Freeman Spogli Institute for International Studies Program on Energy and Sustainable Development Stanford University


Research at PESD


Text Messaging for Health in Rural China

REAP Project
Ongoing

Problem

Previous studies conducted by REAP have shown that between 25 to 40 percent of
elementary school students in rural China suffer from iron deficiency anemia (IDA),primarily as a result of poor nutrition. Additional research has demonstrated that IDA has severe consequences for educational outcomes in children of all ages with respect to grades, attendance, and attainment. Fortunately, one study conducted by REAP has shown that reducing anemia by increasing iron and hemoglobin levels can significantly raise student test scores.

In a recent REAP study, a program that provided multivitamins with iron was found to directly increase student hemoglobin counts and math test scores. Unfortunately, such a program is not scalable due to resource constraints and other practical considerations. Although our intervention was shown to be effective, multivitamins are often difficult, if not impossible, to obtain in rural areas. Compounding this problem is the difficulty many rural families have in understanding the utility of taking vitamins.

In an attempt to determine other methods to effectively increase children’s iron intake,
REAP conducted an information campaign in one rural area to educate families about anemia. As part of the intervention, REAP held mass training sessions for parents at local elementary schools to explain anemia, its effects, and how to avoid it. Unfortunately, these sessions seem to have had little effect in changing behavior.

Goals

REAP aims to determine whether SMS (text messaging) is an effective means for improving rural families’ understanding of the anemia problem. Specific research questions include:

  • Does following up traditional means of disseminating information (e.g., informational pamphlets and parent meetings) with text messaging reinforce the informational content and increase the effectiveness of traditional interventions?
  • Are passive reminders (weekly mobile phone messages) more or less effective than active participation (asking a quiz question to encourage review of old text messages)?
  • How does intra-household communication operate? Will there be a different outcome if the mother has a phone as opposed to the father?

Our intervention will provide a better understanding of whether families of rural schoolchildren will adjust their health behaviors when educated about the importance of good nutrition through a series of targeted text messages.

Approach

Project Sample

The project sample consists of 8000 randomly selected rural parents and grandparents of fourth grade students in Ningxia Hui Autonomous Region. Located in an arid, remote part of northwest China, Ningxia was selected as the focus of this intervention because it is among the country’s poorest regions.

Baseline Survey

The cell phone numbers of local families were collected as part of the baseline survey. Data was also collected on the hemoglobin levels, height, weight, and psychological health of children, as well as parents’ knowledge of anemia (i.e., its causes, its effect on academic performance, how to avoid it).

Project Intervention

Half of the cell phone numbers collected during the baseline survey will be included in the text messaging intervention. Text messages containing various health and nutrition information messages will be sent to participants for a total of 50 weeks.

A subset of the cell phone numbers included in the intervention will receive, in addition to the weekly health and nutrition messages, short, single-question multiple choice quizzes during weeks 4, 12, and 50 of the intervention. As part of the quiz, recipients will be invited to respond to the message with the correct answer. Respondents who answer the quiz questions correctly will then have a reward payment of ten RMB charged to their phones.

Evaluation

After the intervention, data on the number of phone numbers that responded to each quiz, a record of each respondent’s answer to the quizzes, and a record of which phone numbers received the ten RMB prize will be collected.

This data will then be used to answer the following questions about the two interventions (i.e., quiz or no quiz):

  • Did either intervention work?
  • Did the interventions raise hemoglobin levels, test scores, knowledge, and physical/psychological indicators?
  • Which intervention was more effective?

This data will help to reveal whether SMS text messaging can effectively improve rural families’ understanding of the anemia problem.

Results

We found that sending text messages about nutrition/anemia only had no effect.  However, sending both text messages and quiz questions significantly affected parental health knowledge, nutrition, student health and academic performance. Text messages and quiz questions appeared to have an effect on household purchases: parents bought more dietary supplements. 

Intensity of messages also appeared to have an effect.  If more quiz questions were answered, parental health knowledge improved more.  Further, receiving more half weekly messages improved math test scores (given that the quiz questions were sent).

We also found that the recipient of the text message affected the effectiveness of the text message.  Sending quiz questions to the mom instead of the dad produced greater increases in parental knowledge and student health level.

Conclusions

We report evidence that a mobile phone intervention that sends both a weekly text message and a monthly, interactive quiz question has a positive impact on health and educational performance in rural areas. We hope that future research will help us better understand the underlying mechanism of how the text messages work, and thus enable an even more effective intervention.