Process evaluation learnings from the PLAY study: recommendations for nurturing care and early childhood development interventions in under resourced contexts

Background Effective interventions during the first year of life are complex, but have potential for lasting impact. This study aimed to evaluate a nurturing care intervention designed to improve early childhood development, providing recommendations for future interventions in under resourced contexts. Methods The PLAY Study intervention was delivered as a randomised controlled trial to 171 women in South Africa during the first year postpartum. The intervention consisted of personalised behavioural feedback on video recorded mother-infant interactions using wearable ‘headcams’ and on accelerometer derived infant movement behaviours, weekly content and resources delivered via an app targeting breastfeeding, responsive and nurturing care, play and development, and maternal mental health, and mental health screening and referrals. Acceptability of the intervention, as well as barriers and facilitators to delivery were assessed using a mixed methods approach including questionnaires, focus group discussions, and staff interviews. Results The intervention was very acceptable, and participants expressed a need for the content delivered via the app. Perceived facilitators included regular contact and support provided by the research staff, and the effectiveness of the intervention components. Barriers included competing interests related to participants’ emotional and mental health, and poor service delivery in South Africa affecting the functioning of referral systems and electricity supply, thus impacting tracing and attendance. Key learnings for future interventions include the desire for and feasibility of data-free app-based health literacy content aligned with existing healthcare information, the positive impact of providing regular support and attention to mothers in this setting, and the importance of considering participants’ circumstances when designing health promotion interventions. Conclusions There is a need and desire for interventions supporting mothers in caring for their infants in South Africa, which is amplified by a need for mental health and social support from the community and healthcare providers. While personalised behavioural feedback was well received, the feasibility of delivering such interventions in this context is limited and requires further technological development. Conversely, well designed, data-free app-based interventions are scalable, acceptable and endorsed by mothers in South Africa. Trial registration Pan African Clinical Trials Registry on 10 February 2022 (identifier: PACTR202202747620052).