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Eating healthily and being physically active during pregnancy are important for maternal and offspring health. Maternity healthcare is a key arena for health promotion; however, 20% of pregnant women in Sweden are foreign-born, which may reduce reach due to language and cultural barriers. The aims of this study were to explore healthcare professionals’ perceptions about (a) promoting health behaviors (i.e., healthy diet, physical activity, and weight gain) among Arabic- and Somali-speaking pregnant women and (b) how a translated version of the previously evaluated Swedish app (HealthyMoms) can be tailored and used as a tool in their clinical work. Healthcare professionals in Swedish maternity care (n = 14) were interviewed. Data were analyzed using inductive thematic analysis. Healthcare professionals expressed challenges in health promotion work, including cultural and educational aspects and low awareness of health behaviors among women themselves and their social environment. Further, a lack of resources within the clinical practice and a need for cultural awareness among healthcare professionals were highlighted. Finally, it was perceived that a translated app has potential to provide basic and culturally adjusted information, facilitate communication and thus has potential to become a helpful tool in maternity care to support healthy lifestyle behaviors in Arabic- and Somali-speaking pregnant women.

Eating healthily and being physically active during pregnancy are important for maternal and offspring health. Maternity healthcare is a key arena for health promotion; however, 20% of pregnant women in Sweden are foreign-born, which may reduce reach due to language and cultural barriers. The aims of this study were to explore healthcare professionals' perceptions about (a) promoting health behaviors (i.e., healthy diet, physical activity, and weight gain) among Arabic- and Somali-speaking pregnant women and (b) how a translated version of the previously evaluated Swedish app (HealthyMoms) can be tailored and used as a tool in their clinical work. Healthcare professionals in Swedish maternity care (

ALF Grants, Region Ostergotland, Grant/Award Numbers: LIO-893101, LIO-941191; Bo and Vera Ax:son Johnsons' Foundation; Karolinska Institutet; Lions Forskningsfond; The Strategic Research Area Health Care Science, Karolinska Institutet/Umea University; The Swedish Research Council, Grant/Award Number: 2016-01147; The Swedish Research Council for Health, Working Life and Welfare (Forte), Grant/Award Numbers: 2017-00088, 2018-01410; The Swedish Society of Medicine, Background: Pregnancy has been identified as a window for childhood obesity prevention. Although lifestyle interventions in pregnancy can prevent excessive gestational weight gain (GWG), little is known whether such interventions also affect infant growth and body composition. Objectives: To investigate (i) the effects of a 6-month lifestyle intervention (the HealthyMoms app) on infant body composition 1–2 weeks postpartum, and (ii) whether a potential intervention effect on infant body composition is mediated through maternal GWG. Methods: This is a secondary outcome analysis of the HealthyMoms randomized controlled trial. Air-displacement plethysmography was used to measure body composition in 305 healthy full-term infants. Results: We observed no statistically significant effect on infant weight (β = 0.004, p = 0.94), length (β = 0.19, p = 0.46), body fat percentage (β = 0.17, p = 0.72), or any of the other body composition variables in the multiple regression models (all p ≥ 0.27). Moreover,we observed nomediation effect through GWG on infant body composition. Conclusions: Our findings support that HealthyMoms may be implemented in healthcare to promote a healthy lifestyle in pregnant women without compromising offspring growth. Further research is required to elucidate whether lifestyle interventions in pregnancy also may result in beneficial effects on infant body composition and impact future obesity risk., ALF Grants, Region Ostergotland LIO-893101 LIO-941191, Bo and Vera Ax:son Johnsons' Foundation, Karolinska Institutet, Lions Forskningsfond, Strategic Research Area Health Care Science, Karolinska Institutet/Umea University, Swedish Research Council x, European Commission 2016-01147, Swedish Research Council for Health, Working Life and Welfare (Forte) 2017-00088 2018-01410, Swedish Society of Medicine

