==== Front PLOS Glob Public Health PLOS Glob Public Health plos PLOS Global Public Health 2767-3375 Public Library of Science San Francisco, CA USA 10.1371/journal.pgph.0000821 PGPH-D-22-01021 Research Article Medicine and Health Sciences Health Care Health Education and Awareness Medicine and Health Sciences Women's Health Maternal Health Pregnancy Medicine and Health Sciences Women's Health Obstetrics and Gynecology Pregnancy Biology and Life Sciences Nutrition Medicine and Health Sciences Nutrition Research and Analysis Methods Research Design Qualitative Studies Biology and Life Sciences Nutrition Diet Food Medicine and Health Sciences Nutrition Diet Food Biology and Life Sciences Psychology Behavior Parenting Behavior Social Sciences Psychology Behavior Parenting Behavior People and Places Population Groupings Age Groups Children Infants People and Places Population Groupings Families Children Infants Medicine and Health Sciences Women's Health Maternal Health Antenatal Care Acceptability and feasibility of video-based health education for maternal and infant health in Dirashe District, South Ethiopia: A qualitative study Acceptability and feasibility of video-based interventions https://orcid.org/0000-0002-4380-0601 Godana Boynito Wanzahun Conceptualization Data curation Formal analysis Funding acquisition Investigation Methodology Project administration Resources Software Supervision Validation Visualization Writing – original draft Writing – review & editing 1 2 * https://orcid.org/0000-0002-4673-6975 Tessema Godana Yaya Data curation Formal analysis Investigation Project administration Resources Supervision Writing – original draft Writing – review & editing 3 https://orcid.org/0000-0002-1433-1332 Temesgen Kidus Data curation Project administration Resources Supervision Writing – original draft Writing – review & editing 1 De Henauw Stefaan Conceptualization Funding acquisition Methodology Resources Software Supervision Validation Writing – review & editing 2 https://orcid.org/0000-0002-1363-0170 Abbeddou Souheila Conceptualization Data curation Funding acquisition Investigation Methodology Project administration Resources Supervision Validation Visualization Writing – review & editing 2 1 School of Public Health, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia 2 Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium 3 Department of Midwifery, College of Medicine and Health Sciences, Arba Minch University, Arba Minch, Ethiopia Robinson Julia Editor PLOS: Public Library of Science, UNITED STATES The authors have declared that no competing interests exist. * E-mail: wanzanati2011@gmail.com, wanzahungodana.boynito@ugent.be 29 6 2023 2023 3 6 e000082127 6 2022 8 5 2023 © 2023 Godana Boynito et al 2023 Godana Boynito et al https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Evidence about innovative methods to facilitate nutrition education counseling and promote the intended behavior change at scale is limited. We assessed the acceptability and feasibility of a video-based health education intervention aiming to promote community care for pregnant women, mothers, and infants in the Dirashe District, Ethiopia. Using a phenomenological study design, the experiences of study participants in a trial testing the effectiveness of video-based health education on birth outcomes and nutritional status of mothers and their infants six months postpartum were assessed. Focus group discussions (FGDs) and key informant interviews (KIIs) were used to collect the data. The study was conducted in the Dirashe District, South Ethiopia. Five FGDs and 41 KII were conducted among video implementers, mothers, nurses, and health extension workers (HEWs) in eight intervention villages. All data were collected with a tape recorder. The tape-recorded data were transcribed and then translated into English. Data were analyzed using thematic content analysis. The videos delivered messages about nine themes on health, nutrition, and hygiene related to mothers and infants. Overall, the video-based health education interventions was acceptable and feasible. Messages delivered were found to be clear, easily understandable, culturally acceptable, and relevant to the needs of the mothers. Feasibility was affected by the nature of the work, lack of help, and overlapping duties of the HEWs. The video-based health education intervention was acceptable and feasible. It was suggested that determining a common location/venue to show the videos, involving husbands, and involving HEWs could improve the intervention. Trial registration: The effectiveness “parent” study was registered as a clinical trial with the U.S. National Institute of Health (www.ClinicalTrials.gov; NCT04414527). The qualitative study included recipients from the same cohort (participating mothers from the intervention group), in addition to video implementers, health extension workers the Health Development Army, and nurses from the intervention communities. Flemish Interuniversity Council (Belgium, VLIR-UOS) Global Minds Fund of Ghent University GMF.CAB.2021.0030.01 This work was supported by the Flemish Interuniversity Council (Belgium, VLIR-UOS), which funded the research through its Institutional University Cooperation (IUC) coordinated by KU Leuven (Belgium) and Arba Minch University (Ethiopia) (https://www.vliruos.be/en/projects/project/22?pid=3604). This qualitative research was funded through the Global Minds Fund of Ghent University https://www.ugent.be/en/research/funding/devcoop/globalmindsfund.htm (GRANT GMF.CAB.2021.0030.01). The funders had no role in the study design, data collection and analysis, decision to publish, or the preparation of the manuscript. Data AvailabilityData used in this analysis are available at https://data.qdr.syr.edu/. Data Availability Data used in this analysis are available at https://data.qdr.syr.edu/. ==== Body pmcIntroduction The United Nations (UN) articulated the determination and commitment of the member states to end preventable child and maternal deaths by 2030, as specified in Sustainable Development Goal 3 (SDG 3) [1]. Antenatal care (ANC) is a critical strategy for reducing maternal mortality, as it facilitates the identification and mitigation of risk factors early in pregnancy and postpartum [2]. Appropriate, timely, and frequent use of ANC enables the delivery of essential services, including malaria treatment, immunization, nutrition and health counseling, and micronutrient supplementations [2–6]. Health service delivery through the health extension program makes care for mothers and children accessible to the community. The home-to-home visit strategy enables the identification of early pregnancies, and the ONE to FIVE network, a group of six people, with one person acting as the leader who coordinates the other five people in a specific activity, supports nutrition and health educational interventions that promote preventive health behaviors to improve maternal and neonatal health through better knowledge, attitudes, and practices [7]. Ethiopia adopted and implemented the ANC guidelines of the World Health Organization (WHO) in 2004 [3]. The guidelines recommend at least four antenatal visits for women with low-risk pregnancies, and evidence-based content, including iron and folic acid supplementation, must be provided for each visit. The maternal mortality rate in Ethiopia remains high (420 maternal deaths per 100,000 live births in 2016) [7, 8]. The national Demographic and Health Survey (DHS) indicated that 62% of mothers attempted at least one ANC visit during pregnancy in 2016, only 66% of mothers received nutrition counseling during the ANC visit, and 70% reported difficulties accessing health services. This is indicative of the disparity that exists between what is required by a growing population and a society’s service capacity. Health services must be made accessible to the community, and different approaches should be adopted [7–9]. The limited coverage of ANC is caused by the lack of logistical resources, of training provided to service providers, and of clear policy directions in the service delivery system [9]. In many low- and middle-income countries, including Sub-Saharan Africa, health care providers do not routinely provide women with information as part of ANC or fail to provide information in a way that is understood by and is practical for women [7, 10–12] Acceptability, fidelity and feasibility influence sustainability and scalability of any intervention. Hence, these factors should be considered at different stages of the intervention development, evaluation and implementation, in different settings and over time [13–15]. Success of behavior change communication (BCC) in improving maternal and child nutritional status and in increasing adherence to recommended practices during pregnancy, lactation and early childhood are largely determined by the importance given by the community and the health workers [16]. Several platforms to deliver BCC programs are currently tested. Using cordless projectors and locally created videos gives organizations more quality control over the end message, expand the number of people reached, allow for the use of non-expert facilitators, and allow for contextually appropriate information [17]. They can also be used in areas without access to electricity, helping to bridge the digital divide, and serving as a leapfrog technology for areas that would otherwise not have access to media. Traditional methods of dissemination such as pamphlets and flipcharts exclude people with low literacy and are not environmentally conscious. Fatigue over repeated messages is also a concern in behavior change interventions. In addition, messages of video-based education improve retention of the intended behavior, its acceptance and adherence [17–19]. Our knowledge about innovative methods that can facilitate NEC and promote the intended behavior changes at scale, and their acceptability and feasibility, is limited. A cluster randomized controlled intervention study was conducted in Dirashe district Southern Ethiopia with the aim to assess the effects of video-based health education on nutritional status of pregnant mothers and their infants (from 0 to 6 months). To provide insight into the acceptability and feasibility of video-based BCC, we investigated the beliefs, attitudes, needs, and situations of video implementers, beneficiaries, and health extension workers (HEWs) at the end of the study. This