Effect of Short, Animated Video Storytelling on Maternal Knowledge and Satisfaction in the Perinatal Period in South Africa: Randomized Controlled Trial

"Especially as internet access and smartphone penetration increase across South Africa, there may be a growing role for innovative approaches that encourage engagement with perinatal health services through high-satisfaction, easily scalable add-ons, like SAS [short, animated storytelling] videos."



An important component of South Africa's efforts to achieve the 2030 Sustainable Development Goals lies in improving maternal knowledge by increasing access to health information in the perinatal period. As part of these efforts, in 2014, the South African National Department of Health introduced the mHealth intervention MomConnect, a free service that offers informational text messages among other resources for pregnant women. Within 3 years, the programme had reached more than 1.5 million pregnant women. This randomised controlled trial (RCT) explores the effect of short, animated storytelling (SAS) videos, aligned with MomConnect messaging, on maternal knowledge and maternal satisfaction in the perinatal period in the City of Tshwane Metropolitan District of Gauteng, South Africa.



Developed through a collaborative, human-centred design process, the intervention, called Amandla Mama ("motherly strength" or "power to the mother" in the South African languages of isiZulu and isiXhosa), consisted in a collection of 10 SAS videos focused on perinatal health topics. During the content creation process, research partners at the Clinton Health Access Initiative in South Africa shared a collection of prototypes with women attending antenatal clinic visits. The expectant mothers were asked to give feedback on the topics, style, length, narratives, audio, and visual design of the prototypes. This feedback, along with previous research on global preferences for animated character design, also informed the final 10 intervention videos, which were animated by a local South African animator. The videos were delivered through WhatsApp to participants in this study; each video could be viewed only once to prevent sharing between mothers in the intervention and control groups.



Women enrolled in antenatal care programmes at 2 public health facilities in the Tshwane District of South Africa were randomly assigned to either the SAS intervention group or the standard-of-care (SOC) control group. SOC in South Africa includes regular antenatal counseling at the local clinic and optional enrollment in MomConnect. In addition to having access to regular antenatal care, mothers assigned to the SAS intervention group were sent the 10 SAS intervention videos on WhatsApp. One month later, participants responded to telephone surveys assessing their knowledge. The intervention group then participated in a nested evaluation of user satisfaction.



The researchers surveyed 204 participants, almost all of whom self-identified as Black. The results of the regression model of overall knowledge scores showed that, after adjusting for demographic variables, watching the short videos slightly increased the overall knowledge score by an average of 0.28. Thus, measured knowledge gains were small within a participant population that was already receiving perinatal health messages similar to the ones included in the SAS videos through antenatal clinics. For mothers who lack access to maternity clinics, MomConnect and SAS videos could play a role in transmitting perinatal health messages to hard-to-reach communities in ways that overcome education and literacy barriers. The higher knowledge scores observed in older participants with higher education levels suggest that boosting maternal knowledge in younger mothers with lower education levels should continue to be a public health priority in South Africa.



Maternal satisfaction was high overall, with a pooled average satisfaction score of 4.71 on a 5-point Likert scale. The lowest-scoring questions had to do with technical difficulties, including the speed and ease of downloading as well as the ease of viewing videos on mobile devices. Probing from the interviewers revealed that internet access can still be challenging in many communities. In addition, mobile devices are often shared within a family (or are the property of the husband), and finding a quiet, private location in which to view the videos could present logistical issues for some participants.



The researchers reflect on the fact that, while previous studies have shown the promise of animated video health education, most of this research has been conducted in high-income countries. More research in underresourced settings is needed, especially as access to mobile technology increases in the Global South. Future studies should explore the effect of SAS videos on maternal knowledge in hard-to-reach populations with limited access to antenatal care, although real-world logistical challenges persist when implementing studies in underresourced South African populations.



In conclusion: "Because of the 'glocalizable' character designs used in the Amandla Mama series, these videos could also easily and cost-effectively be adapted for other language groups in South Africa and other countries. Health promotion agencies in South Africa might even consider translating and dubbing short, animated video content to make it accessible for all South African mothers - a potentially powerful step toward overcoming both language and literacy barriers to maternal health education."



Editor's note: The entire video series is available in Multimedia Appendices 2-11 and Google Drive. These videos can be freely used by community health organisations for health promotion purposes.