Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Maryland, USA
Center for Health Policy Research, University of California Los Angeles, Los Angeles, California, USA.
BMJ Glob Health. 2022 Mar;7(3). doi: 10.1136/bmjgh-2021-007154.
The China Healthy Cities (Counties) public health initiative has been at the forefront of China's efforts to counteract the growing challenges in the urban environment since the 1990s. It primarily focuses on improving the urban living environment. However, the nationwide health impacts of the initiative remain unexplored.
We constructed nationwide county-level and city-level panel data from 1996 to 2012 using data on under-5 mortality rates (U5MR), the list of China healthy cities and counties and socioeconomic factors. We used a two-step staggered difference-in-differences approach that exploits variations in the timing of achieving the title of China Healthy City/County. Subgroup analyses by region were performed.
We included 707 cities in the China Healthy Cities study, and 1631 counties in the China Healthy Counties study. Our results indicate substantial and significant reductions in U5MR associated with the public health initiative in China. The association varies across regions with different socioeconomic statuses. China Healthy Cities were significantly associated with a reduction of 0.7/1000 (95% CI -1.2 to -0.2) in under-5 mortality 5 years after cities gained the title and a decrease of 1.4/1000 (95% CI -2.2 to -0.6) 10 years afterward. Cities from western China saw the largest statistically significant gains with 3.2/1000 and 7.2/1000 reductions in child mortality after 5 and 10 years, respectively. China Healthy Counties were also associated with significant reductions in under-5 mortality 8 years after achieving the title; it was associated with 2.6/1000 reductions in under-5 mortality nationwide and 3.8/1000 reductions in eastern China. Our results are robust to heterogeneous treatment effects across cities/counties over time and various model specifications.
Our results suggest significant reductions in under-5 mortality associated with this public health intervention focusing on living environment conditions. Future research could explore differential effects across regions and clarify the underlying causal mechanisms.
自 20 世纪 90 年代以来，中国健康城市（县）公共卫生倡议一直在应对城市环境日益增长的挑战方面处于领先地位。它主要侧重于改善城市生活环境。然而，该倡议对全国范围的健康影响仍未得到探索。
我们利用 1996 年至 2012 年期间的 5 岁以下儿童死亡率（U5MR）数据、中国健康城市和农村名单以及社会经济因素，构建了全国县级和市级面板数据。我们使用了两步交错差分差异法，利用实现中国健康城市/县称号的时间变化来进行分析。还进行了按地区划分的亚组分析。
我们纳入了中国健康城市研究中的 707 个城市和中国健康农村研究中的 1631 个县。我们的研究结果表明，中国的公共卫生倡议与 5 岁以下儿童死亡率的显著降低有关。这种关联因社会经济地位不同的地区而异。获得中国健康城市称号 5 年后，与儿童死亡率降低 0.7/1000（95%置信区间 -1.2 至 -0.2）有关，10 年后降低 1.4/1000（95%置信区间 -2.2 至 -0.6）。来自中国西部的城市在儿童死亡率方面取得了最大的统计学显著降低，分别降低了 3.2/1000 和 7.2/1000。获得中国健康农村称号 8 年后，与 5 岁以下儿童死亡率显著降低有关；与全国范围内的 2.6/1000 的儿童死亡率降低和东部地区的 3.8/1000 的儿童死亡率降低有关。我们的结果在随时间变化和各种模型规格的异质处理效果方面是稳健的。
我们的研究结果表明，与这项关注生活环境条件的公共卫生干预措施相关的 5 岁以下儿童死亡率显著降低。未来的研究可以探索地区之间的差异效应，并阐明潜在的因果机制。
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