Saudi Cultural Missions Theses & Dissertations
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Item Embargo Exploring Persuasive System Design Features and Users’ Perceptions of an mHealth Breastfeeding App: A Mixed-Method Study(University of Wollongong, 2024-03) Almohanna, Alaa Ali; Than Win, Khin; Meedya, Shahla; Vlahu-Gjorgievska, ElenaThe integration of persuasive technology in healthcare has gained considerable momentum through the proliferation of mobile health applications (mHealth apps). These apps become instrumental tools for providing tailored health support systems, facilitating informed decision-making, and promoting positive behaviours among users in increasingly persuasive ways. Among the various applications of mHealth apps, breastfeeding apps have emerged as invaluable resources for breastfeeding mothers. These apps can offer interactive information, tailored guidance, and support networks. Thus, incorporating persuasive features within these apps would further enhance their efficiency in promoting and supporting breastfeeding practices. The persuasive systems design (PSD) model represents a conceptual framework that informs persuasive technology design. The PSD model highlights four principles for persuasive system content and functionality and provides valuable insights into the key features that can be employed to design persuasive systems that are efficient and impactful. However, despite the prevalence of persuasive features in various mHealth apps, there is a limited understanding of how the intended users perceive these features. Research has primarily focused on the technical aspects of designing and implementing persuasive software features with limited empirical evidence on users' subjective experiences and perspectives regarding these features. This thesis comprises five studies, including quantitative and qualitative, that are thoroughly related and successively build upon each other to jointly achieve the central research aim: an in-depth exploration of user perceptions and experiences of persuasive design principles embedded in a mHealth app designed to support breastfeeding. Firstly, a systematic review was conducted to explore the characteristics of technology-based breastfeeding interventions and their effects on breastfeeding outcomes. Given the rising integration of technology with breastfeeding practices, it's crucial to examine these interventions' design features and impacts on breastfeeding outcomes. The study identified that the most effective features were educational content and personalised support via online forums. These aspects align with the PSD model's primary task support, dialogue support, social support, and credibility support principles. These results support the view that the Milky Way mHealth breastfeeding app would be a feasible tool to support and promote breastfeeding. Therefore, this research utilised the Milky Way app as a novel persuasive approach informed by the PSD model. The app incorporates various design features such as comprehensive information collection, interactive feedback, and social connectivity, all aimed at educating and supporting breastfeeding women. The PSD model comprises software features that have the potential to enhance the persuasive capabilities of mHealth apps; however, there is a limited understanding of how users perceive and experience these features. Recognising the importance of measuring users' perceptions of persuasion, the second study in this thesis aimed to develop and validate an instrument for measuring user perceptions of persuasive design principles in the Milky Way breastfeeding mHealth app. The instrument was designed following best practices and comprised 24 items. A Modified Delphi Study involved experts from academic and clinical backgrounds to assess the items' relevance and clarity. The instrument demonstrated high content validity (CVI), with most items scoring excellent (I-CVI ≥ 0.78), except one. The overall content validity index was moderate to high (S-CVI/Ave was 0.89 and 0.92 for relevance and clarity, respectively), confirming the instrument's validity, relevance, and clarity. In the third study of this thesis, a cross-sectional analysis was conducted on 168 women using convenience sampling to assess the instrument's validity and reliability. Statistical methods, such as Exploratory Factor Analysis (EFA), were employed to investigate the relationship between the PSD categories and app features. Construct validity was assessed with EFA, and reliability was measured using Cronbach's alpha. Results identified a four-factor solution with 23 items explaining 62.71% of the total variance. The instrument showed strong discriminant validity and high internal consistency (Cronbach's alpha α > 0.8). No statistically significant differences in participant responses based on demographic characteristics were found, which suggests that the instrument is applicable across diverse user groups. The study provided valuable insights into the multidimensional nature of the persuasive design principles within the instrument. The fourth study further explored the persuasive aspects of the Milky Way mHealth app's design, functionality, and usability based on 168 women's feedback via an online survey. Quantitative data showed significant positive perceptions of the app's persuasive design features (One-Sample t-Test, p < .001). A qualitative analysis of 288 responses indicated that the app is informative, credible, and supportive of breastfeeding. Additionally, practical design recommendations were suggested. The fifth and final study of this thesis was a qualitative follow-up study consisting of individual semi-structured interviews. These interviews were conducted to gain a comprehensive understanding by empirically exploring participants' experiences with the Milky Way mHealth app's persuasive features. Furthermore, the findings were analysed within the value-sensitive design (VSD) framework to align them with users' values and ethical considerations. Results highlighted the app's reliable educational content and supportive features, with tailored support and evidence- based advice being perceived as significant. A deductive analysis showed a strong alignment between user values and the app's design within the VSD framework. The research findings emphasise the significance of including evidence-based content, tailored support, and social connectivity as persuasive features in mHealth apps. These well-integrated PSD features greatly enhance user experience. The developed research instrument contributes to the advancement of research in the field of persuasive technology and its application in healthcare settings. It addresses a gap in understanding user perceptions of persuasive features. It provides a valuable instrument in establishing the foundation for future studies aiming to explore the persuasive capabilities of mHealth apps or similar technologies and their potential impact on promoting sustainable behaviour change. This research underscores the role of persuasive apps in health behaviour promotion. It also extends the empirical exploration of critical issues related to persuasive systems, specifically examining the consideration of ethical values in designing persuasive systems. The insights contribute to advancing persuasive technology and provide guidance for designing impactful, persuasive health technology aimed at promoting and supporting healthy behaviours. These findings have broader implications for the field of persuasive technology in providing valuable insights for designing useful and user-focused persuasive health technology. They inform researchers and practitioners in developing technologies that efficiently promote and support positive health behaviour change. In the broader context, the study contributes to advancing the understanding and application of persuasive design principles by highlighting the important role of user perceptions of software features in facilitating meaningful behaviour promotion and enhancing the overall user experience in healthcare contexts.39 0Item Restricted Facilitators and Barriers for Breastfeeding among Working Women in Saudi Arabia(University of Newcastle, Australia, 2024-07-23) Aldossary, Alanoud; Cummins, Allison; Prussing, ElysseBackground: Breastfeeding is an essential method of infant feeding that provides many health advantages for both the infant and the mother. Despite the World Health Organization (WHO) and United Nations Children's Fund espousing the benefits of breastfeeding for up to two years of age, returning to paid employment after the baby is born is one of the main reasons that women stop breastfeeding. There are barriers and facilitators for breastfeeding women who return to paid employment in many countries. However, there is scant information about the facilitators and barriers for breastfeeding women returning to work in Saudi Arabia. Furthermore, there is no information from the perspectives of the women, their co-workers and employers, and healthcare providers. Aims: This research explored the facilitators and barriers of breastfeeding as perceived by Saudi women in paid employment. To contextualise Saudi women’s experiences, current workplace policies related to breastfeeding and their operationalisation in the local workplace environment were examined. Also, the experiences of co-workers, line managers and employers have been sought to assess the position of workplace culture in supporting women to continue breastfeeding. Finally, the views of healthcare professionals who work with childbearing women were sought to increase understanding of the roles healthcare workers and healthcare services play in supporting women to initiate and continue breastfeeding after returning to paid employment. Methods: A mixed-methods design was conducted. The qualitative strand of this study explored the facilitators and barriers towards breastfeeding as perceived by women in paid employment, their co-workers, and line managers or employers. Data were collected by oneto-one interviews, transcribed and translated from Arabic to English. Thematic analysis was undertaken through the lens of the theory of planned behaviour to arrive at the themes and subthemes. The quantitative phase has two arms. Arm I examines the resources and spaces available in the workplace to support breastfeeding practices. The settings were in Dammam in the Eastern Province of Saudi Arabia and comprised two government sector locations: Imam Abdulrahman bin Faisal University (IAU) and Maternity and Children Hospital (MCH), and two private sector locations: Alfaisliyah School and Almana General Hospital. Data were collected via direct observation of current workplace policies, and current breastfeeding spaces and resources available to support breastfeeding women in their work environment. Arm II vi explores the role of nurses and midwives in supporting women to initiate and continue breastfeeding after returning to paid employment. A total of 123 nurses and midwives agreed to participate and complete the survey. Data were collected via the participants’ survey completions. Online surveys were conducted using SurveyMonkey and paper surveys were collected by the main researcher. Result: The study showed that immediate family members such as mothers, sisters and grandmothers are important social networks to support breastfeeding women after return to paid employment, and that the woman’s husband plays a critical role in the woman’s continuation of breastfeeding. In addition, healthcare professionals (nurses and midwives) were sources of information for women. However, the perception of breastfeeding support was influenced by aspects such as the knowledge and skills of the healthcare professionals (nurses and midwives). This study showed that workplaces are lacking facilities, such as private rooms with a clean sink