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Despite evidence of the benefits of breastfeeding, <15% of Australian babies are exclusively breastfed to the recommended 6 months. The support of the father is one of the most important factors in breastfeeding success, and targeting breastfeeding interventions to the father has been a successful strategy in previous research. Mobile technology offers unique opportunities to engage and reach populations to enhance health literacy and healthy behavior.
The objective of our study was to use previous research, formative evaluation, and behavior change theory to develop the first evidence-based breastfeeding app targeted at men. We designed the app to provide men with social support and information aiming to increase the support men can offer their breastfeeding partners.
We used social cognitive theory to design and develop the Milk Man app through stages of formative research, testing, and iteration. We held focus groups with new and expectant fathers (n=18), as well as health professionals (n=16), and used qualitative data to inform the design and development of the app. We tested a prototype with fathers (n=4) via a think-aloud study and the completion of the Mobile Application Rating Scale (MARS).
Fathers and health professionals provided input through the focus groups that informed the app development. The think-aloud walkthroughs identified 6 areas of functionality and usability to be addressed, including the addition of a tutorial, increased size of text and icons, and greater personalization. Testers rated the app highly, and the average MARS score for the app was 4.3 out of 5.
To our knowledge, Milk Man is the first breastfeeding app targeted specifically at men. The development of Milk Man followed a best practice approach, including the involvement of a multidisciplinary team and grounding in behavior change theory. It tested well with end users during development. Milk Man is currently being trialed as part of the Parent Infant Feeding Initiative (ACTRN12614000605695).
Breastfeeding is universally recognized as the optimal way for babies to receive nutrition, and breastfeeding offers many well-documented health benefits for both mother and baby [
The influence of the father has been identified as one of the most significant factors influencing the breastfeeding behavior of the mother [
Relatively few father-focused breastfeeding interventions have robustly evaluated breastfeeding outcomes using a randomized controlled trial (RCT) design. However, the Fathers Infant Feeding Initiative (FIFI), conducted by members of our team, trialed a male-facilitated antenatal class for expectant fathers and a follow up social support component consisting of age-relevant information being mailed out to participants [
Mothers have reported that partner support makes a difference to their confidence, as well as helping them to achieve their breastfeeding goals [
Insufficient social support
Frequent exclusion from family support programs
Lack of opportunities to learn and share
Lack of peer support
Expectations about breastfeeding, bonding with baby, and about how life changes after baby arrives
Health and other benefits of breastfeeding
Practical suggestions to help family
Professional services available, for mothers and fathers
Lack of recognition of paternal role
Lack of understanding of importance of paternal support for breastfeeding
Need for more information and practical advice on how men can better support their family
Concerns around having to postpone bonding with baby until breastfeeding has finished, or around other ways to bond with baby besides feeding
Public breastfeeding
Feeling left out of the relationship (with their partner and with the baby)
While specific recommendations from the FIFI study focused on the use of the Internet and DVDs, the technological landscape has changed markedly since the FIFI study was implemented in 2008. Smartphone usage is now virtually ubiquitous in Australia. In July 2014, Deloitte estimated that 81% of Australians aged 14 years and over owned a smartphone [
Mobile technology has been incorporated into health promotion programs targeting various health behaviors. Initiatives have targeted new parents [
Developing mHealth interventions in multidisciplinary teams is a best practice approach recommended by many researchers [
Push notifications are a means by which mobile apps can send information or alerts to users [
The use of technology for information gathering has changed markedly over the last 20 years. Increasingly, people want to interact with technology and use it to socially connect rather than simply passively receiving static information [
Socially connected mobile technology can encourage people to reach out to each other and build communities [
Gamification is the practice of using game-like components to motivate and encourage people in non-game contexts, and it is becoming increasingly popular in health and fitness apps [
We developed the Milk Man app to be trialed as part of the Parent Infant Feeding Initiative (PIFI), which has been previously described [
One of the largest intervention breastfeeding studies to target male partners, the PIFI study will be conducted between 2015 and 2017 and is expected to provide valuable insights into infant feeding outcomes. This paper focuses on the Milk Man app, with particular emphasis on the formative research underpinning its design, development, and preliminary testing.
