A qualitative study of the infant feeding beliefs and behaviours of mothers with low educational attainment

Practicality of the My Baby Now App for Fathers by Fathers: Qualitative Case Study

BACKGROUND

Evolving societal trends are resulting in fathers having an increasing influence on the health-related behaviors that children develop. Research shows that most fathers are committed to their role and when equipped with knowledge, can have a positive impact on their child's health. However, parenting resources typically target mothers, with fathers being excluded. While evolving mobile phone technology provides an efficient means for delivering parenting resources, many fathers find that mobile health (mHealth) technology does not provide material they can engage with.

OBJECTIVE

This study aimed to explore how to make parenting apps more engaging and useful for fathers using an existing parenting mHealth resource, the My Baby Now app, as a case study.

METHODS

A total of 14 purposefully selected, Australian fathers of 7 months to 5-year-old children took part in a qualitative study, comprising either focus groups or interviews. Recorded focus groups and interviews were transcribed verbatim, then coded using a combination of deductive and inductive methods. Reflexive thematic analysis was undertaken to identify patterns and themes.

RESULTS

Current parenting apps provide parenting information that can be unappealing for fathers. To improve paternal engagement with mHealth resources, fathers highlighted the need for father specific information, with an increase in positive imagery and positive descriptions of fathers in their parenting role. There should be father-exclusive domains such as forums, and also push notifications to provide positive reinforcement and encouragement for fathers.

CONCLUSIONS

mHealth has the capacity to deliver information to fathers when needed. This reduces the risk of paternal frustration and disengagement from parenting. Further benefit will be gained by research to understand possible differences in mHealth app usage by fathers of differing socioeconomic position, cultural backgrounds, and family status, such as single fathers and same-sex couples.

Child Beverage Consumption in US Early Care and Education Settings, 2008-2020

OBJECTIVE

Describe young children's beverage intake in early care and education (ECE) settings between 2008 and 2020 across multiple states in the US.

METHODS

Multivariable-adjusted, age-stratified estimates of beverage consumption among children aged 12-60 months (n = 4,457) in ECE centers and homes (n = 846).

RESULTS

During any given day in ECE, younger children had a 79.7% per-meal probability of consuming milk, 8.9% water, 19.8% 100% juice, and 3.2% sugar-sweetened beverages (SSBs), and a per-meal mean intake of 1.5 oz milk, 1.7 oz water, 2.2 oz 100% juice, and 2.9 oz SSBs. Older children had an 87.2% probability of consuming milk, 0.6% water, 2.9% 100% juice, and 4.2% SSBs, and a mean intake of 4.2 oz milk, 2.3 oz water, 3.6 oz 100% juice, and 5.9 oz SSBs.

CONCLUSIONS AND IMPLICATIONS

There is room to improve beverage intake in ECE, with a focus on increasing water and decreasing juice and SSB consumption. These results may justify policies to limit or prohibit juice consumption in ECE.

A qualitative exploration of mothers' perspectives on infant formula use in Uruguay

The transformation of the first-food systems and the widespread availability and marketing of breastmilk substitutes undermine efforts to promote adequate breastfeeding practices. The objective of the present research was to explore mothers' perspectives on infant formula use in Montevideo, the capital of Uruguay. A generic qualitative design was used to explore mothers' perspectives on the factors that act as enablers or barriers for infant formula use. Semi-structured interviews with thirty-four mothers of 0-23 months old children, aged between 25- and 40-years old, were conducted. The interview transcripts were analyzed using content analysis based on inductive-deductive coding considering the framework of the Capability, Opportunity, Motivation, and Behavior (COM-B) model. The discourse of the interviewees enabled the identification of a wide range of barriers and enablers for the use of infant formula, which were related to the three components of the model: capabilities, opportunity, and motivation. The health system emerged as the key determinant of infant formula use. Most of the participants who used infant formula referred to medical indication when explaining the reasons underlying their infant feeding decisions. The working status of the mother and emotional aspects of the child feeding experience were also identified as key enablers of infant formula use, whereas knowledge about health benefits and breastfeeding techniques, support from families and health-professionals, and motivation to breastfeed were key barriers. Taken together, these results suggest that strategies to reduce the use of infant formula in Uruguay should mainly focus on providing opportunities to breastfeed by improving the quality of the support and guidance provided to families in the health system and facilitating greater balance between breastfeeding and work.

Effects of short birth interval on child malnutrition in the Asia-Pacific region: Evidence from a systematic review and meta-analysis

Child malnutrition remains a significant concern in the Asia-Pacific region, with short birth intervals recognised as a potential risk factor. However, evidence of this association is inconclusive. This study aimed to systematically review the existing evidence and assess the summary effects of short birth interval on child malnutrition in the Asia-Pacific region. Five electronic databases were searched in May 2023 to identify relevant studies reporting the association between short birth interval and child malnutrition, including stunting, wasting, underweight, anaemia and overall malnutrition, in Asia-Pacific region between September 2000 and May 2023. Fixed-effects or random-effects meta-analysis was performed to estimate the summary effects of short birth interval on child malnutrition. Out of 56 studies meeting the inclusion criteria, 48 were included in quantitative synthesis through meta-analysis. We found a slightly higher likelihood of stunting (n = 25, odds ratio [OR] = 1.13; 95% confidence interval [CI]: 0.97-1.32) and overall malnutrition (n = 3, OR = 2.42; 95% CI: 0.88-6.65) among children born in short birth intervals compared to those with nonshort intervals, although the effect was not statistically significant. However, caution is warranted due to identified heterogeneity across studies. Subgroup analysis demonstrated significant effects of short birth intervals on child malnutrition in national-level studies and studies with larger sample sizes. These findings underscore short birth intervals as a significant contributor to child malnutrition in the Asia-Pacific region. Implementing effective policies and programs is vital to alleviate this burden, ultimately reducing child malnutrition and associated adverse outcomes, including child mortality.

A great way to bring up health behaviour topics at playgroup: a qualitative evaluation of the Healthy Conversations @ Playgroup program

BACKGROUND

The early years is a critical stage to establish optimal nutrition and movement behaviours. Community playgroups are a relaxed environment for parents with a focus on social connection and supporting parents in their role as 'First Teachers'. Playgroups are therefore an opportunistic setting to promote health behaviours in the early years. To support parents with young children around healthy lifestyle behaviours, the Healthy Conversations @ Playgroup program was delivered in urban and regional areas, across three Australian jurisdictions between 2021-2023.

