Mhealth 2022 9 E31996

JMIR MHEALTH AND UHEALTH Mohamad Pilus et al
Original Paper
Effect of Face-to-Face and WhatsApp Communication of a

Theory-Based Health Education Intervention on Breastfeeding
Self-Efficacy (SeBF Intervention): Cluster Randomized Controlled
Field Trial
Farahana Mohamad Pilus1*, DrPH; Norliza Ahmad1*, PhD; Nor Afiah Mohd Zulkefli1*, PhD; Nurul Husna Mohd
Shukri2*, PhD
1
Department of Community Health, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
2
Department of Nutrition, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia
*
all authors contributed equally
Corresponding Author:
Norliza Ahmad, PhD
Department of Community Health
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
Jalan Hospital Serdang
Serdang, 43400
Malaysia
Phone: 60 97692424
Fax: 60 97692425
Email: lizaahmad@upm.edu.my
Abstract
Background: The exclusive breastfeeding rate in Malaysia is still not satisfactory. Previous studies have shown that breastfeeding
self-efficacy is one of the determinants of exclusive breastfeeding, and it can be improved using social cognitive theory. WhatsApp,
which is widely used among Malaysians, could be leveraged as a platform to deliver health education interventions.
Objective: This study aimed to develop, implement, and evaluate the effect of using a face-to-face and WhatsApp-based health
education intervention based on social cognitive theory, namely the Self-Efficacy in Breastfeeding (SeBF) module, on mothers'
self-efficacy, knowledge, and attitudes in a district in Selangor state.
Methods: This study was a 2-arm, parallel, single-blind, cluster randomized controlled field trial with an intervention and a
control group involving primigravida or multigravida mothers who reside in a district in Selangor state and did not exclusively
breastfeed during their previous pregnancy. All 12 maternity and pediatric clinics in this district were randomly divided into 6
intervention and 6 control groups. A total of 172 pregnant mothers were randomly assigned to the intervention group (n=86) or
the control group (n=86). The control group received usual routine care. The primary outcome was breastfeeding self-efficacy,
while secondary outcomes were knowledge and attitude toward breastfeeding. Each subject was assessed at 4 time points: at
baseline, immediately after the intervention, 4 weeks post partum, and 8 weeks post partum. Generalized mixed model analysis
was applied to measure the effect of health education on breastfeeding self-efficacy, knowledge, and attitude after the intervention.
Results: The response rate was 81% (139/172), with the dropout rate being 7% (6/86) in the intervention group and 31% (27/86)
in the control group. In the intent-to-treat analysis, the intervention group showed a significant increase in the mean total
breastfeeding self-efficacy score 8 weeks after delivery compared with the control group (F21,601=111.73, P<.001). In addition,
the mean total score for breastfeeding knowledge increased significantly in the intervention group after the intervention compared
to the control group (F21,601=8.33, P<.001). However, no significant difference was found in the mean total score for breastfeeding
attitude after the intervention (F21,602=5.50, P=.47).
Conclusions: Face-to-face and WhatsApp-based participation in the SeBF program, designed on the basis of social cognitive
theory, contributed to improved self-efficacy and knowledge about breastfeeding. Further studies need to be conducted with a
https://mhealth.jmir.org/2022/9/e31996 JMIR Mhealth Uhealth 2022 | vol. 10 | iss. 9 | e31996 | p. 1

(page number not for citation purposes)
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longer duration (until 6 months post partum) to evaluate its effectiveness in increasing exclusive breastfeeding. Furthermore, new
strategies in health education need to be developed to improve breastfeeding attitudes.
Trial Registration: Thaiclinicaltrials.org TCTR20200213004; https://www.thaiclinicaltrials.org/show/TCTR20200213004
(JMIR Mhealth Uhealth 2022;10(9):e31996) doi: 10.2196/31996
KEYWORDS
self-efficacy; breastfeeding; intervention; social cognitive theory
Recruitment and Inclusion Criteria

