Participants in the surveys
A total of 1804 caregivers of children were surveyed in the 2012 baseline survey and 754 in the 2018 follow-up survey. In both surveys, mothers and grandparents were the main caregivers, accounting for around 50% and 45% respectively (Table 1). For the 6-11 months child age group, more than 65% of main caregivers were mothers. Mothers who attended junior high school or above increased from 59.8% at baseline to 79.0% at follow-up (P<0.001) and only 4.0% of mothers were illiterate in 2018. The illiteracy rate for grandparents decreased over time but was still very high; 69.1% in 2012 and 60.3% in 2018, and this decrease was not significant (P=0.057).
Tables
Table1 Children’s main caregivers and their education in both surveys
|
|
Baseline survey
(2012)
|
Follow-up survey
(2018)
|
P-values*
|
|
6-11 months
(N=610)
|
12-23 months
(N=1194)
|
Total
(N=1804)
|
6-11 months
(N=247)
|
12-23 months
(N=507)
|
Total
(N=754)
|
Main caregivers
|
|
|
|
|
|
|
|
<0.001
|
Mother
|
|
65.6
|
46.9
|
53.2
|
66.4
|
40.0
|
48.7
|
|
Grandparents
|
|
33.9
|
50.7
|
45.0
|
27.5
|
55.6
|
46.4
|
|
Father
|
|
0.0
|
0.9
|
0.6
|
6.1
|
4.2
|
4.8
|
|
Other
|
|
0.5
|
1.5
|
1.2
|
0.0
|
0.2
|
0.1
|
|
Mothers
|
|
|
|
|
|
|
|
|
Age in years
(median(Q1, Q3))
|
|
25 (23, 30)
|
26 (23, 30)
|
26 (23, 30)
|
28 (26,31)
|
29 (26, 32)
|
29 (26, 31)
|
<0.001
|
Education, % (n)*
|
|
|
|
|
|
|
|
<0.001
|
Illiterate
|
|
14.1
|
14.7
|
14.5
|
3.7
|
4.2
|
4.0
|
|
Primary school
|
|
21.4
|
24.0
|
23.1
|
12.2
|
14.5
|
13.8
|
Junior high school
school
|
|
52.6
|
48.9
|
50.2
|
58.9
|
57.4
|
57.9
|
Senior high school
school or above
|
|
9.9
|
9.4
|
9.6
|
24.0
|
19.7
|
21.1
|
Did not know
|
|
2.0
|
3.0
|
2.7
|
1.2
|
4.2
|
3.2
|
Grandparents
|
|
|
|
|
|
|
|
|
Age in years (median (Q1, Q3))
|
|
50 (46, 55)
|
52 (48, 58)
|
51 (47, 57)
|
52 (49, 57)
|
54 (51, 59)
|
54 (50, 59)
|
<0.001
|
Education, % (n)
|
|
|
|
|
|
|
|
0.057
|
Illiterate
|
|
66.7
|
69.9
|
69.1
|
57.3
|
61.0
|
60.3
|
|
Primary school
|
|
19.8
|
17.5
|
18.1
|
26.5
|
21.6
|
22.6
|
Junior high school
|
|
12.5
|
10.3
|
10.9
|
16.2
|
14.9
|
15.1
|
Senior high school
|
|
0.5
|
1.5
|
1.2
|
0.0
|
1.4
|
1.1
|
Did not know
|
|
0.5
|
0.8
|
0.7
|
0.0
|
1.1
|
0.9
|
* Baseline vs follow-up for the 6-23 months age group.
Participants in the interviews
A total of 17 pregnant women in their second or third trimester and 16 mothers who had a child aged 0-6 months participated in the interviews. The median age was 29 (ranged from 18 to 45) for pregnant women and 31 (ranged from 23 to 40) for mothers. Most of pregnant women and mothers attended junior high school or above, with four of them only attending primary school and two being illiterate. Five pregnant women and two mothers had a job, such as being a teacher, technician, or commercial service worker, and the others stayed at home for housework.
Caregivers’ infant and young child knowledge and practices
As shown in Table 2, caregivers’ feeding knowledge was still poor despite having improved over the years. Less than 10% of caregivers knew that breastfeeding could be continued up to two years, less than 50% of caregivers knew the accurate duration of exclusive breastfeeding, and only around 20% of caregivers knew to start feeding children with meat from the age of 6-8 months. Similarly, infant feeding practices were suboptimal and mostly did not change, except for children who were given iron-rich or iron-fortified foods, which increased from 41.5% at baseline to 70.9% at follow-up (P<0.001). Although more caregivers ever received breastfeeding and complementary feeding information during pregnancy or after delivery at follow-up than at baseline (P<0.001), the proportion was only around 30%.