and refrigerators, to allow breastfeeding women to express breast milk and to store the milk. In addition, this study found that the 70 days of maternity leave was not enough to achieve the goal of breastfeeding and the WHO recommendation of exclusive breastfeeding for six months. Finally, the findings from this study showed the challenges facing breastfeeding women after return to paid employment due to the fact that the private and government sectors might not have sufficient resources to accommodate the needs of breastfeeding women after return to paid employment. Significance of research: The findings from this research have the potential to increase knowledge regarding the factors that facilitate or hinder Saudi women’s decision to initiate breastfeeding and to continue breastfeeding on return to paid employment. Additionally, understanding of Saudi healthcare workers’ current skills and knowledge base related to breastfeeding may be increased. It is conceivable, therefore, that results from this research can support the development of policies and practices that will facilitate breastfeeding initiation and duration rates among Saudi working women.54 0Item Restricted An acute dietary intervention in lactation has variable impacts on the maternal and infant microbiota and milk antimicrobial proteins(The University of Western Australia, 2025-01-01) Sindi, Azhar; Payne, Matthew; Geddes, Donna; Stinson, LisaThe first years of life are a critical period for microbial colonisation of the infant gut, which has been linked with health and disease outcomes in later life. Breastfeeding has been shown to have a significant impact on both composition and function of the infant gut microbiome. This is due to vertical transmission of microbes and exposure to other non-microbial factors, such as antimicrobial proteins, in human milk (HM). Given the importance of HM and the infant gut microbiome for lifelong health, this thesis investigated factors that influence HM composition (both microbial and non-microbial), with a focus on maternal diet as a modifiable determinant. Further, by utilising an acute maternal dietary intervention during lactation, the significance of maternal diet for infant gut composition and function was explored. While many studies have assessed the determinants of the HM microbiota, this has not been investigated in an Australian population. To address this gap, we first collected HM samples from a small cohort (n=29) of Australian mothers to characterise HM bacterial profiles. We investigated potential associations between HM bacterial composition and maternal factors, such as body mass index (BMI), mode of delivery, breast pump use, allergy, and parity, and infant factors, such as sex, mode of feeding, pacifier use, and introduction of solids. Our findings confirmed previous reports that maternal BMI, mode of delivery, and breast pump use are associated with HM bacterial profiles. Additionally, we found that infant pacifier use was associated with an altered HM microbiome, the first report of such a finding. With a more complete picture of the HM microbiome in Australian women and its key determinants, we next sought to focus on maternal diet and its impact on the maternal and infant microbiota, as diet is the single biggest modifiable determinant of the human microbiome. Previous observational studies have linked maternal diet with the HM microbiota. Such studies have also associated maternal diet during pregnancy with the infant gut microbiota. However, the impact of diet during lactation on the maternal and infant microbiota has not been examined. To address this gap, we performed an interventional study, in which exclusively breastfeeding mothers (n=11) were placed on a low-sugar, low-fat, high-fibre diet for two weeks. We analysed maternal faecal and HM samples collected immediately before, immediately after, and 4-8 weeks after the intervention. Full-length 16S rRNA gene sequencing was used for high-resolution bacterial profiling. Additionally, infant faecal samples were collected for shotgun metagenomic sequencing immediately pre- and postintervention to examine the effect of maternal diet on both composition and function of the infant gut microbiome. The intervention had no significant impact on infant gut microbiome composition; however, it was associated with significant changes in the functional capacity of the infant gut microbiome. The intervention also elicited small changes in a low number of bacterial taxa in both the maternal faecal and HM microbiota, some of which persisted 4-8 weeks post-intervention. Given that the dietary intervention shifted the function, but not the composition, of the infant gut microbiome, we next investigated whether the diet modulated other biologically relevant components in HM, namely the antimicrobial proteins lysozyme and lactoferrin. However, given that little is known about daily, circadian, and between-breast variations in the concentrations of lysozyme and lactoferrin, the stability of these proteins in mature HM needed to first be established. HM samples were collected from 18 mothers who undertook our acute dietary intervention across a 3-week period; daily, three times a day, and from both breasts. Both lactoferrin and lysozyme showed small, but statistically significant, variability over time, with significant day-to-day and circadian differences; however, no significant variation was detected between breasts. These findings underscore the need to standardise sample collection time, or to collect samples at multiple time points throughout the day, in order to obtain reliable estimation of HM lysozyme/lactoferrin content. The concentration of HM lysozyme was reduced during the first week of the dietary intervention, while HM lactoferrin levels were lower in the second week of the intervention. Thus, maternal diet may impact HM antimicrobial protein concentrations. We hypothesise that this may be due to