Abstract
Objective
To evaluate adult Attention Deficit Hyperactivity Disorder (ADHD)-related health literacy, its determinants, and public awareness of local Child-Friendly City (CFC) policies in Wenzhou.
Methods
This study adopted a mixed-methods design. The quantitative cross-sectional survey recruited 1792 adults (≥18 years), applying a validated 9-item ADHD knowledge scale to gauge ADHD health literacy. Independent t-tests, one-way Analysis of Variance (ANOVA) and chi-square tests, factorial ANOVA, and Poisson regression respectively analyzed univariate group disparities, multivariate interactions, and independent predictors of literacy outcomes. For the qualitative strand, independent semi-structured interviews with 300 participants (including minors) were conducted to explore public perceptions and awareness of local CFC policies. Thematic analysis was adopted to synthesize interview narratives about policy understanding and dissemination.
Results
Single-factor analysis initially revealed potential associations between educational level, occupation, attitudes toward ADHD, and having relatives or friends with ADHD were significant influencing factors in both regions (all P<0.05), with significant interactions (eg interaction of parental status, age, and educational level; all P<0.05). Yet these associations reversed after adjustment for confounders. Poisson regression, confirmed educational level (β = 0.0624), positive attitude (β = 0.0758) and do not know having relatives or friends with ADHD (β = 0.1002) as positive predictors (β = 0.1002) (all P<0.05). Regarding policy awareness, Dongtou District showed superior understanding overall compared to the Wenzhou Urban Area (all P<0.05), and professional groups (healthcare- and education-related practitioners) exhibited significantly higher awareness levels than the general public.
Conclusions
Wenzhou adults have moderately low ADHD health literacy with regional and social disparities. Higher educational level, positive attitude, and do not know having relatives or friends with ADHD predicted superior literacy, while female gender, urban residence, and professional identities correlate with lower levels. CFC policy awareness is inadequate. Targeted dissemination for high-priority groups and region-adapted support systems are needed.
Keywords: ADHD, health literacy, awareness, child-friendly city, cross-sectional studies
Introduction
Attention Deficit Hyperactivity Disorder (ADHD) is among the most prevalent neurodevelopmental disorders in children worldwide, characterized by persistent inattention, hyperactivity and impulsivity, and frequently accompanied by learning difficulties, social impairments and emotional dysregulation.1 In China, ADHD prevalence among children and adolescents aged 6 to 16 years is estimated at 6.4%,2 and the incidence, prevalence, and disease burden have continued to rise, especially among males and children aged 5 to 9 years.3 Notably, an estimated 2.58% to 6.76% of ADHD symptoms will continue into adulthood, which is highly comorbid with anxiety, mood disorders, etc. However, due to insufficient social cognition and uneven distribution of diagnosis and treatment resources, adult ADHD is often underdiagnosed or misdiagnosed.4,5 Thus, early childhood identification and intervention are critical to improving long-term prognosis.6,7
China’s current ADHD support system faces structural socio-ecological challenges. Parental knowledge gaps, misconceptions and pervasive stigma hinder symptom recognition, acceptance of medical interventions and service provision, thereby exacerbating hardships for affected families.8 In 2022, Wenzhou (Zhejiang) launched its Three-Year Action Plan for Child-Friendly City (CFC) Construction (2022–2024). While this initiative enhances ADHD care opportunities, it is less comprehensive than integrated models in other cities9 (eg, Weifang’s “screening–referral–diagnosis–intervention–rehabilitation” continuum).
Notably, Wenzhou does not yet have baseline data on key stakeholders’ awareness of ADHD, nor has it assessed how well policy provisions align with the real support requirements of impacted children. Local policies’ ability to successfully support children with ADHD is limited by this evidence vacuum, which also makes it more difficult to devise focused treatments.
