Factors Influencing Health Disparities Between Left-behind Children And Non-left-behind Children In Poor Rural China

BackgroundRural left-behind children, a vulnerable population that emerged with the economic and social transition in China, will exist for a long time. The number of the left-behind children has increased sharply. In2005, over58million children were left behind due to rural-urban migration in China, which accounted for28.29%of all children in rural China, and the number of this vulnerable population will continue to rise in the following. Left-behind children are vulnerable in child well-being and development, comprising of access to education, mental health, nutrition, physical health and safety, and so on. Especially, for those left-behind children who live in poor rural areas, where resources for living, health and education are even scarcer, we need to pay more attention.Child health is a basic right as an important component of child well-being and development, and will also determine one's adult health, socioeconomic status and even life achievement. Existing studies on health problems of left-behind children have the following characteristics:Firstly, many existing studies focused on their mental health and socialized development rather than physical health, and very few studies have evaluated physical health, mental health and social well-being comprehensively. Secondly, most of the studies were based on descriptive analysis and there is a lack of in-depth studies on impact of parental migration on child health. Thus, it is still not possible to reveal the definite impact pathway of parental migration on child health. Thirdly, the impacts of parental migration on child health are probably different between disadvantaged rural areas and advantaged rural areas in consideration of disparities of knowledge and social-economic development. Thus, the findings obtained from advantaged areas cannot be applied directly to disadvantaged areas. Theoretically, parental migration may on one hand increase the health input and have positive impact on child health by earn more money; on the other hand, the lack of parental care may have negative impact on health of left-behind children. The extents of these two impacts are still not definite so it is not possible to deduce whether parental migration improve or worsen child health. Therefore, it is necessary to study health of left-behind children in disadvantaged rural areas and explore the impact mechanism of parental migration on child health.Based on the child health production theory, child health determinants theory and the attachment theory, a theoretical framework for exploring the effects of parental migration on child health was established, to reveal the potential intermediary factors influencing the health of left-behind children through the economic resource pathway and the parental care pathway.ObjectivesThe general objective of this study is to explore the effect of parental migration on health status of left-behind children in disadvantaged rural areas through theoretical research and empirical analysis, and propose intervention strategies on health improvement of rural left-behind children. The following specific objectives are included:selecting appropriate health indicators of children; discovering the overall health disparities between left-behind and non-left-behind children in disadvantaged rural areas; proposing a theoretical framework and structuring a empirical model of effect of parental migration on health of left-behind children on basis of children health related theories; analyzing the effect of parental migration on child health and exploring the influence path of parental migration on health of left-behind children; proposing targeted and feasible intervention plans and policy suggestions according to the health status of children and the determinant factors discovered in the analysis of the impact path of parental migration on child health.MethodsA cross-sectional study was conducted, consisting of both quantitative research and qualitative research, from the research project of'Strengthening Capacity Building of Health Systems Research through the Study on Maternal and Child Health in China's Disadvantaged Areas'. The quantitative investigation was conducted in June2010, including student physical examination, student questionnaire survey and guardian questionnaire survey. And a specific qualitative interview was conducted in December2010in the same area, on the basis of the preliminary results of the quantitative research, to reveal the causes and the further explanation of the quantitative results. Ningxia province was selected as the disadvantaged province to conduct the typical survey, and Yuanzhou, Xiji and Pengyang in Guyuan were selected as the sampling counties based on the consideration of the distribution of the population, economic development and geographic location. A total of2017children from seven elementary schools and1125households in the6towns of these three counties were recruited to participate in the quantitative investigation using stratified cluster sampling. Among these children, the data of1474children whose individual and household information were both available were used in this study. The study sample included687left-behind children and787non-left-behind children. The qualitative investigation was conducted in Xiji and Pengyang County and63people were interviewed using purposive sampling.The measurement methods and tools of child health were chosen from three dimensions of physical health, mental health and social well-being according to the definition of WHO. And the demographic and social-economic characteristics were grouped into four categories including children type, contextual characteristics, migration-related characteristics and left-behind characteristics according to the relationship with the parental migration. Univariate analysis was used to select appropriate independent variables, which would be added into child health empirical model. The independent variables comprised both numerical variables and categorical variables, therefore, unconditional logistic regression was used for binary dependent variables and generalized linear model analysis was used for numerical dependent variables.Main Results(1) Physical health disparities between left-behind children and non-left-behind children:Compared with non-left-behind children, the growth and nutritional status of left-behind children were slightly better; the disparity of long-term physical health status (common illness, chronic diseases) was not significant while the short-term physical health status (4-week prevalence) of left-behind children was significantly worse than that of non-left-behind children. The risk of4-week prevalence for left-behind children was1.61times higher than non-left-behind children, especially for those who were left behind with other relatives.Not only can the parental migration itself negatively affect children's heath, but the behavior may also result in the widening gap of physical health status between left-behind children and non-left-behind children through the family care path, which includes aggravating children's burden of farm work, decreasing primary caregiver's attention to children's health, estranging their children and prolong the years of migratory. Specifically, heavy burden of farm work, careless of primary caregivers and stand-off relationship would increase the risk of4-week prevalence by107.6%,149.6%and214.0%, respectively; the risk was rising gradually along with the time of parents' migration until4years after their migration, when the risk began to fall. On the other hand, the parental migration could effectively decrease the risk of4-week prevalence, which brought positive effects to their children, through remittances in the economic path. However these positive effects could not eliminate the negative effects caused by their migration. Therefore the physical health status of left children was still significantly worse.