Diffusion of a micronutrient home fortification program for infants and toddlers in a multi-ethnic population in rural western China.

BACKGROUND: The micronutrient home fortification programs contribute to the prevention of childhood anemia. WHO suggested applying culturally appropriate strategies to implement the micronutrient home fortification programs in various communities. However, there is little knowledge on evidence-based effective diffusion strategies of the micronutrient home fortification programs in multi-ethnic populations. This study aims to examine the diffusion of a micronutrient home fortification program with micronutrient powder (MNP) in a multi-ethnic population by investigating factors associated with being an 'early' or a 'later' adopter of MNP. METHODS: We conducted a cross-sectional study in rural western China. Multistage sampling was used to select children's caregivers in Han, Tibetan, and Yi ethnic communities (N = 570). The diffusion of innovations theory informed the data collection on caregivers' decision process and was applied to classify participants into the MNP adopter categories of 'leaders', 'followers', 'loungers', and 'laggards'. The ordered logistic regression model estimated the factors associated with the MNP adopter categories. RESULTS: Caregivers from the Yi ethnic subgroup were likely to adopt MNP relatively late (AOR = 1.67; 95%CI = 1.09, 2.54) compared with Han and Tibetan ethnic subgroups. Caregivers with more knowledge regarding the MNP feeding method (AOR = 0.71; 95%CI = 0.52, 0.97) and those with stronger self-efficacy in adopting MNP (AOR = 0.85; 95%CI = 0.76, 0.96) were more likely to adopt MNP earlier than others. The following messages and channels also tend to make caregivers adopt MNP earlier: hearing that 'MNP was free' from villagers (AOR = 0.45; 95%CI = 0.20, 0.98), and learning 'MNP feeding method' from township doctors (AOR = 0.16; 95%CI = 0.06, 0.48). CONCLUSIONS: Disparities in adopting MNP existing among different ethnic groups require more effective diffusion strategies in disadvantaged minority ethnic groups. Enhancing self-efficacy in adopting MNP and knowledge on feeding method of MNP have the potential to make caregivers adopt MNP earlier. Peer networks and township doctors can be effective agencies to facilitate the diffusion and adoption of MNP.

[Micronutrient Powders Feeding Behaviors of Baby Caregivers in Remote Rural Areas of Sichuan Province: A Study Based on the Theory of Reasoned Action].

Objective: To explore the status quo and influencing factors of feeding behaviors of micronutrient powders (MNP), or yingyangbao in Pinyin, the Chinese Romanization system, of baby caregivers in remote rural areas of Sichuan Province. Methods: In 2019, caregivers of babies aged 6 to 24 months from 6 counties of Sichuan Province were selected as the respondents of the survey through a multistage cluster random sampling method. Data concerning the baby caregivers' attitude of behavior, subjective norms, behavioral intention, and feeding behaviors about MNP feeding were collected with a questionnaire through a structured interview. Based on the theory of reasoned action, a structural equation model was constructed to explore the influencing factors of feeding behaviors. Results: A total of 1002 valid samples were included in the study. The effective feeding rate of MNP among the baby caregivers was 55.49%. The results of model analysis suggested that attitude of behavior ( ß direct=0.212, 95% CI: 0.105-0.327), subjective norm ( ß direct=0.123, 95% CI: 0.016-0.228), and behavioral intention ( ß direct=0.162, 95% CI: 0.093-0.224) could have a significant direct impact on MNP feeding behaviors. Behavior attitude ( ß indirect=0.044, 95% CI: 0.023-0.073) and subjective norms ( ß indirect=0.018, 95% CI: 0.001-0.040) could have a significant indirect impact on MNP feeding behaviors through the intermediary of behavioral intention. Among the three theoretical elements, attitude of behavior had the largest total effect on the feeding behavior ( ß total=0.256, 95% CI: 0.148-0.366). Conclusion: The effective feeding rate of MNP among baby caregivers in remote rural areas of Sichuan Province is low. The attitude of behavior and subjective norms of caregivers may have a direct impact on their feeding behavior, and both attitude of behavior and subjective norms can have an indirect impact on the feeding behavior through the intermediary of behavioral intention. The influence of attitude of behavior attitude on feeding behavior is greater than that of subjective norms. Future intervention plans for promoting effective MNP feeding should incorporate health education for baby caregivers and their important social relations. Thus, baby caregivers' attitude and willingness for MNP feeding will be strengthened and the effective feeding rate of MNP will be improved accordingly.

Adherence to micronutrient powder for home fortification of foods among infants and toddlers in rural China: a structural equation modeling approach.