Overall, three major research gaps exist. First, no city-level comparative studies explore ADHD awareness among key stakeholders (parents, education-related practitioners, healthcare-related practitioners and community workers) or regional differences between urban and island districts. Second, no empirical studies have integrated the CFC framework with ADHD interventions in China. Third, previous ADHD knowledge studies have shown considerable heterogeneity in study populations and measurement approaches, while the combined influence of individual and contextual factors remains insufficiently explored.10
The research focuses on three central questions and corresponding hypotheses: (1) What are the differences in ADHD health literacy between stakeholder groups and between the Wenzhou Urban Area and Dongtou District? We hypothesized that ADHD health literacy would vary significantly across occupational groups and regions, with participants having greater professional exposure to health or education exhibiting higher levels of knowledge (H1). (2) Which factors most strongly shape public ADHD health literacy? We hypothesized that sociodemographic, occupational, regional, and attitudinal factors—particularly educational attainment, prior ADHD-related exposure, and attitudes toward ADHD—would be significantly associated with ADHD health literacy (H2). (3) How can CFC policies be leveraged to develop a more comprehensive and responsive ADHD support system? We hypothesized that awareness of CFC policies would differ across demographic, occupational, and regional groups, revealing population-specific gaps in policy dissemination that could inform targeted ADHD support strategies (H3).
Rooted in Wenzhou’s CFC construction practice,11 this study examines ADHD health literacy, service experiences, and unmet needs across medical, educational, and community settings. The findings will expand local evidence and improve policy and practice for ADHD care in Wenzhou.
Materials and Methods
Participants
This concurrent mixed-methods study12,13 was conducted in Wenzhou City, Zhejiang Province, China, from July to November 2025. The quantitative questionnaire strand followed STROBE reporting guidelines.14–16 Questionnaire participants were permanent residents aged≥18 years residing in Wenzhou Urban Area and Dongtou District. Figure 1 presents the participant screening flowchart exclusively for the quantitative questionnaire sample.
Figure 1.
Strobe flowchart. strobe, Strengthening the reporting of observational studies in epidemiology. Figure created by the authors.
A total of 2060 questionnaires were distributed. After excluding incomplete questionnaires, 1792 valid responses remained for quantitative analysis (1481 from Wenzhou Urban Area, 311 from Dongtou District), corresponding to an effective response rate of 86.99%. For the qualitative component, 300 independent non-overlapping semi-structured interview records were collected (127 from Wenzhou Urban Area, 173 from Dongtou District). The interview sample contained adult respondents and minor participants below 18 years old; all interview workflows, minor participant safeguards, and consent protocols received unified approval under the institutional ethics permit.
For questionnaire participants, broad occupational categories were adopted for the education- and healthcare-related sectors to maintain consistent classification and avoid excessive fragmentation of occupational subgroups. Specifically, the education-related sector included not only formal in-service teachers but also informal education practitioners (eg, teachers in private after-school care centers, extracurricular instructors, and private tutors). Similarly, the healthcare-related sector encompassed professional medical staff (eg, physicians) as well as auxiliary personnel, including nursing workers and primary-level health workers. This broad classification approach was implemented to minimize confounding bias17,18 associated with overly granular occupational stratification while better capturing the overall characteristics of distinct occupational groups, and it was consistently applied throughout the manuscript.
Measures
Data collection combined standardized self-administered questionnaires and custom semi-structured interview guides.19,20 The questionnaire consisted of two parts: (1) demographic information; (2) ADHD-related knowledge assessment. The awareness assessment was adapted from the ADHD Knowledge Scale developed by Shi Daizhu et al.21 After pre-revision, one item was removed from the original 10-item scale, resulting in a final 9-item scale. The revised scale showed good reliability (Cronbach’s α = 0.753, standardized α = 0.769). One point was assigned for every correct item response; total scores spanned 0–9, with higher values representing stronger ADHD-related knowledge. No official cutoff benchmarks for literacy tier classification were published alongside the original scale; population-level literacy rankings in this study were judged by comparing sample mean scores against the full scoring interval.
The research team developed a semi-structured interview guide to complement quantitative questionnaire outcomes, evaluating cross-regional resident perceptions toward two official municipal policies: the Three-Year Action Plan for Building a Child-Friendly City in Wenzhou (2022–2024)22 and the Regulations of Wenzhou Municipality on Promoting the Construction of a CFC.11
Interview data were collected via open-ended questions and a 5-point descriptive scale (from “very understanding” to “completely do not understand”). The transcribed interview materials underwent thematic analysis to summarize qualitative insights regarding policy outreach performance and resident public participation.
Variables Definition
The outcome variable was ADHD health literacy, measured as the total score on the 9-item ADHD knowledge scale (range 0–9), with higher scores indicating better knowledge.
