Health, income and poverty: evidence from China's rural household survey

Analysis of medical impoverishment and its influencing factors among China's rural near-poor, 2016-2020

Objective

This study investigates the determinants of medical impoverishment among China's rural near-poor, aiming to enhance public health services and establish preventative and monitoring systems.

Methods

Using China Family Panel Studies and World Bank methods, we categorized rural populations and calculated their 2020 Poverty Incidence (PI) and Poverty Gap (PG), with impoverishing health expenditures (IHE) as the primary indicator. We analyzed the data from 2016 to 2020 using a conditional fixed-effects multinomial logit model and 2020 logistic regression to identify factors influencing medical impoverishment risk.

Results

(1) In 2020, the near-poor in China faced a PI of 16.65% post-health expenditures, 8.63 times greater than the non-poor's PI of 1.93%. The near-poor's Average Poverty Gap (APG) was CNY 1,920.67, notably surpassing the non-poor's figure of CNY 485.58. Health expenses disproportionately affected low-income groups, with the near-poor more prone to medical impoverishment. (2) Disparities in medical impoverishment between different economic household statuses were significant (P < 0.001), with the near-poor being particularly vulnerable. (3) For rural near-poor households in China, those with over six members faced a lower risk of medical impoverishment compared to those with three or fewer. Unmarried individuals had a 7.1% reduced risk of medical impoverishment relative to married/cohabiting counterparts. Unemployment was associated with a 9% increased risk. A better self-rated health status was linked to a lower probability of IHE, with the "very healthy" reporting a 25.8% lower risk than those "unhealthy." Chronic disease sufferers in the near-poor and non-poor categories were at an increased risk of 12 and 1.4%, respectively. Other surveyed factors, including migrant status, age, insurance type, gender, educational level, and recent smoking or drinking, were not statistically significant (P > 0.05).

Conclusion

Rural near-poor in China are much more susceptible to medical impoverishment, influenced by specific socio-economic factors. The findings advocate for policy enhancements and health system reforms to mitigate health poverty. Further research should extend to urban areas for comprehensive health poverty strategy development.

Inspecting the "health poverty trap" mechanism: self-reinforcing effect and endogenous force

INTRODUCTION

The term "health poverty trap" describes a vicious cycle in which developing countries or regions become trapped in low levels of health and poverty during the process of modernization. Although significant progress has been made in alleviating poverty in China, there is still a need to further enhance the living conditions of its impoverished population.

METHODS

This research utilizes the data of the three national representative panel surveys from 2014 to 2020. The primary objective is to gain a better understanding of the intricate relationship between health and poverty. To examine the self-reinforcing effects of the cumulative cycle between health and poverty, we employ unconditional quantile regression analysis.

RESULT

The low-income group exhibits lower overall health status compared to the average level. Economic constraints partially hinder the ability of low-income individuals to access healthcare resources, thereby reinforcing the cyclical relationship between health and poverty. Additionally, the unique psychological and behavioral preferences of individuals in health poverty act as indirect factors that further strengthen this cycle. Health poverty individuals can generate endogenous force to escape the "health poverty trap" by enhancing their confidence levels and digital literacy.

CONCLUSIONS

The research examines the coexistence of health gradients and economic inequality among Chinese residents. Additionally, the study explores the endogenous force mechanism of escaping the health poverty trap from psychological and behavioral perspectives. This research also offers insights into optimizing government poverty alleviation programs to effectively address this issue.

Trends and disparities in non-communicable diseases in the Western Pacific region

The WHO Western Pacific region bears disproportionate deaths from non-communicable diseases (NCDs), with increased overall NCD proportional mortality over the past two decades. The disease burden of mental health increased, resulting from rapid ageing, enhanced stress, and the COVID-19 pandemic, but it was largely neglected. The highly diverse cultures, religions, political systems, socioeconomic contexts, lifestyles, and environmental factors probably have led to massive disparities across countries in NCD mortality, risk factors, and NCD management. Geographically, East Asia had the lowest NCD mortality whilst Pacific islands had the highest. Economic booms, ageing, nutrition transition, social stress, prevalent tobacco use, and fast-increasing obesity and hyperglycaemia are important drivers of NCDs. Men tended to have more adverse behavioural and metabolic risk factors. Rural residents are catching up with their urban counterparts in metabolic risk factors and conditions. Sustainable strategies tailored to NCD patterns are needed to fight the NCD epidemic and related disparities.

A cross-sectional study on the moderating effect of self-efficacy on the relationship between sociodemographic variables and nutrition literacy among older adults in rural areas of North Sichuan

Objective

The purpose of this study is to examine the moderating role of self-efficacy among rural elderly individuals in northern Sichuan Province in the relationship between certain sociodemographic variables and nutritional literacy.

