Co‐designing a community lifestyle intervention program to reduce postpartum weight retention

Abstract Background Postpartum weight retention is a major contributor to obesity in later life resulting in long‐term health consequences in women. Postpartum lifestyle interventions are known to be effective in reducing postpartum weight retention and improving the overall health and wellbeing of mothers but have poor reach and engagement. This study describes the engagement of mothers with young children in the development of a theory‐ and evidence‐based intervention to reduce postpartum weight retention. Methods A participatory design methodology with input from a community mothers' group, literature reviews and an expert advisory group was applied. Mothers who were members of ‘Mothers of Preschoolers’ (MOPS) were invited to participate in a focus group discussion and two co‐design workshop sessions. Results Thirteen women participated in a focus group discussion and 12 women in each co‐design workshop. We found that mothers valued having social support from their peers, practical support such as meal delivery, and learning opportunities that focus on the mother's health and wellbeing. The advisory group suggested leveraging the unique skills and prior experiences of mothers within the group and developing a curriculum that mothers can be trained to deliver. Conclusion A program that emphasizes the strengths and value of mothers can increase their self‐worth and self‐confidence resulting in intrinsic motivation to improve lifestyle behaviours. An intervention designed to be implemented by MOPS for its members and incorporated into their regular sessions has the potential for feasibility and acceptability among mothers with young children. Patient or Public Contribution Mothers with young children were part of the program planners and were involved in the design and conduct of this study and in the interpretation of the findings. A member of a community mothers' group recruited other mothers with young children within the group to participate in a series of sessions to discuss their experiences of the postpartum period and preferences for a lifestyle program. The mothers identified the behavioural outcomes and program goals for a postpartum lifestyle program and then generated the program ideas based on these.


| INTRODUCTION
Obesity is a global epidemic affecting millions of people worldwide. 1cording to the World Health Organization, in 2016, 40% of women aged 18 years and over were living with overweight, and 15% with obesity globally. 1[9] Evidence on the efficacy of lifestyle interventions that target diet and physical activity in reducing postpartum weight retention is substantial. 6,10However, interventions are typically characterized by poor uptake and engagement by postpartum women, reducing their impact at a population level. 10Competing demands on the mother's time in the postpartum period may lead to a lack of prioritization of healthy lifestyle behaviours and returning to a healthy weight.Hence, postpartum women can be hard to reach and engage in lifestyle interventions. 6,11There is a clear imperative for implementation strategies to address barriers to intervention uptake and engagement.Such strategies are hypothesized to foster the effective translation of evidence on the efficacy of postpartum lifestyle interventions into practice in real-world settings. 6e strategy to address barriers to engagement is to co-design lifestyle intervention programs with mothers with young children as part of the planning, development, and implementation processes. 6aningful engagement of key stakeholders at each stage of intervention development is necessary to overcome practical obstacles to program implementation and improve the likelihood of positive health impacts. 12Community participatory approaches are effective in reaching hard-to-reach population groups and are key to driving improvement in healthcare by ensuring that contextual factors are captured in intervention development. 13[16] Intervention mapping (IM) is a planning framework that provides a systematic process for effective step-by-step decisionmaking for intervention planning, development, implementation and evaluation. 17,18It has been extensively applied for the design of complex behaviour change interventions and has previously been combined with participatory design approaches for intervention program development. 17,19,20alth professionals have limited time and resources to provide ongoing lifestyle support to mothers after childbirth; therefore, integrating health promotion into existing services such as mothers' groups is both innovative and practical to achieve ongoing support for postpartum women. 11,21There are international and local groups that engage women during the postnatal period (e.g., Mothers of Preschoolers and Centre of Perinatal Excellence [COPE]), offering opportunities to embed curriculum specific to different topics of value to mothers. 22,23Mothers of Preschoolers (MOPS) is an international organization, with groups across more than 70 countries, that partners with churches and organizations worldwide to support mothers. 22MOPS focuses on the mother's wellbeing and provides structured and organized childcare for mothers during MOPS sessions. 24e aim of this study was to describe the co-design of the

| IM and co-design processes
IM is an iterative six-step process with each step consisting of several tasks, which once completed, informs the next step. 17 Steps 4-6 were beyond the scope of this research.