qualitative study aimed to assess the feasibility and acceptability of video-based health education in a local context and to identify the opportunities and challenges of its implementation. Methods and materials Study setting The study was conducted in the Dirashe District, Segen Area People’s Zone, Southern Nations, Nationalities, and People’s Region (SNNPR). This study engaged in a qualitative evaluation of a cluster randomized controlled trial (cRCT), which was implemented in the district. The cRCT included two cohorts of 580 eligible pregnant women who were followed from three months of pregnancy to six months postpartum. Recruitment of the study participants started October 2020 and continued till January 2021. However, the follow up period was till February 2022. The qualitative research was conducted at the end of the parent study during February 2022. Rural communities were cluster randomized at the Health Extension Worker’s (HEW) level to receive health and nutritional education in a video-based approach (Health-Video) or in a standard form (Control, standard counseling). Women in their first pregnancy trimester who reside in rural kebeles of Dirashe District and with a plan to stay for the next 12 months (six-month pregnancy and six months postpartum), were invited to the health center and were recruited if 1) they signed an informed consent form, 2) were at least 18 years old, 3) were permanent resident of the village of the study intervention/control, 4) planned availability during the whole period of the study (12 months); 5) accepted the intervention package including home visits for data collection and morbidity follow up. The study did not include women with severe anemia (hemoglobin <70 g/L), under nutrition (defined as body mass index before pregnancy of <18.5 kg/m2), chronically ill mothers with tuberculosis or other chronic diseases, and reportedly HIV-positive. In addition, individuals with anatomical deformity were excluded due to the difficulty of measurement of height. The intervention cohort (Health-Video) received innovative video-based nutritional and hygienic education, and the second cohort (Control) received national standard counseling. Intervention videos were produced by a local team after intensive training with illuminAid (formally One Mobile Projector per Trainer, OMPT) (https://www.illuminaid.org/). The final version of the videos was reviewed by the study investigators, project members, and the illuminAid. The videos were projected every two weeks at the home of the participating women, and monthly in forum or in group, at nearby health facility, church or at the school. The ten videos implemented covered nine themes about the benefits of taking iron and folic acid tablets (IFA) during pregnancy, vaginal hygiene and perineal care, practices to avoid important worm infections, hygienic practices when preparing food for the mother and her family, additional food intake and diversification, health service utilization (including the importance of deliveries at the hospital with a maternity waiting area [MWA]), colostrum feeding and early initiation, breastfeeding practices and EBF, maternal safety during pregnancy and breastfeeding, and safety precaution during pregnancy. In addition, both groups received national nutrition and health care information, including IFA supplementation, treatment of any symptomatic illness, and deworming in case of symptomatic complaints during the second and third trimesters. Follow up visits of pregnant women at the health centers were done at 6 and 9 months pregnancy, and for the pair mother-infant were carried out within one month after delivery and monthly until 6 months postpartum. Study design A phenomenological qualitative study approach was carried out to explore the acceptability and feasibility of video-based health education among pregnant and lactating women and its barriers and facilitators. Study participants The study population included mothers, video implementers, HEWs, the Health Development Army (HDA), and nurses from the intervention communities. Sample size and sampling Three focus group discussions (FGDs), including 10–12 participants per group with mothers with good adherence to video attendance and two with mothers with poor adherence were conducted until data saturation. Furthermore, eight video implementers, eight HEWs, five HDA mothers, and 16 mothers (two per intervention kebele) were involved in key informant interviews (KIIs). In addition, four nurses were interviewed. All participants were selected using a purposive sampling technique. Data collection tools A pretested semi-structured interview and a FGD guide were used to collect the data. After pretest, unclear questions were corrected or modified. Checklists were used before conducting the discussions and interviews. Data collection Data were collected at the end of the parent study during February 2022. Tape-recorded semi-structured interviews were conducted following both FGDs and KIIs guided by an interview guideline and supplemented by follow-up and probing questions. FGDs and KIIs were conducted after the participants provided written informed consent. The FGDs were moderated by experienced facilitators and assisted by an experienced person from the same culture, to facilitate the quality of data collection in a local language. Field notes were also used to amend the audio-recorded data. All field data were collected in the nearby health post where it is possible to conduct the discussion in optimal conditions. Each FGD lasted from 1hour 25minutes to 1hour 45minutes, while the KII lasted between 35 min—55 min. Data collection was terminated after saturation. Data quality assurance To ensure the quality of the KII and FGD data, different mechanisms were used, including recruiting data collectors and facilitators who had experience conducting qualitative studies. Two days of training on how to conduct KIIs and facilitate FGDs overseen by senior qualitative research experts were given before fieldwork. A senior public health expert supervised the overall process daily during the fieldwork. The quality control of the transcripts and translation was done on 10% of the audio records by the same senior qualitative research expert. Operational definitions and definitions of terms Semi-quantitative reporting: “Majority” is used to indicate more than 75% repetition of the theme, “many” is used for 50–75%, “some” or “several” represents 25–49%, and “a few” represents less than 25% [18]. Acceptability: This was measured using conventional methods, such as adherence, cultural support, clarity, effectiveness, and applicability. Feasibility: This was measured by the cost required to participate in the program, the time to participate, and overlapping duties that may hinder participation. ONE to FIVE Networks: These are a group of six people, with one person who has better leadership skills acting as the leader who coordinates the other five people in a specific activity. The Health Development Army (HDA): The HDA is made up of volunteers who are the leaders of the ONE to FIVE networks [19]. Health extension workers (HEWs): These are female community health workers working at the kebele (village) level in the Ethiopian health system. Good adherer: Participating mother who attended at least 75% of the video projections as per their schedule. Poor adherer: Participating mother who attended less than 75% of the video projections as per their schedule. Data analysis All KIIs and FGDs were captured using voice recorders, and field notes were transcribed verbatim into local language and then translated to English by KII/FGD field facilitators every day. The translation of transcripts was done by experienced data collectors and supervisors and back translation was done to ensure the validity of the translations of the transcripts. The transcripts were checked independently by the supervisors for verification. The data were analyzed through thematic content analysis. Major themes were derived based on the study’s objectives. However, sub-themes were derived from the text itself through repeated reading by the research team. After reading the transcripts, the emergent themes were identified and then coded for each theme to specify individual topics identified during the discussions. Transcripts were coded by two research team members (WG and GY) using Quirkos qualitative software, version 2.1. Statements were grouped by codes according to corresponding themes. Once themes were established, the transcripts were reread to ensure that the themes appropriately reflected the content of the data. All identified themes were confirmed by the researchers to capture discussions from the KII/FGDs. The findings were presented in narratives by thematic areas, based on the objective of the study. The quotes included in the results are typical opinions and views expressed in each KII/FGD to exemplify emergent themes. Ethics Ethical approval for the study including the qualitative research, was obtained from Arba Minch University, College of Medicine and Health Sciences Institutional Research Ethics Review Board (IRB/158/12 dated January 17, 2020) and Ghent University Hospital (UZ Gent BC-06756). The parent trial was registered in the clinical trial registry (NCT04414527). The qualitative study included recipients from the same cohort (participating mothers from the intervention group), in addition to video implementers, health extension workers the Health Development Army, and nurses from the intervention communities. FGDs and KIIs were conducted after all the participants provided written informed consent. Privacy and anonymity of the study participants were respected. Results Sociodemographic characteristics of the study participants All study participants were women aged between 22 and 50 years from the eight intervention kebeles. They were involved in a parent trial that tested the effectiveness of video-based health education on birth outcomes and the nutritional status of mothers and their infants at six months postpartum. The participants included trial participants, HEWs, HDAs, video implementers, and nurses (Table 1). 