OBJECTIVE

This qualitative evaluation aimed to understand how the Healthy Conversations @ Playgroup program was experienced by parents, playgroup coordinators and peer facilitators.

DESIGN

Semi-structured virtual interviews and focus groups were conducted with parents, playgroup coordinators (i.e., person responsible for coordinating the playgroup) and peer facilitators (i.e., trained facilitator for the program) that participated in the Healthy Conversations @ Playgroup study. Transcripts were analysed following a thematic analysis approach.

RESULTS

Twenty-eight playgroup parents, coordinators or peer facilitators participated in one of 8 focus groups or 5 interviews. Four themes were developed: Program strengths and challenges; Setting strengths and challenges; Factors that impact program delivery; Participant's suggestions for future program delivery.

CONCLUSIONS

The Healthy Conversations @ Playgroup program was valued by parents, providing validation and normalisation of parenting practices, and fostering a shared experience of parenting. Playgroups are a convenient setting for families to attend. The dynamic and distracting nature of the playgroup setting were carefully considered when designing the program. Strategies to further enhance program engagement could include use of coordinator or parent champions, tailored delivery, and extending the reach to other family members.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621000055808, registered 22 January 2021, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380890.

Utility of the capability, opportunity, and motivation behaviour (COM-B) model in explaining the negative association between pre-pregnancy body mass index and exclusive breastfeeding at six weeks postpartum

The mechanisms underlying the negative associations between pre-pregnancy body mass index (BMI) and exclusive breastfeeding remain poorly understood. Thus, the study aimed to determine whether the negative associations between high pre-pregnancy BMI and exclusive breastfeeding at six weeks postpartum are mediated by components of the capability, opportunity, and motivation behaviour (COM-B) model. In this prospective observational study, we assigned 360 primiparous women to a pre-pregnancy overweight/obese group (n = 180) and a normal-BMI group (n = 180). A structural equation model was designed to study how capabilities (onset of lactogenesis II, perceived milk supply, breastfeeding knowledge, and postpartum depression), opportunities (pro-breastfeeding hospital practices, social influence, social support), and motivations (breastfeeding intention, breastfeeding self-efficacy, and attitudes towards breastfeeding) affected exclusive breastfeeding at six weeks postpartum in groups of women with different pre-pregnancy BMIs. In all, 342 participants (95.0%) possessed complete data. Women with high pre-pregnancy BMI were less likely to exclusively breastfeed at six weeks postpartum than women with a normal BMI were. We observed a significant negative direct effect of high pre-pregnancy BMI on exclusive breastfeeding at six weeks postpartum and a significantly negative indirect effect of high pre-pregnancy BMI via the explanatory mediating variables of capabilities (onset of lactogenesis II, perceived milk supply, and breastfeeding knowledge) and motivations (breastfeeding self-efficacy) on exclusive breastfeeding at six weeks postpartum. Our findings support certain capabilities (onset of lactogenesis II, perceived milk supply, and breastfeeding knowledge) and motivations (breastfeeding self-efficacy), partially explaining the negative association between high pre-pregnancy BMI and exclusive breastfeeding outcome. We suggest that interventions aimed at promoting exclusive breastfeeding among women with high pre-pregnancy BMI should address the capacity and motivation factors specific to this population.

Opportunities and barriers for maternal nutrition behavior change: an in-depth qualitative analysis of pregnant women and their families in Uttar Pradesh, India

Background

Maternal undernutrition during pregnancy remains a critical public health issue in India. While evidence-based interventions exist, poor program implementation and limited uptake of behavior change interventions make addressing undernutrition complex. To address this challenge, Alive & Thrive implemented interventions to strengthen interpersonal counseling, micronutrient supplement provision, and community mobilization through the government antenatal care (ANC) platform in Uttar Pradesh, India.

Objective

This qualitative study aimed to: (1) examine pregnant women's experiences of key nutrition-related behaviors (ANC attendance, consuming a diverse diet, supplement intake, weight gain monitoring, and breastfeeding intentions); (2) examine the influence of family members on these behaviors; and (3) identify key facilitators and barriers that affect behavioral adoption.

Methods

We conducted a qualitative study with in-depth interviews with 24 pregnant women, 13 husbands, and 15 mothers-in-law (MIL). We analyzed data through a thematic approach using the Capability-Opportunity-Motivation-Behavior (COM-B) framework.

Results

For ANC checkups and maternal weight gain monitoring, key facilitators were frontline worker home visits, convenient transportation, and family support, while the primary barrier was low motivation and lack understanding of the importance of ANC checkups. For dietary diversity, there was high reported capability (knowledge related to the key behavior) and most family members were aware of key recommendations; however, structural opportunity barriers (financial strain, lack of food availability and accessibility) prevented behavioral change. Opportunity ranked high for iron and folic acid supplement (IFA) intake, but was not consistently consumed due to side effects. Conversely, lack of supply was the largest barrier for calcium supplement intake. For breastfeeding, there was low overall capability and several participants described receiving inaccurate counseling messages.

Conclusion

Key drivers of maternal nutrition behavior adoption were indicator specific and varied across the capability-opportunity-motivation behavior change spectrum. Findings from this study can help to strengthen future program effectiveness by identifying specific areas of program improvement.

Infant and young child feeding practices and the factors that influence them: a qualitative study

BACKGROUND

Early child feeding is important for healthy growth and forming positive eating behaviors.

METHODS

This qualitative study sought to describe early childhood feeding behaviors, challenges, and opportunities through four focus group discussions with a diverse group of mothers of at least one child under two years or pregnant with their first child.

RESULTS

Although providing healthy foods was a priority, feeding behaviors reflected the mothers' partial understanding of infant and child nutrition. Mothers sought guidance on early child feeding from several sources, including in-person and virtual relationships but made decisions based largely on their own instincts. Participants consulted clinicians the least often, and mothers often felt frustrated by strict guidelines and negative messaging. Mothers were most receptive to suggestions when they felt supported and valued in the decision-making process.

