{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:43:59Z","timestamp":1785545039958,"version":"3.56.0"},"reference-count":53,"publisher":"JMIR Publications Inc.","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JMIR Res Protoc"],"abstract":"Abstract<\/jats:title>\n \n Background<\/jats:title>\n In Pakistan, one-third of under-5 deaths (58\/1000 live births) are attributable to the high prevalence of stunting (40%), underweight (23%), and wasting (17.7%). Given the suboptimal prevalence of exclusive breastfeeding (EBF; 48%) and the alarmingly low consumption of a minimum acceptable diet (3.6%), mitigation of early-life nutritional risk provides a critical window of opportunity for intervention. Mobile health (mHealth) provides an innovative and low-cost option to improve infant and young child feeding practices (IYCFPs) among mothers.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n This study aims to assess the efficacy of a context-specific mHealth coaching app in promoting EBF and IYCFPs compared to face-to-face (F2F) counseling.<\/jats:p>\n <\/jats:sec>\n \n Methods<\/jats:title>\n \n This is a prospective, parallel-arm randomized controlled trial planned at a secondary care hospital in Karachi, Pakistan. The study will enroll 300 booked singleton pregnant women in the third trimester, who plan to stay in their respective areas for at least 1 year postdelivery, are registered for child immunization at the associated Family Health Center, own smartphones with internet access, are able to read Urdu, and provide consent. Participants in the intervention arm will receive the\n Pehli Ghiza<\/jats:italic>\n mHealth app along with routine standard-of-care F2F counseling. The app will deliver context-specific educational content on breastfeeding and IYCFPs through short videos and messages sent 3 times per week, tailored to the stage of pregnancy and infant age. Participants in the control arm will receive only routine F2F counseling. The standard of care will be delivered at each follow-up visit, which is scheduled at birth, at 6, 10, and 14 weeks, and at 6, 9, and 12 months of the infant\u2019s age. Data will be collected at enrollment and at each follow-up visit using structured questionnaires. Primary outcomes are EBF and the introduction of age-appropriate complementary feeding. Secondary outcomes include early initiation of breastfeeding, continued breastfeeding at 1 year, minimum dietary diversity, meal frequency, minimum acceptable diet, and child health outcomes. Analysis will follow the intention-to-treat principle to detect a 20% absolute improvement in primary outcomes between the intervention and control groups over time and to evaluate between-group differences in feeding practices. Compliance will be determined by the proportion of participants who complete the 6-month coaching program. Usability will be assessed based on features related to design, interface, content, coaching, perception, and personal benefit.\n <\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n The study was approved by the Ethics Review Committee of the Aga Khan University and the National Ethics Committee. Participant recruitment started on February 2, 2026. As of May 18, 2026, 241 participants have been recruited. Follow-ups and outcome assessments are expected to be completed by June 2027.<\/jats:p>\n <\/jats:sec>\n \n Conclusions<\/jats:title>\n \n If effective, the\n Pehli Ghiza<\/jats:italic>\n intervention could support the integration of digital health tools into standard of care in Pakistan and similar low- and middle-income country settings.