Table 2. Summary of Qualitative Findings (SoQF) table.

Summary of review finding	Studies contributing to the review finding	GRADE-CERQual assessment of confidence in the evidence	Supporting data (selection)	Explanation of GRADE-CERQual assessment
Theme 1: Facilitators of recipients’ acceptance of home visits
Finding 1: Acquiring knowledge and skills. Many mothers appreciate the educational element of home visits, whereby through education, hands-on activities, problem-solving and advice they learn new information about their own and child’s health that is relevant and understandable.	38,42,47,51,53,54	High confidence	‘We were taught that the porridge is made in different ways … We also learnt a lot about breastfeeding … That really inspired us as young people.’ (Mother, NDoH Family MUAC Project)51 ‘There are so many things that I learned. I didn’t know that you have to wash your hands before you touch a baby’s bottle, then wash the bottle and prepare food for the baby, I didn’t know that. Even feeding the child, I thought that you just feed the child … I didn’t know the motive behind it, you see … So after she came and explained to me about breastfeeding … telling me that the child must never miss the scale dates [at the clinic], I became alright, I saw myself as a good person and I did things the way she told me to.’ (Mother, Enable Mentor Mother Programme)47
Finding 2: Time to learn and express needs. Many mothers and LHWs perceive home visits as enabling mothers the opportunity to have more time with a healthcare provider compared to in a clinic setting, in turn allowing for greater learning, discussion and expression of needs.	47,50,51,54	High confidence	‘The other thing that we like is that about these people [CHWs] coming to our homes is that they are patient and speak to you in a proper manner unlike the clinic, you can’t even explain at the clinic that the child was vomiting or what was happening because you are already scared. When they [CHWs] come to your house you can explain everything that you see with the child that you are not happy about, you understand?’ (Mother, NDoH Family MUAC Project)51 ‘There are so many people in the clinic … at home you arrive and relax with your patient so that the mother can freely explain the problem and you have time to help her even if you don’t have anything to give but when you go out she would be satisfied.’ (LHW, Eastern Cape Supervision Study)50 ‘During the [CHW] visits there is enough time to talk unlike the time at the clinic. I liked that because we receive more information than we get at the clinic because the time at the clinic is not enough, nurses are rushing to service everyone.’ (Mother, KZN DoH MCH programme)54
Finding 3: Psychosocial support Many mothers value the supportive role of home visits, which they attribute to the respect, responsiveness and encouragement of LHWs and the continuity of their interactions with them.	38,42,47,51,53,54	High confidence	‘Our Mentor Mother is very diligent, I love her … it doesn’t matter where she is, if she is at work, she would say after work I will come and listen to what you are calling me for, here at home we like inviting her even if we just sitting we will just call her.’ (Mother, Enable Mentor Mother Programme)47 ‘The help I get, it’s every time when the Mentor Mother visited me she always encourage, she always give that hope that I must stay strong. I’m not alone.’ (Mother, Mentor Mothers Zithulele)42 ‘When I met [my mentor] I was always crying but she’s the one who wiped away my tears and encouraged me, telling me that, ‘You are not alone who are having [HIV], there are many women living with [HIV]’… The mentor mother plays a big role to me because by coming and visiting it makes my heart become better.’ (Mother, Mentor Mothers Zithulele)42 ‘… [S]he [the child] battled in the beginning, but afterwards they showed me how … I also battled and got impatient, but they encouraged me … and then I learnt with the child.’ (Mother, School-readiness intervention)53
Finding 4: Reduced clinic visits Some mothers and LHWs perceive home visits as reducing the number of clinic visits mothers need to make and value the associated time, convenience and (opportunity) cost savings this generates for mothers.	51	Very low confidence	‘We don’t have a clinic around where we can take the children to, which could be a reason why our children might not be growing well. That is why we are scared to go to the clinics because even if you were to spend your last cent when you get to the clinic, you find one very long queue when you get there at 5am, you will only leave 5pm when they have already closed or at other times you wouldn’t have received assistance.’ (Mother, NDoH Family MUAC Project)51	Finding downgraded because of moderate concerns about methodological limitations, minor concerns about coherence (ambiguous data), serious concerns about relevance (partial and indirect relevance) and serious concerns about adequacy.
