Participant Experiences of an Infant Obesity Prevention Program Delivered via Telephone Calls or Text Messages.

A 3-arm randomised controlled trial implemented in 2017, recruited participants from four Local Health Districts (LHDs) in New South Wales (NSW) to test an early obesity prevention program delivered via telephone calls (telephone) or text messages (SMS). This sub-study explored participants' experience and satisfaction with the program. A multimethod design was used. Quantitative satisfaction questions were completed by participants when their child was six-months old. A purposive sample of participants with varying satisfaction levels was invited for in-depth qualitative interviews. Data were analysed using Excel (quantitative) and inductive thematic analysis (qualitative). Of the 1155 participants recruited: 947 (293 telephone; 338 SMS; 316 control) completed the six-month survey; 34 (14 telephone; 13 SMS; 7 control) were interviewed. Participants' overall program satisfaction was 100% (telephone) and 85% (SMS). Participants' qualitative responses demonstrated appreciation of: personalised stage-based information; opportunity to communicate with health professionals (telephone); linked Healthy Beginnings booklets and SMS mostly as nudges (SMS). There is a clear need for stage-based information, and supplemented modes of delivery i.e., text messages along with telephone calls; with text messages solely seen as nudges or reminders. However, individual preferences vary according to information needs at any given time, time constraints on new mothers and hence, multiple modes of information provision are recommended in order to reach a wider population and for better engagement. Choice and flexibility in mode of delivery has the potential to provide equitable access to information, empowering women with infants to practice recommended health behaviours for infant obesity prevention.

RCT Entities:   Population Interventions Outcomes

1. Introduction

Interventions for the prevention of obesity in early childhood have been delivered to parents, predominantly to mothers, mostly in trial settings. These interventions primarily focus on one or more behaviours such as breastfeeding, introduction of solids and physical activity. However, the mode of delivery of interventions differs between trials, for example: face-to-face via home visits [1,2]; face-to-face via parent groups in the community [3,4]; face-to-face via child care settings [5,6,7]; via internet [8]; via mobile applications or apps [9,10,11]; via text messages [12] and via telephone calls or/and text messages [13,14].

The Healthy Beginnings (HB) trial that delivered a program using a nurse-led home visiting model from the third trimester of pregnancy until two years of infant’s age was effective in the prevention of early childhood obesity, but home visits added significant costs (personnel, time and travel) [1,15]. Public health interventions delivered by telephone and internet-based approaches are proving to be cost-effective [16]. The increased use of, and reliability of mobile phones has led to a transformation in the way health interventions are delivered. Some examples of interventions delivered via mobile phones include: healthy lifestyle program for young adults [17]; healthy eating for children [18]; and health coaching for weight loss in adults [19]. The Communicating Healthy Beginnings Advice by Telephone Randomised Controlled Trial (CHAT RCT) has harnessed the increased use of mobile phone technology to communicate HB messages via telephone calls (telephone) or text messages (SMS) to pregnant women and women with babies to prevent early childhood obesity [13].

This multimethod study was conducted during the CHAT RCT intervention phase, to explore participant satisfaction, following the objectives of process evaluation frameworks [20,21]. Quantitative and qualitative approaches were used to understand participants’ actual experiences during the intervention phase, and to unpack the processes of implementation and behaviour change, which are important for future planning and scaling up to population-level. The aims of this paper were two-fold: (1) to explore participants’ experiences of participation in the program and perceptions of the utility, or otherwise, of the intervention contents delivered via telephone or SMS; and (2) to observe whether the perceptions and experiences differed between participants who received interventions via telephone or via SMS.

2. Methods

2.1. Study Context

The CHAT RCT was conducted across four Local Health Districts (LHDs) within New South Wales (NSW) Australia, where pregnant women were recruited at eight hospital sites between February and July 2017. The study protocol, eligibility criteria, recruitment process and outcomes are reported in detail elsewhere [13,22,23]. In brief, CHAT is a three-arm RCT that compares: mailed HB booklets plus telephone support (telephone); to mailed HB booklets plus text messages or Short Message Service (SMS); to the control arm. Interventions were stage-based and provided at six time points following key developmental milestones from the antenatal period (third trimester) until the end of first year of the infant’s life. The control arm participants were mailed general infant safety promotion materials. Usual care on infant development and safety is delivered by local child and family health services that are not mandatory.

