Health

Objective
Psychological factors shaping maternal diet remain underexplored, particularly in rural contexts. This study examined the associations of psychological symptoms with maternal dietary diversity in rural Western China.

Methods
This cross-sectional study included 2430 women (847 pregnant, 1583 postpartum) selected through multi-stage random cluster sampling. Dietary diversity was assessed using the Woman's Dietary Diversity Score, which was categorized into tertiles. Depression, anxiety, and stress symptoms were measured and integrated into a standardized composite psychological index. Multinomial logistic regression examined associations between psychological symptoms and dietary diversity adjusting for relevant covariates.

Results
In the full sample, using the lowest dietary diversity score tertile as the reference group, depression symptom was associated with lower odds of being in the high dietary diversity group (relative risk ratio [RRR] = 0.71, 95% confidence interval [CI] 0.53–0.95). Anxiety and stress symptoms were associated with lower odds of being in both medium (anxiety: RRR = 0.74, 95% CI 0.58–0.95; stress: RRR = 0.64, 95% CI 0.46–0.89) and high (anxiety: RRR = 0.78, 95% CI 0.61–0.99; stress: RRR = 0.56, 95% CI 0.39–0.79) dietary diversity group. Higher composite index scores were consistently associated with lower odds of being in the medium (RRR = 0.86, 95% CI 0.78–0.95) and high (RRR = 0.83, 95% CI 0.75–0.93) dietary diversity group. Interaction analyses showed significant effects for depression, stress, and the composite psychological index (P for interaction <0.01), but not for anxiety (P for interaction = 0.954).

Conclusion
Psychological symptoms were inversely associated with maternal dietary diversity. Moreover, these associations varied by pregnancy status for depression, stress, and overall psychological distress. Findings support integrating psychological care into maternal nutrition programs in rural settings.

Mental health symptoms are common among caregivers of young children in low-resource settings, yet access to psychological care remains limited due to shortages of specialists, low awareness, and stigma. This qualitative study explored the acceptability and appropriateness of delivering a postnatal mental health intervention for mothers through community and township health centers (CTHCs) in Shanghai, China. We conducted in-depth interviews with 50 mothers of children under 3 years of age, recruited from nine CTHCs and one parenting center, including both those with and without depressive symptoms. Data were analyzed using a rapid analysis approach to identify themes related to perceived values, burdens, motivations, and barriers to participation. Mothers valued interventions that aligned with their personal needs, addressed both parenting knowledge and mental health, offered emotional and social support, and involved family members. Key barriers included time constraints, childcare responsibilities, stigma toward mental health, and accessibility of the location of the intervention. Flexible delivery formats and modes, integration with routine child health services, and nonstigmatizing framing were identified as potential strategies to enhance engagement.

Language development and the home language environment during early childhood are critical for long-term child outcomes. Caregiver mental health may influence early language outcomes directly, but it can also introduce perception bias, which refers to the discrepancies between caregiver self-assessments and the actual status of child language outcomes. This study examines the associations between caregiver mental health symptoms and (1) child language development and home language environment, and (2) caregiver perception bias in self-report assessments of child language development and home language environment. The study recruited 137 rural Chinese households with children aged 16–24 months. Objective measures of child language development and the home language environment were collected using Language Environment Analysis (LENA) technology. Caregiver perception biases were measured by the discrepancies between the objective and caregiver self-report measurements. Results show that caregiver anxiety and stress symptoms were linked to poor child language development, while symptoms of depression and anxiety were associated with less stimulating home language environment. Caregivers with depressive and anxiety symptoms tended to overestimate their children’s language development, and those with depressive symptoms also overestimated their own verbal inputs. These findings call for caution when implementing self-report assessments of early childhood development.

Background: High rates of iron-deficiency anemia among school-age children have been a common issue in developing countries. In 2012, China rolled out a school feeding program (SFP) to address this issue. This study assesses changes in anemia rates, as well as potential factors driving these changes, both 3 and 10 years after the SFP was implemented.

Methods: Data were from two cross-sectional surveys (n = 1510) in northwestern China. T-tests were used to compare the differences in health outcomes of students and their dietary diversity across the different sample years. Regressions were used to examine the associations between health outcomes and dietary diversity.

Results: After the SFP was launched, hemoglobin levels of students improved from 126 to 131 g/L between 2015 and 2022/2023; the rates of anemia and stunting decreased from 17% to 6% and 9% to 1%, respectively. A rise in student dietary diversity and an increase in the share of students that consumed iron-rich foods are two main contributing factors.

