About the Author(s)


Sara Cooper Email symbol
Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa

School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa

Department of Global Health, Stellenbosch University, Cape Town, South Africa

Idriss I. Kallon symbol
Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Denny Mabetha symbol
MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa

Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa

Amanda S. Brand symbol
Centre for Evidence-based Health Care, Division of Epidemiology and Biostatistics, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Tamara Kredo symbol
Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa

Division of Clinical Pharmacology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

School of Family Medicine and Public Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Shakti Pillay symbol
Division of Neonatology, Groote Schuur Hospital, Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa

Gugu Kali symbol
Division of Neonatology, Department of Paediatrics and Child Health, Faculty of Health Sciences, Stellenbosch University, Cape Town, South Africa

Willem Odendaal symbol
Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa

HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa

Department of Psychiatry, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa

Citation


Cooper S, Kallon II, Mabetha D, et al. Home visits for preterm/low birthweight infants in South Africa: Qualitative evidence synthesis. Afr J Prm Health Care Fam Med. 2024;16(1), a4701. https://doi.org/10.4102/phcfm.v16i1.4701

Note: Additional supporting information may be found in the online version of this article as Online Appendix 1, Online Appendix 2 and Online Appendix 3.

Review Article

Home visits for preterm/low birthweight infants in South Africa: Qualitative evidence synthesis

Sara Cooper, Idriss I. Kallon, Denny Mabetha, Amanda S. Brand, Tamara Kredo, Shakti Pillay, Gugu Kali, Willem Odendaal

Received: 31 July 2024; Accepted: 03 Oct. 2024; Published: 20 Nov. 2024

Copyright: © 2024. The Author(s). Licensee: AOSIS.
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 work is properly cited.

Abstract

Background: Prematurity and low birth weight (LBW) are the main causes of neonatal mortality in South Africa (SA). Home visits by lay health workers (LHWs) may be effective in addressing this.

Aim: To inform a national guideline on LHW home visits as part of the Global Evidence, Local Adaptation (GELA) project, we conducted a rapid qualitative evidence synthesis exploring the acceptability, feasibility and equitability of this intervention for preterm and LBW babies.

Setting: We included studies conducted in SA.

Methods: We searched PubMed and Embase until 15 September 2023 and identified eligible studies independently and in duplicate. We synthesised evidence using thematic analysis, assessed study quality using an adaptation of the Critical Appraisal Skills Programme tool and assessed confidence in the review findings using GRADE-CERQual.

Results: The 16 eligible studies included diverse settings and populations in SA. Factors facilitating mothers’ acceptance included the knowledge and skills gained, the psychosocial support offered and improved healthcare access and relationships with facility staff. Distrust in LHWs and stigma associated with home visits were barriers to acceptance. Lay health workers’ acceptance was facilitated by them feeling empowered. The emotional burden of home visits for LHWs, coupled with insufficient training and support, undermined the feasibility of home visits.

Conclusion: A complex range of interacting contextual factors may impact on the implementation of home visit programmes for preterm and LBW infants in SA.

Contribution: This country profile provides insights into how home visits for preterm and LBW infants in SA might be contextually tailored to increase local relevance and in turn effectiveness, with potential relevance for other African countries.

Keywords: preterm and low birthweight (LBW) infants; maternal and child health; home visits; lay health worker; South Africa; acceptability; feasibility and equity; qualitative evidence synthesis.

Introduction

Over the last decade, South Africa (SA) has made significant improvements in maternal, neonatal and child health (MNCH) outcomes, primarily because of investments in human immunodeficiency virus (HIV) health services and prevention of mother-to-child transmission (PMTCT) programmes.1 It is estimated that the maternal mortality ratio (MMR) decreased from 173/100 000 in 2000 to 127/100 000 in 2020,2 under-five mortality rate reduced from 71/1000 in 2000 to 35/1000 in 20223 and the neonatal mortality rate (NMR) dropped from 28/1000 live births in 2000 to 18/1000 live births in 2019.4 However, the country still struggles to reduce health inequalities and reach global MNCH targets.5 Equitable access to affordable high-quality MNCH services remains elusive to many communities in SA.6 Moreover, while the country has made progress towards reducing NMR, prematurity and low birthweight (LBW) rates have not improved significantly. United Nations International Children’s Emergency Fund-World Health Organization (UNICEF-WHO) estimates of LBW prevalence in SA were 17.2%, 16.6% and 16.6% in 2000, 2012 and 2020, respectively.7 Preterm birth complications, including LBW, is the largest cause of neonatal deaths in the country.1,8 The coronavirus disease 2019 (COVID-19) pandemic exacerbated the challenges, and early indications of its impact show dire effects on maternal and child mortality rates and the uptake of maternal services.9 A comparison of COVID-19 versus pre-COVID-19 periods showed a 40% increase in maternal deaths, with a 3% and 10% increase in neonatal mortality and stillbirths, respectively.10 Considering current resource constraints, it is unlikely that SA’s public health system will meet the demands for specialised care for preterm infants.1,8

