Gender-related perceptions among healthcare providers and mothers in a pregnancy and early childhood obesity prevention intervention in Shanghai, China

Abstract

Background

Gendered perceptions can shape parental beliefs, behaviours and practices relevant to childhood obesity prevention during the critical early life period from pregnancy to infancy. We explored how pregnant women, mothers and healthcare providers in maternal child health in Shanghai, China, perceive the influences of gender within an overweight and obesity prevention context.

Methods

We conducted a qualitative descriptive study integrated into the intervention arm of an ongoing early childhood obesity prevention trial. Individual interviews and focus group discussions with pregnant women and mothers participating in the intervention and healthcare providers involved in the delivery of the intervention were conducted (n = 59). We documented perceptions on gender in relation to parental beliefs, behaviours and practices in the context of overweight and obesity prevention. Interviews were audio recorded, transcribed and analyzed using thematic analysis.

Results

Three main themes were identified. First, participants shared expectations for children’s bodies, emphasizing that health was a priority for both boys and girls, but that expectations regarding body figure were generally stricter for girls than for boys. Second, regarding parenting expectations and health behaviours, few gender differences were reported other than boys being expected to engage in more physical activity compared to girls. Third, participants shared their views on gender roles and involvement in parenting, highlighting mothers’ central role in overweight and obesity prevention during pregnancy and early childhood, alongside a desire for greater paternal involvement in parenting and in modelling healthy lifestyle behaviours.

Conclusions

Findings underscore the importance of integrating gender‑related perceptions into early childhood overweight and obesity prevention efforts, beginning prenatally and extending through early childhood. Increasing awareness of these perceptions early in the life course could contribute to more gender-sensitive care and support childhood obesity prevention from the earliest stages of life.

Trial registration

The SCHeLTI protocol was registered on the Chinese registry ChiCTR1800017773 on 2018-08-13 (https://www.chictr.org.cn/hvshowproject.html?id=93827%26v=1.3).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-026-02878-z.

Background

Childhood obesity is a risk factor for chronic health conditions across the lifespan [1]. An estimated 37 million children under 5 years are living with overweight or obesity [2]. The World Health Organization estimates global costs associated with overweight and obesity will reach $3 trillion USD by 2030 [2]. Sex disparities in childhood overweight/obesity are well-documented across settings, including China, where epidemiological data indicate consistently higher prevalence in boys compared to girls [3], a gap that continues to widen [4].

Both sex and gender are known determinants of health, health behaviours and access to healthcare [5, 6]. Sex is defined by male and female biological attributes, whereas gender is socially constructed and is tied to a spectrum of roles, behaviours and expressions [7]. In addition to sex differences in childhood overweight/obesity risk, previous studies have identified differences in factors associated with overweight/obesity in boys and girls [8–10]. For example, a study in Chinese children ages 2–10 years found that, compared to girls, boys were more likely to engage in screen time and consume sugary foods with less parental oversight, while girls were more likely to receive support for physical activity and access to healthier foods [10]. Fewer studies have explored how perceptions on gender shape weight-related beliefs, behaviours and parenting practices [8]. Some studies indicate that parents’ and caregivers’ perceptions on gender in relation to children’s health and body figure can influence parenting practices which in turn influence children’s lifestyle behaviours and weight status [10–12]. However, the origins of these perceptions—beginning in pregnancy and unfolding through early childhood—remain poorly understood.

Similarly, healthcare providers’ perceptions of how parents’ views on gender shapes childhood overweight/obesity can influence the way in which preventive care is delivered during pregnancy and early childhood [13]. The complementary views of healthcare providers, in addition to those of parents/caregivers, are rarely examined in relation to childhood obesity prevention. Understanding these perceptions can provide insight to support gender-sensitive approaches aimed at promoting healthy behaviours and parenting practices for the prevention of obesity starting from the earliest stages of life, when obesity risk originates [6, 8, 14].

To address gaps in understanding the early origins of gender perceptions relevant to childhood obesity, and to integrate the complementary perspectives of pregnant women, new mothers and healthcare providers, we explored how gender-related perceptions influence parental beliefs, practices and obesity prevention behaviours in the Sino-Canadian Healthy Life Trajectories Initiative (SCHeLTI) trial intervention arm. SCHeLTI is an ongoing cluster randomized trial testing an intervention aimed at preventing childhood obesity from preconception through early childhood in Shanghai, China. The intervention has been described in detail [15, 16]. Briefly, it aims to empower parents and child caregivers (e.g. grandparents) to adopt behaviours and parenting practices that support the prevention of obesity using the healthy conversations method [17].