Introduction
Pregnant women between 34 and 37 weeks of gestation, who
Background presented for antenatal care at maternal and child health clinics,
The overall prevalence of exclusive breastfeeding in Malaysia were offered participation in this study, and their eligibility was
was 47.1% (95% CI 43.13-51.18) [1], which is below the assessed. Eligible mothers were primigravida or multigravida
national target of 70% by 2025 [2]. Previous studies have shown women who had not exclusively breastfed during a previous
that breastfeeding self-efficacy is one of the determinants of pregnancy and had a cell phone with Internet access and the
exclusive breastfeeding [3,4]. Breastfeeding self-efficacy refers WhatsApp app. Mothers who were taking medications such as
to a woman's confidence in breastfeeding ability with an infant anticancer drugs and those who had medical or
[3,5]. Several factors are associated with breastfeeding pregnancy-related complications that hindered or complicated
self-efficacy, including support and guidance, experience and breastfeeding (heart disease, cancer, nephritis, active or
stress, postpartum experiences, and social environment [5-7]. untreated tuberculosis, HIV or AIDS, active breast herpes
Social cognitive theory (SCT) has been shown to be effective lesions, and severe malnutrition) were excluded from this study
in previous breastfeeding self-efficacy intervention studies [14]. During recruitment, all participants have been informed
[8-13]. SCT involves a cognitive dynamic process that assesses that intervention was being offered. Mothers who expressed
individuals' beliefs and ability to engage in healthy behaviors interest were provided with participant information sheets and
[8]. informed consent forms.
On the other hand, several methods have been used to deliver Randomization and Allocation Concealment
knowledge and skills to mothers, including face-to-face The cluster comprised 12 maternal and child health clinics in
conversations, phone calls, and web-based applications Hulu Langat District. All chosen health clinics were randomly
[5,10-12,14,15]. WhatsApp, a cross-platform application that allocated into intervention and control groups by a nurse who
works on all major smartphone platforms such as Android, was not involved in this study. All selected clinics were labeled,
iPhone, and Windows Mobile, has approximately 500 million and Stat Trek software was used to perform simple
users worldwide [16]. According to a recent study [17], randomization with a 1:1 allocation ratio [15]. The researcher
WhatsApp is preferred by 98.7% of Malaysian respondents, was only aware of the intervention group's assignment after the
while Facebook Messenger is preferred by 54% of them. Given randomization procedure was completed. Antenatal mothers
the widespread use of WhatsApp, we sought to evaluate the who met the eligibility requirements were recruited and
effectiveness of its use in providing health education to pregnant consented with an equal number of participants assigned to each
women. clinic. Participants were blinded to group assignments.
Participants were blinded to the fact that awareness of being
Objectives
part of the control group could influence their responses to the
This study aimed to determine the effect of an SCT-based questionnaires.
intervention called Self-Efficacy in Breastfeeding (SeBF) to
improve breastfeeding self-efficacy through face-to-face Sample Size Calculation
communication and WhatsApp. The sample size was estimated on the basis of Lemeshow and
Lwanga's Sample Size Determination in Health Studies [18].
Methods The formula for 2 population proportions was used for
hypothesis testing purposes. The sample size calculated was on
Study Design the basis of a 30% increase in breastfeeding self-efficacy in the
This 2-arm, parallel, single-blind cluster randomized controlled control group and a 55% increase in breastfeeding self-efficacy
field trial, comprising an intervention group and a control group, in the intervention group [11], with an α of .05 and β of .20, an
was conducted at maternal and child health clinics in Hulu intraclass correlation coefficient of 0.05 [19], attrition rate of
Langat district, Selangor, Malaysia. The health clinics are 20% [20], and an average cluster size of 20 with a design effect
considered a cluster for this study. The intervention group of 2.45. After adjusting for the clustered design effect, the final
received the SeBF intervention, whereas the control group minimum sample size required was 160 participants, with 80
received standard routine brief counselling by health care participants in the intervention and control groups.
personnel about breastfeeding and breastfeeding pamphlets.

