Nutrition, Care and Education营养、健康和教育

Zhang Linxiu张林秀

(lxzhang.ccap@igsnrr.ac.cn)

Center for Chinese Agricultural PolicyChinese Academy of Sciences 中国科学院农业政策研究中心

On behalf of REAP team代表农村教育行动计划 ( REAP) 团队

Let me first introduce REAP … 首先让我来向大家介绍一下 REAP

• Show video …• 先给大家看一段录象

• In summary :• 总体上说：

– In many cases, China’s government agencies have sources of funds … they are committed to making change … they are looking for ideas about what work and what does not work …

– 在很多情况下中国政府部门是有资金资源 … 他们也希望改善现状… 但是他们也在寻找好的项目，想知道什么有效什么没效…

– This is exactly what Scott’s message was:– 这也是 Scott 主题发言的核心思想 :

• We need to do IE to figure out what works / what does not …• 我们需要影响评估来告诉我们什么有效 / 什么没效 …

• If we do, it can have a big effect• 如果我们开展好影响评估 , 它可以有很大的作用

In my presentation, I want to show the answers to two questions:

在我的报告中 , 我想给大家展示对两个问题的回答 :

Q1: Is this hard to do in China? Q1: 在中国开展影响评估是不是很难 ?

Q2: Can it have an effect? Q2: 如果作了，是否会产生影响 ?

A1: No … it is easy, if it planned in advance …A1: 不…如果在开始时就设计好这就很容易…

A2: Yes … it can have an effectA2: 是… 它能够产生影响

The diet of children: grain / grain / grain …

农村学生的饮食 : 粮食 / 粮食 / 粮食 …

Case Study of Anemia, Multivitamins and Educational Performanc

用我们贫血、多种维生素和学业表现研究项目为例来介绍

Children eat almost no red meat / no green vegetables / no fruit … is this affecting educational performance?

学生几乎吃不到肉 / 绿色素菜 / 水果 … 这样的饮食会影响到学生学业表现吗 ?

Is eating “grain / grain / grain” a problem?

只吃 “粮食 / 粮食 / 粮食” 是个问题吗 ?

• Yes, poor diets micronutrient deficiencies• 是 , 饮食不好 微量元素缺乏

• One of the most common nutritional problems in developing countries is ANEMIA …

• 发展中国家常见的营养问题之一是贫血 …

• If children have anemia, it is well known that it can affect:• 如果一个孩子贫血，这会对这个孩子造成一系列影响 :

– Cognitive ability 认知能力– Physical health 体能健康– Psychological health 心理健康– Behavior 行为表现 – AND EDUCATIONAL PERFORMANCE 以及学业表现

Is anemia a problem in rural China?贫血在中国农村是一个问题吗 ?

• This was the first step in our research program …• 这是我们研究项目第一步要回答的问题…

• In 2008, we set out to do one of the first large scale canvas survey in Shaanxi …

• 2008 年 , 我们在陕西开展了第一个大样本的全面调查…

• What did we do?• 我们是怎么做的 ?

Shaanxi

The first step in studying the prevalence of anemia was to choose a random sample of schools … we worked closely with the Shaanxi gov’t to create a sampling frame … and then chose 66 schools in 8 counties ..

研究贫血状况的第一步是随机选出样本学校 … 我们和陕西省政府相关部门合作建立了一个样本框… 在 8 个县选出了 66 所学校 ..

We conducted field testing for anemia …

我们在实地给学生测血检查贫血…

Table 1. The distribution of sample schools and students across countiesTable 1. 样本学校，样本学生分布情况

Number of schools

学校数量

Number of students

学生数量

Percentage of students

学生比例Total sample

总样本 66 3849 100

By County 分县情况Baihe 白河 7 387 9.3

Jiaxian 佳县 6 245 5.9

Shanyang 山阳 8 488 11.8

Suide 绥德 6 363 8.8

Xunyang 旬阳 21 1,234 29.7

Yangxian 洋县 9 572 13.8

Ziyang 紫阳 4 308 7.4

Zhashui 柞水5 243 5.9

Female 1849 44.5

Male 2,309 55.5

Data source: Authors’ survey

Table 2. The distribution of hemoglobin levels and anemiaTable 2. 血红蛋白测试和贫血情况

Hemoglobin level (g/L)

血红蛋白水平(g/L)

Number of student with anemia

贫血学生数

Percentage of students w/

severe anemia 贫血

学生比例Total sample总样本 122.2 842 21.7

County 分县情况Baihe 白河 121.6 91 23.5

Jiaxian 佳县 124.7 36 14.7

Shanyang 山阳 123.4 86 17.6

Suide 绥德 123.4 66 18.2

Xunyang 旬阳 119.0 406 32.9

Yangxian 洋县 123.6 98 17.1

Ziyang 紫阳 131.2 23 7.5

Zhashui 柞水 127.1 33 13.6Data source: Authors’ survey

39% of sample have Hb levels below 120

39% 学生血红蛋白水平低于120

1501

Randomized Control Trial 随机控制实验[like in agriculture or medicine][ 象农业或医学实验 ]

our questions 我们问题是 : Will iron supplements lead to less anemia?

