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Healthy living practices in families and child health: 5-year follow-up of Taiwan Birth Cohort Study

Objectives We have previously developed the Child Healthy Living Practices in Family (CHLPF) Index and found that the CHLPF Index was concurrently associated with the health of children at age 3. In this follow-up study, we aimed to examine whether healthy living practices in family at age 3 predicted health of children at school age. Design and setting Data came from the Taiwan Birth Cohort Study designed to assess the development and health of 24 200 children born in 2005. Participants A total of 18 553 cohort members whose mothers or primary caregivers had completed 6-month, 3-year, 5-year and 8-year surveys were included for analysis, representing a response rate of 87.3%. Outcome measures A multiple logistic regression model was used to test the relationship between mother-rated children’s health at age 8 and the CHLPF Index level, after controlling for sex, birth outcomes, family structure, parental education, residential area, family income and mother-rated child’s health at age 3. Results The percentage of mother-rated good health at age 8 was 79.7%. Compared with the low CHLPF level, the adjusted OR of mother-rated good health was 1.38 (95% CI 1.19 to 1.60), 1.21 (95% CI 1.10 to 1.35) and 1.17 (95% CI 1.07 to 1.29), respectively, for high, high–low and mid-low CHLPF levels. Moreover, the prevalence of mother-rated good health at age 8 with high-level CHLPF Index in the low-income group was similar to that of the high-income group (83.72% vs 84.18%); the prevalence with low-level CHLPF Index in the low-income group was much lower than that of the high-income group (70.21% vs 78.98%). Conclusions Our study underscores that high level of healthy living practices in early childhood is positively associated with good health at school age, particularly for children from disadvantaged families.

Some changes would improve the manuscript, especially providing more information about some methods issues. Although the authors note that the overall sampling plan is presented elsewhere, they do not describe why they did not use first wave variables, especially significant birth problem variables in consideration of child reported health status assessment. This analysis is restricted to three and 8 year old data even though it appears that earlier data are present.
Secondly, the authors do not clearly indicate whether they use weighting in their analysis to achieve the nationally representative estimates or control for bias in the different sampling cells. Although it might be acceptable not to do so, if it were available it would be an important addition. Somewhat relatedly, the plethora of recent articles on striking differences in health disparities by neighborhood or city might predispose these authors to examine geographic differences, especially among low income families rather than look at individual attributes.
The authors do not include any discussion on parental health behaviors and whether they were included in the study. It seems as if the greatest bias in the study might result not from child behaviors, but parents that were differentially health-oriented in their own behaviors. If such data were available it would be important to include and to speculate not on how to induce such behaviors in children as the authors do, but instead, why some parents behave differently. Was any measure of parent health included?
Finally, the introduction focuses the discussion of health promotion in individual behavior and almost implies "parent-blaming" while not acknowledging the newer studies on health promotion acknowledge the large and significant role that built environment, social policy and health policy all play in healthy outcomes. Some modification of the introduction is probably indicated. Introduction The introduction is generally well written covering a complex and nuanced topic well. Reviewing for clarity of message and some repetitiveness would improve readability. For audiences unfamiliar with the CHLP index, an explanation of this would be extremely helpful. I am unsure, however, of the authors central premised that this cohort study can demonstrate causation above association, given the exposure/treatment if not randomised. However, I defer to the editor/epidemiologist on this. The outcome of interest appears to be mother-rated health, as a measure of overall child health at age 8. If this is the case, then is should be stated. Methods Can this first statement be brought earlier to clarify the main objective of the paper? The intent is much clearer to me based on this statement. Page 8 line 33 Using standard format for the subtitle would assist the reader (i.e. setting and participants as per the STOBE guidelines). Further review of the methods in line with standard reporting would also benefit the reader. It is unclear to me what is meant by the statement on page 9 line 42. For an international audience, could the authors note how the CHLPF index was validated? Results Review again for grammar and flow would be of help. Also reviewing with aim of reporting findings more succinctly would benefit the reader. Page 10 line 24, did you perform test of significance between maternal and paternal education? And If so why? Table 2 please spell out adjusted in the column heading Table 3, stratification by income level and CHLPF shed light on an important effect-modification. Did the authors consider whether these differences between groups are significant and how this could be tested? If not, the findings need to be considered with this in mind.

Discussion
In reporting the main findings, switching between how the outcome measure is referred to is a little confusing. Choosing one way to say this would help flow of reading. Page 14 line 24. It is unclear to me how the results support the statement that findings between ages were consistent and indicates a durable effect. Further in relation to page 14 line 33, I may have overlooked this but I can not see where you have reported the relationship between CHLPF measured at age 3 with motherreported health at age 3. Nor can I see where you have reported CHLPF levels at age 3 and 8 (I can see at age 3 in tables 1, 2 and 3, presumably in the last time although this is not clearly labelled). Page 14 line 45, did you perform a test of significance to support this claim? Perhaps you mean the absolute differences in prevalence became more evident? Page 14 line56. This sentence is unclear to me in its meaning. The discussion would benefit from further editing for flow, clarity and grammar. There are a few sections unclear to me as to what the authors are intending to express. It would also be useful to strengthen the discussion on the implications of the findings (page 15 from line 12), particularly in relation to the modifying effect of low socioeconomic position on child health outcomes. In its current form this seems to over-reach what the results show and it is unclear to me what the authors are intending to state in relation to previous literature. Conclusion This seems disjointed from the main body of the paper and introduces a new concept not previously discussed. Some of the messages in the last paragraph of the discussion I think would sit here better.