Although user engagement is generally considered important for the effectiveness of digital behavior change interventions, there is a lack of such data in pregnancy. The aim of this study was therefore to examine the associations of user engagement with the HealthyMoms app with gestational weight gain, diet quality and physical activity in pregnancy. The study involved secondary analyses of participant data from the intervention group (n = 134) in a randomized controlled trial to determine the effectiveness of a 6-month mHealth intervention (the HealthyMoms app) on gestational weight gain, diet quality and physical activity. In adjusted regression models, the total number of registrations from three self-monitoring features (i.e., for weight-, diet- and physical activity) was associated with lower gestational weight gain (β = − 0.18, P = 0.043) and improved diet quality (β = 0.17, P = 0.019). These findings were mainly attributable to the associations of physical activity registrations with lower gestational weight gain (β = − 0.20, P = 0.026) and improved diet quality (β = 0.20, P = 0.006). However, the number of app sessions and page views were not associated with any of the outcomes. Our results may motivate efforts to increase user engagement in digital lifestyle interventions in pregnancy. However, additional studies are needed to further elucidate the influence of different types of user engagement in digital pregnancy interventions on their effectiveness.Trial registration: ClinicalTrials.gov (NCT03298555); https://clinicaltrials.gov/ct2/show/NCT03298555 (date of registration: October 2, 2017; date of first enrolled participant: October 24, 2017).

Background Excessive gestational weight gain (GWG) is common and associated with negative health outcomes for both mother and child. Mobile health–delivered lifestyle interventions offer the potential to mitigate excessive GWG. The effectiveness of a smartphone app (HealthyMoms) was recently evaluated in a randomized controlled trial. To explore the users’ experiences of using the app, a qualitative study within the HealthyMoms trial was performed. Objective This qualitative study explored participants’ engagement and satisfaction with the 6-month usage of the HealthyMoms app. Methods A total of 19 women (mean age: 31.7, SD 4.4 years; mean BMI: 24.6, SD 3.4 kg/m2; university degree attainment: 13/19, 68%; primiparous: 11/19, 58%) who received the HealthyMoms app in a randomized controlled trial completed semistructured exit interviews. The interviews were audiorecorded and fully transcribed, coded, and analyzed using thematic analysis with an inductive approach. Results Thematic analysis revealed a main theme and 2 subthemes. The main theme, “One could suit many: a multifunctional tool to strengthen women’s health during pregnancy,” and the 2 subthemes, “Factors within and beyond the app influence app engagement” and “Trust, knowledge, and awareness: aspects that can motivate healthy habits,” illustrated that a trustworthy and appreciated health and pregnancy app that is easy to use can inspire a healthy lifestyle during pregnancy. The first subtheme discussed how factors within the app (eg, regular updates and feedback) were perceived to motivate both healthy habits and app engagement. Additionally, factors beyond the app were described to both motivate (eg, interest, motivation, and curiosity) and limit (eg, pregnancy-related complications, lack of time) app engagement. The second subtheme reflected important aspects, such as high trustworthiness of the app, increased knowledge, and awareness from using the app, which motivated participants to improve or maintain healthy habits during pregnancy. Conclusions The HealthyMoms app was considered a valuable and trustworthy tool to mitigate excessive GWG, with useful features and relevant information to initiate and maintain healthy habits during pregnancy. Trial Registration ClinicalTrials.gov NCT03298555; https://clinicaltrials.gov/ct2/show/NCT03298555 International Registered Report Identifier (IRRID) RR2-10.2196/13011

