Abstract

Introduction

School-based universal depression screening (SBUDS) is an effective method for early identification of depression. As parents are the primary decision-makers for their children’s acceptance of healthcare services, this study aims to examine rural and urban parental acceptance of SBUDS.

Methods

The study assessed parental acceptance of SBUDS for their children and its association with self-reported parental perception of depression (i.e., parental knowledge of depression, self-efficacy to identify child depression, and depression stigma) and parental belief regarding the benefits and risks of SBUDS. The analysis included 13,480 parents with at least one child in grades 4–12 from 29 primary and secondary schools in four cities across China.

Results

In this large and diverse sample, 92.4% of the participants supported SBUDS for their children despite concerns about the risks of SBUDS (e.g., accuracy and privacy of screening results). Most parents supported SBUDS starting in 4th (25.5%) or 7th (24.7%) grades, though 7.6% responded no screening should be done. Regression analysis revealed that parents with a higher level of knowledge about depression (OR = 1.496, 95%CI [1.08, 2.073]; P = 0.015) had higher odds of parental acceptance of SBUDS. However, this association was not evident among rural parents stratified by urban-rural locality.

Conclusions

In this survey study, most Chinese parents accept SBUDS for their children despite concerns. Guidelines for maintaining adolescent confidentiality and ensuring the accuracy of results in an SBUDS will require careful consideration. Additionally, the study findings indicate that improving parental knowledge about adolescent depression is essential for promoting parental acceptance of SBUDS.

Introduction

Depressive disorder is a major contributor to the burden of disease in adolescents [1]. The increasing prevalence of depression in adolescents has generated concerns about adolescent mental health [2, 3]. The prevalence of depressive symptoms among Chinese children and adolescents rose from 18.4% in 2000 to 26.3% in 2016 [4]. Depression during adolescence may not only lead to cognitive maladjustment, social dysfunction [5], and academic dysfunction [6], but also increase the risk of self-harm and suicide [7].

Under-identification of mental health problems is a widely recognized barrier to at-risk adolescents accessing mental health services [8]. Depression, as an internalizing symptom, may be challenging for parents, school staff, and other adults to identify [9]. The importance of early detection of depression is being recognized worldwide. Screening for depression in adolescents has been recommended by several professional organizations in the US and the UK [10,11,12,13]. The United States Preventive Services Task Force (USPSTF) [10, 12] and the American Academy of Pediatrics (AAP) [11] both recommend depression screening in adolescents aged 12 years and over in primary care settings. The National Institute for Health and Care Excellence (NICE) in the UK recommends that adolescents aged 11 years and over referred to Child and Adolescent Mental Health Services (CAMHS) should be provided with depression screening routinely [13]. There is evidence to show that depression screening delivered in clinical settings has inequalities by race/ethnicity and region [14, 15]; however, school-based universal depression screening (SBUDS) may bridge the gap. Because adolescents spend most of their time in school, school provides a great opportunity to identify and support children and adolescents who are experiencing depression.

The study by Sekhar and colleagues [16] in 14 American high schools found that SBUDS is an effective method for increasing depression identification and treatment initiation. Governments in China are increasingly promoting SBUDS to identify adolescence depression. The Ministry of Education of China has also proposed the inclusion of universal screening for depression in students’ regular health checks in 2021 [17]. In 2023, the Ministry of Education and 16 other authorities have jointly issued an action plan on enhancing students’ mental health, which requires elementary (higher grades), middle and high schools to conduct universal mental health screening at least once a year [18].

Parents are the main decision-makers for their children’s acceptance of healthcare services. It has been suggested that parental attitudes towards mental health services fundamentally influence service acceptance [19]. Furthermore, parental level of knowledge and depression stigma are likely to influence their response to their child’s depressive symptoms [20]. There is limited knowledge regarding parents’ acceptance and recognize toward adolescent depression and SBUDS content across international samples. While parent response to the SBUDS has been overall positive in previous studies [21,22,23], these views may not be representative of parents in China. Given the high level of stigma towards mental health reported by Chinese adults [24], the implementation of depression screening in Chinese adolescents may be challenging.

