The medium-term impact of a micronutrient powder intervention on anemia among young children in Rural China.

BACKGROUND: Poor development of young children is a common issue in developing countries and it is well established that iron deficiency anemia is one of the risk factors. Research has shown that iron deficiency is a common micronutrient deficiency among children in rural China and can result in anemia. A previous paper using data from the same trial as those used in the current study, but conducted when sample children were younger, found that after 6 months of providing caregivers of children 6-11 months of age free access to iron-rich micronutrient powder (MNP) increased the hemoglobin concentrations (Hb) of their children. However, no effects were found 12 and 18 months after the intervention. The current study followed up the children four years after the start of the original intervention (when the children were 4-5 years old) and aims to assess the medium-term impacts of the MNP program on the nutritional status of the sample pre-school-aged children, including their levels of Hb, the prevalence of anemia, and the dietary diversity of the diets of the children. METHODS: At baseline, this study sampled 1,802 children aged 6-11 months in rural Western China. The intervention lasted 18 months. In this medium-term follow-up study that successfully followed 81% (n = 1,464) of children (aged 49-65 months) from the original study population 4 years after the start of the intervention, we used both intention-to-treat (ITT) effect and average treatment on the treated effect (ATT) analyses to assess the medium-term impacts of the MNP distribution program on the nutritional status of sample children. RESULTS: The ITT analysis shows that the MNP intervention decreased the prevalence of anemia of young children in the medium run by 8% (4 percentage points, p < 0.1). The ATT analysis shows that consuming 100 (out of 540) MNP sachets during the initial intervention led to a decrease in anemia of 4% (2 percentage points, p < 0.1). Among children with moderate anemia at baseline (Hb < 100 g/L), the intervention reduced the probability of anemia by 45% (9 percentage points, p < 0.1), and, for those families that complied by consuming 100 (out of 540) sachets, a 25% (5 percentage points, p < 0.05) reduction in the anemia rate was found. The MNP intervention also led to a persistent increase in dietary diversity among children that were moderately anemic at baseline. The results from the quantile treatment effect analysis demonstrated that children with lower Hb levels at baseline benefited relatively more from the MNP intervention. CONCLUSIONS: The findings of the current study reveal that the MNP intervention has medium-term effects on the nutritional status of children in rural China. The impacts of the MNP program were relatively higher for children that initially had more severe anemia levels. Hence, the implications of this study are that programs that aim to increase caregiver knowledge of nutrition and improve their feeding practices should be encouraged across rural China. Families, policymakers, and China's society overall need to continue to pay more attention to problems of childhood anemia in rural areas. This is particularly crucial for families with moderately anemic children at an early age as it can significantly contribute to improving the anemia status of children across rural areas of China. TRIAL REGISTRATION: ISRCTN44149146 (15/04/2013).

How does climate policy uncertainty affect green technology innovation at the corporate level? New evidence from China.

The frequent occurrence of extreme weather reminds us to focus more attention on sustainable development. A panel of Chinese A-share listed companies is selected as a research sample to explore how climate policy uncertainty has an effect on companies' green technology innovation. According to the empirical findings, corporate green technology innovation is negatively related to the uncertainty of climate policy. By affecting their R&D investments and risk tolerance, corporations' ability to develop in green technologies has been impacted by the uncertainty of climate policy. We also note that due to the nature of business ownership, the detrimental effect of uncertain climate policy on green technology innovation varies slightly between companies. While environmental regulations reinforce the negative impact of climate policy uncertainty, government subsidies can significantly mitigate this negative impact. These results have important theoretical and practical implications for the development of green economy theory and the realization of energy efficiency in various countries.

Passive versus active service delivery: Comparing the effects of two parenting interventions on early cognitive development in rural China.

We present the results of a cluster-randomized controlled trial that evaluates the effects of a free, center-based parenting intervention on early cognitive development and parenting practices in 100 rural villages in China. We then compare these effects to a previous trial of a home-based intervention conducted in the same region, using the same parenting curriculum and public service system, accounting for potential differences between the studies. We find that the center-based intervention did not have a significant impact on child development outcomes, but did lead to increases in the material investments, time investments, and parenting skills of caregivers. The average impact of the center-based intervention on child skills and investments in children was significantly smaller than the home-visiting intervention. Analysis of the possible mechanisms suggests that the difference in effects was driven primarily by different patterns of selection into program participation.

