Abstract

Purpose

The impact of sexual assault or sexual health problems on children and their families due to poor sex education is severe and devastating. Herein, we examined the current status of Preschoolers鈥� Family Sex Education (PFSE) program in Luzhou City, China, and the determinants of parents鈥� practice, focusing on urban-rural differences.

Methods

Using multistage randomized cluster sampling, 4322 parents were recruited from 24 kindergartens. A web-based, self-administered, anonymous questionnaire was used to measure parents鈥� perceptions, attitudes, and practices regarding PFSE. Binary logistic regression was performed to analyze the determinants of parental implementation of PFSE.

Results

The knowledge pass rate, positive attitude rate, and practice pass rate of PFSE among parents of preschoolers were only 47.15%, 34.42%, and 69.04%, respectively, and the rates in rural areas were significantly lower than those in urban areas. Parents鈥� practices were weakest on physiology education and sexual health education. For the total population, PFSE knowledge, attitudes, sense of responsibility for family education, number of difficulties with sex education, support for PFSE, and age of child significantly influenced parents鈥� PFSE practice pass rates. The determinants of urban parents鈥� PFSE practices were similar to those of the total population, but rural parents鈥� PFSE practices were also significantly influenced by left-behind child status.

Conclusion

The PFSE in Luzhou could be improved by increasing parents鈥� attitudes and social communication, especially for those living in rural areas. Effective implementation and practices of PFSE require correcting the attitudes of parents, improving parents鈥� sexual knowledge, and strengthening social communication so as to promote the sexual and reproductive health of children in China, especially those left behind in rural areas.

Introduction

The International Federation of Gynecology and Obstetrics advocates for worldwide implementation of comprehensive sex education (CSE) due to its proven benefits for youth and adolescents [1], including reproductive health gains, reduced interpersonal violence, and improved academic success and well-being [2, 3]. Conversely, the absence of CSE leaves children devoid of self-protection skills and the ability to recognize potential crises, making them susceptible to child sexual abuse (CSA) [4], high-risk behaviors, and unintended pregnancies [5, 6]. According to the World Health Organization, 30% of children under the age of six globally have experienced CSA to varying degrees, with half remaining silent [7]. From 2013 to 2021, 2790 CSA cases involving over 5877 children, mostly under 14 years old, were reported in China [8]. CSE refers to an age-appropriate, culturally relevant approach to educating youth about sexuality and relationships, which provides scientifically accurate, realistic, and non-judgmental information [2]. In 2018, the United Nations Educational, Scientific, and Cultural Organization and the United Nations Population Fund released the International Technical Guidance on Sexuality Education [1], which is an evidence-based framework for designing CSE programs tailored to the needs of countries and institutions. This framework aims to safeguard adolescents鈥� sexual and reproductive health, declaring 鈥渆very adolescent has the right to sex education鈥� [9], and it recognizes sex education as a fundamental adolescent right [3].

Over the past 3 decades, the United States has implemented and advanced its sex education programs for students [10], and Switzerland has integrated sex education into its compulsory education system, including it as part of teachers鈥� professional training [11]. However, many countries, including China, continue to grapple with cultural barriers, resource constraints, and a scarcity of educators. For instance, Iran鈥檚 school system lacks formal programs [12], and India鈥檚 efforts are hindered by a lack of national policy support [1]. Influenced by traditional social norms, sex remains a taboo subject in China [13].

