mHealth Series: Text messaging data collection of infant and young child feeding practice in rural China – a feasibility study

Face–to–face interviews by trained field workers are commonly used in household surveys. However, this data collection method is labor–intensive, time–consuming, expensive, prone to interviewer and recall bias and not easily scalable to increase sample representativeness. The study explored the feasibility of using text messaging to collect information on infant and young child feeding practice in rural China

Relaxation of the one child policy and trends in caesarean section rates and birth outcomes in China between 2012 and 2016: observational study of nearly seven million health facility births.

OBJECTIVE: To examine how the relaxation of the one child policy and policies to reduce caesarean section rates might have affected trends over time in caesarean section rates and perinatal and pregnancy related mortality in China. DESIGN: Observational study. SETTING: China's National Maternal Near Miss Surveillance System (NMNMSS). PARTICIPANTS: 6 838 582 births at 28 completed weeks or more of gestation or birth weight ≥1000 g in 438 hospitals in the NMNMSS between 2012 and 2016. MAIN OUTCOME MEASURES: Obstetric risk was defined using a modified Robson classification. The main outcome measures were changes in parity and age distributions and relative frequency of each Robson group, crude and adjusted trends over time in caesarean section rates within each risk category (using Poisson regression with a robust variance estimator), and trends in perinatal and pregnancy related mortality over time. RESULTS: Caesarean section rates declined steadily between 2012 and 2016 (crude relative risk 0.91, 95% confidence interval 0.89 to 0.93), reaching an overall hospital based rate of 41.1% in 2016. The relaxation of the one child policy was associated with an increase in the proportion of multiparous births (from 34.1% in 2012 to 46.7% in 2016), and births in women with a uterine scar nearly doubled (from 9.8% to 17.7% of all births). Taking account of these changes, the decline in caesarean sections was amplified over time (adjusted relative risk 0.82, 95% confidence interval 0.81 to 0.84). Caesarean sections declined noticeably in nulliparous women (0.75, 0.73 to 0.77) but also declined in multiparous women without a uterine scar (0.65, 0.62 to 0.77). The decrease in caesarean section rates was most pronounced in hospitals with the highest rates in 2012, consistent with the government's policy of targeting hospitals with the highest rates. Perinatal mortality declined from 10.1 to 7.2 per 1000 births over the same period (0.87, 0.83 to 0.91), and there was no change in pregnancy related mortality over time. CONCLUSIONS: China is the only country that has succeeded in reverting the rising trends in caesarean sections. China's success is remarkable given that the changes in obstetric risk associated with the relaxation of the one child policy would have led to an increase in the need for caesarean sections. China's experience suggests that change is possible when strategies are comprehensive and deal with the system level factors that underpin overuse as well as the various incentives at work during a clinical encounter

Text Messaging Data Collection for Monitoring an Infant Feeding Intervention Program in Rural China: Feasibility Study

BACKGROUND: An effective data collection method is crucial for high quality monitoring of health interventions. The traditional face-to-face data collection method is labor intensive, expensive, and time consuming. With the rapid increase of mobile phone subscribers, text messaging has the potential to be used for evaluation of population health interventions in rural China. OBJECTIVE: The objective of this study was to explore the feasibility of using text messaging as a data collection tool to monitor an infant feeding intervention program. METHODS: Participants were caregivers of children aged 0 to 23 months in rural China who participated in an infant feeding health education program. We used the test-retest method. First, we collected data with a text messaging survey and then with a face-to-face survey for 2 periods of 3 days. We compared the response rate, data agreement, costs, and participants’ acceptability of the two methods. Also, we interviewed participants to explore their reasons for not responding to the text messages and the reasons for disagreement in the two methods. In addition, we evaluated the most appropriate time during the day for sending text messages. RESULTS: We included 258 participants; 99 (38.4%) participated in the text messaging survey and 177 (68.6%) in the face-to-face survey. Compared with the face-to-face survey, the text messaging survey had much lower response rates to at least one question (38.4% vs 68.6%) and to all 7 questions (27.9% vs 67.4%) with moderate data agreement (most kappa values between .5 and .75, the intraclass correlation coefficients between .53 to .72). Participants who took part in both surveys gave the same acceptability rating for both methods (median 4.0 for both on a 5-point scale, 1=disliked very much and 5=liked very much). The costs per questionnaire for the text messaging method were much lower than the costs for the face-to-face method: ¥19.7 (US $3.13) versus ¥33.9 (US$5.39) for all questionnaires, and ¥27.1 (US $4.31) versus ¥34.4 (US$5.47) for completed questionnaires. The main reasons for not replying were that participants did not receive text messages, they were too busy to reply, or they did not see text messages in time. The main reasons for disagreement in responses were that participants forgot their answers in the text messaging survey and that they changed their minds. We found that participants were more likely to reply to text messages immediately during 2 time periods: 8 AM to 3 PM and 8 PM to 9 PM. CONCLUSIONS: The text messaging method had reasonable data agreement and low cost, but a low response rate. Further research is needed to evaluate effectiveness of measures that can increase the response rate, especially in collecting longitudinal data by text messaging

