Identifying behavior mediators influencing caregivers of infants participating in an mhealth intervention: qualitative evaluation of the Baby-Feed trial through interviews

Introduction

Background

Rapid weight gain early in life increases the risk of obesity in childhood and later in life (1-3). Certain feeding practices may increase the likelihood of rapid infant weight gain (4), such as early cessation of breastfeeding, early introduction of complementary food and beverages, introduction of juice or sugar-sweetened beverage (SSB)/non-core beverages, and poor diet quality. With rising United States (US) rates of childhood obesity reported, including early toddlerhood (5), more accessible and adaptable tools and resources may be successful in instilling caregivers with increased confidence and application of knowledge in feeding their infants.

Social media and the use of technology have become the quickest way for the public to obtain information. Some infant feeding information posted on websites or parenting phone apps may be valuable and reputable, but many caregivers of childbearing age may also resort to quick messages from social media influencers and/or from trending blogs or parenting groups that may include misinformation and sensationalized feeding information (6,7). Caregivers may seek out medical nutrition advice from their infant’s health care provider/pediatrician; however, the time between well-baby visits at 4 to 6 to 9 months is spaced from 60 to 90 days, and a crucial time during the time of complementary feeding introduction, often when breastfeeding cessation may occur (8-10) and when infant diet diversity should increase (9). Caregivers may not wait to speak to their pediatrician, as it may include triage to an office nurse and a delay to have questions answered, and therefore, will often resort to online information that provides instantaneous answers (11,12). The Baby-Feed website sought to address these limitations by enabling immediate feedback using validated nutrition information and tools.

Rationale and knowledge gap

There are several infant nutrition interventions published in the literature (13); some have been based on a behavior change theory, and only a few included a technology component. However, only very few exist that have thematic analysis to understand the behavior change constructs found in theories that may have contributed to effective outcomes (14). The Social Cognitive Theory (SCT) framework is one of several theories that may provide the mechanisms for the behavioral changes observed in infant nutrition education interventions (15). The framework may explain the acquisition of new behaviors, the change in behavior, as well as the retention of the behavior. Key constructs of SCT may include perceived self-efficacy, outcome expectations, observational learning, and incentive motivation (16). Self-efficacy is one’s confidence in exhibiting behaviors to perform a specific task. Outcome expectations are one’s thoughts about the results of a certain behavior. Observational learning may promote certain behaviors by exposing persons to the display of those behaviors (12). Incentive motivation encourages behaviors motivated by external factors, such as rewards. Although there are no formal SCT guidelines, educational strategies may be effective in influencing behavior either through direct action or by influencing self-efficacy with knowledge, confidence, and motivation (17). For example, the Grow2Gether study incorporated SCT into the intervention design by integrating the observation of a behavior, in which a caregiver was then asked to model that behavior by recording and posting it for others to view, and receive positive feedback, in which the moderator and peers provided “likes” and comments about the demonstration of the behavior (18,19). However, to our knowledge, there are no fully online infant nutrition education interventions that have explored through caregiver interviews how SCT mediators influence behavior change. Qualitative approaches are necessary to gain a deeper understanding of how caregivers interact with the intervention components and which components contribute to changes in behavior.

Objective

To address this knowledge gap, this qualitative study aimed to identify among participants in the Baby-Feed online trial which SCT behavior mediator constructs (self-efficacy, outcome expectation, intentions, and observational learning) influenced them to move from intention to action in feeding behaviors. We present this article in accordance with the SRQR reporting checklist (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-40/rc).

Methods

Overall design

This was a qualitative study among participants in the Baby-Feed online trial to identify which SCT behavior mediators influenced them to move from intention to action in feeding behaviors. For this, the study team interviewed caregivers randomized to the intervention group after the completion of their trial participation. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The institutional review board of Florida International University approved this study (No. IRB-23-0409-AM06). Caregivers of eligible infants electronically signed the informed consent before participation. The study was enrolled at ClinicalTrials.gov prior to initiation of the study (NCT05990439).

