CHAPTER ONE

1.0 INTRODUCTION

1.1 BACKGROUND OF THE STUDY

Exclusive breastfeeding (EBF) — defined as feeding an infant only breast milk for the first six

months of life without any additional food or liquid, including water (World Health Organization

[WHO], 2020) — remains one of the most effective interventions for ensuring child survival and

healthy growth. Globally, the promotion of exclusive breastfeeding has been recognized as a

cornerstone of maternal and child health. The WHO and the United Nations Children’s Fund

(UNICEF) jointly recommend that all infants be exclusively breastfed for the first six months of

life, after which nutritionally adequate complementary foods should be introduced while

continuing breastfeeding up to two years of age or beyond (WHO, 2022; UNICEF, 2021).

Despite these clear benefits, EBF rates remain suboptimal, particularly in low- and middle-

income countries (LMICs), where social, economic, and environmental constraints limit

mothers’ ability to exclusively breastfeed their infants. In Nigeria, breastfeeding is a common

practice, but exclusive breastfeeding remains far below the recommended level. According to the

Nigeria Demographic and Health Survey (NDHS, 2018), only about 29% of infants below six

months were exclusively breastfed. This statistic reflects a considerable gap between knowledge

and practice. Several factors contribute to the low rate of EBF, including cultural norms,

inadequate maternal knowledge, poor counseling from healthcare providers, the influence of

aggressive marketing of breast milk substitutes, and lack of community and workplace support

for breastfeeding mothers (Akinyemi and Owoaje, 2020; Ogbo et al., 2017). In underserved

communities like Nyanya, a densely populated suburban area in the Federal Capital Territory

(FCT), Abuja, these challenges are even more pronounced due to poverty, limited access to
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healthcare services, and insufficient maternal education (Ezeh et al., 2020). The emergence of

mobile health (mHealth) technologies provides an innovative approach to addressing these

challenges. mHealth, as defined by the Global Observatory for eHealth (WHO, 2011), refers to

medical and public health practices supported by mobile devices such as mobile phones, tablets,

and other wireless technologies. In maternal and child health, mHealth interventions have been

used to improve antenatal care attendance, vaccination coverage, and medication adherence

through reminders, education, and behavior change communication (Lee et al., 2021). The

growing mobile phone penetration in Nigeria, with over 100 million active subscribers (GSMA,

2021), creates an opportunity to reach mothers directly with evidence-based breastfeeding

information, counseling, and reminders at minimal cost.

Sustainable models of mHealth interventions integrate digital technology with existing

community and health system structures to ensure continuity and scalability. Such models often

include peer support groups, text messaging, interactive voice response (IVR) systems, and

social media platforms that deliver tailored health messages to mothers and caregivers (Chib et

al., 2015). These models not only facilitate knowledge transfer but also foster social support

networks that reinforce positive breastfeeding behaviors. In underserved communities, where

health workers are scarce, mHealth-supported interventions can bridge the communication gap

between mothers and health professionals, thereby enhancing access to timely information and

emotional encouragement (Okafor et al., 2018).

Nyanya, a peri-urban settlement in Abuja, represents a typical underserved community

characterized by a mixture of low-income families, migrant populations, and limited access to

health infrastructure. Despite national breastfeeding campaigns and awareness programs,

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mothers in Nyanya still face barriers related to misinformation, cultural myths, and limited

maternal leave policies that discourage EBF. The increasing availability of mobile phones among

women in this area presents a unique opportunity to test the effectiveness of mHealth-supported

interventions as a sustainable strategy for promoting exclusive breastfeeding practices (NPC and

ICF, 2019). Empirical evidence from other developing countries suggests that mHealth

interventions can significantly improve breastfeeding knowledge, attitude, and practices. For

instance, a study conducted in Kenya demonstrated that SMS reminders and voice calls from

trained peer counselors led to a notable increase in EBF rates among rural mothers (Lund et al.,

2014). Similarly, in India, mobile-based counseling during postnatal care was associated with a

reduction in early cessation of breastfeeding (Sinha et al., 2020). However, in Nigeria, while

mHealth has been increasingly used in maternal health and immunization programs, limited

studies have explored its application in promoting EBF, particularly in marginalized urban

communities such as Nyanya (Akinyemi and Owoaje, 2020).This study, therefore, seeks to assess

the effectiveness of mHealth-supported sustainable models for promoting exclusive

breastfeeding practices among mothers in underserved communities in Nyanya, Abuja. The

study aligns with global and national health priorities, including the Sustainable Development

Goals (SDGs) — particularly SDG 3, which aims to ensure healthy lives and promote well-being

for all at all ages (United Nations Development Programme [UNDP], 2020). By exploring how

mHealth interventions can be integrated into community health systems, this research will

contribute to evidence-based strategies for improving maternal and child health outcomes in low-

resource settings.

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1.2 STATEMENT OF THE PROBLEM

Exclusive breastfeeding (EBF) is globally recognized as one of the most effective interventions
for improving child survival and maternal health (World Health Organization [WHO], 2022). It
has been estimated that if all infants were exclusively breastfed for the first six months of life,
approximately 820,000 infant deaths could be prevented each year (UNICEF, 2021). Breast milk
provides all the necessary nutrients, antibodies, and hormones essential for optimal infant growth
and immunity. It also reduces the risk of diarrheal diseases, respiratory infections, and
undernutrition—conditions that remain major contributors to infant mortality in sub-Saharan
Africa (Ogbo, et al, 2017). Despite this evidence, exclusive breastfeeding rates remain
unacceptably low in many developing countries, including Nigeria. According to the Nigeria
Demographic and Health Survey (NDHS, 2018), only 29% of infants under six months are
exclusively breastfed, far below the global target of at least 50% by 2025 set by the World
Health Assembly (WHO, 2022). This low rate reflects persistent barriers to effective
breastfeeding promotion and support. In Nigeria, these challenges include inadequate maternal
education, sociocultural beliefs that discourage breastfeeding, the influence of infant formula
marketing, poor counseling from healthcare providers, and insufficient family and community
support (Akinyemi & Owoaje, 2020; Ezeh et al., 2020). Furthermore, urbanization and changing
lifestyles have made it increasingly difficult for mothers, particularly those in informal
employment or low-income households, to adhere to EBF practices. The situation in Nyanya, a
peri-urban settlement in the Federal Capital Territory (FCT), Abuja, mirrors this national trend
but presents unique contextual challenges. Nyanya is characterized by a high population density,
poor sanitation, low literacy levels, and limited access to healthcare facilities (National
Population Commission [NPC] & ICF, 2019). Most residents live in informal housing, and many
women engage in petty trading, domestic labor, or other forms of informal employment that offer
little flexibility for breastfeeding. These socioeconomic constraints often force mothers to
introduce water, herbal mixtures, or artificial milk early, believing it helps relieve hunger or

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thirst in infants. Cultural myths also play a significant role; for instance, some mothers believe
colostrum is “dirty” or that infants need water in Nigeria’s hot climate (Okafor, Olatunji, and
Ogbonna, 2018). Efforts by the Nigerian government and international organizations, such as the
Baby-Friendly Hospital Initiative (BFHI) and national breastfeeding campaigns, have
contributed to improved awareness but not necessarily sustained behavioral change (UNICEF,
2021). The traditional facility-based model of health education is limited in reach, especially
among women in underserved areas who rarely attend antenatal or postnatal clinics. Moreover,
the COVID-19 pandemic further disrupted maternal and child health services, making it even
harder to provide in-person breastfeeding counseling (GSMA, 2021). This underscores the
urgent need for alternative, scalable, and sustainable communication strategies that can deliver
consistent and context-appropriate health messages directly to mothers in their homes and
communities.

In this context, mobile health (mHealth) offers a promising solution. The increasing
accessibility of mobile phones across Nigeria has opened new avenues for health
communication. Recent statistics show that over 90% of Nigerian households own at least one
mobile device, and mobile internet coverage is expanding rapidly even in peri-urban and rural
settings (GSMA, 2021). Through SMS, voice calls, WhatsApp messages, and interactive voice
response (IVR) systems, mHealth programs can deliver real-time information, reminders, and
emotional support to mothers. Evidence from similar interventions in Kenya, India, and
Bangladesh has demonstrated that mHealth can improve maternal knowledge, healthcare
utilization, and infant feeding practices (Lund et al., 2014; Sinha et al., 2020). Despite these
promising findings, there is limited empirical evidence on the effectiveness of mHealth-
supported sustainable models in promoting EBF within Nigerian communities, particularly
underserved ones like Nyanya. Most existing digital health initiatives in Nigeria have focused on
maternal mortality reduction, family planning, or immunization, while breastfeeding promotion
through mHealth remains underexplored (Akinyemi and Owoaje, 2020). Furthermore, many pilot
programs have failed to integrate sustainability mechanisms—such as community engagement,
peer support systems, and alignment with local health policies—necessary for long-term impact.
Without sustainability, mHealth programs risk being short-lived and ineffective once donor
funding or external technical support ends. Another critical problem is the digital divide. While

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mobile phone ownership is widespread, disparities persist in phone literacy, access to reliable
networks, and affordability of data or airtime, particularly among low-income women.
Consequently, even when mHealth tools are available, not all mothers can effectively use them.
In addition, there is a lack of research examining how local cultural values, language
preferences, and gender norms influence the adoption and effectiveness of mHealth interventions
for breastfeeding. Understanding these contextual factors is vital for designing interventions that
are both user-friendly and culturally acceptable. Given these gaps, there is a pressing need to
investigate whether mHealth-supported models—designed to include elements such as
community peer groups, local language messaging, and integration with healthcare providers—
can significantly improve exclusive breastfeeding rates in underserved communities. The
Nyanya context offers an ideal setting for this research due to its blend of urban and rural
characteristics, socio-economic diversity, and accessibility to both health centers and mobile
networks. This study therefore seeks to fill a crucial gap in knowledge by evaluating the
effectiveness of mHealth-supported sustainable models in promoting exclusive breastfeeding
among mothers in Nyanya, Abuja. The findings will provide valuable insights into the practical
feasibility, usability, and impact of such digital health strategies in similar low-resource
environments across Nigeria and sub-Saharan Africa. It will also inform policymakers and health
planners on how to design culturally sensitive, scalable, and sustainable mHealth interventions
that can complement traditional health education programs and contribute to achieving national
and global breastfeeding targets.

1.3 AIM AND OBJECTIVES OF THE STUDY

AIM OF THE STUDY

The main aim of this study is to assess the effectiveness of mHealth-supported sustainable

models in promoting exclusive breastfeeding practices among mothers in underserved

communities in Nyanya, Abuja. This study intends to determine whether integrating mobile

health tools with community-based approaches can improve breastfeeding knowledge, attitudes,

and practices, thereby contributing to better maternal and child health outcomes.

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Specific Objectives

To achieve the stated aim, the study will pursue the following specific objectives:

1. To assess the level of community engagement and peer support in sustaining exclusive

breastfeeding practices among mothers in underserved communities in Nyanya, Abuja.

This objective focuses on understanding the role of social structures, local women’s

networks, and community health workers in reinforcing breastfeeding behavior and

providing emotional and informational support to mothers.

2. To evaluate the effectiveness of mHealth-supported sustainable models for promoting

exclusive breastfeeding before and after the intervention.

3. This involves measuring changes in mothers’ breastfeeding knowledge, attitudes, and

practices following exposure to mobile-based interventions such as text messages, WhatsApp

counseling, and interactive voice responses. It will help to determine whether mHealth

interventions result in measurable improvements in EBF rates compared to pre-intervention

baselines.

4. To identify the usability and accessibility of mHealth tools among mothers in Nyanya.

Since the success of digital health initiatives depends largely on the ability of end-users to

access and use mobile technologies, this objective will examine the extent to which mothers

can interact effectively with the mHealth platforms provided—considering factors such as

phone ownership, literacy level, language preference, and digital skills.

5. To identify the challenges and facilitators in implementing mHealth-supported

sustainable models for promoting exclusive breastfeeding practices.

Understanding the barriers and enabling factors is crucial for scaling up the intervention. This

objective will explore technological, socio-cultural, and infrastructural factors that influence

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 the acceptance and sustainability of mHealth interventions within low-resource settings like

Nyanya.

1.3.1 RATIONALE FOR THE OBJECTIVES

Each of these objectives has been carefully designed to provide a comprehensive understanding

of how mHealth technologies can contribute to improving exclusive breastfeeding rates in

underserved Nigerian communities. The first objective examines the social dimension—

community engagement and peer support—since social influence plays a vital role in sustaining

health behaviors (Akinyemi & Owoaje, 2020). The second objective evaluates the measurable

outcomes of the intervention, providing empirical evidence for policy and program decisions.

The third objective ensures that issues of access and usability are addressed, particularly in

communities where technological literacy and affordability may be constraints. Lastly, the fourth

objective provides insights into practical implementation lessons and sustainability factors,

which are essential for replicating the model in other similar communities across Nigeria and

sub-Saharan Africa. Together, these objectives align with the global agenda for Sustainable

Development Goal 3 (SDG 3), which seeks to ensure healthy lives and promote well-being for

all at all ages (United Nations Development Programme [UNDP], 2020). By leveraging mobile

technology for maternal and child health improvement, this study contributes to national efforts

toward achieving universal health coverage and digital transformation in health systems

1.4 Research Questions

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In line with the aim and objectives of this study, the following research questions have been

formulated to guide the investigation. These questions are designed to elicit empirical data and

provide a clear pathway for analyzing the role and effectiveness of mHealth-supported

sustainable models in promoting exclusive breastfeeding practices in underserved communities.

1. To what extent does community engagement and peer support influence the

sustainability of exclusive breastfeeding practices among mothers in underserved

communities in Nyanya, Abuja?

This question seeks to explore the social and behavioral dynamics that encourage or hinder

continued adherence to exclusive breastfeeding. It examines how peer support groups, family

members, and community health workers influence mothers’ decisions regarding infant

feeding.

2. What is the level of effectiveness of mHealth-supported sustainable models in

promoting exclusive breastfeeding practices before and after the intervention?

This question aims to measure the changes in knowledge, attitude, and practice (KAP) of

mothers following exposure to mHealth interventions. It focuses on determining whether

mobile-based education and support can lead to measurable improvements in breastfeeding

outcomes.

3. How accessible and usable are mHealth tools among mothers in underserved

communities in Nyanya, Abuja?

Accessibility and usability are essential for determining the success of any digital health

intervention. This question assesses mothers’ ability to use mobile phones, interact with

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 health messages, and understand digital content in relation to their literacy level, language

preference, and socioeconomic status.

4. What are the major challenges and facilitators affecting the implementation of

mHealth-supported sustainable models for promoting exclusive breastfeeding?

This question identifies the contextual factors—such as network coverage, cost of airtime,

cultural beliefs, and digital literacy—that may impact the feasibility and long-term

sustainability of mobile-based breastfeeding promotion programs.

