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Breastfeeding plays a major role in the health of mothers and babies and has the potential to positively shape an individual’s life both in the short and long term. In the United Kingdom (UK), although 81% of women initiate breastfeeding, only 1% of women breastfeed exclusively to 6 months as recommended by the World Health Organization. In the UK, women who are socially disadvantaged and younger are less likely to breastfeed at 6 to 8 weeks postpartum. One strategy that aims to improve these statistics is the Baby Buddy app, which has been designed and implemented by the UK charity Best Beginnings to be a universal intervention to help reduce health inequalities, including those in breastfeeding.
This study aimed to retrospectively examine the development of Baby Buddy by applying the Behavior Change Wheel (BCW) framework to understand how it might increase breastfeeding self-efficacy, knowledge, and confidence.
Retrospective application of the BCW was completed after the app was developed and embedded into maternity services. A three-stage process evaluation used triangulation methods and formalized tools to gain an understanding of the potential mechanisms and behaviors used in apps that are needed to improve breastfeeding rates in the UK. First, we generated a behavioral analysis by mapping breastfeeding barriers and enablers onto the Capability, Opportunity, and Motivation-Behavior (COM-B) system using documents provided by Best Beginnings. Second, we identified the intervention functions and policy categories used. Third, we linked these with the behavior change techniques identified in the app breastfeeding content using the Behavior Change Techniques Taxonomy (BCTTv1).
Baby Buddy is a well-designed platform that could be used to change breastfeeding behaviors. Findings from stage one showed that Best Beginnings had defined breastfeeding as a key behavior requiring support and demonstrated a thorough understanding of the context in which breastfeeding occurs, the barriers and enablers of breastfeeding, and the target actions needed to support breastfeeding. In stage two, Best Beginnings had used intervention and policy functions to address the barriers and enablers of breastfeeding. In stage three, Baby Buddy had been assessed for acceptability, practicability, effectiveness, affordability, safety, and equity. Several behavior change techniques that could assist women with decision making around breastfeeding (eg, information about health consequences and credible sources) and possibly affect attitudes and self-efficacy were identified. Of the 39 videos in the app, 19 (49%) addressed physical capabilities related to breastfeeding and demonstrated positive breastfeeding behaviors.
Applying a theoretical framework retrospectively to a mobile app is possible and results in useful information to understand potential health benefits and to inform future development. Future research should assess which components and behavioral techniques in the app are most effective in changing behavior and supporting breastfeeding.
A healthy start to life is crucial for improving life-long health outcomes [
Breastmilk is nutritionally balanced and helps protect infants and children from infections [
The UK National Infant Feeding Survey (2010) showed that although 81% of women initiated breastfeeding, 34% of babies received any breastmilk at 6 months (only 1% were exclusively breastfed), and the country ranks lowest in the world for breastfeeding at 12 months of age [
In 2007, Best Beginnings charity in the UK co-designed digital video discs (DVDs) to support breastfeeding initiation, motivation, and duration, with a focus on benefits and acknowledgement of challenges. The resources were developed with parents, the UK Department of Health, and UNICEF UK. Since the 2008 launch, over 2 million copies of the DVD have been distributed. In 2014, with changing technology, the charity embedded this breastfeeding content into Baby Buddy, a smartphone app. Pregnant women are now more likely to find pregnancy apps useful sources of information and support compared with DVDs or written material [
Baby Buddy was designed to focus on the window of opportunity from preconception to 6 months of age, in which the foundations for a healthy childhood are laid [
The most recent published evaluation of Baby Buddy, the BaBBLeS study (Bumps and Babies Longitudinal Study), measured maternal self-efficacy as the primary outcome. The authors found that there were no differences in maternal self-efficacy outcomes. However, they did perform a post-hoc analysis of breastfeeding and documented a significant increase in “any breastfeeding” at 1 month (odds ratio [OR] 3.08, 95% CI 1.49-6.35) and in “exclusive breastfeeding” at 3 months (OR 1.79, 95% CI 1.02-3.16) [
With this data demonstrating potential behavior change and increased breastfeeding with the use of the Baby Buddy app, further understanding was sought regarding which components of the design and development of the app might have contributed to these results. The Behavior Change Wheel (BCW) and the associated Behavior Change Techniques Taxonomy (BCTTv1) provide a systematic approach that acknowledges the importance of behavioral theory in the design and evaluation of interventions. The BCW has three interrelated concentric layers. The inner layer (Capability, Opportunity, and Motivation-Behavior [COM-B] model) helps understand the behavior that needs to be changed. The middle layer consists of the following possible interventions that could be used to facilitate behavior change: restrictions, education, persuasion, incentivization, coercion, training, enablement, modeling, and environmental restructuring. The outer layer of the wheel assists in identifying which policy opportunities could be utilized to support the delivery of the chosen interventions [
We evaluated the development of Baby Buddy with the BCW and its associated taxonomy using a prespecified three-stage process (
Process of applying the Behavior Change Wheel to the Baby Buddy app.