There is evidence that community-based models of care, including home visits, may be well-positioned to positively impact MNCH outcomes.11,12 These interventions have been shown to be effective in reducing under-five mortality,13,14 rates of maternal depression,15 and improving access to healthcare,16 child growth and development outcomes.17

Since the 1990s, SA has seen a growth in community-based healthcare programmes, which has included various programmes to reduce maternal and child mortality and improve access to healthcare.18,19 In 2011, the National Department of Health (NDoH) launched the ‘Re-engineering of Primary Health Care’ policy, which included lay health workers (LHWs) to promote health and healthcare among pregnant women and mothers in their homes.18 The goal of this initiative, together with other similar interventions,1,15 is to bring appropriate care closer to mothers and babies to help close the service delivery gap in under-resourced communities. Despite good evidence that these types of programmes can positively influence a range of health outcomes, there are a myriad of challenges that impact their acceptability and feasibility, and in turn their effectiveness and scalability.15,20 A better understanding of these issues could provide important insights into how they can be better addressed in the design, implementation and scale-up of home visit interventions for families with preterm and LBW infants in the country.

Qualitative research is well-placed for exploring these complex issues, and the contexts in which they arise.21,22 Qualitative evidence synthesis (QES) – or systematic reviews of qualitative evidence – brings together the evidence from primary qualitative research in a systematic way.23 The findings from a QES can enable richer interpretations and more powerful explanations of phenomena, circumstances or experiences, than can be achieved by a single primary qualitative study.24 Qualitative evidence synthesis is increasingly being used within guideline development and policy formulation to incorporate evidence beyond the effects of interventions, to wider questions about local norms and preferences, equity and human rights issues, acceptability and feasibility of interventions, implementation processes and the impact of socio-political and cultural contexts.21,22,25

The Global Evidence, Local Adaptation (GELA) project aims to maximise the impact of research on poverty-related diseases through enhancing decision makers’ capacity to use global research to develop locally relevant clinical practice guidelines (CPGs) in the field of newborn and child health in SA, Malawi and Nigeria (https://africa.cochrane.org/projects/GELA). To help a national guideline development group (GDG) formulate a guideline recommendation around home visit programmes for families with preterm and LBW infants in SA, GELA sought to identify or produce contextually relevant qualitative evidence on the topic, along with quantitative evidence about intervention costs and effectiveness. Specifically, qualitative evidence was sought to inform judgements about the feasibility, acceptability and equity domains of the GRADE Evidence-to-Decision (EtD) framework, which is used to help decision-makers use evidence to make decisions in a structured and transparent way.26

Through our searches, we identified two relevant QESs with a global scope.20,27 The first27 provides important evidence on the values and preferences of families about the healthcare of preterm or LBW infants, but does not contain any evidence specifically on home visits as an intervention. The second relevant QES20 contains important insights into the barriers and facilitators to home visits to improve access to maternal and child health. However, we considered it to be out-dated (the searches were conducted in 2011) and lacking in qualitative evidence pertaining specifically to families of preterm and LBW infants. In discussion with the SA national GDG, we deemed it necessary to supplement these global QESs with more recent and more local qualitative evidence relevant specifically to home visits for preterm and LBW infants specifically for the SA implementation setting.

The aim of this rapid QES was therefore to: (1) synthesise evidence from qualitative studies investigating SA stakeholders’ views and experiences of home visit programmes for families with preterm and LBW infants in SA; (2) identify the factors influencing the acceptability, feasibility and equity implications of these programmes.

Methods

Search methods

We searched PubMed, Medline and Embase databases for eligible studies from inception up until 15 September 2023 (see Online Appendix 1 for the search strategies). We contacted experts, searched citation lists of included studies and key references and cross-checked studies in the linked effectiveness and economic reviews that were simultaneously conducted to inform the GELA national guideline recommendation.

Inclusion criteria

We included studies that utilised qualitative methods for data collection and analysis; focussed on SA home visit programmes to improve health outcomes for preterm and LBW infants; and explored the views and experiences of any stakeholder involved in, or affected by, their design, receipt, delivery or implementation (e.g. any type or cadre of healthcare worker, patients and their families, peers, policy makers and programme managers).

For this review, we used the following definitions:

A home visit is an intervention where a trained health professional, LHW or volunteer visits the parents and/or caregivers of preterm and/or LBW infants in their home soon after discharge from hospital, to provide psychosocial support, health assessment, promotion and education, and referral services for problems identified. The frequency, duration and content of visits may differ by context.

A preterm infant is an infant born alive before 37 completed weeks of gestation,28 with further sub-divisions into moderate to late preterm (32–36 weeks), very preterm (28–31 weeks) and extremely preterm (less than 28 weeks).

Low birthweight refers to weight at birth of less than 2500 g.29 This could be further categorised into very LBW (< 1500 g) and extremely LBW (< 1000 g).