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Intervention Module method, duration of breastfeeding, expressed breast milk (EBM),

The SeBF intervention was a newly developed module to storage of EBM, complementary foods, and problems with
improve breastfeeding self-efficacy among mothers. The breastfeeding [25]. Each item had categorical responses of
development was based on SCT and prior intervention studies “True,” “False,” or “Not sure.” A correct answer was scored as
[5,8-10,12,15,18]. Breastfeeding self-efficacy was the main aim “1,” while a wrong and an unsure answer were scored as “0.”
as it is one of the important determinants for successful The total knowledge score ranged from “0” to “47,” with higher
exclusive breastfeeding [21]. Based on this intervention's scores representing more knowledge. The internal consistency
success, it will be further evaluated for exclusive breastfeeding of Cronbach α was .70 [25].
purposes. Breastfeeding Attitude
This newly developed SeBF module was consulted and The 16-item Iowa Infant Feeding Attitude Scale was used to
discussed with 2 Public Health Medicine Specialists and a assess mothers' attitudes toward breastfeeding [26,27]. Mothers
Nutrition Specialist. This intervention module applied the SCT were asked to indicate the extent to which they agreed with each
constructs such as observational learning, personal experience, statement on a 5-point Likert scale ranging from 1=“strongly
verbal persuasion, problem-solving, self-efficacy, and outcome disagree” to 5=“strongly agree.” Items endorsing formula
expectation. The SCT constructs used in the SeBF module feeding were reverse-scored (1=5, 2=4, 3=3, 4=2, and 5=1),
showed in Multimedia Appendix 1. and an overall attitude score was calculated from the equally
weighted sum of responses to each item. The total attitude scores
The SeBF module was developed to be delivered face to face
ranged from “16” for a positive attitude toward formula
and through WhatsApp. The intervention consisted of training
breastfeeding to a maximum score of “80” for an attitude
and reinforcement phases. The training phase involved a
favoring breastfeeding. The Cronbach α for this instrument was
face-to-face session of 30 minutes, while the reinforcement
≥.85 [28].
phase involved WhatsApp messages weekly until 4 weeks post
partum. The WhatsApp messages were sent every Monday at Data Collection
2:30 PM for 15 minutes. The WhatsApp group function was The data collection for this study was conducted from January
used to distribute information, concerns, and issues; clarify any to December 2020. Baseline data were collected after
misunderstandings about breastfeeding practice; and provide a participants' recruitment. A second assessment was conducted
reminder to all participants. immediately after the training phase, followed by 4 and 8 weeks
The privacy and confidentiality of the participants were post partum. Concurrently, data from the control group were
protected via a private group formation on WhatsApp. Thus, also collected at the same 4 time points. Attendance at the
no other person apart from those recruited by the researcher maternity and child health clinic was severely affected by the
could have access to the group. In addition, no personal pandemic COVID-19. For the 4- and 8-week postpartum
information was exposed in the WhatsApp group. This module follow-ups, data collection was switched from hard copy
has been pilot-tested among 30 antenatal mothers not included self-administered questionnaires to Google Forms.
in the main study. The SeBF intervention was delivered by a
Statistical Analysis
researcher who is also a medical doctor.
SPSS (version 25; IBM Corp) was used for the analyses.
Study Instruments Shapiro-Wilk, Komolgorov-Smirnov, and histogram tests were
The primary outcome of this intervention study was self-efficacy used to determine normal distribution. In the descriptive study,
in breastfeeding scores, and the secondary outcome represents data were presented as mean, SD, frequency, and percentage
scores on knowledge and attitudes toward breastfeeding. These values. The Pearson chi-square or Fisher exact test was used to
outcomes were assessed in the intervention and control groups determine the homogeneity of baseline data between the
immediately post intervention, 4 weeks post partum, and 8 intervention and control groups for categorical data, and the
weeks post partum. Student t test was used for continuous data. The effectiveness
of the intervention was determined using generalized mixed
Breastfeeding Self-efficacy model analysis (GLMM), which controlled for baseline data
The 13-item Breastfeeding Self-Efficacy Scale–Short Form was covariates such as age, ethnicity, education level, maternal
used to assess mothers' confidence in their ability to successfully employment, and monthly family income. A significance level
breastfeed their infant [22,23]. All items are preceded by the of .05 with a 95% CI was used for the study. Thus, the null
phrase “I can always” and are anchored on a 5-point Likert hypothesis with a P value of >.05 was rejected.
scale, where 1=“not at all confident” and 5=“always confident”
[10]. Each item is presented positively, and the sum of the scores
Ethics Approval
gives a range of 14 to 65, with higher scores indicating greater The National Medical Research Registry granted ethical
breastfeeding self-efficacy [10]. The Cronbach α coefficient approval for this study (NMRR-19-2712-50586). Each
was .90 [24]. respondent provided written and informed consent during the
data collection process. All participants’ information was kept
Knowledge on Breastfeeding strictly confidential. The study was prospectively registered in
A validated questionnaire with 47 items was used to assess the Thai Clinical Trial Registry with identification number
knowledge about breastfeeding. These included general TCTR20200213004.
knowledge, benefits to mothers and babies, effective feeding
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delivery. The dropout rate was 31% (27/86) in the control group
Results and 7% (6/86) in the intervention group. Figure 1 summarizes
Response Rate the final research schedule based on the CONSORT
(Consolidated Standards of Reporting Trials) statement
A total of 139 mothers completed all 4 points of follow-up, (Multimedia Appendix 2) [29].
resulting in a response rate of 81% (139/172) 8 weeks after
Figure 1. Sample recruitment and dropouts throughout the study period.
groups (P>.05). The household income in Malaysia was