10.1371/journal.pgph.0000821.t001 Table 1 Sample size and summarized methods used in the qualitative study. Data collection method Target group Sample size Remark Key informant interview (KII) Mothers with good adherence 8 One mother per kebele Mothers with low adherence 8 One mother per kebele Health Development Army (HDA) 5* One HDA per kebele who has experience Video implementers 8 One per kebele Health extension workers* 8 HEWs per kebele Nurses 4 Site supporting nurses to the video implementers at the kebele Focus Group Discussions Mothers with good adherence 3 One FGDs per group Mothers with low adherence 2 One FGDs per group *Data saturation is one of the criteria to stop the interview Acceptability of video-based health education among pregnant and lactating women The acceptability differed according to the subject covered in the videos and the support provided by the video implementers. The majority of the interviewees reported that the videos were clearly presented, in the local language, culturally adapted, and understandable. “There is something I like. Thank you for teaching us from the very beginning of our pregnancy and for giving us the information on immunizations and follow-up needed for our children. I used to give birth in a health care facility. What they showed us on TV [projector] taught us how to take care of a pregnant mother. They also taught us how to wash hands and breastfeed babies. The video message was clear and easily understandable. The language in which the video was made is our own.” (GA0201) Moreover, the participants reflected on the relevance of the videos and their applicability in their local and personal contexts. “The videos were in our own language, and they are easy to understand and practical. I would love it if we all apply [the messages] to our day-to-day life, which is not difficult in practice.” (FGD 0801) The use of video in antenatal and prenatal care was perceived as an opportunity and as an acceptable means of behavior change communication at the community. “No such video has been shown in the neighborhood before. I’m glad this is the first time. They used to come and teach the mothers. As I worked as a traditional birth attendant before it was banned, the mother had no such opportunity to see health information using drama or roleplays. They are very lucky. They assigned two girls [video implementer and household data collector] to follow up with the women without HEWs. The girls came to me to tell me to advise the mothers who were not going to watch the videos. I am commonly using phrases like ‘consider this as lottery’ since this opportunity was not given to all mothers.” (IDI 0403) Most of the time, the videos were displayed at home by the mothers. However, in some cases, the videos were also displayed in neighbors’ homes and in common areas, such as churches, health posts, and maternity waiting areas of nearby health centers. “The biggest problem is showing [videos] home to home, and some of the houses are not appropriate. Sometimes, we appoint the mothers to show the video at the school. But schools do not allow [this activity], and even in some cases, it is too noisy to show the videos. We also tried churches, but it was still not good. So, it’s important to consider where to show the videos.” (IDI 0601) The extent to which the learned behavior is linked to the health of the beneficiaries may affect acceptability. However, in this study, mothers unanimously liked the videos, as they are linked to their health, but showed also some preferences. “The women said they liked most of the videos but loved the video of giving birth in a health facility. Because, they say that they can be taken care of in an ambulance immediately in case of emergency and this is a lifesaving.” (IDI 0301) Implementer’s related factors in video-based health education among pregnant and lactating women The mothers perceived that the projections made by the video implementers were not always of good quality, and they reported that the low technical skills of the video implementers might have been the cause. They also complained about the limited availability of video implementers. “As I told you on different occasions, there are many mothers who have said why we are not allowed to watch the videos. I was also asking if the video girls could show the videos to all pregnant women, but they said they had been given a list of mothers to whom they should show the videos. I don’t think it is good to treat women in the same community differently. It is better to think about it.” (IDI 0403) Provider’s support enhances acceptability and adherence to a recommendation. Empathy of implementers was captured by their willingness to show the video to a participating mother who missed a visit, and their behavior towards her during the following video show session. The shortage of time for the video implementers was among the factors that the mothers did not appreciate and recommended improvement. “I also feel that it would be better if all mothers could see the videos, and they said [video implementers] that they have no time to show all the mothers in the community. For me, I am very lucky to be part of it.” (FGD 0302) Feasibility of video-based health education among pregnant and lactating women The feasibility of the video intervention was assessed using proxies of 1) cost to the mothers related to the program, 2) time to take part in the video, and 3) lack of help and overlapping duties. In most of the sessions, the recurrent challenge was a shortage of time to take part in the video program. Affordability or financial acceptability is one of the key indicators for utilization of a given service. Beneficiaries were asked if financial access affected the overall acceptability. Indirect costs like time compensations were an indicator to assess cost of a program. “No payment is needed. But one day, the video girl called us to come to the health post to show us the videos, but some mothers did not come on time, and it was working time [for me], and I was very angry at her.” (FGD 0303) “Due to a shortage of time, it would be best if they can show us once per month by combining the videos, and if the day is Sunday afternoon, when we have rest. The problem is that the video girls come the day they want, and sometimes they do not consider our work.” Onota (Good adherer) “Some of our mothers complain about not having time to watch the videos. We are convincing them, but there are still problems. The major problem is with the mothers, who do not have someone helping them.” (IDI 0703) Lack of support for household and farm activities is identified as a hindering factor for adherence to the video schedule and latter its practicability. Lack of support results also in less time for the mothers to attend the video projection sessions, affecting their adherence and the feasibility of the program. “The only thing they find difficult to watch [the videos] is the pressure of work at home. As you know, sometimes when it comes to the working days, it is the mother who needs to stay at home and do all the house activities, as well as prepare food for the day and the next day. Most of the time, the complaint is from a workload.” (IDI 0101) “There is nothing wrong with practicing the lessons from the video. But, since we don’t have a person who helps my husband, I am forced to work and cannot attend many sessions.” (GA 0202) All the study participants discussed and mentioned that there was no cost to participate in the video sessions. “We did not pay, and it is free. But sometimes, when you participate in the forum, it can cost you since you will spend the whole day there in the meeting.” (FGD 0405) “They [mothers] did not request a motivation fee for watching the video. Whatever was provided was for their benefit, and the payment should not be an issue.” (IDI 0201) Facilitators of video-based health education among pregnant and lactating women The facilitators of the video-based intervention were the health facility, the community, and the HDA. The community and the HDA helped the participants continue to follow the videos. The support provided by the health facility was one of the most important themes raised. “We were collaborating with the HEWs, and they helped us. HEWs are well respected, and they convinced the husbands.” (IDI 0101) “It is a good idea to have a continuous view of the video. The person who projects the video also explains the importance of each session and video. It would be better if they could bring all the mothers together so that they could learn from each other. It may also be good to consider including family and friends or other households.” (GA 0201) Barriers to video-based health education among pregnant and lactating women Barriers and challenges to the video projections included access to power to charge the portable projectors, mothers’ attitudes, place to display the videos, husbands’ attitudes, the noise in the vicinity, and disturbances from children. “Sometimes we don’t have electricity, and the battery of the projector is down.” (IDI 0201) “One day while we were watching, it went off [battery of the project], but it’s good that the videos are repeated [in other sessions].” (FGD 0408) Mothers’ attitudes toward the videos were also one of the challenges to the program. “Some of the mothers deliberately miss the video projection day. The attitudes of the household are also a challenge.” (IDI 0201) The type and size of some houses, the continuous disturbances from the children, and the low attention or focus on the video(s) made it difficult to display the video. “Children in the community also disturbed when the video girl came to show the video.” (GA 0201) “Despite the importance of the videos, we have many problems, and sometimes, when you are alone at home and have lots to do and children are around, it is a challenge to follow, even if it was displayed in our language.” (FGD 0309) The noise from cattle and some visitors are also barriers. “I agree with my sister’s comment about disturbances. Yes, kids are disturbances, and also the cattle. Regarding the church, the church may have its own program, and it may not be good as well. So, for me, the household and church are almost similar and are not a good option.” (FGD 0312) “I would say that workload is a major barrier for mothers to watch the videos. The lack of a uniform display area or home, which is not similar for all households, can also be an issue. Sometimes, when it is very difficult to show the video in the mother’s house, we arrange to show the video in the neighbor’s house if the room is good. But this alternative has its own limitations. We cannot control the family and children in the neighbor’s house where we arranged the projection, and sometimes they disturb us.” (IDI 0601) Husbands’ attitudes have also been reported to be a limitation when they are not supportive. However, some show support for their wives. Partner involvement and support differed among the participants. “We had a conflict with my husband the day before the video display, and when she [the video implementer] came to show the video, he started shouting at her and telling her that after you showed her the video(s), she started to not work and said [his wife] that you told her to have rest? It was not good day, and finally, the HEW told him that it is important for me, and he started to allow me.” (FGD 0301) “One day when we showed the video, one of the husbands started to quarrel and said, ‘Did one of our fathers learn how to give birth to us?’ He refused and prohibited his wife from participating. His wife did not follow the video to the end.” (IDI 0601) On the other hand, there are husbands who support their wives to attend and follow the lessons shown in the video sessions. This will in turn affect the uptake of video messages and the achievement of the objective of the behavior change communication. “My husband even encouraged me. But we are in the same kebele, where some husbands are supportive and others are not. I think if there were a similar supportive attitude among all, it would be good.” (FGD 0305) Applications to day-to-day life The benefits of the videos can also be judged by their application to day-to-day life and their contribution to the health of the community. “Yes, I think the program has made a difference. One day, I went to a mother’s house, and when I asked her how she was, she replied, ‘I had anemia, and my blood started to return after taking the pill.’ This is the benefit of the video [IFA] and the practice they implemented.” (IDI 0601) The goal of the behavior change communications was to help the community to apply lessons learned to their daily life. Knowledge of the benefits and ability to apply the learned behavior depends on how the information were presented to the community. She added that “… there is no difficulty in implementing the change. It’s easy. But I think the problem is that illiteracy has a negative impact on women because an educated mother does what she learns. The uneducated applies very little. This is what we get when we ask for feedback.” (IDI 0201) However, some of the mothers raised the issue that the application of the video messages is also affected by support from the families. “For me, everything can be practiced, but it needs the support from family and friends. For example, if we are talking about the workload, it needs family support. Not only this, but even to participate in the session, you need the time that otherwise you are using for work, and this needs your husband or family support.” (FGD 0303) Almost all the participants agreed that the application of video messages to day-to-day life is very important. However, implementation varies among mothers. “There is nothing that I have not done. I went to the maternity waiting room and gave birth at the health facility. I am also taking my baby to the HEWs when he is sick, and I am washing my hands before preparing food.” (GA 0201) “To add to what she told you, there was a pregnancy disease called anemia, and drugs for its treatment [IFA] are given for free. But, what we have been informed in the community regarding this was that the drug causes nausea, discomfort, and vomiting. So we did not take the drug as planned in our previous pregnancies. But, the video explained how to reduce unnecessary side effects and benefit from the drug like taking the drug after a small meal. I can confirm that the benefit is large since we can easily avoid the side effects with minimal adjustments, such as taking the drug with food and before going to bed. I had no problem and gave birth, and we are here today,” (FGD 0803) Acceptable behavior change has a high chance of adoptions. Benefits of the learned behavior and the ease of application enhance further applicability and adoption. “What mothers learn from the video can be easily applied. They say that the video is very good and easily applied to their lives. Despite the workload, most of them said that they apply what they learned.” (IDI 0401) “It is not difficult to apply. All the videos are in our language and culture. I think all the lessons learned from the video are very good and easy to apply. The good thing is that they made it using the cultural context, including the language, the way of living, and even the clothes. But they complain about the additional food that they do not have money to buy; what can they do? Some of the mothers also ask their husband to acquire for them what is in the videos, but they refuse by saying it leads to additional costs.” (IDI 0603) Acceptability of the overall program The acceptability of the video intervention was among the commonly raised themes in the discussions and interviews. “I would like to thank those who prepared these videos in our own language and brought them to our home to show us. I liked the video very much. All the videos were good, especially the one regarding feeding, nutrition, and handwashing. I had given four births before. In our culture, they say that pregnant women should not eat additional food during pregnancy, the reason being that additional food will help the baby to grow and predispose the mother to a risk during birth or C-section, and mothers might even die. But when I watched the video of the mother who was saying a pregnant woman should not eat additional food, the other said she had to. The discussion even debated how many times or how much additional food, like one or two more meals. She also explained that the food would give her energy during labor." (GA0801) Satisfaction with the content of the video, complexity, the comfort it provides, mode of delivery, and credibility of the presenters and also the messages affect the application of the videos. It was repeatedly raised that the degree to which each video is applied depends on the type of video. “Handwashing especially does not cost us, so we can easily apply the messages [the video messages]. We have lots of water. For food, sometimes, you may not have the capacity to buy. First-time pregnant women are always advised not to eat more food because our culture says that the baby will be large, and the mother will face problems when giving birth. But now, thanks to the videos, we have been taught the correct information. I am very happy to have been part of it, and it would be good if others could also see the video and benefit from the information provided. The other thing that I found important was the first milk to the baby and only giving birth at health institutions.” (GA 0501) Acceptability or perception among implementation stakeholders that a given video-based health education is agreeable, or satisfactory is among the key indicators for sustainability. Furthermore, acceptability promotes the implementation and application of lessons that are learned. “All [messages] are easy to implement. The videos helped us follow antenatal care and visit health services. They were also important in getting prepared for where the baby would be born.” (FGD 0206) Adherence to the messages was also verified through a change in practice(s). Adherence is facilitated by personal motivation and could also be socially- motivated. Socially motivated adherence is the desire to change behavior to fit into the social environment which can be taken as an example. “When we asked the mothers whether they were adopting the practices that were communicated in the videos, they indicated that they adopted some but not others. For example, it is easy to implement the messages provided in the video on handwashing, breastfeeding, and shoe wearing. However, additional food, workload, and showers all need a decision from husbands because they need the capacity.” (IDI 0201) Future improvement to video-based health education among pregnant and lactating women Sustainability of any intervention depends on how it incorporates the future improvement areas and tackling the challenges. Participants recommend improving the intervention in the following ways: 1) assigning a place for the video projection, 2) involving the husband/partner, 3) integrating the intervention into the health system through the HEWs, and 4) including videos that target the feeding of young children. One of the major improvement plans was to assign a common place that fits the needs of all the project recipients and ensures the continuation of the intervention. “Regarding the things to be improved, it is basically not the video but the place where we show the videos. In a narrow and small house, it is not easy to watch it freely. When mothers watch it in groups, the place should have ventilation and adequate seats.” (IDI 0501) Sustained behavior change depends on different factors at varying levels. Peer factors are among the facilitators for the sustained change of the learned behavior. Partner involvement was among the key recommendation by the mothers to further implement the program. “It is better to include husbands in the session so that they know that what we are doing is for the baby and the family. The husband must support [the mother] in all the activities and in attending this video education.” (FGD 0806) “It would be good if our husbands watched the videos with us and facilitated things for us to follow the videos correctly. If we watch together, then we do not have to justify our need for more food and rest during pregnancy. On the contrary, they can easily help us because we keep doing a lot of work, including bringing firewood.” (GA 0202) There are also some aspects in the content of the videos that need to be changed if scaling up is intended. Foreseeing the possible obstacles before considering major expansion is very important, including modification in the design and change in implementation strategies. With this regard, modifications of some contents of the video were also recommended. “All videos are good, but some advice provided in some of the videos is not easy to practice, such as intimate hygiene, raw meat [not to eat it], or taking showers in the river [not to practice it]. We commonly use rivers to wash our bodies. To some extent, handwashing is also affected by the nature of the work we are involved in. Women can easily wash their hands when they are at