Co-design and implementation of a mHealth intervention targeting fathers and mothers to improve breastfeeding

BMC Medical Informatics and Decision Making, Volume 23, No. 1, Year 2023

Interpretação

Background: Evidence has shown that SMS text message-based health education is effective in improving exclusive breastfeeding. However, there is limited evidence on the development and design of SMS messaging intervention targeting fathers and mothers. Method: This is the formative assessment and intervention design for a larger trial targeting both fathers and mothers for breastfeeding support in Tigray, Ethiopia. A total of 42 parents of children less than 2 years of age were involved in the design process that also included nutrition experts. We recruited 128 expectant couples to the intervention (1-month antenatally) who continued for 3 months postnatally. Results: Sixteen messages were developed specific to feeding in the antenatal and postnatal periods. These messages were revised with parents and experts and pretested with parents. Over 4 months 87% of fathers and mothers received 3 or more SMS text messages. All fathers and 97% of mothers read the weekly SMS text messages. Almost 90% of mothers and fathers indicated their willingness to continue to receive SMS text messages related to infant feeding. Conclusion: Development of SMS based breastfeeding interventions should involve the target population in content design. The role of experts and target population in the co-design process is also crucial. The intervention was developed as part of a study exploring the use of a mHealth intervention targeting both mothers and fathers to improve exclusive breastfeeding to 3 months. It took place in Mekelle, the capital city of the regional state of Tigray in February 2018 to March 2019. This was a three-phase process, phase-1: formative assessment; phase-2: co-design of SMS message and pretesting; phase-3: acceptability testing. The detail of the design is described below. The formative assessment for the intervention included exploring the attitudes, knowledge, beliefs, barriers, and enablers of exclusive breastfeeding as well as experiences of mobile phone use, perceived benefits of using a mobile phone, as well as timing, and frequency preferences for receiving SMS text messages for mothers and fathers. Focus group discussions (FGDs) were undertaken with mothers (two groups), and fathers (two groups), resulting in a total of 42 participants. All mothers and fathers had a child less than 2 years of age, access to a personal mobile phone, and were able to read and understand the local language (Tigrigna) and who had provided informed written consent were eligible to participate. Either the mother or the father was included in the FGD but not both. Details of methods and data analysis are described in the formative studies [17, 18]. Codesign is a process that involves all stakeholders throughout the design process [19]. This is an active collaboration between researchers, users, and developers to understanding the problem, behaviour, and concept development. Involvement of stakeholders during the design of an intervention helps in developing socially, culturally, and contextually acceptable approaches that work within the contexts of the target populations [20, 21]. Text message content was developed that related to predominantly feeding behaviours relevant antenatally, and in the postpartum period and targeted mothers and fathers separately. The initial text messages were developed based on the findings from the FGD and on best-practice by the authors in English, and then translated to the local language (Tigrigna). A total of 32 messages were developed equally distributed between fathers and mothers with the aim to send a text message once a week for 1 month antenatally and for 3 months after the birth of the baby. These messages were then provided to two paediatricians, two paediatric nurses, and two nutritionists who spoke, read and understood Tigrigna. Experts were asked to provide feedback on the content and wording of the text messages. After incorporating the expert feedback, the SMS text messages were reviewed by an additional five fathers and five mothers who had a child less than 2 years of age, access to a personal mobile phone, and were able to read and understand Tigrigna were recruited from the same two health centres as phase-1. Parents provided their consent to participate in the review discussion. Parents were given a chance to read the contents of the SMS before the discussion and were able to describe how the messages made them feel, the clarity of the message, language used or wording, length of the message, and to provide any additional feedback. After development of the SMS text messages, the messages were uploaded into a freely available bulk SMS software, FrontlineSMS (http://www.frontlinesms.com). This system was used to send the messages using the EthioTelecom (Ethiopian Telecommunication) network, the sole-provider of telecommunications in Ethiopia. This software was installed on a personal computer and was connected to a mobile phone with a local SIM card, which helped to access the local network. The use of the FrontlineSMS was to enable the sending of bulk SMS. FrontlineSMS text messaging had been used in a previous breastfeeding intervention [22]. The software is also able to track sent, failed, and the pending status of text messages, which is important in managing the process and documenting SMS delivery. This data was collected each time a message was sent. A list of study participant contacts was created with separate groups for mothers and fathers. Messages were sent every Saturday morning to each group in each study arm. The SMS text messages were pretested with five couples who had a child less than 6 months, could read Tigrinya, and had any type of mobile phone were eligible to participate. Mothers were contacted through their healthcare providers at the health facility during their postnatal clinic visit, immunization, or maternal childcare service appointment. Partners of mothers who agreed to participate were contacted through urban health extension workers. All participants provided informed consent. The participants received a weekly SMS text messages for a period of 1 month. After completing the pre-test, the study participants were requested to provide feedback on simplicity, local and cultural acceptability in terms of language usage and size, and delivery rate of SMS text messaging. Each participant was telephoned to ascertain their satisfaction with the text messaging and if any changes needed to be made. As described in our previous study [23] pregnant mothers and their partners were recruited from three health centres. Participant couples were in their third trimester stage of pregnancy, had access to a personal mobile phone, and were able to read and understand Tigrigna. Each health centre was assigned to one arm of the study; arm 1—mother and father intervention group (both received individual breastfeeding SMS on their own mobile), arm 2—mother only intervention (only the mother received breastfeeding SMS), and arm 3—control group. A total of 128 parents were enrolled in the intervention during their last trimester (43 couples in arm-1, 43 couples in arm-2, and 42 couples in arm-3). Participants in the intervention groups, fathers and mothers in arm 1 and only mothers in arm 2, received 1 month of antenatal SMS, and 3-months of postnatal SMS. Due to adverse outcomes, we lost two couples from each arm. Using face-to-face or telephone interview, 41 fathers from arm—1 and 82 mothers from arms—1 and 2 provided feedback the SMS messages. At the end of each month after giving birth, feedback was obtained on how many SMS messages they received, if they read the message, if they shared the message content with their partner or other people. In addition, at the third month participants also provided feedback on the convenience of the SMS based breastfeeding education, willingness to continue to receive breastfeeding SMS text messages and how influential the SMS based breastfeeding intervention was about breastfeeding. Data were entered IBM SPSS Statistics version 23 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). Descriptive statistics were conducted to describe message delivery and satisfaction for fathers and mothers.

