نبذة مختصرة : Background In South Africa, breastfeeding promotion is a national health priority. Regular perinatal home visits by community health workers (CHWs) have helped promote exclusive breastfeeding (EBF) in underresourced settings. Innovative, digital approaches including mobile video content have also shown promise, especially as access to mobile technology increases among CHWs. We measured the effects of an animated, mobile video series, the Philani MObile Video Intervention for Exclusive breastfeeding (MOVIE), delivered by a cadre of CHWs (“mentor mothers”). Methods and findings We conducted a stratified, cluster-randomized controlled trial from November 2018 to March 2020 in Khayelitsha, South Africa. The trial was conducted in collaboration with the Philani Maternal Child Health and Nutrition Trust, a nongovernmental community health organization. We quantified the effect of the MOVIE intervention on EBF at 1 and 5 months (primary outcomes), and on other infant feeding practices and maternal knowledge (secondary outcomes). We randomized 1,502 pregnant women in 84 clusters 1:1 to 2 study arms. Participants’ median age was 26 years, 36.9% had completed secondary school, and 18.3% were employed. Mentor mothers in the video intervention arm provided standard-of-care counseling plus the MOVIE intervention; mentor mothers in the control arm provided standard of care only. Within the causal impact evaluation, we nested a mixed-methods performance evaluation measuring mentor mothers’ time use and eliciting their subjective experiences through in-depth interviews. At both points of follow-up, we observed no statistically significant differences between the video intervention and the control arm with regard to EBF rates and other infant feeding practices [EBF in the last 24 hours at 1 month: RR 0.93 (95% CI 0.86 to 1.01, P = 0.091); EBF in the last 24 hours at 5 months: RR 0.90 (95% CI 0.77 to 1.04, P = 0.152)]. We observed a small, but significant improvement in maternal knowledge at the 1-month follow-up, but not at the 5-month follow-up. The interpretation of the results from this causal impact evaluation changes when we consider the results of the nested mixed-methods performance evaluation. The mean time spent per home visit was similar across study arms, but the intervention group spent approximately 40% of their visit time viewing videos. The absence of difference in effects on primary and secondary endpoints implies that, for the same time investment, the video intervention was as effective as face-to-face counseling with a mentor mother. The videos were also highly valued by mentor mothers and participants. Study limitations include a high loss to follow-up at 5 months after premature termination of the trial due to the COVID-19 pandemic and changes in mentor mother service demarcations. Conclusions This trial measured the effect of a video-based, mobile health (mHealth) intervention, delivered by CHWs during home visits in an underresourced setting. The videos replaced about two-fifths of CHWs’ direct engagement time with participants in the intervention arm. The similar outcomes in the 2 study arms thus suggest that the videos were as effective as face-to-face counselling, when CHWs used them to replace a portion of that counselling. Where CHWs are scarce, mHealth video interventions could be a feasible and practical solution, supporting the delivery and scaling of community health promotion services. Trial registration The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27, 2018.
Maya Adam and colleagues study a video intervention, delivered by community health workers, to promote breastfeeding in South Africa.
Author summary Why was this study done? Perinatal home visits from trained community health workers (CHWs) have shown promise for increasing the prevalence of exclusive breastfeeding, a national health priority in South Africa. Video-based, mobile health interventions, incorporating narratives and entertainment–education (E–E), have demonstrated potential for engaging community members and improving health knowledge. Few studies have measured the effect of integrating health promotion videos into CHW workflows in underresourced settings. What did the researchers do and find? We developed a mobile, video breastfeeding intervention to be delivered by CHWs (“mentor mothers”) employed by an established community health program during their home visits with 1,502 pregnant participants. We randomized mentor mothers 1:1 to intervention and control arm. All participants served by the same mentor mother either received or did not receive the intervention. In addition to the causal impact evaluation using a randomized controlled trial, we performed a mixed-methods performance evaluation measuring mentor mothers’ time use and gaining insights into mentor mothers’ subjective experiences with the intervention through in-depth interviews. The randomized controlled trial showed no difference in effects between the intervention and control arms. The performance evaluation results showed that mentor mothers in the intervention arm spent approximately 40% of their visit time viewing videos with their participants. What do these findings mean? Instead of serving as a complement to the standard of care, mentor mothers in the video intervention group used it to replace two-fifths of their face-to-face counseling time with participants. The absence of difference between infant feeding outcomes in the 2 study arms implies that the video intervention was as effective as face-to-face counseling, when the CHWs used it to replace a portion of that counselling. Used in addition to face-to-face engagement, video interventions could boost the health promotion efforts of CHWs, and, where CHWs are not available or extremely scarce, mobile video health interventions could become an increasingly feasible and practical solution for the delivery and scaling of community health promotion services. Future research should explore alternative delivery channels for mobile video E–E health interventions and measure, across channels, the potential for these interventions to (a) increase access to health promotion in underresourced communities; (b) support existing CHW programs; and (c) improve health behaviors and outcomes.
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