The main exposure and predictive variables included:
-
(1)
Demographic characteristics: age, gender, educational level and parental status;
-
(2)
Occupational group: education-related practitioners, healthcare-related practitioners, community workers, and the general public;
-
(3)
Social and attitudinal factors: positive attitude toward ADHD, presence of relatives or friends with ADHD (yes/no/don’t know), and economic status;
-
(4)
Regional variable: residence (Wenzhou Urban Area vs Dongtou District).
Statistical Analysis
Before conducting statistical analyses, missing values in the collected data were addressed using the Multiple Imputation by Chained Equations (MICE) method23,24 to ensure data integrity and enhance the reliability of subsequent results. Data were then analyzed with Statistical Analysis Software 9.4 software (SAS Institute, Cary, NC, USA).25 Descriptive statistics—including means, standard deviations, frequencies, and percentages—were used to summarize ADHD awareness and policy knowledge. Group differences in ADHD awareness, attitudes, and policy knowledge were assessed using t-tests, one-way Analysis of Variance (ANOVA), or chi-square tests, depending on variable type. Potential influencing factors were further examined through multiple linear regression and Generalized Linear Model (GLM) analyses.26,27
Results
Demographic Characteristics
This study collected 1792 valid questionnaires, revealing significant demographic heterogeneity between the two regions (Table 1). The urban sample primarily comprised younger, highly educated members of the general public, with women accounting for 60.97% and only 7.02% having received ADHD-related training. The Dongtou Island sample exhibited a more balanced age distribution, with significantly higher proportions of Education-related practitioners (22.51%) and community workers (11.58%) compared to the urban area. The rate of participation in ADHD-related training (13.83%) was approximately double that of the urban area, and the level of emotional empathy toward ADHD was higher.
Table 1.
Demographic Characteristics of Questionnaire Participants in Wenzhou Urban Area and Dongtou District
| Urban Area (n = 1481) | Dongtou District (n = 311) | |
|---|---|---|
| Gender | ||
| Male | 578 (39.03%) | 111 (35.69%) |
| Female | 903 (60.97%) | 200 (64.31%) |
| Age group (years) | ||
| Under 20 | 672 (45.37%) | 48 (15.43%) |
| 20–30 | 387 (26.13%) | 78 (25.08%) |
| 30–45 | 246 (16.61%) | 126 (40.51%) |
| 45–60 | 164 (11.07%) | 55 (17.68%) |
| Over 60 | 12 (0.81%) | 4 (1.29%) |
| Educational level | ||
| Primary | 19 (1.28%) | 10 (3.22%) |
| Junior high | 109 (7.36%) | 26 (8.36%) |
| Senior high | 251 (16.95%) | 86 (27.65%) |
| Bachelor’s | 1034 (69.82%) | 183 (58.84%) |
| Master’s or above | 68 (4.59%) | 6 (1.93%) |
| Do any friends or relatives have ADHD | ||
| Yes | 180 (12.15%) | 35 (11.25%) |
| No | 976 (65.90%) | 229 (73.63%) |
| Do not know | 325 (21.94%) | 47 (15.11%) |
| Have received relevant training | ||
| Received | 104 (7.02%) | 43 (13.83%) |
| Not received | 1377 (92.98%) | 268 (86.17%) |
| Feelings of ADHD | ||
| Very sympathetic | 326 (22.01%) | 102 (32.80%) |
| Relatively sympathetic | 634 (42.81%) | 120 (38.59%) |
| Neutral | 460 (31.06%) | 79 (25.40%) |
| Relatively disgusted | 34 (2.30%) | 10 (3.22%) |
| Very disgusted | 27 (1.82%) | —— |
| Economic status | ||
| Wealthy | 67 (4.52%) | 14 (4.50%) |
| Comfortable | 842 (56.85%) | 176 (56.59%) |
| Basic needs met | 462 (31.20%) | 115 (36.98%) |
| Poor | 110 (7.43%) | 6 (1.93%) |
Determinants and Regional Disparities in ADHD Awareness
Overall ADHD knowledge among adults in Wenzhou was modest, with a mean score of 4.72 out of 9. Significant regional disparities were observed: residents in the Wenzhou urban area demonstrated higher knowledge scores than those in Dongtou District (4.83 vs 4.17, P < 0.001), suggesting unequal distribution of health information resources across geographic contexts.
