BackgroundInfancy is an important period for the promotion of healthy eating, diet and weight. However little is known about how best to engage caregivers of infants in healthy eating programs. This is particularly true for caregivers, infants and children from socioeconomically disadvantaged backgrounds who experience greater rates of overweight and obesity yet are more challenging to reach in health programs. Behaviour change interventions targeting parent-infant feeding interactions are more likely to be effective if assumptions about what needs to change for the target behaviours to occur are identified. As such we explored the precursors of key obesity promoting infant feeding practices in mothers with low educational attainment.MethodsOne–on–one semi-structured telephone interviews were developed around the Capability Opportunity Motivation Behaviour (COM-B) framework and applied to parental feeding practices associated with infant excess or healthy weight gain. The target behaviours and their competing alternatives were (a) initiating breastfeeding/formula feeding, (b) prolonging breastfeeding/replacing breast milk with formula, (c) best practice formula preparation/sub-optimal formula preparation, (d) delaying the introduction of solid foods until around six months of age/introducing solids earlier than four months of age, and (e) introducing healthy first foods/introducing unhealthy first foods, and (f) feeding to appetite/use of non-nutritive (i.e., feeding for reasons other than hunger) feeding. The participants’ education level was used as the indicator of socioeconomic disadvantage. Two researchers independently undertook thematic analysis.ResultsParticipants were 29 mothers of infants aged 2–11 months. The COM-B elements of Social and Environmental Opportunity, Psychological Capability, and Reflective Motivation were the key elements identified as determinants of a mother’s likelihood to adopt the healthy target behaviours although the relative importance of each of the COM-B factors varied with each of the target feeding behaviours.ConclusionsInterventions targeting healthy infant feeding practices should be tailored to the unique factors that may influence mothers’ various feeding practices, taking into account motivational and social influences.

BackgroundChildhood obesity is an ongoing problem in developed countries that needs targeted prevention in the youngest age groups. Children in socioeconomically disadvantaged families are most at risk. Mobile health (mHealth) interventions offer a potential route to target these families because of its relatively low cost and high reach. The Growing healthy program was developed to provide evidence-based information on infant feeding from birth to 9 months via app or website. Understanding user engagement with these media is vital to developing successful interventions. Engagement is a complex, multifactorial concept that needs to move beyond simple metrics.ObjectiveThe aim of our study was to describe the development of an engagement index (EI) to monitor participant interaction with the Growing healthy app. The index included a number of subindices and cut-points to categorize engagement.MethodsThe Growing program was a feasibility study in which 300 mother-infant dyads were provided with an app which included 3 push notifications that was sent each week. Growing healthy participants completed surveys at 3 time points: baseline (T1) (infant age ≤3 months), infant aged 6 months (T2), and infant aged 9 months (T3). In addition, app usage data were captured from the app. The EI was adapted from the Web Analytics Demystified visitor EI. Our EI included 5 subindices: (1) click depth, (2) loyalty, (3) interaction, (4) recency, and (5) feedback. The overall EI summarized the subindices from date of registration through to 39 weeks (9 months) from the infant’s date of birth.Basic descriptive data analysis was performed on the metrics and components of the EI as well as the final EI score. Group comparisons used t tests, analysis of variance (ANOVA), Mann-Whitney, Kruskal-Wallis, and Spearman correlation tests as appropriate. Consideration of independent variables associated with the EI score were modeled using linear regression models.ResultsThe overall EI mean score was 30.0% (SD 11.5%) with a range of 1.8% - 57.6%. The cut-points used for high engagement were scores greater than 37.1% and for poor engagement were scores less than 21.1%. Significant explanatory variables of the EI score included: parity (P=.005), system type including “app only” users or “both” app and email users (P<.001), recruitment method (P=.02), and baby age at recruitment (P=.005).ConclusionsThe EI provided a comprehensive understanding of participant behavior with the app over the 9-month period of the Growing healthy program. The use of the EI in this study demonstrates that rich and useful data can be collected and used to inform assessments of the strengths and weaknesses of the app and in turn inform future interventions.

