Associations between urbanization and the home language environment: Evidence from a LENA study in rural and peri-urban China.

In low- and middle-income countries, urbanization has spurred the expansion of peri-urban communities, or urban communities of formerly rural residents with low socioeconomic status. The growth of these communities offers researchers an opportunity to measure the associations between the level of urbanization and the home language environment (HLE) among otherwise similar populations. Data were collected in 2019 using Language Environment Analysis observational assessment technology from 158 peri-urban and rural households with Han Chinese children (92 males, 66 females) aged 18-24 months in China. Peri-urban children scored lower than rural children in measures of the HLE and language development. In both samples, child age, gender, maternal employment, and sibling number were positively correlated with the HLE, which was in turn correlated with language development.

Pre-operative enteral feeding in single-ventricle CHD patients and necrotising enterocolitis risk.

INTRODUCTION: Enteral feeding prior to cardiac surgery has benefits in pre-operative and post-operative patient statuses. In 2020, to increase pre-operative feeding for single-ventricle patients prior to stage 1 palliation, an enteral feeding algorithm was created. The aim of this study is to monitor the impact of our practice change with the primary outcome of necrotising enterocolitis incidence from birth to 2 weeks following surgical intervention. METHODS: This is a single-site, retrospective cohort study including patients from 1 March, 2018 to 1 July, 2022. Variables assessed include demographics, age at cardiac surgery, primary cardiac diagnosis, necrotising enterocolitis pre-operative and 2 weeks post-operative cardiac surgery, feeding route, feeding type, volume of trophic enteral feeds, and near-infrared spectroscopy. RESULTS: Following implementation of a pre-operative enteral feeding algorithm, the rate of neonates fed prior to surgery increased (39.5-75%, p = .001). The feedings included a mean volume of 28.24 ± 11.16 ml/kg/day, 83% fed breastmilk only, 44.4% tube fed, and 55.5% of infants had all oral feedings. Comparing enterally fed neonates and those not enterally fed, the necrotising enterocolitis incidence from birth to 2 weeks post-op was not significantly increased (p = 0.926). CONCLUSION: As a result of implementing our feeding algorithm, the frequency of infants fed prior to stage I Norwood or Hybrid surgeries increased to 75%, and there was no significant change in the incidence of necrotising enterocolitis. This study confirmed that pre-operative enteral feeds are safe and are not associated with increased incidence of necrotising enterocolitis.

The home language environment in rural China: variations across family characteristics.

BACKGROUND: A rich language environment is an important element of a nurturing home environment. Despite their proven importance, vocabulary and conversation have been shown to vary widely across households-even within the same socio-economic class. One significant gap in the existing literature is its nearly exclusive geographic focus on Western and developed settings, with little attention given to poorer communities in lower/middle income countries. The purpose of this study was to empirically illustrate the characteristics of the home language environment in the low SES, non-Western cultural setting of rural China. METHODS: Using Language Environment Analysis (LENA) automated language-analysis system, this study measured the home language environment of 38 children aged 20-27 months in Northwest rural China. Our primary measures of the home language environment were Adult Word Count (AWC), Conversational Turn Count (CTC) and Child Vocalization Count (CVC). Multivariate linear regression models were used to examine the association between home language environment and family/child characteristics, and language skills (Measured by MacArthur-Bates Communicative Developmental Inventory score). RESULTS: In this paper, by comparison, we found that the home language environment of our rural sample fell far behind that of urban households. We also identify significant, positive correlations between language skills and both AWC and CTC. Our analysis finds no significant correlations between home language environment and family/child characteristics. CONCLUSION: In this paper, we present the first ever findings using the LENA system to measure the home language environment of young children from poor rural communities in China. We found that the home language environment of lower-SES household was significantly worse than high-SES households, and demonstrated the importance of the home language environment to language skills, pointing to a need for more high-quality studies of the home language environment in rural China to better understand possible mechanisms behind low levels of parent-child language engagement and ways to improve the home language environment.

The association between micronutrient powder delivery patterns and caregiver feeding behaviors in rural China.

BACKGROUND: High adherence and proper usage of micronutrient powder (MNP) influence child nutritional outcomes, yet few studies explore the role of delivery patterns. This study explores the association between MNP delivery patterns and MNP feeding behaviors among Han and minority caregivers in rural Western China. METHODS: In August 2019, a total of 1021 caregiver-child pairs were selected through a four-stage cluster sampling process. A cross-sectional survey collected information on caregiver demographics, MNP delivery patterns (channel and frequency), and MNP feeding behaviors (proper usage and adherence). Using logistic regression, we examined which delivery channels and delivery frequencies were associated with proper usage and high adherence. RESULTS: The results indicated that minority caregivers had lower levels of proper MNP usage than did Han caregivers (89.2%), with Tibetan caregivers' reporting the lowest rates of adherence (32.6%). Logistic regression revealed that that township-based channel was significantly correlated with proper usage among Tibetan and Yi caregivers (Odds Ratio, OR = 2.0, p < 0.01; and OR = 3.5, p < 0.001). Overall, the township-based and home-visit channels were significantly correlated with high adherence (OR = 1.7 and OR = 2.3, respectively; p < 0.001); delivery frequency was significantly correlated with high adherence (2 months: OR = 2.2, p < 0.001 and ≤ 1 month: OR = 3.5, p < 0.001) but not correlated with proper usage among the whole sample and individual ethnic groups. CONCLUSIONS: In conclusion, the study finds evidence of a correlation between MNP delivery channel and both proper usage and high adherence as well as a correlation between MNP delivery frequency and high adherence.