Univariate analyses indicated that several demographic and social factors were associated with ADHD awareness (Figure 2 and S1). Higher educational attainment and professional exposure were consistently linked to higher knowledge scores. In both regions, education-related and healthcare-related practitioners showed better understanding of ADHD compared with the general public. Educational level showed a clear gradient effect, with respondents holding bachelor’s degrees or higher scoring significantly higher than those with lower educational attainment.
Figure 2.
Primary outcome.
Notes: (A) Overall score distribution in Wenzhou Urban Area. (B–H) Score distributions in urban stratified by: (B) gender, (C) age, (D) educational level, (E) occupation, (F) attitude towards ADHD, (G) family economic status, (H) parental status. (I) Overall score distribution in Dongtou District. (J-P) Score distributions in island district stratified by: (J) gender, (K) age, (L) educational level, (M) occupation, (N) attitude towards ADHD, (O) family economic status, (P) parental status. The F-statistic and its associated p-value from one-way ANOVA are displayed for each factor subgroup comparison (eg, Prob > F < 0.001). Figure created by the authors.
Age- and gender-related differences were mainly observed in the urban sample. Women and younger adults (20–30 years) showed relatively higher awareness levels, whereas older groups demonstrated lower scores. Notably, urban parents reported lower ADHD knowledge than non-parents, suggesting that parenting burden may limit opportunities for systematic health information acquisition. However, these demographic differences were not statistically significant in the island district, indicating a more homogeneous knowledge distribution in this setting. (For specific results of the one-way ANOVA, please refer to Tables S3–S11).
Factorial ANOVA further revealed significant interaction effects between parental status × age × educational attainment (Table S12) and parental status × attitudes toward ADHD × educational attainment (Table S13) (both P < 0.05). Higher educational attainment mitigates the negative impact of parenting stress on cognitive function, with young parents aged 20–30 exhibiting the most pronounced knowledge-related disadvantages.
Notably, in the multivariable Poisson regression model, univariate subgroup comparisons displayed apparent advantages in ADHD literacy for urban residents and professional practitioners, while these positive associations reversed after adjusting for demographic, regional and attitudinal confounders in multivariate modeling, which could be attributed to confounding socioeconomic and environmental factors. Educational level and positive attitudes toward ADHD were independent positive predictors of knowledge scores. In contrast, female gender, urban residence, and professional identity in the healthcare or education sectors were associated with lower scores after adjustment. In addition, respondents who were uncertain about whether relatives or friends had ADHD demonstrated higher knowledge levels, suggesting increased curiosity or information-seeking behavior within uncertain social contexts (Table 2).
Table 2.
Factors Associated with ADHD Knowledge: Results from Poisson Regression Analysis
| Parameter | Estimate | Standard Error (SE) | Chi-Square | P Value |
|---|---|---|---|---|
| Intercept | 1.291475 | 0.127177 | 103.1223 | <0.0001 |
| Female (vs Male) | −0.132143 | 0.030419 | 18.8710 | <0.0001 |
| Wenzhou Urban (vs Dongtou Island) | −0.162165 | 0.039948 | 16.4787 | <0.0001 |
| Education-related practitioner (vs General public) | −0.102401 | 0.043666 | 5.4996 | 0.0190 |
| Healthcare-related practitioner (vs General public) | −0.200193 | 0.069945 | 8.1918 | 0.0042 |
| Do not know having relatives/friends with ADHD (vs Yes) | 0.100229 | 0.035860 | 7.8119 | 0.0052 |
| Educational level (continuous) | 0.062431 | 0.019185 | 10.5896 | 0.0011 |
| Attitude toward ADHD (continuous) | 0.075792 | 0.013263 | 32.6572 | <0.0001 |
Notes: Poisson regression model examining the association between demographic, occupational, social, and attitudinal factors and ADHD knowledge scores among adults in Wenzhou (n = 1792). All variables shown are statistically significant (p < 0.05). For continuous variables (educational level and attitude toward ADHD), the estimate represents the change in knowledge score per unit increase in the predictor.
Taken together, these findings indicate that ADHD awareness in Wenzhou is shaped by a complex interplay of regional context, educational background, occupational exposure, and attitudinal orientation.
