Exploring the role of community health organizations in promoting public health during a health crisis: a qualitative study of COVID-19 responses in South Africa and Zambia.

While the COVID-19 pandemic amplified the need for accurate and actionable health information, uncertainty and the proliferation of misinformation have contributed to significant mistrust in public health messages, especially among marginalized communities. Community health organizations can play an important role in creating trust and providing targeted health information to vulnerable groups. This qualitative study, which is focused on community health organizations supporting vulnerable populations in South Africa and Zambia, finds that during the pandemic, community health organizations expanded their roles and leveraged their established access and trust to support the communities they serve with health education and services. However, the reliance on external support limits the organizations' ability to respond in an effective and efficient manner during health crises.

"The Videos Gave Weight to Our Work": Animated mHealth Videos and Tablet Technology Boost Community Health Workers' Perceived Credibility in Khayelitsha, South Africa.

Mobile health (mHealth) interventions are increasingly used to support community health workers (CHWs) in low-and middle-income countries. As near-peers within their communities, the credibility of CHWs is sometimes questioned-a recognized barrier to their efficacy. Nested within a large, randomized-controlled trial, this qualitative study captured the experiences of South African CHWs, called "Mentor-Mothers," using tablets and animated videos to promote exclusive breastfeeding. We conducted in-depth telephone interviews with 26 tablet-carrying Mentor-Mothers. We analyzed interview transcripts using a Grounded Theory approach, then developed a theoretical framework, based on an emerging theme, for understanding how tablet technology boosts the perceived credibility of CHWs. Tablet-carrying Mentor-Mothers described an increase in their perceived credibility, which they attributed to overt and signaling effects related to enhanced credibility of (1) their messages, (2) themselves as messengers, and (3) the program employing them. Mobile technology investments in CHWs could enhance their credibility, translating into meaningful investments in the health of under-served communities.

Evaluation of a community-based mobile video breastfeeding intervention in Khayelitsha, South Africa: The Philani MOVIE cluster-randomized controlled trial.

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.

Design preferences for global scale: a mixed-methods study of "glocalization" of an animated, video-based health communication intervention.

BACKGROUND: Designing health communication interventions for global scaling promotes health literacy and facilitates rapid global health messaging. Limited literature explores preferences for animation prototypes and other content characteristics across participants in different global regions. Prior research underscores an urgent need for health communication interventions that are compelling and accessible across culturally and geographically diverse audiences. This study presents feedback from global learners on animation design preferences and other key considerations for the development of educational video content intended for global adaptation and scaling. METHODS: We used a mixed-methods, sequential explanatory design, with a qualitative descriptive approach to the analysis of the qualitative data. We recruited participants from an international group of learners enrolled in a massive open online course. Through an online quantitative survey (n = 330), we sought preferences from participants in 73 countries for animation design prototypes to be used in video-based health communication interventions. To learn more about these preferences, we conducted in-depth interviews (n = 20) with participants selected using maximum variation purposive sampling. RESULTS: Generally, respondents were willing to accept animation prototypes that were free of cultural and ethnic identifiers and believed these to be preferable for globally scalable health communication videos. Diverse representations of age, gender roles, and family structure were also preferred and felt to support inclusive messaging across cultures and global regions. Familiar-sounding voiceovers using local languages, dialects, and accents were preferred for enhancing local resonance. Across global regions, narratives were highlighted as a compelling approach to facilitating engagement and participants preferred short videos with no more than two or three health messages. CONCLUSIONS: Our findings suggest that global learners may be willing to accept simplified visuals, designed for broad cross-cultural acceptability, especially if the content is localized in other ways, such as through the use of locally resonating narratives and voiceovers. Diverse, inclusive portrayals of age, gender roles and family structure were preferred.