A region/country-level Report Card offers an effective approach that uses a traditional grading system (i.e., A+ to F) to comprehensively assess the prevalence of a particular health-related behaviour within a specific region or country (1). This approach is considered a succinct and informative tool because it has exhibited enormous success in increasing public awareness about the importance of targeted health behaviours (1). Not only does it stimulate broader discussion, but it also advocates for essential policy changes that further promote public health.

Given the success of the Physical Activity Report Card for Children and Youth (1–3), a recent study (4) has adopted its conceptual framework to develop a Healthy Eating Report Card for Pre-School Children in Hong Kong. This Healthy Eating Report Card incorporates various indicators related to children’s eating behaviours and family home food environments (FHFEs) to reveal the prevalence of healthy eating among pre-school children in Hong Kong. It also develops a parent-report questionnaire and corresponding benchmarks that are designed based on the guidelines and recommendations of the HKSAR Department of Health for healthy eating (4). However, applying such a region-specific Report Card to evaluate children’s healthy eating behaviours and FHFEs in other regions/countries could pose challenges because the guidelines and recommendations may vary across different geographical and cultural environments (5). To address this gap, it is highly important to develop an internationally applicable version of the Healthy Eating Report Card and its assessment tool. Additionally, the development stage of the measure of the Healthy Eating Report Card for Pre-School Children in Hong Kong does not involve any scale validation, which underscores another methodological limitation in terms of examining the psychometric properties of the assessment tool.

We, therefore, developed a new version of the International Healthy Eating Report Card for Preschool-aged Children and its globally applicable assessment tool of the International Healthy Eating Report Card Scale (IHERCS) based on the guidelines and recommendations of the global health authorities, including the World Health Organisation (6–8), the European Food Safety Authority (9), the American Academy of Pediatrics (10), the Centers for Disease Control and Prevention (11) and the relevant literature (12–18). A significant change in the Report Card involved replacing a prior indicator “Avoidance of Unhealthy Foods” with “Home Healthier Food Availability and Accessibility” by considering the pivotal role of home food availability and accessibility in shaping FHFEs and influencing children’s eating behaviours (19, 20). In addition, the IHERCS expanded from the 21-item parent-report measure in a prior study (4) to include a total of 43 items. The additional items allowed for a more comprehensive assessment of children’s healthy eating behaviours (e.g., children’s unhealthy snack consumption) and FHFEs (e.g., both healthy and unhealthy food availability and accessibility within the home). All the dimensions of IHERCS aligned with the International Healthy Eating Report Card (i.e., Indicators of Children’s Eating Behaviours: (1) Children’s Dietary Patterns and (2) Children’s Mealtime Behaviours and Indicators of FHFEs: (3) Parental Food Choices and Preparation, (4) Home Healthier Food Availability and Accessibility and (5) Family Mealtime Environments). The assessment tool aimed to assess the extent to which preschool-aged children in different cultural contexts adhere to the standards and recommendations of the global health authorities for healthy eating behaviours and get involved in favourable FHFEs. Both English and Chinese versions of the IHERCS are in Appendices A and B.

To the best of our knowledge, there is currently no existing single measure that comprehensively covers all aspects of children’s healthy eating patterns as assessed by the IHERCS. Existing methods for evaluating children’s dietary patterns typically include dietary recalls, dietary records and food checklists (e.g., the Food Frequency Questionnaire) (21). While these assessments provide detailed information on dietary intake, they lack an explicit design for assessing the extent to which children adhere to global guidelines for healthy eating. Parent-reported measures, such as the Behavioural Pediatric Feeding Assessment Scale (BPFAS) and About Your Child’s Eating-Revised, are well-established scales that assess the mealtime behaviours of children (22). However, these measures focus on evaluating the parents’ feeding strategies and feelings about mealtimes rather than solely assessing the frequency of mealtime behaviours for typically developing children. Additionally, there is a lack of established assessment tools designed to evaluate the frequency with which parents adopt healthy food choices and food preparation practices for their children. Validated questionnaires that concurrently assess both the availability and accessibility of healthy and unhealthy food within the household are scarce (20, 23–27), and they do not account for the availability and accessibility of plain water (28). Another validated measure, the Meals in Our Household Questionnaire (MOH), assesses the frequency of structured family mealtime environments, but it does not account for the presence of common distracting objects (e.g., toys, phones and tablets) during mealtime (29).

To address the limitations of the former assessment tools, this study aimed to conduct a cross-cultural study to validate the assessment tool of the IHERCS. In particular, we first examined the factor structure, internal consistency and measurement invariance of the IHERCS across four cultural groups [i.e., Australia, Hong Kong, Singapore and the United States (US)]. The BPFAS and the MOH were then used to examine the convergent and discriminant validity of the IHERCS. The selection of these four countries for this study was based on their representation of a diverse range of developed countries/regions with distinct cultural contexts. Australia and the US are the Western countries representative of the North America and Oceania continents, respectively, while Hong Kong and Singapore are important cities located in Asia and Southeast Asia regions. These four regions are well recognised as developed regions with comparable socioeconomic characteristics [i.e., ranked in a very high Human Development Index category (HDI ≥ 0.9)], and their samples should reflect a diversity of dietary patterns in different cultures (30).

Based on the conceptual framework of the initial Healthy Eating Report Card (4), it was hypothesised that:

The current study aimed to examine the psychometric properties and measurement invariance of the IHERCS among pre-school aged children from four cultural samples in Asian and Western societies (i.e., Australia, Hong Kong, Singapore and the US). The IHERCS included the comprehensive assessment of both children’s eating behaviours and FHFEs. It was designed to examine the extent to which preschool-aged children adhere to the standards and recommendations of the global health authorities for healthy eating. This tool may reveal the prevalence status of healthy eating in preschool-aged children from different cities/countries and may have the potential to increase public awareness of healthy eating practices among young children. In general, as supported by our findings, the IHERCS demonstrated its value as a comprehensive, valid and culturally relevant tool for assessing children’s eating behaviours and FHFEs.