Policy Implementation
To explore the implementation of ADHD-related policies under Wenzhou’s Child-Friendly City framework, this study collected a total of 300 independent semi-structured interview records.
Based on 300 valid interview responses, public awareness of the CFC concept and related regulations is generally low. Awareness of the regulations is lower than awareness of the concept, and significant group heterogeneity exists in awareness distribution (Table 3). Education/Healthcare-related practitioners demonstrated higher awareness than the general public. Middle-aged individuals aged 41–50 showed relatively higher awareness. Residents of Dongtou Island reported a higher proportion of “very understanding + Comparative understanding” responses (46.82%) compared to urban areas (44.09%). Detailed awareness distributions for other interaction factors are presented in Tables S14–S19. Based on these findings, a directed acyclic graph (DAG) was constructed to identify factors influencing policy awareness of child-friendly cities. This analysis confirms that access to information and motivation for participation constitute the core mediating mechanisms for policy awareness (Figure 3).
Table 3.
Awareness of CFC Concepts and Regulations Across Demographic and Regional Groups
| Urban Area (n = 127) | Island District (n = 173) | |
|---|---|---|
| Age group (years) | ||
| Under 18 | 2(1.57%) | 12(6.94%) |
| 18–30 | 59(46.46%) | 66(38.15%) |
| 31–40 | 28(22.04%) | 36(20.81%) |
| 41–50 | 34(26.77%) | 46(26.59%) |
| Over 51 | 4(3.15%) | 13(7.51%) |
| Occupation | ||
| Education-related practitioners | 15(11.81%) | 18(10.40%) |
| Parents | 7(5.51%) | 6(3.47%) |
| Community worker | 11(8.66%) | 20(11.56%) |
| Healthcare-related practitioners | 22(17.32%) | 18(10.40%) |
| General public | 72(56.69%) | 111(64.16%) |
| Understanding of Friendly Cities | ||
| Very understanding | 26(20.47%) | 41(23.70%) |
| Comparative understanding | 15(11.81%) | 38(21.97%) |
| General | 29(22.83%) | 51(29.48%) |
| Do not know/Heard of | 34(26.77%) | 28(16.18%) |
| Completely do not understand | 23(18.11%) | 15(8.67%) |
| Understanding of the regulations | ||
| Very understanding | 27(21.26%) | 29(16.76%) |
| Comparative understanding | 14(11.02%) | 32(18.50%) |
| General | 29(22.83%) | 52(30.06%) |
| Do not know/Heard of | 29(22.83%) | 42(24.28%) |
| Completely do not understand | 28(22.05%) | 18(10.40%) |
Notes: Distribution of self-reported awareness levels among survey participants in Wenzhou Urban Area (n = 127) and Dongtou District (n = 173) areas. Data are presented as n (%). Awareness is categorized into five levels for both the general CFC concept and specific local regulations.
Figure 3.
DAG of factors influencing policy communication effectiveness and their pathways.
Notes: This graph serves only as a conceptual framework; no formal quantitative mediation analysis was conducted in this study. Figure created by the authors.
Discussion
This cross-sectional study reveals that adults in Wenzhou exhibit overall low-to-moderate ADHD awareness, with positive attitude and educational level emerging as key positive predictors—aligning with “affect-driven cognition” and “knowledge acquisition relying on educational foundations” frameworks. Notably, “do not know having relatives or friends with ADHD” unexpectedly predicts higher awareness, a discrepancy potentially attributed to semantic heterogeneity of the “do not know” option and regional differences in information perception. Concurrently, public awareness of CFC policies remains inadequate, reflecting a pronounced “implementation gap” between policy texts and public understanding. These results highlight structural inequalities in health information dissemination and inform context-specific optimization of ADHD support systems and CFC policy implementation.
A regional contrast emerged: univariate analysis showed higher ADHD knowledge scores among urban residents than island residents, but Poisson regression identified urban residence as an independent negative predictor. This discrepancy stems from confounding demographic factors (more young, highly educated individuals in urban areas) masking knowledge-acquisition deficits stemming from fragmented urban information environments. In contrast, island communities’ tight-knit social networks and concentrated occupational information dissemination confer unique advantages, underscoring the need for geographically tailored interventions: digitally driven, targeted public science communication in urban areas, and peer education leveraging education-related practitioners and community networks in island regions.
