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).

Measurement of flourishing: a scoping review.

Introduction: Flourishing is an evolving wellbeing construct and outcome of interest across the social and biological sciences. Despite some conceptual advancements, there remains limited consensus on how to measure flourishing, as well as how to distinguish it from closely related wellbeing constructs, such as thriving and life satisfaction. This paper aims to provide an overview and comparison of the diverse scales that have been developed to measure flourishing among adolescent and adult populations to provide recommendations for future studies seeking to use flourishing as an outcome in social and biological research. Methods: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), we conducted a scoping review across PubMed and EMBASE of studies introducing original flourishing scales (defined as a previously unpublished measure of mental health or wellbeing that used "flourishing" in its definition). Studies focusing on adult populations that were published before April 28, 2023 were considered eligible for inclusion. Results: Out of 781 studies retrieved, we identified seven eligible studies covering seven unique flourishing scales. We find that all seven scales are multidimensional and assess features over monthly or yearly intervals. While most of the scales (six out of seven) include indicators of both hedonic and eudaimonic wellbeing, the operationalization of these dimensions of wellbeing varies considerably between scales. Several of the scales have been translated and validated across multiple geographical contexts, including higher- and lower-income countries. Discussion: Complementing self-report measures with other social, economic, regional, and biological indicators of flourishing may be useful to provide holistic and widely applicable measures of wellbeing. This review contributes to concept validation efforts that can guide strategies to sustain flourishing societies.

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.

Comparing the Quality of Primary Care between Public and Private Providers in Urban China: A Standardized Patient Study.

Previous studies have been limited by not directly comparing the quality of public and private CHCs using a standardized patient method (SP). This study aims to evaluate and compare the quality of the primary care provided by public and private CHCs using a standardized patient method in urban China. We recruited 12 standardized patients from the local community presenting fixed cases (unstable angina and asthma), including 492 interactions between physicians and standardized patients across 63 CHCs in Xi'an, China. We measured the quality of primary care on seven criteria: (1) adherence to checklists, (2) correct diagnosis, (3) correct treatment, (4) number of unnecessary exams and drugs, (5) diagnosis time, (6) expense of visit, (7) patient-centered communication. Significant quality differences were observed between public CHCs and private CHCs. Private CHC physicians performed 4.73 percentage points lower of recommended questions and exams in the checklist. Compared with private CHCs, public CHC providers were more likely to give a higher proportion of correct diagnosis and correct treatment. Private CHCs provided 1.42 fewer items of unnecessary exams and provided 0.32 more items of unnecessary drugs. Private CHC physicians received a 9.31 lower score in patient-centered communication. There is significant quality inequality in different primary care models. Public CHC physicians might provide a higher quality of service. Creating a comprehensive, flexible, and integrated health care system should be considered an effective approach towards optimizing the management of CHC models.

Effect of Chinese eye exercises on change in visual acuity and eyeglasses wear among school-aged children in rural China: a propensity-score-matched cohort study.

BACKGROUND: Daily "eye exercises," massaging of periocular acupuncture pressure points, have been part of China's national vision care policy in schools for some 50 years. However, the effect of eye exercises on myopia progression and eyeglasses wear has not been definitively investigated. This study evaluates the effectiveness of eye exercises on visual acuity and the propensity of rural children to wear eyeglasses. METHODS: Cohort study in 252 randomly-selected rural schools with baseline in September 2012 and follow up surveys 9 and 21 months later. Outcomes were assessed using propensity-score matching (PSM), multivariate linear regression and logistic regression to adjust for differences between children performing and not performing eye exercises. RESULTS: Among 19,934 children randomly selected for screening, 2374 myopic (spherical equivalent refractive error ≤ - 0.5 diopters in either eye) children (11.9%, mean age 10.5 [Standard Error 1.08] years, 48.5% boys) had VA in either eye ≤6/12 without eyeglasses correctable to > 6/12 with eyeglasses. Among these who completed the 21-month follow up, 1217 (58.2%) children reported practicing eye exercises on school days and 874 (41.8%) did not. After propensity-score matching, 1652 (79%) children were matched: 826 (50%) in the Eye Exercises group and 826 (50%) in the No Exercise group. Performing eye exercises was not associated with change in LogMAR uncorrected visual acuity and wear of eyeglasses, using either logistic regression or PSM at 9 or 21 months. CONCLUSIONS: We found no evidence for an effect of eye exercises on change in vision or eyeglasses wear. TRIAL REGISTRATION: The original trial (Registration site: http://isrctn.org. Registration number: ISRCTN03252665) was retrospectively registered 25/09/2012.