Dietary diversity and mental health in preschoolers in rural China.

OBJECTIVE: To investigate the prevalence of mental health problems among preschoolers in rural China and examine the relationship between dietary diversity and mental health. DESIGN: A cross-sectional survey analysis was performed. Child mental health was assessed with the Strengths and Difficulties Questionnaire (SDQ). Child dietary diversity was assessed with the dietary diversity score (DDS), which was calculated based on nine food groups using a 24-h recall method. Data were analysed using unadjusted and adjusted logistic regression models. SETTING: Two nationally designated poverty counties in Hunan Province of China. PARTICIPANTS: Preschoolers (n 1334) aged 3-5 years, preschools (n 26). RESULTS: Of 950 preschoolers with data on both dietary diversity and mental health, 663 (70 %) were classified as having at least one kind of mental health problem. The prevalences of emotional symptoms, conduct problems, symptoms of hyperactive/inattention, peer relationship problems and poor prosocial behaviour were 39, 27, 23, 12 and 26 %, respectively. Male preschoolers showed higher risks of having mental health problems than their female counterparts on each SDQ subscale except for conduct problems. Moreover, a higher DDS was significantly associated with a lower likelihood of having symptoms of hyperactivity/inattention, peer relationship problems and prosocial behaviour problems after adjustment for confounders (preschoolers' age, gender, cognitive ability, parental migration status, primary caregiver's education and household socio-economic status). CONCLUSIONS: The prevalence of mental health problems was high among preschoolers in rural China. Improving child dietary diversity might be an important strategy to consider in the design of interventions to improve child mental health.

Parental Migration and Early Childhood Development in Rural China.

Nearly one-quarter of all children under age 2 in China are left behind in the countryside as parents migrate to urban areas for work. We use a four-wave longitudinal survey following young children from 6 to 30 months of age to provide first evidence on the effects of parental migration on development, health, and nutritional outcomes in the critical first stages of life. We find that maternal migration has a negative effect on cognitive development: migration before children reach 12 months of age reduces cognitive development by 0.3 standard deviations at age 2. Possible mechanisms include reduced dietary diversity and engagement in stimulating activities, both known to be causally associated with skill development in early life. We find no effects on other dimensions of physical and social-emotional health.

Do Infant Feeding Practices Differ Between Grandmothers and Mothers in Rural China? Evidence From Rural Shaanxi Province.

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.

[Factors analysis on caregivers' compliance behaviors in nutrition packages feeding by PRECEDE theory in poor rural areas of Southern Shaanxi Province].

OBJECTIVE: To explore the main factors on caregivers' compliance behaviors in nutrition packages feeding in poor rural areas of Southern Shaanxi Province based on PRECEDE theory in terms of the predisposing factors( related knowledge and intentions of themselves), the enabling factors( social conditions and skills of behavior fulfillment) and the reinforcing factors( attitude of the important people around and rewards for persistent behavior). METHODS: The target villages were selected using multistages random sampling method( county-township-village) in the poor counties of Southern Shaanxi Province. Then we investigated all of the main caregivers whose family have an infant aged 6-12 months in these sampling villages. A follow-up investigation was conducted 6 months after the nutrition packages were given. A structured questionnaire was applied to collect data, which including the information about the nutrition packages feeding behavior of the caregivers and the related factors to their behaviors based on the PRECEDE theory, and the social demographic information of infants and their caregivers. Information about the questionnaire by the face-to-face interview at their home was collected. At the same time, we counted empty nutrition packages by the method of onsite enumeration, and checked with the questionnaire to obtain the information of caregivers' feeding behavior. Single factor analysis and multivariate Logistic regression analysis was used to analyze the factors associated with caregivers 'compliance to feed their infants nutrition packages. RESULTS: A total of 910 samples were interviewed, and the rate of caregivers' compliance to feed their infants nutrition packages was 64. 0%. The willing of caregivers to feed their infants nutrition packages( OR = 1. 582, 95% CI1. 117-2. 242) was a favorable predisposing factor to promote caregivers feed their infants nutrition packages. The preference of infants to nutrition packages( OR = 5. 116, 95% CI4. 064-6. 441), villages' encouragement( OR = 1. 527, 95% CI 1. 094-2. 132) as well as infants' changes in health status( OR = 1. 615, 95% CI 1. 231-2. 118) were positive reinforcing factors of feeding nutrition packages compliance of caregivers. CONCLUSION: The compliance of caregivers feed nutrition packages to their infants is low. The reinforcing factors are the key factors that affected the feeding behavior of caregivers' nutrition packages.

