Effectiveness and cost-effectiveness of a 12-month automated text message intervention for weight management in postpartum women with overweight or obesity: protocol for the Supporting MumS (SMS) multisite, parallel-group, randomised controlled trial.

INTRODUCTION: The reproductive years can increase women's weight-related risk. Evidence for effective postpartum weight management interventions is lacking and engaging women during this life stage is challenging. Following a promising pilot evaluation of the Supporting MumS intervention, we assess if theory-based and bidirectional text messages to support diet and physical activity behaviour change for weight loss and weight loss maintenance, are effective and cost-effective for weight change in postpartum women with overweight or obesity, compared with an active control arm receiving text messages on child health and development. METHODS AND ANALYSIS: Two-arm, parallel-group, assessor-blind randomised controlled trial with cost-effectiveness and process evaluations. Women (n=888) with body mass index (BMI) ≥25 kg/m2 and within 24 months of giving birth were recruited via community and National Health Service pathways through five UK sites targeting areas of ethnic and socioeconomic diversity. Women were 1:1 randomised to the intervention or active control groups, each receiving automated text messages for 12 months. Data are collected at 0, 6, 12 and 24 months. The primary outcome is weight change at 12 months from baseline, compared between groups. Secondary outcomes include weight change (24 months) and waist circumference (cm), proportional weight gain (>5 kg), BMI (kg/m2), dietary intake, physical activity, infant feeding and mental health (6, 12 and 24 months, respectively). Economic evaluation examines health service usage and personal expenditure, health-related quality of life and capability well-being to assess cost-effectiveness over the trial and modelled lifetime. Cost-utility analysis examines cost per quality-adjusted life-years gained over 24 months. Mixed-method process evaluation explores participants' experiences and contextual factors impacting outcomes and implementation. Stakeholder interviews examine scale-up and implementation. ETHICS AND DISSEMINATION: Ethical approval was obtained before data collection (West of Scotland Research Ethics Service Research Ethics Committee (REC) 4 22/WS/0003). Results will be published via a range of outputs and audiences. TRIAL REGISTRATION NUMBER: ISRCTN16299220.

Healthy eating and lifestyle in pregnancy (HELP): a cluster randomised trial to evaluate the effectiveness of a weight management intervention for pregnant women with obesity on weight at 12 months postpartum.

OBJECTIVE: To assess whether a weight management intervention for pregnant women with obesity was effective in reducing body mass index (BMI) 12 months after giving birth. METHODS: Pragmatic, cluster randomised controlled trial (RCT) with embedded cost-effectiveness analysis. 598 women with a BMI of ≥30 kg/m2 (between 12 and 20 weeks gestation) were recruited from 20 secondary care maternity units in England and Wales. BMI at 12 months postpartum was the primary outcome. A range of clinical and behavioural secondary outcomes were examined. INTERVENTIONS: Women attending maternity units randomised to intervention were invited to a weekly weight management group, which combined expertise from a commercial weight loss programme with clinical advice from midwives. Both intervention and control participants received usual care and leaflets on diet and physical activity in pregnancy. RESULTS: Mean (SD) BMI at 12 months postpartum was 36.0 kg/m2 (5.2) in the control group, and 37.5 kg/m2 (6.7) in the intervention group. After adjustment for baseline BMI, the intervention effect was -0.02 (95% CI -0.04 to 0.01). The intervention group had an improved healthy eating score (3.08, 95% CI 0.16 to 6.00, p < 0.04), improved fibre score (3.22, 1.07 to 5.37, p < 0.01) and lower levels of risky drinking at 12 months postpartum compared to the control group (OR 0.45, 0.27 to 0.74, p < 0.002). The net incremental monetary benefit was not statistically significantly different between arms, although the probability of the intervention being cost-effective was above 60%, at policy-relevant thresholds. CONCLUSIONS: There was no significant difference between groups on the primary outcome of BMI at 12 months. Analyses of secondary outcomes indicated improved healthy eating and lower levels of risky drinking. TRIAL REGISTRATION: Current Controlled Trials ISRCTN25260464.

Smoking during pregnancy, stigma and secrets: Visual methods exploration in the UK.

BACKGROUND: Moral judgements are commonly directed towards mothers through reference to health behaviour in pregnancy, and working-class mothers are particularly subject to this moral gaze. AIM: To gain an in-depth understanding of the health issues affecting 10 low income pregnant women from deprived areas of south Wales, UK. METHODS: Participants completed visual activities (timelines, collaging or thought bubbles and dyad sandboxing) prior to each interview. Participants' visual representations were used in place of a topic guide, to direct the interview. Guided by feminist principles, 28 interviews were completed with 10 women. Data were analysed thematically. FINDINGS: Smoking was discussed at length during interviews, and this paper focuses on this issue alone. Five of the participants had smoked during pregnancy. Negative reactions were directed towards pregnant women who smoked in public, resulting in maternal smoking being undertaken in private. Participants also reported awkward relationships with midwives and other health professionals, including receipt of public health advice in a judgemental tone. DISCUSSION: Smoking during pregnancy is a particularly demonised and stigmatised activity. This stigma is not always related to the level of risk to the foetus, and instead can be seen as a moral judgement about women. We urgently need to move from individualised neo-liberal discourses about the failure of individual smokers, to a more socio-ecological view which avoids victim blaming. CONCLUSION: Stigma from friends, family, strangers and health professionals may lead to hidden smoking. This is a barrier to women obtaining evidence based stop smoking support.