Methods

Convenience sampling was used to select 264 elderly individuals aged 60 and above from rural communities in Cangxi County, Guangyuan City, Yilong County, Nanchong City, and Bazhou District, Bazhong City, Sichuan Province. A self-designed questionnaire, including sociodemographic variables, the General Self-Efficacy Scale (GSES), and the Nutrition Literacy Questionnaire for the Elderly (NLQ-E), was administered through face-to-face interviews using a paper-based version. The relationships between sociodemographic variables, self-efficacy, and nutritional literacy in the elderly were analyzed using SPSS 26.0 and the Process plugin to examine the relationships between variables and to test for moderation effects.

Results

(1) There were significant differences in nutrition literacy scores among elderly people of different ages, genders, marital statuses, educational levels, personal monthly living expenses, dental conditions, and number of chronic diseases (p < 0.05). (2) When elderly individuals have lower self-efficacy, their nutritional literacy is lower as they become older, and they have poorer nutritional literacy with a higher number of chronic diseases.

Conclusion

General population demographic data has a significant impact on the nutritional literacy level of elderly people in rural areas of northern Sichuan. Self-efficacy plays a moderating role in the relationship between age and nutritional literacy, as well as the relationship between the number of chronic diseases and nutritional literacy.

Relationship between the health poverty vulnerability and multimorbidity patterns identified with latent class analysis aged 45 years or more adults in Northwestern China: A cross-section study

This study aims to identify multimorbidity patterns and examine whether health poverty vulnerability (HPV) varies among adults aged 45 years or more. Data from 4338 participants were extracted from a Chinese cross-sectional study. Latent class analysis was used to identify multimorbidity patterns based on 11 self-reported chronic diseases. A 3-stage feasible generalized least-squares method was used to measure the HPV. The associations and influencing factors were analyzed using the Tobit model. The mean HPV values were 0.105 ± 0.225 and 0.329 ± 0.357, based on extreme poverty and those of low- and middle-income countries' poverty line, respectively. Four latent multimorbidity patterns were identified, comprising hypertension (57.33%), cardiovascular diseases (19.94%), the musculoskeletal system (13.09%), and spine (9.64%). The HPV value from hypertension (coefficient [Coef] =0.03, 95% confidence interval (CI) = 0.00-0.05) was significantly higher than that of the musculoskeletal system based on extreme poverty. In addition, the HPV values for hypertension (Coef =0.08, 95% CI = 0.05-0.11), spine (Coef =0.06, 95% CI = 0.02-0.11), and cardiovascular diseases (Coef =0.07, 95% CI = 0.03-0.11) were significantly high based on low- and middle-income countries' poverty line. Age ≥75 years, registered poor households, catastrophic medical expenditure, and toilet style were major risk factors. Although the multimorbidity pattern-induced HPV has been significant improved on extreme poverty, it still poses a very serious challenge with regard to low- to middle-income countries' poverty line. The sensitivity analysis proved the robustness of the results. Policymakers should focus on adults with 3 multimorbidity patterns, namely, registered poor households, age ≥75 years, and catastrophic health expenditure, to adopt targeted interventions to prevent and eliminate HPV.

Inequalities in unmet health care needs under universal health insurance coverage in China

BACKGROUND

Expanding health insurance is a critical step towards universal health coverage due to its positive effect on reducing unmet health care needs and enhancing equitable access to health care. Despite previous studies on the socioeconomic factors associated with unmet health care needs, few studies have analysed the inequalities in such needs and the impact of universal health insurance coverage on addressing them. This study aimed to measure the contribution of social health insurance (SHI) coverage to inequalities in financially and non-financially constrained unmet health care needs among middle-aged and elderly Chinese adults.

METHODS

The study data were obtained from the China Health and Retirement Longitudinal Study (2011-2015). A total of 11,592 respondents reporting outpatient care needs and 6320 reporting inpatient care needs were included. The concentration index (CI) was employed to measure the extent of income-related inequalities in unmet health care needs. A decomposition method based on a probit model was used to investigate the contribution of SHI to the inequalities.

RESULTS

The incidence rates of unmet outpatient needs due to financial and non-financial constraints were 4.68% and 24.78%, respectively; these rates were 18.69% and 15.73% for unmet inpatient needs. The CIs of unmet outpatient needs due to financial and non-financial constraints were - 0.1872 and 0.0195, respectively; these values were - 0.1558 and 0.0352 for unmet inpatient needs. The percentages of the contribution of SHI to the CIs of financially constrained unmet outpatient and inpatient needs were 0.2639% and 1.8898%, respectively. Moreover, the percentages of the contribution of SHI to the CIs of non-financially constrained unmet outpatient and inpatient needs were - 0.4513% and - 6.4192%, respectively.

CONCLUSION

The universal coverage of SHI in China increased pro-poor inequalities in financially constrained unmet health care needs but decreased pro-rich inequalities in non-financially constrained unmet needs. Additionally, the contribution of SHI to inequalities in financially constrained unmet needs for inpatient care was stronger than that for outpatient care. Policy-makers are advised to introduce favourable reimbursement policies for patients with poor socioeconomic conditions and address both financial and non-financial barriers to promote equitable access to health care for the entire population.

