%0 Journal Article %@ 2561-326X %I JMIR Publications %V 5 %N 3 %P e18240 %T Delivering Perinatal Health Information via a Voice Interactive App (SMILE): Mixed Methods Feasibility Study %A Militello,Lisa %A Sezgin,Emre %A Huang,Yungui %A Lin,Simon %+ Martha S Pitzer Center for Women, Children & Youth, College of Nursing, The Ohio State University, 1585 Neil Ave, 145 Newton Hall, Columbus, OH, 43210, United States, 1 3128135007, militello.14@osu.edu %K perinatal care %K infant mortality %K health education %K mobile health %K feasibility studies %K family %K mobile phone %K webcasts as topic %K user-computer interface %D 2021 %7 1.3.2021 %9 Original Paper %J JMIR Form Res %G English %X Background: Perinatal health care is critically important for maternal health outcomes in infants. The United States fares considerably worse than comparable countries for maternal and infant mortality rates. As such, alternative models of care or engagement are warranted. Ubiquitous digital devices and increased use of digital health tools have the potential to extend the reach to women and infants in their everyday lives and make a positive impact on their health outcomes. As voice technology becomes more mainstream, research is prudent to establish evidence-based practice on how to best leverage voice technology to promote maternal-infant health. Objective: The aim of this study is to assess the feasibility of using voice technology to support perinatal health and infant care practices. Methods: Perinatal women were recruited from a large Midwest Children’s Hospital via hospital email announcements and word of mouth. Owing to the technical aspects of the intervention, participants were required to speak English and use an iPhone. Demographics, patterns of technology use, and technology use specific to perinatal health or self-care practices were assessed at baseline. Next, participants were onboarded and asked to use the intervention, Self-Management Intervention–Life Essentials (SMILE), over the course of 2 weeks. SMILE provided users with perinatal health content delivered through mini podcasts (ranging from 3 to 8 minutes in duration). After each podcast, SMILE prompted users to provide immediate verbal feedback to the content. An exit interview was conducted with participants to gather feedback on the intervention and further explore participants’ perceptions of voice technology as a means to support perinatal health in the future. Results: In total, 19 pregnant women (17 to 36 weeks pregnant) were consented. Themes identified as important for perinatal health information include establishing routines, expected norms, and realistic expectations and providing key takeaways. Themes identified as important for voice interaction include customization and user preferences, privacy, family and friends, and context and convenience. Qualitative analysis suggested that perinatal health promotion content delivered by voice should be accurate and succinctly delivered and highlight key takeaways. Perinatal health interventions that use voice should provide users with the ability to customize the intervention but also provide opportunities to engage family members, particularly spouses. As a number of women multitasked while the intervention was being deployed, future interventions should leverage the convenience of voice technology while also balancing the influence of user context (eg, timing or ability to listen or talk versus nonvoice interaction with the system). Conclusions: Our findings demonstrate the short-term feasibility of disseminating evidence-based perinatal support via podcasts and curate voice-captured data from perinatal women. However, key areas of improvement have been identified specifically for perinatal interventions leveraging voice technology. Findings contribute to future content, design, and delivery considerations of perinatal digital health interventions. %M 33646136 %R 10.2196/18240 %U https://formative.jmir.org/2021/3/e18240 %U https://doi.org/10.2196/18240 %U http://www.ncbi.nlm.nih.gov/pubmed/33646136 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e23514 %T Development of a Breech-Specific Integrated Care Pathway for Pregnant Women: Protocol for a Mixed Methods Study %A Morris,Sara %A Geraghty,Sadie %A Sundin,Deborah %+ Edith Cowan University, Building 21, Level 4, Room 449, 270 Joondalup Drive, Joondalup, 6027, Australia, 61 9399 6190, s_cardona@live.com.au %K breech presentation %K midwifery %K methodology %K Delphi technique %D 2021 %7 23.2.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: The development of an integrated care pathway with multidisciplinary input to standardize and streamline care for pregnant women experiencing breech presentation at 36 or more weeks of gestation poses several challenges because of the divisive and contentious nature of the phenomenon. Although many clinicians are interested in obtaining the skills required to safely support women desiring a vaginal breech birth, the primary trend in most health care facilities is to recommend a cesarean section. Objective: This paper aims to discuss the mixed methods approach used in a doctoral study conducted to generate new knowledge regarding women’s experiences of breech birth in Western Australia and professional recommendations regarding the care of women experiencing breech presentation close to or at term. This study was designed to inform the development of an integrated care pathway for women experiencing a breech presentation. This mixed methods approach situated within the pragmatic paradigm was determined to be the optimal way for incorporating multidisciplinary recommendations with current clinical practice guidelines and consumer feedback. Methods: A mixed methods study utilizing semistructured interviews, an electronic Delphi (e-Delphi) study, and clinical practice guideline appraisal was conducted to generate new data. The interviews were designed to provide insights and understanding of the experiences of women in Western Australia who are diagnosed with a breech presentation. The e-Delphi study explored childbirth professionals’ knowledge, opinions, and recommendations for the care of women experiencing breech presentation close to or at term. The clinical practice guideline appraisal will examine the current national and professional breech management and care guidelines. This study has the potential to highlight areas in practice that may need improvement and enable clinicians to better support women through what can be a difficult time. Results: Data collection for this study began in November 2018 and concluded in March 2020. Data analysis is currently taking place, and the results will be disseminated through publication when the analysis is complete. Conclusions: The results of this study will guide the development of an integrated care pathway for women experiencing a breech presentation close to or at term, with the hope of moving toward standardized breech care for women in Western Australia. This study protocol has the potential to be used as a research framework for future studies of a similar nature. International Registered Report Identifier (IRRID): DERR1-10.2196/23514 %M 33620329 %R 10.2196/23514 %U https://www.researchprotocols.org/2021/2/e23514 %U https://doi.org/10.2196/23514 %U http://www.ncbi.nlm.nih.gov/pubmed/33620329 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e22790 %T Mobile Remote Monitoring of Intimate Partner Violence Among Pregnant Patients During the COVID-19 Shelter-In-Place Order: Quality Improvement Pilot Study %A Krishnamurti,Tamar %A Davis,Alexander L %A Quinn,Beth %A Castillo,Anabel F %A Martin,Kelly L %A Simhan,Hyagriv N %+ Department of General Internal Medicine, University of Pittsburgh School of Medicine, 200 Meyran Avenue, Parkvale Building Suite 200, Pittsburgh, PA, 15213, United States, 1 4126924855, tamark@pitt.edu %K COVID-19 %K social isolation, sheltering-in-place %K intimate partner violence %K domestic violence %K pregnancy %K telemedicine %K telehealth %D 2021 %7 19.2.2021 %9 Original Paper %J J Med Internet Res %G English %X Background: Intimate partner violence (IPV) is one of the leading causes of pregnancy-related death. Prenatal health care providers can offer critical screening and support to pregnant people who experience IPV. During the COVID-19 shelter-in-place order, mobile apps may offer such people the opportunity to continue receiving screening and support services. Objective: We aimed to examine cases of IPV that were reported on a prenatal care app before and during the implementation of COVID-19 shelter-in-place mandates. Methods: The number of patients who underwent voluntary IPV screening and the incidence rate of IPV were determined by using a prenatal care app that was disseminated to patients from a single, large health care system. We compared the IPV screening frequencies and IPV incidence rates of patients who started using the app before the COVID-19 shelter-in-place order, to those of patients who started using the app during the shelter-in-place order. Results: We found 552 patients who started using the app within 60 days prior to the enforcement of the shelter-in-place order, and 407 patients who used the app at the start of shelter-in-place enforcement until the order was lifted. The incidence rates of voluntary IPV screening for new app users during the two time periods were similar (before sheltering in place: 252/552, 46%; during sheltering in place: 163/407, 40%). The overall use of the IPV screening tool increased during the shelter-in-place order. A slight, nonsignificant increase in the incidence of physical, sexual, and psychological violence during the shelter-in-place order was found across all app users (P=.56). Notably, none of the patients who screened positively for IPV had mentions of IPV in their medical charts. Conclusions: App-based screening for IPV is feasible during times when in-person access to health care providers is limited. Our results suggest that the incidence of IPV slightly increased during the shelter-in-place order. App-based screening may also address the needs of those who are unwilling or unable to share their IPV experiences with their health care provider. %M 33605898 %R 10.2196/22790 %U http://www.jmir.org/2021/2/e22790/ %U https://doi.org/10.2196/22790 %U http://www.ncbi.nlm.nih.gov/pubmed/33605898 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 4 %N 1 %P e25388 %T Investigation of Digital Technology Use in the Transition to Parenting: Qualitative Study %A Donelle,Lorie %A Hall,Jodi %A Hiebert,Bradley %A Jackson,Kimberley %A Stoyanovich,Ewelina %A LaChance,Jessica %A Facca,Danica %+ Arthur Labatt Family School of Nursing, Faculty of Health Science, Western University, FNB Rm. 2356, 1115 Richmond St., London, ON, N6A 5B9, Canada, 1 5196612111 ext 86565, ldonelle@uwo.ca %K parenting %K digital health %K technology %K health literacy %K information seeking %D 2021 %7 17.2.2021 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: The transition to parenting—that is, the journey from preconception through pregnancy and postpartum periods—is one of the most emotionally charged and information-intense times for individuals and families. While there is a developing body of literature on the use and impact of digital technology on the information behaviors of children, adolescents, and young adults, personal use of digital technology during the transition to parenting and in support of infants to 2 years of age is relatively understudied. Objective: The purpose of this study was to enhance our understanding of the ways digital technologies contribute to the experience of the transition to parenting, particularly the role these technologies play in organizing and structuring emerging pregnancy and early parenting practices. Methods: A qualitative descriptive study was conducted to understand new parents’ experiences with and uses of digital technology during 4 stages—prenatal, pregnancy, labor, and postpartum—of their transition to becoming a new parent. A purposive sampling strategy was implemented using snowball sampling techniques to recruit participants who had become a parent within the previous 24 months. Focus groups and follow-up interviews were conducted using semistructured interview guides that inquired about parents’ type and use of technologies for self and family health. Transcribed audio recordings were thematically analyzed. Results: A total of 10 focus groups and 3 individual interviews were completed with 26 participants. While recruitment efforts targeted parents of all genders and sexual orientations, all participants identified as heterosexual women. Participants reported prolific use of digital technologies to direct fertility (eg, ovulation timing), for information seeking regarding development of their fetus, to prepare for labor and delivery, and in searching for a sense of community during postpartum. Participants expressed their need for these technologies to assist them in the day-to-day demands of preparing for and undertaking parenting, yet expressed concerns about their personal patterns of use and the potential negative impacts of their use. The 3 themes generated from the data included: “Is this normal; is this happening to you?!”, “Am I having a heart attack; what is this?”, and “Anyone can put anything on Wikipedia”: Managing the Negative Impacts of Digital Information. Conclusions: Digital technologies were used by mothers to track menstrual cycles during preconception; monitor, document, and announce a pregnancy during the prenatal stage; prepare for delivery during labor/birth stage; and to help babies sleep, document/announce their birth, and connect to parenting resources during the postpartum stage. Mothers used digital technologies to reassure themselves that their experiences were normal or to seek help when they were abnormal. Digital technologies provided mothers with convenient means to access health information from a range of sources, yet mothers were apprehensive about the credibility and trustworthiness of the information they retrieved. Further research should seek to understand how men and fathers use digital technologies during their transition to parenting. Additionally, further research should critically examine how constant access to information affects mothers’ perceived need to self-monitor and further understand the unintended health consequences of constant surveillance on new parents. %M 33595440 %R 10.2196/25388 %U https://pediatrics.jmir.org/2021/1/e25388 %U https://doi.org/10.2196/25388 %U http://www.ncbi.nlm.nih.gov/pubmed/33595440 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 23 %N 2 %P e23295 %T Remote Examination and Screening for Domestic Abuse. Comment on “Online Antenatal Care During the COVID-19 Pandemic: Opportunities and Challenges” %A Grimes,Hannah Lee %A Uppal,Ramnik %+ University of Cambridge Clinical School, Hills Road, Cambridge, United Kingdom, 44 01223 336700, hlg42@cam.ac.uk %K spouse abuse %K domestic abuse %K apps %K patient information %K antenatal care %K COVID-19 %D 2021 %7 17.2.2021 %9 Letter to the Editor %J J Med Internet Res %G English %X %M 33595438 %R 10.2196/23295 %U https://www.jmir.org/2021/2/e23295 %U https://doi.org/10.2196/23295 %U http://www.ncbi.nlm.nih.gov/pubmed/33595438 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 2 %P e22222 %T Pediatric Respiratory and Enteric Virus Acquisition and Immunogenesis in US Mothers and Children Aged 0-2: PREVAIL Cohort Study %A Morrow,Ardythe L %A Staat,Mary A %A DeFranco,Emily A %A McNeal,Monica M %A Cline,Allison R %A Conrey,Shannon C %A Schlaudecker,Elizabeth P %A Piasecki,Alexandra M %A Burke,Rachel M %A Niu,Liang %A Hall,Aron J %A Bowen,Michael D %A Gerber,Susan I %A Langley,Gayle E %A Thornburg,Natalie J %A Campbell,Angela P %A Vinjé,Jan %A Parashar,Umesh D %A Payne,Daniel C %+ Department of Environmental and Public Health Sciences, Division of Epidemiology, University of Cincinnati College of Medicine, 160 Panzeca Way, Cincinnati, OH, 45220, United States, 1 513 505 1994, morrowa@ucmail.uc.edu %K birth cohort %K RSV %K influenza %K rotavirus %K norovirus %K vaccines %K vaccine effectiveness %K immunology %K pediatrics %D 2021 %7 12.2.2021 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Acute gastroenteritis (AGE) and acute respiratory infections (ARIs) cause significant pediatric morbidity and mortality. Developing childhood vaccines against major enteric and respiratory pathogens should be guided by the natural history of infection and acquired immunity. The United States currently lacks contemporary birth cohort data to guide vaccine development. Objective: The PREVAIL (Pediatric Respiratory and Enteric Virus Acquisition and Immunogenesis Longitudinal) Cohort study was undertaken to define the natural history of infection and immune response to major pathogens causing AGE and ARI in US children. Methods: Mothers in Cincinnati, Ohio, were enrolled in their third trimester of pregnancy, with intensive child follow-up to 2 years. Blood samples were obtained from children at birth (cord), 6 weeks, and 6, 12, 18, and 24 months. Whole stool specimens and midturbinate nasal swabs were collected weekly and tested by multipathogen molecular assays. Saliva, meconium, maternal blood, and milk samples were also collected. AGE (≥3 loose or watery stools or ≥1 vomiting episode within 24 hours) and ARI (cough or fever) cases were documented by weekly cell phone surveys to mothers via automated SMS text messaging and review of medical records. Immunization records were obtained from registries and providers. follow-up ended in October 2020. Pathogen-specific infections are defined by a PCR-positive sample or rise in serum antibody. Results: Of the 245 enrolled mother–child pairs, 51.8% (n=127) were White, 43.3% (n=106) Black, 55.9% (n=137) publicly insured, and 86.5% (n=212) initiated breastfeeding. Blood collection was 100.0% for mothers (n=245) and 85.7% for umbilical cord (n=210). A total of 194/245 (79.2%) mother–child pairs were compliant based on participation in at least 70% (≥71/102 study weeks) of child-weeks and providing 70% or more of weekly samples during that time, or blood samples at 18 or 24 months. Compliant participants (n=194) had 71.0% median nasal swab collection (IQR 30.0%-90.5%), with 98.5% (191/194) providing either an 18- or 24-month blood sample; median response to weekly SMS text message surveys was 95.1% (IQR 76.5%-100%). Compliant mothers reported 2.0 AGE and 4.5 ARI cases per child-year, of which 25.5% (160/627) and 38.06% (486/1277) of cases, respectively, were medically attended; 0.5% of AGE (3/627) and 0.55% of ARI (7/1277) cases were hospitalized. Conclusions: The PREVAIL Cohort demonstrates intensive follow-up to document the natural history of enteric and respiratory infections and immunity in children 0-2 years of age in the United States and will contribute unique data to guide vaccine recommendations. Testing for pathogens and antibodies is ongoing. International Registered Report Identifier (IRRID): RR1-10.2196/22222 %M 33576746 %R 10.2196/22222 %U http://www.researchprotocols.org/2021/2/e22222/ %U https://doi.org/10.2196/22222 %U http://www.ncbi.nlm.nih.gov/pubmed/33576746 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e18154 %T He Korowai Manaaki (Pregnancy Wraparound Care): Protocol for a Cluster Randomized Clinical Trial %A Lawton,Beverley %A Storey,Francesca %A Sibanda,Nokuthaba %A Bennett,Matthew %A Lambert,Charles %A Geller,Stacie %A Edmonds,Liza %A Cram,Fiona %+ Centre for Women's Health Research, Victoria University of Wellington, 44 Kelburn Parade, Wellington, 6140, New Zealand, 64 021463762, bev.lawton@vuw.ac.nz %K maternity %K inequity %K Indigenous health %K Māori %K pregnancy %K Kaupapa Māori %K socioeconomic %K primary health care %K methodology %D 2021 %7 29.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Maternal and infant health inequities between Māori (the Indigenous peoples of Aotearoa New Zealand) and New Zealand European women are well documented and cannot be explained solely by socioeconomic status. A research center-iwi (tribal group) partnership aims to address these disparities and improve maternal and infant health outcomes by implementing an augmented maternity care pathway (He Korowai Manaaki) to improve access to services and evidence-informed care. Objective: The objective of this study is to test whether an augmented maternity care pathway improves Māori infant health outcomes. Methods: This is a Kaupapa Māori (by, with, and for Māori) cluster randomized clinical trial involving 8 primary care practices allocated to either an intervention arm or control arm. The intervention arm comprises an augmented maternity care pathway (He Korowai Manaaki) offering clinical care through additional paid health care appointments and improved access to social support (eg, housing, transport). The control arm is usual care. The primary outcome is increased timely vaccination for Māori infants, defined as all age-appropriate vaccinations completed by 6 months of age. Results: Recruitment commenced in November 2018 and was completed in June 2020, with 251 enrolled women recruited in intervention primary care practices before 20 weeks of pregnancy. Publication of results is anticipated in late 2023. Conclusions: The results will inform primary health care policy including whether the provision of augmented maternal care pathways reduces disparities in the structural determinants of health. If effective, He Korowai Manaaki will strengthen the health and well-being of pregnant Māori women and their babies and improve their health outcomes, laying a strong foundation for lifelong health and well-being. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12619001155189; https://tinyurl.com/yypbef8q International Registered Report Identifier (IRRID): DERR1-10.2196/18154 %M 33512321 %R 10.2196/18154 %U http://www.researchprotocols.org/2021/1/e18154/ %U https://doi.org/10.2196/18154 %U http://www.ncbi.nlm.nih.gov/pubmed/33512321 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 10 %N 1 %P e19073 %T Mobile Health Intervention in the Maternal Care Pathway: Protocol for the Impact Evaluation of hAPPyMamma %A Bonciani,Manila %A De Rosis,Sabina %A Vainieri,Milena %+ Management and Healthcare Laboratory, Institute of Management and Department EMbeDS, Sant’Anna School of Advanced Studies, Piazza Martiri della Libertà, 33, Pisa, 56127, Italy, 39 3462405234, m.bonciani@santannapisa.it %K mHealth %K maternal care pathway %K impact evaluation %K quasiexperimental study %D 2021 %7 19.1.2021 %9 Protocol %J JMIR Res Protoc %G English %X Background: Mobile health (mHealth) has great potential to both improve the quality and efficiency of care and increase health literacy and empowerment of patient users. There are several studies related to the introduction of mHealth tools for supporting pregnancy and the postnatal period, with promising but not yet rigorously evaluated impacts. This article presents the protocol for evaluating an mHealth intervention (hAPPyMamma) applied in the maternal and child care pathway of a high-income country (in a pilot area of Tuscany Region, Italy). Objective: The protocol describes hAPPyMamma and the methods for evaluating its impact, including the points of view of women and practitioners. The research hypothesis is that the use of hAPPyMamma will facilitate a more appropriate use of available services, a better care experience for women, and an improvement in the maternal competencies of the women using the app compared to the control group. The protocol also includes analysis of the organizational impact of the introduction of hAPPyMamma in the maternal pathway. Methods: A pre-post quasiexperimental design with a control group is used to undertake difference-in-differences analysis for assessing the impact of the mHealth intervention from the mothers’ points of view. The outcome measures are improvement of maternal health literacy and empowerment as well as experience in the maternal care pathway of the control and intervention groups of sampled mothers. The organizational impact is evaluated through a quantitative and qualitative survey addressing professionals and managers of the maternal care pathway involved in the intervention. Results: Following study recruitment, 177 women were enrolled in the control group and 150 in the intervention group, with a participation rate of 97%-98%. The response rate was higher in the control group than in the intervention group (96% vs 67%), though the intervention group had less respondent loss at the postintervention survey (10% compared to 33% of the control group). Data collection from the women was completed in April 2018, while that from professionals and managers is underway. Conclusions: The study helps consolidate evidence of the utility of mHealth interventions for maternal and child care in developed countries. This paper presents a protocol for analyzing the potential role of hAPPyMamma as an effective mHealth tool for improving the maternal care pathway at individual and organizational levels and consequently helps to understand whether and how to scale up this intervention, with local, national, and international scopes of application. International Registered Report Identifier (IRRID): DERR1-10.2196/19073 %M 33464218 %R 10.2196/19073 %U http://www.researchprotocols.org/2021/1/e19073/ %U https://doi.org/10.2196/19073 %U http://www.ncbi.nlm.nih.gov/pubmed/33464218 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 12 %P e23273 %T Effectiveness of WeChat for Improving Exclusive Breastfeeding in Huzhu County China: Randomized Controlled Trial %A Wu,Qiong %A Huang,Yiwen %A Liao,Zijun %A van Velthoven,Michelle Helena %A Wang,Wei %A Zhang,Yanfeng %+ Capital Institute of Pediatrics, No. 2 Yabao Road, Chaoyang District, Beijing, 100020, China, 86 10 85695554, summyzh@126.com %K breastfeeding %K exclusive breastfeeding %K WeChat %K mHealth %K randomized controlled trial %D 2020 %7 3.12.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: The benefits of breastfeeding for both infants and mothers have been well recognized. However, the exclusive breastfeeding rate in China is low and decreasing. Mobile technologies have rapidly developed; communication apps such as WeChat (one of the largest social networking platforms in China) are widely used and have the potential to conveniently improve health behaviors. Objective: This study aimed to assess the effectiveness of using WeChat to improve breastfeeding practices. Methods: This 2-arm randomized controlled trial was conducted among pregnant women from May 2019 to April 2020 in Huzhu County, Qinghai Province, China. Pregnant women were eligible to participate if they were aged 18 years or older, were 11 to 37 weeks pregnant with a singleton fetus, had no known illness that could limit breastfeeding after childbirth, used WeChat through their smartphone, and had access to the internet. A total of 344 pregnant women were recruited at baseline, with 170 in the intervention group and 174 in the control group. Women in the intervention group received breastfeeding knowledge and promotion information weekly through a WeChat official account from their third month of pregnancy to 6 months postpartum. The primary outcome of exclusive and predominant breastfeeding rate was measured 0-1 month, 2-3 months, and 4-5 months postpartum. Results: At 0-1 month postpartum, the exclusive breastfeeding rate was significantly higher in the intervention group than that in the control group (81.1% vs 63.3%; odds ratio [OR] 2.75, 95% CI 1.58-4.78; P<.001). Similarly, mothers in the intervention group were more likely to provide predominantly breast milk (OR 2.77, 95% CI 1.55-4.96; P<.001) and less likely to give dairy products to their children (OR 0.40, 95% CI 0.21-0.75; P=.005). There was no statistically significant difference for exclusive breastfeeding rate 2-3 months (P=.09) and 4-5 months postpartum (P=.27), though more children in the intervention group were exclusively breastfed than those in the control group 2-3 months postpartum (intervention: 111/152, 73.0%; control: 96/152, 63.2%) and 4-5 months postpartum(intervention: 50/108, 46.3%; control: 46/109, 42.2%). Conclusions: This study is the first effort to promote exclusive breastfeeding through WeChat in China, which proved to be an effective method of promoting exclusive breastfeeding in early life. WeChat health education can be used in addition to local breastfeeding promotion programs. Trial Registration: Chinese Clinical Trial Registry ChiCTR1800017364; http://www.chictr.org.cn/showproj.aspx?proj=29325 International Registered Report Identifier (IRRID): RR2-10.1186/s12889-019-7676-2 %M 33270026 %R 10.2196/23273 %U https://www.jmir.org/2020/12/e23273 %U https://doi.org/10.2196/23273 %U http://www.ncbi.nlm.nih.gov/pubmed/33270026 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 2 %P e22121 %T Advanced Health Information Technologies to Engage Parents, Clinicians, and Community Nutritionists in Coordinating Responsive Parenting Care: Descriptive Case Series of the Women, Infants, and Children Enhancements to Early Healthy Lifestyles for Baby (WEE Baby) Care Randomized Controlled Trial %A Kling,Samantha MR %A Harris,Holly A %A Marini,Michele %A Cook,Adam %A Hess,Lindsey B %A Lutcher,Shawnee %A Mowery,Jacob %A Bell,Scott %A Hassink,Sandra %A Hayward,Shannon B %A Johnson,Greg %A Franceschelli Hosterman,Jennifer %A Paul,Ian M %A Seiler,Christopher %A Sword,Shirley %A Savage,Jennifer S %A Bailey-Davis,Lisa %+ Evaluation Sciences Unit, Division of Primary Care and Population Health, Department of Medicine, School of Medicine, Stanford University, 1265 Welch Rd x216, Stanford, CA, 94305, United States, 1 605 726 3392, skling@stanford.edu %K early obesity prevention %K responsive parenting %K health information technology %K coordination of care %K clinical care %K pragmatic intervention %K data sharing %D 2020 %7 24.11.2020 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Socioeconomically disadvantaged newborns receive care from primary care providers (PCPs) and Women, Infants, and Children (WIC) nutritionists. However, care is not coordinated between these settings, which can result in conflicting messages. Stakeholders support an integrated approach that coordinates services between settings with care tailored to patient-centered needs. Objective: This analysis describes the usability of advanced health information technologies aiming to engage parents in self-reporting parenting practices, integrate data into electronic health records to inform and facilitate documentation of provided responsive parenting (RP) care, and share data between settings to create opportunities to coordinate care between PCPs and WIC nutritionists. Methods: Parents and newborns (dyads) who were eligible for WIC care and received pediatric care in a single health system were recruited and randomized to a RP intervention or control group. For the 6-month intervention, electronic systems were created to facilitate documentation, data sharing, and coordination of provided RP care. Prior to PCP visits, parents were prompted to respond to the Early Healthy Lifestyles (EHL) self-assessment tool to capture current RP practices. Responses were integrated into the electronic health record and shared with WIC. Documentation of RP care and an 80-character, free-text comment were shared between WIC and PCPs. A care coordination opportunity existed when the dyad attended a WIC visit and these data were available from the PCP, and vice versa. Care coordination was demonstrated when WIC or PCPs interacted with data and documented RP care provided at the visit. Results: Dyads (N=131) attended 459 PCP (3.5, SD 1.0 per dyad) and 296 WIC (2.3, SD 1.0 per dyad) visits. Parents completed the EHL tool prior to 53.2% (244/459) of PCP visits (1.9, SD 1.2 per dyad), PCPs documented provided RP care at 35.3% (162/459) of visits, and data were shared with WIC following 100% (459/459) of PCP visits. A WIC visit followed a PCP visit 50.3% (231/459) of the time; thus, there were 1.8 (SD 0.8 per dyad) PCP to WIC care coordination opportunities. WIC coordinated care by documenting RP care at 66.7% (154/231) of opportunities (1.2, SD 0.9 per dyad). WIC visits were followed by a PCP visit 58.9% (116/197) of the time; thus, there were 0.9 (SD 0.8 per dyad) WIC to PCP care coordination opportunities. PCPs coordinated care by documenting RP care at 44.0% (51/116) of opportunities (0.4, SD 0.6 per dyad). Conclusions: Results support the usability of advanced health information technology strategies to collect patient-reported data and share these data between multiple providers. Although PCPs and WIC shared data, WIC nutritionists were more likely to use data and document RP care to coordinate care than PCPs. Variability in timing, sequence, and frequency of visits underscores the need for flexibility in pragmatic studies. Trial Registration: ClinicalTrials.gov NCT03482908; https://clinicaltrials.gov/ct2/show/NCT03482908 International Registered Report Identifier (IRRID): RR2-10.1186/s12887-018-1263-z %M 33231559 %R 10.2196/22121 %U http://pediatrics.jmir.org/2020/2/e22121/ %U https://doi.org/10.2196/22121 %U http://www.ncbi.nlm.nih.gov/pubmed/33231559 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 11 %P e19953 %T Effect of a Text Messaging–Based Educational Intervention on Cesarean Section Rates Among Pregnant Women in China: Quasirandomized Controlled Trial %A Su,Yanfang %A Heitner,Jesse %A Yuan,Changzheng %A Si,Yafei %A Wang,Dan %A Zhou,Zhiying %A Zhou,Zhongliang %+ School of Public Policy and Administration, Xi’an Jiaotong University, 28# Xianning West Road, Xi'an, China, 86 18291498261, zzliang1981@xjtu.edu.cn %K cesarean section %K short message service %K SMS text messaging %K quasirandomized controlled trial %K mobile health %D 2020 %7 3.11.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Consensus exists that appropriate regional cesarean rates should not exceed 15% of births, but China’s cesarean rate exceeds 50% in some areas, prompting numerous calls for its reduction. At present, China’s 2016 two-child policy has heightened the implications of national cesarean section trends. Objective: This study leveraged pervasive cellular phone access amongst Chinese citizens to test the effect of a low-cost and scalable prenatal advice program on cesarean section rates. Methods: Participants were pregnant women presenting for antenatal care at a clinic in Xi’an, China. Assignment was quasirandomized and utilized factorial assignment based on the expecting mother’s birthday. Participants were assigned to one of the following four groups, with each receiving a different set of messages: (1) a comparison group that received only a few “basic” messages, (2) a group receiving messages primarily regarding care seeking, (3) a group receiving messages primarily regarding good home prenatal practices, and (4) a group receiving text messages of all groups. Messages were delivered throughout pregnancy and were tailored to each woman’s gestational week. The main outcome was the rates of cesarean delivery reported in the intervention arms. Data analysts were blinded to treatment assignment. Results: In total, 2115 women completed the trial and corresponding follow-up surveys. In the unadjusted analysis, the group receiving all texts was associated with an odds ratio of 0.77 (P=.06), though neither the care seeking nor good home prenatal practice set yielded a relevant impact. Adjusting for potentially confounding covariates showed that the group with all texts sent together was associated with an odds ratio of 0.67 (P=.01). Notably, previous cesarean section evoked an odds ratio of 11.78 (P<.001), highlighting that having a cesarean section predicts future cesarean section in a subsequent pregnancy. Conclusions: Sending pregnant women in rural China short informational messages with integrated advice regarding both care-seeking and good home prenatal practices appears to reduce women’s likelihood of undergoing cesarean section. Reducing clear medical indications for cesarean section seems to be the strongest potential pathway of the effect. Cesarean section based on only maternal request did not seem to occur regularly in our study population. Preventing unnecessary cesarean section at present may have a long-term impact on future cesarean section rates. Trial Registration: ClinicalTrials.gov NCT02037087; https://clinicaltrials.gov/ct2/show/NCT02037087. International Registered Report Identifier (IRRID): RR2-10.1136/bmjopen-2015-011016 %M 33141099 %R 10.2196/19953 %U https://mhealth.jmir.org/2020/11/e19953 %U https://doi.org/10.2196/19953 %U http://www.ncbi.nlm.nih.gov/pubmed/33141099 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 9 %P e19378 %T Impact of a Blended Periconception Lifestyle Care Approach on Lifestyle Behaviors: Before-and-After Study %A van der Windt,Melissa %A van der Kleij,Rianne Maria %A Snoek,Katinka Marianne %A Willemsen,Sten Paul %A Dykgraaf,Ramon Henny Maria %A Laven,Joop Stephanus Elisabeth %A Schoenmakers,Sam %A Steegers-Theunissen,Régine Patricia Maria %+ Department of Obstetrics and Gynecology, Erasmus University Medical Center, PO Box 2040, Rotterdam, 3000CA, Netherlands, +31 107038255, r.steegers@erasmusmc.nl %K eHealth %K periconception period %K lifestyle intervention %D 2020 %7 30.9.