Background
Despite global progress in reducing maternal, newborn and child mortality, more than 5 million children, around the world, die before reaching their fifth birthday [
1]. Rates of under-5 mortality are highest in sub-Saharan Africa and, in 2015, 45% of these deaths occurred in newborns. A majority of under-5 deaths are the result of preventable diseases, the incidence of which could be reduced by implementing health-promoting maternal-child behaviors, such as exclusive breastfeeding (EBF) [
1‐
4].
The health benefits of EBF, especially in low- and middle-income countries (LMIC), have been well documented [
5]. For the child, these include protection against infectious diseases, improved measures of intelligence and decreased risk of becoming overweight and developing diabetes. EBF also confers health benefits for the mother, including a reduced risk of breast and ovarian cancer [
5]. Globally, EBF could save an estimated 823,000 under-5 lives each year, as well as preventing 20,000 maternal deaths from breast cancer. Yet, despite World Health Organization recommendations that children should be exclusively breastfed for the first 6 months of life, EBF rates hover at only 37% in LMIC [
5].
South Africa has one of the lowest rates of EBF in the world [
5]. Estimates of EBF rates under-6 months in South Africa range from 8% [
5,
6] to the most generous estimate, 32% [
7]. Furthermore, the percentage of children exclusively breastfed appears to decrease sharply over the first 6 months, from 44% of infants aged 0–1 month to 24% of infants aged 4–5 months [
7]. The health problems that result are largely due to unsafe formula feeding and the widespread practice of introducing solid foods early (often before 3 months) into the infant’s diet [
8]. In South Africa, some reports suggest that more than 70% of infants are given solid foods before reaching 6 months, the recommended age for initiating complementary feeding [
8]. Unsafe formula feeding, including the use of bottles with poorly cleaned nipples, can lead to diarrheal disease [
9] from pathogens entering the gut. Solid foods, introduced too early into a child’s diet, can also cause gastro-intestinal infections as well as nutrient deficiencies when these foods displace breastmilk without providing adequate nutrient density [
10]. The limited availability of reliable national data on infant feeding in South Africa complicates the design and evaluation of infant feeding interventions [
8]. However, systematic reviews of the literature suggest that large-scale interventions focused on educating mothers can increase the prevalence of EBF and decrease infant mortality [
11‐
14].
The narrative entertainment-education (E-E) approach to health education appears to be a promising strategy for promoting health behavior change [
15,
16]. E-E content endeavors to deliver health messaging through an entertainment media framework. A growing body of scientific evidence suggests that E-E is an effective approach towards positively influencing beliefs, attitudes and behaviors [
15,
17‐
20]. Especially in populations with low motivation and/or a reduced ability for cognitively evaluating the intended health messaging, E-E may be a powerful health education strategy [
15]. The characteristics of effective E-E include: a) appealing narratives, b) high production quality, c) persuasive messages that are unobtrusive and d) high potential for involvement or identification with the presenters or characters portrayed [
15]. While E-E can take many forms, a video-based approach readily supports the harmonious integration of these characteristics.
Video-based content, optimized for mobile devices, may also facilitate broad dissemination of health education, especially as the global penetration of mobile technology increases. Recent advances in mobile messaging have already begun to facilitate the delivery of health messages at scale [
21‐
23] and researchers are increasingly recognizing the potential for mobile phones and tablets to play an important role in health education interventions in LMIC [
23‐
26]. South Africa is an example of a LMIC at the forefront of mobile health (mHealth) initiatives, due to its rapidly expanding penetration of mobile phones and national internet infrastructure [
27‐
29]. National, maternal-child mHealth initiatives built around free, text-based SMS messaging have attracted global attention and been well received [
30,
31]. General “tech-savviness” in South Africa continues to grow, with 37% of adults reporting smartphone ownership and 42% reporting daily internet usage in 2016 [
32]. Active experimentation with WhatsApp, a widely used mobile communication tool that supports the transfer of videos, is also underway in many sectors, including health [
33,
34].