Understanding health behaviour in pregnancy and infant feeding intentions in low-income women from the UK through qualitative visual methods and application to the COM-B (Capability, Opportunity, Motivation-Behaviour) model.

BACKGROUND: Health behaviours during pregnancy and the early years of life have been proven to affect long term health, resulting in investment in interventions. However, interventions often have low levels of completion and limited effectiveness. Consequently, it is increasingly important for interventions to be based on both behaviour change theories and techniques, and the accounts of pregnant women. This study engaged with pregnant women from deprived communities, to understand their subjective experiences of health in pregnancy. METHODS: The study adopted a women-centred ethos and recruited a purposive sample of ten pregnant women, who lived in deprived areas and were on low incomes. Participants engaged with three creative techniques of visual data production (timelines, collaging and dyad sandboxing), followed by elicitation interviews. One participant only engaged in the initial activity and interview, resulting in a total of 28 elicitation interviews. This in-depth qualitative approach was designed to enable a nuanced account of the participants' thoughts, everyday experiences and social relationships. Data were deductively coded for alcohol, smoking and infant feeding and then mapped to the COM-B model (Capability, Opportunity, Motivation - Behaviour). RESULTS: Five participants had experience of smoking during pregnancy, four had consumed alcohol during pregnancy, and all participants, except one who had exclusively formula fed her child, disclosed a range of infant feeding experiences and intentions for their current pregnancies. Considerable variation was identified between the drivers of behaviour around infant feeding and that related to abstinence from tobacco and alcohol during pregnancy. Overall, knowledge and confidence (psychological capability), the role of partners (social opportunity) and support from services to overcome physical challenges (environmental opportunity) were reported to impact on (reflective) motivation, and thus women's behaviour. The role of the public in creating and reinforcing stigma (social opportunity) was also noted in relation to all three behaviours. CONCLUSIONS: When designing new interventions to improve maternal health behaviours it is important to consider the accounts of pregnant women. Acknowledging pregnant women's subjective experiences and the challenges they face in negotiating acceptable forms of motherhood, can contribute to informed policy and practice, which can engage rather than isolate potential user groups.

Negotiating Closed Doors and Constraining Deadlines: The Potential of Visual Ethnography to Effectually Explore Private and Public Spaces of Motherhood and Parenting.

Pregnancy and motherhood are increasingly subjected to surveillance by medical professionals, the media, and the general public, and discourses of ideal parenting are propagated alongside an admonishment of the perceived "failing" maternal subject. However, despite this scrutiny, the mundane activities of parenting are often impervious to ethnographic forms of inquiry. Challenges for ethnographic researchers include the restrictions of becoming immersed in the private space of the home where parenting occurs and an institutional structure that discourages exploratory and long-term fieldwork. This paper draws on four studies, involving thirty-four participants, that explored their journeys into the space of parenthood and their everyday experiences. The studies all employed forms of visual ethnography, including artifacts, photo elicitation, timelines, collage, and sandboxing. The paper argues that visual methodologies can enable access to unseen aspects of parenting and engender forms of temporal extension, which can help researchers to disrupt the restrictions of tightly time bounded projects.

"Keeping it on your radar"-assessing the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood: A qualitative study from the early detection of type 1 diabetes in youth study.

AIMS: The aim of this study was to explore from the perspectives of key stakeholders involved in the pathway to diagnosis, the barriers and facilitators to a timely diagnosis of type 1 diabetes in childhood. METHODS: Qualitative interviews and free-text analyses were undertaken in 21 parents with a child diagnosed with type 1 diabetes, 60 parents without a child diagnosed with type 1 diabetes, 9 primary healthcare professionals, 9 teachers and 3 community diabetes liaison nurses. Data were analysed thematically and 30% double coded. RESULTS: Two key themes were identified, namely the importance of widespread awareness and knowledge and seeking healthcare professional help. Parents with a child diagnosed with type 1 diabetes described seeking opinions from a number of individuals prior to seeking health professional help. Healthcare professionals recognized the rarity of the condition and the need for it to be kept on their "radar", to ensure they considered it when examining an unwell child. The process of obtaining a primary healthcare appointment was identified as potentially playing a crucial role in the diagnostic process. However, most parents with a child diagnosed with type 1 diabetes described receiving an appointment on the day they sought it. CONCLUSIONS: Knowledge and awareness of type 1 diabetes in childhood remain limited in the general population and misconceptions persist relating to how children present with this serious condition. An effective community-based intervention to raise awareness amongst key stakeholders is required to ensure children receive a timely diagnosis once symptomatic.