This stage aimed to assess the in-depth understanding of breastfeeding as a target behavior in the development of the app and the context in which it occurs. Barriers and enablers to target behaviors were identified in the provided data (survey, interview, and focus group reports), and then, these were mapped to the COM-B tool [
This stage determined the aspects included in Baby Buddy and if they could influence breastfeeding behavior. The middle layer of the BCW was used by the research team to map which “intervention” components could address the barriers and enablers to breastfeeding (restrictions, education, persuasion, incentivization, coercion, training, enablement, modeling, and environmental restructuring) [
This stage identified evidence of the use of behavioral change techniques (BCTs) within the design of Baby Buddy. We used the APEASE criteria as defined in the BCW (affordability, practicability, effectiveness, affordability, safety, and equity) [
Best Beginnings defined breastfeeding as a key behavior requiring more support and demonstrated a thorough understanding of the context in which breastfeeding occurs based on the following sources of evidence: (1) The Infant Feeding Survey (2010) [
Best Beginnings selected specified target actions that were needed to support breastfeeding. They undertook extensive consultation with stakeholders, including the UK Department of Health, UNICEF, and women and their families. A multidisciplinary team approach was adopted in the creation of the steering committee. The following six target behaviors to support breastfeeding were identified as a priority by Best Beginnings: (1) Advising on commencing breastfeeding; (2) Giving information on correct positioning and attachment for breastfeeding; (3) Knowing how to express breast milk; (4) Knowing what is normal in the first few months of breastfeeding; (5) Knowing how to overcome breastfeeding challenges; and (6) Planning to breastfeed for 6 months or more.
Breastfeeding behaviors were described with who, what, when, where, how often, and with whom (
Specifying breastfeeding as a target behavior [
Question | Response |
Women, with a focus on young women under 25 years intending to breastfeed | |
Offer breast first | |
Within the first hour of birth and then for every feed demanded | |
At the birthplace and then anywhere they choose to feed the infant | |
Every feed | |
With the support of staff initially and then independently with the support of family and friends or professionals if required |
We found evidence to support that the constructs of capability, opportunity, and motivation were explored as described below.
Best Beginnings explored social norms, peer influence, and the value of social support in sustaining breastfeeding. For example, women were asked to discuss breastfeeding in the context of their roles in their families, the presence or absence of support, the influences of cultural values, and the impact of migration, isolation, and loneliness. Peer and clinical support, demonstrations, practice, and feedback were seen as important to enable women to breastfeed. Perceived barriers, such as difficulties positioning and attaching, low milk production (physical capability), fear of failure, and anxiety/depression (psychological capability), were identified as needing to be addressed by the intervention functions (
Support was identified as the primary enabler for both physical and social opportunity to breastfeed. Clinical/specialist, peer, community, and technology supports (apps, social media, and online resources) were documented as facilitators for breastfeeding. Best Beginnings sought to understand environmental factors that may help, interfere, or prevent breastfeeding efforts. Economic barriers and the physical environment were discussed, and there were several themes related to challenges in finding a way to initiate and maintain breastfeeding behaviors in the context of roles as employees, mothers, and partners (
Reviewed data demonstrated that motivation is best facilitated by early planning, goal setting, and positive belief reinforcement. Peer support normalizes the challenges of breastfeeding and encourages self-determination. Best Beginnings documented support as crucial to helping alleviate negative thoughts or low confidence. Self-efficacy to change beliefs and habits, and low health literacy barriers were explored to assess the ability of individuals to act on health advice and planned care and to uncover culturally specific values that may improve interventions in specific target groups (
Intervention functions were able to be identified in the video content for Baby Buddy, which included the lead information and education resource within the app. The most common functions were education, training, and modeling. Mapping of the breastfeeding video content to the BCW (COM-B, TDF, and intervention functions) is shown in
Mapping of breastfeeding video content to the Capability, Opportunity, and Motivation-Behavior (COM-B) tool.