给学生服用维生素 更少贫血 ? If parents knew about their children’s nutritional

status, would there be less anemia?如果父母知道更多信息 更少贫血 ?

Does lower anemia lead to better school performance?

贫血减少 学习表现更好 ?

1. Baseline survey 基线调查

2. POLICY EXPERIMENT 政策实验

RCT’s

3. Evaluation survey 评估调查

treated处理组

Control控制组

Three Stages 三个阶段

So, what did we then do to try to solve anemia … and study its effect on education

那么 , 我们探讨如何来解决贫血问题 …以及对学业表现等的影响

Randomized Control Trial[like in agriculture or medicine]

our questions: Will iron supplements lead to less anemia?

If parents knew about their children’s nutritional status, would there be less anemia?

Does lower anemia lead to better school performance?

1. Baseline survey2. POLICY EXPERIMENT

RCT’s

3. Evaluation survey

treated

control

Three Stages

1. Our objective: answer these questions

2. Our outcomes:

So what have we done so far on this slide?

3. Theory of change: better nutrition leads to better health and schooling

4. Overall evaluation questions

Randomized Control Trial 随机控制实验[like in agriculture or medicine][ 象农业或医学实验 ]

our questions 我们问题是 : Will iron supplements lead to less anemia?

给学生服用维生素 更少贫血 ? If parents knew about their children’s nutritional

status, would there be less anemia?如果父母知道更多信息 更少贫血 ?

Does lower anemia lead to better school performance?

贫血减少 学习表现更好 ?

1. Baseline survey 基线调查

2. POLICY EXPERIMENT 政策实验

RCT’s

3. Evaluation survey 评估调查

treated处理组

Control控制组

Three Stages 三个阶段

So, what did we then do to try to solve anemia … and study its effect on education那么 , 我们探讨如何来解决贫血问题 …以及对学业表现等的影响

Partly Done 部分完成了

Step 1: Baseline survey for anemia (October 2008) was already done …

第一步 : 测血的基线调查已完成 (2008 年 10 月 ) …

Shaanxi陕西

66 School Study … in 8 Poorest Counties in Shaanxi

营养与教育第 I 期在陕西省 8 个特困县的 66 所小学开展研究，其中：

In 24 Schools (≈1400 fourth grade students) We gave students a direct supplement with 1 vitamin per day

24 所学校（ 1400 个学生） 直接给孩子补充“ 21 金维他”

In 12 Schools (≈ 800 fourth grade students) We send the parents a letter, informing them of whether or not their child had anemia

12 所学校（ 1000 个学生） 给家长发一封信，告之孩子的贫血状况

In the other 30 Schools (≈ 1800 fourth grade students) we did nothing: these are our CONTROL schools

30 所学校（ 1800 students ） 对照组

We first took our 66 schools … and divided them into three distinct identical sets of schools我们选出 66 所学校… 将它们分成 3 组条件完全一样的学校

Standardized Math Test

In all 66 schools (vitamin schools + information schools + control schools) We also did a baseline survey for math scores …

在所有 66 所学校 ( 维生素学校 + 信息学校 + 控制学校 ) 我们也对数学进行了基线标准测试 …

When we are done with the baseline (but before any intervention), it is like having “triplets” … the schools that will get the vitamins; the schools that get information and the control schools are identical!当我们做完基线调查后 ( 但是在干预前 ), 这三组学校就象“三胞

胎” -其各种特征完全一样 !