BACKGROUND: The WHO recommends daily use of micronutrient powder for infants and toddlers at risk of micronutrient deficiencies in low-and-middle-income countries. China has established a micronutrient powder distribution program in many rural townships and villages, yet adherence to micronutrient powder remains suboptimal; a little is known about the behavioral inputs that may influence adherence. This study examines direct and indirect behavioral inputs in micronutrient powder adherence among caregivers in rural western China following the Integrated Behavioral Model (IBM) framework. METHODS: Cross-sectional data were collected from April to May 2019 among 958 caregivers of children aged 6 to 24 months in six counties. Data were collected on micronutrient powder adherence behavior, direct behavioral inputs (knowledge and skills, intention, salience, environmental constraints, and habits), and indirect behavioral inputs (attitudes, perceived social norms, and personal agency). Structural equation modeling (SEM) adjusted for sociodemographic covariates was used to evaluate the IBM framework. RESULTS: Mean micronutrient powder adherence in the previous seven days was 53.02%, and only 22.86% of caregivers consistently fed micronutrient powder from the start of micronutrient powder distribution at six months of age. The SEM model revealed small- to medium-sized effects of salience (ß = 0.440, P < 0.001), intention (ß = 0.374, P < 0.001), knowledge and skills (ß = 0.214, P < 0.001), personal agency (st. effect = 0.172, P < 0.001), environmental constraints (ß=-0.142, P < 0.001), and caregiver generation (ß = 0.119, P < 0.05) on micronutrient powder adherence. Overall, 54.7% of the variance in micronutrient powder adherence was explained by the IBM framework. Salience had the largest impact on micronutrient powder adherence (Cohen's f 2 = 0.227). Compared to parent caregivers, grandparents had a higher degree of micronutrient powder adherence on average (P < 0.001), and behavioral inputs were consistent among both parent and grandparent caregivers. CONCLUSION: There is a need to improve micronutrient powder adherence among rural caregivers. The IBM framework showed a high degree of explanatory power in predicting micronutrient powder adherence behavior. The findings suggest that increased reminders from doctors regarding micronutrient powder and coaching to improve personal agency in micronutrient powder feeding may increase adherence.

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.

Provider competence in hypertension management and challenges of the rural primary healthcare system in Sichuan province, China: a study based on standardized clinical vignettes.

BACKGROUND: Improving primary care providers' competence is key to detecting and managing hypertension, but evidence to guide this work has been limited, particularly for rural areas. This study aimed to use standardized clinical vignettes to assess the competence of providers and the ability of the primary healthcare system to detect and manage hypertension in rural China. METHODS: A multi-stage random sampling method was administered to select target health facilities, providers, and households. The clinical vignette script was developed to evaluate provider competence in managing first-visit patients with symptoms of hypertension. Logistic regression was used to explore the factors correlated with provider competence. Provider referral and management rates were combined with patients' facility sorting behaviors to assess the ability of the rural healthcare system to manage hypertension in three policy scenarios. RESULTS: A total of 306 providers and 153 facilities were enrolled in our study. In the 306 clinical vignette interactions, 25.9% of providers followed the national guidelines for hypertension consultation. The correct diagnosis was achieved by only 10.1% of providers, and 30.4% of providers were able to prescribe the correct treatment. Multi-variable regression results showed that younger providers (OR = 0.85, 95%CI: 0.73, 0.98) and those who work in township health centers (OR = 4.47, 95%: 1.07, 18.67) were more likely to provide a correct diagnosis. In a free-selection scenario, 29.8% of patients with hypertension were managed correctly throughout the rural system. When all patients first visit village clinics, system-level correct management is reduced to 20.5% but increases to 45.0% when all patients first visit township health centers. CONCLUSIONS: Rural primary care providers do not have enough competence to detect and treat hypertension cases in China to an acceptable degree. Policy constraints may limit the competence of the rural healthcare system. Research to improve detection and treatment competence in hypertension and optimize health policy is needed.

Association of COVID-19 Lockdown during the Perinatal Period with Postpartum Depression: Evidence from Rural Areas of Western China.

COVID-19 lockdown has posed unique challenges to postpartum women, but its association with postpartum depression is not well understood in the Global South. This study aims to evaluate the association between COVID-19 lockdown and postpartum depression in rural areas of western China. A multi-stage random cluster sampling method was used to select a cohort of pregnant and postpartum women with infants aged 0-6 months. We conducted an in-person survey before the COVID-19 lockdown and a phone survey right after the lockdown ended. We used multivariate regression models to evaluate the association between lockdown and postpartum depression. Subgroup analysis was performed to explore the role of social support. The overall prevalence of postpartum depression was 13.3%. Postpartum women who experienced the lockdown were less likely to be depressed than those who did not (adjusted odds ratio (aOR) = .43, 95% confidence interval (CI) = [.27, .70]). Lockdown was negatively associated with postpartum depression among postpartum women with low level of social support (aOR = .30, 95% CI = [.18, .51]). COVID-19 lockdown was associated with lower likelihood of postpartum depression, potentially due to increased support from family. Future research is needed to explore targeted interventions to prevent postpartum depression among women from migrant worker families in rural China.

