Baby Buddy App for Breastfeeding and Behavior Change: Retrospective Study of the App Using the Behavior Change Wheel
Authors: Musgrave Loretta M , Baum Alison , Perera Nilushka , Homer Caroline SE , Gordon Adrienne 
Published: April 2021

Background
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.

Objective
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.

Methods
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).

Results
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.

Conclusions
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.