The Philani Mobile Video Intervention for Exclusive Breastfeeding (MOVIE) Study: a Cluster-randomized Controlled Trial of a Mobile Video Entertainment-education Intervention to Promote Exclusive Breastfeeding in South Africa

Background

The health benefits of exclusive breastfeeding (EBF), especially in low- and middle-income countries (LMIC), have been well documented. These include protection against infectious diseases, improved measures of intelligence and decreased risk of becoming overweight and developing diabetes. Globally, EBF could save the lives of an estimated 823 000 children under the age of five each year. Yet, despite World Health Organization recommendations that children should be exclusively breastfed for the first six months of life, EBF rates hover at only 37% in LMIC.

South Africa has one of the lowest rates of EBF in the world. Estimates of EBF rates under six months in South Africa range from 8% to the most generous estimate, 32% reported in the South Africa Demographic and Health Survey 2016. The health problems that result are largely due to unsafe formula feeding and the widespread practice of introducing solid foods early (often before three months) into the infant's diet. In South Africa, more than 70% of infants are given solid foods before reaching six months, the recommended age for initiating complementary feeding. Unsafe formula feeding and early introduction of solid foods can lead to diarrheal disease from pathogens entering the gut, as well as nutrient deficiencies when the foods introduced displace breastmilk without providing adequate nutrient density. The limited availability of reliable national data on infant feeding in South Africa complicates the design and evaluation of infant feeding interventions. 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.

Narrative, entertainment-education (E-E) approaches to health education have emerged as potentially powerful strategies for promoting positive health behavior change. E-E involves the delivery of health messages by embedding them in an entertainment media framework. A substantial body of research suggests that E-E is an effective way of influencing beliefs, attitudes and behaviors. The characteristics of particularly impactful E-E media include: a) appealing narratives, b) high-quality production, c) persuasive messages that are unobtrusive and d) high potential for involvement or identification with the presenters or characters portrayed. While E-E can take many forms, a video-based approach readily supports the optimized 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 health (mHealth) messaging have already begun to facilitate the delivery of health messages at scale and researchers are increasingly recognizing the potential for mobile phones and tablets to play an important role in health education interventions in LMIC. South Africa is an example of a LMIC at the forefront of mHealth initiatives, due to its rapidly expanding penetration of mobile phones. National, maternal-child mHealth initiatives built around free, text-based messaging have attracted global attention and been well received. General "tech-savviness" in South Africa continues to grow, with 37% of adults reporting "smartphone" ownership and 42% reporting daily internet usage in 2016. Active experimentation with "WhatsApp", a widely used mobile communication tool that supports the transfer of videos, is also underway in many sectors, including health.