"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.

Experiences of workplace breastfeeding in a provincial government setting: a qualitative exploratory study among managers and mothers in South Africa.

BACKGROUND: Return to employment is a major barrier to breastfeeding continuation, globally and in the Southern African context. The Lancet Breastfeeding Series revealed an explicit need for research exploring breastfeeding as a workplace issue in low- and middle-income countries. A dearth of research on workplace breastfeeding in South Africa calls for attention to this topic. This study sought to explore breastfeeding at work experiences from the perspective of employed mothers and senior managers in a provincial government setting in South Africa. METHODS: The study adopted an exploratory qualitative design with multi-perspective semi-structured interviews. Snowball sampling was employed to recruit twelve participants, senior managers (n = 4) and employed mothers (n = 8), from two provincial government departments in Cape Town, South Africa. Interviews were conducted between April and August 2018 to capture participants' experiences with breastfeeding in the workplace. Thematic analysis was used to analyse data. RESULTS: Four key themes that described experiences of workplace breastfeeding emerged which further traversed three critical maternity periods: pregnancy, maternity leave, and return to work. The prevalent themes were: 1) Knowledge about the legislation and breastfeeding support benefits. Most participants only knew about the legislated four months maternity leave and time off for prenatal visits but lacked knowledge about comprehensive maternity benefits; 2) Perceptions and experiences of breastfeeding in the workplace. Breastfeeding was perceived to be a mother's responsibility and a private issue. As a result, most participants stopped breastfeeding prior to or immediately upon return to work after maternity leave; 3) Barriers to breastfeeding continuation, such as the absence of a conversation about infant feeding plans between managers and mothers; and 4) Recommendations to improve breastfeeding support at work from an individual, organisational and national level. CONCLUSIONS: Our study contributions emphasise that breastfeeding support from managers should begin prior to the mother taking maternity leave, and that in addition to providing supportive facilities (such as private space and breastmilk storage), immediate supervisor support may be critical in fostering breastfeeding-friendly workplaces for mothers. Management implications for advancing workplace breastfeeding support in the public sector are presented.