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

BACKGROUND: Anemia early in life has been associated with delayed cognitive and motor development. The WHO recommends home fortification using multiple micronutrient powders (MNPs) containing iron as a strategy to address anemia in children under two. We evaluated the effects of a program freely distributing MNP sachets to caregivers of infants in rural China. METHODS: We conducted a cluster-randomized controlled trial in Shaanxi province, enrolling all children aged 6-11 months in target villages. Following a baseline survey, investigators randomly assigned each village/cluster to a control or treatment group. In the treatment group, caregivers were instructed to give MNPs daily. Follow-up was after 6, 12, and 18 months of intervention. Primary outcomes were hemoglobin concentrations and scores on the Bayley Scales of Infant Development. RESULTS: One thousand, eight hundred and-two eligible children and their caregivers were enrolled. At baseline 48% (870) of children were anemic and 29% (529) were developmentally delayed. Six hundred and-ten children (117 villages) were assigned to the control group and 1192 children (234 villages) were assigned to the treatment group. Assignment to the treatment group was associated with an improvement in hemoglobin levels (marginal effect 1.77 g/L, 95% CI 0.017-3.520, p-value = 0.048) and cognitive development (marginal effect 2.23 points, 95% CI 0.061-4.399, p-value = 0.044) after 6 months but not thereafter. There were no significant effects on motor development. Zero effects after the first 6 months were not due to low compliance, low statistical power, or changes in feeding behavior. Hemoglobin concentrations improved in both the treatment and control groups over the course of the study; however, 22% (325) of children remained anemic at endline, and 48% (721) were cognitively delayed. CONCLUSIONS: Providing caregivers with MNP sachets modestly hastened improvement in hemoglobin levels that was occurring absent intervention; however, this improvement did not translate into improved developmental outcomes at endline. TRIAL REGISTRATION: ISRCTN44149146 ; prospectively registered on 15th April 2013.

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.

OBJECTIVES: To test whether text message reminders sent to caregivers improve the effectiveness of a home micronutrient fortification program in western China. METHODS: We carried out a cluster-randomized controlled trial in 351 villages (clusters) in Shaanxi Province in 2013 and 2014, enrolling children aged 6 to 12 months. We randomly assigned each village to 1 of 3 groups: free delivery group, text messaging group, or control group. We collected information on compliance with treatments and hemoglobin concentrations from all children at baseline and 6-month follow-up. We estimated the intent-to-treat effects on compliance and child anemia using a logistic regression model. RESULTS: There were 1393 eligible children. We found that assignment to the text messaging group led to an increase in full compliance (marginal effect = 0.10; 95% confidence interval [CI] = 0.03, 0.16) compared with the free delivery group and decrease in the rate of anemia at end line relative to the control group (marginal effect = -0.07; 95% CI = -0.12, -0.01), but not relative to the free delivery group (marginal effect = -0.03; 95% CI = -0.09, 0.03). CONCLUSIONS: Text messages improved compliance of caregivers to a home fortification program and children's nutrition.

[Risk factors for anemia in infants aged 6-12 months from rural areas of southern Shaanxi Province, China].

