DOI: https://doi.org/10.21203/rs.3.rs-1792964/v1
Background: Since mothers with gestational diabetes mellitus and their babies have increased risks for diabetes, obesity, and cardiovascular complications, breastfeeding, which helps lower the risks, is strongly recommended for them. However, due to various barriers, the rate of breastfeeding remains low among mothers with gestational diabetes mellitus. Hence, this study aimed to develop a mobile application to help promote breastfeeding in mothers with gestational diabetes mellitus who are vulnerable to infection, especially in the current coronavirus disease (COVID-19) situation in which social distancing is mandated.
Method: The Method of App Selection based on Users' Needs (MASUN), a method used in designing app structure and user interface (UI) by considering user needs, was used to develop the “Breastfeeding for Gestational Diabetes Mellitus App (BFGDM App)” by reflecting the needs of target users (i.e., mothers with gestational diabetes mellitus). Four personas were created based on the experiences of four mothers with gestational diabetes mellitus, and the personas’ needs were assessed and prioritized. Two professors and a clinical instructor in women’s health nursing conducted an expert review and revised the contents.
Results: The final version of the BFGDM App included the following components to promote breastfeeding in mothers with gestational diabetes mellitus: baby growth, breastfeeding records, information about mothers with gestational diabetes mellitus, information about breastfeeding, videos demonstrating breastfeeding methods and breast massage techniques, breastfeeding success stories, a message board, a section for frequently asked questions and the answers (Q&A), and links to breastfeeding education centers.
Conclusions: The use of the BFGDM App is expected to help prevent complications in mothers with diabetes mellitus and their babies, and promote maternal and child health through improved breastfeeding practices, especially in social distancing situations resulting from COVID-19.
Gestational diabetes mellitus is diabetes diagnosed during pregnancy. According to the International Diabetes Federation (IDF) (2019) report, 15.8% of pregnant women worldwide develop diabetes mellitus, and 75-90% of them suffer from gestational diabetes mellitus [1]. In Korea, the annual prevalence of gestational diabetes mellitus is a rapidly increasing trend [2]. Over the last 10 years, the prevalence of gestational diabetes mellitus among pregnant women over the age of 35 has increased by an average of 12.7% [3], indicating an increased risk of gestational diabetes mellitus in advanced maternal age.
Gestational diabetes mellitus increases the risks of complications in mothers as well as newborn babies. In mothers, the risks of preterm labor, dystocia of labor, and polyhydramnios are increased [4,5], and in newborn babies, the feral death rate and the risks of neurological disorder, heart defect, respiratory distress syndrome, fetal macrosomia, neonatal hypoglycemia, and neonatal jaundice are increased [4,5]. In addition, it was reported that the likelihoods of developing type 2 diabetes and childhood obesity were more than seven times higher in babies of mothers with gestational diabetes mellitus compared to those of healthy mothers [6]. Accordingly, effective prepartum and postpartum management are necessary for maternal and child health.
Breast milk is the most beneficial source of nutrients for newborn babies and infants. A previous study revealed that compared to formula-fed babies, breastfed babies showed a lower morbidity rate in respiratory disorders, digestive disorders, constipation, eczema, and allergy, and were psychologically more stable [7]. The World Health Organization (WHO) and the United Nations Children’s Emergency Fund (UNICEF) recommend exclusive breastfeeding for at least the first 6 months after birth. In Korea, a 2016 survey showed that the rate of exclusive breastfeeding was 95.6% at birth, but it steadily decreased afterward, to 18.3% by 6 months. According to a 2018 survey, the rate at 6 months after birth further decreased to 2.3%, showing a sharp decrease in trend [8].
Some reasons for the decreasing rate of breastfeeding in Korea are inability of mothers to initiate breastfeeding at all because of illness or breast pain and due to insufficient milk production [9]. When mothers with gestational diabetes mellitus breastfeed, serotonin production increases, which stimulates beta cells to multiply and reduce oxidative stress in the pancreas [10]. Accordingly, breastfeeding not only helps control blood sugar levels by decreasing insulin resistance in mothers but also lowers, in a long term, the likelihood of the babies to develop childhood obesity, type 2 diabetes mellitus, and cardiovascular disease. Thus, mothers with gestational diabetes mellitus are strongly recommended to breastfeed [11]. However, the rate of breastfeeding is lower in mothers with the condition than in healthy mothers because of physical discomfort due to delayed development of mammary glands and dystocia of labor [12].
