Health and health equity among rural poor residents in the context of China’s targeted poverty alleviation policy: evidence from Shaanxi province


 Background: China’s targeted poverty alleviation policy is having a profound impact on the country’s rural economic and social development now. This study aimed to learn about the health status and health equity of rural poor residents under the implementation of the policy. It further explores the factors affecting the health status and health equity of rural poor residents, in order to contribute to the improvement of the policy.Methods: Data from 1,233 rural poor residents were derived from a questionnaire survey from 12 prefecture-level cities and areas of Shaanxi province in 2017, and a self-evaluation of health was used to reflect the health status. A concentration index was applied to measure the inequity of the health status of rural poor residents. The decomposition method was employed to explore the source of health inequity.Results: The results showed that 44.56% of rural poor residents in Shaanxi province had a poor or very poor health status, which was affected by their economic level, gender, age, the degree of education, and marital status. Additionally, participation in industry development, relocation, health poverty alleviation, and basic living standards were significantly correlated with the health status. The concentration index of the health status of rural poor residents in Shaanxi province was 0.0327. The primary contributors to the health inequity in different regions varied, but the economic level and the degree of education were the most significant factors, and the targeted poverty alleviation policy had a significant impact on the health equity.Conclusions：The results indicated that the health status of rural poor residents in Shaanxi province was generally poor, there was a pro-rich inequity in the health status, and the degree of education and economic level were the primary factors affecting the health status and health equity. The targeted poverty alleviation policy greatly impacted the health status and health equity, and the difference in health status would lead to the inequity of benefits of the targeted poverty alleviation policy. In the future, the policy should focus on ensuring the sustainable development ability of rural residents with poor health status.

3 inequity of benefits of the targeted poverty alleviation policy. In the future, the policy should focus on ensuring the sustainable development ability of rural residents with poor health status.

Background
Health is not only a direct component of the well-being of humans but also a human capital that increases the development capacity of individuals, families, and society [1].
There is a close relationship between health and poverty, and poor residents with a poor health status due to the lack of health investment and access to health care, leads to the exacerbation of their own poverty. Previous studies have shown that lower socioeconomic levels tend to reduce residents' enthusiasm to invest in health, and groups with lower socioeconomic status tend to face higher health risks [2]. Therefore, the development of public health through national systems and policies plays an important role in promoting individual health and eliminating poverty [3].At the same time, ensuring the health equity of different social and economic status groups has always been an important goal of medical and health system reforms in various countries. Health equity is an important part of social equity and justice, which is the basis of ensuring that different groups have equal access to resources and viability [4].
For a long time, the Chinese government has made great efforts to promote the health of citizens and eliminate poverty. The most striking is China's targeted poverty alleviation policy in the new era. Since 2013, China's targeted poverty alleviation strategy has become an important tool and source of power to help rural poor residents shake off poverty and build a moderately well rounded prosperous society. Targeted poverty alleviation means to promote the income, living standards, and health of rural poor residents through comprehensive poverty reduction measures. "The 13th five-year plan for poverty alleviation (2016)" has set the development goals of "ensuring that the rural 4 poor have enough food and clothing under the current standards, and that compulsory education, basic medical care and housing are secure". We have formulated a targeted poverty alleviation policy system consisting of developing competitive industries, locating jobs elsewhere, relocation, improving education, providing better health-care, better ecological protection, guaranteeing basic living standards, and social poverty alleviation, which was listed in Table 1 poverty-stricken areas, which expands the identification and targeting of anti-poverty in rural areas from a single income dimension to multiple dimensions such as income, education, health, and living standards. The policy establishes a comprehensive, accurate and long-term poverty alleviation mechanism, which demonstrates China's strong capacity for national governance and the socialist nature of eradicating poverty, improving people's livelihood and achieving common prosperity [5]. Ensuring the fairness of benefits for poor residents is also an important principle for the implementation of the targeted poverty alleviation policy, therefore it is important to focus on the health and health equity of the rural poor residents.
Although, previous research had paid some attention to the China's targeted poverty alleviation policies, the health and health equity of the rural poor residents under the policy have not been addressed. The previous research focused on the following aspects.
First, it explores relevant policy innovations such as land policies in the implementation process of the targeted poverty alleviation strategy [7,8]. Second, the implementation effect of the targeted poverty alleviation policy is evaluated based on different perspectives and methods [9][10][11][12]. Third, it analyzes the challenges and innovation paths of the implementation of the targeted poverty alleviation policy [13,14]. Therefore, this study uses the data from rural poor residents in Shaanxi province from 2017 to describe and analyze the health status and health equity of rural poor residents.
Shaanxi province is a key region for the implementation of China's targeted poverty alleviation strategy. And by the end of 2018, there are still 29 poverty-stricken counties with 775,500 poor residents. And affected by the natural environment, Shaanxi province is divided into three regions: Shanbei, Guanzhong and Shannan. Shanbei is the loess plateau, Guanzhong is the plain, and Shannan is the mountainous area, and the economic and social development levels of the three regions are quite different. so, it is also necessary to analyze the health status and health equity of rural poor residents from the perspective of regional difference. The identification standards for poor residents in Shaanxi province include: first, the net per capita annual income of residents is less than 3,070 yuan; Second, food and clothing (including safe drinking water) are not guaranteed, and compulsory education, basic medical care, and housing security have not been effectively addressed. In addition, the data will explore the influencing factors of health equity, which is conducive to improving the implementation of the targeted poverty alleviation and promoting the health equity of rural residents. Health equity is a very rich concept, which involves many aspects of health status, needs, and utilization of health services [18]. This study focuses on the equity of health status to see if different rural poor residents have the same health status.

