Tackling caregiver depression in rural China: A Q&A

After studying early childhood development in China for several years, Alexis Medina, assistant director of Stanford’s Rural Education Action Program (REAP), and her colleagues got a question from a colleague that opened up a whole new line of inquiry. I spoke with Medina recently to learn more:

How did your project on caregiver depression get started?

We have been studying early childhood development in rural China since 2012. We’ve learned that rural babies and toddlers in China lag behind global averages on a number of outcomes, including nutrition, cognition and both language and social-emotional development. Parenting behaviors are also lacking — less than half of rural parents read to, play with or tell stories to their young children. And fewer than 10% of families engage in all three behaviors.

During a seminar in London, an Oxford psychology professor asked us if part of the reason for these low cognition levels and low rates of engagement might be maternal or grandmother depression. We hadn’t considered this before, and felt it was worthy of deeper study.

What did your study find?

We added in a measure of adult depression to our survey forms, and then conducted a large-scale survey of 1,787 caregivers across 118 villages in one northwestern province. When the results (which appear in Frontiers in Psychology) came back, we were shocked. Nearly one-quarter of women caregivers showed signs of depression. As our Oxford friend predicted, depressed caregivers were also significantly more likely to have children with social-emotional delays.

We also found a large generational disparity: under 20% of mothers showed signs of depression, compared with 35% of grandmothers. This was actually the opposite of what we expected going into the study.

In our study, we also conducted a series of in-depth household interviews with 55 of the caregivers to delve deeper into the potential contributing factors associated with depression. We uncovered some interesting trends that we think of as side effects of a rapidly changing society.

For example, we found that depressed grandmothers consistently felt out of place both within their own household and in society at large. These women were brought up in a struggling rural economy to be farmers and farmers’ wives. Many cannot read. They feel like they’re unemployable in the modern economy, and therefore unable to meaningfully contribute to their family. Meanwhile, they’re often saddled with full-time childcare for energetic toddlers whose parents are off in the big cities working skilled jobs. They are tired, they are lonely and they repeatedly told us that they feel ‘worthless.’

How does mental health differ in China?

We know from our research that there is little understanding of mental health among rural families. We found indications of depression among many rural women caring for toddlers, yet less than half of these had even heard of depression. Mental health is highly stigmatized. And there are a lot of misconceptions, such as assuming everyone with a mental health issue will behave in extreme ways: ‘standing naked in freezing water,’ ‘doing stupid things’ or engaging in violence. And treatment is nearly non-existent.

There is relatively more research done on mental health in urban areas of China. This research shows that levels of stress, anxiety and depression are also quite high. Although there are still large misperceptions about the sources of mental health problems and ways of treating these conditions among urban Chinese, their understanding is much better than that of rural Chinese residents.

What are the next steps?

Our next steps will be to explore ways of addressing these high rates of caregiver depression. We’ve built over 100 village-based parenting centers, where caregivers and their children can visit and play together six days a week. By building a sense of community and empowering caregivers, we hope to help alleviate some of the depressive symptoms we’ve observed. One of our graduate students is currently measuring the impact of these centers on caregiver depression.

We’re also working on an intervention that will provide caregivers with monthly, in-home mental health support. We would like to also learn more about any existing resources offered through rural health centers, and see if we can work with local governments to build on existing programs.

On the most fundamental level, there needs to be more awareness of the issues — from both families and health care workers — so that talking about mental health can become less stigmatized.

Photo by Laura Jonsson courtesy of REAP

This is a reposting of my Scope blog story, courtesy of Stanford School of Medicine.

A look at health care reform — in China

Photo courtesy of Karen Eggleston

The struggles with health insurance reform here in the United States piqued my curiosity about what we could learn from other countries. I reached out to Karen Eggleston, PhD, a senior fellow at the Freeman Spogli Institute for International Studies at Stanford, who researches health care systems and health reform in Asia, especially China.

What is health insurance like in China?

“The original system was linked to the centrally planned economy. Communes in rural areas supported the barefoot doctors and state-owned enterprises provided people with health care coverage in the urban areas. But when China converted to a market-based economy, this had to change. So long story short, they’ve put into place a new system of health coverage based on government subsidized insurance for rural and non-employed urban populations, as well as an employee-based medical insurance for the employed urban population. As I like to tell my US colleagues, if you think providing coverage for 40 million uninsured people is a challenge then think about covering over 800 million uninsured — that’s what China was dealing with.

Many westerners would be surprised to know that Chinese have almost complete freedom when choosing their doctor or hospital.”

How has this expanded coverage impacted health and survival?

“There is a lot of evidence that the expanded health insurance improved access to care and helped protect households from high health care expenditures, but it’s actually pretty difficult to pin down the effects on health and survival.

In a recent study in Health Affairs, we looked at the New Cooperative Medical Scheme that provides health insurance to rural areas. We used the fact that it was introduced over time in different counties to look at the effect it had later, correlating this data with cause-specific mortality data from China’s CDC. We didn’t see a significant impact on mortality rate due to expanded medical coverage.

This was and wasn’t surprising. It may take a long time for the results to manifest. But it’s also quite well known in health economic research that health and survival are often shaped by non-medical factors like lifestyle.”

What are some of the biggest health care challenges in China?

“As China urbanizes hundreds of millions of people at a time, they are changing their diet and living a more sedentary lifestyle. As a result, they’re now getting what are sometimes called the diseases of affluence, such as diabetes. Like many developing countries, China’s healthcare system was setup to deal primarily with acute conditions and to control infectious diseases. Now, they need to sustainably finance and manage programs to prevent and care for people with chronic diseases.

A lot of China’s care is also based in hospitals, so they need to strengthen primary care — ironic for a country so famous for barefoot doctors. Physicians’ career trajectories are better in urban hospitals and patients know that’s where the best physicians are. But new policies are trying to lure patients and doctors to primary care.”

What other factors are affecting health in China?

“China has a rapidly aging population — largely due to their triumph in extending lives by controlling infectious diseases and lifting millions out of poverty, and also related to low fertility. This demographic change reinforces the challenge of preventing and controlling chronic disease.

We also know that people with more education tend to have better health and survival than people with lower education. China’s economic growth has brought a rapid increase in living standards but also a rise in inequality, in both rural and urban areas. One of the best ways to address this is to improve opportunities of education for the disadvantaged. This isn’t typically thought of as a health policy, but actually studies have shown education can have long lasting effects on health and survival.”

This is a reposting of my Scope blog post, courtesy of Stanford School of Medicine.