High adherence and its influencing factors on multiple micronutrient powders (MNPs).

Adherence to home fortification of foods with multiple micronutrient powders (MNPs) is an essential indicator of effective implementation of MNP programmes. A meta-analysis was conducted to evaluate the high adherence rate (HAR) to MNPs and further investigate the factors that influence HAR. We searched PubMed, Web of Science, Embase, CAB Abstracts, MEDLINE (OVID), Cochrane Library, China National Knowledge Infrastructure, Wanfang and VP, from the date of database inception to 9 November 2020. We included peer-reviewed observational studies that investigated adherence to MNPs. Data on the HAR to MNPs and influencing factors on HAR were extracted and then pooled together. A total of 10 studies were included. The pooled HAR to MNPs was 63.28% (51.12%-74.64%). Among HARs, rates were higher in middle-income countries (65.21%) than low-income countries (55.23%). Parental age over 30 years (maternal age OR = 1.25, 95% CI: 1.08-1.44; paternal age OR = 1.17, 95% CI: 1.04-1.32), children aged 18-36 months (OR = 1.45, 95% CI: 1.12-1.88), maternal educational attainment of college or above (OR = 1.38, 95% CI:1.10-1.73), caregiver with the perception that other mothers use MNPs (OR = 1.52, 95% CI:1.19-1.95), caregiver being aware of the importance of iron (OR = 1.42, 95% CI: 1.18-1.71), caregiver having correct knowledge of MNPs (OR = 1.36, 95% CI:1.19-1.57) and caregiver reporting children have no side effects from MNPs (OR = 2.77, 95% CI: 2.46-3.11) were contributing factors to high adherence to MNPs. The overall HAR to MNPs was relatively low; hence, effective and trusted communication channels need to be established, along with more thorough dissemination of the knowledge of MNPs to caregivers, to improve MNPs adherence rates, especially in low-income countries.

[Evaluation of Accuracy and Influencing Factors for Diagnosis of Two Chronic Diseases by Primary Healthcare Providers in Sichuan Rural Areas Based on Standardized Patients].

Objective We used standardized patients to evaluate the accuracy and explore the influencing factors of the diagnosis of unstable angina pectoris and type 2 diabetes by primary healthcare providers in Sichuan rural areas,aiming to provide a scientific basis for improving the diagnosis accuracy of primary healthcare providers for the two chronic diseases. Methods A multi-stage stratified random cluster sampling method was adopted to select 100 villages from 50 townships in 5 districts/counties in Zigong city,Sichuan province. General and internal medicine practioners who were on duty on the survey day were enrolled in the survey.Two rounds of data collection were conducted.In the first round,the basic information of providers from township health centers and village clinics was collected.One month after the the first survey,standardized patients were used to collect the information related to the diagnosis of unstable angina pectoris and type 2 diabetes by rural primary providers.Logistic regression was carried out to analyze the factors influencing the diagnosis accuracy. Results A total of 172 rural primary healthcare providers were enrolled in the survey,who completed 186 standardized patient visits and showed the correct diagnosis rate of 48.39%.Specifically,the correct diagnosis rates of unstable angina pectoris and type 2 diabetes were 18.68%(17/91) and 76.84%(73/95),respectively.The providers with medical practitioner qualifications were more likely to make correct diagnosis(OR=4.857,95%CI=1.076-21.933, P=0.040).The providers who involved more necessary consultation and examination items in the diagnosis process had higher probability of correct diagnosis(OR=1.627,95%CI=1.065-2.485, P=0.024).Additionally,the providers were more likely to make a correct diagnosis for type 2 diabetes than for unstable angina pectoris(OR=6.306,95%CI=3.611-11.013, P<0.001). Conclusions The overall diagnosis accuracy of unstable angina pectoris and type 2 diabetes was relatively low among primary healthcare providers in Sichuan rural areas.The training of diagnosis process can be taken as a key for improving providers' practice ability so as to increase the diagnosis accuracy of chronic diseases.

[Psychological Status and Influencing Factors of Staff at Centers for Disease Control and Prevention in Sichuan Province during the Outbreak of Coronavirus Disease 2019].