In order to inform the implementation of the SBUDS program, this cross-sectional survey aims, for the first time, to examine the acceptance of SBUDS among Chinese parents and its associations with parental perception of depression (parental knowledge of depression, and self-efficacy to identify child depression) and beliefs regarding the benefits and risks of SBUDS. The novel survey incorporated previous research and questionnaires, along with input from experts, and was administered to parents of students from different regions, grades, and types of schools.

Method

Study design and participants

This cross-sectional survey was conducted in China from June 13 to November 15, 2023. Respondents meeting those criteria were self-identified parents of a child enrolled in grades 4–12. Study participants included parents with at least 1 child in primary and secondary school (grades 4–12) from 29 schools in the 3 cities (Hefei, Bozhou, and Ma’anshan) from Anhui Provinces and 1 city (Baoshan) from Yunnan Province in China (Supplement Fig.Ìý1). Anhui Province is located in East China, and Yunnan Province is located in southwest China with the largest number of ethnic minorities. Schools were selected to account for school level and urban/rural environment. In each selected city, 2 primary (1 rural, 1 urban), 2 junior high (1 rural, 1 urban), and 3 senior high schools (1 key senior high school, 1 ordinary senior high school, and 1 vocational senior high school) were selected. For each school, at least 100 parents from each class (grades 4–12) were recruited randomly.

Questionnaire surveys were administered in two different ways. The vast majority of parental data was collected through electronic self-reported questionnaires on the Wenjuan Xing platform (). A paper-based questionnaire was employed for rural parents in Bozhou, as electronic self-report questionnaires posed a challenge for local parents to utilize effectively.

More than 14,700 participants were included in the survey; 13,480 participant responses were included in the analysis after excluding incomplete and invalid responses (i.e., participants other than the parents, missing information on parental identity data, and participants who spent less than 2Ìýs/item on average [25]) (Supplement Fig.Ìý2). The study was approved by the Biomedical Ethics Committee of Anhui Medical University (Project Number 83220402). Informed consent and assent were obtained from all parents included in the study. The participants provided informed consent before completing the self-reporting questionnaire. All responses from parents were collected anonymously.

Measures

The study assessed parental acceptance of SBUDS for their children and its association with self-reported parental perception of depression (i.e., parental knowledge of depression, self-efficacy to identify child depression, and depression stigma) and parental beliefs regarding the benefits and risks of SBUDS.

Due to the lack of an available measure of parental attitudes toward SBUDS, a questionnaire about parental acceptance of SBUDS was developed through two rounds of Delphi expert consultation based on literature review and documentation. The development process and content of the questionnaire were detailed in a recent article [26]. A total of 12 experts from six provinces and cities were invited to participate in the Delphi study. Self-made questionnaire items aimed to understand parental acceptance of SBUDS, parental knowledge of depression, and beliefs regarding the benefits and risks of SBUDS [26]. Detailed information on measurement is given in the eMethods in the Supplement.

Demographic factors of children (e.g., sex, age, region of school, grade, ethnic, etc.) and parents (e.g., sex, age, work status, household socioeconomic status, education level, etc.) were derived from questionnaires.

Statistical analysis

All quantitative variables were reported as frequencies, percentages, and mean (SD) values. Differences in study participant characteristics and information were compared with parental acceptance of the SBUDS using χ²/F statistics.

A two-stage, multivariate analysis was performed. First, a conducted a logistic regression was conducted to identify factors associated with parental acceptance of SBUDS, including respondent characteristics, parental cognition of depression, and parental attitudes toward SBUDS. All confounding factors were controlled for, including child age, child sex, school level, urban-rural status, parent age, parent sex, parental education level, work status, and economic level. In the second stage, these analyses were further computed separately for urban and rural parents. Statistical analyses were conducted using SPSS, version 27.0.

Results

Characteristics of participants

Of the 13,480 parents, 9323 (69.2%) were mothers, with a mean (SD) age of 40.6 (5.3) years, 8948 (66.5%) working, 4842 (35.9%) with senior high school level or above, 8331 (61.8%) with a child attending an urban school, and 6460 (47.9%) answering on behalf of a primary school or junior high school student (TableÌý1), with an average response time of 13.5 (± 1.6) minutes.