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Periconception lifestyle behaviors affect maternal, paternal, offspring, and transgenerational health outcomes. Previous research in other target populations has shown that personalized lifestyle interventions, in which face-to-face counseling and eHealth (“blended care”) are combined, may effectively target these lifestyle behaviors. Objective: We aimed to assess the effectiveness of a periconceptional lifestyle intervention on the improvement of specific lifestyle components. Methods: A blended periconception lifestyle care approach was developed, combining the outpatient lifestyle counseling service “Healthy Pregnancy” with the eHealth platform “Smarter Pregnancy” (www.smarterpregnancy.co.uk) in which lifestyle was coached for 24 weeks. All couples contemplating pregnancy or already pregnant (≤12 weeks of gestation) who visited the outpatient clinics of the Department of Obstetrics and Gynecology at the Erasmus University Medical Center (Erasmus MC), Rotterdam, the Netherlands, between June and December 2018, were invited to participate. We measured changes in lifestyle behaviors at weeks 12 and 24 compared with baseline. Generalized estimating equations were used to analyze the changes in lifestyle behaviors over time. Subgroup analyses were performed for women with obesity (BMI ≥30 kg/m2), women pregnant at the start of the intervention, and those participating as a couple. Results: A total of 539 women were screened for eligibility, and 450 women and 61 men received the blended periconception intervention. Among the participating women, 58.4% (263/450) were included in the preconception period. Moreover, 78.9% (403/511) of the included participants completed the online lifestyle coaching. At baseline, at least one poor lifestyle behavior was present in most women (379/450, 84.2%) and men (58/61, 95.1%). In the total group, median fruit intake increased from 1.8 to 2.2 pieces/day (P<.001) and median vegetable intake increased from 151 to 165 grams/day (P<.001) after 24 weeks of online coaching. The probability of taking folic acid supplementation among women increased from 0.97 to 1 (P<.001), and the probability of consuming alcohol and using tobacco in the total group decreased from 0.25 to 0.19 (P=.002) and from 0.20 to 0.15 (P=.63), respectively. Overall, the program showed the strongest effectiveness for participating couples. Particularly for vegetable and fruit intake, their consumption increased from 158 grams/day and 1.8 pieces/day at baseline to 190 grams/day and 2.7 pieces/day at the end of the intervention, respectively. Conclusions: We succeeded in including most participating women in the preconception period. A high compliance rate was achieved and users demonstrated improvements in several lifestyle components. The blended periconception lifestyle care approach seems to be an effective method to improve lifestyle behaviors. The next step is to further disseminate this approach and to perform a randomized trial to compare the use of blended care with the provision of only eHealth. Additionally, the clinical relevance of these results will need to be substantiated further. %M 32996885 %R 10.2196/19378 %U http://www.jmir.org/2020/9/e19378/ %U https://doi.org/10.2196/19378 %U http://www.ncbi.nlm.nih.gov/pubmed/32996885 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e13686 %T Maternal Parenting Electronic Diary in the Context of a Home Visit Intervention for Adolescent Mothers in an Urban Deprived Area of São Paulo, Brazil: Randomized Controlled Trial %A Fatori,Daniel %A Argeu,Adriana %A Brentani,Helena %A Chiesa,Anna %A Fracolli,Lislaine %A Matijasevich,Alicia %A Miguel,Euripedes C %A Polanczyk,Guilherme %+ Department of Psychiatry, University of Sao Paulo Medical School, 785 R Dr Ovídio Pires de Campos, Sao Paulo, Brazil, 55 11961626183, daniel.fatori@gmail.com %K mHealth %K early childhood development %K maternal care %K randomized clinical trial %K daily diary %K ambulatory assessment %D 2020 %7 28.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pregnancy during adolescence is prevalent in low- and middle-income countries (LMICs), which is associated with various adverse outcomes that can be prevented with home visiting programs. However, testing these interventions in LMICs can be challenging due to limited resources. The use of electronic data collection via smartphones can be an alternative and ideal low-cost method to measure outcomes in an environment with adverse conditions. Objective: Our study had two objectives: to test the efficacy of a nurse home visiting intervention on maternal parenting and well-being measured by an electronic daily diary (eDiary), and to investigate the compliance rate of the eDiary measurement method. Methods: We conducted a randomized controlled trial to test the efficacy of Primeiros Laços, a nurse home visiting program, for adolescent mothers living in an urban deprived area of São Paulo, Brazil. A total of 169 pregnant adolescents were assessed for eligibility criteria, 80 of whom were included and randomized to the intervention (n=40) and control group (care as usual, n=40). Primeiros Laços is a home visiting intervention delivered by trained nurses tailored to first-time pregnant adolescents and their children, starting during the first 16 weeks of pregnancy until the child reaches 24 months of age. Participants were assessed by blind interviewers at 8-16 weeks of pregnancy (baseline), 30 weeks of pregnancy, and when the child was 3, 6, and 12 months of age. At 18 months, participants were assessed regarding maternal parenting and parental well-being using a 7-consecutive-day eDiary. The smartphone app was programmed to notify participants every day at 9:00 PM over a period of seven days. Results: We were able to contact 57/80 (71%) participants (29 from the intervention group and 28 from the control group) when the child was 18 months of age. Forty-eight of the 57 participants (84%) completed at least one day of the eDiary protocol. The daily compliance rate ranged from 49% to 70%. Our analyses showed a significant effect of the intervention on parental well-being (B=0.32, 95% CI [0.06, 0.58], P=.02) and the maternal parenting behavior of the mother telling a story or singing to the child (odds ratio=2.33, 95% CI [1.20, 4.50], P=.01).Our analyses showed a significant effect of the intervention on parental well-being (B=0.32, P=.02) and the maternal parenting behavior of the mother telling a story or singing to the child (odds ratio=2.33, P=.01). Conclusions: The Primeiros Laços intervention improved maternal parenting and parental well-being, demonstrating its promise for low-income adolescent mothers. The compliance rate of the eDiary assessment showed that it was generally accepted by adolescent mothers with limited resources. Future studies can implement ambulatory assessment in LMICs via smartphones to measure mother and child behaviors. Trial Registration: ClinicalTrials.gov NCT02807818; https://clinicaltrials.gov/ct2/show/NCT02807818 %M 32720906 %R 10.2196/13686 %U https://mhealth.jmir.org/2020/7/e13686 %U https://doi.org/10.2196/13686 %U http://www.ncbi.nlm.nih.gov/pubmed/32720906 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 7 %P e12417 %T Continuous 7-Month Internet of Things–Based Monitoring of Health Parameters of Pregnant and Postpartum Women: Prospective Observational Feasibility Study %A Saarikko,Johanna %A Niela-Vilen,Hannakaisa %A Ekholm,Eeva %A Hamari,Lotta %A Azimi,Iman %A Liljeberg,Pasi %A Rahmani,Amir M %A Löyttyniemi,Eliisa %A Axelin,Anna %+ School of Nursing and Department of Computer Science, University of California, 106D Berk Hall, Irvine, CA, 92697-3959, United States, 1 949 824 3590, a.rahmani@uci.edu %K prenatal care %K postnatal care %K wearable electronics %K biosensing %K cloud computing %K mHealth %K physical activity %K sleep %K heart rate %D 2020 %7 24.7.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Monitoring during pregnancy is vital to ensure the mother’s and infant’s health. Remote continuous monitoring provides health care professionals with significant opportunities to observe health-related parameters in their patients and to detect any pathological signs at an early stage of pregnancy, and may thus partially replace traditional appointments. Objective: This study aimed to evaluate the feasibility of continuously monitoring the health parameters (physical activity, sleep, and heart rate) of nulliparous women throughout pregnancy and until 1 month postpartum, with a smart wristband and an Internet of Things (IoT)–based monitoring system. Methods: This prospective observational feasibility study used a convenience sample of 20 nulliparous women from the Hospital District of Southwest Finland. Continuous monitoring of physical activity/step counts, sleep, and heart rate was performed with a smart wristband for 24 hours a day, 7 days a week over 7 months (6 months during pregnancy and 1 month postpartum). The smart wristband was connected to a cloud server. The total number of possible monitoring days during pregnancy weeks 13 to 42 was 203 days and 28 days in the postpartum period. Results: Valid physical activity data were available for a median of 144 (range 13-188) days (75% of possible monitoring days), and valid sleep data were available for a median of 137 (range 0-184) days (72% of possible monitoring days) per participant during pregnancy. During the postpartum period, a median of 15 (range 0-25) days (54% of possible monitoring days) of valid physical activity data and 16 (range 0-27) days (57% of possible monitoring days) of valid sleep data were available. Physical activity decreased from the second trimester to the third trimester by a mean of 1793 (95% CI 1039-2548) steps per day (P<.001). The decrease continued by a mean of 1339 (95% CI 474-2205) steps to the postpartum period (P=.004). Sleep during pregnancy also decreased from the second trimester to the third trimester by a mean of 20 minutes (95% CI –0.7 to 42 minutes; P=.06) and sleep time shortened an additional 1 hour (95% CI 39 minutes to 1.5 hours) after delivery (P<.001). The mean resting heart rate increased toward the third trimester and returned to the early pregnancy level during the postpartum period. Conclusions: The smart wristband with IoT technology was a feasible system for collecting representative data on continuous variables of health parameters during pregnancy. Continuous monitoring provides real-time information between scheduled appointments and thus may help target and tailor pregnancy follow-up. %M 32706696 %R 10.2196/12417 %U http://formative.jmir.org/2020/7/e12417/ %U https://doi.org/10.2196/12417 %U http://www.ncbi.nlm.nih.gov/pubmed/32706696 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 7 %P e19916 %T Online Antenatal Care During the COVID-19 Pandemic: Opportunities and Challenges %A Wu,Huailiang %A Sun,Weiwei %A Huang,Xinyu %A Yu,Shinning %A Wang,Hao %A Bi,Xiaoyu %A Sheng,Jie %A Chen,Sihan %A Akinwunmi,Babatunde %A Zhang,Casper J P %A Ming,Wai-Kit %+ Department of Public Health and Preventive Medicine, School of Medicine, Jinan University, No 602 Huangpu Avenue West, Tianhe District, Guangzhou, 510000, China, 86 14715485116, wkming@connect.hku.hk %K coronavirus disease %K COVID-19 %K SARS-CoV-2 %K online prenatal education %K pregnancy %K online education %K antenatal %K telehealth %K convenience %K inequality %D 2020 %7 22.7.2020 %9 Viewpoint %J J Med Internet Res %G English %X People across the world have been greatly affected by the ongoing coronavirus disease (COVID-19) pandemic. The high infection risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in hospitals is particularly problematic for recently delivered mothers and currently pregnant women who require professional antenatal care. Online antenatal care would be a preferable alternative for these women since it can provide pregnancy-related information and remote clinic consultations. In addition, online antenatal care may help to provide relatively economical medical services and diminish health care inequality due to its convenience and cost-effectiveness, especially in developing countries or regions. However, some pregnant women will doubt the reliability of such online information. Therefore, it is important to ensure the quality and safety of online services and establish a stable, mutual trust between the pregnant women, the obstetric care providers and the technology vis-a-vis the online programs. Here, we report how the COVID-19 pandemic brings not only opportunities for the development and popularization of online antenatal care programs but also challenges. %M 32658860 %R 10.2196/19916 %U http://www.jmir.org/2020/7/e19916/ %U https://doi.org/10.2196/19916 %U http://www.ncbi.nlm.nih.gov/pubmed/32658860 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17665 %T The Effect of Women’s Differential Access to Messages on Their Adoption of Mobile Health Services and Pregnancy Behavior in Bangladesh: Retrospective Cross-Sectional Study %A Alam,Mafruha %A Banwell,Cathy %A Lokuge,Kamalini %+ Australian National University, 62 Mills Road, National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, ACT, 2601, Australia, 61 6125 5602, mafruha.alam@gmail.com %K mHealth %K inequality %K access %K pregnancy %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Text or voice messages have been used as a popular method for improving women’s knowledge on birth preparedness and newborn health care practices worldwide. The Aponjon service in Bangladesh provides twice-weekly messages to female subscribers about their pregnancy and newborn care on mobile phones that they own or share with family members. It is important to understand whether women’s singular access to a phone affects their service satisfaction and the adoption of health messages before deploying such interventions in resource-limited settings. Objective: This study aims to evaluate the effect of women’s singular and shared access to mobile phone messages on their service utilization and perceived behavioral change around birth preparedness and pregnancy care. Methods: In 2014, Aponjon conducted a retrospective cross-sectional survey of 459 female subscribers who received text or voice messages during their pregnancy by themselves (n=253) or with family members (n=206). We performed multivariable regression analyses to investigate the association between pregnant women’s differential access to messages and other socioeconomic factors and outcomes of service satisfaction, ability to recall service short code, ability to identify danger signs of pregnancy, preference for skilled delivery, arrangement of a blood donor for delivery and pregnancy complications, maternal nutrition, use of potable drinking water, and washing hands with soap for hygiene. Results: In the multivariable analysis, women who had singular access to messages had higher odds of reporting high satisfaction (odds ratio [OR] 1.72, 95% CI 1.12-2.63; P=.01), recalling the service short code (OR 2.88, 95% CI 1.90-4.36; P<.001), consuming nutritious food 5 times a day (OR 1.58, 95% CI 1.04-2.40; P=.03), and following the instructions of Aponjon on drinking potable water (OR 1.90, 95% CI 1.17-3.09; P=.01) than women who shared access with family members. Women’s differential access to messages did not affect their knowledge of danger signs and preparedness around delivery. Adolescent women and women aged 20-24 years had lower odds of planning safe deliveries than older women (aged≥25 years). Secondary education was statistically significantly associated with women’s ability to recall the short code and pregnancy danger signs, plan safe delivery, and select blood donors for emergencies. Higher family income was associated with women’s satisfaction, recognition of danger signs, and arrangement of blood donors and nutritious diet. Women who received more than 4 antenatal care visits had higher odds of liking the service, preferring skilled delivery, recalling danger signs, and consuming nutritious food. Conclusions: The capacity of women to independently access mobile phone messages can improve their adoption of mobile health services and some pregnancy health care practices. A holistic approach and equitable support are required to improve access to resources and knowledge of delivery preparedness among low-literate and younger women in low-income households. %M 32706694 %R 10.2196/17665 %U https://mhealth.jmir.org/2020/7/e17665 %U https://doi.org/10.2196/17665 %U http://www.ncbi.nlm.nih.gov/pubmed/32706694 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17535 %T Feasibility and Acceptability of an Adapted Mobile Phone Message Program and Changes in Maternal and Newborn Health Knowledge in Four Provinces of Afghanistan: Single-Group Pre-Post Assessment Study %A Lebrun,Victoria %A Dulli,Lisa %A Alami,Sayed Omar %A Sidiqi,Arzoo %A Sultani,Ahmad Shah %A Rastagar,Sayed Haroon %A Halimzai,Iftikhar %A Ahmadzai,Sharif %A Todd,Catherine S %+ Global Health, Population, and Nutrition, FHI 360, 359 Blackwell St #200, Durham, NC, 27701, United States, 1 9195447040 ext 11640, vlebrun@fhi360.org %K Afghanistan %K mobile apps %K pregnant women %K maternal health %K newborn health %K social and behavior change %K mHealth %K voice message %K SMS %D 2020 %7 20.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile phone apps for health promotion have expanded in many low- and middle-income countries. Afghanistan, with high maternal and newborn morbidity and mortality rates, a fragile health infrastructure, and high levels of mobile phone ownership, is an ideal setting to examine the utility of such programs. We adapted messages of the Mobile Alliance for Maternal Action (MAMA) program, which was designed to promote healthy behaviors during pregnancy and a newborn’s first year of life, to the Afghan context. We then piloted and assessed the program in the provinces of Kabul, Herat, Kandahar, and Balkh. Objective: The aim of this study was to assess the feasibility and acceptability of the MAMA pilot program, and to examine changes in reported maternal, newborn, and child health (MNCH) knowledge and attitudes among participants from baseline to follow up. Methods: We conducted a single-group study with data collected within 10 weeks of enrollment, and data collection was repeated approximately 6 months later. Data were collected through face-to-face interviews using structured questionnaires. Eligible participants included pregnant women who had registered to receive fully automated mobile health messages and their husbands. Assessment questionnaires queried sociodemographic details; knowledge, attitudes, and health care-seeking practices; and intervention experience and acceptability at follow up. The number of messages received by a given phone number was extracted from the program database. We descriptively analyzed the feasibility and acceptability data and compared the change in MNCH knowledge between baseline and follow-up measures using the McNemar Chi square test. Results: Overall, 895 women were enrolled in the MAMA program. Data from 453/625 women (72.5% of the pretest sample) who received voice (n=302) or text (n=151) messages, and 276/427 men (64.6% of the pretest sample) who received voice (n=185) or text (n=91) messages contributing data at both time points were analyzed. At follow up, 699/729 (95.9%) participants were still enrolled in the MAMA program; voice message and SMS text messaging subscribers received 43 and 69 messages on average over the 6-month period, respectively. Participants who were voice message subscribers and female participants more commonly reported missing messages compared with the text message subscribers and men; predominant reasons for missed messages were the subscribers being busy with chores or not having their shared phone with them. Over 90% of men and women reported experiencing benefits from the program, mainly increased knowledge, and 226/453 (49.9%) of the female participants reported referring someone else to the program. Most of the participants (377/453, 83.2% women and 258/276, 93.5% men) believed it was beneficial to include husbands in the program. Joint decision making regarding maternal and child health care increased overall. The proportions of participants with correct knowledge significantly increased for all but one MNCH measure at follow up. Conclusions: This assessment indicates that the pilot MAMA program is feasible and acceptable in the Afghan context. Further research should be conducted to determine whether program participation leads to improved MNCH knowledge, health practices, and health service utilization in this fragile setting prior to larger scale up. %M 32706690 %R 10.2196/17535 %U https://mhealth.jmir.org/2020/7/e17535 %U https://doi.org/10.2196/17535 %U http://www.ncbi.nlm.nih.gov/pubmed/32706690 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e18543 %T Improving the Quality of Antenatal Care Using Mobile Health in Madagascar: Five-Year Cross-Sectional Study %A Benski,Anne Caroline %A Schmidt,Nicole C %A Viviano,Manuela %A Stancanelli,Giovanna %A Soaroby,Adelia %A Reich,Michael R %+ Takemi Program in International Health, Harvard TH Chan School of Public Health, 677 Huntington Ave, Boston, MA, 02115, United States, 1 787397261, cbenski@hsph.harvard.edu %K mobile health %K maternal health %K antenatal care %K quality of care %K mobile phone %D 2020 %7 8.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Despite many efforts, maternal mortality remains a major burden in most developing countries. Mobile health (mHealth) has the potential to improve access to obstetric care through apps that help patients and providers. Objective: This study aimed to use mHealth to provide antenatal care (ANC) to 1446 pregnant women in a rural area in Madagascar and evaluate the quality of ANC provided by an mHealth system designed to change the behaviors of providers and patients. Methods: We included 1446 women who attended ANC visits in rural Madagascar from 2015 to 2019 using an mHealth system called Pregnancy and Newborn Diagnostic Assessment (PANDA). This cross-sectional study used data from different participants, with information collected over several years, to analyze the outputs related to the quality of ANC over time. Specifically, we examined the timing of the first ANC visit, the relationship between the visit duration and the risk factors among pregnant women, and the number of ANC visits per woman. Results: Following the implementation of the mHealth system in 2015, we observed that women started to come earlier for their first ANC visit; more women attended their first ANC visit in the second trimester of pregnancy in 2019 than in the previous years (P<.001). In 2019, fewer women attended their first ANC visit in the third trimester (57/277, 20.6%) than in 2015 (147/343, 42.9%). There were statistically significant associations between the ANC visit durations and the risk factors, including age (>35 years; 25.0 min, 95% CI 24.0-25.9), educational level (longer visit for women with lower than primary education and for women who attended university and shorter for women with primary school–level education; 40.7 min, 95% CI 30.2-51.3 and 25.3 min, 95% CI 24.4-26.3 vs 23.3 min, 95% CI 22.9-23.8; P=.001), experience of domestic violence during pregnancy, gravidity, parity, infectious diseases (HIV, malaria, and syphilis), and level of anemia. Statistically significant associations were observed for all quality indicator variables. We observed a statistically significant increase in the number of ANC visits per woman over time from 2015 to 2017; the number of ANC visits per woman then became stable after the third year of implementing the PANDA mHealth system. Conclusions: This study shows the potential of an mHealth system to improve the quality of ANC, change provider behavior by standardizing ANC visits, and change patient behavior by increasing the willingness to return for subsequent visits and encouraging ANC attendance early in pregnancy. As this is an exploratory study, further studies are necessary to better understand how mHealth can change behavior and identify the conditions required for behavioral changes to persist over time. %M 32673263 %R 10.2196/18543 %U https://mhealth.jmir.org/2020/7/e18543 %U https://doi.org/10.2196/18543 %U http://www.ncbi.nlm.nih.gov/pubmed/32673263 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 7 %P e17183 %T Effect of a Health System–Sponsored Mobile App on Perinatal Health Behaviors: Retrospective Cohort Study %A Cawley,Caroline %A Buckenmeyer,Hannelore %A Jellison,Trina %A Rinaldi,Joseph B %A Vartanian,Keri B %+ Center for Outcomes Research and Education, Providence Portland Medical Center, 5251 NE Glisan Street, Portland, OR, 97213, United States, 1 503 215 2594, Keri.Vartanian@providence.org %K mobile health %K perinatal health %K health behaviors %D 2020 %7 6.7.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Pregnancy mobile apps are becoming increasingly popular, with parents-to-be seeking information related to their pregnancy and their baby through mobile technology. This increase raises the need for prenatal apps with evidence-based content that is personalized and reliable. Previous studies have looked at whether prenatal apps impact health and behavior outcomes among pregnant and postpartum individuals; however, research has been limited. Objective: The primary objective of this study is to assess whether the use of a health system–sponsored mobile app—Circle by Providence—aimed at providing personalized and reliable health information on pregnancy, postpartum recovery, and infant care is associated with improved health outcomes and increased healthy behaviors and knowledge among users. Methods: This observational study compared app users and app nonusers using a self-reported survey and electronic medical records. The study took place over 18 months and was conducted at Providence St. Joseph Health in Portland, Oregon. The sample included patients who received prenatal care at one of seven Providence clinics and had a live birth at a Providence hospital. Recruitment occurred on a rolling basis and only those who completed the survey were included. Survey respondents were separated into app users and app nonusers, and survey responses and clinical outcomes were compared across groups using univariate and adjusted multivariate logistic regression. Results: A total of 567 participants were enrolled in the study—167 in the app user group and 400 in the nonuser group. We found statistically significant differences between the two groups for certain behavior outcomes: subjects who used the app had 75% greater odds of breastfeeding beyond 6 months postpartum (P=.012), were less likely to miss prenatal appointments (P=.046), and were 50% more likely to exercise 3 or more times a week during pregnancy (P=.04). There were no differences in nutritional measures, including whether they took prenatal vitamins, ate 5 fruits or vegetables a day, or drank caffeine. We found no differences in many of the infant care outcomes; however, there was an increase in awareness of “purple crying.” Finally, there were no significant differences in measured clinical health outcomes, including cesarean births, length of hospital stays (in minutes), low birth weight infants, preterm births, small-for-gestational-age births, large-for-gestational-age births, and neonatal intensive care unit stays. Conclusions: The use of the Circle app, which provides access to personalized and evidence-based health information, was associated with an increase in certain healthy behaviors and health knowledge, although there was no impact on clinical health outcomes. More research is needed to determine the impact of mobile prenatal apps on healthy pregnancies, clinical health outcomes, and infant care. %M 32628123 %R 10.2196/17183 %U https://mhealth.jmir.org/2020/7/e17183 %U https://doi.org/10.2196/17183 %U http://www.ncbi.nlm.nih.gov/pubmed/32628123 %0 Journal Article %@ 2292-9495 %I JMIR Publications %V 7 %N 2 %P e14078 %T The Mobile Alliance for Maternal Action Text Message–Based mHealth Intervention for Maternal Care in South Africa: Qualitative User Study %A Coleman,Jesse %A Eriksen,Jaran %A Black,Vivian %A Thorson,Anna %A Hatcher,Abigail %+ Wits Reproductive Health & HIV Institute, School of Medicine, University of Witwatersrand, 22 Esselen Street, Hillbrow, Johannesburg, 2001, South Africa, 27 833991066, denots@gmail.com %K maternal health %K text messaging %K focus groups %K South Africa %K mHealth %K reproductive health %K limited resource settings %K public health %K prenatal care %K postnatal care %D 2020 %7 29.6.2020 %9 Original Paper %J JMIR Hum Factors %G English %X Background: Using mobile technology to support health care (mobile health [mHealth]) has been shown to improve health outcomes across a multitude of health specialties and across the world. Exploring mHealth user experiences can aid in understanding how and why an intervention was successful. The Mobile Alliance for Maternal Action (MAMA) was a free maternal mHealth SMS text messaging service that was offered to pregnant women in Johannesburg, South Africa, with the goal of improving maternal, fetal, and infant health outcomes. We conducted focus group discussions with MAMA users to learn about their experiences with the program. Objective: The aim of this qualitative study was to gather opinions of participants of the MAMA maternal mHealth service regarding health care atmosphere, intervention use, and intervention feedback. Methods: Prenatal and postnatal women (N=15) from public antenatal and postnatal care sites in central Johannesburg who were receiving free maternal health text messages (MAMA) participated in 3 focus group discussions. Predefined discussion topics included personal background, health care system experiences, MAMA program recruitment, acceptability, participant experiences, and feedback. Results: The feedback regarding experiences with the health system were comprised of a few reports of positive experiences and many more reports of negative experiences such as long wait times, understaffed facilities, and poor service. Overall acceptability for the maternal text message intervention was high. Participants reflected that the messages were timely, written clearly, and felt supportive. Participants also reported sharing messages with friends and family. Conclusions: These findings suggest that maternal mHealth interventions delivered through text messages can provide timely, relevant, useful, and supportive information to pregnant women and new mothers especially in settings where there may be mistrust of the health care system. %M 32459628 %R 10.2196/14078 %U http://humanfactors.jmir.org/2020/2/e14078/ %U https://doi.org/10.2196/14078 %U http://www.ncbi.nlm.nih.gov/pubmed/32459628 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 5 %P e17361 %T Effectiveness of Internet-Based Electronic Technology Interventions on Breastfeeding Outcomes: Systematic Review %A Almohanna,Alaa Ali %A Win,Khin Than %A Meedya,Shahla %+ School of Computing and Information Technology, University of Wollongong, Northfields Ave, Wollongong, 2522, Australia, 61 402592326, aaa933@uowmail.edu.au %K breastfeeding %K mobile app %K mobile phone %K mHealth %K internet %K computers %K systematic review %D 2020 %7 29.5.2020 %9 Review %J J Med Internet Res %G English %X Background: Supporting women to initiate and continue breastfeeding is a global challenge. A range of breastfeeding interventions employing electronic technologies (e-technologies) are being developed, which offer different delivery modes and features over the internet; however, the impact of internet-based e-technologies on breastfeeding outcomes remains unclear. Objective: This study aimed to identify the characteristics of current internet-based breastfeeding interventions employing e-technologies and investigate the effects of internet-based e-technologies on breastfeeding outcomes. Methods: A systematic search was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the following databases: Scopus, Web of Science, the Cochrane Database of Systematic Reviews, ScienceDirect, Google Scholar, the Association for Computing Machinery, SpringerLink, and Institute of Electrical and Electronics Engineers Xplore. Results: This systematic review included 16 studies published between 2007 and 2018, with 4018 women in 8 countries. The characteristics of the interventions were grouped based on (1) mode of delivery (web-based, mobile phone apps, and computer kiosk), (2) purpose of the interventions (education and support), and (3) key strategies (monitoring and breastfeeding tracking, personalization, online discussion forum, web-based consultation, and breastfeeding station locators). Combining educational activities with web-based personalized support through discussion forums appeared to be the most effective way to improve breastfeeding outcomes and long-term exclusive breastfeeding rates. Monitoring and breastfeeding trackers appeared to be the least effective ways. Conclusions: This study demonstrated a variety of internet-based e-technologies that professionals can use to promote, educate, and support breastfeeding women. Future internet-based breastfeeding interventions employing e-technologies might consider improving interaction with mothers and personalizing the content of the proposed interventions. %M 32469315 %R 10.2196/17361 %U http://www.jmir.org/2020/5/e17361/ %U https://doi.org/10.2196/17361 %U http://www.ncbi.nlm.nih.gov/pubmed/32469315 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e17179 %T Assessing Feasibility of an Early Childhood Intervention Using Mobile Phones Among Low-Income Mothers of Newborns: Qualitative Interview Study %A Zhang,Donglan %A Jin,Lan %A Liang,Di %A Geng,Ruijin %A Liu,Yun %A Ling,Yu %A Jiang,Fan %A Zhang,Yunting %+ Child Health Advocacy Institute, National Children’s Medical Center, Shanghai Children’s Medical Center, 1678 Dongfang Road, Pudong, Shanghai, China, 86 21 3862606, zhangyunting@scmc.com.cn %K mobile health %K interview %K health belief model %K early child development %D 2020 %7 28.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: Many children aged younger than 5 years living in low- and middle-income countries are at risk for poor development. Early child development (ECD) programs are cost-effective strategies to reduce poverty, crime, school dropouts, and socioeconomic inequality. With the spread of low-cost mobile phones and internet access in low- and middle-income countries, new service delivery models such as mobile phone–aided interventions have a great potential to improve early childhood development. Objective: This study aimed to identify the beliefs on importance of ECD, feasibility of a proposed intervention using mobile phones and factors that may affect the usability of the intervention among mothers of newborns in a poverty-stricken area in southwestern China. Methods: We conducted an in-depth, semistructured interview study of 25 low-income mothers of newborns recruited from two county hospitals in Yunnan Province. We applied the health belief model and cultural competence theories to identify the facilitators, barriers, and preferences among the target population for parenting knowledge. Results: The results showed that the participants had low health literacy and high perceived needs for learning ECD knowledge. At the same time, they experienced several barriers to learning parenting information and following evidence-based instructions including having limited time, limited financial resources, and different opinions on childcare among family members. Many participants preferred to receive personalized messages tailored to their specific needs and preferred videos or graphics to text only in the messages. Many favored a separate module to support postpartum mental health. Conclusions: The study assessed the acceptability of an early childhood intervention using mobile phones to meet the needs of the target population based on their beliefs, traits, and preferences and provided suggestions to refine the intervention to improve its usability. %M 32463374 %R 10.2196/17179 %U http://formative.jmir.org/2020/5/e17179/ %U https://doi.org/10.2196/17179 %U http://www.ncbi.nlm.nih.gov/pubmed/32463374 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 5 %P e17300 %T Content and Quality of Infant Feeding Smartphone Apps: Five-Year Update on a Systematic Search and Evaluation %A Cheng,Heilok %A Tutt,Alison %A Llewellyn,Catherine %A Size,Donna %A Jones,Jennifer %A Taki,Sarah %A Rossiter,Chris %A Denney-Wilson,Elizabeth %+ Susan Wakil School of Nursing and Midwifery, Faculty of Medicine and Health, The University of Sydney, 88 Mallett Street, Camperdown, 2050, Australia, 61 1800793864, jessica.cheng@sydney.edu.au %K breast feeding %K bottle feeding %K infant food %K readability %K consumer health information %K breastfeeding %K mobile apps %K smartphones %D 2020 %7 27.5.