Study On The ’Diffusion-Motivate-Sustain’ Mechanism Of Micronutrient Home Fortification Program For Infants And Toddlers In Remote Rural Areas In Western China:Based On The Diffusion Innovation Theory

BackgroundAdequate nutrition is the key to the health and development of children,laying the foundation for their better future.During the past decade,the nutritional status of children under 5 years old in China has improved,but childhood malnutrition remains a critical problem in remote rural areas in western China.To improve nutrition among children in remote areas in China,the government has implemented the‘Child Nutrition Improvement Program’,which provides free soy-based micronutrient powder（referred to as‘Ying Yang Bao,YYB’）to children aged 6-24 months in program areas.Although the YYB has been proven safe and efficient to improve children’s nutrition,the challenges of implementing the YYB program continued due to the limited diffusion of the YYB program and the difficulty of maintaining adherence to the YYB among children’s caregivers.Therefore,accelerating the diffusion of the YYB program and encouraging the decision-making to sustain effective adoption among children’s caregivers is the key to implementing the YYB program.However,few studies have explored the diffusion and adoption of YYB from the comprehensive perspectives.To provide the scientific evidence for the implementation management of the YYB program,this study aims to regard the YYB program as an innovation,and to investigate the diffusion pattern of the YYB program based on the innovation diffusion theory,explore the mechanism of the decision-making process in adopting YYB,then analyze the trajectory of adherence to YYB.Objectives1.To investigate the diffusion of the YYB program among child caregivers in remote rural areas in western China based on the diffusion curve from the Diffusion Innovation Theory.2.To clarify the mechanism of the decision-making process in adopting YYB among children’s caregivers in remote rural areas in western China based on the Innovation-Decision Process Framework from Diffusion Innovation Theory.3.Based on the longitudinal data,a latent variable growth model was applied to elucidate the trajectory of adherence to YYB among children’s caregivers in remote rural areas in western China.MethodsA multi-stage sampling method was used to obtain the study population.First,to select the sample counties,we identified YYB program counties in Sichuan Province.From these counties,2 rural Han counties,2 rural Tibetan counties,and 2 rural Yi counties were selected.Second,we randomly selected 6 sample townships within each sampled county.Townships that housed the county seat were excluded.A total of 36townships were enrolled.Third,7 or 8 villages were selected from each sampled township.If there were no villages with populations of 800 or more,2 small neighboring villages were combined and considered as 1 village-level sampling unit.A total of 283villages.Finally,all caregivers with an infant in the target age range（6–24 months）were enrolled in each sample village.A longitudinal follow-up survey was conducted to obtain information on the whole process of adopting YYB among caregivers with children aged 6–24 months.In specific,households with children aged 6–24 months were included in May 2019 in the first survey round,two rounds of follow-up surveys were conducted every six months.In the field survey,the trained investigators collected data using structured questionnaires by face-to-face interview at home.The questionnaire was mainly included the characteristics of participants,the cognition of YYB,and adoption of YYB,information communication and delivery mode of YYB,and social system.Three research topics were included in our study:the diffusion pattern of the YYB program,the decision-making process in adopting YYB,and the trajectory of adherence to YYB.The data analysis methods of the first research topic（examine the diffusion pattern of the YYB program）includes（1）the diffusion curve of the YYB program was drawn based on the YYB decision period（the period from the first knowledge to start to feed YYB child）and YYB adoption rate,then classifying different types of YYB adopters according to the YYB decision period;（2）Chi-square tests were used to analyze the adopters’needs