Publications

Maternal mental health issues are pervasive in rural China, yet community-based interventions are scarce. To address this gap, we developed the Thinking Healthy Extended Program, a nonspecialist-led intervention designed to promote mental health among female caregivers of children under the age of three, including mothers and grandmothers, in resource-constrained areas of China. Drawing on an adapted Stages of Implementation Science framework, this study describes the Exploration and Installation phases of a four-phase intervention development process. During the Exploration phase, we assessed caregivers’ mental health needs and preferences for intervention delivery through in-depth interviews. The Installation phase comprised three stages: developing the overall curriculum structure, identifying and validating curriculum topics, and integrating these topics into a comprehensive curriculum based on feedback from interviews, focus group discussions, and cognitive walkthroughs. The development process took place from 2022 to 2024 in a prefecture in southwestern China and involved 73 caregivers of children aged 6-36 months. The resulting 24-session curriculum integrates simplified cognitive reframing techniques, behavioral activation, caregiving skills, and peer support. This study demonstrates the feasibility of a systematic and participatory approach to developing a mental health intervention for low-resource populations.

In rural China, there is an urgent need for investment and innovative approaches for addressing adolescent mental health issues. This embedded mixed-methods study examines the effectiveness of a social-emotional learning (SEL) program in rural primary schools across China and the factors affecting compliance among teachers delivering the program. Pre- and post-intervention surveys assessed its effect on 2027 students in 49 schools, and 38 teachers were interviewed during the intervention. Results show that SEL courses improved student mental health. Some teachers reported increased workload and lack of support, while others noted the importance of mental health education and positive student outcomes. Performance incentives and the positive perceptions of SEL among teachers were crucial for effective delivery, though workload and lack of support often limited commitment. Overall, enhancing rural students' well-being through SEL programs requires raising awareness for SEL among teachers and building institutional support.

This study examines how center-based parenting interventions aimed at improving early child development in rural China affect the mental health of caregivers. Data from an analytic sample of 615 caregiver–child dyads (children aged 6 to 24 months, 48.5% girls; data collection: 2015–2017) in a 2-year cluster randomized controlled trial conducted in 100 villages showed that the intervention had no significant effect on caregiver depressive (β = − .047, SE = .079), anxiety (β = .040, SE = .076), or stress (β = .032, SE = .081) symptoms. Subgroup analyses found no significant difference in effects on mental health by prespecified characteristics after adjustment for multiple comparisons, except that the caregivers of children without social–emotional delay at baseline exhibited lower depression scores after the intervention (β = − .205, SE = .097, p = .043). The findings suggest that the center-based parenting intervention focused solely on strengthening parenting skills may be insufficient to improve caregiver mental health over 2 years.

Objectives
Considering the importance of caregiver mental health for early childhood development, this study investigates risk and protective factors of mental health of mothers and grandmothers caring for infants and toddlers in rural China.

Methods
Using survey data from 777 primary caregivers of children aged 5 to 25 months, we apply regression analysis and structural equation modeling to examine associations between social support, mental health literacy, parenting-related hardships, and mental health among mothers and grandmothers.

Results
The study finds that 33% of the caregivers report symptoms of mental health problems, with grandmothers experiencing more severe symptoms. Poor caregiver mental health is associated with lower child language (p < 0.05) and social-emotional development (p < 0.001). Social support and mental health literacy are associated with better mental health, but this association was not statistically significant among either the mothers or the grandmothers alone.

Conclusions
Enhancing caregiver mental health is crucial for children’s development. Social support and mental health literacy are predictors of mental health. Future research should examine the effect of improving social support and mental health literacy on the mental health of caregivers for young children.

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.

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.