We were unable to identify any qualitative studies of home visits to improve health outcomes specifically for preterm and LBW infants in SA. We therefore broadened the scope of the review to include qualitative studies of home visit interventions or programmes to improve MNCH outcomes more broadly. In line with a global review on this topic,20 we used the following definitions in this regard:

Child healthcare is aimed at improving the health of children less than 5 years of age.

Maternal healthcare aims to improve reproductive health, ensuring safe motherhood, or is directed at women in their role as carers for children aged less than 5 years.

Study selection

Two review authors independently assessed the titles and abstracts of the identified records to evaluate eligibility. We retrieved the full text of all potentially relevant abstracts and assessed these papers independently and in duplicate. We resolved disagreements by discussion or, when required, by involving a third review author. Where the same study, using the same sample and methods, was presented in different reports, we collated these reports so that each study (rather than each report) was the unit of interest in our review. Figure 1 comprises a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram showing our search results and the process of screening and selecting studies for inclusion.

FIGURE 1: Study flow diagram.

Data extraction and analysis

We first extracted characteristics of the studies (citation, publication date, setting, duration, participants’ details, etc.) and thereafter its results. We used a thematic synthesis method as our analytical approach.30 Key concepts and themes (reported anywhere within the primary qualitative studies) were extracted for each study in Nvivo, together with supporting participant quotes. We also developed a brief, structured summary for each study, capturing the main conclusions. The extracted data, together with the structured study summaries, were then compared and contrasted across studies to identify commonalities and potential differences. To support this process and further organise the similarities and differences across studies, we drew on the constructs of the EtD framework for qualitative evidence – specifically seeking content on acceptability, feasibility and equity.21,31 Once the findings had been organised into themes, we re-read the included studies to check that all key study findings were captured by the review findings. One review author led the data extraction and analysis process, which was cross-checked by a second review author. The emerging findings were also discussed and workshopped with the other review authors.

Study appraisal and confidence in the review findings

We assessed the methodological limitations for each study using criteria employed in previous Cochrane reviews.32,33,34 One review author conducted the assessment, which was cross-checked by a second review author. The criteria used were originally based on the Critical Appraisal Skills Programme (CASP) tool35 but they have since gone through several iterations. The adapted tool includes the following eight questions to assess methodological limitations:

  1. Were the settings and context described adequately?

  2. Was the sampling strategy described, and was this appropriate?

  3. Was the data collection strategy described and was this appropriate?

  4. Was the data analysis described, and was this appropriate?

  5. Were the claims made/findings supported by sufficient evidence?

  6. Was there evidence of reflexivity?

  7. Did the study demonstrate sensitivity to ethical concerns?

  8. Any other concerns?

We assessed how much confidence decision-makers and other users can place in individual review findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.36 GRADE-CERQual evaluates confidence in a review finding based on four key components: (1) the adequacy of data supporting the review finding; (2) the relevance of the individual studies contributing to the review finding; (3) the methodological limitations of the individual qualitative studies contributing to the review finding; and (4) the coherence of the review finding. The assessment of each of these four components is then used to make a judgement about the overall confidence in the evidence supporting the review findings, which can be judged as high, moderate, low or very low. Two review authors applied GRADE-CERQual together, and the final assessment was based on discussion and consensus among all the review authors. All findings started as high confidence and were then graded down if there were important concerns regarding any of the GRADE-CERQual components.

Our GRADE-CERQual assessments and associated confidence in the review findings incorporated the fact that the body of evidence contributing to the review findings pertains to home visits and peer support in relation to MNCH more broadly, and not in relation to preterm and LBW infants’ health more specifically (i.e. ‘indirect’ evidence) (see Evidence Profiles – Online Appendix 2). In particular, and in line with the GRADE-CERQual approach, when making our assessments on relevance, we evaluated whether there are likely to be significant differences between preterm and LBW infants and infants that are not preterm and LBW that would reduce our confidence in relation to each review finding. To facilitate these judgements, we drew on the QES on what matters to families about the healthcare of preterm or LBW infants,27 and also consulted with experts on the topic of preterm or LBW infants in South Africa.

Results of the search

No studies were identified that focussed on preterm and LBW infants specifically. In all, 16 studies – from 18 full texts – met our broadened inclusion criteria of MNCH (Figure 1).37,38,39,40,41,42,43,44,45,46,47,48,49,50,51,52,53,54 All included studies were published between 2010 and 2023. Details of the included studies are shown in Table 1.

TABLE 1: Characteristics of included studies (16 studies from 18 full texts).
TABLE 1 (Continues …): Characteristics of included studies (16 studies from 18 full texts).
Review findings

We have organised the findings into four themes, which separate recipients’ and LHWs’ acceptance of home visits and the factors that influence this: (1) Facilitators of recipients’ acceptance of home visits; (2) Barriers to recipients’ and the broader community’s acceptance of home visits; (3) Facilitators of LHWs’ acceptance of home visits; (4) Barriers to LHWs’ acceptance of home visits and the feasibility of home visits. None of the studies identified or described potential impacts of home visits on equity issues explicitly, and thus we do not report any findings in this regard. We refer throughout to those delivering the intervention as LHWs.