The advancement of sex education in Western countries compared to Asian regions underscores the significance of geographical factors, such as urban or rural settings, in shaping children鈥檚 access to sex education [14]. In economically and culturally disadvantaged areas, the issue of sex education for children and adolescents is particularly pronounced [15]. The urban-rural disparity in sex education is not just a geographical issue but also a social phenomenon that significantly impacts the distribution and effectiveness of sex education resources. According to China鈥檚 National Bureau of Statistics of China, in 2020, urban and rural populations accounted for 63.89% and 36.11% of the total population, respectively [16]. This imbalanced in population distribution directly affects the accessibility and outcomes of sex education, especially in the realm of preschool sex education. Urban areas benefit from better educational resources and trained professionals, facilitating comprehensive sex education programs. In contrast, rural areas face challenges due to limited resources and a lack of trained educators, resulting in less effective sex education [17]. As a result, children in rural regions may receive inadequate or inconsistent sex education, which can leave them more vulnerable to risks such as sexual abuse and unintended pregnancies. Addressing these disparities necessitates targeted efforts to enhance educational resources and teacher training in rural areas, ensuring that all children, regardless of their geographical location, have access to quality sex education.

Family and school are undoubtedly the two main places for children to receive sex education, but under China鈥檚 exam-based education, insufficient class time and shortage of teachers result in an ineffective sex education program [18]. In addition, parents are reluctant to talk to children about sex due to a lack of knowledge and ability [19, 20]. For the vast majority of Chinese children, sex is viewed as something that they will naturally understand when they grow up [18]. The mysterious and private nature of sex has been ingrained in the vast majority of Chinese people since childhood. The implementation of Preschoolers鈥� Family Sex Education (PFSE), a comprehensive family sex education program for children ages 3鈥�6 in which parents and other primary caregivers provide appropriate sex education to preschoolers, should alleviate this embarrassing state of affairs [21].

The PFSE project represents a pioneering initiative in China鈥檚 sex education landscape. Implemented in urban and rural kindergartens across Luzhou City, the project targets parents and primary caregivers, utilizing community intervention experiments to enhance their knowledge and skills in sex education. Managed by the Sex Education Team from Southwest Medical University, the project employs a scale-based assessment to evaluate its effectiveness. Although the intervention phase was affected by the COVID-19 pandemic, the baseline survey in 2021 provided valuable data. This study focuses on analyzing these baseline data to assess parents鈥� knowledge, attitudes, and practices regarding PFSE. Understanding the outcomes of the PFSE project is crucial for identifying effective strategies and addressing urban-rural disparities in sex education, thereby informing the development of more targeted and impactful family sex education programs.

In the Chinese preschool context, children are stratified into Nursery (3鈥�4 years), Junior (4鈥�5 years), and Senior (5鈥�6 years) classes, with educational content varying according to their developmental milestones. This formative period represents a crucial juncture for fostering safety comprehension, addressing sexual shame, and mitigating CSA risks [7, 22]. Talking to children about sexuality early on establishes it as a normal topic and avoids awkward and fraught interventions that inevitably occur too late [23]. PFSE is anticipated to confer a range of benefits to preschoolers, such as improvement in social competencies, autonomy, and responsible behaviors, and decreased sexual risk behaviors, so as to nurture the development of attitudes and behaviors that are aligned with societal norms [3, 24].

China鈥檚 liberalization of attitudes about sex, high CSA rates, and young victims鈥� ages have heightened parents鈥� awareness of sex education responsibilities [25,26,27]. At the same time, the Chinese government has enacted laws supporting family sex education [28], including the 2020 Law on Minors鈥� Protection [29], the 2021 Program for Children鈥檚 Development [30], and the 2022 Family Education Promotion Law [31]. Parents, as ideal sex educators, can address children鈥檚 needs in a timely manner through daily communication, but they are influenced by gender [32, 33], education [34, 35], familial sexual communication [36], knowledge [37], beliefs [38], and child鈥檚 gender [32]. In China, urbanization drives rural parents to cities, leaving 鈥渓eft-behind children鈥� in rural areas with limited access to sex education [39,40,41]. Chinese college students鈥� low sex education rates, especially at home [42,43,44,45], reflect this rural crisis. Rural children face heightened risks of high-risk sexual behaviors and severe health consequences [46]. Thus, sex education programs must prioritize rural populations鈥� needs and challenges [47].