BackgroundInfant feeding practices, including breastfeeding and optimal formula feeding practices, can play a role in the prevention of childhood obesity. The ubiquity of smartphone ownership among women of childbearing age provides important opportunities for the delivery of low-cost, broad reach parenting interventions delivered by mobile phone (mHealth or mobile health interventions). Little is known about how parents engage with mHealth programs targeting infant feeding and how such programs might influence infant feeding practices.ObjectiveThe objectives of this study were to explore participant views on (1) factors influencing engagement with the Growing healthy program, an mHealth program targeting healthy infant feeding practices from birth to 9 months of age, and (2) the ways in which the program influenced behavioral determinants of capability, opportunity, and motivation for breastfeeding and optimal formula feeding behaviors.MethodsSemistructured, telephone interviews were conducted with a purposeful sample (n=24) of mothers participating in the Growing healthy program. Interviews explored participants’ views about engagement with the program and its features, and the ways the program influenced determinants of infant feeding behaviors related to breastfeeding and optimal formula feeding. The interview schedule was informed by the Capability, Opportunity, Motivation, and Behavior (COM-B) model.ResultsParticipants reported that engagement fluctuated depending on need and the degree to which the program was perceived to fit with existing parenting beliefs and values. Participants identified that the credibility of the program source, the user friendly interface, and tailoring of content and push notifications to baby’s age and key transition points promoted engagement, whereas technical glitches were reported to reduce engagement. Participants discussed that the program increased confidence in feeding decisions. For breastfeeding mothers, this was achieved by helping them to overcome doubts about breast milk supply, whereas mothers using formula reported feeling more confident to feed to hunger and satiety cues rather than encouraging infants to finish the bottle. Participants discussed that the program provided around-the-clock, readily accessible, nonjudgmental information and support on infant feeding and helped to reinforce information received by health professionals or encouraged them to seek additional help if needed. Participants reflected that their plans for feeding were typically made before joining the program, limiting the potential for the program to influence this aspect of motivation. Rather, the program provided emotional reassurance to continue with current feeding plans.ConclusionsOur findings suggest that engagement with the program was influenced by an interplay between the program features and needs of the user. Participants reported that the program enhanced confidence in feeding decisions by providing a 24/7 accessible, expert, nonjudgmental support for infant feeding that comple...

BackgroundInternet websites and smartphone apps have become a popular resource to guide parents in their children’s feeding and nutrition. Given the diverse range of websites and apps on infant feeding, the quality of information in these resources should be assessed to identify whether consumers have access to credible and reliable information.ObjectiveThis systematic analysis provides perspectives on the information available about infant feeding on websites and smartphone apps.MethodsA systematic analysis was conducted to assess the quality, comprehensibility, suitability, and readability of websites and apps on infant feeding using a developed tool. Google and Bing were used to search for websites from Australia, while the App Store for iOS and Google Play for Android were used to search for apps. Specified key words including baby feeding, breast feeding, formula feeding and introducing solids were used to assess websites and apps addressing feeding advice. Criteria for assessing the accuracy of the content were developed using the Australian Infant Feeding Guidelines.ResultsA total of 600 websites and 2884 apps were screened, and 44 websites and 46 apps met the selection criteria and were analyzed. Most of the websites (26/44) and apps (43/46) were noncommercial, some websites (10/44) and 1 app were commercial and there were 8 government websites; 2 apps had university endorsement. The majority of the websites and apps were rated poor quality. There were two websites that had 100% coverage of information compared to those rated as fair or poor that had low coverage. Two-thirds of the websites (65%) and almost half of the apps (47%) had a readability level above the 8th grade level.ConclusionsThe findings of this unique analysis highlight the potential for website and app developers to merge user requirements with evidence-based content to ensure that information on infant feeding is of high quality. There are currently no apps available to consumers that address a variety of infant feeding topics. To keep up with the rapid turnover of the evolving technology, health professionals need to consider developing an app that will provide consumers with a credible and reliable source of information about infant feeding, using quality assessment tools and evidence-based content.