Objective To assess the psychological status of staff at the centers for disease control and prevention(CDC) in Sichuan during the outbreak of coronavirus disease 2019(COVID-19) and explore the influencing factors. Methods The staff at Sichuan provincial,municipal,and county(district)-level CDC were selected by convenience sampling.Their basic information,work status,training status,work difficulties,and support from the work group were collected from the self-filled questionnaires online.The Generalized Anxiety Disorder Scale and the 9-question Patient Health Questionnaire were respectively employed to measure the anxiety and depression of the staff.The stepwise Logistic regression was carried out to analyze the influencing factors of anxiety and depression in CDC staff. Results Among the 653 staff,58.35% and 50.06% presented anxiety and depression,respectively.The regression results showed that age(OR=0.95,95%CI=0.92-0.97) and mental support from the work group(OR=0.61,95%CI=0.45-0.82) were the protective factors while physical fatigue(OR=1.82,95%CI=1.20-2.74),work pressure(OR=1.61,95%CI=1.21-2.12),and insufficient protective equipment(OR=1.92,95%CI=1.06-3.49) were the risk factors for depression of CDC staff.Age(OR=0.97,95%CI=0.94-0.99),length of sleep per day(OR=0.74,95%CI=0.56-0.96),and participation in technical training(OR=0.33,95%CI=0.12-0.95) were the protective factors while mental fatigue(OR=1.68,95%CI=1.18-2.41),work pressure(OR=2.94,95%CI=2.08-4.17),and unclear incentive system for overtime(OR=1.99,95%CI=1.23-3.23) were the risk factors for the anxiety of CDC staff. Conclusion The anxiety and depression status of CDC staff during the COVID-19 outbreak were worrying,which were mainly affected by age,sleep,supply of protective equipment,incentive system,fatigue,and work pressure.

[Association of Dietary Diversity with Growth and Development of Children in Multi-ethnic Rural Areas of Sichuan Province].

Objective To understand the growth and dietary diversity status of children in multi-ethnic areas of Sichuan province,and to explore the associations of dietary diversity with growth and development indicators. Methods Children of 18-36 months old and their primary caregivers were selected with multi-stage cluster random sampling method from rural areas of Han,Tibetan,and Yi ethnic groups in Sichuan province. The sociodemographic information of children and their caregivers was collected using self-designed questionnaire.The dietary diversity score(DDS)was calculated according to the criteria in the Guidelines for Measuring Household and Individual Dietary Diversity released by the Food and Agriculture Organization of the United Nations.The body height(length)and body weight of each child were measured by standard equipment for anthropological measurement,and the height for age Z score(HAZ),weight for age Z score(WAZ),and weight for height Z score(WHZ) were calculated.Multivariate linear regression was performed to analyze the relationship between dietary diversity and growth indicators of children. Results A total of 1092 children were enrolled in this study,and the prevalence of stunting(HAZ<-2),underweight(WAZ<-2),and wasting(WHZ<-2)was 21.1%,4.9%,and 2.5%,respectively.The children had the mean DDS of 4.8±1.7,and 45.3% of children had poor dietary diversity(DDS≤4).The children of Han ethnic group(5.8±1.4)had higher DDS than those of Tibetan ethnic group(4.9±1.6)and Yi ethnic group(3.9±1.6)(P<0.001).The results of multivariate linear regression indicated that DDS was positively correlated with HAZ(ß=0.206,95%CI=0.158-0.254,P<0.001)after adjustment of sex,age,birth weight,preterm birth,and parental body height.After further adjustment of family fixed assets,ethnic group,caregiver's type,and caregiver's education background,the correlation between DDS and HAZ remained significant(ß=0.077,95%CI=0.026-0.128, P=0.003). Conclusions The children in the multi-ethnic rural areas of Sichuan province showed troublesome growth and development status and low dietary diversity,which were conspicuously different between ethnic groups,especially in the rural areas of Yi ethnic group.The dietary diversity was positively associated with HAZ.It is recommended to carry out nutrition and health education according to the local dietary characteristics and thus improve the growth and development of children in multi-ethnic rural areas in Sichuan.

[Ethnic differences in influencing factors of caregivers' first complementary food addition behavior in western rural areas].

OBJECTIVE: To investigate the status quo and influencing factors of the first-time complementary food addition behavior of caregivers in the multi-ethnic background in the western rural areas. METHODS: In 2019, a multi-stage stratified cluster random sampling was used to selecting research subjects in western rural areas. A structured questionnaire was designed by ourselves with literature review and expert consultation method, and information such as sociodemographic characteristics, feeding knowledge, and complementary food addition of 1290 caregivers and infants were collected, ordered multi-classification Logistic regression was used to analyze the influencing factors of the first complementary food addition behavior of the Han nationality and the minority nationality. RESULTS: In the western rural areas, only 8.22% of the caregivers had better behavior of first complementary food addition, and 16.31% of the caregivers in the Han group had a good behavior of first complementary food addition. In the minority population, only 3.64% of infant caregivers had a good behavior of first complementary food addition. In Han, parents, as caregivers, had better first complementary food addition behavior than grandparents(OR=1.7829, 95% CI 1.1651-2.7283). Among ethnic minorities, education(OR=1.753, 95%CI 1.190-2.581), family fixed assets(OR=3.870, 95%CI 1.959-7.645)and feeding knowledge(OR=3.396, 95%CI 2.749-4.195) were the promoting factors for the first complementary food addition behavior. CONCLUSION: In western rural areas, caregivers' behavior of adding complementary food for the first time is generally poor.

