Can a Text Message a Week Improve Breastfeeding?
Can a Text Message a Week Improve Breastfeeding?
This was a pilot study to test proof of concept for an automated two-way text messaging service to support women to breastfeed. We aimed to test the ability of an automated mobile phone text messaging intervention, as a means to provide support for breastfeeding women, to increase any breastfeeding rates and to improve self-efficacy towards breastfeeding and active coping. MumBubConnect increased exclusive breastfeeding rates however did not impact on any or predominant breastfeeding rates. MumBubConnect has demonstrated that mobile support was well accepted as a means of support and while there was no significant difference in self-efficacy there was a significant difference in positive/active coping. MBC has significantly reduced attrition in women exclusively breastfeeding, when compared to the comparison group. This remained significant after controlling for factors normally associated with breastfeeding duration. While the intervention was trialled in a group of women who were potentially more likely to breastfeed the ubiquitous nature of mobile phone technology means that the likelihood of MBC reaching more difficult to reach women (less likely to breastfeed) is high. We anticipate that the results of a larger clinical trial would demonstrate the effectiveness of MBC to significantly correlate to improving exclusive breastfeeding rates at four and six months of age, but also any breastfeeding representing optimal breastfeeding practices.
The women recruited for the MBC intervention and the comparison groups were more likely to breastfeed compared to women nationally. Given the available data collected in 2004 and 2010 indicates little if no change in breastfeeding rates at less than six months, it is unlikely that breastfeeding rates changed between the collection of data from the intervention and comparison groups. For infants in the sample aged up to four months, 96% and 98% of infants were receiving any breastmilk in the trial and comparison group respectively, compared to 68.7% based on nationally collected data. Women in the comparison group had a greater prevalence of exclusive breastfeeding at time one potentially due to the younger average age of infants and the higher income of women. Despite this, while the women in the intervention group were more likely to breastfeed, the intervention would appear to have had an impact on extending the duration of exclusive breastfeeding.
The literature demonstrates that all forms of extra support have an effect on exclusive breastfeeding duration. Professional and lay support separately and together have effects on prolonging breastfeeding, with lay support more effective in extending exclusive breastfeeding. Face-to-face support appears to have a larger treatment effect than telephone support, although pro-active telephone support does improve breastfeeding duration and exclusivity. Support only offered to women who seek assistance is unlikely to be effective. All forms of support reviewed, relied however, on time provided by peers or professionals and were relatively intensive in terms of cost and infrastructure. MBC has the potential to provide the same or greater effects, which could be universally provided and is low-cost. This potential warrants further investigation.
Self-efficacy has been well documented as being a key determinant of breastfeeding duration, and this was not affected by MBC. All women recruited to both the intervention and the comparison groups had high levels of self-efficacy and these were maintained over the nine week period. However, other factors are known to influence self-efficacy including higher perceptions of social support and physiologic and emotional states such as pain, anxiety and stress. Given the significant results of factors contributing to self-efficacy, MBC could have a more profound impact among women with lower identified self-efficacy levels in the early post-partum period. The impact could also be dose-related, that is if the women received more text messages for a longer period of time the effect may have been greater and changes in self-efficacy may have been seen. These elements remain to be investigated.
To our knowledge the "Ways of Coping Checklist" has not been applied to breastfeeding behaviour. Previously, the WCCL in its earlier and revised forms has been used to investigate coping behaviours related to chronic or life-threatening illnesses, being a carer, and in managing burn-out, stress and anxiety. Breastfeeding is a learned skill that can be challenging to manage and can create high levels of stress and anxiety and how women cope with this is potentially important in determining best methods of support. The indications are that the intervention assisted women in enabling them to problem solve and to seek additional support. In addition, they were less likely to blame themselves, undertake avoidance or engage in wishful thinking. MBC appears to have significantly increased engagement in active coping strategies; with women in the intervention increasing and women in the comparison group decreasing active coping. In addition, emotions-focussed coping increased in both groups but the increase for the women in the comparison group was almost three times that of women receiving the intervention. These are all indications that MBC has had a positive impact on empowering women to manage their breastfeeding experience by increasing active coping strategies.
