Parental migration, care-giving practices and left-behind children’s nutritional health in rural China: A mixed-methods approach A thesis submitted to The University of Manchester for the degree of Doctor of Philosophy in the Faculty of Medical and Human Sciences 2015 Nan Zhang School of Nursing, Midwifery, and Social Work Table of Contents List of Tables .............................................................................................................. 5 List of Figures ............................................................................................................. 7 List of Abbreviations ................................................................................................. 8 Abstract ..................................................................................................................... 11 Declaration ................................................................................................................ 12 Publications from thesis ........................................................................................... 13 Acknowledgement .................................................................................................... 15 Chapter 1 Introduction ............................................................................................ 16 1.1 Rural-urban migration in China ............................................................................. 17 1.2 The importance of nutrition in child development ................................................. 20 1.3 Potential links between migration and child nutrition ........................................... 22 1.4 Conceptual framework on child nutrition .............................................................. 24 1.5 Research aims and outline of thesis ....................................................................... 26 Chapter 2 Literature review ................................................................................... 28 2.1 Migration and left-behind children’s development ................................................ 29 2.1.1 The global context .......................................................................................................... 29 2.1.2 The Chinese context ....................................................................................................... 34 2.2 Search strategy ....................................................................................................... 36 2.2.1 Review strategy .............................................................................................................. 36 2.2.2 Search literature .............................................................................................................. 36 2.2.3 Considerations of quality checking ................................................................................ 37 2.3 Quantitative research review .................................................................................. 38 2.3.1 Cross-sectional evidence ................................................................................................ 38 2.3.2 Limitations of cross-sectional evidence ......................................................................... 39 2.3.3 Longitudinal evidence .................................................................................................... 40 2.3.4 Limitations of longitudinal evidence .............................................................................. 43 2.4 Qualitative research review .................................................................................... 45 2.4.1 Care-giving practices for left-behind children ................................................................ 45 2.4.2 Limitations of previous studies ...................................................................................... 47 2.5 Summary ................................................................................................................ 48 Chapter 3 Methodology ........................................................................................... 58 3.1 Mixed methodology ............................................................................................... 59 3.1.1 Mixed methods ............................................................................................................... 59 3.1.2 Rationale for mixed methods.......................................................................................... 60 3.1.3 Considerations ................................................................................................................ 61 3.2 Quantitative methods ............................................................................................. 66 3.2.1 Study aims, objectives, and hypotheses .......................................................................... 66 3.2.2 Data sources ................................................................................................................... 66 3.2.3 Target population and attrition ....................................................................................... 68 3.2.4 Nutritional outcomes ...................................................................................................... 70 3.2.5 Exposures and covariates ............................................................................................... 73 3.2.5 Statistical analysis .......................................................................................................... 77 3.3 Qualitative methods ............................................................................................... 81 2 3.3.1 Rationale for the qualitative study design ...................................................................... 81 3.3.2 Research site ................................................................................................................... 81 3.3.3 Sampling and recruitment .............................................................................................. 86 3.3.4 Ethical concerns ............................................................................................................. 91 3.3.5 Data collection ................................................................................................................ 93 3.3.6 Data analysis .................................................................................................................. 95 3.3.7 Rigour and reflexivity .................................................................................................... 96 Chapter 4 Patterns and distributions of under-and over-nutrition among rural children: Evidence from rural China ................................................................... 102 4.1 Introduction .......................................................................................................... 103 4.2 Methods................................................................................................................ 106 4.2.1 Study design and subjects ............................................................................................. 106 4.2.2 Nutritional outcomes .................................................................................................... 107 4.2.3 Variables....................................................................................................................... 110 4.3 Results .................................................................................................................. 111 4.4 Conclusions .......................................................................................................... 112 Chapter 5 Does the timing of parental migration matter for child growth? A life course study on left-behind children in rural China .......................................... 119 5.1 Abstract ................................................................................................................ 121 5.2 Background .......................................................................................................... 122 5.3 Methods................................................................................................................ 123 5.3.1 Data .............................................................................................................................. 123 5.3.2 Target population ......................................................................................................... 124 5.3.3 Variables....................................................................................................................... 124 5.3.4 Analysis ........................................................................................................................ 125 5.4 Results .................................................................................................................. 128 5.5 Discussion ............................................................................................................ 130 5.6 Conclusion ........................................................................................................... 134 Chapter 6 Gender differences in parental migration and left-behind children’s macronutrient intakes in rural China: A multilevel analysis ............................ 143 6.1 Abstract ................................................................................................................ 145 6.2 Introduction .........................................................................................................