A pilot programme that used text messages to relay information and encouragement to caregivers in an impoverished region of rural Ecuador significantly improved the nutrition and health of children.
The programme, Texting for Nutrition was a 14-month randomised controlled trial developed after four years of collaboration with local nutritionists, health service providers and caregivers. Children whose caregivers received text messages through the programme got sick less, gained weight and were admitted to the hospital less often than those who did not.
Challenge
Chimborazo is a rural, mountainous region of Ecuador with a large indigenous population. More than 53 percent of households live in poverty, access to nutritious foods is severely limited, and clean water, bathrooms, and latrines are in short supply. Children eat a diet heavy in potatoes and salt and low in fruits and vegetables and often suffer from malnutrition.
In 2012, 49 percent of children in Chimborazo under the age of five were stunted, a manifestation of chronic malnutrition in which a child’s height for age is more than two standard deviations below the median of the World Health Organization Child Growth Standards. That was the worst stunting rate in Latin America and comparable to the Sub-Saharan African countries of Botswana, Ghana and South Africa. Stunting and other forms of under-nutrition lead to higher risks of infections and impair cognitive and motor development, learning capacity and school performance. They are responsible for nearly half of all child deaths globally.
In Chimborazo, high in the Andes mountains, small indigenous communities are separated from each other by miles of poorly-constructed, unpaved roads. Taking children to health checkups often requires traversing long distances to health centres far from home. Residents treat their water infrequently and hand washing is uncommon. About 20 percent of the population lacks access to any type of bathroom or latrine. Mothers often lack basic knowledge of when to integrate solid foods into their children’s diet alongside breast milk. While the government has repeatedly promoted the use of vitamins and other supplements in the region, it has not had great success.
Approach
Technical assistance projects in Chimborazo financed by the Japanese Social Development Fund created a strong network of relationships with regional health clinics, doctors, nurses and other service providers. World Bank researchers fanned out in the area starting in 2013 and found that most children under three in rural areas of Chimborazo rarely attended health checkups. Working with staff in public daycare centres and rural health centres, World Bank researchers reached out to 3,000 families to participate in the text messaging study.
For 14 months starting in January 2015, 2,000 families received regular text messages - as many as two a week. Another 1,000 families studied received no text messages.
The text messages encouraged mothers and other caregivers to take their children for regular checkups, give them iron supplements and other micronutrients provided by the government, boil their water to make it potable, wash their hands regularly, and improve their food preparation and general hygiene. Parents with young infants were encouraged to breastfeed their children and sent texts on how to resolve breastfeeding challenges.
All caregivers in the study were already enrolled in nutrition and monitoring programmes offered through local health clinics. But researchers recognised that when participants went home, they often did not follow advice they had been given. Enter the text messages, personalised to each participant and their children and signed by representatives of the regional government. Sent twice a week with some breaks, they were designed to be encouraging, positive, and non-judgmental.
One of the World Bank researchers involved in the project, Megan Rounseville, recounted her experience with one mother, who juggled multiple jobs with caring for her five children and her animals, alone for months at a time while her husband was away at work. At the end of her long days, having just arrived up a steep, sinuous mountain road and with another trek still needed out to the fields to collect her cows, she told Rounseville that boiling water and giving her children vitamins often seemed impossible. Getting encouraging text messages helped, she told Rounseville, even though she, like many others, had spotty or no cell phone service at home. She was able to check her texts just once a week on her trips to the local market, rather than on the days they were intended by the researchers to be received.
Among families who received regular text messages, the prevalence of respiratory illnesses decreased by 29 percent.
Results
The results, even accounting for the difficulties caregivers encountered with phone service, were revealing. Among families who were sent the texts, children under two gained weight (an indicator of better health and a predictor for growth), and the prevalence of respiratory illnesses decreased by 29 percent. The number of children who developed fever requiring hospitalisation went down nine percent. Children whose caregivers got the text messages also reported an improvement in overall child health.
“We know there are very clear structural causes of malnutrition. We are talking about food security, hygiene, vaccinations, the education of the mothers, and change is not so easy,” said Ana Maria Oviedo, senior economist in the Poverty and Equity Global Practice of the World Bank.
“What we found is that texting is not, of course, a solution to any of this on its own. It is a complement. It cannot solve the structural problems of malnutrition, but it can encourage the parents or the caregivers to behave a little bit differently, to change their behaviour so that, within constraints, they actually do their part.”
Beneficiaries
“The messages were very useful, especially those that gave us instructions on how to wash and cook food, as well as those that reminded us of the importance of cleanliness in the home. Through technological advances, we can inform ourselves and communicate.”
— Mary Abarca, mother of two in Chambo district
World Bank contribution
Texting for Nutrition was a part of the Ecuador Poverty Diagnostic for Water Supply, Sanitation and Hygiene, a joint project of four World Bank Global Practices: Health, Poverty, Social Protection and Jobs, and Water. The total project cost was US$ 662,000, mostly from the Water and Sanitation (WASH) Trust Fund.
Moving forward
Discussions are ongoing on replicating the texting programme, with the government of Ecuador actively interested in scaling up the effort to bring it to other provinces outside of Chimborazo. The team is also interested in applying the programme to parts of Peru, where the government has done well in addressing malnutrition, but where anaemia rates continue to be elevated.
Lessons learned from the pilots are also being incorporated in other programmes.
(Source: World Bank)