dietary effects on maternal systemic inflammation. Together, these data demonstrate the importance of maternal factors, including BMI and maternal diet and infant feeding practices, including breast pump and pacifier use, as potential modifiers of HM microbial composition. In addition, a controlled maternal dietary intervention elicited small but significant changes to the maternal faecal and HM microbiota, and to HM antimicrobial proteins. While these changes were associated with significant alterations to the functional potential of the infant gut microbiome, they did not affect its composition. The data presented in this thesis therefore highlight potential limitations of maternal diet as a target to improve infant health via manipulation of the microbiome.17 0Item Restricted Bridging the gap between mother’s needs to breastfeed and institutional policies: A mixed methods study exploring factors influencing breastfeeding.(University of Sheffield, 2024-01-29) Alasmari, Sarah; Barnes, SarahPrevious studies on factors influencing breastfeeding practices in the Arab Gulf countries, including the Kingdom of Saudi Arabia, have mostly provided quantitative findings that mainly assessed mother-related factors, such as their knowledge, attitudes, and practices, in addition to demographics. This highlighted the need for in-depth exploration of barriers to breastfeeding in the Kingdom of Saudi Arabia beyond the mothers themselves, such as those created by institutional and socio-cultural factors. Methods This research adopted a mixed methods approach and a socio-ecological framework specifically adapted for the Saudi context. The research consisted of three parts, the first of which was a systematic review of breastfeeding practices and associated factors in the Arab Gulf region. The second was a cross-sectional study involving primary data collection among healthcare professionals to identify their awareness, knowledge, and views on the Baby-Friendly Hospital Initiative (BFHI). The third and final study utilised semi-structured interviews among Saudi mothers in Riyadh city to explore barriers to breastfeeding practices, and to understand the mothers’ needs for support in relation to breastfeeding. Data were analysed thematically before findings from the quantitative and qualitative studies were integrated using the socio-ecological framework. Results The systematic review identified a broad range of factors that influenced breastfeeding practices. These were categorised according to the socio-ecological framework. In the quantitative study, healthcare professionals (n=109) participated in the survey, with approximately 50% aware of the policies favourable to breastfeeding in their workplaces. Knowledge regarding the Ten Steps to Successful Breastfeeding (TSSBF) was assessed using a questionnaire based on the literature review, the hospital self-appraisal and monitoring tool (World Health Organization, 2009) and the implementation guide to the revised Baby-Friendly Hospital Initiative (WHO, 2018). The majority of participants (71%) were knowledgeable about TSSBF. 98% of participants held positive views about BFHI and agreed that it increased breastfeeding rates; 85% found that the initiative was time-consuming; 93% agreed that there was no access to ongoing lactation and breastfeeding support; and 73% of participants expressed positive attitudes towards infant breastfeeding. In the qualitative study, two main themes emerged: firstly, barriers to breastfeeding; and secondly, mothers’ needs for breastfeeding support. Barriers to breastfeeding included lack of knowledge and practical demonstrations before and after birth, physical problems such as C-section delivery and sore nipples, as well as lack of privacy, family size and employed status. Family and socio-cultural barriers identified as potentially important influences on breastfeeding practices among Saudi mothers were: inadequate family support, conflicting views and advice about BF, criticism of the BF mother, and visitors from social networks, in addition to the cultural norms of beauty and taboo topics of women’s reproductive health. Barriers within the health system concerned inadequate information before the birth, and help with BF before discharge from hospital, and postnatally. Other barriers were the availability of formula milk and healthcare professionals’ insensitivity to mothers’ needs. The findings indicated that action was needed in different layers of the socio-ecological framework to broaden awareness of the importance of breastfeeding and provide society-wide support for breastfeeding. Furthermore, healthcare professionals need to be able to implement the TSSBF in full, including immediate and uninterrupted skin-to-skin contact and support for mothers to with initiation of BF as soon as possible after birth, and rooming-in. Conclusion This study which provides insights into a variety of barriers that influence breastfeeding practices among Saudi women. Even though participants held positive views about breastfeeding, a considerable number felt disincentivised to breastfeed their infants. This phenomenon was shaped in a large part by the social nexus formed by mothers’ husbands, family members and social networks, healthcare professionals, hospital practices, and policies, which together influenced mothers’ decisions and capabilities to breastfeed. The study has highlighted the important role that hospitals can play in ensuring that mothers receive correct and thorough education on breastfeeding, as well as adequate practical support from appropriately trained healthcare professionals. Overall, this research project contributes to the existing body of breastfeeding literature by providing new insights into the potential influence of traditional cultural customs in Saudi Arabia and highlighting that implementation of the BFHI may require a range of additional actions depending on the country context and culture.29 0