5. In what ways can mHealth interventions be integrated with existing maternal and child

health programs to improve exclusive breastfeeding practices in underserved Nigerian

communities?

This final question aims to provide practical insights for health policymakers and program

implementers on how mobile technology can complement traditional health promotion

systems for greater impact.

Purpose of the Research Questions

The formulation of these research questions is intended to guide both the quantitative and

qualitative aspects of the study. Quantitative data will help determine measurable effects of

mHealth interventions—such as changes in exclusive breastfeeding rates—while qualitative data

will provide contextual insights into mothers’ experiences, perceptions, and challenges.

Together, these questions will allow for a holistic evaluation of mHealth as a sustainable and

culturally adaptable tool for improving maternal and child health outcomes in underserved

communities like Nyanya.

1.5 RESEARCH HYPOTHESES

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In line with the objectives and research questions of this study, the following hypotheses have

been formulated to guide the quantitative aspect of the investigation. These hypotheses are

designed to test the relationships between mHealth-supported sustainable models and exclusive

breastfeeding practices in underserved communities in Nyanya, Abuja.

1.6.1 HYPOTHESIS ONE

 Null Hypothesis (H₀₁): There is no significant relationship between community engagement

and peer support and the sustainability of exclusive breastfeeding practices among mothers in

underserved communities in Nyanya, Abuja.

 Alternative Hypothesis (H₁₁): There is a significant relationship between community

engagement and peer support and the sustainability of exclusive breastfeeding practices

among mothers in underserved communities in Nyanya, Abuja.

This hypothesis aims to test whether social and peer interactions contribute meaningfully to
sustaining exclusive breastfeeding practices when supported through mHealth interventions. It
evaluates the social cohesion and community support elements that may enhance behavioral
change.

1.6.2 Hypothesis Two

 Null Hypothesis (H₀₂): mHealth-supported sustainable models do not significantly improve

exclusive breastfeeding knowledge, attitudes, and practices among mothers in underserved

communities in Nyanya, Abuja.

 Alternative Hypothesis (H₁₂): mHealth-supported sustainable models significantly improve

exclusive breastfeeding knowledge, attitudes, and practices among mothers in underserved

communities in Nyanya, Abuja.

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 This hypothesis directly examines the core of the study — the effectiveness of mHealth

interventions — by comparing breastfeeding-related outcomes before and after exposure to

the digital health program. It helps determine the causal relationship between mobile

technology use and behavioral change.

1.6.3 HYPOTHESIS THREE

 Null Hypothesis (H₀₃): There is no significant association between the accessibility and

usability of mHealth tools and mothers’ participation in exclusive breastfeeding practices in

Nyanya, Abuja.

 Alternative Hypothesis (H₁₃): There is a significant association between the accessibility

and usability of mHealth tools and mothers’ participation in exclusive breastfeeding practices

in Nyanya, Abuja.

This hypothesis explores the technological and behavioral dimensions of mHealth use. It
examines whether the ability to easily access and use mobile-based tools influences adherence to
exclusive breastfeeding recommendations.

1.6.4 HYPOTHESIS FOUR

 Null Hypothesis (H₀₄): There are no significant challenges or facilitators that affect the

implementation of mHealth-supported sustainable models for promoting exclusive

breastfeeding in Nyanya, Abuja.

 Alternative Hypothesis (H₁₄): There are significant challenges and facilitators that affect

the implementation of mHealth-supported sustainable models for promoting exclusive

breastfeeding in Nyanya, Abuja. This hypothesis focuses on identifying external and internal

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 factors that may either enhance or impede the success of mHealth interventions, including

technological barriers, socio-cultural influences, and policy-related factors.

1.6.5 PURPOSE OF THE HYPOTHESES

The formulation of these hypotheses provides a structured framework for testing the

relationships among variables related to mobile health, community engagement, and

breastfeeding outcomes. Statistical tests such as chi-square, logistic regression, and

correlation analysis will be applied to determine the strength and significance of these

relationships. The results will offer evidence-based insights for policy formulation, health

education strategies, and digital health program design in similar underserved communities

across Nigeria.

1.6 Significance of the Study

Exclusive breastfeeding (EBF) remains one of the most cost-effective and evidence-based

strategies for reducing infant mortality and promoting maternal and child health. However, in

Nigeria, EBF rates remain far below the recommended global standards, particularly among

women in underserved areas like Nyanya, Abuja (National Population Commission [NPC] &

ICF, 2019). This research is significant because it aims to provide evidence on how mobile

health (mHealth)-supported sustainable models can effectively promote and sustain

exclusive breastfeeding practices in low-resource settings. The study is expected to generate

both theoretical and practical contributions to public health, digital health innovation, and

maternal-child welfare.

1.6.1 Contribution to Public Health Practice

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The findings from this study will provide valuable insights into innovative strategies for

improving maternal and child health outcomes. By assessing the effectiveness of mHealth-

supported interventions, the research will demonstrate how digital technologies can

complement traditional public health systems. This is particularly relevant in Nigeria, where

healthcare resources are overstretched, and many mothers in peri-urban and rural areas lack

consistent access to healthcare professionals (Akinyemi & Owoaje, 2020). Through mobile

platforms such as SMS, WhatsApp, and interactive voice response (IVR) systems, health

education can reach mothers directly, transcending the limitations of distance, literacy, and

time.

The study will thus contribute to achieving Sustainable Development Goal 3 (SDG 3),

which seeks to ensure healthy lives and promote well-being for all at all ages, as well as SDG

9, which focuses on innovation and infrastructure development (United Nations

Development Programme [UNDP], 2020).

1.6.2 Significance to Mothers and Caregivers

For mothers and caregivers in underserved communities, the study will offer a sustainable

and accessible means of receiving breastfeeding information and support. Many mothers in

Nyanya face barriers such as misinformation, cultural myths, and lack of time to attend

health talks. An mHealth-supported approach provides flexibility, allowing mothers to

receive reminders, motivational messages, and educational tips at their convenience. It also

creates a platform for continuous learning and communication with health workers or peer

supporters. As a result, mothers can develop confidence, motivation, and self-efficacy in

practicing exclusive breastfeeding. This empowerment will not only improve infant feeding

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 practices but also enhance maternal well-being and bonding with their infants (WHO, 2022;

UNICEF, 2021).

1.6.3 RELEVANCE TO HEALTHCARE PROVIDERS AND POLICY MAKERS

The study’s findings will be crucial for healthcare providers, community health workers,

and policymakers who are responsible for designing and implementing maternal and

child health programs. Currently, most breastfeeding promotion efforts in Nigeria rely

heavily on face-to-face counseling and facility-based health education. While effective in

some cases, these approaches have limited reach and sustainability in resource-

constrained settings (Ogbo et al., 2017). By evaluating the effectiveness of mHealth

interventions, this research can guide health authorities in developing cost-effective,

scalable models that integrate digital tools into existing maternal and child health

programs.

Policy makers can also use the evidence generated from this study to formulate digital

health policies and frameworks that prioritize breastfeeding promotion as part of

Nigeria’s national eHealth and mHealth strategies. Furthermore, the study will highlight

potential challenges—such as network connectivity, digital literacy, and affordability—

that should be considered when scaling up digital health initiatives nationwide.

1.6.4 Contribution to Academic and Theoretical Knowledge

From an academic perspective, this study adds to the growing body of literature on digital

health and maternal-child nutrition. While there is considerable research on mHealth

applications for antenatal care and immunization, studies exploring its role in exclusive

breastfeeding promotion in Nigeria are scarce (Chib, van Velthoven, & Car, 2015; Lee et

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 al., 2021). This research fills that gap by providing context-specific evidence from an

underserved Nigerian community.

Additionally, the study will contribute to the theoretical understanding of behavior

change communication (BCC) models and their integration with technology-based

interventions. By analyzing how mothers respond to digital reminders, peer support

messages, and interactive health content, the study can help refine behavior change

frameworks applicable to mobile health interventions in Africa.

1.6.5 Implications for Sustainable Development

The study also carries significant implications for sustainable development in Nigeria. By

introducing a sustainable mHealth-supported model, the research demonstrates how low-cost

digital solutions can be embedded into existing community health systems without depending on

continuous external funding. Sustainability in this context means creating interventions that are

community-driven, locally adaptable, and scalable across similar environments.

For instance, training local women as peer counselors or digital ambassadors can create a self-

sustaining cycle of health education and behavioral reinforcement within the community. This

participatory approach ensures local ownership and long-term continuity even after the study

concludes. As such, the outcomes of this research could serve as a model for other regions

seeking to integrate mobile technology into maternal and child health promotion.

1.6.6 Broader Socioeconomic Impact

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Beyond health benefits, improving exclusive breastfeeding practices has broader

socioeconomic implications. According to UNICEF (2021), increased breastfeeding rates

can save countries billions of dollars annually by reducing healthcare costs and

improving workforce productivity. For poor households, breastfeeding eliminates the cost

of formula feeding and reduces child illness-related expenses. Thus, promoting EBF

through mHealth not only improves health outcomes but also contributes to poverty

reduction and economic stability for low-income families in Nyanya and similar

communities.

Summary

In summary, this study is significant because it addresses a major public health issue—

low exclusive breastfeeding rates—through an innovative, sustainable, and technology-

driven approach. It provides a framework for understanding how mobile health

interventions can be effectively implemented and sustained in low-resource

environments. The results will benefit mothers, health practitioners, policymakers, and

researchers by offering actionable insights into using digital tools to promote health

equity and achieve national and global breastfeeding targets.

1.7 Scope of the Study

The scope of this study defines the boundaries within which the research will be

conducted, focusing on geographical coverage, population characteristics, conceptual

framework, methodological orientation, and temporal limits. Clarifying these aspects

ensures that the study remains feasible, relevant, and aligned with its stated objectives.

1.7.1 Geographical Scope

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This research is geographically delimited to Nyanya, a peri-urban community located

within the Abuja Municipal Area Council (AMAC) of the Federal Capital Territory

(FCT), Nigeria. Nyanya represents a densely populated, underserved area characterized

by socioeconomic diversity, informal settlements, and limited access to quality healthcare

facilities (National Population Commission [NPC] & ICF, 2019). It serves as a

convergence point for low-income earners, traders, artisans, and migrants from various

parts of the country. The area was chosen because it typifies many underserved

communities in Nigeria where exclusive breastfeeding practices are low due to limited

maternal education, cultural myths, and inadequate access to health information.

Conducting this research in Nyanya provides an opportunity to generate findings that

may be generalized to other similar urban and peri-urban contexts across Nigeria.

MAP: Showing Study Area.

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Source: [Link]

1.7.2 Population Scope

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The target population for this study includes mothers with infants aged 0–6 months

residing in Nyanya, Abuja. This demographic group is the most relevant for assessing

exclusive breastfeeding (EBF) practices, as EBF is recommended only for infants within

this age range (World Health Organization [WHO], 2022). Other key participants will

include community health workers, peer counselors, and local health authorities, who

play crucial roles in promoting maternal and child health. Their inclusion will help to

provide triangulated data that combine mothers’ perspectives with professional and

community insights. The study population will also include participants who have access

to mobile phones or other basic mobile communication tools, as the intervention is

mHealth-based.

1.7.3 Conceptual Scope

Conceptually, the study focuses on evaluating the effectiveness of mHealth-supported

sustainable models in promoting exclusive breastfeeding practices. It will explore

concepts such as exclusive breastfeeding, mHealth, community engagement, peer

support, digital accessibility, and behavioral change communication (BCC). The research

emphasizes both the technological and behavioral dimensions of mHealth, considering

how mobile-based tools (such as SMS reminders, WhatsApp messages, and voice calls)

can influence breastfeeding knowledge, attitudes, and practices among mothers. The

study will not focus on other aspects of infant feeding such as complementary feeding or

mixed feeding practices beyond six months.

1.7.4 Methodological Scope

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Methodologically, the study adopts a mixed-methods research design, integrating both

quantitative and qualitative approaches. The quantitative aspect will involve structured

questionnaires to assess changes in mothers’ breastfeeding knowledge, attitudes, and

practices before and after the mHealth intervention. The qualitative aspect will involve

focus group discussions (FGDs) and key informant interviews (KIIs) with health workers

and peer counselors to gain deeper insights into the barriers and facilitators affecting

mHealth adoption and exclusive breastfeeding behavior. Data will be analyzed using

statistical software such as SPSS for quantitative data and NVivo or manual coding for

qualitative data. Ethical principles including informed consent, confidentiality, and

voluntary participation will be strictly observed.

1.7.5 TEMPORAL SCOPE

The study is temporally bounded to the period between 2024 and 2025, covering both

the pre-intervention and post-intervention phases. This timeframe allows for adequate

data collection, intervention implementation, and assessment of outcomes. The duration

is also sufficient to observe short-term behavioral changes resulting from mHealth

exposure among participating mothers.

1.7.6 LIMITATIONS OF THE SCOPE

While the study’s scope provides a structured and feasible framework, certain limitations

are acknowledged. These include possible network disruptions, language barriers among

non-literate participants, and limited generalizability beyond similar socio-demographic

settings. However, these limitations will be mitigated through careful sampling,

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translation of messages into local languages, and engagement of community health

workers for interpretation and support.

Summary

In summary, this study is delimited to assessing the effectiveness, accessibility, and

sustainability of mHealth-supported interventions in promoting exclusive breastfeeding

among mothers in Nyanya, Abuja. By focusing on a well-defined population, timeframe,

and set of concepts, the research ensures methodological clarity, contextual relevance,

and practical applicability for broader maternal and child health interventions in Nigeria.

1.8 Operational Definition of Terms

For clarity and uniform understanding of the concepts used in this study, the following

key terms are operationally defined according to their relevance within the research

context.

1.8.1 Exclusive Breastfeeding (EBF)

Exclusive breastfeeding refers to the practice of feeding an infant only breast milk for

the first six months of life, without giving any other liquids or solid foods—not even

water—except for oral rehydration solution, drops, or syrups of vitamins, minerals, or

medicines (World Health Organization [WHO], 2022). In this study, EBF is measured as

the proportion of mothers in Nyanya who feed their infants exclusively with breast milk

for up to six months. The focus is on mothers’ knowledge, attitudes, and self-reported

practices regarding exclusive breastfeeding before and after the mHealth intervention.

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1.8.2 Mobile Health (mHealth)

Mobile Health (mHealth) is defined as the use of mobile phones, tablets, and other

wireless technologies to support the delivery of public health and medical services

(WHO, 2011). In this study, mHealth refers to mobile phone-based interventions such

as SMS text messages, WhatsApp group support, and interactive voice reminders

designed to educate, motivate, and remind mothers about the benefits and techniques of

exclusive breastfeeding. It also includes two-way communication platforms that allow

mothers to ask questions or receive feedback from health workers.