This study was funded by the Swedish Research Council (2016-01147 to ML) and additionally supported by the Swedish Research Council for Health, Working Life and Welfare (Forte, 2017-00088 to PH; 2018-01410 to ML); Bo and Vera Ax:son Johnsons' Foundation (to ML); the Strategic Research Area Health Care Science, Karolinska Institutet/Umea University (to PH); the Swedish Society of Medicine (to PH); Karolinska Institutet (to PH); Lions Forskningsfond (to PH); and ALF Grants, Region Ostergotland (ML). MHL was supported by a grant from Yrjo Jahnsson Foundation. The funders had no role in study design, conduct, or reporting of the trial. The authors thank all the participants in the trial as well as Eva Flinke and Ellinor Nilsson for invaluable help with data collection, the midwives in Region Ostergotland for help with the recruitment, Hanna Henriksson and Christina Alexandrou for valuable help developing the content of the app, Jan Fjellstrom and Nils Lidstrom at ScientificMed for development of the app and technical support, and Anna Karin Lindroos and Eva Warensjo Lemming for support with the Riksmaten FLEX method (adaptations, data processing, and interpretation of results)., Background: Excessive gestational weight gain (GWG) during pregnancy is a major public health concern associated with negative health outcomes for both mother and child. Scalable interventions are needed, and digital interventions have the potential to reach many women and promote healthy GWG. Most previous studies of digital interventions have been small pilot studies or have not included women from all BMI categories. We therefore examined the effectiveness of a smartphone app in a large sample (n=305) covering all BMI categories. Objective: To investigate the effectiveness of a 6-month intervention (the HealthyMoms app) on GWG, body fatness, dietary habits, moderate-to-vigorous physical activity (MVPA), glycemia, and insulin resistance in comparison to standard maternity care. Methods: A 2-arm parallel randomized controlled trial was conducted. Women in early pregnancy at maternity clinics in Östergötland, Sweden, were recruited. Eligible women who provided written informed consent completed baseline measures, before being randomized in a 1:1 ratio to either an intervention (n=152) or control group (n=153). The control group received standard maternity care while the intervention group received the HealthyMoms smartphone app for 6 months (which includes multiple features, eg, information; push notifications; self-monitoring; and feedback features for GWG, diet, and physical activity) in addition to standard care. Outcome measures were assessed at Linköping University Hospital at baseline (mean 13.9 [SD 0.7] gestational weeks) and follow-up (mean 36.4 [SD 0.4] gestational weeks). The primary outcome was GWG and secondary outcomes were body fatness (Bod Pod), dietary habits (Swedish Healthy Eating Index) using the web-based 3-day dietary record Riksmaten FLEX, MVPA using the ActiGraph wGT3x-BT accelerometer, glycemia, and insulin resistance. Results: Overall, we found no statistically significant effect on GWG (P=.62); however, the data indicate that the effect of the intervention differed by pre-pregnancy BMI, as women with overweight and obesity before pregnancy gained less weight in the intervention group as compared with the control group in the imputed analyses (–1.33 kg; 95% CI –2.92 to 0.26; P=.10) and completers-only analyses (–1.67 kg; 95% CI –3.26 to –0.09; P=.031]). Bayesian analyses showed that there was a 99% probability of any intervention effect on GWG among women with overweight and obesity, and an 81% probability that this effect was over 1 kg. The intervention group had higher scores for the Swedish Healthy Eating Index at follow-up than the control group (0.27; 95% CI 0.05-0.50; P=.017). We observed no statistically significant differences in body fatness, MVPA, glycemia, and insulin resistance between the intervention and control group at follow up (P≥.21). Conclusions: Although we found no overall effect on GWG, our results demonstrate the potential of a smartphone app (HealthyMoms) to promote healthy dietary behaviors as well as to decrease weight gain during pregnancy in women with overweight and obesity., Swedish Research Council European Commission 2016-01147, Swedish Research Council, Swedish Research Council for Health Working Life & Welfare (Forte) 2017-00088 2018-01410, Vera Ax:son Johnsons' Foundation, Strategic Research Area Health Care Science, Karolinska Institutet/Umea University, Swedish Society of Medicine, Karolinska Institutet, Lions Forskningsfond, ALF Grants, Region Ostergotland, Yrjo Jahnsson Foundation

