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The equity and effectiveness of China's 2009 folic acid supplementation programme for long-term child development.

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Title: The equity and effectiveness of China's 2009 folic acid supplementation programme for long-term child development.
Authors: Liang N; School of Economics and Management, Harbin Institute of Technology, Shenzhen, People's Republic of China.; Institute for Global Health and Development, Peking University, Beijing, People's Republic of China., Huang C; Institute for Global Health and Development, Peking University, Beijing, People's Republic of China.; China Center for Health Economic Research (CCHER), National School of Development, Peking University, Beijing, People's Republic of China.; School of Economics, Peking University, Beijing, People's Republic of China., Pan Q; School of Economics and Management, Harbin Institute of Technology, Shenzhen, People's Republic of China.
Source: Global health action [Glob Health Action] 2026 Dec 31; Vol. 19 (1), pp. 2691381. Date of Electronic Publication: 2026 Jun 22.
Publication Type: Journal Article
Language: English
Journal Info: Publisher: Taylor & Francis Country of Publication: United States NLM ID: 101496665 Publication Model: Print-Electronic Cited Medium: Internet ISSN: 1654-9880 (Electronic) Linking ISSN: 16549880 NLM ISO Abbreviation: Glob Health Action Subsets: MEDLINE
Imprint Name(s): Publication: <2016- > : Philadelphia, PA : Taylor & Francis
Original Publication: Häggeby : Co-Action Publishing
MeSH Terms: Folic Acid*/administration & dosage , Folic Acid*/therapeutic use , Child Development*/drug effects , Neural Tube Defects*/prevention & control , Dietary Supplements*, China/epidemiology ; Humans ; Female ; Child ; Male ; Adolescent ; Rural Population ; Pregnancy ; Socioeconomic Factors
Abstract: Background: Maternal folic acid supplementation is a cornerstone of public health for preventing neural tube defects (NTDs), yet its long-term impact on child development remains underexplored.
Objective: This study evaluates the long-term cognitive and mental health associations of maternal folic acid supplementation by utilising China's 2009 Folic Acid Supplementation Programme for rural women as a quasi-experimental framework.
Methods: We analysed 1,953 children aged 10-15 years from the 2020 China Family Panel Studies. Using provincial NTD prevalence in 2009 from the Maternal and Child Health Surveillance system as a proxy for intervention intensity, we employed difference-in-differences models to estimate associations, adjusting for demographic and parental covariates.
Results: Maternal folic acid supplementation was significantly associated with improved outcomes among girls: higher memory scores ( INLINEMATH [95% CI], 0.232 [0.069, 0.394]), enhanced numerical reasoning skills (5.234, [2.188, 8.279]), lower Center for Epidemiological Studies Depression Scale score (-0.523 [-0.933, -0.113]), and reduced likelihood of depressive symptoms (-0.024 [-0.048, -0.001]). No comparable associations were observed in the boys. Although cognitive associations were observed across socioeconomic status (SES) groups among girls, the mental health associations were concentrated among girls from higher-SES families. Results were robust to adjustment for covariates.
Conclusions: This study highlights sex-specific, long-term associations of maternal folic acid supplementation but reveals that socioeconomic disparities may constrain mental health gains. Thus, universal nutrition interventions alone may be insufficient to bridge health equity gaps. The findings should be interpreted within the broader nutritional ecology and alongside concurrent macro-social changes that shape child development outcomes.
