SYDNEY MEDICAL SCHOOL

SMS for Optimal Nutrition

Beijing Health Research Lecture Series

A/Prof. Mu Li

School of Public Health & China Studies Centre The University of Sydney

Mu.li@sydney.edu.au

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

Prevalence:

Overall - from 5.2% in 1991 to 13.2% in 2006

Boys - from 4.8% in 1991 to 15.4% in 2006

Girls - from 5.4% in 1991 to 11.0% in 2006

BMI:

Overall - from 17.4 kg/m² in 1991 to 18.3 kg/m² in 2006

(Cui et al. Int J Pediatr Obe 2010)

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Overweight & obesity prevalence in older children (7-17 years)

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, eg. 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

New framework of action to optimal child nutrition

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(Lancet 2013, 382: 427-51)

› 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

› mHealth is the use of mobile phones to promote healthy behaviour, increase use of health services, improve adherence to health advice, and increase access to health information.

› One growing application of mHealth is mobile messaging, whereby health information and promotion messages are sent directly to end users.

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mHealth

SMS interventions have proven to be effective in:

› 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

- Reporting notifiable diseases cases or outbreak

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mHealth approach to health promotion

› Text4baby a US-based program: sending text messages to traditionally

underserved pregnant women, encouraging them to adopt healthy

attitudes, beliefs, and behaviours during pregnancy (Evans et al., BMC Public Health.

2012;12:1031).

› Wired Mothers program in Zanzibar, Tanzania: sending pregnant women text messages with appointment reminders and health education information, giving the pregnant women phone vouchers to call health care providers directly with questions (Lund et al, BJOG.

2012;119(10):1256–1264)

› an mHealth pilot project in Malawi aimed at improving knowledge and uptake of home- and facility-based MCH care practices found Mobile SMS health messages had higher successful delivery and led to higher intended or actual behaviour change among subscribers, compared with voice messages (Crawford et al, Global Health: Science and Practice 2014, 2:35-46)

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mHealth application in maternal and child health

The pilot 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 promotion

pregnancy

Antenatal class CHC MH Dr

childbirth

6wks postpartum

exam

Check up Up 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, and at users’ convenience

- 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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Advantage of SMS

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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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 99

breast 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=653 n (%)

Awareness of WHO

breastfeeding guideline Intention to BF Intention to exclusive BF

Higher score n (row%)

P Yes

n(row%) P Yes

n(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) <0.001 Higher 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

0

10

20

30

40

50

60

70

系列1

(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 %

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)

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AOR(95%

CI)

P Variables Total

No. (%)

Interventio

n

No. (%)

Control

No. (%)

Exclusive breastfeeding

at 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 regularly

before 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. 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, Jiang et al,

JAMA Pediatrics, 2014)

• 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, Jiang et al, JAMA Pediatrics, 2014)

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