Problem

Despite considerable improvements in education of rural students in China during the past decade, alarming disparities persist between the academic performance of rural and urban students. Among the numerous challenges faced by rural students, poor health and nutrition is both a prevalent and significant issue. Recent studies by REAP and our affiliates show that from 25 to 40 percent of children are anemic (and have poor nutrition). Our studies also show that boarding students living away from their parents and students who eat lunch in school cafeterias are more likely to be anemic.

Poor health and nutrition are a set back to rural children's performance

 

Is poor nutrition and health a constraint to the educational performance of students from poor rural areas? The strong link between better educational outcomes and improved health and nutrition status is corroborated by a large number of studies, including evidence-based studies that have been conducted in China during recent years. Specifically, when a REAP intervention team gave students multivitamins in 24 elementary school schools in Shaanxi, anemia rates fell and standardized test scores rose by 0.4 standard deviations (akin to moving from a “C+” to a “B”).

 

Using all of the data and observations that we have gained over the past couple of year (mostly in Shaanxi province), REAP sent a “policy brief” to the State Council through the Chinese Academy of Sciences in December 2009. In the policy brief, most fundamentally we reported the extremely high rates of anemia; the impact on anemia of providing multivitamins (and letters to the parents--in the case of children living at home); and most poignantly, the effect of reducing anemia on educational performance ==> leads to our call for schools to become more involved with student care--nutrition and health as an input into education. What was the response? In briefest terms, the policy brief was “approved” and will be the basis for further policy action. The policy approval was also personally signed by: Wen Jiabao, himself (the Premiere); the Vice Premier in charge of Education--Li Keqiang; and Liu Yandong, a standing member of Central Committee. In short, having three such prominent members sign our brief and begin to put it into policy is a HUGE step forward for the Nutrition & Education agenda.

 

More than anything this signals that battling anemia among children in rural China is clearly on the policy agenda. In fact, policy makers at provincial/county levels are eager for innovative interventions that would help them create a sustainable program to eliminate anemia (and address other health, nutrition shortcomings). For example, partly in response to our work and the policy brief (and also due to their own commitment to better nutrition), in September 2009 the provincial governor of Shaanxi announced that he was committing the province to providing every student in the province one egg (or one glass of milk) per day. His hope was that improved nutrition would result in healthier students and better educational performance. The Ningxia provincial Department of Education did the same in September 2010. Unfortunately, the new initiative of the Shaanxi and Ningxia provincial governors should not be expected to do anything to overcome anemia. The reason is because eggs--despite being a nutritious food--contain almost no iron, and neither does milk. Therefore, we sent a note to Shaanxi and Ningxia governments saying: One egg is not enough. You can read more about our one egg project here. This then is the origins of the proposed collaboration. Our overall goal is to find innovative ways of battling anemia, going beyond the one egg per day.

Innovation under way

In fact, we have already started. In November 2009, REAP conducted a large scale randomized controlled trial called “Is One Egg Enough?” at 60 boarding primary schools randomly selected from 10 counties in Shaanxi province. Below is the study design:

1. Treatment Group A: One egg per day + Multivitamin: 15 schools

In the first subset of 15 schools, all fourth grade students will receive a vitamin with minerals or 21 SUPER-VITA (in tablet form) daily, administered by their homeroom teachers who will receive instructions and training. Students who return home on weekends will receive two multivitamins to take on their own, with clear directions.

2. Treatment Group B: One egg per day + VitaMeal: 15 schools

In another subset of 15 schools, VitaMeal (a fortified porridge-like mixture of rice and lentils containing essential nutrients provided by NuSkin Enterprises’ Nourish the Children Initiative) will be supplied to all schools. School canteen managers will be given clear instructions on how to prepare one serving of VitaMeal as a meal for each boarding student every school day. REAP will provide a subsidy (2.5 RMB/30 servings of VitaMeal) for costs from cooking VitaMeal.

3. Control Group: One egg per day ONLY: 30 schools

In the remaining 30 schools, students receive no intervention more than one egg per day. However, it is important to note that all boarding students in all 60 schools will be consuming an egg every school day. Their baseline and evaluation health status and performance will be monitored by REAP, compared to the schools who receive an intervention.