Data collection and quality control
Organization and implementation 8 The research team carried out a questionnaire survey on rural poor residents in Shaanxi province by recruiting students on the summer holiday social practice program for college students of Xi'an Jiaotong University in 2017. The summer social practice program for college students is organized and implemented by the youth league committee of Xi'an Jiaotong University. The university, together with 12 cities and districts of Shaanxi province, has established a social practice base for college students. Every summer holiday, the university will send outstanding college students to various cities and districts to work as interns in township party, government organizations, and public institutions under its jurisdiction. The research team recruited these college students as investigators to implement the questionnaire survey, and these students from the same county made up the survey team. The questionnaire included basic information of rural poor residents such as health status, income, age, the degree of education, gender and marital status, their living conditions, and their participation in the targeted poverty alleviation policy.

Sampling method
First, a three-stage sampling survey method combining probability and non-probability sampling was adopted. We selected counties (districts) with rural areas from 12 municipals in Shaanxi province, and the typical rural administrative village was selected in the counties (districts). Last, each rural village randomly selected six eligible poor households as the subject of survey. The sampling process was carried out by each survey team in accordance with scientific, typical, and convenient principles.

Data quality control
First, the college students from the social practice that participated in the survey were trained ahead of time, the structure and content of the questionnaire were explained, and the matters needing attention and principles in the questionnaire survey were 9 emphasized. Second, every member of this survey can use the survey data to conduce a research so that they will be more responsible. Third, A preliminary investigation was conducted and the questionnaire was revised according to the problems found in the preliminary survey so that the scientificity of the formal questionnaire was guaranteed.
Fourth, we used one-to-one interview to answer the questionnaire, which means that our investigators ask the rural poor residents and fill out questionnaires based on the answer.
And problems existing in the survey were solved timely through network communication during the implementation of the survey. Last, we checked the questionnaires the students returned. According to the general requirements of social survey, the questionnaires is valid if there is no logic error and the main questions had been answered. After Eliminating questionnaires that lack key information such as health status, income, age, the degree of education, gender and marital status, a total of 1,233 valid samples were obtained after removing the samples under the age of 16.

Description of the health status of rural poor residents
Descriptive statistical analysis was used to describe the health status of rural poor residents, and chi-square test was used to analyze whether there were statistically significant differences in the health status of poor residents in different regions.