Socioeconomic deprivation, medical services accessibility, and income-related health inequality among older Chinese adults: evidence from a national longitudinal survey from 2011 to 2018

BACKGROUND

Health inequality poses a challenge to improving the quality of life of older adults as well as the service system. The literature rarely explores the moderating role of medical services accessibility in the association between socioeconomic deprivation and health inequality.

OBJECTIVE

This study examines the socioeconomic deprivation and medical services accessibility associated with health inequality among older Chinese adults, which will contribute to the medical policy reform.

METHODS

Using data from the 2011, 2014, and 2018 waves of the Chinese Longitudinal Healthy Longevity Survey (CLHLS), we analyse 14,232 older adults. This paper uses a concentration index (CI) to measure the income-related health inequality among the target population and employs a recentered influence function-concentration index-ordinary least squares (RIF-CI-OLS) model to empirically analyse the correlation between socioeconomic deprivation and health inequality among older Chinese adults. Based on the correlation analysis, we discuss the moderating effect of medical services accessibility.

RESULTS

We find that health inequality exists among older Chinese adults and that the relative deprivation in socioeconomic status (SES) is significantly associated with health inequality (β∈  [0.1109,  0.1909], P < 0.01). The correlation between socioeconomic deprivation and health inequality is moderated by medical services accessibility, which means that an increase in medical services accessibility can weaken the correlation between socioeconomic deprivation and health inequality.

CONCLUSION

China needs an in-depth reform of its medical services accessibility system to promote the equitable distribution of medical services resources, strengthen medical costs and quality management, and ultimately mitigate the SES reason for health inequality among older Chinese adults.

Health Poverty Alleviation Project in Rural China: Impact on Poverty Vulnerability, Health Status, Healthcare Utilization, Health Expenditures

BACKGROUND

China has lead to the inception of the Health Poverty Alleviation Project (HPAP) in 2015. While the previous studies suggest that, despite its apparent reduction in patients' financial strain, the long-term poverty reduction effects are yet to be fully elucidated. This study explores HPAP's enduring impact on poverty reduction and the potential moral hazards.

METHODS

Data were obtained from four waves of the China Health and Retirement Longitudinal Study (CHARLS) spanning 2011-2018. We employed difference-in-differences (DID) models to gauge HPAP's influence on participants' poverty vulnerability, health outcomes, and healthcare utilization. The dynamic DID model is employed to test the robustness of HPAP policy effects. The mediation effect models were used to understand HPAP policy outcomes through physical examinations and inpatient care.

RESULTS

Our dataset encompassed 40,384 participants, of which 5946 (14.72%) had been exposed to HPAP and 34,438 (85.28%) had not access. Our findings reveal that HPAP decreases poverty vulnerability by 3.3% (p < 0.01) and attenuates health deterioration by 1.84% (p < 0.01). Furthermore, HPAP enhances inpatient care utilization by 9.34% (p < 0.01) and self-treatment behaviors by 4.1% (p < 0.01) while significantly slashing outpatient and inpatient expenses (p < 0.05). The implementation of HPAP has significantly reduced healthcare costs by 72.8% (p < 0.05) out-of-pocket (OOP) payments of outpatient care during the past month for the last time, and 89.39% (p < 0.05) out-of-pocket (OOP) payments of inpatient care during past the year for the last time. Mechanistic analyses have shown that the indirect effect of the HPAP policy decreases poverty vulnerability by -0.132% (p < 0.05) physical examinations and -0.309% (p < 0.05) inpatient care.

CONCLUSION

The HPAP initiative markedly attenuates poverty vulnerability and forestalls health decline among the rural populace. Moreover, HPAP bolsters healthcare service use, such as physical examinations and inpatient care, primarily attributed to the release of pent-up demand rather than moral hazards.

A comprehensive review of the production, adoption and sustained use of biomass pellets in Ghana

Ghana's Renewable Energy Master Plan of 2019 includes the production and use of biomass pellets. However, pellets have neither been developed commercially nor included in Ghana's energy mix. This paper reviewed the prospect of production, adoption and sustained use of pellets in Ghana. Besides having abundant biomass resources, Ghana has high market demand and relevant policies for pellet development. The production of pellets can significantly replace traditional household biomass demand and improve environmental and health quality. However, the production and use of pellets are limited due to technical, financial, social and policy issues. Our estimates show that 3% of the annual national average household income will be spent on pellet demand for cooking, with the highest burden on rural households in Ghana. Practical measures are required since the cost of pellets and gasifier stoves may limit pellet adoption and use in Ghana. Based on study findings, it is recommended that the government of Ghana establishes a robust supply chain and provides infrastructure for pellet production and use. Existing renewable energy policies should be reviewed to remove ambiguities, attract investment, and build capacity in the renewable energy sector. Apart from raising public awareness of the benefits of pellets use, the government of Ghana should ensure that continuous and thorough impact assessments are undertaken to assess the implications of pellet production and use. This review will inform policymaking on achieving sustainable production, adoption and use of pellets and assess Ghana's contribution to achieving the United Nations' sustainable development goals.