home, but this is difficult when they are at the farm. I am not clear about the idea of some videos and their applications. I am thinking that if the husbands are involved, then it can even encourage the mother to be part of the video [intervention].” (IDI 0402) Involving HEWs is also one of the most important and commonly mentioned themes. HEWs are the key and building blocks of the community health system of Ethiopia. Community health services should include and involve them to further enhance the acceptability of the new health program and its continuity. This is only possible with the government support to community health program or the health extension program. Financial support can allow the continuation of the program beyond the project life, while its integration in the national health strategy allows its scalability. “It would be nice if the video presentation would continue in the waiting maternity home to give health information to pregnant women. If it can be integrated into our work [HEW] and be shown at the health facility when women come in for regular visits, they can also involve husbands or Health Development Army leaders, and they can contribute to the change in the community.” (IDI 0702) “It would be good to keep showing the videos. The video girls say that they may not have a budget and need to stop it. Maybe they can give the equipment [projectors] to the HEWs, who can show the videos to our mothers. The video can even be shown by HDA since it is not complicated. It is also best to involve their husbands in video presentations.” (IDI 0303) Discussion In the context of the cRCT “Effects of video-based health education on the nutritional status of pregnant mothers and their infants (from 0 to 6 months) in Dirashe District, Southern Ethiopia”, ten videos covering nine themes around maternal and child nutrition, health and hygiene were projected during the 12 months intervention. The current qualitative research investigates the beliefs, attitudes, needs and situation of the video implementers, the mothers, and the health officials. Acceptability and its indicators Video-based health education was accepted by the participants and the health stakeholders at the health service and community levels. The video-based intervention was reportedly feasible for implementation in the community through the existing community health system. It has been hypothesized that messages related to health, food, agriculture, or infectious diseases provided in the form of videos are better understood, retained, and implemented, which also results in higher adherence to recommended practices [17–19]. This result is reached if the intervention is accepted. The success of BCC in improving maternal and child nutritional status and in increasing adherence to recommended feeding practices during pregnancy, lactation, and early childhood are largely determined by their importance, as attributed by the community and health workers [19]. Furthermore, the success of these practices lies in their uptake by the participants and their adherence [20–22]. Several platforms for delivering BCC programs have been tested for acceptability and feasibility. A feasibility study using a community-led video approach to promote maternal, infant, and young child nutrition in Odisha, India, explored the retention and comprehension of video content viewed by self-help group (SHG) members. The SHG members’ knowledge of the nutrition messages promoted in the videos was high for messages related to IYCF practices. The acceptance and utility of the information were also good [23]. Acceptability is measured using practices and behavior change. Multiple approaches to BCC implemented in North Ethiopia also showed that there was improvement in the practices of mothers regarding empowering new generations to improve nutrition and economic opportunities [24]. The acceptability in this study considered several indicators: i) relevance (i.e., whether the video intervention answers the needs of the mothers and community) [25, 26], ii) how easy it was to implement the intervention/practicability [22, 27, 28]; iii) was it culturally appropriate [25–28], and vi) was it easy to understand [25]. The results of our study are in line with previous studies [22, 28] that assessed acceptability from different perspectives. The messages delivered in the video-based health education of the current trial were reportedly relevant, understandable, culturally appropriate, and easy to implement. The educational package delivered in a video form was locally prepared using multiple approaches, such as testimony, comedy, and dramas and/or roleplays, in the form of questions and answers, group discussions, and deductive approaches. Culturally respectful interventions are more likely to be accepted [22, 27, 28]. A study conducted in Zambia identified that acceptability is increased, and behavior change is enhanced when video-based health education interventions are implemented in the same setting and use similar cultural characteristics [26]. Feasibility of video-based health education interventions The feasibility of this type of BCC intervention includes factors ranging from ease (including administrative) of use or implementation [18, 26, 29], technical and logistical capacity (e.g., electric supply) [18, 26], and time dedicated to using the intervention [18, 29]. Fig 1 provides a summary of facilitators and challenges of acceptability and feasibility of video-based health education for maternal and infant health in the Dirashe District, South Ethiopia. 10.1371/journal.pgph.0000821.g001 Fig 1 Thematic map for the acceptability and feasibility of video-based health education for maternal and infant health in the Dirashe District, South Ethiopia. Fig 1 showing the thematic map for the acceptability and feasibility of video-based health education for maternal and infant health in the Dirashe District, South Ethiopia. The structured assessment of feasibility (SAFE) tool, which was among the recommended measures of feasibility [30] proposed 16 items for the measurement of feasibility that also affect acceptability, such as culture, additional material resources, staff training, and flexibility. A study in Afghanistan identified that feasibility is also affected by factors that affect acceptability, such as culture, settlement/geography, hard-to-reach areas (access), shortage of time, user friendliness (reduced cost of training), technology (effectiveness), capacity building and support (cost saving), and program design and trainability [18]. Feasibility considers the cost required, the time needed, and the support provided. The videos were projected at the home of the participants, which involved their surroundings, including children, cattle, and the neighborhood, as sources of disturbances. Previous studies on feasibility reported similar findings [30, 31]. Furthermore, our study showed that time consumption and flexibility (or lack thereof) due to overlapping duties were among the constraints preventing participants from attending the video sessions. Matching the prioritized goals in terms of relevance and application to the interests of the participants were facilitators. Factors affecting acceptability Acceptability is also affected by environmental context, household support, and attitude. This was a highly emergent point in our study, and it is in agreement with studies on the acceptability of digital health interventions [15, 22]. In this study, attitude was identified as one of the limiting factors in the acceptability of the video intervention. This is in line with previous findings [15, 27]. Partner attitudes affected the participants’ level of commitment, and their involvement in the video intervention was also reported as a key factor in improving the intervention. A similar finding was reported in Uganda, where video-based health education interventions that aimed to enhance perinatal care and uptake of health services were more accepted when the partner was involved and had a supportive attitude [28]. Community and family support are important facilitators of acceptability. A scoping review of acceptability showed that increased support from family and community strengthens the acceptability of interventions [15, 27]. Partner support and their involvement in service uptake after video-based health education interventions were also improved and were measures of acceptability. The other way to measure acceptability is by practicability and taking responsibility [26]. Similarly, the integration of the video project within existing community health services has also been recommended to improve implementation [15, 29, 31]. Assessment of acceptability using adherence Acceptability can be assessed using proxies, such as adherence to the intervention. In our study, adherence was measured as attendance at the video projection sessions and willingness to implement the messages provided. A study in Ghana identified acceptability as commonly measured using the level of participant adherence [32]. The other way to measure acceptability is by assessing the impact on behavior, such as confidence to use and implement the intervention among the service providers. Confidence has an effect at work, which can contribute to the effectiveness and attainment of objectives [29]. In addition, knowledge and awareness after the intervention were assessed as part of acceptability and its effects on practicing the behavior change learned [26]. Behavior changes and acceptance further help service providers improve efficiency and effectiveness in their work [29]. Our study has several strengths, including the timing of the interviews, the diverse profile and involvement of the interviewees and participants, and the innovative aspect of the intervention itself. The interviews were conducted shortly after the end of the intervention and during the data collection period. All the participants in this study contributed as implementers, facilitators, data collectors, or as the target population. However, we recognize the limitations of this study, which include the lack of external validity and the low possibility of generalizing the findings to other interventions and communities in different settings outside of the Ethiopian region. In addition, due to the security reasons, the researchers were not able to meet the participants after analysis was completed, and therefore feedback was not collected. Conclusions and implications