Quantitative assessment of multidimensional health disparities and their determinants among vulnerable children

Introduction

Children represent one of the most at-risk populations within society. Among them, those classified as vulnerable, defined as those exposed to higher risks compared to their peers constitute a group warranting particular concern. In the context of food insecurity, the spread of infectious diseases, climate change, and ongoing humanitarian crises, safeguarding fundamental rights such as access to health care, adequate nutrition, and education, presents significant challenges. Vulnerable children experience multidimensional deprivation and are exposed to considerable risks to their health and overall well-being (1). Although progress has been made globally in protecting the rights and interests of children, a substantial proportion remains marginalized. Regional disparities persist in promoting healthy development among children worldwide. Health conditions related to malnutrition are becoming increasingly prevalent, and systemic challenges, including educational inequality, remain unresolved (2).

At the current trajectory, only one-quarter of countries are expected to meet 70% of the child-related targets outlined in the United Nations Sustainable Development Goals by 2030, leaving a substantial number of children in environments where basic rights remain unmet (1). Therefore, it is crucial to examine the health of vulnerable children through a multidimensional lens, identifying disparities and associated determinants. Such analyses are essential to address their comprehensive health needs and to support efforts aimed at promoting health equity.

From an international perspective, the term “vulnerable children” specifically refers to those living in severely challenging circumstances, comprising a particularly high-risk subgroup within the broader pediatric population (3). This designation considers various factors impacting child development, including socioeconomic deprivation, family dysfunction, and specific social or legal statuses. Such a definition enables more precise identification of children requiring support across different levels of need and serves as a foundation for formulating targeted interventions and protection policies aimed at safeguarding fundamental rights and supporting healthy development (4). Vulnerable children are disproportionately affected by adverse conditions such as poverty, disrupted or incomplete family structures, physical and psychological disorders, and exposure to environmental harm. These factors significantly impede their typical growth and developmental trajectories.

The health status and corresponding needs of vulnerable children have remained a key focus within academic discourse both domestically and internationally. Existing literature addresses health concerns experienced by vulnerable children across physiological, psychological, and social dimensions, emphasizing the multifaceted challenges that they face. With regard to nutritional health, a report published by the United Nations International Children’s Emergency Fund (UNICEF) in June 2024 highlighted a severe state of food insecurity and limited dietary diversity among children (1). Approximately 181 million children under the age of 5 were reported to experience severe food poverty, accounting for one-quarter of the global population in this age group. These children exhibited a 50% higher mortality risk compared to their peers, primarily due to deficiencies in protein, vitamins, and essential minerals.

Among vulnerable children (aged >6 months), 80% primarily consumed starchy staple foods such as breast milk, milk, rice, corn, and wheat; fewer than 10% had access to fruits and vegetables, while less than 5% consumed nutrient-rich animal products such as eggs, poultry, and fish (5-8). Significant regional disparities were observed. In certain African countries, approximately 40% of vulnerable children experienced stunted growth in height and weight over a period of 2–3 years due to malnutrition. In the most severely affected regions, over 80% of caregivers reported that their children had gone without food for an entire day (9-13).

Psychological health concerns among vulnerable children are predominantly characterized by conditions such as post-traumatic stress disorder (PTSD), separation anxiety disorder, and symptoms associated with abandonment. Research has demonstrated that 60% of children with a history of abuse developed PTSD symptoms, with 35% of cases persisting for more than two years and only 15% receiving professional psychological intervention (14-16). Among children with incarcerated parents or parents who are severely ill, elevated levels of separation anxiety were frequently observed, with significantly higher scores reported on the Social Anxiety Scale for Children (SASC) compared to peers without such circumstances (17,18). Significant disparities in access to psychological health services have been observed between urban and rural regions, as well as across different socioeconomic groups. Findings from Australian studies indicated that the availability of child psychological consultants in rural areas was only one-fifth of that in urban settings. Additionally, the proportion of children from low-income families receiving psychological support was 40% lower than that of children from high-income households (19,20). Despite elevated health risks, access to health services remains limited for many vulnerable children, largely due to institutional barriers embedded within health policy implementation. These systemic exclusions contribute to the widening of existing health disparities (21-23).