References: Lancet Glob Health. 2017 Feb;5(2):e217-e228. (PMID: 28104188)
Science. 2006 Jun 30;312(5782):1900-2. (PMID: 16809525)
JAMA. 2013 Feb 13;309(6):570-7. (PMID: 23403681)
Int J Epidemiol. 2011 Oct;40(5):1154-6. (PMID: 22039190)
Nutrients. 2025 Dec 18;17(24):. (PMID: 41470905)
JAMA Psychiatry. 2018 Jul 1;75(7):747-748. (PMID: 29801055)
Econ Polit Wkly. 2013 Aug 31;48(35):79-86. (PMID: 26663948)
JAMA Psychiatry. 2018 Feb 1;75(2):176-184. (PMID: 29299606)
Adv Nutr. 2019 May 1;10(3):502-519. (PMID: 31093652)
Am J Public Health. 2005 Nov;95(11):1917-22. (PMID: 16195513)
Int J Epidemiol. 2019 Dec 1;48(6):2010-2017. (PMID: 31257442)
Eur J Pediatr. 2011 Nov;170(11):1391-400. (PMID: 21594574)
Neuropsychologia. 2008 Apr;46(5):1349-62. (PMID: 18262207)
BMJ. 2017 Oct 4;359:j4273. (PMID: 28978695)
Nutrients. 2018 Mar 20;10(3):. (PMID: 29558383)
Lancet Glob Health. 2013 Aug;1(2):e77-e86. (PMID: 25104162)
JAMA. 2011 Oct 12;306(14):1566-73. (PMID: 21990300)
Sci Rep. 2023 Jun 12;13(1):9541. (PMID: 37308528)
Am J Clin Nutr. 2025 Sep;122(3):695-702. (PMID: 40653274)
Lancet Neurol. 2006 Nov;5(11):949-60. (PMID: 17052662)
Acta Paediatr. 2018 Aug;107(8):1370-1378. (PMID: 29469926)
BMC Med. 2021 Mar 10;19(1):73. (PMID: 33750355)
EClinicalMedicine. 2023 Dec 12;67:102366. (PMID: 38169713)
Lancet Glob Health. 2022 Jul;10(7):e1053-e1057. (PMID: 35617975)
Int J Mol Sci. 2021 Jun 15;22(12):. (PMID: 34203717)
Epigenomics. 2016 Jun;8(6):863-79. (PMID: 27319574)
BMC Med. 2019 Oct 31;17(1):196. (PMID: 31672132)
J Youth Adolesc. 1991 Apr;20(2):149-66. (PMID: 24265004)
N Engl J Med. 1999 Nov 11;341(20):1485-90. (PMID: 10559448)
JAMA. 2010 Dec 22;304(24):2716-23. (PMID: 21177506)
Am J Clin Nutr. 2018 Apr 1;107(4):566-575. (PMID: 29635492)
Glob Health Action. 2014 Jun 06;7:23623. (PMID: 24909407)
Nutrients. 2017 Nov 02;9(11):. (PMID: 29099069)
Paediatr Child Health. 2004 Oct;9(8):575-598. (PMID: 19680490)
Am J Psychiatry. 2018 Jul 1;175(7):607-619. (PMID: 29558816)
J Health Econ. 2021 Sep;79:102490. (PMID: 34247127)
Public Health Nutr. 2005 Apr;8(2):117-32. (PMID: 15877905)
Contributed Indexing: Keywords: Folic acid supplementation; child development; health equity; quasi-experimental design; socioeconomic status
Local Abstract: [plain-language-summary] Main findings: Maternal folic acid supplementation was associated with sex-specific, long-term cognitive and mental health outcomes among girls aged 10–15, with mental health associations exclusively concentrated among those from families with higher-socioeconomic status.Added knowledge: Leveraging a national programme as a quasi-experimental framework, this study provided evidence that the associations of folic acid supplementation may extend beyond birth defect prevention while revealing that within a complex nutrition and psychosocial environment, universal biomedical interventions risk inadvertently exacerbating socioeconomic inequalities in adolescent mental health when implemented in isolation.Global health impact for policy and action: Where applicable, policymakers in low- and middle-income countries should consider moving beyond ‘one-size-fits-all’ biomedical approaches by integrating nutrition programmes with targeted psychosocial support, to ensure that the potential benefits of public health investments are shared equitably across socioeconomic groups and in alignment with the Sustainable Development Goals.
Substance Nomenclature: 935E97BOY8 (Folic Acid)
Entry Date(s): Date Created: 20260622 Date Completed: 20260622 Latest Revision: 20260813
Update Code: 20260813
PubMed Central ID: PMC13288903
DOI: 10.1080/16549716.2026.2691381
PMID: 42328968
Database: MEDLINE
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  Data: &lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Liang+N%22&quot;&gt;Liang N&lt;/searchLink&gt;; School of Economics and Management, Harbin Institute of Technology, Shenzhen, People&#39;s Republic of China.; Institute for Global Health and Development, Peking University, Beijing, People&#39;s Republic of China.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Huang+C%22&quot;&gt;Huang C&lt;/searchLink&gt;; Institute for Global Health and Development, Peking University, Beijing, People&#39;s Republic of China.; China Center for Health Economic Research (CCHER), National School of Development, Peking University, Beijing, People&#39;s Republic of China.; School of Economics, Peking University, Beijing, People&#39;s Republic of China.&lt;br /&gt;&lt;searchLink fieldCode=&quot;AU&quot; term=&quot;%22Pan+Q%22&quot;&gt;Pan Q&lt;/searchLink&gt;; School of Economics and Management, Harbin Institute of Technology, Shenzhen, People&#39;s Republic of China.