CONCLUSIONS

In order to help mothers provide the best nutrition for their young children, clinicians should use positive tones, provide flexibility when possible, and work to create open lines of communication with parents.

Perinatal support for breastfeeding using mHealth: A mixed methods feasibility study of the My Baby Now app

Despite the well-known benefits of breastfeeding, breastfeeding rates remain suboptimal, particularly for women with lower socioeconomic position. Although popular, breastfeeding apps are often poor quality; their impact on breastfeeding knowledge, attitudes, confidence and intentions is unknown. A mixed method pre-post feasibility study was conducted to: 1) explore the feasibility of the My Baby Now app in providing perinatal breastfeeding support; 2) examine the impact on breastfeeding knowledge, attitudes, confidence and intentions; 3) to examine any differences in acceptability and impact of the app according to maternal education. The My Baby Now app was offered to pregnant women 20-30 weeks gestation. Breastfeeding knowledge and intentions were collected at baseline (T1) and 36-38 weeks gestation (T2); attitudes and confidence were collected at baseline, T2 and T3 (8-12 weeks post-partum). App engagement was measured via app analytics. Qualitative interviews were conducted with a purposeful sample following T3. Of 266 participants recruited, 169 (64%) completed T2 and 157 (59%) completed T3. Mothers without university education rated the app to be higher quality, more useful and impactful than mothers with university education. From T1-T2, breastfeeding knowledge (59.6% vs. 66.5%, p < 0.001) and exclusive breastfeeding intentions (76.6% vs. 80.9%, p < 0.001) increased. Breastfeeding attitudes and confidence scores also increased significantly across T1-T2 and T1-T3. App engagement during pregnancy predicted changes in breastfeeding attitudes from T1-T2 among participants without university education. App engagement did not predict changes in breastfeeding knowledge, confidence or intentions. Future randomised controlled studies should examine the effectiveness of mHealth interventions on breastfeeding outcomes.

Infant Appetitive Phenotypes: A Group-Based Multi-Trajectory Analysis

Background: Examining appetitive traits with person-centered analytical approaches can advance the understanding of appetitive phenotype trajectories across infancy, their origins, and influences upon them. The objective of the present study was to empirically describe appetitive phenotype trajectories in infancy and examine the associations with infant and parent factors.

Materials and Methods: In this longitudinal cohort study of Australian infants, parents completed three online surveys ~3 months apart, beginning when the infant was <6 months. Appetitive traits were assessed with the Baby Eating Behavior Questionnaire (BEBQ) and parent feeding practices with the Feeding Practices and Structure Questionnaire (FPSQ) infant and toddler version. Parent demographics and cognitions were also collected. Infant weight and length were transcribed from health records and converted to a BMI z-score. Group-based trajectory modeling identified appetitive phenotype trajectories using the BEBQ. Multilevel modeling examined change in feeding practices and child BMI z-score over time by appetitive phenotype trajectories.

Results: At time 1, 380 participants completed the survey (mean infant age 98 days), 178 at time 2 (mean infant age 198 days), and 154 at time 3 (mean infant age 303 days). Three multi-trajectory appetitive phenotype groups were identified and labeled as (Phenotype 1) food avoidant trending toward low food approach (21.32% of infants), (Phenotype 2) persistently balanced (50.53% of infants), and (Phenotype 3) high and continuing food approach (28.16% of infants). Formula feeding was more common in Phenotype 1 (p = 0.016). Parents of infants in Phenotype 1 were more likely to rate them as being more difficult than average, compared to infants with phenotypes 2 or 3. Phenotype 2 had the greatest increase in persuasive feeding over time [0.30; 95% CI (0.12, −0.47)].

Conclusions: Distinct multi-trajectory appetitive phenotype groups emerge early in infancy. These trajectories appear to have origins in both infant and parent characteristics as well as parent behaviors and cognitions. The infant multi-trajectory appetitive phenotype groups suggest that for some infants, difficulties in self-regulating appetite emerge early in life. Investigation of infant multi-trajectory appetitive phenotype groups that utilize a range of measures, examine relationships to key covariates and outcomes, and extend from infancy into childhood are needed.

Health providers' and pregnant women's perspectives about smoking cessation support: a COM-B analysis of a global systematic review of qualitative studies

Background

Smoking cessation in pregnancy has unique challenges. Health providers (HP) may need support to successfully implement smoking cessation care (SCC) for pregnant women (PW). We aimed to synthesize qualitative data about views of HPs and PW on SCC during pregnancy using COM-B (Capability, Opportunity, Motivation, Behaviour) framework.

Methods

A systematic search of online databases (MEDLINE, EMBASE, PsycINFO and CINAHL) using PRISMA guidelines. PW’s and HPs’ quotes, as well as the authors’ analysis, were extracted and double-coded (30%) using the COM-B framework.

Results

Thirty-two studies included research from 5 continents: twelve on HPs’ perspectives, 16 on PW’s perspectives, four papers included both. HPs’ capability and motivation were affected by role confusion and a lack of training, time, and resources to provide interventions. HPs acknowledged that advice should be delivered while taking women’s psychological state (capability) and stressors into consideration. Pregnant women’s physical capabilities to quit (e.g., increased metabolism of nicotine and dependence) was seldom addressed due to uncertainty about nicotine replacement therapy (NRT) use in pregnancy. Improving women’s motivation to quit depended on explaining the risks of smoking versus the safety of quit methods. Women considered advice from HPs during antenatal visits as effective, if accompanied by resources, peer support, feedback, and encouragement.

Conclusions

HPs found it challenging to provide effective SCC due to lack of training, time, and role confusion. The inability to address psychological stress in women and inadequate use of pharmacotherapy were additional barriers. These findings could aid in designing training programs that address HPs’ and PW’s attitudes and supportive campaigns for pregnant smokers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03773-x.

Parental considerations during complementary feeding in higher income countries: a systematic review of qualitative evidence

OBJECTIVE

Worldwide data suggest a clash between parental complementary feeding practices and recommendations. Understanding the circumstances under which parents form their feeding practices is a crucial step to improve such practices. This paper aimed to systematically review the existing qualitative literature and synthesise the factors that parents take into consideration in relation to complementary feeding.