Professional identity also yielded counterintuitive results: univariate analysis indicated higher ADHD knowledge among healthcare- and education-related practitioners, but regression models positioned these identities as independent negative predictors. This reflects that their knowledge-related advantages derive from occupation-associated knowledge and attitudes rather than professional identity itself, and are deeply intertwined with regional information ecosystems. In island communities with dense social networks, these professionals serve as core information disseminators; in urban areas, individual educational level and positive attitude exert stronger influences, diluting professional identity-based advantages. This suggests occupation functions as a “carrier” for knowledge-based communication, whose effectiveness depends on local information environment support.
Notably, previous studies have suggested that ADHD-related knowledge disparities in Western contexts stem from racial and cultural divides.28–30 In contrast, the ADHD-related knowledge differences observed in this study are rooted in context-specific factors associated with regional development in China. For instance, knowledge-related differences based on gender, age, and household economic status were only significant in urban area, while on islands they either showed no statistical significance or only marginal statistical significance. This discrepancy may stem from the island’s socioeconomic structure differing from urban area: the island primarily relies on fishing and tourism, where gender roles are relatively blurred, and men and women participate more equally in family and societal responsibilities. Furthermore, although economically advantaged island families possess the capacity to prioritize child health, limited information channels, monotonous health communication formats, and lack of systematic approaches prevent the establishment of a sustained, effective knowledge-education environment, making it difficult to translate economic resources into knowledge-based resources.
Additionally, univariate analysis of variance revealed that women in Wenzhou’s urban areas scored significantly higher than men on overall ADHD knowledge. However, after adjusting for confounding factors such as education level, occupation, and region via Poisson regression, female gender emerged as a relatively negative predictor of knowledge scores among Wenzhou’s adult population. This finding contradicts previous research focused on family settings, which indicated that mothers generally recognized ADHD symptoms more than fathers before receiving professional intervention.31,32 The inconsistency requires careful interpretation considering the study design and statistical logic.
Two core reasons exist: First, as the female-to-male ratio in the study sample was disproportionately high (60.97% in urban area, 64.31% in island district), potentially introducing selection bias. This gender imbalance may reflect sociocultural contexts where women show greater willingness and attention toward children’s health issues, leading to higher inclusion rates in cross-sectional surveys. This aligns with existing research.33–35 This self-selection bias may overestimate women’s knowledge-related advantages in single-factor analyses. Second, the interaction of confounding factors. After adjusting for variables such as occupation and education, the occupational advantage of men—who are relatively more likely to be employed in healthcare/education—was isolated, revealing the inherent “relatively negative effect” of gender itself.
The deeper logic is that gender differences are not merely about “knowledge-related superiority or inferiority”, but may reflect divergent patterns in knowledge structures and acquisition pathways. This interpretation is consistent with established frameworks of gender-related differences in learning and information processing. For instance, Hakami found that gender interacted with learning outcome domains, with males outperforming females in skills-related tasks while females excelled in knowledge recall,36 suggesting that gender-based advantages are domain-specific rather than global.
Our findings align with this pattern. Males in our sample demonstrated superior performance on specialized knowledge items such as “possible causes of ADHD” (Table S20), excelling at absorbing fragmented, targeted information; females’ knowledge systems, ho, wever, emphasized holistic and practice-oriented approaches, covering practical content like symptom recognition and intervention pathways. These complementary patterns suggest that the observed gender differences reflect divergent knowledge acquisition styles rather than overall knowledge superiority. This disparity suggests that future public education must move beyond a “one-size-fits-all” approach. Instead, it should design differentiated communication strategies tailored to gender‑specific knowledge-acquisition characteristics—for example, delivering specialized science articles to men while providing scenario-based practical guides to women.