2.2. Study Design

A multimethod sequential explanatory design with two phases was used to evaluate participants’ perceptions of the intervention contents and their experiences of participation in the CHAT RCT [24,25,26]. The design includes a quantitative phase and a follow-up qualitative phase. The purpose of this design was to use the qualitative results to further explain and interpret the findings from the quantitative phase [27].

2.2.1. Phase 1—Quantitative Survey

Participant demographic characteristics on age, parity, country of birth, language spoken at home, household income, educational status, marital status and aboriginality were collected at baseline.

In the first phase, quantitative satisfaction data were collected from all CHAT RCT participants at the six-month follow-up survey. The survey included closed-item satisfaction questions about the program where participants rated satisfaction on a 5-point Likert scale (very satisfied to very unsatisfied) (Table 1). Questions also included whether they would recommend the program to other mothers and if they would like to participate in a further qualitative study. The survey was administered via telephone using computer assisted telephone interviewing (CATI). Participant responses were collected on a Microsoft Access database and exported to Excel for analysis.

Table 1

Satisfaction questions administered at the six-month quantitative survey.

Satisfaction Questions	Telephone Participants	SMS Participants	Control Participants
Overall Healthy Beginnings program	✓	✓
Healthy Beginnings booklets	✓	✓
Receiving advice on baby’s growth and your health through telephone	✓
Receiving advice on baby’s growth and your health through SMS		✓
Timeliness of calls from nurses	✓
Timeliness of the SMS		✓
Type of advice nurses provide you with	✓
Type of advice the SMS provide you with		✓
Quality of service provided	✓	✓
Responses you have received after sending an SMS		✓
Would you recommend the Healthy Beginnings program to other mothers?	✓	✓	✓

2.2.2. Phase 2—Qualitative Interviews

In the second phase, qualitative interview data were collected post six-month survey (at around 12 months of infant’s age) and during the intervention phase. Participants who expressed interest in participating in further research at the six-month survey were eligible. Participants who met the inclusion criteria from the two intervention arms of the study and whose satisfaction levels with the program and program contents varied between satisfied and not satisfied were purposively selected by the first author (M.E.) to include a heterogenous sample [28]. Control participants were purposively selected to include participants who recommended or did not recommend the program to others. Participants were invited to participate in the qualitative interviews via email along with the information sheet and consent form. The email was followed by a text message sent to participants by a project team member for nomination of a suitable interview date and time. ME interviewed participants at the nominated dates and times. Prior to commencement of interviews, verbal consent was obtained and recorded.

Using the framework described by Patton [29], interviews were semi-structured to explore emerging themes associated with participants’ experiences and perceptions. An interview guide was developed following the satisfaction questions from the quantitative survey (Appendix B). Open-ended questions (tailored to the intervention arm of participants i.e., telephone, SMS or control) were asked, giving participants the opportunity to express their individual experiences. Prompts were used to elicit greater detail and for participants to elaborate on their experiences. Interview questions were pilot tested and modified for flow prior to administering to participants. All interviews were conducted by ME, who is trained and experienced in qualitative research methods. Interviews were conducted via telephone between March and June 2018 at a time convenient to participants (including evenings and weekends). This approach allowed flexibility in participation and was minimally intrusive [4,30,31,32]. The average interview duration was 20 min. Interviews were digitally audio recorded, transcribed verbatim and transcripts were cross-checked against recordings to ensure accuracy.

Authors M.E. and S.T. followed the principles of inductive thematic analysis [33] to generate an initial coding frame. Each researcher independently applied the coding frame to three interviews (one from each trial arm) and compared the analyses for consistency of codes, refined codes and eliminated discrepancies. The remaining transcripts were then coded by M.E. Following coding, themes were generated, refined in an iterative manner with four main themes identified: (1) overall opinion of the program; (2) mode of delivery; (3) intervention contents; and (4) contextual/psychosocial issues.

