The Philani MOVIE study: a cluster-randomized controlled trial of a mobile video entertainment-education intervention to promote exclusive breastfeeding in South Africa

Background: In South Africa, rates of exclusive breastfeeding remain low and breastfeeding promotion is a national health priority. Mobile health and narrative entertainment-education are recognized strategies for health promotion. In-home counseling by community health workers (CHWs) is a proven breastfeeding promotion strategy. This protocol outlines a cluster-randomized controlled trial with a nested mixed-methods evaluation of the MObile Video Intervention for Exclusive breastfeeding (MOVIE) program. The evaluation will quantify the causal effect of the MOVIE program and generate a detailed understanding of the context in which the intervention took place and the mechanisms through which it enacted change. Findings from the study will inform the anticipated scale-up of mobile video health interventions in South Africa and the wider sub-Saharan region. Methods: We will conduct a stratified cluster-randomized controlled trial in urban communities of the Western Cape, to measure the effect of the MOVIE intervention on exclusive breastfeeding and other infant feeding practices. Eighty-four mentor-mothers (CHWs employed by the Philani Maternal Child Health and Nutrition Trust) will be randomized 1:1 into intervention and control arms, stratified by neighborhood type. Mentor-mothers in the control arm will provide standard of care (SoC) perinatal in-home counseling. Mentor-mothers in the intervention arm will provide SoC plus the MOVIE intervention. At least 1008 pregnant participants will be enrolled in the study and mother-child pairs will be followed until 5 months post-delivery. The primary outcomes of the study are exclusive breastfeeding at 1 and 5 months of age. Secondary outcomes are other infant feeding practices and maternal knowledge. In order to capture human-centered underpinnings of the intervention, we will conduct interviews with stakeholders engaged in the intervention design. To contextualize quantitative findings and understand the mechanisms through which the intervention enacted change, end-line focus groups with mentor-mothers will be conducted. Discussion: This trial will be among the first to explore a video-based, entertainment-education intervention delivered by CHWs and created using a community-based, human-centered design approach. As such, it could inform health policy, with regards to both the routine adoption of this intervention and, more broadly, the development of other entertainment-education interventions for health promotion in under-resourced settings. Trial Registration: The study and its outcomes were registered at clinicaltrials.gov (#NCT03688217) on September 27th, 2018

Home visits by neighborhood Mentor Mothers provide timely recovery from childhood malnutrition in South Africa: results from a randomized controlled trial

Abstract Background Child and infant malnourishment is a significant and growing problem in the developing world. Malnourished children are at high risk for negative health outcomes over their lifespans. Philani, a paraprofessional home visiting program, was developed to improve childhood nourishment. The objective of this study is to evaluate whether the Philani program can rehabilitate malnourished children in a timely manner. Methods Mentor Mothers were trained to conduct home visits. Mentor Mothers went from house to house in assigned neighborhoods, weighed children age 5 and younger, and recruited mother-child dyads where there was an underweight child. Participating dyads were assigned in a 2:1 random sequence to the Philani intervention condition (n = 536) or a control condition (n = 252). Mentor Mothers visited dyads in the intervention condition for one year, supporting mothers' problem-solving around nutrition. All children were weighed by Mentor Mothers at baseline and three, six, nine and twelve month follow-ups. Results By three months, children in the intervention condition were five times more likely to rehabilitate (reach a healthy weight for their ages) than children in the control condition. Throughout the course of the study, 43% (n = 233 of 536) of children in the intervention condition were rehabilitated while 31% (n = 78 of 252) of children in the control condition were rehabilitated. Conclusions Paraprofessional Mentor Mothers are an effective strategy for delivering home visiting programs by providing the knowledge and support necessary to change the behavior of families at risk

Depressed mood in pregnancy: Prevalence and correlates in two Cape Town peri-urban settlements

<p>Abstract</p> <p>Background</p> <p>The disability associated with depression and its impact on maternal and child health has important implications for public health policy. While the prevalence of postnatal depression is high, there are no prevalence data on antenatal depression in South Africa. The purpose of this study was to determine the prevalence and correlates of depressed mood in pregnancy in Cape Town peri-urban settlements.</p> <p>Methods</p> <p>This study reports on baseline data collected from the Philani Mentor Mothers Project (PMMP), a community-based, cluster-randomized controlled trial on the outskirts of Cape Town, South Africa. The PMMP aims to evaluate the effectiveness of a home-based intervention for preventing and managing illnesses related to HIV, TB, alcohol use and malnutrition in pregnant mothers and their infants. Participants were 1062 pregnant women from Khayelitsha and Mfuleni, Cape Town. Measures included the Edinburgh Postnatal Depression Scale (EPDS), the Derived AUDIT-C, indices for social support with regards to partner and parents, and questions concerning socio-demographics, intimate partner violence, and the current pregnancy. Data were analysed using bivariate analyses followed by logistic regression.</p> <p>Results</p> <p>Depressed mood in pregnancy was reported by 39% of mothers. The strongest predictors of depressed mood were lack of partner support, intimate partner violence, having a household income below R2000 per month, and younger age.</p> <p>Conclusions</p> <p>The high prevalence of depressed mood in pregnancy necessitates early screening and intervention in primary health care and antenatal settings for depression. The effectiveness and scalability of community-based interventions for maternal depression must be developed for pregnant women in peri-urban settlements.</p> <p>Trial registration</p> <p>ClinicalTrials.gov: <a href="http://www.clinicaltrials.gov/ct2/show/NCT00972699">NCT00972699</a>.</p

Multiple risk factors during pregnancy in South Africa: the need for a horizontal approach to perinatal care.