Therefore, to promote effective breastfeeding capable of preventing complications and promoting the health of mothers with gestational diabetes mellitus as well as their babies, it is necessary to develop programs that would encourage breastfeeding practices. Currently, considering the global social distancing policies resulting from the COVID-19 pandemic, which has encouraged non-face-to-face activities, mobile app-based breastfeeding intervention programs are expected to be effective in mothers with gestational diabetes mellitus and babies who are vulnerable to infection. We searched for breastfeeding-related apps developed so far in Google Play Store and App Store and found that, as of May 2022, 251 apps were available in Google Play Store and 91 were available in App Store. Most of the available apps were for recording breastfeeding times and breastfeeding instructions for parents. Only ten apps related to gestational diabetes mellitus were found in Google Play and App Stores, and they were either apps providing dietary information specific to gestational diabetes mellitus or diabetes management apps briefly introducing gestational diabetes mellitus. Therefore, there was apparently no app for breastfeeding specifically targeting mothers with gestational diabetes mellitus. Consequently, this study aims to develop an easily accessible app-based breastfeeding promotion program for mothers with gestational diabetes mellitus, which can be applied by those experiencing difficulty in breastfeeding by using smartphones, to promote maternal and child health through improved breastfeeding health behavior.
2.1 Materials and Methods
Study Design
The study was conducted to develop the app structure and user interface (UI) of the “Breastfeeding for Gestational Diabetes Mellitus App (BFGDM App).” To do so, the “Method of App Selection based on User’s Needs” (MASUN) was referenced [13]. With MASUN, healthcare professionals who are not app developers can relatively easily design app structure and UI, reflecting user needs. This approach has been used to design apps for women experiencing menstrual cramps [14], for children with obesity and their guardians [15], and for geriatric hospital nurses caring for patients with bed sores [16]. To design the BFGDM App, four mothers with gestational diabetes mellitus who had an experience in breastfeeding and three researchers in women’s health nursing (a professor with expertise in health informatics and nursing informatics, another professor with over 15 years of teaching experience in college, and a clinical instructor) participated in the study. In total, the study was conducted with seven participants between January 20 and April 30, 2022.
Step 1: Target selection
The participants and researchers discussed gestational diabetes mellitus and breastfeeding. Target app users and app users’ problems were selected based on the difficulties and questions of the participants and key contents that should be included. The study received ethical approval from the Chungbuk National University Committee of CBNU-202202-HR-0023. After seeking the consent of the participants, the study began.
Step 2: Brainstorming and Mind mapping
Concept mapping was used to systematically and flexibly organize complex problems [17]. Group concept mapping is a collaborative process that is strict, scientifically reliable, and an important practical tool. It has been widely used in health management projects [17-19]. Of various concept mapping methods, group brainstorming and mind mapping were used in this study. Brainstorming is a process that helps in generating ideas and in gaining an in-depth understanding of a topic, and mind mapping is a tool to show a core idea and new ideas derived from the core idea [20].
Step 3: Development of Persona and Scenario
Conventionally, a systematic approach without a model tailored to a particular user group was employed in designing smartphone apps but using profiles and personas has become a more valuable approach [21]. Personas help technology developers to gain an in-depth understanding of diverse target users, and they are an important feature in user-centered design [22]. They provide a guideline to technology developers in creating a software interface for users with specific health needs [21]. In this study, four personas and scenarios were created and the app functions, which would be needed by each persona, were organized into a list.
Step 4: Needs list and priority consideration
Based on the personas and scenarios developed in Step 3, user needs were organized into categories. The categories served as the criteria for the menu and functions to be included in designing the app structure and UI.
Step 5: App structure and UI design
The designs for the app structure and UI of the BFGDM App were drafted by reflecting the user needs derived in Step 4. Pen and paper were used in drafting the designs so that they would be simple and easy for the researchers.
Four mothers with gestational diabetes mellitus who had experience in breastfeeding and two professors and one clinical instructor in women’s health nursing reviewed and revised the draft designs (a total of seven).
Step 6: Final setting up of “Mental Healing App” app structure and UI
The app structure and UI of the BFGDM App were derived based on the researchers’ expert review and revision. A mobile UI designer finalized the designs.
RESULTS
Step 1: Target selection
Mothers with gestational diabetes mellitus and their supporters were determined as target users based on consensus reached in discussions by two groups consisting of mothers with gestational diabetes mellitus and researchers. They made a decision to offer mobile breastfeeding care.
Step 2: Brainstorming and Mind mapping
In this step, brainstorming and mind mapping were conducted in two groups consisting of two mothers with gestational diabetes mellitus and a researcher. Seven researchers organized problems relevant to the targets and generated ideas [Figure 1].
Step 3: Development of Persona and Scenario
Persona A. – Mother with gestational diabetes mellitus
She lives with her husband in Cheonan, South Chungcheong Province. Her parents and parents-in-law live nearby. Currently, she is taking a leave of absence from a job due to pregnancy. This is her first pregnancy and she is diagnosed with gestational diabetes mellitus. Housewife. Name: Jin-Ah Kim (age 38, female).
