rural China: A Cluster-Randomized Controlled Trial. The American journal of tropical medicine and hygiene Liu, C., Lu, L., Zhang, L., Luo, R., Sylvia, S., Medina, A., Rozelle, S., Smith, D. S., Chen, Y., Zhu, T. 2017

    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.

    View details for DOI 10.4269/ajtmh.16-0354

    View details for PubMedID 28093533

  • More Poop, More Precision: Improving Epidemiologic Surveillance of Soil-Transmitted Helminths with Multiple Fecal Sampling using the Kato-Katz Technique AMERICAN JOURNAL OF TROPICAL MEDICINE AND HYGIENE Liu, C., Lu, L., Zhang, L., Bai, Y., Medina, A., Rozelle, S., Smith, D., Zhou, C., Zang, W. 2017; 97 (3): 870–75

    Abstract

    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 Ascaris lumbricoides, Trichuris trichiura, 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.

    View details for PubMedID 28722571

    View details for PubMedCentralID PMC5590569

  • Exploring the risk factors of suicidal ideation among the seniors in Shandong, China: A path analysis JOURNAL OF AFFECTIVE DISORDERS Ge, D., Sun, L., Zhou, C., Qian, Y., Zhang, L., Medina, A. 2017; 207: 393-397

    Abstract

    Suicide is a global public health problem that has a significant negative influence on individuals, families and the society. The objective of this study is to explore the risk factors associated with suicidal ideation among the elderly in Shandong Province, China.A total of 3313 participants (60+) of Shandong Province, China were included in this study. Suicidal ideation was assessed by using questions from the NCS (National Comorbidity Survey). Multiple logistic regression analysis was performed to examine the factors associated with suicidal ideation. Path analysis was conducted to test the direct and indirect association between factors and suicidal ideation.The prevalence of suicidal ideation among the seniors in Shandong, China was 4.2%. Depression had the strongest direct (β=0.303, p-value<0.05) and total effect (β=0.303), life satisfaction (β=-0.103, p-value<0.05; β=-0.136, p-value<0.05), economic status (β=-0.046, p-value<0.05; β=-0.040, p-value<0.05) had both direct and indirect impacts on suicidal ideation. Social support (β=-0.040, p-value<0.05) had indirect influence on suicidal ideation. Depression was a mediator between life satisfaction, economic status, social support and suicidal ideation.The data used in this study was cross-sectional, and the relationship between identified factors and suicidal ideation cannot be interpreted as cause-effect.Depression was the strongest influencing factor of suicidal ideation among the elderly, followed by life satisfaction, economic status. Active intervention measures focusing on the depression screening and treatment both in urban and rural communities should be taken to prevent suicide.

    View details for DOI 10.1016/j.jad.2016.09.031

    View details for Web of Science ID 000389088600055

  • The gender gap among school children in poor rural areas of western China: evidence from a multi-province dataset INTERNATIONAL JOURNAL FOR EQUITY IN HEALTH Zhou, H., Mo, D., Zhou, C., Medina, A., Shi, Y., Zhang, L., Rozelle, S. 2016; 15

    Abstract

    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.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.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.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.

    View details for DOI 10.1186/s12939-016-0442-5

    View details for Web of Science ID 000384376800004

    View details for PubMedID 27686497

    View details for PubMedCentralID PMC5041561

  • Exploring the risk factors of suicidal ideation among the seniors in Shandong, China: A path analysis. Journal of affective disorders Ge, D., Sun, L., Zhou, C., Qian, Y., Zhang, L., Medina, A. 2016; 207: 393-397

    Abstract

    Suicide is a global public health problem that has a significant negative influence on individuals, families and the society. The objective of this study is to explore the risk factors associated with suicidal ideation among the elderly in Shandong Province, China.A total of 3313 participants (60+) of Shandong Province, China were included in this study. Suicidal ideation was assessed by using questions from the NCS (National Comorbidity Survey). Multiple logistic regression analysis was performed to examine the factors associated with suicidal ideation. Path analysis was conducted to test the direct and indirect association between factors and suicidal ideation.The prevalence of suicidal ideation among the seniors in Shandong, China was 4.2%. Depression had the strongest direct (β=0.303, p-value<0.05) and total effect (β=0.303), life satisfaction (β=-0.103, p-value<0.05; β=-0.136, p-value<0.05), economic status (β=-0.046, p-value<0.05; β=-0.040, p-value<0.05) had both direct and indirect impacts on suicidal ideation. Social support (β=-0.040, p-value<0.05) had indirect influence on suicidal ideation. Depression was a mediator between life satisfaction, economic status, social support and suicidal ideation.The data used in this study was cross-sectional, and the relationship between identified factors and suicidal ideation cannot be interpreted as cause-effect.Depression was the strongest influencing factor of suicidal ideation among the elderly, followed by life satisfaction, economic status. Active intervention measures focusing on the depression screening and treatment both in urban and rural communities should be taken to prevent suicide.