VERSION 1 -AUTHOR RESPONSE
Reviewer(s)' Comments to Author: #Reviewer 1 Reviewer Name: Kelly Kelleher Institution and Country: Nationwide Children's Hospital -Columbus, OH, USA Please state any competing interests or state "None declared": No competing interest to report.

1.
This manuscript presents the results from two waves of a national cohort study from Taiwan focused on parent reported child health status and health behaviors in the home. As the authors note, the topic of health promotion for young children and families is coming into its own, there is little longitudinal data on a large scale and the association of low cost interventions is especially underrepresented. Several strengths are noteworthy in the manuscript. The use of a nationally representative cohort is particularly important along with the longitudinal nature of the datasets. The high rates of reporting are also useful and the inclusion of diverse demographic factors provides a broad insight. Answers: Thank you for the comments. The adjustment has been made based on the suggestions.

2.
Some changes would improve the manuscript, especially providing more information about some methods issues. Although the authors note that the overall sampling plan is presented elsewhere, they do not describe why they did not use first wave variables, especially significant birth problem variables in consideration of child reported health status assessment. This analysis is restricted to three and 8-year old data even though it appears that earlier data are present. Answers: Thank you for the comments. More details and explanations of the data usage have been added to the Method/ Participants section as the following statement: (1) Overall sampling plan (Please refer to the Page 8 of the manuscript) Participants The nationally representative cohort begun with 24,200 infants born in 2005 was initially taken from 206,741 live births based on the National Birth Report Database using two-stage stratified random sampling. First, the 359 townships were identified as primary sampling units (PSU), and were stratified into 12 levels according to their urbanization and total fertility rate. Second, individuals were sampled from PSU, and the samples were determined by probability proportionate to size (PPS). The sampling rate was approximately 11.7%. (2) The first wave variables of TBCS (Please refer to the Page 9 of the manuscript) In this study, the birth weight and gestational age, the potential factors that may affect children"s health assessment, were controlled for the analysis. Data of 3-year-old was used because studies indicated that some forms of adolescent or adults" behaviors could be tracked and observed in the third year of life17-19. Moreover, the data of 8-year-old was analyzed to compare with the data of 3year-old in order to examine if the familial influence has a long-term effect after the children go to primary school.

3.
Secondly, the authors do not clearly indicate whether they use weighting in their analysis to achieve the nationally representative estimates or control for bias in the different sampling cells. Although it might be acceptable not to do so, if it were available it would be an important addition. Somewhat relatedly, the plethora of recent articles on striking differences in health disparities by neighborhood or city might predispose these authors to examine geographic differences, especially among low income families rather than look at individual attributes. Answers: (1) Thanks for your comments. In the present study, we do not use weighting to analysis data. The main reason was that the data came from the Taiwan Birth Cohort Study (TBCS), which employs two-stage stratified random sampling from 206,741 live births in 2005 based on the National Birth Report Database. Please kindly refer to the Participants section of Methods in the manuscript (Page 9). The paragraph is stated as below:

Participants
The nationally representative cohort begun with 24,200 infants born in 2005 was initially taken from 206,741 live births based on the National Birth Report Database using two-stage stratified random sampling. First, the 359 townships were identified as primary sampling units (PSU), and were stratified into 12 levels according to their urbanization and total fertility rate. Second, individuals were sampled from PSU, and the samples were determined by probability proportionate to size (PPS). The sampling rate was approximately 11.7%. (2) Thank you for the reminder. Also, we have considered health disparities causing by the impact of neighborhood or residential area in the present study. Therefore, we analyzed residential area which was categorized three groups (rural township, urban township, and city) in the model as a control variable to obtain more precise results. Please refer to the Covariates section of Methods (Page 10) in the manuscript as the following statement: Covariates. Sociodemographic characteristics are associated with health19-22. Therefore, demographic characteristics (child"s sex), and parents" socioeconomic status before 3 years old (family structure, family income, maternal education, paternal education, and residential area) were included in the advanced analysis.

4.
The authors do not include any discussion on parental health behaviors and whether they were included in the study. It seems as if the greatest bias in the study might result not from child behaviors, but parents that were differentially health-oriented in their own behaviors. If such data were available it would be important to include and to speculate not on how to induce such behaviors in children as the authors do, but instead, why some parents behave differently. Was any measure of parent health included? Answers: Thanks for your question and suggestion. In this study, the Child-Healthy Living Practices in Families (CHLPF) Index was comprised of the five elements that were parent-instructed actions including: whether (i) vegetables and fruits are eaten daily; (ii) physical activities are practiced daily; (iii) hands are washed before meals and after using the bathroom; (iv) TV-viewing is less than 2 hours per day; (v) the child is exposed to secondhand smoke at home. In addition to the support from the literature review, the other consideration of choosing these five elements was because they were highly related to parental behaviors and habits that were practiced at home. Young children are taught first by their parents at home to form their health behaviors. However, we believe having parents" actual behaviors would be a more direct path to speculate the behaviors in young children"s. it is a pity that the measure of parental health behaviors was not included. But we will keep the suggestion in mind for a holistic study in the future.