Baseline Data categorized as the B40 (below 40% of population) group, the
Table 1 provides an overview of the baseline data for the M40 (middle 40% of population) group, and the T20 (top 20%
respondents. There were no significant differences in categorical of the population) group [30].
or continuous variables between the intervention and control

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Table 1. Distribution of continuous and categorical variables at baseline (n=172).

Variables Intervention (n=86) Control (n=86) Difference between the conditions
Fisher exact test or P value
t test (df)
Mother’s current age (years), n (%) N/Aa .25
19-24 24 (28) 18 (21)

25-35 57 (66) 66 (77)
36-45 5 (6) 2 (2)
Ethnicity, n (%) N/A .09
Malay 73 (85) 75 (87)
Chinese 4 (5) 2 (2)
Indian 3 (3) 8 (9)
Others 6 (7) 1 (1)
Highest education level, n (%) N/A .48
Primary 2 (2) 5 (6)
Secondary 28 (33) 25 (29)
Higher education 56 (65) 56 (65)
Mother’s employment status, n (%) N/A .33
Unemployed 28 (32) 24 (28)
Self-employed 4 (5) 9 (10)
Government sector 7 (8) 11 (13)
Private sector 47 (55) 42 (49)
Total monthly household income (Malaysian Ringgit [RM]; 1 RM=US $0.22)b, n (%) N/A .25
B40 (<RM 4850) 62 (72) 58 (67)

M40 (RM 4850-10,959) 23 (27) 23 (27)
T20 (>RM 10,960) 1 (1) 5 (6)
Total score for breastfeeding self-efficacy, mean (SD) 22.44 (6.82) 24.38 (8.61) –1.63 (169) .11
Total score for breastfeeding knowledge, mean (SD) 22.44 (6.83) 24.12 (8.27) –1.45 (169) .15
Total score for breastfeeding attitudes, mean (SD) 56.27 (7.00) 56.97 (6.69) –0.67 (169) .51
a
N/A: not applicable.
b
Household income was categorized on the basis of the Department of Statistics Malaysia’s classification of B40, M40, and T20.
F21,601=8.331, P<.001, respectively). However, there was no

