REAP Publications

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.

Purpose: Previous research has found an association between with early childhood development (ECD) and paternal beliefs and evidence suggests that paternal beliefs about their own role in child rearing might affect parental involvement. However, there has been no such empirical study in rural China. This study examines the interrelationships among paternal beliefs, parental involvement and ECD among rural Chinese children.

Design/methodology/approach: Data used for this study were collected from 6-to-42-month-old children and their primary caregivers in southwestern China in 2020. ECD was assessed by the Bayley Scales of Infant and Toddler Development-III. Paternal beliefs were assessed with the Role of the Father Questionnaire. The non-parametric regression methods were used to construct the factor scores of ECD. The ordinary least squares models, the mediation models and the bootstrapping approach were employed to investigate the interrelationships of paternal beliefs, parental involvement and ECD.

Findings: A large share of the sample children displayed delays in cognitive, language and social-emotional development. Paternal involvement significantly mediated the link between paternal beliefs and child cognitive and social-emotional development, while maternal involvement mediated the associations between paternal beliefs and child language and social-emotional development.

Originality/value: This study provides a unique contribution by utilizing unique data fathers' beliefs and their involvement in parenting to investigate the underlying mechanisms of how the role of fathers in parenting can lead to the improvement of early child developmental outcomes. This study also provides the first empirical evidence on the role of paternal beliefs in fostering human capital formation during the early stages of life in rural China. This study suggests that shifting paternal beliefs and improving parental involvement are effective pathways to benefit rural children in their early development.

The massive flow of migrants from rural to urban areas in China over the past decades has sparked concerns about the development of left-behind children. Drawing on a six-round, longitudinal cohort survey in rural China from 2013 to 2023 that follows children from 6 months to 11 years of age, we analyse the effects of two maternal migration patterns – persistent migration (migration without return) and return migration (migration followed by return) – on the cognitive development and nutrition of left-behind children from infancy to early adolescence. The results show that persistent maternal migration has adverse effects on the cognitive development and increased the BMI of left-behind children. In contrast, maternal migration had no significant effect on either cognitive development or any indicator of nutrition when the mother later returned. Persistent maternal migration had a strong, long-term negative effect on the cognitive development of left-behind children especially when mothers migrate within one or one and a half years after childbirth; maternal migration also had a short-term, negative effect on cognitive development when mothers migrate when the child is between 2 and 3 years old. These effects are likely driven by the lower levels of stimulating parenting practices and dietary diversity provided by the stand-in primary caregivers of left-behind children.

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.

China’s urbanization has created growing peri-urban communities, where children face challenges to early childhood development (ECD) despite proximity to developed urban areas. Little is known about how the environmental factors of ECD differ between rural migrants and new urban residents. To address this, we sampled 77 peri-urban households with 18–24-month-old Han Chinese children to examine the associations between early cognitive and language development, parental self-efficacy, stimulating parenting practices, and the home language environment measured with Language Environment Analysis (LENA). We find that rural migrants and new urban residents exhibited no significant difference in any child or household characteristic except parental residency. There was no significant difference in the family environment factors or early cognitive or language development, either. However, parental self-efficacy and stimulating parenting practices both predicted better cognitive and language development in rural migrant households, whereas only conversation turn counts predicted better language development in new urban resident households.

Background
The quality of parenting can affect the developmental outcomes of young children. This study aims to investigate the associations between parenting quality and the early childhood development of children under age 3 across four major rural subpopulations in China.

Methods
Using a stratified cluster sampling method, 760 children aged 6–36 months and their primary caregivers in four rural subpopulations from four provinces and a metropolis in China were surveyed. Child development was assessed by the Third Edition of the Bayley Scales of Infant and Toddler Development. Parenting quality was measured using the Family Care Indicators. Data were analyzed using descriptive statistics, t-tests, multivariable regression analysis, and linear regression analysis.

Results
Across the four subpopulations, prevalences of delays of the sample children in four domains — cognition, language, social-emotional, and motor development are 52%, 45%, 52%, and 19%, respectively. The proportion of children with any type of delay is 82%, while over half (53%) have delays in at least two areas, and 27% have delays in three or more areas. Child’s mother as the primary caregiver, maternal education levels, and family asset values are all positively associated with the quality of parenting. Notably, low levels of parenting quality in rural China are linked to high rates of developmental delays.

Conclusions
This study demonstrates that the level of parenting quality is significantly associated with early childhood developmental outcomes. Results highlight the need for raising investments in family care to improve early childhood development in different rural subpopulations in China.

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.