5.
Finally, the introduction focuses the discussion of health promotion in individual behavior and almost implies "parent-blaming" while not acknowledging the newer studies on health promotion acknowledge the large and significant role that built environment, social policy and health policy all play in healthy outcomes. Some modification of the introduction is probably indicated. Answers: Thank you for the question. We acknowledged that, other than family, built environment, social policy and health policy all play a significant role in healthy outcomes. Therefore, we tackled socioecological perspective to initiate the statement, but tended to focus more on the familial factors to see its long-lasting impact on children"s health. Even so, we agree that built environment, social policy and health policy are all worth recognized so we revised the statement to make the concept more complete. Please refer to the Introduction section (Page 6) in the manuscript as the following statement: From a socio-ecological perspective (the interrelations between organisms and their environments), health promotion shapes health habits to help improve people"s health and well-being2-4, that can be applied through different aspects like families, communities, social welfare, health care and health policy as a more comprehensive and integrative child health support to improve child and family well-being5. Most centrally, family is the core base for children to promote their healthy life. #Reviewer 2 Reviewer Name: Dr Danielle C Butler Institution and Country: The Australian National University, Australia Please state any competing interests or state "None declared": None declared Comments Overall The paper presents an interesting and important analysis, examining the relationship of early childhood health practices with longer term outcomes. One of the stated objectives to determine is family healthy practices mitigate the negative consequences associated with lower socioeconomic positions (referred to as poverty). It is not clear to me how this analysis has addressed this latter point. Further clarification on this point would be extremely helpful and possibly input from a statistician or epidemiologist regarding the analysis approach. More generally, review for flow, clarity, grammar and repetitiveness would benefit the reader. 1.
Abstract (1) Line 12 For those unfamiliar with this index it would be helpful to have line explaining what this is or what is measures. Is this an index measuring behaviours at the family/area level or an intervention? In addition, does health promotion refer to a program or improved health levels? I think it means the latter, but it is unclear in the current form. Answers: Thanks for your comments. Please refer to the Objections of abstract (Page 2) in the manuscript as the following statement: Objectives: In a prior cross-sectional research, we developed the Child Healthy Living Practices in Family (CHLPF) Index and find that the CHLPF Index was concurrently associated with the health of children at age three. In this follow-up study we aimed to examine whether healthy living practices in family at age three predicted health of children at school age.
(2) Line 33 review for clarity and grammar Answers: Please refer to the Participants of abstract (Page 2) in the manuscript as the following statement: Participants: A total of 18,553 cohort members who completed 6-month, 3-year, 5-year, and 8-year surveys were included for analysis, representing a response rate of 87.3%. (3) Results from line 40. Editing this in line with abstract provided in the emailed invitation would improve readability and clarity. Answers: Please refer to the Results of abstract (Page 2) in the manuscript as the following statement: Results: The percentage of mother-rated good health at age 8 was 79.7%. Compared with the low CHLPF level, the adjusted odds ratio of good mother-rated health was 1.38 (95% Confidence Interval, CI = 1.19-1.60), 1.21 (95% CI=1.10-1.35), and 1.17 (95% CI = 1.07-1.29), respectively, for high, highlow, and mid-low CHLPF levels. Moreover, the prevalence of mother-rated good health at age 8 increased by 13.51% from low to high CHLPF level for the low-income group, while the comparable figure is 5.2% for the high-income group.
(4) Line 6, suggest use association rather than effect (the latter implies causation) Answers: Please refer to the Objections of abstract (Page 2) in the manuscript as the following statement: Objectives: In a prior cross-sectional research, we developed the Child Healthy Living Practices in Family (CHLPF) Index and find that the CHLPF Index was concurrently associated with the health of children at age three. In this follow-up study we aimed to examine whether healthy living practices in family at age three predicted health of children at school age.
(5) Strengths and limitation Suggest review this to clarify the strengths and limitations, rather than repeating findings Answers: Thank you for the reminder. The section has been adjusted to: (page 3) Strengths and limitations of this study 1.
This study uses the dataset from the Taiwan Birth Cohort Study (TBCS), which was the first large-scale, nationally representative, and longitudinal study on a 1-year-long birth cohort in Taiwan.

2.
The TBCS focuses on documenting children"s health and developmental trajectories, investigating the social determinants of children"s health and well-being, and examining the early determinants of adult health from the life course perspective.

3.
There is little longitudinal data on a large scale and the association of low cost interventions is especially underrepresented. 4.
The data regarding child health were parent-rated; as such, these responses might be subject to social desirability and causing potential reporting bias. 5.
Through the 5-year interval, the real-life changes of the participated families were not taken into account and investigated. The possible influences may not be avoided.

2.
Introduction (1) The introduction is generally well written covering a complex and nuanced topic well. Reviewing for clarity of message and some repetitiveness would improve readability. For audiences unfamiliar with the CHLP index, an explanation of this would be extremely helpful. I am unsure, however, of the authors central premised that this cohort study can demonstrate causation above association, given the exposure/treatment if not randomized. However, I defer to the editor/epidemiologist on this. Answers: Thank you for the comments. (1) The CHLPF Index has been explained in the Variables section of the Methods in the manuscript. Please refer to Page 9-10 in the manuscript as the following statements: Variables Child-healthy family living practices (CHLPF) Index. The independent variable of this study was the CHLPF Index, which was developed to evaluate the degree of a 3-year-old"s child-healthy family living practices15. The index is comprised of five elements: whether (i) vegetables and fruits are eaten daily; (ii) physical activities are practiced daily; (iii) hands are washed before meals and after using the bathroom; (iv) TV-viewing is less than 2 hours per day; (v) the child is exposed to secondhand smoke at home. All five elements were stratified into low (scale ≤ 1), mid-low (scale = 2), mid-high (score = 3), and high (score ≥ 4) CHLPF levels.
The elements in the CHLPF Index were first chosen based on the previous literature which substantiated that these five elements are highly associated with children"s health and also imply the level of a family adopting approaches that can enhance children"s health and prevent them from diseases 15. Subsequently, the CHLPF index has been validated through exploratory factor analysis Introduction Building on literature review 5 and our prior research 15, we hypothesized that early development of child-healthy family living practices before 3 years old (36 months) leads to positive effects on health outcomes later on. In the current study, we aimed to examine whether healthy living practices in family at age three predicted health of children at school age. (2) The outcome of interest appears to be mother-rated health, as a measure of overall child health at age 8. If this is the case, then is should be stated. the nature of the data has been explained Answers: The nature of the data has been explained under the Children"s mother-rated health section. Please refer to the Variables section of Methods (Page 10) in the manuscript as the following statements: Children"s mother-rated health. The dependent variable was the mother-rated health of the eight-year-old which was measured by the children"s mothers or primary caregivers, who were asked "How would you rate your child"s health status on the whole?" The response was rated on a 5-point scale: very good, good, fair, poor, and very poor. This variable was recoded as a "1" for "very good" and "good", and as a "0" for "fair", "poor", and "very poor".