Measurement of health equity
A simple way to measure health equity is to test whether two groups (the poor and the rich) have the same health level. Currently, there are many methods to measure health equity, including the method of concentration curve and concentration index, method of Lorenz curve and gini-coefficient Lorenz curve, atkinson index, and chi-square value Method [19]. Although the method of concentration index and lorenz curve and gini coefficient is similar to the way of expression. The concentration index not only provides an indicator of health inequity but can also be decomposed proportionally into contributions of different inequity of health determinants [20]. Referring to existing studies on health equity of Chinese residents [21,22], this research uses the centralized index method to measure the health equity of rural poor residents. The concentration index is used to investigate the inequity degree of a certain variable associated with social and economic status, which dynamically reflects the effect of the variable influenced by income [23]. The concentration index is calculated using Equation 1 [21].
where C is concentration index, y is health status, u is the mean of health status, r is the fractional rank of income, ranging from 0 to 1. The value of the concentration index is -1 to 1. If the concentration index is 0, this shows that rural poor residents with different economic levels have the same health status. A positive concentration index indicates that people with higher incomes are healthier than those with lower incomes. Conversely, a negative concentration index indicates that people with lower incomes are healthier than those with higher incomes.
The method of decomposition of the concentration index is used to analyze the contributions of various determinants of health to the inequity in health status.
Decomposition of the concentration index is proposed by Wagstaff, which is a straightforward way to decompose the measured degree of inequity into the contributions of various explanatory factors [24]. The positive value of contribution means that the variable contributes to pro-rich inequity, that is, richer individuals have a better health status than the poor, and vice versa [20]. We use the OLS linear regression to decompose the health inequity of rural poor residents, because the health status of rural poor residents is a count variable. First, a regression model should be given as Equation 2.

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Where y i is the health status; x m is income; x n are need variables; x p are other variables; β m , β n and β p are coefficients; ε i is the implied error term, which includes approximation errors. Then the concentration index for y can be written as Equation 3: concentration indexes of x m , x n , and x p . The terms on the right side of Equation 3 denotes the contributions of income, need variables, other variables, and the implied error to inequity.

Outcome variable
Health is a complex concept, so there are many methods and indicators to measure the health status of residents. The European five-dimensional health scale (EQ-5D) is widely used by researchers due to its simplicity and high credibility [25][26][27]. Zhang divided the health of the elderly into three aspects: physical health, cognitive function, and selfevaluated health [28]. Li measured the health status of rural Chinese residents by whether they had been ill in the past two weeks and whether they suffered from chronic diseases [29].  [31]. Taking the experience that using self-reported health to measure the health status of people for reference, this study thinks that Self-rated health status can accurately and directly reflect rural poor residents' understanding of their overall health status, including Both physical health and mental health. Therefore, this study reflects the health status of rural poor residents through self-reported health questionnaires. The self-evaluation questions about health is "how do you feel about your physical health?", and the answer includes five dimensions of very poor, poor, average, good, and very good, with a value of 1-5.

Independent variables
Since this study uses the method of centralized exponential decomposition to analyze the influencing factors of health equity, the independent variables in this study include three categories: income, need variables, and other variables. Income is measured by self-  Table 2.   and female health status, the proportion of male residents with general health status or above was 55.06%, while the corresponding proportion of female residents was 59.69%.

Comparison of health status of rural poor residents under different sociodemographic characteristics
The health status of poor residents in different age groups was significantly different. The proportion of poor health status of rural poor residents over 60 years old is 62.54%, which was significantly higher than that of rural poor residents under 60 years old. Rural poor residents with different education levels had different health conditions. The health status of rural poor residents with a junior high school education or above was significantly better than that of those without an education or primary school education. And rural poor residents who are married and cohabiting were in better health status than those who are unmarried, divorced, or widowed. Judging from the participation of rural poor residents from the targeted poverty alleviation policies, there was a significant correlation between participation in industry development and their health status. The health status of residents participating in industry development was significantly better than that of residents not participating in industry development. The proportion of those who participated in the relocation with good health status and very good health status was 25.14% and 2.23%, while the corresponding proportion of those who did not participate in the relocation was 21.55% and 1.79%. There was no significant relationship between participation in employment helping and rural poor residents' health status. There was a significant difference between the poor residents who enjoyed healthy poverty alleviation and those who did not, and the proportion of poor health of the former was 47.41%, which was significantly higher than the latter's 31.21%. There was a significant difference between the health status of rural poor residents who enjoyed the basic living standard guaranteeing policy and those who did not, a total of 51.89% of rural poor residents who were entitled to the basic living standard guaranteeing policy had very poor health, while the corresponding proportion of the poor residents who were not was 31.17%. These results show that there is a close relationship between the health status of rural poor residents and poverty, and participation in poverty alleviation policies. Industry development and relocation are developmental policies from which healthier residents are more likely to benefit. However, health poverty alleviation and basic living standard guaranteeing are welfare-oriented policies, and the effect on poor residents with poor health is more obvious.