Description of the Baby-Feed online trial

This was a randomized, controlled, parallel trial that tested an educational website providing real-time feedback on infant feeding and weight gain among 155 caregivers with infants less than 4 months old and followed them until their infant completed the scheduled 9-month well-baby visit (20). Eligibility criteria for enrollment into the study included: a primary caregiver of a healthy, term infant <4 months of age, willing to participate through the 9-month well-baby visit, have access to internet on a mobile device or laptop, agree to receive text messaging service for communication and reminders, and English or Spanish language literate. All participants were asked to complete a general socio-demographics questionnaire at enrollment and the following at or near the 4-, 6-, and 9-month well-baby visit with their healthcare provider: a validated infant food frequency questionnaire (FFQ) (21), and the weight and length as recorded in the well-baby visit.

Description of the Baby-Feed website

The Baby-Feed web application was developed using the SCT and the Health Self-Empowerment Theory (HSET), as previously described in a prior publication (22). Briefly, Baby-Feed requires mothers to complete a validated infant FFQ (14), which is deployed in the web portal with images to help calculate portion sizes. Once the caregivers complete the FFQ, those assigned to the intervention group will see automated results with specific feedback about which foods and nutrients are consumed adequately, below, or above the recommendations. Those caregivers will also be asked to click on the “Recommendations” tab to see the age-specific recommended food amounts and the “Tracking” tab to track how well their infant’s intake is meeting dietary recommendations for their age group. It also includes a “Growth Chart” tracker to monitor and report how well their infant is gaining weight and increasing length. Lastly, caregivers can watch or read “Educational Resources by Nutrition Experts” for additional food and education knowledge. The Baby-Feed website is available in English and Spanish.

Participants

Participants were recruited to the trial using multiple sources and strategies, such as using social media posts, blast university alumni emails, physical flyers, and incentivized snowball referrals from March through October 2024. Details of the recruitment strategies have been published elsewhere (23).

A total of 75 caregivers were randomized to the intervention group and were potentially eligible for the qualitative interview. For this qualitative component, when intervention participants completed the trial, they received a 1-minute feedback Qualtrics survey via email or text message, and upon submission, received a thank-you response and were asked about their interest in a follow-up video call interview. If they were interested, a researcher scheduled a time to conduct the interview.

Interview

The interview consisted of five semi-structured interview questions for caregivers to identify which SCT behavior mediators influenced feeding their baby. The questions were developed based on the incorporation of the SCT from a comprehensive literature review, with one or two questions per construct (Table 1).

Participants were provided with the disclaimer at the start of the interview that their complete transparency and valuable feedback were appreciated, and that the researcher would not be offended by their responses, only that their discussion was valued for future improvements to the site and technology. As the first author personally recruited some of the participants, including a former colleague, she clearly stated that this would not impact their answers to the questions. After the formalized questions, the interviewer also encouraged open feedback on their website experience.

As the Baby-Feed trial is an online study, all the interviews were conducted by A.G. from December 2024 to April 2025 on the university’s secure Zoom platform, which was set up to provide a basic transcription of the interview. Participants provided verbal permissions for video, audio, and written transcription. Most caregivers elected to be at home while conducting the interview, and a majority had their infant and/or other children present during the interview. Interviews lasted for 10–20 minutes, depending on the amount of feedback they provided. Participants received a $20 e-gift card for their participation after the completion of the interview. No follow-up interviews were conducted.

Socio-demographics questionnaire

As part of the main trial, all participants completed a socio-demographics questionnaire that included questions on the caregiver and the infant. Caregiver questions included their relationship to the infant, birth year, ethnicity, highest level of education completed, number of children, WIC participation, and self-reported weight and height. Their body mass index (BMI) was calculated as kg/m² and categorized into normal, overweight, and obese categories. Infant-specific questions included their baby’s gender, date of birth, birth weight, and length.

Data analysis

Theoretical approach

This qualitative study was constructed using a systematic methodology of inductive and deductive research. This deductive qualitative research uses existing theory to examine themes and narratives of interpersonal stories and inquiry obtained from the interviews (24). With the use of SCT as an explanatory theory about factors affecting the behavior change of caregivers, we chose to apply methods associated with deductive and inductive analysis. A combination of initial deductive analysis to examine and categorize the evidence for the theory; the primary researcher (A.G.) initiated inductive analysis through interviews as the foundation of the analysis, followed by theme identification; A.G. and M.M. applied open coding with a thematic approach to data analysis of the transcribed interviews (25).