| Theoretical framework
6][27] The TDF is an integrative framework that can facilitate a comprehensive assessment of behavioural determinants. 26,27The TDF consists of 14 domains that are an expansion of the three core components of the COM-B model and together form the hub of the Behaviour Change Wheel, a method for characterizing and designing behaviour change interventions. 25

| Participants
The co-design process focused on two levels of the socioecological model-individual (mothers with young children) and organizational (mothers' group-MOPS) levels.Mothers with young children (5 years and under) were recruited from MOPS, a community of mothers with preschoolers who meet together to be supported, encouraged and equipped as they raise children.This research was conducted in partnership with one MOPS group in Metropolitan Victoria Australia.

| Literature reviews
The needs assessment included literature reviews and focus group discussions.The following reviews were conducted: (i) a systematic review and meta-analysis to evaluate the intervention characteristics associated with weight loss in postpartum women using the Template for Intervention Description and Replication framework 28 ; (ii) a systematic review and meta-analysis to identify the most effective behavioural strategies in changing postpartum women's physical activity and healthy eating behaviours 29 ; (iii) a narrative review to examine the implementation challenges of postpartum lifestyle interventions 6 ; and (iv) a mixed-methods systematic review to understand the barriers and facilitators to a healthy lifestyle in postpartum women from the perspective of women and healthcare providers mapped to the TDF and COM-B domains. 11

| Focus group discussion
A focus group discussion was conducted over Zoom (version 5.11.1) with mothers of children 5 years and under who were members of MOPS recruited by convenience sampling.Participants were approached via email, and their contacts were obtained through a MOPS leader who was also a member of a consumer group for cardiometabolic health research in postpartum women.
The discussion guide (Supporting Information S1: Table S1) followed the strengths, weaknesses, opportunities and threats approach to understanding the capabilities of MOPS in supporting the health and wellbeing of its members. 30The discussion was facilitated by a female allied health professional (MSc.)conducting research with postpartum women (M.M.).Two female dietitians and researchers with PhDs (L.J. M. and S. L.) were also present and took notes during the discussion.The researchers had no prior relationship with the participants.Participants were aware that the study was part of the facilitator's PhD research.The discussion was video-recorded and transcribed verbatim by a transcription service provider, GoTranscript.The transcribed data were thematically analysed using NVivo, the text was reviewed line-by-line and initial codes were assigned.These codes were then organized and refined to generate subthemes and themes through an iterative process by two authors (M.M. and S. L.) (Supporting Information S1: Table S2).[BCTs] for influencing determinants of the target population) known to be effective in achieving the change objectives 32,33 were identified and mapped to the determinants and change objectives by one researcher (M.M.).The identification of BCTs was conducted using published literature. 32The change objectives grouped under each determinant were then operationalised into practical strategies that can be implemented within MOPS.Practical program strategies (program ideas or specific activities) were generated by the planning group during a second co-design workshop by workshopping tools, skills and processes needed to achieve the program outcomes and objectives.It was also informed by the findings of the needs assessment.The program ideas were discussed and ranked according to their feasibility, impact and acceptability.An expert advisory group was consulted to further refine the program components.Following the workshops, practical strategies aligned with the change methods were identified and integrated with the program ideas generated by the planning and advisory groups.The findings of the focus group discussion and co-design workshops were shared with the participants for comments or correction.Participants did not request any changes.

| Participant characteristics
Thirteen mothers who were members of MOPS participated in the focus group discussion and 12 in the co-design workshops.One participant dropped out due to other commitments.The mean age of participants was 37.1 ± 4.8 years.More than two-thirds of the participants (69%) were born overseas: Saudi Arabia (n = 1), Malaysia (n = 2), China (n = 2), Hong Kong (n = 1), Philippines (n = 1), and United States (n = 1).Only four (31%) were born in Australia.Most participants were university graduates, while one had an advanced diploma, and another one only completed high school.Only five participants (39%) were in paid employment.The number of children of participants ranged from one to four (mean 2.4).

