Nationwide Household Survey Research Articles

Social inequalities shape climate change adaptation among Indian farmers

Abstract Agricultural technologies are vital for farmers adapting to climate change. However, while efforts have focused on improving access and initial adoption, little attention has been given to social disparities in rates of adoption and the benefits derived from these technologies. Our study investigates the adoption of groundwater irrigation technology in India, a transformative innovation that has historically enhanced productivity and food security, and helped agricultural households adapt to a changing climate. We use a nationwide household survey sample that spans nearly a decade, capturing a key period of groundwater expansion in India. Our analysis reveals that members of highly marginalized social groups are less likely to adopt groundwater irrigation technologies, and less likely to sustain their use of the technologies for long periods of time. Furthermore, the household-level benefits of the technologies–operationalized through the relationship between technology adoption and income–appear lower for households belonging to historically marginalized groups compared to the historically advantaged. Our study underscores the importance of addressing social inequalities in both adoption as well as the sustained utilization of agricultural technologies and other climate adaptation tools. Disparities in the utilization of these technologies can hinder farmers’ ability to access new innovations and adapt to increasing threats from climate change. Targeted policies and interventions are essential to not only provide historically marginalized groups access to technological innovations, but also facilitate their effective utilization.

Incidence and prevalence of traumatic and non-traumatic wounds and burns and access to wound care in Sierra Leone; data from a nationwide household survey (PRESSCO) 2020

ObjectivesThis wound section of the PREvalence Study on Surgical COnditions (PRESSCO) determines the incidence and prevalence of wounds and burns in Sierra Leone. It further describes access to wound care and wound-related healthcare-seeking behaviour. MethodsBetween October 2019 and March 2020, a nationwide cross-sectional household survey was performed. The survey was based on Surgeons OverSeas Assessment of Surgical Need (SOSAS). Additional questions relating to wounds and burns were added. Following randomization, 25 households in 75 clusters were sampled. Severe wounds were clinically examined. ResultsOf the 3600 individuals included, 143 had developed 151 wounds, including burns (15.2%) during the year preceding the interview (incidence 4.2%). A total of 77 people had 83 wounds and burns at the time of the survey (prevalence 2.3%), of which 23 were severe (prevalence 0.6%). Burn incidence and prevalence were 0.6% and 0.1%, respectively. Most wounds were on extremities (73.5%), often resulting from cuts (32.8%), falls (22.4%), or road traffic accidents (RTA; 16.4%). Risk factors for developing a wound were male sex (p=0.004), older age (p=0.037) and smoking (p=0.001). Severe wounds had a median duration of 18 months. For 70.2% of wounds, care at a health facility was sought. Only 49.9% of households reported financial capacity to visit a secondary health facility. For 56 (37.1%) of wounds, the desired care was not obtainable. An estimated 44,000 (95% CI 29,760 – 67,410) people in Sierra Leone suffer from a severe wound. An estimated 11,000 (95% CI 6,416 – 18,268) annual deaths occur due to wounds, predominantly due to RTA’s (66.7%) and accidental injuries (20.0%). ConclusionsWounds and burns account for an extensive burden on the health and economics of the individual, the household, and the Sierra Leonean society. For over one-third of wounds, the desired surgical care was not obtainable.

Assessment of quality of antenatal care services and associated factors in Malawi: Insights from a nationwide household survey.