The number of acutely food insecure people worldwide has doubled since 2017, increasing demand for early warning systems (EWS) that can predict food emergencies. Advances in computational methods, and the growing availability of near-real time remote sensing data, suggest that big data approaches might help meet this need. But such models have thus far exhibited low predictive skill with respect to subpopulation-level acute malnutrition indicators. We explore whether updating training data with high frequency monitoring of the predictand can help improve machine learning models’ predictive performance with respect to child acute malnutrition by directly learning the dynamic determinants of rapidly evolving acute malnutrition crises. We combine supervised machine learning methods and remotely sensed feature sets with time series child anthropometric data from EWS’ sentinel sites to generate accurate forecasts of acute malnutrition at operationally meaningful time horizons. These advances can enhance intertemporal and geographic targeting of humanitarian response to impending food emergencies that otherwise have unacceptably high case fatality rates.

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.

Background: The content of children’s screen exposure and interactive coviewing with caregivers are important determinants of early childhood development (ECD) that have been overlooked in past research in resource-limited rural regions. Given the prevalence of digital devices and diverse digital content today, determining screen use practices that minimize the negative impacts on children’s development is crucial for promoting healthy screen use among children.

Objective: This study aims to examine screen exposure among children aged <3 years in rural China and investigate its relationship with ECD outcomes, focusing on duration, content, coviewing, and interaction.

Methods: The sample includes all children aged between 6 and 26 months and their primary caregivers residing in the study area. A survey of screen exposure and household characteristics was conducted for 1052 eligible households. Caregivers reported the duration of screen exposure, defined as the average daily screen time over the past month; the content of exposure, defined by the time spent on educational and child-friendly content; and the caregiver’s presence and interaction with the child during exposure. ECD outcomes were evaluated using the third edition of the Bayley Scales of Infant and Toddler Development assessment scale and the Brief Infant Toddler Social Emotional Assessment. Ordinary least squares regression, logistic regression, and chi-square tests were conducted.

Results: In total, 28.23% (297/1052) of the children in our sample were first exposed to screens before the age of 12 months. Children exposed to screens had an average daily screen time of 27.57 (SD 38.90) minutes. Children who were exposed to screens before the age of 12 months and those who had longer screen time between the ages of 12 and 18 months were more likely to be at risk of motor developmental delays. Children exposed to educational content for >15 minutes on a daily basis had fewer social-emotional or behavioral problems than those with no screen exposure and a lower risk of delay in motor skills development than those exposed to educational content for <15 minutes on a daily basis. Caregiver interaction during screen exposure was associated with a lower risk of cognitive and language delays and better socioemotional skills.

Conclusions: The type of content viewed and how caregivers engaged in children’s screen time were strongly associated with ECD outcomes. Guiding parents to select educational content for their children and engaging in interactive coviewing may better protect children from the negative effects of screen exposure. The findings complement conclusions regarding the impact of screen exposure on ECD in resource-limited rural areas.

Using reading performance data from a randomized controlled trial of 5224 fifth-grade students in East China, this paper provides a novel test of the hypothesis that evoking a gender stereotype creates gender gaps in education through self-fulfilling prophecies. We found that without intervention, boys performed worse than girls did in reading tests. Evoking a gender stereotype by indicating the expected outperformance of girls over boys in reading had a significantly negative effect on boys and an insignificant effect on girls. As a result, the net effect on the gender gap in reading performance was economically important but statistically insignificant. We also found evidence that increased anxiety was likely the underlying mechanism. Finally, a heterogeneous analysis showed that boys from environments with biased gender role beliefs were more susceptible to the intervention.

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.

This paper examines whether education can play a role in mitigating gender inequality in the process of sectoral reallocation of labour. We exploit the exogenous variations in educational attainment induced by the implementation of the 1986 Compulsory Education Law (CEL) in China. Using data from the 2018 wave of the China Family Panel Studies (CFPS) and a cohort difference-in-differences (DID) approach, we find that the CEL narrowed the gender gap in education for rural residents, but it did not reduce gender inequality in labour market outcomes, such as wage labour participation and wage rate. Our analysis reveals that this persistent inequality in labour market outcomes can be attributed to gender differences in migration and occupational choices. Specifically, rural males exposed to the CEL were more likely to migrate outside local provinces and work in low-skilled manufacturing sectors, while rural females tended to stay within local counties and work in low-skilled service sectors. Furthermore, we provide evidence that their differential migration responses are driven by household labour divisions and social gender norms, rather than disparities in cognitive skills.

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.

Despite investments in teacher education programs, teacher shortages persist in rural areas of many low- and middle-income countries. Using data from 1860 tuition-free students, we examine factors influencing enrollment in China's Tuition-Free Normal Education (TNE) program and their implications for teacher recruitment and retention in rural schools. Descriptive analysis and OLS regression reveal that TNE students mostly come from larger, poorer families, and enroll for job security and financial benefits. Many aspire to teach but resist rural placements, risking non-compliance. These findings can guide the design and reform of programs to attract qualified teachers to rural areas in China and abroad.

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.