Methods

Design, setting and participants

Qualitative description, informed by Naturalistic Inquiry, was used to generate rich, low-inference accounts of participants’ perspectives and experiences [18, 19]. This approach acknowledges multiple context-dependent realities and emphasizes inductive interpretation grounded in participants’ accounts [20]. Qualitative description is particularly valuable in health research, as it captures nuanced, practice-relevant insights that reflect the lived experiences of healthcare users and providers, thereby informing clinical and preventative care practices [21]. In this paper, we use the terms “pregnant women” and “mothers” inclusively to refer to individuals who were pregnant or who identified as mothers, regardless of gender.

The study was conducted from July to December 2023, in healthcare centers and hospitals from four participating SCHeLTI districts; two central areas (Xuhui and Minhang) and two suburban areas (Songjiang and Fengxian). The study was integrated into a larger process evaluation of the SCHeLTI intervention exploring the feasibility, acceptability and perceived effectiveness of the intervention, and as such only included participants from Maternal Child Health clusters randomized to the trial’s intervention arm. The intervention was delivered using the same content, procedures, and intensity for boys and girls, with no sex- or gender-specific tailoring in its design or implementation. Any gender-related differences explored in the qualitative analysis therefore reflect participants’ experiences and contextual factors rather than differential intervention delivery.

Purposive sampling was used to ensure a balanced representation of participants across ongoing phases of the SCHeLTI study (i.e. pregnancy and birth to 3 years) and the abovementioned Shanghai districts. The sample size was pre-determined based on participant inclusion in the qualitative process evaluation study in which this study was embedded, and included 59 participants from two sub-groups: (1) 28 women, including 12 pregnant women and 16 mothers of children ages 0–3 years from the intervention arm of the SCHeLTI study (while partners/fathers were not excluded, recruitment for the process evaluation targeted the primary caregiver who received the intervention, who were women and mothers in most cases); and (2) 31 healthcare providers who supported the delivery of the SCHeLTI intervention. The latter included pediatric healthcare providers in community health centers, intervention staff, and maternal and child healthcare managers all involved in the SCHeLTI intervention. Pregnant women, mothers, and healthcare providers were included to capture complementary perspectives across the continuum of care involved in the delivery and uptake of the intervention. The inclusion of participants from different stakeholder groups allows for a more comprehensive understanding of views relevant to our research question.

This study was approved by the Ethics Committee of the School of Public Health, Fudan University (IRB#2023-08-1073) and Université de Sherbrooke, Canada (IRB#2024–5424). All participants provided informed consent.

Data collection

Data were collected through individual interviews and focus group discussions conducted by co-authors HJ, XYL, AXY, FYZ. Both women and healthcare providers participated in interviews (totaling 45 individual interviews), while 14 healthcare providers participated in one of three focus groups. Eight of the 45 individual interviews were conducted via Tencent, a web-based video calling platform, and the remainder were done in-person. Among the three focus groups, one was a mix of in-person and online attendance, and the others were in-person.

Socio-demographic information was collected through self-administered questionnaires prior to completing interviews/focus groups. A topic guide was used during interviews and focus groups (Supplemental File 1). Among pregnant women and mothers, questions focused on: (1) Gendered expectations around growth and weight gain (e.g. beliefs about birth weight and early weight gain, including whether expectations differ for boys and girls); (2) Feeding intentions and practices (e.g. plans or experiences with infant feeding and whether these would be different for boys and girls); (3) Parenting and health behaviours (e.g. approaches to child nutrition, physical activity, screen time, and sleep, and whether standards differ based on gender); and (4) Perceptions of body shape and gender (e.g. how the child’s future body shape is envisioned and whether these expectations are influenced by gendered ideals). Healthcare providers were invited to share their perspectives, drawing on their clinical experience, about how parents’ behaviours and attitudes may differ based on gender. The topic guide focused on: (1) Parental influence on child weight (e.g. how maternal and paternal overweight/obesity may influence a child’s health and weight trajectory); (2) Parenting norms for lifestyle behaviours by gender (e.g. whether parents/caregivers have different standards for boys and girls in relation to nutrition, physical activity, screen time, sleep, and breastfeeding); and (3) Parents’ perceptions of body shape (e.g. whether parents/caregivers hold different concerns about body shape for boys versus girls, and how providers interpret or respond to these differences). Interviews and focus group discussions were audio-recorded, transcribed using iFLYREC and reviewed for accuracy. Interviews lasted 45–90 min, while focus groups lasted approximately 60 min each, covering topics related to the SCHeLTI process evaluation in addition to gender-related perceptions. Only data pertaining to the latter are included in the current study.