OBJECTIVE: To investigate the prevalence of anemia and related risk factors in infants aged 6-12 months from rural areas of southern Shaanxi Province. METHODS: A questionnaire survey was used to collect the basic information on infants aged 6-12 months and their families from rural areas of southern Shaanxi Province, China. The content of hemoglobin was measured in these infants. A multivariate logistic stepwise regression analysis was performed to determine the risk factors for the development of anemia in infants. RESULTS: A total of 1 802 infants and their families participated in the survey, and there were 1 770 valid samples. A total of 865 infants (865/1 770, 48.87%) were found to have anemia. The multivariate logistic stepwise regression analysis showed that breastfeeding after birth (lack of scientific supplementary food) increased the risk of anemia in infants (OR=1.768, P<0.01). Addition of supplementary food which met the criteria for minimum feeding frequency recommended by WHO (OR=0.779, P<0.05) and formula milk feeding (OR=0.658, P<0.01) were protective factors against anemia in infants. CONCLUSIONS: In the rural areas in southern Shaanxi Province, anemia in infants aged 6-12 months is still a serious public health problem. Improper feeding can increase the risk of anemia in infants, and scientific addition of supplementary food is the key to reducing anemia in infants.

THE PREVALENCE OF ANEMIA IN CENTRAL AND EASTERN CHINA: EVIDENCE FROM THE CHINA HEALTH AND NUTRITION SURVEY.

Although China has experienced rapid economic growth over the past few decades, significant health and nutritional problems remain. Little work has been done to track basic diseases, such as iron-deficiency anemia, so the exact prevalence of these health problems is unknown. The goals of this study were to assess the prevalence of anemia in China and identify individual, household and community-based factors associated with anemia. We used data from the 2009 China Health and Nutrition Survey (CHNS), including the measurement of hemoglobin levels among 7,261 individuals from 170 communities and 7 provinces in central and eastern China. The overall prevalence of anemia was 13.4% using the WHO's blood hemoglobin thresholds (1968). This means in China's more developed central and eastern regions up to 180 million people may be anemic. Some vulnerable subgroups were disproportionately affected by anemia. Seniors (aged 60 years and above) were more likely to be anemic than younger age cohorts, and females had higher anemia prevalence among all age groups except among children aged 7 to 14 years. We found a negative correlation between household wealth and the presence of anemia, suggesting anemia prevalence may decline as China's economy grows. However, the prevalence of anemia was greater in migrant households, which should be experiencing an improved economic status.

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

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.

Emotional Warmth and Rejection Parenting Styles of Grandparents/Great Grandparents and the Social-Emotional Development of Grandchildren/Great Grandchildren.

Parenting styles are crucial in the process of forming social emotions in children. They are also vital for creating effective family policies in order to improve a child's early development. As such, it is important to acknowledge the enduring association of parenting styles across generations, as well as their impact on early child development. In this study, the question as to whether the warm and hostile parenting styles of a parent/grandparent mediate the relationships between the emotional warmth and rejection parenting styles of a grandparent/great grandparent, as well as the subsequent social-emotional development of a grandson/great grandson and/or a granddaughter/great granddaughter, was examined. Cross-sectional assessment data from 194 primary caregivers of children between 6 and 36 months were analyzed using mediation analyses. In addition, moderated mediation models were used to test heterogeneity effects. This study found evidence that the warm and hostile parenting styles of a parent/grandparent mediated the associations between the emotional warmth and rejection parenting styles of a grandparent/great grandparent, as well as the subsequent socio-emotional development of a grandchild/great grandchild. Parents/grandparents tend to use a warm parenting style when the child is a boy, thereby resulting in fewer socio-emotional problems. This study provides empirical evidence for the purposes of preventive services to improve caregivers' parenting styles in the early stages of a child's development. Researchers and family practitioners should continue to support families with intervention or therapeutic techniques in order to mitigate potential lasting consequences.

Preschool or/and kindergarten? The long-term benefits of different types of early childhood education on pupils' skills.