Primary and Secondary Outcomes
significant difference between the two groups for attitudes
Table 2 compares breastfeeding self-efficacy, knowledge about toward breastfeeding.
breastfeeding, and attitudes toward breastfeeding between the
intervention and control groups at baseline, immediately after Figure 2 shows that breastfeeding self-efficacy improved in the
training, and 4 and 8 weeks post partum. Bivariate analyses intervention group over all 4 time points. The control group had
show no significant difference between intervention and control an almost identical pattern to that of the intervention group.
groups for all time points, except for the total score for Although the control group showed an almost similar trend to
knowledge 8 weeks post partum. the intervention group, it did not reach a high level of
self-efficacy at 8 weeks after the intervention. Regarding
Table 3 shows the GLMM results for the values of self-efficacy, breastfeeding knowledge, Figure 3 shows that the overall rating
knowledge, and attitude toward breastfeeding after controlling of breastfeeding knowledge improved for all respondents in the
for covariates. The results show a significant difference between intervention group compared to that in the control group. Figure
the intervention and control groups for self-efficacy and 4 shows that attitudes toward breastfeeding did not improve
knowledge of breastfeeding (F21,601=111.728, P<.001 and after the intervention study.

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Table 2. Breastfeeding self-efficacy, knowledge, and attitudes between intervention and control groups at baseline, immediately after the intervention,
and 4 and 8 weeks post partum.
Variables At baseline Immediately post intervention 4 weeks post partum 8 weeks post partum
Total score of self-efficacy
Intervention group score, mean (SD) 22.44 (6.82) 24.02 (6.37) 52.60 (9.29) 53.34 (9.16)
Control group score, mean (SD) 24.38 (8.61) 24.37 (8.55) 51.22 (9.32) 51.89 (8.44)
t test (df) –1.63 (169) –0.30 (169) 0.95 (161) 0.90 (145)
P value .11 .76 .34 .37
95% CI for difference of means –6.43 to –0.71 –4.28 to 0.41 –1.50 to 4.26 –1.58 to 4.20
Total score of knowledge
t test (df) –1.45 (169) –0.08 (169) 0.94 (157) 2.54 (141)
P value .15 .94 .35 .01a
95% CI for difference of means –3.97 to 0.61 –2.32 to 2.13 –1.09 to 3.08 0.65 to 5.29
Total score of attitudes
t test (df) –0.67 (170) –0.69 (170) –1.13 (158) –1.25 (140)
P value .50 .49 .27 .24
95% CI for difference of means –2.76 to 1.37 –0.72 to 1.04 –3.33 to 0.93 –4.11 to 1.05
a
Statistically significant at P<.05.
Table 3. The effect of health education on mothers' overall ratings of self-efficacy, knowledge, and attitudes toward breastfeeding.
Outcomes and parameters F test (df) P valuea
Total scores of breastfeeding self-efficacy
Group 0.85 (1, 601) .36
Time 413.95 (3, 601) <.001b
Group×time 111.73 (21, 601) <.001b
Total scores of breastfeeding knowledge
Group 6.38 (1, 601) .02b
Time 4.29 (3, 601) .005b
Group×time 8.33 (21, 601) <.001b
Total scores of breastfeeding attitudes
Group 0.91 (1, 602) .34
Time 0.38 (3, 602) .77
Group×time 5.50 (21, 602) .47
a
Using a generalized linear mixed model adjusted for respondents’ age, ethnicity, level of education, employment, and household income.
b
Statistically significant at P<.05.

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Figure 2. Total scores on self-efficacy, showing the interaction between group and time, for all respondents.
Figure 3. Total scores on breastfeeding knowledge, showing the interaction between group and time, for all respondents.
Figure 4. Total scores of attitudes on breastfeeding showing the interaction between group and time, for all respondents.