IMPORTANCE There is limited information as to whether telephone or short message service (SMS) support is effective in improving infant feeding practices and tummy time and reducing screen time. OBJECTIVE To determine the effectiveness of either nurse-led telephone or SMS support in improving infant feeding practices and tummy time and reducing screen time. DESIGN, SETTING, AND PARTICIPANTS This study was part of a 2-year, 3-group parallel, randomized clinical trial conducted from February 23, 2017, to November 30, 2018, among 1155 women in the third trimester of pregnancy in New South Wales, Australia. It reports the main outcomes at 6 and 12 months of child age. All analyses were conducted on an intention-to-treat principle. INTERVENTIONS The intervention consisted of staged information booklets mailed to the intervention groups, each followed by either a nurse-led telephone support session or SMS intervention, antenatally and at 1, 3, 5, 7, and 10 months after birth. MAIN OUTCOMES AND MEASURES The primary outcomes were infant feeding practices at both 6 and 12 months and tummy time at 6 months. The secondary outcome was screen time at 12 months. RESULTS Of 1155 mothers, 947 (82%; mean [SD] age, 32.5 [5.0] years) completed follow-up surveys at 6 months; 920 mothers (80%) completed follow-up surveys at 12 months. Compared with the control group, telephone support led to higher odds of appropriate timing of introducing solid foods (adjusted odds ratio [AOR], 1.68 [95% CI, 1.22-2.32]), cup use (AOR, 1.54 [95% CI, 1.12-2.13]), and early-start tummy time (AOR, 1.63 [95% CI, 1.18-2.25]) at 6 months and higher odds of having no screen time (AOR, 1.80 [95% CI, 1.28-2.53]) and no bottle at bedtime (AOR, 1.73 [95% CI, 1.23-2.42]) at 12 months. Use of SMS also led to higher odds than the control group of having no screen time (AOR, 1.28 [95% CI, 1.08-1.52]) and having no bottle at bedtime (AOR, 1.29 [95% CI, 1.10-1.51]) at 12 months. No significant differences were found in breastfeeding rates between the telephone support, SMS support, and control groups. CONCLUSIONS AND RELEVANCE Both the nurse-led telephone support and SMS interventions were effective in reducing screen time and bottle use at bedtime. Telephone support was also effective in promoting the appropriate timing of the introduction of solid foods, early-start tummy time, and cup use.

BackgroundMobile health (mHealth) programs hold great promise for increasing the reach of public health interventions. However, mHealth is a relatively new field of research, presenting unique challenges for researchers. A key challenge is understanding the relative effectiveness and cost of various methods of recruitment to mHealth programs.ObjectiveThe objectives of this study were to (1) compare the effectiveness of various methods of recruitment to an mHealth intervention targeting healthy infant feeding practices, and (2) explore factors influencing practitioner referral to the intervention.MethodsThe Growing healthy study used a quasi-experimental design with an mHealth intervention group and a concurrent nonrandomized comparison group. Eligibility criteria included: expectant parents (>30 weeks of gestation) or parents with an infant <3 months old, ability to read and understand English, own a mobile phone, ≥18 years old, and living in Australia. Recruitment to the mHealth program consisted of: (1) practitioner-led recruitment through Maternal and Child Health nurses, midwives, and nurses in general practice; (2) face-to-face recruitment by researchers; and (3) online recruitment. Participants’ baseline surveys provided information regarding how participants heard about the study, and their sociodemographic details. Costs per participant recruited were calculated by taking into account direct advertising costs and researcher time/travel costs. Practitioner feedback relating to the recruitment process was obtained through a follow-up survey and qualitative interviews.ResultsA total of 300 participants were recruited to the mHealth intervention. The cost per participant recruited was lowest for online recruitment (AUD $14) and highest for practice nurse recruitment (AUD $586). Just over half of the intervention group (50.3%, 151/300) were recruited online over a 22-week period compared to practitioner recruitment (29.3%, 88/300 over 46 weeks) and face-to-face recruitment by researchers (7.3%, 22/300 over 18 weeks). No significant differences were observed in participant sociodemographic characteristics between recruitment methods, with the exception that practitioner/face-to-face recruitment resulted in a higher proportion of first-time parents (68% versus 48%, P=.002). Less than half of the practitioners surveyed reported referring to the program often or most of the time. Key barriers to practitioner referral included lack of time, difficulty remembering to refer, staff changes, lack of parental engagement, and practitioner difficulty in accessing the app.ConclusionsOnline recruitment using parenting-related Facebook pages was the most cost effective and timely method of recruitment to an mHealth intervention targeting parents of young infants. Consideration needs to be given to addressing practitioner barriers to referral, to further explore if this can be a viable method of recruitment.