Theoretical coding

The transcription of the 20 interviews was initially written by Zoom’s built-in transcription feature and proofread by M.M., who provided a grammatical review by listening to the voice-recorded Zoom video, and then provided a final written transcription. A.G. also completed an additional proofreading of the transcription as a final validation. Independent reviews by the research team to record and transcribe were provided to avoid any personal influence, followed by a discussion of any discrepancies. The validity of the final transcription was checked with one participant, who received an emailed copy of their transcription, and it was found to be acceptable. An initial codebook was generated from the constructs used to analyze the interviews. The transcripts were thematically coded by labeling segments in response to the research question until the theme changed. Two researchers independently coded the first five transcripts. Coding disagreements and inconsistencies were resolved with a verbal discussion between A.G. and M.M. for the determined 10 themes, and after, each of the transcripts was separately re-coded again to obtain a Kappa Cohen agreement greater than 85%. Reliability was then re-assessed with the newly added codes. The study team applied the established definition of data saturation as the point at which interviews produced minimal new elements of themes (26), which were noted within five interviews. To increase details on specific elements of the theme, interviews were continued and capped at 20 interviews, when no additional themes or data emerged. All 20 transcripts were then uploaded and coded using NVivo 15 Analysis Software (QSR International Pty Ltd., Cardigan, UK), and the codebook became more refined, adding new codes as needed until no new codes or relationships were found.

Results

All 20 participant interviews were conducted within a week after the completion of the Baby-Feed trial. Although eligibility in the study included English or Spanish literacy and any primary caretaker, only English-speaking mothers, by chance, elected to partake in the interviews.

From the demographics of the participants (Table 2), most were in the 30–35-year-old range (55%), White/Caucasian (75%), were first-time mothers (50%), with least a 4-year college degree (85%), and not enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal nutrition assistance program (90%). Only 1 participant (5%) was Hispanic. Also, 50% were classified as overweight and 45% as healthy weight.

The SCT constructs were the basis for themes identified from the coding of the 20 interviews (Table 3), as shown below.

Themes for construct 1: self-efficacy

(How did participating in the study influence your confidence in feeding your baby?): helpful, confirmation and confidence, sharing with others, guidance, guidelines, and recommendations and accuracy.

Caregivers overwhelmingly found the Baby-Feed Website to improve their self-efficacy in making feeding decisions. Interestingly, most caregivers included in their response to Question 1, whether this was their first child or if they had other children, even though the question did not ask specifically for this answer, inferring a baseline that they had more confidence to start with when they had other children, or less confidence when it was their first child, but regardless, the Baby-Feed website provided an additional layer of building their confidence. All first-time mothers (n=10; 100%) found that Baby-Feed slightly to greatly increased their confidence. When expanding their response to their confidence, 100% of caregivers responded with an immediate discussion of the “Educational Resources by Nutrition Experts” section of the Baby-Feed website. Also, 80% of all caregivers recalled the easily accessible videos they had watched at various times during the intervention and, in which 100% of first-time mothers found them helpful. For example, a caregiver shared that “I found it really helpful the resources around like that first step, transitioning to solids, because it just gave me some like concrete things to anchor on, and then I could go with my instincts after that. So, I felt, I don’t remember exactly, honestly the details of what was shared, but I remember during that transition, I felt like the resources were really helpful. And there was a video about safe feeding that really made me feel more confident to make that transition. Like to know her feet in the highchair should be resting flat on a surface, … there was a lot of specifics that made me feel more confident.” Another caregiver shared: “I felt validated that feeding solids before 6 months was not in fact the recommendation out there. Because when you go to the pediatrician at your 4-month visit, they’re like, oh, if they’re showing readiness, you can start. But I know that the (American) Academy of Pediatrics and others say technically no solids before 6 months. So, I appreciated that fact that it was what it was showing.”

Themes for construct 2: outcome expectations

(How do you think the color-coding system results from the infant FFQ and the food tracking influenced your baby’s weight gain, and what color were you expecting to see on your baby’s growth chart?): color coding—no influence.

Themes for construct 3: incentive motivation

(When receiving “green” results within the Baby-Feed Website, did you find yourself wanting more green outcomes each time you completed the FFQ or tracking goals?): color coding, green is good, words, not colors.