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  Data: Background: Maternal folic acid supplementation is a cornerstone of public health for preventing neural tube defects (NTDs), yet its long-term impact on child development remains underexplored.&lt;br /&gt;Objective: This study evaluates the long-term cognitive and mental health associations of maternal folic acid supplementation by utilising China&#39;s 2009 Folic Acid Supplementation Programme for rural women as a quasi-experimental framework.&lt;br /&gt;Methods: We analysed 1,953 children aged 10-15 years from the 2020 China Family Panel Studies. Using provincial NTD prevalence in 2009 from the Maternal and Child Health Surveillance system as a proxy for intervention intensity, we employed difference-in-differences models to estimate associations, adjusting for demographic and parental covariates.&lt;br /&gt;Results: Maternal folic acid supplementation was significantly associated with improved outcomes among girls: higher memory scores ( INLINEMATH [95% CI], 0.232 [0.069, 0.394]), enhanced numerical reasoning skills (5.234, [2.188, 8.279]), lower Center for Epidemiological Studies Depression Scale score (-0.523 [-0.933, -0.113]), and reduced likelihood of depressive symptoms (-0.024 [-0.048, -0.001]). No comparable associations were observed in the boys. Although cognitive associations were observed across socioeconomic status (SES) groups among girls, the mental health associations were concentrated among girls from higher-SES families. Results were robust to adjustment for covariates.&lt;br /&gt;Conclusions: This study highlights sex-specific, long-term associations of maternal folic acid supplementation but reveals that socioeconomic disparities may constrain mental health gains. Thus, universal nutrition interventions alone may be insufficient to bridge health equity gaps. The findings should be interpreted within the broader nutritional ecology and alongside concurrent macro-social changes that shape child development outcomes.
– Name: Ref
  Label: References
  Group: RefInfo
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(PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2229801055%22&quot;&gt;29801055)&lt;/searchLink&gt;&lt;br /&gt;Econ Polit Wkly. 2013 Aug 31;48(35):79-86. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2226663948%22&quot;&gt;26663948)&lt;/searchLink&gt;&lt;br /&gt;JAMA Psychiatry. 2018 Feb 1;75(2):176-184. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2229299606%22&quot;&gt;29299606)&lt;/searchLink&gt;&lt;br /&gt;Adv Nutr. 2019 May 1;10(3):502-519. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2231093652%22&quot;&gt;31093652)&lt;/searchLink&gt;&lt;br /&gt;Am J Public Health. 2005 Nov;95(11):1917-22. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2216195513%22&quot;&gt;16195513)&lt;/searchLink&gt;&lt;br /&gt;Int J Epidemiol. 2019 Dec 1;48(6):2010-2017. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2231257442%22&quot;&gt;31257442)&lt;/searchLink&gt;&lt;br /&gt;Eur J Pediatr. 2011 Nov;170(11):1391-400. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2221594574%22&quot;&gt;21594574)&lt;/searchLink&gt;&lt;br /&gt;Neuropsychologia. 2008 Apr;46(5):1349-62. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2218262207%22&quot;&gt;18262207)&lt;/searchLink&gt;&lt;br /&gt;BMJ. 2017 Oct 4;359:j4273. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2228978695%22&quot;&gt;28978695)&lt;/searchLink&gt;&lt;br /&gt;Nutrients. 2018 Mar 20;10(3):. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2229558383%22&quot;&gt;29558383)&lt;/searchLink&gt;&lt;br /&gt;Lancet Glob Health. 2013 Aug;1(2):e77-e86. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2225104162%22&quot;&gt;25104162)&lt;/searchLink&gt;&lt;br /&gt;JAMA. 2011 Oct 12;306(14):1566-73. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2221990300%22&quot;&gt;21990300)&lt;/searchLink&gt;&lt;br /&gt;Sci Rep. 2023 Jun 12;13(1):9541. 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(PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2221177506%22&quot;&gt;21177506)&lt;/searchLink&gt;&lt;br /&gt;Am J Clin Nutr. 2018 Apr 1;107(4):566-575. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2229635492%22&quot;&gt;29635492)&lt;/searchLink&gt;&lt;br /&gt;Glob Health Action. 2014 Jun 06;7:23623. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2224909407%22&quot;&gt;24909407)&lt;/searchLink&gt;&lt;br /&gt;Nutrients. 2017 Nov 02;9(11):. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2229099069%22&quot;&gt;29099069)&lt;/searchLink&gt;&lt;br /&gt;Paediatr Child Health. 2004 Oct;9(8):575-598. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2219680490%22&quot;&gt;19680490)&lt;/searchLink&gt;&lt;br /&gt;Am J Psychiatry. 2018 Jul 1;175(7):607-619. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2229558816%22&quot;&gt;29558816)&lt;/searchLink&gt;&lt;br /&gt;J Health Econ. 2021 Sep;79:102490. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2234247127%22&quot;&gt;34247127)&lt;/searchLink&gt;&lt;br /&gt;Public Health Nutr. 2005 Apr;8(2):117-32. (PMID: &lt;searchLink fieldCode=&quot;PM&quot; term=&quot;%2215877905%22&quot;&gt;15877905)&lt;/searchLink&gt;
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  Data: &lt;i&gt;Keywords: &lt;/i&gt;Folic acid supplementation; child development; health equity; quasi-experimental design; socioeconomic status&lt;br /&gt;&lt;i&gt;Local Abstract: &lt;/i&gt;[plain-language-summary] &lt;b&gt;Main findings:&lt;/b&gt; Maternal folic acid supplementation was associated with sex-specific, long-term cognitive and mental health outcomes among girls aged 10–15, with mental health associations exclusively concentrated among those from families with higher-socioeconomic status.&lt;b&gt;Added knowledge:&lt;/b&gt; Leveraging a national programme as a quasi-experimental framework, this study provided evidence that the associations of folic acid supplementation may extend beyond birth defect prevention while revealing that within a complex nutrition and psychosocial environment, universal biomedical interventions risk inadvertently exacerbating socioeconomic inequalities in adolescent mental health when implemented in isolation.&lt;b&gt;Global health impact for policy and action:&lt;/b&gt; Where applicable, policymakers in low- and middle-income countries should consider moving beyond ‘one-size-fits-all’ biomedical approaches by integrating nutrition programmes with targeted psychosocial support, to ensure that the potential benefits of public health investments are shared equitably across socioeconomic groups and in alignment with the Sustainable Development Goals.
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        Value: 10.1080/16549716.2026.2691381
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        Text: English
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    Subjects:
      – SubjectFull: China epidemiology
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      – SubjectFull: Humans
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      – SubjectFull: Female
        Type: general
      – SubjectFull: Child
        Type: general
      – SubjectFull: Male
        Type: general
      – SubjectFull: Adolescent
        Type: general
      – SubjectFull: Rural Population
        Type: general
      – SubjectFull: Pregnancy
        Type: general
      – SubjectFull: Socioeconomic Factors
        Type: general
      – SubjectFull: Folic Acid administration & dosage
        Type: general
      – SubjectFull: Folic Acid therapeutic use
        Type: general
      – SubjectFull: Child Development drug effects
        Type: general
      – SubjectFull: Neural Tube Defects prevention & control
        Type: general
      – SubjectFull: Dietary Supplements
        Type: general
    Titles:
      – TitleFull: The equity and effectiveness of China's 2009 folic acid supplementation programme for long-term child development.
        Type: main
  BibRelationships:
    HasContributorRelationships:
      – PersonEntity:
          Name:
            NameFull: Liang N
      – PersonEntity:
          Name:
            NameFull: Huang C
      – PersonEntity:
          Name:
            NameFull: Pan Q
    IsPartOfRelationships:
      – BibEntity:
          Dates:
            – D: 31
              M: 12
              Text: 2026 Dec 31
              Type: published
              Y: 2026
          Identifiers:
            – Type: issn-electronic
              Value: 1654-9880
          Numbering:
            – Type: volume
              Value: 19
            – Type: issue
              Value: 1
          Titles:
            – TitleFull: Global health action
              Type: main
ResultId 1