3.
Methods (3) Can this first statement be brought earlier to clarify the main objective of the paper? The intent is much clearer to me based on this statement. Answers: Thank you for the suggestions. Yes, the first statement has been revised and moved to ahead of METHOD section (Page 7) to clarify the intent as the following statements.
Building on literature review 5 and our prior research 15, we hypothesized that early development of child-healthy family living practices before 3 years old (36 months) leads to positive effects on health outcomes later on. In the current study, we aimed to examine whether healthy living practices in family at age three predicted health of children at school age.
(4) Page 8 line 33 Using standard format for the subtitle would assist the reader (i.e. setting and participants as per the STOBE guidelines). Further review of the methods in line with standard reporting would also benefit the reader. Answers: Thanks for your reminder. The subtitles of METHOD section (Page 7-11) were reorganized based on the STROBE guidelines and the characters of the data.
It is unclear to me what is meant by the statement on page 9 line 42 Answers: Thanks for your reminder. The statement was deleted and re-written in this paragraph.
(6) For an international audience, could the authors note how the CHLPF index was validated? Answers: The information of CHLPF validation has been added to the Variable/ Child-healthy family living practices (CHLPF) Index section (Page 9-10). The statement is explained as below: The elements in the CHLPF Index were first chosen based on the previous literature which substantiated that these five elements are highly associated with children"s health and also imply the level of a family adopting approaches that can enhance children"s health and prevent them from diseases 15. Subsequently, the CHLPF index has been validated through exploratory factor analysis (EFA) and confirmative factor analysis (CFA) 15. The results of EFA indicated that CHLPF index explained 28.21% of the total variance. The indicators of goodness of fit of CFA showed a good model fit (RMSEA=0.025, CFI=0.967, NFI=0.965, χ2/df=13.27).

4.
Results (1) Review again for grammar and flow would be of help. Also reviewing with aim of reporting findings more succinctly would benefit the reader. Answers: Thank you for the comment. We have reviewed with aim of reporting findings more succinctly and thoroughly for better readability. (2) Page 10 line 24, did you perform test of significance between maternal and paternal education? And If so why? Answers: Yes, we did. We wanted to present the similar pattern between maternal and paternal education on the gradient for mother-rated good health. However, it was not the mainly focused issue so we removed the sentence "Paternal and maternal education levels were not significantly different".
(3) Table 2 please spell out adjusted in the column heading Answers: The revision has been made (Page 16). Thank you.
(4) Table 3, stratification by income level and CHLPF shed light on an important effectmodification. Did the authors consider whether these differences between groups are significant and how this could be tested? If not, the findings need to be considered with this in mind. Answers: The interaction between CHLPF levels and family income groups was not significantly different using the logistic regression analysis. The result shows that stratification by CHLPF index and family income dose not present an effect-modification. However, Table 3 presented the main effect of CHLPF index for mother-rated good health, especially for the low-income group. We found that the difference between low-and high-CHLPF levels (13.5%) of low-income group was higher than that (5.2%) of high-income group. This discrepancy suggested that healthy living practices in families are crucial for enhancing child health, especially for children with socioeconomic disadvantages.
Please refer to the Results section in the manuscript (Page 15) and the Discussion section (Page 19) as the following statements: RESULTS In terms of the prevalence of good mother-rated health, the difference between the CHLPF levels was larger in the low-income group (age 3: 15.33%; age 8: 13.51%) than in the high-income group (age 3: 10.76%; age 8: 5.20%). In addition, the difference between the high-and low-income was much smaller for the high-CHLPF level at age 3 (0.14%) and age 8 (0.46%), respectively, than for the low-CHLPF level (age 3: 4.71%; age 8: 8.77%).

DISCUSSION
In terms of the prevalence of good mother-rated health, the difference between the CHLPF levels was larger in the low-income group (age 3: 15.33%; age 8: 13.51%) than in the high-income group (age 3: 10.76%; age 8: 5.20%). In addition, the difference between the high-and low-income was much smaller for the high-CHLPF level at age 3 (0.14%) and age 8 (0.46%), respectively, than for the low-CHLPF level (age 3: 4.71%; age 8: 8.77%). In addition, the discrepancy between the high-and lowincome was much smaller for the high-CHLPF level at age 3 and age 8, respectively, than for the low-CHLPF level, suggesting that health living practices could outweigh the impact of family income on children"s health and effectively close the harm of health disparity.