Even for South Africans who do not yet have access to mobile phones, a feasible dissemination pathway lies in the delivery of educational videos by community health workers (CHWs) who bring teaching tablets to their in-home counseling sessions [
35]. Interventions that support women in their homes have demonstrated efficacy in improving breastfeeding rates [
36]. The Philani Maternal Child Health and Nutrition Trust [
37] is an example of a successful community based organization, employing “mentor-mothers”, CHWs who offer in-home health promotion counseling to pregnant women and mothers within their neighborhoods. Data from both case studies and quantitative research suggest additional improvements in breastfeeding rates when synergistic interventions – for example, mass media interventions – are used to supplement successful community-based programs [
36]. Developing interventions that boost the efficacy of community-based programs may be a critical step towards ending preventable child and maternal deaths by 2030 (as called for by the World Health Organization and UNICEF) [
38]. Prior research in South Africa suggests that such synergistic interventions are even more effective when they are created in close collaboration with community-based programs, actively involving local stakeholders in the content creation process [
39].
Applying a human-centered design (HCD) approach to the development of health education interventions may be a powerful way of tailoring these interventions to the specific settings and needs of their target communities, a priority identified in the 2016
Lancet Series on Breastfeeding [
36]. The HCD approach has been described as “constructive, experiential and rooted in the needs and context of end-users of a product or service” [
40], with the end goal of developing novel solutions to pressing problems. The creation of health education using an HCD approach involves several principles and practices that have been well characterized in the literature [
41]. These include focusing on an empathic understanding of the target audience, creating content through a process of rapid prototyping, gathering of feedback and responsive iteration. Finally, the HDC approach is characterized by a relatively high tolerance for ambiguity and failure during the design process [
40,
42].
Recent systematic reviews of mHealth interventions for improving maternal and neonatal health outcomes have called for: 1) strong experimental research designs including randomized controlled trials, 2) feasibility research, 3) government involvement and 4) integration of mHealth interventions into the healthcare system [
23]. The Philani MOVIE intervention will be evaluated using a randomized-controlled trial, which follows a successful, qualitative feasibility study [
35] involving the same population of CHWs who will be delivering the intervention in this trial. The 13-video Philani MOVIE intervention was created in collaboration with the Western Cape Department of Health, the South African National Department of Health, the Philani Maternal Child Health and Nutrition Trust and UNICEF, among other local stakeholders. By integrating the Philani MOVIE intervention into the successful, community-based Philani Mentor Mother Outreach Program [
37], we aim to explore the potential for innovative, mobile video interventions to positively impact breastfeeding rates in South Africa, an important predictor of maternal and neonatal health outcomes.
Aims
This study will achieve the following specific research aims: To
1.
Establish the
a.
Effectiveness of the Philani MOVIE intervention for increasing the practice of exclusive breastfeeding
b.
Effectiveness of the Philani MOVIE intervention for improving other infant feeding practices and maternal knowledge about infant feeding
2.
Determine the usefulness of human-centered design principles when applied to the development of mobile health interventions
3.
Elucidate the mechanisms of intervention action and the acceptability of the intervention to CHWs.
Discussion
The trial described in this paper aims to measure the causal effect of a mobile, video-based entertainment-education intervention, developed using human-centered design principles, on infant feeding behaviors in under-resourced South African communities. Nested qualitative components, involving interviews with local stakeholders and FGDs with mentor-mothers, will explore the development of the intervention and contextualize the results of the trial, while helping to characterize the mechanisms through which the Philani MOVIE intervention enact change.
The application of HCD principles is a new and promising complementary approach to the design of global health interventions [
40]. A key principle of HCD is the idea that content should be created with the needs and context of the target community in mind. The intervention in this trial is based on a strong theory of change and was developed as part of a human-centered design study. Multiple cycles of formative feedback and rapid iteration generated an intervention that is intended to be rooted in the needs and context of the communities it addresses. Creating educational videos that are primarily visual, with carefully scripted audio tracks that convey health messages simply, can further align such content with the needs and context of its target community, especially in low-literacy settings. Additionally, translation of the content (into all 11 South African national languages) could further increase the scalability of the intervention and is underway. The organization of the intervention into short, modular videos was intended to optimize engagement and facilitate their flexible use and dissemination via multiple mobile technology pathways.