AI Digest

Study Justification:

– The study aimed to improve exclusive breastfeeding rates by developing a mobile health (mHealth) intervention targeting both fathers and mothers.
– Previous evidence has shown that SMS text message-based health education is effective in improving exclusive breastfeeding.
– However, there is limited evidence on the development and design of SMS messaging interventions specifically targeting fathers and mothers.

Highlights:

– The study involved a formative assessment and intervention design for a larger trial in Tigray, Ethiopia.
– 42 parents of children under 2 years of age were involved in the design process, along with nutrition experts.
– 128 expectant couples were recruited to the intervention, receiving SMS text messages for 1 month antenatally and 3 months postnatally.
– Results showed that 87% of fathers and mothers received 3 or more SMS text messages, and all fathers and 97% of mothers read the weekly messages.
– Almost 90% of mothers and fathers indicated their willingness to continue receiving SMS text messages related to infant feeding.

Recommendations:

– Development of SMS-based breastfeeding interventions should involve the target population in content design.
– The role of experts and the target population in the co-design process is crucial for developing socially, culturally, and contextually acceptable approaches.

Key Role Players:

– Researchers
– Users (fathers and mothers)
– Developers
– Nutrition experts

Cost Items for Planning Recommendations:

– Research team salaries
– Translation services
– Software and technology (e.g., FrontlineSMS)
– Mobile phone and SIM card expenses
– SMS text message delivery costs
– Participant recruitment and compensation
– Data collection and analysis tools (e.g., IBM SPSS Statistics)
Please note that the provided information is a summary of the study and publication. For more detailed information, please refer to the original publication in BMC Medical Informatics and Decision Making, Volume 23, No. 1, Year 2023.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a formative assessment and intervention design for a larger trial targeting both fathers and mothers for breastfeeding support. The study involved a total of 42 parents in the design process and recruited 128 expectant couples for the intervention. The results show that a high percentage of fathers and mothers received and read the SMS text messages, and indicated their willingness to continue receiving them. However, the abstract does not provide information on the study design, sample size, statistical analysis, or specific outcomes measured. To improve the strength of the evidence, the abstract should include more details on the study design, methodology, and specific outcomes measured, as well as the statistical analysis conducted. This would provide a clearer understanding of the study’s findings and increase the confidence in the evidence.