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Parents use apps to access information on child health, but there are no standards for providing evidence-based advice, support, and information. Well-developed apps that promote appropriate infant feeding and play can support healthy growth and development. A 2015 systematic assessment of smartphone apps in Australia about infant feeding and play found that most apps had minimal information, with poor readability and app quality. Objective: This study aimed to systematically evaluate the information and quality of smartphone apps providing information on breastfeeding, formula feeding, introducing solids, or infant play for consumers. Methods: The Google Play store and Apple App Store were searched for free and paid Android and iPhone Operating System (iOS) apps using keywords for infant feeding, breastfeeding, formula feeding, and tummy time. The apps were evaluated between September 2018 and January 2019 for information content based on Australian guidelines, app quality using the 5-point Mobile App Rating Scale, readability, and suitability of health information. Results: A total of 2196 unique apps were found and screened. Overall, 47 apps were evaluated, totaling 59 evaluations for apps across both the Android and iOS platforms. In all, 11 apps had affiliations to universities and health services as app developers, writers, or editors. Furthermore, 33 apps were commercially developed. The information contained within the apps was poor: 64% (38/59) of the evaluations found no or low coverage of information found in the Australian guidelines on infant feeding and activity, and 53% (31/59) of the evaluations found incomplete or incorrect information with regard to the depth of information provided. Subjective app assessment by health care practitioners on whether they would use, purchase, or recommend the app ranged from poor to acceptable (median 2.50). Objective assessment of the apps’ engagement, functionality, aesthetics, and information was scored as acceptable (median 3.63). The median readability score for the apps was at the American Grade 8 reading level. The suitability of health information was rated superior or adequate for content, reading demand, layout, and interaction with the readers. Conclusions: The quality of smartphone apps on infant feeding and activity was moderate based on the objective measurements of engagement, functionality, aesthetics, and information from a reliable source. The overall quality of information on infant feeding and activity was poor, indicated by low coverage of topics and incomplete or partially complete information. The key areas for improvement involved providing evidence-based information consistent with the Australian National Health and Medical Research Council’s Infant Feeding Guidelines. Apps supported and developed by health care professionals with adequate health service funding can ensure that parents are provided with credible and reliable resources. %M 32459187 %R 10.2196/17300 %U http://mhealth.jmir.org/2020/5/e17300/ %U https://doi.org/10.2196/17300 %U http://www.ncbi.nlm.nih.gov/pubmed/32459187 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 4 %N 5 %P e16202 %T Identifying the Needs for a Web-Based Postpartum Platform Among Parents of Newborns and Health Care Professionals: Qualitative Focus Group Study %A Laureij,Lyzette T %A Breunis,Leonieke J %A Steegers-Theunissen,Regine P M %A Rosman,Ageeth N %+ Department of Health Care Studies, Rotterdam University of Applied Sciences, IVG, RS.06.121, PO Box 25035 Rotterdam, 3001 HR, Rotterdam, 3000 CA, Netherlands, 31 6 425 27 919, a.n.rosman@hr.nl %K newborn %K focus groups %K postpartum period %K postnatal care %K eHealth %K pregnancy %K obstetrics %K qualitative research %D 2020 %7 26.5.2020 %9 Original Paper %J JMIR Form Res %G English %X Background: During the turbulent postpartum period, there is an urgent need by parents for support and information regarding the care for their infant. In the Netherlands, professional support is provided during the first 8 days postpartum and for a maximum of 8 hours a day. This care is delivered by maternity care assistants (MCAs). Despite the availability of this extensive care, a majority of women prefer to make use of a lesser amount of postpartum care. After this period, access to care is less obvious. Where parents are automatically offered care in the first 8 days after birth, they must request care in the period thereafter. To compensate for a possible gap in information transfer, electronic health (eHealth) can be a valuable, easily accessible addition to regular care. Objective: We explored the needs and preferred content by new parents and health care professionals of a web-based platform dedicated to the postpartum period and identified barriers and facilitators for using such a platform. Methods: We conducted 3 semistructured focus groups among (1) parents of newborns, (2) MCAs, and (3) clinicians and administrators in maternity care. A topic list based on a framework designed for innovation processes was used. Thematic content analysis was applied. Results: In the focus group for parents, 5 mothers and 1 male partner participated. A total of 6 MCAs participated in the second focus group. A total of 5 clinicians and 2 administrators—a member of a stakeholder party and a manager of a maternity care organization—participated in the third focus group. All user groups underlined that a platform focusing on the postpartum period was missing in current care, especially by parents experiencing a gap following the intensive care ending after the first week of childbirth. Parents indicated that they would perceive a postpartum platform as a proper source of reliable information on topics regarding breastfeeding, growth, and developmental milestones, but also as a tool to support them in seeking care with appropriate professionals. They also emphasized the need to receive personalized information and the opportunity to ask questions via the platform. MCAs acknowledged added value of providing additional information on topics that they address during the early postpartum period. MCAs as well as clinicians and administrators would guide parents to such a platform for additional support. All user groups experienced disadvantages of using an authentication procedure and filling out extra questionnaires to receive tailored information. Conclusions: Our research shows that parents of newborns, MCAs, and clinicians and administrators foresee the additional value of a web-based postpartum platform for at least the whole postpartum period. The platform should be easily accessible and personalized. Content on the platform should contain information regarding breastfeeding, growth, and developmental milestones. A chat function with professionals could be considered as an option. %M 32452805 %R 10.2196/16202 %U http://formative.jmir.org/2020/5/e16202/ %U https://doi.org/10.2196/16202 %U http://www.ncbi.nlm.nih.gov/pubmed/32452805 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 4 %P e17328 %T The Development and Evaluation of a Text Message Program to Prevent Perceived Insufficient Milk Among First-Time Mothers: Retrospective Analysis of a Randomized Controlled Trial %A Demirci,Jill R %A Suffoletto,Brian %A Doman,Jack %A Glasser,Melissa %A Chang,Judy C %A Sereika,Susan M %A Bogen,Debra L %+ Department of Health Promotion & Development, University of Pittsburgh School of Nursing, 3500 Victoria St, Suite 440, Pittsburgh, PA, 15261, United States, 1 4126489236, Jvr5@pitt.edu %K breast feeding %K perceived insufficient milk %K text messaging %K short message service %K cell phone %K mobile phone %K telemedicine %K mHealth %K randomized controlled trial %D 2020 %7 29.4.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Several recent trials have examined the feasibility and efficacy of automated SMS text messaging to provide remote breastfeeding support to mothers, but these texting systems vary in terms of design features and outcomes examined. Objective: This study examined user engagement with and feedback on a theory-grounded SMS text messaging intervention intended to prevent perceived insufficient milk (PIM)—the single, leading modifiable cause of unintended breastfeeding reduction and cessation. Methods: We recruited 250 nulliparous individuals intending to breastfeed between 13 and 25 weeks of pregnancy in southwestern Pennsylvania. Participants were randomly assigned with equal allocation to either an SMS intervention to prevent PIM and unintended breastfeeding reduction or cessation (MILK, a Mobile, semiautomated text message–based Intervention to prevent perceived Low or insufficient milK supply; n=126) or a control group receiving general perinatal SMS text messaging–based support via the national, free Text4Baby system (n=124). Participants in both groups received SMS text messages 3 to 7 times per week from 25 weeks of pregnancy to 8 weeks postpartum. The MILK intervention incorporated several automated interactivity and personalization features (eg, keyword texting for more detailed information on topics and branched response logic) as well as an option to receive one-on-one assistance from an on-call study lactation consultant. We examined participant interactions with the MILK system, including response rates to SMS text messaging queries. We also sought participant feedback on MILK content, delivery preferences, and overall satisfaction with the system via interviews and a remote survey at 8 weeks postpartum. Results: Participants randomized to MILK (87/124, 70.2% white and 84/124, 67.7% college educated) reported that MILK texts increased their breastfeeding confidence and helped them persevere through breastfeeding problems. Of 124 participants, 9 (7.3%) elected to stop MILK messages, and 3 (2.4%) opted to reduce message frequency during the course of the study. There were 46 texts through the MILK system for individualized assistance from the study lactation consultant (25/46, 54% on weekends or after-hours). The most commonly texted keywords for more detailed information occurred during weeks 4 to 6 postpartum and addressed milk volume intake and breastfeeding and sleep patterns. MILK participants stated a preference for anticipatory guidance on potential breastfeeding issues and less content addressing the benefits of breastfeeding. Suggested improvements included extending messaging past 8 weeks, providing access to messaging for partners, and tailoring content based on participants’ pre-existing breastfeeding knowledge and unique breastfeeding trajectory. Conclusions: Prenatal and postpartum evidence–based breastfeeding support delivered via semiautomated SMS text messaging is a feasible and an acceptable intervention for first-time mothers. To optimize engagement with digital breastfeeding interventions, enhanced customization features should be considered. Trial Registration: ClinicalTrials.gov NCT02724969; https://clinicaltrials.gov/ct2/show/NCT02724969 %M 32347815 %R 10.2196/17328 %U https://mhealth.jmir.org/2020/4/e17328 %U https://doi.org/10.2196/17328 %U http://www.ncbi.nlm.nih.gov/pubmed/32347815 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 4 %P e17011 %T Mobile Health for Perinatal Depression and Anxiety: Scoping Review %A Hussain-Shamsy,Neesha %A Shah,Amika %A Vigod,Simone N %A Zaheer,Juveria %A Seto,Emily %+ Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, 155 College Street 4th Floor, Toronto, ON, M5T 3M6, Canada, 1 416 978 4326, neesha.hussainshamsy@mail.utoronto.ca %K mental health %K depression %K anxiety %K pregnancy %K postpartum %K smartphone %K mobile phone %K text message %K mHealth %D 2020 %7 13.4.2020 %9 Review %J J Med Internet Res %G English %X Background: The perinatal period is a vulnerable time during which depression and anxiety commonly occur. If left untreated or undertreated, there may be significant adverse effects; therefore, access to rapid, effective treatment is essential. Treatments for mild-to-moderate symptoms according to a stepped-care approach involve psychoeducation, peer support, and psychological therapy, all of which have been shown to be efficaciously delivered through digital means. Women experience significant barriers to care because of system- and individual-level factors, such as cost, accessibility, and availability of childcare. The use of mobile phones is widespread in this population, and the delivery of mental health services via mobile phones has been suggested as a means of reducing barriers. Objective: This study aimed to understand the extent, range, and nature of mobile health (mHealth) tools for prevention, screening, and treatment of perinatal depression and anxiety in order to identify gaps and inform opportunities for future work. Methods: Using a scoping review framework, 4 databases were searched for terms related to mobile phones, perinatal period, and either depression or anxiety. A total of 477 unique records were retrieved, 81 of which were reviewed by full text. Peer-reviewed publications were included if they described the population as women pregnant or up to 1 year postpartum and a tool explicitly delivered via a mobile phone for preventing, screening, or treating depression or anxiety. Studies published in 2007 or earlier, not in English, or as case reports were excluded. Results: A total of 26 publications describing 22 unique studies were included (77% published after 2017). mHealth apps were slightly more common than texting-based interventions (12/22, 54% vs 10/22, 45%). Most tools were for either depression (12/22, 54%) or anxiety and depression (9/22, 41%); 1 tool was for anxiety only (1/22, 4%). Interventions starting in pregnancy and continuing into the postpartum period were rare (2/22, 9%). Tools were for prevention (10/22, 45%), screening (6/22, 27%), and treatment (6/22, 27%). Interventions delivered included psychoeducation (16/22, 73%), peer support (4/22, 18%), and psychological therapy (4/22, 18%). Cost was measured in 14% (3/22) studies. Conclusions: Future work in this growing area should incorporate active psychological treatment, address continuity of care across the perinatal period, and consider clinical sustainability to realize the potential of mHealth. %M 32281939 %R 10.2196/17011 %U http://www.jmir.org/2020/4/e17011/ %U https://doi.org/10.2196/17011 %U http://www.ncbi.nlm.nih.gov/pubmed/32281939 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 3 %N 1 %P e14355 %T Hidden Communities of Practice in Social Media Groups: Mixed Methods Study %A Skelton,Kara %A Evans,Retta %A LaChenaye,Jenna %+ Department of Health, Behavior and Society, Johns Hopkins University, 624 N Broadway, Baltimore, MD, 21205, United States, 1 2055633412, kara.skelton@jhu.edu %K online social support %K breastfeeding %K social media %K social support system %D 2020 %7 24.3.2020 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Although most US mothers initiate breastfeeding, suboptimal breastfeeding rates still exist. Although breastfeeding is a complex process, social support has been linked with increases in positive breastfeeding outcomes. Recent technological advances, including the development of social networking sites, provide mothers with convenient access to a unique array of audiences from which to seek advice about parenting, including breastfeeding. However, little is known about how the use of the sites—specifically groups centered around breastfeeding—influences breastfeeding knowledge, attitudes, or behaviors. Objective: This mixed methods study aimed to explore utilization of an existing probreastfeeding Facebook group and how utilization influences breastfeeding-related knowledge, attitudes, and behaviors. Methods: Participants were recruited online through Facebook wall posts from within the existing group. Mothers aged between 18 and 50 years who were pregnant and intended to breastfeed, were currently breastfeeding, or had recently weaned their infant in the past 3 years were eligible to participate. Participants engaged in online focus group discussions (n=21) and individual interviews (n=12). Inductive content analysis of qualitative data led to the conceptualization and contextualization of a breastfeeding community of practice (COP). Using qualitative results, a quantitative survey was then developed to assess the prevalence of qualities of a COP as well as how COP usage influenced breastfeeding-related attitudes and knowledge. A total of 314 mothers completed the online survey. Results: Qualitative findings showed an overall sense of community, with subthemes of group trust, interaction, and the promotion of breastfeeding. A majority (287/314, 91.5%) of mothers initiated breastfeeding, with 69.0% (216/314) of mothers reporting exclusive breastfeeding their infant at 6 months. Approximately 98.5% (309/314) of mothers reported that the Facebook group captured and stored knowledge; therefore, information could be easily accessed and applied. In addition, 96.2% (302/317) of mothers reported that the Facebook group motivated them to share breastfeeding-related knowledge. Conclusions: The results suggest that this existing probreastfeeding Facebook group exhibits characteristics of an online COP, which was organically formed. Utilization of the Facebook group, in the context of an online COP, could be beneficial in impacting breastfeeding-related knowledge, attitudes, and behaviors. However, further examination and exploration of breastfeeding COPs, including using this type of model as a method of lactation support or as a telemedicine framework, is a clear need. %M 32207693 %R 10.2196/14355 %U http://pediatrics.jmir.org/2020/1/e14355/ %U https://doi.org/10.2196/14355 %U http://www.ncbi.nlm.nih.gov/pubmed/32207693 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 22 %N 3 %P e15172 %T The Effectiveness of a Guided Internet-Based Tool for the Treatment of Depression and Anxiety in Pregnancy (MamaKits Online): Randomized Controlled Trial %A Heller,Hanna M %A Hoogendoorn,Adriaan W %A Honig,Adriaan %A Broekman,Birit F P %A van Straten,Annemieke %+ Department of Psychiatry, Amsterdam Universitair Medische Centra, Vrije Universiteit Amsterdam, de Boelelaan 1117, Amsterdam, 1081 HV, Netherlands, 31 204440196, hm.heller@amsterdamumc.nl %K pregnancy %K depression %K anxiety %K internet %K pregnancy outcome %K treatment %D 2020 %7 23.3.2020 %9 Original Paper %J J Med Internet Res %G English %X Background: Pregnant women with symptoms of depression or anxiety often do not receive adequate treatment. In view of the high incidence of these symptoms in pregnancy and their impact on pregnancy outcomes, getting treatment is of the utmost importance. A guided internet self-help intervention may help to provide more women with appropriate treatment. Objective: This study aimed to examine the effectiveness of a guided internet intervention (MamaKits online) for pregnant women with moderate to severe symptoms of anxiety or depression. Assessments took place before randomization (T0), post intervention (T1), at 36 weeks of pregnancy (T2), and 6 weeks postpartum (T3). We also explored effects on perinatal child outcomes 6 weeks postpartum. Methods: This randomized controlled trial included pregnant women (<30 weeks) with depressive symptoms above threshold (ie, Center for Epidemiological Studies Depression scale [CES-D] >16) or anxiety above threshold (ie, Hospital Anxiety and Depression Scale-Anxiety subscale [HADS-A] >8) or both of them. Participants were recruited via general media and flyers in prenatal care waiting rooms or via obstetricians and midwives. After initial assessment, women were randomized to (1) MamaKits online in addition to treatment as usual or (2) treatment as usual (control condition). MamaKits online is a 5-week guided internet intervention based on problem solving treatment. Guidance was was provided by trained students pursuing a Master's in Psychology. Outcomes were based on a Web-based self-report. Women in the control condition were allowed to receive the intervention after the last assessment (6 weeks postpartum). Results: Of the 159 included women, 79 were randomized to MamaKits online, 47% (79/37) of whom completed the intervention. Both groups showed a substantial decrease in affective symptoms on the CES-D, HADS-A, and Edinburgh Postnatal Depression Scale over time. In the intervention group, affective symptoms decreased more than that in the control group, but between-group effect sizes were small to medium (Cohen d at T3=0.45, 0.21, and 0.23 for the 3 questionnaires, respectively) and statistically not significant. Negative perinatal child outcomes did not differ between the 2 groups (χ21=0.1; P=.78). Completer analysis revealed no differences in outcome between the treatment completers and the control group. The trial was terminated early for reasons of futility based on the results of an interim analysis, which we performed because of inclusion problems. Conclusions: Our study did show a significant reduction in affective symptoms in both groups, but the differences in reduction of affective symptoms between the intervention and control groups were not significant. There were also no differences in perinatal child outcomes. Future research should examine for which women these interventions might be effective or if changes in the internet intervention might make the intervention more effective. Trial Registration: Netherlands Trial Register NL4162; https://tinyurl.com/sdckjek %M 32202505 %R 10.2196/15172 %U http://www.jmir.org/2020/3/e15172/ %U https://doi.org/10.2196/15172 %U http://www.ncbi.nlm.nih.gov/pubmed/32202505 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 8 %N 2 %P e14737 %T Using Text Messaging to Improve Access to Prenatal Health Information in Urban African American and Afro-Caribbean Immigrant Pregnant Women: Mixed Methods Analysis of Text4baby Usage %A Blackwell,Tenya M %A Dill,LeConte J %A Hoepner,Lori A %A Geer,Laura A %+ Department of Environmental and Occupational Health Sciences, SUNY Downstate Health Sciences University, School of Public Health, 450 Clarkson Avenue, Brooklyn, NY, United States, 1 7182703101, tblackwell@arthurasheinstitute.org %K Text4baby %K mHealth %K pregnancy %K text messaging %K health information %K prenatal health %K disparities %D 2020 %7 13.2.2020 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The Text4baby (T4B) mobile health (mHealth) program is acclaimed to provide pregnant women with greater access to prenatal health care, resources, and information. However, little is known about whether urban African American and Afro-Caribbean immigrant pregnant women in the United States are receptive users of innovative health communication methods or of the cultural and systematic barriers that inhibit their behavioral intent to use T4B. Objective: This study aimed to understand the lived experiences of urban African American and Afro-Caribbean immigrant pregnant women with accessing quality prenatal health care and health information; to assess usage of mHealth for seeking prenatal health information; and to measure changes in participants’ knowledge, perceptions, and behavioral intent to use the T4B mHealth educational intervention. Methods: An exploratory sequential mixed methods study was conducted among pregnant women and clinical professionals for a phenomenological exploration with focus groups, key informants, interviews, and observations. Qualitative themes were aligned with behavioral and information technology communications theoretical constructs to develop a survey instrument used. repeated-measures pre- and post-test design to evaluate changes in participants’ knowledge, attitudes, and beliefs, of mHealth and T4B after a minimum of 4 weeks’ exposure to the text message–based intervention. Triangulation and mixing of both qualitative and quantitative data occurred primarily during the survey development and also during final analysis. Results: A total of 9 women participated in phase 1, and 49 patients signed up for T4B and completed a 31-item survey at baseline and again during follow-up. Three themes were identified: (1) patient-provider engagement, (2) social support, and (3) acculturation. With time as a barrier to quality care, inadequate patient-provider engagement left participants feeling indifferent about the prenatal care and information they received in the clinical setting. Of 49 survey participants, 63% (31/49) strongly agreed that T4B would provide them with extra support during their pregnancy. On a Likert scale of 1 to 5, participants’ perception of the usefulness of T4B ranked at 4.26, and their perception of the compatibility and relative advantage of using T4B ranked at 4.41 and 4.15, respectively. At follow-up, there was a 14% increase in participants reporting their intent to use T4B and a 28% increase from pretest and posttest in pregnant women strongly agreeing to speak more with their doctor about the information learned through T4B. Conclusions: Urban African American and Afro-Caribbean immigrant pregnant women in Brooklyn endure a number of social and ecological determinants like low health literacy, income, and language that serve as barriers to accessing quality prenatal health care and information, which negatively impacts prenatal health behaviors and outcomes. Our study indicates a number of systematic, political, and other microsystem-level factors that perpetuate health inequities in our study population. %M 32053117 %R 10.2196/14737 %U http://mhealth.jmir.org/2020/2/e14737/ %U https://doi.org/10.2196/14737 %U http://www.ncbi.nlm.nih.gov/pubmed/32053117 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 2 %P e16335 %T Voices in Evidence-Based Newborn Care: A How-to-Guide on Developing a Parent-Facing Podcast %A Parga-Belinkie,Joanna %A Merchant,Raina M %+ Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Division of Neonatology, 2NW35, Philadelphia, PA, 19104, United States, 1 5164268898, jo.parga@gmail.com %K neonatology %K social media %K medical education %K patient education %D 2019 %7 20.12.2019 %9 Tutorial %J JMIR Pediatr Parent %G English %X Podcasting is becoming a more popular form of media. Its use in medical education is being researched—but what about its use in public education? In this tutorial, the authors offer a how-to-guide on starting a public or patient-facing podcast. The authors hope to inspire more physicians to utilize this type of media to share evidence-based information. More research is needed looking into how podcasting can be used to help with patient education. %M 31859674 %R 10.2196/16335 %U http://pediatrics.jmir.org/2019/2/e16335/ %U https://doi.org/10.2196/16335 %U http://www.ncbi.nlm.nih.gov/pubmed/31859674 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e14219 %T A Baby Formula Designed for Chinese Babies: Content Analysis of Milk Formula Advertisements on Chinese Parenting Apps %A Zhao,Jing %A Li,Mu %A Freeman,Becky %+ School of Public Health, Sydney Medical School, The University of Sydney, Edward Ford Building A27, Sydney, 2006, Australia, 61 04 0650 2156, jzha5010@uni.sydney.edu.au %K infant formula %K food policy %K health promotion %K marketing %K mobile app %K parenting %K breastfeeding %K advertisement %D 2019 %7 29.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: China is the largest market for infant formula. With the increasing use of smartphones, apps have become the latest tool used to promote milk formula. Formula manufacturers and distributors both have seized the popularity of apps as an avenue for marketing. Objective: This study aimed to identify and analyze milk formula ads featured on Chinese pregnancy and parenting apps, to build the first complete picture of app-based milk formula marketing techniques being used by milk formula brand variants on these apps, and to more fully understand the ad content that potentially undermines public health messaging about infant and young child feeding. Methods: We searched for free-to-download Chinese parenting apps in the 360 App Store, the biggest Android app store in China. The final sample consisted of 353 unique formula ads from the 79 apps that met the inclusion criteria. We developed a content analysis coding tool for categorizing the marketing techniques used in ads, which included a total of 22 coding options developed across 4 categories: emotional imagery, marketing elements, claims, and advertising disclosure. Results: The 353 milk formula ads were distributed across 31 companies, 44 brands, and 79 brand variants. Overall, 15 of 31 corporations were international with the remaining 16 being Chinese owned. An image of a natural pasture was the most commonly used emotional image among the brand variants (16/79). All variants included branding elements, and 75 variants linked directly to e-shops. Special price promotions were promoted by nearly half (n=39) of all variants. A total of 5 variants included a celebrity endorsement in their advertising. A total of 25 of the 79 variants made a product quality claim. Only 14 variants made a direct advertisement disclosure. Conclusions: The purpose of marketing messages is to widen the use of formula and normalize formula as an appropriate food for all infants and young children, rather than as a specialized food for those unable to breastfeed. Policy makers should take steps to establish an appropriate regulatory framework and provide detailed monitoring and enforcement to ensure that milk formula marketing practices do not undermine breastfeeding norms and behaviors. %M 31782743 %R 10.2196/14219 %U http://mhealth.jmir.org/2019/11/e14219/ %U https://doi.org/10.2196/14219 %U http://www.ncbi.nlm.nih.gov/pubmed/31782743 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 11 %P e15530 %T Delivering a Post-Partum Weight Loss Intervention via Facebook or In-Person Groups: Protocol for a Randomized Feasibility Pilot Trial %A Waring,Molly E %A Libby,Brooke A %A Moore Simas,Tiffany A %A Bracken,Madison L %A Bibeau,Jessica L %A Herrera,Valeria %A Wang,Justin %A Pagoto,Sherry L %+ Department of Allied Health Sciences, UConn Center for mHealth and Social Media, University of Connecticut, 358 Mansfield Road, Unit 1101, Storrs, CT, 06269, United States, 1 8604861446, molly.waring@uconn.edu %K postpartum period %K weight loss %K social media %K pilot study %D 2019 %7 28.11.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Postpartum weight retention contributes to long-term weight gain and obesity for many women. Lifestyle interventions with numerous visits are logistically challenging for many postpartum women. Delivering a lifestyle intervention via social media may overcome logistic challenges to participation in in-person weight loss programs. Objective: The objective of this study is to conduct a randomized feasibility pilot trial of a 6-month postpartum weight loss intervention delivered via Facebook or in-person groups with 72 postpartum women with overweight or obesity. Methods: Women with overweight or obesity who are 8 weeks to 12 months postpartum (N=72) will be recruited from the Hartford, Connecticut community. Eligible participants must also own an iPhone or Android smartphone and be an active Facebook user. Participants will receive a 6-month postpartum weight loss intervention based on the Diabetes Prevention Program lifestyle intervention and adapted for postpartum women. Participants will be randomized to receive the intervention via a private Facebook group or in-person group meetings. Assessments will occur at baseline, weekly during the intervention, at 6 months (at the end of the intervention), and at 12 months. Primary feasibility outcomes are recruitment, sustained participation, contamination, retention, and feasibility of assessment procedures including measurement of costs to deliver and receive the intervention. We will describe 6- and 12-month weight loss as an exploratory outcome. Results: Recruitment began in September 2018. The first wave of the intervention began in February 2019, and the second wave of the intervention is expected to begin in fall 2019. We anticipate completing follow-up assessments in fall 2020, and results will be analyzed at that time. Conclusions: Results will inform the design of a large randomized controlled trial to assess whether delivering a postpartum weight loss intervention via Facebook is noninferior for weight loss and more cost-effective than delivering the intervention via traditional in-person groups. International Registered Report Identifier (IRRID): DERR1-10.2196/15530 %M 31778116 %R 10.2196/15530 %U http://www.researchprotocols.org/2019/11/e15530/ %U https://doi.org/10.2196/15530 %U http://www.ncbi.nlm.nih.gov/pubmed/31778116 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 11 %P e13604 %T Iterative Adaptation of a Mobile Nutrition Video-Based Intervention Across Countries Using Human-Centered Design: Qualitative Study %A Isler,Jasmin %A Sawadogo,N Hélène %A Harling,Guy %A Bärnighausen,Till %A Adam,Maya %A Kagoné,Moubassira %A Sié,Ali %A Greuel,Merlin %A McMahon,Shannon A %+ Heidelberg Institute of Global Health, Heidelberg University, Im Neuenheimer Feld 130/3, Heidelberg, 69120, Germany, 49 06221 565344, mcmahon@uni-heidelberg.de %K mHealth %K Burkina Faso %K mothers %K Community Health Workers %K pregnancy %K diet %K dgital health %D 2019 %7 11.11.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Mobile health (mHealth) video interventions are often transferred across settings. Although the outcomes of these transferred interventions are frequently published, the process of adapting such videos is less described, particularly within and across lower-income contexts. This study fills a gap in the literature by outlining experiences and priorities adapting a suite of South African maternal nutrition videos to the context of rural Burkina Faso. Objective: The objective of this study was to determine the key components in adapting a suite of maternal nutrition mHealth videos across settings. Methods: Guided by the principles of human-centered design, this qualitative study included 10 focus group discussions, 30 in-depth interviews, and 30 observations. We first used focus group discussions to capture insights on local nutrition and impressions of the original (South African) videos. After making rapid adjustments based on these focus group discussions, we used additional methods (focus group discussions, in-depth interviews, and observations) to identify challenges, essential video refinements, and preferences in terms of content delivery. All data were collected in French or Dioula, recorded, transcribed, and translated as necessary into French before being thematically coded by two authors. Results: We propose a 3-pronged Video Adaptation Framework that places the aim of video adaptation at the center of a triangle framed by end recipients, health workers, and the environment. End recipients (here, pregnant or lactating mothers) directed us to (1) align the appearance, priorities, and practices of the video’s protagonist to those of Burkinabe women; (2) be mindful of local realities whether economic, health-related, or educational; and (3) identify and routinely reiterate key points throughout videos and via reminder cards. Health workers (here, Community Health Workers and Mentor Mothers delivering the videos) guided us to (1) improve technology training, (2) simplify language and images, and (3) increase the frequency of their engagements with end recipients. In terms of the environment, respondents guided us to localize climate, vegetation, diction, and how foods are depicted. Conclusions: Design research provided valuable insights in terms of developing a framework for video adaptation across settings, which other interventionists and scholars can use to guide adaptations of similar interventions. %M 31710302 %R 10.2196/13604 %U http://mhealth.jmir.org/2019/11/e13604/ %U https://doi.org/10.2196/13604 %U http://www.ncbi.nlm.nih.gov/pubmed/31710302 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e13935 %T Mobile Health Coaching on Nutrition and Lifestyle Behaviors for Subfertile Couples Using the Smarter Pregnancy Program: Model-Based Cost-Effectiveness Analysis %A Oostingh,Elsje C %A Ophuis,Robbin H %A Koster,Maria PH %A Polinder,Suzanne %A Lingsma,Hester F %A Laven,Joop SE %A Steegers-Theunissen,Régine PM %+ Erasmus University Medical Center, Postbus 2040, Rotterdam, 3000 CA, Netherlands, 31 107038255, r.steegers@erasmusmc.nl %K preconception %K subfertility %K IVF treatment %K pregnancy %K cost-effectiveness %D 2019 %7 23.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The health care costs for reproductive care have substantially increased with the use of in vitro fertilization (IVF) treatment. The mobile health (mHealth) coaching program Smarter Pregnancy is an effective intervention to improve nutrition and lifestyle behaviors and pregnancy rates in (sub)fertile couples, including those who undergo IVF treatment. Therefore, we hypothesize that this mHealth program can also reduce health care costs associated with IVF treatment. Objective: This study aimed to evaluate the cost-effectiveness of the mHealth coaching program Smarter Pregnancy and compare it to usual care in women of subfertile couples who start their first IVF cycle. Methods: This model-based cost-effectiveness analysis was performed on data from couples undergoing IVF treatment at the Erasmus MC, University Medical Center Rotterdam. A decision tree model was used to assess the incremental cost-effectiveness ratio (ICER) of ongoing pregnancies and costs of use of the mHealth program as compared to usual care. A probabilistic sensitivity analysis was performed to consider the uncertainty surrounding the point estimates of the input parameters. Results: Based on our model including 793 subfertile women undergoing IVF treatment, use of the mHealth program resulted in 86 additional pregnancies and saved €270,000 compared to usual care after two IVF cycles, with an ICER of –€3050 (95% CI –3960 to –540) per additional pregnancy. The largest cost saving was caused by the avoided IVF treatment costs. Sensitivity analyses showed that the mHealth program needs to increase the ongoing pregnancy rate by at least 51% after two IVF cycles for cost saving. Conclusions: The mHealth coaching program Smarter Pregnancy is potentially cost saving for subfertile couples preceding their first IVF treatment. Implementation of this mHealth program in routine preconception care for subfertile couples should be seriously considered, given the relatively low costs and promising cost-effectiveness estimates. %M 31647476 %R 10.2196/13935 %U http://mhealth.jmir.org/2019/10/e13935/ %U https://doi.org/10.2196/13935 %U http://www.ncbi.nlm.nih.gov/pubmed/31647476 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 10 %P e12444 %T Health Research Using Facebook to Identify and Recruit Pregnant Women Who Use Electronic Cigarettes: Internet-Based Nonrandomized Pilot Study %A Lee,Harold H %A Hsieh,Yuli Patrick %A Murphy,Joe %A Tidey,Jennifer W %A Savitz,David A %+ Department of Social and Behavioral Sciences, Harvard TH Chan School of Public Health, 428F, 401 Park Dr, Boston, MA, 02215, United States, 1 617 432 1135, hhlee@hsph.harvard.edu %K e-cigarette %K pregnancy %K social media %D 2019 %7 18.10.2019 %9 Original Paper %J JMIR Res Protoc %G English %X Background: Participant recruitment is often a challenge, particularly enrolling individuals with relatively rare characteristics. The wide reach of social media may provide a mechanism to overcome these challenges. Objective: This paper aimed to provide information to researchers who seek to recruit participants from rare populations using social media for studies with demanding protocols. We aimed to describe a pilot study protocol that identified and enrolled pregnant women (second or third trimester) who were exclusive users of electronic cigarettes (e-cigarettes). We have described the recruitment methods, time, and cost; examined advertisement types that were more or less successful; discussed participant retention and relationship management; and described the process of collecting biological data. Methods: In an open-access, nonrandomized pilot study, we placed Facebook advertisements that were selectively targeting women who were likely to be pregnant and interested in e-cigarettes or vaping. The advertisements invited individuals to complete a fully automated eligibility screener based on Qualtrics. Eligible participants were asked to (1) complete a Web-based survey that collected detailed information on the use of e-cigarettes, including the exact type of device and electronic liquid, (2) report the frequency and intensity of e-cigarette use for 3 months before pregnancy and during each trimester, and (3) provide a saliva specimen for a nicotine biomarker assay. We collected a photograph of each participant’s e-cigarette device, 8 weeks after the mother’s due date, to allow corroboration of the self-report and the baby’s birth weight and gestational age from the participant’s physician. Results: Participants were recruited between August 19 and October 26, 2017. We enrolled 20 participants in 2 months at a cost of US $3421.28. Baseline data were collected for all 20 participants. Of the 20 women enrolled, 16 provided a saliva sample, 4 provided a photo of the e-cigarette device, and 10 provided physician contact information. Of the 10 physicians contacted by mail, 6 responded with information on the participants and their babies. Conclusions: Study findings suggest that Facebook’s targeting criteria should focus on e-cigarette users to maximize advertisement exposure of potentially eligible women. In addition, saliva sample collection was feasible among pregnant women (second or third trimester) who were exclusive e-cigarette users, but obtaining photographs and physician reports was problematic and called for further refinement. These lessons are likely useful to others who are seeking to use social media to recruit participants from rare populations into studies with demanding protocols. %M 31628785 %R 10.2196/12444 %U https://www.researchprotocols.org/2019/10/e12444 %U https://doi.org/10.2196/12444 %U http://www.ncbi.nlm.nih.gov/pubmed/31628785 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 10 %P e13321 %T An Analytical Mobile App for Shared Decision Making About Prenatal Screening: Protocol for a Mixed Methods Study %A Abbasgholizadeh Rahimi,Samira %A Archambault,Patrick M %A Ravitsky,Vardit %A Lemoine,Marie-Eve %A Langlois,Sylvie %A Forest,Jean-Claude %A Giguère,Anik M C %A Rousseau,François %A Dolan,James G %A Légaré,France %+ Centre de recherche sur les soins et les services de première ligne de l’Université Laval, Université Laval, 2525, Chemin de la Canardière, Québec, QC, Canada, 1 418 525 4437, France.Legare@mfa.ulaval.ca %K shared decision making %K multiple criteria decision analysis %K analytic hierarchy process %K decision aid %K prenatal screening %K mobile app %D 2019 %7 8.10.