|
Step 1: Needs assessment-The logic model of the problem

| Literature reviews
The findings of the literature reviews have all been published previously 6,11,28,29 and are summarized in Supporting Information S1: Table S3.Postpartum lifestyle programs that include diet and physical activity components, delivery by a health professional, and behavioural strategies relating to self-regulation are effective for weight management. 28,29Some gaps were identified in the implementation of postpartum lifestyle programs such as not including postpartum women and community members as key stakeholders in the development process and suboptimal reporting of intervention characteristics. 6Barriers and facilitators to engaging in healthy lifestyle behaviours in the postpartum period were identified, for example, lack of knowledge regarding the benefits of healthy lifestyle behaviours, social support, and limited time and skills of health professionals in providing lifestyle support. 11These barriers contribute to low engagement in postpartum lifestyle intervention programs. 6

| Focus group
The findings of the focus group discussions provided insight into the barriers and facilitators faced by MOPS in supporting the health and wellbeing of its members (Table 1).Six themes emerged from the thematic analysis of the focus group discussions (i) creating a supportive environment that enables peer and social support; (ii) providing practical support such as delivering meals; (iii) inspiring leadership from MOPS leaders that values motherhood; (iv) providing learning opportunities that focus on mothers' health and wellbeing; (v) reach and accessibility of MOPS; (vi) lack of resources for childminding.MOPS sought to create a supportive environment to encourage relationship building between mothers and other members of the community and to support healthy family relationships.
MOPS provides an avenue for mothers to enjoy the company of one another and be supported by their peers.MOPS wanted to provide inspiring leadership with an emphasis on pastoral care and championing mothers to make them feel loved and valued.MOPS sought to nurture mothers in a holistic way targeting the physical, mental, social, emotional and spiritual wellbeing of the mother.This could be strengthened through the inclusion of physical activity components within MOPS sessions and by creating learning opportunities through engaging expert speakers.They considered it important for them to provide practical support such as meal delivery or assistance with childminding, especially in the early postpartum period and to mothers experiencing adversity.MOPS felt a need to expand their reach and make programs more accessible to mothers and felt limited in resources to accommodate more mothers because they relied on volunteers for childminding.

| Program goal and logic model
The findings of the needs assessment informed the development of a logic model identifying key areas to target and the program goals (Figure 1).The overall goal of the program was to reduce postpartum weight retention and improve the health and wellbeing of mothers with young children.We decided to focus on the behaviour of mothers with young children (individual level) as the target population group and the MOPS mothers' group (organizational level) as the environment for program implementation.Using the TDF and COM-B as a guide, the logic T A B L E 1 Facilitators and barriers faced by MOPS in improving the health of its members.1).S4.