\n <\/jats:p>\n <\/jats:sec>","DOI":"10.2196\/93181","type":"journal-article","created":{"date-parts":[[2026,7,20]],"date-time":"2026-07-20T17:12:22Z","timestamp":1784567542000},"page":"e93181-e93181","source":"Crossref","is-referenced-by-count":0,"title":["Efficacy of a Mobile Health App in Promoting Breastfeeding and Young Child Feeding Practices in Pakistan: Protocol for a Randomized Controlled Trial"],"prefix":"10.2196","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-7223-352X","authenticated-orcid":false,"given":"Rozina","family":"Nuruddin","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0032-3307","authenticated-orcid":false,"given":"Rehama","family":"Iqbal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8575-2946","authenticated-orcid":false,"given":"Nuruddin","family":"Mohammed","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6186-0704","authenticated-orcid":false,"given":"Khadija Barkat Ali","family":"Vadsaria","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5326-3643","authenticated-orcid":false,"given":"Sidrah","family":"Nausheen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3470-9475","authenticated-orcid":false,"given":"Saleem","family":"Sayani","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0766-4064","authenticated-orcid":false,"given":"Iqbal","family":"Azam","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1010","published-online":{"date-parts":[[2026,7,20]]},"reference":[{"key":"R1","unstructured":"The state of food security and nutrition in the world 2024: financing to end hunger, food insecurity and malnutrition in all its forms. World Health Organization; 2024. URL: https:\/\/www.who.int\/publications\/m\/item\/the-state-of-food-security-and-nutrition-in-the-world-2024 [Accessed 20-06-2026]"},{"key":"R2","unstructured":"Child malnutrition. UNICEF. URL: https:\/\/data.unicef.org\/topic\/nutrition\/malnutrition\/ [Accessed 20-06-2026]"},{"key":"R3","unstructured":"National nutrition survey 2018: key findings report. UNICEF Pakistan; 2019. URL: https:\/\/www.unicef.org\/pakistan\/media\/1951\/file\/Final%20Key%20Findings%20Report%202019.pdf [Accessed 20-06-2026]"},{"key":"R4","unstructured":"Pakistan Country Nutrition Profiles. Global Nutrition Report. Jan 28, 2026. URL: https:\/\/globalnutritionreport.org\/resources\/nutrition-profiles\/asia\/southern-asia\/pakistan\/ [Accessed 20-06-2026]"},{"key":"R5","unstructured":"Nutrition country profile: Pakistan. World Health Organization; 2023. URL: https:\/\/applications.emro.who.int\/docs\/WHOEMNUT302E-eng.pdf [Accessed 20-06-2026]"},{"key":"R6","unstructured":"Levels and trends in child mortality. UNICEF; 2024. URL: https:\/\/data.unicef.org\/resources\/levels-and-trends-in-child-mortality-2024 [Accessed 20-06-2026]"},{"key":"R7","unstructured":"World Food Program Pakistan. The economic consequences of undernutrition in Pakistan: an assessment of losses. Government of Pakistan; 2017. URL: https:\/\/www.pc.gov.pk\/uploads\/report\/Economic_Consequences.pdf [Accessed 18-02-2026]"},{"issue":"9890","key":"R8","doi-asserted-by":"publisher","first-page":"427","DOI":"10.1016\/S0140-6736(13)60937-X","article-title":"Maternal and child undernutrition and overweight in low-income and middle-income countries","volume":"382","author":"Black","journal-title":"Lancet"},{"key":"R9","unstructured":"Infant and young child feeding. World Health Organization. 2023. URL: https:\/\/www.who.int\/news-room\/fact-sheets\/detail\/infant-and-young-child-feeding [Accessed 20-06-2026]"},{"key":"R10","unstructured":"National nutrition survey 2011. Government of Pakistan; 2011. URL: https:\/\/pndajk.gov.pk\/uploadfiles\/downloads\/NNS%20Survey.pdf [Accessed 28-01-2026]"},{"issue":"1","key":"R11","doi-asserted-by":"publisher","DOI":"10.1186\/s12905-024-02996-2","article-title":"Exclusive breastfeeding and its association with intimate partner violence during pregnancy: analysis from Pakistan demographic and health survey","volume":"24","author":"Khalid","journal-title":"BMC Womens Health"},{"issue":"3","key":"R12","first-page":"329","volume":"63","author":"Farrukh","journal-title":"Pak Armed Forces Med J"},{"issue":"1","key":"R13","doi-asserted-by":"publisher","DOI":"10.1136\/bmjph-2024-002462","article-title":"Labour companionship and respectful treatment of women during childbirth: a cross-sectional study across 16 hospitals in