Table 2, the summary of the qualitative findings (SoQF), provides a summary of each review finding, references to the studies contributing data to each finding and quotations as supporting data. It also details our assessment of confidence in the evidence, as well as an explanation of this assessment, based on the GRADE-CERQual approach.36 Detailed descriptions of our confidence assessment are included in the evidence profiles in Online Appendix 2. Our assessment of the methodological strengths and limitations of included studies is included in Online Appendix 3.

TABLE 2: Summary of Qualitative Findings (SoQF) table.
TABLE 2 (Continues …): Summary of Qualitative Findings (SoQF) table.
TABLE 2 (Continues …): Summary of Qualitative Findings (SoQF) table.
TABLE 2 (Continues …): Summary of Qualitative Findings (SoQF) table.
TABLE 2 (Continues …): Summary of Qualitative Findings (SoQF) table.
TABLE 2 (Continues …): Summary of Qualitative Findings (SoQF) table.
TABLE 2 (Continues …): Summary of Qualitative Findings (SoQF) table.

Theme 1: Facilitators of recipients’ acceptance of home visits

The studies found the following aspects about home visits that mothers value and which may facilitate their acceptance of them: (1) Acquiring knowledge and skills; (2) Time to learn and express needs; (3) Psychosocial support; (4) Reduced clinic visits; (5) Better access to, and relationships with, clinics and clinic staff; (6) LHWs coming from same community; (7) Incorporating innovative digital technologies; and (8) Mothers reported positive impacts of these different elements.

Finding 1: Acquiring knowledge and skills (High confidence)

Many mothers expressed appreciation of the educational element of home visits, whereby through information provision, hands-on activities and problem-solving they learnt new information about their own and their children’s health. Some mothers described how the practical advice and information they received from LHWs was relevant to their lives and also conveyed in a way that they could easily understand.

Finding 2: Time to learn and express needs (High confidence)

Many mothers emphasised that home visits provided them the opportunity to have more time with a healthcare provider, allowing them to express their needs and discuss different topics without time constraints. Some contrasted this with their experiences of healthcare facilities, explaining how staff in these settings are usually extremely busy and lack adequate time for consultation. Many mothers also described feeling anxious when attending clinics and finding it difficult to ask questions, often leaving the clinic feeling that they had not received the information or treatment they required. In contrast, many mothers appreciated what they described as LHWs’ patience during home visits and their willingness to take the time to explain important topics while addressing their questions and concerns.

Finding 3: Psychosocial support (High confidence)

Some mothers highlighted the importance of the supportive role played by home visits. Specifically, they spoke about the emotional support LHWs provided, allowing them to discuss their problems and listen to them with compassion and respect. Many spoke about how LHWs helped alleviate their sense of loneliness and alienation or offered them hope and encouragement when they felt hopeless. Mothers also highlighted the responsiveness of LHWs, often available to help after hours and when a problem arises. Some mothers appreciated the continuity of their interactions with LHWs, which they felt created a support structure that they could rely on.

Finding 4: Reduced clinic visits (Very low confidence)

Some mothers described how home visits reduced the number of clinic visits needed, with the resultant time, convenience and cost savings they experienced. Many mothers indicated that clinic visits were expensive and time-consuming, often requiring them to travel very early in the morning and spend the whole day at the clinic. This was seen as a major challenge for accessing healthcare.

Some LHWs similarly described how the mothers they visited often highlighted the many challenges they face in accessing healthcare facilities, including practical issues of distance and transport, childcare constraints and competing household work pressures. They highlighted how mothers frequently indicated how they appreciated being visited at home because of the time, effort and (opportunity) costs this saved them.

Finding 5: Better access to, and relationships with, clinics and clinic staff (moderate confidence)

Many mothers spoke about how home visits enhanced their access to, and relationships with clinics and clinic staff; for example, they described how access to clinics could be facilitated by LHWs providing them with a signed referral letter for clinic staff. Other mothers spoke about the communication channel LHWs provided, giving them helpful information on how to efficiently navigate clinic appointments. Some mothers felt that home visits empowered them as a result of the knowledge and skills provided, which in turn helped them to feel more confident and equipped to communicate with nurses and ask questions.

Finding 6: Lay health workers coming from same community (Moderate confidence)

For some mothers, acceptance of home visits appeared to be facilitated by LHWs from the same community; many described how this made LHWs more familiar and approachable and/or able to understand their lived experiences and contexts better. This enhanced the trust between many mothers and LHWs. In addition, some mothers appreciated that LHWs from the same community were in close proximity and therefore easily accessible in an emergency. Some LHWs also indicated a preference for working with mothers within their own communities, suggesting that this facilitated trust and relationship-building and in turn acceptance among mothers. Many LHWs described this as essential for their work.

