Table 2 Overview of results of the Amagugu Asakhula feasibility study in Soweto

Adoption

Mixed results.

“I thought maybe it’s like just too much work and everything.” (CHW who dropped out of the intervention delivery, FGD)

“Everybody at first is sceptical (others murmuring in agreement) about the programme, and then when you get to learn about what the programme offers then you start enjoying it.” (Caregiver, FGD)

“Even sister [name of CHW] was good to me, because she came home and she introduced this thing to me and then she explained everything to me. Even though I was like with, like her, because I was sceptical like hayi [no]. (laughing, others laughing too) I don't have time to sit down and do this thing. But she, she made me understand that it is not for me, it is for me and my child (someone else says "yes" in the background).” (Caregiver, FGD)

“When they came and they say like it's like a crèche [preschool], nè [right], you are teaching your child and all that and in your mind you are thinking ‘Ah I don't have time for that like, how do I teach a child this and that?’ You understand. So, I mean at first nè…I was not really interested, I was just doing [name of CHW] a favour. To be honest.” (Caregiver, FGD)

Acceptability

Acceptable to both CHWs and caregivers.

Moderator: “So what about the fact that the community health workers were coming to your homes with this programme…?”

Caregiver 1: “I prefer home visits. Because it's drawing attention to the other kids as well. I can teach my neighbour’s child as well.” (…)

Moderator: “Did any of you find it somehow uncomfortable that these were home visits? Or any other comments or feedback?”

Caregiver 2: “Not really, because they do visit.” (…)

Caregiver 3: “[The CHWs] should come. It’s something we are used to. Because they do the home visits, so it was very nice doing something different…” (laughter)

Caregiver 4: “Like ‘How are you feeling today, did you take your medicine?’ This [intervention] was like WOW. Something else. It was nice.” (FGD)

Interviewer: “What about your impressions of how acceptable it was for the community health workers to do this type of, you know, longer home visits and several sessions and actually really going through almost teaching things…? How acceptable is it to do that kind of tasks compared to what the normal work is?”

Key informant: “Uh huh (laughs) well it's, to be truthful, it was easy. Why I’m saying it was easy, because…our scope of practice is to educate the families, to educate the individuals, is to educate, educate… So it was easy for us because we already engaged with those houses. We already knew where to go to assist, and we already knew people, who to talk to, who to educate to, who’ve got children.” (Key informant interview)

Appropriateness

Appropriate for caregivers. The CHWs are also suited to deliver the intervention based on their skills and the scope of work.

“Then after [the CHW] told me that ‘This thing, it’s a project with kids, so I don’t know how you’re going to feel about it.’ Then I said ‘Of course I will try and force my children to have the better education and I want to see my children being happy.’” (Caregiver, FGD)

“If it is done by community health workers I think it’s good because they are our foot soldiers to the community. That’s why they are sent… I think they are the good people for the [Amagugu Asakhula] programme.” (Key informant interview)

Implementation and fidelity

Mixed results. Some specific descriptions by caregivers indicated high fidelity of intervention activities and content, but CHWs had also made changes to intervention.

Caregiver 1: “Then I realised that raising a baby is like planting a seed [referring to an intervention activity involving the planting of seeds].”

Caregiver 2: “Yes.”

Caregiver 1: “You have to give it all your attention, take care of it and love it, so that is what I learned.” (FGD)

“Here, all of us we were doing the training with the caregivers differently... You would have expected us to follow the manual exactly the things, ‘Tell the caregivers what will affect the brain development of a child…’ like follow exactly the manual. Yet we did those things in our own understanding and in our own ways where it helped us.” (Participating CHW, FGD)

Feasibility and context

Not feasible to be delivered by CHWs linked to a PHC facility. Only partially successful implementation. Challenges suggest evaluation components will be difficult to carry out through CHWs. Considerable organisational and structural barriers to integrating the intervention to the work of CHWs.

“Community health workers try to find every excuse not to do things and can walk around aimlessly just clocking up visits. That’s what’s happening.” (Key informant interview)

“But the strike…it strains a lot of people, meaning most of the people didn’t want to go work anymore. Didn’t want to work, because they were thinking ‘Ah, the government is failing us again.’ Ah, you know. So it’s yeah, it kills our jobs, like yeah, yeah it affected our job like so badly, so badly.” (Key informant interview)

“They [CHWs] can’t do [work] with an empty stomach... They need to get paid so that they have that energy so that they can do whatever.” (CHW who dropped out, FGD)

“Yes, people will be like ‘Okay, will we get extra money for it?’ (sighs) That’s not motivation, that’s being selfish.” (Key informant interview)