in terms of the health communication and delivery mode of YYB;（3）Linear Regression Models were used to analyze the associated factors of the YYB decision period;（4）Ordered Logit Regression Models were used to analyze the associated factors of the YYB adopter types.The data analysis methods of the second research topic（explore the decision-making process in adopting YYB）includes（1）descriptive analysis was used to explore the characteristics of the decision-making process in adopting YYB among children’s caregivers;（2）Pearson/Spearman correlation analysis were used to analyze the correlates of the decision-making process in adopting YYB;（3）Path Analysis was used to explore the associated factors of the decision-making process in adopting YYB.The data analysis methods of the third research topic（explore the trajectory of adherence to YYB）includes（1）descriptive analysis was used to investigate the time-constant and time-varying characteristics in the process of adopting YYB among children’s caregivers;（2）Pearson/Spearman correlation analysis was used to analyze the correlates of the trajectory of adherence to YYB;（3）Latent Growth Models were applied to examine the time-constant and time-varying factors influencing the trajectory of adherence to YYB.Since the study samples were from three ethnic groups,we also analyzed ethnic differences in each topic.Results1.Findings on examining the diffusion pattern of the YYB program（1）General characteristics of the YYB decision period:A total of 833 children and their caregivers from the first survey round were enrolled in data analysis.Caregivers heard about YYB at the mean child age of 6 months,decided to use YYB at the mean child age of 7.3 months（SD:5.0）,received the YYB at the mean child age of 7.8 months（SD:4.1）,and fed the child MNP first time at the mean child age 8.3 months（SD:4.6）.The YYB decision period in the whole study population was on average 18.6 months（SD:9.1）.Caregivers of the Yi group had a longer YYB decision period than Han and Yi groups（P=0.007）.（2）Diffusion of the YYB program:When the YYB decision period was 15 months,the diffusion curve of the YYB program reached the critical point（most caregivers started to feed YYB）,and the adoption rate of the YYB accelerated at this point.The curve plateaus when the increase regarding the diffusion slowed down and eventually approached a horizontal line when approximately 90%of caregivers fed the child YYB.Han and Tibetan ethnic groups had a higher slope of curves than the Yi ethnic group during the YYB diffusion.（3）Associated factors of the YYB decision period:In the full sample,after controlling for other factors,caregivers had a higher knowledge of YYB（β=-0.39,95%CI:-0.64,-0.13）,they were more like to have a shorter YYB decision period.In the Han group,caregivers had a higher knowledge of YYB（β=-0.34,95%CI:-0.68,-0.01）,they were more like to have a shorter YYB decision period.In the Tibetan group,we did not find the associated factors of the YYB decision period.In the Yi group,caregivers had positive parenting values（more expectations for children’s health and Academic achievement in the future）（β=-1.10,95%CI:-1.94,-0.26）,they were more like to have a shorter YYB decision period.（4）Associated factors of the YYB adopter types:In the full sample,after controlling for other factors,caregivers tended to have emotionally calm personality traits（β=-0.17,95%CI:-0.32,-0.02）,higher knowledge of YYB（β=-0.08,95%CI:-0.13,-0.04）,and higher self-efficacy in feeding YYB（β=-0.09,95%CI:-0.16,-0.02）,and received the YYB information from township doctor for the first time（β=-0.51,95%CI:-1.01,-0.11）,they were more likely to the early adopters.Compared with receiving the information on‘the YYB cost’,caregivers who received the information on‘the YYB health benefits’were more likely to be late adopters（β=0.32,95%CI:0.02,-0.62）.In the Han group,caregivers tended to have emotionally calm personality traits（β=-0.31,95%CI:-0.61,-0.01）and higher knowledge of the YYB（β=-0.13,95%CI:-0.21,-0.05）,they were more likely to the earlier adopters.In the Tibetan group,we did not find the associated factors of the YYB adopter types.In the Yi group,caregivers were more likely to be early adopters if they had stronger self-efficacy in feeding YYB（β=-0.14,95%CI:-0.27,-0.01）and positive