South African children's long-term health and well-being is jeopardized during their mothers' pregnancies by the intersecting epidemics of HIV, alcohol use, low birth weight (LBW; &lt;2,500&nbsp;g) related to poor nutrition, and depressed mood. This research examines these overlapping risk factors among 1,145 pregnant Xhosa women living in 24 township neighborhoods in Cape Town, South Africa. Results revealed that 66&nbsp;% of pregnant women experienced at least one risk factor. In descending order of prevalence, 37&nbsp;% reported depressed mood, 29&nbsp;% were HIV+, 25&nbsp;% used alcohol prior to knowing that they were pregnant, and 15&nbsp;% had a previous childbirth with a LBW infant. Approximately 27&nbsp;% of women had more than one risk factor: depressed mood was significantly associated with alcohol use and LBW, with a trend to significance with HIV+. In addition, alcohol use was significantly related to HIV+. These results suggest the importance of intervening across multiple risks to maternal and child health, and particularly with depression and alcohol use, to positively impact multiple maternal and infant outcomes

To evaluate if increased supervision and support of South African Government health workers' home visits improves maternal and child outcomes: study protocol for a randomized control trial.

BackgroundConcurrent epidemics of HIV, depression, alcohol abuse, and partner violence threaten maternal and child health (MCH) in South Africa. Although home visiting has been repeatedly demonstrated efficacious in research evaluations, efficacy disappears when programs are scaled broadly. In this cluster randomized controlled trial (RCT), we examine whether the benefits of ongoing accountability and supervision within an existing government funded and implemented community health workers (CHW) home visiting program ensure the effectiveness of home visiting.Methods/designIn the deeply rural, Eastern Cape of South Africa, CHW will be hired by the government and will be initially trained by the Philani Programme to conduct home visits with all pregnant mothers and their children until the children are 2&nbsp;years old. Eight clinics will be randomized to receive either (1) the Accountable Care Condition in which additional monitoring and accountability systems that Philani routinely uses are implemented (4 clinics, 16 CHW, 450 households); or (2) a Standard Care Condition of initial Philani training, but with supervision and monitoring being delivered by local government structures and systems (4 clinics, 21 CHW, 450 households). In the Accountable Care Condition areas, the CHW's mobile phone reports, which are time-location stamped, will be monitored and data-informed supervision will be provided, as well as monitoring growth, medical adherence, mental health, and alcohol use outcomes. Interviewers will independently assess outcomes at pregnancy at 3, 6, 15, and 24&nbsp;months post-birth. The primary outcome will be a composite score of documenting maternal HIV/TB testing, linkage to care, treatment adherence and retention, as well as child physical growth, cognitive functioning, and child behavior and developmental milestones.DiscussionThe proposed cluster RCT will evaluate whether routinely implementing supervision and accountability procedures and monitoring CHWs' over time will improve MCH outcomes over the first 2&nbsp;years of life.Trial registrationClinicalTrials.gov registration #NCT02957799 , registered on October 26, 2016

To evaluate if increased supervision and support of South African Government health workers’ home visits improves maternal and child outcomes : study protocol for a randomized control trial

CITATION: Rotheram-Borus, M. J., et al. 2017. To evaluate if increased supervision and support of South African Government health workers’ home visits improves maternal and child outcomes : study protocol for a randomized control trial. Trials, 18:368, doi:10.1186/s13063-017-2074-5The original publication is available at https://trialsjournal.biomedcentral.comBackground: Concurrent epidemics of HIV, depression, alcohol abuse, and partner violence threaten maternal and child health (MCH) in South Africa. Although home visiting has been repeatedly demonstrated efficacious in research evaluations, efficacy disappears when programs are scaled broadly. In this cluster randomized controlled trial (RCT), we examine whether the benefits of ongoing accountability and supervision within an existing government funded and implemented community health workers (CHW) home visiting program ensure the effectiveness of home visiting. Methods/Design: In the deeply rural, Eastern Cape of South Africa, CHW will be hired by the government and will be initially trained by the Philani Programme to conduct home visits with all pregnant mothers and their children until the children are 2 years old. Eight clinics will be randomized to receive either (1) the Accountable Care Condition in which additional monitoring and accountability systems that Philani routinely uses are implemented (4 clinics, 16 CHW, 450 households); or (2) a Standard Care Condition of initial Philani training, but with supervision and monitoring being delivered by local government structures and systems (4 clinics, 21 CHW, 450 households). In the Accountable Care Condition areas, the CHW’s mobile phone reports, which are time-location stamped, will be monitored and data-informed supervision will be provided, as well as monitoring growth, medical adherence, mental health, and alcohol use outcomes. Interviewers will independently assess outcomes at pregnancy at 3, 6, 15, and 24 months post-birth. The primary outcome will be a composite score of documenting maternal HIV/TB testing, linkage to care, treatment adherence and retention, as well as child physical growth, cognitive functioning, and child behavior and developmental milestones. Discussion: The proposed cluster RCT will evaluate whether routinely implementing supervision and accountability procedures and monitoring CHWs’ over time will improve MCH outcomes over the first 2 years of life.AFRIKAANSE OPSOMMING: Geen opsomming beskikbaarhttps://trialsjournal.biomedcentral.com/articles/10.1186/s13063-017-2074-5/open-peer-reviewPublisher's versio