BACKGROUND Excessive gestational weight gain (GWG) during pregnancy is a major public health concern associated with negative health outcomes for both mother and child. Scalable interventions are needed, and digital interventions have the potential to reach many women and promote healthy GWG. Most previous studies of digital interventions have been small pilot studies or have not included women from all BMI categories. We therefore examined the effectiveness of a smartphone app in a large sample (n=305) covering all BMI categories. OBJECTIVE To investigate the effectiveness of a 6-month intervention (the HealthyMoms app) on GWG, body fatness, dietary habits, moderate-to-vigorous physical activity (MVPA), glycemia, and insulin resistance in comparison to standard maternity care. METHODS A 2-arm parallel randomized controlled trial was conducted. Women in early pregnancy at maternity clinics in Östergötland, Sweden, were recruited. Eligible women who provided written informed consent completed baseline measures, before being randomized in a 1:1 ratio to either an intervention (n=152) or control group (n=153). The control group received standard maternity care while the intervention group received the HealthyMoms smartphone app for 6 months (which includes multiple features, eg, information; push notifications; self-monitoring; and feedback features for GWG, diet, and physical activity) in addition to standard care. Outcome measures were assessed at Linköping University Hospital at baseline (mean 13.9 [SD 0.7] gestational weeks) and follow-up (mean 36.4 [SD 0.4] gestational weeks). The primary outcome was GWG and secondary outcomes were body fatness (Bod Pod), dietary habits (Swedish Healthy Eating Index) using the web-based 3-day dietary record Riksmaten FLEX, MVPA using the ActiGraph wGT3x-BT accelerometer, glycemia, and insulin resistance. RESULTS Overall, we found no statistically significant effect on GWG (P=.62); however, the data indicate that the effect of the intervention differed by pre-pregnancy BMI, as women with overweight and obesity before pregnancy gained less weight in the intervention group as compared with the control group in the imputed analyses (–1.33 kg; 95% CI –2.92 to 0.26; P=.10) and completers-only analyses (–1.67 kg; 95% CI –3.26 to –0.09; P=.031]). Bayesian analyses showed that there was a 99% probability of any intervention effect on GWG among women with overweight and obesity, and an 81% probability that this effect was over 1 kg. The intervention group had higher scores for the Swedish Healthy Eating Index at follow-up than the control group (0.27; 95% CI 0.05-0.50; P=.017). We observed no statistically significant differences in body fatness, MVPA, glycemia, and insulin resistance between the intervention and control group at follow up (P≥.21). CONCLUSIONS Although we found no overall effect on GWG, our results demonstrate the potential of a smartphone app (HealthyMoms) to promote healthy dietary behaviors as well as to decrease weight gain during pregnancy in women with overweight and obesity. CLINICALTRIAL ClinicalTrials.gov NCT03298555; https://clinicaltrials.gov/ct2/show/NCT03298555 INTERNATIONAL REGISTERED REPORT RR2-10.2196/13011

BACKGROUND Physical inactivity is globally recognized as a major risk factor for morbidity, particularly the incidence of noncommunicable diseases. Increasing physical activity (PA) is therefore a public health priority. Engaging in active transportation (AT) is a viable approach for promoting daily PA levels. Mobile health interventions enable the promotion of AT to a larger population. The Smart City Active Mobile Phone Intervention (SCAMPI) study was a randomized controlled trial designed to evaluate the ability of a behavior change program delivered via a smartphone app to motivate participants to increase their PA by engaging in AT. OBJECTIVE This qualitative study aims to examine the acceptance and user experience of the app promoting AT that was used in the SCAMPI trial (the TRavelVU Plus app). METHODS A total of 17 residents of Stockholm County (13 women; age range 25-61 years) who completed the 3-month app-based behavioral change program (delivered through the TRavelVU Plus app) in the SCAMPI randomized controlled trial during 2018 agreed to participate in a semistructured telephone-based interview. These participants were well representative of the whole intervention group (n=127) in terms of baseline characteristics such as age, sex, and area of residence. The interviews were audiorecorded, transcribed verbatim, and analyzed using an inductive qualitative content analysis. RESULTS The content analysis revealed 2 themes and 4 subcategories. The first theme, “main motivators: monitoring and messages,” highlighted that monitoring AT and being able to set weekly goals using the app were the primary motivators reported by study participants. The second theme, “acceptable but modifiable,” reflects that the app was well accepted and effectively encouraged many participants to use more AT. Nevertheless, there were functions in the app that require modification. For example, while the semiautomated travel tracking feature was appreciated, participants found it time-consuming and unreliable at times. CONCLUSIONS This study contributes novel insight into adults’ experiences of using a mobile app to promote the use of AT. The results showed that the app was well accepted and that self-monitoring and goal setting were the main motivators to engage in more AT. The semiautomated tracking of AT was appreciated; however, it was also reported to be energy- and time-consuming when it failed to work. Thus, this feature should be improved going forward. CLINICALTRIAL ClinicalTrials.gov NCT03086837; https://clinicaltrials.gov/ct2/show/NCT03086837 INTERNATIONAL REGISTERED REPORT RR2-10.1186/s12889-018-5658-4