Video title |
Capability | Opportunity | Motivation | ||||||
Physical | Psychological | Social | Physical | Reflective | Automatic |
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Breastfeeding as a young mum | Yes | Yes | Yes | Yes | Yes | Yes |
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A practical choice | Yes | Yes | Yes | Yes | Yes | Yes |
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Feelings about breastfeeding | Yes | Yes | Yes | Yes | Yes | Yes |
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What’s so good about breastfeeding? | No | Yes | Yes | Yes | Yes | Yes |
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What if I bottle fed before? | Yes | Yes | Yes | Yes | Yes | Yes |
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Asking for help to get started | Yes | Yes | Yes | Yes | No | No |
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What will my partner think? | No | No | Yes | No | Yes | No |
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Your first milk - colostrum | Yes | Yes | No | No | Yes | Yes |
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Your baby’s first feed | Yes | Yes | Yes | Yes | No | Yes |
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Skin to skin | Yes | Yes | Yes | Yes | No | Yes |
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Good positioning tips from a midwife | Yes | No | Yes | No | No | Yes |
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Getting the position right | Yes | No | No | Yes | No | Yes |
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Good positioning demonstration | Yes | Yes | No | Yes | Yes | No |
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Keeping your baby close | Yes | Yes | Yes | Yes | Yes | Yes |
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How dads can help? - Lenny | No | No | Yes | Yes | No | No |
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Breastfeeding out and about | No | Yes | Yes | No | Yes | Yes |
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When and how often should I feed my baby? | Yes | Yes | Yes | Yes | Yes | Yes |
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How dads can help? - Andy | No | No | Yes | Yes | Yes | No |
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Where can I find support? | Yes | Yes | Yes | Yes | Yes | No |
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Overcoming mastitis | Yes | Yes | Yes | Yes | Yes | Yes |
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Support from health professionals | Yes | Yes | Yes | Yes | Yes | Yes |
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Some common challenges | Yes | Yes | No | Yes | Yes | No |
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Good and bad attachment graphic | Yes | No | No | Yes | No | No |
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Breastfeeding to a year and beyond | Yes | Yes | Yes | Yes | Yes | Yes |
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Why breastfeed for at least six months? | Yes | Yes | Yes | Yes | Yes | Yes |
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Breastfeeding and weening | Yes | Yes | Yes | Yes | Yes | Yes |
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Why express? | Yes | Yes | Yes | Yes | Yes | Yes |
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How to hand express? | Yes | Yes | No | Yes | Yes | Yes |
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How to use a breast pump? | Yes | No | No | Yes | Yes | No |
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Expressing when you’re back at work | Yes | Yes | No | Yes | Yes | No |
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Storing and using expressed breast milk | No | No | No | Yes | Yes | No |
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Early challenges with expressing milk | Yes | Yes | No | Yes | Yes | No |
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Your breast milk | Yes | Yes | Yes | Yes | Yes | Yes |
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How skin-to-skin contact can help you express? | Yes | Yes | Yes | Yes | Yes | Yes |
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Using a breast pump | Yes | No | Yes | Yes | Yes | No |
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Expressing with a breast pump and storing your milk | Yes | Yes | Yes | Yes | Yes | Yes |
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Colostrum - your baby’s first food | Yes | Yes | No | Yes | No | Yes |
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Signs your baby is ready to feed independently | No | Yes | Yes | Yes | Yes | No |
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Breastfeeding twins or triplets | Yes | No | No | Yes | Yes | No |
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Findings support that the Baby Buddy app and its embedding process were designed to complement maternity and postnatal health service and policy [
Identification of BCTs was achieved by applying the BCTTv1 to the content of the app. After each piece of content was categorized using broad intervention categories, further analysis was carried out to identify exactly which BCTs were used (
The APEASE criteria were used to evaluate if Best Beginnings had undertaken activities to ascertain acceptability, practicability, effectiveness, affordability, safety, and equity when moving breastfeeding content to a mobile app. The evidence was analyzed and judged against the previous DVD-based breastfeeding intervention, “Bump to breastfeeding.” Baby Buddy met the APEASE criteria for a viable digital intervention suitable for further testing, development, and implementation (
Baby Buddy maps retrospectively well to the BCW. This may explain why there have been positive results in recent studies [
The use of participatory engagement and co-creation methods in the development of Baby Buddy are two design techniques that have positively influenced decision making, attitudes, and self-efficacy concerning breastfeeding, particularly among those who are socially disadvantaged and younger. We identified several BCTs used in Baby Buddy that could assist women with decision making around breastfeeding (eg, BCT 5.1 Information about health consequences and 9.1 Credible source). BCTs that influence attitudes and self-efficacy were also identified (eg, BCT 5.3 Information about social and environmental consequences and 13.2 Framing/reframing).