DESIGN

A systematic review was undertaken. Four electronic databases were searched for qualitative studies published after 2001 exploring parental experiences during complementary feeding. A framework that included authors' outcomes of interest was used to extract and synthesise study findings. The Standards for Reporting Qualitative Research were used to critically assess the included studies.

SETTING

Upper-middle- and high-income countries.

PARTICIPANTS

Parents with a child below the age of 3 years.

RESULTS

A total of forty-seven studies met the eligibility criteria and were included in this systematic review. The themes were organised into three main categories: (1) factors related to introduction of complementary foods; (2) factors related to the type of complementary foods and (3) factors related to both timing and type. The selected literature highlights: prevalent baby cues that prompt parents to introduce solid foods; parents' views on the recommended timing of complementary feeding; factors that drive the choice of complementary foods and perceived value in advice received from health professionals and grandmothers.

CONCLUSIONS

This systematic review indicates factors that can be barriers to complying with the complementary feeding guidelines, and therefore, its findings are pertinent to improving parental feeding practices through intervention studies and through infant feeding education in a primary care setting.

Barriers and enablers to caregivers' responsive feeding behaviour: A systematic review to inform childhood obesity prevention

Responsive infant feeding is a critical component of childhood obesity prevention. However, there is little guidance for caregivers on how to do this successfully. The first step to developing an intervention to promote responsive feeding is to systematically identify its barriers and enablers. Searches were conducted in CINAHL, Cochrane Library, Medline, Embase, PubMed, PsycINFO, Maternity, and Infant Care from inception to November 2020. All study designs were included if they reported a barrier or enabler to responsive feeding during the first 2 years of life. We used a "best fit" framework synthesis, with the Capacity, Opportunity, Motivation, and Behaviour (COM-B) model. The Mixed Method Appraisal Tool (MMAT) was used to assess study quality. Forty-three studies were included in the review. Barriers (n = 36) and enablers (n = 21) were identified across five COM-B domains: psychological capacity, physical and social opportunity, and reflective and automatic motivation. Enablers were recognition of infant feeding cues, feeding knowledge and family and friends. Caregiver attitude toward control of feeding was a barrier, together with health care professional advice about formula feeding and breastfeeding expectation. These barriers and enablers provide a comprehensive evidence base to guide intervention development to improve responsive feeding and prevent obesity across individual and population levels.

The Perceptions and Needs of French Parents and Pediatricians Concerning Information on Complementary Feeding

Appropriate complementary feeding (CoF) is the key to preventing childhood obesity and promoting long-term health. Parents must be properly informed through the CoF process. Pediatricians have opportunities to interact with parents during the CoF transition and influence parental feeding decisions. They can convey public health nutrition messages to parents. With the release of new CoF recommendations in France in 2019, and from the perspective of their conversion into official public health communication material, the aim of this study was to explore parents’ and pediatricians’ perceptions and needs regarding information on CoF. Two online surveys were disseminated to gather information on CoF communication and guidance: one for parents (n = 1001, January 2020); one for pediatricians (n = 301, October 2019). The results showed that the importance of CoF for children’s healthy growth was well recognized by both parents and pediatricians. Parents acknowledged pediatricians as the most influential source of advice; and pediatricians were aware of their responsibility in counselling parents on CoF. However, pediatricians neglected the fact that parents gave high trust to their personal network when looking for advice. The Internet was a well-recognized source of information according to all. Diverging from what pediatricians considered useful, parents were interested in practical advice for implementing CoF. This study highlights common expectations and points of divergence between parents’ needs and pediatricians’ perceptions of those needs with regard to CoF information.

Development and Qualitative Pretesting of Child Feeding and Obesity Prevention Messages for Parents of Infants and Toddlers

BACKGROUND

Consistent, evidence-based child feeding guidance targeted to parents of children ages birth to 24 months (B-24) is needed for early childhood obesity prevention.

OBJECTIVE

The aim was to develop and pretest a comprehensive set of child feeding and obesity prevention messages for parents of children ages B-24.

DESIGN

A qualitative, 2-phase protocol, grounded in social and behavior change, was used as a conceptual interview framework to pilot test early childhood feeding messages with parents.

PARTICIPANTS/SETTING

Participants were parents (n = 23) of children ages B-24.

METHODS

A core set of 12 messages and supporting materials were developed for parents of children ages B-24 based on previous research findings, current research evidence, and feeding guidance. Parents were individually interviewed using a semistructured script along with additional questions to rank perceptions of message qualities.

MAIN OUTCOME MEASURES

Overall comprehension, importance, believability, ease of implementation, and likelihood of use of messages were assessed.

STATISTICAL ANALYSIS PERFORMED

Data analysis included qualitative thematic analysis and descriptive statistics for Likert-scaled responses.

RESULTS

Participants were primarily female, non-Hispanic White, with a mean age of 33.3 ± 6.8 years and at least a bachelor's degree. Overall, most messages were understood, believable, perceived as important, and feasible by parents. Messages related to starting solid foods, encouraging child control of intake and self-feeding, and food allergen guidance were perceived as more difficult and less likely to be implemented by parents.

CONCLUSIONS

Additional research is needed to evaluate actual implementation of messages by diverse parents and resulting outcomes including impact on child weight.

Exploring Feeding Practices and Food Literacy in Parents with Young Children from Disadvantaged Areas

Early childhood provides an opportunity to optimize growth and development and parents play a fundamental role in forming healthy eating habits in their children. A healthy diet improves quality of life and wellbeing and reduces the risk of chronic disease. The aim of this research was to explore parents' experiences of feeding 0-5-year-old children and food literacy behaviors. This qualitative study employed a general inductive inquiry approach. Participants were recruited through community-based parenting organizations in disadvantaged areas. Eight focus groups were conducted with 67 parents (92.5% female) living in socially disadvantaged areas within metropolitan Perth of Western Australia. Ten themes emerged from the preliminary analysis and were aligned with domains of relatedness, autonomy, and competence within the self-determination theory. Themes included relatedness (1) feeding is emotional, (2) variations in routine and feeding structures, (3) external influences, autonomy (4) power struggles, (5) it must be quick and easy, (6) lack of strategies for feeding autonomy, competency (7) whatever works, (8) healthy is important but for some unattainable, (9) improvements in food literacy skills, and (10) conflicting information overload. This research informed the development of a food literacy program for parents. Parents faced many challenges when trying to provide healthy food. This research has shown parents would benefit from support to achieve healthy eating practices for their families.

