SYDNEY MEDICAL SCHOOL

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 Forum28-29 November 2013

The University of Sydney

A/Prof. Mu LiChina Studies Centre and School of Public Health

The University of Sydney

Trend data

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

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Background

( Li et al, Chin J Pediatr 2008)

Childhood obesity has become a major public health concern in China

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1986 1996 2006

› 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)

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Overweight and obesity prevalence in older children

Shift in BMI at 95 percentile in children aged 6 years

(Popkin AJCN 91 (supp):284S-288S, 2010)

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Obes

non-Obes

N=SBP DBP WC HipC W/HR

Comparison of Bp, waist C, Hip C and W/H C ratio in 3-6 y-o obese and normal weight children

( Li et al, Chin J Paediatr 2008)

- 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

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Reported associated factors in China

› 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.

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Protective effect of breastfeeding against childhood obesity

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

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The project

› Aim: to evaluate the feasibility and effectiveness of SMS in support of breastfeeding and infant feeding in urban China

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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.

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MCH services in Shanghai

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2&3 trimester

register

Home visit

Antenatal care

1st month postpartum

BF promotionpregnancy

Antenatal classCHC MH Dr

childbirth

6wks postpartum exam

Check upUp to 2 years

Maternity Hop

Maternity Hop

CHC MH Dr

Maternity Hop

CH /Paediatric

Antenatal class

10 steps of successful BF

BF advice

BF advice

BF advice

1 trimester

Delivery

Check up

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

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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.

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› Communications technologies such as SMS have enabled us to deliver the innovative public health program.

The pilot study and findings

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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

Breastfeeding knowledge n= %

breast milk is the best food for infants < 4 months 651 99breast milk can meet all nutrition requirements for infants < 4 months 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

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1. Breastfeeding knowledge in pregnant women

(Jiang et al Breastfeeding Medicine, 2012)

Characteristics N=653n (%)

Awareness of WHO breastfeeding guideline

Intention to BF Intention to exclusive BF

Higher score n (row%)

P Yes n(row%)

P Yesn(row%)

P

Age

<25 77(11.8) 33(42.9) 0.003* 67(87.0) 0.330* 30(39.0) 0.755*25-29 384(58.8) 211(54.9) 350(91.4) 114(29.7)≥30 192(29.4) 120(62.5) 176(91.7) 70(36.5)Maternal education level

Junior middle school

21(3.2) 6(28.6) <0.001* 20(95.2) 0.522* 16(76.2) 0.897*

Senior middle school

70(10.7) 27(38.6) 64(91.4) 44(62.9)

College and above

562(86.1) 331(58.9) 509(90.7) 379(67.4)

Partner’s education level

Junior middle school

14(2.1) 4(28.6) <0.001* 13(92.9) 0.788* 9(64.3) 0.969*

Senior middle school

58(8.9) 19(32.8) 53(91.4) 40(69.0)

College and above

581(89.0) 341(58.7) 527(90.9) 390(67.1)

Awareness of breastfeeding recommendations†

Lower 289(44.3) 248(85.8) <0.001 162(56.1) <0.001Higher 364(55.7) 345(95.0) 127(43.9)

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Factors associated with awareness and intention to Breastfeed

* Mantel-Haenszel chi-square tests† (mean score 3.6; median score 4.0)

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2. Sources of breastfeeding knowledge

(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 pregnancyBefore pregnancy During pregnancy

n % n %

Use of mobile phone 655 100 622 95

Average send SMS/day

Do not send 46 7 134 20

<10 502 76 467 71

10-30 66 10 20 3

not sure 36 6 33 5

Average monthly mobile phone costs

< 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

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)

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)

   

AOR(95% CI)

 PVariables Total

No. (%)Intervention

No. (%)

ControlNo. (%)

Exclusive breastfeedingat the 6th month*(n=549)          Yes 58 (10.6) 40 (15.1) 18 (6.3) 2.67(1.45-

4.91)0.002

No 491(89.4) 225 (84.9) 266(93.7) 1   

Introduction of solid food regularlybefore the 4th month* (n=551)

Yes 15 (2.7) 4 (1.5) 11 (3.8) 0.27(0.08- 0.94)

0.039

No 536(97.3) 261 (98.5) 275(96.5) 1  

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6. EBF and 6 months and introduction of solid foods before 4 months

(Jiang et al. Lancet 382 (Suppl.1):4. DOI: 10.1016/S0140-6736(13)62165-0, 2013)

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)

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Thank you

谢谢