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Strengthen the Evidence for Maternal and Child Health Programs

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Evidence Tools
MCHbest. Breastfeeding.

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Strategy. Text Message-Based Support

Approach. Provide breastfeeding education and support through two-way text messaging interventions to encourage breastfeeding

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Overview. Despite peer counselors and mothers favorably describing communication via text messaging, there are few trials of interventions to test the effectiveness of text messaging used to provide breastfeeding support. Research indicates that mothers tended to be more likely to meet their breastfeeding goals when texting with peer counselors,[1] that 2-way text messaging enabled peer counselors to shorten the time-to-first-contact with mothers after giving birth,[2] and that text messages could be used to reinforce education on breastfeeding.[3]

Evidence. Emerging Evidence. Strategies with this rating typically trend positive and have good potential to work. They often have a growing body of recent, but limited research that documents effects. However, further study is needed to confirm effects, determine which types of health behaviors and conditions these interventions address, and gauge effectiveness across different population groups. (Clarifying Note: The WWFH database calls this "mixed evidence").

Access the peer-reviewed evidence through the MCH Digital Library or related evidence source. (Read more about understanding evidence ratings).

Source. Peer-Reviewed Literature

Outcome Components. This strategy has shown to have impact on the following outcomes (Read more about these categories):

  • Health and Health Behaviors/Behavior Change. This strategy improves individuals' physical and mental health and their adoption of healthy behaviors (e.g., healthy eating, physical activity).
  • Environmental Health. This strategy improves the impact of physical, chemical, and biological factors in the environment on health.
  • Utilization. This strategy improves the extent to which individuals and communities use available healthcare services.

Detailed Outcomes. For specific outcomes related to each study supporting this strategy, access the peer-reviewed evidence and read the Intervention Results for each study.

Intervention Type. Health Teaching (Education and Promotion) (Read more about intervention types and levels as defined by the Public Health Intervention Wheel).

Intervention Level. Community-Focused

Examples from the Field. Access descriptions of ESMs that use this strategy directly or intervention components that align with this strategy. You can use these ESMs to see how other Title V agencies are addressing the NPM.

Sample ESMs. Here are sample ESMs to use as models for your own measures using the Results-Based Accountability framework (for suggestions on how to develop programs to support this strategy, see The Role of Title V in Adapting Strategies).

Quadrant 1:
Measuring Quantity of Effort ("What/how much did we do?")

PROCESS MEASURES:

  • Number of breastfeeding women enrolled in the text message-based support program. (Measures program enrollment)
  • Number of peer counselors or lactation consultants trained to provide support via text messaging. (Assesses workforce development)
  • Number of text messages sent to provide breastfeeding education, encouragement, and problem-solving support to women. (Evaluates service delivery)

OUTCOME MEASURES:

  • Total number of women who actively engaged with the text message-based support program (e.g., replied to messages, asked questions). (Captures participant engagement)
  • Number of women who reported that the text message-based support helped them meet their breastfeeding goals. (Measures goal attainment)
  • Number of days women continued to breastfeed while participating in the text message-based support program. (Assesses breastfeeding duration)

Quadrant 2:
Measuring Quality of Effort ("How well did we do it?")

PROCESS MEASURES:

  • Percent of text messages that were personalized and tailored to each woman's specific needs, concerns, and preferences. (Measures individualization)
  • Percent of text message exchanges that were initiated by women seeking support, rather than prompted by the program. (Evaluates proactive support-seeking)
  • Percent of women who reported that the frequency and timing of text messages were appropriate and helpful. (Assesses program receptivity)

OUTCOME MEASURES:

  • Percent of women who reported high satisfaction with the convenience, accessibility, and helpfulness of the text message-based support. (Measures user experience)
  • Percent of breastfeeding concerns or challenges that were addressed and resolved through text message exchanges with peer counselors or lactation consultants. (Captures problem resolution)
  • Percent of women who exclusively breastfed their infants at 3 and 6 months postpartum while participating in the text message-based support program. (Assesses breastfeeding exclusivity)

Quadrant 3:
Measuring Quantity of Effect ("Is anyone better off?")

PROCESS MEASURES:

  • Number of community partners (e.g., WIC clinics, pediatric practices) that promoted and referred women to the text message-based support program. (Measures community engagement)
  • Number of quality improvement cycles conducted to refine and optimize the content, timing, and delivery of the text message-based support. (Assesses continuous improvement)
  • Number of women who continued to use the text message-based support program for breastfeeding help beyond the initial postpartum period. (Evaluates program retention)

OUTCOME MEASURES:

  • Number of breastfeeding women who reported increased confidence and self-efficacy in managing breastfeeding challenges as a result of the text message-based support. (Captures empowerment)
  • Number of referrals made to connect women with additional breastfeeding resources and services based on needs identified through text message exchanges. (Measures care coordination)
  • Number of women who served as peer mentors or advocates for the text message-based support program after benefiting from it themselves. (Assesses ripple effect)

Quadrant 4:
Measuring Quality of Effect ("How are they better off?")

PROCESS MEASURES:

  • - Percent of low-income or underserved women enrolled in the text message-based support program. (Measures equitable access)
  • - Percent of text messages that were culturally and linguistically appropriate for the diverse populations served. (Evaluates cultural relevance)
  • - Percent of women who opted to continue receiving text message-based support beyond the initial program duration. (Assesses sustained engagement)

OUTCOME MEASURES:

  • - Percent reduction in breastfeeding disparities between women who participated in the text message-based support program and those who did not, stratified by race, ethnicity, and socioeconomic status. (Measures equity impact)
  • - Percent of women from communities with historically low breastfeeding rates who reported increased breastfeeding knowledge, confidence, and duration after participating in the text message-based support program. (Captures progress in underserved areas)
  • - Percent increase in breastfeeding initiation and duration rates at the population level, attributable to the availability and utilization of text message-based support programs. (Assesses population-level change)

Note. When looking at your ESMs, SPMs, or other strategies:

  1. Move from measuring quantity to quality.
  2. Move from measuring effort to effect.
  3. Quadrant 1 strategies should be used sparingly, when no other data exists.
  4. The most effective measurement combines strategies in all levels, with most in Quadrants 2 and 4.

Learn More. Read how to create stronger ESMs and how to measure ESM impact more meaningfully through Results-Based Accountability.

References

1 Harari, N., Rosenthal, M. S., Bozzi, V., Goeschel, L., Jayewickreme, T., Onyebeke, C., ... & Perez‐Escamilla, R. (2018). Feasibility and acceptability of a text message intervention used as an adjunct tool by WIC breastfeeding peer counsellors: The LATCH pilot. Maternal & child nutrition, 14(1), e12488.

2 Martinez-Brockman, J. L., Harari, N., Segura-Pérez, S., Goeschel, L., Bozzi, V., & Pérez-Escamilla, R. (2018). Impact of the Lactation Advice Through Texting Can Help (LATCH) trial on time to first contact and exclusive breastfeeding among WIC participants. Journal of nutrition education and behavior, 50(1), 33-42.

3 Palacios, C., Campos, M., Gibby, C., Meléndez, M., Lee, J. E., & Banna, J. (2018). Effect of a multi-site trial using short message service (SMS) on infant feeding practices and weight gain in low-income minorities. Journal of the American College of Nutrition, 37(7), 605-613.

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.