Multilevel factors influencing parental food decision-making across childhood stages in China: a qualitative study...

China faces a double burden of childhood malnutrition. Parents are key dietary gatekeepers, yet limited research has examined how food decision-making evolves across child developmental stages. This study explored multilevel, dynamic determinants of parental food choices across infancy, preschool and primary school age in Zhejiang, China.

Using visual ethnography, 29 caregivers completed 7-day photographic food diaries followed by in-depth interviews. Data were thematically analysed using an inductive-deductive approach within a socioecological framework. A causal loop diagram was developed to examine cross-level interactions.

Feeding strategies shifted from strong parental control in infancy to increasing child autonomy during preschool years and to time-pressured, convenience-oriented routines in primary school age, often with greater reliance on energy-dense, processed or takeaway foods. Picky-eating strategies evolved from direct food and texture modifications in infancy to gradual exposure and experiential methods in older children. Across stages, parental decisions were shaped by interacting influences including child health priorities, food safety concerns, time constraints, nutrition knowledge and children's preferences. Grandparents, cultural food norms, traditional beliefs and digital information environments could either support or undermine healthy feeding. Systems analysis further identified reinforcing pathways, including time pressure, convenience reliance, greater child autonomy, grandparent caregiving (eg, indulgent practices), unclear age-specific guidance and digital marketing or misleading online information, that may sustain less healthy practices. In contrast, balancing pathways, including parental prioritisation of child health, stronger nutrition knowledge and trust in school meals and health professionals, supported healthier behaviours, including dietary diversity, home-cooked meals and appropriate supplement use.

Parental food decision-making is developmental, dynamic and shaped by interacting socioecological influences. System-based, age-specific interventions should provide clear guidance through trusted institutions, engage parents and grandparents, strengthen food safety and healthy food environments, regulate digital marketing of unhealthy foods and improve nutrition transparency to support healthier childhood diets in China.