Mothers' and Grandmothers' misconceptions and socio-cultural factors as barriers to exclusive breastfeeding: A qualitative study involving Health Workers in two rural districts of Ghana

BACKGROUND

Education on exclusive breastfeeding (EBF) practices is usually given in the form of health talks by health workers (HWs). The need for HWs to be well-informed about cultural practices and misconceptions that act as barriers to EBF has been documented in literature. This information can guide HWs in developing interventions such as health talks which are culturally sensitive. However, this has not been explored from the perspectives of HWs in Ghana. In this paper, we report mothers' and grandmothers' misconceptions and cultural practices that are barriers to EBF in two rural districts in Ghana from the perspectives of Community Health Workers and Community Health Volunteers.

METHODS

We used qualitative data collected in the Kwahu Afram Plains South and North Districts of Ghana through nine focus group discussions (FGDs) among HWs and followed the data saturation principle. All FGDs were audio-taped, transcribed verbatim and translated from local dialects to English. The emerging themes were used in writing a narrative account, guided by the principles of the thematic analysis.

RESULTS

Our main findings included mothers' and grandmothers' perceptions that HWs themselves do not practice EBF. Mothers had the perception that grandmothers did not practice EBF but their children grew well, and gestures of babies suggested their readiness to start eating. Misconceptions revealed included beliefs that breastmilk is watery in nature and does not satisfy infants. Another misconception was that babies gain weight faster when not exclusively breastfed but fed on infant formulas. A custom of giving corn flour mixed with water or light porridge during the first few days after birth to welcome newborns was also reported.

CONCLUSIONS

The reports of the HWs revealed that several socio-cultural factors and misconceptions of mothers and grandmothers negatively influence EBF practices of mothers. Findings from this study highlight the need for HWs to provide culturally appropriate counselling services on breastfeeding not only to mothers but also to grandmothers and fathers in order to promote EBF and reap its benefits.

"They Just Need to Come Down a Little Bit to your Level": A Qualitative Study of Parents' Views and Experiences of Early Life Interventions to Promote Healthy Growth and Associated Behaviours

The first 1000 days is a critical window of opportunity to promote healthy growth and associated behaviours. Health professionals can play an important role, in part due to the large number of routine contacts they have with parents. There is an absence of research on the views of parents towards obesity prevention and the range of associated behaviours during this time period. This study aimed to elicit parents’ views on early life interventions to promote healthy growth/prevent childhood obesity, particularly those delivered by health professionals. Semi-structured interviews were conducted with 29 parents (24 mothers, 5 fathers) who were resident in Ireland and had at least one child aged under 30 months. Data were analysed using reflexive thematic analysis. Two central themes were generated: (1) navigating the uncertainty, stress, worries, and challenges of parenting whilst under scrutiny and (2) accessing support in the broader system. Parents would welcome support during this critical time period; particularly around feeding. Such support, however, needs to be practical, realistic, evidence-based, timely, accessible, multi-level, non-judgemental, and from trusted sources, including both health professionals and peers. Interventions to promote healthy growth and related behaviours need to be developed and implemented in a way that supports parents and their views and circumstances.

Hidden Realities of Infant Feeding: Systematic Review of Qualitative Findings from Parents

A growing, global conversation, regarding realities and challenges that parents experience today is ever-present. To understand recent parent's attitudes, beliefs, and perceptions regarding infant feeding, we sought to systematically identify and synthesize original qualitative research findings. Following the Enhancing Transparency in Reporting the Synthesis of Qualitative Research (ENTREQ) framework, electronic databases were searched with a priori terms applied to title/abstract fields and limited to studies published in English from 2015 to 2019, inclusive. Study quality assessment was conducted using the Critical Appraisal Skills Programme (CASP) checklist, and thematic analyses performed. Of 73 studies meeting inclusion criteria, four major themes emerged. (1) Breastfeeding is best for an infant; (2) Distinct attitudes, beliefs, and perceptions of mothers that breastfeed, and those that could not or chose not to breastfeed, are evident; (3) Infant feeding behaviors are influenced by the socio-cultural environment of the family, and (4) Parent's expectations of education and support addressing personal infant feeding choices from health care providers are not always met. This systematic review, guided by constructs within behavioral models and theories, provides updated findings to help inform the development of nutrition education curricula and public policy programs. Results can be applied within scale-up nutrition and behavioral education interventions that support parents during infant feeding.

Professional and non-professional sources of formula feeding advice for parents in the first six months

Breastfeeding is beneficial to both the mother and infant, yet many infants are either partially or fully fed with formula milk. Those parents feeding with formula receive less support from professional sources than those breastfeeding and may rely on more non‐professional sources for advice, and this contributes to negative emotional experiences such as guilt. This paper explores the sources of advice for formula feeding, factors associated with using professional or non‐professional sources and compares these sources with those used for breastfeeding advice. A secondary analysis of Australian survey data from 270 mothers was performed. Mothers of six‐month‐old infants participated in an online survey, providing information on advice they received or read about formula feeding and/or breastfeeding from professional and non‐professional sources. A fifth of mothers who were formula feeding did not receive any formula feeding advice from professional sources, and only a small fraction (4.5%) of mothers breastfeeding did not received any breastfeeding advice from professional sources. Compared with those mothers breastfeeding receiving breastfeeding advice, fewer mothers formula feeding receive formula feeding advice from both professional and non‐professional sources. The tin of formula was the most used source of formula advice. Mothers feeding with formula at six months were more likely to have received formula feeding advice from professional sources if they had been fully formula feeding before their infant was under the age of three months. Further research is needed to understand the specific barriers to accessing formula feeding advice and what other factors influence access to formula feeding advice.