PRELIMINARY RESULTS: Continued high rates of anemia … for example, it is >30% in Ningxia in 2010. The groups that took vitamins and were offered nutrient-supplemented VitaMeal outperformed those that only received eggs … both in terms of reduction of anemia and grade improvements.

Giving children nutritional supplements in the form of multivitamins or vitameal can enhance their academic performance

Opportunity for another innovation: Taking the message to the parents and making it “stick”

Now we have opportunity to try to find another innovative way to battle anemia and eliminate the adverse health effects and increase educational performance … and this intervention will depend on an approach that is consistent with what education people do best: develop curriculum and teach teachers, students and parents about how to overcome anemia and generally improve nutrition.

 

We also are interested in how to best deliver the message and then follow up with the reminders to try to keep parents accessing the ‘message’ so they can act on it.

 

Goals

Understand if developing an innovative curriculum kit that will supplement health class for 3^rd to 6^th grade students and teachers and directly give the message to parents in a set of pilot schools will:

• improve nutrition and the knowledge of teacher, students and parents about nutrition;
• reduce the level of anemia;
• increase educational performance

Develop and examine the effectiveness (on the same outcome variables) of ways to use new technologies: mobile phones and postal mailings (for those without mobile phones) and TV spots to follow up with parents and try to reinforce the message so they put it into action on a day by day basis.

Approach

Winter 2011: Preparation

Choose 40 towns in 4 counties which would be appropriate for implementing a pilot program.

Randomly assign the 40 towns into two groups: a) Pilot (treatment) towns: 20 towns; b) Control counties: the other 20 towns.

Develop innovative curriculum—based on posters and pamphlets – and designed to involve partnerships of teachers, parents and students (This will build on our past work. These will form the basis of the curriculum. Samples available on request.)

Winter 2011 – Spring 2011: Three-Step Randomized Control Trial (part 1)

Step 1: Baseline Survey in January 2011.

Collect information on: Pilot (Treatment) towns/schools; Control towns/schools

Information includes: Student Hb levels; Anthropometric measures; Take standardized test; School/parent/student characteristics

Step 2: Intervention between March 2011 and May 2011.

Pilot (Treatment)counties: 20 towns/schools. REAP implements the curriculum according to an innovative design of the teaching program … with parents / teachers / students. See Appendix A for an outline of the design of the program.

Control counties: 20 towns/schools. Nothing (they do not know they are not included).

Step 3: Evaluation Survey in June 2011.

Collect information on: Pilot (Treatment) counties; Control counties

Information includes: Students Hb levels; Anthropometric measures; Take standardized test; School/parent/student characteristics

Summer 2011 – Fall 2011: Two-Step Randomized Control Trial (part 2)

[note: we will do the follow up Outreach in half of the treatment schools (10) and half of the control schools (10) … in the other half of the treatment schools (10) and in the other half of the control schools (10), we will not follow up]           

A teaching program will be implemented for the pilot group on important aspects of nutrition

 

Step 4: Intervention between July 2011 and November 2011.

Pilot (Round 2 Treatment) towns/schools: use mobile phones for those with mobile phones (and postal follow up for those without mobile phones) and RE-send the material in the curriculum as a series of 25 weekly follow-up messages

Round 2 Control towns/schools: 20 towns/schools will receive no follow up (they do not know they are not included).

Step 5: Evaluation Survey in December 2011.

Collect info on: Pilot (Treatment) counties; Control counties

Information includes: Students Hb levels; Anthropometric measures; Take standardized test; School/parent/student characteristics

December 2011: Evaluation Analysis, Report Write-up

Following year: Dissemination Activities; Discuss expanding follow up to TV spots

Important parameters:

• Pilot counties/towns/schools must be randomly selected
• The pilots should be in poor towns (where anemia rates are high)
• Curriculum design will be innovative—but must be carefully implemented
• Follow up outreach will be twofold and will repeat the material in the original curriculum, but, will be clear and stand-alone (so we will be able to judge the effectiveness of ONLY using mobile-messaging)
• Alternative plan: use TV spots (facilitated by Yongye International’s contacts in CCTV 7)

Implementation is by Chinese Academy of Sciences / Xibei University  / Ningxia University

Evaluation

 

Evaluation of program will be performed by REAP/Stanford through acquiring information on students' Hb levels, anthropometric measures, standardized test results, school/parent/student characteristics for pilot and control counties.

Results

This project is classified as on-going.