Table 2 Caregivers’ infant and young child feeding knowledge and practices in both surveys
Indicators
|
Baseline survey
(2012)
|
Follow-up survey
(2018)
|
P-values
|
n†
|
N‡
|
Percentage (%)
|
n*
|
N§
|
Percentage (%)
|
|
Feeding knowledge
|
|
|
|
|
|
|
|
Caregivers knowing the duration of exclusive breastfeeding
|
336
|
1804
|
18.6
|
298
|
754
|
39.5
|
<0.001
|
Caregivers knowing continued breastfeeding until two years
|
42
|
1804
|
2.3
|
47
|
754
|
6.23
|
<0.001
|
Caregivers knowing introduction of complementary foods at 6-8 months
|
779
|
1804
|
43.2
|
485
|
754
|
64.3
|
<0.001
|
Caregivers knowing starting feeding children with meat at 6-8 months
|
383
|
1804
|
21.2
|
148
|
754
|
19.6
|
0.362
|
Feeding practices
|
|
|
|
|
|
|
|
Children breastfed until two years§
|
39
|
502
|
7.8
|
15
|
179
|
8.4
|
0.068
|
Children given complementary foods at 6-8 months¶
|
259
|
319
|
81.2
|
101
|
123
|
82.1
|
0.823
|
Children aged 6-23 months given iron-rich or iron-fortified foods during the past 24 hours
|
749
|
1804
|
41.5
|
533
|
754
|
70.7
|
<0.001
|
Children aged 6-23 months were given meat during the past 24 hours
|
715
|
1804
|
39.6
|
329
|
754
|
43.6
|
0.061
|
Minimum dietary diversity††
|
929
|
1804
|
51.5
|
420
|
754
|
55.7
|
0.052
|
Minimum meal frequency∮
|
508
|
1804
|
28.2
|
211
|
754
|
28.0
|
0.928
|
Minimum acceptable¢
|
188
|
1804
|
10.4
|
90
|
754
|
11.9
|
0.262
|
Information sources
|
|
|
|
|
|
|
|
Caregivers ever received breastfeeding information during pregnancy or after delivery
|
469
|
1804
|
26.0
|
265
|
754
|
35.2
|
<0.001
|
Caregivers ever received complementary feeding information during pregnancy or after delivery
|
293
|
1804
|
16.2
|
195
|
754
|
25.9
|
<0.001
|
†Number of caregivers who responded positive on the knowledge/practices.
‡Total number of mother eligible for the question.
- Only children aged 20 to 23 months were used to calculate this indicator (From “Indicators for assessing infant and young child feeding practices”).
¶Only children aged 6 to 8 months were used to calculate this indicator (From “Indicators for assessing infant and young child feeding practices”).
††Minimum dietary diversity: the indictor was four out of seven food groups per day. The proportion of children aged 6-23 months who receive foods from four or more food groups was estimated (From “Indicators for assessing infant and young child feeding practices”).
∮Minimum meal frequency: the proportion of breastfed and non-breastfed children aged 6–23 months who received solid, semi-solid, or soft foods (also including milk for non-breastfed children) the minimum number of times or more (From “Indicators for assessing infant and young child feeding practices”).
¢Minimum acceptable diet: Proportion of children aged 6–23 months who reached a minimum dietary diversity and minimum meal frequency (From “Indicators for assessing infant and young child feeding practices”)..
In the semi-structured interviews, pregnant women and mothers generally did not have a clear idea about exclusive breastfeeding and its recommended duration. All the interviewed pregnant women thought children should be given water during the exclusive breastfeeding period (up to six months after delivery) due to the following reasons: children may get sweaty, be thirsty, their mouths may be dry, water can replenish children’s energy and because other peoples’ advice.
Interviewed pregnant woman 1 (aged 37 years, 37 weeks of gestation, primary school education, shuangshu township) said, “Children may be thirsty (if fed only by breast milk), just like adults drink milk, milk is milk, water is water.”
Mothers’ reasons to give water to their children were: children were thirsty, refused breast milk, their stools were dry, no breast milk after delivery, hospital information. In addition, mothers fed formula or noodles to their children younger than six months, as they thought breast milk was not enough for children. The duration of exclusive breastfeeding given by pregnant women and mothers varied from 3 months to 12 months.
Interviewed mother 1 (aged 28 years, child aged 5 months, junior college education, Xishan township) said, “Sometimes, my child’s digestion was not good, that is, his stool was dry, I would give him some water to help him digest.”
Interviewed mother 2 (aged 31 years, child aged 2 months, middle school education, Shuangshu township)said, “The doctor told me I should give some water to my child.”
Sources of infant feeding information
Around 50% of caregivers reported having received feeding information from their relatives and friends, followed by health facilities and communities accounting for about 30% (Figure 1). Information from mass media and books dropped from around 20% in 2012 to less than 10% in 2018, whereas Internet and mobile phones as an information source increased to more than 10% in 2018.
In the interviews, pregnant women and mothers said that they received feeding information from the Internet (Baidu search engine) (n=18), hospitals (n=17), apps on their smartphones (n=13), the elder people (n=7), their own experience (n=4), maternal and child health booklets developed by local health institutions (n=2), and books (n=1).