Subpersona A– Support provider
He lives in Cheonan, Sough Chungcheong Province and works as a public official. He helps the pregnant wife and assists in child caring. The husband of Jin-Ah Kim. Name: Hyeong-Gyu, Park (age 40, male)
Persona B– Mother with gestational diabetes mellitus
She lives with her husband and their first child in Suwon, Gyeonggi Province. Diagnosed with gestational diabetes mellitus during the second pregnancy. Housewife. Name: Na-Hyeon Kim (age 33, female)
Subpersona B– Support provider
She lives in Suwon, Gyeonggi Province. She and Na-Hyeon were clients at the same postnatal care center during Na-Hyeon’ first childbirth. She breastfed her baby successfully. Housewife. Name: Mi-Ran Choi (age 35, female)
Step 4: Needs list and priority consideration
1) Needs derived for Personal A were as follows.
2) Needs derived for Personal B were as follows.
Step 5: App structure and UI design
Researchers developed needs lists and determined priorities for the four personas, and summarized the structure and components of the BFGDM-App in a table [Table 1].
Table 1. List of priority-based user needs for BFGDM-Apps
|
Baby Development |
Recoding |
Information |
Statistics and graphs |
Community |
Professional Institutions |
|
Name |
Date |
Characteristics of breast milk in gestational diabetic mothers |
Baby's statistics (height, weight) |
Frequently asked questions and answers |
Information from breastfeeding specialist organizations (URL) |
|
Height |
Number of breastfeeding |
Benefits of breastfeeding in gestational diabetic mothers |
Breastfeeding statistics (Daily, monthly) |
Board |
|
|
Weight |
Breastfeeding time: Stop-watch |
Breastfeeding success stories |
Statistics of the number of breast- massage performed |
||
|
Growth and Development |
Location of lactating breast |
Breastfeeding method (video) |
|||
|
Developmental information by monthly age |
Number of breast massages |
Breast trouble management |
Step 6: Final setting up of “Mental Healing App” app structure and UI
After the design of UI was drafted based on the summary table, the researchers conducted an expert review. Based on the expert review and revisions, the draft design was revised and the app structure and UI of the BFGDM App were derived [Figure 2-1, 2, 3]. Thereafter, a total of four rounds of discussion were held with the mobile UI designer to finalize the design of the UI. Specific UI design features were as follows. The first screen consisted of login and invitation code areas, and the menu screen was designed such that a click on a submenu would open the corresponding menu. The screen for baby growth consisted of areas in which the user could record the baby’s height and weight. A click on age by month showed a normal growth chart to check the baby’s current growth status against the norms. The data screen was designed to show the daily frequency of breastfeeding recorded via a stopwatch and a link to breastfeeding statistics so that the user could check the results. The screen for breastfeeding information was designed to show written texts regarding the features of breast milk for mothers with gestational diabetes mellitus, advantages of breastfeeding to mothers with the condition, breastfeeding success stories, and videos showing breastfeeding methods and breast massage techniques to provide a guide for breast management during breastfeeding. Lastly, the community screen was designed so that the user could search for answers to fundamental questions regarding breastfeeding using an FAQ and communicate with one another through a message board.
Mothers with gestational diabetes mellitus and their babies have increased risks for diabetes, obesity, and cardiovascular complications [4,5], and breastfeeding is reported to help lower the risks [10,11]. However, due to various barriers, the rate of breastfeeding is low among mothers with gestational diabetes mellitus [12]. This study is of significance because in the current situation in which people adhere to social distancing due to COVID-19, a mobile application design was developed to help mothers with diabetes mellitus who are vulnerable to infection and have difficulty breastfeeding. As of May 2022, apps for breastfeeding and management of gestational diabetes mellitus were developed separately, and thus, mothers with gestational diabetes mellitus need to use at least two apps to get help with breastfeeding. The development of the BFGDM App allows mothers with the condition to use a single app, which increases accessibility and convenience in usage.
To promote breastfeeding in mothers with diabetes mellitus, the application design was developed by referring to MASUN [14]. In addition, to improve the app’s usability, the app structure and UI were implemented based on the experiences and needs of four mothers with gestational diabetes mellitus and also on user needs derived by three researchers in women’s health nursing (two professors and a clinical instructor), who were not app developers, by using the method specified in MASUN [23]. The methodology of involving end users of the to-be-developed app in the process of implementing the UI and creating a draft design before finalizing it has been utilized in previous studies [16, 23], as well. The method of this study can be used by researchers who plan to create a mobile app UI for target users with a small number of study participants over a relatively short time [16]. The BFGDM App was developed to promote breastfeeding in mothers with gestational diabetes mellitus with focus on addressing their questions and difficulties and stimulating community activity to increase the motivation for breastfeeding, by providing overall information regarding breastfeeding, how to breastfeed, breastfeeding journal, breast management techniques, and breastfeeding Q & A.