Concentration index and decomposition of health inequity of rural poor residents
The concentration index of the health status of rural poor residents in Shaanxi province and different regions is shown in Table 4.  The decomposition of the health status inequity of the rural poor residents is shown in 0.2016%, respectively, which suggested that these policies may do more to improve the health status of the richer residents. However, the contribution rate of relocation policy to the inequity of health status is -3.8396%, which indicated that the relocation policy was more conducive to improving the health status of poorer residents. The decomposition results of health status concentration index of rural poor residents in 22 the different regions of Shaanxi province, Shanbei, Guanzhong, and Shannan, are shown in Table 6[see additional file 1]. In Shanbei, the most significant contributors to health status inequity of rural poor residents were the relocation policy (-121.1139), the degree of education (115.6037%), and economic level (114.2978%), which suggests that the degree of education increased the inequity of health status which is sloped towards the richer, the residents with a higher economic level were more likely to be in a better health status, and relocation policy was more conducive to improving the health status of poorer

Discussion
We used the sampling survey data of rural poor residents in Shaanxi province in 2017, and found that while the economic level of rural poor residents was low (mean=13395.11±374.99 yuan), the overall health status of residents was poor, and the proportion of poor or very poor health status by a self-evaluation was as high as 44.56%.
Through chi-square test analysis, it is found that there were significant differences in the health status of rural poor residents in different regions of Shaanxi province, and there were significant correlations between economic level, the degree of education, marital status, age, and health status. There were significant differences in the health status of rural poor residents who participated in industry development, relocation, enjoyed the health poverty alleviation policy, and basic living standard guaranteeing policy. According to the calculations of the concentration index of rural poor residents' health status and its decomposition, we found that there was an inequity sloped towards the richer for health status. Economic level, and the degree of education were the most important factors influencing the inequity of health status, and the targeted poverty alleviation policy had an important influence on the inequity of health status of rural poor residents.
The research found that the degree of education of rural poor residents in Shaanxi was very low. In terms of the overall situation of Shaanxi province, 31.99% of rural poor residents had no schooling, and just 5% of rural poor residents had a high school education degree or above. The proportion of rural poor residents in Shanbei who had no schooling was as high as 64.58%. The degree of education is an important component of residents' individual development ability. In the framework of the family sustainable livelihood analysis, education is an important component of livelihood capital [32], and it has a profound impact on the livelihood choices of rural families and their living conditions. A transnational study showed that education is a leading factor of income 24 inequity [33], and poverty has a negative impact on the quantity and quality of education development, which is can lead to poverty [34]. The research results showed that poor residents with a lower degree of education are likely to have a poorer health status, and the association was significant in age groups where 30<Age < 61 and Age>60. For a long time, the relationship between education and health has been highly concerned by researchers [35,36]. play a critical role in poverty reduction [37], which shows that a higher economic level is conducive to a better education investment and health level.
It is found that the marital status of rural poor residents in Shaanxi province has a significant impact on their health status, and the health status of married cohabitation residents is significantly better than that of unmarried, divorced, or widowed residents. It has been found that marital status influences individual health status through mediating variables such as social psychological stress [38]. A study from South Korea added to the evidence that an individual's health behavior and disease status are linked to marital status [39]. In China's social context, family economic level is closely related to men's marital status, and adult men from poor families have a weaker position in the marriage market. According to the definition of forced male bachelors in rural areas [40], unmarried men aged 28 and above in rural areas are called forced male bachelors. The marriage squeeze has a significant negative impact on men's quality of life [41]. The forced male bachelors in our survey accounted for 11.31% of all the rural poor male residents, and the 25 proportion of these men with poor health status is as high as 67%. Therefore, we can come to the conclusion that there is also a close link between poverty, marriage, and health status.
There was an important finding showing a significant relationship between participation in the targeted poverty alleviation programs and the health status of rural poor residents.
First, according to the results of the chi-square test, the health status of the poor residents who participated in industry development was significantly better than that of the poor residents who did not participate in industry development. After controlling the influence of age on the health status and participation in industry development, the difference was still significant. There are two ways to explain this result. One is that poor residents increase their household income by taking part in industry development, which is conducive to improving their health status; another is that poor health status is not showed that the health status of rural poor residents who enjoyed the health poverty alleviation project and basic living standard guaranteeing project may be worse off. This is because the residents with a poor health status have a higher utilization rate of medical services and medical expenses, and the majority of the poor residents who enjoy the basic living standard guaranteeing project are those who lack the ability to work. In turn, this reflects the support and protection of the targeted poverty alleviation policy to the weak, and also reflects the "targeted" of the policy design.