1.8.3 Sustainable Model

A sustainable model, in the context of this research, refers to an intervention framework

that can be maintained over time with minimal external support. It involves local

ownership, affordability, and integration into existing community and healthcare systems

(Lee et al., 2021). For this study, the sustainable model includes the use of trained

community peer counselors, locally tailored mobile messages, and partnerships with

healthcare facilities to ensure continuity after the research period.

1.8.4 Underserved Community

An underserved community is defined as a population with limited access to essential

healthcare, education, and digital resources, often due to poverty, inadequate

infrastructure, or marginalization (NPC & ICF, 2019). In this study, “underserved

community” specifically refers to Nyanya, a peri-urban settlement in Abuja characterized

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by overcrowding, low-income households, and insufficient maternal and child health

services.

1.8.5 Peer Support

Peer support refers to the assistance and encouragement provided by individuals who

share similar experiences or backgrounds (Akinyemi & Owoaje, 2020). In this study,

peer support involves local women or mothers trained to use mHealth tools to offer

emotional and informational support to breastfeeding mothers within their communities.

Peer support groups will be used to foster trust, shared learning, and motivation to sustain

exclusive breastfeeding.

1.8.6 Community Engagement

Community engagement is the process of actively involving community members in

planning, implementing, and sustaining health interventions that affect them (Chib, van

Velthoven, & Car, 2015). Within this study, community engagement includes the

participation of community leaders, health volunteers, and mothers’ associations in

designing and implementing the mHealth program to promote exclusive breastfeeding.

1.8.7 Effectiveness

Effectiveness is defined as the degree to which an intervention achieves its intended

outcome under real-world conditions (Sinha et al., 2020). In this study, effectiveness will

be measured by changes in mothers’ exclusive breastfeeding knowledge, attitudes, and

reported practices before and after exposure to the mHealth intervention.

1.8.8 Usability and Accessibility

24
Usability refers to how easily participants can interact with the mHealth tools, while

accessibility refers to their ability to access those tools given available technology and

resources (GSMA, 2021). The study will assess usability through mothers’ feedback on

the clarity, frequency, and helpfulness of the mobile messages, and accessibility through

their level of phone ownership, literacy, and connectivity.

1.8.9 Intervention

An intervention in this context refers to a planned, structured activity designed to

produce behavioral change. The mHealth intervention in this study includes text

reminders, voice messages, and WhatsApp support groups intended to promote and

reinforce exclusive breastfeeding behavior among mothers in Nyanya.

25
 CHAPTER TWO
LITERATURE REVIEW

2.0 INTRODUCTION

The importance of exclusive breastfeeding (EBF) as a cornerstone for child survival and

maternal health cannot be overstated. The World Health Organization (WHO, 2022) recommends

that infants be exclusively breastfed for the first six months of life, as breast milk provides the

ideal nutrition, strengthens the immune system, and reduces the risk of morbidity and mortality

among infants. Globally, breastfeeding is recognized as one of the most cost-effective public

health interventions to improve child health outcomes (UNICEF, 2021). Despite these proven

benefits, global EBF rates remain low, particularly in low- and middle-income countries

(LMICs) where cultural, social, and economic factors hinder optimal infant feeding practices

(Ogbo, Ogeleka, and Awosemo, 2017). In Nigeria, breastfeeding is a near-universal practice, but

the rate of exclusive breastfeeding remains low. According to the Nigeria Demographic and

Health Survey (NDHS, 2018), only 29% of infants under six months are exclusively breastfed,

falling short of the global target of 50% by 2025 (WHO, 2022). This situation is even more

concerning in underserved and peri-urban areas like Nyanya in Abuja, where socio-economic

disparities, misinformation, and limited access to healthcare services contribute to suboptimal

breastfeeding practices (National Population Commission [NPC] and ICF, 2019). These

communities often experience multiple barriers, including poverty, cultural taboos, and

inadequate health education, which collectively impede adherence to EBF recommendations.

26
Given these challenges, health systems are increasingly exploring innovative strategies to bridge

the information and service delivery gaps. One such innovation is mobile health (mHealth)—the

use of mobile and wireless technologies to support healthcare delivery and public health

initiatives (World Health Organization, 2011). mHealth interventions have been widely applied

in maternal and child health programs globally to improve health knowledge, encourage

behavior change, and increase access to essential healthcare services (Lee, Chib, and Kim, 2021).

Through tools such as text messaging, interactive voice responses, mobile applications, and

social media platforms, mHealth has demonstrated potential in enhancing maternal education and

engagement (GSMA, 2021).

The increasing accessibility of mobile phones in Nigeria provides an unprecedented opportunity

to scale health interventions among women of reproductive age. The Global System for Mobile

Communications Association (GSMA, 2021) reports that over 90% of Nigerian households own

at least one mobile phone, and mobile network penetration has reached even the remotest

communities. This technological advancement creates a powerful platform for disseminating

health information to mothers and caregivers, particularly in areas where health workers are

scarce or overstretched. To ensure that digital interventions achieve lasting impact, sustainability

is essential. Sustainable models of mHealth integrate technological innovation with existing

community health structures and local health policies. These models are designed to be scalable,

culturally adaptable, and self-sustaining, ensuring that benefits persist even after initial funding

or external support phases (Akinyemi and Owoaje, 2020). By embedding mHealth initiatives

within community health frameworks and leveraging peer support and local leadership,

sustainable models help foster ownership, participation, and long-term behavioral change.

27
This chapter presents a comprehensive review of literature on exclusive breastfeeding and the

role of mHealth in promoting maternal and child health in underserved settings. It begins with a

conceptual framework that discusses the concept of exclusive breastfeeding, its importance, and

the barriers limiting its practice. It then explores the role of community engagement, peer

support, and mHealth tools as sustainable strategies for promoting EBF. Furthermore, the chapter

reviews relevant theoretical frameworks that underpin behavior change communication (BCC) in

digital health interventions. The empirical review section synthesizes findings from global,

regional, and Nigerian studies related to mHealth and exclusive breastfeeding, highlighting

lessons learned and gaps that justify the present study. By integrating these dimensions, this

chapter aims to establish a strong theoretical and empirical foundation for evaluating the

effectiveness of mHealth-supported sustainable models in promoting exclusive breastfeeding

practices in underserved communities like Nyanya, Abuja. Understanding the relationship

between digital interventions, community engagement, and breastfeeding behavior will not only

enrich academic knowledge but also inform health policy and programmatic decisions in

Nigeria’s quest to achieve the Sustainable Development Goals (SDGs), particularly Goal 3 —

ensuring healthy lives and promoting well-being for all at all ages (United Nations Development

Programme [UNDP], 2020)

2.1 CONCEPTUAL FRAMEWORK

2.1.1 CONCEPT OF EXCLUSIVE BREASTFEEDING (EBF)

Exclusive breastfeeding (EBF) refers to the act of feeding an infant only breast milk for the first

six months of life, with no additional liquids or solids—not even water—except for oral

rehydration solution, drops, or syrups of vitamins, minerals, or medicines (World Health

Organization [WHO], 2022). Breast milk is a natural, complete, and ideal food for infants,
28
providing all necessary nutrients, antibodies, and enzymes required for healthy growth and

development during the early stages of life. It is easily digestible, hygienic, and provides both

nutritional and immunological protection against common childhood diseases such as diarrhea,

pneumonia, and malnutrition (UNICEF, 2021).

Breastfeeding, in general, has both biological and emotional dimensions. Biologically, it

provides essential nutrients and immune protection, while emotionally, it fosters bonding

between mother and child. The exclusivity of breastfeeding during the first six months is critical,

as early introduction of water or complementary feeds may expose the infant to pathogens and

undermine breast milk intake. WHO and UNICEF recommend EBF up to six months, followed

by the introduction of nutritionally adequate complementary foods while continuing

breastfeeding up to two years or beyond (WHO, 2022). Globally, EBF rates have been

increasing, but progress remains uneven. According to WHO (2020), approximately 44% of

infants under six months were exclusively breastfed worldwide in 2020. However, the target set

by the World Health Assembly—to reach at least 50% by 2025—remains unmet in many

countries. In sub-Saharan Africa, EBF rates vary widely, ranging from as high as 70% in

Rwanda to below 25% in Nigeria and Chad (UNICEF, 2021). In Nigeria, breastfeeding is

culturally valued, yet the practice of exclusive breastfeeding remains low. Many mothers initiate

breastfeeding within the first hour after birth, but exclusive breastfeeding for the full six months

is rarely sustained (National Population Commission [NPC] & ICF, 2019). This gap between

initiation and continuation is often due to limited maternal knowledge, sociocultural practices,

and weak health system support. In urban and peri-urban areas like Nyanya, Abuja, where

mothers engage in informal work and face economic pressures, maintaining exclusive

breastfeeding becomes even more challenging. Hence, interventions such as mHealth-supported

29
communication and peer support have been proposed to help bridge this behavioral gap.

Exclusive breastfeeding also has significant policy implications. Nigeria’s National Infant and

Young Child Feeding (IYCF) policy aligns with WHO recommendations, emphasizing exclusive

breastfeeding for six months. However, implementation remains inconsistent across regions due

to resource limitations and lack of tailored community-based interventions (Federal Ministry of

Health [FMoH], 2020). In this context, the integration of digital technologies like mobile health

presents a promising avenue for reaching more mothers with accurate information and

continuous motivation.

2.1.2 IMPORTANCE AND BENEFITS OF EXCLUSIVE BREASTFEEDING

The importance of exclusive breastfeeding is multidimensional—spanning health, economic, and

social domains. Breastfeeding is one of the simplest and most effective strategies for preventing

infant mortality. According to WHO (2020), optimal breastfeeding could prevent about 13% of

deaths among children under five globally. Breast milk contains essential macronutrients and

micronutrients—proteins, fats, carbohydrates, vitamins, and minerals—in perfect balance for the

infant’s physiological needs. It also provides antibodies and immune-modulating factors that

protect against infections, especially diarrhea and pneumonia, which are leading causes of child

morbidity and mortality in Nigeria (Ogbo et al., 2017). From a maternal health perspective,

exclusive breastfeeding offers protective effects against postpartum hemorrhage, breast and

ovarian cancers, and type 2 diabetes (Victora et al., 2016). Breastfeeding also supports maternal-

infant bonding, contributing to emotional well-being and reduced stress levels. Psychologically,

it enhances the mother’s sense of responsibility and attachment, which are essential for child

development.

30
Economically, breastfeeding is cost-effective and environmentally sustainable. It eliminates the

financial burden of purchasing infant formula, sterilizing feeding bottles, and treating

preventable childhood illnesses associated with artificial feeding (Rollins et al., 2016). At the

household level, EBF contributes to poverty reduction by saving family income, while at the

national level, increased breastfeeding rates reduce healthcare costs and improve workforce

productivity through healthier children and mothers. A UNICEF (2021) report estimated that

Nigeria could save over ₦20 billion annually in healthcare costs if EBF rates increased to 50%.

At the community level, breastfeeding contributes to achieving the Sustainable Development

Goals (SDGs), especially SDG 2 (zero hunger) and SDG 3 (good health and well-being). Breast

milk is a sustainable, renewable resource that ensures food security for infants, even in

emergencies or food-insecure situations. Culturally, it reinforces maternal roles and provides an

entry point for engaging communities in broader health education programs. However, despite

these advantages, many mothers face challenges that prevent them from exclusively

breastfeeding for six months. The persistence of cultural beliefs, inadequate health education,

and poor workplace policies undermine EBF promotion. Recognizing these challenges has

motivated researchers and policymakers to explore innovative solutions—such as mobile health

(mHealth)—to strengthen breastfeeding promotion efforts, particularly among hard-to-reach

populations.

2.1.3 Barriers to Exclusive Breastfeeding Practices

While the benefits of EBF are well-established, multiple barriers impede its practice across

different contexts. These barriers are socio-cultural, economic, health system-related, and

individual-level challenges that collectively hinder optimal infant feeding behaviors.

31
a. Socio-Cultural Barriers

Cultural beliefs and traditional practices strongly influence infant feeding in Nigeria. In many

communities, there is a widespread misconception that newborns require water, especially in hot

climates like Abuja (Okafor, Olatunji, and Ogbonna, 2018). Other mothers believe colostrum—

the first yellowish breast milk—is “dirty” or harmful, leading them to discard it. Family elders,

particularly grandmothers, often pressure new mothers to introduce herbal mixtures or pap (a

maize-based porridge) early, undermining EBF adherence (Akinyemi and Owoaje, 2020).

b. Economic and Occupational Barriers

Economic hardship and work-related challenges are major barriers, especially among women in

informal employment. Many mothers in peri-urban settlements like Nyanya are self-employed

traders or artisans who must resume work soon after childbirth, limiting time for breastfeeding.

The absence of supportive workplace policies, such as maternity leave or breastfeeding-friendly

spaces, exacerbates the problem. For low-income mothers, formula feeding may appear more

convenient despite being less safe and more costly in the long run (Ogbo et al., 2017).

c. Health System Barriers

The healthcare system also plays a role in perpetuating suboptimal feeding practices. Inadequate

counseling during antenatal and postnatal visits, inconsistent health worker knowledge, and lack

of follow-up support reduce mothers’ confidence in maintaining EBF (Ezeh et al., 2020).

Furthermore, the aggressive marketing of infant formula by multinational companies undermines

breastfeeding messages and contributes to misinformation (Rollins et al., 2016).

32
d. Knowledge and Perceptual Barriers

Some mothers have limited understanding of the nutritional value of breast milk and the risks

associated with mixed feeding. Misconceptions about insufficient breast milk production lead

them to supplement with formula or water. Studies also reveal that young and first-time mothers

are more likely to discontinue EBF early due to anxiety or lack of confidence (Sinha et al.,

2020). This underscores the importance of continuous education and emotional support—areas

where mHealth interventions can play a transformative role.

e. Technological and Communication Barriers

In the context of digital health interventions, challenges such as low literacy levels, limited

mobile network coverage, and inability to afford data or airtime can impede mHealth adoption.

For interventions to be successful, they must be user-friendly, linguistically appropriate, and

accessible to women with varying levels of education and digital literacy (GSMA, 2021).

f. Policy and Institutional Barriers

Although Nigeria’s IYCF policy advocates for exclusive breastfeeding, weak implementation,

limited funding, and lack of enforcement of the International Code of Marketing of Breast-Milk

Substitutes remain significant obstacles. Health institutions often lack structured community-

based support mechanisms to reinforce EBF messages after hospital discharge (FMoH, 2020).