5.
Discussion (1) In reporting the main findings, switching between how the outcome measure is referred to is a little confusing. Choosing one way to say this would help flow of reading. Answers: Thank you for the comment. Yes, we have adjusted the statements and made the description flow better. (2) Page 14 line 24. It is unclear to me how the results support the statement that findings between ages were consistent and indicates a durable effect. Further in relation to page 14 line 33, I may have overlooked this but I can not see where you have reported the relationship between CHLPF measured at age 3 with mother-reported health at age 3. Nor can I see where you have reported CHLPF levels at age 3 and 8 (I can see at age 3 in tables 1, 2 and 3, presumably in the last time although this is not clearly labelled). Answers: Thank you for the comment. In order to clarify the comparison between the results from the data of 3and 8-year-old. We have shown the findings for 3-year-old along with the that for the 8-year-old in the Table 3 (Page 17 of the manuscript). As the findings are exhibited side-by-side in the Table 3, the comparisons can be clearly recognized and elaborated. Further explanations were annotated in the discussion section. (3) Page 14 line 45, did you perform a test of significance to support this claim? Perhaps you mean the absolute differences in prevalence became more evident? Answers: Thank you for the comment. Yes. And we meant that the absolute differences in prevalence became more evident. Please refer to the Results section in the manuscript (Page 15) and the Discussion section (Page 19) as the following statements:

RESULTS
In terms of the prevalence of good mother-rated health, the difference between the CHLPF levels was larger in the low-income group (age 3: 15.33%; age 8: 13.51%) than in the high-income group (age 3: 10.76%; age 8: 5.20%). In addition, the difference between the high-and low-income was much smaller for the high-CHLPF level at age 3 (0.14%) and age 8 (0.46%), respectively, than for the low-CHLPF level (age 3: 4.71%; age 8: 8.77%).

DISCUSSION
In terms of the prevalence of good mother-rated health, the difference between the CHLPF levels was larger in the low-income group (age 3: 15.33%; age 8: 13.51%) than in the high-income group (age 3: 10.76%; age 8: 5.20%). In addition, the difference between the high-and low-income was much smaller for the high-CHLPF level at age 3 (0.14%) and age 8 (0.46%), respectively, than for the low-CHLPF level (age 3: 4.71%; age 8: 8.77%). In addition, the discrepancy between the high-and lowincome was much smaller for the high-CHLPF level at age 3 and age 8, respectively, than for the low-CHLPF level, suggesting that health living practices could outweigh the impact of family income on children"s health and effectively close the harm of health disparity.
(4) Page 14 line56. This sentence is unclear to me in its meaning. Answers: Thank you for the comment. The sentence is rewritten as below and please refer to the Discussion section (Page 20) in the manuscript as the following statements: Moreover, through the 5 years interval, the actual changes of the participated families such as financial status or marital status were not taken into account and investigated. Such an impact on children"s healthy living practices in families could be overlooked.

(5)
The discussion would benefit from further editing for flow, clarity and grammar. Answers: Thank you for the comment. The revised version has been reviewed again by a professional editor who is a native speaker in English. However, if there is still improvement needed to make for better readability, we are more than happy to have a journal editor to help with our article.

(6)
There are a few sections unclear to me as to what the authors are intending to express. It would also be useful to strengthen the discussion on the implications of the findings (page 15 from line 12), particularly in relation to the modifying effect of low socioeconomic position on child health outcomes. In its current form this seems to over-reach what the results show and it is unclear to me what the authors are intending to state in relation to previous literature. Answers: Thank you for the comments on adjusting the discussion on the implication of findings. Please refer to the Discussion section (Page 18-19) in the manuscript as the following statements: This study also identified that the association between good child healthy family living practices and children"s health has been continuous and remained stronger in the low-income families. The gradients consistently remained similar across all income levels, and the absolute differences in the prevalence of mother-rated good health were more evident as the income level declined. In the present study, the lowest prevalence of children with good mother-rated health was observed in the group of children who were in the low CHLPF level and low-income families. However, with the health living practices involved in the daily routine, the prevalence of good health can be elevated by 15.33% at 3-year-old and by 13.51% at 8-year-old, suggesting that healthy living practices in families are crucial for enhancing child health, especially for children with socioeconomic disadvantages. In addition, the discrepancy between the high-and low-income was much smaller for the high-CHLPF level at age 3 and age 8, respectively, than for the low-CHLPF level, suggesting that health living practices could outweigh the impact of family income on children"s health and effectively close the harm of health disparity.
Healthy living practices in families are crucial and effective for boosting child health, especially for children with disadvantage families. Making effort to follow through basic health routines as doing health living practices in family could compensate the impact of health disparity. The durable effect substantiated by this longitudinal study indicated that the environment in which children are raised establishes a solid foundation for their future health 10.
For policy implication, the long-term effects of child-healthy family living practices, with inexpensive and feasible approaches, on promoting child health should make them attractive to low-income parents because they are relatively reasonable and primarily require that they become daily routines rather than daily purchases of health products.

6.
Conclusion This seems disjointed from the main body of the paper and introduces a new concept not previously discussed. Some of the messages in the last paragraph of the discussion I think would sit here better. Answers: Thank you for the comments on adjusting discussion and conclusion sections. We have carefully revised the sections and elaborated our thoughts for better expression. Hopefully the statements bring out the best meanings of our work. Please refer to the Conclusions section (Page 20) in the manuscript as the following statements: CONCLUSION From the socio-ecological perspective, family environment is one fundamental determinant to the development of children"s healthy lifestyle. Our study confirmed that healthy living practices in family have long-term effects on the general health of children and contribute to the mitigation of income disparities in child health. To serve the best interests of children, therefore, our findings have important policy implications for child health through early familial intervention on health living practices.

