Malnutrition among children in Indonesia: It is still a problem

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Engaging disadvantaged mothers through mHealth to support infant feeding behaviours that promote healthy weight gain

University of Technology Sydney. Faculty of Health.Eating behaviours are learned from the beginning of life and it is these habits that are carried throughout the life stages, affecting weight gain. Parental feeding behaviours including early cessation of breast feeding, formula feeding, early introduction to solids and introduction to non-core foods are considered to be correlates of excess weight gain. Further, there are socio-economic disparities which coexist, where families from a lower socio-economic status (SES) are more likely to practise unhealthy feeding behaviours. It is essential to understand how to effectively encourage these parents to make healthier infant feeding decisions. One emerging approach is to deliver health interventions through digital technologies also known as mobile health (mHealth). Interventions delivered through an mHealth approach have been shown to influence positive behaviour change in the management and prevention of chronic diseases. Yet there are very few studies which have developed mHealth interventions to support infant feeding. The research in which this thesis is embedded was designed to develop and test an mHealth intervention (the Growing healthy program) that delivers expert advice to mothers of young infants about healthy infant feeding behaviours. This thesis includes a number of studies that were conducted to guide the development of the Growing healthy program and to evaluate the outcomes regarding participant engagement with the program and the uptake of healthy infant feeding behaviours. […] This thesis provides a unique contribution to the existing literature by reporting the findings of a feasibility study to support mothers with healthy infant feeding behaviours through an mHealth program. As well as being the first infant feeding program delivered through mHealth, it is also the first study to utilise an Engagement Index to measure participant engagement in an mHealth intervention. This work therefore provides valuable information to inform future trials regarding intervention components that enhance engagement among this demographic. The Engagement Index provides an effective method to analyse engagement that can be implemented and adapted to suit any mHealth intervention

A story of she: collective feminist film making at home (between Japan and Scotland).

‘Speculative Fiction: Practicing Collectively’ is the title of the ongoing collective film practice, produced between different people and places, on screen, and in homes, in Scotland and Japan. Situated in critical feminist perspectives, the authors collective approach uses digital spaces as a platform for collaboration and co-learning opportunities, meant as explicitly feminist acts of sharing knowledge and ways of knowing, and mutual learning. In this contemporary moment when COVID-19 has forced the authors to “socially” distance, the online format and cross-cultural nature of the project supports such deliberate sharing practices, and their dialogue across disparate geographies and perspectives. The film is made of three sections, each of which has been produced in different constellations of collaboration, different ways of being together. It will be shown in its entirety at an exhibition at Tokyo Arts and Space in December 2020; the first section of the film, which you can view alongside this short article, was also exhibited online, via a Japanese art and cultural support project in August 2020. This first film was created collectively in response to a theme devised by Natsumi Sakamoto and Rachel Grant: attending to everyday labour, care, and gender roles at home. Sakamoto, a member of Back and Forth Collective, a transnational feminist artist collective founded in Tokyo, invited two Japanese artists from the collective. Duffy, Clarke and McWhinney were invited as artists based in Scotland. This article is also collectively written and edited. The film is still being produced, emerging through three stages of production. The central point of departure for our collaboration was the essay ‘The Carrier Bag Theory of Fiction’ (1986) by speculative feminist writer Ursula K. Le Guin. The first film involved the authors producing short films as individuals, with explicit instructions, to create a narrative around a fictional ‘she’ and to visualise it with film, animation, and performance documentation. This was followed by a lively discussion that addressed gender issues and stereotypes in Japan and the UK, including the controversies around women breastfeeding, motherhood, housework, childcare and care work, which remain too often invisible, un-paid, and undervalued. The following section presents diverse reflections on the key idea –home– in relation to the artists’ individual practices, their work, and/or the making of the first part of our film, which was made in the Spring of 2020, under lockdown. The final section addresses the collective nature of this ongoing experiment

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

Obesity prevention in infants using m-Health: the Growing Healthy program

About one quarter of Australian pre-school children are overweight. Early 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 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. This is referred to as mobile or m-health. The Growing Healthy study aimed to explore the feasibility of providing information and support for healthy parenting through electronic media in the form of an application for smart phones (app) and a website. Our background research suggested this as an emerging and promising area for engagement with families with young children and may provide a referral option for primary health care providers. It is also an intervention with a relatively low cost and potential for high reach. As families with young children have high levels of engagement with PHC services, these could be leveraged to recruit study participants via referral to the app. Complementing and not replacing the information and support provided by these existing primary health care services was an important objective as was ensuring the online information and support aligned with that provided by primary health care services and national guidelines. The aim was to make the app a ‘trusted source’ of information and support for families with children from birth to nine months of age.The research reported in this paper is a project of the Australian Primary Health Care Research Institute which is supported by a grant from the Australian Government Department of Health and Ageing under the Primary Health Care Research Evaluation and Development Strategy

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\u27 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\u27s 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

Preventing obesity in infants: the growing healthy feasibility trial protocol

INTRODUCTION: Early 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. METHODS: This 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 DISSEMINATION: This study received approval from the University of Technology Sydney Ethics committee and will be disseminated via peer-reviewed publications and conference presentations

Assessing user engagement of an mHealth intervention: development and implementation of the growing healthy app engagement index

Background: Childhood 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.Objective: The 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.Methods: The 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.Results: The 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).Conclusions: The 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

Transforming Obesity Prevention for CHILDren (TOPCHILD) Collaboration: Protocol for a Systematic Review with Individual Participant Data Meta-Analysis of Behavioural Interventions for the Prevention of Early Childhood Obesity

INTRODUCTION: Behavioural interventions in early life appear to show some effect in reducing childhood overweight and obesity. However, uncertainty remains regarding their overall effectiveness, and whether effectiveness differs among key subgroups. These evidence gaps have prompted an increase in very early childhood obesity prevention trials worldwide. Combining the individual participant data (IPD) from these trials will enhance statistical power to determine overall effectiveness and enable examination of individual and trial-level subgroups. We present a protocol for a systematic review with IPD meta-analysis to evaluate the effectiveness of obesity prevention interventions commencing antenatally or in the first year after birth, and to explore whether there are differential effects among key subgroups. METHODS AND ANALYSIS: Systematic searches of Medline, Embase, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycInfo and trial registries for all ongoing and completed randomised controlled trials evaluating behavioural interventions for the prevention of early childhood obesity have been completed up to March 2021 and will be updated annually to include additional trials. Eligible trialists will be asked to share their IPD; if unavailable, aggregate data will be used where possible. An IPD meta-analysis and a nested prospective meta-analysis will be performed using methodologies recommended by the Cochrane Collaboration. The primary outcome will be body mass index z-score at age 24±6 months using WHO Growth Standards, and effect differences will be explored among prespecified individual and trial-level subgroups. Secondary outcomes include other child weight-related measures, infant feeding, dietary intake, physical activity, sedentary behaviours, sleep, parenting measures and adverse events. ETHICS AND DISSEMINATION: Approved by The University of Sydney Human Research Ethics Committee (2020/273) and Flinders University Social and Behavioural Research Ethics Committee (HREC CIA2133-1). Results will be relevant to clinicians, child health services, researchers, policy-makers and families, and will be disseminated via publications, presentations and media releases. PROSPERO REGISTRATION NUMBER: CRD42020177408