Benin, Malawi, Tanzania and Uganda","volume":"3","author":"El-Halabi","journal-title":"BMJ Public Health"},{"issue":"10","key":"R14","doi-asserted-by":"publisher","DOI":"10.1136\/bmjopen-2023-077008","article-title":"Barriers and coping responses towards infant and young child feeding practices in rural Ethiopia: a descriptive qualitative study","volume":"13","author":"Gizaw","journal-title":"BMJ Open"},{"issue":"1","key":"R15","doi-asserted-by":"publisher","DOI":"10.1186\/s41256-021-00206-2","article-title":"Barriers and facilitators for early and exclusive breastfeeding in health facilities in Sub-Saharan Africa: a systematic review","volume":"6","author":"Kinshella","journal-title":"Glob Health Res Policy"},{"issue":"1","key":"R16","doi-asserted-by":"publisher","DOI":"10.1186\/s13006-022-00495-4","article-title":"Barriers and facilitators to exclusive breastfeeding in rural Pakistan: a qualitative exploratory study","volume":"17","author":"Riaz","journal-title":"Int Breastfeed J"},{"issue":"1","key":"R17","doi-asserted-by":"publisher","DOI":"10.2196\/mhealth.8873","article-title":"The impact of mHealth interventions: systematic review of systematic reviews","volume":"6","author":"Marcolino","journal-title":"JMIR Mhealth Uhealth"},{"key":"R18","unstructured":"Household integrated economic survey (HIES) 2024\u20132025. Pakistan Bureau of Statistics, Government of Pakistan; 2025. URL: https:\/\/www.pbs.gov.pk\/wp-content\/uploads\/2020\/07\/HIES-2024-25-Report-Final-1.pdf [Accessed 28-01-2026]"},{"key":"R19","unstructured":"Smartphone penetration rate as share of connections in Pakistan from 2014 to 2020. Statista. URL: https:\/\/www.statista.com\/statistics\/671542\/smartphone-penetration-as-share-of-connections-in-pakistan [Accessed 20-06-2026]"},{"key":"R20","unstructured":"GSMA highlights Pakistan\u2019s digital progress and potential to spur accelerated economic growth. GSMA. URL: https:\/\/www.gsma.com\/newsroom\/press-release\/gsma-highlights-pakistans-digital-progress-and-potential-to-spur-accelerated-economic-growth [Accessed 20-06-2026]"},{"key":"R21","unstructured":"Telecom indicators overview. Pakistan Telecommunication Authority (PTA). URL: https:\/\/www.pta.gov.pk\/#telecom-indicators-info [Accessed 28-01-2026]"},{"issue":"2","key":"R22","volume":"37","author":"Arif","journal-title":"J Media Studies"},{"issue":"3","key":"R23","doi-asserted-by":"publisher","DOI":"10.3390\/nu17030414","article-title":"A mobile-based approach to enhance knowledge of infant and young child feeding among teenage mothers in Nigeria: a randomized controlled trial","volume":"17","author":"Sosanya","journal-title":"Nutrients"},{"issue":"1","key":"R24","doi-asserted-by":"publisher","DOI":"10.1111\/mcn.13702","article-title":"Text messages to improve young child diets: results from a cluster\u2010randomized controlled trial in Kanchanpur, Nepal","volume":"22","author":"Cunningham","journal-title":"Matern Child Nutr"},{"issue":"1","key":"R25","doi-asserted-by":"publisher","first-page":"10","DOI":"10.36685\/phi.v10i1.756","article-title":"Effect of mHealth based intervention on maternal knowledge and practices of child care: a quasi-experimental study","volume":"10","author":"Siswati","journal-title":"Public Health of Indonesia"},{"key":"R26","doi-asserted-by":"publisher","DOI":"10.12688\/f1000research.17037.3","article-title":"Effectiveness of a mobile health intervention on infant and young child feeding among children \u2264 24 months of age in rural Islamabad over six months duration","volume":"8","author":"Akber","journal-title":"F1000Res"},{"key":"R27","doi-asserted-by":"publisher","DOI":"10.1016\/j.ijmedinf.2023.105240","article-title":"Evaluation of the usability and utility of LactApp, a mHealth for breastfeeding support","volume":"180","author":"Quifer-Rada","journal-title":"Int J Med Inform"},{"issue":"21","key":"R28","doi-asserted-by":"publisher","DOI":"10.3390\/nu17213477","article-title":"The effect of mHealth on exclusive breastfeeding and