BACKGROUND: Developing countries have witnessed great progress in early childhood education (ECE) enrollment rate over the past three decades. Preschool and kindergarten are the two most common types of ECE in developing countries. Questions remain as to which of the two types of ECE is more effective in promoting child development in developing countries, including both cognitive and non-cognitive skills. The objective of this paper is to examine the long-term benefits of attending preschool or/and kindergarten on pupils' cognitive and non-cognitive skills in rural China. METHODOLOGY: We pooled data from two large-scale surveys conducted by the authors themselves at 136 rural primary schools in 20 counties from three provinces in northwestern China in 2009. The final study sample consisted of 9,839 pupils who both reported their ECE experience and completed cognitive and non-cognitive tests. We measured pupils' cognitive skills by standardized math test scores and grade retention, and their non-cognitive skills by both self-reported self-efficacy, mental health, and teacher-reported behaviors. Inverse Probability Weighting (IPW) was used to balance the pre-treatment variables between the treatment (Any ECE, Preschool Only, Kindergarten Only, or Preschool+Kindergarten) and comparison (No ECE) groups. RESULTS: Results from IPW show that compared with their peers without any ECE experience, pupils with any ECE experience perform better in cognitive skills (0.118 standard deviations (s.d.) increase in the TIMSS, 7.1 percentage point (pp) decrease in the probability of grade retention) but not in non-cognitive skills. By ECE types, attending kindergarten only is associated with a 0.150 s.d. increase in the TIMSS, a 7.0 pp decrease in the probability of grade retention, and a 0.059 s.d. decrease in the index of behavioral problems of pupils. Moreover, attending both preschool and kindergarten predicts a lower probability of grade retention, but attending preschool only has few benefits. Heterogenous analyses suggest that the long-term benefits of ECE are more prominent among the Han pupils from households with higher socio-economic status. CONCLUSIONS: Our findings imply that increasing access to ECE can be an effective instrument to improve pupils' skills in less-developed rural areas of China, especially their cognitive skills. Among different types of ECE, attending kindergarten contributes more to pupils' skill development in rural China than other types. We call for strengthened efforts to ensure equal access to quality ECE for preschool-aged children in rural China.

Anaemia among students of rural China's elementary schools: prevalence and correlates in Ningxia and Qinghai's poor counties.

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.

High anemia prevalence in western China.

We assessed the prevalence of anemia among schoolchildren in western China as determined by seven cross-sectional surveys involving 12,768 children aged 8-12 years. Subjects were selected randomly from 283 primary schools in 41 economically disadvantaged counties of Ningxia, Qinghai, Shaanxi and Sichuan Provinces. Data were collected through questionnaires and hemoglobin levels were measured. The anemia prevalence was 34% using the WHO hemoglobin cutoff of < 120 g/l. Boarding students and girls were more likely to be anemic. The prevalence of anemia in schoolchildren was high. Iron deficiency is a significant nutrition issue in China.

Home Environment and Early Development of Rural Children: Evidence from Guizhou Province in China.

Delays in early child development are among the aspects underlying the persistent developmental gaps between regions and social strata. This study seeks to examine the relationship between the home environment and early child development in less-developed rural areas by drawing on data from 445 children from villages in Guizhou province in southwest China. A demographic questionnaire, the Home Observation Measurement of the Environment (HOME), and the Bayley Scales of Infant Development, version III (BSID-III), were used to measure the child's demographic characteristics, home environment, and early development outcomes, respectively. Our data show that the sample children suffer a delay in various dimensions of child development and a deficit in the HOME scale. The results from a hierarchical regression model suggest that the availability of learning material at home, caregivers' responsiveness and organization sub-scales are significantly positively correlated with the early development of sample children, after controlling for general socioeconomic status, health, and nutrition, and this correlation differs by gender. These results imply that the provision of learning material to households, promoting caregivers' responsiveness and organization in less-developed rural areas could improve early child development among deprived children.

Association of dietary diversity and cognition in preschoolers in rural China.