The findings from over two thousand preschool-aged children provided robust support for the construct validity (i.e., established through factor structure, convergent validity, discriminant validity) and measurement invariance. The findings were in line with our hypothesis that supported the robustness of the construct validity of the IHERCS. Moreover, we successfully established full configural invariance and metric invariance for both the scale of children’s eating behaviours and the scale of FHFEs across the four cultural contexts indicating that the model structure was invariant across samples. However, full scalar invariance could not be established for either of these scales. While partial scalar invariance was achieved for the scale of FHFEs after relaxing specific constrained parameters, the same level of scalar invariance was not confirmed for the scale of children’s eating behaviours. This was potentially attributed to cultural differences in the interpretation and scoring of the items of children’s eating behaviours (39).

The IHERCS represented an extended version of the assessment tool of the Healthy Eating Report Card for Pre-School Children in Hong Kong used in the prior study (4). It is the first validated parent-reported measure designed to comprehensively assess a wide range of children’s eating behaviours and FHFEs. Compared to other validated assessment tools for children’s dietary patterns and mealtime behaviours (e.g., the Food Frequency Questionnaire and the BPFAS), the scale of children’s eating behaviours in the IHERCS is relatively shorter and simpler, but the sixteen items of the scale can still provide a comprehensive assessment of preschool children’s adherence to dietary patterns and the frequency of mealtime behaviours. This makes the IHERCS particularly suitable for large-scale studies (21, 31), as it may reduce the response burden on participants while efficiently assessing the eating behaviour of young children. Additionally, the IHERCS may also be utilised in evaluating the effectiveness of interventions or public health policy that aims to promote preschool children’s healthy eating patterns.

The scale of FHFEs in the IHERCS extensively assesses various family-related factors that may influence children’s eating behaviours, including parents’ personal and behavioural factors (i.e., parental food choices and preparation), physical environment factors (i.e., home food availability and accessibility), and family social environmental factors (i.e., family mealtime environments) (20). By initially assessing the frequency with which parents make healthy food choices and adopt healthy cooking practices for their children, the IHERCS offers new insights into the evaluation of children’s FHFEs by taking parental factors of children’s eating behaviours into account. Moreover, the IHERCS provides a concise instrument for assessing the availability and accessibility of both healthy and unhealthy food within the household, including the assessment for plain water. Unlike other assessments (e.g., the MOH) that solely assess TV-related distraction during mealtime, the IHERCS considers other common distracting objects during mealtime (e.g., phones and toys) (29). As such, this comprehensive approach in the scale of FHFEs allows for a holistic evaluation of the parental and family-related factors of children’s eating behaviours.

In sum, our study presents the first cross-cultural psychometric validation study of the IHERCS, which can be considered an international tool to assess the eating behaviours and FHFEs of preschool-aged children that was designed based on the guidelines of global health authorities for healthy eating. The positive findings from our study supported the use of the IHERCS as a reliable assessment tool for revealing the prevalence of healthy eating among children in different cultural settings. Despite the strengths and novelty of our study, we have to acknowledge a few study limitations. First, with a cross-sectional design, our study could not reveal the temporal stability of children’s eating behaviours and FHFEs over time, and the test–retest reliability of the IHERCS remains unclear. Additionally, our study did not include any measures of health-related outcomes (e.g., self-rated health, quality of life and mental health), so we were unable to examine the criterion validity and predictive validity of the IHERCS. Future studies should adopt a longitudinal design to examine the temporal stability of the IHERCS, and the extent to which the scale is predictive of other behavioural or health outcomes over time (40). Second, the study only relied on parent-reported measures to assess children’s eating behaviours and FHFEs, so the responses could be susceptible to social desirability and self-serving biases. The homogeneous Likert-scale type of responses in our survey-based study could induce common method variance due to general response tendency, resulting in possibly inflating inter-factor correlations and internal reliability of the IHERCS within our study (41, 42). Future studies may consider completing the IHERCS in an objective manner by introducing independent assessors, observational techniques (e.g., dietary recalls), and verification by dietitians to enhance the accuracy and objectivity of responses.

The present study developed and evaluated the construct validity (i.e., factor structure, convergent and discriminant validity), and measurement invariance of the IHERCS across four cultural settings (i.e., Australia, Hong Kong, Singapore and the US). The IHERCS was designed to align with the indicators of the International Healthy Eating Report Card for Preschool-Aged Children, with the aim of providing a comprehensive assessment of eating behaviours and FHFEs among preschool-aged children in different cultural settings. The current findings provided preliminary support for the factor structure and internal consistency. Configural invariance and metric invariance were supported, but only partial scalar invariance was found in the scale of FHFEs. The IHERCS also met the convergent and discriminant validity. We hope the initial evidence of the psychometric properties of the IHERCS will stimulate future studies in applying this report card tool in assessing a wide range of aspects of eating behaviours and FHFEs across different cultures.

The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

The studies involving humans were approved by Human Research Ethics Committee of the Education University of Hong Kong. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

AW: Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Validation, Writing – original draft, Writing – review & editing. KC: Conceptualization, Investigation, Project administration, Supervision, Writing – review & editing. J-BL: Conceptualization, Investigation, Project administration, Supervision, Writing – review & editing. SX: Formal analysis, Investigation, Methodology, Writing – review & editing, Validation. DC: Conceptualization, Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Writing – review & editing.