Mothers’ Facebook posts about infant health: findings from the Grow2Gether study

Study participants included the forty-three mothers from the intervention arm of the randomized controlled trial testing Grow2Gether, a peer-based Facebook group intervention aimed at promoting healthy growth in infancy. The forty-four mothers randomized to the Grow2Gether control group of text message appointment reminders were not included in the present study because they did not participate in the Facebook groups. Details of the Grow2Gether intervention have been previously described [20, 21]. Participating mothers were recruited to Grow2Gether at their obstetrics appointments between the 20th and 34th week of pregnancy. To be eligible, these mothers were: 1) receiving prenatal care from a Hospital of the University of Pennsylvania obstetrics practice; 2) age 18 years and older; 3) able to provide informed consent; 4) able to speak, read and write in English; 5) enrolled in Medicaid; 6) overweight or obese; 7) planning for their child to receive primary care services at Children’s Hospital of Philadelphia (CHOP); 9) in possession of a smartphone with both a data and text plan and 10) able to use their phone to obtain photographs and videos prior to enrollment. Any pregnant woman with a major comorbidity (medical or psychological) or pregnant with multiples was excluded.

At 2 months pre-partum, participants were placed into one of four different Facebook groups based on due date. As previously described [20, 21], the private Facebook groups were moderated by a psychologist who was an African American mother of young children. All groups included the same weekly video-based curriculum that was based on AAP Bright Futures guidelines and addressed four main topics: 1) infant feeding practices, 2) sleep, 3) positive parenting, and 4) maternal well-being. The weekly video-based curriculum was designed based on intervention development interviews with 29 mothers and focus groups with 30 pediatric providers. The mothers who participated in the intervention development interviews were recruited from the same geographic region and were socio-demographically similar to the mothers who ultimately participated in the intervention. The pediatric clinicians practiced at pediatric primary care centers that served this same population. The videos were approximately 3–5 min long and featured mothers and infants (many from the same community as the participants) discussing the curriculum content and modeling relevant behaviors [20]. The moderator posted the videos and a brief written summary of the video content, asked discussion questions, and encouraged participants to share experiences and ask questions about their infants. The moderator checked the group several times a day. In order to ensure nothing inappropriate or offensive was posted, the moderator had to approve all posts before they were posted to the group. Throughout the study period, there was only one post not approved as written. We do not have an accurate timestamp to calculate how long it took the moderator to respond to mother’s questions. However, as a rule, the moderator encouraged participants to answer each others questions before posting herself. Mothers were required to post in the group at least once in order to receive their first incentive payment. After the first post, it was suggested that they log in at least weekly to the Facebook group, but there were no additional requirements regarding how to use the group. At enrollment, all participants completed a sociodemographic survey. The Facebook intervention lasted for 11 months, beginning at 2 months pre-partum and continuing until 9 months post-partum. The study was approved by the Children’s Hospital of Philadelphia Institutional Review Board.

All posts, defined as a wall post, photo or comment, by mothers from 2 months pre-partum to 9 months post-partum were imported into QSR NVivo 10 software (QSR, Burlington, MA). For analysis of the questions that mothers posted about their infants’ health or development, two members of the research team (SK and RG) independently coded all posted questions and iteratively developed the coding scheme. All questions were coded by health topic (Table 2). For each topic, the most recent relevant AAP recommendation that was current during the study period of 2014–2015 was identified. This included AAP Clinical Practice Guidelines, AAP Policy Statements, AAP committee publications, or Bright Futures guidelines [22]. In the case of guidelines for oral teething gels, for which AAP News [23] references FDA guidelines but there is no specific AAP Policy Statement, the FDA warning [24] and the corresponding recommendations from the American Academy of Pediatric Dentistry were used [25]. Peer answers to questions were then coded for consistency with AAP recommendations. Posts by the moderator, including any responses to participant questions, were not coded and were not included in the analysis. Answers that were neither consistent nor in contradiction with AAP recommendations were coded as neutral while answers that directly contradicted or aligned with AAP recommendations were coded as such. All posts were also categorized by whether they were a comment on a moderator’s post, a comment on another participant’s post, or were a unique wall post. For all analyses, discrepancies in coding were discussed until a consensus was achieved.

Separately, to analyze whether mothers’ posts aligned with AAP recommendations, two independent coders (SK and RG) reviewed all other posts (posts that were not questions or responses to other participants’ questions) to determine if they demonstrated practices or beliefs inconsistent with AAP recommendations (Table 3). The recommendation-inconsistent practices were then further categorized by health/safety topic (e.g., sleep position, solid food introduction, walkers). For example, a photo posted of an infant sleeping in the prone position would be coded as a recommendation-inconsistent practice about sleep position since this practice is in contradiction with current AAP back to sleep recommendations [26].

A total of 43 mothers with an average age of 26 years participated in the Grow2Gether Facebook groups (Table 1). Reflecting the study’s focus on low-income mothers, 60% had an annual household income of less than $10,000, 26% were food insecure (as measured by a validated two-item food insecurity screener [27]), and 63% were high school graduates or had less education. Eighty-six percent of participants were Black and 67% had limited health literacy.

Mothers frequently asked questions in their groups. Specifically, mothers asked 61 questions focused on infant health and development (Table 2). Of the 61 health questions asked, 13 were comments to a post by the moderator, the remainder were either a comment on a post by another participant or were unprompted. The most frequent topics asked about were solid food introduction (8/61), teething (8/61), and breastfeeding (7/61). Overall, feeding (including breastfeeding, solid feeding, formula use) was by far the most frequently asked about topic, accounting for over one-third of mothers’ questions. For example, one mother posted, “is anyone else’s baby greedy...I feel like my son wants to eat every 30 minutes...Help Me.” Another mother asked the group, “I plan to breast feed but what is a good age to stop at?” On the topic of teething, one mother asked “question for the group. It’s about teething. Any recommendations on what to do. I tried teethers and I tried baby oragel and nothing seems to work. These last few nights she has been screaming and it hurts there is nothing I can do to make it stop.”

The vast majority of questions received at least one response and participants posted a total of 77 answers to each other’s questions. Over 90% of the answers were neutral (i.e. neither directly aligned with nor in contradiction with) AAP guidelines. For example, when one mother asked a question about teething, another replied “my baby is doing the same. I bought him a teething ring. He loves it and chews on it like it’s food.” No participant answers directly aligned with AAP guidelines. Six participant answers contradicted AAP guidelines and, of those, half (3/6) were on the topic of introducing solid foods. For example, when one mother asked for tips on getting her infant to eat solids, another mother replied “someone told me mix the baby food inside the bottle.”

Participants posted 73 instances of advice or images inconsistent with AAP and Bright Futures guidelines (Table 3) on a variety of topics. Of the 73 guideline inconsistent practices, 20 were comments to a post by the moderator; the remainder were either comments to a post by another participant or were unprompted. Unsafe sleep practices and screen time were the topics with the most recommendation-inconsistent posts. Fifty-three percent of the recommendation-inconsistent practices were related to unsafe sleep practices, with posts demonstrating co-sleeping, prone sleep positioning, or unsafe sleep environments. For example, one mother posted a photo depicting her infant sleeping prone while co-sleeping with her sibling.

Participants also commonly posted photos or descriptions of their infants enjoying screen time. One mother asked the group “is anybody else baby into TV? [My baby] loves Elmo!!!” Similarly, when asked about her daily routine with her baby, another mother posted “[my baby] sleeps thru the night and wakes up early morning like 7:30-8 for a change and a warm bottle and a Lil tv.”