Given the disparity between national sex education strategy and outcomes, the dearth of sexuality education at home necessitates urgent policy evaluation and determinant identification for adjustments. However, previous studies of sex education in China focused on older children rather than on preschoolers [48, 49]. To the best of our knowledge, few studies have examined PFSE and its urban-rural differences, and no studies in China have assessed PFSE using scales with high reliability and validity. The Theory of Planned Behavior (TPB), widely used to understand adolescent sexual behaviors [50], provides a robust framework for analyzing parents鈥� intentions and behaviors in relation to sex education. The TPB suggests that parental engagement in sex education is influenced by a combination of attitudes, subjective social norms, and perceived capabilities [51, 52]. Specifically, attitudes refer to positive or negative beliefs about sex education, subjective norms encompass perceived expectations from others, and perceived behavioral describes confidence in the ability to provide sex education. By applying the TPB, this study assesses how these factors shape parental involvement in the PFSE project, with a particular focus on urban-rural differences.

In this study, we conducted a cross-sectional survey among parents of preschoolers in Luzhou, China. Under the framework of the TPB, the survey aimed to: (1) assess parents鈥� current knowledge, attitudes, and practices related to PFSE; (2) explore the urban-rural differences of PFSE; and (3) identify the factors associated with PFSE practices and urban-rural disparities. Our findings provide valuable insights and recommendations for future practice in developing and implementing PFSE programs to promote children鈥檚 sexual health.

Materials and methods

Study design and sample

The data for this study were collected from a kindergarten-based comprehensive education program in Luzhou, a third-tier city in southeastern Sichuan Province, located at the border of Sichuan, Yunnan, Guizhou, and Chongqing. Its economic and educational levels are representative of many cities in China. The data were gathered through a cross-sectional survey conducted by the Sex Education Team of Southwest Medical University from January to March 2021, that involved 4,322 parents of preschool children from 24 kindergartens in both urban and rural areas of Luzhou. The sample size was determined based on previous research and expected differences in PFSE practices. We aimed for a sample of 4,322 parents to achieve 90% power to detect significant differences in PFSE practices between rural and urban areas, assuming a large effect size and a significance level of 0.05. This sample size provided sufficient statistical power to detect meaningful differences and explore influencing factors, ensuring the robustness of our findings.

The survey took place before the implementation of the PFSE program, which focuses on training parents. Multi-stage stratified cluster sampling was used in the study. Based on the economic situation of the seven administrative districts of Luzhou in the last 2 years, they were divided into three economic levels [53]: two districts (Jiangyang and Longmatan) were in good economic condition, two districts (Naxi and Luxian) were in average economic condition, and three districts (Hejiang, Gulin, and Xuyong) were economically disadvantaged. Therefore, in the first stage, one administrative district (Longmatan, Naxi and Hejiang) was selected from each economic category. In the second phase, we randomly selected eight kindergartens in each district, including four urban kindergartens and four rural kindergartens. To be included, kindergartens needed to be large in size, with >鈥�100 students and >鈥�10 teachers.

Data collection and procedure

The surveys were conducted by trained investigators from the Sex Education Team. They administered the questionnaires during school hours in the selected kindergartens. Eligibility criteria for participation included: (1) parents who frequently care for preschool children (one child per parent); (2) those with basic cognitive and learning abilities; and (3) those willing to participate in the survey. Exclusion criteria were: (1) parents who had recently participated in similar sex education programs; and (2) those with language barriers that hindered communication. One parent of each sampled child was invited to participate voluntarily. The investigators explained the consent form in detail, ensuring participants understood the confidentiality and voluntary nature of the study. Out of 4,419 parents surveyed, 4,398 agreed to participate, resulting in a consent rate of 99.5%. After administering the face-to-face questionnaire, 4,322 were deemed valid, with a validity rate of 98.3%. The survey used was a self-administered 鈥淨uestionnaire on Knowledge, Beliefs, and Behavioral Status Related to Sexuality Education in Early Childhood (Parent鈥檚 Version).鈥�

Measures

Sociodemographic variables

Sociodemographic characteristics included residence (rural鈥�=鈥�1, urban鈥�=鈥�2), nature of kindergarten (public鈥�=鈥�1, private鈥�=鈥�2), sex of parents (male鈥�=鈥�1, female鈥�=鈥�2), age of parents, parental education level, parental occupation (teachers or doctors鈥�=鈥�1, others鈥�=鈥�0; we believe that there is a close relationship between whether parents are teachers or doctors and children鈥檚 sex education), average annual gross family income, family type (original family鈥�=鈥�1, single parent family鈥�=鈥�2, reconstituted family鈥�=鈥�3), sex of children (male鈥�=鈥�1, female鈥�=鈥�2), grade (from elementary age class to older class), and left-behind children and one-child family status. Sex was defined as the biological sex of the student. Parental educational level was based on the highest level of education parents had completed.

PFSE knowledge, attitude, and practice scales

Using the key concepts and learning objectives in the International Technical Guidance on Sex Education as a guiding framework in combination with the characteristics of Chinese society and customs, and referring to the early childhood sex education curriculum written by the children鈥檚 sex education expert Hu Jiawei [54] and related literature [55], a three-part questionnaire of knowledge, attitude, and practices for 3鈥�6-year-old children was designed and reported in other literature [56]. Based on the teacher questionnaire, the parent questionnaire was obtained by adding an item on 鈥渆xpression of love in life鈥� in the parent population. The overall Cronbach鈥檚 伪 value of the parent questionnaire was 0.801, and the Cronbach鈥檚 伪 values of the dimensions were 0.726, 0.805 and 0.898, respectively, indicating good reliability and validity. An English version of the scales is provided as a supplementary file (Supplementary File 1).

PFSE Knowledge (PFSE-K): The level of PFSE Knowledge was measured by using a nine-item scale (e.g., 鈥淲hat are the private parts of boys?鈥�). Each question was given a score of 1 point for a correct answer and 0 points for a wrong answer or do not know, and the total score ranged from 0 to 9 points. The higher the total score was, the better the knowledge of PFSE. A total score鈥�鈮�鈥�6 was defined as PFSE-K pass.

PFSE Attitude (PFSE-A): Attitudes toward PFSE were evaluated using an eight-item scale (e.g., 鈥淒o you agree that young children should be told the scientific names of the reproductive organs (e.g., penis, testicles, labia)?鈥�) to assess individuals鈥� attitudes toward family sex education for young children. The scale was scored using a Likert scale, with 1鈥�=鈥塗otally disagree, 2鈥�=鈥塖omewhat disagree, 3鈥�=鈥塏eutral, 4鈥�=鈥塻omewhat agree, and 5鈥�=鈥塁ompletely agree. The total scale score ranged from 8 to 40, with higher scores indicating more positive attitudes toward PFSE. A total score鈥�鈮�鈥�32 was defined as PFSE-A positive.

PFSE practices (PFSE-P): Parental PFSE practices were evaluated using an 11-item scale (e.g., 鈥淗ow many times in your previous life have you taught young children about the differences between male and female bodies?鈥�, See Table听1 for details), which was scored using a Likert scale with 0鈥�=鈥�0, 1鈥�=鈥�1鈥�2 times, 2鈥�=鈥�3鈥�4 times, and 3鈥�=鈥塵ore than 5 times. The total scale score ranged from 0 to 33, with higher scores indicating better family sex education behaviors of parents of children. A total score鈥�鈮�鈥�20 was defined as PFSE-P pass.