[Relationship between Personality Traits and Nutrition Package Feeding Behaviors of Infant Caregivers in Remote Rural Areas of Sichuan Province].

Objective To analyze the personality traits and nutrition package feeding behaviors of infant caregivers in remote rural areas of Sichuan province and explore the relationship between them. Methods A multi-stage random cluster sampling method was employed to select the infants of 6-24 months old and their caregivers in the remote rural areas of Sichuan province.A structured questionnaire was designed to collect the basic characteristics of infants and their caregivers,as well as the feeding behaviors of the caregivers.The Ten-Item Personality Inventory in China was used to evaluate the caregivers' personality traits in five dimensions:extraversion,agreeableness,conscientiousness,emotional stability,and openness.Multivariate Logistic regression was adopted to analyze the relationship between personality traits and nutrition package feeding behaviors of infant caregivers. Results A total of 895 pairs of infants and their caregivers were investigated.The caregivers showed the average scores of 9.01±2.64,10.60±1.99,9.41±2.06,9.01±2.38,and 8.57±2.29 in the dimensions of extraversion,agreeableness,conscientiousness,emotional stability,and openness,respectively.The effective feeding rate of nutrition package was 53.3% (477/895).The results of regression analysis showed that under the premise of controlling for other factors,the caregiver's conscientious personality (OR=1.08,95%CI=1.004-1.153,P=0.038) was the protective factor for the effective feeding of nutrition package. Conclusion The feeding behavior of infant caregivers in the remote rural areas of Sichuan province remains to be improved,and the caregivers with high conscientious personality are more likely to feed their infants effectively.

[Effect of Information Communication on Micronutrient Powders (or Yingyangbao) Feeding Behaviors of Different Generations of Baby Caregivers in Rural Areas].

Objective: To evaluate the status of information communication concerning micronutrient powders (MNP), or yingyangbao in Pinyin, the Chinese Romanization system, in areas covered by the Child Nutrition Improvement Project in a province in southwest China, and to investigate the effect of different communication channels and message communicated on the feeding behaviors of different generations of caregivers. Methods: In October 2019, 6 counties, including two counties with predominantly Han population, two counties with substantial Tibetan population, and two counties with substantial Yi population, were selected from a province in southwest China through multistage random cluster sampling. A total of 816 pairs of babies and their caregivers from 108 villages in 36 townships were enrolled for the study. The age of the babies ranged between 6 months to 24 months. A structured questionnaire concerning the demographic data of the babies and their caregivers, the communication channel of information on MNP and the message communicated, and the caregivers' MNP feeding behaviors was designed to collect data through face-to-face interviews. Logistic regression was done to analyze the effect of MNP information communication on the feeding behaviors of caregivers from different generations. Results: Caregivers acquired information on MNP from village and township physicians (85.66%), surrounding populations (15.81%), and brochures and mass media (4.78%). The messages they received included the free availability of MNP (37.50%), feeding methods (49.26%), and the benefits of giving babies MNP (57.84%). Among the caregivers, 89.95% knew about the availability of MNP, 69.73% were aware of the benefits, and 84.07% actually received MNP. The correct feeding rate was 68.26% and the total effective feeding rate was 49.14%. The effective feeding rate of caregivers of the grandparents' generation (59.07%) was higher than that of the caregivers of the parents' generation (45.08%) ( P<0.05). Logistic regression analysis suggested that, for caregivers of the parents' generation, information communication channel of village and township physicians (odds ratio [ OR]=2.20, 95% confidence interval [ CI]: 1.13-4.31) and communication messages on feeding methods ( OR=1.80, 95% CI: 1.19-2.73) and benefits of MNP ( OR=2.40, 95% CI: 1.61-3.57) facilitated their effective feeding behavior, while communication message concerning the free availability of MNP ( OR=0.58, 95% CI: 0.38-0.87) inhibited their effective feeding behavior. For caregivers of the grandparents' generation, information communication channel of village and township physicians ( OR=2.95, 95% CI: 1.12-7.76) and communication messages on the feeding methods ( OR=2.86, 95% CI: 1.34-6.09) were facilitating factors of their effective feeding behaviors. Conclusion: The main channel of MNP information delivered to caregivers from the areas covered by the study was face-to-face explanation by doctors. The message communicated mainly involved three aspects--the administration method, the benefits and free availability of MNP. The channel and message of MNP information communnication had different effects on the feeding behaviors of caregivers of the parents' and grandparents' generations. Future research should focus on developing targeted information communication strategies according to the characteristics of populations from different generations, so as to improve the caregivers' feeding behavior.