2.3. Ethics Approval and Consent for Participation

The CHAT RCT is registered with the Australian Clinical Trial Registry (ACTRN12616001470482p) on 21 October 2016. This research was approved by the Sydney Local Health District Ethics Committee (approval number X16-0360 & LNR/16/RPAH/495). All interviewees provided verbal consent; permission to record the interview was also requested and obtained. Participants were offered a $20 gift voucher.

3. Results

Of the 1155 CHAT RCT participants, 947 (82%) completed the six-month survey. At the six-month survey, 761 (80%) participants agreed to participate in further research, of which 61 were approached for this qualitative study. Of the 61 participants who were approached, 36 (59%) participants consented to be interviewed of which two participants did not answer the telephone on three separate occasions. Qualitative interviews were conducted with 34 participants—14 (telephone), 13 (SMS) and 7 (control).

3.1. Demographics of Participants

Table 2 shows the demographic characteristic of the participants. The majority of participants were: first-time mothers; born overseas; spoke English at home; ≥30 years of age; university qualified; household income ≥AU$ 80,000; employed; and in a married or de-facto relationship (Table 2).

Table 2

Demographic characteristics of participants.

Characteristic	Category	All CHAT RCT ParticipantsN = 947	Non-Interviewed ParticipantsN = 913	Interviewed ParticipantsN = 34	p-Value *
		n (%)	n (%)	n (%)
Intervention arm	Telephone calls + Booklets	293 (31)	279 (30)	14 (41)	0.2249
	Text messages + Booklets	338 (36)	325 (36)	13 (38)
	Control (usual care)	316 (33)	309 (34)	7 (21)
Parity	First-time mother	515 (54)	492 (54)	23 (68)	0.1138
	Not first-time mother	432 (46)	421 (46)	11 (32)
Country of Birth	Australia	361 (38)	344 (38)	17 (50)	0.1464
	Other	586 (62)	569 (62)	17 (50)
Aboriginal status	Non-Aboriginal	925 (98)	892 (98)	33 (97)	0.8077
	Aboriginal	22 (2)	21 (2)	1 (3)
Language spoken at home	English	525 (55)	502 (55)	23 (68)	0.1446
	Other	422 (45)	411 (45)	11 (32)
Age (years)	≥30	661 (70)	633 (69)	28 (82)	0.1044
	<30	286 (30)	280 (31)	6 (18)
Education	University	642 (68)	615 (67)	27 (79)	0.1398
	Other	305 (32)	298 (33)	7 (21)
Household income	≥AUS$80,000	551 (58)	525 (58)	26 (76)	0.0885
	<AUS$80,000	301 (32)	295 (32)	6 (18)
	Don’t know	95 (10)	93 (10)	2 (6)
Employment status	Employed	604 (64)	577 (63)	27 (79)	0.0534
	Other	343 (36)	336 (37)	7 (21)
Marital status	Married/de-facto partner	887 (94)	855 (94)	32 (94)	0.9192
	Other	60 (6)	58 (6)	2 (6)

* Chi-square test of independence was performed to examine the relation between characteristics of interviewed and non-interviewed participants.

3.2. Participants’ Responses at the Six-Month Quantitative Survey

Table 3 reports the findings of participants’ responses, including all participants from the RCT and those who participated in this qualitative sub-study.

Table 3

Aggregate participants’ responses to satisfaction questions at the six-month survey.

Satisfaction Questions	Telephone Participants		SMS Participants		Control Participants
	All Participants (N = 293)	Participants Interviewed (N = 14)	All Participants (N = 338)	Participants Interviewed (N = 13)	All Participants(N = 316)	Participants Interviewed(N = 7)
	Very Satisfied/Satisfiedn (%)	Very Satisfied/Satisfiedn (%)	Very Satisfied/Satisfiedn (%)	Very Satisfied/Satisfied n (%)	Very Satisfied/Satisfiedn (%)	Very Satisfied/Satisfiedn (%)
Overall Healthy Beginnings programme	286 (98)	14 (100)	294 (94)	11 (85)
Healthy Beginnings booklets	278 (95)	13 (93)	293 (94)	12 (92)
Receiving advice on baby’s growth and your health through telephone	284 (97)	13 (93)
Receiving advice on baby’s growth and your health through SMS			283 (90)	9 (69)
Timeliness of calls from nurses	275 (94)	12 (86)
Timeliness of the SMS			282 (90)	8 (62)
Type of advice nurses provide you with	286 (98)	14 (100)
Type of advice the SMS provide you with			275 (88)	9 (69)
Quality of service provided	288 (98)	12 (86)	299 (96)	11 (85)
Responses you have received after sending an SMS			212 (68)	5 (38)
Would you recommend the Healthy Beginnings program to other mothers?	290 (99)	13 (93)	330 (98)	11 (85)	298 (94%)	5 (71%)