Implications for School Health Policy, Practice, and Equity: Increase in funding allotted to the SFP over time appears to be a key element in improving the health and nutrition of rural students.

Conclusions: SFP in rural China exemplifies the concrete advantages in improving the health and potential educational outcomes of students.

Background: Poor mental health affects caregivers' parenting practices and threatens the early development of children under 2 years old. This study examined the correlations between caregivers' mental health and parenting practices among 5- to 24-month-old children in rural China.

Methods: Data were collected in two cohorts (October 2022 and March 2023) from 948 households randomly sampled from 120 villages. Dependent variable: parenting practices measured by the Family Care Indicators (FCI). Independent variables: caregiver mental health (DASS-21), perceived social support (MSPSS) and socioeconomic status (SES; household asset index, caregiver education). Models adjusted for child age, child sex, caregiver age and household size, with standard errors clustered at the village level.

Results: Although caregivers provided more play materials for their children compared to previous research, the variety of play materials did not improve. Depressive symptoms among caregivers were associated with inadequate parenting practices, particularly with providing a lower variety of play materials. Both lower SES and more severe caregiver depressive symptoms were linked to less stimulating parenting, whereas higher perceived social support was associated with more stimulating practices and partially attenuated these SES- and mental health–related disparities.

Conclusion: Although rural Chinese caregivers now supply more play materials, limited diversity and widespread caregiver mental health risks persist. Strengthening caregiver mental health and social support could enrich home stimulation and improve early childhood development.

The connections between bullying and student well-being in rural areas are not well understood, particularly among younger, more vulnerable students. This study aims to explore the relationship between bullying experiences and the academic performance and mental health of primary and junior high school students in rural China. The sample comprised 1609 students from 30 schools (20 primary schools and 10 junior high schools) in Gansu province. A self-report questionnaire was used to collect data on students’ demographics, bullying experiences, mental health, and social support. Additionally, a 30-minute standardized math test was administered to assess academic performance. Results indicated that bullying was prevalent in rural settings, with 42.64% of students reporting being bullied and 12.74% experiencing it weekly. A significant correlation was found between bullying experiences and both lower academic performance and higher risk of mental health problems, such as depression and anxiety. These correlations became more pronounced with increased frequency of bullying incidents. We also found that female students and younger students who were bullied were more likely to report mental health issues. Furthermore, social support could diminish, but not entirely counteract, the adverse associations between bullying and mental health. These findings highlight the prevalence of bullying among rural students in this age group and demonstrate the associated negative outcomes for their mental health and academic performance. They also emphasize the need for targeted attention and the development of intervention programs, including enhanced school-based anti-bullying initiatives and improved social support systems.

Background
Mindfulness-based interventions (MI) have shown efficacy in improving mental health among adults; however, the results for younger populations remain inconsistent Research on this topic in low- and middle-income countries is still limited. This study seeks to address this gap by examining the impact of a mindfulness-based intervention on Chinese migrant youth.

Methods
A randomized controlled trial delivering mindfulness and life skills mentorship to 653 migrant students aged 9 to 17 in China. Quantitative results in depression and anxiety were examined between Mindfulness Training group (MT group, n = 167), the Mindfulness Training plus Life Skill Training group (MT + LS group, n = 118), and Control group (n = 368) using student t-tests and Differences-in-Differences. Qualitative study from 20 interviews was conducted using a semi-structured interview and deductive approach.

Results
Quantitatively, participants in intervention group did not show significantly different anxiety and depression symptoms compared to control groups post intervention. Nevertheless, qualitative data highlighted several key benefits of the mindfulness intervention, including improved emotional regulation and increased social support among participants.

Conclusions
A volunteer-led, two-month mindfulness and life skills intervention with Chinese migrant youth did not yield statistically significant reduction in depression or anxiety symptoms. While no notable quantitative benefits were observed, qualitative findings suggested enhanced application of mindfulness and emotional regulation skills among participants that the quantitative measures failed to capture.

Background
Under-resourced communities in rural China have long faced limitations in accessing and utilising caregiver and child healthcare (CCH). The COVID-19 pandemic exacerbated health inequities globally, while its precise impacts on CCH remain understudied. We report differences in parental migration, maternal mental health, household and nutrition expenditures, child feeding practices, and prenatal, postnatal, and childbirth care following pandemic lockdowns in rural China.

