Effectiveness of a mobile health intervention on infant and young child feeding among children ≤ 24 months of age in rural Islamabad over six months duration

Introduction

Childhood under-nutrition is a major public health problem which has been contributing extensively to childhood mortality and morbidity¹. Globally; 45% of child mortality results from ‘undernutrition’ which highlights the right of every child to good nutrition. According to World Health Organization (2018), globally more than 100 million children were found to be stunted, and nearly 52 million were found to be wasted in 2016 alone. Adequate nutrition is required for optimal growth and development of children². Evidence indicates that under-nutrition leads to severe cognitive and behavioural disabilities throughout life if not managed in early infancy^3–5. The magnitude of malnutrition is extensive in the South Asian region leading to high rates of stunting, wasting, and disease burden⁵. One of the major causes of these high indicators of undernutrition is poor infant and young child feeding (IYCF) practices. The WHO and United Nations International Children’s Emergency Fund (UNICEF) recommends early initiation of breastfeeding within an hour after birth, and exclusive breastfeeding for the first 6 months during infancy with timely and appropriate initiation of complementary feeding⁶. Despite this recommendation, the recognized adverse effects of malnutrition and undernutrition among infants and children have been significantly reported in various studies^7–9.

Regarding infant and young child feeding practices, around 40% of infants from 0–6 months of age had been exclusively breastfed, worldwide⁶. Whereas, only a few children acquire adequate nutrition along with proper complementary feeding which is appropriate for their age group they belong to⁶. In low-and middle-income countries (LMICs), these sub-optimal feeding practices of infants and young children contribute to the prevailing burden of malnourishment. According to the Pakistan Demographic Health Survey (PDHS, 2018), 38% of children under five years of age are stunted and 17% are severely stunted. However; the national findings also indicate an improved nutritional status of children which has resulted in the decline of stunting from 45% to 38% among children as reported by previous findings of PDHS 2012–2013^2,10,11. Lack of knowledge, lower socio-economic status, and relatively low levels of education of mothers or caregivers can be attributed to suboptimal IYCF practices¹².

Emphasis has been laid on implementing effective innovative interventions to improve nutrition among children particularly in poor resource countries. One of the most effective strategies laid down by WHO to improve IYCF practices is effective counseling on proper nutritional practices through community health workers^13,14. In Pakistan, these community health workers are referred to as Lady Health Workers (LHWs), recruited under the National Program for Family Planning and Primary Health Care¹⁵. With support from WHO, the government of Pakistan launched the ‘Lady Health Workers Programme’ in 1994, which was mainly aimed to provide an effective grassroot level system for accessing primary health care¹⁵. This program was aspired to bridge the communities for accessing primary healthcare through LHWs. Moreover; among the various roles and responsibilities under this program, the LHWs are also expected to provide nutritional counseling. However, the deliverables by LHWs somehow are affected due to being overburdened¹⁶.

Thus, it is imperative that a facilitating system if is provided to these LHWs will help to reduce their workload. Among some of the innovative strategies of providing health service, mobile health or mhealth, is gaining momentum in low- and middle-income countries. As defined by WHO mhealth is the “provision of health services and information via mobile and wireless technologies”¹⁷. The innovation and use of information and technology through mhealth has been vastly employed to address access, resource utilization, and coverage gaps. Many LMICs including those in South Asia have been employing mhealth approach through the Community Health Workers or peer counselors to improve healthcare as an innovative strategy^18,19. A study conducted in Bangladesh demonstrated gaps in IYCF related service delivery which prompted the need of healthcare messages, including information related to emergency and medical care, to be delivered through mobile phones. The potential benefits and necessity of mhealth led the technology to embrace community-based nutrition services to improve the service delivery and coverage related to IYCF nutrition. Mass-scale behavioural interventions that actively included social mobilization at the community-level, media campaigns, and counseling by trained workers have also been found useful^19–21. Evidence from India suggests that IYCF related nutrition among children can be improved using counseling strategies aimed at the parents²². Limited evidence is available from Pakistan indicating effectiveness of mhealth related to IYCF nutrition as mhealth has not been extensively opted for IYCF nutrition solely. Although there lies significant opportunities including use of mhealth in masses, advocacy, intersectoral collaboration and training of community health workers regarding IYCF nutrition²³. Therefore, considering the current situation in Pakistan, we planned to pilot mhealth technology with counseling through LHWs. For this intervention we first conducted a formative study in collaboration with Lady Health Worker (LHW) programme, which helped in the development and implementation of a mhealth based program to counsel women on proper nutritional practices related to infant and young children (IYCF) in a rural periphery located in Islamabad.