Prior studies have indicated that the multidimensional health of vulnerable children encompasses physiological, psychological, and social domains, as well as their interaction with support systems. Key determinants of survival and general health needs include material stability, environmental safety, and comprehensive health protection. These elements directly influence both the accessibility and depth of quality of life (QoL) among this population. In terms of educational and developmental needs, equitable access to educational resources, individualized support, and opportunities for social participation are essential. Positive social engagement and adequate educational support contribute to the social development of children facing adversity, while a lack of such support may intensify individual anxiety (24-26).

In terms of family and social support, vulnerable children benefit from stable, high-quality familial relationships, multi-stakeholder support networks, and socially inclusive environments. Notably, the role of family responses to psychological health needs plays a key role in shaping the sense of self-worth and identity among children facing adversity (27,28). Existing literature consistently identifies household income, parental educational attainment, and the stability of family structure as central determinants of health among vulnerable children. Health inequality emerges as a central component of health vulnerability, functioning both as an outcome of accumulated health risks and as a factor that further compounds difficulties in areas such as education and personal safety.

While previous studies have emphasized individual health dimensions or isolated influencing factors, few have systematically addressed the multidimensional health profile of vulnerable children using integrated frameworks or comparative approaches. Consequently, these studies fall short in systematically examining the influence of social determinants particularly at the family level on the health risks faced by vulnerable children. Multidimensional investigations into health disparities among this population remain limited, and empirical analyses incorporating composite indicators such as QoL, psychological well-being, and social interaction are notably scarce.

To address this gap, the present study used a cross-sectional survey to assess health disparities between vulnerable and non-vulnerable children and to examine the potential impact of family-related factors on child health outcomes. The objective was to conduct an in-depth analysis of disparities in the areas of family-related socioeconomic indicators and individual psychological indicators. The findings aim to inform the design of precision-based interventions and targeted services, providing an evidence-based foundation for the prevention and management of health risks, and contributing to the development of more comprehensive and effective child health policies. We present this article in accordance with the SURGE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0161/rc).

Methods

Participants

Children enrolled in 14 primary schools located in Shanxi Province, China, were selected using convenience sampling between March 2025 and June 2025. Schools were selected following a principle of hierarchical coverage: urban schools included central urban primary schools, peri-urban (urban-rural fringe) primary schools, and county-level primary schools, while rural schools were selected by randomly sampling all primary schools within a given township. The sample size was determined according to the standard guideline of 5 to 10 participants per questionnaire item. As the questionnaire comprised of 98 items, the optimal sample size was calculated to be between 490 and 980 (29).

Data collection was carried out in each school using cluster sampling. Random selection was conducted at the class level, with efforts made to maintain a consistent sample size across all grade levels. A total of 1,560 questionnaires were distributed. Of these, 1,493 were returned, and 1,464 were deemed valid, yielding a validity rate of 98.1%. Among the valid respondents, 1,181 (80.7%) were categorized as non-vulnerable children, and 283 (19.3%) were identified as vulnerable children. Statistically significant differences were observed between the two groups in terms of place of residence, household economic level, parental education level, and parental marital status (Tables 1,2).

• Inclusion criteria: children aged 6 to 12 years were eligible for inclusion. The classification of vulnerable children encompassed those experiencing economic hardship, those with physical disabilities, and those facing guardianship challenges. This classification included children identified as requiring priority support within the educational and social service systems. Eligible participants included one or more of the following categories: left-behind children in rural areas, vulnerable children residing in either urban or rural settings, children from single-parent or blended families, orphans, children with disabilities, children exhibiting psychological concerns, those subjected to bullying, and children exposed to adverse family environments. “Left-behind children in rural areas” refers to minors under 16 years of age with rural household registration whose parents have migrated for work (either both parents, or one parent while the other lacks caregiving capacity), and who therefore cannot live with their parents.
• Exclusion criteria: children presenting with learning difficulties were excluded from the study.

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Shanxi Medical University (No. 2023039). Written informed consent was obtained from all patients’ guardians.

Measurement instruments

Three standardized instruments were utilized in this study: the QoL Scale for Children and Adolescents (QLSCA), the SASC, and the Children’s Loneliness Scale (CLS) (30-32). These instruments were employed to comprehensively assess the physical, psychological, and social health status of vulnerable children and to facilitate comparison of general health outcomes between vulnerable and non-vulnerable children.