(2) Mental health disparities between left-behind children and non-left-behind children:Generally, the mental health of left-behind children was worse than that of non-left-behind children. For instance, left-behind children had a lower level of self-cognition but heavier loneliness and social anxiety. There was a statistically significant difference in the level of loneliness between those two groups since the average score of Children's Loneliness Scale (hereinafter referred to as CLS) for left-behind children was0.92points higher. Among left-behind children, the mental health for those with mother outside and father at home was worst.The mental health disparity between left-behind and non-left-behind children was caused by the differences of household economic status, primary caregivers' educational level, to the relationship of children and their caregivers. The results showed that if the household per capita income increases by1unit, the children's CLS score will be decreased by0.02points on average; if the primary caregiver's educational level increases by1unit, the average CLS score is decreased by0.01points; if the primary caregiver do not pay much attention on the children, the children will feel1.07times higher loneliness; if the relationship between primary caregivers and children is not close, the loneliness level of children will be1.10times higher.Unlike physical health status, the parental migration did not bring positive effects to children's mental health through economical support, but only had significantly negative effects. Specifically, the loneliness levels of the four kinds of left-behind children who were often in bad mood caused by out of reach with parents, who considered their parents ignore themselves, who hardly missed their migratory parents and who were keen to together with their parents in cities are1.07,1.07,1.06and1.03times more than the control group, respectively;1year increase of the age when children began to left-behind leads to a0.01decrease of average score of CLS; as the contact between parents and children becomes less, the children would feel lonelier. It can be obviously find that parental migration affected left-behind children's mental health through the household care path.(3) Social well-being disparities between left-behind children and non-left-behind children:Compared with non-left-behind children, left-behind children had worse social-life ability, interpersonal communication ability, behavioral performance, academic performance and overall social well-being, among which differences in social-life ability and interpersonal communication ability were statistically significant.Although parental migration did not have significant effect on children's social well-being by itself, it could cause changes of primary caregiver's age, education level, anxiety/depression level and relationship with children, which may result in social well-being disparities between left-behind children and non-left-behind children. In details, the older their primary caregiver were, the better social well-being the children had; the possibility of high social well-being of children who lived with illiteracy primary caregiver was only0.68times that of children living with educated primary caregiver; however, when primary caregiver was in bad mental status (perceived anxiety or depression), the possibility of high social well-being of children was1.64times that of children with primary caregiver who had better mental status; the possibility of high social well-being of children having non-intimate relationship with their primary caregiver was rarely0.60times that of children who were closely related with their primary caregiver.At the same time, parental migration had significant influence on the social well-being of left-behind children by increasing the financial support to their families. Furthermore, the better the financial condition of the family, the higher possibility that left-behind children were able to survive in social society; the social well-being of the left-behind children whose parents constantly wired the money back to home was much better than those left-behind children whose parents did not.Although parental migration brought no significant negative effects to their left-behind children due to the variables deriving from their reducing care, it still had significant effect on social well-being of left-behind children through changing characteristics of primary caregivers. In Addition, judging from the fact that social well-being of left-behind children was not as good as that of non-left-behind children, accumulative negative effects from the reducing child care still exceeded the positive effects from increasing financial support.Conclusions and Policy ImplicationsThis study found that there was difference in health status between left-behind children and non-left-behind children in poor rural areas of China. The physical health and mental health of left-behind children were significant poorer than those of non-left-behind children; but difference in social well-being was not significant. There were disparities in the exposure to health risk factors between left-behind children and non-left-behind children. Compared with non-left-behind children, left-behind children were more likely to be exposed to the risk factors of physical health (children labor, low attention from primary caregiver, non-intimate relationship between primary caregiver and children), but less likely to be exposed to the risk factors of social well-being (older caregiver). The positive influence of parental migration by increasing financial support was much lower than the negative influence by reducing care for children. When left-behind children lived together with grandparents, had caregivers with higher education level, and responded positive attitude to parents' working outside, they could get better health status.The policy should aim to reduce the exposure to risk factors of left-behind children's physical and mental health and social well-being, but increase the exposure to protection factors of health status, and narrow the health gap between left-behind and non-left-behind children. The following policy implications can be drawn and proposed:(1) For those children with poor physical health, strategies such as community support for reducing burden of farm work of left-behind children, providing community education for improving attention of caregivers to children and their capacity on health care, and reducing the accumulated left-behind time would be useful.(2) For those children with poor mental health, the effective interventions include improving economic situation of family, training courses for caregivers to improve their capacity in educating and caring children, increasing the frequency of contact between parents and left-behind children, strengthening commutation between parents and children and between teachers and students to help children accept the fact of parent working outside, avoiding working outside when children are too young, reducing the possibility of living in school, and improving living conditions and mental care in school for children who have to live in school.(3) For those children with poor social well-being, the useful interventions include improving economic situation of family, training courses for caregivers to improve their capacity in educating and caring children, increasing the frequency of contact between parents and left-behind children, and avoiding working outside when children are too young.(4) For all kinds of left-behind children, the interventions include strengthening community between parents and children, trying to let grandparents taking care of children, schools also should pay attention to mental health of left-behind children; government should increase input to increase job opportunities.