Innovative approach of delivering health promotion program in a urban setting: experience from a mobile phone short message healthy infant feeding promotion study Urbanisation and Health in China Forum 28-29 November 2013 The University of Sydney A/Prof. Mu Li China Studies Centre and School of Public Health The University of Sydney SYDNEY MEDICAL SCHOOL Acknowledgement › Shanghai based researchers Hong Jiang, Qiaozhen, Hu, Dongling Yang, Gengsheng He, Xu Qian › Sydney based researchers Mu Li, Li Ming Wen, Michael Dibley, Louise Baur 2 Background Childhood obesity has become a major public health concern in China 1986 1996 2006 ( Li et al, Chin J Pediatr 2008) 3 Overweight and obesity prevalence in older children › For 7-15 year olds the national obesity prevalence: from less than 0.5% in 1985 to around 13% in 2005 in boys living in urban settings (Cui et al. Int J Pediatr Obe 2010) 4 Shift in BMI at 95 percentile in children aged 6 years (Popkin AJCN 91 (supp):284S-288S, 2010) Comparison of Bp, waist C, Hip C and W/H C ratio in 3-6 y-o obese and normal weight children SBP DBP WC HipC W/HR N= Obes non-Obes ( Li et al, Chin J Paediatr 2008) 6 Reported associated factors in China - Low exclusive breastfeeding and ‘any’ breastfeeding, 15.8% and 49.2% at 6 months, respectively - Started complementary food too early (before 4 months) or too late - Imbalanced complementary feeding, higher carbohydrate-based - Poor infant feeding knowledge and practices - Others • Delivery by C-section • High birth weight of the newborns • Higher BMI parents, particularly mother's pre-pregnancy BMI 7 Protective effect of breastfeeding against childhood obesity › Arenz S, et al. Breast-feeding and childhood obesity - systematic review. Int J Obes. 2004;28:1247-56. › Dewey KG. Is Breastfeeding Protective Against Child Obesity? J Hum Lact. 2003;19(1):9-18. › Owen CG, et al. Effect of Infant Feeding on the Risk of Obesity Across the Life Course: A Quantitative Review of Published Evidence. Pediatrics. 2005;115(5):1367-77. › Koletzko B, et al. Can infant feeding choices modulate later obesity risk? Am J Clin Nutr. 2009;89(5):1502S-8. 8 SMS or web-based interventions have proven to be effective in (mhealth, ehealth): › Behaviour change - smoke cessation - dietary behaviour change - physical activity and weight management › Patient management › patients’ blood pressure and diabetes management - Adhesion to anti-viral therapy › Disease surveillance 9 The project › Aim: to evaluate the feasibility and effectiveness of SMS in support of breastfeeding and infant feeding in urban China 10 Community health centre (CHC) 社区卫生服务中心: - A pregnant woman is required to register and receives the ‘Pregnant Women Healthcare Card’ around 12 weeks gestation at the CHC This is the best time to reach nearly 100% of the pregnant women. - After giving birth, the new mother is referred back to the CHC in her household registration area to be followed up by the CHC in the first 6 weeks. - CHC is also responsible for child growth and development check ups from 0-6 years: 4 scheduled health checks in the first year (around 2, 4, 6 and 9 months), twice yearly from 1-3 years, and yearly thereafter. 11 pregnancy MCH services in Shanghai BF promotion 1 trimester register CHC MH Dr Antenatal care Maternity Hop Antenatal class childbirth Delivery Maternity Hop 10 steps of successful BF 1st month postpartum Home visit CHC MH Dr BF advice 6wks postpartum exam Check up Maternity Hop BF advice Up to 2 years Check up CH /Paediatric BF advice 2&3 trimester Antenatal class 12 Short message service (SMS): - The advantages of using SMS to support interventions for new mothers: - avoidance of travel to health facilities and waiting time - flexible program delivery - messages can be delivered quickly and simultaneously to a large group of mothers - communication can be interactive between health providers and mothers with tailored response - relatively low cost 13 The Intervention › We developed a community-based health promotion program to support new mothers to breastfeed their babies and to adopt healthy infant feeding practices using SMS. › The study was carried out in four Community Health Centers (CHCs). Two CHCs were assigned to the intervention group and two other CHCs were assigned as the control group. › Communications technologies such as SMS have enabled us to deliver the innovative public health program. 