33
Summary

In summary, exclusive breastfeeding is a vital component of child survival and maternal health,

yet its practice remains low in Nigeria due to a complex interplay of socio-cultural, economic,

and systemic barriers. Addressing these barriers requires multifaceted interventions that combine

health education, community engagement, and innovative digital strategies. Mobile health

(mHealth) presents an opportunity to overcome these challenges by delivering targeted

messages, reminders, and peer support to mothers in real time. The next section explores the role

of health education, community engagement, and sustainable mHealth models as promising

approaches to promoting exclusive breastfeeding in underserved communities like Nyanya,

Abuja.

2.1.4 Role of Health Education and Community Support in Exclusive

Breastfeeding

Health education is a central strategy in promoting exclusive breastfeeding (EBF), as it

empowers mothers with knowledge, skills, and motivation to make informed feeding decisions.

According to Akinyemi and Owoaje (2020), effective breastfeeding promotion depends on both

the quality of information provided and the supportive environment in which mothers make

decisions. Health education in maternal and child health (MCH) aims to increase awareness of

the benefits of EBF, dispel myths, and foster behavioral change through communication,

counseling, and continuous engagement.

34
Health education interventions are particularly essential in low- and middle-income countries

(LMICs), where myths, cultural beliefs, and misinformation often influence infant feeding

practices. For instance, many Nigerian mothers believe infants need water in addition to breast

milk due to the hot climate (Ogbo, Ogeleka, & Awosemo, 2017). Others are influenced by family

elders who promote early introduction of complementary foods. In such contexts, structured

health education programs delivered through antenatal clinics, postnatal visits, and community

campaigns can improve mothers’ understanding and commitment to EBF (Ezeh, Adebayo, &

Akintunde, 2020).

Health workers and community health extension officers play a vital role in health education

delivery. They provide direct counseling to mothers during antenatal and postnatal periods,

emphasizing the benefits of breastfeeding, proper positioning, and common challenges such as

sore nipples or perceived milk insufficiency. However, health education alone is often

insufficient to ensure behavioral change unless supported by community engagement and peer

support mechanisms (Lee, Chib, and Kim, 2021).

Community-based approaches are critical because mothers’ decisions are heavily influenced by

social norms and collective beliefs. Community support creates an enabling environment where

breastfeeding is normalized, encouraged, and celebrated. Peer support groups—where

experienced mothers share their experiences with new mothers—have been shown to

significantly increase EBF duration and confidence (Chola et al., 2019). These peer networks

help mothers overcome isolation and provide real-time emotional support when facing

breastfeeding challenges.

35
In underserved communities like Nyanya, where health facilities are overstretched, community

health volunteers and traditional birth attendants often serve as the first source of health advice.

Integrating them into breastfeeding promotion programs ensures cultural relevance and local

ownership (NPC & ICF, 2019). In addition, involving fathers, grandmothers, and religious

leaders in community sensitization activities can help dismantle harmful myths and promote

collective responsibility for child health.

Recent studies have demonstrated that when health education is complemented with social

support structures, EBF rates improve significantly. For example, a study in Ghana found that

women who participated in community mother-to-mother support groups were twice as likely to

practice EBF as those who did not (Aryeetey and Dykes, 2018). Similarly, in northern Nigeria,

community-based peer counseling increased the likelihood of EBF among women in rural

settlements (Adeyemi et al., 2020).

In summary, health education and community support are mutually reinforcing strategies. Health

education increases knowledge and self-efficacy, while community engagement sustains

motivation through social influence and shared experiences. In this light, mobile health

(mHealth) interventions can act as an extension of health education—delivering continuous,

personalized messages and virtual peer support that complement face-to-face counseling,

especially in resource-limited settings.

2.1.5 Mobile Health (mHealth): Concept, Tools, and Applications

The term mobile health (mHealth) refers to the use of mobile and wireless technologies—such as

mobile phones, smartphones, tablets, and personal digital assistants—to support healthcare

delivery and public health practices (World Health Organization [WHO], 2011). mHealth is part
36
of the broader field of eHealth, which encompasses the use of information and communication

technologies (ICTs) for health. According to WHO (2022), mHealth interventions are

increasingly being used in developing countries to improve access to healthcare information,

promote behavior change, and enhance disease prevention and control.

The growth of mobile phone penetration in sub-Saharan Africa has created new opportunities for

digital health interventions. The Global System for Mobile Communications Association

(GSMA, 2021) reports that mobile phone adoption in Nigeria exceeds 90%, with over 180

million subscribers and expanding internet connectivity across urban and peri-urban areas. This

widespread accessibility makes mobile phones an ideal platform for delivering maternal and

child health information to large populations at low cost. mHealth tools vary in form and

function but generally fall into several categories:

1. Short Message Service (SMS) and Text Messaging – One of the most common forms of

mHealth, SMS is used to send reminders, educational tips, and motivational messages to

patients or clients. In maternal health, SMS can remind mothers of antenatal appointments,

immunization schedules, or provide weekly breastfeeding advice (Lund et al., 2014).

2. Interactive Voice Response (IVR) Systems – These systems deliver pre-recorded messages

that users can access via phone calls. IVR is particularly useful for populations with low

literacy levels, allowing messages to be delivered in local languages (Lee et al., 2021).

3. Mobile Applications (Apps) – Smartphone applications offer interactive features such as

digital diaries, breastfeeding trackers, or real-time chat with healthcare providers. However,

their adoption is limited in low-income areas due to cost and digital literacy constraints

(Sinha et al., 2020).

37
4. Social Media and Messaging Platforms – Platforms such as WhatsApp and Facebook have

become increasingly important in health promotion. WhatsApp, in particular, allows for the

creation of support groups where mothers can share experiences, ask questions, and receive

guidance from healthcare professionals (GSMA, 2021).

5. Mobile Data Collection Tools – These tools enable health workers to collect, monitor, and

report community health data in real time. For instance, ODK (Open Data Kit) and

CommCare are used by NGOs and ministries of health to track maternal and child health

indicators. In the context of exclusive breastfeeding promotion, mHealth interventions focus

on three main objectives: (a) improving maternal knowledge, (b) influencing positive

attitudes, and (c) supporting behavior change through reminders and reinforcement (WHO,

2022). A systematic review by (Lee et al. 2021) revealed that mobile-based education

programs have significantly increased EBF initiation and continuation rates in low-resource

settings by providing timely, consistent, and culturally appropriate health messages.

Furthermore, mHealth interventions enhance the continuity of care by bridging

communication gaps between mothers and healthcare providers. This is particularly

important in communities where healthcare workers are few or clinics are located far from

residential areas. Through mHealth platforms, mothers can receive postnatal advice, ask

questions, and report breastfeeding challenges without physically visiting health centers.

However, the success of mHealth interventions depends on several factors, including

message relevance, frequency, language, and delivery timing. Studies in Nigeria show that

tailored, interactive messages in local languages are more effective than generic one-way

communication (Akinyemi & Owoaje, 2020). mHealth interventions that integrate peer

discussion and community involvement tend to achieve higher retention and behavioral

38
 impact compared to those relying solely on technology. In conclusion, mHealth represents a

transformative approach to health communication. It leverages the ubiquity of mobile devices

to extend health education beyond physical clinics, making healthcare information accessible

to even the most underserved populations. The next sub-section discusses how sustainable

models of mHealth can be developed to ensure long-term impact, scalability, and integration

with existing health systems.

2.1.6 Sustainable Models of mHealth in Public Health Interventions

While mHealth innovations have demonstrated considerable promise, the sustainability of such

programs remains a major concern, especially in developing countries. Many mHealth projects

are launched as pilot programs with external funding, but they fail to persist once donor support

ends (Chib, van Velthoven et al, 2015). A sustainable mHealth model is one that continues to

deliver benefits over time by being cost-effective, community-driven, and institutionally

integrated. According to Lee et al. (2021), sustainability in mHealth depends on three interrelated

factors: technological feasibility, institutional support, and community ownership. Technological

feasibility refers to the availability of reliable mobile networks, affordable devices, and user-

friendly platforms. Institutional support involves alignment with government policies, integration

into national health information systems, and ongoing training for health workers. Community

ownership ensures that the intervention is culturally relevant and locally managed, enhancing

long-term adoption.

Sustainable mHealth models often incorporate the following key features:

1. Integration with Existing Health Systems:

39
2. For mHealth to be effective, it must complement—not replace—existing healthcare

structures. Successful models embed mobile technology into routine maternal health

programs, allowing health workers to use digital platforms to follow up with mothers and

collect real-time data (WHO, 2022).

3.

4. Community Participation and Peer Networks:

5. Engaging communities in program design, implementation, and evaluation fosters local

ownership. Training community members as digital health champions or peer counselors

ensures continuity even after the project phase ends (Chola et al., 2019).

6. Cost-Effectiveness and Scalability:

Sustainability also requires financial viability. Interventions that rely on low-cost

technologies, such as SMS and WhatsApp, are more scalable than app-based platforms

requiring smartphones or data subscriptions (GSMA, 2021). Governments and NGOs can

scale such models by integrating them into existing maternal health programs.

7. Cultural and Linguistic Adaptation:

Tailoring messages to local languages and cultural contexts increases acceptance and

comprehension. Programs that consider literacy levels, gender dynamics, and traditional

beliefs are more likely to achieve behavioral impact (Akinyemi and Owoaje, 2020).

8. Monitoring and Evaluation Mechanisms:

Sustainable models include continuous feedback loops and data analytics to track

performance, identify challenges, and adapt strategies. Mobile data platforms can facilitate

real-time monitoring of breastfeeding indicators, allowing timely intervention. Globally,

several examples illustrate sustainable mHealth initiatives. In Kenya, the “MomConnect”

40
 program, supported by the Ministry of Health, has successfully used SMS and interactive

platforms to reach over 2 million mothers with health information (Lund et al., 2014). The

program’s success is attributed to government ownership and integration into the national

health information system. Similarly, in India, the “Mobile Kunji” initiative combined

mobile voice messages with community health worker engagement, resulting in significant

improvements in maternal knowledge and breastfeeding practices (Sinha et al., 2020). In

Nigeria, few large-scale mHealth programs exist, but smaller initiatives like “HelloMama”

have shown encouraging results. Implemented in several states, Hello Mama delivers voice

and text messages to pregnant women and new mothers, covering topics such as antenatal

care, delivery, and infant feeding (GSMA, 2021). However, sustainability challenges persist

due to inconsistent funding, weak coordination, and limited government adoption. For

mHealth-supported breastfeeding interventions to be sustainable in settings like Nyanya,

Abuja, they must be context-sensitive, community-driven, and aligned with national

health priorities. Local adaptation is critical: messages should reflect cultural beliefs about

breastfeeding, and communication should occur in accessible languages. Moreover,

partnerships with mobile network operators, healthcare institutions, and community leaders

can enhance long-term viability.

Summary

In essence, mHealth has emerged as a powerful tool for strengthening health education and

promoting behavior change. However, to achieve lasting results, interventions must move

beyond pilot projects toward sustainable, scalable models that integrate technology with

community structures and public health systems. By combining mobile health with peer support

41
and continuous education, underserved communities can overcome many barriers to exclusive

breastfeeding.

2.2 EMPIRICAL REVIEW

Empirical literature provides evidence-based insights into how mobile health (mHealth) and

community-supported interventions have been applied to improve exclusive breastfeeding (EBF)

practices across the world. It also identifies key success factors, challenges, and research gaps

that justify the present study in underserved communities like Nyanya, Abuja. This review is

organized into three major subsections: (1) global studies, (2) studies from sub-Saharan Africa,

and (3) evidence from Nigeria.

2.2.1 GLOBAL EVIDENCE ON MHEALTH AND EXCLUSIVE

BREASTFEEDING

Over the last two decades, mHealth has emerged as a powerful tool in promoting maternal and

child health globally. It provides a low-cost, scalable platform for delivering health information,

reminders, and support to mothers during pregnancy and the postnatal period. Several studies

from high- and middle-income countries have demonstrated the positive influence of mobile

technology on breastfeeding behaviors. For example, Lund et al. (2014) conducted a randomized

controlled trial (RCT) in India where mothers received SMS messages containing breastfeeding

information and motivational content twice weekly for six months. The study reported a 32%

increase in EBF rates compared to the control group. Similarly, Sinha et al. (2020) examined the

“Mobile Kunji” initiative in Bihar, India, which combined mobile voice messages with face-to-

face counseling from community health workers. The findings revealed significant

42
improvements in maternal knowledge, early initiation of breastfeeding, and continuation of EBF

for six months.

In another large-scale intervention, the text4baby program in the united states provided free text

messages to expectant and new mothers covering health topics including breastfeeding, nutrition,

and infant care. evaluations of the program found that participants were more likely to initiate

and sustain ebf compared to non-participants, particularly when messages were interactive and

personalized (gazmararian et al., 2014). These findings highlight that digital communication,

when tailored to user needs, can effectively influence health behavior across socioeconomic

groups. a systematic review by lee, chib, and kim (2021) synthesized findings from 25 studies on

mhealth for maternal and child health. the review concluded that mobile-based interventions

consistently improved maternal health literacy, increased antenatal attendance, and positively

influenced ebf practices. however, it also emphasized that program success depends on message

quality, delivery timing, and the inclusion of peer or community support mechanisms. programs

that relied solely on one-way sms communication often faced challenges in sustaining

engagement over time. Another important finding from global research is the role of language

and cultural adaptation in improving mHealth effectiveness. For instance, in Bangladesh, the

“Aponjon” program used interactive voice messages in local languages and achieved a 20%

increase in EBF adherence (Khatun et al., 2015). This underscores that culturally tailored content

enhances comprehension and acceptance of digital health interventions. Furthermore, mHealth

has proven especially useful in postnatal follow-up and breastfeeding counseling. Studies from

the United Kingdom, Canada, and Australia have shown that digital platforms offering real-time

communication between mothers and lactation consultants improve breastfeeding duration and

maternal satisfaction (McKinney et al., 2018). These experiences demonstrate that mHealth can
43
supplement traditional health services by providing ongoing, accessible support beyond the

hospital environment. In summary, global evidence confirms that mHealth interventions—

especially those integrating education, reminders, and peer interaction—are effective in

improving EBF rates. However, sustainability, cultural relevance, and inclusivity remain

challenges that require contextual adaptation in low-resource settings.

2.2.2 Evidence from Sub-Saharan Africa

In sub-Saharan Africa, where health systems often struggle with human resource shortages and

limited infrastructure, mHealth has emerged as an innovative approach to improving maternal

and child health outcomes. Numerous studies have been conducted across countries such as

Kenya, Ghana, Uganda, and South Africa, demonstrating varying degrees of success in applying

mHealth for breastfeeding promotion and maternal education. In Kenya, one of the earliest and

most cited mHealth projects, “MomConnect,” was launched in 2014 by the Ministry of Health

with support from WHO and UNICEF. The program used SMS and interactive voice messages

to send health information to pregnant women and new mothers. A study by LeFevre et al.