The QLSCA consists of 13 dimensions that can be further grouped into four broader factors. The psychosocial functioning factor includes dimensions such as teacher-student relationships (e.g., interactions with teachers and feelings about these interactions), peer relationships, parent-child relationships, learning ability and attitudes, and self-concept. The physical and psychological health factor comprises somatic sensations, negative emotions, and attitudes toward homework. The living environment factor includes living convenience, opportunities for activities, and physical exercise ability. The quality-of-life satisfaction factor reflects self-satisfaction and other dimensions related to overall subjective well-being.

The SASC assesses children’s social anxiety across two dimensions and contains a total of 10 items. The first dimension, fear of negative evaluation, includes six items and focuses on children’s concerns about being judged negatively in social situations. These items capture children’s sensitivity to others’ opinions and reflect their underlying feelings of insecurity during social interactions. The second dimension, social avoidance and distress, consists of four items and evaluates children’s behavioral responses and emotional experiences in social situations, particularly avoidance behaviors and distress caused by anxiety. Together, these two dimensions provide a relatively comprehensive assessment of children’s social anxiety.

The CLS includes 24 items, of which 16 are core items used to directly measure children’s feelings of loneliness and social dissatisfaction. These items capture children’s experiences of rejection and isolation within social relationships. The remaining eight items are filler items related to children’s interests, hobbies, and daily activities. These filler items are designed to reduce children’s focus on loneliness-related questions, thereby minimizing potential psychological pressure, while also indirectly reflecting how daily life experiences may influence feelings of loneliness. Overall, the scale provides a comprehensive picture of children’s loneliness by assessing multiple aspects such as peer relationships, friendship quality, and levels of social participation.

Statistical analysis

A cross-sectional survey design was used in this study. The primary outcome variable, “if in difficulty”, was treated as a binary categorical variable (no difficulty =0; difficulty =1). Independent variables included general demographic characteristics (e.g., place of residence, sex, age), family-related socioeconomic indicators (e.g., household economic level, parental education level, parental marital status), and scores derived from individual psychological assessment scales (e.g., teacher-student relationship, self-concept, and total QoL score).

Group differences in categorical variables (e.g., place of residence, sex) were assessed using the Chi-squared test. Continuous variables (e.g., age, scale scores) were first tested for normality using the Shapiro-Wilk test. Variables followed a normal distribution were compared using the independent samples t-test. For variables not conforming to a normal distribution, rank differences were analyzed using the Mann-Whitney U test. A multivariate logistic regression analysis was conducted, with “if in difficulty” as the dependent variable (no difficulty =0; difficulty =1). Variables with P<0.1 in the univariate analysis were included in the logistic regression model, using a forward stepwise method. The odds ratio (OR), 95% confidence interval (95% CI), and Wald statistics were reported to identify independent influencing factors.

Reliability and validity testing of measurement instruments

The reliability and validity of the following three scales were assessed in this study: the QLSCA, the SASC, and the CLS. The results indicated that all three instruments demonstrated satisfactory psychometric properties.

• Internal consistency reliability: internal consistency was assessed using Cronbach’s alpha (α). The coefficients were as follows: QLSCA (49 items), α=0.919; SASC (10 items), α=0.866; and CLS (24 items) α=0.875. All values exceeded the commonly accepted threshold of 0.70, indicating high internal consistency and strong reliability within each scale.
• Construct validity: construct validity was assessed using the Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy and Bartlett’s test of sphericity. The QLSCA yielded a KMO value of 0.936 and a Bartlett’s test approximate chi-square of 21,851.692 (df=1,176, P<0.001). For the SASC, the KMO value was 0.918, with a Bartlett’s test chi-square value of 5,175.732 (df=45, P<0.001). For the CLS, the KMO value was 0.928, and the Bartlett’s chi-square value was 11,326.777 (df=276, P<0.001). KMO values greater than 0.90 are classified as “excellent” and the statistically significant results of Bartlett’s test (P<0.001) confirm the suitability of these datasets for exploratory factor analysis. These findings demonstrated that all three scales possessed strong construct validity.

Common method bias (CMB) assessment

To account for potential effects of CMB associated with self-reported data, several questionnaire items were reverse-scored, and participant privacy was protected throughout data collection. Harman’s single-factor test was applied during data processing to assess the extent of CMB.

The unrotated factor analysis identified 24 factors with eigenvalues greater than 1, collectively explaining 62.58% of the total variance. The first factor accounted for 20.70% of the variance, which was substantially below the commonly accepted threshold of 40%. These findings suggested that the impact of CMB was not significant.

