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China’s competitive education system has produced notably high learning outcomes, but they may be costly. One potential cost is high levels of anxiety. China has launched several initiatives aimed at improving student mental health. However, little is known about how effective these programs and policies are. The goal of this paper was to examine anxiety levels among children and adolescents in rural China, and to identify which subpopulations were particularly vulnerable to anxiety. Data were aggregated from 10 different school-level surveys conducted in rural areas of five provinces between 2008 and 2015. In total, 50,361 students were evaluated using the 100-item, nine-subcategory Mental Health Test (a variation of the Children’s Manifest Anxiety Scale). Seven percent of students were at risk for overall anxiety. However, over half of students were at risk for at least one subcategory of anxiety. Students at higher risk for anxiety included students from poorer counties and families, female students, secondary school students, and students with lower levels of academic performance. Many students in rural China are at risk for anxiety, and certain student subpopulations are particularly vulnerable. We suggest that China’s government review and update student mental health programs and policies.

China’s rapid urbanization in the past several decades have been accompanied by rural labor migration. An important question that has emerged is whether rural labor migration has a positive or negative impact on the depressive symptoms of children left behind in the countryside by their migrating parents. This paper uses a nationally representative panel dataset to investigate whether parental migration impacts the prevalence of depressive symptoms among left-behind children in China. Using DID and PSM-DID methods, our results show that parental migration significantly increases the depression scores of 10 and 11-year-old children by 2 points using the CES-D depression scale. Furthermore, we also find that the negative effect of decreased parental care is stronger than the positive effect of increased income in terms of determining the depressive symptoms status of children in rural China.

In this study, the authors investigated three questions: whether students' outcomes were improved by grading participation more intensely; who benefits most from increased participation; and, whether students who would benefit from more intensive grading choose it when they are given the choice. An eight-month field experiment was used to elicit students' preferences for and randomly assign them to different grading intensities. The authors found that grading students on weekly participation is more effective than biweekly and that students who prefer not to be graded weekly, with lower GPAs and lower self-control scores, benefit most from the weekly participation grading intervention. When students were given a choice, however, those who would benefit the most were no more likely to choose weekly grading than were others.

Studies in high-income countries have found that female physicians exhibit better performance than their male counterparts. However, it is largely unclear whether these findings are influenced by case and patient mix bias. We aimed to objectively assess differences in clinical practice and treatment between female and male primary care providers in rural China. In this cross-sectional study, we used standardised patients to assess provider performance in clinical practice, yielding objective performance measures free from case and patient mix bias. We included 309 primary providers who received 412 visits from standardised patients in township health centres in rural areas of three provinces in western, central, and eastern China. All providers were visited by standardised patients who were trained to consistently present three disease cases. Clinical process was graded against checklists based on national and international guidelines of recommended questions and exams to be performed. Assessment of treatment considered the appropriateness of medicine dispensed and referrals made, as well as the types and quantity of medicines dispensed. Unadjusted comparisons of the performance of male and female providers used Ordinary Least Squares (OLS) regressions controlling for disease cases. Adjusted comparisons additionally controlled for facility fixed effects and provider characteristics. We obtained ethics approval from the institutional review boards of Stanford University, USA, and Sichuan University, China. Informed consent was obtained verbally from all providers participating in the study. Consent from village and township providers was obtained as part of the facility survey approximately 5 weeks before visits. All individuals who participated as standardised patients were trained to protect themselves from any invasive tests or procedures. In unadjusted comparisons, female providers completed 0·76 (95% CI 0·05–1·47) more clinical checklist items on average than male providers, representing an increase of 15% over the mean number of checklist items completed by male providers (5·04 items). Female providers were also 15 percentage points (95% CI 0–30) more likely to give appropriate treatment than male providers (38%). Although, there was no significant difference in unadjusted comparisons (43% for female providers and 41% male providers), female providers prescribed significantly fewer unnecessary or harmful medicines such as antibiotics than male providers after controlling for facility fixed effects and other provider characteristics (–21 percentage points, 95% CI −41 to −2). This study finds that female providers prescribe fewer unnecessary or harmful treatments in primary care than male providers in rural China after controlling for potential sources of bias. No difference between female and male providers was found for other measures of clinical process quality after adjusting for observable characteristics. 111 Project (Grant B16031), the Laboratory of Modern Teaching Technology of the Ministry of Education, Shaanxi Normal University, National Natural Science Foundation of China (Grant 71703083), the National Social Science Fund Youth Project (Grant 15CJL005), the National Natural Science Foundation of China (Grant 71703084), and the Knowledge for Change program at The World Bank (Grant 7172469).

Large and increasing numbers of rural-to-urban migrants provided new challenges for tuberculosis control in large cities in China and increased the need for high quality tuberculosis care delivered by clinics in urban migrant communities. Based on a household survey in migrant communities, we selected and separated clinics into those that mainly serve migrants and those that mainly serve local residents. Using standardized patients, this study provided an objective comparison of the quality of tuberculosis care delivered by both types of clinics and examined factors related to quality care. Only 27% (95% confidence interval (CI) 14–46) of cases were correctly managed in migrant clinics, which is significantly worse than it in local clinics (50%, 95% CI 28–72). Clinicians with a base salary were 41 percentage points more likely to demonstrate better case management. Furthermore, clinicians with upper secondary or higher education level charged 20 RMB lower out of pocket fees than less-educated clinicians. In conclusion, the quality of tuberculosis care accessed by migrants was very poor and policies to improve the quality should be prioritized in current health reforms. Providing a base salary was a possible way to improve quality of care and increasing the education attainment of urban community clinicians might reduce the heavy barrier of medical expenses for migrants

IntroductionCOPE investigated the prevalence, patterns and determinants of prisoner self-harm during the COVID-19 pandemic, compared with pre-pandemic. The project used the natural experiment of the pandemic to understand effects of prison environments on self-harm.MethodsCOPE was a mixed-methods study involving all prisons within England and Wales. Participants included 80 437 prisoners identified from routine data sources, 71 (ex)prisoners consulted and 89 staff interviewed (average experience: 18.5 years). The main outcome measure was the rate of self-harm incidents reported. Secondary measures included qualitative assessments of prisoner and staff experiences related to self-harm during the pandemic. Qualitative outcomes were derived from thematic grouping of inmate consultation responses and framework analysis of staff responses. The exposure was the pandemic period from March 2020 to December 2021.ResultsThere were gender differences in prisoner self-harm rates during the pandemic. In women’s prisons, the pandemic was associated with a 7% overall increase in self-harm (95% CI 2% to 13%) and a 43% increase in self-harm requiring hospitalisation (11% to 83%). Conversely, men’s prisons saw an 8% self-harm decrease (6% to 11%) and a 21% decrease in self-harm hospitalisation. Policy interventions, for example, in-cell telephones and additional phone credit were linked to reduced self-harm in men’s prisons. Introducing video visits was associated with an increase in self-harm in women’s and men’s prisons. Qualitative analysis revealed a complex interplay of factors influencing these outcomes, including tension between the risk of mental health deterioration because of greater isolation and the perceived safety benefits of a restricted regime.ConclusionsThe pandemic, and policy changes, were associated with changes in prisoner self-harm. Distinct patterns emerged between genders underscoring the need for gender-specific prison policies, especially during crisis management. Furthermore, the complex relationship between policy implementation and self-harm highlighted the importance of tailoring prison environments to effectively address the population’s diverse needs.