Background Physical inactivity is globally recognized as a major risk factor for morbidity, particularly the incidence of noncommunicable diseases. Increasing physical activity (PA) is therefore a public health priority. Engaging in active transportation (AT) is a viable approach for promoting daily PA levels. Mobile health interventions enable the promotion of AT to a larger population. The Smart City Active Mobile Phone Intervention (SCAMPI) study was a randomized controlled trial designed to evaluate the ability of a behavior change program delivered via a smartphone app to motivate participants to increase their PA by engaging in AT. Objective This qualitative study aims to examine the acceptance and user experience of the app promoting AT that was used in the SCAMPI trial (the TRavelVU Plus app). Methods A total of 17 residents of Stockholm County (13 women; age range 25-61 years) who completed the 3-month app-based behavioral change program (delivered through the TRavelVU Plus app) in the SCAMPI randomized controlled trial during 2018 agreed to participate in a semistructured telephone-based interview. These participants were well representative of the whole intervention group (n=127) in terms of baseline characteristics such as age, sex, and area of residence. The interviews were audiorecorded, transcribed verbatim, and analyzed using an inductive qualitative content analysis. Results The content analysis revealed 2 themes and 4 subcategories. The first theme, “main motivators: monitoring and messages,” highlighted that monitoring AT and being able to set weekly goals using the app were the primary motivators reported by study participants. The second theme, “acceptable but modifiable,” reflects that the app was well accepted and effectively encouraged many participants to use more AT. Nevertheless, there were functions in the app that require modification. For example, while the semiautomated travel tracking feature was appreciated, participants found it time-consuming and unreliable at times. Conclusions This study contributes novel insight into adults’ experiences of using a mobile app to promote the use of AT. The results showed that the app was well accepted and that self-monitoring and goal setting were the main motivators to engage in more AT. The semiautomated tracking of AT was appreciated; however, it was also reported to be energy- and time-consuming when it failed to work. Thus, this feature should be improved going forward. Trial Registration ClinicalTrials.gov NCT03086837; https://clinicaltrials.gov/ct2/show/NCT03086837 International Registered Report Identifier (IRRID) RR2-10.1186/s12889-018-5658-4

Air displacement plethysmography utilises a two-component model to assess body composition, which relies on assumptions regarding the density of fat-free mass (FFM). To date, there is no evidence as to whether Lohman’s or Wells et al.’s FFM density values are more accurate in young children. Therefore, the aims of this study were to compare total body fat percentage (TBF%) assessed using the BodPod with both Lohman’s and Wells et al.’s FFM density values with TBF% from the three-component (3C) model in forty healthy Swedish children aged 5·5 years. Average TBF% calculated using Lohman’s FFM density values underestimated TBF% in comparison with the corresponding value assessed using the 3C model (22·2 (sd 5·7) and 25·1 (sd 5·5) %, respectively; Pet al.’s FFM density values and the 3C model (24·9 (sd 5·5) and 25·1 (sd 5·5) %, respectively; P=0·614). The Bland and Altman plots for TBF% using both Lohman’s and Wells et al.’s FFM density values did not show any bias across the range of body fatness (Lohman: r 0·056, P=0·733 and Wells et al.: r −0·006, P=0·970). These results indicate that Wells et al.’s FFM density values should be used when assessing body composition with the paediatric option for BodPod in 5-year-old children. However, future studies are needed to confirm these results in other populations, including a wider age range of children.