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Decisions about prenatal screening to assess the risk of genetic conditions such as Down syndrome are complex and should be well informed. Moreover, the number of available tests is increasing. Shared decision making (SDM) about testing could be facilitated by decision aids powered by mobile technology. Objective: In this mixed methods study, we aim to (1) assess women’s needs and preferences regarding using an app for considering prenatal screening, (2) develop a decision model using the analytical hierarchy process, and (3) develop an analytical app and assess its usability and usefulness. Methods: In phase 1, we will assess the needs of 90 pregnant women and their partners (if available). We will identify eligible participants in 3 clinical sites (a midwife-led birthing center, a family practice clinic, and an obstetrician-led hospital-based clinic) in Quebec City and Montreal, Canada. Using semistructured interviews, we will assess participants’ attitudes toward mobile apps for decision making about health, their current use of apps for health purposes, and their expectations of an app for prenatal testing decisions. Self-administered questionnaires will collect sociodemographic information, intentions to use an app for prenatal testing, and perceived importance of decision criteria. Qualitative data will be transcribed verbatim and analyzed thematically. Quantitative data will be analyzed using descriptive statistics and the analytic hierarchy process (AHP) method. In phase 2, we will develop a decision model using the AHP whereby users can assign relative importance to criteria when deciding between options. We will validate the model with potential users and a multidisciplinary team of patients, family physicians, primary care researchers, decision sciences experts, engineers, and experts in SDM, genetics, and bioethics. In phase 3, we will develop a prototype of the app using the results of the first 2 phases, pilot test its usefulness and usability among a sample of 15 pregnant women and their partners (if available), and improve it through 3 iterations. Data will be collected with a self-administered questionnaire. Results will be analyzed using descriptive statistics. Results: Recruitment for phase 1 will begin in 2019. We expect results to be available in 2021. Conclusions: This study will result in a validated analytical app that will provide pregnant women and their partners with up-to-date information about prenatal screening options and their risks and benefits. It will help them clarify their values and enable them to weigh the options to make informed choices consistent with their preferences and values before meeting face-to-face with their health care professional. The app will be easy to update with the latest information and will provide women with a user-friendly experience using their smartphones or tablets. This study and the resulting app will contribute to high-quality SDM between pregnant women and their health care team. International Registered Report Identifier (IRRID): DERR1-10.2196/13321 %M 31596249 %R 10.2196/13321 %U https://www.researchprotocols.org/2019/10/e13321 %U https://doi.org/10.2196/13321 %U http://www.ncbi.nlm.nih.gov/pubmed/31596249 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 10 %P e14699 %T Dropout and Abstinence Outcomes in a National Text Messaging Smoking Cessation Intervention for Pregnant Women, SmokefreeMOM: Observational Study %A Kamke,Kristyn %A Grenen,Emily %A Robinson,Cendrine %A El-Toukhy,Sherine %+ Division of Intramural Research, National Institute on Minority Health and Health Disparities, National Institutes of Health, 7201 Wisconsin Ave, RM 533M, Bethesda, MD, 20814, United States, 1 301 594 4743, sherine.el-toukhy@nih.gov %K smoking cessation %K pregnancy %K women's health %K mHealth %K text messaging intervention %D 2019 %7 7.10.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Population-level text messaging smoking cessation interventions may reduce racial and ethnic differences in smoking among pregnant women. Objective: Our objective was to examine racial and ethnic differences in dropout, response, and abstinence rates among users of a US national, publicly available text messaging cessation intervention targeting pregnant women, SmokefreeMOM. Methods: Participants were online subscribers to SmokefreeMOM who set a prospective quit date within the 9 months before their due date. We examined demographics, smoking frequency, number of cigarettes smoked per day, and prequit time (up to 14 days of preparation time before quit date) as correlates of response rate and abstinence at 8 time points: quit date, day 7, day 14, day 21, day 28, day 35, day 42 (intervention end), and day 72 (1-month follow-up). We conducted survival analysis of time from quit date to dropout by race and ethnicity. Results: The mean age of the analytic sample of 1288 users was 29.46 (SD 7.11) years. Of these, 65.81% (848/1288) were white, 16.04% (207/1288) were black, 8.86% (114/1288) were Latina, and 9.29% (120/1288) were multiracial, American Indian/Alaska Native, Native Hawaiian Pacific Islander, or other; 82.68% (1065/1288) had some college education or less. Point-prevalence abstinence was 14.51% (157/1082) on quit day, 3.51% (38/1082) at intervention end, and 1.99% (21/1053) at 1-month follow-up. Black users (hazard ratio 0.68, 95% CI 0.51-0.91) and those with a high school degree or less (hazard ratio 0.66, 95% CI 0.49-0.89) or some college education (hazard ratio 0.75, 95% CI 0.57-0.99) were less likely to drop out than whites or users with a bachelor’s degree or higher. Response and abstinence rates were similar across race, ethnicity, and education. Conclusions: Enrollment was low among racial and ethnic minority women but high among less-educated women. Abstinence at intervention end and 1-month follow-up was lower than that in controlled trials of text messaging cessation interventions for pregnant women (range 7%-20%). Increasing the reach, engagement, and effectiveness of SmokefreeMOM, especially among women with high rates of smoking during pregnancy, must be prioritized. %M 31593542 %R 10.2196/14699 %U https://mhealth.jmir.org/2019/10/e14699 %U https://doi.org/10.2196/14699 %U http://www.ncbi.nlm.nih.gov/pubmed/31593542 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e13947 %T Information and Communication Systems to Tackle Barriers to Breastfeeding: Systematic Search and Review %A Tang,Kymeng %A Gerling,Kathrin %A Chen,Wei %A Geurts,Luc %+ e-Media Research Lab, KU Leuven, Andreas Vesaliusstraat 13, Leuven, 3000, Belgium, 32 16 32 24 97, kymeng.tang@kuleuven.be %K breastfeeding %K technology %K review %D 2019 %7 27.9.2019 %9 Review %J J Med Internet Res %G English %X Background: Breastfeeding has many benefits for newborns, mothers, and the wider society. The World Health Organization recommends mothers to feed newborns exclusively with breastmilk for the first 6 months after birth, but breastfeeding rates in many countries fail to align with the recommendations because of various barriers. Breastfeeding success is associated with a number of determinants, such as self-efficacy, intention to breastfeed, and attitudes toward breastfeeding. Information and communication technology (ICT) has been leveraged to support breastfeeding by means of improving knowledge or providing practical supports in different maternal stages. Previous reviews have examined and summarized the effectiveness and credibility of interventions; however, no review has been done from a human-computer interaction perspective that is concerned with novel interaction techniques and the perspective of end users. Objective: The objective of this review was to provide a comprehensive overview of existing digital interventions that support breastfeeding by investigating systems’ objective, technology design, validation process, and quality attributes, both in terms of clinical parameters as well as usability and user experience. Methods: A systematic search was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in the following libraries: PubMed, Science Direct, Association for Computing Machinery Digital Library (ACM Digital Library), and Institute of Electrical and Electronics Engineers Xplore (IEEE Xplore). Results: A total of 35 papers discussing 30 interventions were included. The main goals of these interventions were organized into 4 categories: breastfeeding education (n=12), breastfeeding promotion (n=8), communication support (n=6), and daily practical support (n=4). Of the interventions, 13 target mothers in the postnatal period. Most interventions come in forms of client communication systems (n=18), which frequently leverage Web technologies, text message, and mobile apps to provide breastfeeding support. Systems predominantly focus on mothers; validation strategies were rather heterogeneous, with 12 user studies concerning usability and user experience and 18 clinical validation studies focusing on the effects of the interventions on breastfeeding determinants; 5 papers did not report results. Generally, straightforward systems (eg, communication tools or Web-based solutions) seem to be more effective than complex interventions (eg, games). Conclusions: Existing information and communication systems offer effective means of improving breastfeeding outcomes, but they do not address all relevant periods in parenthood (eg, the antenatal period) and often do not involve important stakeholders, such as partners. There is an opportunity to leverage more complex technical systems to open up avenues for the broader design of ICT to support breastfeeding; however, considering evaluation outcomes of existing support systems of higher complexity, such systems need to be designed with care. %M 31573903 %R 10.2196/13947 %U https://www.jmir.org/2019/9/e13947/ %U https://doi.org/10.2196/13947 %U http://www.ncbi.nlm.nih.gov/pubmed/31573903 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e14445 %T Disparities in Electronic Patient Portal Use in Prenatal Care: Retrospective Cohort Study %A Ukoha,Erinma P %A Feinglass,Joe %A Yee,Lynn M %+ Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California San Francisco, 550 16th Street, San Francisco, CA, 94143, United States, 1 415 476 5192, erinma.ukoha@ucsf.edu %K patient portals %K socioeconomic factors %K pregnancy %K cohort studies %D 2019 %7 23.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Electronic patient portals are websites that provide individuals access to their personal health records and allow them to engage through a secure Web-based platform. These portals are becoming increasingly popular in contemporary health care systems. Patient portal use has been found to be beneficial in multiple specialties, especially in the management of chronic disease. However, disparities have been identified in portal use in which racial and ethnic minorities and individuals with lower socioeconomic status have been shown to be less likely to enroll and use patient portals than non-Hispanic white persons and individuals with higher socioeconomic status. Electronic patient portal use by childbearing women has not been well studied, and data on portal use during pregnancy are limited. Objective: This study aimed to quantify the use of an electronic patient portal during pregnancy and examine whether disparities related to patients’ demographics or clinical characteristics exist. Methods: This was a retrospective cohort study of women who received prenatal care at an academic medical center from 2014 to 2016. Clinical records were reviewed for portal use and patient data. Patients were considered enrolled in the portal if they had an account at the time of delivery, and enrollees were compared with nonenrollees. Enrollees were further categorized based on the number of secure messages sent during pregnancy as active (≥1) or inactive (0) users. Bivariable chi-square and multivariable Poisson regression models were used to calculate the incidence rate ratio of portal enrollment and, if enrolled, of active use based on patients’ characteristics. Results: Of the 3450 women eligible for inclusion, 2530 (73.33%) enrolled in the portal. Of these enrollees, 72.09% (1824/2530) were active users. There was no difference in portal enrollment by maternal race and ethnicity on multivariable models. Women with public insurance (adjusted incidence rate ratio; aIRR 0.60, 95% CI 0.49-0.84), late enrollment in prenatal care (aIRR 0.78, 95% CI 0.69-0.89 for second trimester and aIRR 0.50, 95% CI 0.39-0.64 for third trimester), and high-risk pregnancies (aIRR 0.82, 95% CI 0.75-0.89) were significantly less likely to enroll. Conversely, nulliparity (aIRR 1.10, 95% CI 1.02-1.20) and having more than 8 prescription medications at prenatal care initiation (aIRR 1.19, 95% CI 1.06-1.32) were associated with greater likelihood of enrollment. Among portal enrollees, the only factor significantly associated with active portal use (ie, secure messaging) was nulliparity (aIRR 1.11, 95% CI 1.01-1.23). Conclusions: Among an obstetric population, multiple clinical and socioeconomic factors were associated with electronic portal enrollment, but not subsequent active use. As portals become more integrated as tools to promote health, efforts should be made to ensure that already vulnerable populations are not further disadvantaged with regard to electronic-based care. %M 31586367 %R 10.2196/14445 %U https://www.jmir.org/2019/9/e14445 %U https://doi.org/10.2196/14445 %U http://www.ncbi.nlm.nih.gov/pubmed/31586367 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e14734 %T Wearable Digital Sensors to Identify Risks of Postpartum Depression and Personalize Psychological Treatment for Adolescent Mothers: Protocol for a Mixed Methods Exploratory Study in Rural Nepal %A Poudyal,Anubhuti %A van Heerden,Alastair %A Hagaman,Ashley %A Maharjan,Sujen Man %A Byanjankar,Prabin %A Subba,Prasansa %A Kohrt,Brandon A %+ Division of Global Mental Health, Department of Psychiatry and Behavioral Sciences, George Washington School of Medicine and Health Sciences, 2120 L Street, Suite 600, Washington, DC, 20037, United States, 1 (202) 741 2888, bkohrt@gwu.edu %K developing countries %K feasibility studies %K mobile health %K mother-child interaction %K postpartum depression %K psychotherapy %D 2019 %7 11.09.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: There is a high prevalence of untreated postpartum depression among adolescent mothers with the greatest gap in services in low- and middle-income countries. Recent studies have demonstrated the potential of nonspecialists to provide mental health services for postpartum depression in these low-resource settings. However, there is inconsistency in short-term and long-term benefits from the interventions. Passive sensing data generated from wearable digital devices can be used to more accurately distinguish which mothers will benefit from psychological services. In addition, wearable digital sensors can be used to passively collect data to personalize care for mothers. Therefore, wearable passive sensing technology has the potential to improve outcomes from psychological treatments for postpartum depression. Objective: This study will explore the use of wearable digital sensors for two objectives: First, we will pilot test using wearable sensors to generate passive sensing data that distinguish adolescent mothers with depression from those without depression. Second, we will explore how nonspecialists can integrate data from passive sensing technologies to better personalize psychological treatment. Methods: This study will be conducted in rural Nepal with participatory involvement of adolescent mothers and health care stakeholders through a community advisory board. The first study objective will be addressed by comparing behavioral patterns of adolescent mothers without depression (n=20) and with depression (n=20). The behavioral patterns will be generated by wearable digital devices collecting data in 4 domains: (1) the physical activity of mothers using accelerometer data on mobile phones, (2) the geographic range and routine of mothers using GPS (Global Positioning System) data collected from mobile phones, (3) the time and routine of adolescent mothers with their infants using proximity data collected from Bluetooth beacons, and (4) the verbal stimulation and auditory environment for mothers and infants using episodic audio recordings on mobile phones. For the second objective, the same 4 domains of data will be collected and shared with nonspecialists who are delivering an evidence-based behavioral activation intervention to the depressed adolescent mothers. Over 5 weeks of the intervention, we will document how passive sensing data are used by nonspecialists to personalize the intervention. In addition, qualitative data on feasibility and acceptability of passive data collection will be collected for both objectives. Results: To date, a community advisory board comprising young women and health workers engaged with adolescent mothers has been established. The study is open for recruitment, and data collection is anticipated to be completed in November 2019. Conclusions: Integration of passive sensing data in public health and clinical programs for mothers at risk of perinatal mental health problems has the potential to more accurately identify who will benefit from services and increase the effectiveness by personalizing psychological interventions. International Registered Report Identifier (IRRID): DERR1-10.2196/14734 %M 31512581 %R 10.2196/14734 %U http://www.researchprotocols.org/2019/8/e14734/ %U https://doi.org/10.2196/14734 %U http://www.ncbi.nlm.nih.gov/pubmed/31512581 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 9 %P e13967 %T The Use of and Experiences With Telelactation Among Rural Breastfeeding Mothers: Secondary Analysis of a Randomized Controlled Trial %A Kapinos,Kandice %A Kotzias,Virginia %A Bogen,Debra %A Ray,Kristin %A Demirci,Jill %A Rigas,Mary Ann %A Uscher-Pines,Lori %+ RAND Corporation, 1200 South Hayes Street, Arlington, VA, 22202, United States, 1 703 413 1100 ext 5361, kkapinos@rand.org %K telehealth %K telemedicine %K breastfeeding %K lactation %K lactation support %K rural health %D 2019 %7 03.09.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Telelactation services connect breastfeeding mothers to remotely located lactation consultants through audio-visual technology and can increase access to professional breastfeeding support in rural areas. Objective: The objective of this study was to identify maternal characteristics associated with the demand for and use of telelactation and to describe visit characteristics. Methods: We conducted a descriptive study within the context of a randomized controlled trial. Participant survey data and vendor electronic medical record data were used to assess video call characteristics like timing, duration, topics discussed, and participant satisfaction. Recruitment occurred from 2016-2018 at a rural critical access hospital in Pennsylvania. The 102 women enrolled in the study were given access to unlimited, on-demand video calls with lactation consultants through a mobile phone app and were tracked for 12 weeks following their postpartum hospitalization. Results: A total of 94 participants out of 102 recruits (92%) participated in the final, 12-week survey assessment were included in the analysis. Of those, 47 (50%) participants reported participating in one or more video calls, and 31 (33%) completed one or more calls that included a substantive discussion of a breastfeeding challenge. Participants who used telelactation (21/31, 68%; P=.02) were more likely to be working at 12 weeks postpartum compared to others (26/63, 41%), were less likely (12/31, 39%; P=.02) to have prior breastfeeding experience on average compared to nonusers (41/63, 65%), and were less likely to have breastfed exclusively (16/31, 52%; P<.001) prior to hospital discharge compared to mothers who didn’t use telelactation services (51/63, 81%). Most video calls (58/83, 70%) occurred during the infant’s first month of life and 41% (34/83) occurred outside of business hours. The most common challenges discussed included: breast pain, soreness, and infection (25/83, 30%), use of nipple shields (21/83, 25%), and latch or positioning (17/83, 24%). Most telelactation users (43/47, 91%) expressed satisfaction with the help received. Conclusions: Telelactation is an innovation in the delivery of professional breastfeeding support. This research documents both demand for and positive experiences with telelactation in an underserved population. Trial Registration: ClinicalTrials.gov NCT02870413; https://clinicaltrials.gov/ct2/show/NCT02870413 %M 31482848 %R 10.2196/13967 %U https://www.jmir.org/2019/9/e13967/ %U https://doi.org/10.2196/13967 %U http://www.ncbi.nlm.nih.gov/pubmed/31482848 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12915 %T Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 2): Qualitative Study %A Shorey,Shefaly %A Ng,Esperanza Debby %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School of Medicine, National University of Singapore, Clinical Research Centre, MD 11, Level 2, 10 Medical Drive, Singapore, 117597, Singapore, 65 6601 1294, nurssh@nus.edu.sg %K depression %K mothers %K postpartum %K qualitative %K social support %K telecommunication %K digital health %K peer support %K peer-to-peer support %K online support groups %K internet %D 2019 %7 29.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Social support is known to reduce risks of postnatal depression (PND) and improve maternal emotional well-being. However, the Asian cultural context is often neglected when appraising maternal needs and mothers’ preferences for social support. While many preventive efforts have experimented with technology, professionals, and paraprofessionals in providing social support to mothers in need, most studies determined the effectiveness of their interventions through quantitative measurements of maternal outcomes. Experiences and feedback from both participants and administrators are rarely discussed, especially in an Asian setting. Objective: The goal of the research was to evaluate the postnatal experiences of Asian mothers at risk of PND and the perceptions of peer volunteers regarding a technology-based peer-support intervention program (PIP). Methods: A qualitative semistructured interview was conducted with 20 Asian mothers at risk of depression (10 from the control group and 10 from the intervention group) and 19 peer volunteers from a randomized controlled trial. The PIP included weekly correspondence between peer volunteers and mothers through any telecommunication means over 4 weeks. All interviews were approximately 30 to 60 minutes long, audiotaped, transcribed verbatim, and analyzed using thematic analysis. Study findings were reported according to the Consolidated Standards of Reporting Trials checklist. Results: Two overarching themes comprising five subthemes were generated: postnatal experience (a bouncy ride, a way forward) and evaluation of the PIP (valuable, flexible, and supportive program; building blocks of a good relationship; and lessons learned and the road ahead). Mothers from both the control and interventions groups were generally satisfied with hospital care and the support received from family. They also shared similar breastfeeding challenges and needs for more informed decisions and follow-up support from the hospital. However, mothers who received the PIP tended to have more positive outlooks of their birth experiences. Overall, peer volunteers and mothers involved in the PIP found the PIP useful and expressed satisfaction with the program’s flexibility. They also shared their personal takeaways, the qualities of their friendships, and the need for extended correspondence time and recommended outreach to non–at-risk mothers. Conclusions: The positive endorsement of the PIP by peer volunteers and mothers suggests the success of the PIP in maintaining positive maternal emotional well-being during the postpartum period. With the help of technology, hospitals can easily provide additional peer support to at-risk mothers in addition to existing standard care offered to these mothers. Trial Registration: ISRCTN Registry ISRCTN14864807; http://www.isrctn.com/ISRCTN14864807 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.9416 %M 31469080 %R 10.2196/12915 %U http://www.jmir.org/2019/8/e12915/ %U https://doi.org/10.2196/12915 %U http://www.ncbi.nlm.nih.gov/pubmed/31469080 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 8 %P e12410 %T Evaluation of a Technology-Based Peer-Support Intervention Program for Preventing Postnatal Depression (Part 1): Randomized Controlled Trial %A Shorey,Shefaly %A Chee,Cornelia Yin Ing %A Ng,Esperanza Debby %A Lau,Ying %A Dennis,Cindy-Lee %A Chan,Yiong Huak %+ Alice Lee Centre for Nursing Studies, Yong Loo Lin School Of Medicine, National University of Singapore, Clinical Research Centre, MD 11, Level 2, 10 Medical Drive, Singapore, 117597, Singapore, 65 6601 1294, nurssh@nus.edu.sg %K anxiety %K loneliness %K postpartum depression %K social support %K technology %K digital health %K peer support %K peer-to-peer support %K online support groups %K internet %D 2019 %7 29.08.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The frenzy of postbirth events often takes a toll on mothers’ mental well-being, leaving them susceptible to postpartum psychological disorders such as postnatal depression (PND). Social support has been found to be effective in restoring the emotional well-being of new mothers. Therefore, mothers need to be supported during the crucial postpartum period to buffer the negative after effects of childbirth and to promote healthier maternal well-being. Objective: This study aimed to evaluate the effectiveness of a technology-based peer-support intervention program (PIP) on maternal outcomes during the early postpartum period. Methods: A randomized, parallel-armed controlled trial was conducted. The study recruited 138 mothers (69 in intervention group, 69 in control group) at risk of PND from a tertiary hospital in Singapore. To support these mothers, 20 peer volunteers were recruited by word of mouth and trained by a psychiatrist in social support skills before the intervention commenced. The 4-week–long intervention included a weekly follow-up with a peer volunteer through phone calls or text messages. The intervention group received peer support in addition to the standard care offered by the hospital. The control group only received postnatal standard care. Maternal outcomes (PND, postnatal anxiety [PNA], loneliness, and perceived social support) were measured with reliable and valid instruments. Data were collected immediately postpartum, at 1 month postpartum and at 3 months postpartum. The general linear model was used to compare the groups for postpartum percentage changes in the outcome variables at first and third months, and the linear mixed model was used to compare the trend over the study period. Results: There was a statistically significant difference in Edinburgh Postnatal Depression Scale scores (d=–2.11; 95% CI −4.0 to −0.3; P=.03) between the intervention and control groups at 3 months postpartum after adjusting for covariates. The intervention group had a significant change over time compared with the control group. Conclusions: The technology-based PIP was found to be effective in reducing the risk of PND among new mothers and showed a generally positive trend in reducing PNA and loneliness and increasing perceived social support. This study highlights the importance of training paraprofessionals to provide needed support for new mothers postpartum. A further long-term evaluation of the PIP on maternal and family outcomes and its cost-effectiveness is needed to inform clinical practices. Trial Registration: ISRCTN Registry ISRCTN14864807; https://www.isrctn.com/ISRCTN14864807 International Registered Report Identifier (IRRID): RR2-10.2196/resprot.9416 %M 31469084 %R 10.2196/12410 %U http://www.jmir.org/2019/8/e12410/ %U https://doi.org/10.2196/12410 %U http://www.ncbi.nlm.nih.gov/pubmed/31469084 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 8 %P e13271 %T Improving Mental Health in Pregnancy for Refugee Women: Protocol for the Implementation and Evaluation of a Screening Program in Melbourne, Australia %A Boyle,Jacqueline Anne %A Willey,Suzanne %A Blackmore,Rebecca %A East,Christine %A McBride,Jacqueline %A Gray,Kylie %A Melvin,Glenn %A Fradkin,Rebecca %A Ball,Natahl %A Highet,Nicole %A Gibson-Helm,Melanie %+ Monash Centre for Health Research and Implementation, School of Public Health and Preventive Medicine, Monash University, 43-51 Kanooka Gve, Clayton, Melbourne, 3168, Australia, 61 (613) 85722670, jacqueline.boyle@monash.edu %K mental health %K refugees %K transients and migrants %K pregnancy %K prenatal care %K mass screening %D 2019 %7 19.08.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Identifying mental health disorders in migrant and refugee women during pregnancy provides an opportunity for interventions that may benefit women and their families. Evidence suggests that perinatal mental health disorders impact mother-infant attachment at critical times, which can affect child development. Postnatal depression resulting in suicide is one of the leading causes of maternal mortality postpartum. Routine screening of perinatal mental health is recommended to improve the identification of depression and anxiety and to facilitate early management. However, screening is poorly implemented into routine practice. This study is the first to investigate routine screening for perinatal mental health in a maternity setting designed for refugee women. This study will determine whether symptoms of depression and anxiety are more likely to be detected by the screening program compared with routine care and will evaluate the screening program’s feasibility and acceptability to women and health care providers (HCPs). Objective: The objectives of this study are (1) to assess if refugee women are more likely to screen risk-positive for depression and anxiety than nonrefugee women, using the Edinburgh Postnatal Depression Scale (EPDS); (2) to assess if screening in pregnancy using the EPDS enables better detection of symptoms of depression and anxiety in refugee women than current routine care; (3) to determine if a screening program for perinatal mental health in a maternity setting designed for refugee women is acceptable to women; and (4) to evaluate the feasibility and acceptability of the perinatal mental health screening program from the perspective of HCPs (including the barriers and enablers to implementation). Methods: This study uses an internationally recommended screening measure, the EPDS, and a locally developed psychosocial questionnaire, both administered in early pregnancy and again in the third trimester. These measures have been translated into the most common languages used by the women attending the clinic and are administered via an electronic platform (iCOPE). This platform automatically calculates the EPDS score and generates reports for the HCP and woman. A total of 119 refugee women and 155 nonrefugee women have been recruited to evaluate the screening program’s ability to detect depression and anxiety symptoms and will be compared with 34 refugee women receiving routine care. A subsample of women will participate in a qualitative assessment of the screening program’s acceptability and feasibility. Health service staff have been recruited to evaluate the integration of screening into maternity care. Results: The recruitment is complete, and data collection and analysis are underway. Conclusions: It is anticipated that screening will increase the identification and management of depression and anxiety symptoms in pregnancy. New information will be generated on how to implement such a program in feasible and acceptable ways that will improve health outcomes for refugee women. International Registered Report Identifier (IRRID): DERR1-10.2196/13271 %M 31429411 %R 10.2196/13271 %U http://www.researchprotocols.org/2019/8/e13271/ %U https://doi.org/10.2196/13271 %U http://www.ncbi.nlm.nih.gov/pubmed/31429411 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 7 %P e12666 %T Tracker-Based Personal Advice to Support the Baby’s Healthy Development in a Novel Parenting App: Data-Driven Innovation %A Otte,Renée A %A van Beukering,Alice J E %A Boelens-Brockhuis,Lili-Marjan %+ Philips Research, Family Care Solutions, High Tech Campus 34, Room 3 065, Eindhoven, 5656AE, Netherlands, 31 402748877, renee.otte@philips.com %K data analytics %K data-driven science %K mHealth %K mobile apps %K infant development %K infant health %K parenting %D 2019 %7 24.07.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The current generation of millennial parents prefers digital communications and makes use of apps on a daily basis to find information about child-rearing topics. Given this, an increasing amount of parenting apps have become available. These apps also allow parents to track their baby’s development with increasing completeness and precision. The large amounts of data collected in this process provide ample opportunity for data-driven innovation (DDI). Subsequently, apps are increasingly personalized by offering information that is based on the data tracked in the app. In line with this, Philips Avent has developed the uGrow app, a medical-grade app dedicated to new parents for tracking their baby’s development. Through so-called insights, the uGrow app seeks to provide a data-driven solution by offering parents personal advice that is sourced from user-tracked behavioral and contextual data. Objective: The aim of this study was twofold. First, it aimed to give a description of the development process of the insights for the uGrow app. Second, it aimed to present results from a study about parents’ experiences with the insights. Methods: The development process comprised 3 phases: a formative phase, development phase, and summative phase. In the formative phase, 3 substudies were executed in series to understand and identify parents’ and health care professionals’ (HCPs) needs for insights, using qualitative and quantitative methods. After the formative phase, insights were created during the development phase. Subsequently, in the summative phase, these insights were validated against parents’ experience using a quantitative approach. Results: As part of the formative phase, parents indicated having a need for smart information based on a data analysis of the data they track in an app. HCPs supported the general concept of insights for the uGrow app, although specific types of insights were considered irrelevant or even risky. After implementing a preliminary set of insights in a prototype version of the uGrow app and testing it with parents, the majority of parents (87%) reported being satisfied with the insights. From these outcomes, a total of 89 insights were implemented in a final version of the uGrow app. In the summative phase, the majority of parents reported experiencing these insights as reassuring and useful (94%), as adding enjoyment (85%), and as motivating for continuing tracking for a longer period of time (77%). Conclusions: Parents experienced the insights in the uGrow app as useful and reassuring and as adding enjoyment to their use of the uGrow app and tracking their baby’s development. The insights development process we followed showed how the quality of insights can be guaranteed by ensuring that insights are relevant, appropriate, and evidence based. In this way, insights are an example of meaningful DDI. %M 31342901 %R 10.2196/12666 %U https://mhealth.jmir.org/2019/7/e12666/ %U https://doi.org/10.2196/12666 %U http://www.ncbi.nlm.nih.gov/pubmed/31342901 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 7 %P e12587 %T Exploring the Impact of a Mobile Health Solution for Postpartum Pelvic Floor Muscle Training: Pilot Randomized Controlled Feasibility Study %A Dufour,Sinéad %A Fedorkow,Donna %A Kun,Jessica %A Deng,Shirley Xiaoxuan %A Fang,Qiyin %+ School of Rehabilitation Science, McMaster University, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada, 1 905 525 9140, sdufour@mcmaster.ca %K postpartum %K pelvic floor %K mobile health %K feasibility study %K wireless technology %K wearable technology %K computer games %K biofeedback %D 2019 %7 11.07.