| Step 3: Program design
The theoretical methods and practical strategies for achieving the change objectives are shown in Table 3  develop program components that can be delivered by mothers and integrated within existing services for mothers (i.e., mothers' group).
We attempted to address the challenges of poor engagement and high attrition which are inherent in existing postpartum lifestyle intervention programs. 5,34This study provides valuable insight for future researchers and program developers, addressing the current evidence gap in sufficient reach and engagement among mothers. 5,6,34e participatory design approach allowed us to design program components that were grounded in theory and evidence and to map strategies to mechanisms and methods that bring about the needed changes for mothers with young children. 17  | 11 of 15 health and wellbeing of mothers with young children.This facilitated the tailoring of the program components to their specific needs to promote better adherence. 35om the systematic reviews we undertook as part of the needs assessment and the focus group discussions, it was evident that social support was necessary for engaging in healthy lifestyle behaviours in postpartum women. 11This agrees with previous findings in postpartum lifestyle programs and highlights the importance of enlisting community groups and nontraditional health service providers to support healthy lifestyles. 36,37Utilizing nonprofessional avenues for support is a potentially sustainable pathway for program delivery that reduces the burden on the limited time of health professionals.Mothers' groups are a support network for mothers with babies of similar ages and are a viable and costeffective method to provide community-based support to mothers. 38,39We found that mothers in this community group were positively disposed towards peer coaching and valued experienced mothers as mentors. 38Previous research has utilized peer support to promote weight control and the overall health and wellbeing of mothers through training and supporting peer mentors. 37,40Peer-led interventions offer a valuable low-resource and sustainable strategy to provide necessary ongoing support to mothers with young children to reduce postpartum weight retention and mitigate the burden of maternal obesity. 41Training mothers to deliver programs may be an effective strategy that leverages their skills and experiences while simultaneously addressing their need for support.
Provision of practical support to relieve household chores including meal preparation, and childminding is critical to enabling women to engage in self-care and health-promoting behaviours early postpartum.This finding aligns with the current literature including our systematic review. 11,36This is very important because many women prioritize their role as mothers and their family responsibilities over their self-care. 36,42Therefore, programs that address this need by providing relief from these responsibilities are likely to result in better engagement.The provision of childminding services during sessions was a major strength of the MOPS mothers' group.
Delivering healthy meals to mothers who had recently given birth or were facing difficulties such as illnesses or loss was considered beneficial in supporting their health and wellbeing, offering an opportunity for mothers to mutually support one another during life challenges.This was particularly important for participants in this study given that 69% were migrants and had limited access to family support.
Another key finding of our focus group discussion is the need for inspiring leadership that values motherhood.This is necessary to achieve the program outcomes of increasing self-esteem and selfworth, coping with stress and supporting mothers to build confidence.The current health approaches do not do this, but rather employ a deficit-based approach, which views mothers with postpartum weight retention as a 'problem'.Our program components suggest a strength-based approach, looking into the resources and strengths of mothers, elevating and valuing motherhood, and validating the successes of individual mothers within the group, thereby building confidence and self-worth.One systematic review that formed part of our needs assessment revealed the need for increasing self-worth and enjoyment of the activity to promote healthy lifestyles in postpartum women. 11Previous research also suggests that self-worth is central to physical activity adherence. 43erefore, having a program that builds confidence and self-worth in mothers is likely to result in intrinsic motivation (a key component of behaviour change) to improve lifestyle behaviours.This might be the missing key to enabling this population group to be motivated; inspiring leadership sets the culture for it.
We also found that providing learning opportunities for mothers through health education and engaging experts was considered valuable by mothers.Health professional-delivered interventions have been reported to be associated with effective weight loss in lifestyle interventions for postpartum women. 28This may be because health professionals are viewed as a source of credible information. 36wever, long-term lifestyle support is essential for weight management and health professionals have limited capacity to provide ongoing lifestyle support to postpartum women because of the time and resources required to take on this role. 21The recent coronavirus disease-19 pandemic has put more strain on the healthcare system in many countries, including Australia, further reducing access to health services, particularly preventive services. 44Therefore, there is a need to consider alternative pathways and models of care for sustainable partnerships between health professionals and community service providers to provide credible, long-term support for the ongoing provision of lifestyle counselling and support for postpartum women to address maternal obesity.
Expanding the reach and increasing accessibility to mothers who live farther away was considered necessary to increase the program's impact.Literature suggests that enlisting the support of community organizations can expand the reach and effectiveness of health promotion activities. 45Also, programs with good penetration and participation rates are those integrated with existing services used by postpartum women. 46Integrating programs into existing services reduces the barriers of time constraints and lack of childcare that usually deter mothers from engaging in lifestyle programs. 11though our program components have been developed within the context of a mothers' group in Australia, the lessons learnt have relevance for researchers and health practitioners internationally for adaptation and translation in similar settings.Also, MOPS being an international group could extend the findings more broadly, and beyond Australia.Some limitations should be acknowledged.We did not involve maternal and child health (MCH) services, a potential stakeholder that has been identified as an acceptable avenue for program delivery by postpartum women. 47However, community mothers' groups provide more opportunities for social support and engagement for a longer duration than MCH services.Furthermore, although the family plays a significant role in influencing the lifestyle choices of mothers, we did not include influencing family members' behaviour as a program outcome. 48While our project resources did not enable expansion to the family, it is recommended that future research consider incorporating the family or the key support person as an interpersonal level of the program.In addition, further research is needed to develop the curriculum, training manuals and other materials, pilot, implement, and evaluate the program on effects and processes corresponding to steps 4, 5 and 6 of the IM approach.These findings are important for practice and policy to urgently address obesity issues in mothers through low-resource programs that have the potential to increase reach and engagement through integration with existing services.

