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

Abstract

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.

Conflict of interest statement

I have read the journal’s policy and the authors of this manuscript have the following competing interests: MT is a member of PLOS Medicine’s Editorial Board. The other co-authors have declared no competing interests.

Figures

Fig 1. Philani MOVIE study setting.

Left panel: map of the Western Cape Province, South Africa, (illustration by Sufian Ahmed). Right panel A: a Philani mentor mother walking between home visits. Right panel B: collage of homes and shops in Khayelitsha, South Africa. Right panel C: Bird’s eye view of Khayelitsha, a sprawing informal settlement (photos by Maya Adam). MOVIE, MObile Video Intervention for Exclusive breastfeeding.

Fig 2. Participant flow diagram for the Philani MOVIE study.

LTFU, loss to follow-up; MM, mentor mother; MOVIE, MObile Video Intervention for Exclusive breastfeeding.

Fig 3. Philani MOVIE video topics and duration.

Links to the videos used in the intervention can be found in the supporting information section (S1 File) at the end of this manuscript. MOVIE, MObile Video Intervention for Exclusive breastfeeding.

Fig 4. Theory of change.

EBF, exclusive breastfeeding; eELM, extended ELM; ELM, Elaboration Likelihood Model.

Fig 5. Infant feeding results at 1 month and 5 months.

MOVIE, MObile Video Intervention for Exclusive breastfeeding; RR, risk ratio.

Fig 6. Per-visit time tracking and video viewing by arm.

This figure illustrates the total mean time mentor mothers spent counseling participants as well as the mean proportion of that time spent watching videos versus face-to-face counseling in both groups.