The acceptability and feasibility of the video-based health education intervention were good based on the conventional and SAFE guidelines for the measurement of feasibility. This video-based health education can be seen as an alternative way of behavior change communication targeting mothers and their infants. Upscaled successfully, this intervention can overcome the barriers of logistics, as well as community and husband support. Some of the messages should also be tested for feasibility and acceptability to tailor them to local contexts. Supporting information S1 Checklist Reporting qualitative studies. (DOCX) Click here for additional data file. S1 File Protocol for clinical trial registry. (HTML) Click here for additional data file. S1 Text Focus group checklist. (DOCX) Click here for additional data file. S2 Text Data collection tools. (DOCX) Click here for additional data file. We are very grateful to the participants in the Dirashe District. Our appreciation goes to the health officials and community health workers for facilitating the implementation of the study. We would like to thank our data collectors, especially Katanso Karso, Godana Kusse, and the health extension workers in the study kebeles, for their support. Finally, we would like to thank our qualitative study participants for their time. 10.1371/journal.pgph.0000821.r001 Decision Letter 0 Majumder Md Anwarul Azim Academic Editor © 2023 Md Anwarul Azim Majumder 2023 Md Anwarul Azim Majumder https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version0 8 Sep 2022 PGPH-D-22-01021 Acceptability and feasibility of video-based health education for maternal and infant health in Dirashe district, South Ethiopia: A qualitative study PLOS Global Public Health Dear Dr. Godana, Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. Please submit your revised manuscript by Oct 23 2022 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. We look forward to receiving your revised manuscript. Kind regards, Md Anwarul Azim Majumder, PhD Academic Editor PLOS Global Public Health Journal Requirements: 1. Please amend your detailed Financial Disclosure statement. This is published with the article. It must therefore be completed in full sentences and contain the exact wording you wish to be published. a. State the initials, alongside each funding source, of each author to receive each grant. b. State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.” If you did not receive any funding for this study, please simply state: “The authors received no specific funding for this work.” 2. Please provide separate figure files in .tif or .eps format only and remove any figures embedded in your manuscript file. Please also ensure that all files are under our size limit of 10MB. For more information about how to convert your figure files please see our guidelines: https://journals.plos.org/globalpublichealth/s/figures 3. We noticed that you used "unpublished" in the manuscript. We do not allow these references, as the PLOS data access policy requires that all data be either published with the manuscript or made available in a publicly accessible database. Please amend the supplementary material to include the referenced data or remove the references. 4. We have noticed that you have uploaded Supporting Information files, but you have not included a list of legends. Please add a full list of legends for your Supporting Information files after the references list.  5. In the online submission form, you indicated that your data will be submitted to a repository upon acceptance.  We strongly recommend all authors deposit their data before acceptance, as the process can be lengthy and hold up publication timelines. Please note that, though access restrictions are acceptable now, your entire data will need to be made freely accessible if your manuscript is accepted for publication. This policy applies to all data except where public deposition would breach compliance with the protocol approved by your research ethics board. If you are unable to adhere to our open data policy, please kindly revise your statement to explain your reasoning and we will seek the editor's input on an exemption. Please be assured that, once you have provided your new statement, the assessment of your exemption will not hold up the peer review process. Additional Editor Comments (if provided): Please address the reviewers' comments and improve the paper. [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented. Reviewer #1: Yes Reviewer #2: Yes ********** 2. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: Yes Reviewer #2: N/A ********** 3. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #2: No ********** 4. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #2: Yes ********** 5. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: Congratulations to this very well conducted study. I read the manuscript with interest and can highlight that it is well-structured. The methods have been described in detail and are adequate. However, I do have one major concern which relates to the results section: This section is far too long, mainly because it consists of very many direct quotes. I suggest to delete some of these quotes and describe the results more in a summary. This is a substantial concern which the authors need to address. Reviewer #2: The article presents acceptability and feasibility of video counseling package for antenatal care, post-pregnancy care for mother and infant in Ethiopia. It appears that this paper presents some part of a trial. The article needs form refinement and appropriate presentation. 1. Please give some detailed information about the main study/trial and linkage of the qualitative study in the overall study implementation and usage. 2. The rationale for using video based counseling in Ethiopian context should be mentioned in the introduction. 3. The specific comments on the manuscript are marked in the document attached. ********** 6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public. For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Florian Fischer Reviewer #2: Yes: Manoja Kumar Das ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 10.1371/journal.pgph.0000821.r002 Author response to Decision Letter 0 Submission Version1 22 Oct 2022 Attachment Submitted filename: Response to Reviewers.docx Click here for additional data file. 10.1371/journal.pgph.0000821.r003 Decision Letter 1 Stortz Johannes Staff Editor © 2023 Johannes Stortz 2023 Johannes Stortz https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version1 13 Feb 2023 PGPH-D-22-01021R1 Acceptability and feasibility of video-based health education for maternal and infant health in Dirashe district, South Ethiopia: A qualitative study PLOS Global Public Health Dear Dr. Godana, Thank you for submitting your manuscript to PLOS Global Public Health. After careful consideration, we feel that it has merit but does not fully meet PLOS Global Public Health’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process. The manuscript has been evaluated by ten reviewers, and their comments are available below. Please note that upon resubmission of the revised manuscript, we invited the two previous reviewers but only one of them provided a review. We were therefore required to obtain an additional review from another external reviewer. Unexpectedly, we received eight additional reviews after reaching out to the scientific community. The reviewers have raised concerns regarding the reporting, methodology and language of this study. Please address all reviewers’ comments where possible. Specifically, we would like to emphasize that several reviewers raised concerns regarding the length of the results section and potentially identifying information about the study participants.  Could you please revise the manuscript to carefully address the concerns raised? Please submit your revised manuscript by Mar 27 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at globalpubhealth@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pgph/ and select the 'Submissions Needing Revision' folder to locate your manuscript file. Please include the following items when submitting your revised manuscript: A rebuttal letter that responds to each point raised by the editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'. A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'. An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter. We look forward to receiving your revised manuscript. Kind regards, Johannes Stortz, PhD Staff Editor PLOS Global Public Health Journal Requirements: Additional Editor Comments (if provided): [Note: HTML markup is below. Please do not edit.] Reviewers' comments: Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #3: (No Response) Reviewer #4: (No Response) Reviewer #5: (No Response) Reviewer #6: (No Response) Reviewer #7: (No Response) Reviewer #8: (No Response) Reviewer #9: (No Response) Reviewer #10: (No Response) ********** 2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented. Reviewer #1: Partly Reviewer #3: Partly Reviewer #4: Yes Reviewer #5: Yes Reviewer #6: Yes Reviewer #7: Partly Reviewer #8: Yes Reviewer #9: Yes Reviewer #10: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: N/A Reviewer #3: N/A Reviewer #4: Yes Reviewer #5: N/A Reviewer #6: N/A Reviewer #7: N/A Reviewer #8: Yes Reviewer #9: N/A Reviewer #10: N/A ********** 4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: Yes Reviewer #6: Yes Reviewer #7: Yes Reviewer #8: Yes Reviewer #9: Yes Reviewer #10: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: Yes Reviewer #3: Yes Reviewer #4: Yes Reviewer #5: No Reviewer #6: Yes Reviewer #7: Yes Reviewer #8: Yes Reviewer #9: Yes Reviewer #10: Yes ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The manuscript has improved but the major issue which I have pointed to in the last round of reviews still remains: The results section mainly included direct quotations. I am missing a synthesis of results going beyond only putting together the quotes from qualitative interviews. There is more abstraction and interpretation needed. Reviewer #3: In the sampling, authors talk about mothers with good adherence and poor adherence, how was that defined and based on what information In data collection tools...checklists were used....what checklists and for what purpose In result theme 1, the acceptability....were there any issues/challenges on acceptability while this was a qualitative study, languages like determinants should be avoided when possible The objective was to study "assess feasibility and acceptability" but some points discussed are not in line with that The topic "quantitative measure...." in the discussion is not relevant since the findings are not clearly discussed, more over this is a qualitative study, discussing about quantitative measures is not good scientific practice. Reviewer #4: Thank you for the opportunity to review this qualitative study on the acceptability and feasibility of video-based health education for maternal and infant health in South Ethiopia. It was an interesting topic to read about and was well structured. 