This research adds to the literature by describing the design and development of, to our knowledge, the first breastfeeding app targeted at men. The app uses carefully considered mobile strategies to engage men with an issue that is typically seen as the domain of women, and the results will add to the literature on mHealth and health promotion, particularly with respect to what works for targeting men with breastfeeding initiatives.
We developed the Milk Man app as a socially connected information and support resource for men. It is focused on breastfeeding and infant feeding, but includes broader information on topics including early parenting, being a supportive partner, and local service providers. It is based on evidence about the main factors affecting fathers’ support of their breastfeeding partners and is informed by social cognitive theory (SCT). As part of the formative research process, we completed a marketing audit of current advertising campaigns investigating how health messages, products, and services were being designed for the target group. This information helped guide the design of the app. Breastfeeding interventions are often targeted at the mother, resulting in fathers reportedly feeling excluded from family support programs [
Milk Man was informed by focus groups with men in the target group, in addition to consultation with health professionals. We refined it through a testing phase comprising beta testing and user testing with men in the target group. User testing involved participants completing a think-aloud walkthrough, as well as completing the Mobile Application Rating Scale (MARS) [
Development process for Milk Man.
SCT is a social learning model that operates at the interpersonal level, assuming an interaction between the social environment, the psychosocial determinants of behavior, and the individual [
Reciprocal determinism is a key principle of SCT, describing the influence of both personal factors and the social environment on a person’s behavior. The factors that affect fathers’ decisions about and capacity to support breastfeeding are broad and include a combination of environmental and personal influences. Two specific social environmental factors that have been identified in the literature for this target group are the sometimes complex issues related to public breastfeeding, and the role that health professionals can have [
We based the design of the Milk Man app and its engagement model on SCT constructs, to address the key issues affecting men’s support for their breastfeeding partners. The specific constructs of observational learning and goal setting were key components. In seeking to address self-efficacy, the app encourages problem solving between couples.
Milk Man engagement techniques mapped to social cognitive theory (SCT).
Key factors | SCT constructs | Engagement technique in Milk Man app | |
Men feel they do not receive enough social support with pregnancy and early parenting. | Observational learning |
Connected social support function via the guided “conversation” feature. |
|
Men have gaps in knowledge around breastfeeding, pregnancy, and early parenthood. | Outcome expectations |
Provision of information via the library, including practical solutions and support service contact details. |
|
Men report lack of recognition of paternal role and understanding of their supportive role. | Self-efficacy |
Focus on empowering men to understand their role through the library and the conversation. |
|
Men report specific barriers, including bonding postponement, public breastfeeding, and feeling left out. | Self-regulation |
Forum for men to share information and an opportunity for discussion about solutions to barriers. |
We specifically designed the app to be attractive and engaging to the target group. The app is contemporary, delivers important information in a fun and lighthearted manner, and contains quirky imagery throughout. Milk Man contains engagement strategies that aim to keep men interested in using the app. The main engagement strategies are the use of push notifications, social connectivity via a guided conversation, an information library, and gamification.
The Milk Man app has new content being added in the form of conversation topics twice a week. Push notifications are used to alert users to new discussion topics.
Milk Man aims to socially connect men by engaging them in a guided conversation. The conversation consists of a series of topics initiated by the app administration team twice a week. Participants receive a push notification alerting them to new topics and inviting them to participate in the conversation. On swiping the notification, they are taken directly to that conversation within the app. Topics are either posts or polls. A post, shown in
Users can add comments to the conversation, and “upvote” (that is, like or recommend) other users’ comments. A poll is a multiple choice question, where users can choose an answer and view the aggregated responses of other users. Users are placed into conversation groups on the basis of the estimated due date of their baby, enabling age-relevant information to be sent at appropriate times.
Milk Man conversation function.