(2018) reported that mothers enrolled in MomConnect were 1.5 times more likely to initiate EBF

and continue for at least six months than those who did not participate. The program’s success

has been attributed to government ownership, integration into national health systems, and its use

of local languages for communication. Similarly, in Ghana, Aryeetey and Dykes (2018)

implemented a mobile messaging project combined with mother-to-mother peer support groups.

The study showed significant improvement in mothers’ knowledge and self-efficacy toward

EBF. Participants reported that mobile reminders helped them overcome forgetfulness and

44
provided emotional support during challenging times. This combination of digital messages and

peer counseling reflects the principle of sustainability through community engagement.

In Uganda, Kibuule et al. (2017) explored the use of WhatsApp-based education groups for rural

mothers. The results revealed improvements in knowledge about breastfeeding benefits, as well

as stronger social networks among participants. Mothers described the platform as convenient

and supportive, especially for those unable to attend in-person clinics. However, issues such as

limited internet access and low digital literacy among older women were noted as barriers. South

Africa has also contributed valuable evidence. The MAMA (Mobile Alliance for Maternal

Action) project tested voice and SMS interventions across rural and urban regions. Findings

indicated that consistent exposure to mobile messages increased adherence to EBF and reduced

early introduction of water and formula (Cole-Lewis et al., 2016). Importantly, the study

emphasized that frequency and timing of messages were crucial in maintaining behavioral

impact. A cross-country study by GSMA (2021) in six African nations revealed that mHealth

interventions addressing maternal and child health significantly improved EBF rates by an

average of 17% when compared to baseline levels. The study identified several critical factors

for success: affordability of mobile services, integration with existing health structures, and local

stakeholder engagement. It further highlighted that the most effective programs were those that

combined digital tools with human support systems, such as community health workers and peer

networks. Despite these positive results, sustainability challenges persist in sub-Saharan Africa.

Many mHealth initiatives depend on donor funding, making long-term continuity uncertain.

Additionally, gender disparities in mobile phone ownership—where men are more likely to own

phones than women—limit access for some mothers (GSMA, 2021). There is also the challenge

45
of ensuring data privacy and confidentiality, particularly when sensitive maternal information is

transmitted through shared phones.

Overall, evidence from Africa suggests that mHealth has considerable potential to enhance EBF

practices and maternal health outcomes. However, its success depends on context-specific

design, affordability, community engagement, and integration with health systems. The findings

underscore the need for more localized studies to explore these dynamics in specific settings

such as Nigeria’s underserved communities.

2.2.3 EMPIRICAL STUDIES IN NIGERIA

In Nigeria, the use of mobile health technology to promote maternal and child health is growing,

but empirical evidence remains limited compared to other regions. Several pilot projects and

small-scale studies, however, demonstrate promising results in improving health education,

behavioral change, and exclusive breastfeeding practices. Akinyemi and Owoaje (2020)

examined the effectiveness of mobile phone text messaging for health education among mothers

in Ibadan, southwestern Nigeria. Their quasi-experimental study found a significant increase in

mothers’ knowledge and intention to practice EBF after receiving regular SMS reminders and

educational tips for three months. The authors concluded that mHealth interventions could bridge

communication gaps in urban low-income communities, provided messages are short, relevant,

and culturally appropriate.

Another study by Ezeh, Adebayo, and Akintunde (2020) in Lagos assessed the use of WhatsApp

groups for maternal health education among first-time mothers. Participants reported that the

interactive discussions helped them clarify misconceptions about breastfeeding, particularly

regarding colostrum and water supplementation. The study emphasized that social interaction
46
and feedback were key motivators for sustained EBF practices, aligning with the Social

Cognitive Theory’s emphasis on peer learning and reinforcement.

A notable national project, Hello Mama, implemented between 2016 and 2019 in Ebonyi and

Cross River States, used voice calls and SMS messages to educate pregnant women and new

mothers on topics including breastfeeding, immunization, and infant nutrition (GSMA, 2021).

An independent evaluation revealed improved EBF awareness and increased use of maternal

health services. The program’s voice-based approach was especially effective for illiterate users,

demonstrating the potential for mHealth to reach marginalized groups. However, challenges such

as intermittent network coverage, language barriers, and limited government integration hindered

scalability.

Similarly, Okafor, Olatunji, and Ogbonna (2018) explored EBF determinants in southeastern

Nigeria and found that information access was a major predictor of breastfeeding behavior. The

authors recommended leveraging mobile communication tools to deliver consistent, evidence-

based messages to mothers, especially in underserved areas. A community-based study by

Adeyemi et al. (2020) in northern Nigeria combined mobile reminders with peer counseling and

found a 28% increase in the proportion of mothers exclusively breastfeeding for six months

compared to control communities. The integration of mHealth with existing community

structures was cited as the key success factor. These results demonstrate that blended approaches

—combining technology and interpersonal communication—are more effective than standalone

digital interventions. However, despite these successes, challenges remain. Chukwuma and Isah

(2021) noted that many mHealth initiatives in Nigeria face sustainability issues due to donor

dependence, weak policy frameworks, and limited government ownership. Furthermore,

47
disparities in mobile phone ownership between urban and rural women limit the reach of digital

interventions. There is also a need for culturally sensitive messaging that addresses local beliefs

and myths about breastfeeding.

Another gap in Nigerian research is the lack of rigorous experimental designs evaluating the

impact of mHealth on breastfeeding outcomes. Most existing studies are descriptive or quasi-

experimental, with limited longitudinal data. Additionally, few studies have examined the

sustainability aspect of mHealth models—how they can be maintained and scaled through

community participation and institutional support.

These gaps justify the current study, which aims to assess the effectiveness of mHealth-

supported sustainable models for promoting exclusive breastfeeding in underserved communities

such as Nyanya, Abuja. By focusing on sustainability, community engagement, and contextual

adaptation, this research addresses both practical and theoretical voids in the existing Nigerian

literature.

Summary of Empirical Findings

Across global, regional, and national studies, several key insights emerge:

1. Effectiveness: mHealth interventions consistently improve maternal knowledge,

attitudes, and practices related to EBF.

2. Engagement: Programs that combine mobile technology with human interaction—such

as peer counseling or health worker follow-up—achieve higher impact.

3. Cultural Adaptation: Localization of language and message content increases

comprehension and acceptance.

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 4. Sustainability Challenges: Many programs rely heavily on external funding and lack

integration into government systems.

5. Evidence Gaps in Nigeria: Few studies have examined the long-term sustainability and

scalability of mHealth-supported models in peri-urban underserved settings.

These findings reinforce the need for the present study, which will provide context-specific

evidence on how mobile health can be leveraged to promote sustainable exclusive

breastfeeding practices among mothers in Nyanya, Abuja.

2.3 THEORETICAL FRAMEWORK

Theoretical frameworks provide the foundation upon which research is built. They offer a lens

for understanding how and why particular interventions produce desired outcomes. In public

health research, theories help explain the determinants of behavior and guide the design of

interventions aimed at influencing those behaviors (Glanz, Rimer, & Viswanath, 2015). This

study is grounded in three interrelated theories widely applied in health promotion and digital

communication: the Health Belief Model (HBM), the Social Cognitive Theory (SCT), and the

Diffusion of Innovation (DOI) Theory. Each provides a different but complementary

perspective for understanding how mobile health (mHealth) interventions can influence

exclusive breastfeeding practices among mothers in underserved communities such as Nyanya,

Abuja.

2.3.1. The Health Belief Model (HBM)

The Health Belief Model (HBM), developed by Rosenstock in the 1950s, is one of the most

widely used frameworks in health behavior research. It posits that individuals’ engagement in
49
health-promoting behaviors depends on their perceptions of personal risk and the benefits of

taking preventive action (Glanz et al., 2015). The model includes six key constructs:

1. Perceived Susceptibility – An individual’s belief about the likelihood of experiencing a

health problem.

2. Perceived Severity – The perceived seriousness of the condition and its consequences.

3. Perceived Benefits – The belief in the effectiveness of the recommended behavior in

reducing risk.

4. Perceived Barriers – The perceived obstacles that hinder engagement in the behavior.

5. Cues to Action – Triggers that stimulate the adoption of the behavior.

6. Self-Efficacy – The confidence in one’s ability to perform the behavior successfully.

Applied to exclusive breastfeeding, the HBM suggests that a mother’s decision to practice

EBF depends on her perception of the benefits of breastfeeding (such as child immunity and

health), the severity of potential risks from artificial feeding (e.g., infections or malnutrition),

and her ability to overcome practical barriers (e.g., time, work, or cultural pressures). In this

study, mHealth serves as a cue to action by sending mothers timely reminders, educational

messages, and motivational content about the benefits of EBF. For example, SMS or

WhatsApp messages reinforcing the importance of exclusive breastfeeding for preventing

infant diarrhea can heighten perceived susceptibility and severity, prompting mothers to

maintain EBF practices. Moreover, mobile-based peer support networks enhance self-

efficacy, giving mothers the confidence to persist despite challenges.

Empirical evidence supports the use of HBM in digital interventions. Akinyemi and Owoaje

(2020) demonstrated that health messages grounded in perceived benefits and barriers
50
 effectively improved breastfeeding practices among Nigerian women. Similarly, Sinha et al.

(2020) found that mothers who received tailored mHealth messages emphasizing

breastfeeding advantages showed higher adherence to EBF than those receiving generic

health advice. Thus, in the context of Nyanya, the HBM helps explain how mHealth

interventions can modify maternal perceptions—transforming awareness into sustained

behavior through continuous digital cues, reinforcement, and confidence-building.

2.3.2. Social Cognitive Theory (SCT)

The Social Cognitive Theory (SCT), proposed by Albert Bandura (1986), emphasizes that

learning occurs through observation, imitation, and modeling of others’ behavior. SCT posits

that behavior change results from the dynamic interaction between personal factors,

environmental influences, and behavioral patterns—a concept known as reciprocal

determinism. The theory also highlights self-efficacy as a central determinant of behavior,

suggesting that individuals are more likely to engage in an action when they believe they can

perform it successfully. SCT is particularly relevant to community-based and peer-supported

mHealth interventions. It provides a framework for understanding how mothers learn and adopt

EBF practices by observing and interacting with their peers or health workers within a supportive

environment. Mobile platforms such as WhatsApp groups and voice call forums can facilitate

observational learning by allowing mothers to share experiences, challenges, and success stories.

These virtual communities act as social models that shape attitudes, normalize EBF, and reduce

stigma associated with traditional beliefs (Chola et al., 2019).

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In this study, SCT explains how behavioral reinforcement occurs through continuous social

interaction and feedback. For example, when a mother shares a success story about overcoming

workplace challenges to continue breastfeeding, others learn and are inspired to emulate similar

behaviors. mHealth interventions leverage these mechanisms by creating virtual peer networks

that replicate face-to-face community support, thus enhancing self-efficacy and motivation.

Furthermore, SCT aligns with the participatory approach of sustainable health models.

Community engagement, peer mentorship, and locally adapted communication strategies are

integral to SCT’s emphasis on environmental and social influences. Evidence from Kenya’s

“MomConnect” program and Nigeria’s “HelloMama” project shows that digital peer learning

and community support substantially improved maternal knowledge and EBF adherence (Lund

et al., 2014; GSMA, 2021).

Therefore, SCT complements the HBM by addressing the social dimension of breastfeeding

behavior change—demonstrating that knowledge alone is insufficient without social

reinforcement and perceived self-efficacy. Together, they provide a dual lens for understanding

both individual motivation and community-level support mechanisms in mHealth interventions.

2.3.3. Diffusion of Innovation (DOI) Theory

The Diffusion of Innovation (DOI) Theory, developed by Everett Rogers in 1962, explains how

new ideas, behaviors, or technologies spread within a social system over time. The theory

identifies five key stages in the adoption process: knowledge, persuasion, decision,

implementation, and confirmation (Rogers, 2003). It also categorizes adopters into innovators,

early adopters, early majority, late majority, and laggards based on their willingness to embrace

new ideas. In the context of mHealth and exclusive breastfeeding, the DOI theory provides a

52
framework for understanding how mothers adopt digital health interventions and integrate them

into their daily routines. mHealth platforms introduce a new way of accessing and sharing health

information—an innovation in communication for many low-resource communities. Mothers’

decisions to use such platforms depend on factors such as perceived relative advantage (e.g.,

convenience and accessibility), compatibility (alignment with cultural norms), complexity (ease

of use), trialability, and observability (visibility of positive results). In this study, the diffusion

process can be observed in how mothers in Nyanya are introduced to mHealth tools (knowledge

stage), persuaded through testimonies and peer influence (persuasion), decide to engage with the

platform (decision), use it regularly (implementation), and encourage others to join based on

positive experiences (confirmation). Community health workers and peer counselors act as

change agents—facilitating awareness and promoting adoption of mHealth practices across the

community.

Empirical studies demonstrate the usefulness of the DOI theory in digital health promotion. Chib

et al. (2015) found that cultural compatibility and simplicity of technology were key predictors

of mHealth adoption among women in low-income communities in the Philippines. Similarly, in

sub-Saharan Africa, interventions that involved community leaders and early adopters achieved

faster diffusion and higher participation rates (Lee et al., 2021). The DOI theory is especially

relevant for ensuring the sustainability and scalability of mHealth interventions. It emphasizes

the importance of social networks, opinion leaders, and peer advocacy in spreading innovations.

In Nyanya, identifying respected mothers, traditional leaders, and health volunteers as local

champions can accelerate the diffusion of mHealth-supported breastfeeding promotion.

53
2.3.4. Integration of Theories in the Current Study

This study integrates the HBM, SCT, and DOI theories to create a comprehensive framework for

understanding the effectiveness of mHealth-supported sustainable models in promoting EBF.

 From the Health Belief Model, the study draws on individual-level constructs—

perceptions of benefits, barriers, and self-efficacy—that determine mothers’ readiness to

engage in EBF.

 From Social Cognitive Theory, the study incorporates the role of social learning, peer

support, and community engagement in reinforcing behavior through modeling and

feedback.

 From Diffusion of Innovation Theory, the study integrates the process of technology

adoption, emphasizing the importance of early adopters, change agents, and

communication channels in spreading mHealth use across communities.

Together, these theories provide a holistic understanding of how mothers acquire knowledge

(HBM), internalize behaviors through social interaction (SCT), and adopt new technologies

(DOI) that support sustained exclusive breastfeeding. The framework recognizes that

behavior change in maternal health is multifaceted—requiring not only awareness but also

continuous social reinforcement and access to enabling tools. By situating mHealth within

this multi-theoretical context, the study acknowledges both the behavioral and technological

dynamics of EBF promotion. This integrated framework will guide data collection, analysis,

and interpretation—linking mothers’ perceptions, digital engagement, and breastfeeding

outcomes in Nyanya, Abuja.