| CONCLUSION
This article describes how we systematically applied a participatory design methodology combined with a IM approach to co- components of a postpartum lifestyle program with MOPS, a community mothers' group.This study addressed the research question: what intervention components are preferred by mothers with young children in a community mother's group to reduce postpartum weight retention and improve health and wellbeing? 2 | METHODS The steps in IM are (1) needs assessment-logic model of the problem; (2) defining program outcomes and objectives-logic model of change; (3) program design; (4) program production; (5) program implementation plan; (6) program evaluation plan.The current study presents a modified IM approach that includes steps 1-3 as described below.

Step 1
involved an assessment of the determinants of behaviour and environmental contributors to the problem (postpartum weight retention) the program seeks to address through epidemiological, behavioural and social analysis of the population at risk (mothers with young children).A thorough assessment of the capacity and needs of the target population (mothers with young children) and the program setting (MOPS) was undertaken to inform the program goals.2.4.1 | The program planning group Program planning and advisory groups were established to provide input, guidance and oversight in the program component design process.The planning group included 12 mothers with young children who were members and/or leaders of MOPS and four researchers with expertise in postpartum lifestyle research, dietetics, behavioural sciences, implementation science and health psychology.The advisory group (n = 2) were researchers with PhDs who have expertise in health psychology, maternal health, lifestyle medicine and program component design.

2. 5 |
Step 2: Program outcomes and objectives-The logic model of change The second step focused on specifying detailed outcomes for the program.During a co-design workshop with the planning group, behavioural outcomes at the individual (mothers with young children) level and environmental outcomes at the organizational level (MOPS) were specified.Drawing on information generated during step 1, performance objectives (explicit behaviours needed to achieve each behavioural and environmental outcome) were specified for each outcome.A matrix of change objectives (what needs to change in the identified determinants to achieve the performance objectives) was constructed by mapping performance objectives to the determinants of behaviour according to the TDF and COM-B model.A separate matrix was created for individual and organizational levels.

2. 6 |
Step 3: Program design In this step, the planning group worked from the logic model of change established in step 2 to conceptualize and design the program components.Theoretical methods (i.e., behaviour change techniques

| 7 of 15 influences
, social/professional role and identity, beliefs about capabilities and beliefs about consequences of MOPS were identified.Using the information from step 1, the selected determinants (according to the TDF and COM-B model) were mapped to the performance objectives to create change objectives for the program as shown in Supporting Information S1: Table