The app also contains a library of static, evidence-based information tailored specifically to fathers (see
The app uses leaderboards, badges, and points to encourage engagement with both the social conversation and the static library of information. Users are awarded points for commenting on posts, contributing to the conversation, voting on polls, receiving upvotes from other users, and reading library articles. Users can see their score and rank on the leaderboard.
Milk Man library.
Gamification features used in Milk Man.
Following internal review with the research team, we tested the initial app concept with members of the target group in a series of 3 focus groups. We recruited a purposive sample of men (n=18) through existing networks, including through the university staff and student body and a local playgroup. Participants were required either to be expecting a baby or to have a baby under the age of 6 months. The focus groups aimed to investigate the acceptability of the engagement strategies, provide guidance in the framing of the app, and ensure the proposed approach and content were appropriate. Participants were asked to complete a brief demographic survey before starting the session. The lead author recorded, transcribed, and reviewed the focus groups to maintain dependability [
We held 2 separate consultative sessions with health professionals from 2 of the maternity hospital sites (1 public and 1 private) participating in the PIFI study. Before the session, we developed an outline of the library content to be included within the app, and this outline formed the basis for the discussion with stakeholders. We invited health professionals to comment on the proposed design, engagement strategies, and content of the app.
App testing was divided into 2 phases: beta testing and user testing. The beta testing involved providing early versions of the app to experienced app testers, who examined it for errors, crashes, layout issues, software bugs, or other problems. Beta testing was not carried out by members of the target group, as we were not seeking design and functionality feedback at this stage. Rather, it was tested by 4 experienced software testers, as well as members of the research team. We incorporated feedback into successive iterations of the app.
The second phase of testing, user testing, involved obtaining feedback on the app’s functionality, design, and usability. It was important that this phase of testing was carried out by members of the target group, as the objective was to gain an indication of the way in which the app was likely to be used and received by those for whom it was intended. Therefore, we invited participants to the testing phase if they were either expecting a baby or had a baby under the age of 6 months, and had previously expressed interest in the focus groups, but had not attended an earlier group. Once they had consented, we first asked participants to undertake a think-aloud walkthrough of the app, and then to complete the MARS [
Think-aloud walkthroughs are an industry standard approach in software development and a well-recognized way of testing mobile health apps [
As the participants explored the app independently, the researcher monitored a checklist of 10 tasks and marked each off as it was completed. At the completion of the walkthrough, we specifically asked users to complete any tasks on the checklist that they had not completed unprompted. In keeping with best practice in conducting think-aloud studies, the researcher remained quiet throughout the study, speaking only to remind the participant to keep talking aloud and to issue tasks at the end. We recorded and transcribed the think-aloud sessions.
Released in December 2014, the MARS is a comprehensive questionnaire used for rating mobile health apps with reference to 5 key criteria. The first 4
A total of 18 men attended the 3 focus groups. Participants were aged between 30 and 43 years. Most were married (n=14), just under half were expecting a baby (n=8), and just over half had a new baby aged under 6 months (n=10).
All men owned either an iPhone or Android smartphone, and all said that they kept their phone close at hand and referred to it throughout the day. All participants had some third-party apps on their smartphone. Most participants were positive about the idea of apps for new fathers. Most of the comments about the use of push notifications were positive, although some mentioned that they should be used judiciously and the content should be relevant.
I think the lesson really is notification fatigue. You know some people like them, some people don’t. I suppose if you got far too many you just become disinterested and that can actually be more dangerous than not getting a notification.
There was a mixed response to the idea of a discussion forum for men to connect to each other. Some participants were very enthusiastic about the idea, while others stated they would not use it. Some of the reasons participants gave for ambivalence about a forum were not trusting the information, preferring to talk to people in real life, and that information on forums can be alarmist and cause unnecessary concern.
I don’t know, I wouldn’t talk to a stranger for starters on an app and then I mean you go, we go to barbeques and friends’ house and their kids are ratbags or this and that and you can’t tell your mate how to look after their kid, it’s their kid. You don’t know what they’ve been through the night before, you don’t know what they’ve eaten the night before, so I wouldn’t ask someone for advice on my child in that sense.