Provision of quality antenatal care (ANC) to pregnant women is essential for reducing maternal and newborn mortality. ANC provides an opportunity for early identification of conditions that increase the risk of adverse pregnancy outcomes. However, there is limited evidence regarding the quality of ANC received by women in Malawi. This study aimed to assess the quality of ANC and associated factors in Malawi. National representative data from the 2019-2020 Malawi Multiple Indicator Cluster Survey was used for this cross-sectional study. A total of 6,287 weighted sample of women aged 15 to 49 years who had a live birth and received ANC at least once within two years preceding the survey were included in the analysis. Descriptive statistics were used to estimate the magnitude of quality ANC and multivariable logistic regression was computed to identify associated factors. Of the 6,287 women, only 12.6% (95% CI: 11.4-13.9) received quality ANC. The likelihood of receiving quality ANC was significantly higher among women who had four to seven ANC contacts (AOR = 2.10; 95% CI: 1.79-2.49), made at least eight ANC contacts (AOR = 3.40; 95% CI: 1.90-6.09) and started ANC within the first trimester (AOR = 1.30; 95% CI: 1.10-1.53). On the other hand, women who had only primary education (AOR = 0.62; 95% CI:0.48-0.82) and had five or more births (AOR = 0.56; 95% CI: 0.40-0.78) were less likely to receive quality ANC. The findings reveal that quality of ANC in Malawi is low. These findings suggest the need for targeted interventions aimed at improving access to and utilization of ANC services among women with lower education and higher parity. Strengthening efforts to promote early ANC initiation and increasing the number of ANC contacts could significantly enhance the quality of ANC received by women in Malawi.

Unequal household carbon emissions and potential determinants in China: Evidence from nationwide household surveys

Reducing carbon emissions from households can significantly contribute to achieving carbon neutrality. This study examined household carbon emissions and explored potential issues of inequality in China from 2010 to 2018. We found that the average carbon emissions of all households increased over the years, with the housing category experiencing the highest growth rate of 52.25%. Household carbon emissions are not the same across different regions and income groups. Inequality in carbon emissions is the highest in the eastern part of the country, followed by the central and western regions, and the lowest in the northeast. Carbon emissions inequality is highest among middle-income households, followed by high-income households, and the lowest among low-income households. These differences can be attributed to various factors such as population, technology, and socio-economic status. This study recommends implementing regional carbon taxes and income differential tax policies to address household carbon emissions inequalities.

Public information disclosure practices and civic participation: The roles of social justice perceptions and internet use

This study examined the relationship between public information disclosure practices and civic participation and the roles of social justice perceptions and internet use in that relationship. Our data comes from the 2019 Chinese Social Survey (CSS, 2019), a large nationwide household survey across 31 provinces (autonomous regions and municipalities). To ensure data relevance to our main variables, we conducted screening, resulting in the retention of data from 9 621 participants (female = 56 73%; mean age = 46 62 years, SD = 14 22 years). The results indicated that public information disclosure practices were associated with higher levels of civic participation. Specifically, public information disclosure practices were positively associated with institutional civic participation and negatively associated with non-institutional civic participation. Moreover, citizens' perception of social justice indirectly mediated civic participation. Internet use moderated the relationship between public information disclosure practices and the perception of social justice. These findings underscore the importance of types of public information disclosures in routine civil society governance. By implication, public information disclosures are tools for empowered civic participation with social justice

Inequalities in non-communicable disease management in China and progress toward universal health coverage: an analysis of nationwide household survey data from 2004 to 2018