Results

Association between demographic characteristics and difficulty status

A significantly higher proportion of children experiencing difficulty resided in rural areas (64.0%) compared to those not experiencing difficulty (48.8%) (χ²=21.082, P<0.001). Children in the difficulty group were slightly older (11.67±1.02 years) than those in the no difficulty group (11.45±1.16 years) (t=−3.174, P=0.002). The children in the difficulty group had a slightly lower mean height (150.18±10.59 vs. 152.10±9.65 cm, t=2.941, P=0.003). No statistically significant difference was found in sex distribution between the two groups (χ²=0.696, P=0.404). With respect to academic performance, the proportion of children classified as having “average” and “poor” academic outcomes were significantly higher in the difficulty group (54.4% and 11.3%, respectively) than in the no difficulty group (45.0% and 6.8%, respectively) (Z=−4.422, P<0.001). Regarding psychological needs, the proportion of children identified as having psychological needs was significantly greater in the difficulty group (12.7%) compared to the no difficulty group (1.2%) (χ²=92.092, P<0.001) (Tables 1,2).

Association between socioeconomic factors and difficulty status

Significantly higher proportions of children with “average”, “poor”, and “fairly poor” economic levels were observed in the difficulty group (56.2%, 7.4%, and 1.4%, respectively) compared to the no difficulty group (47.2%, 1.9%, and 0.2%, respectively) (Z=–5.285, P<0.001). Similarly, the proportion of children living in “average” and “poor” living conditions were higher in the difficulty group (56.4% and 4.3%, respectively) (Z=–5.723, P<0.001). Parental education level was inversely associated with difficulty status. A greater proportion of children in the difficulty group had fathers and mothers whose highest education level was “primary school level or below” (11.3% vs. 5.3% and 13.1% vs. 5.5%, respectively) (Z_father=−6.749, Z_mother=−7.320; both P<0.001).

Family structure also demonstrated significant differences. The proportion of children living with both parents was significantly lower in the difficulty group (29.7%) compared to the no difficulty group (65.3%), whereas the proportion of children living with grandparents (36.0%) and with a single parent (14.8%) were significantly higher in the difficulty group (χ²=264.672, P<0.001). Significant differences were observed in parental marital status. The proportion of children whose parents were “separated,” “divorced,” or “single” were substantially higher in the difficulty group (24.7%, 41.3%, and 12.0%, respectively) than in the no difficulty group (0.1%, 0.2%, and 0%, respectively). In contrast, only 21.9% of children in the difficulty group came from households with a “complete marriage” (χ²=1,067.355, P<0.001).

Differences in QLSCA

The QLSCA assesses four primary domains: psychosocial function, physio-psychological health, living environment, and satisfaction with QoL. Significant differences were observed between the difficulty and no difficulty groups across all primary factors, as well as the specific dimensions within each factor (Table 3).

Psychosocial functioning

Significantly lower scores were observed in the difficulty group compared to the no difficulty group for the dimensions of teacher–student relationship (t=5.374, P<0.001), peer relationship (t=3.983, P<0.001), parent–child relationship (t=5.903, P<0.001), learning ability and attitudes (t=4.761, P<0.001), and self-concept (t=4.235, P<0.001). These findings indicate greater interpersonal challenges in familial, school, and peer contexts among children in the difficulty group. The lower scores further indicate that physiological perception and engagement in learning were adversely affected by the presence of difficulty.

Physio-psychological health

Significantly lower scores were recorded in the difficulty group compared to the no difficulty group in the dimensions of somatic sensation (t=4.795, P<0.001), negative emotions (t=2.882, P=0.004), and attitudes towards homework (t=3.105, P=0.002). These results indicate disadvantages in access to daily life resources, participation in physical activities, and aspects of functional development among children in the difficulty group. The difference observed in the total score of physio-psychological health (t=4.552, P<0.001) further supports the potential adverse impact of difficulty on the integration of physiological and psychological health domains.

Living environment

Children in the difficulty group demonstrated significantly lower scores in life convenience (t=4.975, P<0.001), opportunities for activities (t=7.297, P<0.001), motor ability (t=4.068, P<0.001), and the total score of living environment (t=7.124, P<0.001). These findings indicate that the abundance of resources, functional accessibility, and overall comfort of the living environment were significantly reduced in the difficulty group compared to the no difficulty group.

