Exclusive breastfeeding (EBF) practices significantly decrease mortality and morbidity in children less than five years of age, resulting in improved child survival and health [1,2]. EBF during the first six months of life can reduce infant mortality by preventing diarrhea and acute respiratory infections . Increasing the rate of EBF in the first 6 months of life to at least 50% is one of the six World Health Organization (WHO) global nutrition targets for 2025 .
Global rates of optimal breastfeeding practices, especially EBF, have remained stagnant over the past two decades both in India and other low-and middle-income countries (LMICs), with only one in three infants under 6 months being exclusively breastfed . The most recent India National family health survey (NFHS)found that for the first six months of life, 56.4% of infants in Karnataka, India were exclusively breastfed . Achieving EBF requires a multi-pronged approach that involves both health care providers and policy makers, along with community participation and support [6,7].
One strategy for increasing EBF is the use of community-based programs that use peer counselors to educate and support mothers. Such programs have shown to be effective in increasing initiation and duration of breastfeeding in diverse populations and settings, including LMICs. Successful peer counselor programs have been shown to address diverse health-related problems, including HIV prevention, immunizations, alcohol use, and depression in several LMICs. [8,9,10,11,12,13,14,15,16,17,18]. Effective training of peer counselors is a crucial prerequisite for the success of such programs.
Mobile health (mHealth ) applications (apps) use mobile devices such as smartphones or handheld mobile tablets to enhance teaching, collaboration, and provision of medical care . Such mHealth apps are increasingly popular as a way to reach rural populations in LMICs that have strong internet access capability [20,21,22]. Because such access is commonly available in India, mHealth-based programs have the potential to provide scalable public health interventions .
There is evidence that mHealth-supported community programs can improve behaviors of Indian mothers, including the uptake of health services among pregnant and breastfeeding women with HIV . A recent meta-analyses of studies conducted in six countries suggested that mHealth may be associated with improved maternal breastfeeding attitude, knowledge, and initiation, and EBF duration . Two additional reviews found evidence of positive results on EBF and other neonatal and maternal outcomes but stressed the need for both strong research methods and personalized contact . Itremains unknown, though, whether utilizing mHealth platforms to enhance peer counselor efforts is effective at improving infant feeding behaviors of mothers in India.
As part of an NIH-supported research project, we adapted the WHO’s breastfeeding curriculum to the local culture and trained rural mothers with prior breastfeeding experiences to serve as breastfeeding Peer Counselors (PCs). The training prepared them to counsel and support antepartum and postpartum mothers around the topic of EBF and infant feeding. To maximize the utility of the peer counselors, we designed the delivery of training content via a mHealth app on a Samsung Android tablet. The present article describes our curriculum in the state of Karnataka, India for supporting new mothers to exclusively breastfeed. The Ethics Committee of the Jawaharial Nehru Medical College from Belagavi, India approved the conduct of our work.
Peer Counselor Training Curriculum
Using the results of qualitative research that we conducted through focus group discussions, we adapted the World Health Organization’s breastfeeding counseling course and Haider and colleagues’ breastfeeding PCs training module to the cultural setting of the southern Karnataka state in the Kannada language [27,28,8]. Local breastfeeding situation and misconception and dangers of use of top feeding were incorporated in the curriculum since the results of our formative research described mixed practices about prelacteal and supplemental feeding, reflecting older, traditional views. Names and figures in the module were based on how women looked and spoke in local communities. The involvement of the mother-in-law was added, as well as specifics about cultural practices such the use of tim tim (herbal drops) and guti (locally made gruel mixtures).The research staff were experienced in the content area and are designated as national breastfeeding trainers in India; additional guidance was sought from twelve nursing and obstetric experts for the development of the curriculum.
Fifty-six potential peer counselors were identified by staff from five Primary Health Centers (PHCs) and 25 were selected who met the inclusion criteria of (1) residing in the local community; (2) having breastfed within the past 5 years; (3) having at least 10 years of formal education; (4) having an available mobile phone; (5) being familiar with operating an Android phone; and (6) being able to read, write, and communicate in the local language.
A three-day peer counselor training was conducted in the local language at the academic health center. Two days were dedicated to breastfeeding education. The last day was dedicated to a half-day on the use of the mHealth app with the remaining time for protocol training and skills assessment. Pedagogy across the three days included interactive lectures, demonstrations, brainstorming sessions, case-based learning, and role-playing.
Training materials comprised a branded BEST4Baby kit with the following contents to support in-home breastfeeding counseling sessions with new mothers:
- Life-size newborn doll to demonstrate positioning;
- A skin-colored sock to prepare breast model for demonstrating proper latching;
- A digital scale for weighing and to assess the growth of the infant;
- A nipple plunger to mitigate the problem of an inverted nipple;
- A Samsung Android tablet with BEST4Baby app pre-loaded with wireless service and secured to allow for its sole use with the app.
Training content included fourthree key components: breastfeeding knowledge, counseling and communication skills, the use of the BEST4Baby app, and familiarity with overall peer counselors’ responsibilities for each of the nine visits in the protocol for expectant or new mothers. Each session’s learning objectives, the learning strategies, and the evaluation process were predefined. The curriculum was designed to educate peer counselors for delivering timely information related to the mother’s stage of gestation (e.g., antepartum at 28 -32 weeks and 32-36 weeks ) and the infant’s age (e.g., postpartum at 1-3 days, 15 days, 1 month, 2, 4 and 6 months) during nine home visits to provide support to the first time mothers to exclusively breastfeed. Tables 1 and 2 provide specific information about the curriculum content.
The BEST4Baby app was designed to reinforce training by allowing peer counselors to use the device during and after the training sessions and while in the field. The design of the app was included a step-by-step guide for each of the visits to cover relevant topics for that particular visit. The peer counselors were given the opportunity to use the app, including the process of logging in, scheduling visits, and practicing each visit. Time was allotted to interactively practice the content of the training modules incorporated in the app.
We evaluated participants in the breastfeeding training curriculum on knowledge, self-efficacy, skills in counseling, and usability of the mHealth application. These skill sets were evaluated employing a 30 item survey, adapted from the literature, to reflect curriculum content, validated in advance by twelve nursing and obstetric content experts [29,30]. The survey contained 20 knowledge items (e.g., colostrum is the first breast milk; breastfeeding helps in mother and child bonding); three counseling items (e.g., mother has a complaint about something that you, as a peer counselor, know little about. how do you respond?); two self-efficacy items (e.g., how confident are you in your ability to address mother’s concerns about breastfeeding?) and five observational skill items (e.g., is the infant correctly positioned?). Possible scores ranged from 0 to 20 on knowledge, 0-3 on counseling, 0-8 on self-efficacy, and 0-10 on skills subscales. At the end of the training, we also evaluated the usability of the app, using a modified System Usability Scale, a simple, widely available 10-item survey based on a 5-point Likert scale . In addition to descriptive statistics, we ran mixed-effect linear regression models to assess pre-post training changes.
The 25 peer counselors had an average age of 29 years (SD 4.4; range 23-40), 88% were married for an average of 11 years; 56% had attended at least 11-16 years of school and 76% had some form of formal work experience. Mean scores significantly improved from pre- to post-training on the breastfeeding knowledge (p <.0001), counseling (p=.0006), and skills (p=.0006) modules. Scores on the self-efficacy module did not change significantly. After the half-day training, scores on the Peer Counselor Usability Scale for the app were found to be highly usable, with the 25 peer counselors reporting an average score of 87.5 (SD ±8.2; range 72.5-100).