The effect gap of hypertension health management services in poverty and non-poverty counties on the hypertension control: evidence from China Chronic Diseases Risk Factors Surveillance

BACKGROUND

The Chinese government implemented the health poverty alleviation project (HPAP) since 2016 in poverty counties (PCs). To evaluate the effect of the HPAP on hypertension health management and control in PCs is vital for the policy improvement.

METHODS

China Chronic Disease and Risk Factors Surveillance programme were conducted from August 2018 to June 2019. A total of 95,414 participants aged 35 and above from 59 PCs and 129 non-poverty counties (NPCs) were involved in this study. Hypertension prevalence, hypertension control, treatment and health management prevalence, and physical examination proportion were calculated and compared by PCs and NPCs. Logistic regression was employed to explore the association between hypertension control and management services.

RESULTS

The hypertension prevalence in NPCs was significantly higher than that in PCs (NPCs 46.1% vs. PCs 41.2%, P < 0.001). The NPCs participants had a higher hypertension control prevalence (NPCs 32.7% vs. PCs 27.3%, P < 0.001) and treatment prevalence (NPCs 86.0% vs. PCs 80.0%, P < 0.001) than that in PCs. The proportion of physical examination in one year in NPCs was significantly higher than that in PCs (NPCs 37.0% vs. PCs 29.5%, P < 0.001). The proportion of diagnosed hypertension patients without hypertension health management in NPCs was significantly higher than that in PCs (NPCs 35.7% vs. PCs 38.4%, P < 0.001). Multivariable logistic regression showed that standardized and non-standardized hypertension health management were positively correlated with hypertension control in NPCs, and standardized hypertension health management was positively correlated with hypertension control in PCs.

CONCLUSIONS

These findings show the equity and accessibility gap of health resources still existed between PCs and NPCs under the influence of the HPAP. Hypertensive health management was effective for hypertension control in both PCs and NPCs. However, the quality of management services still needs to be improved.

The association between financial support of adult children to their parents and informal care provision in China and its differences in household registration, residence arrangement and community-based care services: 2008 ~ 2018

BACKGROUND

The changes in demographic and family structures have weakened the traditional norms of filial piety and intergenerational relationships dramatically. This study aims to examine the dynamic association between financial support of adult children to their parents and informal care provision in China and its differences in household registration, residence arrangement and community-based care services.

METHODS

Data was derived from the 2008-2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS), which is a longitudinal survey of a nationally representative sample of individuals aged 60 and over. Random effects model was used to assess the association between financial support and informal care provision of adult children to their parents.

RESULTS

It was found that financial support showed an upward trend while informal care provision showed a download trend from 2008 to 2018. The result indicated a significant and negative association between financial support and informal care provision of adult children to their parents (B = -0.500, 95% confidence interval (CI) = -0.761 to -0.239). And the association was significant among elderly people who were from urban areas (B = -0.628, 95% CI = -0.970 to -0.287), co-resided with adult children (B = -0.596, 95% CI = -0.939 to -0.253), and had community-based services (B = -0.659, 95% CI = -1.004 to -0.315).

CONCLUSION

Financial support was negatively associated with informal care provision of adult children to their parents in China, and the association has differences in household registration, residence arrangement and community-based care services. It is suggested that policymakers should prioritize planning interventions for elderly care services and establish a family caregiver support system.

Barriers to Breast Cancer-Screening Adherence in Vulnerable Populations

Breast cancer screening through periodic mammography has been effective in decreasing mortality and reducing the impact of this disease. However, adherence to screening does not meet the desired expectations from all populations. The main objective of this review is to explore the barriers that affect adherence to breast cancer-screening programs in vulnerable populations according to race and/or ethnicity in order to propose measures to reduce the lack of adherence. We conducted a search of publications in the PubMed Central and Scopus databases. The eligible criteria for the articles were as follows: original quantitative studies appearing in SJR- and/or JCR-indexed journals from 2016 to 2021 in English or Spanish. Most of them present common barriers, such as race/ethnicity (47%), low socioeconomic (35.3%) and educational levels (29.4%), no family history of cancer and being single (29.4%), medical mistrust and a health information gap (23.5%), lack of private health insurance (17.6%) and not having annual health checks (17.6%). The target populations with the lowest adherence were Black, Asian, Hispanic and foreign women. Implementing awareness campaigns focused on these populations should be promoted, as well as working on diversity, cultural acceptance and respect with healthcare workers, in order to improve breast cancer-screening adherence worldwide.

Disparities of obesity and non-communicable disease burden between the Tibetan Plateau and developed megacities in China

Background

Non-communicable diseases (NCDs) including risk factors, e.g., obesity, are the major causes of preventable deaths in China, yet NCD disparities in China remain under-studied.

Objective

This study aimed to compare the determinants and burden of NCDs within four selected provinces in mainland China: the least developed Qinghai-Tibet Plateau group (PG, Tibetan Autonomous Region [TAR] and Qinghai Province) and most developed megacity group (MCG, Shanghai, and Beijing).