Against the backdrop of China’s post-1978 economic transformation, recent challenges such as COVID-19 have prompted speculations about rising popular pessimism regarding current inequalities and opportunities to get ahead. This study compares findings from three new nationally representative surveys conducted in 2023 with three earlier surveys from 2004, 2009, and 2014. Results reveal a significant attitudinal shift, with 2023 respondents expressing markedly more critical views about the fairness of current inequality patterns. Respondents in the 2023 surveys increasingly attribute poverty versus wealth to structural factors like unequal opportunities rather than to variations in individual merit. Respondents also reported lower expectations for future income growth compared with the earlier surveys. While not indicating imminent threats to political stability, such trends suggest that China’s leaders will likely face increasing skepticism and even critical popular responses as they try to mobilize their citizens to confront the serious challenges that China faces in coming years.

Purpose: This mixed-methods study examined how differences in parental time, knowledge, and economic constraints, as well as community socioeconomic contexts, may contribute to differences in home language environment and child language ability outcomes between peri-urban and rural households in China.

Method: We conducted an explanatory sequential mixed-methods analysis using data from 158 children aged 18–24 months among peri-urban and rural households with low socioeconomic status (SES) in southwestern China. Audio recordings were collected from each household and analyzed using the Language ENvironment Analysis system. The Mandarin version of the MacArthur–Bates Communicative Development Inventories was administered to each child's primary caregiver. We also conducted qualitative interviews with primary caregivers in 31 peri-urban and 32 rural households. Interviews were recorded, transcribed, and coded.

Results: The quantitative results reveal that children in peri-urban households heard less adult speech and had lower language ability than children in rural households. Directed content analysis of interviews found that peri-urban caregivers faced more severe time constraints and less favorable community socioeconomic contexts than rural primary caregivers. Taken together, these findings suggest that differences in time constraints and community socioeconomic contexts between the two populations are the most likely factors contributing to the inferior language environment and language ability among children in peri-urban households.

Conclusion: The mixed-methods study indicated that parental time constraints and community socioeconomic contexts should be considered alongside SES for a comprehensive understanding of factors influencing parental investment in the home language environment in China.

The literature has shown that cognitive and non-cognitive development before the age of three is associated with children’s levels of development at later ages. However, the extent to which the different pathways of cognitive and non-cognitive development before age three (between 6–12 months and 22–30 months of age) are associated with developmental outcomes at primary school age remains unknown. This study aims to examine this research question using three waves of longitudinal data collected from 1087 children aged 9 to 10 years and their primary caregivers in rural China. Results demonstrated four pathways of cognitive and non-cognitive development between 6–12 months and 22–30 months of age. The four pathways include: “never delayed”, “persistently delayed”, “improving”, or “deteriorating.” Children that experienced either persistently delayed or deteriorating development had lower levels of cognitive and non-cognitive development and performed worse academically than children that were never delayed when they were 9–10 years old. Maternal education attainment, family assets, and whether the child was born prematurely all predicted the child’s entry into different developmental pathways. Findings suggest that early childhood development screening and interventions that aim to facilitate healthy early development among children under three years old are needed for rural China’s young children.

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.

Using a longitudinal data set developed from surveys of 1,285 children (and their families), as well as 683 preschools teachers in 382 preschools in rural western China, we examined the association between preschool quality and the development (cognitive and social-emotional skills) of preschool children. The findings showed that 55 % of the sample children were cognitively delayed, and 49 % of the children were social-emotionally delayed at age 3. The rates of delay decreased to less than 40 % when the children were at preschool age. Although other factors were associated with the decline in development delays, according to the findings, preschool attendance respectively led to an improvement of 0.47 SD (p = 0.001) in child cognitive development (i.e., the fall in delays). More specifically, the global quality and the structural quality of preschools improved child cognitive development by 0.11 SD (p = 0.001) and 0.09 SD (p = 0.004), respectively. The findings of the subgroup analyses suggested that children from disadvantaged backgrounds benefited more from being able to attend quality preschools. Preschool quality also helped to improve developmental outcomes (cognitive abilities and social-emotional skills): for children that were developmentally delayed before age 3, but not for those children that were not delayed when they were 3 years old; for children with lower educated parents, but not for those with more highly educated parents; for children that were from relatively poor families, but not for those that were from relatively rich families; and for children that were attending preschools in rural areas, but not for those who were attending a preschool in an urban area.

In rural China, there exists a gender gap in academic achievement where girls outperform boys, suggesting similar differences in early language development. Moreover, recent research has revealed that children in peri-urban communities have worse language outcomes than children in rural communities. This study examines the impact of gender on early language development in low-SES, peri-urban Chinese communities. Data from 81 children (56.79% boys) aged 18-24 months (Mage = 21.16) living in peri-urban China were collected using two caregiver-reported tests for child language development and ability, and language environment analysis technology for measuring the home language environment. Results show that in peri-urban communities, girls were generally exposed to more adult-child conversations and showed higher counts of vocalizations than did boys; girls scored higher on language development measures than did boys. The implications of these findings on the gender gap and child development are discussed.