Child feeding and stunting prevalence in left-behind children: a descriptive analysis of data from a central and western Chinese population

Objectives: To examine the effect of parental rural-to-urban internal migration on nutritional status of left-behind children and how this is related to guardianship. Methods: We used UNICEF China’s maternal and child health survey data to investigate stunting prevalence and feeding practices in children left behind by rural-to-urban internal migrant parents. We also assessed the effects of primary guardianship which is related closely with parental migration. Results: Of 6,136 children aged 0-3 years, over one third was left behind by one or both parents. About 13% were left behind by mothers, leaving guardianship primarily to grandmothers. Left-behind status was not associated with stunting, yet children who were cared for primarily by their fathers had a 32% increase of stunting compared to children cared for by the mothers (adjusted odds ratio[aOR]=1.32;95% confidence interval=1.04-1.67). Children with migrant mothers were less likely to receive age-appropriate breastfeeding (aOR=0.04;0.02-0.10) and a minimum acceptable diet (aOR=0.56;0.39-0.79) compared with non-left-behind children. Conclusions: Guardian’s feeding behaviours varied, and was inappropriate for both children affected and not affected by parent’s rural-to-urban internal migration. Community-based infant and young child feeding counselling and support should be provided to all caregivers

Closing the know-do gap for child health: UNICEF's experiences from embedding implementation research in child health and nutrition programming.

UNICEF operates in 190 countries and territories, where it advocates for the protection of children's rights and helps meet children's basic needs to reach their full potential. Embedded implementation research (IR) is an approach to health systems strengthening in which (a) generation and use of research is led by decision-makers and implementers; (b) local context, priorities, and system complexity are taken into account; and (c) research is an integrated and systematic part of decision-making and implementation. By addressing research questions of direct relevance to programs, embedded IR increases the likelihood of evidence-informed policies and programs, with the ultimate goal of improving child health and nutrition.This paper presents UNICEF's embedded IR approach, describes its application to challenges and lessons learned, and considers implications for future work.From 2015, UNICEF has collaborated with global development partners (e.g. WHO, USAID), governments and research institutions to conduct embedded IR studies in over 25 high burden countries. These studies focused on a variety of programs, including immunization, prevention of mother-to-child transmission of HIV, birth registration, nutrition, and newborn and child health services in emergency settings. The studies also used a variety of methods, including quantitative, qualitative and mixed-methods.UNICEF has found that this systematically embedding research in programs to identify implementation barriers can address concerns of implementers in country programs and support action to improve implementation. In addition, it can be used to test innovations, in particular applicability of approaches for introduction and scaling of programs across different contexts (e.g., geographic, political, physical environment, social, economic, etc.). UNICEF aims to generate evidence as to what implementation strategies will lead to more effective programs and better outcomes for children, accounting for local context and complexity, and as prioritized by local service providers. The adaptation of implementation research theory and practice within a large, multi-sectoral program has shown positive results in UNICEF-supported programs for children and taking them to scale

A financial road map to scaling up essential child health interventions in 75 countries