Throughout the Baby-Feed website, results, such as the FFQ feedback, food tracking results, and the growth chart plotted measurements, were provided to participants via a traffic color coding system (red, yellow, and green) as well as color-coded words (above, adequate, or below). Most participants, 95% (n=19) did not notice the color-coding of FFQ intake feedback and therefore did not find the colors influential, and only two participants recalled that the food tracking results were also color coded. Although it was found that caregivers did not recall specifically seeing “green” on the food sections of the website, the participants that did notate seeing the green color, found that it was motivating. A participant stated “Yeah, of course, I want to have green. I remembered because I didn’t give her the solid food as much as she wanted to eat formula, so I got a red color. I fed too much formula, but the food was still green, but I know I should give her more solid food too.” However, 80% of the participants did recall that the infant’s growth measurement results included a color plotting as a green section, representing a healthy infant growth trajectory, as they had expected. A participant commented “Green! It matched with what information I was given at the pediatrician, so I thought it was accurate, which I liked.”

Themes for construct 4: observational learning

(Which of the short videos and websites did you watch or read, and what do you remember the most?): videos, reading newsletters.

A modification from the Baby-Feed pilot study included a section in the intervention providing “Educational Resources by Nutrition Experts”. Many of the videos were ~60 seconds, although some were up to 5 minutes, and ranged from cartoons to nutrition expert demonstrations to brief educations. 55% of the participants found the videos to be very helpful. A participant noted, “I know I remember in particular a video on how to feed your baby. I have ADHD… I learn better with my hands and learn better when it’s in front of me. … I did retain some information in regards to it because it really did help me not be scared to feed him like regular food.” Another participant noted: “I’m trying to think back because it would take me to YouTube and I think it had to do with like how to prepare and like cut the food, because choking, obviously, I was super worried about that in the beginning.” The section also included more traditional age group handouts, with the ability to print. A participant commented: “The newsletters, I think those were more helpful. Oh. What about the newsletters? I think it was just the way that it was organized, and I just remember looking at it and being like, okay, I can give more of this. There was something about breastfeeding that I thought was helpful; I printed those out and put them on my fridge. It was really for my father-in-law, who also takes care of him while I’m working.” Sharing the knowledge was also reported, as 15% of caregivers shared the educational information with others (friends, spouse, and grandfather).

Other feedback

Although not directly asked for specific feedback, some participants shared comments and suggestions at the end of the interview. There were operational suggestions, such as to improve the general layout to make it easier to complete on a cellphone, and some just wanted to state their appreciation of the study, and others were looking for further research opportunities.

Discussion

Key findings

The purpose of this qualitative study was to identify which SCT behavior mediators (self-efficacy, outcome expectation, intentions, observational learning) influenced caregivers to move them from intention into action in feeding behaviors. Based on the results of this qualitative study, first-time mothers who were interviewed reported the most increase in confidence compared to mothers with additional children, which is supported by the literature that most first-time parents are insecure about their parenting skills (27,28), and may be more engaged (2,3).

A large focus on the website was providing immediate feedback to parents based on their input in the infant FFQ and food tracking data, while using a commonly understood feedback tool, representing the construct of outcome expectations and incentive motivation. To do this, we used color-coding (green, yellow, red), as seen in commonly known traffic lights and their instructions (go, slow, and stop) which would be easily understood by caregivers. However, results from the caregivers found that this was not innately noted by caregivers, possibly due to the amount of color and size of words that would be seen from a mobile screen versus a laptop computer. Although the website was accessible from a mobile phone and laptop, all caregivers used the phone to access the website, which may have impacted answers, as color and font size may have been more easily identified on a larger screen. Some caregiver did report an increased recognition of the green color on the growth chart, representing the healthy trajectory, which may have been more visible due to amount of color or even an increased familiarity with growth charts, since this discussion of infant growth does occur at well-baby visits, which corresponds with the timing of completing the task of entering growth measurements from that doctor visit into the Baby-Feed website.