REVIEWER
Kelly Kelleher Ohio State University USA REVIEW RETURNED 11-Feb-2020

GENERAL COMMENTS
This revised manuscript presents the results of a parent report survey on behaviors and health of young children from Taiwan. The topic is important as previously noted and the inclusion of a national probability survey is useful. Many of the original strengths are retained, and the reviewers have been responsive to most of the prior concerns raised. They have provided more insight into some of the methods, the analyses and the cautionary notes. Overall, the manuscript is much improved. However, there are two primary concerns remaining: a. There are still editing changes needed throughout the manuscript to assist with clarity and grammar. b. More importantly, the authors continue to make powerful, causative statements that were cautioned against in the first reviews. Some changes were made, but most were not. As evidence of some in the paper that all imply strong causation: a. P20L44: the "intervention yields (ie causes) benefits" b. P21L22 "Healthy living outweighs poverty" (This is definitely not true.) c. Conclusion: "Confirmed effectiveness" There are a few other minor edits that are important. On p6 L40, community factors are increasingly understood to be at least as important as "fundamental factors" affecting long term health. Similarly, the authors imply that three year old assessment was important because it was the earliest time to detect healthy behaviors for later in life on page 10 L15, but the terminology is confusing. Lastly, on p21 L47, the authors say these behavior changes are inexpensive and the literature would strongly disagree. Behavior change in families is one of the most challenging and expensive things to do.

REVIEWER
Dr Danielle Butler Australian National University, Australia REVIEW RETURNED 27-Feb-2020

GENERAL COMMENTS
Thank you to the authors for their considered responses and revisions. This has made a marked improvement to readability and comprehension of the study findings.
The following are key changes/clarifications that would improve the manuscript.
1. There have been important improvements in the use of language to better reflect the design of the study (being a cohort study therefore demonstrating association and not causality). However, the manuscript still uses language which implies the study is demonstrating effect/causation which is not the case. For example: pg 33 line 21-24.
2. Expansion of table 3 make the findings of analyses stratified by income much clearer, and the authors have sought to report this interesting interaction between income and the CHFLP index in much greater detail in the last three paragraphs of the results. However, I wonder if all the detail in the text detracts from the main message of this part of the results. The summary provided on page 45 line 55 gives this quite clearly and I think more succinct reporting along these lines would improve readability.
3. In relation to table 3, the way this is reported in the abstract, results and discussion still reads as though the authors have undertaken a statistical test or performed the appropriate statistical analysis to demonstrate that the relationship between the CHFLP and mother-reported child health varies according to income level. It is not apparent to me in the reported results that this is what the authors have done. Perhaps formal statistical review may be warranted to clarify this. This may be beyond scope of the current study, but how the reporting of the study findings needs to be careful not to overreach what the analysis has shown. 4. Sections in the introduction and discussion are still unclear in their meaning and in need of reviewing for grammar, typographical errors, clarity and flow.
5.Clearly stating that the CHLPF index measures parent-reported child health practices (as opposed to the parent's behaviour or the family's behaviour), as explained in the response to the other reviewer, would be helpful to the reader.

1.
There are still editing changes needed throughout the manuscript to assist with clarity and grammar.
[Responses] Thank you for the comments. The entire manuscript has been rechecked by a professional editing service (certification is attached).

2.
More importantly, the authors continue to make powerful, causative statements that were cautioned against in the first reviews. Some changes were made, but most were not. As evidence of some in the paper that all imply strong causation.
[Responses] Thank you for the comments. Revisions have been made throughout the paper to avoid implying strong causation. The following revisions have been made:

P20L44: the "intervention yields (ie causes) benefits" [Responses]
We have revised the paragraph; please refer to Page 14 of the manuscript: Our findings were consistent with the literature that healthy living practices promote health in general.10, 15, 23 More importantly, our study found that the association between CHLPF and children"s health was sustained over time. The findings of long-term effect support that the environment in which children are raised establishes a solid foundation for their future health.10 Therefore, a feasible approach to ensure children"s future health is to encourage parents and families to establish healthy practices or habits with their children.24 For example, restricting both child and parental television-viewing time early on would decrease television exposure.25 2.2 P21L22 "Healthy living outweighs poverty" (This is definitely not true.) [Responses] We have revised the paragraph; please refer to Page 14-15 of the manuscript: This study also identified that the association between CHLPF and children"s health was sustained and remained stronger in the low-income families. Particularly, we observed that children with good healthy living practices in low-income families would be healthier than children with poor healthy living practices in high-income families. Therefore, we suggest that healthy living practices in families are crucial for enhancing child health, especially for children with socioeconomic disadvantages. Moreover, the discrepancy in the prevalence of mother-rated good health between high-and lowincome groups increased across all CHLPF Index levels as children grew up (e.g. low-CHLPF Index level: 4.71% at age three versus 8.77% at age eight). Therefore, making the effort to follow through basic health routines as part of CHLPF early in the child"s life could compensate the impact of health disparity.

Conclusion: "Confirmed effectiveness" [Responses]
We have revised the paragraph; please refer to Page 15 of the manuscript: CONCLUSION From the socio-ecological perspective, our study indicates that healthy living practices in the family have long-term effects on the general health of children and contribute to mitigating child health disparities. To serve the best interests of children, therefore, our findings have important policy implications for child health through early familial intervention on healthy living practices.