Methods
We compared two groups of families with children who grew to the age of six months either before or during lockdowns. We enrolled eligible households from 80 rural townships, randomly selected from four poverty-designated counties in Sichuan Province, China. We interviewed the control group of primary caregivers in November and December of 2019 (pre-COVID-19), and the case group in May of 2020 (approximately five months into the pandemic). Statistical analyses included t tests and linear regressions with adjustments. P-values <0.05 were considered statistically significant.

Results
Compared to the control group, the case group presented significantly lower paternal migration and more favourable maternal mental health. Caregiving behaviours (including household and nutrition expenditures) and child feeding practices did not differ, except for higher spending on infant micronutrient supplements. Prenatal health services utilisation, including home visits, was slightly higher, while postnatal services utilisation was lower.

Conclusions
Our findings suggest that many aspects of CCH in rural China were similar or improved during the early pandemic lockdowns. These data highlight the importance of promoting targeted public health interventions, such as mental health support initiatives, accessible perinatal care options, and family-centred education campaigns, in under-resourced communities and during future healthcare crises.

Achieving minimum dietary diversity (MDD), a crucial indicator of infant and young child diet quality, remains a challenge in rural China, especially for infants aged 6–11 months. This study examined the rate of MDD attainment in rural China, identified its determinants using the Capability, Opportunity, Motivation, and Behavior (COM-B) model and Bayesian network analysis, and estimated the potential impact of improving each modifiable determinant. A multi-stage sampling design selected 1328 caregivers of infants aged 6–11 months across 77 rural townships in China. Data were collected through a cross-sectional survey via in-person household interviews. Bayesian network analysis identified key factors influencing MDD attainment and their interrelationships, while Bayesian inference estimated MDD attainment probabilities. Results showed that only 22.2 % of the sample infants attained MDD. Bayesian network analysis revealed that caregiver knowledge (a proxy of capability), self-efficacy and habits (proxies of motivation), and infant age directly influenced MDD attainment. Social support (a proxy of opportunity) indirectly promoted MDD attainment by boosting self-efficacy and habit. Notably, simultaneous improvements in knowledge, self-efficacy, and habit could increase MDD attainment by 17.6 %, underscoring the potential effectiveness of interventions focused on enhancing caregiver capability and motivation. The critically low MDD attainment rate among rural Chinese infants highlights the urgent need for targeted interventions. Strategies should prioritize enhancing caregiver feeding knowledge, self-efficacy, and habit formation to improve infant dietary diversity. Addressing these key factors could substantially boost MDD attainment in rural China.

The effects of psychological factors on complementary feeding behavior have been widely described, yet the mechanisms underlying the complex relationships among personality traits, self-efficacy, and complementary feeding behavior remain unclear. This cross-sectional study was conducted using a multi-stage cluster sampling process to select caregiver-child dyads in Western rural China. Personality traits, self-efficacy, and complementary feeding behavior were evaluated respectively. Both multiple logistic regression and Bayesian network structure (BNs) were used to explore these associations. A total of 787 caregiver-child dyads were enrolled. Results from multiple logistic regression indicated that caregivers with medium (OR = 2.05, p < 0.001) or high (OR = 1.58, p = 0.04) levels of extraversion, as well as those with high self-efficacy recording complementary feeding (OR = 2.08, p < 0.001), significantly increased the likelihood of meeting the criteria for the Infant and Child Feeding Index (ICFI) qualification. Further, BNs were employed to elucidate the pathways of influence, revealing a direct association between the caregiver's level of extraversion, level of self-efficacy and the ICFI. Additionally, the analysis indicated that a caregiver's openness indirectly influenced the ICFI through its influence on self-efficacy regarding complementary feeding. This is one of few studies exploring associations between personality traits, self-efficacy, and complementary feeding behavior. The study highlights the importance of understanding individual differences in caregiving and suggests that interventions should focus on enhancing caregivers' self-efficacy, rather than solely targeting personality traits.

Background: Micronutrient powder (MNP or Yingyangbao, a dietary supplement that contains multiple vitamins and minerals) programs can reduce the risk of anemia among children. One such program in China distributed free MNP to children aged 6–24 months in poor rural areas. However, there are indications that the generation of primary caregiver (i.e., parent or grandparent) may influence MNP feeding behavior. The purpose of this study was to investigate the prevalence and influencing factors of effective MNP feeding behavior among parents and grandparents in a rural developing setting.

Methods: We conducted a cross-sectional study of 884 caregivers and children in formerly impoverished rural areas of Sichuan Province using multi-stage random sampling. Data were collected on caregivers’ MNP feeding behavior, their core perceptions and health beliefs about MNP, children’s responses to MNP, MNP delivery patterns, and demographic characteristics. Influencing factors of parents’ and grandparents’ MNP feeding behavior were analyzed using two-level logistic regression.