Applying the principles of community-based research [
80,
81] to the design and production of this intervention facilitated the HCD approach to its development. We harnessed the strengths and resources within the target communities by soliciting their feedback on early prototypes and their active participation in the content creation process. The resulting intervention includes the stories and voices of local community mothers, presented alongside the parallel narratives of local celebrities. The decision to represent a variety of ethnicities, was made in an attempt to create an intervention that would resonate broadly across multiple South African demographics. The idea of including celebrities’ stories originated within the community and was implemented with the goal of emphasizing the common aspirations and challenges faced by many new mothers. These narrative elements were also included as positive peripheral cues, to optimize peripheral processing of health messages through realistic identification with community mothers and wishful identification with celebrity mothers. As a result, the intervention aims to inhibit resistance to attitude change (counter-arguing) as posited by the theoretical models underpinning this intervention. By partnering closely with target communities and local stakeholders during the intervention development, we were able to: a) identify and build on the strengths and resources within our target communities, b) collaboratively define priority problems and the desired characteristics of the intervention intended to address them and c) use an iterative-feedback process, with a high tolerance for failure and rapid reiteration, to create an intervention that is closely tailored to the needs and context of the target audience.
In the Philani MOVIE intervention, mobile and other emerging technologies facilitate the dissemination, but also the iterative HCD development of the content. The use of Google Drive to collaboratively edit scripts in parallel with version control and the ability to share drafts of video content with community members by WhatsApp facilitated a brisk production timeline for the intervention. The use of WhatsApp and other messaging tools to solicit rapid feedback at key decision points, even from community collaborators who were uncomfortable using email, may eventually prove to be a powerful addition to the production workflow for community-based health education content.
In addition to facilitating the content creation process, the growing penetration of smartphones, tablet technology and general tech-savviness in LMIC yield promising pathways for disseminating content to under-resourced communities. This dissemination can be a) mediated by community health workers or b) direct-to-learner approaches in future initiatives where every family has access to a smartphone or tablet. In anticipation of these emerging pathways, we find ourselves compelled to create a comprehensive, multi-lingual, free, accessible, engaging and impactful “video library for health”. Such a library would allow for timely updating, ongoing iterative improvement and broad dissemination of critical, preventive health education messages.
To this end, our research is intended to support capacity building for a “next generation” of digital, maternal-child health education, a generation of innovative educational tools, rooted in the needs and contexts of the audiences they intend to serve. By doing so, we believe we have an opportunity to support the adoption of behaviors that will form the cornerstone of healthier and more prosperous futures for mothers and children around the world. This cluster-randomized controlled trial serves to provide rigorous scientific evidence about the causal effectiveness of one particular intervention in this broader workstream.
Acknowledgements
We wish to acknowledge:
1. The Patrick J. McGovern Foundation for funding this research.
2. Erfan Mojaddam and Kim Walker for designing the mobile technology used to disseminate the intervention in this study.
3. The Digital MEdIC South Africa production team for their role in creating the intervention.
4. The Stanford Center for Health Education for supporting Digital MEdIC South Africa.
5. The Philani Mentor Mothers for their critical role in implementing this study on the ground.
6. Stellenbosch University for their role in supporting the early design phase of this study.
7. The ELMA Foundation for their generous support of our health education initiatives in South Africa.
8. The South African collaborating institutions and partners who co-created the 100% Breastfed Intervention, including: UNICEF, The National Dept. of Health, the Western Cape Dept. of Health, The University of Cape Town, The University of Limpopo, Stellenbosch University, the University of Witwatersrand, the DG Murray Trust and the Philani Maternal Child Health and Nutrition Trust.