4. Discussion
dietary behaviors
RECRUITMENT
This paper outlines the outcomes and key learnings from a pragmatic implementation of an adapted digital health program into the MMH antenatal service. The outcomes suggest that the program could feasibly be implemented with the considerable time and effort required to adapt and embed the program within the interdependent, but unaligned, hospital systems. While the recruited sample was underpowered, promisingly, clinically meaningful or statistically significant changes were observed in dietary behaviors (fruit and vegetables) and diet quality indices and overall physical activity. Greater proportions of women in the txt4two group gained within the IOM ranges for their ppBMIs. The numerous process negotiations and reflections on enablers provide guidance for future work, adapting and embedding evidence-based programs across different clinical settings. This research adapted an evidence-based intervention for a new implementation context. The use of adapted, previously tested interventions reduces the need to develop a new program and saves time and money, while expanding the availability of evidence-based treatments across clinical settings and demographically different populations [Hospitals are a series of complex administrative and clinical systems. Any intervention needs to operate through active contextual exchanges and influence, and be influenced by, system mechanisms [Despite the numerous barriers faced in integrating and adapting the txt4two program, as well as the lower recruitment and retention rate, it remained effective at changing the dietary behaviors and physical activity levels. The original txt4two program resulted in a lower reduction in physical activity (with over 80% of goals set relating to physical activity) [Future health services redesign projects that attempt to take findings from RCTs, especially related to digital health solutions, into the real world that have a number of considerations for a more streamlined approach. As new programs are embedded into services in response to health consumer needs, the enduring question of communication, recruitment, and continued engagement within education requires further refinement and research. This study showed that it took time to gain traction with recruitment and required additional, often novel (to research), avenues that aligned with usual hospital communication processes. An awareness of these avenues (by researchers and clinician–researchers), as well as a willingness to integrate programs (into hospital communication and data systems by those who manage them), is required to deeply and routinely embed interventions into business as usual for greater and more rapid impact, evaluation, and monitoring.