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Chen, Y.;  Sylvia, S.;  Dill, S.;  Rozelle, S. Structural Determinants of Child Health in Rural China. Encyclopedia. Available online: (accessed on 12 April 2024).
Chen Y,  Sylvia S,  Dill S,  Rozelle S. Structural Determinants of Child Health in Rural China. Encyclopedia. Available at: Accessed April 12, 2024.
Chen, Yunwei, Sean Sylvia, Sarah-Eve Dill, Scott Rozelle. "Structural Determinants of Child Health in Rural China" Encyclopedia, (accessed April 12, 2024).
Chen, Y.,  Sylvia, S.,  Dill, S., & Rozelle, S. (2022, November 11). Structural Determinants of Child Health in Rural China. In Encyclopedia.
Chen, Yunwei, et al. "Structural Determinants of Child Health in Rural China." Encyclopedia. Web. 11 November, 2022.
Structural Determinants of Child Health in Rural China

Many factors could 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. 

health inequity child health rural China

1. The Causal Effect of Family Income on Children’s Health

First, family income may have a direct causal effect on children’s health as poor families are less able to purchase nutritious foods and other health inputs for their children. In light of the empirical difficulties associated with estimating causal effects, it is uncommon for studies to address the question of whether the estimated relationship is causal. Recent efforts have used natural experiments to quantify the direct effects of family income on child health outcomes. International examples include the experimental programs offering conditional cash transfers in Mexico [1][2] and Ecuador [3]. By exogenously increasing the family income through an experiment offering cash transfer, these studies have generally found that increasing the family income leads to improvements in the health status of children in poor families [4]. Another similar income-support program is to provide old-age pensions for the elderly. Such programs directly transfer cash to the elderly and their families, which may also have intergenerational effects on children. For example, Duflo and Case examined South Africa’s pension program and found a positive effect of program participation on child growth [5][6].
The above evidence from the international literature demonstrates the direct income effect on children’s health and suggests one possible channel of explaining the poor health of children living in rural areas of China. Consistent with the international literature, studies from China mostly came to a similar conclusion. Among them, Zheng et al. relied on the implementation of a pension scheme for rural residents that exogenously increased the family income of the rural elderly [7]. As the researchers will discuss below, many children in rural areas live under the care of grandparents. The pension program is expected to increase the family’s income when grandparent caregivers receive the pension payments. The research found a significant effect on the health status of children and identified an increase in the consumption of high-protein food by children as the main mechanism by which higher incomes affected child health [7].

2. Disparity in Child Health at Birth

Another possible mechanism underlying the health gaps of rural children in China could be disparities in child health at birth. Children in rural areas or from poor families could be at greater risk of being born with health problems due to inadequate prenatal care or other maternal characteristics associated with poverty. Such health problems may include low birth weight, prematurity, or birth defects. Poor birth outcomes could cause a disparity in health among young children and have lasting effects on health at later ages.
China has made outstanding progress in reducing maternal and child mortality over the past few decades. However, profound disparities in maternal and childcare delivery persist between rural and urban areas. For example, despite narrowing urban–rural differences between 1990 and 2019, the infant mortality rate in rural areas was still 1.9 times higher than in urban areas in 2019 [8]. A part of this disparity could stem from differences in the maternal and child health systems implemented in urban and rural areas [9]. China has implemented a comprehensive maternal and child health care program to promote prenatal health care in urban areas since 1987, while a similar program was only initiated in rural areas in 2000. Although the national initiative covered all poor rural areas by 2005 (which has been shown to have substantially improved prenatal care in rural areas), research shows that significant variations exist across regions [10][11][12][13], and prenatal care in some poor rural areas is still below the national average [12]. Other studies, mainly conducted in western China where most of the minority ethnic populations reside, found that although caregivers in some rural regions do receive some amount of perinatal care during pregnancy and after birth, large shares do not attend the recommended number of prenatal or postnatal care visits [11][14]. Prenatal care was most often inadequate for ethnic minorities and less educated women [10]. Another example is the inadequate nutrition of pregnant women, which is also correlated with poverty and child health at birth. A study by Ma et al. found a high prevalence of inadequate dietary diversity during pregnancy in rural China, which has been posited as a cause of high rates of anemia in young infants [15][16].
The above evidence has demonstrated that poor prenatal care among rural pregnant women may be a contributor to the lower health outcomes of rural neonates, generating cumulative adverse effects on health at later ages. At the same time, the researchers acknowledge that these factors during pregnancy do not fully account for birth outcome disparities. For example, recent research has proposed a life-course approach to addressing early life disadvantages, arguing that disparities in birth outcomes are not just a result of factors that occur during the nine months of pregnancy but also from the entire life course of the mother prior to pregnancy [17][18]. Rural women may experience disproportionate health costs as a result of social and economic inequalities that they have experienced over the course of their lives, and these experiences may be contributing to the urban–rural disparities that are observed among the health of newborns.