its associated factors among women in south Ethiopia: a cluster randomized controlled trial","volume":"17","author":"Gilano","journal-title":"Nutrients"},{"issue":"4","key":"R29","doi-asserted-by":"publisher","DOI":"10.1111\/mcn.13662","article-title":"The impacts of an mHealth intervention targeting parents on health service usage and out\u2010of\u2010pocket costs in the first 9 months of life: the Growing healthy app","volume":"20","author":"Laws","journal-title":"Matern Child Nutr"},{"issue":"2","key":"R30","doi-asserted-by":"publisher","first-page":"154","DOI":"10.1080\/03630242.2024.2448519","article-title":"A smartphone-based application to improve breastfeeding duration and self-efficacy: a randomized controlled clinical trial","volume":"65","author":"de Mello Sa","journal-title":"Women Health"},{"issue":"1","key":"R31","doi-asserted-by":"publisher","DOI":"10.2196\/mhealth.8998","article-title":"Effectiveness and appropriateness of mHealth interventions for maternal and child health: systematic review","volume":"6","author":"Chen","journal-title":"JMIR Mhealth Uhealth"},{"issue":"1","key":"R32","doi-asserted-by":"publisher","DOI":"10.1186\/s41043-023-00487-y","article-title":"Assessing the effect of mHealth on child feeding practice in African countries: systematic and meta-analysis","volume":"42","author":"Gilano","journal-title":"J Health Popul Nutr"},{"issue":"1","key":"R33","doi-asserted-by":"publisher","DOI":"10.1186\/s12916-024-03417-9","article-title":"Impact of mHealth interventions on maternal, newborn, and child health from conception to 24 months postpartum in low- and middle-income countries: a systematic review","volume":"22","author":"Knop","journal-title":"BMC Med"},{"key":"R34","doi-asserted-by":"publisher","DOI":"10.1177\/20552076241309520","article-title":"The effectiveness of digital health versus standard care on exclusive breastfeeding duration among postpartum mothers in LMIC: systematic review and meta-analysis","volume":"10","author":"Thepha","journal-title":"Digit Health"},{"key":"R35","doi-asserted-by":"crossref","unstructured":"Khalil MA Jan S Ali W Khan A . MotherCare app for expectant mothers in interior parts of Pakistan. In: Innovations in Global Maternal Health. IGI Global Scientific Publishing; 2020:147-167. [doi: 10.4018\/978-1-7998-2351-3.ch006]","DOI":"10.4018\/978-1-7998-2351-3.ch006"},{"key":"R36","doi-asserted-by":"crossref","unstructured":"Sajjad UU Shahid S . Baby+: a mobile application to support pregnant women in Pakistan. Presented at: MobileHCI \u201916: Proceedings of the 18th International Conference on Human-Computer Interaction with Mobile Devices and Services Adjunct; Sep 6-9, 2016; Florence, Italy. [doi: 10.1145\/2957265.2961856]","DOI":"10.1145\/2957265.2961856"},{"key":"R37","doi-asserted-by":"publisher","DOI":"10.1177\/2055207618789281","article-title":"Digitization of the health sector in Pakistan: challenges and opportunities to online health communication: a case study of MARHAM social and mobile media","volume":"4","author":"Ittefaq","journal-title":"Digit Health"},{"issue":"2","key":"R38","doi-asserted-by":"publisher","DOI":"10.2196\/16081","article-title":"Operability, acceptability, and usefulness of a mobile app to track routine immunization performance in rural Pakistan: interview study among vaccinators and key informants","volume":"8","author":"Zaidi","journal-title":"JMIR Mhealth Uhealth"},{"key":"R39","doi-asserted-by":"publisher","DOI":"10.54393\/pjhs.v5i03.1346","article-title":"Unveiling the factors behind delayed introduction of complementary feeding and its impact on infant nutrition: a case study in Peshawar, Pakistan","volume":"31","author":"Jan","journal-title":"Pak J Health Sci"},{"key":"R40","doi-asserted-by":"crossref","unstructured":"Critical Thinking in Clinical Research: Applied Theory and Practice Using Case Studies. Oxford University Press; 2018. [doi: 10.1093\/med\/9780199324491.001.0001]","DOI":"10.1093\/med\/9780199324491.001.0001"},{"key":"R41","doi-asserted-by":"crossref","unstructured":"Hagger