Results: Total effective MNP feeding behavior rate among caregivers was 40.95%. Grandparents demonstrated higher MNP adoption than parents (χ2 = 4.445, P = 0.035). After controlling for sociodemographic characteristics, grandparents were more likely than parents to achieve effective MNP adoption (OR = 1.360, P = 0.035); child’s preference for MNPs (ORparental subgroup = 1.736, ORgrandparental subgroup = 1.496; P < 0.050) and caregiver’s self-efficacy (ORparental subgroup = 1.157, ORgrandparental subgroup = 1.393; P < 0.050) were influencing factors of feeding behavior for caregivers of both generations. Parents were also influenced by perceived barriers to feeding MNPs (OR = 0.904, P = 0.040), while grandparents were more strongly influenced by child’s discomfort to MNPs (OR = 0.240, P = 0.023) and caregiver’s knowledge about MNPs (OR = 1.557, P = 0.014).

Conclusion: Future efforts to improve the feeding behavior of caregivers in MNP programs both in China and abroad should improve children’s preference for MNP by changing its composition and taste, and increase caregivers’ feeding self-efficacy through health education. Moreover, parents should be taught to cope with time and ability barriers that may limit MNP adoption, while grandparents should be emphasized the importance and potential side effects of MNP.

The diffusion of high-yielding crop varieties has been a key driver for agricultural productivity. This study examines the relationship between the adoption of high-yielding crop varieties of two staple crops—wheat and maize—and infant mortality in rural China. Using data from 1954 to 1987, we find a significant reduction in infant mortality linked to high-yielding crop varieties diffusion, an association that remains robust even after excluding the Great Famine years. We investigate potential mechanisms driving this relationship, including increased grain production, improved infant nutrition, and changes in maternal characteristics. Additionally, our analysis unveils a spectrum of heterogeneous relationships between high-yielding crop varieties adoption and infant mortality across factors such as infant gender, maternal characteristics, and policy regulation. These findings reaffirm the positive and lasting benefits of dissemination of high-yielding crop varieties for human welfare and provide valuable policy insights for developing nations grappling with food and nutritional insecurity.

This study aims to compare the ratings of primary caregivers and teachers of any mental health problems of preschool children in rural China. The primary caregivers and teachers provided their ratings of mental health of 1,191 sample rural preschool children (mean age = 56.8 months; 587 girls) using the Strengths and Difficulties Questionnaire (SDQ). According to the findings, primary caregivers consistently gave their children higher SDQ scores and identified more symptoms across the different categories of mental health problems (i.e., normal, borderline, and abnormal) than teachers. The correlations between the ratings of caregivers and the ratings of teachers were low. The study also identifies the characteristics of children, caregivers, and teacher that were correlated with the differences in the ratings. Specifically, boys, children that were identified by scales of cognitively development as being delayed, and those that parented with authoritarian style were more likely to be rated differently by primary caregivers and teachers. In addition, primary caregivers from relatively poor families rated their children differently from teachers, compared with primary caregivers from relatively rich families. Regarding teachers, they tended to rate on child mental health differently from primary caregivers when they were male or at older age. These findings suggest considering multi-informant reports when assessing the mental health problems of preschool children in different settings. In addition, understanding factors linked to informant discrepancies can potentially improve the accuracy of the assessments.

Background
Despite the benefits of exclusive breastfeeding, the proportion of exclusively breastfed children remains low in rural China. Self-efficacy is one of the most crucial modifiable factors predicting breastfeeding behavior. However, existing instruments in China do not specifically measure self-efficacy for exclusive breastfeeding but rather measure self-efficacy for any breastfeeding. Furthermore, they have been validated only in high-income Chinese settings. We sought to adapt and validate an instrument to measure exclusive breastfeeding self-efficacy within rural Chinese contexts.

Methods
We introduced relevant items to Dennis’ Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF), which can assess maternal self-efficacy for exclusive breastfeeding. It was then implemented in a multistage random cluster sampling design and cross-sectional survey with home-visit interviews among women 0–6 months postpartum (n = 654) in the rural areas of four counties in Sichuan, China. We performed item-total and adjusted item-total correlations, as well as exploratory factor analysis to remove redundant items and determine the latent factor structure. We further applied confirmatory factor analysis to test the dimensionality of the scale. We then assessed the reliability of the scale and conducted tests of predictive and divergent validity. Known group comparisons were made by primiparous status and breastfeeding support level. We compared the validated Exclusive Breastfeeding Self-Efficacy Scale with the BSES-SF in terms of reliability and validity to explore the added value of scale modification.