OBJECTIVE: To estimate the additional resources required to scale up interventions to reduce child mortality and morbidity within the context of the fourth Millennium Development Goal’s aim to reduce mortality among children aged < 5 years by two-thirds by 2015. METHODS: A costing model was developed to estimate the financial resources needed in 75 countries to scale up priority interventions that address the major causes of mortality among children aged < 5 years, including malnutrition, pneumonia, diarrhoea, malaria and key newborn causes of death such as sepsis. Calculations were made using bottom-up and ingredients-based approaches; this allowed financial costs to be estimated for each intervention, country and year. Costs reflect WHO guidelines on inputs and delivery strategies and encompass the delivery of interventions at community and facility levels. These costs also include programme-specific investments needed at national level and district level. FINDINGS: The scale-up scenario predicts that an additional US$52.4 billion will be required for the period 2006-2015. This represents an increase in total per-capita health expenditure in the 75 countries of US$ 0.47 in 2006; this is projected to increase to US$ 1.46 in 2015. Projected costs in 2015 are equivalent to increasing the average total health expenditure from all financial sources in the 75 countries by 8% and raising general government health expenditure by 26% over 2002 levels. (The latest data available at the time of the study were for 2002.) The scale-up scenario indicates that countries with weak health systems may experience difficulties mobilizing enough domestic public funds. CONCLUSIONS: While the results are approximate estimates, they show a substantial investment gap that low- and middle-income countries and their development partners need to bridge to reach the fourth Millennium Development Goal

Breastfeeding rates in central and western China in 2010: implications for child and population health

OBJECTIVE: To describe breastfeeding practices in rural China using globally recommended indicators and to compare them with practices in neighbouring countries and large emerging economies. METHODS: A community-based, cross-sectional survey of 2354 children younger than 2 years in 26 poor, rural counties in 12 central and western provinces was conducted. Associations between indicators of infant and young child feeding and socioeconomic, demographic and health service variables were explored and rates were compared with the most recent data from China and other nations. FINDINGS: Overall, 98.3% of infants had been breastfed. However, only 59.4% had initiated breastfeeding early (i.e. within 1 hour of birth); only 55.5% and 9.4% had continued breastfeeding for 1 and 2 years, respectively, and only 28.7% of infants younger than 6 months had been exclusively breastfed. Early initiation of breastfeeding was positively associated with at least five antenatal clinic visits (adjusted odds ratio, aOR: 3.48; P < 0.001) and negatively associated with delivery by Caesarean (aOR: 0.53; P < 0.001) or in a referral-level facility (aOR: 0.6; P = 0.014). Exclusive breastfeeding among children younger than 6 months was positively associated with delivery in a referral-level facility (aOR: 2.22; P < 0.05). Breastfeeding was not associated with maternal age or education, ethnicity or household wealth. Surveyed rates of exclusive and continued breastfeeding were mostly lower than in other nations. CONCLUSION: Despite efforts to promote breastfeeding in China, rates are very low. A commitment to improve infant and young child feeding is needed to reduce mortality and morbidity

Inequality in early childhood neurodevelopment in six poor rural counties of China: a decomposition analysis

Abstract Background Previous studies about inequality in children’s health focused more on physical health than the neurodevelopment. In this study, we aimed to evaluate the inequality in early childhood neurodevelopment in poor rural China and explore the contributions of socioeconomic factors to the inequality. Method Information of 2120 children aged 0 to 35 months and their households in six poor rural counties of China was collected during July – September, 2013. Age and Stages Questionnaire-Chinese version, concentration index and decomposition analysis were used to assess the neurodevelopment of early childhood, measure its inequality and evaluate the contributions of socioeconomic factors to the inequality, respectively. Result The prevalence of suspected developmental delay in children under 35 months of age in six poor rural counties of China was nearly 40%, with the concentration index of −0.0877. Household economic status, caregivers’ depressive symptoms, learning material and family support for learning were significantly associated with children’s suspected developmental delay, and explained 34.1, 14.1, 8.9 and 7.0% of the inequality in early childhood neurodevelopment, respectively. Conclusion The early childhood neurodevelopment in the surveyed area is poor and unfair. Factors including household economic status, caregivers’ depressive symptoms, learning material and family support for learning are significantly associated with children’s suspected developmental delay and early developmental inequality. The results highlight the urgent need of monitoring child neurodevelopment in poor rural areas. Interventions targeting the caregivers’ depressive symptoms, providing learning material and developmental appropriate stimulating activities may help improve early childhood neurodevelopment and reduce its inequality