Impact of Text Message Reminders on Caregivers’ Adherence to a Home Fortification Program Against Child Anemia in Rural Western China: A Cluster-Randomized Controlled Trial

摘要

Objectives. To test whether text message reminders sent to caregivers improve the effectiveness of a home micronutrient fortification program in western China. Methods. We carried out a cluster-randomized controlled trial in 351 villages (clusters) in Shaanxi Province in 2013 and 2014, enrolling children aged 6 to 12 months. We randomly assigned each village to 1 of 3 groups: free delivery group, text messaging group, or control group. We collected information on compliance with treatments and hemoglobin concentrations from all children at baseline and 6-month follow-up. We estimated the intent-to-treat effects on compliance and child anemia using a logistic regression model. Results. There were 1393 eligible children. We found that assignment to the text messaging group led to an increase in full compliance (marginal effect?=?0.10; 95% confidence interval [CI]?=?0.03, 0.16) compared with the free delivery group and decrease in the rate of anemia at end line relative to the control group (marginal effect?=??0.07; 95% CI?=??0.12, ?0.01), but not relative to the free delivery group (marginal effect?=??0.03; 95% CI?=??0.09, 0.03). Conclusions. Text messages improved compliance of caregivers to a home fortification program and children’s nutrition. Anemia is one of the most prevalent nutritional disorders among preschool-aged children in developing countries. 1 Despite overall improvements in child health in China over the past 3 decades, the prevalence of anemia among children younger than 5 years in rural areas is still high. 2–4 One national survey demonstrated that although the prevalence of anemia had decreased among infants aged 6 to 12 months from 35.0% in 2005 to 28.2% in 2010, the disease’s prevalence is still nontrivial. 4,5 Other studies have found similarly high rates (e.g., 23% in Guangxi Province; 58% in Gansu). 6,7 Although anemia is influenced by many factors, iron deficiency is the major cause, accounting for about half of the disease’s global incidence. 8–10 The development of daily-use micronutrient packets containing microencapsulated iron offers a way to provide key micronutrients to iron-deficient children. 11 In China, research shows that 90% of anemia in children stems from iron deficiency. 12 Research on the effectiveness of micronutrient supplementation, however, is mostly limited to studies based on small, nonrandomized samples. 13–18 Although supplementation has potential if caregivers systematically comply with supplement programs, there are indications that, internationally, lack of compliance has been a barrier to its success. 19–21 Unfortunately, almost no research has been conducted on how supplementation can best be delivered or how caregivers can be persuaded to regularly give their children micronutrient supplements. One study evaluated household compliance to a micronutrient supplement distribution program in Kenya. 20 Another study in Bangladesh compared the relative effectiveness of different approaches to administering micronutrient supplements to individuals. 21 Although both studies found low compliance, researchers concluded that the nature of the delivery strategy was associated with decreased rates of anemia in children. 20,21 The authors of both studies, however, suggested that the relatively low rates of use of the micronutrient supplement indicated generally poor project design, and that systematic research was needed to evaluate the impact of alternative delivery strategies on caregiver compliance and infant outcomes. We studied how text messaging could influence the effectiveness of micronutrient supplement programs. Text messaging technology has changed the face of communications globally and in China. A large percentage (67%) of households in the world have mobile phones. 22 An even larger percentage (>?90%) of households in China—even in rural areas—have mobile phones. 23 Mobile technology is increasingly used as a way to promote health and prevent disease, 24,25 although text message–based programs have often met with mixed results. Internationally, the application of text messaging for behavioral change in smoking cessation, antiobesity behavior modification, and diabetes management has shown positive results. 26–28 In China, a short message service (SMS) intervention was found to promote longer duration of exclusive breastfeeding for mothers. The study, however, did not follow a randomized controlled trial (RCT) design and was underpowered. 29 There are also examples of text messaging programs that do not work. Factors identified as leading to the programs’ failure included limited phone access, privacy concerns, phone maintenance, and text message content. 30–32 A recent literature review of text messaging’s effect on health concluded that most studies were not carried out systematically. 33 Using a cluster RCT design, we aimed to test whether text message reminders sent to caregivers’ mobile devices would improve the effectiveness of a home micronutrien