Effectiveness of Web-based Educational Intervention on Breastfeeding Self-efficacy and Breastfeeding Outcomes

Study Design A randomized controlled trial design, two-arm, with a 1:1 allocation ratio, will be conducted. The participants will be allocated in the intervention group or control group using block randomization with a block size of 4. The statistician, who will not join in the recruitment process, will generate the sequence of random allocation. To maintain the allocation concealment, we will use opaque sealed envelopes that contain the sequence numbers. Due to the nature of the study, it is difficult to blind the participants. Only the data collector will be blinded to the participant's group assignment.

Participants and setting The mother and her spouse will be invited to participate in this study during the prenatal period from a public hospital and health care center in Jakarta. The inclusion criteria of mothers are: (a) primiparous and singleton pregnancy at 12-34 weeks' gestation, (b) age ≥ 20 years, (c) tend to breastfeed the infant, (d) the husband willing to participate in the educational program, (e) capable to use a cell phone, (f) can access the internet, (g) fluent in reading and writing Bahasa. We will not include the mothers and their partners in the study if they have no time to join in the online educational intervention. Mothers will be excluded if they have conditions as follows: (a) presence of congenital anomaly for the baby, (b) chronic disease or high-risk complications during pregnancy and after delivery. To recruit suitable participants, we will approach the eligible mothers and fathers using online recruitment via whatsapp from the patient list during antenatal check-up and flyer at the hospital and health center. All participants will be provided online informed consent.

Sample size calculation The sample size will be estimated based on a previous study of breastfeeding self-efficacy intervention (Ansari, Abedi, Hasanpoor, & Bani, 2014). A two-sided two-sample unequal variance t-test is needed (Julious, 2004) to detect a medium effect size in self-efficacy between intervention and control group (Ansari, Abedi, Hasanpoor, & Bani, 2014) using 80% power at a 5% significance level (alpha). Considering the drop-outs rate and pandemic situation in Indonesia, we will recruit 160 pairs of participants (200 pairs of mothers and fathers for each group) in this study.

Intervention The intervention program will be pilot tested before the formal study. The content validity of the intervention will be conducted by the breastfeeding expert panel including one obstetric specialist, two lactation consultants, one educator and one pediatrician (Appendix 7). The participants in the intervention group will receive standard usual care in primary health care and the web-based educational intervention. The development of the educational intervention is based on the Breastfeeding Self-Efficacy Theory (BSE) (Dennis, 1999) The strategies will be developed from the four sources of breastfeeding self-efficacy framework (Dennis, 1999) including (a) performance accomplishment (past breastfeeding experience); (b) vicarious experience for example observation of others individual performance, whether live, recorded, or printed) (Dennis, 1999; Kingston et.al., 2007); (c) verbal persuasion (i.e. encouragement from a lactation consultant); (d) physiological and emotional arousal (i.e. reducing negative interpretation like pain, fatigue, anxiety or stress). The educational program will be consisted of six sessions which cover 4 elements of breastfeeding self-efficacy theory.

To support the educational program, the researchers will discuss with the expert of information system to prepare the website. The website will be created by using hosting and domain services. Each session of education program will be delivered by written information and video. Additionally, massage board for each session will be provided to allow mothers to ask the question regarding the topic. The website will be designed to be compatible with mobile phone, computer, and also tablets. After the expert approve the applicability of the website, the pilot study will be conducted with 10 mothers and fathers.