    View details for DOI 10.1016/j.jad.2016.09.031

    View details for PubMedID 27770731

  • 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 AMERICAN JOURNAL OF PUBLIC HEALTH Zhou, H., Sun, S., Luo, R., Sylvia, S., Yue, A., Shi, Y., Zhang, L., Medina, A., Rozelle, S. 2016; 106 (7): 1256-1262

    Abstract

    To test whether text message reminders sent to caregivers improve the effectiveness of a home micronutrient fortification program in western China.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.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).Text messages improved compliance of caregivers to a home fortification program and children's nutrition.

    View details for DOI 10.2105/AJPH.2016.303140

    View details for Web of Science ID 000377939700048

    View details for PubMedID 27077354

    View details for PubMedCentralID PMC4984765

  • To Board or Not to Board: Evidence from Nutrition, Health and Education Outcomes of Students in Rural China CHINA & WORLD ECONOMY Wang, A., Medina, A., Luo, R., Shi, Y., Yue, A. 2016; 24 (3): 52-66

    View details for DOI 10.1111/cwe.12158

    View details for Web of Science ID 000379957200005

  • Nutritional Deficiencies, the Absence of Information and Caregiver Shortcomings: A Qualitative Analysis of Infant Feeding Practices in Rural China. PloS one Yue, A., Marsh, L., Zhou, H., Medina, A., Luo, R., Shi, Y., Zhang, L., Kenny, K., Rozelle, S. 2016; 11 (4)

    Abstract

    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.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.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.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.

    View details for DOI 10.1371/journal.pone.0153385

    View details for PubMedID 27073864

    View details for PubMedCentralID PMC4830571

  • Who are rural China's village clinicians? CHINA AGRICULTURAL ECONOMIC REVIEW Xue, H., Shi, Y., Medina, A. 2016; 8 (4): 662-676
  • Catastrophic health expenditure: a comparative analysis of empty-nest and non-empty-nest households with seniors in Shandong, China. BMJ open Yang, T., Chu, J., Zhou, C., Medina, A., Li, C., Jiang, S., Zheng, W., Sun, L., Liu, J. 2016; 6 (7)

    Abstract

    The aim of this study was to compare the catastrophic health expenditure (CHE) prevalence and its determinants between empty-nest and non-empty-nest elderly households.Shandong province of China.A total of 2761 elderly households are included in the analysis.CHE incidence among elderly households was 44.9%. The CHE incidence of empty-nest singles (59.3%, p=0.000, OR=3.19) and empty-nest couples (52.9%, p=0.000, OR=2.45) are both statistically higher than that of non-empty-nest elderly households (31.4%). An inverse association was observed between CHE incidence and income level in all elderly household types. Factors including 1 or more household elderly members with non-communicable chronic diseases in the past 6 months, 1 or more elderly household members being hospitalised in the past year and lower household income, are significant risk factors for CHE in all 3 household types (p<0.05). Health insurance status was found to be a significant determinant of CHE among empty-nest singles and non-empty-nest households (p<0.05).CHE incidence among elderly households is high in China. Empty-nest households are at higher risk for CHE than non-empty-nest households. Based on these findings, we suggest that special insurance be developed to broaden the coverage of health services and heighten the reimbursement rate for empty-nest elderly in the existing health insurance schemes. Financial and social protection interventions are also essential for identified at-risk subgroups among different types of elderly households.

    View details for DOI 10.1136/bmjopen-2015-010992

    View details for PubMedID 27381206

    View details for PubMedCentralID PMC4947795

  • Parental migration and smoking behavior of left-behind children: evidence from a survey in rural Anhui, China. International journal for equity in health Yang, T., Li, C., Zhou, C., Jiang, S., Chu, J., Medina, A., Rozelle, S. 2016; 15 (1): 127-?