OBJECTIVES: We sought to investigate the cognition of preschoolers in rural China and examine the relationship between dietary diversity and cognition. METHODS: We performed a cross-sectional survey analysis. In 1334 preschoolers ages 3 to 5, from 26 preschools in two nationally designated poverty counties in Hunan Province in China, we calculated the dietary diversity score (DDS) using a 24-h recall method. To measure children's cognitive ability, we assessed the Working Memory Index and Verbal Comprehension Index on the Mandarin-language version of the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition. Multiple linear regression models were used to estimate the association between DDS and cognitive test scores. RESULTS: A total of 22% of children had a Working Memory Index that was either extremely low or borderline, and 31% of children had a Verbal Comprehension Index that was either extremely low or borderline. The mean (± SD) DDS was 5.65 ± 1.30. Those preschoolers with medium DDS (5 or 6) or high DDS (7 to 9) scored higher on both Working Memory Index-respectively, mean difference (MD), 1.327; 95% confidence interval (CI), 0.246-3.901; and MD, 2.067, 95% CI, 0.261-4.641-and Verbal Comprehension Index-MD, 0.168; 95% CI, 0.072-2.135; and MD, 0.398; 95% CI, 0.032-2.137-than did those with low DDS (0 to 4). CONCLUSIONS: Consuming a more diverse diet may contribute to better cognition in preschoolers. Future research is needed to better understand the possible causal effect of dietary diversity on cognitive development.

Nutrition, Cognition, and Social Emotion among Preschoolers in Poor, Rural Areas of South Central China: Status and Correlates.

Existing empirical evidence suggests that the prevalence of undernutrition in remote and poor, rural areas is still high among Chinese children. While evidence reveals that undernutrition may detrimentally affect child development, studies focusing on rural Chinese preschoolers are sparse. Using the baseline survey of a preschool's free nutritious lunch pilot program, this study examined the relationship between child undernutrition and developmental outcomes among a preschool-aged sample in poor, rural areas of China. We conducted the baseline survey in Hunan province in south central China in September 2018. A total of 1293 preschoolers living in two (then) nationally designated poverty counties in rural Hunan served as our study sample. Children's nutritional statuses were measured using height-for-age z-score, weight-for-age z-score, and anemia, while their cognitive and socio-emotional skills were assessed using the Wechsler Preschool and Primary Scale of Intelligence (WPPSI) and Strengths and Difficulties Questionnaire (SDQ), respectively. We find that 33% of sample preschoolers were anemic, whereas the incidences of stunting and wasting were 11% and 2%, respectively. About 54% of the sample children had delay in at least one of the developmental domains measured in this study. Our findings provide suggestive evidence supporting that children from certain backgrounds tend to experience worse nutritional and developmental outcomes than their counterparts. After controlling for socioeconomic status, we observed that both anemia and stunting were negatively associated with children's cognitive performance; however, they were not associated with socio-emotional performance. As such, this study suggests that free lunch programs have the potential to change children's developmental trajectory in preschool. We believe that our results will contribute to the debate surrounding whether the nutritious lunch program in China should be expanded to the preschool education level.

Early childhood development and parental training interventions in rural China: a systematic review and meta-analysis.

INTRODUCTION: Inadequate care during early childhood can lead to long-term deficits in skills. Parenting programmes that encourage investment in young children are a promising tool for improving early development outcomes and long-term opportunities in low-income and middle-income regions, such as rural China. METHODS: We conducted a systematic review and a meta-analysis to investigate the prevalence of early developmental delays and stimulating parenting practices as well as the effect of parental training programmes on child development outcomes in rural China. We obtained data in English from EconPapers, PubMed, PsycARTICLES, Cochrane Library, Web of Science and Scopus (Elsevier) and in Chinese from China National Knowledge Infrastructure, Wanfang Data and VIP Information. We conducted frequentist meta-analyses of aggregate data and estimated random-effects meta-regressions. Certainty of evidence was rated according to the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS: We identified 19 observational studies on the prevalence of developmental delays and stimulating parenting practices for children under 5 years of age (n=19 762) and ten studies on the impact of parental training programmes on early child development (n=13 766). Children's risk of cognitive, language and social-emotional delays in the rural study sites (covering 14 provinces mostly in Central and Western China) was 45%, 46%, and 36%, respectively. Parental training programmes had a positive impact on child cognition, language and social-emotional development. CONCLUSION: There is evidence to suggest that early developmental delay and the absence of stimulating parenting practices (ie, reading, storytelling and singing with children) may be prevalent across rural, low-income and middle-income regions in Central and Western China. Results support the effectiveness of parental training programmes to improve early development by encouraging parental engagement. TRIAL REGISTRATION NUMBER: This study was registered with PROSPERO (CRD42020218852).