The feasibility, engagement, acceptability, and potential effectiveness of an SMS text messaging model of care delivered to families during the first 2000 days were evaluated as part of an observational study with a nonrandomized control arm. This study involved 2 cross-sectional surveys conducted with a convenience sample of birthing parents located in the Hunter New England Local Health District (HNELHD) of NSW, Australia. As the 1-way SMS text messaging program (HB4HNEKids) was initially launched in October 2021 to parents attending 5 pilot CFHN services across 3 diverse local government areas (Armidale, Cessnock, and Newcastle/Lake Macquarie), the cross-sectional surveys include a subsample of participants who had received HB4HNEKids and a concurrent non–randomized comparison group of parents who did not receive HB4HNEKids. The first cross-sectional survey was undertaken between May and December 2022 and included birthing parents 5‐7 months post partum. The second cross-sectional survey was conducted between August 2023 and July 2024 and included birthing parents 12‐14 months post partum (Figure 1).

This repeat cross-sectional study is reported in accordance with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) guidelines for cross-sectional studies (Checklist 1).

Ethics approval for all maternal data was obtained from the Hunter New England Human Research Ethics Committee (16/11/16/4.07), Aboriginal Health and Medical Research Council (1236/16), and The University of Newcastle Human Research Ethics Committee (H-2017‐0032). This research was conducted in compliance with informed consent guidelines, and study participant informed consent was sought prior to completion of surveys and implied upon the completion of a survey. Participant data were collected and securely stored using the REDCap (Research Electronic Data Capture), compliant with health service privacy and confidentiality policies. Data were anonymized, deidentified, and stored so that only authorized individuals could access the data. This research did not offer participants compensation for participating in the SMS text messaging program (HB4HNEKids) or the surveys.

Within the survey, birthing parents were asked questions related to Aboriginal and/or Torres Strait Islander origin, country of birth, residential postcode, current employment status (full-time, part-time, casual, paid or unpaid maternity leave, unemployed, home duties, studies, retired, full-time carers, and unable to work due to health problems), timing of their return to work after birth (in months), and the child’s date of birth. The survey items are based on those used in previous surveys with postpartum women [49]. Participant education status, first or subsequent pregnancy status, and maternal age data had been collected via previous surveys or medical record data. Participant residential postcode was used to determine geographical remoteness (“major cities” or “regional or remote”) using the Accessibility/Remoteness Index of Australia [50]. Postcode was also used to determine socioeconomic areas (“most disadvantaged” or “least disadvantaged”) using 2016 socioeconomic indexes for areas [51].

Data were analyzed by an independent statistician using SAS statistical software (version 9.3, SAS Institute). Descriptive statistics were used to describe (1) characteristics of the samples, (2) feasibility outcomes, (3) program engagement outcomes, and (4) acceptability outcomes. Chi-square test or t test was used to compare the characteristics of participants between those who had received HB4HNEKids and those who had not (usual care control).

Sample size calculations were not conducted for this pilot feasibility study [52]. However, to explore the potential impact of the program on child breastfeeding, nutrition, and movement behaviors, as well as parental well-being outcomes (effectiveness), separate logistic regression analyses were conducted to examine differences between survey respondents who had received the HB4HNEKids program and those who had not (usual care control). Unadjusted and adjusted analyses were conducted at both time points. Analyses were adjusted for a range of key participant characteristics including parent age, Aboriginal and Torres Strait Islander status, highest level of education, socioeconomic status, and level of remoteness. Participants with missing data were excluded from analyses. Dichotomous outcomes were presented as odds ratios and 95% CIs, and continuous outcomes were presented as mean differences (MDs) and 95% CIs. A P value of <.05 was considered statistically significant.

During the 2.5-year pilot period (October 2021 to July 2024) of the HB4HNEKids program a total of 8501 families across the 5 CFHN services were eligible to receive the program. A total of 6243 families commenced the program (6243/8501, 73.4%), from which 430 families later withdrew, giving a 6.9% (430/6243) dropout rate. A total of 377,969 SMS text messages were sent during the pilot period (average of 61 messages per family).