In the telephone arm, the satisfaction levels of participants who were qualitatively interviewed were about the same as that of all telephone call participants. Participants who were qualitatively interviewed expressed 100 percent satisfaction with the ‘program’ and ‘type of advice provided by nurses’ (Table 3).

In the SMS arm, the satisfaction levels of participants who were qualitatively interviewed were lower than that of all SMS participants except for satisfaction of ‘HB booklets’ where interviewed participants expressed 92% satisfaction (Table 3).

Table 4 represents the satisfaction level of participants who were qualitatively interviewed. Most participants expressed satisfaction with the program and program contents.

Table 4

Satisfaction of participants (who were interviewed) with program and program contents at the six-month survey.

Satisfaction Questions	Telephone Participants Interviewed(N = 14)	SMS Participants Interviewed(N = 13)
	Very Satisfied/Satisfied n (%)	Very Satisfied/Satisfied n (%)
Overall Healthy Beginnings programme	14 (100)	11 (85)
Healthy Beginnings booklets	13 (93)	12 (92)
Receiving advice on baby’s growth and your health through telephone	13 (93)
Receiving advice on baby’s growth and your health through SMS		8 (62)
Timeliness of calls from nurses	12 (86)
Timeliness of the SMS		8 (62)
Type of advice nurses provide you with	14 (100)
Type of advice the SMS provide you with		9 (69)
Quality of service provided	12 (86)	11 (85)
Responses you have received after sending an SMS		5 (38)

3.3. Participants’ Satisfaction with Program at Qualitative Interviews

The four main themes are represented below: (1) overall opinion of the program; (2) mode of delivery; (3) intervention contents; and (4) contextual/psychosocial issues. Themes and sub-themes with illustrative quotes from the interviews are reported in detail in Appendix C.

3.3.1. Theme 1: Overall Opinion of the Program

Table 5 contains quotes representing participants’ overall opinion of program. Participants appreciated the stage-based delivery of the program received via telephone or SMS with linked booklets. The personalised messages provided comfort to those participants who considered themselves isolated when they were home with the newborn. Participants were concerned about the discrepancies on age of introduction of solids provided in the program compared to that received from other sources. First-time mothers rated the program highly and recommended the program to other first-time mothers. Second time mothers, newly arrived participants to the country and those without family support also felt that they benefitted from the program. Participants acknowledged the need for additional support and information as opposed to making an appointment to see a General Practitioner (GP).

Table 5

Quotes supporting participants’ overall opinion of the program.

Overall Opinion of the Program
“The booklet sort of explains what to start feeding them, when the time is right and … just new things that they are going to be learning at that stage …” (Satisfied telephone participant T10)
“When I receive the text messages, when alone at home with the baby, when you get a message like that, it sort of brightens your day … oh, someone is thinking about me …” (Satisfied SMS participant S3)
“I also found it useful just to engage with somebody else … sometimes you become isolated. It’s good to have somebody else check in on you now and then … I could actually discuss topics that reflected my need.” (Satisfied telephone participant T2)
“I have to say for that bit, I was a little bit confused because there was so much conflicting advice … I felt like there was a lot of conflicting advice out there about when I should have started her on solids.” (Unsatisfied SMS participant S4)
“I would highly recommend other mothers to be a part of this program. It has been useful and it has been a really great way of adjusting to being a new mother.” (Satisfied SMS participant S1)
“I would like every, at least first-time mum, to experience all this. I think it’s a blessing to have such a program.” (Satisfied telephone participant T12)
“I’m a second time mother. I forget from the first one … The booklet is new information for me. May be the first one I do the wrong thing, you know … so this one is good for me.” (Satisfied telephone participant T5)
“Some mothers do want some extra support and going to a GP is hard and you need to make an appointment, so this is over the telephone, it’s easier to access information.” (Partially satisfied text message participant S13)

3.3.2. Theme 2: Mode of Delivery

Quotes related to participants’ perception on delivery of interventions via telephone calls or text messages or HB booklets are provided in Table 6.

