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.

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 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.

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.