Satisfaction with QoL

A significantly lower score in satisfaction with QoL was observed in the difficulty group compared to the no difficulty group (t=5.929, P<0.001). This result corresponded with disadvantages identified across related sub-dimensions (e.g., self-satisfaction, satisfaction with others), indicating the presence of a reinforcing pattern of multidimensional deprivation and decline in subjective well-being.

Total QoL score

The total QoL score in the difficulty group (142.50±18.47) was significantly lower than that in the no difficulty group (151.84±18.11) (t=7.760, P<0.001). This result indicates that the presence of difficulty was associated with a substantial negative impact on overall QoL across multiple domains.

Differences in social interaction and loneliness symptoms

Children in the difficulty group had significantly higher scores for: Fear of negative evaluation (t=−4.199, P<0.001); Social avoidance and distress (t=−4.358, P<0.001), and the total score of social interaction (t=−4.461, P<0.001), compared to the no difficulty group. These findings suggest that children in the difficulty group exhibited heightened social anxiety and withdrawal behaviors. Loneliness symptoms were significantly higher in the difficulty group compared to the no difficulty group (t=−5.953, P<0.001), reflecting more pronounced social isolation and emotional deprivation (Table 4).

Multivariate logistic regression analysis

To identify independent predictors, variables with P<0.05 in the univariate analyses were included in the multivariate logistic regression model (Table 5). Following statistical analysis, four significant predictors were identified. Higher maternal education was identified as a protective factor, with children of mothers possessing higher education levels being at a significantly lower potential risk of experiencing difficulty (OR =0.605, 95% CI: 0.419–0.876, P=0.008). Regarding parental marital status, the presence of a complete marriage was associated with a significantly reduced likelihood of difficulty in children (OR =0.020, 95% CI: 0.006–0.067, P<0.001). Therefore, the presence of identified psychological needs was associated with a decreased potential risk of difficulty (OR =0.017, 95% CI: 0.007–0.041, P<0.001). This likely reflects ascertainment bias: children in the difficulty group are more closely monitored by support systems, making their psychological needs more likely to be identified and recorded than those of children in the no difficulty group. A higher total score of social interaction problems was associated with an increased potential risk of difficulty (OR =1.089, 95% CI: 1.013–1.170, P=0.021), indicating that more severe impairments in social interaction significantly elevated the likelihood of children experiencing difficulty.

Discussion

The multidimensional analysis of health among vulnerable children revealed significant differences between vulnerable and non-vulnerable groups across domains including physical health, psychological well-being, social support, and the protection of rights and interests. Further analysis was conducted to examine the influence of family-related factors on specific dimensions of health within this population. Children experiencing multidimensional health difficulties may face adverse consequences that can affect academic performance, limit future occupational choices, and contribute to long-term psychological distress and reduced social adaptability (33). These disadvantages may persist into their adulthood, increasing the risk of intergenerational poverty. Without effective intervention, these diverse health-related disadvantages may become entrenched, perpetuating systemic inequities and impeding progress toward broader societal goals related to educational and social equity (34).

In the long term, the development of vulnerable children may be constrained in adulthood, leading to the loss of potential human capital, which poses challenges to the sustainable development of society and increases the burden on social welfare systems, public health services, and allied services (35). Therefore, it is imperative that future health policies targeting vulnerable children incorporate evaluative indicators related to family supervision. In addition, key social determinants of health, such as parental education level, household composition, and guardianship status, should be integrated into targeted professional interventions within social work practice (36). Emphasis should be placed on strengthening the role and participation of public health social work in advancing the health and welfare of vulnerable children.

Health promotion and growth support

Vulnerable children demonstrated pervasive disadvantages in physical development and QoL, reflecting systemic challenges across multiple health-related dimensions. Disparities between urban and rural settings, along with differences across educational grade levels, underscored issues related to environmental adaptability that hinder individual development and raise concerns regarding social equity. Among children of the same age group, those in the difficulty group exhibited a lower average height (150.18 cm) compared to the no difficulty group (152.10 cm). These differences may be attributed to factors such as household economic hardship and reduced caregiving capacity. Limited dietary diversity and residence in environments lacking sanitary infrastructure may compromise nutrient absorption and overall physical growth (37-39).

