This case focuses on children/infants aged 6-12 months as the life course phase/demographic group claiming iron deficiency as the exposure and anemia as the negative health outcome . Through the intervention of daily text message reminders aimed at warding off micronutrient deficiency and anemia during infancy, the long-term goal can be hypothesized to thwart visual and auditory system malfunctioning and other poor developmental outcomes in later growth . This aligns with the “fetal origins hypothesis” according to which adult poor health outcomes can arise in “developmental plasticity” owing to undernutrition during fetal development and infancy (“critical period”) .
The “critical period” roots of adult poor health outcomes are also closely intertwined with neglected maternal health. Given the context of rural western China and its history of material deprivation, such “macro-social” contexts of poverty shape the “psychological dispositions” and health status of the rural populations. This is to say that the lower socio-economic status stemming from poverty manifest as iron and other micronutrient deficiency in malnourished mothers, resulting in micronutrient deficit fetuses (and infants).
Drawing from studies conducted in Kenya and Bangladesh, researchers found that supplementation alone was not enough and that care providers’ compliance with prescribed supplement dosage was critical to curing this micronutrient deficiency in infants .
The intervention was designed as a cluster Randomized Control Trial (RCT) in rural China, (where villages were the clusters) to test whether sending text message reminders to caregivers’ mobile phones would have any incremental effect on the potency of a home micronutrient fortification program. Mobile technology was used to channel the intervention because approximately 67% of the target population possessed cell phone devices .
The researchers set to meet this overarching goal via three milestones, namely, to look into the compliance of caregivers to home micronutrient fortification programs, analyzing the impact of sending text message reminders to caregivers and seeing whether sending text message reminders has any effect on child nutrition, particularly on anemia. The study comprised of three experimental arms: 2 treatment and one control group.
Two cohorts of children in the age group of 6-12 months were selected and the intervention lasted for 6 months for each cohort. The care providers in treatment group 1 (Free Delivery Group) received direct healthcare training on nutrition and feeding practices. The second treatment group (Text Messaging Group) received daily text short message service (SMS) reminders for 6 months in addition to the same treatment as the Free Delivery Group. Both of these groups were given plastic envelopes to store the micronutrient supplement powder (“NurtureMate”) and were told to return the empty envelops to the survey team at the coda of the study, which would be used to estimate degree of compliance.
The degree of compliance was estimated by “counted the total number of opened and unopened packets and divided the number of opened packets by the number of days that had elapsed between the passing out of the packets and the follow-up survey, and then multiplied by 7”, furthermore, households falling within the experiment arms were also asked to report the amount of packets used on a weekly basis. Apart from the estimate for compliance, the impact of this intervention was also measured by collecting hemoglobin concentrations from all care providers and infants by survey nurses at Xi’an Jiaotong Medical School. “Finger blood analysis of hemoglobin concentrations” was used to administer the anemia level among infants.
Where collection of hemoglobin samples can be seen as a measure of the impact of the intervention, it is also worth noting how it is a source for potential bias in this study, since these were the only indicators used to judge micronutrient deficiency instead of examining whole blood for nutritional deficiencies. Despite showcasing favorable results, the observed dropout rate for this study was “relatively high” at 23.4%. This inconsistency largely accrued to incomplete data and familial relocations (in search for job opportunities). It is also not clear if there was blinding of participant and/or researchers in order to avoid potential biases in this RCT.
Nonetheless, this intervention had many elements that worked towards the impressive results of the experiment. Training the care providers in the “Free Delivery Group” (FDG) and “Text Messaging Group” (TMG) potentially reduced the possibility of caregivers not utilizing the micronutrient powder for their infants due to lack of knowledge/literacy. Furthermore, data collections encompassed arrangements to record various demographic dimensions of the infants, parents and households, household socio-economic status and the primary caregivers’ pre-conceived knowledge on feeding practice, which adds to the accuracy, credibility and transparency of the study.
However, using collected empty packets of the micronutrient powder at the end of the survey as a proxy for compliance can spell as an opportunity to taint the very accuracy, credibility and transparency that this study strived for. On one hand it may lead to underestimation of compliance (the primary caregivers may misplace the empty packets but followed through with the dosage to their infants), on the other, it can amount to overestimation of compliance (primary caregivers may sell the micronutrient powder for extra money but return the empty packets to the enumerators). Self-reporting by households too, can lead to over-estimation of compliance. In order to counter this potential misplacement of compliance estimates, surveillance cameras could be installed in all the RCT to accurately monitor compliance after due accommodation of ethical and privacy concerns.
Compliance follows the successful implementation of any intervention. Having said that, the successful replication of daily text message reminders hinges on the tri-axis of availability, affordability and accessibility of cell phones in a defined target community. For this purpose, a number of proxies can be formulated to measure each of these three key components. To measure availability, we need to look at the mobile stores and connectivity towers in and around the community. Affordability can be looked at through the lens of socio-economic status (SES), which in turn can be measured through the average income and education levels of the community and proportion of households availing federal and/or state sanctioned social welfare schemes aimed at underprivileged/disadvantaged populations. A major driver of the success of this intervention is elementary digital literacy, therefore, it must be ensured that all those administered in the treatment arm must know how to use a mobile phone (which can also be used as a proxy for accessibility). Other proxies for accessibility can be the distance of the mobile store from residential areas and the availability of support services such as transportation to facilitate reaching said mobile stores.