Of the 780 birthing parents approached, a total of 383 (49% response rate) eligible participants completed the 6-month survey, whereby 26% (99) of survey participants had received the HB4HNEKids program. Of the 626 birthing parents approached, a total of 283 (45% response rate) participants completed the 12-month survey, from which 37% (104) survey participants had received the HB4HNEKids program. The 2 cross-sectional samples were similar in terms of birthing parent’s age, education status, socioeconomic status, and remoteness of geographical location (Table 1). The 12-month sample included a higher proportion of participants identifying as Aboriginal and/or Torres Strait Islander (66/283, 23%), compared with the 6-month sample (43/383, 11%). By 12 months the proportion of participants on parental leave had significantly dropped, with 8% (22/283) of participants on parental leave, compared with 45% (173/383) at 6 months. Correspondingly, more participants engaged in employment at 12 months (188/283, 66% vs 114/383, 30%, respectively).

Participants who had received HB4HNEKids at the 6-month survey had a higher proportion from “least disadvantaged” areas and higher proportion residing in major cities than usual care control participants. Similar differences between groups were found at 12 months. Additionally, HB4HNEKids participants had a lower proportion of participants identifying as Aboriginal and/or Torres Strait Islander and a higher proportion of participants who had completed tertiary education.

Of the survey participants receiving the HB4HNEKids program (n=200), 76% (73/96) and 83% (86/104) of participants from the 6-month and 12-month survey, respectively, reported that they always or very often read the HB4HNEKids SMS text messages. Participants from the 6-month survey reported spending an average of 7.43 minutes engaged in the SMS text message content of HB4HNEKids, while participants from the 12-month survey reported an average of 5.83 minutes engaged in the content. In addition, 43% (41/96) of participants from the 6-month survey and 31% (32/104) of participants from the 12-month survey reported that they always or very often clicked on the website links provided in the messages (Table 2).

At 6 months and 12 months, most parents reported that the program was acceptable (Table 3), with more than 90% of parents agreeing or strongly agreeing with statements related to the overall acceptability of the program, timing of the messages, and message content. More than 80% of parents found the embedded website links acceptable.

This study sought to evaluate the feasibility, engagement, and acceptability of the pilot HB4HNEKids program and explore its potential effectiveness on a range of child and parental health and well-being outcomes including breastfeeding, child nutrition, child movement, and parental mental well-being. Findings indicated that the program was feasible to deliver to families in HNELHD via CFHN services and is met with high acceptability and strong engagement from parents. Furthermore, the evaluation found that the program was likely effective in improving child vegetable intakes and parental mental well-being at 12-months. These findings provide support for further development and improvement of the program with formal testing as part of a larger RCT.

This pragmatic evaluation demonstrates that the 1‐ to 4-week CFHN service visit (attended by >80% of families in HNELHD) is a feasible way of enrolling new families into a mHealth program at scale. There remains scope to further optimize the reach of HB4HNEKids, given just 73.4% (6243/8501) of eligible families coming through the pilot CFHN services were enrolled into the program. However, the initial reach of the HB4HNEKids program appears relatively high in contrast with other digital health interventions (DHIs), with systematic reviews of DHIs reporting a median reach of just 21.8%‐33.6% [53]. Engagement is another critical factor in determining the success of DHIs, with systematic review evidence suggesting that engagement is associated with a variety of improved health behaviors including fruit and vegetable intake, weight status, smoking, and physical activity [54-56]. Our results indicate good participant engagement with the HB4HNEKids program, with most HB4HNEKids participants reporting that they “always” or “very often” read the SMS text messages, spending on average of 6 minutes interacting with each message. While a systematic review by Grady et al [57] found that SMS text messages are a key DHI design feature associated with engagement, the extensive co-design process undertaken in the design of the HB4HNEKids program may also be driving strong engagement rates [58]. This combined with low opt-out rates and high parent-reported acceptability, the HB4HNEKids program holds significant promise for reaching and engaging parents in health promotion content during the first 2000 days.

Vegetable intake is a key indicator of a healthy diet providing an important source of essential vitamins and minerals [59]; however, only 18.5% of Australian children aged 2‐3 years meet the recommended intake for vegetables, dropping to just 3.8% in children aged 4‐8 years [60]. Although data collected from parents within the HNE region of NSW, Australia, indicate that children aged 12 months are not meeting the recommended serves of vegetables each day (2‐3 serves), the evaluation indicates that children from families who were receiving HB4HNEKids were having 0.23 of a serve more vegetables per day than those from families in the usual care group [61] and represents an effect size consistent with other interventions that have demonstrated efficacy at increasing children’s vegetable intake in home and community settings [62]. Although this effect size is modest in absolute terms, this increase aligns with the magnitude of change commonly observed in early life dietary interventions and reflects a behavioral shift that is difficult to achieve during the introduction-to-solids period [63,64]. Small increments in vegetable intake at this developmental stage may nonetheless carry clinical relevance, as early exposure contributes to flavor acceptance, supports the establishment of healthier dietary trajectories, and enhances intake of key micronutrients such as folate, vitamin A precursors, and potassium [59]. Evidence indicates that even limited increases in vegetable consumption can reduce the risk of micronutrient inadequacy [65] and are prospectively associated with healthier dietary patterns linked to lower noncommunicable disease risk in adulthood [66]. Therefore, future research to assess the sustainment of the program’s effects over time is warranted to better quantify the child- and population-level benefit of the HB4HNEKids program.