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Summary

In conclusion, the theoretical framework of this study combines three complementary models

—HBM, SCT, and DOI—to explain how mHealth-supported sustainable models can

promote exclusive breastfeeding. The HBM addresses personal motivation and perceived

risk; SCT emphasizes learning through observation and peer influence; and DOI explains

how digital innovations are adopted and sustained in communities.

This integrated approach provides a robust foundation for analyzing the interplay between

technology, community engagement, and maternal health behavior.

2.4 Summary of Literature and Research Gap

The review of literature presented in this chapter provides a comprehensive overview of

theoretical and empirical evidence on exclusive breastfeeding (EBF), mobile health

(mHealth), and sustainable models for promoting maternal and child health. It highlights the

importance of exclusive breastfeeding, identifies the barriers to its practice, and evaluates the

potential of mHealth-supported interventions to overcome those barriers, particularly in

underserved settings such as Nyanya, Abuja.

The conceptual review established that exclusive breastfeeding is one of the most cost-

effective interventions for improving infant survival and maternal health. Breast milk offers

complete nutrition, immune protection, and emotional bonding benefits during the first six

months of life (World Health Organization [WHO], 2022; UNICEF, 2021). Despite these

benefits, global and national EBF rates remain below recommended levels. In Nigeria, only

about 29% of infants under six months are exclusively breastfed (National Population

55
Commission [NPC] and ICF, 2019). Barriers such as cultural beliefs, economic hardship,

limited maternal knowledge, and weak healthcare systems have been identified as major

contributors to low EBF rates (Ogbo, Ogeleka, and Awosemo, 2017; Akinyemi and Owoaje,

2020).

The review further emphasized that health education and community support play pivotal

roles in influencing breastfeeding behavior. Health education increases mothers’ knowledge

and confidence, while community engagement fosters collective support and social

reinforcement. Evidence from African and global studies demonstrates that combining these

approaches—through peer support groups, local health workers, and family involvement—

significantly improves EBF outcomes (Aryeetey and Dykes, 2018; Adeyemi et al., 2020).

The section on mobile health (mHealth) explored its conceptual foundations and practical

applications in public health. mHealth has transformed healthcare communication by

leveraging mobile and wireless technologies to deliver real-time, personalized health

messages. Studies reviewed globally (Lund et al., 2014; Sinha et al., 2020; Lee, Chib, and

Kim, 2021) and regionally (LeFevre et al., 2018; Chola et al., 2019) confirm that mHealth

interventions—especially those combining SMS, voice calls, and peer interaction—can

significantly increase exclusive breastfeeding initiation and continuation rates. However,

program effectiveness depends on contextual factors such as message quality, cultural

relevance, user literacy, and technology accessibility (GSMA, 2021).

A key contribution of this review is the discussion on sustainable models of mHealth.

Sustainability is critical for long-term impact and scalability. Evidence suggests that the most

successful mHealth initiatives are those that integrate digital tools into existing health
56
systems, ensure community participation, and build local capacity (Chib, van Velthoven, and

Car, 2015; Lee et al., 2021). Programs such as Kenya’s MomConnect and India’s Mobile

Kunji illustrate how sustainability can be achieved through government ownership and

cultural adaptation. However, sustainability challenges persist across Africa, including

limited funding, inconsistent government support, and inadequate monitoring systems.

The theoretical framework underpinning this study—comprising the Health Belief Model

(HBM), Social Cognitive Theory (SCT), and Diffusion of Innovation (DOI) Theory—

provides a multidimensional perspective on behavioral change and technology adoption. The

HBM emphasizes personal perceptions and motivations; SCT highlights social learning, peer

influence, and self-efficacy; while DOI explains how innovations spread through

communities. Integrating these frameworks offers a comprehensive understanding of how

mHealth-supported sustainable models can influence EBF practices among mothers in

underserved communities such as Nyanya, Abuja.

The empirical review further revealed consistent global evidence that mHealth interventions

improve maternal knowledge and EBF rates. In sub-Saharan Africa, programs such as

MomConnect (Kenya) and MAMA (South Africa) demonstrated measurable improvements in

breastfeeding behavior through digital messaging and community engagement (LeFevre et

al., 2018; Cole-Lewis et al., 2016). In Nigeria, smaller-scale studies such as HelloMama and

various WhatsApp-based education projects have also yielded positive results (Akinyemi and

Owoaje, 2020; Ezeh et al., 2020). However, these studies are limited in scope, duration, and

sustainability assessment.

Identified Research Gaps

57
Despite significant progress in mHealth and EBF research, several gaps remain that justify

the current study:

1. Limited Focus on Sustainability:

Most mHealth initiatives in Nigeria have been short-term and donor-driven, with limited

consideration for sustainability beyond the project lifecycle. Few studies have evaluated

how community engagement and institutional integration affect long-term outcomes of

mHealth-supported breastfeeding interventions (Chukwuma and Isah, 2021).

2. Scarcity of Studies in Peri-Urban and Underserved Settings:

The majority of Nigerian studies have been conducted in urban centers such as Lagos or

Ibadan, with little focus on peri-urban settlements like Nyanya, Abuja. These

communities face unique challenges—such as poor infrastructure, mixed cultural

influences, and high mobility—that require context-specific solutions (NPC and ICF,

2019).

3. Limited Integration of Behavioral Theories:

While global research often employs behavioral models like HBM or SCT to guide

intervention design, many Nigerian studies lack explicit theoretical grounding. This limits

understanding of the psychological and social mechanisms driving behavior change in

EBF promotion.

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4. Gaps in Measuring Effectiveness and Usability:

Existing Nigerian mHealth studies often measure knowledge improvement but rarely

assess the actual behavioral outcomes (e.g., sustained six-month EBF). Moreover, few

studies have examined the usability and accessibility of digital tools among low-literacy

mothers in underserved areas (GSMA, 2021).

5. Insufficient Data on Peer and Community Support Mechanisms:

Although peer influence is known to be critical for behavioral sustainability, limited

empirical data exist on how digital peer networks (e.g., WhatsApp groups) interact with

community structures to reinforce exclusive breastfeeding practices (Ezeh et al., 2020).

6. Lack of Mixed-Methods Evidence:

Most Nigerian mHealth studies rely on quantitative surveys without integrating

qualitative insights from mothers, health workers, and community leaders. A mixed-

methods approach can provide a more holistic understanding of mHealth adoption,

cultural acceptability, and behavioral outcomes.

Conclusion of the Literature Review

In summary, the literature affirms the potential of mHealth-supported sustainable models

as an innovative, cost-effective strategy for promoting exclusive breastfeeding. Global

and regional studies demonstrate positive outcomes, yet contextual variations necessitate

localized adaptation. In Nigeria, research gaps remain in sustainability assessment,

theoretical application, and the integration of digital and community-based approaches.

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The present study seeks to fill these gaps by evaluating the effectiveness of mHealth-

supported sustainable models for promoting exclusive breastfeeding in underserved

communities in Nyanya, Abuja. By employing a mixed-methods design and emphasizing

community engagement, this study aims to contribute new evidence that supports

scalable, culturally sensitive, and sustainable digital health interventions aligned with

Nigeria’s maternal and child health goals and the Sustainable Development Goals (SDG

3 and SDG 9)

2.3 Summary of Literature and Research Gap

The growing body of literature has shown that although mHealth interventions are

increasingly recognized as effective platforms for enhancing maternal and child health

outcomes, their integration into national health systems and sustainability beyond pilot

phases remain key limitations (Chib, van Velthoven, and Car, 2015). In many developing

countries, including Nigeria, mHealth projects have been largely donor-dependent,

implemented as short-term initiatives without clear transition plans to government

ownership or community-led management. As a result, the long-term benefits and

scalability of these interventions have been inconsistent.

A major insight from the literature is that the success of mHealth interventions depends

heavily on human interaction. While digital messages provide convenience and

consistency, mothers often require opportunities to discuss, clarify, and seek reassurance

from trusted sources, such as community health workers (CHWs) or peers. For instance,

studies from Ghana and Uganda (Aryeetey and Dykes, 2018; Kibuule et al., 2017)

revealed that the combination of mobile messages and peer counseling was more

60
 effective in improving EBF adherence than messages alone. This finding aligns with

Bandura’s (1986) Social Cognitive Theory, which emphasizes observational learning and

social reinforcement as essential for sustaining behavioral change.

The Role of Cultural Context

The literature also highlights the critical role of cultural context in shaping the acceptance and

effectiveness of mHealth interventions. Exclusive breastfeeding is not only a health behavior but

also a cultural practice influenced by community beliefs, traditions, and family dynamics. For

instance, in many Nigerian communities, elderly women and grandmothers exert considerable

influence over infant feeding decisions. In such cases, digital messages directed only at mothers

may be insufficient unless the broader family unit is also engaged. This finding was echoed by

Okafor, Olatunji, and Ogbonna (2018), who argued that EBF interventions must account for

family hierarchies and traditional norms that affect maternal decision-making.

The inclusion of culturally adapted communication—using local dialects, relatable metaphors,

and visual cues—can significantly increase message comprehension and acceptance. Evidence

from Bangladesh and India (Khatun et al., 2015; Sinha et al., 2020) demonstrated that

localization of mHealth content improved EBF compliance by 15–20%. However, very few

Nigerian studies have systematically evaluated cultural tailoring in digital health communication,

representing a key research gap this study aims to address.

Technological and Infrastructural Challenges

Another gap identified relates to the technological and infrastructural barriers facing mHealth

implementation in Nigeria. Although mobile phone penetration has increased dramatically over

61
the last decade, network coverage and data affordability remain challenges, particularly in peri-

urban and rural areas (GSMA, 2021). Power supply issues also affect the ability of mothers to

consistently access mobile services. Furthermore, low digital literacy among less-educated

mothers limits engagement with text-heavy or app-based interventions. Most reviewed studies

recommend adopting voice-based platforms or interactive voice response (IVR) systems to

overcome literacy barriers and reach a wider audience. The HelloMama project, for instance,

successfully used voice messages in local languages to reach illiterate women in Ebonyi and

Cross River states (GSMA, 2021).

However, no known study has yet evaluated the combined effectiveness of multi-channel

mHealth systems—for instance, integrating SMS, voice calls, and WhatsApp support groups—

in promoting EBF in Nigeria. This is another significant gap that the current research seeks to

fill, particularly in the context of Nyanya, Abuja, where diverse socioeconomic backgrounds

coexist.

Institutional and Policy Gaps

Institutional and policy-related gaps were also evident across the literature. Nigeria’s National

Health Policy and the National Strategic Plan for Infant and Young Child Feeding (FMoH, 2020)

both recognize breastfeeding promotion as a national priority. Nevertheless, there is limited

evidence of policy integration between digital health strategies and breastfeeding programs.

Most mHealth interventions have been implemented by non-governmental organizations (NGOs)

or donor agencies, often operating parallel to government systems rather than as part of them

(Chukwuma and Isah, 2021). This fragmentation limits data sharing, standardization, and

sustainability. Strengthening government engagement and establishing formal linkages between

62
health ministries, mobile network providers, and local communities are essential for scaling

mHealth-supported breastfeeding initiatives nationwide.

Behavioral Determinants and Psychosocial Dimensions

Another underexplored area concerns the behavioral determinants and psychosocial influences

that affect mothers’ adherence to exclusive breastfeeding. While many studies document

improved knowledge levels following mHealth interventions, fewer have assessed behavioral

intentions and long-term adherence. Research in South Africa and Kenya (Cole-Lewis et al.,

2016; LeFevre et al., 2018) found that message exposure initially increased EBF rates but that

behavioral decay occurred after 3–4 months if continuous reinforcement was not provided. This

underscores the need for sustainable support mechanisms, such as peer networks, mobile forums,

and digital reminders extending throughout the six-month breastfeeding period.

Moreover, there is limited research examining maternal self-efficacy in the Nigerian context.

According to the Health Belief Model (Glanz et al., 2015), self-efficacy—the belief in one’s

ability to execute a behavior—is a strong predictor of health behavior adoption. mHealth systems

that incorporate personalized feedback and success tracking (for example, progress dashboards

or milestone notifications) have been shown to improve mothers’ confidence and motivation to

continue EBF (Lee et al., 2021). Evaluating such features among mothers in Nyanya can provide

new insights into how digital tools influence behavioral sustainability.

Equity and Gender Gaps

Gender disparities also represent a crucial research gap. Studies have shown that women in low-

income households are less likely to own personal phones or control their usage (GSMA, 2021).
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In some communities, male partners control access to communication devices, potentially

limiting women’s engagement with mHealth interventions. Very few Nigerian studies have

examined the gender dynamics surrounding mHealth participation. Addressing this gap requires

exploring strategies for inclusive digital access, such as family-centered interventions that

involve fathers and caregivers in breastfeeding education through shared messaging platforms.

Sustainability and Scalability Considerations

A consistent theme throughout the literature is the question of sustainability. Although pilot

mHealth programs often yield impressive short-term outcomes, their benefits tend to diminish

once external funding ends. As Chib et al. (2015) and GSMA (2021) noted, the sustainability of

digital health programs depends on three interlinked factors:

1. Institutional Ownership – The extent to which national or local health authorities adopt

and manage the program post-implementation.

2. Community Participation – The involvement of beneficiaries in program design,

feedback, and management to ensure relevance and ownership.

3. Financial Viability – The presence of funding models or cost-sharing mechanisms that

ensure program continuity.

The current study addresses this sustainability gap by assessing not only the effectiveness of

mHealth-supported models but also their potential for long-term integration into

community and health system structures in Nyanya.

Methodological Gaps

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 From a methodological standpoint, most Nigerian mHealth studies employ descriptive or

quasi-experimental designs, often limited to small sample sizes and short observation

periods. Very few have used mixed-methods approaches, combining quantitative and

qualitative data to capture both measurable outcomes and contextual insights.

Additionally, few have assessed effectiveness across multiple indicators, such as

maternal knowledge, behavioral adherence, and infant health outcomes. The present

study seeks to address these limitations through a robust methodological framework

involving diverse data sources, triangulation, and statistical analysis of EBF-related

indicators.

Emerging Opportunities

The literature also highlights emerging opportunities that could enhance mHealth-supported

EBF programs. These include:

 Integration of Artificial Intelligence (AI) to personalize message delivery based on user

responses and behavioral patterns (Lee et al., 2021).

 Partnerships with Mobile Network Operators (MNOs) to reduce communication costs

and extend network reach.

 Use of social media platforms, such as WhatsApp and Facebook, for real-time peer

engagement and community mobilization.

 Open-source health applications that enable government agencies and NGOs to adapt

existing tools rather than developing costly new systems.

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By harnessing these opportunities, Nigeria can build scalable, context-appropriate digital

ecosystems that support maternal health behavior change, even in resource-limited settings.