Although the Internet seemed to be one of the most important sources for feeding information, pregnant women and mothers did not completely believe this information. They often referred to comments from other people, health workers, elder people at home or books before they accepted a specific piece of information.
Interviewed pregnant woman 2 (aged 24 years, 23 weeks of gestation, middle school education, Weiyuan township) said:” I still believe doctors, and the information from the internet is only as a reference”.
Interviewed mother 3 (aged 27 years, child aged 5 days, junior college education, Weiyuan township)said: “I often searched several browsers at the same time and reviewed comments from other people, but I did not believe completely most of the time.”
Interviewed mother 4 (aged 24 years, child aged 1 day, technical secondary school education, Weiyuan township) said: “I often read the information which had the most comments.”
Use of smartphone and WeChat
Smartphone and WeChat app usage were very popular among mothers. More than 80% of mothers were currently using both smartphone and WeChat app in their smartphones (Table 3). However, only around half of the grandparents were currently using smartphones, and less than 30% of them used WeChat app. Nearly 80% of mothers used WeChat for more than one hour every day. Around 30% of caregivers followed Infant and young child feeding official accounts, and 75.4% of them were willing to receive information from WeChat official accounts.
Table 3 Mothers’ and grandparents’ use of smartphones and WeChat in the follow-up survey in 2018 (N=493†)
|
Mothers
|
Grandparents
|
Total
|
|
(n/N)
|
%
|
(n/N)
|
%
|
(n/N)
|
%
|
Smartphone use
|
|
|
|
|
|
|
Currently using smartphones
|
(260/292)
|
89.0
|
(106/201)
|
52.7
|
(366/493)
|
74.2
|
Smartphone can access the internet
|
(236/260)
|
90.8
|
(56/106)
|
52.8
|
(292/366)
|
79.8
|
Ways to access the internet
|
|
|
|
|
|
|
WiFi at home or the workplace
|
(157/258)
|
60.9
|
(43/62)
|
69.4
|
(200/320)
|
62.5
|
Mobile traffic
|
(96/258)
|
37.2
|
(17/62)
|
27.4
|
(113/320)
|
35.3
|
Other
|
(5/258)
|
1.9
|
(2/62)
|
3.2
|
(7/320)
|
2.2
|
WeChat use
|
|
|
|
|
|
|
Currently using WeChat
|
(236 /292)
|
80.8
|
(58/201)
|
28.9
|
(294/493)
|
59.6
|
Using WeChat for more than one hour every day
|
(183/236)
|
77.5
|
(33/58)
|
56.9
|
(286/294)
|
73.5
|
Following infant and young child feeding official accounts
|
(92/236)
|
39.0
|
(7/58)
|
12.1
|
(99/294)
|
33.7
|
Willing to receive information from official accounts
|
(178/236)
|
75.4
|
(34/58)
|
58.6
|
(212/294)
|
72.1
|
†Among 754 interviewed caregivers, there were 292 mothers and 201 caregivers.
In the in-depth interviews, all the pregnant women and mothers had smartphones and used WeChat, and most of them used WeChat at least more than one year. Messaging, moments, official accounts, news, and WeChat group were the most used functions. However, only one pregnant woman and two mothers followed the infant and young child feeding-related official accounts, and they explained that they had never heard of those official accounts (n=20), or they thought it was unnecessary (n=3). Participants who followed could read and review the contents in official accounts when they were free.
Interviewed pregnant woman 3 (aged 27 years, 14 weeks of gestation, middle school education, Shuangshu township) said: “My (previous) children are very healthy, so I did not follow (the infant and young child feeding official accounts).”
Use experience of the WeChat feeding health education platform
Most interviewed pregnant women and mothers stated that the interface of the module block was good enough, and they liked it. One mother said using the interface was not so smooth.
For the feeding lecture classroom module, four pregnant women and five mothers liked pictures and text for feeding knowledge as they thought it was easy to understand, they got used to reading text, or they thought videos were too fast or a bit slow. Seven pregnant women and eight mothers liked videos for feeding knowledge as they believed that videos were easy to understand, simple and convenient to watch. Other pregnant women and mothers expressed that pictures, text and videos were ‘OK’ for them. Most pregnant women and mothers said that they were interested in the feeding lecture classroom, and that the contents were easy to understand and useful.
Pregnant women wanted to know information on breastfeeding positions, how to increase breast milk supply, spitting up, child health, how to hold a baby, cough, sleep and antenatal care. Mothers wanted to know more about breastfeeding and complementary feeding, food allergies, illnesses, and growth development.
For the Baby Growth Chart module, five pregnant women and three mothers expressed that they could not understand the growth chart after they filled in the growth data.
Thirteen pregnant women and 14 mothers were willing to use this function to monitor the growth of their children. However, interviewed mother 5 (aged 33 years, child aged 2 days, Primary school education, Weiyuan township) said, “I don’t understand the function, so I would not use it.”