Results
Our modification of the BSES-SF to target exclusive breastfeeding produced 19 items. This was further reduced to 15 items based on adjusted item-total correlations and exploratory factor analysis, forming the Exclusive Breastfeeding Self-Efficacy Scale. This scale had three dimensions: “Breast milk supply and quality,” “Breastfeeding skills,” and “Exclusive breastfeeding” subscales. The Exclusive Breastfeeding Self-Efficacy Scale demonstrated strong internal consistency and overall reliability with a Cronbach’s alpha coefficient of 0.91. Predictive and divergent validity and known group comparison assessments supported its validity. Robust psychometric evaluations demonstrated enhanced validity and reliability compared to the original BSES-SF.

Conclusions
Our Exclusive Breastfeeding Self-Efficacy Scale is valid and reliable for measuring exclusive breastfeeding self-efficacy within rural Chinese contexts and is ready for adaptation and validation for clinical and programmatic use elsewhere, particularly within LMICs.

Purpose: Depression is a growing public health concern around the world. For adolescents, depression not only impedes healthy development, but is negatively associated with academic performance. The purpose of this paper is to examine the prevalence of adolescent depressive symptoms in a sample of rural primary and junior high school students. Additionally, we examine various factors to identify subgroups within the sample that may be more vulnerable to depression. Finally, we explore the extent to which depression correlates with academic performance and conduct a series of heterogeneity analyses.

Patients and Methods: We utilize cross-sectional data derived from 30 schools in underdeveloped regions of rural China encompassing primary and junior high school students (n = 1,609).

Results: We find a high prevalence of depression, with 23% and 9% of students experiencing general depression (depression score ≥ 14) and severe depression (depression score ≥ 21), respectively. Female gender, elevated stress and anxiety levels, boarding at school, exposure to bullying, and having depressed caregiver(s) are positively correlated with depressive symptoms, while high social support exhibits a negative association. Importantly, our analyses consistently show a significantly negative link between depression and academic performance, which is measured using standardized math tests. For instance, transitioning from a non-depressed state to a state of general depression (depression score ≥ 14) is linked to a decline of 0.348– 0.406 standard deviations in math scores (p < 0.01). Heterogeneity analyses reveal that this adverse relationship is more pronounced for male students, boarding students, those with lower social support, individuals with more educated mothers, and those with lower family assets.

Conclusion: Our findings underscore the high prevalence of depression in rural schools and the detrimental impact on academic performance. We advocate for the implementation of policies aimed at reducing student depression, particularly within vulnerable populations and subgroups.

Cognitive and social-emotional development in the first three years of life is associated with later skills. However, little is known about the paths of developmental delays in both cognitive and social-emotional skills before age 3 or to what extent these paths predict later developmental outcomes. The aim of this study is to examine the associations between the different paths of developmental delays in both cognitive and social-emotional skills of children before age 3 and the levels of development of the children when they are preschool age. Using a longitudinal data collected at three time points from 1245 children and their caregivers in rural China, we identified four different paths of developmental delays in cognitive and social-emotional before age 3 and examined how these paths are associated with different levels of developmental outcomes at preschool age. We used a non-parametric standardization approach and an ordinary least squares model to perform our analyses. Findings show that rates of developmental delays in either cognitive or social-emotional domain or both domains are high at all different time points, ranging from 20% to 55% for cognitive delays and 42% to 61% for social-emotional delays. Over half of children experienced deteriorating levels of either cognitive or social-emotional development before age 3. A large share of children was found to be persistently delayed in either domain. Only a small share of children raised their levels of development in either domain before age 3. In addition, we identified certain socioeconomic status of the family that are associated with never or deteriorating path of child developmental delays. More importantly, we revealed that different paths of developmental delays before age 3 have predictive power on different levels of developmental outcomes at preschool age. Our results suggest that actions are needed at the earliest times to improve child development when children are still infants or toddlers.