Observational learning may enable effective ways for communication strategies, as the videos were referenced by all participants, while less participants referenced the newsletters; however, those that did report on the newsletters found them very helpful and were able to reiterate specific topics that they read, which does imply better memory recall, possibly due to the length compared to the short videos. The medium (newsletters versus videos) may also be a contributing factor for recall, thus having multiple variations of learning format allows for individual learning preferences and the ability to reach more people. When asked the secondary question of what they remember most, many added to the conversation on how they implemented the information into practice. Participants noted, “it particularly helped with how to cut vegetables and steam them”, “watching for food readiness, like sitting up and opening their mouth”. And putting into practice, another participant stated, the video “what not to eat as it provided me with some new food options for him and good tips. So, when I am thinking of a meal for him, instead of just grilled cheese, I have found some new ideas for meals.”

Strengths and limitations

Strengths of the study included using deductive and inductive analysis, which is valuable in mixed methods research. It allows qualitative analysis using the same theoretical framework used in both the quantitative and qualitative studies. This facilitates integration, as constructs are developed from the initial SCT theory. However, the study had a few limitations. One is that the interview method reveals caregiver perceptions and recall rather than their actual behaviors. Although caregiver interviews were conducted within days after completing the study, many stated that they could not remember specific details, leading to some interviews that were limited in obtaining information. Although 20 interviews provided saturation, specific valuable feedback may have been missed from the other participants in the intervention, as they only represented 25% of intervention participants. As participants who completed the study sooner were more likely to have an earlier opportunity to elect to participate in the qualitative study, it may have, by chance, limited the diversity of parents completing the interviews. A lack of economic and racial diversity in this subset compared to the study may limit generalizations and findings. Lastly, answers to the questions may have been different if the participants were directed to complete the study on a laptop computer versus a mobile phone, as screen size may have impacted what was read/viewed; however, this may have also impacted completion of the study, as participants used the phone for ease of accessibility.

Comparison with similar research

Previous published studies have shown that during infancy, intervention studies that are based on theory with the inclusion of technology may be more effective for changing behaviors than those that lack this (13,19,29). Specifically, caregiver knowledge and their behaviors, as constructs found in SCT, may be important factors in minimizing the risk of childhood obesity as seen by other large randomized published trials (14,30,31). These studies found that the incorporation of SCT and technology resulted in improved outcomes such as the acquisition of new behaviors, the change in behavior, as well as the retention of the behavior.

Explanations of findings

The findings of this study provide the SCT as a fit for the purpose of the theoretical framework within this nutritional intervention. As a qualitative study complementing a quantitative study, it provides a valuable snapshot of how SCT can support an effective behavior change strategy. As an interpersonal theory, this study supports how their characteristics intertwine with a multitude of environmental factors, such as technology, to follow current nutrition guidance to mitigate childhood obesity.

Implications and actions needed

This qualitative study adds to the literature the value of the SCT implemented into child obesity intervention studies and provides a deeper understanding of the complexity of caregiver behavior in feeding decisions for their infants. With an ever-increasing high reliance on internet resources, the use of technology in infant care will continue to be vital for ease of reach and education.

Conclusions

Gaining knowledge on which SCT behavior mediators influenced caregivers in their infant feeding decisions is vital to the success of interventions such as Baby-Feed. Self-efficacy, outcome expectations, observed learning, and incentive motivation are SCT constructs identified by caregivers in the use of the Baby-Feed website, and moved caregivers from behavior intention into action. Additionally, there was reinforcement by caregivers with online resources that are easily accessible, from reputable sources, and provide instantaneous, personalized results are implemented as learned behaviors. In designing future child obesity intervention studies, theory, such as the SCT, should be incorporated into the study protocol, as an effective theory to predict and explain nutrition behavior and change. The Baby-Feed website may be a valuable resource that could be utilized successfully to complement infant feeding guidance provided by health care providers at well-baby visits.

Acknowledgments

We thank all the participants of the study for their dedication to supporting infant nutrition research.

Footnote

Reporting Checklist: The authors have completed the SRQR reporting checklist. Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-40/rc

Data Sharing Statement: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-40/dss

Peer Review File: Available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-40/prf

Funding: This study was supported by the Academy of Nutrition and Dietetics Pediatric Nutrition Practice Group (grant awarded to A.G.; administered at Florida International University under Dr. C.P., principal investigator).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-25-40/coif). A.G. is a current employee of Mead Johnson Nutrition, which has no affiliation with this study. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the institutional review board of Florida International University (No. IRB-23-0409-AM06). Caregivers of eligible infants electronically signed the informed consent before participation.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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