Table 1 Participants鈥� practices of PFSE [$\:(\stackrel{-}{x}\pm\:s$)]

Other information about PFSE

This survey was conducted by asking parents 鈥淲ho do you think should be responsible for sex education for young children?鈥� to obtain parents鈥� awareness of family responsibilities. Question options included (a) father, (b) mother, (c) caregiver other than parents, (d) teacher, (e) sex education specialist, (f) government, (g) doctor, and (h) other. Choosing any of options 1鈥�3 was considered to be an indication that the respondent perceives that the family has responsibility for PFSE. Respondents were also asked 鈥淲hat are the difficulties in implementing PFSE?鈥�, and the possible answers to this question were (a) Chinese people are afraid to talk about 鈥渟ex鈥� and there is a lack of a relaxed social environment, (b) family members are not very supportive of sex education, (c) there is a lack of time/effort, (d) they do not have much knowledge about sex, (e) they feel that it is not natural to talk about sex with their children and they feel sorry for it, (f) they lack communication methods and skills to educate their children about sex education, and (g) there is a lack of systematic teaching materials or curricula on early childhood sex education that can be used as a model for the children. Respondents could choose one, two, or multiple answers. Parents were also asked whether they consent to PFSE (1鈥�=鈥墆es, 2鈥�=鈥塶o).

Analysis

EpiData Version 3.1 software (EpiData Association., Odense, Denmark) and double entry were used to build the database. Subsequently, SPSS Statistics Version 22.0 (IBM, Inc., Armonk, NY, USA) was used for data analysis. The continuous data conforming to a normal distribution were described by mean鈥�卤鈥塻tandard deviation (SD) and analyzed by t-tests; the categorical data were described by percentage and analyzed by chi-squared tests. The demographic variables with P鈥�<鈥�0.10 or that have been widely reported in the literature (i.e., father鈥檚 education level, mother鈥檚 education level, average annual gross family income, father鈥檚 occupation, mother鈥檚 occupation) were entered into the multivariate logistic regression models as covariates. Multivariate logistic regression models were performed to explore the parental practice pass rate of PFSE, and the adjusted odds ratios and 95% confidence intervals were calculated. All hypothesis tests were two-sided, and P鈥�<鈥�0.05 was considered to be statistically significant. Because the multifactor analysis was based on default complete data, missing data were not dealt with separately.

Ethical consideration

This study was approved by the Ethics Committee of the Affiliated Hospital of Southwest Medical University, China (No. KY2022240) and the local education bureau. Written informed consent was obtained from the participants.

Results

Sociodemographic characteristics of the participants

Table听2 shows the sociodemographic characteristics of the participants. Public and private kindergartens each accounted for half of the total. The ratio of respondents living in rural and urban areas was close to 3:7, with mothers dominating at 81.07%. Nearly half of their children were in the older classes, the gender ratio of the children was almost equal, and about 30% of children were classified as left behind children and 30% were only children (Table听2).

Table 2 Sociodemographic characteristics of the participants

Parental involvement in PFSE

Less than half of parents had adequate PFSE knowledge, about one-third held positive attitudes, and less than 70% had adequate parenting practices, with urban parents outperforming rural parents in all three areas. Although 96.18% of parents were aware of their responsibility for sex education, less than half of them support PFSE, with a higher rate of support in urban areas. The percentage of parents who think that there are difficulties in the process of sex education was as high as 96.66%, with parents in urban areas reporting more difficulties (Table听3).

Table 3 Parental involvement in PFSE [n (%)]

A comparative analysis of practice of PFSE in rural and urban areas revealed that the top three items with the worst parental performance were D2) names and functions of reproductive organs, D1) teaching children where boys鈥� and girls鈥� bodies are different, and D3) wiping buttocks correctly, with D2 and D1 being worse in rural areas. In addition, D7, which corresponds to being able to express love to the child, also differed between rural and urban areas, with urban parents significantly outperforming rural parents. Overall, the sex education practices of PFSE in urban areas were better than those in rural areas (Table听1).