Background: The association between sleep patterns and young students’ mental health, which is crucial for their development, remains understudied in rural China. Therefore, the relationship between sleep patterns and mental health among primary and junior high school students in rural China was examined. Method: A total of 1592 primary and junior high school students from rural areas of Gansu Province were surveyed, and the Depression Anxiety and Stress Scale (DASS) was utilized to assess mental health, alongside self-reported data on their daily sleep patterns. Results: Significant sleep inadequacies were identified: 28% of students received less than 8 h of sleep on weekdays, and 19% went to bed later than recommended. On weekends, 38% of students had delayed bedtimes, though only 7.2% received less than 8 h of sleep. Notably, a “U-shaped” relationship was uncovered between sleep duration and mental health for students on weekends, with optimal mental health correlated with receiving 10–11 h of sleep, while both shorter and longer sleep durations on weekends worsened outcomes. This pattern is absent on weekdays. Additionally, adequate sleep and an earlier bedtime was linked to a 6–8% decrease in mental health risks. Conclusions: These findings provide valuable insights for policymakers seeking to enhance student mental well-being in rural settings, emphasizing the importance of implementing measures that promote balanced sleep habits among young students.

Purpose
China’s rapid urbanization has been associated with increased mental health challenges, especially in rural-to-urban migrant children. This study evaluates the effects of mindfulness and life-skills (LS) training on emotional regulation and anxiety symptoms from a randomized controlled trial aimed at improving the mental health of Chinese migrant children.

Methods
Two intervention arms—mindfulness training (MT) and MT plus LS mentorship (MT + LS)—were compared to a waitlist control group of 368 migrant children aged 9–17 years. Volunteers were trained to deliver interventions to 285 migrant children in small groups of 15 for eight weeks weekly. Social integration varied: migrant children mixed with local children at public schools were considered highly integrated, those in migrant-only classrooms at public schools had intermediate levels of integration, and children in private migrant schools had low integration. Emotion regulation and anxiety symptoms were assessed preintervention, postintervention, and three months postintervention.

Results
Postintervention and compared to the control group, children with high social integration in the MT arm showed increased cognitive reappraisal ability (p < .05) but higher physical anxiety (p < .01). Children with high social integration in the MT + LS arm had lower anxiety symptoms of harm avoidance (p < .01) and physical anxiety (p < .05). Children with low social integration in the MT + LS arm showed lower cognitive reappraisal (p < .01) and poorer overall emotion regulation abilities (p < .01). Three months later, children with intermediate integration in the MT + LS arm had lower separation anxiety (p < .05) and harm avoidance anxiety (p < .05). No other groups showed significant improvements in emotion regulation or reducing in anxiety symptoms three months postintervention.

Discussion
Mindfulness and LS training may benefit Chinese migrant children who have higher levels of social integration but increase anxiety in those with lower social integration. Future research should consider the sociocultural context in which a treatment is implemented.

Childhood is a crucial period of psychological and social development, rendering individuals susceptible to developing mental health issues. Unfortunately, many countries around the world, including China, are facing a shortage of child psychiatrists, which is a significant concern. This Comment was conducted to clarify the current number of child psychiatrists in mainland China, to analyze the reasons for the shortages and to provide constructive suggestions for solving the current shortage.

Background
Comorbidity in mental disorders is prevalent among adolescents, with evidence suggesting a general psychopathology factor (“p” factor) that reflects shared mechanisms across different disorders. However, the association between the “p” factor and protective factors remains understudied. The current study aimed to explore the “p” factor, and its associations with psycho-social functioning, in Chinese adolescents.

Methods
2052 students, aged 9–17, were recruited from primary and secondary schools in Shanghai, China. Multiple rating scales were used to assess psychological symptoms and psycho-social functioning. Confirmatory factor analysis was conducted to verify the fit of models involving different psychopathology domains such as externalizing, internalizing, and the “p” factor. Subsequently, structural equation models were used to explore associations between the extracted factors and psycho-social functioning, including emotion regulation, mindful attention awareness, self-esteem, self-efficacy, resilience, and perceived support.

Results
The bi-factor model demonstrated a good fit, with a “p” factor accounting for 46 % of symptom variation, indicating that the psychological symptoms of Chinese adolescents could be explained by internalizing, externalizing, and the “p” factor. Psychologically, a higher “p” was positively correlated with emotion suppression and negatively correlated with mindful attention awareness, emotion reappraisal, self-esteem, and resilience. Socially, a higher “p” was associated with decreased perceived support.

Limitations
Only common symptoms were included as this study was conducted at school. Furthermore, the cross-sectional design limited our ability to investigate causal relationships.

Conclusions
A “p” factor exists among Chinese adolescents. Individuals with higher “p” factor levels were prone to experience lower levels of psycho-social functions.