In the 24 vitamin schools, we gave 1 over-the-counter vitamin / day (these could be bought in any supermarket in Beijing)Vitamins have 5 mgs of iron … Vitamins given to students from November to May24 所学校（ A 组）每天一片“ 21 金维他”从 2008 年 11月到 2009 年 5月，每天给每个学生补充一片含铁的多元维生素“ 21 金维他”（每片含铁 5毫克） …

Stage 2: The interventions第 2 步： 实施干预

In the 12 “information-only” schools, we tried to inform the parents of their child’s anemia

status 12 所学校（ B 组）：

营养信息干预

The letter was simple and told the parent:“What is anemia? What are its effects? What should you do? go to a doctor / eat better diet 给家长发一封信，告诉他们 （“贫血是什么？贫血有什么影响 ? 孩子贫血应该怎么办 ? 看医生”）

Note: children in these schools received NO vitamins

这些学校学生不提供维生素

Letter to Parents 给家长的一封信• Health Evaluation Report (Moderately Anemic Child) • Dear ______________________ (student name) ’s parents!•  • As researchers from the Xi’an Jiaotong University, whom have recently conducted a study

(“Child Nutrition and Education”) at your child’s school, we would like to firstly thank you for supporting our work! As part of this study, we tested your child for anemia, and are including the results below:

•  • According World Health Organization (WHO) standards, hemoglobin levels lower than

115g/L indicate anemia. Based on our test results, your child’s hemoglobin levels are ____________________g/L, which indicates that your child is moderately anemic. Anemia can negatively affect a child’s development, physical strength and endurance, attention span, cognitive thinking and memory, which all impact educational effectiveness and academic achievement. Anemia also can affect disease susceptibility and spread. Therefore, parents should be particularly attentive about their child’s anemia – early identification of anemia allows faster prevention.

•  • Since your child is anemic, we suggest you pay close attention to

his/her eating habits: 1) give your child iron-rich foods, including liver (pig, cow, sheep, etc.); animal blood; lean meats (pork, beef, lamb, etc.); fish and shrimp; and bean products (tofu, soy milk, etc) (ideally make sure your child eats one bowl of meat, an egg or an equivalent amount of bean products), and also use iron-fortified soy sauce. 2) Simultaneously, consume fresh vegetables and fruits for sufficient Vitamin C (every day, your child should eat an apple or the equivalent of another fruit). 3) Schedule accordingly three meals per day, and correct bad habits of eating imbalanced meals. Also, it is important to prevent intestinal worm infections (if necessary, de-worming medication is available), and to keep physically fit.

•  • Regarding your child’s moderate anemia, we strongly recommend you

seek your doctor for medical assistance as soon as possible, to raise your child’s hemoglobin levels and ensure your child’s health! Currently, common iron supplements include: LiuSuanYa iron, FuMaSuan iron, PuTaoTangSuanYa iron, LiFeiNeng (if there are side effects, please seek medical attention). Best wishes for your child’s healthy development! 

•Respectfully yours,

•Xi’an Jiaotong University Medical Center

•12.10.2008

•  

30 control schools 30 所对照组学校

Zero: no vitamins / no letter …

不采取任何干预：不给维生素 / 不给家长发信 …

Evaluation Survey (stage 3)评估调查 ( 第三步 )

Will iron supplements less anemia? 补充铁元素 贫血减少 ?

If parents know less anemia?如果父母知道 贫血减少 ?

Lower anemia Better school performance?贫血降低 学校学生学业表现改善 ?

Baseline survey基线调查

POLICY EXPERIMENT政策实验RCT’s

Evaluation survey评估调查

Treated处理组

Control控制组

Stage 3

Evaluation survey (June 2009)Re-taking the standardized academic tests and Psy test…… after 5 months of vitamins + letter to parent.评估调查 (2009 年 6 月 )重复基线调查的所有测试…… 在给学生发 5 个月维生素和家长发信后

Re-taking the Hb Test (June 2009)Still anemic or not?

重测血红蛋白水平 (2009 年 6 月 ) 看是否贫血 ?

Summarize:

• Our counterfactual … our approach to attribution:– Randomization … it was possible in this case

• Level of randomization schools (you can not randomize over individuals … that is give vitamins to some students in a class but not others)

• Is there bias? Is the control group different than the treatment groups? NO … because we made sure groups were the same before starting!!

Results结果

Findings (all students) 研究发现Total reduction in moderate rates of anemia (iron deficiencies):贫血率下降：

Initial levels干预前 Final levels干预后

(< 120 hb) (<120 hb)

39% 27%

Severe anemia fell from 21.7 percent to 15.3 percent严重贫血的学生贫血率从 21.7%下降到 15.3%

Testing results of Hypotheses (for children in vitamin schools, Hb count increase significantly compare to

children from control schools) 对学生贫血状况的影响

-3

-2

-1

0

1

2

3

vitamins letter to parents control

Difference statistically significant at 95% level

of confidence差异在 95% 的水平上显著

Hemoglobin血红蛋白水平与对照组的差异

Type A Schools

Type B Schools

Type C Schools

Smaller, but also statistically significant effect of providing information to the parents信息干预也有助于缓解学生的贫血状况，但是效果没有服用维生素那么大

服用维生素 给家长发信 对照

More importantly, we also found positive effects on Standardized Math test Scores in vitamin intervention school