Resumo

The intervention was developed as part of a study exploring the use of a mHealth intervention targeting both mothers and fathers to improve exclusive breastfeeding to 3 months. It took place in Mekelle, the capital city of the regional state of Tigray in February 2018 to March 2019. This was a three-phase process, phase-1: formative assessment; phase-2: co-design of SMS message and pretesting; phase-3: acceptability testing. The detail of the design is described below. The formative assessment for the intervention included exploring the attitudes, knowledge, beliefs, barriers, and enablers of exclusive breastfeeding as well as experiences of mobile phone use, perceived benefits of using a mobile phone, as well as timing, and frequency preferences for receiving SMS text messages for mothers and fathers. Focus group discussions (FGDs) were undertaken with mothers (two groups), and fathers (two groups), resulting in a total of 42 participants. All mothers and fathers had a child less than 2 years of age, access to a personal mobile phone, and were able to read and understand the local language (Tigrigna) and who had provided informed written consent were eligible to participate. Either the mother or the father was included in the FGD but not both. Details of methods and data analysis are described in the formative studies [17, 18]. Codesign is a process that involves all stakeholders throughout the design process [19]. This is an active collaboration between researchers, users, and developers to understanding the problem, behaviour, and concept development. Involvement of stakeholders during the design of an intervention helps in developing socially, culturally, and contextually acceptable approaches that work within the contexts of the target populations [20, 21]. Text message content was developed that related to predominantly feeding behaviours relevant antenatally, and in the postpartum period and targeted mothers and fathers separately. The initial text messages were developed based on the findings from the FGD and on best-practice by the authors in English, and then translated to the local language (Tigrigna). A total of 32 messages were developed equally distributed between fathers and mothers with the aim to send a text message once a week for 1 month antenatally and for 3 months after the birth of the baby. These messages were then provided to two paediatricians, two paediatric nurses, and two nutritionists who spoke, read and understood Tigrigna. Experts were asked to provide feedback on the content and wording of the text messages. After incorporating the expert feedback, the SMS text messages were reviewed by an additional five fathers and five mothers who had a child less than 2 years of age, access to a personal mobile phone, and were able to read and understand Tigrigna were recruited from the same two health centres as phase-1. Parents provided their consent to participate in the review discussion. Parents were given a chance to read the contents of the SMS before the discussion and were able to describe how the messages made them feel, the clarity of the message, language used or wording, length of the message, and to provide any additional feedback. After development of the SMS text messages, the messages were uploaded into a freely available bulk SMS software, FrontlineSMS (http://www.frontlinesms.com). This system was used to send the messages using the EthioTelecom (Ethiopian Telecommunication) network, the sole-provider of telecommunications in Ethiopia. This software was installed on a personal computer and was connected to a mobile phone with a local SIM card, which helped to access the local network. The use of the FrontlineSMS was to enable the sending of bulk SMS. FrontlineSMS text messaging had been used in a previous breastfeeding intervention [22]. The software is also able to track sent, failed, and the pending status of text messages, which is important in managing the process and documenting SMS delivery. This data was collected each time a message was sent. A list of study participant contacts was created with separate groups for mothers and fathers. Messages were sent every Saturday morning to each group in each study arm. The SMS text messages were pretested with five couples who had a child less than 6 months, could read Tigrinya, and had any type of mobile phone were eligible to participate. Mothers were contacted through their healthcare providers at the health facility during their postnatal clinic visit, immunization, or maternal childcare service appointment. Partners of mothers who agreed to participate were contacted through urban health extension workers. All participants provided informed consent. The participants received a weekly SMS text messages for a period of 1 month. After completing the pre-test, the study participants were requested to provide feedback on simplicity, local and cultural acceptability in terms of language usage and size, and delivery rate of SMS text messaging. Each participant was telephoned to ascertain their satisfaction with the text messaging and if any changes needed to be made. As described in our previous study [23] pregnant mothers and their partners were recruited from three health centres. Participant couples were in their third trimester stage of pregnancy, had access to a personal mobile phone, and were able to read and understand Tigrigna. Each health centre was assigned to one arm of the study; arm 1—mother and father intervention group (both received individual breastfeeding SMS on their own mobile), arm 2—mother only intervention (only the mother received breastfeeding SMS), and arm 3—control group. A total of 128 parents were enrolled in the intervention during their last trimester (43 couples in arm-1, 43 couples in arm-2, and 42 couples in arm-3). Participants in the intervention groups, fathers and mothers in arm 1 and only mothers in arm 2, received 1 month of antenatal SMS, and 3-months of postnatal SMS. Due to adverse outcomes, we lost two couples from each arm. Using face-to-face or telephone interview, 41 fathers from arm—1 and 82 mothers from arms—1 and 2 provided feedback the SMS messages. At the end of each month after giving birth, feedback was obtained on how many SMS messages they received, if they read the message, if they shared the message content with their partner or other people. In addition, at the third month participants also provided feedback on the convenience of the SMS based breastfeeding education, willingness to continue to receive breastfeeding SMS text messages and how influential the SMS based breastfeeding intervention was about breastfeeding. Data were entered IBM SPSS Statistics version 23 (IBM Corp. Released 2015. IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). Descriptive statistics were conducted to describe message delivery and satisfaction for fathers and mothers.