Finding 7: Incorporating innovative digital technologies (Very low confidence)

Two studies explored the impact and experiences of incorporating digital devices containing mobile video content as health promotion and teaching tools during LHW home visits.37,39 Both studies found that digital tools were highly valued by mothers, which also enhanced their acceptance of home visits. Some LHWs felt that video messages assisted with capturing mothers’ attention and maintaining their interest. Many LHWs reported that mothers would at times spontaneously express interest in watching additional or new videos on arrival at their household. Many LHWs felt that the video messages underscored and legitimised the advice they provided. Because the videos echoed the early perinatal health messages that mentor mothers delivered prior to video viewing, LHWs felt that the mothers they counselled were more likely to trust them and value their expertise. They also thought that the digital technologies themselves enhanced their perceived authority in the community by signifying that they were employed by a well-funded, well-established programme, and by allowing them to demonstrate technological skills in front of the mothers they visited.

Finding 8: Perceived positive psychological and behavioural impact (Moderate confidence)

Many mothers described several positive effects they perceived to have experienced because of the above-mentioned elements of home visits. For some, these visits reportedly facilitated behaviour change through the knowledge and skills gained, or through the sense of external accountability they felt from having a monthly or bimonthly visitor whom they respected. Others described gaining a sense of agency and confidence in health-related decision-making, even when they were unable or unwilling to fully adhere to the advice. Many mothers described feeling empowered by the home visits, which encouraged them to take better responsibility for their own health and that of their child’s. Some mothers described feeling a greater sense of well-being and hope because of the positive outcomes that they had observed in themselves or their children, and the fact that they had received something worthwhile.

Theme 2: Barriers to recipients’ and the broader community’s acceptance of home visits

The studies revealed various barriers to acceptance of home visits among mothers and the broader community. Here two findings emerged as particularly prominent: (1) Distrust of LHWs for several reasons; and (2) Stigma associated with home visits.

Finding 9: Distrust of lay health workers (High confidence)

Distrust of LHWs emerged as a major overarching factor contributing to mothers’ and the broader communities’ reservations of home visits. The reasons for this distrust included issues related to (1) Privacy and confidentiality; (2) LHW gender; and (3) Perceived competencies of LHWs.

Finding 9.1. Privacy and confidentiality (Moderate confidence)

Some mothers distrusted LHWs because of concerns related to privacy and confidentiality. These mothers indicated that LHWs could not be trusted as they did not maintain client confidentiality, reportedly gossiping or disclosing private information to others in the community. This was perceived to be a particularly significant concern when LHWs came from the same community as mothers. It was also seen as a concern when LHWs used digital devices, as found by one of the studies exploring the impact and experiences of incorporating digital device tools during home visits.39 Many LHWs reported that some clients were concerned that the devices were being used as voice or video recorders, which was found to be an integral component of some mothers’ more general concerns regarding LHWs, in terms of maintaining their privacy and confidentiality.

The home, as a communal consultation space for receiving services, was reported to present further challenges to privacy and confidentiality. Some mothers and LHWs indicated how discussing confidential information at home was challenging if family members were present and could lead to unwanted disclosure of sensitive information. Both mothers and LHWs explained how visits sometimes caused contention or led to curiosity from family members, which undermined the trust relationship between the LHW and the mother.

Finding 9.2: Gender of the LHW (Very low confidence)

Another potential factor contributing to mothers’ distrust of LHWs is related to the gender of the LHW. In respect of male LHWs, it was suggested that mothers may be concerned for their safety and may be doubtful about what they could teach them. It was also suggested that some male partners of women being visited expressed concerns about a man discussing topics that were perceived to be of a sensitive and personal nature. This was thus an additional factor potentially reducing the acceptability of male LHWs visiting households in the antenatal and postnatal periods.

Finding 9.3: Perceived lack of competencies of lay health workers (Moderate confidence)

An additional factor contributing to maternal distrust is related to LHWs’ perceived lack of competencies as healthcare service providers. Some studies revealed various factors that could undermine recipients’ confidence in LHW competencies. The relationship between LHWs and clinic staff was one such factor, with studies showing how clinic staff were crucial in supporting confidence in LHWs; if clinic staff appeared to question LHWs’ competency or trustworthiness, this could undermine LHW credibility in the eyes of the community.

While some LHWs described trusting and good working relationships with clinic staff, others reported clinic staff treating them with contempt and disrespect, and conveying a lack of confidence in their ability to provide appropriate services. Lay health workers provided examples in this regard, such as clinical staff not accepting their referrals, not taking them seriously, or not drawing on them to help in busy times. Many LHWs felt that this treatment affected their perceived competency by the community and undermined community trust in their ability to provide care.

Other factors identified as potentially undermining confidence in the competency of LHWs included individuals in wealthier households with potentially higher educational levels than LHWs undermining their role; perceptions of LHWs as voluntary and temporary workers occupying a lower status than nurses; and poor LHW performance and access to essential medical equipment.

Finding 10: Stigma associated with home visits (Moderate confidence)

In addition to distrust, stigma associated with home visits was an additional factor undermining its acceptance among mothers and the broader community. Many LHWs indicated that certain people in the community had little knowledge of what their work entailed and believed that they only visited people living with HIV, which led to stigma regarding home visits. Other LHWs suggested that there was stigma surrounding perceptions that they only visit mothers who are emotionally struggling, and that some mothers feared they would be judged if they received home visits.