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self-efficacy for breastfeeding, their attitude ratings remained

Discussion unchanged [27]. Furthermore, a study conducted in India found
Principal Findings that the number of mothers with a favorable attitude dropped
from the first to the third follow-up visit, despite improved
The purpose of the current study was to develop, implement, knowledge at the baseline visit [36]. The most frequently cited
and evaluate the effect of the SeBF intervention on breastfeeding reasons for their change in attitude toward breastfeeding were
self-efficacy among antenatal mothers in Hulu Langat District, a perception of insufficient milk secretion, concern for the baby's
Selangor. The module was developed on the basis of SCT and health, concern that the baby would not gain enough weight on
delivered face to face and on WhatsApp. The findings showed breastfeeding alone until 6 months, and complications such as
that the intervention group had significantly increased their breast engorgement and sore nipples during breastfeeding [36].
breastfeeding self-efficacy and knowledge scores compared to Increasing the intensity of WhatsApp communication may help
the control group. These significant changes could be improve the breastfeeding attitude and subsequently increase
contributed by the use of the SCT, namely observational breastfeeding self-efficacy [11,12].
learning, personal experience, verbal persuasion, and
problem-solving to fulfil the end expectation and breastfeeding Strengths and Limitations
self-efficacy [31-33]. It included an antenatal period that began This study was a randomized controlled field trial with a
at the earliest 34 weeks of pregnancy and a postpartum period reasonable participation rate and adequate follow-up despite
that lasted until 8 weeks post partum. It helped ensure that all the COVID-19 pandemic during data collection. Randomized
intervention participants received an adequate and optimal dose assignment to the intervention and control groups makes the
of the SeBF intervention during the most critical period, from two comparable and increases validity [36]. It is the first study
the third trimester of pregnancy to 8 weeks post partum [32]. to employ innovative teaching and follow-up techniques for
Numerous approaches, including educational talk, practical breastfeeding intervention using WhatsApp. Modification of
breastfeeding videos, model demonstrations, and group educational materials and linking of responses to more
discussions, contributed to respondents’ increased self-efficacy. accessible and appealing social media platforms are critical
The usage of mobile technology, specifically WhatsApp, may components of modern education [37].
have improved the primary and secondary outcomes. It
facilitated the communication between the researcher and the However, this study has some limitations. Because of the
participants in the intervention group. Hence, any problems self-completed questionnaire used in this study, social
faced by the mothers can be solved immediately. WhatsApp desirability may have been observed, with individuals
was chosen because it is a popular social media platform among responding positively being considered successful breastfeeding
Malaysians [30]. Therefore, it is readily used rather than mothers. This study may also not be relevant to individuals who
requesting the respondents to install other new applications for do not have access to a smartphone, as the follow-up of the
this study. intervention was conducted via WhatsApp. Furthermore, it is
difficult to track whether the intervention group read and
Comparison With Prior Work digested the material distributed on WhatsApp. In the future,
This study’s findings are consistent with those of a previous the researcher should ask respondents random questions to
study conducted in Iraq [13], indicating a significant difference determine if they understood the intervention material.
in the change in mean breastfeeding self-efficacy scores between Replicating this intervention may be difficult with limited human
mothers who received the intervention and those who did not resources since it will impose an additional demand on health
receive the intervention by applying SCT in their study. This care personnel. While some health care facilities may be able
study found that although all pregnant women in the study had to provide educational talk, group discussions, and WhatsApp
some prenatal visits before enrollment, their breastfeeding group follow-ups, others may find it time consuming and
knowledge was poor. This suggests the need to educate women difficult. Before adopting a clinic-level intervention,
about breastfeeding during their routine antenatal appointments considerations of appropriateness, time, and human resources
[34]. Overall knowledge scores were higher in the intervention are required.
group than in the control group. An Iranian study found that
women who received antenatal education have significantly Conclusions
higher knowledge scores, which resulted in higher mean Participation in the SeBF intervention, a face-to-face and
breastfeeding self-efficacy scores; 53.98 (SD8.50) in the WhatsApp-based intervention using SCT, significantly improved
intervention group and 43.41 (SD 8.12) in the control group self-efficacy and knowledge about breastfeeding. Nevertheless,
(P=.001) [13]. Another study in Canada reported the same result, this study showed that respondents' attitudes did not improve.
with a significant increase in participants' knowledge scores This study showed that WhatsApp could be a practical tool in
following the educational breastfeeding intervention (mean complementing breastfeeding health education to mothers. The
knowledge scores of 24.14, SD 4.08 post intervention vs 11.43, user-friendly application can deliver simple and easy-to-read
SD 4.78 before the intervention, P=.001) [35]. health messages and facilitate communication between health
There is no significant difference in the mean total score of care providers and mothers. In future, the study period should
breastfeeding attitude between intervention and control groups extend to 6 months to examine the module's capability in
in this study. Our finding is consistent with a study in Jordan, attaining the exclusive breastfeeding goals. Furthermore, new
which found that despite an improvement in respondents'