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Another issue of great importance is that under the background of implementing the targeted poverty alleviation policies, there was an inequity sloped towards the richer in the health status of rural poor residents in Shaanxi province and different regions.
Leading that the higher the family economic level is, the better the health status of the residents may be. Although the Chinese government has long been committed to promoting health equity of different groups through the reform of the medical security system, economic level inequity has always been an important factor affecting the equity of the utilization of health services and health status of residents [22]. Although the health poverty alleviation project is conducive to reducing the medical burden of rural poor residents, it is still based on the new rural cooperative medical system, which cannot completely eliminate the impact of the family economic level on the equity of the utilization of health care services for rural poor residents [42].

Strengths and limitations
This research draws from a rare concern and discussion on the health and health equity of rural poor residents in the context of China's targeted poverty alleviation policy.
Additionally, factors affecting the health status and health equity of rural poor residents were studied by using first-hand survey data, and the research conclusion can significantly improve the effect and equity of the targeted poverty alleviation policy. But there are also some limitations: first, the situation of rural poor residents in different areas of China cannot be equally compared. Due to the difficulty of obtaining data of rural poor residents, we only use the survey data of Shaanxi province for analysis. In the following research, we will focus on the situation of different provinces. Second, health equity is a complex concept. This paper only considered the equity of health status based on given results, but did not consider the utilization of health services from rural poor residents. Through the self-evaluation of health, this can reflect an individual's whole health status, but result deviation caused by subjective reasons is inevitable. Third, this study focused on the impact of the participation in the targeted poverty alleviation policies on the equity of the health status of rural poor residents, but didn't involve the factors that may affect the health equity in the implementation process of the targeted poverty alleviation policies, which will lead towards another research question. Finally, with the in-depth implementation of the targeted poverty alleviation policy, its impact on the health status of rural poor residents is seen as a dynamic process. The next step is to focus on the dynamic mechanism of the targeted poverty alleviation policy's impact on the health status of rural poor residents, which may be more meaningful.

Conclusion
This study showed that the rural poor residents in Shaanxi province have a poor health status and low degree of education, with a high proportion of forced male bachelors. The health status of rural poor residents was significantly correlated by family economic level, the degree of education, and marital status, and whether to participate in industry development, relocation, health poverty alleviation, and utilizing the standard guaranteeing project. The research found that there was an inequity sloped towards the richer on the health status of rural poor residents, the family economic level, and the degree education level, which were the most important factors affecting the health status of poor residents. The targeted poverty alleviation policy had an important impact on the health equity of rural poor residents, thus deeply affecting their sustainable development ability. Under the current targeted poverty alleviation policy system, poor residents with 29 poor health status are faced with the double dilemma of increasing family economic income and improving health status, which is shown as the key needed to consolidate and improve the targeted poverty alleviation effect. Therefore, through more scientific and rational policy design, the economic level and health status of poor residents with poor health status should be developed simultaneously, and the equity of policies benefiting different poor residents should be guaranteed, so as to prevent the occurrence of new relative poverty.

Abbreviations
Not applicable.

Ethics approval and consent to participate
Ethics approval for this study was given by the medical ethics committee of Health Science Center of Xi'an Jiaotong University (approval number 2016-416). Approved by the ethics committee, we obtained verbal consent from study participants. Prior to the survey, we informed the survey contents in detail and assured them that the data were for research only.

Consent for publication
Not applicable.

Availability of data and material
The data used in this study belong to our research team, and data does not involve any personal privacy information. Other authors who want to use the data may contact the author.