Table 1 Comparisons of socio-demographic characteristics and associated factors between parent with and without supportive attitude of school-based universal depression screening

Acceptance of SBUDS among Chinese parents

Overall, 12,453 (92.4%) were willing to accept the SBUDS; the majority elected the 4th grade (25.5%) or the 7th grade (24.7%) to start screenings (Supplement Fig.Ìý3).

Child and parental factors associated with the acceptance of SBUDS

Parents were more likely to accept SBUDS for a rural child than for an urban child (rural, 93.6%; urban, 91.6%; P < 0.001) (TableÌý1). In addition, parents of junior high school students (93.5%) were significantly more likely to support SBUDS (primary school, 92.8%; senior high school, 91.7%; P = 0.002). Parents who were employed were more likely to accept the SBUDS than those who were unemployed (92.7% vs. 90.8%; P &±ô³Ù; 0.001).

It is apparent that a majority of parents agree or strongly agree that depression screening is beneficial (80.6–85.5%) (Fig.Ìý1 and Supplement TableÌý1). Among them, parents who accepted the SBUDS were more likely to agree with the benefits of the SBUDS compared with those who rejected the SBUDS (all Ps &±ô³Ù; 0.001). While a statistically significantly higher proportion of those who rejected the SBUDS were more likely to be concerned about the accuracy (43.4% vs. 35.5%) and privacy (42.2% vs. 30.0%) of screening outcomes compared with those who accepted the SBUDS (all Ps &±ô³Ù; 0.001).

Fig. 1

Parental beliefs regarding benefits and risks of SBUDS. Statistically significant results are displayed in bold (*p < 0.05, **p < 0.01, ***p &±ô³Ù; 0.001). SBUDS: school-based universal depression screening

In multivariable logistic regression analyses, rural parents (OR = 1.31, 95%CI [1.12, 1.533], P < 0.001), and parents with a job (OR = 0.82, 95%CI [0.697, 0.964], P = 0.016) were significantly more likely to accept the SBUDS (TableÌý2). Overall, parents with higher knowledge of depression (OR = 1.496, 95%CI [1.08, 2.073]; P = 0.015), parents with higher beliefs regarding the benefits of SBUDS (OR = 1.174, 95%CI [1.156, 1.193], P < 0.001), and lower beliefs regarding the risks of SBUDS (OR = 0.913, 95%CI [0.897, 0.929], P < 0.001) had higher odds of parental acceptance of SBUDS.

Table 2 Factors associated with parental acceptance of school-based universal depression screening for students

Urban-rural stratified analyses of parental factors associated with the acceptance of SBUDS

Our urban-rural-stratified analyses exhibited the associations between parental beliefs regarding benefits of SBUDS (urban: OR = 1.18, 95% CI [1.157, 1.204], P < 0.001; rural: OR = 1.165, 95% CI [1.132, 1.199], P < 0.001) and risks of SBUDS (urban: OR = 0.901, 95% CI [0.881, 0.92], P < 0.001; rural: OR = 0.941, 95% CI [0.912, 0.971], P < 0.001) with parental acceptance towards SBUDS (see Fig.Ìý2 and Supplement TableÌý2), agreeing with the total sample result afore-mentioned. However, the association between higher parental knowledge of depression (OR = 1.701, 95%CI [1.146, 2.526], P = 0.008) and higher parental acceptance of SBUDS was only observed among urban parents. Additionally, lower parental self-efficacy to identify a child’s depression (OR = 0.964, 95%CI [0.936, 0.993], P = 0.015) and higher parental acceptance of SBUDS were only observed among urban parents.

Fig. 2

Multivariate logistic regression model of parental perception and belief with parental acceptance of school-based depression universal screening. SBUDS, school-based universal depression screening; OR, Odd ratio. Adjusted for covariates such as child age, child sex, school level, urban-rural status, parent age, parent sex, parental education level, working status, and economic level

Discussion

To our knowledge, this cross-sectional survey with a large and diverse sample provides the first China-based evidence of parental acceptance of school-based universal depression screening (SBUDS), which is important given that beliefs about depression identification may vary by context and culture. The sample of Chinese parents who participated in this study strongly supported the SBUDS. Most parents supported school-based universal depression screening starting in grade 4 or grade 7.

