The intention to use Kangaroo Mother Care among first-time mothers 15-24 years in Kinshasa, DRC: An application of the Integrated Behavioral Model

Using secondary data from Kinshasa, this study applies the Integrated Behavioral Model to find that attitudes, social norms, self-efficacy, and autonomy significantly predict Kangaroo Mother Care intentions among first-time mothers aged 15–24, with age-specific variations highlighting the need for tailored, empowering interventions.

The Gist

The Big Picture: A "Skin-to-Skin" Safety Blanket

Imagine a newborn baby who is born too small or too early. They are like a tiny, fragile seed that needs extra warmth to grow. Kangaroo Mother Care (KMC) is the solution: it's a method where the mother (or father) holds the baby skin-to-skin, like a kangaroo carrying its joey in a pouch. This keeps the baby warm, helps them breathe, and helps them gain weight. It's a low-cost, life-saving trick that works wonders.

However, just because a life-saving tool exists doesn't mean everyone knows how to use it or feels comfortable using it. This paper asks: Do young, first-time moms in Kinshasa, Congo, want to use this "pouch" method if they have a tiny baby?

The Cast of Characters

The researchers looked at 1,918 young women (ages 15 to 24) who were expecting their first baby. They used a mental map called the Integrated Behavioral Model (IBM) to figure out what goes on inside a person's head when they decide to do something new.

Think of the IBM as a three-legged stool that holds up a person's decision to act:

1. Attitude: How do you feel about it? (Do you think it's good?)
2. Norms: What do others think? (Do your friends do it? Do your family members approve?)
3. Agency: Can you actually do it? (Do you have the confidence and the freedom to make the choice?)

What the Researchers Found

The team asked these young moms: "If you had a tiny baby, would you be very likely to use KMC?" About half of them said, "Yes, absolutely."

Here is what made them say "Yes":

• The "Yes" Crowd (Attitude): If a mom approved of the idea, she was 12 times more likely to intend to do it. It's like having a green light; if you think the idea is great, you're ready to go.
• The "What Others Think" Crowd (Norms):
  • Descriptive Norms: If a mom thought, "Hey, half or more of the other young moms in my neighborhood are doing this," she was much more likely to want to do it too. It's the "if they can do it, I can do it" effect.
  • Normative Expectations: If a mom felt that the people she loves most (her partner, her mom, her friends) thought she should do it, she was much more likely to intend to do it.
• The "I Can Do It" Crowd (Agency):
  • Confidence: Moms who generally felt confident in their ability to solve problems were more likely to want to try KMC.
  • Freedom: This is a big one. If a mom felt she could do KMC even if her family said "no," she was more likely to intend to do it. This is about having the steering wheel in your own hands.

The Age Twist: The "Younger vs. Older" Difference

The paper found a fascinating difference between the 15–19-year-olds and the 20–24-year-olds.

• The Older Group (20–24): They were generally more likely to want to use KMC than the younger group. For them, having "freedom" (autonomy) didn't change their mind much; they were already pretty set on doing it.
• The Younger Group (15–19): For these very young moms, freedom was the key. If a 15–19-year-old felt she had the power to make her own choice, her desire to use KMC shot up. If she felt controlled by others, her desire dropped.
  • Analogy: Think of the younger moms as a car with a very sensitive accelerator. If you give them the freedom to press it (autonomy), they speed up toward KMC. If you take the keys away, they stop. The older moms are like a car with a steady cruise control; they are moving forward regardless of who is holding the keys.

What Didn't Matter (Surprisingly)

The researchers thought that knowing why KMC was good (the benefits) would be the biggest driver. They thought if a mom could list five reasons why it's great, she'd be eager to do it.

• The Reality: Knowing the benefits didn't really change their intention. Even if a mom didn't know the specific medical benefits, if she felt supported by her community and had the freedom to choose, she still wanted to do it.
• Analogy: It's like knowing the exact ingredients in a delicious cake doesn't make you want to eat it as much as seeing everyone else enjoying it and having the permission to take a slice.

The Bottom Line

The paper concludes that to get young moms in Kinshasa to use Kangaroo Mother Care, you can't just hand them a pamphlet with medical facts. You have to:

1. Build the Community: Show them that other young moms are doing it and that their families support it.
2. Empower the Youngest: Specifically for the 15–19-year-olds, programs need to help them feel like they have the power to make their own health decisions, even if their family is hesitant.

The study suggests that a mix of community support (norms) and personal empowerment (autonomy) is the secret sauce to getting these young mothers ready to use this life-saving "pouch" method.