Our mhealth intervention was deployed on pregnant and lactating mothers from July 2016 to December 2016 in rural Islamabad. The aim was to test the feasibility and acceptance of mhealth intervention among the target population. A pre-intervention survey was conducted one month prior to the intervention in June 2016 followed by a post intervention survey conducted in May to June 2018 to determine the effectiveness of mhealth intervention in improving infant and young child feeding (IYCF) nutrition related knowledge, attitude and practices among pregnant and lactating mothers in rural Islamabad (Both surveys are available as Extended data²⁴). The specific objective of this post-intervention study was to compare the pre and post mhealth intervention related knowledge, attitude & practices of pregnant and lactating mothers regarding IYCF.

Methods

Study population

As mentioned, our intervention was deployed to pregnant and lactating women residing in Tarlai, Islamabad (See Figure 1). The study area is covered by the Lady Health Workers (LHWs) who are considered as the first level healthcare providers in this community. Upon availability and approval from the district health office, 10 LHWs were randomly selected and trained on IYCF. Out of these 10 LHWs, 05 were selected on basis of their best performance during the IYCF training. The sampling frame was based on these five selected LHW-wise households where pregnant or lactating mothers residing within the catchment area of Tarlai, Islamabad and have children of ≤2 years of age who were willing to participate in the study were recruited and registered. Their husbands were also invited to participate and after obtaining consent the post-intervention study was conducted. Non-residents, non-consenting cases and mothers with serious co-morbidities were excluded from the study.

Figure 1. Intervention Phase among pregnant & lactating mothers in rural Islamabad from July to December 2016.

Results

Table 1 shows baseline characteristics of the 135 mothers, out of which 49 (36.3%) women belong to the age group of 25 to 29 years of age. The mean age of these pregnant and lactating mothers was 30.5 years ± 4.5 SD. Out of 135 women, 71 (52.6%) had 3 children and on average had 7 family members. Most women i.e. 59 (43.7%) had their education up to Matriculation and Intermediate followed by primary level of education for 48 (35.6%) of the women. The occupation status of 128 (94.8%) of these women was ‘unemployed’. The birth place of children as reported by 77 (57.3%) of women was a government facility, and the mode of delivery of 86 (63.7%) women was reported as ‘normal’. The common source of water was ‘tap water’ in the households according to 50 (37%) of women.

The overall pre-intervention knowledge of 34 pregnant mothers regarding breastfeeding, exclusive breastfeeding and complementary feeding was 75.6%which decreased to 46.7% among 21of these women even after the mhealth intervention. This emphasizes the need of increasing awareness among pregnant women, in particular (Table 2). Overall, findings of our survey elucidated that the mhealth intervention was effective in improving the overall knowledge of mothers regarding IYCF from 74 (54.8%) in 2016 to 94 (69.6%) in 2018 after the intervention (Table 4)

The overall attitude regarding IYCF among 59 (43.7%) of the mothers before intervention, and among 86 (63.7%) of the mothers after intervention, was found to be positive. Whereas; overall practices of 22 (16.3%) mothers before intervention and 88 (65.2%) of the mothers after intervention were found adherent to good practices (Table 3). A noticeable percentage increase in knowledge related to prelacteal feeding considered as harmful and the benefits of colostrum was 28.2% and 23%, respectively (Table 2).

A percentage difference of 46.4 was observed in attitude of mothers towards consistency of food consumed by their children, which was 12.1% before intervention, and was found to be adequate among 58.5% of the mothers after intervention. Furthermore, practices regarding complementary feeding and additional foods during the first six months of infancy were 0.0% before the intervention which was significantly raised to 66.7% among these mothers (Table 4). In addition, 55 (40.7%) of the mothers reported to be visited ‘once’ by LHW, followed by 49 (36.3%) of the mothers who were visited ‘twice’ on a monthly basis (Table 1). Pre- and post-intervention findings are available as Underlying data²⁴.