Background: Maternal empowerment - the capacity to make decisions within households - is linked to better child feeding and nutritional outcomes, but few studies have considered the mediating role of caregiver knowledge. Further, existing literature centres primarily on the husband-wife dyad while overlooking grandmothers as important childcare decision-makers.

Methods: We collected primary data through household surveys in 2019 and 2021 from 1190 households with infants zero to six months living in rural western China. We identified the primary and secondary caregivers for each infant and assessed their feeding knowledge and practices, as well as infant nutritional status. We constructed a maternal empowerment index using a seven-item decision-making questionnaire and examined the relationship between maternal empowerment in childcare and household decisions, caregivers' feeding knowledge, and infant feeding practices and nutritional outcomes.

Results: Mothers had significantly higher levels of feeding knowledge than secondary caregivers (most were grandmothers, 72.7%), with average knowledge scores of 5.4 vs. 4.1, respectively, out of 9. Mothers and secondary caregivers with higher levels of feeding knowledge had significantly higher exclusive breastfeeding rates by 13-15 percentage points (P < 0.01) and 11-13 percentage points (P < 0.01), respectively. The knowledge of secondary caregivers was even more strongly associated with not feeding formula (15 percentage points, P < 0.01). Mothers empowered to make childcare decisions were more likely to exclusively breastfeed (12-13 percentage points, P < 0.01), less likely to formula feed (9-10 percentage points, P < 0.05), and more likely to have children with higher Z-scores for length-for-age (0.32-0.33, P < 0.01) and weight-for-age (0.24-0.25, P < 0.05). Effects remained after controlling for maternal feeding knowledge.

Conclusions: While mothers' and grandmothers' feeding knowledge was both important for optimal infant feeding, grandmothers' knowledge was particularly critical for practicing exclusive breastfeeding. Given the disparity in feeding knowledge between the two caregivers, our study further shows that mothers empowered in childcare decision-making were more likely to exclusively breastfeed their infants. This implies that some mothers with adequate knowledge may not practice optimal feeding because of lower decision-making power. Overall, our study highlights the role of secondary caregivers (grandmothers) in infant care and suggests that future child nutritional interventions may benefit from involving secondary caregivers (grandmothers).

Background: To explore the associations between anxiety and depression symptoms and academic burnout among children and adolescents in China, and to examine the role of resilience and self-efficacy in addressing academic burnout.

Methods: A total of 2,070 students in grades 4–8 were recruited from two primary and three middle schools in Shanghai, completed the Elementary School Student Burnout Scale (ESSBS), the Multidimensional Anxiety Scale for Children-Chinese (MASC-C), the Center for Epidemiological Studies Depression Scale (CES-D), the Connor-Davidson Resilience Scale (CD-RISC), and the General Self-Efficacy Scale (GSES), with 95.04% effective response rate. Multivariable regression analyses examining the associations between anxiety / depression symptoms and academic burnout (as well as the associations between resilience / self-efficacy and academic burnout) were performed using STATA 16.0 and SmartPLS 3.0.

Results: Anxiety symptoms (β = 0.124, p < 0.01) and depression symptoms (β = 0.477, p < 0.01) were positively correlated with academic burnout. Resilience partially mediated the association between depression symptoms and academic burnout (β = 0.059, p < 0.01), with a mediation rate of 12.37%. Self-efficacy partially mediated the associations between anxiety symptoms and academic burnout (β = 0.022, p < 0.01) and between depression symptoms and academic burnout (β = 0.017, p < 0.01), with mediation rates of 17.74% and 3.56%, respectively. Resilience and self-efficacy together (β = 0.041, p < 0.01) formed a mediating chain between depression symptoms and academic burnout, with a mediation rate of 8.6%.

Conclusions: Anxiety and depression symptoms were positively associated with academic burnout. Resilience and self-efficacy were found to mediate the associations partially.

Background
Mental health problems among children at preschool age are a common issue across the world. As shown in literature, a caregiver’s parenting style can play a critical role in child development. This study aims to examine the associations between a caregiver’s parenting style and the mental health problems (or not) of their child when he/she is at preschool age in rural China.

Methods
Participants were children, aged 49 to 65 months, and their primary caregivers. The primary caregivers of the sample children completed the Parenting Styles and Dimensions Questionnaire, Short Version, the Strengths and Difficulties Questionnaire, and a questionnaire that elicited their socio-demographic characteristics. The level of cognitive development of each sample child was assessed using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition. Pearson correlation analysis, linear regression analysis, and multivariable regression analysis were used to analyze the data.