3.
There are a few other minor edits that are important. On p6 L40, community factors are increasingly understood to be at least as important as "fundamental factors" affecting long term health.
[Responses] Thank you for the comments and suggestions. We recognize that it is not easy to understand for the "fundamental factors" in the sentence "Because family is involved in daily health promotion for children, the family context and its embedded routines are the fundamental factors in shaping children"s long-term health, health behaviour, and lifestyles." of revision 1 (p6 L40). However, we explain the concept that family is important for shaping children"s health, health behaviour, and lifestyles during growth from literature review. Therefore, the revision has been made on Page 4 of the manuscript: For children, the family is a major socializer that forms an important proximal environment for developing routines, capacity, knowledge, and norms for healthy living.6-8 If begun in early childhood, these familial factors can, in response to risks and adversities, promote positive health outcomes and reduce negative outcomes for children.9 Because family is involved in daily health promotion for children,10 the family context and its embedded routines are essential for shaping children"s health, health behaviour, and lifestyles during growth.11-13 4.
Similarly, the authors imply that three years old assessment was important because it was the earliest time to detect healthy behaviors for later in life on page 10 L15, but the terminology is confusing.
[Responses] Thank you for the comments. The study aimed to investigate the association between mother-rated good health at age eight and the CHLPF Index level at age three. Moreover, we used stratified analysis to identify whether the association between good CHLPF and health remained stronger in the low-income families from age three to school age. We have revised the statements; please refer to the Data analysis section (Page 8), and Discussion (Page 14-15) of the manuscript: Page 8: Data analysis Data analysis First, a Pearson"s chi-square (χ2) test was used to examine the association of the prevalence of mother-rated good health at age eight with CHLPF Index and other covariates. Subsequently, a multiple logistic regression model was used to test the relationships between CHLPF levels and health at age eight, after controlling for sex, family structure, family income, maternal education, paternal education, residential area, and mother-rated child"s health at age three. Finally, a stratified analysis was presented the prevalence of mother-rated good heath by the CHLPF Index and family income level at ages eight and three, respectively. The software SAS 9.4 was used for all analyses in the current study.
Page 14-15: Discussion DISCUSSION This study also identified that the association between CHLPF and children"s health was sustained and remained stronger in the low-income families. Particularly, we observed that children with good healthy living practices in low-income families would be healthier than children with poor healthy living practices in high-income families. Therefore, we suggest that healthy living practices in families are crucial for enhancing child health, especially for children with socioeconomic disadvantages. Moreover, the discrepancy in the prevalence of mother-rated good health between high-and lowincome groups increased across all CHLPF Index levels as children grew up (e.g. low-CHLPF Index level: 4.71% at age three versus 8.77% at age eight). Therefore, making the effort to follow through basic health routines as part of CHLPF early in the child"s life could compensate the impact of health disparity.

5.
Lastly, on p21 L47, the authors say these behavior changes are inexpensive and the literature would strongly disagree. Behavior change in families is one of the most challenging and expensive things to do.
[Responses] Thank you for the comments. We agree that behaviour change is one of the most challenging and expensive aspects for a family. Therefore, we have revised the description as "Therefore, a feasible approach to ensure children"s future health is to encourage parents and families to establish healthy practices or habits with their children."; please refer to Page 14 of the manuscript: Our findings were consistent with the literature that healthy living practices promote health in general.10, 15, 23 More importantly, our study found that the association between CHLPF and children"s health was sustained over time. The findings of long-term effect support that the environment in which children are raised establishes a solid foundation for their future health.10 Therefore, a feasible approach to ensure children"s future health is to encourage parents and families to establish healthy practices or habits with their children.24 For example, restricting both child and parental television-viewing time early on would decrease television exposure.25 This study also identified that the association between CHLPF and children"s health was sustained and remained stronger in the low-income families. Particularly, we observed that children with good healthy living practices in low-income families would be healthier than children with poor healthy living practices in high-income families. Therefore, we suggest that healthy living practices in families are crucial for enhancing child health, especially for children with socioeconomic disadvantages. # Reviewer 2: Danielle Butler 1.
There have been important improvements in the use of language to better reflect the design of the study (being a cohort study therefore demonstrating association and not causality). However, the manuscript still uses language which implies the study is demonstrating effect/causation which is not the case. For example: pg 33 line 21-24.
[Responses] Thank you for the comments. The following revisions have been made accordingly throughout the paper:

1.1
Page 5 Policy analyses claim that healthy family practices in early childhood continue to positively affect children"s health.14 If this claim is confirmed, it should be used as the basis for developing and strengthening children"s long-term health. However, most of the existing literature used crosssectional designs that demonstrated the association of CHLPF with health outcomes at a specific point in time.16 Thus, a longitudinal follow-up study that would investigate the associations between major variables6 is warranted to examine the long-term implications of these practices.

1.2
Page 14 Our findings were consistent with the literature that healthy living practices promote health in general.10, 15, 23 More importantly, our study found that the association between CHLPF and children"s health was sustained over time. The findings of long-term effect support that the environment in which children are raised establishes a solid foundation for their future health.10 Therefore, a feasible approach to ensure children"s future health is to encourage parents and families to establish healthy practices or habits with their children.24 For example, restricting both child and parental television-viewing time early on would decrease television exposure.25

1.3
Page 14-15 This study also identified that the association between CHLPF and children"s health was sustained and remained stronger in the low-income families. Particularly, we observed that children with good healthy living practices in low-income families would be healthier than children with poor healthy living practices in high-income families. Therefore, we suggest that healthy living practices in families are crucial for enhancing child health, especially for children with socioeconomic disadvantages. Moreover, the discrepancy in the prevalence of mother-rated good health between high-and lowincome groups increased across all CHLPF Index levels as children grew up (e.g. low-CHLPF Index level: 4.71% at age three versus 8.77% at age eight). Therefore, making the effort to follow through basic health routines as part of CHLPF early in the child"s life could compensate the impact of health disparity.