Analysis

Data were analyzed using thematic analysis, a methodical and rigorous yet flexible approach for identifying patterns within qualitative data [22]. This analysis method enabled us to examine perspectives across participants and to highlight similarities and differences by systematically sorting and collating codes into categories and developing themes on gender-related perceptions in the context of obesity prevention. First, team members (FZ and HJ) read the transcripts to familiarize themselves with the data. One Chinese researcher (FZ) translated transcripts into English for the Canadian researcher (KC) with intermediate understanding of Mandarin Chinese who analyzed transcript sections focused on gender perceptions. The English translation was checked within the Chinese research group for accuracy and to ensure that the cultural meaning was maintained. Next, two researchers (KC and FZ) independently coded transcripts using NVivo versions 12 and 14 and discussed codes through an iterative process, until consensus was reached. A single coding framework was developed combining data from all three participant groups (i.e. pregnant women, mothers, and healthcare providers), albeit with group-specific codes incorporated to reflect distinctions across groups. Throughout the data analysis process, Chinese and Canadian researchers (KC, HJ, LM, ODJG, NA, CH & AVH) met regularly to discuss codes, categories and themes, with final themes confirmed through an iterative process of analysis and exchanges among researchers.

The work presented herein draws on an international multidisciplinary collaboration in which protocol development and funding acquisition were jointly undertaken by researchers in China and Canada. While data collection was conducted by the Chinese team for logistical reasons, the cross-cultural and cross-linguistic analytic process leveraged the complementary strengths of both groups. Canada has a long-standing history of advancing sex- and gender-based analysis in health research, and co-authors HJ and CH are SCHeLTI trial’s sex and gender champions. Because most Canadian team members are not fluent in Mandarin Chinese, we used a structured “translation-and-discussion” process that enhanced analytic rigor by enabling collective interpretation across linguistic and cultural contexts. Moreover, our diverse professional and cultural backgrounds shaped our engagement with this study. Collective expertise in public health, psychology, nursing, and medicine informed our interest in the social and biological factors influencing early obesity risk and guided our interpretation of participants’ accounts. Most members of the research team identified as women, and nearly half were based in Canada, which may have influenced how data were interpreted. Throughout the research process, analytic memos and collaborative cross-cultural discussions supported ongoing reflexivity ensuring a rigorous, transparent analytic process.

Results

Sociodemographic characteristics of pregnant women and mothers and of healthcare providers are shown in Tables 1 and 2, respectively. Among pregnant women, two had other children, and among mothers, all but two were first-time parents. Thematic analysis of transcripts revealed three main themes described below along with supporting quotes.

Table 1.

Characteristics of participating pregnant women and mothers

Group	Pregnant women (N = 12) n (%)	Mothers (N = 16) n (%)
Sex
Female  Male	12 (100)	16 (100) -
Sex of Child
Female  Male	- -	7 (43.7) 9 (56.2)
Age, years, Mean ± SD	33.0 ± 2.5	33.8 ± 3.3
Permanent residency
Shanghai	4 (33.3)	12 (75.0)
Other province	8 (66.6)	4 (25.0)
Education level
University degree	11 (91.6)	13 (81.2)
Less than University degree	1 (0.08)	3 (18.7)

Table 2.

Characteristics of participating healthcare providers

	Healthcare providers (N = 31) n (%)
Age, years, Mean ± SD	45.2 ± 9.8
Sex
Male	2 (6.5)
Female	29(93.5)
Education level
University degree	26 (83.8)
Less than University degree	5 (16.1)
Job classification
Junior or mid-career	23 (74.1)
Associate senior	7 (22.5)
Senior Management	1 (3.2)
Years of career experience
Less than 10 years	9 (29.0)
10–20 years	10 (32.2)
More than 20 years	12 (38.7)

Theme 1: Gendered views on body figure and health

The first theme illustrated women’s and mothers’ desire for their child’s overall health along with distinct expectations regarding boys’ and girls’ body figures. Although, some pregnant women and mothers mentioned preferences for their child’s body, physical appearance or weight, all mentioned that their child’s health was equally or more important than body figure and physical appearance: “It’s just as well to be healthy.” (Mother-11 of a 15-month-old girl).