Like other trials such as the original Health Beginnings RCT [26], our evaluation did not indicate a statistically significant difference in current breastfeeding rates between the HB4HNEKids and usual care participants. These findings are inconsistent with those of a recent systematic review of SMS text message–based interventions, with meta-analyses showing that they were effective at improving exclusive breastfeeding rates particularly when they engage families in the prenatal period [25]. However, given our pilot study was not powered for this outcome and still observed a 5-point prevalence difference in current breastfeeding rates (favoring HB4HNEKids participants) at 6 months and 12 months, this result is nonetheless highly encouraging. Even so, further development and optimization of the breastfeeding content offered within the program, or expanding the program to engage families earlier (ie, antenatally), could be of value.

In contrast with the original Healthy Beginnings RCT that found that families receiving SMS text message support (combined with accompanying printed resources) were significantly more likely to “never have screen time” than the control (adjusted odds ratio 1.28, 95% CI 1.08‐1.52; P<.05) [26], our evaluation did not indicate any differences between HB4HNEKids and usual care participants screen time behaviors or any other movement behaviors at 12 months. While the SMS text message content of the HB4HNEKids program related to child screen time and movement behavior during the first 12 months mirrored that of the original Healthy Beginnings SMS text message content and focused on increasing parental knowledge of child movement and screen time guidelines (eg, 1 message on movement guidelines, 1 message on restrained time guidelines, and 1 message on screen time recommendations), the omission of the booklet content from HB4HNEKids could be driving this difference. However, given that formative research suggests that parents would prefer to be engaged in content focused on the benefits of certain movement and screen time behaviors, rather than the risks [67], there remains opportunity to strengthen parent-directed SMS text message content to better address known barriers and facilitators to child screen time and movement behaviors during the first 12 months.

The perinatal period demands significant emotional, psychological, social, and physical adaptation from parents and represents a period of change that can have implications on parental well-being and mental health outcomes. Parental mental health and well-being are of key importance during this early life stage, as it can influence parent-child relationships, the quality of care provided, and in turn the child’s life trajectory [68-70]. Outside of the standardized mental health screening conducted by primary care services, there is limited support embedded within health services to generally support parental well-being [71,72]. Thus, the improved mental well-being scores at 12 months among those receiving the program compared with those who did not (MD 1.51, 95% CI 0.45-2.57; P=.005) are important.

The results of this evaluation must be considered within the context of our study limitations. These include the use of our convenience sampling methods, which included only a small subsample of participants who had received the HB4HNEKids program, thus not providing data that are representative of the whole HNE region. Furthermore, given our response rates of approximately 45%‐49%, our findings may be subject to nonresponse bias. Given the cross-sectional nature of our evaluation, and that HB4HNEKids and comparison participants were not randomly allocated, we cannot be certain that the differences in child vegetable intakes and parental mental well-being outcomes are explicitly due to the SMS text messaging program [73]. Furthermore, most of the outcomes assessed within this evaluation were self-reported by participants and may be influenced by self-report, social desirability, or recall biases. However, where possible, validated survey tools were used. This pilot study was not powered to detect statistically significant differences between groups for many of the outcomes assessed, including proportion of currently breastfeeding and proportion of children meeting physical activity guidelines. The HB4HNEKids program is currently operating as a complimentary mHealth program alongside an existing routinely offered health service. The insight offered through this evaluation of a real-world health service intervention (while acknowledging the limitations stated) would be strengthened with the opportunity to evaluate the program using more robust methodologies and a larger sample size.

This evaluation of the pilot HB4HNEKids SMS text messaging program indicates that the program is feasible to deliver at scale, alongside routine CFHN care and is highly acceptable and engaging to parents. Our findings indicate possible efficacy of the program for improving child vegetable intake and parental mental well-being at 12 months. However, further evaluation of the program within larger representative samples using robust methodology is needed to determine the true impact of this innovative program.