Discussion

For child survival, growth and development, a key strategy is to improve IYCF related practices which is becoming an essential component of child health programs in various countries²⁹. The results of our post-mhealth intervention survey regarding IYCF conducted in a rural territory in Islamabad yielded to be effective in improving the knowledge, attitude, and practices of pregnant and lactating mothers. Based on findings of our earlier research conducted on the same study population we found that community-based nutritional intervention such as ‘mhealth’ offer new opportunities for effective and efficient service delivery, resource utilization, and improving access to healthcare³⁰.

Improving IYCF practices in poor resource setting can be effectively contextualized through information technology involving mhealth. Specific socio-cultural and socio-economic barriers hindering access of mothers for acquiring information related to IYCF must be overcome in order to reduce the prevailing burden of preventable malnutrition³¹. Studies suggest that maternal literacy plays important role whereas healthcare services can be augmented through the use of mobile phone-based technology such as mhealth^31,32. It offers enormous opportunities for improving health indicators related to maternal, new born and child health specifically in rural settings. It was found in one study that mhealth or SMS-based health education could provide an essential chance to educate pregnant and lactating mothers about antenatal care (ANC) visits, child birth, and education related to family planning³². This indicates that there is a potential capacity to implement mhealth based IYCF which may render opportunities for scaling up the intervention in rural Islamabad. The findings of our survey elucidate that specific focus should be placed on the components of knowledge related to breastfeeding and exclusive breastfeeding during early infancy. However; relevance and quality of mhealth to other components of maternal and child health must be rigorously studied to promote the proliferation of mobile phones as a source of acquiring health information in LMICs.

Despite the improvement in overall knowledge, attitude and practices of women related to IYCF in our study, certain important components related to breastfeeding showed steady findings. The knowledge of women regarding advisable duration of breastfeeding, early initiation of breastfeeding after birth, and timely complementary feeding initiation with additional food to be given to in early 6 months of infancy showed no significant change after mhealth intervention. This could be attributed to a prolong washout period after the deployment of mhealth intervention among the mothers or it can possibly subject to recall bias. Despite this more than a quarter of women in our study still practised and considered prelacteal feed such as honey and water as advantageous for the infant. This was found to be consistent to the findings of research studies conducted in Myanmar, Ethopia & India where prelacteal feeding was perceived as a cultural practice and was related to maternal beliefs^33–36.

There seems to be a paucity of relevant available literature on assessing the effectiveness of mhealth, particularly in the context of infant and young child nutrition particularly in Pakistan³⁰, which signifies its importance in implementing such interventions in poor resource settings. In contrast to our earlier research findings on testing the acceptance of mhealth among women residing in Tarlai Kalan Islamabad, a study from Sri Lanka demonstrated that women preferred to interact with healthcare providers on their maternity and child health needs³⁷. Contrary to it, in our study majority of women favoured the use of mobile phones to access information related to infant and young child feeding. On the basis of which, we therefore recommend scaling up of the health intervention in poor resource settings for the purpose of providing knowledge and increasing awareness regarding IYCF. Our study findings reflect that extensive mobile coverage has emerged as an innovative tool in rural Islamabad, and has acted as a facilitator which can effectively reach the underserved communities for providing health as well as education regarding infant and young child nutrition.

Conclusion

Our study indicates that community-based nutritional interventions using mhealth are innovative and effective in increasing IYCF related knowledge, attitude and practices among mothers. Cost-effectiveness of such behaviour change approaches and interventions should be assessed for future implementation in maternal and child health related programmes. Further experimental studies must be explored to validate the findings in Pakistani context.

Software availability

The source code of android phone-based application developed for the Lady Health Workers (LHWs) under the project “Sehatmnd Kl” is the property of Maternal, Neonatal and Child Health Research Network (MNCHRN) and cannot be made public.

All content used in the app to provide information to the recruited mothers is available as Extended data²⁴.

Data availability