3. Poor Health of Rural Caregivers

Poorer child health in rural areas may also be affected by the health status of their parents or caregivers. The first possible pathway is through the intergenerational transmission of poor parental health. For example, Eriksson et al. estimated the intergenerational transmission of health in China and found that 15% to 27% of the rural–urban disparity in child health can be derived from the inequality in the health of their parents [19]. When rural parents are in poor health, this decreases the socioeconomic status of rural children and is then associated with an increased risk of illness and can cause delays in early childhood development. Another possible pathway is through the poor care provided by less healthy or weaker caregivers. One example is the prevalent perinatal mental health problems among rural mothers in China. These problems have received little attention given the inadequate surveillance system for auditing mental health in China [20]. Jiang et al. found that depression, anxiety, and stress symptoms among rural mothers were significantly associated with reduced hand washing practice and a higher probability of infant morbidity [21].
In addition, the high volume of rural–urban migration in some regions of China (coupled with China’s strict household registration system) has resulted in a large number of rural children under the care of grandparent caregivers who often have poor health or are living with chronic conditions [22][23]. In China, rapid urbanization has contributed to the increased number of young parents who migrate to cities for work and leave their children in rural villages. Although migrant parents wish to take their children with them, the household registration system in China limits the access of rural migrants to urban resources including education, health care, and other social programs, creating barriers to family migration even if parents would like to keep their families together [22]. As of 2010, “left behind children (LBC)” numbered 61 million in China, with 80% living in rural villages [24].
Grandparents play a vital role in caring for LBC in rural areas, which can pose significant challenges. The National Sampling Survey in rural China showed that about 90% of grandparent caregivers of LBC aged over 50 and no more than 6% of grandmothers were educated more than primary school [25]. Based on a study of the elderly in rural China, about 6% of rural grandparent caregivers reported that they could barely provide child care due to poor health and 27% reported the child care to be challenging [25]. As a result, the relatively poor care given by some grandparents and the deprivation of parental care could cause delays in the health and development of rural LBC. In one study of this issue, Yue et al. investigated the impact of parental migration on young children from 6 to 30 months in 11 poor counties in rural China and found that parental migration during the earliest periods significantly reduced child cognitive development [26]. This delay in child development was largely mirrored by the reduction in dietary diversity and engagement in stimulating activities. Zhang et al. came to a similar conclusion using the nationally representative data from Chinese Family Panel Studies: grandparent care is strongly associated with delays in early child development, which is particularly disadvantageous for LBCs living in rural areas [27].

