A new publication shares results from a qualitative study in Khayelitsha, South Africa involving South African “Mentor-Mothers”. The findings indicate that using tablet devices and educational videos can help legitimize CHWs in the eyes of patients and improve their experiences delivering care.
Community health workers (CHWs) bridge critical gaps in frontline healthcare provision around the world. They are embedded within their communities, speak the local languages, and experience many of the same challenges as their patients, making them effective and trustworthy healthcare providers. CHWs’ “near-peer” status is largely advantageous — for example, they can impact maternal and child health decisions by sharing relatable personal experiences as mothers or caregivers.
“The near-peer status of community health workers globally has always been regarded as their biggest benefit, as it allows for better discussion and persuasion to healthy life habits, across a variety of programmes from exclusive breastfeeding to safe sex practices,” said Nophiwe Job, Research Analyst at Digital Medic.
However, CHWs also report encountering skepticism about their credibility as health professionals. Paired with adequate support, technology tools have potential to help CHWs signal their competency and legitimacy. In fact, mobile health interventions are often leveraged to assist CHWs in client interactions and boost their overall efficacy.
Building on prior research around the use of technology to improve CHWs’ perceived status, Digital Medic co-developed a qualitative study within a larger randomized-controlled trial of a mobile video-based breastfeeding intervention in Khayelitsha, South Africa.
A study within a study
The study involved collaborators at the University of Cape Town, Heidelberg University, Johns Hopkins University, Icahn School of Medicine at Mount Sinai, and the Philani Maternal Child Health and Nutrition Trust (Philani). Philani, a non-governmental community health organization based in South Africa’s Western Cape, runs a program involving CHWs known as “Mentor-Mothers”. Mentor-Mothers work with new and expectant mothers in their communities, supporting them with key health information through pregnancy, breastfeeding, and early childhood care.
This study aimed to explore how using mobile tablets and animated educational videos during home visits affected Mentor-Mothers’ experiences promoting breastfeeding among their clients. Ultimately, it led to valuable insights around how technology can influence CHWs’ perceived status in their communities and as members of the health workforce.
“Originally, we wanted to understand the practicality of introducing digital technology to the complicated problem of exclusive breastfeeding,” explained Job. “It was after a few months of using videos in their daily work that Mentor-Mothers reported improved trust and credibility.”
The original trial, known as the Philani MOVIE Study, found a video intervention to be as effective as in-person counseling in promoting exclusive breastfeeding. All Mentor-Mothers in the study received tablets to use in their home visits; the control group used them to collect health data, and the intervention group used them to both collect data and share animated health videos. The approach and results of this quantitative study were published in PLOS Medicine in 2021.
At the end of the MOVIE Study, the researchers conducted in-depth telephone interviews with 26 Mentor-Mothers who had used the tablets, to understand how the devices might impact their experiences and effectiveness. These first-hand accounts enhanced and added context to the quantitative data.
“It can be challenging for researchers who don’t live within the participant community to explain quantitative findings,” said Dr. Maya Adam of Stanford University, who led the research effort. “Nesting a qualitative analysis in a quantitative trial provides valuable insights into how and why an intervention may or may not have been effective.”
Documenting CHW experiences
Though their work can be affected by difficulties related to poverty, safety, and limited resources, Mentor-Mothers remain committed and compassionate. Kwanie Mbewu, a Senior Program Manager at Philani at the time of the study, commented: “The Mentor-Mothers’ attitudes towards their work is incredible. These are people that are resourceful themselves, that have developed coping mechanisms for challenges in their own lives. At Philani we added a bit of training to their personal experiences, so they could share with others.”
In the post-intervention interviews, Mentor-Mothers described their typical daily work experiences, preconceptions about using technology prior to the study, and the challenges and outcomes of incorporating the tablets and videos into their home visits.
At first, some Mentor-Mothers were hesitant to start using tablets, worried that they might create more work and complexity, but they gradually accepted that the devices could be helpful. One Mentor-Mother explained: “It seemed like it was going to be hard to use tablets, as if we were going to do something unfamiliar but when I got to the field I realized that what I thought was going to be hard, it’s something I am always doing only that there was an additional tool.”