Methods

Studies, reports, and other official sources with comparable data for NCD burden and related determinants for the four provinces were searched. Geographic, demographic, socioeconomic, and dietary characteristics and selected health indicators (e.g., life expectancy) were extracted from the China Statistical Yearbook and China Health Statistics Yearbook. Data on NCD burdens were extracted from the National Chronic Disease and Risk Factor Surveillance Study and other nationally representative studies.

Results

The overall NCD mortality rates and prevalence of metabolic risk factors including obesity, hypertension, and diabetes in mainland China have increased in the past 20 years, and this trend is expected to continue. The PG had the highest level of standardized mortality rates (SMRs) on NCDs (711.6-896.1/100,000, 6th/6-level); the MCG had the lowest (290.6-389.6/100,000, 1st/6-level) in mainland China. The gaps in SMRs were particularly high with regard to chronic respiratory diseases (PG 6th^/6-level, MCG 1st/6-level) and cardiovascular diseases (6th/6 and 4th/6 in TAR and Qinghai; 1st/6-level and 2nd/6-level in Shanghai and Beijing). In contrast, the prevalence rates of obesity, hypertension, and diabetes were generally higher or comparable in MCG compared to PG. Diabetes prevalence was particularly high in MCG (5th/5-level, 13.36-14.35%) and low in PG (1st/5-level, 6.20-10.39%). However, awareness, treatment, and control of hypertension were poor in PG. Additionally, PG had much lower and severely inadequate intakes of vegetables, fruits, and dairy products, with additional indicators of lower socioeconomic status (education, income, etc.,) compared with MCG.

Conclusion

Evidence showed large disparities in NCD burden in China's provinces. Socioeconomic disparity and dietary determinants are probably the reasons. Integrated policies and actions are needed.

Pathway of Effects of Socioeconomic Status on Rural Left-behind Children to Receive Oral Health Services: A Structural Equation Modeling

In a rural area with a high proportion of left-behind children (LBC), we aimed to identify the pathway of influence of socioeconomic status (SES) on LBCs to receive oral health services after individualized advice. Between September and October 2020, in a rural area of Yunnan, a survey of 238 LBC and 210 non-left-behind children (NLBC) showed that 91.9% and 94.2% had primary teeth caries, respectively. Their caregivers were advised on (1) dental care: bringing the children to seek professional dental care; and (2) self-care: supervising the children's oral health behaviors. Two to three months later, the children and their caregivers were visited to assess the compliance with these items of advice. Structural equation modeling (SEM) was used to handle the association between SES and compliance with the advice. A heatmap was used to visualize the data of reasons for seeking dental care or not. A total of 183 (87.1%) NLBCs and 206 (86.6%) LBCs were given the above advice; 32.9% of caregivers complied with dental care advice without a statistical difference between the LBC and NLBC group; 69.9% of caregivers of NLBCs complied with self-care advice, statistically more than those LBCs (59.2%). The education of caregivers was significantly associated with compliance with both advice items in univariate analysis. SES had a direct effect on the children being left behind and the level of oral health knowledge and awareness of the caregivers. Being left behind did not have an independent effect on receiving oral health services for children. "Dental disease was not severe" and "having no pain" were the main reasons for not seeking dental care. There was no clear grouping of participants with different background information based on the reasons given for seeking or not seeking dental care. Our study pointed to the importance of SES level. Being left behind alone may not be a risk factor for missing oral health services among rural children.

Seeking policy solutions in a complex system: experimentalist governance in China's healthcare reform

The proliferation of "wicked" policy problems in complex systems requires an experimental approach of problem-solving. Experimentalist governance offers a conducive framework through which to seek policy solutions amidst high levels of complexity in a multilevel governance structure. This study conceptualizes four distinctive experimental modalities based on varying levels of technical complexity and interest complexity, both of which represent salient constraints for policy reforms in a complex system, the health sector in particular. Trail-blazing pilots, crowdsourcing pilots, managed pilots, and road-testing pilots are all associated with distinct mechanisms of experimentation in a multilevel governance structure. Through four illustrative cases from China's massive experimental program of public hospital reform, this study demonstrates how experimentalist governance seeks policy solutions in the health sector. Should governance arrangements, policy capacity, pragmatism, and informational devices become aligned in a conducive way, experimentalist governance can play an instrumental role in seeking solutions for difficult problems in a complex policy system. A governance structure capable of policy learning and adaptive management is the key.