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The postpartum period is a vulnerable time for the pelvic floor. Early implementation of pelvic floor muscle exercises, appropriately termed as pelvic floor muscle training (PFMT), in the postpartum period has been advocated because of its established effectiveness. The popularity of mobile health (mHealth) devices highlights their perceived utility. The effectiveness of various mHealth technologies with claims to support pelvic floor health and fitness is yet to be substantiated through systematic inquiry. Objective: The aim of this study was to determine the acceptability, feasibility, and potential effect on outcomes of an mHealth device purposed to facilitate pelvic floor muscle training among postpartum women. Methods: A 16-week mixed methods pilot study was conducted to evaluate outcomes and determine aspects of acceptability and feasibility of an mHealth device. All participants received standardized examination of their pelvic floor muscles and associated instruction on the correct performance of PFMT. Those randomized to the iBall intervention received instructions on its use. Schedules for utilization of the iBall and PFMT were not prescribed, but all participants were informed of the standard established recommendation of PFMT, which includes 3 sets of 10 exercises, 3 to 4 times a week, for the duration of the intervention period. Quantitative data included the measurement of pelvic floor muscle parameters (strength, endurance, and coordination) following the PERFECT assessment scheme: Incontinence Impact Questionnaire scores and the Urogenital Distress Inventory (UDI-6) scores. Aspects of acceptability and feasibility were collected through one-to-one interviews. Interview transcripts were analyzed using Thorne’s interpretive description approach. Results: A total of 23 women with a mean age of 32.2 years were randomized to an intervention group (n=13) or a control group (n=10). Both groups improved on all measures. The only statistically significant change was the UDI-6 score within both groups at 16 weeks compared with baseline. There was no statistically significant difference between the intervention group and control group on any outcomes. Most participants using the iBall (n=10, 77%) indicated value in the concept of the mHealth solution. Technical difficulties (n=10, 77%), a cumbersome initiation process (n=8, 61%), and discomfort from the device (n=8, 61%) were reasons impeding intervention acceptability. Most participants (n=17, 74%) indicated that the initial assessment and training was more useful than the mHealth solution, a tenet that was echoed by all control group participants. Conclusions: Our pilot study demonstrated the potential for mHealth solution–enhanced PFMT in the early postpartum period. Usability issues in hardware and software hindered feasibility and acceptance by the participants. Our findings can inform the redesign of mHealth solutions that may be of value if acceptability and feasibility issues can be overcome. Trial Registration: ClinicalTrials.gov NCT02865954; https://clinicaltrials.gov/ct2/show/NCT02865954 %M 31298221 %R 10.2196/12587 %U http://mhealth.jmir.org/2019/7/e12587/ %U https://doi.org/10.2196/12587 %U http://www.ncbi.nlm.nih.gov/pubmed/31298221 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 7 %P e14289 %T Mothers’ Perceptions of the Internet and Social Media as Sources of Parenting and Health Information: Qualitative Study %A Moon,Rachel Y %A Mathews,Anita %A Oden,Rosalind %A Carlin,Rebecca %+ University of Virginia, PO Box 800386, Charlottesville, VA, 22908, United States, 1 4349245521, rym4z@virginia.edu %K internet %K parenting %K social media %K focus groups %D 2019 %7 09.07.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Traditionally, guidance and support to new parents have come from family, friends, and health care providers. However, the internet and social media are growing sources of guidance and support for parents. Little is known about how the internet and social media are used by parents of young infants and specifically about parental perceptions of the internet and social media as sources of parenting and infant health information. Objective: The aim of this study was to explore, using qualitative methods, parental perceptions of the advantages and disadvantages of the internet and social media as sources of parenting and health information regarding their infant. Methods: A total of 28 mothers participated in focus groups or individual interviews. Probing questions concerning parenting and health information sources were asked. Themes were developed in an iterative manner from coded data. Results: The central themes were (1) reasons that mothers turn to the internet for parenting and health information, (2) cautionary advice about the internet, and (3) reasons that mothers turn to social media for parenting and health information. Mothers appreciated the ability to gather unlimited information and multiple opinions quickly and anonymously, but recognized the need to use reputable sources of information. Mothers also appreciated the immediacy of affirmation, support, and tailored information available through social media. Conclusions: The internet and social media are rapidly becoming important and trusted sources of parenting and health information that mothers turn to when making infant care decisions. %M 31290403 %R 10.2196/14289 %U https://www.jmir.org/2019/7/e14289/ %U https://doi.org/10.2196/14289 %U http://www.ncbi.nlm.nih.gov/pubmed/31290403 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 1 %P e12157 %T Gamifying Breastfeeding for Fathers: Process Evaluation of the Milk Man Mobile App %A White,Becky %A Giglia,Roslyn C %A White,James A %A Dhaliwal,Satvinder %A Burns,Sharyn K %A Scott,Jane A %+ School of Public Health, Curtin University, GPO Box U1987, Bentley, Perth, 6845, Australia, 61 8 9266 9050, jane.scott@curtin.edu.au %K mHealth %K app %K breastfeeding %K fathers %K gamification %K socially connected %K push notifications %D 2019 %7 20.06.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Mobile technology offers unique opportunities to reach people with health promotion interventions. Breastfeeding is an important public health issue, and fathers are a key support. Milk Man is a father-focused breastfeeding app that sought to engage fathers with information and conversation about breastfeeding, with the goal to impact positively on breastfeeding duration. Objective: The study aimed to describe the process evaluation of the Milk Man app that was trialed in the Parent Infant Feeding Initiative randomized controlled trial. Methods: The app used an information library, gamification, push notifications, and social connectivity via a Web-based conversation forum, which included polls and conversation starters, to engage fathers with breastfeeding information. Fathers had access to the app from approximately 32 weeks of gestation to 6 months postpartum. Process evaluation data were collected from a self-completed questionnaire administered via a Web-based link sent to participants at 6 weeks postpartum, and app analytics data were collected directly from the app. Quantitative data from both sources and qualitative responses to open-ended questions were used to triangulate findings to investigate patterns of usage and the effectiveness of each app engagement strategy to motivate and engage users. Results: A total of 80.3% (586/730) of participants, who were randomized to receive the app, downloaded Milk Man. Push notifications and interest in what other fathers had posted in the forum were the 2 main motivators to app use. Fathers used the app most while their partners were still pregnant and in the weeks immediately after the birth of their baby. Perspectives on the gamification strategy were varied. However, at 6 weeks postpartum, approximately one-third of fathers still using the app said that the gamification elements were encouraging the app use. The ease of use of the app and the design were important elements that were rated positively. The conversation forum emerged as the hub of app activity; all but 1 of the most accessed library articles and external organization links had been prompted as part of a conversation starter. Fathers posted comments in the conversation forum 1126 times (average of 2.21 per user) and voted in polls 3096 times (average of 6 per user). Conclusions: These results demonstrate that the Milk Man app was an acceptable source of breastfeeding information and support that fathers and fathers-to-be are prepared to use throughout the perinatal period. The app showed encouraging results with facilitating conversation between partners. The conversation forum was clearly central to the success of the app, and fathers provided suggestions for improvement. Gamification results were varied, yet it was a key motivator for some users. These results provide valuable insight into the acceptability of the engagement strategies, including motivations for use and user perspectives on the app. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12614000605695; https://www.anzctr.org.au /Trial/Registration/TrialReview.aspx?ACTRN=12614000605695  %M 31518324 %R 10.2196/12157 %U http://pediatrics.jmir.org/2019/1/e12157/ %U https://doi.org/10.2196/12157 %U http://www.ncbi.nlm.nih.gov/pubmed/31518324 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 1 %P e12524 %T Online Information About Periviable Birth: Quality Assessment %A Haragan,Adriane F %A Zuwiala,Carly A %A Himes,Katherine P %+ Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Research Institute, University of Pittsburgh, 300 Halket Street, Pittsburgh, PA, 15228, United States, 1 412 973 2249, himekp@upmc.edu %K periviable birth %K patient education %K patient counseling %K Internet resources %D 2019 %7 7.6.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Over 20,000 parents in the United States face the challenge of participating in decisions about whether to use life support for their infants born on the cusp of viability every year. Clinicians must help families grasp complex medical information about their baby’s immediate prognosis as well as the risk for significant long-term morbidity. Patients faced with this decision want supplemental information and frequently seek medical information on the Internet. Empirical evidence about the quality of websites is lacking. Objective: We sought to evaluate the quality of online information available about periviable birth and treatment options for infants born at the cusp of viability. Methods: We read a counseling script to 20 pregnant participants that included information typically provided by perinatal and neonatal providers when periviable birth is imminent. The women were then asked to list terms they would use to search the Internet if they wanted additional information. Using these search terms, two reviewers evaluated the content of websites obtained via a Google search. We used two metrics to assess the quality of websites. The first was the DISCERN instrument, a validated questionnaire designed to assess the quality of patient-targeted health information for treatment choices. The second metric was the Essential Content Tool (ECT), a tool designed to address key components of counseling around periviable birth as outlined by professional organizations. DISCERN scores were classified as low quality if scores were 2, fair quality if scores were 3, and high quality if scores were 4 or higher. Scores of 6 or higher on the ECT were considered high quality. Interreviewer agreement was assessed by calculated kappa statistic. Results: A total of 97 websites were reviewed. Over half (57/97, 59%) were for-profit sites, news stories, or personal blogs; 28% (27/97) were government or medical sites; and 13% (13/97) were nonprofit or advocacy sites. The majority of sites scored poorly in DISCERN questions designed to assess the reliability of information presented as well as data regarding treatment choices. Only 7% (7/97) of the websites were high quality as defined by the DISCERN tool. The majority of sites did not address the essential content defined by the ECT. Importantly, only 18% of websites (17/97) indicated that there are often a number of reasonable approaches to newborn care when faced with periviable birth. Agreement was strong, with kappa ranging from .72 to .91. Conclusions: Most information about periviable birth found on the Internet using common search strategies is of low quality. News stories highlighting positive outcomes are disproportionately represented. Few websites discuss comfort care or how treatment decisions impact quality of life. %M 31518325 %R 10.2196/12524 %U http://pediatrics.jmir.org/2019/1/e12524/ %U https://doi.org/10.2196/12524 %U http://www.ncbi.nlm.nih.gov/pubmed/31518325 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 6 %N 5 %P e10778 %T A Group-Based Online Intervention to Prevent Postpartum Depression (Sunnyside): Feasibility Randomized Controlled Trial %A Duffecy,Jennifer %A Grekin,Rebecca %A Hinkel,Hannah %A Gallivan,Nicholas %A Nelson,Graham %A O'Hara,Michael W %+ Department of Psychiatry, College of Medicine, University of Illinois at Chicago, 912 S Wood, Chicago, IL, 60612, United States, 1 3124131225, jduffecy@gmail.com %K postpartum depression %K cognitive behavioral therapy %K internet %K social support %D 2019 %7 28.05.2019 %9 Original Paper %J JMIR Ment Health %G English %X Background: Postpartum depression (PPD) has a 20% 3-month prevalence rate. The consequences of PPD are significant for the mother, infant, and the family. There is a need for preventive interventions for PPD, which are effective and accessible; however, many barriers exist for women who attempt to access perinatal depression prevention programs. Internet interventions for the treatment and prevention of depression are widely accepted as efficacious and may overcome some of the issues pertaining to access to treatment barriers perinatal women face. However, internet interventions offered without any human support tend to have low adherence but positive outcomes for those who do complete treatment. Internet support groups often have high levels of adherence but minimal data supporting efficacy as a treatment for depression. Taken together, these findings suggest that combining the treatment components of individual interventions with the support provided by an internet support group might create an intervention with the scalability and cost-effectiveness of an individual intervention and the better outcomes typically found in supported interventions. Objectives: This study aimed to describe the development of a cognitive behavioral therapy (CBT) internet intervention with peer support to prevent PPD and examine preliminary depression and site usage outcomes. Methods: User-centered design groups were used to develop the internet intervention. Once the intervention was developed, women who were 20 to 28 weeks pregnant with symptoms of depression (Patient Health Questionnaire-8 scores of 5-14) but who had no major depression diagnosis were enrolled in a randomized controlled trial (RCT) to compare 8 weeks of a CBT-based internet intervention with peer support to an individual internet intervention designed to prevent PPD. Assessments took place at baseline, 4 weeks, 8 weeks (end of treatment), and then 4 weeks and 6 weeks postpartum. Results: A total of 25 women were randomized. Of these, 24 women completed the RCT. Patient Health Questionnaire-9 scores at 6 weeks postpartum remained below the clinical threshold for referral for treatment in both groups, with depression measures showing a decrease in symptoms from baseline to postpartum. At 6 weeks postpartum, only 4% (1/24) met the criteria for PPD. There was no difference between groups in adherence to the intervention, with an average of 14.55 log-ins over the course of treatment. Conclusions: Results suggest women were responsive to both peer support and individual internet interventions to prevent PPD and that peer support may be a useful feature to keep participants adherent. Trial Registration: ClinicalTrials.gov NCT02121015; https://clinicaltrials.gov/ct2/show/NCT02121015 (archived by WebCite at http://www.webcitation.org/765a7qBKy) %M 31140443 %R 10.2196/10778 %U http://mental.jmir.org/2019/5/e10778/ %U https://doi.org/10.2196/10778 %U http://www.ncbi.nlm.nih.gov/pubmed/31140443 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e12794 %T Using Smartphone-Based Psychoeducation to Reduce Postnatal Depression Among First-Time Mothers: Randomized Controlled Trial %A Chan,Ko Ling %A Leung,Wing Cheong %A Tiwari,Agnes %A Or,Ka Lun %A Ip,Patrick %+ Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong,, China (Hong Kong), 852 2766 5709, koling.chan@polyu.edu.hk %K smartphone technology %K postnatal depression %K psychoeducation %K randomized controlled trial %D 2019 %7 14.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Smartphone-based psychoeducation interventions may be a low-cost, user-friendly alternative to resource-consuming, face-to-face antenatal classes to educate expectant mothers. Objective: This study aimed to empirically examine whether such an intervention would lead to reduced postnatal depression, anxiety, or stress and result in a better health-related quality of life. Methods: A single-blind randomized controlled trial was conducted in Hong Kong. All first-time expectant mothers with less than 24 weeks of gestation remaining and attending the antenatal clinic at a public hospital were included. Participants were assigned to the intervention group or the control group by drawing lots. The lots, presented in sealed opaque envelopes, were randomly designated as “intervention” or “control” by stratified randomization. The intervention, a psychoeducational mobile app, was provided in addition to the treatment as usual (TAU) services from the hospital. Follow up with participants took place at 4 weeks postpartum. The primary outcome was the difference in the levels of antenatal and postnatal depression, assessed by the Edinburgh Postnatal Depression Scale (EPDS). The intention-to-treat approach was employed in the analyses. Results: The final sample was 660 expectant mothers (nintervention=330 and ncontrol=330). The mean difference in EPDS scores between the two groups was −0.65 (95% CI −1.29 to 0.00; P=.049) after adjusting for confounding factors. Associations were found between participation in the intervention and reduced depression, and attendance in TAU classes and increased stress levels. Conclusions: The smartphone-based intervention plus TAU services was effective in reducing postnatal depression at 4 weeks postpartum compared with a control condition of TAU only, making this a cost-effective alternative to TAU education for expectant mothers. Limitations of the study included the short postpartum period after which the follow-up assessment was conducted and the inclusion of first-time mothers rather than all mothers. Trial Registration: HKU Clinical Trials Registry HKUCTR-2024; http://www.hkuctr.com/Study/Show/ 34f62a2f6d594273a290491827206384 %M 31094354 %R 10.2196/12794 %U http://mhealth.jmir.org/2019/5/e12794/ %U https://doi.org/10.2196/12794 %U http://www.ncbi.nlm.nih.gov/pubmed/31094354 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 1 %P e12364 %T Features and Educational Content Related to Milk Production in Breastfeeding Apps: Content Analysis Informed by Social Cognitive Theory %A Sidhu,Suhail %A Ma,Kaoer %A Sadovnikova,Anna %+ LiquidGoldConcept, Inc, , Ypsilanti, MI,, United States, 1 916 905 3544, anna@liquidgoldconcept.com %K milk production %K milk supply %K human lactation %K breastfeeding %K breastfeeding app %K smartphone app %K Social Cognitive Theory %K breastfeeding self-efficacy %D 2019 %7 01.05.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Low milk production is one of the main reasons for premature breastfeeding cessation. Smartphone apps have the potential to assist mothers with promoting, interpreting, tracking, or learning about milk production. It is not known whether breastfeeding apps contain high-quality, engaging, and diverse content and features that could be used by mothers to increase their breastfeeding self-efficacy and answer their questions about milk production. Objective: The overarching objective of this study was to identify and evaluate features and content within breastfeeding apps that could be used by mothers to increase breastfeeding self-efficacy and answer their questions about milk production. The secondary objectives were to quantify the diversity of representation of breastfeeding experiences within breastfeeding apps and to define the type of organization that is most likely to create free apps and/or apps with high-quality, engaging, and diverse features and content related to milk production. Methods: Breastfeeding apps were identified in the Apple App Store. All features that assist mothers with tracking, promoting, or interpreting milk production in the first 0-6 months postpartum were noted. Every screen containing educational information about milk production was identified and saved for review. Images of mothers and caretakers within the selected screenshots were assessed. Three scoresheets informed by Social Cognitive Theory were created to evaluate all identified features, educational content, and images representing the breastfeeding experience. Results: Forty-one breastfeeding apps were reviewed. Only seven apps contained both features and educational content related to milk production. Thirteen apps that contained educational content related to milk production received a mean combined content and cultural diversity score of 15.3 of 78. Of the 48 photos reviewed in screenshots that contained educational content on milk production, 87.5% (n=42) were of white women and their infants. For-profit companies and large organizations were most likely to create free apps and apps that received high scores on the combined content and diversity or features scoresheet, respectively. Conclusions: Features and educational content related to milk production and breastfeeding imagery within breastfeeding apps were evaluated using three novel scoresheets informed by Social Cognitive Theory. Few apps contained both features that promote breastfeeding self-efficacy and high-quality, engaging, educational content with images of diverse caretakers. Thus, it is likely that parents, especially those from minority or low-income groups, have limited options when selecting a breastfeeding app. App developers could use the scoresheets and findings in this review to develop breastfeeding apps that assist mothers with interpreting, tracking, or learning about milk production through high-quality and engaging features, content, and imagery. %M 31518317 %R 10.2196/12364 %U http://pediatrics.jmir.org/2019/1/e12364/ %U https://doi.org/10.2196/12364 %U http://www.ncbi.nlm.nih.gov/pubmed/31518317 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 5 %P e10520 %T A Mobile Prenatal Care App to Reduce In-Person Visits: Prospective Controlled Trial %A Marko,Kathryn I %A Ganju,Nihar %A Krapf,Jill M %A Gaba,Nancy D %A Brown,James A %A Benham,Joshua J %A Oh,Julia %A Richards,Lorna M %A Meltzer,Andrew C %+ Department of Emergency Medicine, George Washington University School of Medicine and Health Sciences, 2120 L Street NW, Suite 450, Washington, DC, 20037, United States, 1 202 741 2952, ameltzer@mfa.gwu.edu %K prenatal care %K mobile applications %K patient monitoring %K patient safety %K patient satisfaction %K technological innovations %K controlled clinical trial %K mobile health %D 2019 %7 01.05.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Risk-appropriate prenatal care has been asserted as a way for the cost-effective delivery of prenatal care. A virtual care model for prenatal care has the potential to provide patient-tailored, risk-appropriate prenatal educational content and may facilitate vital sign and weight monitoring between visits. Previous studies have demonstrated a safe reduction in the frequency of in-person prenatal care visits among low-risk patients but have noted a reduction in patient satisfaction. Objective: The primary objective of this study was to test the effectiveness of a mobile prenatal care app to facilitate a reduced in-person visit schedule for low-risk pregnancies while maintaining patient and provider satisfaction. Methods: This controlled trial compared a control group receiving usual care with an experimental group receiving usual prenatal care and using a mobile prenatal care app. The experimental group had a planned reduction in the frequency of in-person office visits, whereas the control group had the usual number of visits. The trial was conducted at 2 diverse outpatient obstetric (OB) practices that are part of a single academic center in Washington, DC, United States. Women were eligible for enrollment if they presented to care in the first trimester, were aged between 18 and 40 years, had a confirmed desired pregnancy, were not considered high-risk, and had an iOS or Android smartphone that they used regularly. We measured the effectiveness of a virtual care platform for prenatal care via the following measured outcomes: the number of in-person OB visits during pregnancy and patient satisfaction with prenatal care. Results: A total of 88 patients were enrolled in the study, 47 in the experimental group and 41 in the control group. For patients in the experimental group, the average number of in-person OB visits during pregnancy was 7.8 and the average number in the control group was 10.2 (P=.01). There was no statistical difference in patient satisfaction (P>.05) or provider satisfaction (P>.05) in either group. Conclusions: The use of a mobile prenatal care app was associated with reduced in-person visits, and there was no reduction in patient or provider satisfaction. Trial Registration: ClinicalTrials.gov NCT02914301; https://clinicaltrials.gov/ct2/show/NCT02914301 (Archived by WebCite at http://www.webcitation.org/76S55M517) %M 31042154 %R 10.2196/10520 %U https://mhealth.jmir.org/2019/5/e10520/ %U https://doi.org/10.2196/10520 %U http://www.ncbi.nlm.nih.gov/pubmed/31042154 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 8 %N 4 %P e11800 %T Expanding Access to Depression Treatment in Kenya Through Automated Psychological Support: Protocol for a Single-Case Experimental Design Pilot Study %A Green,Eric P %A Pearson,Nicholas %A Rajasekharan,Sathyanath %A Rauws,Michiel %A Joerin,Angela %A Kwobah,Edith %A Musyimi,Christine %A Bhat,Chaya %A Jones,Rachel M %A Lai,Yihuan %+ Duke Global Health Institute, Duke University, Box 90519, Durham, NC, 27708, United States, 1 919 681 7289, eric.green@duke.edu %K telemedicine %K mental health %K depression %K artificial intelligence %K Kenya %K text messaging %K chatbot %K conversational agent %D 2019 %7 29.04.2019 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression during pregnancy and in the postpartum period is associated with a number of poor outcomes for women and their children. Although effective interventions exist for common mental disorders that occur during pregnancy and the postpartum period, most cases in low- and middle-income countries go untreated because of a lack of trained professionals. Task-sharing models such as the Thinking Healthy Program have shown great potential in feasibility and efficacy trials as a strategy for expanding access to treatment in low-resource settings, but there are significant barriers to scale-up. We are addressing this gap by adapting Thinking Healthy for automated delivery via a mobile phone. This new intervention, Healthy Moms, uses an existing artificial intelligence system called Tess (Zuri in Kenya) to drive conversations with users. Objective: The objective of this pilot study is to test the Healthy Moms perinatal depression intervention using a single-case experimental design with pregnant women and new mothers recruited from public hospitals outside of Nairobi, Kenya. Methods: We will invite patients to complete a brief, automated screening delivered via text messages to determine their eligibility. Enrolled participants will be randomized to a 1- or 2-week baseline period and then invited to begin using Zuri. Participants will be prompted to rate their mood via short message service every 3 days during the baseline and intervention periods. We will review system logs and conduct in-depth interviews with participants to study engagement with the intervention, feasibility, and acceptability. We will use visual inspection, in-depth interviews, and Bayesian estimation to generate preliminary data about the potential response to treatment. Results: Our team adapted the intervention content in April and May 2018 and completed an initial prepilot round of formative testing with 10 women from a private maternity hospital in May and June. In preparation for this pilot study, we used feedback from these users to revise the structure and content of the intervention. Recruitment for this protocol began in early 2019. Results are expected toward the end of 2019. Conclusions: The main limitation of this pilot study is that we will recruit women who live in urban and periurban centers in one part of Kenya. The results of this study may not generalize to the broader population of Kenyan women, but that is not an objective of this phase of work. Our primary objective is to gather preliminary data to know how to build and test a more robust service. We are working toward a larger study with a more diverse population. International Registered Report Identifier (IRRID): DERR1-10.2196/11800 %M 31033448 %R 10.2196/11800 %U http://www.researchprotocols.org/2019/4/e11800/ %U https://doi.org/10.2196/11800 %U http://www.ncbi.nlm.nih.gov/pubmed/31033448 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11620 %T Evaluation of Mobile Apps Targeted to Parents of Infants in the Neonatal Intensive Care Unit: Systematic App Review %A Richardson,Brianna %A Dol,Justine %A Rutledge,Kallen %A Monaghan,Joelle %A Orovec,Adele %A Howie,Katie %A Boates,Talia %A Smit,Michael %A Campbell-Yeo,Marsha %+ School of Nursing, Dalhousie University, PO Box 15000, Forrest Bldg, 5869 University Avenue, Halifax, NS, B3H4R2, Canada, 1 9024944283, marsha.campbell-yeo@dal.ca %K parenting %K intensive care units, neonatal %K review %K mobile health %K mHealth %K mobile apps %K eHealth %K education, nonprofessional %K infant, premature %D 2019 %7 15.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Parents of preterm infants increasingly use their mobile phone to search for health information. In a recent review, websites targeted toward parents with infants in the neonatal intensive care unit (NICU) were found to have poor to moderate quality educational material; however, there is a dearth of literature regarding mobile apps for NICU parents. Objective: This study aimed to identify and evaluate apps targeting parents of infants in the NICU for quality of information, usability, and credibility. Methods: We systematically searched the Apple App Store and Google Play using 49 key terms (eg, “preterm infant”) from July 26 to August 18, 2017. English apps targeting NICU parents that cost less than $20 were included. Apps for health care professionals, e-books/magazines, or nonrelevant results were excluded. In total, 3 tools were used for evaluation: Mobile Application Rating Scale (MARS) to measure quality; Patient Education Materials Assessment Tool for Audiovisual Materials (PEMAT-AV) to measure the app’s content usability; and Trust it or Trash It to measure credibility. Results: The initial search yielded 6579 apps, with 49 apps eligible after title and description screening. In total, 27 apps met the eligibility criteria with 9 apps available in both app stores; of those, the app with the most recent update date was chosen to be included in the analysis. Thus, 18 unique apps were included for final analysis. Using MARS, 7 apps (7/18, 39%) received a good score on overall quality (ie, 4.0 out of 5.0), with none receiving an excellent score. In addition, 8 apps (8/18, 44%) received a PEMAT-AV score between 51% and 75% on the understandability subscale, and 8 apps (8/18, 44%) scored between 76% and 100% on the actionability subscale. Trust It or Trash It deemed 13 apps (13/18, 72%) as trash for reasons including no identification of sources or lack of current information, with only 5 (5/18, 28%) deemed trustworthy. Reviewer’s expert evaluation found 16 apps contained content that matched information provided by multiple sources; however, most apps did not meet other objective measurement items to support credibility. When comparing the MARS overall quality and subjective quality scores with trustworthiness of apps, there was no statistically significant difference. A statistically significant difference was found between the 2 MARS quality scores, indicating that, on average, apps were ranked significantly lower on subjective quality compared with overall quality measures. Conclusions: This evaluation revealed that of the available apps targeting NICU parents, less than half should be considered as acceptable educational material. Over two-thirds of the apps were found to have issues regarding credibility and just over a quarter were considered good quality. The apps currently available for NICU parents are lacking and of concern in terms of quality and credibility. %M 30985282 %R 10.2196/11620 %U http://mhealth.jmir.org/2019/4/e11620/ %U https://doi.org/10.2196/11620 %U http://www.ncbi.nlm.nih.gov/pubmed/30985282 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 4 %P e10887 %T Midwives’, Obstetricians’, and Recently Delivered Mothers’ Perceptions of Remote Monitoring for Prenatal Care: Retrospective Survey %A Lanssens,Dorien %A Vandenberk,Thijs %A Lodewijckx,Joy %A Peeters,Tessa %A Storms,Valerie %A Thijs,Inge M %A Grieten,Lars %A Gyselaers,Wilfried %+ Limburg Clinical Research Program, Mobile Health Unit, Hasselt University, Agoralaan, Diepenbeek, 3590, Belgium, 32 11 26 85 33, dorien.lanssens@uhasselt.be %K remote monitoring %K gestational hypertensive diseases %K questionnaires %K monitoring, ambulatory %K hypertension, pregnancy-induced %K surveys and questionnaires %D 2019 %7 15.04.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: The Pregnancy Remote Monitoring (PREMOM) study enrolled pregnant women at increased risk of developing hypertensive disorders of pregnancy and investigated the effect of remote monitoring in addition to their prenatal follow-up. Objective: The objective of this study was to investigate the perceptions and experiences of remote monitoring among mothers, midwives, and obstetricians who participated in the PREMOM study. Methods: We developed specific questionnaires for the mothers, midwives, and obstetricians addressing 5 domains: (1) prior knowledge and experience of remote monitoring, (2) reactions to abnormal values, (3) privacy, (4) quality and patient safety, and (5) financial aspects. We also questioned the health care providers about which issues they considered important when implementing remote monitoring. We used a 5-point Likert scale to provide objective scores. It was possible to add free-text feedback at every question. Results: A total of 91 participants completed the questionnaires. The mothers, midwives, and obstetricians reported positive experiences and perceptions of remote monitoring, although most of them had no or little prior experience with this technology. They supported a further rollout of remote monitoring in Belgium. Nearly three-quarters of the mothers (34/47, 72%) did not report any problems with taking the measurements at the required times. Almost half of the mothers (19/47, 40%) wanted to be contacted within 3 to 12 hours after abnormal measurement values, preferably by telephone. Conclusions: Although most of midwives and obstetricians had no or very little experience with remote monitoring before enrolling in the PREMOM study, they reported, based on their one-year experience, that remote monitoring was an important component in the follow-up of high-risk pregnancies and would recommend it to their colleagues and pregnant patients. Trial Registration: ClinicalTrials.gov NCT03246737; https://clinicaltrials.gov/ct2/show/NCT03246737 (Archived by WebCite at http://www.webcitation.org/76KVnHSYY) %M 30985286 %R 10.2196/10887 %U https://www.jmir.org/2019/4/e10887/ %U https://doi.org/10.2196/10887 %U http://www.ncbi.nlm.nih.gov/pubmed/30985286 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 4 %P e11664 %T Neighborhood Deprivation and the Effectiveness of Mobile Health Coaching to Improve Periconceptional Nutrition and Lifestyle in Women: Survey in a Large Urban Municipality in the Netherlands %A Gootjes,Dionne V %A van Dijk,Matthijs R %A Koster,Maria PH %A Willemsen,Sten P %A Steegers,Eric AP %A Steegers-Theunissen,Régine PM %+ Department of Obstetrics and Gynecology, Erasmus Medical Center, University Medical Center Rotterdam, Doctor Molewaterplein 40, Rotterdam, 3015 GD, Netherlands, 31 107043598, r.steegers@erasmusmc.nl %K pregnancy %K telemedicine %K lifestyle %K nutritional status %K preconception care %D 2019 %7 11.04.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: In 2011, we launched the Smarter Pregnancy mobile health (mHealth) coaching program, which has shown to effectively improve inadequate nutrition and lifestyle behaviors in women before and during pregnancy. It is known that in deprived neighborhoods, risk factors for adverse pregnancy outcomes like inadequate nutrition and lifestyle behaviors accumulate. However, it has not yet been investigated whether the Smarter Pregnancy program is equally effective in women living in deprived neighborhoods. Objective: This paper aimed to study the associations between neighborhood deprivation and improvement of inadequate nutrition and lifestyle behaviors of women who were either contemplating pregnancy or already pregnant and subscribed to the Smarter Pregnancy program. Methods: We performed an additional analysis on data from women who used the Smarter Pregnancy program from 2011 to 2016. The program comprised 24 weeks of coaching on 5 nutrition and lifestyle behaviors, of which adequate intakes or lifestyle behaviors were defined as an intake of 200 grams or above of vegetables, 2 pieces of fruit, daily folic acid supplement use of 400 µg per day, and no smoking or alcohol consumption. Neighborhood deprivation was determined according to the status scores of the Netherlands Institute for Social Research. Logistic regression analyses and generalized estimating equation models were used to assess the associations between the neighborhood status score (NSS) and the improvement of inadequate nutrition and lifestyle behaviors, taking into account the behaviors at baseline. We adjusted the analyses for maternal age, body mass index, geographic origin, pregnancy status, and participation as a couple. Results: Of the 2554 women included, 521 participated with their male partner. Overall, daily vegetable intake was most frequently inadequate at the start of the program (77.72, 1985/2554). Women with a higher NSS (ie, nondeprived neighborhood) smoked less often (adjusted odds ratio [OR] 0.85; 95% CI 0.77-0.93), consumed alcohol more often (adjusted OR 1.14, 95% CI 1.04-1.24), and were less likely to complete the 24 weeks of coaching (OR 0.91, 95% CI 0.88-0.95) compared with women who lived in a neighborhood with a low NSS (ie, deprived). In the total group, the relative improvement of inadequate nutrition and lifestyle behaviors after 24 weeks of coaching was between 26% and 64%. NSS was negatively associated with this improvement, indicating that women with a higher NSS were less likely to improve inadequate nutrition and lifestyle behaviors, especially vegetable intake (adjusted OR 0.89, 95% CI 0.82-0.97). Conclusions: The Smarter Pregnancy mHealth coaching program empowers women to improve inadequate nutrition and lifestyle behaviors. Unexpectedly, the program seemed more effective in women living in deprived neighborhoods. It is important to unravel differences in needs and behaviors of specific target groups to further tailor the mHealth program on the basis of demographic characteristics like neighborhood deprivation. %M 30973345 %R 10.2196/11664 %U https://mhealth.jmir.org/2019/4/e11664/ %U https://doi.org/10.2196/11664 %U http://www.ncbi.nlm.nih.gov/pubmed/30973345 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 2 %N 1 %P e12355 %T What Women With Disabilities Write in Personal Blogs About Pregnancy and Early Motherhood: Qualitative Analysis of Blogs %A Litchman,Michelle L %A Tran,MJ %A Dearden,Susan E %A Guo,Jia-Wen %A Simonsen,Sara E %A Clark,Lauren %+ College of Nursing, University of Utah, 10 South 2000 East, Salt Lake City, UT, 84112, United States, 1 801 585 9612, Michelle.Litchman@nurs.utah.edu %K disabled persons %K pregnancy %K blog %K women’s health %K parenting %K mothers %K spinal cord injury %K autism %K traumatic brain injury %D 2019 %7 14.03.2019 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: More than 1 in 10 women of reproductive age identify as having some type of disability. Most of these women are able to become pregnant and have similar desires for motherhood as women without disability. Women with disability, however, face greater stigma and stereotyping, additional risk factors, and may be less likely to receive adequate reproductive health care compared with their peers without disability. More and more individuals, including those with disability, are utilizing the internet to seek information and peer support. Blogs are one source of peer-to-peer social media engagement that may provide a forum for women with disability to both share and obtain peer-to-peer information and support. Nevertheless, it is not clear what content about reproductive health and pregnancy and/or motherhood is featured in personal blogs authored by women with spinal cord injury (SCI), traumatic brain injury (TBI), spina bifida, and autism. Objective: The objective of this study was twofold: (1) to examine the information being shared in blogs by women with 4 types of disabilities, namely, SCI, TBI, spina bifida, and autism, about reproductive health, disability, health care, pregnancy, and motherhood; and (2) to classify the content of reproductive health experiences addressed by bloggers to better understand what they viewed as important. Methods: Personal blogs were identified by searching Google with keywords related to disabilities, SCI, TBI, spina bifida, and autism, and a variety of keywords related to reproductive health. The first 10 pages of each database search in Google, based on the relevance of the search terms, were reviewed and all blogs in these pages were included. Blog inclusion criteria were as follows: (1) written by a woman or care partner (ie, parent or spouse) of a woman with a self-identified diagnosis of SCI, TBI, spina bifida, or autism; (2) focused on the personal experience of health and health care during the prepregnancy, prenatal, antepartum, intrapartum, and/or postpartum periods; (3) written in English; and (4) published between 2013 and 2017. A descriptive and thematic qualitative analysis of blogs and corresponding comments was facilitated with NVivo software and matrix analysis. Results: Our search strategy identified 125 blogs that met all the inclusion criteria; no blogs written by women with spina bifida were identified. We identified 4 reproductive health themes featured in the blog of women with disabilities: (1) (in)accessible motherhood, (2) (un)supportive others, (3) different, but not different, and (4) society questioning motherhood. Conclusions: This analysis of personal blogs about pregnancy and health care written by women with SCI, TBI, and autism provides a glimpse into their experiences. The challenges faced by these women and the adaptations they made to successfully navigate pregnancy and early motherhood provide insights that can be used to shape future research. %M 31518332 %R 10.2196/12355 %U http://pediatrics.jmir.org/2019/1/e12355/ %U https://doi.org/10.2196/12355 %U http://www.ncbi.nlm.nih.gov/pubmed/31518332 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 7 %N 2 %P e10645 %T Women Using Mobile Phones for Health Communication Are More Likely to Use Prenatal and Postnatal Services in Bangladesh: Cross-Sectional Study %A Tang,Shangfeng %A Ghose,Bishwajit %A Hoque,Md Rakibul %A Hao,Gang %A Yaya,Sanni %+ School of International Development and Global Studies, University of Ottawa, 120 University Private, Ottawa, ON, K1N5J1, Canada, 1 6132624856, brammaputram@gmail.com %K antenatal care %K facility delivery services %K postnatal care %K mHealth %K Bangladesh %D 2019 %7 28.02.2019 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: The public health system in Bangladesh has been struggling to provide coverage and utilization of basic maternal health care services in pursuit of achieving maternal and child mortality-related goals. Interestingly, the rapid popularization of mobile technology in the country is transforming the landscape of health care access and delivery. However, little is known regarding the use of mobile phones from the perspective of maternal health care service utilization. Objective: In this study, we aimed to investigate the prevalence and sociodemographic pattern of mobile phone use for health services among women and relationship between the use of mobile phone use and the uptake of essential maternal health services (MHSs). Methods: Cross-sectional data from the Bangladesh Demographic and Health Survey on 4494 mothers aged between 15 and 39 years were used in the analysis. Using mobile phones to get health services or advice was hypothesized to have a positive association with the uptake of basic MHSs (antenatal care, ANC, facility delivery services, postnatal care) and postnatal care for the newborn. Data were analyzed using bivariate and multivariable techniques. Results: More than a quarter (1276/4494, 28.4%; 95% CI 26.8-30.3) of the women aged 15-39 years reported using mobile phones to get health services with significant sociodemographic variations in the use of mobile phones. Analysis of the specific purposes revealed that, in most cases, mobile phones were used to contact service providers and consult with the same about what to do, whereas a smaller proportion reported using mobile phone for the purposes of arranging money and transportation. Multivariable analysis showed that compared with respondents who reported not using mobile phones for health care services, those who used them had higher odds of making 3+ ANC visits and delivering at a health facility. The odds were slightly higher for rural residents than for those in the urban areas. Conclusions: The findings of this study conclude that women who use mobile phones are more likely to use ANC and professional delivery services than those who do not. More in-depth studies are necessary to understand the mechanism through which mobile phone-based services enhance the uptake of maternal health care. %M 30816850 %R 10.2196/10645 %U http://mhealth.jmir.org/2019/2/e10645/ %U https://doi.org/10.2196/10645 %U http://www.ncbi.nlm.nih.gov/pubmed/30816850 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e11065 %T Evaluation of Mothers’ Perceptions of a Technology-Based Supportive Educational Parenting Program (Part 2): Qualitative Study %A Shorey,Shefaly %A Ng,Esperanza Debby %+ National University of Singapore, Level 2 Clinical Research Centre, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K education %K mothers %K parenting %K technology %D 2019 %7 13.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Transitioning into parenthood can be stressful as parents struggle to cope with new parenting responsibilities. Although perinatal care in hospitals aims to improve parental outcomes, there is a general consensus that it is suboptimal and insufficient. Therefore, many studies have designed intervention methods to supplement support for parents during this stressful period. However, studies often focus on parental outcomes as indicators of their interventions’ success and effectiveness. Studies evaluating participants’ experiences and feedback are limited. Objective: This study aimed to examine the experiences and perceptions of participants who participated in a supportive education parenting program intervention study. Methods: A qualitative semistructured interview was conducted with 16 mothers (6 control and 10 intervention) from a randomized controlled trial. The supportive education parenting program received by the intervention group included 2 phone-based perinatal educational sessions, a phone-based educational session after childbirth, and a 1-month postpartum access to a mobile health app. The interviews were approximately 30- to 60-min long, audiotaped and transcribed verbatim, and analyzed using thematic analysis. Study findings were reported according to the Consolidated Criteria for Reporting Qualitative Research checklist. Results: The 3 main themes evaluating mothers’ experiences and perceptions were generated: (1) changed perspective toward parenthood, (2) journey from pregnancy to after birth, and (3) a way forward. Mothers from the intervention group mostly had good perinatal experiences with sufficient support received, which elevated their emotional well-being and increased parenting involvement. Mothers in the control group, although satisfied with the hospital care received, were more stressed and shared a need for professional advice and extra support. Apart from technical enhancements, mothers also requested extended social support during early pregnancy up to 1 year postpartum, taking into consideration Asian cultural practices. Conclusions: Mothers who received the intervention were overall satisfied with the support provided by the technology-based supportive educational parenting program. The success of the educational program in this study highlights the need to supplement standard care in hospitals with technology-based educational programs. Future research should include fathers’ perceptions to attain an in-depth understanding of overall participants’ experiences and needs in the future development of supportive and educational programs. %M 30758295 %R 10.2196/11065 %U https://www.jmir.org/2019/2/e11065/ %U https://doi.org/10.2196/11065 %U http://www.ncbi.nlm.nih.gov/pubmed/30758295 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 2 %P e10816 %T Effectiveness of a Technology-Based Supportive Educational Parenting Program on Parental Outcomes (Part 1): Randomized Controlled Trial %A Shorey,Shefaly %A Ng,Yvonne Peng Mei %A Ng,Esperanza Debby %A Siew,An Ling %A Mörelius,Evalotte %A Yoong,Joanne %A Gandhi,Mihir %+ Clinical Research Centre, Alice Lee Centre for Nursing Studies, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K parents %K social support %D 2019 %7 13.02.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: Transitioning into parenthood can be stressful for new parents, especially with the lack of continuity of care from health care professionals during the postpartum period. Short hospital stays limit the availability of support and time parents need to be well equipped with parenting and infant care skills. Poor parental adjustment may, in turn, lead to negative parental outcomes and adversely affect the child’s development. For the family’s future well-being, and to facilitate a smoother transition into parenthood, there is a need for easily accessible, technology-based educational programs to support parents during the crucial perinatal period. Objective: This study aimed to examine the effectiveness of a technology-based supportive educational parenting program (SEPP) on parenting outcomes during the perinatal period in couples. Methods: A randomized, single-blinded, parallel-armed, controlled trial was conducted. The study recruited 236 parents (118 couples) from an antenatal clinic of a tertiary hospital in Singapore. Eligible parents were randomly assigned to the intervention group (n=118) or the control group (n=118). The SEPP is based on Bandura’s self-efficacy theory and Bowlby’s theory of attachment. Components of the intervention include 2 telephone-based educational sessions (1 antenatal and 1 immediately postnatal) and a mobile health app follow-up for 1 month. The control group only received routine perinatal care provided by the hospital. Outcome measures including parenting self-efficacy (PSE), parental bonding, perceived social support, parenting satisfaction, postnatal depression (PND), and anxiety were measured using reliable and valid instruments. Data were collected over 6 months at 4 time points: during pregnancy (third trimester), 2 days postpartum, 1 month postpartum, and 3 months postpartum. Outcomes were standardized using baseline means and SDs. Linear mixed models were used to compare the groups for postpartum changes in the outcome variables. Results: The intervention group showed significantly better outcome scores than the control group from baseline to 3 months postpartum for PSE (mean difference, MD, 0.37; 95% CI 0.06 to 0.68; P=.02), parental bonding (MD −1.32; 95% CI −1.89 to −0.75; P<.001), self-perceived social support (MD 0.69; 95% CI 0.18 to 1.19; P=.01), parenting satisfaction (MD 1.40; 95% CI 0.86 to 1.93; P<.001), and PND (MD −0.91; 95% CI −1.34 to −0.49; P<.001). Postnatal anxiety (PNA) scores of the intervention group were only significantly better after adjusting for covariates (MD −0.82; 95% CI −1.15 to −0.49; P<.001). Conclusions: The technology-based SEPP is effective in enhancing parental bonding, PSE, perceived social support and parental satisfaction, and in reducing PND and PNA. Health care professionals could incorporate it with existing hands-on infant care classes and routine care to better meet parents’ needs and create positive childbirth experiences, which may in turn encourage parents to have more children. Trial Registration: ISRCTN Registry ISRCTN48536064; http://www.isrctn.com/ISRCTN48536064 (Archived by WebCite at http://www.webcitation.org/6wMuEysiO). %M 30758289 %R 10.2196/10816 %U http://www.jmir.org/2019/2/e10816/ %U https://doi.org/10.2196/10816 %U http://www.ncbi.nlm.nih.gov/pubmed/30758289 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 21 %N 1 %P e11454 %T Differences Between Mothers and Fathers of Young Children in Their Use of the Internet to Support Healthy Family Lifestyle Behaviors: Cross-Sectional Study %A Laws,Rachel %A Walsh,Adam D %A Hesketh,Kylie D %A Downing,Katherine L %A Kuswara,Konsita %A Campbell,Karen J %+ Institute for Physical Activity and Nutrition, School of Exercise and Nutrition Sciences, Deakin University, 221 Burwood Highway, Burwood, VIC, Geelong, 3125, Australia, 61 432388593, r.laws@deakin.edu.au %K child %K family %K healthy lifestyle %K infant %K internet %K obesity %K parents %D 2019 %7 23.01.2019 %9 Original Paper %J J Med Internet Res %G English %X Background: In early life, both mothers and fathers are important influences on their children’s diet, active play, and obesity risk. Parents are increasingly relying on the internet and social media as a source of information on all aspects of parenting. However, little is known about the use of Web-based sources of information relevant to family lifestyle behaviors and, in particular, differences between mothers’ and fathers’ use and sociodemographic predictors. Objective: The objective of this study was to examine if mothers and fathers differ in their use of the internet for information on their own health and their child’s health, feeding, and playing and to examine sociodemographic predictors of the use of the internet for information on these topics. Methods: We conducted a secondary analysis on data collected from mothers (n=297) and fathers (n=207) participating in the extended Infant Feeding, Activity and Nutrition Trial (InFANT Extend) when their children were 36 months of age. The main outcome variables were the use of the internet for information gathering for parents’ own health and child health, feeding, and playing. Binary logistic regression was used to examine the sociodemographic predictors of outcomes. Results: Compared with fathers (n=296), a higher proportion of mothers (n=198) used the internet for information on their own health (230, 78.5% vs 93, 46.5%), child health (226, 77.1% vs 84, 42.4%), child feeding (136, 46.3% vs 35, 17.5%), and child play (123, 42.1% vs 28, 14.0%) and intended to use Facebook to connect with other parents (200, 74.9% vs 43, 30.5%). Despite the high use of the internet to support family health behaviors, only 15.9% (47/296) of mothers reported consulting health practitioners for advice and help for their own or their child’s weight, diet, or physical activity. Sociodemographic predictors of internet use differed between mothers and fathers and explained only a small proportion of the variance in internet use to support healthy family lifestyle behaviors. Conclusions: Our findings support the use of the internet and Facebook as an important potential avenue for reaching mothers with information relevant to their own health, child health, child diet, and active play. However, further research is required to understand the best avenues for engaging fathers with information on healthy family lifestyle behaviors to support this important role in their child’s life. Trial Registration: ISRCTN Registry ISRCTN81847050; http://www.isrctn.com/ISRCTN81847050 %M 30674450 %R 10.2196/11454 %U http://www.jmir.org/2019/1/e11454/ %U https://doi.org/10.2196/11454 %U http://www.ncbi.nlm.nih.gov/pubmed/30674450 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e12206 %T How Women Evaluate Birth Challenges: Analysis of Web-Based Birth Stories %A Konheim-Kalkstein,Yasmine L %A Miron-Shatz,Talya %A Israel,Leah Jenny %+ Center for Medical Decision Making, Ono Academic College, Tzahal Street 104, Kiryat Ono,, Israel, 972 8452020258, yasmine.kalkstein@msmc.edu %K patient-centered care %K decision making %K parturition %K women’s health %D 2018 %7 18.12.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Birth stories provide an intimate glimpse into women’s birth experiences in their own words. Understanding the emotions elicited in women by certain types of behaviors during labor and delivery could help those in the health care community provide better emotional care for women in labor. Objective: The aim of this study was to understand which supportive reactions and behaviors contributed to negative or positive emotions among women with regard to their labor and delivery experience. Methods: We sampled 10 women’s stories from a popular blog that described births that strayed from the plan. Overall, 90 challenging events that occurred during labor and delivery were identified. Each challenge had an emotionally positive, negative, or neutral evaluation by the woman. We classified supportive and unsupportive behaviors in response to these challenges and examined their association with the woman’s emotional appraisal of the challenges. Results: Overall, 4 types of behaviors were identified: informational inclusion, decisional inclusion (mostly by health care providers), practical support, and emotional support (mostly by partners). Supportive reactions were not associated with emotional appraisal; however, unsupportive reactions were associated with women appraising the challenge negatively (Fisher exact test, P=.02). Conclusions: Although supportive behaviors did not elicit any particular emotion, unsupportive behaviors did cause women to view challenges negatively. It is worthwhile conducting a larger scale investigation to observe what happens when patients express their needs, particularly when challenges present themselves during labor, and health care professionals strive to cater to them. %M 31518300 %R 10.2196/12206 %U http://pediatrics.jmir.org/2018/2/e12206/ %U https://doi.org/10.2196/12206 %U http://www.ncbi.nlm.nih.gov/pubmed/31518300 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e11513 %T Video-Delivered Family Therapy for Home Visited Young Mothers With Perinatal Depressive Symptoms: Quasi-Experimental Implementation-Effectiveness Hybrid Trial %A Cluxton-Keller,Fallon %A Williams,Melony %A Buteau,Jennifer %A Donnelly,Craig L %A Stolte,Patricia %A Monroe-Cassel,Maggie %A Bruce,Martha L %+ Department of Psychiatry, Geisel School of Medicine at Dartmouth College, 1 Medical Center Drive, Lebanon, NH, 03756, United States, 1 603 650 4724, Fallon.P.Cluxton-Keller@dartmouth.edu %K videoconferencing %K family therapy, depression %D 2018 %7 10.12.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: The Federal Maternal, Infant, and Early Childhood Home Visiting Program is a national child abuse prevention strategy that serves families at risk for child maltreatment throughout the United States. Significant portions of the clients are young mothers who screen positive for clinically significant perinatal depressive symptoms and experience relational discord that worsens their symptoms. Although home visitors refer those who screen positive for depression to community-based treatment, they infrequently obtain treatment because of multiple barriers. These barriers are compounded for home visited families in rural areas. Objective: This pilot study aimed to explore the feasibility, acceptability, and effectiveness of a video-delivered family therapy intervention on reducing maternal depressive symptoms and improving family functioning and emotion regulation. Methods: A total of 13 home visited families received the video-delivered family therapy intervention. This study included a historical comparison group of mothers (N=13) who were previously enrolled in home visiting and screened positive for clinically significant perinatal depressive symptoms but refused treatment. A licensed marriage and family therapist delivered the family therapy intervention using Health Insurance Portability and Accountability Act–compliant videoconferencing technology on a computer from an office. Families participated in sessions in their homes using cell phones, tablets, and computers equipped with microphones and video cameras. Outcomes were measured following the final therapy session (post intervention) and 2 months later (follow-up). Depressive symptom scores of mothers who received the video-delivered family therapy intervention were compared with those of mothers in the historical comparison group over a 6-month period. Univariate statistics and correlations were calculated to assess measures of feasibility. Percentages and qualitative thematic analysis were used to assess acceptability. Wilcoxon signed-rank tests were used to assess changes in maternal and family outcomes. Results: No families dropped out of the study. All families reported that the technology was convenient and easy to use. All families reported high satisfaction with the video-delivered intervention. Nearly all families reported that they preferred video-delivered family therapy instead of clinic-based therapy. Therapeutic alliance was strong. Mothers demonstrated a statistically significant reduction in depressive symptoms (P=.001). When compared with mothers in the historical comparison group, those in the family therapy intervention showed a significant reduction in depressive symptoms (P=.001). Families demonstrated statistically significant improvements in family functioning (P=.02) and cognitive reappraisal (P=.004). Conclusions: This pilot study yielded preliminary findings that support the feasibility, acceptability, and effectiveness of the video-delivered family therapy intervention for underserved home visited families in rural areas. Our findings are very promising, but more research is needed to ultimately influence mental health practices and policies that pertain to video-delivered mental health interventions in unsupervised settings (eg, homes). %M 30530456 %R 10.2196/11513 %U http://mental.jmir.org/2018/4/e11513/ %U https://doi.org/10.2196/11513 %U http://www.ncbi.nlm.nih.gov/pubmed/30530456 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 11 %P e11508 %T The Association Between the Use of Antenatal Care Smartphone Apps in Pregnant Women and Antenatal Depression: Cross-Sectional Study %A Mo,Yushi %A Gong,Wenjie %A Wang,Joyce %A Sheng,Xiaoqi %A Xu,Dong R %+ XiangYa School of Public Health, Central South University, 238 Shangmayuanling Lane, Xiangya Road, KaiFu District, Changsha,, China, 86 13607445252, gongwenjie@csu.edu.cn %K antenatal care %K antenatal depression %K app %K mobile phone %D 2018 %7 29.11.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Antenatal care smartphone apps are increasingly used by pregnant women, but studies on their use and impact are scarce. Objective: This study investigates the use of antenatal care apps in pregnant women and explores the association between the use of these apps and antenatal depression. Methods: This study used a convenient sample of pregnant women recruited from Hunan Provincial Maternal and Child Health Hospital in November 2015. The participants were surveyed for their demographic characteristics, use of antenatal care apps, and antenatal depression. Factors that influenced antenatal pregnancy were analyzed using logistic regression. Results: Of the 1304 pregnant women, 71.31% (930/1304) used antenatal care apps. Higher usage of apps was associated with urban residency, nonmigrant status, first pregnancy, planned pregnancy, having no previous children, and opportunity to communicate with peer pregnant women. The cutoff score of the Edinburgh Postnatal Depression Scale was 10, and 46.11% (601/1304) of the pregnant women had depression. Logistic regression showed that depression was associated with the availability of disease-screening functions in the apps (odds ratio (OR) 1.78, 95% CI 1.03-3.06) and spending 30 minutes or more using the app (OR 2.05, 95% CI 1.19-3.52). Using apps with social media features was a protective factor for antenatal depression (OR 0.33, 95% CI 0.12-0.89). Conclusions: The prevalence of the use of prenatal care apps in pregnant women is high. The functions and time spent on these apps are associated with the incidence of antenatal depression. %M 30497996 %R 10.2196/11508 %U http://mhealth.jmir.org/2018/11/e11508/ %U https://doi.org/10.2196/11508 %U http://www.ncbi.nlm.nih.gov/pubmed/30497996 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 5 %N 4 %P e10007 %T A Mobile App for the Self-Report of Psychological Well-Being During Pregnancy (BrightSelf): Qualitative Design Study %A Doherty,Kevin %A Barry,Marguerite %A Marcano-Belisario,José %A Arnaud,Bérenger %A Morrison,Cecily %A Car,Josip %A Doherty,Gavin %+ School of Computer Science and Statistics, Trinity College Dublin, College Green, Dublin,, Ireland, 353 1 8963858, Gavin.Doherty@tcd.ie %K engagement %K mental health %K mHealth %K midwifery %K perinatal depression %K pregnancy %K self-report %K well-being %K mobile phone %D 2018 %7 27.11.2018 %9 Original Paper %J JMIR Ment Health %G English %X Background: Maternal mental health impacts both parental well-being and childhood development. In the United Kingdom, 15% of women are affected by depression during pregnancy or within 1 year of giving birth. Suicide is a leading cause of perinatal maternal mortality, and it is estimated that >50% of perinatal depression cases go undiagnosed. Mobile technologies are potentially valuable tools for the early recognition of depressive symptoms, but complex design challenges must be addressed to enable their use in public health screening. Objective: The aim of this study was to explore the issues and challenges surrounding the use of mobile phones for the self-report of psychological well-being during pregnancy. Methods: This paper presents design research carried out as part of the development of BrightSelf, a mobile app for the self-report of psychological well-being during pregnancy. Design sessions were carried out with 38 participants, including pregnant women, mothers, midwives, and other health professionals. Overall, 19 hours of audio were fully transcribed and used as the basis of thematic analysis. Results: The study highlighted anxieties concerning the pregnancy journey, challenges surrounding current approaches to the appraisal of well-being in perinatal care, and the midwife-patient relationship. Designers should consider the framing of perinatal mental health technologies, the experience of self-report, supporting self-awareness and disclosure, providing value to users through both self-report and supplementary features, and designing for longitudinal engagement. Conclusions: This study highlights the needs, motivations, and anxieties of women with respect to technology use in pregnancy and implications for the design of mobile health technologies. %M 30482742 %R 10.2196/10007 %U http://mental.jmir.org/2018/4/e10007/ %U https://doi.org/10.2196/10007 %U http://www.ncbi.nlm.nih.gov/pubmed/30482742 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 11 %P e11624 %T Comparing the Effectiveness of Clinicians and Paraprofessionals to Reduce Disparities in Perinatal Depression via the Mothers and Babies Course: Protocol for a Cluster-Randomized Controlled Trial %A Jensen,Jessica K %A Ciolino,Jody D %A Diebold,Alicia %A Segovia,Melissa %A Degillio,Aria %A Solano-Martinez,Jesus %A Tandon,S Darius %+ Center for Community Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, 750 N Lake Shore Drive, Suite 680, Chicago, IL, 60611, United States, 1 3125036808, jessica.jensen@northwestern.edu %K depression %K postpartum %K pregnancy %K randomized controlled trial %K community health %D 2018 %7 20.11.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Postpartum depression is highly prevalent in low-income women and has significant health and mental health effects on mother and child. Home visiting (HV) programs provide services to large numbers of perinatal women in the United States and are a logical setting for delivering mental health services. Although there are interventions that reduce the risk of developing postpartum depression among low-income women, none have used nonhealth or nonmental health professionals as interventionists. Objective: This study aimed to outline the protocol of a cluster randomized trial funded by the Patient-Centered Outcomes Research Institute that evaluates whether the Mothers and Babies (MB) group intervention, when led by paraprofessional home visitors, is more efficacious than usual care. It will also examine if MB, when led by home visitors, is not inferior to MB delivered by mental health professionals (MHPs). MB has previously demonstrated efficacy when delivered by MHPs, and pilot work indicated promising results using home visitors to deliver the intervention. Methods: A cluster randomized trial is being conducted with 38 HV programs. Sixteen HV programs will deliver MB using MHPs, 16 will deliver MB using paraprofessional home visitors, and 6 will deliver usual HV services. The study employs a modified covariate-constrained randomization design at the site level. We anticipate recruiting 933 women aged ≥16 years enrolled in HV programs, who are 33 or more weeks’ gestation and speak either English or Spanish. Women in the 2 intervention arms will receive the 6-session MB group intervention. Baseline, postintervention, 12-week postpartum, and 24-week postpartum assessments will be conducted to assess client outcomes. The primary outcome will be the change in Quick Inventory of Depressive Symptomatology Self-Report 16 scores from baseline to 24-week follow-up. Secondary outcomes associated with core MB content will also be examined. Semistructured interviews will be conducted with home visitors and MHPs who are group facilitators and 90 study participants to gain data on intervention successes and challenges. Analyses will proceed at the participant level. Primary analyses for depressive symptoms score at 24 weeks postpartum will involve a linear mixed model, controlling for baseline symptoms and other covariates, and random effects to account for clustering. Results: We have recruited 838 women through the end of August 2018. Recruitment will be completed at the end of September 2018. Conclusions: There is considerable potential to disseminate MB to HV programs throughout the United States. Should our results demonstrate home visitor efficacy when compared with usual care and/ noninferiority between home visitors and MHPs in improving mental health outcomes, no additional financial resources would be required for the existing HV staff to implement MB. Should this study determine that home visitors are less effective than MHPs, we will generate more wide-scale evidence on MB effectiveness when led by MHPs. Trial Registration: ClinicalTrials.gov NCT02979444; https://clinicaltrials.gov/ct2/show/NCT02979444 (Archived by Webcite at http://www.webcitation.org/archive.php) International Registered Report Identifier (IRRID): PRR1-10.2196/11624 %M 30459138 %R 10.2196/11624 %U http://www.researchprotocols.org/2018/11/e11624/ %U https://doi.org/10.2196/11624 %U http://www.ncbi.nlm.nih.gov/pubmed/30459138 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e11344 %T Exploring Social Media Group Use Among Breastfeeding Mothers: Qualitative Analysis %A Skelton,Kara Renee %A Evans,Retta %A LaChenaye,Jenna %A Amsbary,Jonathan %A Wingate,Martha %A Talbott,Laura %+ Department of Health, Behavior and Society, Johns Hopkins University, 624 N Broadway, Baltimore, MD, 21205, United States, 1 205 563 3412, kara.skelton@jhu.edu %K social media %K milk %K human %K breastfeeding %D 2018 %7 05.11.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Breastfeeding is well known as the optimal source of nutrition for the first year of life. However, suboptimal exclusively breastfeeding rates in the United States are still prevalent. Given the extent of social media use and the accessibility of this type of peer-to-peer support, the role of social networking sites in enabling and supporting breastfeeding mothers needs to be further explored. Objective: This study aimed to leverage mothers’ attitudes and behaviors of social media usage to understand effects on breastfeeding outcomes. Methods: Participants were recruited from 1 probreastfeeding social media group with over 6300 members throughout the United States. Online focus group discussions were conducted with 21 women; interviews were conducted with 12 mothers. Qualitative data were aggregated for thematic analysis. Results: Participants indicated that the social media group formed a community of support for breastfeeding, with normalizing breastfeeding, empowerment for breastfeeding, resource for breastfeeding, and shared experiences in breastfeeding as additional themes. Conclusions: According to participants, social media groups can positively influence breastfeeding-related attitudes, knowledge, and behaviors as well as lead to longer duration of breastfeeding. The results of this study should be taken into account when designing interventions for breastfeeding mothers. %M 31518305 %R 10.2196/11344 %U http://pediatrics.jmir.org/2018/2/e11344/ %U https://doi.org/10.2196/11344 %U http://www.ncbi.nlm.nih.gov/pubmed/31518305 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e11062 %T Time Series Visualizations of Mobile Phone-Based Daily Diary Reports of Stress, Physical Activity, and Diet Quality in Mostly Ethnic Minority Mothers: Feasibility Study %A Comulada,W Scott %A Swendeman,Dallas %A Rezai,Roxana %A Ramanathan,Nithya %+ Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, 10920 Wilshire Boulevard, Suite 350, Los Angeles, CA, 90024, United States, 1 3107948278, wcomulada@mednet.ucla.edu %K changepoint %K diet quality %K mobile phone %K moving average %K physical activity %K stress %K time series %D 2018 %7 05.11.