Can Nepal achieve nutritional targets by 2030? A trend analysis of childhood undernutrition in Nepal from 2001 to 2016.

OBJECTIVE: This study assesses the prevalence of childhood undernutrition from 2001 to 2016 and estimate projections of undernutrition for 2016-2030 in Nepal. DESIGN: The study used data from four rounds of a cross-sectional survey of Nepal Demographic and Health Survey (NDHS) conducted in 2001, 2006, 2011 and 2016. Descriptive analyses were conducted to calculate prevalence, binary logistic regression was used to test the significance of trends over time and autoregressive integrated moving average model was used to forecast the prevalence of childhood undernutrition. SETTINGS: The children and household member datasets from four NDHS were merged to assess the trends of childhood undernutrition in Nepal. PARTICIPANTS: A total of 16 613 children (8399 male and 8214 female) under 5 years of age were selected for anthropometric measurements using a stratified cluster random sampling method. RESULTS: Overall results show a decline in prevalence of stunting from 57·2 % to 35·8 % (P < 0·001), underweight from 42·7 % to 27 % (P < 0·001) and wasting from 11·2 % to 9·7 % (P < 0·05) from 2001 to 2016. However, different population subgroups have a higher prevalence of undernutrition than national average. Further, the analyses show that the prevalence of stunting will decline to 14·3 % and wasting to 8·4 % by 2030. CONCLUSION: A remarkable decrease in the prevalence of stunting and underweight has been observed over the last 15 years. Nepal is likely to achieve the nutritional targets for stunting but not for wasting by 2030. Given large subpopulation variations, further improvement in undernutrition require more specific, targeted and localised programmes.

[Feeding patterns and influencing factors of infants under 0-6 months of age in rural areas of Nanchong City in 2019].

OBJECTIVE: To evaluate the feeding patterns of infants under 6 months of age in rural areas of Nanchong City, Sichuan Province, and to explore the driving factors of different feeding patterns. METHODS: A total of 837 pairs of infants under 6 months of age(<183 days of age) and their primary caregivers(450 male infants and 387 female infants, with an average age of(2.9±1.8) months, most of the primary caregivers were mothers(95.70%)) were selected by multi-stage random cluster sampling in Nanchong City in 2019.An electronic tablet equipped with a computer assisted system was used to input the face-to-face inquiry questionnaire to collect information, mainly including the sociodemographic characteristics of the subjects, infant feeding patterns, mothers' feeding knowledge, mothers' feeding attitudes, family support for breastfeeding, negative support from the surrounding population and other relevant information. Using disordered multi-classification Logistic regression, excluding non-maternal nursing samples, non-lactating mothers and mothers unable to breastfeed due to disease, 789 pairs of infants and their mothers were included in the regression model. After controlling the demographic characteristics of infants and their mothers, the independent influencing factors of exclusive breastfeeding relative to mixed feeding and artificial feeding were analyzed. RESULTS: The rates of exclusive breastfeeding, mixed feeding and artificial feeding were 35.13%(294/837), 50.30%(421/837) and 14.57%(122/837) in rural areas of Nanchong. Compared with mixed feeding, mothers with high feeding knowledge(OR=2.06, 95%CI 1.47-2.86) were more likely to exclusively breastfeed. Compared with artificial feeding, mothers with high feeding knowledge(OR=2.48, 95%CI 1.36-4.54), positive attitude towards breastfeeding(OR=2.57, 95%CI 1.12-5.87) and high family support for breastfeeding(OR=3.01, 95%CI 1.73-5.24) were more likely to exclusively breastfeed, and mothers with negative support from the surrounding population(OR=0.37, 95%CI 0.14-0.98) were more likely to carry out artificial feeding. CONCLUSION: In rural areas of Nanchong City, Sichuan Province, three ways of exclusive breastfeeding, mixed feeding and artificial feeding coexist. Mixed-feeding is the main method, and the rate of exclusive breastfeeding is low. Mothers' feeding knowledge is an important factor influencing feeding patterns, and breastfeeding attitudes and breastfeeding family support are the main drivers of artificial feeding.

[Status and influencing factors of breastfeeding behavior in rural areas of Han, Tibetan and Yi nationalities in Sichuan Province].