We stopped trusting anything that wasn’t from a doctor ’cause we got 50 opinions and my wife ended up freaking out.
Some participants suggested that humor and a lighthearted tone would be appropriate, and that the app should be quick and easy to use.
For me lighthearted would be better. Even the best baby I think that first period is probably strap in and get through it kind of time. So if I have to read a textbook of really...dry text I’m probably not going to do it. But if it’s something quick and easy that...tells me that what I’m seeing in front of me is correct [I’m more likely to use it].
Push notifications can add that element to the humor.
Reinforcing findings from the literature, men were also clear on wanting practical tips for helping their partner, with information ideally delivered in short, summarized formats, including bullets points and checklists. Access to more detailed information could be provided via links.
I want bullet points and if I want to read into it more I’ll look into it more if I’ve got the time.
Checklists, perhaps a list of [reasons why] my baby won’t stop crying and then people could maybe leave suggestions. Doing an upvoting, downvoting vetted type system. Say “try this top answer, this worked really well” [or] “that didn’t work, give me another thing on the list to try.”
Participants’ experiences with mobile apps were varied, as were responses to the proposed engagement strategies. Some participants had experience sourcing and using apps for parenting and pregnancy, while others identified specific barriers to their use, including issues with trusting information and preferring face-to-face interaction. In general, fathers supported targeting fathers with such an approach, and the focus groups provided good insights into how to structure the app’s engagement strategies.
To provide input about the content and engagement strategies proposed for the app, 16 health professionals attended 1 of 2 sessions. All participants were hospital-based midwives working with new and expectant parents. Some had additional, specialist roles: they were lactation consultants or parent educators, or they were in charge of discharge and follow-up of patients. Some specialized in working with aboriginal families, with young families, or with families requiring complex care relating to issues with alcohol and other drugs, or mental health problems.
The health professionals were generally enthusiastic about the app, and in particular about having men as the focus of the intervention.
Knowing the success of the woman’s breastfeeding experience is single-handedly influenced more by the support that [partners] give at home, than any other factor...makes [partners] feel like, “hey, I can do something to help.”
They want to help, but they don’t know how they can help.
The health professionals offered views that reinforced those from the focus groups, about keeping the tone of the app lighthearted, and ensuring the information provided was short and to the point.
Lighthearted and informative, because otherwise you’ll lose them, and they won’t come back if they’re finding it too heavy and judgmental.
Are you using dot form? Because I just find, they won’t read a whole big [article]. You just need dot points [and] keywords.
Pictures and dot points will work well.
Health professionals also offered specific content recommendations, including websites and online videos they typically used with new parents. They further advised the need to include information about postnatal depression for fathers and to focus on the message that every breastfeeding is a success.
A total of 4 new or expectant fathers participated in the user testing phase. Of these 4 recruited participants, 3 had a baby aged under 6 months, while 1 was expecting a child. The age range was 34–44 years.
User testing via the think-aloud walkthrough identified 6 issues related to usability and functionality. Usability issues included text in the comments section being too small, a lack of clarity about how the points system worked, and the need for an important icon to be more prominent. In terms of functionality, 3 additional features were suggested: the ability for users to post their own questions, the inclusion of a tutorial or walkthrough to explain the different sections of the app, and the ability to later change the avatar they had selected on creating a user profile.
Most participants completed the 10 tasks on the walkthrough checklist while independently using the app, without needing to be prompted. In each case, they completed all of the remaining items when prompted.
We averaged the MARS scores from each user list them in
Average (out of 5) Mobile Application Rating Scale (MARS) scores for each category applied to the Milk Man breastfeeding app.