Prevention and control of non-communicable diseases (NCDs) become a policy priority in Universal Health Coverage (UHC) in China, while NCD management has never been comprehensively estimated at national and subnational levels. We aimed to assess NCD management in China nationally and in key subpopulations, investigate inequalities from multidimensions, and further examine its association with health financing and resources. Data included were from China Chronic Disease and Risk Factors Surveillance (CCDRFS) and China Health and Nutrition Survey (CHNS). Following the WHO recommended frameworks, we selected eight NCD health service and risk management indicators and used meta-analysis to construct the composite NCD index. We explored the trends in and projections of NCD management index and indicators at national and subnational levels by using Bayesian regression models with average annual percentage change (AAPC) from 2004 to 2018 and probability of reaching the UHC target by 2030. We further conducted comprehensive inequality analyses of NCD indicators from multidimensions with patterns of changes over time using absolute difference and relative ratio. Finally, we quantified the associations between NCD management performance with health financing and resources using stochastic frontier analysis. In China, the NCD management index increased slowly from 62.0% (95% CI 36.0 to 84.0) in 2004 to 64.3% (95% CI 44.0 to 82.2) in 2018, with lagging performance being observed in prevention domain (AAPC-0.1%, 95% CrI-1.0 to 0.8). And all management indicators presented low probabilities of accomplishing 2030 targets in China. Notably, based on subnational analysis, diverse tendency and magnitude of inequalities in multiple NCD indicators were identified with widening gaps between genders (non-overweight, diabetes treatment), age groups (non-use of tobacco), urban-rural areas (non-use of alcohol, non-use of tobacco), regions (sufficient physical activity), and wealth quintiles (non-overweight, sufficient physical activity). Additionally, it was observed that compared with urban area, rural area had constantly lower health resources and presented 2.2% lower NCD management performance in 2018. Importantly, we found that health financing and resources especially distributed in primary health care (PHC) facilities were closely and positively associated with NCD management performance. A 1000 yuan increase of government health expenditure (GHE) per capita and a 10 increase of medical beds per 1000 capita in PHC facilities were associated with a 4.0% (95% CI 2.0 to 6.0) and 6.8% (95% CI 0.2 to 13.5) increase of NCD management index, respectively. The progress towards NCD management is slow at national level and in key subpopulations in China, with great challenges of existing and widening inequalities between genders, age groups, urban-rural areas, regions and socioeconomic groups. Rural and old people were still vulnerable populations who were lagging behind in NCD prevention and control. Optimising resource allocation by strengthening PHC especially in rural area, developing tailor-made programmes targeting specific populations such as old individuals, simultaneously integrating gender, education, and economic interventions to reduce inequalities should be prioritised to help China tackle NCDs during the progress towards UHC. National Natural Science Foundation of China.

Community prevalence of psychiatric disorders: Findings from a nationwide survey in Bangladesh

ObjectiveTo determine the community prevalence of psychiatric disorders in adult population and describe the prevalence by age, men-women, urban-rural strata. MethodsA nationwide household survey was conducted in 2019 where adults aged 18 years and above were selected by a multicentric, stratified, systematic random approach. The Self-Reporting Questionnaire (SRQ) was used for screening purpose and screened positive individuals were interviewed by research psychiatrists and diagnosed according the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria. ResultsOverall adult response rate for this survey was 90.4%. In total, of the 7270 adults, 1570 (21.6%) came positive on the SRQ. Overall prevalence of mental disorders found was 18.7% ((95% CI: 17.4%−20.0%). Women reported higher prevalence of psychiatric disorders than men (21.5% vs 15.7%). No significant difference was observed between urban and rural residents (18.9% vs 18.7%). Most common psychiatric disorders found were depressive disorders (6.7%), anxiety disorders (4.7%), somatic symptom and related disorders (2.3%), sleep-wake disorders (1%) and schizophrenia spectrum disorders (1%). ConclusionsThe study revealed that a substatial proportion of adults received diagnoses for psychiatric disorders. Once again, our findings emphasize the need for development of comprehensive mental healthcare services.

Common mental disorders among women in reproductive age group: An analysis of national mental health survey, India 2016.

Common mental disorders (CMDs) have a higher prevalence among women in their reproductive age (WRA) compared to the general population. Large Indian epidemiological studies focusing on the prevalence and socioeconomic correlates of CMDs among WRA are lacking. The associated disability and treatment gap particularly in the women population is unknown. To estimate the current prevalence, correlates, disability, socioeconomic impact, and treatment gap of CMDs among WRA from a nationally representative sample from India. The National Mental Health Survey of India 2016 is a multisite nationwide household survey conducted across India using a uniform methodology. Overall, 39,532 adults were surveyed with a response rate of 88%. The diagnosis was based on Mini International Neuropsychiatric Interview 6.0.0. CMDs among WRA (18-49 years) for this secondary analysis included depression and anxiety disorders. The prevalence of CMDs among WRA in India was 5.83%. Two important risk factors for CMDs included being divorced and living in the urban metro. Nearly 70% of women reported disabilities of varying severity. The overall treatment gap was around 82% (urban nonmetro > metro > rural population). On average, the cost of treatment of CMDs was ₹ 2,000 per month. CMDs are prevalent among WRA groups with significant disabilities and treatment gaps in India. The disability and treatment gap associated with CMDs among WRA can be handled by integrating mental health into general medical/obstetric care.