Parents鈥� pass rate of PFSE-K, PFSE-A, and PFSE-P

The pass rate of PFSE-P in this study was 69.04% (2984/4322), with a 95% confidence interval of 67.66鈥�70.42%. Based on chi-squared tests or trend chi-squared tests, the following respondents had a higher pass rate (P鈥�<鈥�0.05) for PFSE-P: female, living in the city, having higher education level, being a medical professional or an educator, being the parent of an only child, being the parent of a left-behind child, having a higher annual household income, having more knowledge about PFSE, having more positive attitudes towards PFSE, being supportive of PFSE, believing that the family has the responsibility for sex education, and perceiving more difficulties in sex education (Table听4).

Table 4 Parents鈥� pass rate of PFSE practices with different characteristics [n (%)]

Logistic regression analysis of determinants of parents鈥� PFSE practice

The determinants of PFSE-P pass were analyzed by fitting a binary logistic regression model using the Forward STEP (Conditional) method, with PFSE-P result as the dependent variable (1鈥�=鈥塸ass, 0鈥�=鈥塮ail) and the factors that were statistically significant in the univariate analysis as the independent variables. After controlling for other confounding factors, parents having the following characteristics had a higher pass rate of PFSE practices: PFSE-K pass (odds ratio (OR)鈥�=鈥�1.31, P鈥�<鈥�0.001), PFSE-A positive (OR鈥�=鈥�1.49, P鈥�<鈥�0.001), belief that the family is responsible for sex education (OR鈥�=鈥�1.85, P鈥�<鈥�0.001), feel double educational difficulties (OR鈥�=鈥�1.21, P鈥�=鈥�0.022), feel multiple educational difficulties (OR鈥�=鈥�1.64, P鈥�<鈥�0.001), supportive of PFSE (OR鈥�=鈥�1.59, P鈥�<鈥�0.001), and having children in middle age class (OR鈥�=鈥�1.26, P鈥�=鈥�0.014) and older class (OR鈥�=鈥�1.39, P鈥�<鈥�0.001). The factors associated with PFSE practices among urban parents were similar to those of the total population. Although the PFSE practices of rural parents were not affected by the age of children, they were affected by whether or not children were left behind, as parents of left-behind children had a lower pass rate of PFSE-P (OR鈥�=鈥�0.75, P鈥�=鈥�0.020) (Table听5 and Table S1).

Table 5 Logistic regression analysis of determinants of parents鈥� PFSE practice [adjusted odds ratio (95% confidence intervals)]

Discussion

Our results suggest that parents of preschoolers in Luzhou have poor knowledge, attitude, and practices of PFSE and that the problem is more severe in rural areas. We found that parental knowledge and attitude toward PFSE, children鈥檚 age, and the number of difficulties in implementing sex education were all independent determinants of parents鈥� practices of PFSE. These relationships were true for both rural and urban areas. However, left-behind child status was an additional independent influence on the PFSE practices in rural areas, where the situation was worse than in urban areas. Our results illustrate that there is still a lot of room for improvement in PFSE. Future interventions should focus on improving parents鈥� knowledge and skill of PFSE, guiding parents to take responsibility for PFSE, improving their attitudes, and creating a favorable social environment while paying special attention to families with left-behind children in rural areas. The results provide an important reference point for future PFSE intervention efforts.