Mobile technologies are increasingly used by individuals to extend and manage relationship connections with selected "experts", as well as to gather information and marketing offers, anytime, anywhere. Mobile phones may be useful in delivering health-related services because they are: personal (targeted and individualised); portable (always on and always-on-us); connected (human-to-human, human-to-machine); and intelligent (increased capacity at the mobile level). There are indications that mobile technologies offer opportunities for technology-enhanced social connections, that promote positive health behaviours. The MBC intervention has provided evidence that women preferred this modality over other forms of telephone, web-based or face-to-face support due to: the personalised messages (even though they knew they were automated); being asked about how they were feeling, rather than admitting defeat and asking for help; responding on their terms, rather than being dictated by a telephone call or an appointment time. In response from the women, future iterations of the service may incorporate the ability to free text and to initiate a text when required.
This research has demonstrated that a mobile phone intervention has the potential to impact coping strategies of mothers to improve breastfeeding exclusivity and duration. Using mobile phone technologies provides an opportunity to broadly and cheaply provide an affordable, proximal, personalised and customised means for influencing breastfeeding behaviours. There is also scope to further explore the WCCL, emotions and accountability as constructs that could contribute to the explanation of breastfeeding behaviours.
This study was a proof of concept, that is, a mobile phone intervention could positively impact on breastfeeding behaviors. There are a number of limitations the most notable is that the trial was not randomised and the control and intervention groups were not run concurrently. While a randomised control trial was originally planned the overwhelming need expressed by women in the community for additional support meant that the researchers were uncomfortable in not providing the intervention to all women during the trial. In addition, the marketing component of the intervention made it difficult to limit exposure of the control group if run simultaneously. While there were limitations in the non-concurrent design there was also one distinct advantage. The MBC intervention had a significant social marketing component and was accompanied by significant media, delaying the control group reduced the likelihood of recognition of key messages from the intervention. Careful consideration will be given to the design of the effectiveness trial given the identified difficulties for population based interventions.
In addition, both intervention and comparison groups were pro-breastfeeding; and the samples were diverse but still weighted towards women with higher socioeconomic status. Recruitment via the media could have resulted in a volunteer bias.
This trial did not include an "attention" text, in other words it is unclear if it was the messages contained within the text or the fact that they received a text that created the effect. Any ongoing trial will need to carefully consider an attention text which does not provide information or problem solving with respect to feeding or aspects related to feeding. Finally, there was a higher attrition of women from the comparison group who were lost to follow up. This could have impacted on the groups but also provides indication that the MBC intervention actively engaged women over the eight weeks.
Discussion
This was a pilot study to test proof of concept for an automated two-way text messaging service to support women to breastfeed. We aimed to test the ability of an automated mobile phone text messaging intervention, as a means to provide support for breastfeeding women, to increase any breastfeeding rates and to improve self-efficacy towards breastfeeding and active coping. MumBubConnect increased exclusive breastfeeding rates however did not impact on any or predominant breastfeeding rates. MumBubConnect has demonstrated that mobile support was well accepted as a means of support and while there was no significant difference in self-efficacy there was a significant difference in positive/active coping. MBC has significantly reduced attrition in women exclusively breastfeeding, when compared to the comparison group. This remained significant after controlling for factors normally associated with breastfeeding duration. While the intervention was trialled in a group of women who were potentially more likely to breastfeed the ubiquitous nature of mobile phone technology means that the likelihood of MBC reaching more difficult to reach women (less likely to breastfeed) is high. We anticipate that the results of a larger clinical trial would demonstrate the effectiveness of MBC to significantly correlate to improving exclusive breastfeeding rates at four and six months of age, but also any breastfeeding representing optimal breastfeeding practices.
The women recruited for the MBC intervention and the comparison groups were more likely to breastfeed compared to women nationally. Given the available data collected in 2004 and 2010 indicates little if no change in breastfeeding rates at less than six months, it is unlikely that breastfeeding rates changed between the collection of data from the intervention and comparison groups. For infants in the sample aged up to four months, 96% and 98% of infants were receiving any breastmilk in the trial and comparison group respectively, compared to 68.7% based on nationally collected data. Women in the comparison group had a greater prevalence of exclusive breastfeeding at time one potentially due to the younger average age of infants and the higher income of women. Despite this, while the women in the intervention group were more likely to breastfeed, the intervention would appear to have had an impact on extending the duration of exclusive breastfeeding.
The literature demonstrates that all forms of extra support have an effect on exclusive breastfeeding duration. Professional and lay support separately and together have effects on prolonging breastfeeding, with lay support more effective in extending exclusive breastfeeding. Face-to-face support appears to have a larger treatment effect than telephone support, although pro-active telephone support does improve breastfeeding duration and exclusivity. Support only offered to women who seek assistance is unlikely to be effective. All forms of support reviewed, relied however, on time provided by peers or professionals and were relatively intensive in terms of cost and infrastructure. MBC has the potential to provide the same or greater effects, which could be universally provided and is low-cost. This potential warrants further investigation.