More concerning is that young parents/guardians aged 20–30 in the urban area exhibited the lowest ADHD awareness levels in Factorial Analysis (possibly due to smaller sample size or different parenting stress), forming a “knowledge gap”. These knowledge-related misconceptions and attitudinal contradictions among parents regarding ADHD have been corroborated by multiple domestic empirical studies. For example, a survey of elementary school parents in Hangzhou revealed that only 36.9% could correctly identify ADHD cases. Over half (53.6%) believed medical intervention was unnecessary, and a significant 61.0% opposed medication. The study further indicated that fathers exhibited significantly lower disease recognition and willingness to seek medical care compared to mothers, while mothers exhibited stronger resistance to pharmacological treatment.37,38 It is worth noting, however, that opposition to medication does not necessarily indicate a lack of knowledge—such attitudes may also reflect legitimate concerns about side effects or value-based preferences regarding psychoactive drug use in children. This nuanced pattern highlights the complexity of parental attitudes toward ADHD and cautions against simplistic interpretations that equate treatment hesitancy with knowledge deficits.
Additionally, in the urban sample, controlling for demographic and attitudinal confounders revealed a significant negative association between parental identity and ADHD knowledge levels (Table S21), further corroborating the knowledge-related disadvantage among urban parents. The findings collectively indicate that Chinese parents’ knowledge-related issues regarding ADHD stem not merely from factual knowledge gaps, but also from value-based attitudes, difficulties in recognition, low willingness to seek medical care, and significant treatment concerns. This discovery runs counter to the widely held lay belief that parenthood inherently enhances health-related knowledge and literacy—a belief that, while pervasive in everyday discourse, has received limited empirical support in the context of child mental health. These results suggest that interventions targeting young urban parents urgently require lightweight, contextualized designs that are deeply integrated into daily parenting routines. This phenomenon was absent in the island sample, suggesting that their relatively tight-knit community support networks may effectively buffer the negative impact of parenting stress on parental knowledge-related processes. Existing research indicates a significant correlation between parental knowledge of ADHD and healthcare-related practitioners-seeking behavior: parents with greater knowledge reserves are more likely to seek medical help and have better medication adherence when their children exhibit ADHD-related symptoms.39,40 Therefore, enhancing parental ADHD awareness is crucial. Science communication and advocacy should recognize the information gap among parenting-stressed parents, avoid oversimplified attributions, and prioritize targeted parent-focused interventions.
Public awareness of CFC policy was extremely low in this study: only 22.33% of participants across both regions reported being “very understanding” of the CFC concept, while 18.67% showed a “very understanding” of relevant regulations. This low policy awareness coexists with insufficient ADHD knowledge, collectively indicating a failure of grassroots dissemination within current public health and social policy frameworks. In preliminary univariate analyses, only occupation and place of residence emerged as significant predictors of awareness of CFC-related policies and regulations. This suggests that policy awareness mirrors occupational and geographical stratification patterns similar to those observed for ADHD awareness. Professionals exhibit higher awareness rates, while island residents indicate superior “comparative understanding” awareness compared to urban residents. This profoundly reveals the “last mile” challenge in policy dissemination: information often stagnates within administrative systems and professional circles, failing to effectively reach the broadest public, particularly ordinary families.
Complementing these policy efforts, addressing healthcare resource disparities is critical to sustaining ADHD awareness and intervention capacity. Given China’s significant disparities in healthcare resource distribution across regions, urban-rural divides, and population groups—compounded by market economy profit-seeking tendencies and institutional mechanisms that concentrate high-tech equipment and medical talent in economically developed areas—there exists a vast gap in basic healthcare service levels.41,42 Professional groups such as healthcare and education practitioners should leverage their expertise: brief professional development interventions, for example, can substantially enhance teachers’ understanding of ADHD, representing a cost-effective way to expand the reach of accurate information.43 Concurrently, public awareness campaigns must prioritize fostering positive attitudes toward ADHD and leveraging “emotional resonance” to promote knowledge internalization—building on our finding that attitude is a core cross-regional predictor of knowledge levels. Efforts should also improve information accessibility and comprehensibility across socioeconomic groups, ensuring no population is left behind despite the weak correlation between economic status and awareness.
Overall, the two non-overlapping sample pools serve distinct analytical goals: population-level associations between ADHD literacy and covariates are quantified via adult questionnaire data; independent interview outputs elaborate contextual drivers behind uneven CFC policy awareness across groups. Enhancing public ADHD awareness is a multidimensional endeavor that requires aligning policy dissemination, resource allocation, and targeted communication—with multi-stakeholder collaboration at its core.