Oral healthcare seeking behavior of Malaysian adults in urban and rural areas: findings from the National Health and Morbidity Survey 2019

BackgroundThe development and implementation of appropriate strategies to enhance oral health in the community can be aided by an understanding of oral healthcare seeking behavior among urban and rural populations. The purpose of this study was to identify the factors associated with oral healthcare seeking behavior of the Malaysians in urban and rural locations who self-reported dental problems.MethodsThe National Health and Morbidity Survey 2019, a cross-sectional nationwide household survey that focused on non-institutionalised Malaysians, provided the data for this study on adults in Malaysia who were 18 years of age and older. A two-stage stratified random sampling technique was employed to ensure national representativeness. Data was collected using a multilingual (Malay and English), structured, and validated questionnaire via face-to-face interviews from July to October 2019. The dependent variable was oral healthcare seeking behavior (sought oral healthcare and self-medication). Independent variables were predisposing, enabling and health needs factor based on Andersen’s Behavioral Model. Descriptive statistics were used to describe the characteristics and oral healthcare seeking behavior of the respondents. The relationship between the independent and dependent variables were investigated using multivariable logistic regression analysis.ResultsThe analysis comprised a total of 10,134 respondents, representing about 18.2 million Malaysian adults aged 18 and above. The overall prevalence of Malaysian adults who self-reported dental problems was low (5.5%) and was slightly higher in the rural than urban population. Almost half sought treatment from healthcare practitioners, and almost a quarter self-medicated. Ethnicity was associated with seeking healthcare and self-medication among urban dwellers. Among the rural population, income level was associated with seeking healthcare while education level was associated with self-medication.ConclusionDisparities in oral healthcare seeking behaviors exist between Malaysians living in urban and rural areas. Future policies should adopt focused strategies that concentrate on oral healthcare accessibility and health literacy of the vulnerable and rural populations to achieve the best oral healthcare for this population group.

Graphic health warnings and plain packaging in the Philippines: results of online and household surveys.

In line with Article 11 of the WHO Framework Convention on Tobacco Control, the Philippines has implemented graphic health warnings on cigarette packs. To date, there has been no published literature evaluating the perceived effectiveness of GHWs in the Philippines. This study aims to contribute to the evidence on the perceived effects of graphic health warnings (GHWs) in cigarette packaging and the potential impact of plain packaging in the Philippines. The study involved an online convenience survey and a nationwide household survey. Mock-up sets of cigarette packs based on the Philippines' law on GHWs, and Thailand's and Singapore's plain packaging were shown to respondents to rate their attractiveness, quality, taste, cost, social appeal, appeal to youth, noticeability, appeal to non-smokers, attempt to quit, ease of quitting, discouraging smoking, and perceived harm to health on a five-point Lickert scale. The online and household surveys recruited 2,701 respondents in total. Online and household survey respondents considered plain packaging with larger graphic health warnings and visible quitlines from Thailand and Singapore to be more effective in discouraging them from smoking. Both sets of survey respondents also found mock-ups from Thailand and Singapore more motivating for them to attempt quitting than cigarette pack mock-ups from the Philippines. The study concludes that current graphic health warnings in the Philippines are ineffective in instilling health consciousness among Filipinos. Policymakers should consider larger graphic health warnings and plain packaging of cigarettes to motivate smokers to quit and discourage Filipinos from smoking.

Anti-urbanization and rural development: Evidence from return migrants in China

There is a noticeable trend toward return migration in both developed and developing countries, including China. Nonetheless, return migration in China has received relatively scant scholarly attention. It is underexplored whether return migrants and local workers are complements or substitutes. In this study, we develop a theoretical model to disclose the mechanism of return migration on villagers. Using a novel self-collected nationwide household survey dataset combining agricultural production and income information in rural China, we examine how return migrants affect rural household income, including income growth, relative income, and expected income growth. The results show that return migrants negatively impact rural household income. This impact is driven by the competition effect and the spillover effect between return migrants and local villagers. We also analyze the identities of return migrants before and after returning to distinguish the transmission channels. Our findings suggest that the government should persist in its encouragement of urbanization and promote return migrants to carry out work that complements local villagers.