4 |
DISCUSSIONIn this article, we describe the application of a participatory design methodology integrated with IM (steps 1-3) to inform the co-design of program components that support mothers with young children (5 years and under) to reduce postpartum weight retention and improve health and wellbeing.To the best of our knowledge, this study is the first to incorporate evidence from reviews, stakeholder data, behaviour change theories and utilize a participatory approach to F I G U R E 1 Logic model of MOPS.MOPS, Mothers of Preschoolers lifestyle program.
This methodology enabled us to consider and address several factors that influence behaviour at the individual and organizational levels.The qualitative component of this work supported the identification of resources and specific contextual needs of the mothers' group in supporting the T A B L E 2 Program outcomes and performance objectives for the intervention by socioecological level according to mothers of young children and MOPS.
Our study has several strengths.It represents a major contribution to postpartum lifestyle research as it is the first, to our knowledge, to systematically develop evidence-and theory-based peer-led lifestyle program components that can be integrated within community mothers' groups.The program design was strengthened by the community participatory approach.Capturing the experiences and perspectives of the target population optimizes potential feasibility for adoption and acceptability.This enhances the translation of health research into practice in real-world settings.Incorporating the IM approach guided the development of program components in partnership with key stakeholders and allowed us to explicitly incorporate theory and evidence in the development process.
design evidence-informed and theory-based program components, to reduce postpartum weight retention and improve the health and wellbeing of mothers with young children.In future research, the program curriculum and materials must be developed, piloted, implemented, and evaluated.Leveraging mothers' groups for the implementation of lifestyle programs to reduce postpartum weight retention and support the health and wellbeing of mothers has the potential to improve program reach and engagement, leading to large-scale impact.A novel finding of our study is the focus on a strength-based approach of valuing motherhood through inspiring leadership to improve self-worth and confidence for healthy lifestyle behaviours.
that … you know, that you're not alone.You know that you're not such a failure as a mom, you know, it just gave me so much confidence and I've only attended one session … I pulled myself out from, and now I'm-I'm seriously eating better.And, you know, I just-it just gave me so much confidence and I'm eating better … I actually watch what I wear, you know, I actually like try to look good because, and feel good because, yeah, because I guess I was uplifted.#11sometimesyou even lose a bit of yourself because you're like, 'Where's my identity now?' … I've left a career to become a mother, … so I just love how MOPS champions mothers.It gives opportunity for them to have their souls fed … And then the mother's are nurtured as well.#8MOPS is so intentional to sow into the mom's life and to build relationships between the moms and just there's so much joy.So I think that that is so good for our health.#8being introduced to MOPS by the actual CEO of MOPS International.She, like, flew down from America and, like, gave a talk about-Um, like, a really inspiring talk.#2love radically because MOPS was birthed from this desire to want to, um, not only cherish and nourish mothers, so that they may flourish.#2Mentoringfrom older mums Um, from there, uh, we have mentors as well.So moms who have raised their children past the preschooler age that can speak into, um, and give hope and encouragement to moms who are still in-in that, um, stage of parenting preschoolers.#12 I think it's good for mothers to see that they're not going through the journey alone.#8 Peer support And, uh, is-is very healthy environment for a mother.And I find out they open my mind and they respect me the way I am, and they connect me with the community straight away, and is changed me.#10 Um, and so just hearing other women and other moms share about their struggles.I started to realize like, 'Oh, I'm not the only one going through this particular struggle.'#4 Provides company looking for like company and-and other moms that are at home that can share their time with me.#5 Like when I-when I finally made it to MOPS, it was almost just like a-a breath of fresh air just over me because, um, if I didn't, you know, I-I missed the connection and it just feeds my soul.#7 Providing practical support such as delivering meals Practical support free meals are funded to reach out to bless those moms who, um, you know, who just got a recent diagnosis that their child is, um, experiencing something just so shocking.#12 I think even just offering to bring over a meal and, um, a cup of tea or to look after children.#13 …our group is really good at doing is to provide meals for each other and during lockdown, we did, um, like food hug deliveries.#12 So like if I need a babysitter, for instance, I could say, 'Hey,' at anybody, 'Can I drop my kids…' And then … I can reciprocate that, um, you know, take someone else's kids.Um, and so the support can continue, even outside of the actual meeting.nutritious-these nutritious meals that have been specially curated, right, for the wellbeing and the nurturing of moms as they're breastfeeding their kids, or, um, whatever part of their pregnancy journey, um, they're on perhaps.#12 what makes MOPS unique and special is that it's moms helping moms that there's a-a limit to what moms can actually do, because you have your own kids who are pre-schoolers.Um, model summarized the key determinants, behavioural outcomes and health outcomes for each potential level of the program (Figure

Table 2
shows the program outcomes and specific performance objectives relating to each potential level of the program (mothers and MOPS).The behavioural outcomes chosen by mothers were to eat a healthy diet, engage in regular physical activity, increase selfesteem and self-worth and cope with stress.The outcome for MOPS as an organization was to support mothers to build confidence to achieve holistic health goals.Mothers' knowledge, skills, behavioural regulation, social influence, beliefs about capabilities and intentions were identified as determinants of mothers' behaviour at the individual level.At the organizational level, knowledge, skills, socialT A B L E 1 (Continued)… last year doing lockdown, MOPS was … online, um, and I could join because, um, you know, all my kids are asleep.And it was like, just to catch up with other mums and there was heaps of support from the MOPS group….And, um, it was just really good for my mental health, because, um, it was Example of strategies to achieve change objectives for mothers (individual level) and MOPS (organizational level).Refer to Supporting Information S1: TableS4for reference to the change objectives.
T A B L E 3 a b Constructs derived from literature.c