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Health behavior patterns reported through daily diary data are important to understand and intervene upon at the individual level in N-of-1 trials and related study designs. There is often interest in relationships between multiple outcomes, such as stress and health behavior. However, analyses often utilize regressions that evaluate aggregate effects across individuals, and standard analyses target single outcomes. Objective: This paper aims to illustrate how individuals’ daily reports of stress and health behavior (time series) can be explored using visualization tools. Methods: Secondary analysis was conducted on 6 months of daily diary reports of stress and health behavior (physical activity and diet quality) from mostly ethnic minority mothers who pilot-tested a self-monitoring mobile health app. Time series with minimal missing data from 14 of the 44 mothers were analyzed. Correlations between stress and health behavior within each time series were reported as a preliminary step. Stress and health behavior time series patterns were visualized by plotting moving averages and time points where mean shifts in the data occurred (changepoints). Results: Median correlation was small and negative for associations of stress with physical activity (r=−.14) and diet quality (r=−.08). Moving averages and changepoints for stress and health behavior were aligned for some participants but not for others. A third subset of participants exhibited little variation in stress and health behavior reports. Conclusions: Median correlations in this study corroborate prior findings. In addition, time series visualizations highlighted variations in stress and health behavior across individuals and time points, which are difficult to capture through correlations and regression-based summary measures. %M 30684407 %R 10.2196/11062 %U https://formative.jmir.org/2018/2/e11062/ %U https://doi.org/10.2196/11062 %U http://www.ncbi.nlm.nih.gov/pubmed/30684407 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 10 %P e11039 %T A Short Message Service Intervention for Improving Infant Feeding Practices in Shanghai, China: Planning, Implementation, and Process Evaluation %A Jiang,Hong %A Li,Mu %A Wen,Li Ming %A Baur,Louise A %A He,Gengsheng %A Ma,Xiaoying %A Qian,Xu %+ Global Health Institute, School of Public Health, Fudan University, Mailbox 175, No. 138 Yixueyuan Road, Shanghai, 200032, China, 86 21 64179976, h_jiang@fudan.edu.cn %K mHealth %K short message service %K breastfeeding %K infant feeding practices %K health services %K planning and development %K implementation %K process evaluation %D 2018 %7 29.10.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Although mobile health (mHealth) has been widely applied in health care services, few studies have reported the detailed process of the development and implementation of text messaging (short message service, SMS) interventions. Objective: Our study aims to demonstrate the process and lessons learned from a community-based text messaging (SMS) intervention for improving infant feeding in Shanghai, China. Methods: The intervention included planning and development, implementation, and process evaluation. A 3-phase process was adopted during planning and development: (1) a formative study with expectant and new mothers to explore the barriers of appropriate infant feeding practices; (2) a baseline questionnaire survey to understand potential intervention approaches; and (3) development of the text message bank. The text messaging intervention was delivered via a computer-based platform. A message bank was established before the start of the intervention containing information on the benefits of breastfeeding, preparing for breastfeeding, early initiation of breastfeeding, timely introduction of complementary foods, and establishing appropriate feeding practices, etc. An expert advisory committee oversaw the content and quality of the message bank. Process evaluation was conducted through field records and qualitative interviews with participating mothers. Results: We found that the text messaging intervention was feasible and well received by mothers because of its easy and flexible access. The weekly based message frequency was thought to be appropriate, and the contents were anticipatory and trustworthy. Some mothers had high expectations for timely response to inquiries. Occasionally, the text messages were not delivered due to unstable telecommunication transmission. Mothers suggested that the messages could be more personalized. Conclusions: This study demonstrates the feasibility and value of text messaging intervention in filling gaps in delivering health care services and promoting healthy infant feeding practices in settings where personal contact is limited. %M 30373728 %R 10.2196/11039 %U http://mhealth.jmir.org/2018/10/e11039/ %U https://doi.org/10.2196/11039 %U http://www.ncbi.nlm.nih.gov/pubmed/30373728 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e9 %T Mobile Phone Access and Willingness Among Mothers to Receive a Text-Based mHealth Intervention to Improve Prenatal Care in Northwest Ethiopia: Cross-Sectional Study %A Endehabtu,Berhanu %A Weldeab,Adane %A Were,Martin %A Lester,Richard %A Worku,Abebaw %A Tilahun,Binyam %+ eHealthLab Ethiopia, Department of Health Informatics, University of Gondar, PO Box 196, Gondar,, Ethiopia, 251 913875066, binigcms@gmail.com %K mHealth %K mobile phone %K pregnant women %K SMS %K willingness %K Ethiopia %K antenatal care %K maternal health %D 2018 %7 17.10.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Maternal mortality remains high in many low- and middle-income countries where limited access to health services is linked to low antenatal care utilization. Effective communication and engagement with care providers are vital for the delivery and receipt of sufficient health care services. There is strong evidence that simple text-based interventions can improve the prenatal care utilization, but most mobile health (mHealth) interventions are not implemented on a larger scale owing to the lack of context and preliminary evidence on how to make the transition. Objective: The objective of this study was to determine access to mobile phones by pregnant women attending antenatal care as well as willingness to receive a text message (short message service, SMS)–based mHealth intervention for antenatal care services and identify its associated factors among pregnant women attending an antenatal care clinic in Gondar Town Administration, Northwest Ethiopia, Africa. Methods: A cross-sectional quantitative study was conducted among 422 pregnant women attending antenatal care from March 27 to April 28, 2017. Data were collected using structured questionnaires. Data entry and analysis were performed using Epi-Info version 7 and SPSS version 20, respectively. In addition, descriptive statistics and bivariable and multivariable logistic regression analyses were performed. Furthermore, odds ratio with 95% CI was used to identify factors associated with the willingness to receive a text message–based mHealth intervention. Results: A total of 416 respondents (response rate 98.6%, 416/422) were included in the analysis. About 76.7% (319/416) of respondents owned a mobile phone and 71.2% (296/416) were willing to receive an SMS text message. Among the mobile phone owners, only 37.6% (120/319) were having smartphones. Of all women with mobile phones, 89.7% (286/319) described that they are the primary holders of these phones and among them, 85.0% (271/319) reported having had the same phone number for more than a year. Among the phone owners, 90.0% (287/319) described that they could read and 86.8% (277/416) could send SMS text messages using their mobile phones in their day-to-day activities. Among pregnant women who were willing to receive SMS text messages, about 96.3% (285/296) were willing to receive information regarding activities or things to avoid during pregnancy. Factors associated with willingness were youth age group (adjusted odds ratio [AOR] 2.869, 95% CI 1.451-5.651), having attained secondary and higher educational level (AOR 4.995, 95% CI 1.489-14.773), and the frequency of mobile phone use (AOR 0.319, 95% CI 0.141-0.718). Conclusions: A high proportion of pregnant women in an antenatal care clinic in this remote setting have a mobile phone and are willing to receive an SMS text message–based mHealth intervention. Age, educational status, and the frequency of mobile phone use are significantly associated with the willingness to receive SMS text message–based mHealth interventions. %M 31518334 %R 10.2196/pediatrics.9618 %U http://pediatrics.jmir.org/2018/2/e9/ %U https://doi.org/10.2196/pediatrics.9618 %U http://www.ncbi.nlm.nih.gov/pubmed/31518334 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 9 %P e176 %T Longitudinal Validity and Reliability of Brief Smartphone Self-Monitoring of Diet, Stress, and Physical Activity in a Diverse Sample of Mothers %A Swendeman,Dallas %A Comulada,Warren Scott %A Koussa,Maryann %A Worthman,Carol M %A Estrin,Deborah %A Rotheram-Borus,Mary Jane %A Ramanathan,Nithya %+ Department of Computer Science, University of California, Los Angeles, 10920 Wilshire Boulevard, Los Angeles, CA, 90024, United States, 1 213 915 6729, nithyaar@gmail.com %K self-monitoring %K mHealth %K diet %K physical activity %K stress %K multi-method %K mobile phones %K C-reactive protein %D 2018 %7 21.9.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Multiple strategies can be used when self-monitoring diet, physical activity, and perceived stress, but no gold standards are available. Although self-monitoring is a core element of self-management and behavior change, the success of mHealth behavioral tools depends on their validity and reliability, which lack evidence. African American and Latina mothers in the United States are high-priority populations for apps that can be used for self-monitoring of diet, physical activity, and stress because the body mass index (BMI) of mothers typically increases for several years after childbirth and the risks of obesity and its’ sequelae diseases are elevated among minority populations. Objective: To examine the intermethod reliability and concurrent validity of smartphone-based self-monitoring via ecological momentary assessments (EMAs) and use of daily diaries for diet, stress, and physical activity compared with brief recall measures, anthropometric biomeasures, and bloodspot biomarkers. Methods: A purposive sample (n=42) of primarily African American (16/42, 39%) and Latina (18/42, 44%) mothers was assigned Android smartphones for using Ohmage apps to self-monitor diet, perceived stress, and physical activity over 6 months. Participants were assessed at 3- and 6-month follow-ups. Recall measures included brief food frequency screeners, physical activity assessments adapted from the National Health and Nutrition Examination Survey, and the nine-item psychological stress measure. Anthropometric biomeasures included BMI, body fat, waist circumference, and blood pressure. Bloodspot assays for Epstein–Barr virus and C-reactive protein were used as systemic load and stress biomarkers. EMAs and daily diary questions assessed perceived quality and quantity of meals, perceived stress levels, and moderate, vigorous, and light physical activity. Units of analysis were follow-up assessments (n=29 to n=45 depending on the domain) of the participants (n=29 with sufficient data for analyses). Correlations, R2 statistics, and multivariate linear regressions were used to assess the strength of associations between variables. Results: Almost all participants (39/42, 93%) completed the study. Intermethod reliability between smartphone-based EMAs and diary reports and their corresponding recall reports was highest for stress and diet; correlations ranged from .27 to .52 (P<.05). However, it was unexpectedly low for physical activity; no significant associations were observed. Concurrent validity was demonstrated for diet EMAs and diary reports on systolic blood pressure (r=−.32), C-reactive protein level (r=−.34), and moderate and vigorous physical activity recalls (r=.35 to.48), suggesting a covariation between healthy diet and physical activity behaviors. EMAs and diary reports on stress were not associated with Epstein–Barr virus and C-reactive protein level. Diary reports on moderate and vigorous physical activity were negatively associated with BMI and body fat (r=−.35 to −.44, P<.05). Conclusions: Brief smartphone-based EMA use may be valid and reliable for long-term self-monitoring of diet, stress, and physical activity. Lack of intermethod reliability for physical activity measures is consistent with prior research, warranting more research on the efficacy of smartphone-based self-monitoring of self-management and behavior change support. %M 30249576 %R 10.2196/mhealth.9378 %U http://mhealth.jmir.org/2018/9/e176/ %U https://doi.org/10.2196/mhealth.9378 %U http://www.ncbi.nlm.nih.gov/pubmed/30249576 %0 Journal Article %@ 2561-326X %I JMIR Publications %V 2 %N 2 %P e18 %T Adapting a Behavioral Weight Loss Intervention for Delivery via Facebook: A Pilot Series Among Low-Income Postpartum Women %A Silfee,Valerie J %A Lopez-Cepero,Andrea %A Lemon,Stephenie C %A Estabrook,Barbara %A Nguyen,Oanh %A Wang,Monica L %A Rosal,Milagros C %+ Division of Preventive and Behavioral Medicine, Department of Medicine, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA, 01655, United States, 1 508 856 3173, Milagros.Rosal@umassmed.edu %K Facebook %K health disparities %K postpartum women %K social media %K weight loss %D 2018 %7 10.09.2018 %9 Original Paper %J JMIR Formativ Res %G English %X Background: Efforts to translate evidence-based weight loss interventions, such as the Diabetes Prevention Program (DPP), to low-income postpartum women have resulted in poor intervention attendance and high attrition. Strategies that improve engagement and retention in this population are needed to maximize the reach of evidence-based weight loss interventions. Objective: The objective of this study was to adapt a DPP-based weight loss intervention (Fresh Start) for Facebook delivery and to evaluate its feasibility among low-income postpartum women. Methods: This study comprised 3 single-group pilot studies where feasibility outcomes iteratively informed changes from one pilot to the next. We paralleled the in-person program for Facebook delivery by translating the protocol to a content library of Facebook posts with additional posts from lifestyle coaches. Low-income postpartum women were recruited from Women, Infants, and Children (WIC) clinics in Worcester, Massachusetts. Participants were enrolled into a 16-week weight loss intervention delivered via Facebook. During the first 8 weeks, Facebook intervention posts were delivered 2 times per day, with additional posts from coaches aiming to stimulate interaction among participants or respond to participants’ questions and challenges. For the following 8 weeks, posts were delivered once per day without additional coaching. Feasibility outcomes were engagement (defined by number of likes, comments, and posts measured throughout intervention delivery), acceptability, and retention (survey at follow-up and assessment completion rate, respectively). Changes in weight were also assessed at baseline and follow-up. Results: Pilot 1 had a retention rate of 89% (24/27), and on average, 62% (17/27) of women actively engaged with the group each week during the 8-week coached phase. Mean weight loss was 2.6 (SD 8.64) pounds, and 79% (19/27) would recommend the program to a friend. Pilot 2 had a retention rate of 83% (20/24), and on average, 55% (13/24) of women actively engaged with the group weekly during the 8-week coached phase. Mean weight loss was 2.5 (SD 9.23) pounds, and 80% (16/24) would recommend the program to a friend. Pilot 3 had a retention rate of 88% (14/16), and on average, 67% (11/16) of women actively engaged with the group weekly during the 8-week coached phase. Mean weight loss was 7.0 (SD 11.6) pounds, and 100% (16/16) would recommend the program to a friend. Conclusions: Our findings demonstrated that a Facebook-delivered intervention was acceptable and could be feasibly delivered to low-income postpartum women. Future research is needed to evaluate the efficacy of a Facebook-delivered weight loss intervention. %M 30684423 %R 10.2196/formative.9597 %U http://formative.jmir.org/2018/2/e18/ %U https://doi.org/10.2196/formative.9597 %U http://www.ncbi.nlm.nih.gov/pubmed/30684423 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e10435 %T Sudden Infant Death Syndrome and Safe Sleep on Twitter: Analysis of Influences and Themes to Guide Health Promotion Efforts %A Pretorius,Kelly A %A Mackert,Michael %A Wilcox,Gary B %+ School of Nursing, The University of Texas at Austin, 1710 Red River Street, Austin, TX, 78701, United States, 1 512 471 7913, kpretorius@utexas.edu %K sudden infant death %K sudden unexpected infant death %K accidental suffocation in a sleeping environment %K infant mortality %K safe sleep %K sleep environment %K social media %K Twitter %K health communication %K public health %D 2018 %7 07.09.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: In the United States, sudden infant death syndrome (SIDS) is the leading cause of death in infants aged 1 month to 1 year. Approximately 3500 infants die from SIDS and sleep-related reasons on a yearly basis. Unintentional sleep-related deaths and bed sharing, a known risk factor for SIDS, are on the rise. Furthermore, ethnic disparities exist among those most affected by SIDS. Despite public health campaigns, infant mortality persists. Given the popularity of social media, understanding social media conversations around SIDS and safe sleep may assist the medical and public health communities with information needed to spread, reinforce, or counteract false information regarding SIDS and safe sleep. Objective: The objective of our study was to investigate the social media conversation around SIDS and safe sleep to understand the possible influences and guide health promotion efforts and public health research as well as enable health professionals to engage in directed communication regarding this topic. Methods: We used textual analytics to identify topics and extract meanings contained in unstructured textual data. Twitter messages were captured during September, October, and November in 2017. Tweets and retweets were collected using NUVI software in conjunction with Twitter’s search API using the keywords: “sids,” “infant death syndrome,” “sudden infant death syndrome,” and “safe sleep.” This returned a total of 41,358 messages, which were analyzed using text mining and social media monitoring software. Results: Multiple themes were identified, including recommendations for safe sleep to prevent SIDS, safe sleep devices, the potential causes of SIDS, and how breastfeeding reduces SIDS. Compared with September and November, more personal and specific stories of infant loss were demonstrated in October (Pregnancy and Infant Loss Awareness Month). The top influencers were news organizations, universities, and health-related organizations. Conclusions: We identified valuable topics discussed and shared on Twitter regarding SIDS and safe sleep. The study results highlight the contradicting information a subset of the population is exposed to regarding SIDS and the continued controversy over vaccines. In addition, this analysis emphasizes the lack of public health organizations’ presence on Twitter compared with the influence of universities and news media organizations. The results also demonstrate the prevalence of safe sleep products that are embedded in safe sleep messaging. These findings can assist providers in speaking about relevant topics when engaging in conversations about the prevention of SIDS and the promotion of safe sleep. Furthermore, public health agencies and advocates should utilize social media and Twitter to better communicate accurate health information as well as continue to combat the spread of false information. %M 31518314 %R 10.2196/10435 %U http://pediatrics.jmir.org/2018/2/e10435/ %U https://doi.org/10.2196/10435 %U http://www.ncbi.nlm.nih.gov/pubmed/31518314 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 8 %P e10095 %T A Liftless Intervention to Prevent Preterm Birth and Low Birthweight Among Pregnant Ghanaian Women: Protocol of a Stepped-Wedge Cluster Randomized Controlled Trial %A Kwegyir-Afful,Emma %A Verbeek,Jos %A Aziato,Lydia %A Seffah,Joseph D %A Räsänen,Kimmo %+ Institute of Public Health and Clinical Nutrition, School of Medicine, University of Eastern Finland, 3rd Floor, Canthia, Yliopistonranta 1C, Kuopio, FI-70211, Finland, 358 0404495521, emmakwe@uef.fi %K heavy lifting %K Ghana %K low birthweight %K liftless intervention %K low-and middle-income countries %K physical activity %K preterm birth %K randomized controlled trial %K stepped-wedge %D 2018 %7 23.08.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Preterm birth (PTB) is a leading cause of infant morbidity and mortality worldwide. Every year, 20 million babies are born with low birthweight (LBW), about 96% of which occur in low-income countries. Despite the associated dangers, in about 40%-50% of PTB and LBW cases, the causes remain unexplained. Existing evidence is inconclusive as to whether occupational physical activities such as heavy lifting are implicated. African women bear the transport burden of accessing basic needs for their families. Ghana’s PTB rate is 14.5%, whereas the global average is 9.6%. The proposed liftless intervention aims to decrease lifting exposure during pregnancy among Ghanaian women. We hypothesize that a reduction in heavy lifting among pregnant women in Ghana will increase gestational age and birthweight. Objective: To investigate the effects of the liftless intervention on the incidence of PTB and LBW among pregnant Ghanaian women. Methods: A cohort stepped-wedge cluster randomized controlled trial in 10 antenatal clinics will be carried out in Ghana. A total of 1000 pregnant participants will be recruited for a 60-week period. To be eligible, the participant should have a singleton pregnancy between 12 and 16 weeks gestation, be attending any of the 10 antenatal clinics, and be exposed to heavy lifting. All participants will receive standard antenatal care within the control phase; by random allocation, two clusters will transit into the intervention phase. The midwife-led 3-component liftless intervention consists of health education, a take-home reminder card mimicking the colors of a traffic light, and a shopping voucher. The primary outcome are gestational ages of <28, 28-32, and 33-37 weeks. The secondary outcomes are LBW (preterm LBW, term but LBW, and postterm), compliance, prevalence of low back and pelvic pain, and premature uterine contractions. Study midwives and participants will not be blinded to the treatment allocation. Results: Permission to conduct the study at all 10 antenatal clinics has been granted by the Ghana Health Service. Application for funding to begin the trial is ongoing. Findings from the main trial are expected to be published by the end of 2019. Conclusions: To the best of our knowledge, there has been no randomized trial of this nature in Ghana. Minimizing heavy lifting among pregnant African women can reduce the soaring rates of PTB and LBW. The findings will increase the knowledge of the prevention of PTB and LBW worldwide. Trial Registration: Pan African Clinical Trial Register (PACTR201602001301205); http://apps.who.int/trialsearch/ Trial2.aspx?TrialID=PACTR201602001301205 (Archived by WebCite at http://www.webcitation.org/71TCYkHzu) Registered Report Identifier: RR1-10.2196/10095 %M 30139723 %R 10.2196/10095 %U http://www.researchprotocols.org/2018/8/e10095/ %U https://doi.org/10.2196/10095 %U http://www.ncbi.nlm.nih.gov/pubmed/30139723 %0 Journal Article %@ 2561-6722 %I JMIR Publications %V 1 %N 2 %P e7 %T Engaging Men in Prenatal Health via eHealth: Findings From a National Survey %A Mackert,Michael %A Guadagno,Marie %A Lazard,Allison %A Donovan,Erin %A Rochlen,Aaron %A Garcia,Alexandra %A Damásio,Manuel José %A Crook,Brittani %+ Center for Health Communication, The University of Texas at Austin, 1 University Station A1200, Austin, TX, 78712, United States, 1 5172143200, mariea@utexas.edu %K health communication %K fathering %K expectant fathers %K prenatal health %D 2018 %7 09.08.2018 %9 Original Paper %J JMIR Pediatr Parent %G English %X Background: Pregnancy outcomes in the United States rank among the worst of countries with a developed health care system. Although traditional prenatal health primarily focuses on women, promising findings have emerged in international research that suggest the potential of including men in prenatal health interventions in the United States. eHealth apps present a promising avenue to reach new and expectant fathers with crucial parenting knowledge and healthy, supportive behaviors. Objective: The aim was to explore the perceived role of men in prenatal health, acceptability of eHealth to positively engage men during pregnancy, and participant-suggested ways of improving a prenatal health app designed for new and expectant fathers. Methods: A nationally representative sample of adult males (N=962) was recruited through an online survey panel. A third-party market research and digital data collection agency managed the recruitment. The sample had a mean age of 30.2 (SD 6.3) years and included both fathers (413/962, 42.9%) and non-fathers (549/962, 57.1%). Nearly 12.0% (115/962) of participants had a partner who was pregnant at the time of the survey. Results: Despite perceived barriers, such as time constraints, financial burdens, and an unclear role, men believe it is important to be involved in pregnancy health. The majority of participants (770/944, 81.6%) found the site to contain useful and interesting information. Most substantially, more than three-quarters (738/962, 76.7%) of the sample said they would share the site with others who would benefit from the information. Participants recommended the addition of interactive modules, such as a financial planning tool and videos, to make the site stronger. Conclusions: We explored the use of targeted eHealth to introduce men to prenatal education. Results indicate men are favorable to this intervention. Additional refinement should include interactive tools to further engage men in this important issue. Reaching men at the prenatal phase is an early “teachable moment”—where new/expectant fathers are open to information on how to help their partners have a healthy pregnancy and promote the health of their unborn children. Findings will further inform best practices for engaging men in pregnancy, which is crucial for improving maternal and child health outcomes in the United States. %M 31518311 %R 10.2196/pediatrics.9513 %U http://pediatrics.jmir.org/2018/2/e7/ %U https://doi.org/10.2196/pediatrics.9513 %U http://www.ncbi.nlm.nih.gov/pubmed/31518311 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 7 %P e153 %T Forecasting the Value for Money of Mobile Maternal Health Information Messages on Improving Utilization of Maternal and Child Health Services in Gauteng, South Africa: Cost-Effectiveness Analysis %A LeFevre,Amnesty %A Cabrera-Escobar,Maria A %A Mohan,Diwakar %A Eriksen,Jaran %A Rogers,Debbie %A Neo Parsons,Annie %A Barre,Iman %A Jo,Youngji %A Labrique,Alain %A Coleman,Jesse %+ Department of Public Health Sciences, Karolinska Institutet, SE-171 77, Stockholm,, Sweden, 46 852480000, denots@gmail.com %K mHealth %K cost effectiveness %K cost utility analysis %K digital health %D 2018 %7 27.07.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Limited evidence exists on the value for money of mHealth information programs in low resource settings. Objective: This study sought to model the incremental cost-effectiveness of gradually scaling up text messaging services to pregnant women throughout Gauteng province, South Africa from 2012 to 2017. Methods: Data collection occurred as part of a retrospective study in 6 health centers in Gauteng province. Stage-based short message service (SMS) text messages on maternal health were sent to pregnant women twice per week during pregnancy and continued until the infant’s first birthday. Program costs, incremental costs to users, and the health system costs for these women were measured along with changes in the utilization of antenatal care visits and childhood immunizations and compared with those from a control group of pregnant women who received no SMS text messages. Incremental changes in utilization were entered into the Lives Saved Tool and used to forecast lives saved and disability adjusted life years (DALYs) averted by scaling up program activities over 5 years to reach 60% of pregnant women across Gauteng province. Uncertainty was characterized using one-way and probabilistic uncertainty analyses. Results: Five-year program costs were estimated to be US $1.2 million, 17% of which were incurred by costs on program development and 31% on SMS text message delivery costs. Costs to users were US $1.66 to attend clinic-based services, nearly 90% of which was attributed to wages lost. Costs to the health system included provider time costs to register users (US $0.08) and to provide antenatal care (US $4.36) and postnatal care (US $3.08) services. Incremental costs per DALY averted from a societal perspective ranged from US $1985 in the first year of implementation to US $200 in the 5th year. At a willingness-to-pay threshold of US $2000, the project had a 40% probability of being cost-effective in year 1 versus 100% in all years thereafter. Conclusions: Study findings suggest that delivering SMS text messages on maternal health information to pregnant and postpartum women may be a cost-effective strategy for bolstering antenatal care and childhood immunizations, even at very small margins of coverage increases. Primary data obtained prospectively as part of more rigorous study designs are needed to validate modeled results. %M 30054263 %R 10.2196/mhealth.8185 %U http://mhealth.jmir.org/2018/7/e153/ %U https://doi.org/10.2196/mhealth.8185 %U http://www.ncbi.nlm.nih.gov/pubmed/30054263 %0 Journal Article %@ 2291-5222 %I JMIR Publications %V 6 %N 2 %P e38 %T Digital Peer-Support Platform (7Cups) as an Adjunct Treatment for Women With Postpartum Depression: Feasibility, Acceptability, and Preliminary Efficacy Study %A Baumel,Amit %A Tinkelman,Amanda %A Mathur,Nandita %A Kane,John M %+ Department of Community Mental Health, University of Haifa, Abba Khoushy Ave 199, Haifa,, Israel, 972 482 4011, abaumel@univ.haifa.ac.il %K mhealth %K postpartum depression %K perinatal mood disorder %K peer support %K online %K self-help %D 2018 %7 13.02.2018 %9 Original Paper %J JMIR Mhealth Uhealth %G English %X Background: Peer support is considered to be an important framework of support for mothers experiencing postpartum depression (PPD); however, some barriers exist that may limit its use including peer availability and mothers’ lack of time due to child care. Objective: This non-randomized study was designed to examine the feasibility, acceptance, and preliminary clinical outcomes of using 7 Cups of Tea (7Cups), a digital platform that delivers self-help tools and 24/7 emotional support delivered by trained volunteers, as an adjunct treatment for mothers diagnosed with PPD. Methods: Mothers with PPD were referred during intake to the study coach who provided guidance about 7Cups. 7Cups features included self-help tools and chats with trained volunteers who had experienced a perinatal mood disorder in their past. Acceptability was measured by examining self-reports and user engagement with the program. The primary outcome was the Edinburgh Postnatal Depression Scale (EPDS) change score between pre- and postintervention at 2 months, as collected in usual care by clinicians blinded to the study questions. Using a propensity score matching to control for potential confounders, we compared women receiving 7Cups to women receiving treatment as usual (TAU). Results: Participants (n=19) proactively logged into 7Cups for a median of 12 times and 175 minutes. Program use was mostly through the mobile app (median of mobile use 94%) and between 18:00 and 08:00 when clinicians are unavailable (68% of total program use time). Participants chatted with volunteers for a total of 3064 minutes and have indicated in their responses 0 instances in which they felt unsafe. Intent-to-treat analysis revealed that 7Cups recipients experienced significant decreases in EPDS scores (P<.001, Cohen d=1.17). No significant difference in EPDS decrease over time was found between 7Cups and TAU, yet the effect size was medium favoring 7Cups (P=.05, Cohen d=0.58). Conclusions: This study supports using a computerized method to train lay people, without any in-person guidance or screening, and engage them with patients diagnosed with mental illness as part of usual care. The medium effect size (d=0.58) favoring the 7Cups group relative to TAU suggests that 7Cups might enhance treatment outcomes. A fully powered trial has to be conducted to examine this effect. %M 29439944 %R 10.2196/mhealth.9482 %U http://mhealth.jmir.org/2018/2/e38/ %U https://doi.org/10.2196/mhealth.9482 %U http://www.ncbi.nlm.nih.gov/pubmed/29439944 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 2 %P e37 %T Text-Based Program Addressing the Mental Health of Soon-to-be and New Fathers (SMS4dads): Protocol for a Randomized Controlled Trial %A Fletcher,Richard %A May,Chris %A Attia,John %A Garfield,Craig Franklin %A Skinner,Geoff %+ Family Action Centre, Faculty of Health and Medicine, University of Newcastle, Academic Office Block, University Drive, Callaghan, 2308, Australia, 61 0429152405, richard.fletcher@newcastle.edu.au %K perinatal %K fathers %K online intervention %K randomized controlled trial %K mental health %D 2018 %7 06.02.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Recent estimates indicating that approximately 10% of fathers experience Paternal Perinatal Depression (PPND) and the increasing evidence of the impact of PPND on child development suggest that identifying and assisting distressed fathers is justified on public health grounds. However, addressing new fathers’ mental health needs requires overcoming men’s infrequent contact with perinatal health services and their reluctance to seek help. Text-based interventions delivering information and support have the potential to reach such groups in order to reduce the impact of paternal perinatal distress and to improve the wellbeing of their children. While programs utilising mobile phone technology have been developed for mothers, fathers have not been targeted. Since text messages can be delivered to individual mobile phones to be accessed at a time that is convenient, it may provide a novel channel for engaging with “hard-to-reach” fathers in a critical period of their parenting. Objective: The study will test the efficacy of SMS4dads, a text messaging program designed specifically for fathers including embedded links to online information and regular invitations (Mood Tracker) to monitor their mood, in order to reduce self-reported depression, anxiety and stress over the perinatal period. Methods: A total of 800 fathers-to-be or new fathers from within Australia will be recruited via the SMS4dads website and randomized to the intervention or control arm. The intervention arm will receive 14 texts per month addressing fathers’ physical and mental health, their relationship with their child, and coparenting with their partner. The control, SMS4health, delivers generic health promotion messages twice per month. Messages are timed according to the babies’ expected or actual date of birth and fathers can enroll from 16 weeks into the pregnancy until their infant is 12 weeks of age. Participants complete questionnaires assessing depression, anxiety, stress, and alcohol at baseline and 24 weeks postenrolment. Measures of coparenting and parenting confidence are also completed at baseline and 24 weeks for postbirth enrolments. Results: Participant were recruited between October 2016 and September 2017. Follow-up data collection has commenced and will be completed in March 2018 with results expected in June 2018. Conclusions: This study’s findings will assess the efficacy of a novel text-based program specifically targeting fathers in the perinatal period to improve their depression, anxiety and distress symptoms, coparenting quality, and parenting self-confidence. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12616000261415; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370085 (Archived by WebCite at http://www.webcitation.org/6wav55wII). %M 29410387 %R 10.2196/resprot.8368 %U http://www.researchprotocols.org/2018/2/e37/ %U https://doi.org/10.2196/resprot.8368 %U http://www.ncbi.nlm.nih.gov/pubmed/29410387 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e35 %T The Effectiveness and Cost-Effectiveness of Web-Based and Home-Based Postnatal Psychoeducational Interventions for First-Time Mothers: Randomized Controlled Trial Protocol %A He,Honggu %A Zhu,Lixia %A Chan,Sally Wai Chi %A Chong,Yap-Seng %A Jiao,Nana %A Chan,Yiong Huak %A Luo,Nan %A Shorey,Shefaly %+ Alice Lee Centre for Nursing Studies, National University of Singapore, Level 2 Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294 ext 1294, nurssh@nus.edu.sg %K mothers %K education %K postpartum period %K Internet %D 2018 %7 31.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: In addition to recuperating from the physical and emotional demands of childbirth, first-time mothers are met with demands of adapting to their social roles while picking up new skills to take care of their newborn. Mothers may not feel adequately prepared for parenthood if they are situated in an unsupported environment. Postnatal psychoeducational interventions have been shown to be useful and can offer a cost-effective solution for improving maternal outcomes. Objective: The objective of this study was to examine the effectiveness and cost-effectiveness of Web-based and home-based postnatal psychoeducational programs for first-time mothers on maternal outcomes. Methods: A randomized controlled three-group pre- and posttests experimental design is proposed. This study plans to recruit 204 first-time mothers on their day of discharge from a public tertiary hospital in Singapore. Eligible first-time mothers will be randomly allocated to either a Web-based psychoeducation group, a home-based psychoeducation group, or a control group receiving standard care. The outcomes include maternal parental self-efficacy, social support, psychological well-being (anxiety and postnatal depression), and cost evaluation. Data will be collected at baseline, 1 month, 3 months, and 6 months post-delivery. Results: The recruitment (n=204) commenced in October 2016 and was completed in February 2017, with 68 mothers in each group. The 6-month follow-up data collection was completed in August 2017. Conclusions: This study may identify an effective and cost-effective Web-based postnatal psychoeducational program to improve first-time mothers’ health outcomes. The provision of a widely-accessed Web-based postnatal psychoeducational program will eventually lead to more positive postnatal experiences for first-time mothers and positively influence their future birth plans. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 45202278; http://www.isrctn.com/ISRCTN45202278 (Archived by WebCite at http://www.webcitation.org/6whx0pQ2F). %M 29386175 %R 10.2196/resprot.9042 %U http://www.researchprotocols.org/2018/1/e35/ %U https://doi.org/10.2196/resprot.9042 %U http://www.ncbi.nlm.nih.gov/pubmed/29386175 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 7 %N 1 %P e4 %T Effectiveness of a Technology-Based Supportive Educational Parenting Program on Parental Outcomes in Singapore: Protocol for a Randomized Controlled Trial %A Shorey,Shefaly %A Ng,Yvonne Peng Mei %A Siew,An Ling %A Yoong,Joanne %A Mörelius,Evalotte %+ National University of Singapore, Level 2, Clinical Research Centre, Block MD 11, 10 Medical Drive, Singapore, 117597, Singapore, 65 66011294, nurssh@nus.edu.sg %K parents %K satisfaction %K perinatal %K self-efficacy %K social support %D 2018 %7 10.01.2018 %9 Protocol %J JMIR Res Protoc %G English %X Background: Supportive educational programs during the perinatal period are scarce in Singapore. There is no continuity of care available in terms of support from community care nurses in Singapore. Parents are left on their own most of the time, which results in a stressful transition to parenthood. There is a need for easily accessible technology-based educational programs that can support parents during this crucial perinatal period. Objective: The aim of this study was to describe the study protocol of a randomized controlled trial on a technology-based supportive educational parenting program. Methods: A randomized controlled two-group pretest and repeated posttest experimental design will be used. The study will recruit 118 parents (59 couples) from the antenatal clinics of a tertiary public hospital in Singapore. Eligible parents will be randomly allocated to receive either the supportive educational parenting program or routine perinatal care from the hospital. Outcome measures include parenting self-efficacy, parental bonding, postnatal depression, social support, parenting satisfaction, and cost evaluation. Data will be collected at the antenatal period, immediate postnatal period, and at 1 month and 3 months post childbirth. Results: Recruitment of the study participants commenced in December 2016 and is still ongoing. Data collection is projected to finish within 12 months, by December 2017. Conclusions: This study will identify a potentially clinically useful, effective, and cost-effective supportive educational parenting program to improve parental self-efficacy and bonding in newborn care, which will then improve parents’ social support–seeking behaviors, emotional well-being, and satisfaction with parenting. It is hoped that better supported and satisfied parents will consider having more children, which may in turn influence Singapore’s ailing birth rate. Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 48536064; https://www.isrctn.com/ISRCTN48536064 (Archived by WebCite at http://www.webcitation.org/6wMuEysiO) %M 29321127 %R 10.2196/resprot.8062 %U http://www.researchprotocols.org/2018/1/e4/ %U https://doi.org/10.2196/resprot.8062 %U http://www.ncbi.nlm.nih.gov/pubmed/29321127 %0 Journal Article %@ 2368-7959 %I JMIR Publications %V 4 %N 4 %P e42 %T Pregnant Women’s Perceptions of the Risks and Benefits of Disclosure During Web-Based Mental Health E-Screening Versus Paper-Based Screening: Randomized Controlled Trial %A Kingston,Dawn %A Biringer,Anne %A Veldhuyzen van Zanten,Sander %A Giallo,Rebecca %A McDonald,Sarah %A MacQueen,Glenda %A Vermeyden,Lydia %A Austin,Marie-Paule %+ University of Calgary, 2500 University Ave NW, Calgary, AB, T2N 1N4, Canada, 1 4032202634, dawn.kingston@ucalgary.ca %K pregnancy %K mental health %K screening %K prenatal care %K computers %D 2017 %7 20.10.2017 %9 Original Paper %J JMIR Ment Health %G English %X Background: Pregnant women’s perceptions of the risks and benefits during mental health screening impact their willingness to disclose concerns. Early research in violence screening suggests that such perceptions may vary by mode of screening, whereby women view the anonymity of e-screening as less risky than other approaches. Understanding whether mode of screening influences perceptions of risk and benefit of disclosure is important in screening implementation. Objective: The objective of this randomized controlled trial was to compare the perceptions of pregnant women randomized to a Web-based screening intervention group and a paper-based screening control group on the level of risk and benefit they perceive in disclosing mental health concerns to their prenatal care provider. A secondary objective was to identify factors associated with women’s perceptions of risk and benefit of disclosure. Methods: Pregnant women recruited from maternity clinics, hospitals, and prenatal classes were computer-randomized to a fully automated Web-based e-screening intervention group or a paper-based control. The intervention group completed the Antenatal Psychosocial Health Assessment and the Edinburgh Postnatal Depression Scale on a computer tablet, whereas the control group completed them on paper. The primary outcome was women’s perceptions of the risk and benefits of mental health screening using the Disclosure Expectations Scale (DES). A completer analysis was conducted. Statistical significance was set at P<.05. We used t tests to compare the means of the risk and benefit subscales between groups. Results: Of the 675 eligible women approached, 636 (94.2%) agreed to participate and were randomized to the intervention (n=305) and control (n=331) groups. There were no significant baseline differences between groups. The mode of screening was not associated with either perceived risk or benefit of screening. There were no differences in groups in the mean scores of the risk and benefit of disclosure subscales. Over three-quarters of women in both intervention and control groups perceived that mental health screening was beneficial. However, 43.1% (272/631) of women in both groups reported feeling very, moderately, or somewhat vulnerable during mental health screening. We found that women of low income, those treated previously for depression or anxiety, and those pregnant with their first child were more likely to perceive greater risk. However, these associations were very small. Conclusions: Pregnant women in both the e-screening and paper-based screening groups perceived benefit and risk of disclosure similarly, suggesting that providers can implement the mode of screening that is most ideal for their clinical setting. Regardless of the mode of screening, a substantial number of women reported feeling vulnerable during mental health screening, highlighting the importance of the need to reduce women’s vulnerability throughout the screening process with strategies such as addressing women’s concerns, explaining the rationale for screening, and discussing how results will be used. Trial Registration: Clinicaltrials.gov NCT01899534; https://clinicaltrials.gov/ct2/show/NCT01899534 (Archived by WebCite at http://www.webcitation.org/6tRKtGC4M) %M 29054833 %R 10.2196/mental.6888 %U http://mental.jmir.org/2017/4/e42/ %U https://doi.org/10.2196/mental.6888 %U http://www.ncbi.nlm.nih.gov/pubmed/29054833 %0 Journal Article %@ 1438-8871 %I JMIR Publications %V 18 %N 9 %P e236 %T The Implementation of Internet Interventions for Depression: A Scoping Review %A Drozd,Filip %A Vaskinn,Linda %A Bergsund,Hans Bugge %A Haga,Silje Marie %A Slinning,Kari %A Bjørkli,Cato Alexander %+ National Network for Infant Mental Health, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, PO Box 4623 Nydalen, Oslo, 0405, Norway, 47 975 16 188, filip.drozd@r-bup.no %K depression %K scoping review %K implementation %K Internet interventions %D 2016 %7 08.09.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: Depression is one of the most common mental health problems among adults, but effective treatments are not widely accessible. The Internet holds promise as a cost-effective and convenient delivery platform of interventions for depression. However, studies suggest that Internet interventions are not widely available in routine settings. Objective: The aim of this study was to review the literature and examine whether there are systematic differences in reporting of the various implementation components on Internet interventions for depression, and then to examine what is known about and is characteristic of the implementation of these Internet interventions in regular care settings. Methods: We performed a scoping review, drawing upon a broad range of the literature on Internet interventions for depression in regular care, and used the active implementation framework to extract data. Results: Overall, the results suggested that knowledge about the implementation of Internet interventions for depression in regular care is limited. However, guided support from health professionals emphasizing program adherence and recruitment of end users to the interventions emerged as 2 main themes. We identified 3 additional themes among practitioners, including their qualifications, training, and supervision, but these were scarcely described in the literature. The competency drivers (ie, staff and user selection, training, and supervision) have received the most attention, while little attention has been given to organizational (ie, decision support, administration, and system intervention) and leadership drivers. Conclusions: Research has placed little emphasis on reporting on the implementation of interventions in practice. Leadership and organizational drivers, in particular, have been largely neglected. The results of this scoping review have implications for future research and efforts to successfully implement Internet interventions for depression in regular care. %M 27608548 %R 10.2196/jmir.5670 %U http://www.jmir.org/2016/9/e236/ %U https://doi.org/10.2196/jmir.5670 %U http://www.ncbi.nlm.nih.gov/pubmed/27608548 %0 Journal Article %@ 1929-0748 %I JMIR Publications %V 5 %N 3 %P e140 %T Baby Steps - An Online Program Promoting the Well-Being of New Mothers and Fathers: A Study Protocol %A Hamilton,Kyra %A Kavanagh,David %A Connolly,Jennifer %A Davis,Leigh %A Fisher,Jane %A Halford,Kim %A Hides,Leanne %A Milgrom,Jeannette %A Rowe,Heather %A Sanders,Davina %A Scuffham,Paul A %A Tjondronegoro,Dian %A Walsh,Anne %A White,Katherine M %A Wittkowski,Anja %+ Centre for Children's Health Research, Institute of Health and Biomedical Innovation, Queensland University of Technology, 62 Graham Street, Brisbane, 4101, Australia, 1 7 3069 7327, david.kavanagh@qut.edu.au %K Perinatal %K Wellbeing %K Fathers %K Mothers %K Online Intervention %K Randomized Controlled Trial %K Quality of Life %K Mental Health %D 2016 %7 01.07.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Parental well-being can be seriously impacted during the challenging perinatal period. Most research and support services focus on perinatal psychopathology, leaving a need for programs that recognize and enhance the strengths and well-being of parents. Furthermore, fathers have received minimal attention and support relative to mothers, despite experiencing perinatal distress. New parents have limited time and energy to invest in program attendance, and web-based programs provide an ideal platform for delivering perinatal well-being programs. Such programs are globally accessible, available at any time, and can be accessed anywhere with an Internet connection. Objective: This paper describes the protocol of a randomized controlled trial investigating the effects on first-time parents’ perinatal well-being, comparing two versions of the online program Baby Steps. Methods: The clinical trial will randomize 240 primiparous mother-father couples to either (1) Babycare, an online information-only program providing tips on selected childcare issues, or (2) Well-being, an online interactive program including all content from the Babycare program, plus parental well-being-focused content with tools for goal-setting and problem solving. Both programs will be supported by short message service (SMS) texts at two, four, seven, and ten weeks to encourage continued use of the program. Primary outcomes will be measures of perinatal distress and quality of life. Secondary outcomes will be couple relationship satisfaction, parent self-efficacy, and social support. Cost-effectiveness will also be measured for each Baby Steps program. Results: Participant recruitment commenced March, 2015 and continued until October, 2015. Follow-up data collection has commenced and will be completed May, 2016 with results expected in July, 2016. Conclusions: Perinatal distress has substantial impacts on parents and their infants, with potential to affect later childhood adjustment, relationships, and development. This study aims to test the impact of a highly accessible online program to support parental coping, and maximize the well-being of both parents. By including fathers in the program, Baby Steps has the potential to engage and support this often neglected group who can make a substantial contribution to familial well-being. ClinicalTrial: Australian & New Zealand Clinical Trials Registry: ANZCTR12614001256662; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=367277 (Archived by WebCite at http://www.webcitation.org/6ibUsjFIL) %M 27370711 %R 10.2196/resprot.5706 %U http://www.researchprotocols.org/2016/3/e140/ %U https://doi.org/10.2196/resprot.5706 %U http://www.ncbi.nlm.nih.gov/pubmed/27370711 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 2 %P e18 %T A Thematic Analysis of Stigma and Disclosure for Perinatal Depression on an Online Forum %A Moore,Donna %A Ayers,Susan %A Drey,Nicholas %+ Centre for Maternal and Child Health, School of Health Sciences, City University London, Northampton Square, London, EC1V OHB, United Kingdom, 44 207 040 5060, Donna.Moore.1@city.ac.uk %K perinatal %K online %K Internet %K depression %K eHealth %D 2016 %7 19.05.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Perinatal mental illness is a global health concern; however, many women do not get the treatment they need to recover. Some women choose not to seek professional help and get no treatment because they feel stigmatized. Online forums for various health conditions, including perinatal mental health, can be beneficial for members. Little is known about the role that online forums for perinatal mental illness play in reducing stigma and subsequent disclosure of symptoms to health care providers and treatment uptake. Objective: This study aimed to examine stigma and disclosure in forums and describe any potential disadvantages of forum use. Methods: An online forum for mothers was examined and 1546 messages extracted from 102 threads from the antenatal and postnatal depression section. These messages were subjected to deductive systematic thematic analysis to identify common themes regarding stigma and disclosure of symptoms and potential disadvantages of forum use. Results: Two major themes were identified: stigma and negative experiences of disclosure. Stigma had 3 subthemes: internal stigma, external stigma, and treatment stigma. Many women were concerned about feeling like a “bad” or “failed” mother and worried that if they disclosed their symptoms to a health care provider they would be stigmatized. Posts in response to this frequently encouraged women to disclose their symptoms to health care providers and accept professional treatment. Forum discourse reconstructed the ideology of motherhood as compatible with perinatal mental illness, especially if the woman sought help and adhered to treatment. Many women overcame stigma and replied that they had taken advice and disclosed to a health care provider and/or taken treatment. Conclusions: Forum use may increase women's disclosure to health care providers by challenging their internal and external stigma and this may strengthen professional treatment uptake and adherence. However, a few posts described negative experiences when disclosing to health care providers. %M 27197516 %R 10.2196/mental.5611 %U http://mental.jmir.org/2016/2/e18/ %U https://doi.org/10.2196/mental.5611 %U http://www.ncbi.nlm.nih.gov/pubmed/27197516 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 5 %N 2 %P e65 %T Comparing Brief Internet-Based Compassionate Mind Training and Cognitive Behavioral Therapy for Perinatal Women: Study Protocol for a Randomized Controlled Trial %A Kelman,Alex R %A Stanley,Meagan L %A Barrera,Alinne Z %A Cree,Michelle %A Heineberg,Yotam %A Gilbert,Paul %+ Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, United States, 1 650 396 9349, akelman@paloaltou.edu %K perinatal depression %K comparative trial %K Internet intervention %K Amazon Mechanical Turk %D 2016 %7 15.04.2016 %9 Protocol %J JMIR Res Protoc %G English %X Background: Depression that occurs during the perinatal period has substantial costs for both the mother and her baby. Since in-person care often falls short of meeting the global need of perinatal women, Internet interventions may function as an alternate to help women who currently lack adequate access to face-to-face psychological resources. However, at present there are insufficient empirically supported Internet-based resources for perinatal women. Objective: The aim of this study is to compare the relative efficacy of Internet-based cognitive behavioral therapy (CBT) to a novel Internet-based compassionate mind training approach (CMT) across measures of affect, self-reassurance, self-criticizing, self-attacking, self-compassion, depression, and anxiety. While CBT has been tested and has some support as an Internet tool for perinatal women, this is the first trial to look at CMT for perinatal women over the Internet. Methods: Participants were recruited through Amazon Mechanical Turk (MTurk) and professional networks. Following completion of demographic items, participants were randomly assigned to either the CBT or CMT condition. Each condition consisted of 45-minute interactive didactic and follow-up exercises to be completed over the course of two weeks. Results: Post course data was gathered at two weeks. A 2x2 repeated measures analysis of variance will be conducted to analyze differences between conditions at post course. Conclusions: The implications of the trial will be discussed as well as the strengths and limitations of MTurk as a tool for recruitment. We will also briefly introduce the future directions along this same line of research. Trial Registration: ClinicalTrials.gov NCT02469324; https://clinicaltrials.gov/ct2/show/NCT02469324 (Archived by WebCite at http://www.webcitation.org/6fkSG3yuW) %M 27084301 %R 10.2196/resprot.5332 %U http://www.researchprotocols.org/2016/2/e65/ %U https://doi.org/10.2196/resprot.5332 %U http://www.ncbi.nlm.nih.gov/pubmed/27084301 %0 Journal Article %@ 2368-7959 %I JMIR Publications Inc. %V 3 %N 1 %P e11 %T Adjusting an Available Online Peer Support Platform in a Program to Supplement the Treatment of Perinatal Depression and Anxiety %A Baumel,Amit %A Schueller,Stephen M %+ The Feinstein Institute for Medical Research, 350 Community Dr, Manhasset, NY, 11030, United States, 1 7184708267, abaumel@northwell.edu %K online %K peer %K support %K perinatal %K postpartum %K depression %K anxiety %D 2016 %7 21.03.2016 %9 Original Paper %J JMIR Mental Health %G English %X Background: Perinatal depression and anxiety are common and debilitating conditions. Novel, cost effective services could improve the uptake and the impact of mental health resources among women who suffer from these conditions. E-mental health products are one example of such services. Many publically available e-mental health products exist, but these products lack validation and are not designed to be integrated into existing health care settings. Objective: The objective of the study was to present a program to use 7 Cups of Tea (7Cups), an available technological platform that provides online peer (ie, listener) based emotional support, to supplement treatment for women experiencing perinatal depression or anxiety and to summarize patient’s feedback on the resultant program. Methods: This study consisted of two stages. First, five clinicians specializing in the treatment of perinatal mood disorders received an overview of 7Cups. They provided feedback on the 7Cups platform and ways it could complement the existing treatment efforts to inform further adjustments. In the second stage, nine women with perinatal depression or anxiety used the platform for a single session and provided feedback. Results: In response to clinicians’ feedback, guidelines for referring patients to use 7Cups as a supplement for treatment were created, and a training program for listeners was developed. Patients found the platform usable and useful and their attitudes toward the trained listeners were positive. Overall, patients noted a need for support outside the scheduled therapy time and believed that freely available online emotional support could help meet this need. Most patients were interested in receiving support from first time mothers and those who suffered in the past from perinatal mood disorders. Conclusions: The study results highlight the use of 7Cups as a tool to introduce accessible and available support into existing treatment for women who suffer from perinatal mood disorders. Further research should focus on the benefits accrued from such a service. However, this article highlights how a publicly available eHealth product can be leveraged to create new services in a health care setting. %M 27001373 %R 10.2196/mental.5335 %U http://mental.jmir.org/2016/1/e11/ %U https://doi.org/10.2196/mental.5335 %U http://www.ncbi.nlm.nih.gov/pubmed/27001373 %0 Journal Article %@ 1438-8871 %I JMIR Publications Inc. %V 18 %N 3 %P e54 %T Internet Cognitive Behavioral Therapy for Women With Postnatal Depression: A Randomized Controlled Trial of MumMoodBooster %A Milgrom,Jeannette %A Danaher,Brian G %A Gemmill,Alan W %A Holt,Charlene %A Holt,Christopher J %A Seeley,John R %A Tyler,Milagra S %A Ross,Jessica %A Ericksen,Jennifer %+ Parent-Infant Research Institute, Department of Clinical & Health Psychology, Heidelberg Repatriation Hospital Austin Health 330 Waterdale Road Heidelberg Heights, Melbourne, 3081, Australia, 61 03 9496 ext 4468, alan.gemmill@austin.org.au %K postnatal depression %K postpartum depression %K cognitive behavioral therapy %K Internet-based intervention %K randomized controlled trial %D 2016 %7 07.03.2016 %9 Original Paper %J J Med Internet Res %G English %X Background: There are few published controlled trials examining the efficacy of Internet-based treatment for postnatal depression (PND) and none that assess diagnostic status (clinical remission) as the primary outcome. This is despite the need to improve treatment uptake and accessibility because fewer than 50% of postnatally depressed women seek help, even when identified as depressed. Objective: In a randomized controlled trial (RCT), we aimed to test the efficacy of a 6-session Internet intervention (the MumMoodBooster program, previously evaluated in a feasibility trial) in a sample of postnatal women with a clinical diagnosis of depression. The MumMoodBooster program is a cognitive behavioral therapy (CBT) intervention, is highly interactive, includes a partner website, and was supported by low-intensity telephone coaching. Methods: This was a parallel 2-group RCT (N=43) comparing the Internet CBT treatment (n=21) to treatment as usual (n=22). At baseline and at 12 weeks after enrollment, women’s diagnostic status was assessed by telephone with the Standardized Clinical Interview for DSM-IV (SCID-IV) and symptom severity with the Beck Depression Inventory (BDI-II). Depression symptoms were measured repeatedly throughout the study period with the Patient Health Questionnaire (PHQ-9). Results: At the end of the study, 79% (15/19) of women who received the Internet CBT treatment no longer met diagnostic criteria for depression on the SCID-IV (these outcome data were missing for 2 intervention participants). This contrasted with only 18% (4/22) remission in the treatment as usual condition. Depression scores on the BDI-II showed a large effect favoring the intervention group (d=.83, 95% CI 0.20-1.45). Small to medium effects were found on the PHQ-9 and on measures of anxiety and stress. Adherence to the program was very good with 86% (18/21) of users completing all sessions; satisfaction with the program was rated 3.1 out of 4 on average. Conclusions: Our results suggest that our Internet CBT program, MumMoodBooster, is an effective treatment option for women clinically diagnosed with PND. This is one of only two controlled evaluations of specialized online psychological treatment among women clinically diagnosed with PND. MumMoodBooster appears to be a feasible, effective treatment option, which is potentially accessible to large numbers of women in metropolitan, rural, and remote areas. Future work might be focused profitably on establishing comparability with face-to-face treatments and purely self-guided delivery. We have commenced a larger RCT comparing MumMoodBooster with face-to-face CBT. Trial Registration: Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12613000113752; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=363561 (Archived by WebCite® at http://www.webcitation.org/6f64kuyLf). %M 26952645 %R 10.2196/jmir.4993 %U http://www.jmir.org/2016/3/e54/ %U https://doi.org/10.2196/jmir.4993 %U http://www.ncbi.nlm.nih.gov/pubmed/26952645 %0 Journal Article %@ 1929-0748 %I JMIR Publications Inc. %V 4 %N 4 %P e120 %T An Internet-Based Intervention (Mamma Mia) for Postpartum Depression: Mapping the Development from Theory to Practice %A Drozd,Filip %A Haga,Silje Marie %A Brendryen,Håvar %A Slinning,Kari %+ National Network for Infant Mental Health, Centre for Child and Adolescent Mental Health, Eastern and Southern Norway, PO Box 4623 Nydalen, Oslo, N-0405, Norway, 47 975 16 188, filip.drozd@r-bup.no %K early intervention %K Internet %K intervention mapping %K Mamma Mia %K postpartum depression %K pregnancy %K well-being %D 2015 %7 12.10.2015 %9 Original Paper %J JMIR Res Protoc %G English %X Background: As much as 10-15% of new mothers experience depression postpartum. An Internet-based intervention (Mamma Mia) was developed with the primary aims of preventing depressive symptoms and enhancing subjective well-being among pregnant and postpartum women. A secondary aim of Mamma Mia was to ease the transition of becoming a mother by providing knowledge, techniques, and support during pregnancy and after birth. Objective: The aim of the paper is to provide a systematic and comprehensive description of the intervention rationale and the development of Mamma Mia. Methods: For this purpose, we used the intervention mapping (IM) protocol as descriptive tool, which consists of the following 6 steps: (1) a needs assessment, (2) definition of change objectives, (3) selection of theoretical methods and practical strategies, (4) development of program components, (5) planning adoption and implementation, and (6) planning evaluation. Results: Mamma Mia is a fully automated Internet intervention available for computers, tablets, and smartphones, intended for individual use by the mother. It starts in gestational week 18-24 and lasts up to when the baby becomes 6 months old. This intervention applies a tunneled design to guide the woman through the program in a step-by-step fashion in accordance with the psychological preparations of becoming a mother. The intervention is delivered by email and interactive websites, combining text, pictures, prerecorded audio files, and user input. It targets risk and protective factors for postpartum depression such as prepartum and postpartum attachment, couple satisfaction, social support, and subjective well-being, as identified in the needs assessment. The plan is to implement Mamma Mia directly to users and as part of ordinary services at well-baby clinics, and to evaluate the effectiveness of Mamma Mia in a randomized controlled trial and assess users’ experiences with the program. Conclusions: The IM of Mamma Mia has made clear the rationale for the intervention, and linked theories and empirical evidence to the contents and materials of the program. This meets the recent calls for intervention descriptions and may inform future studies, development of interventions, and systematic reviews. %M 26476481 %R 10.2196/resprot.4858 %U http://www.researchprotocols.org/2015/4/e120/ %U https://doi.org/10.2196/resprot.4858 %U http://www.ncbi.nlm.nih.gov/pubmed/26476481 %0 Journal Article %@ 1929-073X %I JMIR Publications Inc. %V 4 %N 3 %P e14 %T Readability of Information Related to the Parenting of a Child With a Cleft %A De Felippe,Nanci %A Kar,Farnaz %+ School of Dentistry, Division of Orthodontics, University of Minnesota, Rm 6-320A, Moos Tower, 515 Delaware St SE, Minneapolis, MN, 55455, United States, 1 612 625 3652, farah049@umn.edu %K cleft lip %K cleft palate %K parenting %K readability %K literacy %D 2015 %7 08.07.2015 %9 Original Paper %J Interact J Med Res %G English %X Background: Many parents look to various sources for information about parenting when their child has a cleft lip and/or palate. More than 8 million Americans perform health-related searches every day on the World Wide Web. Furthermore, a significant number of them report feeling “overwhelmed” by the language and content of the information. Objective: The purpose of this study is to determine the readability of information related to parenting a child with cleft lip and/or palate. It was hypothesized that the readability of such materials would be at a level higher than 6th grade. Methods: In February of 2012, a Web-based search was conducted using the search engine Google for the terms “parenting cleft lip and palate.” Results: A total of 15 websites, 7 books, and 8 booklets/factsheets (N=30) entered the readability analysis. Flesch-Kincaid Grade Level, Fog Scale Level, and Simple Measure of Gobbledygook (SMOG) index scores were calculated. The reading level of the websites and books ranged from 8th to 9th and 9th to10th grade, respectively. The average reading level of the booklets/factsheets was 10th grade. Overall, the mean readability of the media resources analyzed was considered “hard to read.” No statistically significant mean difference was found for the readability level across websites, books, and booklets/factsheets (Kruskal-Wallis test, significance level .05). Conclusions: When considering websites, books, booklets, and factsheets analyzed, the average readability level was between 8th and 10th grade. With the US national reading level average at 8th grade and the general recommendation that health-related information be written at a 6th grade level, many parents may find the text they are reading too difficult to comprehend. Therefore, many families might be missing out on the opportunity to learn parenting practices that foster optimal psychosocial development of their children. %M 26155814 %R 10.2196/ijmr.4210 %U http://www.i-jmr.org/2015/3/e14/ %U https://doi.org/10.2196/ijmr.4210 %U http://www.ncbi.nlm.nih.gov/pubmed/26155814 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 16 %N 1 %P e6 %T Keywords to Recruit Spanish- and English-Speaking Participants: Evidence From an Online Postpartum Depression Randomized Controlled Trial %A Barrera,Alinne Z %A Kelman,Alex R %A Muñoz,Ricardo F %+ Palo Alto University, 1791 Arastradero Road, Palo Alto, CA, 94304, United States, 1 650 433 3854, abarrera@paloaltou.edu %K Internet intervention %K prevention %K depression, postpartum %K research subject recruitment %K women %K Spanish speaking %D 2014 %7 09.01.2014 %9 Original Paper %J J Med Internet Res %G English %X Background: One of the advantages of Internet-based research is the ability to efficiently recruit large, diverse samples of international participants. Currently, there is a dearth of information on the behind-the-scenes process to setting up successful online recruitment tools. Objective: The objective of the study was to examine the comparative impact of Spanish- and English-language keywords for a Google AdWords campaign to recruit pregnant women to an Internet intervention and to describe the characteristics of those who enrolled in the trial. Methods: Spanish- and English-language Google AdWords campaigns were created to advertise and recruit pregnant women to a Web-based randomized controlled trial for the prevention of postpartum depression, the Mothers and Babies/Mamás y Bebés Internet Project. Search engine users who clicked on the ads in response to keyword queries (eg, pregnancy, depression and pregnancy) were directed to the fully automated study website. Data on the performance of keywords associated with each Google ad reflect Web user queries from February 2009 to June 2012. Demographic information, self-reported depression symptom scores, major depressive episode status, and Internet use data were collected from enrolled participants before randomization in the intervention study. Results: The Google ads received high exposure (12,983,196 impressions) and interest (176,295 clicks) from a global sample of Web users; 6745 pregnant women consented to participate and 2575 completed enrollment in the intervention study. Keywords that were descriptive of pregnancy and distress or pregnancy and health resulted in higher consent and enrollment rates (ie, high-performing ads). In both languages, broad keywords (eg, pregnancy) had the highest exposure, more consented participants, and greatest cost per consent (up to US $25.77 per consent). The online ads recruited a predominantly Spanish-speaking sample from Latin America of Mestizo racial identity. The English-speaking sample was also diverse with most participants residing in regions of Asia and Africa. Spanish-speaking participants were significantly more likely to be of Latino ethnic background, not married, completed fewer years of formal education, and were more likely to have accessed the Internet for depression information (P<.001). Conclusions: The Internet is an effective method for reaching an international sample of pregnant women interested in online interventions to manage changes in their mood during the perinatal period. To increase efficiency, Internet advertisements need to be monitored and tailored to reflect the target population’s conceptualization of health issues being studied. Trial Registration: ClinicalTrials.gov NCT00816725; http://clinicaltrials.gov/show/NCT00816725 (Archived by WebCite at http://www.webcitation.org/6LumonjZP). %M 24407163 %R 10.2196/jmir.2999 %U http://www.jmir.org/2014/1/e6/ %U https://doi.org/10.2196/jmir.2999 %U http://www.ncbi.nlm.nih.gov/pubmed/24407163 %0 Journal Article %@ 14388871 %I JMIR Publications Inc. %V 15 %N 11 %P e242 %T MomMoodBooster Web-Based Intervention for Postpartum Depression: Feasibility Trial Results %A Danaher,Brian G %A Milgrom,Jeannette %A Seeley,John R %A Stuart,Scott %A Schembri,Charlene %A Tyler,Milagra S %A Ericksen,Jennifer %A Lester,Whitney %A Gemmill,Alan W %A Kosty,Derek B %A Lewinsohn,Peter %+ Oregon Research Institute, 1776 Millrace Drive, Eugene, OR, 97403, United States, 1 541 484 2123 ext 2201, briand@ori.org %K postpartum depression %K Web-based intervention %D 2013 %7 01.11.2013 %9 Original Paper %J J Med Internet Res %G English %X Background: Postpartum depression (PPD)—the most common complication of childbirth—is a significant and prevalent public health problem that severely disrupts family interactions and can result in serious lasting consequences to the health of women and the healthy development of infants. These consequences increase in severity when left untreated; most women with PPD do not obtain help due to a range of logistical and attitudinal barriers. Objective: This pilot study was designed to test the feasibility, acceptability, and potential efficacy of an innovative and interactive guided Web-based intervention for postpartum depression, MomMoodBooster (MMB). Methods: A sample of 53 women who satisfied eligibility criteria (<9 months postpartum, ≥18 years of age, home Internet access and use of personal email, Edinburgh Postnatal Depression Survey score of 12-20 or Patient Health Questionnaire score from 10-19) were invited to use the MMB program. Assessments occurred at screening/pretest, posttest (3 months following enrollment), and at 6 months follow-up. Results: All six sessions of the program were completed by 87% (46/53) of participants. Participants were engaged with the program: visit days (mean 15.2, SD 8.7), number of visits (mean 20.1, SD 12.2), total duration of visits in hours (mean 5.1, SD 1.3), and number of sessions viewed out of six (mean 5.6, SD 1.3) all support high usage. Posttest data were collected from 89% of participants (47/53) and 6-month follow-up data were collected from 87% of participants (46/53). At pretest, 55% (29/53) of participants met PHQ-9 criteria for minor or major depression. At posttest, 90% (26/29) no longer met criteria. Conclusions: These findings support the expanded use and additional testing of the MMB program, including its implementation in a range of clinical and public health settings. Trial Registration: Clinicaltrials.gov NCT00942721; http://clinicaltrials.gov/ct2/show/NCT00942721 (Archived by WebCite at http://www.webcitation.org/6KjYDvYkQ). %M 24191345 %R 10.2196/jmir.2876 %U http://www.jmir.org/2013/11/e242/ %U https://doi.org/10.2196/jmir.2876 %U http://www.ncbi.nlm.nih.gov/pubmed/24191345