对学生标准化数学考试成绩的正面影响

-3

-2

-1

0

1

2

3

4

vitamins letter to parents control

Difference statistically significant at 95% level

of confidence差异在 95% 的水平上显著Math scores数学得分

Type A Schools

Type C Schools

Type B Schools

However, no statistically significant effect on math test score by providing information to the parents然而 , 只给家长一封信并不能显著提高数学成绩

服用维生素 给家长发信 对照

Is about 0.2 shift in standard deviation of the standardized math test distribution a large effect? 0.2 个标准差的移动对于学业表现变化言意味

着什么，效果明显或不明 ?• The Tennessee STAR program reduced class size from twenty-two to fifteen

improved test scores by about 0.21 standard deviations (Krueger and Whitmore 2001).

• 美国田纳西的 STAR 关于小班化的项目（将班级人数从 22 减少到 15 个） 对学生测试成绩的影响是 0.21 个标准差的移动 (Krueger and Whitmore 2001).

• The Indian Balsakhi Program that provided tutoring for under-performing children in grade 3 or 4 improved test scores by 0.27 standard deviations (Banerjee et al 2007).

• 印度关于给 3-4年级后进儿童提供辅导的项目 对学生测试成绩的影响是0.27 个标准差的移动 (Banerjee et al 2007).

• A merit scholarship program for girls in Kenya increased test scores by 0.28 standard deviations (Kremer, Miguel, and Thornton 2009)

• 肯尼亚一个关于女童奖学金的项目对学生测试成绩的影响是 0.28 个标准差的移动 (Kremer, Miguel, and Thornton 2009)

In summary小结

• We believe REAP has discovered a very fundamental problem Anemia is a problem in Rural Shaanxi …

• 我们相信 REAP 发现贫血是一个根本问题 在陕西贫困农村是一个问题…

• It is problem of poor nutrition in schools … it is problem of the knowledge of parents …

• 这是学校营养不好有关 … 这也和父母营养知识不足有关…

• We also found that improving nutrition leads to improvements in educational performance …

• 我们研究也发现改善营养可以促进学生学业表现明显改善 …

Anemia is not just a problem in rural Shaanxi Province in 2008

学生贫血不仅仅是陕西省的问题，其他贫困地区状况同样值得重视

[results of REAP studies] [REAP 的研究结果 ]

• Province Survey time Anemia rate• 样本省 调查时间 贫血比例• Ningxia宁夏 2009 31%• Qinghai青海 2009 52%• Shaanxi 陕西 2009 32%• Shaanxi 陕西 2010 30%• Sichuan四川 2010 32%

• So you can see, this answers the first question • 所以你可以看到我们用行动回答了第一个问题

Q1: Can we do Impact Evaluation in China?Q1: 在中国可否开展影响评估 ?

A1: yes … easy / fun / you learn a lot … if you start early … plan well (this is what the afternoon session is for … in fact, if you attend today and tomorrow’s session, you can create your own proposal to EVALUATE your own project!!

A1: 是 … 不难 / 有趣 / 你可学到很多 … 如果开始的早… 计划得好 ( 这是今天下午要讲的 … 实际上 , 如果你参加今天下午和明天一天的讨论你就可以自己设计评估项目建议书了 !!

Q2: Does it have an impact? Q2: 这样做有效果吗 ?

Snowball滚雪球效应• Ningshan Vitamin Project• 项目 2:宁陕维生素项目• Paying for Performance (Ningxia and Qinghai)• 项目 3:按绩效付酬项目 (宁夏和青海 )• Is One Egg Enough? (Shaanxi)• 项目 4: 是否一个鸡蛋就够 ? ( 陕西 )

• Teaching Parents and Teachers and Principals about Nutrition (Ningxia)• 项目 5: 校长 /老师 / 家长 / 学生互动共同克服贫血• What Does One Egg Do? (Gansu)• 项目 6: 一个鸡蛋的效应 ? (宁夏 )• Effectiveness and Efficiency of “Chewable Vitamins for Children” (Gansu)• 项目 7:儿童咀嚼维生素的效果和效益 (宁夏 / 甘肃 )

• Besty Buy Tool Kit? [combining vitamins; deworming; eyeglasses and dorm room management into one package … for 1.5 yuan per day, we can raise test scores by 0.3 to 0.5 standard deviations!)

• 项目 8: 营养健康工具包 ? [结合维生素、驱虫、视力矫正和寄宿制管理等 … 以每天 1.5 元的成本，我们可以在短期内让学生的成绩提高 0 。 3 到 0。 5 个标准差 )

• …

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2011

New this year

2010新

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