Results
The prevalence of mental health problems among sample children at preschool age was high (31.6%). If a caregiver practices an authoritative parenting style, it was found to be negatively associated with the mental health problems of their child. In contrast, a caregiver’s authoritarian parenting style was positively associated with the mental health problems of their child. Compared to those in a subgroup of primary caregivers that used a combination of low authoritative and low authoritarian parenting style, primary caregivers that used a combination of high authoritarian and low authoritative or a combination of high authoritative and high authoritarian were found to have positive association with child health problems. A number of demographic characteristics were found to be associated with the adoption of different parenting styles.

Conclusion
Different parenting styles (including authoritative, authoritarian, and combination of authoritative and authoritarian) of the sample caregivers had different associations with the mental health problems of the sample children. Parenting programs that aim to improve the parenting styles (favoring authoritative parenting styles) should be promoted in an effort to improve the status of child mental health in rural China.

Objectives
Patient satisfaction is an essential indicator of the doctor-patient relationship. This study aimed to investigate the relationship between primary care quality and patient satisfaction for non-communicable diseases (NCDs) in rural western China.

Methods
The study utilized the standardized patients (SPs) approach to present typical symptoms of unstable angina and diabetes to rural healthcare providers. After the consultations, the SPs completed a satisfaction survey. Ordinary least squares and quantile regression were used to examine the association between quality of primary care and patient satisfaction.

Results
We examined 178 anonymous SPs visits. The results showed that higher process quality for angina SPs was correlated with stronger satisfaction for provider ability at a low quantile of ability satisfaction. For diabetes SPs, higher process quality increased overall satisfaction at a low quantile of overall satisfaction, whereas a correct diagnosis significantly contributed to communication satisfaction at a high quantile of communication satisfaction.

Conclusions
The study found positive associations between process and diagnosis quality and SPs satisfaction. Notably, the influence of process quality was most significant among patients with lower satisfaction levels.

Background
Poor development of young children is a common issue in developing countries and it is well established that iron deficiency anemia is one of the risk factors. Research has shown that iron deficiency is a common micronutrient deficiency among children in rural China and can result in anemia. A previous paper using data from the same trial as those used in the current study, but conducted when sample children were younger, found that after 6 months of providing caregivers of children 6–11 months of age free access to iron-rich micronutrient powder (MNP) increased the hemoglobin concentrations (Hb) of their children. However, no effects were found 12 and 18 months after the intervention. The current study followed up the children four years after the start of the original intervention (when the children were 4–5 years old) and aims to assess the medium-term impacts of the MNP program on the nutritional status of the sample pre-school-aged children, including their levels of Hb, the prevalence of anemia, and the dietary diversity of the diets of the children.

Methods
At baseline, this study sampled 1,802 children aged 6–11 months in rural Western China. The intervention lasted 18 months. In this medium-term follow-up study that successfully followed 81% (n = 1,464) of children (aged 49–65 months) from the original study population 4 years after the start of the intervention, we used both intention-to-treat (ITT) effect and average treatment on the treated effect (ATT) analyses to assess the medium-term impacts of the MNP distribution program on the nutritional status of sample children.

Results
The ITT analysis shows that the MNP intervention decreased the prevalence of anemia of young children in the medium run by 8% (4 percentage points, p < 0.1). The ATT analysis shows that consuming 100 (out of 540) MNP sachets during the initial intervention led to a decrease in anemia of 4% (2 percentage points, p < 0.1). Among children with moderate anemia at baseline (Hb < 100 g/L), the intervention reduced the probability of anemia by 45% (9 percentage points, p < 0.1), and, for those families that complied by consuming 100 (out of 540) sachets, a 25% (5 percentage points, p < 0.05) reduction in the anemia rate was found. The MNP intervention also led to a persistent increase in dietary diversity among children that were moderately anemic at baseline. The results from the quantile treatment effect analysis demonstrated that children with lower Hb levels at baseline benefited relatively more from the MNP intervention.

Conclusions
The findings of the current study reveal that the MNP intervention has medium-term effects on the nutritional status of children in rural China. The impacts of the MNP program were relatively higher for children that initially had more severe anemia levels. Hence, the implications of this study are that programs that aim to increase caregiver knowledge of nutrition and improve their feeding practices should be encouraged across rural China. Families, policymakers, and China’s society overall need to continue to pay more attention to problems of childhood anemia in rural areas. This is particularly crucial for families with moderately anemic children at an early age as it can significantly contribute to improving the anemia status of children across rural areas of China.