Exclusive breastfeeding (EBF), the practice of a baby receiving only breast milk, no other foods or liquids, significantly decreases mortality and morbidity in children less than five years of age, resulting in improved child survival and health [1, 2]. Exclusive breastfeeding can reduce infant mortality by preventing diarrhea and acute respiratory infections [3]. Increasing the rate of EBF in the first six months of life to at least 50 % is one of the six World Health Organization (WHO) global nutrition targets for 2025 [4].

Global rates of optimal breastfeeding practices, especially EBF, have remained stagnant over the past two decades in India and other low-and middle-income countries (LMICs), with only one in three infants under six months being exclusively breastfed [3]. The most recent India National Family Health Survey found that for the first six months of life, 56.4 % of infants in Karnataka, India were exclusively breastfed [5]. Achieving EBF requires a multi-pronged approach that involves both healthcare providers and policymakers, along with community participation and support [6, 7].

One strategy for increasing EBF is the use of community-based programs that use peer counselors (PCs) to educate and support mothers. Such programs have shown to be effective in increasing the initiation and duration of breastfeeding in diverse populations and settings, including LMICs. Successful PC programs have been shown to address a myriad of health-related problems, including HIV prevention, immunizations, alcohol use, and depression in several LMICs [8,9,10,11,12,13,14,15,16,17,18]. Effective training of PCs is a crucial prerequisite for the success of such programs.

Mobile health (mHealth) applications (apps) use mobile devices such as smartphones or handheld mobile tablets to enhance teaching, collaboration, and provision of medical care [19]. Such mHealth apps are increasingly popular to reach rural populations in LMICs with strong internet access capability [20,21,22], and is commonly available in India, mHealth-based programs have the potential to provide scalable public health interventions [23].

There is evidence that mHealth-supported community programs can improve the behaviors of Indian mothers, including the uptake of health services among pregnant and breastfeeding women with HIV [24]. A recent meta-analysis of studies conducted in six countries suggested that mHealth may be associated with improved maternal breastfeeding attitude, knowledge, initiation, and EBF duration [25]. Two additional reviews found evidence of positive results on EBF and other neonatal and maternal outcomes but stressed the need for both strong research methods and personalized contact [26]. It remains unknown, though, whether utilizing mHealth platforms to enhance PC efforts is effective at improving the infant feeding behaviors of mothers in India.

As part of a funded research project, BEST4Baby, we adapted the WHO’s breastfeeding curriculum to the local culture and trained rural mothers with prior breastfeeding experiences to serve as breastfeeding peer counselors. The training prepared them to counsel and support antepartum and postpartum mothers around the topic of EBF and infant feeding. To maximize the utility of the PCs, we designed the delivery of training content via a mHealth app on a Samsung Android tablet. The present article describes our curriculum in the state of Karnataka, India for supporting new mothers to exclusively breastfeed and documents pre-post changes of the peer counselors training curriculum.

Development of the training curriculum

Using the results of qualitative research that we conducted through focus group discussions, we adapted the World Health Organization’s breastfeeding counseling course, and Haider and colleagues’ breastfeeding PCs training module to the cultural setting of the southern Karnataka state in the Kannada language [8, 27, 28]. Local breastfeeding practices, misconception and dangers of the use of top feeding were incorporated into the curriculum since the results of our formative research described mixed practices about prelacteal and supplemental feeding, reflecting older, traditional views. Names and figures in the module were based on how women looked and spoke in local communities. From the formative research, the involvement of the mother-in-law was added, as well as specifics about cultural practices such as the use of tim tim (herbal drops) and guti (locally made gruel mixtures). Research staff were experienced in the content area and are designated as national breastfeeding trainers in India; additional guidance was sought from twelve nursing and obstetric experts to develop the curriculum.

Training curriculum

A three-day PC training was conducted in the local language at the academic health center. Two days were dedicated to breastfeeding education, skills building, and the use of Best4Baby kit, such as a doll for positioning. The last day was dedicated to a half-day on the use of the mHealth app, with the remaining time for protocol training and skills assessment. Pedagogy across the three days included interactive lectures, demonstrations, brainstorming sessions, case-based learning, role-playing, and continued positive feedback to enhance self-efficacy specific to breastfeeding teaching and support.

Training materials included a branded kit with the following contents to support in-home breastfeeding counseling sessions with new mothers:

Life-size newborn doll to demonstrate positioning;

A skin-colored sock to prepare a breast model for demonstrating proper latching;

A digital scale for weighing and assessing the growth of the infant;

A nipple plunger to mitigate the problem of an inverted nipple;

A Samsung Android tablet with the BEST4Baby app pre-loaded with wireless service and secured to allow for its sole use with the app.

Training content covered three key components: breastfeeding knowledge, counseling and communication skills, the use of the BEST4Baby app, and familiarity with overall PC responsibilities for each of the nine visits in the protocol for expectant or new mothers. Each session’s learning objectives, learning strategies, and evaluation process were predefined. The curriculum was designed to educate PCs for delivering timely information related to the mother’s stage of gestation (e.g., antepartum at 28 -32 weeks and 32-36 weeks) and the infant’s age (e.g., postpartum at 1-3 days, 15 days, 1 month, 2, 4 and 6 months) during nine home visits to provide support to the first-time mothers to practice exclusive breastfeeding. Tables 1 and 2 provide specific information about the curriculum content.

Table 1 Peer counsellor training contentTable 2 Peer counselor training curriculum

The BEST4Baby app was designed to reinforce training by allowing PCs to use the device during and after the training sessions and in the field. A complete description of app content with screenshots is described in the work by Ma and colleagues [29]. The app's design included a step-by-step guide for each visit to cover relevant topics for that visit. Educational videos for the PCs to share with the mothers in the app included content on early initiation of breastfeeding, breastfeeding techniques, breastfeeding position and attachment, expression of breast milk, and myths of breastfeeding, The PCs were given the opportunity to use the app, including the process of logging in, scheduling visits, and practicing each visit. Time was allotted to practice the content of the training modules incorporated in the app.