Materiais

N/A

Inovações

The recommendation to improve access to maternal health is the co-design and implementation of a mHealth intervention targeting fathers and mothers to improve breastfeeding. This intervention involves the use of SMS text messages to provide health education and support for exclusive breastfeeding. The intervention was developed through a three-phase process: formative assessment, co-design of SMS messages, and acceptability testing.

During the formative assessment phase, attitudes, knowledge, beliefs, barriers, and enablers of exclusive breastfeeding were explored, along with experiences of mobile phone use. Focus group discussions were conducted with parents of children under 2 years of age who had access to a personal mobile phone. The findings from these discussions informed the development of the SMS text messages.

In the co-design phase, experts in pediatrics and nutrition reviewed and provided feedback on the content and wording of the text messages. The messages were then reviewed by additional parents who had a child under 2 years of age and could read and understand the local language. Their feedback on message clarity, language, and length was incorporated into the final messages.

The SMS text messages were sent using a bulk SMS software called FrontlineSMS, which allowed for tracking of message delivery. The messages were sent once a week for 1 month antenatally and for 3 months postnatally. Pretesting of the messages was conducted with couples who had a child under 6 months and could read the local language. Their feedback on simplicity, acceptability, and delivery rate of the messages was used to further refine the intervention.

The intervention was implemented with expectant couples recruited from health centers. The couples were assigned to different study arms, with some receiving SMS messages targeting both mothers and fathers, some targeting only mothers, and a control group. Feedback on message delivery and satisfaction was collected from fathers and mothers throughout the intervention period.

Overall, the co-design and implementation of this mHealth intervention targeting fathers and mothers for breastfeeding support showed promising results. The majority of fathers and mothers received and read the SMS text messages, and expressed willingness to continue receiving messages related to infant feeding.

This recommendation, as described in the publication “BMC Medical Informatics and Decision Making,” Volume 23, No. 1, Year 2023, highlights the importance of involving the target population and experts in the design process of SMS-based interventions. By tailoring the intervention to the specific needs and preferences of the target population, it has the potential to improve access to maternal health and promote exclusive breastfeeding.

AI Innovations Description

This recommendation, as described in the publication “BMC Medical Informatics and Decision Making,” Volume 23, No. 1, Year 2023, highlights the importance of involving the target population and experts in the design process of SMS-based interventions. By tailoring the intervention to the specific needs and preferences of the target population, it has the potential to improve access to maternal health and promote exclusive breastfeeding.

AI Innovations Methodology

To simulate the impact of the recommendations described in the abstract on improving access to maternal health, the following methodology can be used:

1. Study Design: Conduct a randomized controlled trial (RCT) to evaluate the effectiveness of the mHealth intervention targeting fathers and mothers to improve breastfeeding. Randomly assign expectant couples to different study arms: one group receiving SMS messages targeting both mothers and fathers, another group receiving messages targeting only mothers, and a control group.

2. Sample Selection: Recruit expectant couples from health centers in the target area. Ensure that the couples have access to personal mobile phones and can read and understand the local language.

3. Intervention Implementation: Implement the mHealth intervention by sending SMS text messages once a week for 1 month antenatally and for 3 months postnatally. Use a bulk SMS software, such as FrontlineSMS, to send and track message delivery.

4. Data Collection: Collect data on message delivery and satisfaction from both fathers and mothers throughout the intervention period. This can be done through telephone interviews or face-to-face interviews. Gather information on the number of messages received, message reading rates, sharing of message content, convenience of the intervention, willingness to continue receiving messages, and the influence of the intervention on breastfeeding practices.

5. Data Analysis: Analyze the collected data using descriptive statistics to describe message delivery and satisfaction for fathers and mothers. Compare the outcomes between the different study arms to assess the impact of the intervention on improving access to maternal health.

6. Evaluation: Evaluate the effectiveness of the mHealth intervention by assessing the percentage of fathers and mothers who received and read the SMS text messages, as well as their willingness to continue receiving messages related to infant feeding. Compare these outcomes with the control group to determine the impact of the intervention.

7. Reporting: Summarize the findings of the simulation in a report, including the percentage of message delivery, reading rates, and satisfaction levels among fathers and mothers. Discuss the implications of the results for improving access to maternal health and promoting exclusive breastfeeding.

By following this methodology, researchers can simulate the impact of the recommendations described in the abstract and gain insights into the effectiveness of the mHealth intervention in improving access to maternal health.

Autor

Dima Health

Identifiers:

DOI: 10.1186/s12911-023-02125-3

Research Areas:

Community Interventions, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Technology and Innovations

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Exploratory Study, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative

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