Yunwei Chen

All Publications

• Maternal empowerment, feeding knowledge, and infant nutrition: Evidence from rural China. Journal of global health Chen, Y., Guo, Y., Wu, Y., Medina, A., Zhou, H., Darmstadt, G. L. 2024; 14: 04094

  Abstract

  Background: Maternal empowerment - the capacity to make decisions within households - is linked to better child feeding and nutritional outcomes, but few studies have considered the mediating role of caregiver knowledge. Further, existing literature centres primarily on the husband-wife dyad while overlooking grandmothers as important childcare decision-makers.Methods: We collected primary data through household surveys in 2019 and 2021 from 1190 households with infants zero to six months living in rural western China. We identified the primary and secondary caregivers for each infant and assessed their feeding knowledge and practices, as well as infant nutritional status. We constructed a maternal empowerment index using a seven-item decision-making questionnaire and examined the relationship between maternal empowerment in childcare and household decisions, caregivers' feeding knowledge, and infant feeding practices and nutritional outcomes.Results: Mothers had significantly higher levels of feeding knowledge than secondary caregivers (most were grandmothers, 72.7%), with average knowledge scores of 5.4 vs. 4.1, respectively, out of 9. Mothers and secondary caregivers with higher levels of feeding knowledge had significantly higher exclusive breastfeeding rates by 13-15 percentage points (P<0.01) and 11-13 percentage points (P<0.01), respectively. The knowledge of secondary caregivers was even more strongly associated with not feeding formula (15 percentage points, P<0.01). Mothers empowered to make childcare decisions were more likely to exclusively breastfeed (12-13 percentage points, P<0.01), less likely to formula feed (9-10 percentage points, P<0.05), and more likely to have children with higher Z-scores for length-for-age (0.32-0.33, P<0.01) and weight-for-age (0.24-0.25, P<0.05). Effects remained after controlling for maternal feeding knowledge.Conclusions: While mothers' and grandmothers' feeding knowledge was both important for optimal infant feeding, grandmothers' knowledge was particularly critical for practicing exclusive breastfeeding. Given the disparity in feeding knowledge between the two caregivers, our study further shows that mothers empowered in childcare decision-making were more likely to exclusively breastfeed their infants. This implies that some mothers with adequate knowledge may not practice optimal feeding because of lower decision-making power. Overall, our study highlights the role of secondary caregivers (grandmothers) in infant care and suggests that future child nutritional interventions may benefit from involving secondary caregivers (grandmothers).Registration: Parent trial registration: ISRCTN16800789.

  View details for DOI 10.7189/jogh.14.04094

  View details for PubMedID 38845456

• Gap in protective behaviors between Han and minority ethnicities during COVID-19 pandemic in rural western China: A decomposition analysis. Preventive medicine reports Ye, R., Wu, Y., Sun, C., Wang, Q., Ma, Y., Chen, Y., Pappas, L., Feng, C., Rozelle, S., Zhou, H. 2024; 39: 102617

  Abstract

  Understanding the ethnic gap in protective behavior and its explanatory factors is a promising step for reducing pandemic-induced disparities. However, no studies have endeavored to identify the factors contributing to a gap in protective behaviors between Han and minority ethnicities during COVID-19 pandemic in rural China. We aimed to analyze the gap in protective behaviors between Han and minority residents in rural China. We conducted cross-sectional studies in multi-ethnic rural China in 2020. A total of 1640 participants from Han and minority groups were invited to participate. The decomposition method was applied to analyze the gap in protective behaviors and its associated factors between the Han and minority groups. Participants in the Han group had a higher protective behavioral score (9.26 ± 1.20) than the minority group (8.97 ± 1.50), yielding a significant gap in protective behaviors between Han and minority ethnicities of 0.29. Socio-demographic characteristics, health status, the degree of knowledge held about COVID-19, and psychological responses to COVID-19 explained 79.3 % (0.23/0.29) of the behavioral gap between the Han and minority groups. The difference in household asset levels was the largest explained contributor to the behavioral gap (52.17 %) (0.12/0.23), followed by fear felt for COVID-19 (-21.74 %) (-0.05/0.23). Differences in educational attainment, degree of knowledge held about COVID-19, and self-efficacy in response to COVID-19 each explained 17.4 % (0.04/0.23) of the behavioral gap. In conclusion, Han group show greater protective behaviors than minority ethnic groups. To drive better protective behavior in the most vulnerable communities, targeted, group-specific COVID-19 preventative messages deployed in public health communication strategies is suggested to enhance individual confidence in coping with the pandemic while creating a healthy amount of fear for public health crisis.