IntroductionEarly childhood is an important period for establishing behaviours that will affect weight gain and health across the life course. Early feeding choices, including breast and/or formula, timing of introduction of solids, physical activity and electronic media use among infants and young children are considered likely determinants of childhood obesity. Parents play a primary role in shaping these behaviours through parental modelling, feeding styles, and the food and physical activity environments provided. Children from low socio-economic backgrounds have higher rates of obesity, making early intervention particularly important. However, such families are often more difficult to reach and may be less likely to participate in traditional programs that support healthy behaviours. Parents across all socio-demographic groups frequently access primary health care (PHC) services, including nurses in community health services and general medical practices, providing unparalleled opportunity for engagement to influence family behaviours. One emerging and promising area that might maximise engagement at a low cost is the provision of support for healthy parenting through electronic media such as the Internet or smart phones. The Growing healthy study explores the feasibility of delivering such support via primary health care services.MethodsThis paper describes the Growing healthy study, a non-randomised quasi experimental study examining the feasibility of an intervention delivered via a smartphone app (or website) for parents living in socioeconomically disadvantaged areas, for promoting infant feeding and parenting behaviours that promote healthy rather than excessive weight gain. Participants will be recruited via their primary health care practitioner and followed until their infant is 9 months old. Data will be collected via web-based questionnaires and the data collected inherently by the app itself.Ethics and disseminationThis study received approval from the University of Technology Sydney Ethics committee and will be disseminated via peer-reviewed publications and conference presentations.

Background: Childhood obesity is a global problem. Early obesity prevention interventions are complex and differ in effectiveness. Novel frameworks, taxonomies and experience from the Early Prevention of Obesity in CHildren (EPOCH) trials were applied to unpack interventions. Objectives: Deconstruct interventions into their components (target behaviours, delivery features and behaviour change techniques [BCTs]). Identify lessons learned and future recommendations for intervention planning, delivery, evaluation and implementation. Methods: This multi-methods study deconstructed the four EPOCH interventions into target behaviours, delivery features and BCTs from unpublished and published materials using systematic frameworks. Additionally, semi-structured interviews were conducted with intervention facilitators and principal investigators. Results: Each trial targeted between 10 and 14 obesity-related behaviours. Key variations in delivery features related to intensity, delivery mode and tailoring. BCTs consistently used across trials included goal-setting, social support, shaping knowledge, role-modelling and credible source. Recommendations from interview analyses include the importance of stakeholder collaboration and consideration of implementation throughout the study process. Conclusions: The combination of frameworks, methodologies and interviews used in this study is a major step towards understanding complex early obesity prevention interventions. Future work will link systematic intervention deconstruction with quantitative models to identify which intervention components are most effective and for whom.