Additionally, significantly lower scores in life convenience and access to recreational activities were observed among children in the difficulty group. The results across QoL dimensions indicated insufficient environmental support for growth in this population. Specifically, inadequate living conditions and limited access to safe, structured activities may restrict developmental stimulation and widen disparities between vulnerable and non-vulnerable children. Lower scores in dimensions such as teacher–student, peer, and parent–child relationships reflected a weaker social support network among vulnerable children, which are known to adversely impact both physiological and psychological health outcomes (40,41).

Furthermore, lower scores in dimensions measuring emotional regulation and attitudes toward academic tasks indicated that psychological well-being and engagement in learning were substantially impacted by the presence of difficulty. As grade levels increased, declines were noted in socio-psychological function, despite some improvement in learning ability. Simultaneously, reductions in somatic sensation and physio-psychological health were observed. Notably, children in grades 5 and 6 reported significantly lower satisfaction with QoL compared to those in grade 3, which may be partially attributed to increased academic pressure negatively influencing emotional and socio-psychological functioning. Although this study observed grade-related trends, a definitive correlation between advancing grade level and increased difficulty has not been established in existing studies.

Educational development and psychological health

Vulnerable children often begin their formal education at a disadvantage, making it difficult to bridge the academic gap over time due to limited access to family-based education and after-school tutoring (42). Persistent academic underachievement may contribute to a heightened sense of alienation from school life and pose latent risks to psychological well-being (43). The absence of adequate family support and educational resources has been linked to difficulties in keeping pace with classroom instruction, contributing to declining academic performance (44). These outcomes reflect the broader structural inequities and the constraints of a developmentally disadvantaged environment (45).

The study found that 65.7% of children identified as experiencing difficulty exhibited poor academic performance, a proportion substantially higher than that observed among non-vulnerable children, thereby reflecting significant disparities in educational equity. Furthermore, when psychological needs are inadequately addressed, a cascade of adverse consequences may follow. Although only 12.7% of vulnerable children explicitly reported psychological needs, compared to 1.2% among non-vulnerable children, this disparity underscores the insufficient provision of psychological support services within the vulnerable group. Children navigating chronic adversity and poverty may deprioritize emotional needs, often due to survival-related stressors. Unmet psychological needs can manifest as negative emotional states, which then can impair learning engagement and social functioning (46).

Elevated levels of social anxiety and symptoms of loneliness were also documented among vulnerable children, with notable sex-based differences (47). Males exhibited higher scores in dimensions such as somatic sensation, whereas their scores for social interaction anxiety and overall totals were lower compared to females. The combined effects of social anxiety and perceived loneliness appeared to contribute to greater social withdrawal among vulnerable children, particularly those experiencing academic difficulties and unfavorable family environments. This pattern of avoidance may intensify psychological loneliness and hinder social development, thereby placing these children at a disadvantage in terms of interpersonal relationships.

Family support and community integration

Vulnerable children were found to reside in households characterized by low economic status and unstable family structures. Only 21.9% lived with both parents in a complete marital relationship, while high proportions of children were from families affected by parental separation or divorce. A relatively large number of parents had attained only primary school education or below. These findings suggest that family economic status, parental education levels, and family structure stability may constitute the foundational support system essential for child development. Disadvantage in any one of these areas has been identified as a primary underlying factor contributing to developmental difficulties among vulnerable children. The relative impact of each factor may vary across contexts and health domains (48).

First, limited household economic resources were found to restrict access to developmental opportunities and essential services. As a result, vulnerable children were more likely to experience reduced life conveniences and limited participation in enriching activities. Economic constraints may reduce parental investment in the growth and well-being of children. This disparity contributes to an early developmental gap between vulnerable and non-vulnerable children.

Second, parental education levels influence caregiving capacity and the ability to provide developmental guidance and educational support. Parents with education limited to the primary level often face challenges in providing academic assistance, whereas those with education at the junior college level or higher tend to place greater emphasis on the holistic development of their children. For instance, parental attainment of a senior high school or technical secondary school education was associated with stronger learning ability, more positive learning attitudes, and reduced negative emotional experiences in children. Higher maternal education was associated with a reduced risk of children encountering developmental difficulties and improved access to emotional support and developmental resources. However, maternal education level did not demonstrate a significant effect on the presence of psychological problems in children, suggesting that such issues may require professional intervention.