parenting values（more expectations for children’s health and Academic achievement in the future）（β=-0.20,95%CI:-0.34,-0.05）;caregivers were more likely to be the late adopters if they had a premature child（β=1.04,95%CI:0.08,-0.05）.2.Findings on exploring the decision-making process in adopting YYB（1）General characteristics of the decision-making process in adopting YYB:The decision-making process in adopting YYB including awareness（YYB cognition）,decision（decision for the first time）,implementation（age-appropriate obtaining and feeding YYB）,and sustainment（adherence to YYB）stages.Among 833 child caregivers,the mean score of the YYB cognition was 19.0（SD:5.2）,and caregivers usually decided to use YYB at the mean child age of 7.3 months（SD:5.0）,59.4%of caregivers received the YYB at the child age of 6 months,41.6%of caregivers fed YYB at the child age of 6 months,and 53.2%of caregivers feeding children four YYB packets and above per week.Compared with the Tibetan and Yi groups,caregivers in the Han group had relatively higher scores on YYB cognition and better practice in obtaining and feeding YYB,Caregivers in the Yi group had a relatively later time in deciding to adopt YYB than Han and Tibetan groups（all P<0.05）.（2）Association between the different stages of the decision-making process in adopting YYB:In the decision-making process,the earlier decision time was associated with the higher YYB cognition（β=-0.20,95%CI:-0.27,-0.12）.Age-appropriate obtaining YYB was associated with the earlier decision time（β=-0.51,95%CI:-0.56,-0.45）.Age-appropriate feeding YYB was associated with age-appropriate obtaining YYB（β=0.70,95%CI:0.66,0.76）.Higher adherence to YYB was positively associated with age-appropriate obtaining YYB（β=0.18,95%CI:0.11,0.25）.（3）Associated factors of the decision-making process in adopting YYB:The results of the path analysis showed that 1)in the full sample,in the awareness stage,more family members cared about child nutrition（β=0.46,95%CI:0.41,0.52）,caregivers were more likely to have a higher level of YYB cognition.During the decision stage,caregivers had positive parenting values（β=-0.08,95%CI:-0.15,-0.01）and higher social support（β=-0.08,95%CI:-0.16,-0.01）,they were likely to decide to adopt the YYB earlier.During the sustain stage,caregivers had stronger self-efficacy in feeding YYB（β=0.50,95%CI:0.43,0.57）,they were more likely to adhere to YYB.2)In the Han group,in the awareness stage,more family members cared about child nutrition（β=0.47,95%CI:0.37,0.56）,caregivers were more likely to have a higher level of YYB cognition.In the sustain phase,caregivers had stronger self-efficacy in feeding YYB（β=0.50,95%CI:0.39,0.61）,they were more likely to adhere to YYB.3)In the Tibetan group,in the awareness stage,more family members cared about child nutrition（β=0.50,95%CI:0.39,0.61）.During the implementation stage,compared to those who took the YYB at the township health center and received the YYB at home,caregivers who took the YYB at the village clinic were less likely to obtain the YYB at child age of 6 months（β=-0.23,95%CI:-0.43,-0.03）.During the sustain stage,caregivers had stronger self-efficacy in feeding YYB（β=0.49,95%CI:0.34,0.65）,they were more likely to adhere to YYB.4)In the Yi group,in the awareness stage,more family members cared about child nutrition（β=0.49,95%CI:0.39,0.59）,caregivers were more likely to have a higher level of YYB cognition.During the decision stage,caregivers had positive parenting values（β=-0.19,95%CI:-0.31,-0.06）,they were likely to decide to adopt the YYB earlier.During the sustain stage,caregivers had stronger self-efficacy in feeding YYB（β=0.43,95%CI:0.30,0.56）,they were more likely to adhere to YYB.3.Findings on exploring the trajectory of adherence to YYB（1）Trajectory of adherence to YYB:A total sample of 1608 caregivers who completed the questionnaires in the first,second,and third survey rounds were included in data analysis.In the full sample,the adherence rates of YYB in the first,second,and third survey rounds were 50.3%,63.7%,and 60.0%,respectively.In the Han group,the adherence rates of YYB in the first,second,and third survey rounds were 59.4%,70.3%,and 71.9%,respectively.In the Tibetan group,the adherence rates of YYB in the first,second,and third survey rounds were 46.3%,56.8%,and 48.2%,respectively.In the Yi group,the adherence rates of YYB in the first,second,and third survey rounds were45.8%,62.8%,and 57.5%,respectively.Adherence rate in Han group was higher than Tibetan and Yi groups in each survey round（all P<0.05）.