Theme 3: Facilitators of lay health workers’ acceptance of home visits

The studies reported two issues that improved LHWs’ acceptance of home visits: (1) it offered them a sense of empowerment; and (2) they enjoyed using digital technologies during the visit.

Finding 11: Empowering, validating, employment and convenience (Moderate confidence)

A number of studies indicated in general terms that LHWs tended to be supportive of home visits and their associated role in them. Some reasons were provided, although details were relatively lacking in this regard. These included the sense of empowerment, dignity, purpose and strength LHWs gained from being respected as healthcare workers in their community. Some LHWs felt valued as individuals who were seen to be able to make a difference for their community, while others reported seeing the impact their visits make. This provided them with a sense of value and worth. Many described feeling pride in earning a salary. A few spoke about the added benefit and convenience around being able to work within their own community, where many residents seeking formal employment are forced to migrate and live away from their families.

Finding 12: Incorporating innovative digital technologies (Very low confidence)

The two studies that explored the impact and experiences of incorporating digital devices during home visits (Finding 7) found the devices were highly valued by LHWs.37,39 This enhanced their acceptance of their home visiting role more generally. Many LHWs felt that the digital devices lightened their workload as they did not need to perform all health counselling verbally and could therefore focus on other important tasks. For example, they highlighted how the use of videos allowed them to perform other administrative- and health-related tasks, such as note-taking or completing referrals while mothers engaged with the videos. Many LHWs also reported that they felt these devices helped to convey a sense of importance about their work, which boosted their confidence, morale and sense of self-worth.

Theme 4: Barriers to lay health workers’ acceptance of home visits and the feasibility of home visits

The studies revealed various challenges LHWs face when conducting home visits which may reduce both their acceptance and feasibility of home visits. These challenges are grouped into four findings: (1) Boundaries and burdens; (2) Training, supervision and support; (3) Practical and logistical challenges; and (4) Human resource-related issues.

Finding 13: Boundaries and emotional burdens (High confidence)

Many LHWs spoke about the difficulties they experience in maintaining boundaries and navigating between professional and personal obligations. This was particularly the case when LHWs came from the same community as the mothers they visit. In such cases, LHWs indicated that they have less ability to draw boundaries because they are always available for their clients. Some also felt obligated to attend to mothers’ needs after hours. Lay health workers described how the realities of poverty and community violence they confront daily made it at times difficult to maintain the boundaries of the programme, and what they are meant to provide.

Some LHWs described finding it difficult to separate themselves from their clients’ problems, particularly when they shared similar burdens (e.g. HIV, poverty and crime), or when they felt emotionally connected to clients. They described this as distressing and painful, and taking a toll on their emotional well-being.

Lay health workers described various other burdens they face. Many noted that being close to mothers invited the possibility that gossip about someone’s health could be pinned back on them, even if they were not to blame. Some spoke about the jealousy they experience from community members because of being employed in a context of low employment rates. A few described how their LHW role had disrupted the dynamics in their homes, because of shifts in cultural expectations with, for example, the financial independence they had gained threatening their husbands.

Finding 14: Training, supervision and support (High confidence)

Gaps in knowledge and expertise were identified as a major challenge across LHW home visit programmes albeit to varying degrees. Many LHWs expressed concern that they did not have the necessary information and skills to provide the recommended care. They felt that this deficit undermined their performance during home visits and impacted on their perceived credibility by the mothers under their care.

This finding was similarly identified in studies evaluating LHW practices where it was noted that many LHWs displayed important gaps in knowledge and expertise. These studies found that LHWs did not always provide all essential content or perform the practices considered critical for their routine activities. One study evaluated the fidelity of core intervention skills taught in training LHWs.46 The study found that, while the core knowledge and skills that were taught were widely observed among LHWs, the more complex interpersonal skills (e.g. soliciting questions or reflecting clients’ feelings and concerns) were not readily observed across all LHWs or during all visits.

This deficit in knowledge and skills was attributed to inadequate training that LHWs receive, together with poor supervision and support. While some LHWs appeared to be positive about their initial training, many felt that they had received insufficient refresher training. Moreover, LHWs reported operating largely in isolation, with limited access to the support and supervision needed to carry out their work effectively. In particular, some expressed dissatisfaction with the limited in-field supervision they received, with supervision reportedly often being conducted at clinics or on the phone.