Table 6

Quotes related to participants’ perception of mode of delivery.

Mode of Delivery
Telephone calls
“It was good to talk to a nurse … it was comforting to know it had come from a health professional rather than me having to go down to the doctor and probably get the same answer.” (Satisfied telephone participant T13)
“The phone calls have been beneficial … individualised feedback, they would explain things until I understood them myself and not just as if it was to a whole group of people.” (Partially satisfied telephone participant T3)
“It was always very difficult coordinating the phone call time … Maybe because I don’t have a routine baby. I wouldn’t know for sure when I was going to be free on any day, so often I would call when it was a good time for me, but of course the nurses would be busy. Often we’d play phone tag for weeks trying to get hold.” (Satisfied telephone participant T1)
“It was good to talk to a nurse … if you had concerns about something … I got to ask them a question via text message and they came back to me the next day with a response.” (Satisfied telephone participant T13)
Text messages
“I would be thinking about something was going on with breastfeeding or something and the next day I would get, just by chance a message … it kind of made me go, yes I am doing the right thing … I think I was probably happy with the text messages because I often didn’t have time for a telephone call.” (Satisfied SMS participant S5)
“I didn’t really benefit very much from the text messages. I did look at the text messages … just found the booklets more useful … I feel like it was a nice addition, but I don’t feel like it’s necessary to get the text messages.” (Satisfied SMS participant S1)
“But maybe a mix of the two…because text messages you are not as likely to remember it all, so may be a phone call or something might have built that… I think that everyone is different, so I think you need to give kind of a choice…probably recommend a couple of phone calls in there.” (Satisfied SMS participant S5)
HB booklets
“It was all useful to me…my husband, he also found it really useful, so we both kind of have the same views on the content.” (Satisfied SMS participant S1)
“It was handy to have a source of authority to say that this is why I’m not feeding him those things.” (Satisfied telephone participant T1)
“It was described in a very easy way, the booklet. I can understand… so it was easy. In terms of the nurses’ calls may be sometimes a little bit of tension but it’s fine.” (Satisfied telephone participant T7)

Telephone Calls

Participants took comfort in receiving telephone calls from a nurse and appreciated talking to them about their concerns. The participants expressed their preference for receiving information that was tailored to their needs rather than given as a group. Despite reporting that the program was convenient, several participants found it difficult to make time for the calls. On occasions, it took several weeks for participants to be contacted by the intervention nurses. Participants were time poor due to responsibilities such as caring for infants. They appreciated and preferred the flexibility of communicating via telephone calls or text messages.

Text Messages

Participants found it convenient to read the text messages in their own time when baby was asleep. Messages were reassuring and gave participants the confidence to continue breastfeeding. Other participants considered text messages as mere reminders or nudges that did not provide additional benefits to them in comparison to the booklets. Participants expressed a need for choice of receiving interventions and recommended combination modes of text messages plus telephone calls or text messages plus email.

HB Booklets

Participants considered HB booklets as handy resources that they could refer to anytime and a resource they could share with their partners. HB booklets were also used to present credible information to their family and was used as a source of authority to encourage practice of desired behaviours. Participants from culturally and linguistically diverse background found the booklets easy to understand. These participants preferred the booklets in comparison to conversing in English, which they found difficult at times.

3.3.3. Theme 3: Intervention Contents

Participants provided their opinion on contents of the stage-based intervention, key quotes are included in Table 7.

Table 7

Participants’ quotes on intervention contents.

