Chengchao Zhou

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

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

Adherence to tuberculosis treatment among migrant pulmonary tuberculosis patients in Shandong, China: a quantitative survey study.

Adherence to TB treatment is the most important requirement for efficient TB control. Migrant TB patients’ “migratory” nature affects the adherence negatively, which presents an important barrier for National TB Control Program in China. Therefore, TB control among migrants is of high importance.The aim of this study is to describe adherence to TB treatment among migrant TB patients and to identify factors associated with adherence. A total of 12 counties/districts of Shandong Province, China were selected as study sites. 314 confirmed smear positive TB patients were enrolled between August 2nd 2008 and October 17th 2008, 16% of whom were non-adherent to TB therapy. Risk factors for non-adherence were: the divorced or bereft of spouse, patients not receiving TB-related health education before chemotherapy, weak incentives for treatment adherence, and self supervision on treatment. Based on the risk factors identified, measures are recommended such as implementing health education for all migrant patients before chemotherapy and encouraging primary care workers to supervise patients.

Maternal and child mortality in China

www.thelancet.com Vol 383 March 15, 2014 953 target of Millennium Development Goal (MDG) 4 was to reduce mortality in children younger than 5 years by two-thirds between 1990 and 2015, and the target for MDG5 was to reduce the maternal mortality ratio by threequarters during the same period. In 2008, the Countdown to 2015 initiative identified 68 priority countries (including China) for accelerated action on maternal, newborn, and child health. During the past decades, China has made substantial progress in reducing maternal and child mortality. In June, 2013, China National Health and Family Planning Commission released the 2012 data from the National Maternal and Child Mortality Surveillance System. Mortality rates in pregnant women, neonates, postneonatal infants, and children younger than 5 years are shown in the table. These data suggest that China has achieved MDG4 ahead of schedule and is expected to achieve MDG5 in 2015. The dramatic reductions in maternal and child mortality rates are undisputedly attributed to China’s economy and health-care services. For 2012, national health expenditure was estimated to be ¥2·89 trillion, and health costs per head was about ¥2135·8. Effective interventions including antenatal care, hospital delivery, neonatal visits, and management of pregnant women and children younger than 3 years have greatly improved. Notably, in 1991, the rate of hospital births in China was only 50·6%, but raised 99·2% 20 years later. S ince 2000, the Chinese Government adopted many measures to improve the health of women and children, such as the project AG receives funding from Cancer Research UK and Economic and Social Research Council for TobaccoTactics.org. JB and MM declare that they have no competing interests.

Tuberculosis detection and the challenges of integrated care in rural China : a cross-sectional standardized patient study

Background Despite recent reductions in prevalence, China still faces a substantial tuberculosis (TB) burden, with future progress dependent on the ability of rural providers to appropriately detect and refer TB patients for further care. This study (a) provides a baseline assessment of the ability of rural providers to correctly manage presumptive TB cases; (b) measures the gap between provider knowledge and practice and; (c) evaluates how ongoing reforms of China’s health system—characterized by a movement toward “integrated care” and promotion of initial contact with grassroots providers—will affect the care of TB patients. Methods/Findings Unannounced standardized patients (SPs) presenting with classic pulmonary TB symptoms were deployed in 3 provinces of China in July 2015. The SPs successfully completed 274 interactions across all 3 tiers of China’s rural health system, interacting with providers in 46 village clinics, 207 township health centers, and 21 county hospitals. Interactions between providers and standardized patients were assessed against international and national standards of TB care. Using a lenient definition of correct management as at least a referral, chest X-ray or sputum test, 41% (111 of 274) SPs were correctly managed. Although there were no cases of empirical anti-TB treatment, antibiotics unrelated to the treatment of TB were prescribed in 168 of 274 interactions or 61.3% (95% CI: 55%–67%). Correct management proportions significantly higher at county hospitals compared to township health centers (OR 0.06, 95% CI: 0.01–0.25, p < 0.001) and village clinics (OR 0.02, 95% CI: 0.0–0.17, p < 0.001). Correct management in tests of knowledge administered to the same 274 physicians for the same case was 45 percentage points (95% CI: 37%–53%) higher with 24 percentage points (95% CI: −33% to −15%) fewer antibiotic prescriptions. Relative to the current system, where patients can choose to bypass any level of care, simulations suggest that a system of managed referral with gatekeeping at the level of village clinics would reduce proportions of correct management from 41% to 16%, while gatekeeping at the level of the township hospital would retain correct management close to current levels at 37%. The main limitations of the study are 2-fold. First, we evaluate the management of a one-time new patient presenting with presumptive TB, which may not reflect how providers manage repeat patients or more complicated TB presentations. Second, simulations under alternate policies require behavioral and statistical assumptions that should be addressed in future applications of this method. Conclusions There were significant quality deficits among village clinics and township health centers in the management of a classic case of presumptive TB, with higher proportions of correct case management in county hospitals. Poor clinical performance does not arise only from a lack of knowledge, a phenomenon known as the “know-do” gap. Given significant deficits in quality of care, reforms encouraging first contact with lower tiers of the health system can improve efficiency only with concomitant improvements in appropriate management of presumptive TB patients in village clinics and township health centers.