Self-efficacy has been well documented as being a key determinant of breastfeeding duration, and this was not affected by MBC. All women recruited to both the intervention and the comparison groups had high levels of self-efficacy and these were maintained over the nine week period. However, other factors are known to influence self-efficacy including higher perceptions of social support and physiologic and emotional states such as pain, anxiety and stress. Given the significant results of factors contributing to self-efficacy, MBC could have a more profound impact among women with lower identified self-efficacy levels in the early post-partum period. The impact could also be dose-related, that is if the women received more text messages for a longer period of time the effect may have been greater and changes in self-efficacy may have been seen. These elements remain to be investigated.
To our knowledge the "Ways of Coping Checklist" has not been applied to breastfeeding behaviour. Previously, the WCCL in its earlier and revised forms has been used to investigate coping behaviours related to chronic or life-threatening illnesses, being a carer, and in managing burn-out, stress and anxiety. Breastfeeding is a learned skill that can be challenging to manage and can create high levels of stress and anxiety and how women cope with this is potentially important in determining best methods of support. The indications are that the intervention assisted women in enabling them to problem solve and to seek additional support. In addition, they were less likely to blame themselves, undertake avoidance or engage in wishful thinking. MBC appears to have significantly increased engagement in active coping strategies; with women in the intervention increasing and women in the comparison group decreasing active coping. In addition, emotions-focussed coping increased in both groups but the increase for the women in the comparison group was almost three times that of women receiving the intervention. These are all indications that MBC has had a positive impact on empowering women to manage their breastfeeding experience by increasing active coping strategies.
Mobile technologies are increasingly used by individuals to extend and manage relationship connections with selected "experts", as well as to gather information and marketing offers, anytime, anywhere. Mobile phones may be useful in delivering health-related services because they are: personal (targeted and individualised); portable (always on and always-on-us); connected (human-to-human, human-to-machine); and intelligent (increased capacity at the mobile level). There are indications that mobile technologies offer opportunities for technology-enhanced social connections, that promote positive health behaviours. The MBC intervention has provided evidence that women preferred this modality over other forms of telephone, web-based or face-to-face support due to: the personalised messages (even though they knew they were automated); being asked about how they were feeling, rather than admitting defeat and asking for help; responding on their terms, rather than being dictated by a telephone call or an appointment time. In response from the women, future iterations of the service may incorporate the ability to free text and to initiate a text when required.
This research has demonstrated that a mobile phone intervention has the potential to impact coping strategies of mothers to improve breastfeeding exclusivity and duration. Using mobile phone technologies provides an opportunity to broadly and cheaply provide an affordable, proximal, personalised and customised means for influencing breastfeeding behaviours. There is also scope to further explore the WCCL, emotions and accountability as constructs that could contribute to the explanation of breastfeeding behaviours.
Limitations
This study was a proof of concept, that is, a mobile phone intervention could positively impact on breastfeeding behaviors. There are a number of limitations the most notable is that the trial was not randomised and the control and intervention groups were not run concurrently. While a randomised control trial was originally planned the overwhelming need expressed by women in the community for additional support meant that the researchers were uncomfortable in not providing the intervention to all women during the trial. In addition, the marketing component of the intervention made it difficult to limit exposure of the control group if run simultaneously. While there were limitations in the non-concurrent design there was also one distinct advantage. The MBC intervention had a significant social marketing component and was accompanied by significant media, delaying the control group reduced the likelihood of recognition of key messages from the intervention. Careful consideration will be given to the design of the effectiveness trial given the identified difficulties for population based interventions.
In addition, both intervention and comparison groups were pro-breastfeeding; and the samples were diverse but still weighted towards women with higher socioeconomic status. Recruitment via the media could have resulted in a volunteer bias.
This trial did not include an "attention" text, in other words it is unclear if it was the messages contained within the text or the fact that they received a text that created the effect. Any ongoing trial will need to carefully consider an attention text which does not provide information or problem solving with respect to feeding or aspects related to feeding. Finally, there was a higher attrition of women from the comparison group who were lost to follow up. This could have impacted on the groups but also provides indication that the MBC intervention actively engaged women over the eight weeks.
Source...