MS Cameron LD Hamilton K Hankonen N Lintunen T . Changing behavior: a theory-and evidence-based approach. In: The Handbook of Behavior Change. Cambridge University Press; 2020:1-14. [doi: 10.1017\/9781108677318.001]","DOI":"10.1017\/9781108677318.001"},{"key":"R42","unstructured":"The community infant and young child feeding counselling package. UNICEF. Jan 28, 2026. URL: https:\/\/www.unicef.org\/documents\/community-iycf-package [Accessed 20-06-2026]"},{"key":"R43","unstructured":"Weaning: from breast milk to family food, a guide for health and community workers. World Health Organization; 1988. URL: https:\/\/iris.who.int\/server\/api\/core\/bitstreams\/d9bb2bf2-cc14-454d-ae73-fc8f76afe225\/content [Accessed 20-06-2026]"},{"key":"R44","unstructured":"Improving young children\u2019s diets during the complementary feeding period. UNICEF; 2020. URL: https:\/\/www.unicef.org\/media\/93981\/file\/Complementary-Feeding-Guidance-2020.pdf [Accessed 20-06-2026]"},{"key":"R45","unstructured":"Guiding principles for complementary feeding of the breastfed child. Pan American Health Organization (PAHO), World Health Organization (WHO); 2003. URL: https:\/\/iris.paho.org\/items\/11cce90e-91e9-45a1-b26a-80f0edcd9e04 [Accessed 20-06-2026]"},{"key":"R46","unstructured":"September 2016 (issue 1): baby\u2019s first solid foods. The Aga Khan University Hospital; 2016. URL: https:\/\/ecommons.aku.edu\/cgi\/viewcontent.cgi?article=1004&context=nutrition_update [Accessed 20-06-2026]"},{"key":"R47","unstructured":"mixpanel. 2026. URL: https:\/\/mixpanel.com\/home [Accessed 20-06-2026]"},{"key":"R48","doi-asserted-by":"crossref","unstructured":"Monteiro M Moreira M Arzileiro T Amado P . Improving sleep awareness: design and development of an m-health app. In: Perspectives on Design and Digital Communication. Springer; 2020:161-173. [doi: 10.1007\/978-3-030-49647-0_10]","DOI":"10.1007\/978-3-030-49647-0_10"},{"key":"R49","unstructured":"Indicators for assessing infant and young child feeding practices: definitions and measurement methods. World Health Organization; 2021. URL: https:\/\/iris.who.int\/server\/api\/core\/bitstreams\/79267f92-de90-4e1f-a162-4c1042c56929\/content [Accessed 20-06-2026]"},{"key":"R50","unstructured":"Indicators for assessing infant and young child feeding practices. World Health Organization; 2008. URL: https:\/\/iris.who.int\/server\/api\/core\/bitstreams\/59d64165-8956-4d24-a483-a829285f564d\/content [Accessed 20-06-2026]"},{"key":"R51","unstructured":"Malnutrition in all its forms. World Health Organization. 2026. URL: https:\/\/www.emro.who.int\/nutrition\/double-burden-of-nutrition\/malnutrition-in-all-its-forms.html [Accessed 20-06-2026]"},{"issue":"3","key":"R52","doi-asserted-by":"publisher","first-page":"265","DOI":"10.1016\/j.jadohealth.2010.12.015","article-title":"Psychometric testing of the breastfeeding self-efficacy scale-short form among adolescents","volume":"49","author":"Dennis","journal-title":"J Adolesc Health"},{"issue":"5","key":"R53","doi-asserted-by":"publisher","DOI":"10.2196\/15773","article-title":"A mobile app lifestyle intervention to improve healthy nutrition in women before and during early pregnancy: single-center randomized controlled trial","volume":"22","author":"van Dijk","journal-title":"J Med Internet Res"}],"container-title":["JMIR Research Protocols"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.researchprotocols.org\/2026\/1\/e93181","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,31]],"date-time":"2026-07-31T22:23:46Z","timestamp":1785536626000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.researchprotocols.org\/2026\/1\/e93181"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,20]]},"references-count":53,"URL":"https:\/\/doi.org\/10.2196\/93181","relation":{},"ISSN":["1929-0748"],"issn-type":[{"value":"1929-0748","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,20]]},"article-number":"v15i9890e93181"}}