Intervention Contents
Breastfeeding
“I saw a lactation consultant and I also went to the breastfeeding drop-in clinic. I also went to a twins breastfeeding class at [name of hospital].” (Partially satisfied SMS participant S2)
“I stopped breastfeeding at five months old … we had breastfeeding issues … so I kind of felt like, if I didn’t breastfeed her that I was being judged.” (Satisfied SMS participant S1)
Introduction to solids
“Information on introduction to solids was useful because I have no idea what to give the baby when he can start solids … In terms of feeding solids may be some more information is better because … I am still feeding him by the spoon.” Satisfied telephone participant T4
“Well, my husband’s family were pushing very strongly that I feed him things like custard, sweetened with honey and things like that … It was handy to have a source of authority.” (Satisfied telephone participant T1)
“The nurse said don’t give solids to the baby at three months … The reason why nurse said not to bring in solids is because his digestive system was just growing.” (Satisfied telephone participant T12)
“The only thing that really stood out was the breastfeeding fine until six months and start solids. I didn’t do that with my other children. I only done it with this one because I read it in the book. I done it a lot earlier.” (Satisfied SMS participant S10)
Tummy time
“Sometimes mothers know a lot of things but when someone talks to them about tummy time … it’s kind of like a reminder … oh no, that’s right, we’ve got to do that today.” (Satisfied telephone participant T6)
“The booklets reminded me about tummy time and I really got onto tummy time …” (Partially satisfied telephone participant T14)
“I don’t do it a lot actually, just because I was so busy.” (Partially satisfied SMS participant S2)
Screen time
“A lot was stressed on tummy time and about screen time, and I’m glad I wasn’t doing screens anyway …” (Satisfied telephone participant T6)
“My baby watches TV. I know she shouldn’t … I need to do things like go to the toilet, or cook dinner … it’s just in the background.” (Satisfied SMS participant S1)
Sleep and settling
“The nurses used to tell me how many hours our baby should sleep and how to put the music on or try to give them the environment where he can sleep more without disturbing.” (Satisfied telephone participant T12)
“I definitely supplemented especially the sleep parts with some other books that I had… that was the one thing she struggled with unfortunately … Tresillian (an early parenting service) even came out to help us as well … I think I needed a bit more information on that.” (Unsatisfied SMS participant S4)
Goal-setting
“I liked how they had goals … they summarised the call and sent you emails with your goals written down. Sometimes I would pass those emails on to my family just to let them know what stage I was up to …” (Satisfied telephone participant T1)

Breastfeeding

Generally, participants without breastfeeding issues considered the advice provided on breastfeeding was useful. Participants who experienced issues such as low milk supply, mastitis and latching were likely to explore services beyond the program to receive help in managing those issues. Participants who were unable to continue breastfeeding for as long as specified, felt like they were judged by the program providers.

Introduction to Solids

Although most participants found the information on solids useful, there was a general lack of awareness on when to start solids. Participants reported that they sought information on solid feeding from other sources including family members, doctors, the internet and classes. In some instances, it appeared that family members had a strong influence on participants’ decisions with regards to feeding solids, while for others, the program enabled participants to convince family members on choice of food for infant. In particular, the telephone calls with the nurses were likely to influence participants’ decision to delay the introduction of solids until after 6 months. Some mothers made an effort to feed according to the guidelines for their current child even if they did not for their previous child.

Tummy Time

Participants needed to be reminded, and appreciated the reminders, that encouraged them about early commencement of practice of tummy time. Some participants expressed they were too busy for tummy time.

Screen Time

Telephone calls and text message reminders on tummy time and screen time recommendations raised participants’ awareness. Some participants allowed infants to watch television in order for them to carry out household chores or to go to the toilet.

Sleep and Settling

Some participants acknowledged that strategies and support provided via telephone to manage infant’s sleep were helpful. Other participants expressed that they struggled to get information on how to settle their babies to sleep and reported seeking support beyond the program to help manage their infant’s sleeping pattern.

Goal-Setting

Although participants considered goal-setting important, they experienced challenges with achieving goals due to balancing parenting responsibilities, doing household chores or returning to work. Participants appreciated the follow-up emails sent by intervention nurses that participants shared with family members. Goal-setting strategies also helped participants manage baby’s reflux, breastfeeding issues or preparation of home-made infant solid foods.