（2）Associated factors of the trajectory of adherence to YYB:the results of the Latent Growth Model showed that 1)in the full sample,after controlling for other factors,more family members cared about child nutrition（β=0.37,95%CI:0.03,0.40）,caregivers had the higher the initial level of adherence to YYB;compared to those who taken the YYB at the township health center and received the YYB at home,caregivers who taken the YYB at the village clinic had a lower initial level of adherence to YYB（β=-0.35,95%CI:-0.56,-0.15）.Caregivers who received YYB information mainly through mass media（β=0.39,95%CI:0.11,0.66）had a faster change rate of adherence to YYB.Long-term higher levels of YYB knowledge(β_t1=0.29,β_t2=0.35,β_t3=0.24),and long-term stronger self-efficacy in feeding YYB(β_t1=0.63,β_t2=0.47,β_t3=0.61),consistently increased the likelihood of adherence to YYB.2)In the Han group,the child who was naturally delivered（β=0.48,95%CI:0.12,0.84）,their caregivers had a faster change rate of adherence to YYB.Long-term stronger self-efficacy in feeding YYB(β_t1=0.17,β_t2=0.27,β_t3=0.57)and children have a higher level of acceptance with YYB(β_t1=0.32,β_t2=0.32,β_t3=0.18),consistently increased the likelihood of adherence to YYB.3)In the Tibetan group,caregivers tended to have agreeableness personality traits（β=0.54,95%CI:0.04,1.03）,caregivers had a higher initial level of adherence to YYB.Caregivers who received YYB information mainly through doctors（β=-0.69,95%CI:-0.71,-0.36）had a slower change rate of adherence to YYB.Longer-term stronger self-efficacy in feeding YYB(β_t1=0.28,β_t2=0.30,β_t3=0.35),consistently increased the likelihood of adherence to YYB.4)In the Yi group,compared to those who took the YYB at the township health center and received the YYB at home,caregivers who took the YYB at the village clinic had a lower initial level of adherence to YYB（β=-0.35,95%CI:-0.60,-0.60）.Caregivers who had experience with feeding YYB before（β=-0.31,95%CI:-0.55,-0.08）,were more likely to have a slower change rate of adherence to YYB.Long-term higher levels of YYB knowledge(β_t1=0.31,β_t2=0.49,β_t3=0.50),consistently increased the likelihood of adherence to YYB.ConclusionsBased on the Diffusion Innovation Theory,we found that the YYB program diffused slowly in remote rural areas in western China,especially in the Yi ethnic area.YYB knowledge,received YYB information from township doctors,and positive parenting value would accelerate the diffusion of YYB program.To accelerate the diffusion of the YYB program in remote rural areas in western China,population health education targeting YYB knowledge improvement was suggested,we also recommended encouraging township doctors to deliver YYB information and paying more attention to the positive parenting values in Yi ethnic area.According to the Innovation-Decision Process Framework,we found that the individual decision-making process in adopting YYB among caregivers included awareness,decision（decision for the first time）,implementation（age-appropriate obtaining YYB and age-appropriate consuming YYB）,and sustain stages,the decision stage and the implementation stage was especially important.Moreover,the impact factors of different stages were different.To motivate the decision-making process in adopting YYB,we suggest that paying attention to the decision and implementation stages and applying different strategies in different stages.Furthermore,we found that during the process of implementation of the YYB program in remote rural areas in western China,caregivers’adherence to YYB improved,but the adherence was still lower generally.Adherence rate was decreased during 18-24 months of child age,especially in Tibetan and Yi areas.Moreover,YYB knowledge,self-efficacy,and children’s acceptance of YYB would impact the sustainment of YYB adherence.To sustain the YYB adherence,we recommended paying attention to the stage of 18-24 months of child age in Tibetan and Yi areas,strengthening health education on YYB knowledge and feeding self-efficacy,as well as paying more attention to children’s acceptance of YYB.