Similar to previous studies [21,22,23], Chinese parents generally support the SBUDS. A nationally representative study in the United States reported that 70.5% of parents of middle and high school students found the SBUDS appropriate [21]. Another investigation of 678 US parents of adolescents aged 12–18 in New Jersey concluded that 76.4% of parents agreed that SBUDS was necessary for students aged 12-18²³.In addition, our finding that parental acceptance of SBUDS (92.4%) in China was higher than in previous investigations [21,22,23] provides confidence in the implementation of SBUDS in China. Surprisingly, rural parents were more likely to accept the SBUDS than urban parents. Due to differences in access to health services between urban and rural areas [27, 28], rural parents may be more dependent on schools to provide SBUDS and other mental health services. Rural students probably have a higher risk of mental health problems [29]. In rural schools with limited mental resources, coping with the difficulties presented by children with depression for schools and their families presents a significant challenge.

Beyond supporting the acceptability of SBUDS to parents, the study also reveals parents’ concerns about the risks of SBUDS, which may be valuable for developing an acceptable program. Accuracy of screening results was the most frequently mentioned risk of SBUDS by parents and is also reflected in other studies [23, 30]. Indeed, there is evidence that depression screening in adolescents generates many false positives [31], which may identify more students than those actually need services [8, 32, 33]. Ensuring accurate diagnosis has been proposed in the USPSTF’s recommendation for adolescent depression screening [12]. Similarly, the Chinese government’s mental health action plan for students [18] also calls for implementing and standardizing school-based depression screening protocols.

Privacy protection during the measurement and feedback process is a challenge for schools and a primary concern of parents regarding screening programs [23, 30]. In a school setting, privacy disclosure may cause students to feel uncomfortable or lead to increased bullying [34], which can exacerbate mental health problems [35]. As such, the ethical issues and potential harms of the SBUDS program should be well considered. It is necessary to handle the identification and feedback process sensitively to reduce parental anxiety about their children receiving potential harm.

Although parents who participated in this study expressed relatively high levels of self-efficacy in identifying child depression, our finding suggested that this might not always prove to be beneficial in the detection of their children’s depression, particularly among parents in urban areas. Parents with high levels of self-efficacy in identifying child depression may feel relatively well-equipped to respond to their children’s depressive symptoms in time, and they may be less dependent on school to address this problem. As parents with higher levels of knowledge about depression are more likely to accept the SBUDS, increased education of parents about depression may help to improve their acceptance of the SBUDS and reduce the barriers to accessing mental health services for at-risk adolescents due to their misunderstanding of depression. It is noteworthy that the study found that no evidence of an association between parental knowledge of depression and parental acceptance of SBUDS was not evident among rural parents stratified by urban-rural locality. This may be attributable to the lower family participation [36] and available mental health resources [27] among rural families.

Encouraging the identification of adolescent depression should come with increased access to mental health services for all adolescents in need. Although SBUDS has been widely supported by Chinese parents, school-based universal depression screening is still a challenge for the child and adolescent mental health system in China [27, 37, 38].

Limitations

There are several limitations to note with this study. This study was cross-sectional, and the results should be interpreted cautiously. Second, this study was conducted in 4 cities from 2 provinces across China, which may limit the representation of the samples despite the geographical distributions considered. Third, although this study adjusted for several important confounders, residual confounding may still exist.

Conclusion

In this large and diverse sample, the findings suggest that most Chinese parents accept school-based universal depression screening for their children despite concerns. The findings on parents’ concerns about the risks of SBUDS implementation are valuable for developing an acceptable program. Guidelines for maintaining adolescent confidentiality and ensuring the accuracy of results in an SBUDS will require careful consideration. Improving parental knowledge about adolescent depression is essential for promoting parental acceptance of SBUDS. Implementation of SBUDS will require further understanding of the perspectives of other stakeholders (e.g., mental health professionals, students, and school staff), as well as further evaluation for identification programs.