The PFSE situation in Luzhou is not encouraging. First, parents鈥� attitudes toward PFSE were generally not positive, which is in contrast to reports by Fang et al. [57, 58], which showed that Chinese parents鈥� attitudes toward sex education have improved in recent years. These differing results may be because we used a more objective and comprehensive scale to assess attitudes toward family sex education, whereas other studies may have addressed the issue using only one or two questions. Our results also suggest that parental attitudes toward sex education, especially PFSE, need further scientific guidance. Second, parents鈥� knowledge about sex education is poor. The subjects of this study were born in the 1980s and 1990s, and their poor mastery of sexual knowledge was influenced by the sex education of Chinese adolescents in the past [59, 60]. Inadequate knowledge among parents is one of the important reasons why PFSE cannot be successfully implemented in Chinese families. Improving parents鈥� knowledge through parental training is undoubtedly the most basic measure for future interventions. Finally, consistent with the results of a large number of similar studies [61, 62], the practices of parents involved in sex education in this study were poor, with a pass rate of less than 70% for PFSE-P. The three questions with lowest scores focused on the areas of physiology education and sexual hygiene education. This result may be due to parents鈥� inadequate knowledge and skills and to the traditional social environment in China. According to traditional beliefs, sex and related topics are not appropriate for intergenerational communication [63], For instance, when children inquire about sex, parents often dodge the question with evasive responses such as 鈥測ou鈥檒l understand when you鈥檙e older鈥� or switch channels during TV scenes involving intimacy, rather than using these moments as opportunities to discuss consent and respectful relationships. The traditional Chinese culture鈥檚 emphasis on female chastity and the stigma around premarital sex and early pregnancy for girls also contribute to this reticence. Thus, the scientific names and functions of male and female body parts and reproductive organs are less frequently discussed in Chinese families than in Western European and American families. As a result, many opportunities for family education are missed. In addition, parents may be concerned that teaching their children about sex too early may increase the risk of precocious maturation and early sexual activity [64]. However, reports suggest that this parental concern is unfounded [65,66,67]. At the preschool stage, scientific sex education by parents is not only effective in parent-children communication [36], but it is also conducive to the elimination of sexual shame in children and to the cultivation of good sexual concepts and sexual morality [68].

As reported in previous studies [60, 63, 69], we found that parents鈥� attitudes, knowledge, and children鈥檚 age were important factors associated with PFSE-P. First, according to the TPB [51], attitude is the first important factor that influences behavior. In our study, parents鈥� attitudes toward PFSE were comprehensively represented by the PFSE-A scale and the three dimensions related to whether or not parents perceive PFSE as a family responsibility and whether or not they are in favor of PFSE. We found a positive correlation between all three dimensions and PFSE literacy. This suggests that future interventions for PFSE should first focus on parental attitudinal guidance and that only when parents have a positive attitude can they recognize the need for PFSE and increase their sense of responsibility for education.

Second, the TPB [51] suggests that perceived behavioral control is the second most important factor influencing behavior. Both parental knowledge and child age are factors related to parents鈥� perceived behavioral control for several reasons. First, the respondents were young Chinese parents born in the 1980s and 1990s who mostly relied on the Internet or self-education to complete their own sex education [64]. Parents with poorer knowledge and skills, on the other hand, encountered more difficulties in the process of sex education and were more likely to avoid or discourage their children鈥檚 sex-related behaviors and problems directly [70]. As a result, parents with poor sexuality knowledge have fewer family sex education practices. However, parents of older toddlers in this study reported higher rates of PFSE practices. As children grow older, they become more curious about sex and related topics and may ask many sex-related questions [7], such as 鈥淲here do I come from?鈥� They may also engage in many sex-related behaviors, such as masturbating, playing with, or exposing their genitals. When parents answer these questions, the likelihood of family sex education increases, and parents are more likely to perceive the need for PFSE. Thus, parental knowledge and the sexual curiosity that accompanies children鈥檚 aging are both important factors influencing parental control over education. Therefore, a second basic strategy for intervening in PFSE is to increase the knowledge and skills of parents and other caregivers through sexual health education.

In the TPB, the subjective norms of sex education are the third important factor influencing PFSE practice [51]. The relevant literature indicates that the inclusiveness of sex education in Chinese society is currently improving [71]. For example, the rights and duties related to family sex education have been written into Chinese regulations [31]. However, changes in the social environment and people鈥檚 attitudes cannot be detected within a short period of time. We also found that the higher the rate of family sex education practice, the more difficulties parents felt. Not surprisingly, people who do not practice PFSE do not really experience difficulties and naturally do not think much about their existence; in contrast, only parents who practice PFSE regularly perceive difficulties more often. Therefore, the number of perceived difficulties is inversely proportional to the pass rate of PFSE practice. At present, the implementation of PFSE in China faces many difficulties. Making progress will require working at the community, school, and family levels, strengthening publicity and public opinion guidance, resolving all kinds of difficulties in children鈥檚 sex education, and creating good community and family support environments for PFSE.