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.

Using daily text messages to improve adherence to infant micronutrient powder (MNP) packets in rural western China: A cluster-randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of daily text messages as a means to improve caregivers' adherence to infant micronutrient powder (MNP) in rural Shaanxi Province of China. METHODOLOGY: 638 infants aged 6-11 months in 234 villages were involved in a cluster-randomized controlled trial (RCT). All caregivers were given free infant MNP packets at baseline in April 2013 and the follow-up survey was in July 2013. We randomly assigned 318 infants in 117 villages to treatment group (receiving daily text message) and 320 infants in the other 117 villages as control group. RESULTS: On average, daily text messages increased the number of MNP packets fed (marginal effect = 4.63; 95% confidence interval (CI) = 0.16, 9.10). The text message is more likely to increase the consumption of MNP packets if the primary caregiver was the mother (marginal effect = 12.19; 95% CI = 0.69, 23.68). Receiving the text message appears to significantly increase the likelihood of full adherence when the primary caregiver can either check (odds ratio = 2.93; 95% CI = 1.34, 6.40) or knows how to send (odds ratio = 3.26; 95% CI = 1.53, 6.97) text messages. CONCLUSION: Daily text messages improved the consumption of infant MNP packets. However, the impact was not large enough to increase the probability of caregivers being fully adherent to the feeding instruction, which is to feed 5-7 packets per week as recommended. In addition, when the mother is the caregiver and when the caregiver can check or knows how to send text messages there is greater adherence by the primary caregivers. TRIAL REGISTRATION: http://www.isrctn.com/ISRCTN44149146.

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.

Nutritional Deficiencies, the Absence of Information and Caregiver Shortcomings: A Qualitative Analysis of Infant Feeding Practices in Rural China.

BACKGROUND AND OBJECTIVES: Development during the first two years of life is critical and has a lasting impact on a child's health. Poor infant and child nutrition can lead to deficiencies in essential micronutrients, which may cause a weakened immune system and lasting effects on children's growth and development. Recent studies in rural Shaanxi Province found an anemia prevalence of 54.3% among rural children aged six to twelve months. While new large-scale, quantitative research has begun to catalogue the extent of child malnutrition and anemia, no effort has yet been made to look more closely at the potential reasons for rural children's nutritional deficiencies through qualitative analysis. This study aims to elucidate some of the fundamental causes of poor complementary feeding practices that may lead to anemia among children in rural Shaanxi Province, China. METHODOLOGY: We interviewed sixty caregivers participating in a large survey on child health and nutrition. We conducted three waves of interviews with children's primary caregivers in seventeen rural villages within four nationally-designated poverty counties in the southern part of Shaanxi Province. RESULTS: The qualitative analysis reveals that poor complementary feeding practices are common across our sample. Information gathered from our interviews suggests that complementary feeding practices are impeded by two constraints: absence of understanding topics related to infant health and nutrition under caregivers, as well as inadequate sources of information on these topics. Poverty does not appear to constrain child feeding practices. CONCLUSION: Our results uncover lack of proper knowledge on infant and child nutrition among rural caregivers in China. This situation causes them to fail incorporating micronutrient rich foods in their children's diet. Age-appropriate complementary feeding can stimulate children's physical and cognitive development, but in its absence it leads to iron-deficiency anemia. We suggest that steps be taken to educate caregivers to improve complementary feeding of their infants and children.

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.

Anemia and feeding practices among infants in rural Shaanxi Province in China.

Anemia is one of the most prevalent public health problems among infants and iron deficiency anemia has been related to many adverse consequences. The overall goal of this study is to examine the prevalence of anemia among infants in poor rural China and to identify correlates of anemia. In April 2013, we randomly sampled 948 infants aged 6-11 months living in 351 villages across 174 townships in nationally-designated poverty counties in rural areas of southern Shaanxi Province, China. Infants were administered a finger prick blood test for hemoglobin (Hb). Anthropometric measurement and household survey of demographic characteristics and feeding practices were conducted in the survey. We found that 54.3% of 6-11 month old infants in poor rural China are anemic, and 24.3% of sample infants suffer from moderate or severe anemia. We find that children still breastfed over 6 months of age had lower Hb concentrations and higher anemia prevalence than their non-breastfeeding counterparts (p < 0.01), and that children who had ever been formula-fed had significantly higher Hb concentrations and lower anemia prevalence than their non-formula-fed counterparts (p < 0.01). The results suggest the importance of iron supplementation or home fortification while breastfeeding.

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.