MARS criterion | Average score |
Aesthetics | 4.3 |
Engagement | 3.8 |
Functionality | 4.6 |
Information | 4.5 |
Total average score | 4.3 |
Formative research was a critical component of the development process used for the Milk Man app. Guided by the existing literature, and theoretically underpinned by the SCT, the app content and functionality were refined and focused through feedback and input from clinical health professionals, members of the target group, and a multidisciplinary team of professionals. These professionals included breastfeeding researchers, health promotion professionals, nutritionists, and a midwife, as well as an app designer and developer. Qualitative data from the formative evaluative phase provided insight into the use of mobile technology by members of the target group and into what engagement strategies might be most effective. While this was not intended to be an exhaustive qualitative study to thematic saturation, there were many overlapping themes and participants provided rich insight to help guide the app development.
The testing phase identified 6 issues, 5 of which we addressed before starting the PIFI trial. The one identified issue that we did not act on was the suggestion that users could post their own conversation topics. We deemed this to be outside the scope of this research and a potential risk, in that topics could be poorly informed and contain inaccurate or misleading information. We added a brief tutorial (usually known as an onboarding exercise), to be displayed to users on first launching the app. This addressed several of the identified issues, including a description of the points system, an explanation of how the app worked, and an explanation of how users would be assigned to a group.
MARS scores were high, indicating good user acceptability, usability, and functionality. While still high, the engagement score was slightly lower. This appeared to relate to participants’ stated need for further instructions, explanations, and the ability to change avatars to better customize their user account, all issues that we addressed in the next iteration of the app.
We have developed a comprehensive evaluation plan to measure the acceptability and effectiveness of the Milk Man app in the PIFI RCT. We will collect data through a mixed methods approach, including a customized analytics framework built into the app and a self-report questionnaire, which users will complete when their baby is 6 weeks old, and again at 26 weeks.
Evaluating adaptive technological interventions such as this requires a comprehensive approach, and we based the evaluation framework for this research on the one proposed by O’Grady et al [
While the use of mobile technology in public health interventions has grown significantly, there are still too few high-quality, adequately powered RCTs evaluating the use of such apps [
This study sought to include the views of members of the target group in the app design and development through focus groups. Participants in the focus groups were aged between 30 and 43 years, meaning that younger fathers were not represented in this sample. This was due to the purposive sampling method used. However, this research builds on the aforementioned FIFI study, in which both younger and older fathers were consulted.
Although we recruited only 4 participants for the testing phase, this number has been previously shown to be effective in identifying most usability issues [
Technology changes quickly. There is a balance to be struck between developing health intervention apps in a thorough, methodical fashion and moving quickly to minimize the risks associated with a changing technological environment. To minimize these risks, we proceeded to the RCT without a pilot study. A larger pilot study of the app, before starting the PIFI study, would have been of value in providing further insight into the way in which men would use the app in a real setting. This may be particularly true of the more interactive components of the app, such as the conversation and the leaderboard; observing men engaging with these features may have further assisted refinement. However, we will be able to monitor this throughout and make those recommendations at the trial’s conclusion.
Milk Man is a theoretically grounded app that provides information and support for the antenatal and postnatal periods and aims to socially connect fathers around a central theme of breastfeeding. We anticipate that providing a platform for men to discuss, share, and support each other through the breastfeeding journey will positively affect the support they offer their partners.
To our knowledge, Milk Man is the first breastfeeding app developed specifically for men. It uses innovative strategies to encourage user engagement. The development of Milk Man has involved stages of formative research, testing, and iteration. The process of design, development, and testing described here follows a best practice approach to app development, including being developed by a multidisciplinary team, being based on behavior change theory, and a having a design process centered on the user.
The comprehensive evaluation plan includes indicators for the app’s engagement strategies, as well as psychosocial and health outcomes up to 6 months after the birth of a child. This will provide valuable insights into what works for reaching the target group, and will ensure that the findings are transferable and that the data will be broadly relevant to future mobile health interventions. We expect results from the PIFI study in 2017.
Fathers Infant Feeding Initiative
Mobile Application Rating Scale
Parent Infant Feeding Initiative
randomized controlled trial
social cognitive theory
The research on which this paper is based is being conducted as part of the Parent Infant Feeding Initiative (PIFI). The study was funded by a Healthway Health Promotion Research Grant (No. 24023). We are grateful to those who have participated, and are participating, in this research.
None declared.