1. In as much as a summary of the main study implementation has been added to the manuscript, it will benefit from a brief summary of how the videos were shown during the study. From the results section, several scenarios are alluded to: videos shown individually and in groups, at home (or other venues in the community) and in the clinic. It will therefore be easier to contextualize the quotes if there is a summary of how the videos were shown during the course of the study or at the very least, how they were intended to have been shown in the Study setting sub-section. 2. It may be beneficial to briefly explain how ‘adherence’ was defined to determine who qualified as having good or low adherence in the operational definitions section. 3. Line 276 “Mothers unanimously liked the videos, as they are linked to their health.” However, the quote given was about what the women’s least favourite video was. You may want to consider using a quote that will better reflect the sub-theme of what was unanimously liked (or change the sub-theme to what the mothers did not like about the videos and present the quote(s) to buttress this sub-them). 4. In the discussion section, you gave a hypothesis which is the foundation of your discussion (lines 528-585). Please add the citation(s) for this hypothesis. 5. A couple of the themes in the Figure 1 were not really explored in the results or the discussion: political environment and empathy of implementers. It will be beneficial to explore these themes further in the manuscript if they were indeed themes that emerged or justify their presence in the figure. 6. A minor point: A few quotes had full participant names attached to them, for example, on line 381. Better to give only the 1st name as is best practice and has been done throughout the paper. On the same line, participant was also identified as “FGD” without a description of what their role was (FGD discussant?). Reviewer #5: This qualitative study demonstrated acceptability and feasibility of video-based health education intervention for maternal and infant health through FGDs and KIIs among different stakeholders in a district in South Ethiopia. 1) Although the authors tried to address the issues highlighted in the first review, the major concerns related to length of result section remains yet. I would like to suggest author to interpret the results more precisely, particularly for the long quotes. 2) Author should be specific about their intervention. They mentioned intervention in different terms like “community-based video intervention”, “video-based intervention”, or “video-based health education”. It should be consistent in whole manuscript. It seems to be a video-based health education intervention, suggested to replace by it. 3) Please use full-form when you mentioned time (e.g., 1 hour 25 minutes to 1 hour 45 minutes in line 167, 35 minutes to 55 minutes in line 168). 4) There are several typo-errors (e.g., 37 KIIs in line 23, 10% in line 175, and so on), please check the whole manuscript. 5) Please check reference styles, few references seem to be inconsistent. Author used both full-form and abbreviation of journal name. Reviewer #6: 1. On L28 and 32the word “good” needs to be clarified. 2. Please remove L151-153- you don’t need to quantify qualitative research. 3. The result section still needs trimming and ramifications. 4. Please interpret the data and put a quote that supports the point you wanted to make. Please select a single quote from one study group that can clearly elaborate on the idea you want to raise. 5. Walayte (FGD discussant)- Please correct the name of the place. 6. Please use a similar labelling format for the quotes. E. g (HDA), (FGD discussant), (FGD) Mention either the study type, the respondent type or both uniformly. 7. Please remove personal identifiers – e.g “Kolla Mashile” if these are names of a district, please mention the district names in the methods section. 8. Please reduce the length of some lengthy quotes. Go for a maximum of 6 lines. Reviewer #7: The manuscript presents a qualitative study conducted at the end of a Cluster Randomized Community Trial. It is an appropriate complement to the main study as it endeavors to evaluate the intervention implemented. On the whole, study focus, logical flow and cohesion of the paper needs improvement. General areas of improvement are as follows: 1. Study focus To enhance understanding and appreciation of the manuscript, the focus/objectives of this qualitative study need to be made very clear in the introduction and run through the other sections of the write up (methodology, results, discussion and conclusion) to ensure logical flow of the manuscript. The variables of acceptability and feasibility as well as the methods and tools of their assessment also need to be explicitly stated. Differing objectives and variables are alluded to in different sections of the manuscript making it challenging to discern the core study focus. 2. Introduction This should be shortened to succinctly make a case for the qualitative study in relation to • Why digital innovative methods to facilitate nutrition education and counselling need to be in place • Importance of looking at the feasibility and acceptability of the video-based health education methods and their linkage to promoting behavior change at scale • The limitation of information provided in ANC. It is unclear what beliefs, attitudes, needs and situations were being investigated. Furthermore, aspects of identifying opportunities and challenges are also referred to but results related to this are not reflected in the abstract nor results section of the paper. Study focus needs to be appropriately synchronized in the title and main body of the paper. 3. Materials and methods Expound on specific procedures, tools and variables of interest for the qualitative study. 4. Results • Provide evidence-based results from the FGDs and KIs that are well linked to the objectives and variables of interest • Need to standardize labelling of quotes by location, data collection method and respondent type. • Ensure privacy and confidentiality of respondent is safeguarded 5. Discussion should • be closely linked to the result • logically flow as per the objectives/results presented without intermingling different issues • show linkage or difference with similar studies done in the same or different context. 6. Conclusion and implications • Conclusions should be drawn from the study results • Implication needs to allude to if acceptability and feasibility was good, what does that mean for maternal and infant health 7. Check grammar and sentence construction ensuring logical connection between the sentences and paragraphs Specific comments are provided in the attached document. Reviewer #8: Based on the findings in the research, I agree with the authors claim that the acceptability and feasibility of video-based health education for maternal and infants in Dirashe district is good. I think that the results are strongly supported with the data provided. I only have minor edits (in tract changes) and comments. I would prefer to reduce the quotations in each theme. About two or maximum of three should be enough to support a theme. For example, in line 288- 'Feasibility of video-based health education among pregnant and lactating women...': there are five quotations which could be reduced to two or a maximum of three of different participants. My overall impression is that the paper is strong and i recommend for it to be published with these minor edits/comments. Reviewer #9: This significant research project uses a phenomenological qualitative study design to examine the feasibility and acceptability of video-based behavioral change communication in the local setting with the goal of enhancing both the health of the mother and the newborn Overall, the manuscript is highly fascinating, straightforward, and condensed. Address the aforementioned suggestions to make the manuscript more valuable. Reviewer #10: (No Response) ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public. For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Florian Fischer Reviewer #3: No Reviewer #4: Yes: Grace Christopher Mambula Reviewer #5: Yes: Md. Obaidur Rahman Reviewer #6: Yes: Anene Tesfa Berhanu Reviewer #7: Yes: Gakenia Wamuyu Maina Reviewer #8: Yes: Yusupha Dibba Reviewer #9: Yes: Trhas Tadesse Berhe Reviewer #10: No ********** [NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.] While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step. 10.1371/journal.pgph.0000821.r004 Author response to Decision Letter 1 Submission Version2 30 Mar 2023 Attachment Submitted filename: Response to reviewers 29032023.docx Click here for additional data file. 10.1371/journal.pgph.0000821.r005 Decision Letter 2 Robinson Julia Staff Editor © 2023 Julia Robinson 2023 Julia Robinson https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Submission Version2 9 May 2023 Acceptability and feasibility of video-based health education for maternal and infant health in Dirashe district, South Ethiopia: A qualitative study PGPH-D-22-01021R2 Dear Godana, We are pleased to inform you that your manuscript 'Acceptability and feasibility of video-based health education for maternal and infant health in Dirashe district, South Ethiopia: A qualitative study' has been provisionally accepted for publication in PLOS Global Public Health. Before your manuscript can be formally accepted you will need to complete some formatting changes, which you will receive in a follow up email. A member of our team will be in touch with a set of requests. Please note that your manuscript will not be scheduled for publication until you have made the required changes, so a swift response is appreciated. IMPORTANT: The editorial