Healthcare professionals' views on supporting young mothers with eating and moving during and after pregnancy: An interview study using the COM-B framework

Young mothers under the age of 20 often have poor nutrition and low levels of physical activity, adversely affecting outcomes for themselves and their babies. The aim of this qualitative study was to explore the experiences of healthcare professionals in supporting young women around eating and moving during and after pregnancy. Seventeen semi-structured interviews were conducted with midwives, family nurse practitioners and health visitors involved in the care of pregnant and post-natal mothers under the age of 20 in England and Wales. Data were analysed using thematic analysis and coded within the theoretical framework of the COM-B model to three areas of capability, motivation and opportunity. For capability, participants were broadly divided between those who had specialist knowledge and training in communication skills to support health behaviours in this population and professionals reliant on tacit knowledge. For opportunity, having enough time was seen as critical because young women's difficult social contexts meant supporting improved health behaviours required relationships of trust to be built. For motivation, participants reported that supporting young women with eating and moving was part of their role. However, the decision to prioritise this support sometimes related to perceived need based on BMI and this was complicated as young women were still growing. Motivation was additionally connected to professionals' own body experiences and health behaviours. Moving habits were less frequently discussed than eating as professionals described how young women tended to walk a lot in their daily lives or found that young women were not interested. Results suggest that to support eating and moving behaviours with young women, professionals need to be trained in communication techniques, enabled with the time to hold space for young women and be able to reflect on their own attitudes and beliefs to support a rounded model of health and wellbeing.

Wakeful Prone "Tummy Time" During Infancy: How Can We Help Parents?

AIMS

This study's purpose is to present facilitators and barriers for wakeful prone positioning or "tummy time" during infancy by exploring the personal perspectives of infant caregivers attempting to provide daily tummy time.

METHODS

The study was qualitative in design, using thematic analysis to identify major and minor themes from semi-structured interviews. The Capability, Opportunity, Motivation - Behavior Model provided a conceptual framework for the interview guide and categorization of major themes.

RESULTS

Within capability, opportunity, and motivation, the major themes of self-efficacy, scheduling, variations, siblings, committed adult help, social responses of acquaintances, and caregiver enjoyment could be barriers or facilitators, depending on the context. Optimized physical circumstances, caregiver interest, perceived benefits to the infant, pride and accomplishment, and obligation were identified as facilitators only. Barriers included negative infant affect.

CONCLUSIONS

These results offer preliminary guidance in a knowledge gap: tummy time support that addresses the self-identified concerns of infant caregivers.

Feeding Infants and Toddlers: A Qualitative Study to Determine Parental Education Needs

Background: Limited evidence-based guidance is available to parents regarding optimal child feeding practices to prevent early childhood obesity from birth to 24 months of age (B-24). The objective of this qualitative study was to determine current child feeding practices, barriers to implementation, and educational needs of parents of varying socioeconomic backgrounds as it relates to responsive feeding to prevent early obesity in children of ages B-24. Methods: One-on-one interviews were conducted with parents (n = 66) of children ages B-24 from both low-and non-low-income households. Interviews were audiorecorded, transcribed verbatim, and analyzed with NVivo using classical qualitative analysis. Results: Participants were primarily female (91%), married (53%), low-income (59%), and were not first-time parents (72%). The results revealed overarching themes, including parents' reported need for information on preparing child meals, optimal dietary intake, affordable healthy foods, promoting child self-feeding, and food and nutrition knowledge. Low-income parents more frequently requested guidance about identifying affordable healthy options and overfeeding while non-low-income parents requested information about food allergens, transitioning to solids, and creating structured mealtimes. Conclusions: Additional and focused outreach to parents of children ages B-24 regarding optimal feeding practices is needed especially on topics related to complementary feeding during the transition to solid food.

Physicians advice, parental practice and adherence to doctor's advice: an original survey on infant feeding

Abstract

Background: Despite several years of guidance on infant feeding, there has been only a slight change in consumer compliance. Therefore, this study aimed to analyse parents feeding practices, explore physicians’ advice about infant feeding and subsequent parent’s adherence to advice.

Methods

A multicentric cross-sectional qualitative and descriptive self-report online study was conducted in volunteers to participate in the study.

Results

Fifty-four physicians (paediatricians and general practitioners) and 600 parents of infants were recruited. Of the infants, 20.2% presented at inclusion with at least one type of functional gastrointestinal disorder. The breastfeeding prevalence was quite low (37.3%). The main initial deviance from guidelines said they observed in infant feeding was the early use of cow’s milk. More than two-thirds of infants older than 8 months were drinking cow’s milk. The introduction of solid foods was globally in line with recommendations. Most physicians gave advice about the different aspects of infant feeding but were seeking more information, as did the parents. A discrepancy between the physicians’ statements and the parents’ perceptions was observed. However the majority (95.4%) of parents reported that they followed totally or partially the advice received, especially by abandoning subsequently the use of cow’s milk in favour of a formula. The main reason for not adhering to the advice was that they did not consider it suitable for their infant and they preferred to rely on their feelings or recommendations from familiars.

Conclusions

This survey provides good insights into parents’ infant feeding practices together with the advice given by their doctor. The gap between practices and current guidelines is notable only for breast-feeding and use of formula. Despite several guidelines professionals and parents seek nutrition information. It highlights the need to deliver consistent, relevant, and less confusing messages about infant feeding.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1697-y) contains supplementary material, which is available to authorized users.

Infant feeding beliefs and practices of Arabic mothers in Australia

BACKGROUND

Culturally sensitive care in the health care system is imperative for optimal outcomes of all patients, especially women and their infants. For Arabic mothers in Australia, there is minimal research exploring their beliefs that could impact on their infant feeding decisions and practices.

AIM

The aim of this study was to explore the experiences, knowledge and influences around infant feeding in Arabic women in Australia.

METHOD

A qualitative descriptive approach was used. Focus groups were conducted with Arabic women in community organisations (Catholic & Islamic) in Sydney. A thematic analysis was undertaken. The Iowa Infant Feeding Attitude Scale (IIFAS) was also used to measure maternal attitudes towards infant feeding.

FINDINGS

A total of 17 women participated in three focus groups. Themes relating to infant feeding were identified, including (1) sources of knowledge and education, particularly, where mothers obtained their infant feeding knowledge, and how this was influenced; (2) cultural beliefs related to the support and direction of family members.; (3) religious beliefs surrounding the continuation of infant feeding practices; (4) social and personal themes as an influence on infant feeding decisions and practices, and (5) factors associated with cessation of exclusive breastfeeding, including the lack of support from health care professionals.