A desire for girls to have an evenly proportioned, leaner and slimmer body was mentioned by some pregnant women and mothers, and by healthcare providers regarding their beliefs of parents’ preferences or expectations. “Girls, I hope to be slimmer.” (Pregnant woman-05); “Girls may be required to be slimmer, because some girls dance at a very young age, then dancing requires not to eat too much.” (Provider-11); and “Mothers may be more concerned about the girl’s body type, one is appearance, another is health.” (Provider-09).

In contrast, two mothers of girls expressed a desire for their daughters to gain weight, perceiving them as too slim. One boy’s mother noted that if she had a girl, it would be OK if she was ‘fatter’ because girls can adjust their weight later in life: “If the girl [is fatter] I think it doesn’t matter, when she grows up, she can adjust herself.” (Mother-14 of a 14-month-old boy). Extending this perspective, some healthcare providers mentioned that parents’ prevailing expectations for girls’ slimmer body figures generally appear later in childhood.

Participants generally expressed that body figure expectations for boys are more lenient. Many mothers of boys mentioned that sons should weigh more, be taller and stronger. For example, “I’ve seen the [growth charts] and it seems that boys will be a little bit taller, a little bit fatter and a little bit heavier than girls at the same stage.” (Mother-09 of a 20-month-old boy).

Healthcare providers noted that during clinical visits, parents are generally less concerned about boys’ body shapes compared to girls’, often appreciating more weight because chubbiness in boys is perceived as cute. “Parents are often less stringent for boys when discussing their children’s body shapes during clinical visits.” (Provider-06); and “If the boy seems to be a little fat, chubby, the parents think it’s quite cute.” (Provider-09).

Similarly, some pregnant women (who generally do not know the baby’s sex before birth) also noted that baby boys should be chubbier than baby girls, provided they remain within healthy BMI parameters: “The boy would be one pound heavier […] the girl a half pound lighter […] After all, [if] it’s a boy, a little bit bigger is fine.” (Pregnant woman-05); and “I think for girls, perhaps just to be slightly leaner within the normal BMI range, and for boys, it’s not so strict, but also to be within a normal BMI range.” (Pregnant woman-08).

Theme 2: Gendered expectations in parenting and lifestyle behaviours

While gendered expectations were present in some areas, perspectives on parenting practices related to lifestyle behaviours, namely breastfeeding, nutrition, physical activity and screen time, were guided more by perceived child needs than by gender norms. The findings were organized into subthemes corresponding to nutrition, physical activity and screen time, each revealing overall similar expectations for boys and girls.

All mothers of boys and most mothers of girls mentioned that their breastfeeding practices were not influenced by the child’s gender or sex, with other factors (e.g. pain) playing a more decisive role. “[Irrespective of my child’s gender, my breastfeeding decisions would have been] the same. [It would depend] if it’s painful or not. If it’s painful, I’ll cut it off because I don’t want any pain.” (Mother-04 of an 18-month-old girl). Of the 13 pregnant women, 12 spoke about their intentions to breastfeed which were independent of the child’s sex. One mother of a girl shared her belief that boys need more breastmilk but that this would not change her breastfeeding practices. Similarly, healthcare providers generally mentioned that mothers’ breastfeeding practices were not influenced by the child’s sex or gender: “[In regard to breastfeeding], it doesn’t matter if it’s a boy or a girl.” (Provider-group-03).

With respect to other nutrition and feeding practices of boys and girls, most mothers noted that they would control their child’s nutrition based on what rather than how much they should eat. For example, mothers noted that they would control their child’s sweet and fat intake for health reasons. Two mothers of boys mentioned that they did not impose any restrictions on their son’s food intake, one due to food pickiness and the other due to the belief that her son was underweight. These views regarding feeding practices are exemplified in the following quotes: “It’s all about feeding on demand. Give her food if she wants it, and don’t force her if she doesn’t want it.” (Mother-11 of a 15-month-old girl); and “[I will control his intake in] the sweets category and the fat and salt category.” (Mother-01 of an 18-month-old boy).

Similarly, few gender-specific expectations pertaining to children’s physical activity were expressed by pregnant women, mothers or healthcare providers: “There aren’t any differences [in physical activity] based on gender.” (Provider-group-03). One pregnant woman noted that it is better for girls to engage in less dangerous sports (“I think it’s probably better for girls not to do more dangerous [physical activity/exercises]” (Pregnant woman-06)), whereas another pregnant woman noted that the level of physical activity should be the same for girls and boys until puberty. Two mothers of boys mentioned they would have different physical activity level expectations if they had a girl. One of them shared that physical strength and fitness is more important for boys because men are expected to support a family in the future: “In the long run, boys are expected to support a family, so a good physique is important” (Mother-12 of a 3-year-old boy). Similarly, some but not all healthcare providers shared that it is more common for parents to encourage boys to be physically active: “Boys are typically encouraged to enroll in sports programs, being physically active is a common expectation” (Provider-06).

Lastly, no gender differences in expectations for children’s screen time were reported. Only one boy’s mother mentioned allowing her son to use screens to give herself and the grandparent caregivers a break from his boundless energy: “The main challenge is that our boy’s energy level is too high. When he’s awake, he’s like a perpetual motion machine, and the grandparent [caregivers] at home can’t keep up with him. We use about 10 minutes to take a break with screens.” (Mother-12 of 3-year-old boy).

Theme 3: Perceived gendered roles in parenting and promoting child health

The third theme captured how pregnant women, mothers and healthcare providers described gendered norms that shape mothers’ and fathers’ involvement in child health promotion and overweight/obesity prevention. Across participants’ accounts, mothers were predominantly positioned as primary caregivers, while fathers were portrayed as integral contributors but whose involvement was perceived to be constrained by sociocultural expectations.

Healthcare providers generally reported that mothers have the most influence on all aspects of the child, including nutrition and physical activity, compared to other family members. While acknowledging that both parents’ genetics influence the child’s body figure, providers remarked that mothers otherwise have a more influential role, especially when it comes to attending medical appointments. “Mums are very influential because dads are often absent [from the appointments], that is, medical check-ups are either with the [grandparent caregivers] or the mums, and dads only sometimes come” (Provider-group-02).

Healthcare providers further noted that mothers are typically their primary point of contact, making maternal perspectives most visible: “Currently, our main contact is the mother, so mother’s perspectives are what we’re most aware of. Occasionally fathers also express concerns [related to the child’s health or weight], but it is less common” (Provider-06). Healthcare providers also perceived mothers as more sensitive to the child’s needs, more involved in direct childcare, and ‘gentler’ than fathers towards their children. “Mothers pay more attention to the details of the child’s body size, while fathers are less concerned…Women are more sensitive to the children’s clothes and the details of life, men may be more concerned about the general health status” (Provider-10); and “To put it bluntly, dads come in less, moms come in more at younger ages and dads are sometimes involved beyond 6 months. I mostly see mums more […] Basically I think it’s still mum who cares more.” (Provider-16). Among mothers of boys who spoke about the role of fathers in raising children, most (4 out of 5) mentioned the perceived limited involvement of their husband/partner. Mothers attributed fathers’ low involvement to factors such as work obligations and a lack of awareness of how they could be involved. “When I need [my husband] to give me a hand, he can help me, but the main force is still me.” (Mother-10 of 2.5-year-old boy). Mothers of boys wished fathers were more involved in sports and physical activities with children, grocery shopping and being more proactive in child-related decisions. Such views were less commonly reported by mothers of girls who spoke about their perceived level of father’s involvement: “He [has been] involved the whole time (from pre-pregnancy until after birth), and I feel like he was just very proactive about it as well” (Mother-11 of a 15-month-old girl). Pregnant women shared their views on the importance of fathers in parenting and child upbringing. Some women noted that their husbands/partners are keen to be involved in the pregnancy care and birth preparation but are not always available due to work obligations: “He’s kinda keen to participate… but because of the time working, it’s probably just in the evenings” (Pregnant woman-12). A common sentiment expressed by all participant groups was the perception that fathers are important for children’s health and development. For example, both mothers and healthcare providers noted that fathers play an important role in the development of lifestyle habits for the child through play and role modeling. “When it comes to outdoor sports, I’m probably more concerned about her safety, and the father is more about letting her be bold and letting go and playing” (Mother-02 of a girl, 3 years old); “Some fathers can’t control their own diet … He likes to eat sweets or sugary drinks and the baby likes to eat the same.” (Provider-group-03); and “The child needs interaction with both parents, and these are necessary for the child’s growth and development” (Provider-12).

Pregnant women and healthcare providers also mentioned the importance of co-parenting and the key role of fathers in supporting the family’s psychological wellbeing, unity, and sense of security. Despite some contrasting perceptions, there was agreement that young children benefit from the distinct contributions of both parents within a balanced and nurturing environment.

The motherly and fatherly roles complement each other. There must be an environment of co-parenting or else the influence on children’s psychology and health will be negatively impacted. Both the parents should spend time with the child but there is no prescriptive amount of time. Most of the time spent with the child should be with both the mother and father together (Pregnant woman-05)

Mom and dad’s qualities are different, their temperaments are different, the mother’s temperament is gentler […] Everyone’s perspectives are different. I think children should be given a complete parenting environment so the child can feel safe and their feeling of safety and security is guaranteed. (Provider-12)

Discussion

This study conducted in Shanghai, China, highlights the value of considering norms and views held by pregnant women, mothers and healthcare providers on gender-related parental beliefs, behaviours, and practices in the context of obesity prevention starting prenatally and into early childhood. This study yielded 3 main findings. First, although expectations regarding stricter body figures for girls versus boys are common, a prevailing perception stresses the importance of health beyond that of body figure for boys and girls alike. Second, pertaining to parenting practices, pregnant women, mothers and providers’ views concerning obesity-related health behaviours were primarily driven by child needs rather than by gender norms, albeit with some gendered expectations in relation to physical activity. Third, perceptions on gendered norms in parental engagement revealed a prevailing view that mothers are more actively involved in parenting during the early childhood years and are central to efforts for the prevention of childhood overweight/obesity, while fathers are seen as important contributors whose greater involvement is desired. We offer a discussion structured around these main findings, drawing on relevant literature to situate each within the broader evidence base.

Gendered expectations for children’s bodies

One dimension highlighted by our study concerns gendered expectations for children’s bodies. Previous studies in China have described how bigger bodies are perceived as stronger and preferred for boys, which may in part contribute to the higher prevalence of overweight/obesity among boys compared to girls in China [4, 23]. A recent qualitative study has shown greater acceptance for being overweight and “chubby” in boys, particularly by grandparents who play important child caregiving roles in China [24]. Broader acceptance for larger body sizes in boys than in girls was also conveyed by some participants in the current study. However, an important insight from our study is the overall prioritization of child health above and beyond body figure expectations for boys and girls, suggesting a potential emerging shift in values and norms. Pregnant women and mothers in this study were recruited from the intervention arm of the SCHeLTI trial evaluating an obesity prevention intervention initiated in preconception or early pregnancy [13]. Exposure to the SCHeLTI intervention may have influenced participants’ gender-related perceptions on childhood overweight/obesity, particularly regarding obesity-related beliefs, behaviours, and parenting practices during early childhood. Findings suggesting potentially evolving norms on gendered expectations for boys and girls’ body figures should thus be confirmed among parents and caregivers not participating in an obesity prevention intervention.

Nevertheless, ongoing leniency in body figure expectations for boys, combined with persisting disparities in overweight/obesity prevalence between boys and girls [25], highlight the need for parents, caregivers and healthcare providers to be more vigilant in overweight/obesity prevention efforts for boys. Health promotion messages emphasizing health and healthy behaviours among parents and children may contribute to reduce gender-related misconceptions, such as the perception that “chubbiness” is endearing, especially in boys.

Gendered expectations for children’s health behaviours

Another related but distinct dimension of our findings involves gendered expectations for children’s health behaviours relevant to obesity prevention. Research has shown that although the proportion of boys and girls who meet physical activity recommendations is low overall, physical activity is consistently higher in boys compared to girls in China [26, 27], and in other parts of the world [28, 29]. Perceptions of parents and healthcare providers on the need for boys to be more physically active than girls from pregnancy onwards may contribute to this disparity. These perceptions early in life can have long-term consequences on physical activity into childhood, adolescence and adulthood, with impacts on preventable chronic diseases through regular physical activity [30, 31]. Further, physical activity level is influenced by biologic and genetic determinants including sex hormones [32]. Health promotion and overweight/obesity prevention efforts to improve physical activity should consider both gender-related determinants and biological determinants to address low physical activity levels via different strategies crafted for girls and boys and their parents and caregivers.

