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
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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)
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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)
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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)
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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
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