Publications

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 (β = 0.440, P < 0.001), intention (β = 0.374, P < 0.001), knowledge and skills (β = 0.214, P < 0.001), personal agency (st. effect = 0.172, P < 0.001), environmental constraints (β=-0.142, P < 0.001), and caregiver generation (β = 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.

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.

As digital devices like computers become more widely available in developing countries, there is a growing need to understand how the time that adolescents spend using these devices for recreational purposes such as playing video games is linked with their mental health outcomes. We measured the amount of time that adolescents in rural China spent playing video games and the association of video game time with their mental health. We collected data from primary and junior high schools in a poor, rural province in northwest China (n = 1603 students) and used the Depression, Anxiety, and Stress Scales (DASS-21) to measure mental health symptoms. The results indicated that the average video game time was about 0.69 h per week. There was a significant association between adolescent video game time and poorer mental health. Each additional hour of playing video games also increased the chance of having moderate or above symptoms. Moreover, boys and non-left-behind children had worse mental health if they played more video games. Our study contributes to literature on the links between recreational screen time and mental health, and it sheds light on an issue addressed by recent government legislation to limit the video game time of minors in China.

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Over the past two decades, the literature has shown a clear gradient between child health and wealth. The same health–wealth gradient is also observed among children in China, with a large gap in health between rural and urban children. However, there are still unanswered questions about the main causes of China’s rural–urban child health inequality. This paper aims to review the major factors that have led to the relatively poor levels of health among China’s rural children. In addition to the direct income effect on children’s health, children in rural areas face disadvantages compared with their urban counterparts from the beginning of life: Prenatal care and infant health outcomes are worse in rural areas; rural caregivers have poor health outcomes and lack knowledge and support to provide adequate nurturing care to young children; there are large disparities in access to quality health care between rural and urban areas; and rural families are more likely to lack access to clean water and sanitation. In order to inform policies that improve health outcomes for the poor, there is a critical need for research that identifies the causal drivers of health outcomes among children. Strengthening the pediatric training and workforce in rural areas is essential to delivering quality health care for rural children. Other potential interventions include addressing the health needs of mothers and grandparent caregivers, improving parenting knowledge and nurturing care, improving access to clean water and sanitation for remote families, and most importantly, targeting poverty itself.

The self-esteem of students may be significantly associated with their academic performance. However, past research in developing contexts on this issue is limited, particularly among early adolescents. Using a sample of 3101 students from rural primary and junior high schools in China, this study measured their self-esteem by the Rosenberg Self-Esteem Scale (RSES) and explored its association with academic performance. Our findings indicate that students in rural China had both significantly lower self-esteem and a higher prevalence of low self-esteem when compared to past studies of similarly aged students both from urban China and internationally. Furthermore, there was a strong positive correlation between a student’s self-esteem and academic performance. A one-SD increase in RSES score (indicating better self-esteem) was associated with an increase of 0.12 SD in standardized math scores (p < 0.001), and students with low self-esteem (RSES score < 25) scored lower on math tests by 0.14 SD (p < 0.001), which were robust and consistent when employing the propensity score matching method. Our study expands the growing body of empirical evidence on the link between self-esteem and academic performance among rural youth in developing countries and emphasizes the need to improve their self-esteem with the aim of helping them achieve academically.

As part of its effort to balance economic development with environmental objectives, China has established a new national park system, with the first five locations formally established in 2021. However, as the new parks all host or are proximate to human populations, aligning the socioeconomic needs and aspirations of local communities with conservation aims is critical for the long-term success of the parks. In this narrative review, the authors identify the ecological priorities and socioeconomic stakeholders of each of the five national parks; explore the tensions and synergies between these priorities and stakeholders; and synthesize the policy recommendations most frequently cited in the literature. A total of 119 studies were reviewed. Aligning traditional livelihoods with conservation, limiting road construction, promoting education and environmental awareness, and supporting the development of a sustainable tourism industry are identified as important steps to balance conservation with economic development in the new national parks.

One out of every three children under age 5 in developing countries lives in conditions that impede human capital development. In this study, we survey the literature on parenting training programs implemented before age 5, with the aim to increase parental investment in human capital accumulation in developing countries. Our review focuses on the implementation and effectiveness of parenting training programs (i.e., training in child psychosocial stimulation and/or training about nutrition). We emphasize the mechanisms that drive treatment-induced change in human capital outcomes and identify the demand- and supply-side behaviors that affect efficacy and effectiveness. Although the literature includes evidence on program features that are associated with successful interventions, further evidence on the dynamics of human capital formation, documentation of medium- to long-term persistence of treatment impacts, and research on the implementation and evaluation of programs at scale are needed to delineate a scalable and inclusive program that provides long-term treatment impacts.

Although eyeglasses have been considered a cost-effective way to combat myopia, the empirical evidence of its impacts on improving learning outcomes is inconsistent. This paper provides empirical evidence examining the effect of providing eyeglasses on academic performance between provinces with a different economic level in western China. Overall, we find a significant impact in Intention-to-Treat analysis and a large and significant local average treatment effect of providing free eyeglasses to students in the poor province but not in the other. The difference in impact between the two provinces is not a matter of experimental design, implementation, or partial compliance. Instead, we find that the lack of impact in the wealthier provinces is mainly due to less blackboard usage in class and wealthier households. Our study found that providing free eyeglasses to disadvantaged groups boosted their academic performance more than to their counterparts.

This study conducts an exploratory analysis of the impacts of a center-based early childhood development intervention on the mental health of caregivers, using data from a cluster-randomized controlled trial of 1664 caregivers (Mage = 36.87 years old) of 6- to 24-month-old children in 100 villages in rural China. Caregivers and children in 50 villages received individual parenting training, group activities and open play space in village parenting centers. The results show no significant overall change in caregiver-reported mental health symptoms after 1 year of intervention. Subgroup analyses reveal heterogeneous effects by caregiver socioeconomic status and identity (mother vs. grandmother). Findings suggest that early childhood development interventions without targeted mental health components may not provide sufficient support to improve caregiver mental health.

Objectives: To examine the association between mental health and executive dysfunction in general adolescents, and to identify whether home residence and school location would moderate that association.

Design: A population-based cross-sectional study.

Setting: A subsample of the Shanghai Children's Health, Education, and Lifestyle Evaluation-Adolescents project. 16 sampled schools in Shangrao city located in downstream Yangtze River in southeast China (December 2018).

Participants: 1895 adolescents (48.8% male) which were divided into three subpopulations: (A) adolescents who have urban hukou (ie, household registration in China) and attend urban schools (UU, n=292); (B) adolescents who have rural hukou and attend urban schools (RU, n=819) and (C) adolescents who have rural hukou and attend rural schools (RR, n=784).

Measures: The Depression Anxiety and Stress Scale-21 was used to assess adolescent mental health symptoms, and the Behaviour Rating Inventory of Executive Function (parent form) was applied to measure adolescent executive dysfunction in nature setting.

Results: Mental health symptoms were common (depression: 25.2%, anxiety: 53.0%, stress: 19.7%) in our sample, and the prevalence rates were lower among UU adolescents than those among the RR and RU, with intersubgroup differences in screen exposure time explaining most of the variance. We found the three types of symptoms were strongly associated with executive dysfunction in general adolescents. We also observed a marginal moderating effect of urban-rural subgroup on the associations: UU adolescents with depression (OR 6.74, 95% CI 3.75 to 12.12) and anxiety (OR 5.56, 95% CI 1.86 to 16.66) had a higher executive dysfunction risk when compared with RR youths with depression (OR 1.93, 95% CI 0.91 to 4.12) and anxiety (OR 1.80, 95% CI 1.39 to 2.33), respectively.

Conclusions: Rural adolescents experienced more mental health symptoms, whereas urban individuals with mental health problems had a higher executive dysfunction risk.

Background: The importance of breastfeeding in low- and middle- income countries is well recognized, yet the importance of postnatal mental health on breastfeeding practices and beliefs in these settings has been understudied. This study investigates the associations between maternal mental health problems, breastfeeding beliefs and breastfeeding practices in rural China.

Methods: Cross-sectional data were collected in November and December 2019 from 742 mothers of infants under 6 months old in rural Sichuan Province, China. Maternal mental health (depression, anxiety, and stress symptoms) was assessed using the Depression, Anxiety, and Stress Scale (short form). Breastfeeding beliefs were assessed using the Iowa Infant Feeding Attitude Scale and Breastfeeding Self-Efficacy Scale (short form). Breastfeeding practices were assessed through a 24-h dietary recall questionnaire. Ordinary least squares regression, multiple logistic regression and heterogeneous effects analyses were used to identify associations between symptoms of mental health problems and breastfeeding outcomes.

Results: The average age of sample infants was 2.7 months. Among mothers, 13% showed symptoms of depression, 16% anxiety, and 9% stress. The prevalence of exclusive breastfeeding in the previous 24 h was 38.0%. Depression symptoms were significantly associated with breastfeeding attitude and breastfeeding self-efficacy. Anxiety and stress symptoms were significantly associated with breastfeeding self-efficacy. There were no significant associations between symptoms of mental health problems and exclusive breastfeeding. The heterogeneous effects analyses revealed that less educated mothers with symptoms of stress had lower odds of exclusive breastfeeding than educated mothers without symptoms of stress. Mothers of younger infants had higher odds of exclusive breastfeeding than the mother of older infants, regardless of depression, anxiety, or stress symptoms.

Conclusion: Symptoms of maternal mental health problems are significantly associated with breastfeeding attitude and self-efficacy; however, these symptoms are not associated with breastfeeding practices. Maternal educational level and infant age may play a role in mothers’ breastfeeding practices. To improve breastfeeding practices, interventions should employ a multi-dimensional approach that focuses on improving maternal mental well-being and considers demographic characteristics.

Resilience can play an important role in enabling disadvantaged students to succeed academically. However, few studies in low-resource contexts have evaluated resilience as a process (including a child’s internal capabilities and external resources, like the internal capabilities of a child’s caregiver) and as an outcome (e.g., academic achievement). In the current study, we examined the associations among students’ self-reported internal capabilities, their external resources (e.g., caregivers’ internal capabilities), and their academic resilience (operationalized as performance on a math test). The study was conducted among 1609 primary and secondary school students in rural China using the Connor–Davidson Resilience Scale (CD-RISC) to measure internal capabilities. Student CD-RISC scores were positively associated with external resources including caregiver CD-RISC scores, maternal education level, high levels of perceived social support, recreational reading, and involvement in group-based activities at school. A one-point increase in students’ CD-RISC scores was associated with a 0.01 SD increase in math score (p < 0.001), and the math scores of students whose CD-RISC scores were in the bottom quartile were 0.18 SD lower than those of their peers (p < 0.01). High levels of perceived social support and recreational reading were also associated with academic resilience in the adjusted equation. Directions for future research and policy implications are discussed.

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.

Behavioral strengths and difficulties among children and adolescents may be significantly associated with their academic performance; however, the evidence on this issue for rural youth in developing contexts is limited. This study explored the prevalence and correlates of mental health from three specific dimensions—internalizing problems, externalizing problems, and prosocial behavior—measured by the Strengths and Difficulties Questionnaire (SDQ), and the association of these dimensions with academic performance in math among a sample of 1500 students in rural China. Our findings indicated that students in rural China had worse behavioral difficulties and poorer prosocial skills when compared to most past studies conducted inside and outside of China. In addition, total difficulties and prosocial scores on the SDQ were significantly associated with student math test scores, as students whose externalizing, internalizing, and prosocial scores were in the abnormal range scored lower in math by 0.35 SD, 0.23 SD, and 0.33 SD, respectively. The results add to the growing body of empirical evidence related to the links between social environment, mental health, and academic performance in developing countries, highlighting the importance of students’ mental health for their academic performance, and of understanding risk factors in the social environment among rural youth in developing countries.

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.

One out of every three children under age 5 in developing countries lives in conditions that impede human capital development. In this study, we survey the literature on parenting training programs implemented before age 5, with the aim to increase parental investment in human capital accumulation in developing countries. Our review focuses on the implementation and effectiveness of parenting training programs (i.e., training in child psychosocial stimulation and/or training about nutrition). We emphasize the mechanisms that drive treatment-induced change in human capital outcomes and identify the demand- and supply-side behaviors that affect efficacy and effectiveness. Although the literature includes evidence on program features that are associated with successful interventions, further evidence on the dynamics of human capital formation, documentation of medium- to long-term persistence of treatment impacts, and research on the implementation and evaluation of programs at scale are needed to delineate a scalable and inclusive program that provides long-term treatment impacts.

This paper examines the impact of parental beliefs on child development outcomes (for both cognitive and social–emotional skills) based on a three-wave longitudinal survey in rural China. The survey waves were conducted when the sample children were 18–30 months, 22–36 months, and 49–65 months, respectively. A total of 815 children and their primary caregivers who participated in all three wave surveys were enrolled in this study. Using difference-in-differences and propensity score matching approaches, the results indicate that strengthened parental beliefs have a positive and significant impact on child social–emotional development. Specifically, between the periods of the Wave 1 survey (when children were 18–30 months old) and the Wave 3 survey (when children were 49–65 months old), and between the Wave 2 survey (when children were 22–36 months old) and the Wave 3 survey, strengthened parental beliefs were causally associated with more favorable child social–emotional scores by 0.44 SD (p < 0.01) and 0.49 SD (p < 0.01), respectively. No significant impact, however, was found between the period of the Wave 1 survey and the Wave 2 survey. In contrast, weakened parental beliefs had a negative and significant impact on child social–emotional development. Specifically, weakened parental beliefs were causally associated with worse child social–emotional abilities by 0.35 SD (p < 0.01), 0.30 SD (p < 0.01), and 0.22 (p < 0.05) for the time period of the Wave 1 to Wave 2, Wave 1 to Wave 3, and Wave 2 to Wave 3, respectively. No significant impact of parental beliefs, however, was found on child cognitive development. In addition, the findings of the mediation analysis show that only a marginal impact of parental beliefs on child social–emotional development can be indirectly explained by parental beliefs through parenting practices. This study calls on policy makers to improve parental beliefs and parenting practices in the hope that it will lead to better child development in rural China.

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.

Academic achievement in middle schools in rural China remains poor for many students. This study examines whether programmes and interventions can improve academic achievement by reviewing rigorous experimental evaluations of nine programmes (11 interventions) on 47,480 rural middle school students in China. The results find none of the interventions improved academic achievement. Moreover, we find no evidence for heterogeneous treatment effects by student gender, age or previous academic achievement. These results may be due in part to the academically-demanding nature of the middle school curriculum, which is applied universally to students with varying levels of cognitive ability.

Although children living in low- and middle-income countries (LMICs) account for 90% of the global population of children, depression, and anxiety among children in LMICs have been understudied. This study examines the prevalence of depression and anxiety and their associations with biological and psychosocial factors among children across China, with a focus on rural areas. We conducted a large-scale epidemiological study of depression and anxiety among 53,421 elementary and junior high school-aged children across China. The results show that 20% are at risk for depression, 6% are at risk for generalized anxiety, and 68% are at risk for at least one type of anxiety. Girls and junior high school students show a higher risk for both depression and anxiety symptoms, while socioeconomic status has varying associations to depression and anxiety symptoms. Our results also show consistent correlations between depression and anxiety symptoms and standard math test scores. These findings underscore the importance of identification, prevention, and treatment of youth depression and anxiety in underdeveloped areas. As China constitutes 15% of the global population of children under age 18, this study offers valuable information to the field of global mental health.

Using a three-wave longitudinal survey conducted in 815 households in rural Western China, this study aims to examine the association between parental self-perception and early childhood development and the mediation effect of parental investment on the association between parental self-perception and child development when the sample children are at different ages in the early childhood (18–30, 22–36, and 49–65 months). The results demonstrate that parental self-perception are positively and significantly associated with child social-emotional development in all three ages of childhood (from 18 to 65 months). Positive and significant association between parental self-perception and child cognitive development is found in the ages from 22 to 65 months. In addition, findings of this study show that parental investment plays a mediating role in the association between parental self-perception and child cognitive development. The study calls on policymakers to help to strengthen parental self-perception and parental investment related to early childhood development, which should result in better child development in rural China.

Extant research continues to establish the importance of teacher job satisfaction to student performance, yet teacher job satisfaction remains under-investigated in rural China. In this paper, we examine the prevalence and correlates of teacher job satisfaction. Using data from 634 teachers across 120 schools in rural China, we find an alarmingly high prevalence of teacher job dissatisfaction: roughly 21% of rural teachers were less than satisfied with their jobs. In addition, we find that several individual- and school-level characteristics, including being a male teacher, being a homeroom teacher, not having a management role in school, being a middle-aged teacher, and a school’s boarding status, are correlated with teacher job dissatisfaction. In sum, the results demonstrate a need for further research and policy interventions to improve teacher job satisfaction in rural schools.

This study documents the COVID-19 disease-control measures enacted in rural China and examines the economic and social impacts of these measures. We conducted two rounds of surveys with 726 randomly selected village informants across seven provinces. Strict disease-control measures have been universally enforced and appear to have been successful in limiting disease transmission in rural communities. The infection rate in our sample was 0.001 per cent, a rate that is near the national average outside of Hubei province. None of the villages reported any COVID-19-related deaths. For a full month during the quarantine, the rate of employment of rural workers was essentially zero. Even after the quarantine measures were lifted, nearly 70 per cent of the villagers still were unable to work owing to workplace closures. Although action has been taken to mitigate the potential negative effects, these disease-control measures might have accelerated the inequality between rural and urban households in China.

The cost-effectiveness of policies providing subsidized health goods is often compromised by limited use of the goods provided. Through a randomized trial involving 251 primary schools in western China, we tested two approaches to improve the cost-effectiveness of a program distributing free eyeglasses to myopic children. Relative to delivery of free eyeglasses to schools, we find that providing vouchers redeemable in local optical shops modestly improved the targeting of eyeglasses to those who would use them without reducing effective coverage. Information provided through a health education campaign increased eyeglass use when eyeglasses were delivered to schools, but had no effect when requiring voucher redemption or when families were only given a prescription for eyeglasses to be purchased on the market. Though most expensive, free delivery to schools with a health education campaign was the most socially cost-effective approach tested and increased effective coverage of eyeglasses by 18.5 percentage points after seven months.