  View details for DOI 10.1016/j.pmedr.2024.102617

  View details for PubMedID 38370983

  View details for PubMedCentralID PMC10873723

• In-Hospital Formula Feeding Hindered Exclusive Breastfeeding: Breastfeeding Self-Efficacy as a Mediating Factor. Nutrients Liu, L., Wu, Y., Xian, X., Feng, J., Mao, Y., Balakrishnan, S., Weber, A. M., Darmstadt, G. L., Chen, Y., Sylvia, S., Zhou, H., Rozelle, S. 2023; 15 (24)

  Abstract

  Breastfeeding self-efficacy (BSE), defined as a mother's confidence in her ability to breastfeed, has been confirmed to predict the uptake of exclusive breastfeeding (EBF). Early experiences during the birth hospital stay, especially in-hospital formula feeding (IHFF), can impact both EBF and maternal breastfeeding confidence. Therefore, our objective was to examine the association between IHFF and EBF outcomes and investigate whether this association is influenced by BSE. The study included 778 infants from a larger cohort study conducted in 2021, with a one-year follow-up in rural areas of Sichuan Province, China. We used a causal mediation analysis to estimate the total effect (TE), natural direct (NDE), and nature indirect effects (NIE) using the paramed command in Stata. Causal mediation analyses revealed that IHFF was negatively associated with EBF (TE odds ratio = 0.47; 95% CI, 0.29 to 0.76); 28% of this association was mediated by BSE. In the subgroup analysis, there were no significant differences in the effects between parity subgroups, as well as between infant delivery subgroups. Our study found that IHFF hindered later EBF and that BSE mediated this association. Limiting the occurrence of in-hospital formula feeding or improving maternal breastfeeding self-efficacy is likely to improve exclusive breastfeeding outcomes.

  View details for DOI 10.3390/nu15245074

  View details for PubMedID 38140332

  View details for PubMedCentralID PMC10746093

• The Psychology of Poverty: A Replication Based on Zimbabwe's Harmonised Social Cash Transfer Programme JOURNAL OF AFRICAN ECONOMIES Ibrahim, M., Chen, Y., Pereira, A., Musa, T., Bathia, D., Handa, S. 2024; 33 (3): 225-239

  View details for DOI 10.1093/jae/ejad013

  View details for Web of Science ID 001038277100001

• Effect of the mHealth-supported Healthy Future programme delivered by community health workers on maternal and child health in rural China: study protocol for a cluster randomised controlled trial. BMJ open Chen, Y., Wu, Y., Dill, S. E., Guo, Y., Westgard, C. M., Medina, A., Weber, A. M., Darmstadt, G. L., Zhou, H., Rozelle, S., Sylvia, S. 2023; 13 (1): e065403

  Abstract

  Millions of young rural children in China still suffer from poor health and malnutrition, partly due to a lack of knowledge about optimal perinatal and child care among rural mothers and caregivers. Meanwhile, there is an urgent need to improve maternal mental health in rural communities. Comprehensive home visiting programmes delivered by community health workers (CHWs) can bridge the caregiver knowledge gap and improve child health and maternal well-being in low-resource settings, but the effectiveness of this approach is unknown in rural China. Additionally, grandmothers play important roles in child care and family decision-making in rural China, suggesting the importance of engaging multiple caregivers in interventions. The Healthy Future programme seeks to improve child health and maternal well-being by developing a staged-based curriculum that CHWs deliver to mothers and caregivers of young children through home visits with the assistance of a tablet-based mHealth system. This protocol describes the design and evaluation plan for this programme.We designed a cluster-randomised controlled trial among 119 rural townships in four nationally designated poverty counties in Southwestern China. We will compare the outcomes between three arms: one standard arm with only primary caregivers participating in the intervention, one encouragement arm engaging primary and secondary caregivers and one control arm with no intervention. Families with pregnant women or infants under 6 months of age are invited to enrol in the 12-month study. Primary outcomes include children's haemoglobin levels, exclusive breastfeeding rates and dietary diversity in complementary feeding. Secondary outcomes include a combination of health, behavioural and intermediate outcomes.Ethical approval has been provided by Stanford University, Sichuan University and the University of Nevada, Reno. Trial findings will be disseminated through national and international peer-reviewed publications and conferences.ISRCTN16800789.