Finding 5: Better access to, and relationships with, healthcare facilities and staff Some mothers perceive home visits as enhancing their access to, and relationships with, healthcare facilities and staff, through the provision of referral letters or logistical information or the confidence they gain from home visits.	47,48,51,54	Moderate confidence	‘But if they are giving birth in a clinic or carrying something from us, they pay attention to them, they don’t queue.’ (Mother, NDoH Family MUAC Project)51 ‘It helped me and she was complimented at the clinic as well. They asked what brought me to the clinic. I told them it was the CHW who said I must come to the clinic. They said she has done well and I went to the clinic early during my pregnancy.’ (Mother, KZN DoH MCH programme)54 ‘You know, when a nurse says something, it’s hard not to know what it means. Because it’s hard to say how you will answer. Right now, when the nurse says something, I say that I have been taught about this too. Even though I don’t have a certificate like you, but I have been taught. Now my mother will be able to fight for herself.’ (Mother, NDoH Family MUAC Project)51	Finding downgraded because of minor concerns about methodological limitations, minor concerns about coherence (ambiguous data), and moderate concerns about adequacy.
Finding 6: LHWs coming from same community Many mothers prefer LHWs coming from the same community as themselves because they feel this makes them more accessible, familiar, approachable, or able to understand their experiences and context. Some LHWs similarly prefer to work with mothers from the same community as they feel this facilitates trust and relationship-building and in turn acceptance among mothers.	41,47,49,50,51,54	Moderate confidence	‘I get in touch with her all the time because she is someone who is lives nearby.’ (Mother, KZN DoH MCH programme)54 ‘I think it is better if the health worker is from the same community as you, because she will know the lives of the people in your community. It will be easy for her to help the people because they are people from her community; a person cares about their community … rather than going to a community that they don’t know anything about.’ (Community member, KZN DoH MCH programme)41 ‘When this program came, they started from the ground up and joined us in our homes, which means that CHW are the people we live with in society and they are the people you can talk to and they will show you.’ (Mother, NDoH Family MUAC Project)51 ‘I was born in [village name]. I also grew up there, they know me, so when I am talking they are able to ask what they do not understand … a person can say: ‘so what will happen with a certain thing?’ They speak freely because they know me.’ (LHW, Eastern Cape Supervision Study)50 ‘I feel very happy because I work with people that I know most of the time, that also know me, trust me and know that I am so-and-so’s child and what my home is like because people are able to be open.’ (LHW, Enable Mentor Mother Programme)51	Finding downgraded because of minor concerns about methodological limitations, moderate concerns about coherence (contradictory data), and minor concerns about relevance (indirect relevance).
Finding 7: Incorporating innovative digital technologies: recipients Incorporating digital devices containing mobile video content as health promotion and teaching tools during home visits are valued by some mothers and may enhance their acceptance of home visits more generally.	37,39	Very low confidence	‘I like it because it uplifts our work. It shows people how important is our work.’ (LHW, Philani Health and Nutrition Project + tablets with teaching videos)39	Finding downgraded because of moderate concerns about methodological limitations, minor concerns about coherence (ambiguous data), serious concerns about relevance (partial relevance) and serious concerns about adequacy.
Finding 8: Perceived positive psychological and behavioural impact Mothers perceive home visits to have various positive effects, including facilitating changes in behaviour, increased confidence in health-related decision-making, a sense of responsibility for their own and child’s health, or feelings of gratitude for receiving something worthwhile.	42,47,51,53	Moderate confidence	‘It makes me feel good when I see she takes her pen and paper … and they do good at school and the teacher asks us to tell them where they have learnt this.’ (Mother, School-readiness intervention)53 ‘CHWs visit homes apart from what we are doing now. They used to come to check if the child is vaccinated and to check many other things. That made us motivated because we knew that the CHW would come to check the card.’ (Mother, NDoH Family MUAC Project)51	Finding downgraded because of minor concerns about methodological limitations, moderate concerns about coherence (ambiguous data), minor concerns about relevance (indirect relevance) and moderate concerns about adequacy.