    Abstract

    Parental migration is most an important factor affecting children's behaviors. Few studies have addressed the association between parental migration and children's smoking behavior in China. This study aims to estimate the current smoking prevalence among children, evaluate the association of parental migration and the smoking behavior of children and identify factors associated with smoking behavior among left-behind children (LBC).A cross-sectional study was conducted in 6 cities in Anhui province during July and August, 2012. All participants were interviewed face-to-face using a standardized questionnaire. Only children 10 to 14 years old that live in rural villages for at least 6 months during the previous year were included in the study.A total of 1343 children met the sampling criteria and participated in the study. Of these, 56 % are LBC and 44 % live with both parents. The average rate of smoking is 3.4 %. The rate of smoking is statistically higher for LBC with both parents out (rate = 6.1 %; OR = 5.59, P < 0.001) than for children living with both parents (1.4 %). Similarly, the rate of LBC with father home only (rate = 5.0 %; OR = 5.60, P = 0.005) is also statistically higher than for children living with both parents when controlling other variables. Factors affecting the smoking behavior of LBC, include gender (i.e., boys), (perceived) school performance and primary caregiver.Parental migration is associated with a significant increase in smoking behavior among children. Intervention studies that target LBC would help to develop strategies to reduce smoking among rural children. Gender-specific strategies and anti-smoking education also appears to be needed to reduce tobacco use among rural LBC.

    View details for DOI 10.1186/s12939-016-0416-7

    View details for PubMedID 27491773

    View details for PubMedCentralID PMC4974696

  • Maternal health services in China's western rural areas: uptake and correlates CHINA AGRICULTURAL ECONOMIC REVIEW Liu, C., Zhang, L., Shi, Y., Zhou, H., Medina, A., Rozelle, S. 2016; 8 (2): 250-276
  • Alcohol consumption is higher among left-behind Chinese children whose parents leave rural areas to work ACTA PAEDIATRICA Jiang, S., Chu, J., Li, C., Medina, A., Hu, Q., Liu, J., Zhou, C. 2015; 104 (12): 1298-1304

    View details for DOI 10.1111/apa.13163

    View details for Web of Science ID 000367536000029

  • China's Left-Behind Children: Impact Of Parental Migration On Health, Nutrition, And Educational Outcomes. Health affairs Zhou, C., Sylvia, S., Zhang, L., Luo, R., Yi, H., Liu, C., Shi, Y., Loyalka, P., Chu, J., Medina, A., Rozelle, S. 2015; 34 (11): 1964-1971

    View details for DOI 10.1377/hlthaff.2015.0150

    View details for PubMedID 26526256

  • Non-use of health care service among empty-nest elderly in Shandong, China: a cross-sectional study BMC HEALTH SERVICES RESEARCH Zhou, C., Ji, C., Chu, J., Medina, A., Li, C., Jiang, S., Zheng, W., Liu, J., Rozelle, S. 2015; 15
  • Soil-Transmitted Helminths in Southwestern China: A Cross-Sectional Study of Links to Cognitive Ability, Nutrition, and School Performance among Children. PLoS neglected tropical diseases Liu, C., Luo, R., Yi, H., Zhang, L., Li, S., Bai, Y., Medina, A., Rozelle, S., Smith, S., Wang, G., Wang, J. 2015; 9 (6)

    Abstract

    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.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.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.

    View details for DOI 10.1371/journal.pntd.0003877

    View details for PubMedID 26110518

    View details for PubMedCentralID PMC4481344

  • Soil-Transmitted Helminths in Southwestern China: A Cross-Sectional Study of Links to Cognitive Ability, Nutrition, and School Performance among Children. PLoS neglected tropical diseases Liu, C., Luo, R., Yi, H., Zhang, L., Li, S., Bai, Y., Medina, A., Rozelle, S., Smith, S., Wang, G., Wang, J. 2015; 9 (6)

    View details for DOI 10.1371/journal.pntd.0003877

    View details for PubMedID 26110518

  • Survey using incognito standardized patients shows poor quality care in China's rural clinics. Health policy and planning Sylvia, S., Shi, Y., Xue, H., Tian, X., Wang, H., Liu, Q., Medina, A., Rozelle, S. 2015; 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.

    View details for DOI 10.1093/heapol/czu014

    View details for PubMedID 24653216

  • Gut instincts: knowledge, attitudes, and practices regarding soil-transmitted helminths in rural China. PLoS neglected tropical diseases Lu, L., Liu, C., Zhang, L., Medina, A., Smith, S., Rozelle, S. 2015; 9 (3)

    Abstract

    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.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.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.