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strategies in health education need to improve breastfeeding attitudes.
Acknowledgments
We would like to express our gratitude to the Director-General of Health Malaysia for authorizing the publication of this paper.
We would also like to thank the Hulu Langat District Health Office and all participating clinics, as well as the mothers who
participated in this study, for their excellent cooperation and support, especially during data collection.
Conflicts of Interest
None declared.
Multimedia Appendix 1
Social Cognitive Theory Constructs Used in SeBF Module.
[DOC File , 43 KB-Multimedia Appendix 1]
Multimedia Appendix 2
CONSORT eHEALTH Checklist (V1.6.2).
[PDF File (Adobe PDF File), 90 KB-Multimedia Appendix 2]
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Abbreviations
EBM: expressed breast milk
GLMM: generalized linear mixed model
SCT: social cognitive theory
SeBF: Self-Efficacy in Breastfeeding
Edited by L Buis; submitted 14.07.21; peer-reviewed by V Khanna; comments to author 27.01.22; revised version received 28.05.22;
accepted 29.06.22; published 14.09.22
Please cite as:
Mohamad Pilus F, Ahmad N, Mohd Zulkefli NA, Mohd Shukri NH
Effect of Face-to-Face and WhatsApp Communication of a Theory-Based Health Education Intervention on Breastfeeding Self-Efficacy
(SeBF Intervention): Cluster Randomized Controlled Field Trial
JMIR Mhealth Uhealth 2022;10(9):e31996
URL: https://mhealth.jmir.org/2022/9/e31996
doi: 10.2196/31996
PMID:
©Farahana Mohamad Pilus, Norliza Ahmad, Nor Afiah Mohd Zulkefli, Nurul Husna Mohd Shukri. Originally published in JMIR
mHealth and uHealth (https://mhealth.jmir.org), 14.09.2022. This is an open-access article distributed under the terms of the
Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution,
and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited.
The complete bibliographic information, a link to the original publication on https://mhealth.jmir.org/, as well as this copyright
and license information must be included.

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JMIR MHEALTH AND UHEALTH Mohamad Pilus et al

Effect of Face-to-Face and WhatsApp Communication of a

https://mhealth.jmir.org/2022/9/e31996 JMIR Mhealth Uhealth 2022 | vol. 10 | iss. 9 | e31996 | p. 1

(JMIR Mhealth Uhealth 2022;10(9):e31996) doi: 10.2196/31996

Recruitment and Inclusion Criteria

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Intervention Module method, duration of breastfeeding, expressed breast milk (EBM),

groups (P>.05). The household income in Malaysia was

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Table 1. Distribution of continuous and categorical variables at baseline (n=172).

19-24 24 (28) 18 (21)

B40 (<RM 4850) 62 (72) 58 (67)

F21,601=8.331, P<.001, respectively). However, there was no

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https://mhealth.jmir.org/2022/9/e31996 JMIR Mhealth Uhealth 2022 | vol. 10 | iss. 9 | e31996 | p. 7

self-efficacy for breastfeeding, their attitude ratings remained

https://mhealth.jmir.org/2022/9/e31996 JMIR Mhealth Uhealth 2022 | vol. 10 | iss. 9 | e31996 | p. 8

strategies in health education need to improve breastfeeding attitudes.

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