The Impact of Multidimensional Poverty on Rural Households' Health: From a Perspective of Social Capital and Family Care

Although absolute poverty has been eliminated in rural China, multidimensional poverty has an unstoppable impact on the self-rated health of rural households through multiple dimensions. This study constructed a moderated mediation model with multidimensional poverty as the independent variable to explore the impact on rural households' self-rated health, social capital as a mediating variable, and family care as a moderating variable. We used the survey data of 382 sample out-of-poverty rural households in Jiangxi, China, in 2020. Our results indicated that multidimensional poverty had a detrimental impact on the self-rated health and social capital of rural households, both of which were significant at the 1% level (β = -0.751, t = -4.775, and β = -0.197, t = -7.08). A test of the mediating effect of social capital using the mediation model found the mediating effect accounting for 84.95% of the entire effect of multidimensional poverty on rural households' self-rated health. Further, the interaction term between family care and multidimensional poverty and its beneficial effect on social capital as well as the interaction term between family care and social capital and its negative effect on rural household' self-rated health are both statistically significant at the 1% level (β = 0.558, t = -5.221 and β = -2.100, t = -3.304). It is revealed that multidimensional poverty affects rural households' self-rated health through social capital and that family care moderates the mediating pathway. Family care exacerbates the negative effect of multidimensional poverty on rural households' self-rated health and weakens the beneficial effect of social capital on rural households' self-rated health. The lower (higher) the level of family care, the more significant the positive (negative) effect of social capital on rural households' health. Therefore, rural households should prioritize building social capital and shifting the responsibility for family care. First, through enhancing housing infrastructure and establishing cultural and educational initiatives, households can improve their viability. Second, increasing engagement in group activities will enhance social networks and boost interpersonal connections. Finally, to lessen the stress on family caregivers, building socialized care services can cover the gap in family care.

Measurement and Decomposition of the Health Poverty of Rural Residents in China

Narrowing the health gap and promoting health equality is the key to effectively blocking the intergenerational transmission of rural poverty. Previous studies have mainly focused on the relationship between health and poverty, but assessments of health poverty are lacking, especially with regard to the health poverty of rural residents. Based on China's large sample household survey data, this study uses the Alkire-Foster (AF) method to measure and decompose the health poverty of rural residents. The results show that the health poverty of Chinese rural residents greatly improved from 2016 to 2018. However, significant regional differences exist with regard to the level of health poverty. The marginal contribution of economic poverty alleviation is diminishing; the equalization of health services and security has shifted to a policy focus. Community environmental management has also become an important aspect of health poverty governance, and individual health literacy and behavior have played an important role in endogenous poverty alleviation. Ultimately, this paper offers some insightful policy implications. This study extends the multidimensional poverty measurement system and reveals the relationship between health poverty and regional economic and social development. The findings also enhance the understanding of the health poverty of rural residents in developing countries.

Understanding the mechanism of energy poverty affecting irrigation efficiency: evidence from rural China

Lower irrigation efficiency and energy poverty cast a pall on the prospects for sustainable development. However, their relationship is poorly understood, particularly in rural China. Using the China Family Panel Studies 2014-2018 waves, this study examines the impact of energy poverty (EP) on irrigation water efficiency (IWE). Result show that EP reduced IWE by 28.3 ~ 42.4%. These results are robust to a variety of estimation methods. The underlying mechanisms, as revealed by structural equation modeling, are that health and non-agricultural employment act as mediators of the EP-IWE relationship. Non-agricultural employment has a positive and statistically significant mediating effect, indicating that efforts to alleviate energy poverty are partially transmitted to IWE.

Does direct settlement of intra-province medical reimbursements improve financial protection among middle-aged and elderly population in China? Evidence based on CHARLS data

In low- and middle-income countries, social health insurance schemes are the main focus of efforts to achieve universal health coverage (UHC) by promoting access to health care and financial protection. Problems with financial protection in China are caused mainly by health insurance fragmentation and a rapid rise in medical expenditure. In this context, China implemented a policy of direct settlement of intra-provincial medical reimbursement in 2014. We evaluated the impact of the policy on financial protection with a population aged 45 and above based on the China Health and Retirement Longitudinal Study from 2011 to 2018. We estimated the policy effects using the difference-in-differences method, based on coarsened exact matching. We found that the policy significantly reduced the catastrophic health expenditures (CHEs) rate by approximately 10% in the population, whether middle-aged or elderly. Subgroup analyses indicated that middle-aged and elderly people living in western China and with lower household incomes received greater protection from the policy. The CHEs rate for the two age groups in western China was reduced by 16.26% and 20.12%, respectively. The CHEs rate was reduced by 24.51% and 17.32% for middle-aged individuals in the lowest and second household income quartiles, respectively, and by 21.31% for older adults in the second household income quartile. The new rural cooperative medical scheme exerted a smaller protective effect than urban medical insurance among the participants aged 60 and older. We found that in addition to optimizing health insurance schemes, more health care reform measures, such as adopting more efficient payment methods and rationalizing medical expenditures, should be combined to help reduce health inequities and accelerate progress toward achieving UHC and the Sustainable Development Goals.

Development trend of primary healthcare after health reform in China: a longitudinal observational study

OBJECTIVES

Reconstructing the primary healthcare system is the focus of the new round of Chinese health reform. Nevertheless, there have been few studies focusing on the strengthening of primary healthcare in Chinese health system.

DESIGN

This study was a longitudinal observational study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The data of this study came from China Health Statistical Yearbook (2009-2018). We evaluated the development of primary healthcare based on the absolute values of health resources allocation and health service provision and evaluated the status of primary healthcare throughout the health system based on the composition ratios of the indicators across the health system. The Cochran-Armitage trend test and linear trend test were used to identify the indicators' trends over time.