Multiple risk factors during pregnancy in South Africa: the need for a horizontal approach to perinatal care.

South African children's long-term health and well-being is jeopardized during their mothers' pregnancies by the intersecting epidemics of HIV, alcohol use, low birth weight (LBW; &lt;2,500 g) related to poor nutrition, and depressed mood. This research examines these overlapping risk factors among 1,145 pregnant Xhosa women living in 24 township neighborhoods in Cape Town, South Africa. Results revealed that 66 % of pregnant women experienced at least one risk factor. In descending order of prevalence, 37 % reported depressed mood, 29 % were HIV+, 25 % used alcohol prior to knowing that they were pregnant, and 15 % had a previous childbirth with a LBW infant. Approximately 27 % of women had more than one risk factor: depressed mood was significantly associated with alcohol use and LBW, with a trend to significance with HIV+. In addition, alcohol use was significantly related to HIV+. These results suggest the importance of intervening across multiple risks to maternal and child health, and particularly with depression and alcohol use, to positively impact multiple maternal and infant outcomes

Are we listening to community health workers? Experiences of the community health worker journey in rural South Africa

Access to healthcare in developing countries remains a challenge. As a result, task-shifting to community health workers (CHWs) is increasingly used to mitigate healthcare worker shortages. Although there is solid evidence of CHW program effectiveness, less is known about CHWs' experiences of becoming and then working daily as CHWs-information that should play an important role in the design of CHW programs. We examined the experiences of a group of CHWs working in a government-run CHW program in South Africa's rural Eastern Cape Province. Semistructured qualitative interviews (N = 9) and focus groups (N = 2) focusing on motivations for becoming a CHW and experiences of working as CHWs were conducted and thematically analyzed. Three themes were identified: (1) becoming a CHW, (2) facing challenges in the field, and (3) gaining community acceptance through respect and legitimacy. In this study, CHWs were motivated by altruism and a desire to help their community. They faced a range of challenges such as limited training, lack of supervision, equipment shortages, logistical issues, and clinics with limited services. Respect and legitimacy through community acceptance and trust is crucial for effective CHW work. CHWs in this study described how confidentiality and their own persistence facilitated the process of gaining respect and legitimacy. CHWs have a unique knowledge of contexts and requirements for successful programs and greater efforts are needed to include their perspectives to improve and develop programs. Recognition is needed to acknowledge the significant personal input required by CHWs for programs to be successful

Male Partners&rsquo; Roles in Infant Feeding Practices: Perspectives of Black Mothers Living with HIV in Three Countries

Currently, mothers living with HIV (LWH) are challenged with different infant feeding guidelines depending on the country they are living in. This may contribute to confusion, stress, and mental health issues related to decision-making about infant feeding as a mother LWH. Yet, their male partners as their closest social capital have important roles to play in reducing or aggravating this psychosocial distress. Hence, we describe the role of male partners in supporting mothers who are living with HIV in the context of infant feeding. It is based on the results of a recent study of the socio-cultural context of infant feeding among Black mothers LWH in three countries; Canada, the USA, and Nigeria. The study was a tri-national, mixed-methods, community-based participatory research (CBPR) project, informed by postcolonialism and intersectionality theories. This paper is based on the qualitative component of the study. It was a focused ethnography (FE) involving 61 in-depth individual interviews (IDIs) with Black- mothers LWH. Thematic analysis guided the interpretation of these data, and trustworthiness was established through member-checking. Black mothers LWH acknowledged the various support roles that their male partners play in easing the practical and emotional burdens of infant feeding in the context of HIV. Male partners&rsquo; roles were captured under three sub-themes: (1) Practical help, (2) Protection of the family, and (3) Emotional support and sounding board. These findings have explicated the evolving ways in which male partners support ACB mothers LWH to promote positive infant feeding outcomes, as well as enhance the emotional and physical well-being of both mother and infant. Our study has explicated the evolving ways in which male partners support Black mothers LWH to promote positive infant feeding outcomes, as well as enhance the emotional and physical well-being of both mother and infant