Despite delayed development of mammary glands and physical discomfort during labor [12] mothers with diabetes mellitus who breastfed stated that with short-term suffering, they were able to reduce the feeling of guilt by providing the babies with the best nutrition and enumerated specific knowledge and emotional support as success factors for breastfeeding [24]. This is consistent with a finding derived from the user needs survey conducted in this study, i.e., informational needs. To provide breastfeeding-specific information, the BFGDM App was designed to show the features of breastmilk for mothers with diabetes mellitus, advantages of breastfeeding to mothers with the condition, success breastfeeding stories, breastfeeding methods, breast massage techniques, and breast problem management in the breastfeeding information screen. It is believed that the detailed information will help app users acquire the knowledge that they need when breastfeeding the baby. In particular, videos demonstrating breastfeeding and breast management methods were included in the app to help users learn the techniques easily. Additionally, the app was designed to make it easy for users to acquire specialized knowledge and learn how to manage breast problems immediately by providing contact information of breast management education centers.
The data screen consisted of recordings about breastfeeding sessions and baby growth. The design components were created by combining the findings derived from the user needs survey and the functions of existing parenting apps (Babytime: over 1 million downloads, a star rating of 4.9; Parenting Diary: over 500,000 downloads, a star rating of 4.8). The components are expected to be helpful to app users in monitoring the status of breastfeeding and the baby’s growth as well as self-management. The advantages of mobile apps include accessibility and self-monitoring capacity. Hence, it is believed that the BFGDM App will self-motivate users to continue breastfeeding. The recording of breastfeeding sessions via a stopwatch was developed with a focus on user convenience, and the function requires only a simple operation. The benefits of using this function are that users can check the previous breastfeeding time and the side used to track the interval between breastfeeding sessions and alternate the breast.
It has been reported that the breastfeeding practice of mothers with diabetes mellitus is influenced by their breastfeeding experience and self-efficacy [9]. The BFGDM App was designed to help increase breastfeeding self-efficacy in mothers with gestational diabetes mellitus, by providing an app that uses a message board to share breastfeeding experiences on the community screen and success breastfeeding stories on the breastfeeding information screen, as well as to inspire users to believe that they can also breastfeed successfully. Therefore, it is expected that in the COVID-19 situation, in which non-face-to-face interaction is encouraged, the use of the BFGDM App will provide emotional support, increased self-efficacy, self-management practices, and experiences of other mothers with the same condition to promote breastfeeding practice for mothers with diabetes mellitus.
The BFGDM App is structured for users to easily obtain information about breastfeeding through texts, graphs, and videos, provide the features that facilitate sharing of breastfeeding experiences, and provide links to breast management education centers. This app will be an important tool in promoting breastfeeding. It can be used to improve the knowledge, experience, and self-efficacy in breastfeeding in mothers with gestational diabetes mellitus, and minimize the impact of the disease on breastfeeding practice among them [9]. In the future, a follow-up study should be conducted to examine the effects of BFGDM App by assessing breastfeeding knowledge, intention, and success in mothers with gestational diabetes mellitus who use the app.
The BFGDM App, developed in this study for breastfeeding in mothers with gestational diabetes mellitus, is an effective tool for promoting breastfeeding in mothers with the condition, especially in social distancing situations resulting from COVID-19. Further studies on app development should be conducted to prevent complications and promote maternal and child health through breastfeeding.
MASUN: The Method of App Selection based on Users' Needs
UI: user interface
BFGDM: Breastfeeding for Gestational Diabetes Mellitus App
Q&A: questions and answers
COVID-19: Coronavirus disease
IDF: International Diabetes Federation
WHO: The World Health Organization
UNICEF: the United Nations Children’s Emergency Fund
Ethics approval and consent to participate
This study was conducted according to the guidelines of the Declaration of Helsinki, and approved by the Institutional Review Board of Chungbuk National University (CBNU-202202-HR-0023). Data collection was conducted after receiving approval from the ethics committee. Written informed consent was obtained from all participants.
Consent for publication
Not applicable
Availability of data and materials
The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Competing interests
The authors declare that they have no competing interests
Funding
This work was supported by the Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Education (NRF-2019R1I1A3A01059963).
Authors' contributions
S. P, J. L., and E. K. conceived and designed the study, performed the data analysis, and wrote the manuscript. All authors have read and approved the final manuscript.
Acknowledgments
The authors would like to thank the mothers who participated in this study.