Synthesis and Research Justification

In summary, the review shows that mHealth-supported interventions hold great promise

for promoting exclusive breastfeeding, especially when combined with community-based

and peer-led approaches. However, critical gaps persist in sustainability, cultural

adaptation, behavioral measurement, and gender inclusivity. Few studies in Nigeria have

holistically addressed these dimensions, particularly in peri-urban underserved

communities like Nyanya, Abuja.

Therefore, the present study is justified on several grounds:

1. It focuses on an underserved peri-urban context, where mixed socioeconomic factors

influence health behavior.

2. It evaluates not just effectiveness, but also sustainability and scalability, providing

policy-relevant insights.

3. It applies a theory-driven and mixed-methods approach, linking behavioral change

models to real-world mHealth implementation.

4. It aims to generate locally grounded evidence to guide digital health policy and

breastfeeding promotion strategies in Nigeria.

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 CHAPTER THREE

RESEARCH METHODOLOGY

3.0 INTRODUCTION

This chapter presents the methods and procedures adopted for conducting the study on the

Effectiveness of mHealth-Supported Sustainable Models for Promoting Exclusive Breastfeeding

Practices in Underserved Communities in Nyanya, Abuja. It describes the research design, study

area, population, sampling technique, data collection tools, and procedures used in ensuring the

reliability and validity of the study. The methodology also explains how data were analyzed and

the ethical considerations observed throughout the research process. The primary objective of

this study is to assess how mobile health (mHealth) interventions can effectively support

exclusive breastfeeding (EBF) practices through sustainable and community-based approaches.

In this regard, the chapter provides a systematic framework that guided the collection and

analysis of both quantitative and qualitative data.

The approach adopted in this study is consistent with global public health research practices that

emphasize evidence-based methods and community engagement (Creswell, 2014). Since the

study involves exploring the perceptions, experiences, and measurable outcomes of mothers,

health workers, and community members in Nyanya, a methodology that combines both

statistical analysis and descriptive insights was deemed appropriate. This chapter, therefore,

establishes the foundation upon which the research findings in subsequent chapters will be

interpreted, ensuring that the study’s conclusions are valid, reliable, and replicable.

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3.1 RESEARCH DESIGN

The research adopted a mixed-methods cross-sectional design, which combines both

quantitative and qualitative research approaches. This design was chosen because it allows for

the comprehensive collection of numerical data from a representative sample while also

providing contextual understanding through qualitative insights (Creswell & Plano-Clark, 2017).

The quantitative component involves the use of structured questionnaires administered to

mothers of infants aged 0–6 months within the Nyanya community to assess their knowledge,

attitudes, and practices related to exclusive breastfeeding, as well as their exposure to and use of

mHealth interventions. The qualitative component includes interviews with key informants

such as community health workers, traditional birth attendants, and local health officials to

explore their experiences and perceptions regarding mHealth initiatives and sustainable

breastfeeding promotion models in underserved settings.

The mixed-methods design is particularly suitable for this study for the following reasons:

1. Comprehensiveness: It enables the triangulation of findings, where quantitative results are

complemented by qualitative insights for a more holistic understanding of mHealth

effectiveness.

2. Depth of Analysis: Quantitative data provide measurable evidence of behavior and

outcomes, while qualitative data offer explanations for observed patterns.

3. Relevance to Public Health: mHealth interventions often involve human behaviors,

technology use, and community participation, which are best understood through multiple

perspectives.

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 The study employed a cross-sectional approach because data were collected at a single

point in time from a defined population rather than over an extended period. This approach is

time-efficient, cost-effective, and suitable for identifying associations between variables,

such as between mothers’ exposure to mHealth programs and their EBF practices.

The conceptual framework guiding this research (developed in Chapter Two) integrates the

Health Belief Model (HBM), Social Cognitive Theory (SCT), and Diffusion of

Innovation (DOI). These models informed the design of the questionnaire, ensuring that

questions captured variables such as perceived benefits, barriers, social influences, and

technology adoption behaviors.

Therefore, the mixed-methods design was the most appropriate for addressing the study’s

objectives, which include:

 Determining the level of awareness and use of mHealth interventions among mothers in

Nyanya;

 Assessing the relationship between mHealth exposure and exclusive breastfeeding

practices;

 Identifying challenges and facilitators influencing the sustainability of mHealth-

supported EBF models in underserved communities.

3.2 POPULATION AND SAMPLING TECHNIQUES

Sample Size Determination

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The sample size for this study was determined using the Cochran formula for estimating a single

population proportion, which is appropriate for cross-sectional and quasi-experimental public

health studies assessing proportions such as exclusive breastfeeding practice.

Formula:

n = \frac{Z^2 \times p \times q}{d^2}

Where:

= minimum required sample size

= standard normal deviate corresponding to 95% confidence level (1.96)

= estimated prevalence of exclusive breastfeeding

=1−p

= margin of error (precision), set at 5% (0.05)

Assumptions Used:

Confidence level: 95%

Z-value: 1.96

Prevalence of exclusive breastfeeding (p): 27% (0.27)

Based on NDHS reports and similar studies in urban and peri-urban Nigerian settings

q: 1 − 0.27 = 0.73

Margin of error (d): 5% (0.05)

Calculation:

n = \frac{(1.96)^2 \times 0.27 \times 0.73}{(0.05)^2}

n = \frac{3.84 \times 0.1971}{0.0025}

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n = \frac{0.757}{0.0025}

n = 302.8

The minimum calculated sample size was therefore 303 respondents.

Adjustment for Non-Response:

To account for possible non-response or incomplete questionnaires, a 5% non-response rate was

added:

n_{adjusted} = \frac{303}{1 - 0.05}

n_{adjusted} = \frac{303}{0.95} = 319

Final Sample Size:

The sample size was rounded up to 320 respondents.

3.3 METHODS OF DATA COLLECTION

The questionnaire method was employed for data collection in this study to obtain

quantitative information from mothers with infants aged 0–6 months in Nyanya,

Abuja. A structured questionnaire was designed based on the study objectives and

relevant literature on exclusive breastfeeding and mHealth interventions. The

instrument consisted of both closed-ended questions and Likert-scale items to

assess respondents’ socio-demographic characteristics, knowledge, attitudes,

practices, exposure to mHealth interventions, effectiveness of mHealth support,

and sustainability factors.

The questionnaire was administered at baseline (pre-intervention) and endline

(post-intervention) to measure changes in exclusive breastfeeding knowledge and

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practices following exposure to the mHealth-supported sustainable model. This

method was chosen because it is cost-effective, allows for the collection of data

from a large population within a short time, and ensures uniformity of responses,

thereby enhancing reliability. To improve accuracy and comprehension, the

questionnaire was interviewer-administered where necessary. The instrument was

pre-tested in a similar community to ensure clarity, validity, and reliability before

final deployment.

3.4 TECHNIQUE FOR DATA ANALYSIS AND MODEL

SPECIFICATION

T-Test on Paired Sample Design

A paired sample t-test (also known as a dependent t-test) is a statistical test used to

compare the means of two related measurements taken from the same group at

different times. In this study, it is used to assess differences between pre-

intervention (baseline) and post-intervention (endline) scores of mothers exposed

to the mHealth-supported sustainable model.

Application in This Study

The paired sample t-test was applied to compare:

Mean knowledge scores on exclusive breastfeeding before and after the mHealth

intervention

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Mean attitude or self-efficacy scores before and after the intervention

Assumptions

The paired sample t-test assumes that:

The data are continuous (interval or ratio scale).

The paired observations come from the same respondents.

The differences between paired observations are approximately normally

distributed.

Formula

d
t = Where:
sd / √ n

d = mean difference between paired observations

sd = standard deviation of the differences

n = number of paired observations

Decision Rule

If p < 0.05, the null hypothesis is rejected, indicating a significant difference

between pre- and post-intervention means.

If p ≥ 0.05, the null hypothesis is not rejected.

Relevance to the Study

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3.5 Justification of Methods

The paired sample t-test is appropriate for this study because it allows for the

evaluation of the effectiveness of the mHealth-supported sustainable model by

determining whether observed changes in exclusive breastfeeding knowledge and

attitudes are statistically significant after the intervention.

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 CHAPTER FOUR

4.0 RESULTS AND DISCUSION

This chapter presents the results of the study titled “Effectiveness of mHealth-Supported

Sustainable Models for Promoting Exclusive Breastfeeding Practices in Underserved

Communities in Nyanya, Abuja.” The chapter is structured to align with the specific objectives

of the research. It begins with a detailed description of the data collection process, demographic

characteristics of respondents, and proceeds to a comprehensive analysis of findings. The

relevance of this chapter is grounded in the global concerns surrounding infant nutrition,

maternal health, and the persistent gaps in exclusive breastfeeding (EBF) adherence in

marginalized communities. Exclusive breastfeeding—the practice of feeding infants solely on

breast milk for the first six months of life—is recognized globally as the most cost-effective,

accessible, and nutritionally complete method of ensuring optimal child development. However,

despite its benefits, adherence to exclusive breastfeeding remains significantly low in many

underserved communities, including Nyanya, Abuja. The emergence of mobile health (mHealth)

technologies represents an innovative shift in the healthcare communication landscape. mHealth

tools—including SMS reminders, mobile applications, WhatsApp support groups, and interactive

voice response (IVR)—provide low-cost, highly scalable platforms for delivering timely health

information. In resource-limited settings, where distance, low literacy, and inadequate health

personnel pose barriers to effective health promotion, mHealth has proven instrumental in

bridging health gaps, supporting behaviour change communication, and strengthening maternal

and child health initiatives.

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The chapter presents baseline and post-intervention findings to evaluate the effectiveness of

these mHealth-supported models. The study also examines peer involvement—such as mother-

to-mother support groups—and community engagement mechanisms, which are crucial to

sustaining breastfeeding behaviours beyond clinical instruction. Special attention is given to the

accessibility, usability, and acceptability of mHealth tools among mothers in Nyanya, Abuja—a

community characterized by socioeconomic constraints, high population density, and limited

access to structured maternal health education. Furthermore, the chapter identifies contextual

facilitators and barriers encountered during implementation. These include digital literacy,

network connectivity, cultural norms, household decision-making dynamics, partner support, and

perceptions surrounding breastfeeding. By exploring these dynamics, this chapter provides

evidence-informed insights essential for scaling mHealth-supported breastfeeding interventions

across underserved Nigerian communities.

Data analysis combines descriptive and inferential statistical techniques—including frequencies,

percentiles, chi-square tests, and paired t-tests—to assess changes before and after the

intervention. The findings are presented in tables and interpreted in relation to the study

objectives and relevant literature.

4.1 SOCIO-DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS

A total of 320 mothers of infants aged 0–6 months participated in the study. Table 4.1 presents

their demographic profile. The sample reflects a typical urban underserved population,

dominated by young mothers aged 25–34 years (61.9%). Most respondents had at least

secondary education (43.1%) and were primarily informal workers (traders and artisans),

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aligning with socioeconomic realities of Nyanya. These demographics provide a relevant basis

for understanding EBF patterns and mHealth adoption potential.

Table 4.1: Socio-Demographic Characteristics of Respondents (N = 320)

Variable Category Frequency (f) Percentage (%)

Age 18–24 years 64 20.0
25–29 years 96 30.0
30–34 years 102 31.9
35 years and above 58 18.1
Marital Status Married 249 77.8
Single 58 18.1
Widowed/Separated 13 4.1
Educational Status No formal education 28 8.8
Primary education 67 20.9
Secondary education 138 43.1
Tertiary 87 27.2
Occupation Trader 113 35.3
Civil servant 62 19.4
Artisan (e.g., hairdresser, tailor) 99 30.9
Unemployed 46 14.4
Parity 1 child 72 22.5
2–3 children 156 48.8
4 or more 92 28.8

Source: Field Survey, 2025

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4.2 Level of Community Engagement and Peer Support in Sustaining Exclusive

Breastfeeding Practices

This objective evaluated the extent to which community-level structures influenced breastfeeding

outcomes. Data were collected on involvement in peer groups, attendance at community

sensitization, and support received from community health volunteers (CHVs), TBAs, and peer

counsellors. Table 4.2 shows that over half of the mothers were involved in community-based

breastfeeding engagements. Interaction with CHVs was particularly high (71.6%), indicating

their critical role in sustaining breastfeeding messaging at community level. Table 4.3 shows that

Peer support played a strong to moderate role in shaping breastfeeding behaviour among

respondents. The popularity of digital peer support groups demonstrates openness to technology-

enhanced interventions.

Table 4.2: Community Engagement in Exclusive Breastfeeding Promotion

Community Engagement Indicator Yes f(%) No f(%)

Participation in community breastfeeding meetings 188 (58.8%) 132 (41.2%)

Exposure to community-led breastfeeding outreach 204 (63.8%) 116 (36.2%)

Interaction with community health volunteers on EBF 229 (71.6%) 91 (28.4%)

Attendance at mother-baby support groups 172 (53.8%) 148 (46.3%)

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Community Engagement Indicator Yes f(%) No f(%)

Breastfeeding demonstrations attended 193 (60.3%) 127 (39.7%)

Source: Field Survey, 2025

Table 4.3: Perceived Influence of Peer Support on Exclusive Breastfeeding

Strong Influence Moderate Low/No Influence

Peer Support Indicator
f(%) f(%) f(%)

Encouragement from other mothers 136 (42.5%) 122 (38.1%) 62 (19.4%)

Learning breastfeeding techniques from

118 (36.9%) 134 (41.9%) 68 (21.3%)
peers

Peer-sharing of breastfeeding
142 (44.4%) 109 (34.1%) 69 (21.6%)
experiences

WhatsApp or SMS peer-support groups 105 (32.8%) 132 (41.3%) 83 (25.9%)

Source: Field Survey, 2025

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4.3 Effectiveness of mHealth-Supported Sustainable Models Before and After

Interventions

This section analyses the observed change in exclusive breastfeeding rates following exposure to

the mHealth intervention.

The intervention included:

1. SMS reminders on breastfeeding tips

2. WhatsApp support groups

3. Interactive voice messages

4. Appointment reminders

5. Digital peer-counselling

6. Weekly educational videos

A pre-post quasi-experimental design was employed. There was a statistically significant

increase in exclusive breastfeeding practices after the mHealth-supported intervention. EBF

improved from 40% to 73.1%, confirming the effectiveness of mHealth tools in driving

behavioural change.

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Table 4.4: Pre- and Post-Intervention Exclusive Breastfeeding Rates

Status Pre-Intervention f(%) Post-Intervention f(%)

Practicing Exclusive Breastfeeding 128 (40.0%) 234 (73.1%)

Not Practicing Exclusive Breastfeeding 192 (60.0%) 86 (26.9%)

Statistical Test: Paired t-Test Analysis

 Mean EBF score before: 1.40

 Mean EBF score after: 2.22

 t = 9.84, p < 0.001

4.4 KNOWLEDGE LEVELS BEFORE AND AFTER MHEALTH INTERVENTION

High knowledge increased dramatically from 19.4% to 60% post-intervention.