1.4
Page 15 CONCLUSION From the socio-ecological perspective, our study indicates that healthy living practices in the family have long-term effects on the general health of children and contribute to mitigating child health disparities. To serve the best interests of children, therefore, our findings have important policy implications for child health through early familial intervention on healthy living practices.

2.
Expansion of table 3 make the findings of analyses stratified by income much clearer, and the authors have sought to report this interesting interaction between income and the CHFLP index in much greater detail in the last three paragraphs of the results. However, I wonder if all the detail in the text detracts from the main message of this part of the results. The summary provided on page 45 line 55 gives this quite clearly and I think more succinct reporting along these lines would improve readability.
[Responses] Thank you for the comments. We have revised the Results; please refer to Page 11 of the manuscript: Table 3 presents the prevalence of mother-rated good health at ages eight and three, stratified by CHLPF Index levels and family income. The prevalence of mother-rated good health at age eight was observed with a significant CHLPF Index upward gradient across all family income levels. Importantly, when children had high-level CHLPF Index in the low income group, the prevalence of mother-rated good health at age eight was similar to the high income group (83.72%, 95% CI 76.20%-89.63% versus 84.18%, 95% CI 81.61%-86.51%, absolute difference=0.46%). However, while children had low-level CHLPF Index in the low income group, the prevalence of mother-rated good health was much lower than that of the high income group (70.21%, 95% CI 67.42%-72.88% versus 78.98%, 95% CI 77.01%-80.85%, absolute difference=8.77%). The CHLPF Index gradients consistently remained similar across all income levels, and the absolute difference at age eight was more evident as the income level declined (5.20% in high income level versus 13.51% in low income level). The pattern of age three was similar to that of age eight.

3.
In relation to table 3, the way this is reported in the abstract, results and discussion still reads as though the authors have undertaken a statistical test or performed the appropriate statistical analysis to demonstrate that the relationship between the CHFLP and mother-reported child health varies according to income level. It is not apparent to me in the reported results that this is what the authors have done. Perhaps formal statistical review may be warranted to clarify this. This may be beyond scope of the current study, but how the reporting of the study findings needs to be careful not to overreach what the analysis has shown.
[Responses] Thank you for the comments. The following revisions have been made throughout the paper:

3.1
Page 2: Abstract Results: The percentage of mother-rated good health at age eight was 79.7%. Compared with the low CHLPF level, the adjusted odds ratio of mother-rated good health was 1.38 (95% confidence interval, CI=1.19-1.60), 1.21 (95% CI=1.10-1.35), and 1.17 (95% CI=1.07-1.29), respectively, for high, highlow, and mid-low CHLPF levels. Moreover, the prevalence of mother-rated good health at age eight with high-level CHLPF Index in the low income group was similar to that of the high income group (83.72% versus 84.18%); the prevalence with low-level CHLPF Index in the low income group was much lower than that of the high income group (70.21% versus 78.98%).

3.2
Page 11: Results Table 3 presents the prevalence of mother-rated good health at ages eight and three, stratified by CHLPF Index levels and family income. The prevalence of mother-rated good health at age eight was observed with a significant CHLPF Index upward gradient across all family income levels. Importantly, when children had high-level CHLPF Index in the low income group, the prevalence of mother-rated good health at age eight was similar to the high income group (83.72%, 95% CI 76.20%-89.63% versus 84.18%, 95% CI 81.61%-86.51%, absolute difference=0.46%). However, while children had low-level CHLPF Index in the low income group, the prevalence of mother-rated good health was much lower than that of the high income group (70.21%, 95% CI 67.42%-72.88% versus 78.98%, 95% CI 77.01%-80.85%, absolute difference=8.77%). The CHLPF Index gradients consistently remained similar across all income levels, and the absolute difference at age eight was more evident as the income level declined (5.20% in high income level versus 13.51% in low income level). The pattern of age three was similar to that of age eight.

3.3
Page 14-15: Discussion This study also identified that the association between CHLPF and children"s health was sustained and remained stronger in the low-income families. Particularly, we observed that children with good healthy living practices in low-income families would be healthier than children with poor healthy living practices in high-income families. Therefore, we suggest that healthy living practices in families are crucial for enhancing child health, especially for children with socioeconomic disadvantages. Moreover, the discrepancy in the prevalence of mother-rated good health between high-and lowincome groups increased across all CHLPF Index levels as children grew up (e.g. low-CHLPF Index level: 4.71% at age three versus 8.77% at age eight). Therefore, making the effort to follow through basic health routines as part of CHLPF early in the child"s life could compensate the impact of health disparity.

4.
Sections in the introduction and discussion are still unclear in their meaning and in need of reviewing for grammar, typographical errors, clarity and flow.
[Responses] Thank you for the comments. The entire manuscript has been revised by a professional editing service (certification is attached).

5.
Clearly stating that the CHLPF index measures parent-reported child health practices (as opposed to the parent's behaviour or the family's behaviour), as explained in the response to the other reviewer, would be helpful to the reader.
[Responses] Thank you for the comments. We have explained and discussed the limitation of CHLPF Index measurement. Please refer to Page 15 of the manuscript: