In this report, we reported quality of care in surveyed areas in China; we observed socioeconomic classifications were associated with availability of children’s books and playthings and age were associated with quality of care; we found that availability of children’s books, playthings and support for learning had negative associations with SDD and better quality of care was a protective factor for SDD.
Quality of care
Quality of care is one of the crucial areas about measuring early childhood development. Overall, when compared to available data of UNICEF (Last update: November 2017) [
7], the quality of care in our surveyed areas was in the middle to upper level, but it still had scope for improvement. For example, the proportion of availability of children’s books in Belarus was as high as 92.0%, while it was only 36.8% in our surveyed areas. Additionally, father’s support for learning was as low as 16.4% in our surveyed areas, which had gaps with many countries (84.9% in Qatar, for instance).
In the field of public health, development of effective intervention strategies requires an understanding of high-risk populations. We compared the different status of quality of care by gender and socioeconomic classification, which can help to identify vulnerable groups. Gender, as an important demographic characteristic, may play a role in quality of care. For example, a previous study has reported family members show more preference to, give attention to, talk to and interact more with boys than girls in Ethiopia or other African countries [
17]. Traditional concept of Chinese child-rearing behaviors was “son preference”, which meant caregivers tended to give boys preferential treatments than girls. In our study, we found that gender had no impact on the quality of care, and girls got equal opportunities to learn, play and develop. Researchers have revealed that poverty is associated with a mass of health problems of children, parental stress and strains in parent–child relationships [
18‐
20]. For example, extreme poverty was strongly linked to restricted learning opportunities and inadequate stimulation at home [
17]. We observed positive associations between socioeconomic classifications and availability of children’s books and playthings. Therefore, it might be suggested that future intervention could focus on the poor children.
The most common way of support for learning in our surveyed areas was taking children outside, and the rates of telling stories and reading books were at a relatively low level. The possible explanation was that caregivers (e.g., elder ones and illiterate ones) lacked the perceptions and skills of telling stories and reading books. In this context, caregivers would be at the core of the intervention. Future intervention programme should highlight the significance and skills about early child development to caregivers and help them to overcome obstacles. Health promotion and education should be conducted, which can help caregivers to do better use of books and playthings, teach them how to read books, tell stories and play with children. For example, researchers used a counseling card (the Mother’s Card) for promotion effective play and communication between caregivers and children in China and it was proved helpful and effective [
21].
In addition, we found the proportion of father’s support for learning was quite low. Previous studies have reported mothers and fathers appeared to engage in different types of interaction with their child and produce different outcomes [
22‐
24]. However, “Absent fathers”, especially in low-income families, has been a concern in many fields, such as social and behavioral science departments and governments [
25]. Traditional concept of Chinese families was that men played the key role in the society (taking financial responsibility for family members, for instance) while women played the key role in the family (taking nursing responsibility, for instance) and it was common that grandparents helped young couples to bring up children. Researchers have found that fathers’ involvement in parenting was less than mothers’ in Chinese families [
26]. Although father’s participation in child-rearing has been highlighted, fathers continue to spend less time with their children than do mothers [
23]. Hence, the limited father’s participation in child-rearing needed improvements.
We found about one tenth of children got poor quality of care, and we observed positive associations between age growth and good quality of care, which indicated younger children needed more attention. As reported by another study in Iran, children aged 18–30 months got more opportunities in average book reading, storytelling, and singing duration than children under 17 months [
27]. Additionally, other researchers observed the youngest group faced the most serious deprivation of learning resources, which could be result from an inaccurate belief in rural China that infants knew nothing except eating and sleeping [
9]. In our study, we obtained similar results and we supported the younger children needed more attention as a vulnerable group.
Associations between quality of care and SDD
We found that availability of children’s books, playthings, support for learning and better quality of care were protective factors for SDD, which was consistent with previous studies. For example, a birth cohort in Brazilian has revealed that children who have not been told stories in the previous week and children who did not have children’s literature at home were more likely to show suspected developmental delay [
28]. Reading aloud and provision of toys are associated with better child cognitive and language development at 21 months among low-income Latino children [
29]. A pregnancy cohort has highlighted that strategies that assist parents with infant interaction skills are protective factors for children at risk of developmental delay [
30]. Our multivariable analysis confirm these findings and improving quality of care is a feasible and effective way to enhance child development.
Researchers have highlighted that fathers’ positive parenting produced better cognitive, social, and emotional development of children [
31]. Positive psychological and emotional aspects of father participation in child-rearing may prevent children from developing symptoms of depression in their pre-teen years [
32]. However, we found father’s support for learning was not statistically associated with SDD in surveyed areas. This may partly because limited father participation was insufficient to show positive child development outcomes. Another possible explanation may be that other relatives (grandfathers, older brothers, for instance) offered “father’s support for learning”, resulting in a bias for analysis. Although no difference was observed between children with/without father’s support for learning, father’s involvements warranted consideration in child health and development, especially in Chinese cultural context. Based on many studies about father-child relationships, a significant contribution of a father to child’s whole life was reported [
33‐
35].
Although we didn’t figure out statistical significance between inadequate care and SDD, inadequate care was always dangerous for young children and may cause accidental injuries.
Strengths and limitations
Child development comes to be a global issue and its significance is highlighted by a body of studies [
3,
4,
36]. However, gaps still exist in China, especially in poor areas. There is a scarcity of literature in rural China regarding the state of child development for children under 60 months that go beyond nutrition and growth outcomes. Our study obtained the developmental outcomes among Chinese rural children by Chinese national cut-off of ASQ-C. Moreover, the indicators about quality of care of MICS have been used among many countries and areas, but there is a lack of information among Chinese children. To our best knowledge, our study was the first report that assessed the status of qualify of care and determined its contributions to SDD in rural China. Our findings may help to recognize vulnerable groups and confirm the associations between quality of care and SDD, which may contribute to inform invention projects about improving child development in rural China.
The present study was subject to certain limitations. First, our data were cross-sectional. Although we demonstrated significant impacts of quality of care on SDD, causal and temporal associations could not be inferred. Additional longitudinal studies, in which biological and family and environmental factors during pregnancy and the postpartum period can be prospectively measured, should be conducted to confirm our findings. Another limitation was that ASQ is only a screen tool for developmental delay. The potential bias caused by misclassification error should be considered when interpreting the findings.