15 The pilot study and findings The participants: › Total 657 pregnant women recruited › Mean age 28 years, (range 20-42) › Education levels: 83% college or above › Professions: 48% professionals or management jobs › Intended time to return to work after giving birth: 73% by 6 months 16 1. Breastfeeding knowledge in pregnant women Breastfeeding knowledge n= % breast milk is the best food for infants < 4 months breast milk can meet all nutrition requirements for infants < 4 months 651 99 404 62 breast feeding is beneficial to baby's health 653 99 breast feeding is beneficial to mother's health 511 78 initiation should be with 30 min of childbirth 46 7 infants should be exclusively breast fed in the first 6 months 151 23 infants should be breast fed up to 24 months 12 2 (Jiang et al Breastfeeding Medicine, 2012) 17 Factors associated with awareness and intention to Breastfeed Characteristics N=653 n (%) Awareness of WHO breastfeeding guideline Higher score P n (row%) Intention to BF Yes n(row%) P Intention to exclusive BF Yes n(row%) P Age <25 77(11.8) 33(42.9) 25-29 384(58.8) 211(54.9) ≥30 192(29.4) 120(62.5) Maternal education level 0.003* 67(87.0) 350(91.4) 176(91.7) 0.330* 30(39.0) 114(29.7) 70(36.5) 0.755* 21(3.2) 6(28.6) Junior middle school 70(10.7) 27(38.6) Senior middle school 562(86.1) 331(58.9) College and above Partner’s education level <0.001* 20(95.2) 0.522* 16(76.2) 0.897* 64(91.4) 44(62.9) 509(90.7) 379(67.4) 14(2.1) 4(28.6) <0.001* Junior middle school 19(32.8) Senior middle 58(8.9) school College and 581(89.0) 341(58.7) above Awareness of breastfeeding recommendations† 13(92.9) Lower Higher 248(85.8) 345(95.0) 289(44.3) 364(55.7) 0.788* 9(64.3) 53(91.4) 40(69.0) 527(90.9) 390(67.1) <0.001 162(56.1) 127(43.9) 0.969* <0.001 * Mantel-Haenszel chi-square tests † (mean score 3.6; median score 4.0) 18 2. Sources of breastfeeding knowledge 70 60 50 40 30 20 10 Series1 0 (Yang et al. Maternal and Child Health Care of China. 26:4704-6, 2011) 19 3. Use of mobile phone before & during pregnancy Before pregnancy During pregnancy n % n % 655 100 622 95 Do not send 46 7 134 20 <10 502 76 467 71 10-30 66 10 20 3 not sure 36 6 33 5 < 30 RMB Yuan 111 17 207 32 30-60 RMB Yuan 257 39 241 37 61-100 RMB Yuan 167 25 113 17 > 100 RMB Yuan 107 16 71 11 Use of mobile phone Average send SMS/day Average monthly mobile phone costs 86% responded that they would accepted breastfeeding and infant feeding information sent by SMS (Yang et al. Maternal and Child Health Care of China. 26:4704-6, 2011) 20 4. Feasibility and acceptability ›Delivering health promotion intervention by SMS appears not only feasible but is well accepted by new mothers with a high retention rate of 89% at 12 months 5. Median duration of exclusive breastfeeding ›Compared with the control group, the intervention group had a significantly longer median duration of EBF at 6 months (11.41 weeks, 95% confidence interval [CI] 10.25 - 12.57 vs 8.87 weeks, 95% CI 7.84 - 9.89; P<0.001) (Jiang et al. Lancet 382 (Suppl.1):4. DOI: 10.1016/S0140-6736(13)62165-0, 2013) 6. EBF and 6 months and introduction of solid foods before 4 months Total No. (%) Interventio n No. (%) Control No. (%) AOR(95% CI) P at the 6th month*(n=549) Yes 58 (10.6) 40 (15.1) 18 (6.3) 0.002 No 491(89.4) 225 (84.9) 266(93.7) 2.67(1.454.91) 1 before the 4th month* (n=551) Yes 15 (2.7) 4 (1.5) 11 (3.8) 0.039 No 261 (98.5) 275(96.5) 0.27(0.080.94) 1 Variables Exclusive breastfeeding Introduction of solid food regularly 536(97.3) (Jiang et al. Lancet 382 (Suppl.1):4. DOI: 10.1016/S0140-6736(13)62165-0, 2013) 22 Conclusion • There is a gap in pregnant women and new mothers’ awareness of the Who breastfeeding guidelines and knowledge on breastfeeding (Jiang et al, Breastfeeding Medicine, 2012) • The current health care can not meet the need (Yang et al, Chinese Maternal and Child healthcare 2011) • 95 % pregnant mothers in this study use mobile phone, 86% willing to receive health promotion SMS (Yang et al, Chinese Maternal and Child healthcare 2011) • Delivering health promotion intervention by SMS appears not only feasible but is well accepted by new mothers (Jiang et al, Lancet, 2013) • SMS health promotion intervention improves median exclusive breastfeeding duration and rate at 6 months and reduce early introduction of solid foods (Jiang et al, Lancet, 2013) 23 Thank you 谢谢 24