Three studies explicitly emphasised the importance of training and supervision for LHWs.40,44,51 In one study assessing the impact of an intervention package, it was found that ongoing support, and increased supervision and training, enhanced LHW knowledge and confidence, increased motivation and a sense of accountability among LHWs.44 In another study, it was found that LHWs were initially unhappy with the intervention as they felt it would add more work.51 However, this perception changed after LHWs received increased supervision and mentorship. Lay health workers in this study described the many positive effects of this supervision and mentorship, including increased knowledge, motivation and confidence. Many also detailed how mentors accompanying them during the home visits improved their communication with mothers. In the third study, it was found that strong supervision and support structures for LHWs were essential for them to carry out their work.40 It was revealed that such support helps LHWs to manage the stress and emotional toll of home visits. Specifically, this study found that, along with technical and informational supervision, other types of supportive supervision for LHWs are required. These include, for example, mentoring and motivating LHWs; managing the administrative, emotional, and safety demands of home visits; and helping them to set boundaries and engage in self-care practices.

Finding 15: Practical and logistical challenges (High confidence)

Some LHWs provided detailed descriptions of the range of practical and logistical challenges they face during home visits, which reportedly make it difficult for them to perform their work successfully. Distance was a common challenge, with many LHWs describing how they often covered vast distances between households, frequently with limited or no access to transportation.

Another challenge was the mobility of mothers; for example, some mothers living in informal settlements relocated frequently. This made following-up with these mothers difficult, especially if the mother had moved to another LHW’s area. Mothers also frequently visited the father of the child or sought work in other areas and were therefore not available for home visits.

Another major challenge commonly shared by LHWs was personal safety. Many reported feeling unsafe when visiting mothers residing in areas prone to violence, crime and drug abuse. Some LHWs described being bitten by mothers’ dogs and occasionally having to cancel a home visit because of dogs impeding access to the home.

Some LHWs often had limited access to essential tools and equipment to conduct their work. They felt that this strongly hindered their ability to perform tasks and undermined programme credibility, and in turn community acceptance. In the study that assessed the impact of an intervention package to increase LHW support and training (Finding 14), LHWs were provided with extra equipment (e.g. scales, backpacks and phones), and access to transport.44 This was found to enable LHWs to deliver improved services, which in turn had a positive effect on perceived programme credibility and community acceptability.

Finding 16: Human resource-related issues (Moderate confidence)

Some studies showed that human resource-related issues, including poor salaries, undermine the feasibility and LHW acceptance of home visits; many LHWs were reportedly unsatisfied with their remuneration. Non-permanent contracts for LHWs and the associated vulnerability were additional issues identified. These factors contributed to high LHW attrition rates.

Discussion

In this review, we aimed to synthesise qualitative evidence on stakeholders’ views and experiences of home visit interventions for families of preterm and LBW infants in SA. A noteworthy result was that no studies were identified that focussed specifically on preterm and LBW infants. We therefore broadened the inclusion criteria of this review to include home visits for MNCH more broadly. The results of this ‘indirect evidence’ therefore need to be viewed with some degree of caution. More research specifically on preterm and LBW infants in SA is needed so that more definitive conclusions can be made regarding the acceptability and feasibility of home visits for this particular population.

None of the studies identified or described potential impacts of home visits on equity issues explicitly, and thus we did not report any findings in this regard. When developing the equity domains of the GRADE EtD framework to inform the SA national guideline recommendation, we used the findings from this review to infer potential impacts of home visits on equity issues. These hypotheses were, however, not included in the findings of this review as they did not emerge directly from the results reported in the primary studies. Again, more research on home visits for preterm and LBW infants in SA is required and particularly the equity implications of this intervention.

The findings of this review revealed a mix of acceptable intervention aspects and reservations among recipients and providers. Many mothers appreciated home visits for various reasons, including the knowledge, skills and psychosocial support it provided, the time it afforded them to learn and express their needs. In addition, home visit had various positive effects on mothers’ relationships with healthcare facilities which included reducing the number of visits needed, enhancing access and improving interactions with clinic staff. However, the findings also revealed various factors that may hinder mothers’ acceptance of home visits, including concerns related to privacy and confidentiality, LHW gender, perceived competencies of LHWs, associated distrust of LHWs and potential stigma associated with home visits.

A similar mixed picture emerged in relation to LHWs’ acceptability of home visits. Data on LHWs’ acceptance of home visit programmes and its facilitators were relatively sparse across the studies. It is unclear whether this reflects limited LHW acceptance of home visits or a tendency of studies to focus more on barriers and challenges. That said, the findings did suggest that many LHWs were supportive of home visits, potentially because of the empowerment, validation and the convenient employment it affords. However, the studies revealed a plethora of challenges LHWs face when conducting home visits which may reduce their acceptance and the feasibility of home visits. These included the emotional toll many LHWs face maintaining boundaries with clients and navigating between professional and personal obligations, the inadequate training, supervision and support they receive, and the multiple practical and logistical challenges they experience which make it difficult to perform necessary tasks and maintain personal safety.