In contrast to physical activity, study participants’ expectations towards breastfeeding practices did not differ between boys and girls. In line with this finding, a study in Bangladesh found that breastfeeding initiation is similar for girls and boys [33]. However, survey data from India found that breastfeeding duration was dependent on gender and birth order: if a daughter was born first, she would be breastfed for a shorter duration in hopes of improving fertility for a subsequent pregnancy with a male child [34]. While gender perceptions may influence breastfeeding practices in some contexts, other factors such as social support, infant health, and the mothers’ knowledge of feeding practices appear to be stronger determinants [35].

Gendered norms in parental engagement

Finally, our study highlights a prevailing view among study participants was the central role of mothers in promoting health and preventing overweight/obesity from pregnancy to early childhood. A study examining maternal and paternal parenting styles in Chinese families found that mothers showed higher authoritative parenting than fathers, a parenting style that involves the provision of firm limits while also being warm and nurturing, and is generally associated with lower child obesity risk [35]. Traditional Chinese parenting views, which have tended to support the notion of “strict fathers, kind mothers” (yan fu ci mu) [36], have more recently shifted towards “involved mothers, detached fathers” [37]. Mothers have been described as more involved in childcare, warmer and sensitive to their children’s needs, and more involved in controlling children’s health compared to fathers [37, 38], which echoes perspectives reported in the current study.

In recent years, China and other countries with growing economies have seen increases in women’s education and contributions to the economy concomitantly with ongoing household and childcare responsibilities [39]. This may be particularly relevant for participants in the SCHeLTI trial and the current qualitative study, given the overall high level of education among women and the potential double burden by which women are expected to provide financially and care for the family [23]. Study participants noted that fathers play an irreplaceable role in the family, namely as role models for healthy lifestyles. Consistent with other recommendations, greater emphasis should be placed on family-wide interventions aimed at engaging all family members in the prevention of childhood overweight/obesity starting early in life [8, 40]. This may be particularly important in countries with shifting economies where women/mothers take on increasing responsibilities outside of the home.

Although specific to the Shanghai context, this study raises awareness on the existence of prevailing gender-related perceptions that can have long-term health implications starting from very early in development. Findings from this study inform the ongoing delivery of the SCHeLTI trial. The healthy conversations method used by healthcare providers in the SCHeLTI intervention to support health behaviour changes among participants appears particularly useful to assess gender-related expectations in a non-judgmental manner and empower families to support their health goals using family-centered care [15, 41]. Findings also emphasize the need for greater efforts to engage male partners and fathers in the SCHeLTI intervention specifically, and more broadly in preconception, prenatal, and early‑childhood obesity prevention initiatives. Lastly, themes generated from this study will bring insights to results from the larger trial, particularly if sex differences in outcomes are found.

Some limitations should be noted. This study stems from an international collaboration between Chinese and Canadian researchers. Interviews were conducted in Mandarin Chinese and translated into English for co-analysis by Chinese and Canadian team members, along with careful verification that cultural meanings were retained in the English versions. Although iterative discussions within the China-Canada research team enriched the analysis process, some nuances in culturally embedded expressions may have been lost despite careful translation and verification procedures. Interview questions on gender perceptions were integrated within a larger qualitative process evaluation exploring the feasibility, acceptability and perceived effectiveness of the SCHeLTI intervention. The study was thus restricted to participants from the intervention arm only, and interviews focused on several topics in addition to inquiring about sex- and gender-related perspectives. Although the intervention did not specifically address gender, perceptions of pregnant women and mothers could have been influenced through participation in the intervention, and that of healthcare providers through the intervention delivery training they received. Although interviews were conducted by researchers not directly involved in the intervention delivery training to healthcare providers, or in the recruitment, intervention delivery and follow-up of pregnant women and mothers for the overall SCHeLTI trial, social desirability bias in the responses provided is possible. Additionally, gender identity of study participants was not assessed. This decision was informed by local cultural norms in Shanghai where direct assessment of gender identity is perceived as intrusive. Perspectives shared by women and mothers in this study may be specific to highly educated women in China, as over 85% had completed a university degree. The high educational level of respondents limits the transferability of findings. However, the educational and demographic characteristics of women and mothers interviewed for this study resemble those of the overall SCHeLTI trial and other birth cohort studies in Shanghai [42, 43], suggesting that the findings may be transferable to populations with higher socioeconomic status in similar large urban centres. Healthcare providers were encouraged to share perspectives based on their clinical practice; however, their perspectives may be biased by their personal views.