Finally, the stability of family structure emerged as a critical source of emotional support for children (49). A complete marital relationship between parents was associated with better multidimensional health outcomes and a reduced likelihood of children encountering developmental difficulties. Variability in health outcomes were noted across different family compositions. For example, children in single-parent households demonstrated higher scores in motor ability and living environment, while those residing with both parents and grandparents presented greater vulnerability in terms of negative emotions and social anxiety.

Protection of rights and interests and the role of psychological support mechanisms

Parental attentiveness to the psychological well-being of children, along with the recognition and fulfillment of their psychological needs, constitutes a core component of the psychological protection framework for vulnerable children. Imbalance within this system represents a central factor contributing to the exacerbation of psychological difficulties and a lower QoL. Parental awareness and responsiveness serve as key external sources of emotional support, addressing emotional expression, basic needs, and psychological safety. For vulnerable children residing in disadvantaged family environments, the risk of developing negative emotional states is heightened. However, parental engagement in a child’s emotional well-being can provide a sense of psychological security, which may be transformed into psychological resilience. This process contributes to reductions in social avoidance behaviors, fosters a more positive outlook on life, and improves satisfaction with overall QoL. By attending to signs of psychological distress, caregivers can facilitate early intervention, reduce emotional burden, and help prevent the escalation of adverse mental health outcomes. Positive parental guidance may assist children in reconstructing cognitive appraisals and alleviating symptoms of social anxiety. When parental involvement is present, emotional bonds between parents and children are strengthened, providing protection against external psychological stressors. Furthermore, parents who are attentive to the psychological needs of their children often serve as effective communicators and are better positioned to provide targeted support aimed at enhancing social skills and socio-psychological functioning.

The psychological needs of children can also serve as internal early warning indicators. However, the extent to which these needs are identified and documented is closely tied to the level of system monitoring a child receives. Children under formal support systems are more likely to have their psychological needs recognized and recorded, whereas unmet needs among children outside such systems may remain unnoticed. Among vulnerable children, psychological needs are primarily associated with emotional companionship, stress relief, and social support. When these needs are not adequately addressed, negative emotional states may emerge, leading to decreased life satisfaction and an elevated risk of experiencing developmental difficulties (50,51).

Limitations of the study

Several limitations should be acknowledged in the interpretation of this study’s findings. First, the sample was derived from primary schools within a single province, which may limit the external validity and generalizability of the results to broader populations of vulnerable children across different geographic or sociocultural contexts. The classification criteria for identifying vulnerable children were based on criteria relevant to the context of Chinese schools, and thus may not fully capture the diversity of vulnerability conditions experienced by vulnerable children in other regions. The study population was limited to children aged 6 to 12 years, and the health status of older age groups within the vulnerable child population was not examined.

Conclusions

This study conducted multidimensional analysis of QoL, social interaction anxiety, and loneliness anxiety among vulnerable children, to examine differences between vulnerable and non-vulnerable children across dimensions including health, family environment, and socio-psychological functioning. This approach enabled the characterization of the multidimensional health profile of vulnerable children and clarified the influence of social factors, particularly family-related variables, on health outcomes. Key influencing factors were identified, and associated needs and strategies were examined in depth.

The findings demonstrated that vulnerable children experienced significant disadvantages in socio-psychological health, physiological health, and the quality of their living environment. Key influencing factors identified include household economic status, parental marital status, parental education level, and the degree of parental attention to the psychological health of children.

To reduce health disparities, future policies should prioritize the incorporation of protective factors for vulnerable families and promote tailored, precision-based intervention strategies that address individual needs. Strengthening the responsiveness of social systems through coordinated efforts across policy, family, and community domains is essential to advancing health equity. This study contributes empirical evidence to the pursuit of global health equity and underscores the key role of family-level social factors in shaping child health outcomes. Future research is warranted to examine additional influencing factors, with the aim of improving the health status and QoL of vulnerable children through multidimensional approaches involving policy, family, and community. Effective intervention strategies should be developed to support and promote the healthy development of this population.

Acknowledgments

We would like to acknowledge the hard and dedicated work of all the staff that implemented the intervention and evaluation components of the study.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0161/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0161/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0161/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-2026-1-0161/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of Shanxi Medical University (No. 2023039). Written informed consent was obtained from all patients’ guardians.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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