OBJECTIVE: To evaluate the status of breastfeeding among infants aged 0-18 months in rural areas of Han, Tibetan and Yi ethnic in Sichuan Province, and to explore the relevant impact factors. METHODS: Using multistage sampling method, choose two Han county, two Tibetan county and two Yi county rural 0-18 months infants and young children with their mother as the subjects in Sichuan Province, to collect mothers and infants and young children's demography, family status, the information such as breastfeeding knowledge and behavior through questionnaires. Unconditional Logistic regression was used to analyze the influencing factors of breastfeeding. RESULTS: Among the 1087 infants, early initiation of breastfeeding rate was 22. 45%, among the 985 infants aged 6 months and above, the rate of exclusive breastfeeding under 6 months was 35. 94%, among the 658 infants aged 12 months and above, the rate of continued breastfeeding at 1 year was 34. 50%. The favorable factors for early initiation of breastfeeding were that normal delivery(OR=2. 80, 95% CI 1. 82-4. 30) and mothers with knowledge of early initiation of breastfeeding behavior(OR=2. 48, 95% CI 1. 69-3. 64). Tibetan mother(OR=1. 56, 95% CI 1. 02-2. 39), very good family economic status(OR=2. 70, 95% CI 1. 47-4. 98), mother's knowledge of exclusive breastfeeding under 6 months(OR=1. 47, 95% CI 1. 07-2. 02) were favorable factors for exclusive breastfeeding behavior under 6 months. Second birth and above(OR=1. 67, 95% CI 1. 11-2. 52) and mothers' knowledge of weaning(OR=3. 96, 95% CI 2. 65-5. 93) were favorable factors for continued breastfeeding at 1 year. CONCLUSION: The status of breastfeeding in the multi-ethnic rural areas of Sichuan Province is poor. The mother's ethnicity, delivery method, and whether they have relevant knowledge, parity and family economic status will affect the breastfeeding behavior of infant mothers.

[The Association Between Abdominal Obesity and Diabetes among Middle-aged and Older Adults with Normal BMI].

OBJECTIVE: To explore the relationship between abdominal obesity and diabetes among middle-aged and older adults with normal body mass index (BMI) and to provide reference information for formulating targeted diabetes prevention and control measures for this population. METHODS: Data were extracted from the China Health and Retirement Longitudinal Study (CHARLS) done in 2015. Middle-aged and older adults who were aged 45 and older and had normal BMI were included in the study. According to their status of diabetes, the subjects were divided into two groups, non-diabetes and diabetes groups. χ 2 test was used to investigate the difference between two groups. Logistic regression was used to do the multivariate analysis of factors influencing diabetes. RESULTS: A total of 5 197 middle-aged and older adults with normal BMI ranging between 18.5 and 24 kg/m 2 were included. The prevalence of diabetes was 11.26% (585/5 197) and the prevalence of abdominal obesity was 41.56% (2 160/5 197). Univariate analysis showed that the difference in age, residence, the status of hypertension, dyslipidemia and abdominal obesity between non-diabetic group and the diabetic group were statistically significant ( P<0.01). The prevalence of diabetes among adults with abdominal obesity was 14.2% (307/2 160) and that among people with no abdominal obesity was 9.2% (278/3 037). Compared with people with no abdominal obesity, the prevalence of diabetes among people with abdominal obesity was higher and the difference were statistically significant ( P<0.01). Multivariate logistic regression analysis showed that, among middle-aged and older adults with normal BMI, those with abdominal obesity, aged 60 years and older, living in urban areas, having hypertension and having dyslipidemia had higher probability of developing diabetes. CONCLUSION: Abdominal obesity and diabetes are becoming a serious problem among middle-aged and older adults with normal BMI and abdominal obesity may be related to higher risks of diabetes. It is recommended that more attention is given to abdominal obesity in this population to reduce the possibilities of diabetes.

[Study on the Relationship between First-Time Complementary Feeding Practice and the Nutritional Status of Infants and Young Children in the Multi-Ethnic Rural Areas of Sichuan Province].