Though there was also a possibility of patient resistance to the devices, the interviewees reported positive feedback from their clients. “We were anticipating hesitation from patients as introducing mobile technologies in healthcare has been reported to bring up fears about privacy,” said Job. “It was interesting to us that the patients welcomed the intervention and found it to validate the information they had been receiving from the Mentor-Mothers.”
The Mentor-Mothers highlighted the impact the videos and tablets had on their perceived credibility, which the researchers broke down into three main dimensions:
- credibility of the message
- credibility of the messenger
- credibility of the program overall.
In the interviews, the Mentor-Mothers reported that tablet usage bolstered all three dimensions.
One Mentor-Mother stated: “There is stigma to be undermined in the township as if we don’t know what we are talking about. Amavidiyo … anike umsebenzi wethu isidima: The videos gave weight to our work.”
She elaborated that the tablets “had a beautiful effect on my job, like when you educate and see the content in the videos, you know you are talking about something they can see in the videos, which adds weight.”
Knowing that women, and particularly teenage mothers, can be uncomfortable interacting with healthcare workers, Job was struck by the Mentor-Mothers’ “reports of improved credibility amongst their patients and how the videos caused their patients to open up more and ask questions.”
Job continued: “Breastfeeding counseling is an effort to improve confidence among mothers. It was delightful to hear that Mentor-Mothers were receiving increased engagement from their patients as a result of the tablets and videos.”
Overall, the in-depth interviews brought aspects of the Mentor-Mothers’ experiences to light that otherwise may not have been recognized. “We had hoped that the Mentor-Mothers would find the tablet technology helpful in accomplishing their day-to-day tasks, but we had not anticipated the extent to which simply carrying and using technology would make them feel more credible,” said Dr. Adam. “When the theme of boosting perceived credibility emerged as one of the commonly cited benefits, it made sense, but without the nested qualitative study, we wouldn’t have known.”
Conclusion: Technology as a scalable tool for CHWs
The larger Philani MOVIE study outcomes suggest that evidence-based health education videos can amplify health promotion efforts, particularly in areas where CHWs are overburdened or scarce. The findings of this qualitative study further indicate that equipping CHWs with tablets and videos can improve their perceived credibility and their personal experiences delivering care.
“I have seen how a tablet can assist in the most rural parts of the Eastern Cape, where, for example, a young mother might be hearing mixed messages about breastfeeding,” said Mbewu. “When a health worker puts down a tablet and says let’s watch this video together, it’s like evidence for them. Especially if the person talking on the tablet is around the same age or speaking the same language as the client.”
Both parts of the study underscore that technology can play a part in relieving CHWs’ workload and improving their effectiveness. As stated in the qualitative paper: “By reducing the burden of face-to-face counseling, (by approx. 40% in our study), accessible mHealth videos could potentially lighten the workload of CHWs while simultaneously supporting consistency of messaging across clients. … where the capacity of CHWs is limited, our study suggests a potential role for tablet-based video interventions to partially substitute face-to-face time spent delivering foundational health messages.”
From a research perspective, Dr. Adam emphasizes that there is more work to be done to expand on this work and further explore mHealth interventions and other ways to support CHWs at scale.
“Implementing large trials in real-world, community-based settings will always be challenging because there are so many variables that are outside of the researchers’ control. Future studies that continue to involve local researchers and community members in defining and implementing trials are more likely to overcome those challenges and yield meaningful data,” Dr. Adam said. “I also think that nested performance evaluations and other mixed-methods approaches yield findings that are more three-dimensional than those that focus on only one approach to conducting research.”
In the paper, the researchers also suggest that government health agencies and local organizations can contribute by allocating funding and resources to CHW technology training and capacity-building efforts. With this support, tablet-based video interventions can be scaled across CHW programs worldwide.
“A CHW is a resource for her community, her family, and for herself; the presence of a CHW in home visits, along with the use of technology, makes access easier,” said Mbewu.
“If you give resources to CHWs and support and supervise them, they have great potential. It’s a cadre that all clinicians – doctors, nurses, and social workers – should respect because they go into homes, see everything, and understand the context. CHWs are the best resource if they are equipped well.”
To review the study’s findings and learn more about the Mentor-Mothers’ experiences, read our paper published via SAGE, Qualitative Health Research. Our breastfeeding and maternal and child health videos are available to view on YouTube.