The challenges to the acceptability and feasibility of LHW home visit programmes identified in this review are not new nor unique to SA. A global QES conducted over a decade ago on LHW programmes to improve access to maternal and child healthcare revealed very similar barriers.20 The review similarly found that, while recipients were generally positive about the programmes, many had concerns about confidentiality when receiving home visits, and questioned the competencies of LHWs. As in our review, this global QES also found that LHWs sometimes find it difficult to manage emotional relationships and boundaries with recipients and face a range of health system constraints related to inadequacies of equipment, support, training and remuneration. And similar to our review, this QES found that these challenges negatively impact on LHWs motivation, their credibility and programme success. These findings were similarly revealed in a recent QES about LHWs’ experiences and perceptions of supervision in programmes targeting maternal and child health in low-and-middle-income countries (LMICs).55 The review found that regular, good-quality training and in-the-field supervision are essential for programme effectiveness, and yet are missing in practice in most maternal and child health LHW programmes in LMICs.

The systemic challenges identified in our QES also appear to be similar to the issues facing LHW programmes in SA more broadly and not uniquely with regards to maternal and child health. Lay health workers and community-oriented care, including LHW home visit programmes, have over the past decade emerged as core elements of SA’s healthcare system, as captured in the 2004 CHW National Policy Framework, and more recently in national strategies such as the re-engineering of primary health care,56 the National Health Insurance (NIH)57 and ward-based outreach teams (WBOTs).58,59,60 However, research on these initiatives has revealed that LHW programmes in South Africa, including home visits, are often fragmented, inadequately planned, poorly supervised, under-resourced and not prioritised politically.59,61,62 These issues are often driven by well-intentioned vertical programmes that are inadequately integrated with facility-based primary health care service delivery63 and do not take the complexity of community-orientated primary care (COPC) into account.64 Adding home visits for LBW and preterm infants and their families as another vertical programme – rather than as part of an integrated primary health care system – risks fuelling similar challenges. Many questions therefore remain regarding the feasibility to scale and sustain LHWs programmes more broadly, and not just in relation to maternal and child health, in South Africa. We attempt to address these questions in Table 3 and the implications for policy and practice in the next section.

TABLE 3: Policy and practice implementation consideration for lay health worker home visiting programmes for families with preterm and low birthweight infants in South Africa.
Implications for policy and practice

Table 3 includes a set of questions and prompts that may help policy makers and other decision-makers when planning, implementing or managing LHW home visit programmes for families with preterm and LBW infants in SA. These questions were developed by drawing on and integrating the findings from this review with (1) the implementation considerations that were developed out of the global review of qualitative research,20 now published as a policy brief65; (2) the principles identified by a scoping review of COPC in Africa, including different models and their effectiveness and feasibility64 and (3) input and discussion among the SA national GDG.

Limitations

Because of the time constraints for developing the SA national guideline, this was a rapid review with associated limitations. We only searched two databases; a more comprehensive search of additional databases, including those not specific to health, may have identified more studies. Only one review author primarily conducted the data analysis process, albeit with discussion and input from other review authors. We recognise that qualitative data analysis is inherently interpretive; more than one review author undertaking these processes independently may have produced different interpretations and enhanced the exploration of alternative explanations. The assessments of methodological strengths and limitations were also undertaken by one review author, albeit checked by a second review author. More than two review authors conducting the assessments independently may have enhanced the rigour of the process.

Conclusion

The findings from this review suggest that a range of complex and interacting contextual factors may impact on the acceptability and feasibility of home visits for maternal and child health in South Africa. In an attempt to address some of these factors visits, we have provided a set of questions that may help policy and decision-makers when planning, implementing or managing such programmes for preterm and LBW infants specific to the South African context.

Acknowledgements

We would like to acknowledge the contribution made by the anonymised peer reviewer, whose critical feedback and valuable insights greatly enhanced the manuscript’s quality.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors’ contributions

S.C., I.I.K., D.M. and W.O. conceived the review topic. S.C. designed the review and led the review process and write-up. S.C. and her research assistant conducted title/abstract and full-text screening. S.C. and W.O. conducted the data management, quality assessment and analysis, with discussion and input from all review authors in the later stages of the analysis (I.I.K., D.M., A.S.B., T.K., S.P., G.K.). S.C. and her research assistant led the GRADE-CERQual assessments of findings with input and verification from I.I.K., D.M., W.O. and other experts in the field. S.C. wrote the manuscript, with input and revisions from all review authors (I.I.K., D.M., A.S.B., T.K., S.P., G.K., W.O.). All review authors approved the final manuscript.

Ethical considerations

This article followed all ethical standards for research without direct contact with human or animal subjects.

Funding information

This review was conducted for the GELA project (https://africa.cochrane.org/projects/GELA) which is funded as part of the EDCTP2 programme supported by the European Union (grant number RIA2020S-3303-GELA). The funder had no role in the design of the study, or in the collection, analysis and interpretation of data, or in writing the manuscript.

A.S.B. and T.K. are partly supported by the Research, Evidence and Development Initiative (READ-It) project. READ-It (project number 300342-104) is funded by UK aid from the UK government; however, the views expressed do not necessarily reflect the UK government’s official policies.

Data availability

The authors confirm that the data supporting the findings of this study are available within the article and Online Appendix 1, Online Appendix 2 and Online Appendix 3.

Disclaimer

The views and opinions expressed in this article are those of the authors and are the product of professional research. The article does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.

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