    View details for DOI 10.1371/journal.pntd.0003643

    View details for PubMedID 25807188

  • Gut Instincts: Knowledge, Attitudes, and Practices regarding Soil-Transmitted Helminths in Rural China PLOS NEGLECTED TROPICAL DISEASES Lu, L., Liu, C., Zhang, L., Medina, A., Smith, S., Rozelle, S. 2015; 9 (3)

    Abstract

    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.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.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.

    View details for DOI 10.1371/journal.pntd.0003643

    View details for Web of Science ID 000352199400096

    View details for PubMedCentralID PMC4373855

  • 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 Li, L., Luo, R., Sylvia, S., Medina, A., Rozelle, S. 2015; 46 (2): 306-321
  • Non-use of health care service among empty-nest elderly in Shandong, China: a cross-sectional study. BMC health services research Zhou, C., Ji, C., Chu, J., Medina, A., Li, C., Jiang, S., Zheng, W., Liu, J., Rozelle, S. 2015; 15: 294-?

    Abstract

    Empty-nest elderly refers to those elderly with no children or whose children have already left home. Few studies have focused on healthcare service use among empty-nest seniors, and no studies have identified the prevalence and profiles of non-use of healthcare services among empty-nest elderly. The purpose of this study is to compare the prevalence of non-use of healthcare services between empty-nest and non-empty-nest elderly and identify risk factors for the non-use of healthcare services among empty-nest seniors.Four thousand four hundred sixty nine seniors (60 years and above) were draw from a cross-sectional study conducted in three urban districts and three rural counties of Shandong Province in China. Non-visiting within the past 2 weeks and non-hospitalization in previous year are used to measure non-use of healthcare services. Chi-square test is used to compare the prevalence of non-use between empty-nesters and non-empty-nesters. Multivariate logistic regression analysis is employed to identify the risk factors of non-use among empty-nest seniors.Of 4469 respondents, 2667(59.7 %) are empty-nesters. Overall, 35.5 % of the participants had non-visiting and 34.5 % had non-hospitalization. Non-visiting rate among empty-nest elderly (37.7 %) is significantly higher than that among non-empty-nest ones (32.7 %) (P = 0.008). Non-hospitalization rate among empty-nesters (36.1 %) is slightly higher than that among non-empty-nesters (31.6 %) (P = 0.166). Financial difficulty is the leading cause for both non-visiting and non-hospitalization of the participants, and it exerts a larger negative effect on access to healthcare for empty-nest elderly than non-empty-nest ones. Both non-visiting and non-hospitalization among empty-nest seniors are independently associated with low-income households, health insurance status and non-communicable chronic diseases. The non-visiting rate is also found to be higher among the empty-nesters with lower education and those from rural areas.Our findings indicate that empty-nest seniors have higher non-use rate of healthcare services than non-empty-nest ones. Financial difficulty is the leading cause of non-use of health services. Healthcare policies should be developed or modified to make them more pro-poor and also pro-empty-nested.

    View details for DOI 10.1186/s12913-015-0974-1

    View details for PubMedID 26219288

    View details for PubMedCentralID PMC4517420

  • Alcohol consumption is higher among left-behind Chinese children whose parents leave rural areas to work. Acta paediatrica (Oslo, Norway : 1992) Jiang, S., Chu, J., Li, C., Medina, A., Hu, Q., Liu, J., Zhou, C. 2015; 104 (12): 1298–1304

    Abstract

    Over the past few decades, a large number of rural residents have migrated to cities in China and left their children behind. This study estimated how many 10- to 14-year-old children in rural Anhui drank alcohol and examined the association between parental migration and children's alcohol use.A cross-sectional study was conducted in six cities in Anhui between July and August 2012. All participants had lived in the study villages for at least six months during the previous year and were interviewed face-to-face using a standardised questionnaire.More than half (57%) of the 1367 subjects were left-behind children, 43% lived with both parents and 9.6% currently drank alcohol. When we controlled for other variables, the rate of alcohol use was statistically higher among left-behind children if both parents had migrated (14.0%) than among children living with both parents (7.8%) (p = 0.002). Boys, children with siblings and those with a poorer academic performance were more likely to drink.Children in rural China were more likely to drink if both their parents had migrated in search of work. School-based interventions could help to reduce alcohol use among rural left-behind children, especially boys.