Do political connections or elite capture matter in access to financial services? Evidence from Indian households

The extant literature has witnessed that local political executives tend to misallocate and limit information and public goods sources for their private gains rather than the overall public interest in developing economies. This results in the development of political connections by the households to access more benefits. Using nationwide household survey data in India, we examine whether households with political connections, also termed elite households, have preferential treatment when they access borrowings and investments from different sources. Using linear and non-linear models, we find that elite capture or political connections significantly influences access to financial services. Elite capture is significantly present when individuals borrow from financial institutions. Political connections play an important role when the borrowing amount is large. Our results provide important policy-level implications to decide whether decentralization in the policies will be more appropriate when designing any plan for financial inclusion.

District-level heterogeneity in overweight or obesity among women of reproductive age: A geo-spatial analysis in India.

Globally by 2030, 38% of the world's population would be overweight, and another 20% would be obese. This has led to rising concerns regarding how swiftly and substantially the world is moving towards this epidemic of "globesity". India too is facing an increased burden of overweight and obese population. The changing dietary patterns are significantly associated with the increasing prevalence of overweight/obesity and related complications, especially among women. Hence, the present study aims to observe the spatial patterns of overweight or obesity among women in reproductive age group in India and factors associated with it. The study analyzed data from a cross-sectional nationwide household survey, i.e. National Family Health Survey (NFHS-4), 2015-16. The primary outcome variable of this study was overweight/obesity among reproductive-age women, which was measured through the body mass index (BMI) of the women. Bivariate and multivariate logistic regression analysis was used to analyze the data. Additionally, for spatial analysis in terms of overweight/obesity among women in India, univariate and bivariate Moran's I index measurements were used along with the usage of spatial regression models. The value of spatial-autocorrelation for overweight or obese was 0.64, which depicts the moderately high prevalence of the overweight/obesity coverage over districts of India. The overall prevalence overweight/obesity among women in India is around 25% and higher proportion of women from urban areas (37.8%), and non-poor (33.4%) economic group reported to be overweight or obese. From spatial lag model, the lag coefficient was found to be 0.28, implying that a change in the prevalence of overweight/obesity among women in a certain district may statistically lag the prevalence of overweight/obesity by 28% in the neighbouring districts. There were significantly high clustering of overweight/obese women and non-poor wealth quintiles in 132 districts, mainly from states of Punjab, Haryana, Gujarat, Maharashtra, Kerala, Tamil Nadu, Karnataka and Andhra Pradesh. Additionally, there was high-high clustering of overweight/obese women and those who ever had caesarean in 82 districts, mostly from Kerala, Tamil Nadu, Andhra Pradesh and Karnataka. The spatial patterns on the prevalence of overweight and obesity in India show that the women belonging to the southern states' districts are more overweight or obese in comparison to other states. The determinants like older age, higher education, urban residence, higher economic status are the key factors contributing to the prevalence of overweight or obesity among women in the reproductive age group. The study concludes and recommends an urgent need of interventions catering to urban women belonging to higher socio-economic status, to reduce the risks of health consequences due to overweight and obesity.

Effect of COVID-19 pandemic on food insecurity in Indonesian households

PurposeThe COVID-19 pandemic has significantly affected access to adequate and nutritious food, resulting in hunger, malnutrition and increased food insecurity. The purpose of this study was to identify the households in Indonesia that were most likely to experience the pandemic's effects.Design/methodology/approachUsing raw data from nationwide Indonesian household socioeconomic and expenditure surveys (SUSENAS 2020 and SUSENAS 2021), food insecurity was measured using the Food Insecurity Experience Scale (FIES). A multinomial logistic regression model was used to analyze the data.FindingsThe prevalence of mild, moderate and severe food insecurity increased from 20.61% to 21.67% and from 1.28% to 1.37%, respectively, between 2020 (the initial stage of the COVID-19 pandemic) and 2021 (the period during which the infection rapidly spread nationwide). The estimation results of the multinomial logistic regression analysis indicated that urban households, which may have had more difficulties with income generation and access to food due to behavioral constraints, were more likely to be affected by the pandemic. Additionally, economically vulnerable poor households, households with low levels of education or unemployed heads were more likely to be affected by the pandemic.Originality/valueTo the best of the authors knowledge, this is the first study to access the impact of economic downturn and social restrictions due to the COVID-19 pandemic on household food insecurity in Indonesia, using the nationwide household survey data.