3.3.4. Theme 4: Contextual/Psychosocial Issues

Difficulties were expressed by participants during participation in the trial (Table 8). Participants were anxious on how to adjust to becoming a new mother and expressed the need for more information, particularly in the early stages after childbirth. A few participants reported feeling overwhelmed by the advice and felt that there was a high expectation of mothers. Participants who had infants with developmental issues were not able to follow the stage-based advice since they needed to deal with the situation at hand.

Table 8

Quotes underpinning participants’ contextual/psychosocial issues.

Contextual/Psychosocial Issues
“I probably struggled initially to adjust to the life change … maybe if there was more information at the beginning that was around … a lot of women feel the same way … adjusting to being a mother is really hard …” (Satisfied SMS participant S1)
“I guess the one thing that I probably struggled with was there’s a lot of expectations on mothers … the advice that you get in terms of … it’s incessant.” (Satisfied telephone participant T2)
“I found all of that kind of information (feeding and eating) frustrating for me personally because I wasn’t able to follow it due to swallowing difficulties … I’d feel like my kid was really delayed because he couldn’t do the things … in the literature or he couldn’t do the things other kids were doing” (Satisfied telephone participant T10)

3.3.5. Control Arm Participants’ Perception

Participants in the control arm considered that the information in the control booklets was very general in nature and expressed a need for support and information more broadly and particularly on feeding of solids. This program did not meet their needs and they sought help from external sources. Despite being in the control arm, participants were satisfied to remain in the program.

“When I really needed help with breastfeeding or questions about solids or brushing teeth or developmental milestones, I would need to either make an appointment with the early childhood health centre or call ABA (Australian Breastfeeding Association) or Tresillian (an early parenting service) or try to find a doctor.” Control participant C4.

4. Discussion

We conducted a process evaluation of the intervention phase of the CHAT RCT to understand participants’ actual experiences of the program; and observed any differences between the perceptions of telephone and SMS participants. Almost all participants in the telephone arm and several participants in the SMS arm reported participation in the program as positive, valued the stage-based information, appreciated the flexibility of intervention provision particularly in relation to the mode of intervention delivery via telephone calls or text messages with linked HB booklets. Based on the p-values in Table 2, it can be interpreted that the interviewed participants were representative of the CHAT population. Many participants appreciated the information in the HB booklets and considered them as handy resources and referred to them at their convenience. In particular, first-time mothers found the program very useful and recommended that the program be delivered to all first-time mothers. Participants’ responses and experiences demonstrate the need for information provision and support. However, due to variable information needs and participants’ time constraints, their preference is for flexibility and choice in mode of delivery.

Participants in the telephone arm valued the telephone calls since they considered the calls were individually tailored to their needs. Participants attributed positive perceptions of the program to the opportunity for them to ask questions of nurses at the time of intervention delivery that enabled discussion of issues and in some instances, participants expressed that the nurses helped them resolve issues and alleviated the need to visit health professionals. Text messages were perceived as convenient by participants in the SMS arm since they could read the messages in their own time, however, the majority of participants preferred the HB booklets to text messages. Many considered the text messages as mere nudges or reminders supplementary to the HB booklets. A few in the SMS arm stated that the text messages lacked personalisation. Participants in the control arm also expressed the need for support and information but were satisfied to remain in the program despite receiving information of a general nature only.

The vast majority of participants welcomed the stage-based interventions delivered to them via telephone calls or text messages with the linked booklets and this has been shown in earlier home-based studies [1]. Although home-based interventions were successful in reaching women, they were resource, time intensive with several logistical issues involved in home visiting. In this program, the convenience of receiving stage-based advice and support via telephone calls or text messages and when participants needed them were appreciated by majority of participants. Studies that reported participants’ views on delivering adult and infant obesity prevention interventions via telephone calls, text messages or apps generally report high satisfaction rating and have been regarded favorably by participants [9,11,12,16,17,34].