    View details for PubMedID 26305042

  • Micronutrient deficiencies and developmental delays among infants: evidence from a cross-sectional survey in rural China. BMJ open Luo, R., Shi, Y., Zhou, H., Yue, A., Zhang, L., Sylvia, S., Medina, A., Rozelle, S. 2015; 5 (10)

    View details for DOI 10.1136/bmjopen-2015-008400

    View details for PubMedID 26438137

  • Text Messaging and its Impacts on the Health and Education of the Poor: Evidence from a Field Experiment in Rural China WORLD DEVELOPMENT Mo, D., Luo, R., Liu, C., Zhang, H., Zhang, L., Medina, A., Rozelle, S. 2014; 64: 766-780
  • Anemia and Feeding Practices among Infants in Rural Shaanxi Province in China NUTRIENTS Luo, R., Shi, Y., Zhou, H., Yue, A., Zhang, L., Sylvia, S., Medina, A., Rozelle, S. 2014; 6 (12): 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.

    View details for DOI 10.3390/nu6125975

    View details for Web of Science ID 000346796100037

    View details for PubMedID 25533008

    View details for PubMedCentralID PMC4277010

  • GENDER INEQUALITY IN EDUCATION IN CHINA: A META-REGRESSION ANALYSIS CONTEMPORARY ECONOMIC POLICY Zeng, J., Pang, X., Zhang, L., Medina, A., Rozelle, S. 2014; 32 (2): 474-491

    View details for DOI 10.1111/coep.12006

    View details for Web of Science ID 000331606300014

  • Do you get what you pay for with school-based health programs? Evidence from a child nutrition experiment in rural China ECONOMICS OF EDUCATION REVIEW Sylvia, S., Luo, R., Zhang, L., Shi, Y., Medina, A., Rozelle, S. 2013; 37: 1-12
  • Neglected Rural Public Health Issue: The Case of Intestinal Roundworms CHINA & WORLD ECONOMY Zhang, L., Cai, Y., Wang, X., Ma, X., Medina, A., Smith, D. S., Rozelle, S. 2013; 21 (3): 25-43
  • Multiple Micronutrient Supplementation Reduces Anemia and Anxiety in Rural China's Elementary School Children JOURNAL OF NUTRITION Zhang, L., Kleiman-Weiner, M., Luo, R., Shi, Y., Martorell, R., Medina, A., Rozelle, S. 2013; 143 (5): 640-647

    Abstract

    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.

    View details for DOI 10.3945/jn.112.171959

    View details for Web of Science ID 000318056700013

    View details for PubMedID 23514770

  • Eggs versus chewable vitamins: Which intervention can increase nutrition and test scores in rural China? CHINA ECONOMIC REVIEW Kleiman-Weiner, M., Luo, R., Zhang, L., Shi, Y., Medina, A., Rozelle, S. 2013; 24: 165-176
  • Eggs versus Chewable Vitamins: Which Intervention Can Increase Nutrition and Test Scores in Rural China? Kleiman-Weiner, M., Luo, R., Zhang, L., Shi, Y., Medina, A., Rozelle, S. 2013
  • Soil-Transmitted Helminth Infections and Correlated Risk Factors in Preschool and School-Aged Children in Rural Southwest China PLOS ONE Wang, X., Zhang, L., Luo, R., Wang, G., Chen, Y., Medina, A., Eggleston, K., Rozelle, S., Smith, D. S. 2012; 7 (9)

    Abstract

    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.

    View details for DOI 10.1371/journal.pone.0045939

    View details for Web of Science ID 000309517500047

    View details for PubMedID 23029330

  • Effectiveness of provider incentives for anaemia reduction in rural China: a cluster randomised trial BRITISH MEDICAL JOURNAL Miller, G., Luo, R., Zhang, L., Sylvia, S., Shi, Y., Foo, P., Zhao, Q., Martorell, R., Medina, A., Rozelle, S. 2012; 345

    Abstract

    To test the impact of provider performance pay for anaemia reduction in rural China.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.72 randomly selected rural primary schools across northwest China.3553 fourth and fifth grade students aged 9-11 years. All fourth and fifth grade students in sample schools participated in the study.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).Student haemoglobin concentrations.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.Financial incentives for health improvement were modestly effective. Understanding interactions with other motives and pre-existing incentives is critical.ISRCTN76158086.