This cross-sectional study has several limitations. First, the cross-sectional design precludes causal inference, reflecting temporal ambiguity—the inability to establish temporal order between exposures and outcomes, a core limitation of cross-sectional studies in causal inference.44,45 Second, the large proportion of general public respondents may introduce selection bias and representation bias,46,47 as the sample composition does not fully reflect the underlying population distribution, potentially affecting the generalizability of our findings. Third, qualitative interview outcomes were mainly presented via descriptive proportional statistics of policy comprehension levels; in-depth thematic mechanism analysis and quantitative mediation tests were not performed. This approach may introduce interpretive bias and information bias,48,49 as it limits the interpretive depth of policy influencing pathways and may not fully capture the nuanced mechanisms underlying policy awareness and health literacy. Future longitudinal or intervention studies are warranted to evaluate strategies for improving ADHD health literacy.
Conclusions
This study addressed three central questions concerning regional and occupational differences in ADHD health literacy, its key determinants, and disparities in Child-Friendly City (CFC) policy awareness in Wenzhou. H1 was partially supported: ADHD health literacy differed across regions and occupational groups in univariate analyses, but some associations changed direction after multivariable adjustment, suggesting that these differences were partly influenced by demographic, regional, and attitudinal characteristics. H2 was largely supported: multiple sociodemographic, occupational, regional, and attitudinal factors were associated with ADHD health literacy, with higher educational attainment and more positive attitudes emerging as consistent positive predictors. H3 was supported: CFC policy awareness differed across occupational and regional groups, revealing uneven policy dissemination and population-specific information gaps.
Overall, improving ADHD health literacy in Wenzhou requires both universal education and targeted, context-specific strategies. Urban populations may benefit from accessible, scenario-based health communication, whereas education-related practitioners, healthcare-related practitioners, and community networks may serve as important dissemination channels in Dongtou District. Integrating targeted ADHD education into CFC initiatives may further strengthen policy communication and support. Future longitudinal and intervention studies are needed to evaluate whether these strategies can causally improve ADHD health literacy and policy engagement.
Acknowledgments
We express gratitude to all the study participants for their cooperation and devotion of time during the data collection period.
Funding Statement
This work was supported by the Soft Science Research Program of Zhejiang Province (2025C35052), the Zhejiang Provincial New Young Talent Program (2025R413C089), the Summit Advancement Disciplines of Zhejiang Province (Wenzhou Medical University - Pharmaceutics), and the Consortium for Infection and Innovation (CII) of The First Affiliated Hospital of Wenzhou Medical University (2025WMU-X001).
Data Sharing Statement
The data supporting the findings of this study are available on request from the corresponding authors.
Ethics Approval
This study was conducted in accordance with the principles of the Declaration of Helsinki. This study was approved by the Ethics Committee of Wenzhou Medical University (Approval No. 2026014). Verbal informed consent was adopted for all adult questionnaire respondents and adult interviewees, given that this was an anonymous cross-sectional survey with no invasive procedures, no collection of personally identifiable information, and minimal risk to participants; the ethics committee formally approved the waiver of written informed consent. For adult participants completing the online questionnaire, verbal consent was documented by respondents actively clicking the “I agree to participate” button on the electronic informed consent page before accessing the survey. For adult interviewees, verbal consent was confirmed after the researcher read aloud the full study information, and the consent status was marked on the interview record form by the researcher. All consent records were stored separately from survey data on an encrypted internal hospital server, accessible only to core research team members, and will be retained for 5 years after study completion before secure destruction. For minor interview participants, written informed consent was obtained from their legal guardians, paired with verbal assent from the minors themselves following a simplified age-appropriate explanation of the study, prior to data collection.
Author Contributions
All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
Disclosure
Dr Jingwei Ye reports Support for the manuscript from the Zhejiang Provincial New Young Talent Program (2025R413C089), during the conduct of the study. Prof. Dr. Dan Wang reports Support for the manuscript from the Consortium for Infection and Innovation (CII) of The First Affiliated Hospital of Wenzhou Medical University (2025WMU-X001), the Summit Advancement Disciplines of Zhejiang Province (Wenzhou Medical University - Pharmaceutics), during the conduct of the study. All authors declare that they have no conflicts of interest in this work.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The data supporting the findings of this study are available on request from the corresponding authors.