Freeman Spogli Institute for International Studies Center on Democracy, Development, and the Rule of Law Stanford University

Research at CDDRL

Overcoming China's Anemia Puzzle in Poor Rural Elementary Schools: School Lunches, Nutrition Supplementation, Education or Deworming?

REAP Project


Educational achievement is rooted in a child’s healthy physical, cognitive, and behavioral development. The healthy development of a child is fueled by good nutrition and a balanced diet. High rates of iron deficiency and anemia among school-age children in rural China indicate that proper nutrition remains a problem in many parts of the country. Past studies suggest that inadequate nutrition has an adverse effect upon educational performance.

[For more on the puzzle of anemia in rural China, see Education Challenge: Nutrition].

Public health practitioners around the world have found multiple strategies for effectively eradicating the incidence of iron deficiency anemia among populations, (see Micronutrient Deficiencies and Interventions.) We seek to build on these lessons from the international literature and explore ways to reduce iron deficiency in rural China.

School meals rarely have enough nutrients to alleviate iron deficiency


Our goals in this project are twofold: a) to improve the nutrition of poor rural elementary students, specifically as related to iron deficiency anemia, in order to raise their educational performance; and b.) to help policy makers understand how they can best act to reduce the incidence of anemia in rural China. If successful, the work in this study will allow policy makers to compare the effectiveness of:

  1. Supplementing lunches with animal based (heme) protein through existing school feeding programs;
  2. Giving iron and multivitamin supplements directly to children in schools;
  3. Delivering school-level and household-level nutritional education campaigns;
  4. Providing deworming medication;
  5. Combining deworming medication with, respectively, treatments 1), 2) and 3).



REAP is documenting the baseline in several dimensions, including physical, cognitive and psychological.

First, we will determine a baseline of how many students are iron deficient. Trained nurses will conduct hemocue blood tests for iron deficiency and iron deficiency anemia.

If funding becomes available, we will test for the incidence of worm infection. We will document anthropometric measures: height-for-weight, height-for-age and weight-for-age.

We will also establish the socio-economic baseline status of the students in the treatment groups and in the control group.


100 schools (43,000 students) randomly selected from poor areas of three provinces of rural China (Shaanxi, Ningxia, Gansu) received one of three treatments:

  1. Lunch program: in 20 schools (with about 10,000 students), a portion of meat—equivalent to 1 ounce per student—will be added to the lunches of students;
  2. Dietary supplementation program: in 20 schools (with about 10,000 students) students will receive a weekly vitamin supplement (in tablet form);
  3. Nutritional education program: 40 schools (with 20,000 students):
  • School staff (administrators, cafeteria staff and teachers) will receive an intensive training course on preparing nutritious and cost-effective school meals, hygiene, food purchasing, and the relationship of these with health and education
  • The families (especially the main guardians) and students will receive an intensive training course on preparing nutritious and cost-effective home meals (and meals consumed away from home), hygiene, food purchasing, the relationship of these with health and education.


in order to provide a baseline against which the results from the treatment groups can be judged, 20 schools (with 10,000 students) will be randomly selected. There will be NO interventions in these schools (except for the running of a baseline and evaluation survey).


A deworming program will be overlaid over the nutrition experimental design. In other words, they will be done in ½ of the treatment schools:

  • Students in 10 “dietary supplementation program” schools will be dewormed (taking a once-per-year deworming tablet); students in 10 “dietary supplementation program program” schools will not be dewormed;
  • Students in 10 “lunch program” schools will be dewormed (taking a once-per-year deworming tablet); students in 10 “lunch program” schools will not be dewormed;
  • Students in 20 “nutritional education program” schools will be dewormed (taking a once-per-year deworming tablet); students in 10 “nutritional education program” schools will not be dewormed

This research design will allow us to be able to compare the effectiveness of the 4 ‘stand alone’ treatments and the 3 ‘combination’ treatments against one another and against the “do nothing” control group.

Implementation (REAP for treatments (2), (3) and deworming; PLAN International for treatment (1)) will include random check-ins to monitor delivery of the treatments: meat being adequately provided in lunches; supplement tablets being given out on the scheduled day of the week; deworming medicine administered; and nutritional information programs completed.

Will an intervention or combination of interventions dramatically improve performance?


REAP will follow up after 6 months, 12 months and every year after (as funding allows) to examine the status of students in treatment and control schools, in the cognitive, physical, psychological and socioeconomic dimensions recorded at baseline.


This project is classified as ongoing.


Stanford University, Stanford Nutrition and Education Support Group, Ministry of Finance and Peking University’s China Institute for Educational Finance Research (CIEFR), PLAN International, Johnson and Johnson (applied)