This study has several strengths. First, it was performed independent of the development team, using a best practice behavior change framework (BCW) as a guide. Second, content mapping to the BCW was conducted by two independent content experts (a midwife and a neonatologist). These two research team members located in Australia were not employed by Best Beginnings and did not have any financial incentive. Third, retrospective alignment of the BCW tools and BCTs enabled the research team to identify potential opportunities to use BCTs for the future development of Baby Buddy to increase effectiveness. Fourth, our study supports the work of Thomson and Crossland who conducted a mixed methods evaluation using the BCW to identify components that support infant feeding in North West UK [
A key limitation of this work is the retrospective application of the BCW. Retrospective mapping of the BCW to the app development process was complex and subjective, and relied on Best Beginnings providing multiple development documents. There was a large volume of qualitative reports supplied to us from Best Beginnings that had been collected from many sources and not presented with later academic review in mind.
Using the BCW has inherent coding, interpretation, and application limitations. However, like other studies, we do believe that there is benefit in “retrofitting” interventions to the BCW even though it may have not been used in the design phase [
A secondary limitation is that the evaluation tools we used were designed for text rather than video content. From our assessment, videos within an app appear to be a powerful influence to support behavior change in breastfeeding. The videos take a “show how” approach rather than a didactic “tell to” approach and feature a mixture of experts, support parents, and peer-to-peer voices. However, as the BCW tools were not designed for video discourse analysis specifically, they may miss some of the nuances in video content (eg, gesturing, body language, and tone). Our findings have identified potential areas for improvement in future iterations of the app, and this is useful information given that the app is constantly being improved.
Our work highlights that applying a theoretical framework retrospectively to a mobile health app is possible and results in useful information to understand potential health benefits and to inform future development. To assess the true impact of behavior change frameworks in the design of mobile health apps, high-quality research that measures formative, process, and clinical outcomes for health behaviors is needed. Further development of Baby Buddy as a universal intervention to reduce health inequalities requires robust prospective research that considers effects on the rate and duration of exclusive breastfeeding.
Reports supplied by Best Beginnings.
Using the Behavior Change Wheel (BCW) to analyze breastfeeding video content in the Baby Buddy app.
Complete analysis of all breastfeeding items.
APEASE (affordability, practicability, effectiveness, affordability, safety, and equity) criteria.
affordability, practicability, effectiveness, affordability, safety, and equity
behavior change technique
Behavior Change Techniques Taxonomy
Behavior Change Wheel
Capability, Opportunity, and Motivation-Behavior
digital video disc
odds ratio
Theoretical Domains Framework
United Kingdom
This study was part of the doctoral thesis of LMM, which was funded through the Ho Kong Fung Ling postgraduate scholarship, the University of Sydney, Charles Perkins Centre, and Faculty of Medicine and Health. This manuscript has no direct funding support.
This project was conducted at the University of Sydney as part of a doctoral thesis (philosophy). LMM and AG contributed to the concept and design of the study. LMM and AG conducted the research and analyzed the data. LMM drafted the first version of the manuscript. AB, NP, and CSEH contributed to writing and editing the manuscript. All authors read and approved the final manuscript.
AB is the CEO and founder of Best Beginnings (UK). NP is the evaluation and impact lead at Best Beginnings (UK). All other authors are Australian researchers and declare that they have no competing interests.