review process is now complete. PLOS will only permit corrections to spelling, formatting or significant scientific errors from this point onwards. Requests for major changes, or any which affect the scientific understanding of your work, will cause delays to the publication date of your manuscript. If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they'll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact globalpubhealth@plos.org. Thank you again for supporting Open Access publishing; we are looking forward to publishing your work in PLOS Global Public Health. Best regards, Julia Robinson Executive Editor PLOS Global Public Health *********************************************************** Reviewer Comments (if any, and for reference): Reviewer's Responses to Questions Comments to the Author 1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation. Reviewer #1: (No Response) Reviewer #4: All comments have been addressed Reviewer #5: All comments have been addressed Reviewer #7: All comments have been addressed ********** 2. Does this manuscript meet PLOS Global Public Health’s publication criteria? Is the manuscript technically sound, and do the data support the conclusions? The manuscript must describe methodologically and ethically rigorous research with conclusions that are appropriately drawn based on the data presented. Reviewer #1: (No Response) Reviewer #4: (No Response) Reviewer #5: Yes Reviewer #7: Yes ********** 3. Has the statistical analysis been performed appropriately and rigorously? Reviewer #1: (No Response) Reviewer #4: (No Response) Reviewer #5: N/A Reviewer #7: N/A ********** 4. Have the authors made all data underlying the findings in their manuscript fully available (please refer to the Data Availability Statement at the start of the manuscript PDF file)? The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception. The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified. Reviewer #1: (No Response) Reviewer #4: (No Response) Reviewer #5: Yes Reviewer #7: Yes ********** 5. Is the manuscript presented in an intelligible fashion and written in standard English? PLOS Global Public Health does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here. Reviewer #1: (No Response) Reviewer #4: (No Response) Reviewer #5: Yes Reviewer #7: Yes ********** 6. Review Comments to the Author Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters) Reviewer #1: The result section has improved a lot. Reviewer #4: (No Response) Reviewer #5: Author made significant revision and tried to address all reviewers' comments. I don't have further comment. Reviewer #7: The authors have adequately addressed the previous comments provided ********** 7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files. Do you want your identity to be public for this peer review? If you choose “no”, your identity will remain anonymous but your review may still be made public. For information about this choice, including consent withdrawal, please see our Privacy Policy. Reviewer #1: Yes: Florian Fischer Reviewer #4: Yes: Grace Christopher Mambula Reviewer #5: Yes: Dr. Md. Obaidur Rahman Reviewer #7: Yes: Gakenia Wamuyu Maina ********** ==== Refs References 1 Nations United . Transforming Our World: The 2030 Agenda for Sustainable Development. Agenda Items 15 and 116. A/RES/70/1, 2015. 2 World Health Organization. Meeting Report: WHO Technical Consultation: Nutrition-Related Health Products and the World Health Organization Model List of Essential Medicines–Practical Considerations and Feasibility: Geneva, Switzerland, 20–21 September 2018. Published 2019. Accessed December 25, 2021. https://apps.who.int/iris/handle/10665/311677 3 United States Agency for International Development (USAID). Basic Maternal and Newborn Care: Basic Antenatal Care JHPIEGO/Maternal and Neonatal Health Program. Course Notebook for Trainers; 2004. 4 Central Statistical Agency (Ethiopia) and Inner-City Fund (ICF) International. Ethiopia Demographic and Health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central Statistical Agency and Inner-City Fund (ICF) International; 2012. 5 The United States Government and Global Maternal & Child Health Efforts, 8. 6 World Health Organization. WHO Guideline on School Health Services: Web Annex A: Compendium. Published 2021. Accessed December 25, 2021. https://apps.who.int/iris/handle/10665/343754 7 Central Statistical Agency (CSA) (Ethiopia) and Inner-city Fund (ICF). Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA and ICF; 2016. 8 Federal Democratic Republic of Ethiopia. Health Sector Development Plan -IV (HSDP-IV) 2010/11-2014/15, Ministry of Health, Addis Ababa, Ethiopia; 2010. 9 Federal Democratic Republic of Ethiopia. Health Sector Transformation Plan 2015/16–2019/20, Ministry of Health, Addis Ababa, Ethiopia; 2015. 10 Kavle JA , Landry M . Addressing barriers to maternal nutrition in low‐ and middle‐income countries: A review of the evidence and programme implications. Matern Child Nutr. 2018;14 (1 ). https://onlinelibrary.wiley.com/doi/10.1111/mcn.12508 11 Nikiema B , Beninguisse G , Haggerty JL . Providing information on pregnancy complications during antenatal visits: Unmet educational needs in sub-Saharan Africa. Health Policy and Planning. 2009;24 (5 ),367–376.19401360 12 Nikièma L , Huybregts L , Martin-Prevel Y , Donnen P , Lanou H , Grosemans J , et al . Effectiveness of facility-based personalized maternal nutrition counseling in improving child growth and morbidity up to 18 months: A cluster-randomized controlled trial in rural Burkina Faso. PLoS ONE. 2017;12 (5 ). 13 Klaic M , Kapp S , Hudson P , Chapman W , Denehy L , Story D , et al . Implementability of healthcare interventions: an overview of reviews and development of a conceptual framework. Implement Sci. 2022;17 (1 ):10.35086538 14 Park SY , Nicksic Sigmon C , Boeldt D . A Framework for the Implementation of Digital Mental Health Interventions: The Importance of Feasibility and Acceptability Research. Cureus. 2022;14 (9 ):e29329.36277565 15 Perski O , Short CE . Acceptability of digital health interventions: Embracing the complexity. Translational Behavioral Medicine. 2021;11 (7 ),1473–1480.33963864 16 United States Agency for International Development (USAID), 2011. Behavior changes interventions and child nutritional status. Evidence from the promotion of improved complementary feeding practices. Infant and Young Child Nutrition Project 455 Massachusetts Ave., NW Washington, DC 20001, June 2011. 17 One Mobile Projector per trainer (OMPT), 2017. Positioning statement https://giw2017.org/organizations/one-mobile-projector-trainer-ompt 18 Lorenzetti L , Tharaldson J , Pradhan S , Rastagar SH , Hemat S , Ahmadzai SAH , et al . Adapting a health video library for use in Afghanistan: Provider-level acceptability and lessons for strengthening operational feasibility. Hum Resour Health. 2020;18 (1 ),35.32429956 19 Balabanova D , Woldie M , Feyissa G , Admasu B , Mitchell K , Mckee M , et al . Facilitating accessible community-oriented health systems: The Health Development Army in Ethiopia. 20 Fisher P , McCarney R , Hasford C , Vickers A . Evaluation of specific and non-specific effects in homeopathy: Feasibility study for a randomised trial. Homeopathy. 2006;95 (4 ),215–222.17015192 21 Hommel KA , Hente E , Herzer M , Ingerski LM , Denson LA . Telehealth behavioral treatment for medication nonadherence: A pilot and feasibility study. European Journal of Gastroenterology & Hepatology. 2013;25 (4 ):469–473.23325274 22 Sekhon M , Cartwright M , Francis JJ . Acceptability of healthcare interventions: an overview of reviews and development of a theoretical framework. BMC Health Serv Res. 2017;17 (1 ),88.28126032 23 Kadiyala S , Terry R , Amy M , and Shruthi C . Using a Community-Led Video Approach to Promote Maternal, Infant, and Young Child Nutrition in Odisha, India: Results from a Pilot and Feasibility Study. Arlington, VA: USAID/Strengthening Partnerships, Results, and Innovations in Nutrition Globally (SPRING) Project 2014. 24 Save the children. Mothers’ Infant and Young Child Feeding Practices and their Determinants in Amhara and Oromia Regions. A Report on Formative Research Findings and Recommendations for Social and Behavior Change Communication Programming in Ethiopia, April 2014. 25 Musiimenta A , Tumuhimbise W , Pinkwart N , Katusiime J , Mugyenyi G , Atukunda EC . A mobile phone-based multimedia intervention to support maternal health is acceptable and feasible among illiterate pregnant women in Uganda: Qualitative findings from a pilot randomized controlled trial. Digital Health. 2021 Jan;7 :205520762098629. 26 Mweemba O , Smith H , Coombe H . Exploring the gender-specific impact of educational film on maternal and child health knowledge and behavior: A qualitative study in Serenje District, Zambia. Int Q Community Health Educ. 2021;41 (2 ),209–223.32249679 27 Hirchak KA , Leickly E , Herron J , Shaw J , Skalisky J , Dirks LG , et al . Focus groups to increase the cultural acceptability of a contingency management intervention for American Indian and Alaska Native Communities. Journal of Substance Abuse Treatment. 2018;90 :57–63. doi: 10.1016/j.jsat.2018.04.014 29866384 28 van der Steen JT , Azizi B , Nakanishi M , Shinan‐Altman S , Mehr DR , Radbruch L , et al . Cross‐cultural acceptability of interventions at the end of life in dementia: Video vignette study design and pilot evaluation (ERC CONT‐END WP1): Dementia—Cross‐cultural investigations. Alzheimer’s & Dementia. 202016 (S7 ). doi: 10.1002/alz.041542 29 Coetzee B , Kohrman H , Tomlinson M , Mbewu N , Le Roux I , Adam M . Community health workers’ experiences of using video teaching tools during home visits—A pilot study. Health Soc Care Community. 2018;26 (2 ),167–175.28872210 30 Bird VJ , Boutillier CL , Leamy M , Williams J , Bradstreet S , Slade M . Evaluating the feasibility of complex interventions in mental health services: Standardised measure and reporting guidelines. British Journal of Psychiatry. 2014;204 (4 ),316–321. 31 Joo JY , Liu MF . Culturally tailored interventions for ethnic minorities: A scoping review. Nurs Open. 2021 Sep;8 (5 ),2078–2090.34388862 32 Klevor MK , Adu-Afarwuah S , Ashorn P , Arimond M , Dewey KG , Lartey A , et al . A mixed method study exploring adherence to and acceptability of small quantity lipid-based nutrient supplements (SQ-LNS) among pregnant and lactating women in Ghana and Malawi. BMC Pregnancy Childbirth. 2016;16 (1 ):253.27577112