Gap in protective behaviors between Han and minority ethnicities during COVID-19 pandemic in rural western China: A decomposition analysis.

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.

Measuring growth in critically ill neonates and children.

Critical illness increases the risk of malnutrition in both infants and children. Malnutrition risk is multifactorial and includes premorbid factors as well as changes in nutrient metabolism and energy demands during critical illness. Inadequate nutrition has been linked to poor health outcomes and prolonged length of stay in the intensive care unit, demonstrating the importance of both recognizing and addressing malnutrition in this population. Assessing growth and identifying malnutrition requires methodical measurement of growth and a collaborative, multimodal approach to nutrition assessment. Among the nutrition assessment and growth evaluation tools, neonatal, preterm, pediatric, and disease-specific growth charts remain an important component of growth assessment and should be used along with a nutrition-focused physical examination. Routine measurement promotes the identification of potential growth delays that may require interventions. Indirect calorimetry adds an additional layer of detail for a complete picture of each infant or child's unique nutrition status and progress. Quality improvement research on a national level is urgently needed to assess the adequacy and availability of resources in neonatal and pediatric critical care units and to further the development of standard clinical outcome measures for nutrition assessment and intervention in the critically ill neonate and child.

Factors of parental investment in the home language environment in peri-urban China: A mixed methods study.

The home language environment is a critical point of investment in early language skills. However, few studies have quantitatively measured the home language environment of low-socioeconomic-status households in non-western settings. This mixed methods study describes the home language environment and early child language skills among households in a low-socioeconomic-status, peri-urban district of Chengdu, China, and identifies factors influencing parental investment in the home language environment. Audio recordings were collected from 81 peri-urban households with children ages 18-24 months and analysed using the Language Environment Analysis (LENATM) system. The Mandarin version of the MacArthur-Bates Communicative Development Inventory was administered to each child's primary caregiver. The quantitative results revealed large variation in home language environments and child language skills among the sample, with relatively low average scores when compared to other Chinese samples. Qualitative interviews with a subset of 31 caregivers revealed that many caregivers face constraints on their knowledge of interactive parenting, compounded, in some households, by time constraints due to work or household responsibilities. The findings indicate a need for increased sources of credible parenting information for peri-urban caregivers of young children to promote investment in the home language environment.

Effectiveness of a government-led, multiarm intervention on early childhood development and caregiver mental health: a study protocol for a factorial cluster-randomised trial in rural China.

INTRODUCTION: The high incidences of both the developmental delay among young children and the mental health problems of their caregivers are major threats to public health in low-income and middle-income countries. Parental training interventions during early childhood have been shown to benefit early development, yet evidence on strategies to promote caregiver mental health remains limited. In addition, evidence on the optimal design of scalable interventions that integrate early child development and maternal mental health components is scarce. METHODS AND ANALYSIS: We design a single-blind, factorial, cluster-randomised controlled, superiority trial that will be delivered and supervised by local agents of the All China Women's Federation (ACWF), the nationwide, government-sponsored social protection organisation that aims to safeguard the rights and interests of women and children. We randomise 125 villages in rural China into four arms: (1) a parenting stimulation arm; (2) a caregiver mental health arm; (3) a combined parenting stimulation and caregiver mental health arm and (4) a pure control arm. Caregivers and their children (aged 6-24 months at the time of baseline data collection) are selected and invited to participate in the 12-month-long study. The parenting stimulation intervention consists of weekly, one-on-one training sessions that follow a loose adaptation of the Reach Up and Learn curriculum. The caregiver mental health intervention is comprised of fortnightly group activities based on an adaptation of the Thinking Healthy curriculum from the WHO. Primary outcomes include measures of child development and caregiver mental health. Secondary outcomes include a comprehensive set of physical, psychological and behavioural outcomes. This protocol describes the design and evaluation plan for this programme. ETHICS AND DISSEMINATION: This study received approval from the Institutional Review Board of Stanford University (IRB Protocol #63680) and the Institutional Review Board of the Southwestern University of Finance and Economics in Chengdu, Sichuan, China. Informed oral consent will be obtained from all caregivers for their own and their child's participation in the study. The full protocol will be publicly available in an open-access format. The study findings will be published in economics, medical and public health journals, as well as Chinese or English policy briefs. TRIAL REGISTRATION NUMBER: AEA RCT Registry (AEARCTR-0010078) and ISRCTN registry (ISRCTN84864201).

Family-level factors of early childhood development: Evidence from rural China.