Socioeconomic Difference and Adequate Antenatal Care in Indonesia: Evidence from a Nationwide Household Survey

BACKGROUND: Inadequate antenatal care (ANC) has been identified as a risk factor for poor pregnancy outcomes in low-income nations. The World Health Organization recommends adequate ANC for a minimum of eight visits. While universal health coverage has been implemented since 2014, Indonesia as fourth largest populous country encounters challenge on socioeconomic disparities. AIM: This study aims to explore the socioeconomic difference of adequate ANC in Indonesia. METHODS: Data from the Indonesia Demographic and Health Survey 2017 was used for the analysis and includes 15,313 mothers age 15–49 who had a last live birth in the 5 years preceding the survey. Multivariate logistic regression was employed to assess correlation between socioeconomic status and adequate ANC. RESULTS: About 20.8% of mothers had adequate ANC and the proportion ranging between 11.4% in the poorest group and 34.5% in the richest group. Poorest (adjusted odds ratio [AOR]: 0.68; 95% CI: 0.54–0.86) and poorer (AOR 0.79; 95% CI: 0.64–0.97) mothers are less likely to have adequate ANC compared to the richest mothers. In addition, mothers who lived in Java-Bali region, had better knowledge on danger sign of pregnancy, exposed to internet every day, health insurance ownerships, and having ANC at health facilities were more likely to have adequate ANC. CONCLUSION: Socioeconomic status was significantly associated with adequate ANC, where inequality was profound among poor mothers. Therefore, specific intervention to expand universal health coverage for poor mothers is essential to reduce socioeconomic disparities.

Effect of farm machinery adoption on household income and food security: evidence from a nationwide household survey in India

An increase in farm productivity and income is crucially linked to farm mechanization. Labour shortage in rural areas and frequent extreme weather events have made a resounding pitch for the deepening of farm mechanization in India. Our study examines the effect of agricultural machinery adoption on net agricultural income, household income, and household consumption in India; the latter is considered as an indicator of food security. A nationwide household survey of 10253 households drawn from the majority of states of India has been used. To assess the impact of machinery adoption on the outcome variables, the endogenous switching regression (ESR) model is used. Of the three types of machineries investigated, such as tractors, electric pumps, and diesel pumps, the average adoption rates are found to be low in the country, i.e., 8% for tractors, 24% for electric pumps, and 14% for diesel pumps. The wide heterogeneity in terms of adoption is mostly rooted in the large geographical differences among the states of India, as machinery adoption is concentrated in the north and north-central plains of the country. The first stage of ESR, which is a probit model, reveals the determinants of mechanization as access to credit, climatic shocks, access to irrigation, and farmer cooperative membership. The average treatment effect estimates from the second stage outcome regression reveal that the adoption of machineries has increased net agricultural income by 31%, household income by 19%, and food consumption by 5%. Given these demonstrable positive effects of mechanization in agriculture, there is a need for deepening of low-cost scale appropriate farm machines suitable for small holders. Government support would play a pivotal role in this direction by making farm credits accessible to smallholders, providing timely subsidies on machinery purchase, and providing required extension services.

Tobacco use by sexual and gender minorities: findings from a Brazilian national survey

ObjectiveThe study aims to identify the prevalence of use of tobacco products by sexual and gender minorities (SGM) in Brazil, the users’ profile and associations between tobacco use and social...