All key behavioural indicators improved significantly. Avoiding water supplementation a major

challenge in Nigeria - showed one of the largest improvements.

Table 4.5: Comparison of Knowledge Levels About Exclusive Breastfeeding

Knowledge Category Pre-Intervention f(%) Post-Intervention f(%)

Low Knowledge 102 (31.9%) 32 (10.0%)

Moderate Knowledge 156 (48.8%) 96 (30.0%)

High Knowledge 62 (19.4%) 192 (60.0%)

Source: Field Survey, 2025

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Table 4.6: Changes in Breastfeeding Behavioural Indicators

Behavioural Indicator Before (%) After (%)

Initiated breastfeeding within 1 hour of birth 49.1 78.4
Breastfed on demand 52.8 82.5
Avoided water supplementation 37.2 74.1
Proper latching positioning 41.6 79.7

Source: Field Survey, 2025

4.4 USABILITY AND ACCESSIBILITY OF MHEALTH TOOLS AMONG

MOTHERS

This objective assessed mothers’ ability to use, navigate, and benefit from mHealth tools.

High levels of mobile phone ownership and SMS engagement indicate strong feasibility for

mHealth adoption.

Majority of the mothers rated the tools highly accessible and easy to use.

Table 4.7: Access to Mobile Devices

Access Indicator Yes f(%) No f(%)

Owns a mobile phone 276 (86.3%) 44 (13.8%)
Has internet access on phone 215 (67.2%) 105 (32.8%)
Uses WhatsApp 198 (61.9%) 122 (38.1%)
Reads SMS regularly 244 (76.3%) 76 (23.8%)

Source: Field Survey, 2025

Table 4.8: Usability Scores of mHealth Tools

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Usability Indicator High (%) Moderate (%) Low (%)
Ease of reading SMS content 68.4 21.9 9.7

Ease of navigating WhatsApp groups 59.7 24.1 16.3

Ability to follow voice instructions 72.8 19.1 8.1

Understanding video demonstrations 63.4 26.2 10.3

Source: Field Survey, 2025

4.5 CHALLENGES AND FACILITATORS IN IMPLEMENTING MHEALTH-

SUPPORTED EBF MODELS

This objective identified real-world constraints and enablers associated with mHealth

interventions. The most prominent challenge was competing household responsibilities, affecting

adherence to message prompts. Network issues and digital literacy gaps also hindered

participation. Convenience of receiving health messages at home was the strongest facilitator.

Peer support and motivation also played major roles. The findings of the study align with

national and global evidence demonstrating the potential of mHealth innovations in improving

maternal and child health outcomes. The results showed that community involvement greatly

enhances breastfeeding adherence. Engagement through mother support groups, community

health volunteers, and breastfeeding outreach proved instrumental. This is consistent with WHO

recommendations emphasizing community-oriented breastfeeding support as a determinant of

sustained EBF.

The intervention significantly increased EBF rates from 40% to 73.1%, demonstrating strong

evidence of mHealth effectiveness. SMS reminders, video demonstrations, and WhatsApp

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support groups enhanced knowledge and influenced behavioural change. High mobile phone

ownership indicates that urban underserved communities are well-positioned for mHealth

adoption. Mothers found SMS and audio formats most user-friendly, suggesting that literacy

barriers can be addressed using voice-based solutions. Despite high effectiveness, challenges

such as poor network connectivity, digital literacy, cultural misconceptions, and household

workload constraints remain obstacles. However, strong facilitators—peer support, health worker

involvement, partner encouragement—counterbalanced these challenges.

Table 4.9: Major Challenges Encountered During Implementation

Challenge Frequency (f) Percentage (%)

Poor network connectivity 156 48.8

Limited digital literacy 124 38.8

Phone battery/charging issues 142 44.4

Shared phone with spouse 97 30.3

Cultural myths about breastfeeding 113 35.3

Competing household responsibilities 178 55.6

Source: Field Survey, 2025

Table 4.10: Facilitators Supporting mHealth-Enhanced EBF Practices

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Facilitator Frequency (f) Percentage (%)

Strong peer-support groups 204 63.8

Personal motivation to breastfeed 253 79.0

Engaging health workers 219 68.4

User-friendly mHealth interface 187 58.4

Encouragement from partners 162 50.6

Convenience of receiving SMS at home 276 86.3

4.6 Discussion

The findings demonstrate that mHealth-supported interventions substantially enhanced exclusive

breastfeeding outcomes in Nyanya’s underserved population. This is clearly reflected in the

dramatic rise in EBF rates from 40% to 73.1% after the intervention. This improvement affirms

that behavioural change communication delivered through mobile technologies can address

longstanding barriers to breastfeeding adherence where conventional health education alone has

been insufficient.

Data show significant involvement of mothers in community breastfeeding meetings (58.8%),

outreach programs (63.8%), and interactions with community health volunteers (71.6%) . Such

high engagement aligns with WHO evidence that community-level support networks are strong

determinants of sustained breastfeeding practices. The findings that peer influence had strong or

moderate sway over most mothers further highlight the value of integrating digital peer-support

mechanisms such as WhatsApp groups.

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Each mHealth strategy - SMS, voice messages, videos, WhatsApp groups, and appointment

reminders - contributed to boosting knowledge and behavioural outcomes. High knowledge

increased from 19.4% to 60% post-intervention, indicating strong health literacy gains . The

increase in key EBF behaviours such as avoiding water supplementation (from 37.2% to 74.1%)

and correct positioning (from 41.6% to 79.7%) demonstrates the practical impact of repeated

digital cues and counselling.

The statistically significant paired t-test (t = 9.84, p < 0.001) provides robust evidence that the

measured improvements were not by chance. This highlights the ability of mHealth tools to act

as both reminders and reinforcements of desired health behaviours, particularly in low-resource,

high-workload environments.

Mobile phone ownership (86.3%), regular SMS reading (76.3%), and WhatsApp use (61.9%)

indicate strong feasibility for sustained mHealth adoption in Nyanya . High usability scores -

especially for voice-based content - suggest that mHealth interventions can overcome literacy

and comprehension barriers, an important factor in underserved communities.

The most prevalent challenge was competing household responsibilities (55.6%), followed by

poor network connectivity (48.8%) and charging issues (44.4%). These constraints reflect

structural and infrastructural limitations common across urban-poor Nigerian settlements.

Cultural myths also persisted, indicating the need for continuous culturally sensitive education.

Nevertheless, facilitators such as convenience of home-based SMS (86.3%), personal motivation,

strong peer networks, and engagement with health workers significantly supported the

intervention’s success. These facilitators demonstrate the importance of combining technological

innovations with human support systems to drive behaviour change.

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87
 CHAPTER FIVE

SUMMARY, CONCLUSION AND RECOMMENDATION

5.1 Summary

The results from the study show that mHealth-supported breastfeeding models are highly

effective in improving exclusive breastfeeding knowledge, attitudes, and practices among

mothers in underserved communities in Nyanya, Abuja. The intervention produced significant

improvements in EBF rates, maternal knowledge, early initiation practices, avoidance of water

supplementation, and general breastfeeding technique. Community engagement and peer-support

structures enhanced behavioural sustainment, while infrastructural and socio-cultural challenges

moderated participation. Overall, the evidence affirms that mHealth approaches are feasible,

acceptable, and impactful in low-resource urban settings.

5.2 Conclusion

This study concludes that mHealth-supported sustainable models represent an effective strategy

for promoting exclusive breastfeeding in underserved communities. The interventions

substantially improved EBF rates, enhanced breastfeeding knowledge, and fostered positive

behavioural change. The results highlight the potential of integrating digital health tools with

community-level structures and peer networks to address breastfeeding barriers. Although

challenges related to connectivity, workload, and cultural pressures persist, the strong facilitators

identified suggest that mHealth can be scaled as a reliable complement to traditional maternal

health services. The findings offer evidence-based justification for adopting mHealth innovations

within national breastfeeding promotion frameworks.

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5.3 Recommendations

I recommend that the Federal Ministry of Health, as well as National Council on Health (NCH),

the National Primary Health Care Development Agency and Healthcare Policy Makers with

other relevant stakeholders should:

1. Strengthen Health System Integration of mHealth Tools

mHealth platforms such as SMS, WhatsApp groups and voice reminders should be integrated

into routine antenatal, postnatal, and immunisation services in primary healthcare centres in

Nyanya and similar underserved regions.

2. Expand Community Health Volunteer Involvement

CHVs should receive additional training on digital counselling, follow-up protocols, and

breastfeeding support to reinforce the intervention’s sustainability.

3. Develop Culturally Tailored and Low-Literacy Content

Since literacy levels vary, audio-based messages, simplified videos, and content in local

languages should be prioritised to enhance comprehension and inclusivity.

4. Address Structural Barriers to Participation

Policies and community programs should target infrastructural limitations such as connectivity,

phone charging access, and women’s workload burdens.

5. Promote Digital Peer Support Models

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WhatsApp peer-support groups and digital mother-to-mother platforms should be strengthened to

sustain motivation and create safe environments for shared learning.

6. Facilitate Multisectoral Partnerships

Collaborations between health authorities, telecom providers, NGOs, and community leaders are

essential to support cost-effective scaling.

7. Conduct Longitudinal Follow-Up

Future research should track breastfeeding duration beyond six months to assess long-term

effects of mHealth interventions on sustained breastfeeding and child nutrition outcomes.

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 REFERENCE:

Akinyemi, O. O., & Owoaje, E. T. (2020). Health education and promotion using digital platforms in
Nigeria. African Journal of Reproductive Health, 24(2), 55–66

GSMA. (2021). The mobile economy: Sub-Saharan Africa 2021. GSMA Intelligence

National Population Commission (NPC) [Nigeria] & ICF. (2019). Nigeria Demographic and Health
Survey 2018. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF

UNICEF. (2021). Infant and young child feeding: Key facts. UNICEF. World Health Organization
(WHO). (2022). Infant and young child feeding. Geneva: WHO.

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 RESEARCH QUESTIONNAIRE

Title: Effectiveness of mHealth-Supported Sustainable Models for Promoting Exclusive

Breastfeeding Practices in Underserved Communities in Nyanya, Abuja, Nigeria

SECTION A: SOCIO-DEMOGRAPHIC CHARACTERISTICS

(Objective: Background characteristics for stratified analysis and confounding control)

1. Age (years):

☐ <20 ☐ 20–24 ☐ 25–29 ☐ 30–34 ☐ ≥35

2. Marital status:

☐ Single ☐ Married ☐ Separated/Divorced ☐ Widowed

3. Highest level of education attained:

☐ No formal education

☐ Primary

☐ Secondary

☐ Tertiary

4. Occupation:

☐ Unemployed/Housewife

☐ Trader

☐ Civil servant

☐ Artisan

☐ Other (specify): __________

5. Average monthly household income:

☐ < ₦50,000

☐ ₦50,000–₦100,000

☐ > ₦100,000

☐ Prefer not to say

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6. Parity (number of children):

☐ 1 ☐ 2–3 ☐ ≥4

7. Age of index child (months):

☐ 0–2 ☐ 3–4 ☐ 5–6

SECTION B: COMMUNITY ENGAGEMENT AND PEER SUPPORT

(Addresses Objective 1)

8. Are you part of any mothers’ support group in your community?

☐ Yes ☐ No

9. If yes, how often do you participate in breastfeeding-related meetings or activities?

☐ Weekly ☐ Monthly ☐ Occasionally ☐ Rarely

10. Do you receive encouragement or advice on exclusive breastfeeding from other mothers?

☐ Yes ☐ No

11. Rate the level of community support you receive for exclusive breastfeeding:

☐ Very poor ☐ Poor ☐ Fair ☐ Good ☐ Very good

12. Peer support from other mothers motivates me to practice exclusive breastfeeding.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

13. Community leaders (e.g., religious/traditional leaders) promote exclusive breastfeeding in my

community.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

SECTION C: EXCLUSIVE BREASTFEEDING KNOWLEDGE AND PRACTICES

(Addresses Objective 2 – Pre- and Post-Intervention)

14. Have you heard of exclusive breastfeeding?

☐ Yes ☐ No

15. Exclusive breastfeeding means feeding an infant with breast milk only for the first 6 months.

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☐ True ☐ False ☐ Don’t know

16. Did you initiate breastfeeding within one hour after delivery?

☐ Yes ☐ No

17. Are you currently practicing exclusive breastfeeding?

☐ Yes ☐ No

18. If no, what other feeds are given? (Multiple responses allowed)

☐ Water

☐ Infant formula

☐ Herbal preparations

☐ Pap/solid food

19. Duration you intend/intended to practice exclusive breastfeeding:

☐ <3 months ☐ 3–5 months ☐ 6 months

20. Since receiving mHealth support, my confidence in practicing exclusive breastfeeding has
improved.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

21. The mHealth messages influenced my decision to continue exclusive breastfeeding.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

SECTION D: USABILITY AND ACCESSIBILITY OF mHEALTH TOOLS

(Addresses Objective 3)

22. Do you own or have regular access to a mobile phone?

☐ Yes ☐ No

23. Type of mobile phone used:

☐ Basic phone ☐ Smartphone

24. Which mHealth platforms were used? (Tick all that apply)

☐ SMS/Text messages

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☐ WhatsApp

☐ Voice calls

☐ Mobile application

25. How often do you receive breastfeeding-related messages via mobile phone?

☐ Daily ☐ Weekly ☐ Occasionally

26. The messages are easy to understand.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

27. The timing of the messages is convenient for me.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

28. I am able to interact (ask questions/respond) using the mHealth platform.

☐ Yes ☐ No

SECTION E: CHALLENGES AND FACILITATORS OF mHEALTH-SUPPORTED MODELS

(Addresses Objective 4)

29. What challenges do you experience in using mHealth tools?

☐ Poor network

☐ Cost of data/airtime

☐ Low phone literacy

☐ Language barriers

☐ None

30. Cultural beliefs discourage exclusive breastfeeding in my community.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

31. Support from my spouse/family encourages me to practice exclusive breastfeeding.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

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32. Health workers’ advice supports my use of mHealth for breastfeeding information.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

33. What factors make mHealth support effective for you?

☐ Regular reminders

☐ Trust in health information

☐ Ability to ask questions

☐ Peer testimonials

SECTION F: OVERALL PERCEPTION AND SUSTAINABILITY

34. Overall, how satisfied are you with the mHealth-supported breastfeeding program?

☐ Very dissatisfied ☐ Dissatisfied ☐ Neutral ☐ Satisfied ☐ Very satisfied

35. I would recommend mHealth-supported breastfeeding programs to other mothers.

☐ Strongly disagree ☐ Disagree ☐ Neutral ☐ Agree ☐ Strongly agree

36. Do you think this model can be sustained in your community?

☐ Yes ☐ No ☐ Not sure

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