RESULTS

From 2009 to 2018, the amounts of health resources allocation and health service provision of Chinese primary healthcare institutions showed a significant upward trend (p<0.001). However, compared with the indicators in 2009, excepting that the proportion of grants from the government in the whole health system has an upward trend, the proportions of other indicators had an escalating trend in 2018 by 3.66% for practicing (assistant) physicians, by 2.69% for nurses, by 3.99% for total revenues, by 5.87% for beds, by 8.39% for outpatient visits.

CONCLUSION

The primary healthcare system has developed rapidly, but its development speed lagged behind the entire health system, resulting in the weakening of its actual functions, which is not in line with the goal of health reform. The government should be more aware of the importance of primary healthcare at all levels of local governments and ensure adequate financial input.

Effects of Disability Severity on the Family Burden of Home-Dwelling Uygur and Kazakh Aged in Rural Western China: Family Function as a Mediator

INTRODUCTION

Caring for the disabled elderly puts heavy burdens on their families. This study aimed to explore family function (FF) as a mediator in the relationship between disability severity (DS) and family burden (FB) of the Uygur and Kazakh home-dwelling disabled elderly cared for by informal caregivers in China.

METHOD

A cross-sectional design with multistage sampling was used to recruit 431 families with Uygur and Kazakh disabled elderly in Bortala, Xinjiang, China. Data were collected using the Activities of Daily Living Scale, Family Burden Interview Schedule, and Family Adaptation, Partnership, Growth, Affection, and Resolve Index Scale and then analyzed using hierarchical regression.

RESULTS

FF had a partial mediating effect on the relationship between DS and FB (β = 0.131; 95% confidence interval [CI] = [0.074, 0.197]; p < .01); the effective rate was 41.46%.

DISCUSSION

Multidisciplinary care teams should implement targeted interventions to improve FF of the disabled elderly to alleviate FB.

The Impact of Multidimensional Health Levels on Rural Poverty: Evidence from Rural China

Poor health and poverty interact and restrict each other. While this relationship is acknowledged, little is known about the extent of its impact. By integrating multisource data, this study used spatial econometric models to quantitatively reveal the relationship between health and rural poverty and explore its intrinsic mechanisms. The results indicated that health-care system input, individual health status, and individual health-seeking behavior have a significantly positive effect on the eradication of rural poverty. The health-care system input is characterized by spatial spillover, significantly contributing to rural poverty alleviation in the region and neighboring regions, as well. However, the effect of health-care system services’ capability was negative. Thus, it is necessary to increase investment in the health-care system and pay attention to both the health status and healthy behaviors of rural residents. Moreover, further effort should be given to the supply-side reform of health services as a breakthrough point.

A bird's eye view on the role of dendritic cells in SARS-CoV-2 infection: Perspectives for immune-based vaccines

Coronavirus disease-19 (COVID-19) is a complex disorder caused by the pandemic diffusion of a novel coronavirus named SARS-CoV-2. Clinical manifestations vary from silent infection to severe pneumonia, disseminated thrombosis, multi-organ failure, and death. COVID-19 pathogenesis is still not fully elucidated, while increasing evidence suggests that disease phenotypes are strongly related to the virus-induced immune system's dysregulation. Indeed, when the virus-host cross talk is out of control, the occurrence of an aberrant systemic inflammatory reaction, named "cytokine storm," leads to a detrimental impairment of the adaptive immune response. Dendritic cells (DCs) are the most potent antigen-presenting cells able to support innate immune and promote adaptive responses. Besides, DCs play a key role in the anti-viral defense. The aim of this review is to focus on DC involvement in SARS-CoV-2 infection to better understand pathogenesis and clinical behavior of COVID-19 and explore potential implications for immune-based therapy strategies.

Influence of geographic conditions on body length of male newborns in Kyrgyzstan

Newborn length has been reported by many researchers to be reduced at high altitudes. However, many of these studies lacked adequate control of the ethnic group which may be confounding the altitude differences. In addition, few studies have examined the sources of variation in birth weight at high altitudes that may be related to ethnic group adaptation to the stresses of this hypoxic environment. In our study, we tested the hypotheses that the effect of altitude differences in newborn length depends on ethnic variation. Samples of 3359 healthy male newborns from different areas in Kyrgyzstan between the years 2003 and 2011 were analyzed for altitude and ethnic variation on male newborn length. Our results indicate significant decrease in male newborn length as a latitude increase. It is concluded that ethnic group difference in pregnancy outcome reflects a better state of adaptation to high altitude in this healthy indigenous population and that long-term genetic selection may be the most plausible explanation for these ethnic differences.