The finding that some participants considered it difficult to adhere to the advice provided, and they considered this program burdensome on top of other commitments and responsibilities, has been shown in other studies [3,35,36]. Lack of compliance with the program was encountered in other infant obesity prevention programs delivered via more traditional modes e.g., face-to-face, and attributed to time constraints, travel distances, busy schedules and return of participants back to work [35,36,37]. Programs need to acknowledge competing commitments of participants and consider providing flexibility and choice. Participants expressed a need to have choice of delivery modes, for example, telephone calls or text messages or combination of both. Their views are similar to those expressed by participants in other obesity prevention programs that suggest innovative approaches to delivering interventions [35], where text messages were considered as supplementary to telephone coaching calls [12,17,34], or where participants preferred a combination of telephone calls and/or emails with social media or online platforms due to changing needs and to enhance engagement [8,9,10,38].

One important finding of this study was related to breastfeeding and solid feeding advice where advice is sought by mothers. For example, credible, non-judgmental support for breastfeeding and infant solid feeding provided by health professionals was appreciated and welcomed by participants. Participants without major breastfeeding issues considered the program helpful but those who faced breastfeeding issues expressed that they needed hands-on, face-to-face practical support. Credible content from reliable sources were valued highly by participants in other infant obesity prevention programs and contributed to increased engagement [9,11]. A few participants in this program expressed concerns that the information they received on timing of introduction to solids conflicted with the information they received from external sources.

Many participants in this program used screen time for infants as a coping strategy in order to undertake household chores, which is consistent with many other studies, and at times was viewed as an educational tool [6,7]. Our results reflect that sleep and settling are major issues that affect mothers and their children. Although studies have provided interventions for sleep and settling prior to this study [39,40,41,42,43,44], perceptions of participants have not been explored previously. In this study, several participants said that they struggled with their infant’s sleep and settling and preferred to receive more information on sleep and settling. Goal-setting was appreciated by some participants but most participants commented that they did not have the time to adhere to interventions on self-care through exercise. While constructive goal setting was viewed positively [34], the capacity of physical activity interventions for parent behaviour modification is limited [16].

Strengths and Limitations

A key strength of this research was the use of multimethod sequential explanatory research design, where qualitative results were used to further explain and interpret the findings from the quantitative phase. The quantitative and qualitative phases were conducted with participants at a time close to the intervention, for completeness of the recollections retrieved by participants regarding their experiences [45,46]. Additionally, converging evidence through triangulation of the quantitative and qualitative data adds to the strength of this study [24,25,26,27].

Some participants were challenged with health/psychosocial issues post-childbirth that prevented them from active participation. There was an option for participants to withdraw at any time but there were no other mechanisms in place for the team to monitor participants’ changing needs, especially of those in the SMS arm. In an RCT environment, there was limited to no flexibility for variation to accommodate the changing needs of mothers. The program was offered to participants fluent in English in an urban setting, therefore the results may not necessarily reflect the perceptions of women who were Indigenous, or from culturally and linguistically diverse backgrounds or remote or rural areas. This is important as the program has the potential to support families in isolated, rural and remote locations and further work would need to be carried out before implementation in this population.

5. Conclusions

Process evaluation of the intervention phase of the CHAT RCT improved our understanding of participants’ perceptions of and satisfaction with the program. Participants’ responses are indicative of their appreciation of the program since it met their needs, particularly information relating to breastfeeding, solid feeding and infants’ sleep. Delivering health promotion messages via telephone calls or text messages has the potential to provide equitable access to information by women from various socio-economic and culturally diverse backgrounds. These findings demonstrated that information-provision can potentially increase women’s health literacy skills and empower them to practice recommended health behaviours for infant obesity prevention.

Participants’ responses indicate a clear need for stage-based information provision with preference of choice and flexibility in mode of intervention delivery due to their changing needs. Future translation or scaling-up of the program should explore the possibility of integrating this program with existing programs such as the New South Wales Get Healthy and the Get Healthy in Pregnancy Services; with appropriate referral pathways to address participants’ psychosocial needs during and post pregnancy. There is a clear need for supplemented modes of delivery i.e., text messages along with telephone calls; with text messages solely seen as nudges or reminders. However, individual preferences vary according to information needs at any given time, time constraints on new mothers and hence, information provision via multiple modes is recommended in order to reach a wider population and for better engagement.