BACKGROUND Active transportation (AT; ie, walking and cycling as a mode for transportation) has been associated with decreased morbidity and mortality; however, low-cost and scalable intervention programs are lacking. OBJECTIVE The goal of the research was to determine the effectiveness of a 3-month behavior change program delivered via a mobile phone app to promote AT (TravelVu Plus) on time spent in moderate-to-vigorous physical activity (MVPA). METHODS For this 2-arm parallel randomized controlled trial, we recruited a population-based sample of 254 adults from Stockholm County who were aged 20 to 65 years and had access to a smartphone. On completion of 1-week baseline measures, the 254 participants were randomized to either the control or intervention group (1:1 ratio). Both groups had access to the standard TravelVu app (Trivector AB) for monitoring their AT for 6 months. The intervention group also received a 3-month behavior change program to promote AT (TravelVu Plus app). Assessors of outcomes were blinded to group allocation. Outcomes were objectively measured MVPA at 3 (primary) and 6 months. Secondary outcomes were AT, attitudes toward AT, and health-related quality of life at 3 and 6 months. RESULTS No effect on MVPA was observed after 3 months (P=.29); however, at 6 months the intervention group had a greater improvement in MVPA than the controls (6.05 minutes per day [95% CI 0.36 to 11.74; P=.04]). A Bayesian analyses showed that there was a 98% probability that the intervention had any effect at 6 months, and a 63% probability that this effect was >5 minute MVPA per day. CONCLUSIONS No effect on MVPA immediately after the intervention period (at 3 months) was observed; however, there was a delayed effect on MVPA (6 minutes per day) at 6 months, which corresponds to approximately 30% of the weekly MVPA recommendation. Our findings suggest that a behavior change program promoting AT delivered via an app may have a relevant effect on PA. CLINICALTRIAL ClinicalTrials.gov NCT03086837; https://clinicaltrials.gov/ct2/show/NCT03086837 INTERNATIONAL REGISTERED REPORT RR2-10.1186/s12889-018-5658-4

Self-rated health is a strong health marker. Migrants have been suggested to have poorer self-rated health than non-migrants (i.e., native-born). However, little is known about whether there are disparities in self-reported health in relation to pregnancy. Therefore, the aim of the current study was to examine the odds of poor self-rated health before, during and after pregnancy in migrant women as compared to women born in Sweden. We utilized population-based data from the Swedish Pregnancy Register containing 0.5 million women born in Sweden (i.e., non-migrant women) and migrant women between 2010 and 2018. Self-rated health was reported on a 5-point scale (from very poor to very good). Very poor and poor health were categorized as poor self-rated health. Logistic regression was utilized to calculate odds ratios (ORs) that were unadjusted and adjusted for covariates (age, parity, educational attainment and body mass index). The results demonstrate disparities in self-rated health across birth regions. In comparison to women born in Sweden, women born in Latin America and the Caribbean, South Asia as well as North Africa and the Middle East had consistently higher odds of poor self-rated health before, during and after pregnancy (ORs ranging from 1.14 to 1.96 in both unadjusted and adjusted models). Although women born in Sub-Saharan Africa did have comparable self-rated health as to women born in Sweden before pregnancy, after accounting for covariates, they had lower odds of poor self-rated health during and after pregnancy (ORs: 0.71 and 0.80 respectively). Therefore, additional measures and support may be needed to tackle disparities in health between migrant and non-migrant women before, during and after pregnancy. Funding Agencies|Swedish Research Council for Health, Working Life and Welfare (Forte) [2017-00088, 2018-01410]; Swedish Research Council (Vetenskapsradet)Swedish Research Council [2016-01147]; European UnionEuropean Union (EU) [707404]