Lastly, this study focuses on perspectives of pregnant women and mothers, while those of male partners and fathers were not documented. Although men and fathers were not excluded during recruitment the for larger process evaluation in which the current study was embedded, none were ultimately recruited. This mirrors the SCHeLTI project context, where only a small number of families had fathers as primary caregivers receiving the intervention. As a result, our findings do not capture male partners’ and fathers’ own perceptions, but instead reflect pregnant women’s, mothers’ and healthcare providers’ views on father’s involvement. Future studies on how gender-related perceptions may shape beliefs, practices and obesity prevention behaviors in parents should explicitly target fathers, reduce barriers to their participation (e.g. rely on male interviewers), and integrate more flexible data collection methods (e.g. shorter interviews during work breaks). Raising awareness of male partners’ and fathers’ critical contributions to child health and obesity prevention will also be essential to strengthening their engagement in maternal and child health research, notably in China.

Conclusions

Our study elicited views from pregnant women, mothers and healthcare providers pertaining to gender-related expectations and perceptions on unborn or very young children in the context of overweight and obesity prevention in Shanghai, China. Our findings suggest that stricter body figure expectations for girls are common, but that parents’ prioritize health over body size for their child. Boys are expected to engage in more physical activity than girls, but there were otherwise few gendered expectations in parenting for other health behaviours at this early developmental stage. In participants’ opinions, mothers are the main influence in families, but there is a desire for fathers to be more involved in parenting activities related to health promotion and obesity prevention. Our findings can inform gender sensitive obesity prevention efforts starting earlier in the life course.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

K Christianson, H Jiang, C Herba and A Van Hulst contributed to the conception and design of the study and led the manuscript drafting and revisions. J Fan, J-P Baillargeon, H Huang, and W Fraser are the Principal Investigators of the SCHeLTI trial. N Abdelouahab coordinated the SCHeLTI trial. H Jiang, F Zeng, A Yan, X Li contributed to data collection for the SCHeLTI process evaluation study. K Christianson and F Zeng, under the supervision of H Jiang, CM Herba and A Van Hulst, performed the data analysis and contributed to the interpretation of results. LC Masse and O De-Jongh Gonzalez contributed to the data analysis and interpretation of results. All authors critically reviewed the manuscript for intellectual content, approved the submission of the final version of the manuscript and agree to be accountable for all aspects of the work.

Funding

This study was funded by the World Health Organization in the context of a process evaluation of the Sino-Canada Healthy Life Trajectories Initiative (SCHeLTI). The SCHeLTI study is funded by the National Natural Science Foundation of China (82261128001, 81974235) and the Canadian Institutes of Health Research (grant number: HLT 151517, HTC 180892). Travel funding for researcher KC was supported by the McCall MacBain Scholarships and the Dr. Alice Benjamin Global Maternal and Child Health Fund Award via the Global Health Scholars program at the McGill University Global Health Programs office. LCM received salary support from the BC Children’s Hospital Research Institute and holds a Professorship in Health Promotion from the School of Population and Public Health at the University of British Columbia. ODJG received a postdoctoral award from Michael Smith Health Research BC. AVH received a Fonds de la Recherche du Québec Junior 2 salary award.

Data availability

Anonymized data that support the findings of this study are available on request from the corresponding author H.J. The data are not publicly available as they contain information that could compromise the confidentiality of research participants.

Declarations

Human ethics and consent to participate

This study was approved by the Ethics Committee of the School of Public Health, Fudan University (IRB#2023-08-1073) and Université de Sherbrooke, Canada (IRB#2024–5424). Participants provided informed consent to participate in the study. All study procedures were in accordance with national ethical standards on human experimentation and with the Helsinki Declaration.

Consent for publication

Not applicable, no individual participant data are presented.

Competing interests

The authors declare no competing interests.