Technical Summary

Technical Summary: The Intention to Use Kangaroo Mother Care Among First-Time Mothers 15-24 Years in Kinshasa, DRC

Problem Statement
Neonatal mortality remains a critical global health challenge, with preterm birth complications being the leading cause of death. The Democratic Republic of Congo (DRC) faces high neonatal mortality rates (27 per 1,000 live births) and a significant prevalence of low birthweight (LBW) and preterm births. Kangaroo Mother Care (KMC)—comprising skin-to-skin contact, exclusive breastfeeding, and early discharge—is a proven, low-cost intervention to reduce neonatal mortality and morbidity. However, implementation in the DRC has been limited, with studies focusing primarily on policy and facility-level barriers rather than caregiver perspectives. Furthermore, research on KMC among adolescent and young first-time mothers (FTMs), a demographic whose infants face higher risks of adverse outcomes, is scarce. Existing literature lacks quantitative data on the behavioral drivers (attitudes, norms, and personal agency) influencing the intention to practice KMC in this specific population.

Methodology
This study utilized secondary data from the 2020 endline survey of the Momentum Project, a quasi-experimental intervention in Kinshasa, DRC, targeting FTMs aged 15-24 years. The analysis included 1,918 participants from six health zones (three intervention, three comparison).

• Theoretical Framework: The study applied a modified Integrated Behavioral Model (IBM). While the full IBM includes factors like knowledge, skills, and environmental constraints, this analysis focused on the intention component, examining three core constructs:
  1. Attitudes: Measured via instrumental attitudes (number of KMC benefits named) and KMC approval.
  2. Perceived Norms: Measured via descriptive norms (perceived prevalence of KMC among peers) and normative expectations (perceived approval from significant others).
  3. Personal Agency: Measured via general self-efficacy and KMC-specific autonomy (the belief that one would practice KMC even if significant others disapproved).
• Variables: The dependent variable was the intention to practice KMC if the respondent had a LBW or preterm baby (coded as "very likely" vs. other responses). Covariates included age, marital status, education, household wealth, employment, and previous knowledge of KMC.
• Analysis: The researchers employed multivariable logistic regression to test five hypotheses regarding the associations between IBM components and KMC intentions, as well as the moderating effects of age and marital status on autonomy.

Key Results

• Prevalence of Intention: Approximately 50.7% of respondents stated they were "very likely" to practice KMC if they had a LBW or preterm infant.
• IBM Component Associations:
  • Attitudes: KMC approval was strongly associated with intention (Adjusted Odds Ratio [AOR] = 12.26). However, instrumental attitudes (the number of benefits named) were not significantly associated with intention.
  • Norms: Both descriptive norms (AOR = 2.59) and normative expectations were significant predictors. Respondents who believed peers practiced KMC or who felt significant others expected them to do so were more likely to intend to practice it.
  • Personal Agency: Both self-efficacy (AOR = 1.03 per unit increase) and KMC autonomy (AOR = 2.00) were positively associated with intention.
• Demographic and Interaction Effects:
  • Age: Women aged 20-24 had 90% higher odds of intending to practice KMC compared to those aged 15-19.
  • Moderation by Age: A significant interaction was found between age and autonomy. For younger women (15-19), higher autonomy significantly increased the probability of intending to practice KMC. For older women (20-24), autonomy levels did not significantly alter the probability of intention.
  • Marital Status: Marital status did not significantly moderate the relationship between autonomy and intention in the primary model, though sensitivity analyses suggested complex interactions when the outcome definition was broadened.
• Sensitivity Analyses: When the dependent variable was redefined to include both "likely" and "very likely" responses, descriptive norms and self-efficacy lost significance, and the interaction between autonomy and marital status became significant.

Significance and Claims
The authors claim this is the first study to quantitatively examine KMC intentions among adolescent and young FTMs in a low-resource setting using the IBM framework. The study contributes to the literature by:

1. Shifting Focus: Moving beyond facility-level barriers to identify caregiver-level drivers of KMC intention.
2. Targeting Vulnerable Populations: Focusing on FTMs 15-24, whose infants are at elevated risk for neonatal mortality.
3. Informing Program Design: The findings suggest that demand-generation strategies for KMC in the DRC should be age-specific. Specifically, interventions for younger mothers (15-19) should prioritize empowering strategies to increase autonomy, as this group's intention is highly sensitive to their ability to act independently of family disapproval. For older mothers, other factors may be more relevant.
4. Complementing Supply-Side Efforts: The results support the need to complement existing facility-based KMC initiatives (such as those by the USAID Integrated Health Project) with community-based, norms-driven approaches that engage partners and extended family to support maternal autonomy and positive social norms.

The authors modestly note that while intention is a necessary predictor of behavior, it does not guarantee uptake. They acknowledge that knowledge, skills, and environmental constraints (which were not fully measured or were outside the scope of the intention-focused model) remain critical for actual practice. Additionally, the cross-sectional design limits causal inference, and social desirability bias may have influenced self-reported intentions.