Tuberculosis detection and the cost of integrated care in rural China: a cross-sectional standardised patient study

Abstract Background Future progress against tuberculosis in China will likely rely on improved detection, particularly in rural areas where prevalence remains high. The ability of rural providers to correctly diagnose Tuberculosis is largely unknown, as are the potential effects on tuberculosis patients of health-system reforms promoting initial contact with grassroots providers. Methods We employed unannounced standardised patients presenting with classic pulmonary tuberculosis symptoms in a representative survey of village, township, and county level providers in three provinces and assessed provider management of standardised patients against international and national standards of care. We then measured the gap between knowledge and practice by comparing doctor care of standardised patients to their performance in clinical vignettes of an identical presumptive tuberculosis case. Finally, we simulated the management of patients at the health-system level under alternative managed care policies accounting for provider referrals. Findings In July, 2015, we successfully completed 274 standardised patient interactions. Of 46 interactions in village clinics, 13 (28%) were correctly managed (95% CI 17–43%), compared with 79 (38%) of 207 in township health centers (32–45%) and 19 (90%) of 21 in county hospitals (71–97%). The same providers were 45 percentage points (95% CI 37–53%) more likely to correctly manage the same case in vignettes. Under existing policy, which allows patients to freely choose initial providers, simulations suggest that 40% (95% CI 34–47%) of patients encountering the health system are correctly managed. This would reduce to 16% with gatekeeping from village clinics and to 37% from township centers. Interpretation We uncovered important quality deficits among grassroots providers in the management of a case of presumptive tuberculosis and a large gap between provider knowledge and practice. In view of the current quality of care, reforms encouraging first contact in village clinics could reduce the rate of detection of patients with tuberculosis. Funding Fundamental Research Funds for the Central Universities and the Research Funds of Renmin University of China (2015030245), the 111 Project (B16031), the National Science Foundation of China (71473152), and the Department of Science and Technology of Shandong Province (BS2012SF010).

Suicidal ideation, plans and attempts among medical college students in china: The effect of their parental characteristics

Medical college students are a high-risk population of suicidal ideation, plan and attempt. However, few studies discuss the effect of parental characteristics on suicidal ideation, plans and attempts among medical college students in China. A total of 2198 respondents answered the questionnaires referring social-demographic characteristics, psychological conditions, parental characteristics, suicidal ideation, plan and attempt. The prevalence of suicidal ideation, plan and attempt among the subjects were 17.9%, 5.2% and 4.3%, respectively. The results of multiple logistic regression showed that male, mothers education level, mothers parenting style, relationship in parents and psychological condition were associated with lifetime suicidal ideation. Male, mothers vocation, mothers parenting style, relationship in parents and psychological conditions were associated with suicide plan. Male, relationship in parents and psychological condition were associated with suicide attempt. Those imply that mother may play more roles on suicidal ideation and plan than father among medical college students in China. Psychological condition has a very strong association with suicidal ideation, plan and attempt.

Catastrophic health expenditure: a comparative analysis of empty-nest and non-empty-nest households with seniors in Shandong, China

Objective 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. Setting Shandong province of China. Participants A total of 2761 elderly households are included in the analysis. Results 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). Conclusions 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.

Pulmonary tuberculosis among migrants in Shandong, China: factors associated with treatment delay.

Objective A timely initiation of treatment is crucial to better control tuberculosis (TB). The aim of this study is to describe treatment delay among migrant patients with TB and to identify factors associated with treatment delay, so as to provide evidence for strategy development and improvement of TB control among migrants in China. Design A cross-sectional study was conducted in Shandong province of China. A total of 314 confirmed smear positive migrant patients with pulmonary TB were included. Univariate logistic regression was used to analyse the association of variables with treatment delay among migrant patients with TB. A multilogistic regression model was developed to further assess the effect of variables on treatment delay. Results Of 314 migrant patients with TB, 65.6% experienced treatment delay (>1 day). Household income level, diagnosis symptom severity, understanding of whether TB is curable or not and knowledge about the free TB treatment policy are factors significantly associated with treatment delay. Conclusions Economic status and knowledge about TB are key barriers to accessing TB treatment. An integrated policy of carrying out TB-related health education and publicising the free TB treatment policy among migrants is needed. Health insurance schemes for migrants should be modified to make them transferrable and pro-poor.

Alcohol consumption is higher among left-behind Chinese children whose parents leave rural areas to work.

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 childrens alcohol use.

Health-related quality of life among adults with and without hypertension: A population-based survey using EQ-5D in Shandong, China

Previous studies have focused on health-related quality of life (HRQoL) in hypertensive individuals, but few studies have attempted to compare HRQoL between hypertensive and normotensive individuals using the EQ-5D in China. Based on a survey of 3509 adults aged 18 + years, we compared HRQoL between hypertensive and normotensive individuals using a chi-square test, t-test and multi-linear regression model. The results indicated that HRQoL in hypertensive individuals was poorer than that of normotensive individuals in all domains of the EQ-5D and its utility index. In addition, education, complications, household income, and family history of HBP were associated with HRQoL among the hypertensive patients. Factors including age, education, household income, health expenditure, place of residence, and family history of high blood pressure (HBP) were found to be associated with HRQoL in normotensive individuals. Interventions targeting at-risk subgroups, such as modifying existing health insurance schemes to improve them for poor individuals, might be helpful to improve HRQoL.