Does Participation in Local Non-agricultural Employment Improve the Mental Health of Elderly Adults in Rural Areas? Evidence From China

A rising rate of suicide among the elderly in rural China has been recognized to be triggered by mental health-associated factors. This study uses 3,397 sampled rural elderly adults from China Labor-force Dynamic Survey in 2016 to explore the response mechanism through which non-agricultural employment participation by the elderly adults in rural China can influence their mental health. Utilizing the Multivariate Regression, Instrumental Variable and Propensity Score Matching methods, we find that, the rural elderly adults who participate in local non-agricultural employment significantly improve their mental health. Self-employment tends to have a greater positive contribution to the mental health of the elderly population than waged employment. Further, work income, need for belongingness and respect, and human capital development significantly mediates the influence of participation in local non-agricultural employment on the mental health of the elderly adults. Finally, we put forward relevant policy suggestions to improving the mental health of the elderly in the countryside.

The impacts of multiple healthcare reforms on catastrophic health spending for poor households in China

Many developing nations witness systemic healthcare reforms where the expansion of health financing mechanisms and reforms of the service delivery system are being rolled out simultaneously. Yet, poorly coordinated reforms and negative interactions between multiple policies may offset synergies and undermine intended reform outcomes. This study examines how multiple healthcare reforms affect catastrophic health spending of low-income households in China. We characterize two broad types of health policy reforms: expansion- and constraint-oriented policies in the domains of financing, services delivery, and pharmaceuticals introduced since 2009. We adopt an innovative methodology by matching macro-level policy text data collected using big data techniques with micro-level health expenditure data drawn from a nationally representative survey. Employing a linear probability analysis and controlling for household and year fixed effects, we find that more expansion-oriented policies, especially in the domain of financing, increased the incidence of catastrophic health spending of poor households. In contrast, constraint-oriented policies, particularly in the domain of health services delivery, lead to a lower incidence of catastrophic health spending. This type of policy is thus better able to mitigate the positive relationship between expansion-oriented policies and the incidence of catastrophic health spending. This study suggests that while the expansion of benefit package in the domain of financing is indeed a decisive move towards universal health coverage, the essential financial protection of the poor cannot be achieved without strong and coordinated supply-side reforms towards cost containment. Health policy makers must take a strategic view of the complex interactions of multiple policy interventions in both financing and service delivery domains.

The Moderating Effect of Community-Level Deprivation on the Association between Individual Characteristics and Smoking Behavior among Chinese Adults: A Cross-Level Study

China joined the World Health Organization (WHO) Framework Convention on Tobacco Control in 2006; however, the overall Chinese smoking rate is still high. The aim of this study is to provide new evidence for the direct effects of community-level deprivation, and the effects of interactions between community-level deprivation and individual characteristics, on smoking intensity, by using cross-sectional data from the 2015 China Health and Nutrition Survey (CHNS). The results show that there is a strong association between community-level deprivation and individual smoking intensity, and that community deprivation moderates the relationship between individual perceived stress and smoking intensity. The findings imply that adequate interventions should be conducted in the context of deprived neighborhoods, and should consider differences between levels of individual perceived stress and between sexes, especially focusing on highly stressed women who live in deprived communities.

Public Medical Insurance and Healthcare Utilization and Expenditures of Older with Chronic Diseases in Rural China: Evidence from NRCMS

China's rural older are the threat from chronic diseases, making it important to evaluate the effect of public health insurance on the health care utilization and expenditures with chronic diseases. In 2003, China initiated a public health insurance, which was called the New Rural Cooperative Medical System (NRCMS). NRCMS is a voluntary program, targeting rural residents with government subsidies and individual contribution. Using the two-stage residual inclusion approach (2SRI), we analyzed the impact of NRCMS on health-care service utilization and expenditure of rural older with chronic diseases by using the 2011 and 2013 China Health and Retirement Survey (CHARLS) data. The results showed NRCMS did not play an effective role on improving the medical services utilization of rural older with chronic diseases. Although NRCMS immediate reimbursement significantly reduced the outpatient service fee, the actual outpatient reimbursement is the opposite. In addition, NRCMS did not significantly decrease their hospitalization expense. Policy makers should pay attention to health management about chronic diseases in rural China, and some measures should be taken to deepen the medical security system reform and improve the public health service system.

The Impact of Public Health Insurance on Household Credit Availability in Rural China: Evidence from NRCMS

A large body of literature has shown that the burden of healthcare can push individuals and households into the burden of medical care and income loss. This makes it difficult for rural or low-income households to obtain and use safe and affordable formal credit services. In 2003, China's government implemented a new rural public health insurance, which was called the New Rural Cooperative Medical Scheme (NRCMS). This study provides evidence of the impact of NRCMS on household credit availability using the China Family Panel Studies (CFPS) for 2010. The tobit regression approach and mediator model are used. The results show that, as a public health insurance system sustained by the participation of government investment, the NRCMS provides good "collateral" and significantly enhances rural households' formal credit availability level. Furthermore, this positive effect is mainly reflected in the economic effect of NRCMS. Our results are robust to alternative statistical methods. Our findings suggest that expanding access, fulfilling the NRCMS mortgage function, and providing more financial services for rural households would have big benefits with regard to easing credit constraints for rural residents.