Examining energy inequality under the rapid residential energy transition in China through household surveys

Since 2013, China has initiated a rapid energy transition that replaces traditional solid fuels with modern clean energy. Despite the tremendous success of the energy transition, its impacts on household energy costs and associated energy inequality remain largely unexplored. Here we use data from a large nationwide household survey to investigate these trends. We find that about two-fifths (43.0%) of surveyed households switched from traditional solid fuels to clean energy during 2013–2017. However, 56.1% to ~61.0% of them were from extremely poor or poor households, causing deep concern for increasing household energy burden. Accordingly, the share of surveyed households in energy poverty increased from 30.1% to 34.2%. Despite the declining inequality in energy cost, a growing inequality in energy burden was revealed during 2013–2017. Our results demonstrate that the energy burden on rural households increased due to the dramatic rise in the cost of clean energy, while urban households tend to spend a lower and decreased proportion of their income on energy. Between 2013 and 2017, China enacted a series of policies to improve air quality by promoting a switch to cleaner fuels for households. This study examines the changes in energy cost and associated energy burden across regions and income groups during this period, finding an increased burden on rural households.

The Effect of Left-Behind Women on Fertilizer Use: Evidence from China's Rural Households Engaging in Rural-Urban Migration.

Rural-urban migration in developing countries has required left-behind women to assume the role of key decision makers and take increasing responsibility for agricultural production. However, little is known about the effect of rural-urban migration on fertilizer use when left-behind women assume key decision-maker roles. This study highlights the effect of left-behind women on fertilizer use, drawing on nationwide household survey data in China. The results indicate that households with recognized left-behind women heads use less fertilizer than those with recognized men heads, while households with de facto left-behind women heads use more fertilizer. Moreover, the average nexus between households with recognized left-behind women heads whose major agricultural income comes from grain crops and fertilize use is negative but small in size and statistically insignificant. The findings indicate that future policy efforts aimed at decreasing rural environmental degradation should place greater emphasis on left-behind women's empowerment in socioeconomic decision-making within and outside the household, thereby contributing to an environment in which left-behind women farmers can succeed in a sustainable way.

Trends and projections of universal health coverage indicators in China, 1993–2030: an analysis of data from four nationwide household surveys

Universal health coverage (UHC) is a core element of Sustainable Development Goals and has become a global healthcare priority. China has been committing to provide all citizens with affordable and equitable basic healthcare over past decades. However, progress towards UHC in China has not been comprehensively assessed. This study aims to comprehensively evaluate the progress towards UHC in China by examining trends in service coverage and financial protection from 1993 to 2018, and estimating the probability of achieving UHC targets by2030. Following the framework proposed by World Health Organization and World Bank, we selected 12 prevention service indicators, 12 treatment service indicators, and two financial protection indicators to evaluate China's progress towards UHC. We used data from four nationally representative household surveys to assess the trends in service coverage and financial protection between 1993 and 2018, as well as their inequalities across subgroups. Meta-analysis was used to construct the composite prevention and treatment indices. The regression-based relative index of inequality was used to measure the income-related inequality of UHC indicators. Bayesian linear regression was conducted to predict progress towards UHC by 2030, and the probability of achieving UHC targets. Of the 24 service coverage indicators used in this study, most of them experienced improvements between 1993 and 2018. The composite prevention index increased from 65.6% (95% CI: 52.1%-77.9%) to 87.7% (95% CI: 81.8%-92.6%) and the composite treatment index increased from 57.1% (95% CI: 43.5%-70.1%) to 75.5% (95% CI: 66.6%-83.5%). The inequalities of service coverage experienced significant declines during this period. Based on our projections, most indicators except ones in the area of non-communicable diseases (NCD) will achieve the 80% coverage target by 2030, and the prevention and treatment indices will increase to 92.7% (95% CrI: 90.3%-94.7%) and 83.2% (95% CrI: 75.1%-88.8%) by then. However, we observed limited reductions in the incidences of catastrophic health expenditure and medical impoverishment. Inequalities in financial protection remained large in2018. China had made significant progress in improving healthcare service coverage and reducing inequalities between 1993 and 2018. However, China faces great challenges in improving financial protection and controlling NCD on its path towards UHC. Establishment of a primary-healthcare-based integrated delivery system and provision of better financial protection for vulnerable population should be prioritized. None.