The home environment and play: The co-creation of an intervention aimed at increasing participation in infant play in a low- income community in Johannesburg, South Africa.

Abstract

Background: Infants require their caregivers to provide opportunities to engage in playful activities that promote early development and encourage further positive health outcomes later in life. Mothers require a certain level of health literacy to access, appraise and understand information to have the capability to make decisions that encourage optimal health for their child. However, some mothers living in low-income settings do not have access to information or adequate support for encouraging play and development. Mobile Health applications have the potential to provide cost effective, scalable interventions and improve health outcomes in low-resources settings, such as South Africa, when effectively implemented. The aim of this thesis was to develop and implement an intervention aimed at improving maternal health literacy around infant play and development and to determine whether this intervention was acceptable, feasible, and effective. Methods: A Community Advisory Group co-created and tested an intervention prototype aimed at increasing maternal health literacy around play and development, through focus group discussions and testing the activities at home. The intervention was then implemented as part of the PLAY study, a Randomised Controlled Trial, conducted from September 2022 to June 2024 (N=133). From 6-12 months postpartum, intervention group participants (n=68) received interactive App-based content promoting health literacy and encouraging infant active play and development. The control group (n=65) received the normal standard of care. The primary outcome was the Health Literacy Questionnaire scores, while secondary outcomes included maternal beliefs about infant physical activity, home affordances for motor development, and infant physical/sedentary behaviors. A combined “opportunities for active play” score was derived from the secondary measures. Data were analysed in STATA, using an intention to treat approach. Descriptive data were reported using N (%) for categorical data and means (Standard Deviation) for continuous data. Wilcoxon rank tests determined the effect of the treatment. Feasibility and acceptability of the intervention were measured and explored at the end of the study (12 months) through participant Focus Group Discussions and semi- structured questionnaire. Results: Community Advisory Group participants suggested that the intervention content be delivered every 1-2 weeks, through a data-free app. Overall, the prototype activities tested at home were deemed 19 acceptable. At intervention baseline, the 67 intervention and 65 control participants averaged 29 years old; most were single (64%) and had completed secondary education (64%). No significant differences were observed at 12 months between groups in maternal Health Literacy Questionnaire (t=-1.05 p=0.3), maternal beliefs (t=0.71; p=0.48), infant physical activity (t-0.15; p=0.88) or sedentary time (-0.89; p=0.38), and opportunities for play (p=0.36). However, the change in Maternal Beliefs score from 6 to 12 months was significant (p=0.00), with the intervention group’s scores increasing on average, 35.44 points compared to an average of 25.7 points in the control group. Participants in the intervention group showed a significant decrease of 1.53 units in the AHEMDS score, compared to the control group, at 12 months When looking at the change in opportunities for play from 6 to 12 months, there was a significant (p=0.001) difference between the intervention and control group, with 27 participants (40%) in the intervention group increasing between 1 and 3 points (compared to 8% in the control group) and 43 participants (42%) of the control group decreasing between 1 and 4 score units (compared to 31% in the intervention group). The health literacy intervention content was found to be highly acceptable based on the questionnaire and Focus Group Discussions. Over 80% of participants attended the 12 month exit appointment. Most of the participants (70%) could access the intervention content over the 12 months of the PLAY Study and of those, 59% looked at content more than once a week and 10% every day. Less than a quarter only looked at the content sporadically. Access was impacted by technical difficulties attributed to using inconsistent external service providers. Other factors which negatively impacted implementation included low intervention dosage, questionnaire burden and resource constraints. Conclusion: While the intervention was found to be highly acceptable to participants, it did not have a significant effect on Health Literacy Questionnaire scores. While adherence numbers were positive, there were numerous implementation challenges which researchers need to consider carefully when planning a complex intervention in a similar low resource context.