  View details for DOI 10.1136/bmjopen-2022-065403

  View details for PubMedID 36669837

• Structural Determinants of Child Health in Rural China: The Challenge of Creating Health Equity. International journal of environmental research and public health Chen, Y., Sylvia, S., Dill, S., Rozelle, S. 2022; 19 (21)

  Abstract

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

  View details for DOI 10.3390/ijerph192113845

  View details for PubMedID 36360724

• The know-do gap in quality of health for chronic non-communicable diseases in rural China FRONTIERS IN PUBLIC HEALTH Meng, S., Wang, Q., Wu, Y., Xue, H., Li, L., Ye, R., Chen, Y., Pappas, L., Akhtar, M., Dill, S., Sylvia, S., Zhou, H., Rozelle, S. 2022; 10: 953881

  Abstract

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

  View details for DOI 10.3389/fpubh.2022.953881

  View details for Web of Science ID 000849119500001

  View details for PubMedID 36062129

  View details for PubMedCentralID PMC9435052

• Explaining the declining utilization of village clinics in rural China over time: A decomposition approach. Social science & medicine (1982) Chen, Y., Sylvia, S., Wu, P., Yi, H. 2022; 301: 114978

  Abstract

  With a goal of improving health system quality and efficiency, reforms of China's health system over the past decade have sought to strengthen primary healthcare in lower-level clinics and health centers. Despite these wide-ranging reforms and initiatives, population-based studies have documented dramatic declines in patients' use of primary care facilities during this period. In this paper, we explore the determinants of this trend in China's rural areas using detailed longitudinal data following a nationally-representative sample of rural households and village clinics from 2011 to 2018. We estimate that between 2011 and 2018, the probability that individuals sought care at village clinics when ill dropped by 44%. At the same time, the utilization of outpatient services in county hospitals increased by 56% and patient self-treatment increased by 20%. Detailed Kitagawa-Oaxaca-Blinder decompositions suggest four primary drivers of this trend: the shifting burden of disease in rural areas, changes in how patients choose to seek care given different disease conditions, declining drug inventory in village clinics, and the decreasing importance of remoteness as a determinant of healthcare seeking behavior. Our results highlight the deteriorating role of village clinics in the rural healthcare system and the increasing importance of self-treatment and higher-tier primary care services.

  View details for DOI 10.1016/j.socscimed.2022.114978

  View details for PubMedID 35461080

  View details for PubMedCentralID PMC10266832

• Early Childhood Reading in Rural China and Obstacles to Caregiver Investment in Young Children: A Mixed-Methods Analysis. International journal of environmental research and public health Li, R., Rose, N., Zheng, Y. M., Chen, Y., Sylvia, S., Wilson-Smith, H., Medina, A., Dill, S., Rozelle, S. 2021; 18 (4)

  Abstract

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

  View details for DOI 10.3390/ijerph18041457

  View details for PubMedID 33557178

• The competence of village clinicians in the diagnosis and treatment of heart disease in rural China: A nationally representative assessment. The Lancet regional health. Western Pacific Guo, W., Sylvia, S., Umble, K., Chen, Y., Zhang, X., Yi, H. 2020; 2: 100026

  Abstract

  While strengthening primary care quality is key to China's health system reforms, evidence to guide this work has been limited, particularly for rural areas. This study provides the first nationally-representative assessment of village doctors' competence in diagnosing and managing presumptive heart disease.A cross-sectional study of village clinics was conducted across five provinces. We presented standardized clinical vignettes to evaluate clinicians' competence in diagnosing and managing unstable angina. Enumerators accompanying mock patients documented the interaction, including questions, physical examinations, diagnoses, and management options provided by the doctor. We measured diagnostic process competence as adherence to "recommended" questions and examinations based on national clinical practice guidelines, diagnostic competence according to whether clinicians provided a correct diagnosis, and management as correct medication and/or referral. Management was assessed twice: following clinicians' own diagnoses determined through questioning and examinations, and after enumerators provided doctors with the correct diagnosis.Clinicians completed 26% (95% CI 24% to 28%) of recommended diagnostic questions and examinations; 20% (14% to 27%) arrived at a correct diagnosis. Rates of correct management were 43% (35% to 51%) following clinicians' own diagnosis and 51% (43% to 59%) after being given the correct diagnosis. When given the correct diagnosis and only asked to provide treatment, clinicians prescribed 82% fewer potentially harmful medications than in treatments based on their own (potentially incorrect) diagnosis.The ability of village doctors to diagnose a textbook case of unstable angina is limited. Deficits in diagnostic competence led to low rates of correct management.

  View details for DOI 10.1016/j.lanwpc.2020.100026

  View details for PubMedID 34327377

  View details for PubMedCentralID PMC8315592