OBJECTIVE: To evaluate the current status of first food supplement and the nutrition of infants and young children in rural areas inhabited by people of Han, Tibetan, and Yi ethnicities in Sichuan Province, and to explore the relationship between the first ever feeding of food supplement and the nutritional status. METHODS: Using a multi-stage randomized cluster sampling method, we selected 2 Han counties, 2 Tibetan counties and 2 Yi counties in rural areas of Sichuan Province. These counties were previously defined as economically poor counties, but had since been lifted out of poverty. They were selected for this study before they came out of poverty. Infants and young children of 12-24 months old and their main caregivers from these counties were the subjects of the study. Structured questionnaires were used to collect information concerning the sociodemographic characteristics of infants and young children and their caregivers, and the first complementary feeding for infants and young children. Infant and young children weight scales and length/height tapes were used to collect the weight and length/height data of infants and young children. Unconditional logistic regression was used to analyze the correlation between the behavior of giving supplementary food for the first time to infants and young children and their nutritional status. RESULTS: A total of 1117 pairs of infants and children and their caregivers were investigated. Regarding the time of first supplementary food addition, nearly half of the caregivers in Han areas started adding supplementary food when the infants were 6 months old, accounting for 43.07% (171/397). Most of the caregivers in Yi and Tibetan areas started giving infants and young children supplementary food when they were less than 6 months old, accounting for 77.18% (301/390) and 47.58% (157/330), respectively. In terms of the types of supplementary food added for the first time, caregivers in Han areas mainly used homemade rice cereal, accounting for 41.56% (165/397), caregivers in Tibetan areas mainly used meat, vegetables or fruits and other complementary foods, accounting for 42.12% (139/330), and caregivers in Yi areas mainly used homemade rice cereal, accounting for 46.41% (181/390). The overall malnutrition rate of infants and young children was 28.83% (322/1117) and the malnutrition rate of infants and young children in Han, Tibetan, and Yi areas were 10.58% (42/397), 24.85 (82/330), and 50.77 (198/390), respectively. The regression analysis results show that after controlling for confounding factors, compared with Han areas, it is more likely for infants and young children in Yi areas to be malnourished ( OR=9.49, 95% CI 6.00-15.00). Compared with adding other types of complementary foods for the first time, infants and young children given iron-fortified rice cereal had a lower risk of malnutrition ( OR=0.54, 95% CI0.29-0.99). CONCLUSION: The multi-ethnic rural areas of Sichuan Province had problems that supplementary foods are added too early, and that the types of supplementary foods added for the first time were not appropriate. In addition, the nutritional status of local infants and young children in these areas was causing concerns. The malnutrition problem of infants and young children was especially prominent in the Yi ethnic areas. Adding iron-fortified rice cereal for the first time could reduce the possibility of malnutrition in infants and young children to a certain extent. It is recommended that attention should be given to the health education intervention of the first supplementary food for infants and young children to effectively improve the nutritional status of infants and young children in these areas.

"At three years of age, we can see the future": Cognitive skills and the life cycle of rural Chinese children.

BACKGROUND: While the Chinese education system has seen massive improvements over the past few decades, there still exists large academic achievement gaps between rural and urban areas, which threaten China's long-term development. Additionally, recent literature has underscored the importance of early childhood development (ECD) in later-life human capital development. OBJECTIVES: We analyze the lifecycle of cognitive development and learning outcomes in rural Chinese children by first examining if ECD outcomes affect cognition levels, then seeing if cognitive delays persist as children grow, and finally exploring connections between cognition and education outcomes. METHODS: We combine data from four recent studies examining different age groups (0-3, 4-5, 10-11, 13-14) to track cognitive outcomes. RESULTS: First, we find that ECD outcomes for children in rural China are poor, with almost one-in-two children being cognitively delayed. Second, we find that these cognitive delays seem to persist into middle school, with almost 37% of rural junior high school students being cognitively delayed. Finally, we show that cognition has a close relationship to academic achievement. CONCLUSION: Our results suggest that urban/rural gaps in academic achievement originate at least in part from differences in ECD outcomes. CONTRIBUTIONS: While many papers have analyzed ECD, human capital, and inequality separately, this is the first paper to explicitly connect and combine these topics to analyze the lifecycle of cognitive development in the context of rural China.

[Effect of utilization of child health services on the nutrition and growth status of infants in poor rural areas in Sichuan and Gansu Province].

OBJECTIVE: To investigate the current situation of the utilization of infant and young child health services in pool rural areas where minorities gathered in Sichuan and Gansu Province and analyze its effect on infant nutrition and growth. METHODS: We choosed 1065 infants and young children aged≤24 months with their mother as the subjects by multistage cluster random sampling in October to November 2014 in poor rural areas where ethnic minorities gathered in Sichuan and Gansu Province. Questionnaires were used to obtain the data of demography and utilization of maternal and child health services, physical examination to obtain the data of growth status, and hemoglobin detection to obtain the hemoglobin level. The relationship between the nutrition and growth status and maternal and child health service utilization was analyzed by the unconditioned Logistic regression analysis. RESULTS: Among the surveyed infants and young children, the underweight rate was 3. 38%, the stunting rate was 10. 52%, and the wasting rate was 2. 25%, the malnutrition prevalence was 12. 58%, and the anemia prevalence was 52. 68%. The children's physical examination rate was 37. 09%, and the systematic management( frequency of physical examination reached the standard) rate of children was 12. 68%. The rate of prophylactic inoculation was 92. 30%, and the rate of reaching the standard of vaccination frequency was 48. 73%. After adjusting the confounding factors, the result showed that utilization of vaccination( OR = 0. 41, 95% CI0. 23-0. 74) and vaccination frequency reaching the standard( OR = 0. 58, 95%CI 0. 36-0. 92) were protective factors for infant malnutrition. Children 's physical examinations frequency reaching the standard( OR = 0. 52, 95%CI 0. 35-0. 79) was a protective factor for infant anemia. CONCLUSION: Reasonable utilization of health services can reduce the poor result of nutrition and growth of infants in poor rural areas where ethnic minorities gather in Sichuan and Gansu provinces.