Theme 2: Barriers to recipients’ and the broader community’s acceptance of home visits
Finding 9: Distrust of LHWs Some mothers and community members are less accepting of home visits because of their distrust of LHWs conducting the home visits.	39,41,50,54	High confidence
Finding 9.1: Privacy and confidentiality Some mothers and community members distrust LHWs because of concerns related to privacy and confidentiality, including that LHWs may disclose private information to community members, or concerns about discussing confidential information during home visits when other family members are present.	39,41,54	Moderate confidence	‘I think they should come from a different community, not the same community as me. … Because if she is from the same community as me she may get tempted and end up telling other people [about my secrets].’ (Community member, KZN DoH MCH programme)41 ‘I know from experience that they [CHWs] do go around talking about other people’s problems.’ (Professional nurse, KZN DoH MCH programme)41 ‘I thought that they [clients] were going to think that you will record them and take pictures of them. I thought they were going to say that as we drink this way […], you are now going to record us and take pictures of us.’ (LHW, Philani Health and Nutrition Project + tablets with teaching videos)39 ‘It would be a problem if she has not told anyone [her HIV status] at home. When the health worker comes, she must state a reason for her visit and [name] can then look for a private place that they could go to so that they can talk alone, because she has not told anyone in her family about her status.’ (Community member, KZN DoH MCH programme)41	Finding downgraded because of minor concerns about methodological limitations, minor concerns about coherence (ambiguous data), minor concerns about relevance (partial relevance) and moderate concerns about adequacy.
Finding 9.2: LHW Gender Some mothers and community members distrust home visits conducted by male LHWs because they have concerns about personal safety, question whether a male could provide maternal healthcare and/or hold certain gendered norms about the role of men in antenatal and postnatal periods.	41	Very low confidence	‘In terms of tradition, if someone is sick at home, we are from the rural areas; we are not from the townships. If a female person is sick at home, even I as the head of the household do not touch her. It’s the women who are neighbours who will come and assist her in whatever way that she needs to be assisted. We men will stay outside. We do not even go inside the house while the sick woman is being assisted by the other women. That is the traditional way.’ (Community member, KZN DoH MCH programme)41	Finding downgraded because of minor concerns about coherence (ambiguous data), serious concerns about relevance (partial relevance) and serious concerns about adequacy.
Finding 9.3: Perceived lack of competencies Some mothers and community members distrust LHWs because they perceive them to lack the competencies of healthcare service providers. Various factors may contribute to this perception, including LHWs relationship with clinic staff, LHWs’ voluntary or temporary employment status, or LHWs having limited access to essential tools and equipment.	41,44,50	Moderate confidence	‘CHWs felt their credibility was challenged by PNs [professional nurses], who made use of their help in busy times but treated them with contempt and disrespect when not needed. These power dynamics played out in the clinics and affected the perceived competency of CHWs by the community and undermined the trust individuals place in the CHW’s ability to provide care.’ (Study author, KZN DoH MCH programme)41 ‘Even if we have those referral forms we still get undermined. They say we think we are doctors and they say this in front of the patient.’ (LHW, KZN DoH MCH programme)41 ‘We feel as if we are not welcome. … If the clinic staff do not respect what we are doing there at the clinic, then how do they expect the community to respect us? They don’t value our presence.’ (LHW, KZN DoH MCH programme)41 ‘CHWs also reported that some community members undermined CHWs because they saw them as voluntary workers, occupying a lower status than nurses. Although CHWs in this program earned a salary, there were discussions about the level of remuneration. Furthermore, CHWs were on temporary contracts as opposed to permanent ones.’ (Study author, Eastern Cape Supervision Study)50 ‘To them it is like we are not employed as compared to those who are working in the clinic so in that case we need to sit down with that person and explain to her about our job and try to show her the help we bring to the community.’ (LHW, Eastern Cape Supervision Study)50 ‘Having transport and all the necessary machines like BP [blood pressure] machines and scales because it gives us dignity and respect from the community.’ (LHW, Eastern Cape Supervision Study)44	Finding downgraded because of minor concerns about coherence (ambiguous data), moderate concerns about relevance (partial relevance) and moderate concerns about adequacy.
Finding 10: Stigma associated with home visits Some mothers and community members are less accepting of home visits because of the stigma associated with them, including the belief that they are only for people living with HIV/AIDS or fear of being judged as weak for needing support.	38,39	Moderate confidence	‘Most of the time my sister, they do not know what is it that we do, they do not know our work. They tell themselves that we visit people that are HIV positive.’ (LHW, Philani Health and Nutrition Project + tablets with teaching videos)39 ‘It is hard for the mom just to say … I need help … you see, we are brought up in this kind of families that … you are a woman, stand for yourself, do this and do this, the right way.’ (LHW, Ububele Mother-Baby Home Visiting project)38	Finding downgraded because of minor concerns about methodological limitations, minor concerns about coherence (ambiguous data), moderate concerns about relevance (partial relevance) and moderate concerns about adequacy.