Family-level factors that characterize the home environment are critical inputs to early language and cognitive development, and potential mechanisms for improving developmental outcomes in vulnerable populations. Many studies conducted in high-income and Western settings highlight stimulating parenting, the home language environment, and parental self-efficacy as possible mechanisms of early development, though less is known about how these family-level factors impact child development in low- or middle-income settings. Even less is known about these family-level factors and early childhood development in rural China, where rates of cognitive and language delay in children aged 0-3 years are as high as 45% and 46%, respectively. Using data collected from 77 rural households with children aged 18-24 months in Southwestern China, this study examines the associations between stimulating parenting, the home language environment, and parental self-efficacy, and early cognitive and language development. The results indicate that stimulating parenting was significantly associated with cognitive, language, and overall development; the home language environment was only significantly associated with language development; and parental self-efficacy was not significantly associated with any developmental outcomes. The implications of such findings reveal mechanisms for supporting healthy child development in rural China.

Academic Performance and the Link with Depressive Symptoms among Rural Han and Minority Chinese Adolescents.

The objectives of this paper were to examine the risk of depression and depressive symptoms among Han and minority children and adolescents in rural China, the links between academic performance and depressive symptoms, and the prevalence of these links among specific subgroups. A total of 8392 4th, 5th, and 6th grade students at 105 sample rural schools in eight low-income counties and districts in a prefectural-level city in Southwestern China were randomly selected using a three-step sampling strategy. A total of 51% of the sample were female (SD = 0.50), and the age range was 7 to 19 years (mean = 11.35 years; SD = 1.05). Using the Patient Health Questionnaire 8-item depression scale, the prevalence of depressive symptoms in the sample was assessed, while data on students' academic performance (standardized math test) and demographic characteristics were also collected. Our results show that the rates of major depression were 19% for Han students, 18% for Tibetan students, and 22% for Yi students; the rates of severe depression were 2% for Han and Tibetan students, and 3% for Yi students. Yi students were at significantly higher risks for major and severe depression than Han students. We conducted multivariate regression and heterogeneous analyses. Academic performance was negatively and significantly correlated to depressive symptoms. Across the whole sample, students with lower math scores, minority students, boys, younger students, and students with migrant parents were most vulnerable to depressive symptoms. The heterogeneous analysis suggests that among poor-performing students, subgroups at higher risk for depression include boys, non-boarding students, and students whose mothers had graduated from high school or above. These findings indicate a need to improve mental health outcomes of rural Han and minority primary school students, targeting academic performance for possible intervention.

The home language environment and early language ability in rural Southwestern China.

Using premier Language Environment Analysis technology to measure and analyze the home language environment, this observational study aims to describe the home language environment and child language ability, drawing on empirical data from 77 households with children aged 18-24 months from rural China. The results show large variation in measures of the home language environment and early language ability, similar to other rural Chinese samples. Results also demonstrate significant correlations between child age and the home language environment, maternal employment and the home language environment, father's educational attainment and the home language environment, adult-child conversations and early language ability, and child vocalizations and early language ability.

Using standardized patients to assess the quality of type 2 diabetes care among primary care providers and the health system: Evidence from rural areas of western China.

Background: Improving type 2 diabetes (T2D) care is key to managing and reducing disease burden due to the growing prevalence of diabetes worldwide, but research on this topic, specifically from rural areas, is limited. This study uses standardized patients (SPs) to assess T2D care quality among primary care providers to access the healthcare system in rural China. Methods: Using multi-stage random sampling, health facilities, providers, and households were selected. SPs were used to evaluate providers' T2D care quality and a questionnaire survey was used to collect patient sorting behaviors from households. Logistic regression was used to explore factors correlated with T2D care quality. Provider referral and treatment rates were combined with patient sorting behaviors to assess the overall quality of T2D management by rural China's healthcare system. Results: A total of 126 providers, 106 facilities, and 750 households were enrolled into this study. During SP interactions, 20% of rural providers followed the national guidelines for T2D consultation, 32.5% gave correct treatment, and 54.7% provided lifestyle suggestions. Multi-variable regression results showed that providers who had earned practicing certificates (ß = 1.56, 95% CI: 0.44, 2.69) and saw more patients (ß = 0.77, 95%: 0.25, 1.28) were more likely to use a higher number of recommended questions and perform better examinations, whereas providers who participated in online training were less likely to practice these behaviors (ß = -1.03, 95%: -1.95, -0.11). The number of recommended questions and examination (NRQE) was the only significant correlated factor with correct treatment (marginal effect = 0.05, 95%: 0.01, 0.08). Throughout the rural healthcare system, 23.7% of T2D patients were treated correctly. Conclusion: The quality of T2D care in rural western China, especially throughout the consultation and treatment process during a patient's first visit, is poor. Online training may not improve T2D care quality and low patient volume was likely to indicate poor care quality. Further research is needed to explore interventions for improving T2D care quality in rural China's healthcare system.

The know-do gap in quality of health for chronic non-communicable diseases in rural China.

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.