Our comparison between urban and rural areas showed that PFSE problems were more pronounced in rural areas in terms of knowledge, attitudes, and practices of sex education, which agrees with a report published by Guo Wei [47]. This disparity can be understood through the lens of the TPB. First, attitudes towards sex education are more negative in rural areas due to a lack of exposure to progressive ideas and stronger adherence to traditional values. Rural parents and guardians often view sex as a taboo subject, which discourages open discussions and education. Second, subjective norms differ significantly between urban and rural communities. In rural areas, homogeneous social networks reinforce conservative norms that do not support sex education, whereas urban environments offer more diverse perspectives that encourage positive attitudes towards PFSE. Third, perceived behavioral control is lower in rural areas due to limited access to sex education resources and lower educational levels among parents or guardians. This lack of knowledge and skills makes it difficult for rural parents to effectively implement PFSE.

The situation is further complicated by the prevalence of left-behind children in rural areas, as reported by Lukolo and van Dyk [27], these children often rely on grandparents for care, who may have even lower awareness and knowledge of sex education. The absence of parents in the PFSE process means that the responsibility falls on grandparents, who may not be equipped to provide adequate sex education. This lack of parental involvement and the reliance on less knowledgeable caregivers further hinder the implementation of PFSE in rural areas.

To enhance sex education in rural areas, particularly for left-behind children, interventions should address these TPB constructs. Improving attitudes can be achieved through media campaigns and community programs that challenge traditional beliefs and promote the benefits of sex education. Shifting subjective norms requires creating supportive social environments where open discussions about sex education are encouraged and normalized. Enhancing perceived behavioral control involves providing training and educational resources to both parents and caregivers to equip them with the knowledge and skills needed to effectively implement PFSE. Additionally, developing community-centered sex education programs led by authoritative organizations can help educate parents and caregivers on age-appropriate discussions of sexual health. Professional counseling services should also be made available to address the emotional and psychological aspects of sexual health for these children. Finally, creating economic incentives for healthcare providers in rural areas can ensure that families have access to the necessary support and education.

Study limitations

This study had several limitations. First, this was a cross-sectional survey, and no causal relationship can be drawn. Second, the issue of sex education is still a conservative issue in contemporary Chinese society, thus the results inevitably suffered from reporting bias. Parents, as the first people responsible for the education of their young children, may have over-reported or suffered from recall bias when asked whether they had conducted family sex education for their own children. Third, a higher percentage of the study population had parents who were teachers and doctors, which may have led to an underestimation of the results of the study due to a higher perception of sex education among caregivers in these professions. Therefore, the extent to which the results of this study apply to all parents of young children is unknown. In addition, family sex education was only reflected through parents鈥� educational information; the study lacked assessment of other caregivers鈥� participation, which should be considered in future studies. Finally, the results of this study are specific to the Luzhou region. They provide a strong reference for regions with comparable economic and educational levels, but further validation is needed when extrapolating to other regions. However, there have been few studies of PFSE in China, and this is one of the few that investigated PFSE using well-designed scales.

Conclusions

In this study, we found that in Luzhou, parents of preschoolers, especially those in rural areas, lack practices, knowledge, and positive attitudes toward PFSE. Parental knowledge, attitudes, children鈥檚 age, and implementation difficulties are independent determinants of PFSE practices in both urban and rural areas. However, in rural areas, left-behind child status further impacts PFSE practices negatively. In rural areas, left-behind children face additional challenges. Therefore, promoting PFSE requires comprehensive health education, changing parents鈥� attitudes, improving their sexual knowledge, and strengthening social support. Future research should explore the long-term effects of PFSE and the effectiveness of various interventions, particularly in diverse cultural and socioeconomic contexts.