Theme 3: Facilitators of lay health workers’ acceptance of home visits
Finding 11: Empowering, validating, employment and convenience LHWs may be generally supportive of home visits because of feeling a sense of empowerment, dignity, purpose, and strength because of their role, valued for making a difference, pride in earning a salary or appreciative of the convenience of their job.	42,49,51	Moderate confidence	‘… encourage us in our work, and that we do our work faithfully so that I will also be proud of reporting on the work that I have done.’ (LHW, NdoH Family MUAC Project)51 ‘that thing of being called nurses … that means there is a big role you play.’ (LHW, Enable Mentor Mother Programme)49 ‘And after ten visits, you can see that I made an impact, even if I didn’t give them money or whatever, but the mother feels better ….’ (LHW, Ububele Mother-Baby Home Visiting project)38 ‘[E]ven if the money is little, that hope of having money at month-end, it can make you feel confident even when you walk on the road.’ (LHW, Enable Mentor Mother Programme)49 ‘Our goal is that the babies must grow with that healthy body … As we visit that woman who is pregnant and living with HIV, we will advise her to go to the clinic so that she can take treatment. The more that they will give birth, the more they will give birth to that baby who is negative. So we make less the population who has HIV.’ (LHW, Mentor Mothers Zithulele)42	Finding downgraded because of minor concerns about methodological limitations, moderate concerns about coherence (ambiguous data), and moderate concerns about adequacy.
Finding 12: Incorporating innovative digital technologies: LHWs Incorporating digital devices containing mobile video content as health promotion and teaching tools during home visits may be valued by LHWs and may enhance their acceptance of home visits more generally.	37,39	Very low confidence	‘I do not want to lie, I became very proud, I saw that it is now that I am working, I saw my dignity because there is that thing [the tablet] […].’ (CHW, Philani Health and Nutrition Project + tablets with teaching videos)39 ‘You enter a house and you would open a folder and we also have the household assessment forms, you have to do it and I think it will minimise the time that you spend in one house.’ (LHW, Philani Health and Nutrition Project + tablets with teaching videos)39	Finding downgraded because of moderate concerns about methodological limitations, minor concerns about coherence (ambiguous data), serious concerns about relevance (partial relevance) and serious concerns about adequacy.
Theme 4: Barriers to lay health workers’ acceptance of home visits and the feasibility of home visits
Finding 13: Boundaries and emotional burdens Many LHWs find it difficult to maintain boundaries with home visiting clients and to balance professional and personal obligations, which can have a negative impact on their emotional well-being.	38,40,49	High confidence	‘It’s painful, because I know how to starve and I started to think about when I was young, living with my sister at Limpopo, starving, no food … I started to think about myself when I was eating food of dogs at the neighbours, and this is the mother I’m visiting, she’s breastfeeding, she’s hungry, she has to eat so that she can breastfeed the baby, and what must I do now? Am I going to sit and say, I can feel your pain? I can’t, I’m a human being. I can’t just say “ja, it’s difficult.”’ (LHW, Ububele Mother-Baby Home Visiting project)38 ‘At home they now know, I just go to sleep when there is something troubling me. My daughter would ask me, “mom, what happened in the field? why do you come home troubled?” I would tell her that, “no, stop, I just need to sleep first,” I would then sleep. When I wake up, [I] tell them that it is because we work with people and sometimes the problems would be too much in the community.’ (LHW, Enable Mentor Mother Programme)49
Finding 14: Training, supervision, and support LHWs of home visiting programmes have many gaps in the necessary knowledge and skills because of inadequate training, supervision, and support. These deficits make it difficult for LHWs to perform their tasks and may in turn undermine programme credibility and community acceptance. Increased training, supervision and support may positively impact on LHWs’ ability to carry out their work because of the increased knowledge, confidence, motivation and sense of accountability it may generate.	40,41,43,44,49,50,51,54	High confidence	‘I do have knowledge but it is not adequate. Perhaps I need to be given additional information. There are questions that they ask where you find that I will not be confident when I respond to them.’ (LHW, KZN DoH MCH programme)54 ‘We discovered that there were things that they didn’t properly understand like the virus in the milk, some said yes there is some said no.’ (Senior researcher, Promise EBF study)40 ‘There is nobody knowing that you are going into the field and actually seeing people, there is no checking up if you … don’t create systems where people know that they will be checked upon, some people will abuse it. The second thing is that the support is also really poor, people feel that they are isolated, on their own, there is nobody who can give them advice, there is nobody who can tell them where the patient should go and that is what is so useful to have a link into the hospital.’ (Programme manager, Eastern Cape Supervision Study)43 ‘She [clinic-based team leader] would say that she will never go to my village because it is far, she never supervised me even for one day.’ (Mother, Eastern Cape Supervision Study)50 ‘She [LHW supervisor] had never gone to the field with me … you find that you do not get assistance with certain things that you need to be assisted in when you visit homes. You end up having to wait for the next meeting at the clinic, and that is the only time you can ask about things that were challenging to you when you were trying to educate the family.’ (LHW, KZN DoH MCH programme)54 ‘The Philani training made a huge difference in my work experience because it had materials; we were trained and received the materials, you get trained then you also do what you were trained for, and clients notice that there’s a huge difference.’ (LHW, Eastern Cape Supervision Study)44 ‘It’s also beneficial to us because I gained a lot of knowledge and understood my work more and it becomes easier as you have a supervisor checking up on you.’ (LHW, Eastern Cape Supervision Study)44 ‘I feel important as a worker that my boss comes to check the work I do.’ (LHW, NDoH Family MUAC Project)51 ‘Would the way we worked be the same if we went out on our own instead of being monitored? No, it wouldn’t be the same.’ (LHW, NDoH Family MUAC Project)51 ‘Telephone call support it’s not effective at all for myself because the peer supporter only tells you what she thinks you need to know but you haven’t seen what she did and that’s the difference. But when you’re there you are able really to give the support that she needs because you’ve seen what she was doing and you see what she needed to do and you also see where she can improve what she could have done.’ (LHW supervisor, Promise EBF study)40
Finding 15: Practical and logistical challenges Many LHWS face various practical and logistical challenges when conducting home visits, including inadequate transportation and essential tools and equipment, mobility of clients, and personal safety issues. These challenges make it difficult for LHWs to perform their tasks and may in turn undermine programme credibility and community acceptance.	39,40,43,44,50,51,54	High confidence	‘It’s [exact hours removed for de-identification] hours walking … and there is no transportation … it becomes so painful but you don’t have a choice because you have to go to work or you have to visit that house.’ (LHW, Eastern Cape Supervision Study)50 ‘One of the biggest challenges is that they relocate from where they are staying in [Place] because they don’t permanently stay in these areas, during follow-up we are told that the person no longer stays there.’ (LHW, NDoH Family MUAC Project)51 ‘The areas are not safe for peer supporters … we had a peer supporter who went visiting the house and somebody was shot … in her presence ….’ (LHW Supervisor, Promise EBF study)40 ‘Those villages are far from each other and … to get to other village you have to pass through the forest and that is not easy for ladies to pass through the forest because there is rape, phones are being robbed … so it won’t be easy.’ (LHW, Eastern Cape Supervision Study)50 ‘I was also afraid because of the places that I go to. The places that I go to criminals will be looking at me.’ (LHW, Philani Health and Nutrition Project + tablets with teaching videos)39 ‘My community health workers don’t have the equipment to work now, even if they go to the households they would wish to take weight of clients and wish to do that and that and they cannot do those things.’ (Operational manager, Eastern Cape Supervision Study)43 ‘I think that is also a problem because when we visit a household we do not have tools of trade.’ (LHW, KZN DoH MCH programme)54
Finding 16: Human resource-related issues Human resource-related issues, including poor salaries, non-permanent contracts and increased workloads, may contribute to the high turnover and attrition rates amongst LHWs in home visiting programmes.	40,43,50,51	Moderate confidence	‘To them it is like we are not employed as compared to those who are working in the clinic so in that case we need to sit down with that person and explain to her about our job and try to show her the help we bring to the community.’ (LHW, Eastern Cape Supervision Study).50 ‘Currently the community healthcare workers … are not permanently employed, they … are uncertain of their employment and once you have job dissatisfaction you don’t get motivated or become productive because you don’t know where you fall under.’ (Operational clinic manager, Eastern Cape Supervision Study)43 ‘I’m still experiencing the Department of Health threatening to take these people, promising them … ‘Ah we are going to offer you something, we want you to go for homebased care training which after that we will give you salary of 3000’ [ZAR]’. And then I ended up losing those people.’ (LHW Supervisor, Promise EBF study)40	Finding downgraded because of minor concerns about methodological limitations, minor concerns about coherence (ambiguous data), and moderate concerns about adequacy.

CHWs, community health worker; DoH, Department of Health; HIV, human immunodeficiency virus; LHW, lay health worker; MCH, maternal and child health; MUAC, mid-upper arm circumference; NDoH, National Department of Health.