CONCLUSION

The Arabic women in this study have expressed their need for further culturally sensitive care surrounding infant feeding knowledge and practices, and for that care to be situated in their community. Further intervention-based studies in the community focusing on culturally competent and sensitive care are recommended.

A Mixed Methods Study to Explore the Effects of Program Design Elements and Participant Characteristics on Parents' Engagement With an mHealth Program to Promote Healthy Infant Feeding: The Growing Healthy Program

Purpose: Mobile health (mHealth) interventions have great potential to promote health. To increase consumer engagement in mHealth interventions it is necessary to address factors that influence the target demographic. The Growing healthy (GH) program is the first obesity prevention program delivered via a smartphone app and website offering evidence-based information on infant feeding from birth until 9 months of age. This sub-study aimed to explore how the design features, quality of the app and participant characteristics influenced parents' engagement with the GH app. Methods: A sequential mixed methods design was used. The GH app participants (225/301) were considered for this sub-study. Participant app engagement was measured through a purpose-built Engagement Index (EI) using app metrics. Participants were categorized as low, moderately or highly engaged based on their EI score upon completing the 9 months program and were then invited to participate in semi-structured telephone interviews. Participants who used the app program, given an EI score and expressed interest to participate in these interviews were eligible. The interviews explored factors that influenced app engagement including delivery features and quality. Thematic analysis networks was used for analysis. Results: 108/225 expressed interest and 18 interviews were conducted from low (n = 3), moderately (n = 7), or highly (n = 8) engaged participants based on purposeful sampling. Participants defined as highly engaged were likely to be a first-time parent, felt the app content to be trustworthy and the app design facilitated easy navigation and regularly opened the push notifications. Participants defined as having low or moderate engagement were likely to have experience from previous children, felt they had sufficient knowledge on infant feeding and the app did not provide further information, or experienced technological issues including app dysfunction due to system upgrades. Conclusions/Implications: This study demonstrated a novel approach to comprehensively analyse engagement in an mHealth intervention through quantitative (Engagement Index) and qualitative (interviews) methods. It provides an insight on maximizing data collected from these programs for measuring effectiveness and to understand users of various engagement levels interaction with program features. Measuring this can determine efficacy and refine programs to meet user requirements.

Solid advice: Complementary feeding experiences among disadvantaged parents in two countries

The initiation of complementary feeding (CF; introducing infants to food/drink other than milk) is recommended close to 6 months and not before 4 months of age. Low socio-economic status (SES) is a determinant of nonadherence to CF recommendations, but there is an evidence gap around reasons for nonadherence among these parents. This study investigated knowledge, attitudes, and practices of disadvantaged families (in terms of SES and social support) and use of guidance for CF, in the Republic of Ireland and Northern Ireland. Parents of infants aged 3-14 months were recruited via community groups. Semistructured focus groups aided by vignettes were used. Data were analysed using an inductive thematic approach. Nineteen focus groups took place with parents (n = 83). A range of factors influence parents when introducing solids. Sources of guidance extend to family, friends, the internet, and commercial resources. Parents experience uncertainty and anxiety during this time, driven by lack of knowledge and conflicting advice. Five major themes were identified: (a) more guidance that is accessible, timely, and respectfully needed; (b) the challenge of choosing safe, nutritious food; (c) "everybody has an opinion"; (d) feelings of inadequacy, embarrassment, and guilt; and (e) decisions are ultimately based on individual circumstances. CF advice should be culturally appropriate, practical, and empowering, emphasising the rationale behind updates to recommendations and consequences of nonadherence. Future training of health professionals for delivery of CF advice and guidance should consider these findings. Compliance with CF recommendations is influenced by health professionals, the wider family, and the commercial baby-food sector.

Mothers' Understanding of Infant Feeding Guidelines and Their Associated Practices: A Qualitative Analysis

There is limited evidence to describe Australian mothers’ understanding of the Australian Infant Feeding Guidelines (AIFG). A qualitative inductive methodological approach was used in this study to explore experiences with the introduction of solid food. Seven focus groups with 42 mothers of children aged 4–18 months were conducted in disadvantaged areas in Perth, Australia. The mean age of infants was 9.6 months and mean age of introduction of solid food was 4.3 months (range 1.2 to 7.5 months). Almost half of the mothers in this study were aware of the AIFG however, only half again could correctly identify the recommended age for introducing solid food. Four themes and nine subthemes emerged from the analysis. Themes were (1) Every child is different (judging signs of readiness); (2) Everyone gives you advice (juggling conflicting advice); (3) Go with your gut—(being a “good” mother); and (4) It’s not a sin to start them too early or too late (—guidelines are advice and not requirements). The findings indicated that in spite of continued promotion of the AIFG over the past ten years achieving the around six months guideline is challenging. Professionals must address barriers and support enablers to achieving infant feeding recommendations in the design education materials and programs.

Consumer Engagement in Mobile Application (App) Interventions Focused on Supporting Infant Feeding Practices for Early Prevention of Childhood Obesity

Background and Aims: There has been increasing interest in using mobile applications ("apps") for innovative health service delivery and public health interventions. This paper describes two independent studies investigating mothers' or pregnant women's perceptions of, interest in and experiences with technological devices, apps and websites about infant feeding practices. Methods: Study 1 was a cross-sectional survey conducted with 107 pregnant women in their third trimester in late 2016 and early 2017. Multiple logistic regression analyses were conducted to examine factors associated with their app usage. The second was a qualitative study of 29 mothers of infants aged <1 year conducted in 2014. Thematic network analysis was used to explore the themes from the transcribed interviews. Results: Study 1 found that the use of apps was common among the pregnant women, with 100% having previously downloaded an app on their phone either free or paid. About 60% had used an app for health purposes. The majority reported that they were likely to use an app promoting healthy infant feeding practices, including 30% extremely likely and 53% very likely. Women with university or other tertiary level of education were more likely to use an app for promoting healthy infant feeding practices than those with other levels of education (adjusted odds ratio 3.22, 95% confidence interval 1.28-8.13). The qualitative interviews found that all the mothers were interested in a mobile program to support them with infant feeding practices. Participants felt they would benefit from individualized messages although did not want them to be sent too frequently. Further, participants also expressed the importance of having non-judgmental information and they were interested in receiving information using different modes such as videos, SMS or an app. Conclusions: Both studies suggest that using apps for promoting healthy infant feeding practices is acceptable from the perspective of mothers. There is great potential for health promotion practitioners to be engaged in app development for the purpose of promoting health in early years and health promotion in general.

Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (Capability, Opportunity, Motivation-Behaviour) model

BACKGROUND

Health behaviours during pregnancy and the early years of life have been proven to affect long term health, resulting in investment in interventions. However, interventions often have low levels of completion and limited effectiveness. Consequently, it is increasingly important for interventions to be based on both behaviour change theories and techniques, and the accounts of pregnant women. This study engaged with pregnant women from deprived communities, to understand their subjective experiences of health in pregnancy.

METHODS

The study adopted a women-centred ethos and recruited a purposive sample of ten pregnant women, who lived in deprived areas and were on low incomes. Participants engaged with three creative techniques of visual data production (timelines, collaging and dyad sandboxing), followed by elicitation interviews. One participant only engaged in the initial activity and interview, resulting in a total of 28 elicitation interviews. This in-depth qualitative approach was designed to enable a nuanced account of the participants' thoughts, everyday experiences and social relationships. Data were deductively coded for alcohol, smoking and infant feeding and then mapped to the COM-B model (Capability, Opportunity, Motivation - Behaviour).

RESULTS

Five participants had experience of smoking during pregnancy, four had consumed alcohol during pregnancy, and all participants, except one who had exclusively formula fed her child, disclosed a range of infant feeding experiences and intentions for their current pregnancies. Considerable variation was identified between the drivers of behaviour around infant feeding and that related to abstinence from tobacco and alcohol during pregnancy. Overall, knowledge and confidence (psychological capability), the role of partners (social opportunity) and support from services to overcome physical challenges (environmental opportunity) were reported to impact on (reflective) motivation, and thus women's behaviour. The role of the public in creating and reinforcing stigma (social opportunity) was also noted in relation to all three behaviours.

CONCLUSIONS

When designing new interventions to improve maternal health behaviours it is important to consider the accounts of pregnant women. Acknowledging pregnant women's subjective experiences and the challenges they face in negotiating acceptable forms of motherhood, can contribute to informed policy and practice, which can engage rather than isolate potential user groups.

Key Lessons and Impact of the Growing Healthy mHealth Program on Milk Feeding, Timing of Introduction of Solids, and Infant Growth: Quasi-Experimental Study

Background

The first year of life is an important window to initiate healthy infant feeding practices to promote healthy growth. Interventions delivered by mobile phone (mHealth) provide a novel approach for reaching parents; however, little is known about the effectiveness of mHealth for child obesity prevention.

Objective

The objective of this study was to determine the feasibility and effectiveness of an mHealth obesity prevention intervention in terms of reach, acceptability, and impact on key infant feeding outcomes.

Methods

A quasi-experimental study was conducted with an mHealth intervention group (Growing healthy) and a nonrandomized comparison group (Baby’s First Food). The intervention group received access to a free app and website containing information on infant feeding, sleep and settling, and general support for parents with infants aged 0 to 9 months. App-generated notifications directed parents to age-and feeding-specific content within the app. Both groups completed Web-based surveys when infants were less than 3 months old (T1), at 6 months of age (T2), and 9 months of age (T3). Survival analysis was used to examine the duration of any breastfeeding and formula introduction, and cox proportional hazard regression was performed to examine the hazard ratio for ceasing breast feeding between the two groups. Multivariate logistic regression with adjustment for a range of child and parental factors was used to compare the exclusive breastfeeding, formula feeding behaviors, and timing of solid introduction between the 2 groups. Mixed effect polynomial regression models were performed to examine the group differences in growth trajectory from birth to T3.

Results

A total of 909 parents initiated the enrollment process, and a final sample of 645 parents (Growing healthy=301, Baby’s First Food=344) met the eligibility criteria. Most mothers were Australian born and just under half had completed a university education. Retention of participants was high (80.3%, 518/645) in both groups. Most parents (226/260, 86.9%) downloaded and used the app; however, usage declined over time. There was a high level of satisfaction with the program, with 86.1% (143/166) reporting that they trusted the information in the app and 84.6% (170/201) claiming that they would recommend it to a friend. However, some technical problems were encountered with just over a quarter of parents reporting that the app failed to work at times. There were no significant differences between groups in any of the target behaviors. Growth trajectories also did not differ between the 2 groups.

Conclusions

An mHealth intervention using a smartphone app to promote healthy infant feeding behaviors is a feasible and acceptable mode for delivering obesity prevention intervention to parents; however, app usage declined over time. Learnings from this study will be used to further enhance the program so as to improve its potential for changing infant feeding behaviors.

Effective Communication Strategies for Nurses to Discuss Infant Feeding with New Mothers During Postpartum Hospitalization

During prenatal care and postpartum hospitalization, nurses have an important role in assisting new mothers to make informed decisions about feeding their newborn infants. There is overwhelming evidence that breastfeeding is beneficial for most new mothers and babies; therefore, perinatal nurses encourage breastfeeding. Newborn infant feeding conversations with women who have chosen to formula feed may be complicated and may cause tension in the nurse-patient relationship. Despite this potential difficulty, these conversations are essential to establish a feeding plan for the newborn infant and to promote healthy outcomes for mothers and babies. Tools are offered for nurses to guide conversations about infant feeding choices and to help to ensure that all mothers receive support and encouragement on their feeding choice.

Factors Influencing Engagement and Behavioral Determinants of Infant Feeding in an mHealth Program: Qualitative Evaluation of the Growing Healthy Program

Background

Infant 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.

Objective

The 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.

Methods

Semistructured, 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.

Results

Participants 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.

Conclusions

Our 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 complemented health professional advice. It is likely that interventions need to commence during pregnancy to maximize the impact on breastfeeding intentions and plans.