    View details for DOI 10.1136/bmj.e4809

    View details for Web of Science ID 000306997800001

    View details for PubMedID 22842354

    View details for PubMedCentralID PMC3406729

  • The Limits of Health and Nutrition Education: Evidence from Three Randomized-Controlled Trials in Rural China CESIFO ECONOMIC STUDIES Luo, R., Shi, Y., Zhang, L., Zhang, H., Miller, G., Medina, A., Rozelle, S. 2012; 58 (2): 385-404
  • Transfer paths and academic performance: The primary school merger program in china INTERNATIONAL JOURNAL OF EDUCATIONAL DEVELOPMENT Mo, D., Yi, H., Zhang, L., Shi, Y., Rozelle, S., Medina, A. 2012; 32 (3): 423-431
  • Soil-Transmitted Helminth Infections and Correlated Risk Factors in Preschool and School-aged Children in Rural Southwest China Wang, X., Medina, A., Chen, Y., Wang, G., Luo, R., Zhang, L., Eggleston, K., Smith, D. Scott, Rozelle, S. 2012
  • Gender Inequality in Education in China: A Meta-Regression Analysis Zeng, J., Pang, X., Zhang, L., Medina, A., Rozelle, S. 2012
  • The Limits of Health and Nutrition Education: Evidence from Three Randomized Controlled Trials in Rural China Shi, Y., Zhang, L., Luo, R., Zhang, H., Miller, G., Medina, A., Rozelle, S. 2012; 58
  • Transfer Paths and Academic Performance: The Primary School Merger Program in China Mo, D., Yi, H., Zhang, L., Shi, Y., Rozelle, S., Medina, A. 2012
  • Effectiveness of provider incentives for anemia reduction in rural China: a cluster randomised trial Sylvia, S., Zhang, L., Luo, R., Miller, G., Shi, Y., Foo, P., Zhao, Q., Martorell, R., Medina, A., Rozelle, S. 2012; 345
  • Anaemia among Students of Rural China's Elementary Schools: Prevalence and Correlates in Ningxia and Qinghai's Poor Counties JOURNAL OF HEALTH POPULATION AND NUTRITION Luo, R., Zhang, L., Liu, C., Zhao, Q., Shi, Y., Miller, G., Yu, E., Sharbono, B., Medina, A., Rozelle, S., Martorell, R. 2011; 29 (5): 471-485

    Abstract

    Although the past few decades have seen rising incomes and increased government attention to rural development, many children in rural China still lack regular access to micronutrient-rich diets. Insufficient diets and poor knowledge of nutrition among the poor result in nutritional problems, including iron-deficiency anaemia, which adversely affect attention and learning of students in school. Little research has been conducted in China documenting the prevalence of nutritional problems among vulnerable populations, such as school-age children, in rural areas. The absence of programmes to combat anaemia among students might be interpreted as a sign that the Government does not recognize its severity. The goals of this paper were to measure the prevalence of anaemia among school-age children in poor regions of Qinghai and Ningxia, to identify individual-, household- and school-based factors that correlate with anaemia in this region, and to report on the correlation between the anaemic status and the physical, psychological and cognitive outcomes. The results of a cross-sectional survey are reported here. The survey involved over 4,000 fourth and fifth grade students from 76 randomly-selected elementary schools in 10 poor counties in rural Qinghai province and Ningxia Hui Autonomous Region, located in the northwest region of China. Data were collected using a structured questionnaire and standardized tests. Trained professional nurses administered haemoglobin (Hb) tests (using Hemocue finger prick kits) and measured heights and weights of children. The baseline data showed that the overall anaemia rate was 24.9%, using the World Health Organization's blood Hb cut-offs of 120 g/L for children aged 12 years and older and 115 g/L for children aged 11 years and under. Children who lived and ate at school had higher rates of anaemia, as did children whose parents worked in farms or were away from home. Children with parents who had lower levels of education were more likely to be anaemic. The anaemic status correlated with the adverse physical, cognitive and psychological outcomes among the students. Such findings are consistent with findings of other recent studies in poor, northwest areas of China and led to conclude that anaemia remains a serious health problem among children in parts of China.

    View details for Web of Science ID 000296910300007

    View details for PubMedID 22106753

    View details for PubMedCentralID PMC3225109

  • Anemia in Rural China's Elementary Schools: Prevalence and Correlates in Ningxia and Qinghai's Poor Counties Luo, R., Zhang, L., Liu, C., Zhao, Q., Shi, Y., Miller, G., Yu, E., Sharbono, B., Rozelle, S., Medina, A., Martorell, R. 2011