4. Lack of Access to Quality Healthcare

Access to quality health care could be another determinant of health status, as rural children with health conditions may receive less effective treatment due to poor access to quality healthcare. Although access to health services and utilization has improved significantly in recent decades, major disparities persist between children in urban and rural areas. While recent studies suggest that utilization of outpatient services are comparable, there are large gaps in the use of inpatient services between rural and urban residents as well as wealth gradients in both rural and urban areas [28][29][30][31].
Few studies directly compare the quality of health services in rural and urban areas, but available evidence suggests significant disparities in the quality of outpatient care. Several studies utilizing unannounced visits by standardized patients and clinical vignettes show large deficits in care in rural clinics and hospitals [32][33][34][35][36]. Based on one study conducted in three provinces, Shi et al. found that village clinicians completed only around 20% of diagnostic checklist items recommended by national guidelines when consulting a case of diarrhea in a young child [37]. The same study also found that only 9% of village clinicians and 14% of doctors in township hospitals correctly treated these patients, and providers were more likely to prescribe unnecessary or potentially harmful drugs. Though not directly comparable, a similar study conducted in an urban area evaluating care for standardized patients presenting with angina and asthma found that doctors in urban community health centers completed 32% of diagnostic checklists on average and correctly treated cases 24% of the time [38].

5. Poor Caregiving Health-Related Behavior

The poor health of rural children may also be due to the poor caregiver health-related behaviors among rural caregivers. Family choices regarding how to feed young children, how often a child sees a doctor, and whether to receive the immunization could have short-term and long-term health implications for children. Several studies in rural China have identified caregiving behaviors in child feeding as a factor in undernutrition and anemia among rural infants and toddlers [15][16][39][40][41][42]. For example, although public health practitioners recommend exclusive breastfeeding for the first six months after birth and continued breastfeeding for the first two years [43], studies have found low rates of exclusive breastfeeding under six months of age as well as over-reliance on formula among rural families. Reduced breastfeeding has also been linked to higher incidence of infant illness in rural areas of China [40].
In addition to inadequate breastfeeding practices, studies have also identified the late introduction of complementary foods, inadequate dietary diversity in complementary feeding, and limited use of micronutrient supplementation among caregivers of young rural children [15][40][41][42]. Inadequate dietary diversity is of particular concern. According to several studies, large shares of caregivers frequently do not provide children with the minimum level of dietary diversity, and micronutrient-rich foods (vegetables, fruits or meat) are provided less frequently than starchy staples such as grains [39][42][44]. These studies have also linked inadequate dietary diversity to micronutrient deficiencies, lower growth and developmental delays among infants and toddlers in rural China [15][39][44].
There are several socioeconomic factors that may contribute to inadequate child feeding practices. For example, maternal out-migration (leaving infants in the care of grandparents) may be one contributing factor in the low rates of breastfeeding in rural China. The extensive commercial promotion of formula in both rural and urban areas may also contribute to diminished breastfeeding rates and over-reliance on formula. Studies have also pointed to lack of information as the primary factor in inadequate feeding behaviors. Studies using both quantitative and qualitative methodologies have found that large shares of rural caregivers are unfamiliar with the causes of nutritional deficiencies such as anemia, their relation to child health and development, and how to adequately provide their children with healthy and complete diets [41][42]. Yue et al. also noted that few rural caregivers have reliable sources of information on child feeding, and many rely instead on their own intuition or previous childrearing experiences [42].

6. Environmental Determinants

Finally, geographic living environments and community resources may also contribute to the health gaps of rural children. Access to clean water and sanitation is one of these factors. China has implemented a rural drinking water program since the 1980s to increase access to safe drinking water for rural families. However, only 55% of rural households had access to on-premises tap water by 2015 [45]. Living in a place with access to tap water is correlated with the family’s socioeconomic status and possibly has long-term implications for child development. Chen et al. examined the impact of early life exposure to tap water and found a significant effect on children’s cognitive development in a sample of rural children aged 10–15 [46].
Another leading environmental factor that affects rural children is injury. Xiong et al., using surveillance data during 2009–2014, reported that injury has become one of the leading causes of death among children younger than five, with injury mortality in rural areas 3.73 times higher than the urban areas. Drowning accounted for 43.63% of these injury-related deaths [47].


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