The findings of this study point to a multifaceted range of considerations made when contextualizing a community-based peer support model for disadvantaged families from a low-income country to a high-income country. These considerations resulted in adaptations on several levels: the overall goal was formulated to focus mainly on social factors rather than health outcomes, the procedures for achieving this goal were based on linkage to services rather than behavioral change, peer supporters with heterogeneous competencies were recruited, and a high degree of flexibility was adopted regarding both the location, frequency and duration of meetings. The findings illustrate how the internal and external context – e.g. the conditions within the organization implementing the model and in the environment to which the model is adapted – influence what is possible and appropriate to do within the model’s framework.
Recurring priorities in high-income contexts
The themes outlined in our results reflect the strategies of some similar programs in high-income countries. These include linking families to other services and improving social determinants such as financial stability, which are components of home visiting interventions such as the Early Head Start and Healthy Families America programs in the US [27]. The latter has also seen a higher retention rate when matching clients and providers based on ethnicity [28], reflecting the priorities highlighted in our findings. Furthermore, flexible field methods allowing for individual tailoring of content, sometimes described as ‘precision home visiting’ [29], are used by interventions such as Family Spirit, a program that serves disadvantaged Native American families [30]. Previous reviews have also highlighted how several paraprofessional home visiting programs have used individual tailoring of the frequency of meetings, mode of contact and location [17], and how the need for such flexibility is greater among highly vulnerable families [31].
Adapting support programs to new settings or groups
The results of our study describe how the Philani model was discussed, received and adapted without a systematic approach to its core components. Our analysis thus provides insight into the results of the informal adaptations to the context in southern Sweden, rather than offering descriptions of how deliberate changes were made based on considerations of differences in sociocultural and material context between Sweden and South Africa.
Previous studies on contextualizing paraprofessional support for families have often focused on external context in the form of cultural aspects at the provider level, to ensure that the content is relevant and delivery takes place in an appropriate and effective manner [32,33,34]. Our results highlight how adaptations can also be made in relation to the wider social context, such as the availability of welfare services, which is less commonly described. This landscape of public services can influence both ‘pull’ and ‘push’ aspects of social innovation transfer, as described by Mulgan and Pulford [13]. The availability and use of services influences the demand for new social innovations, perhaps in particular for third sector initiatives, as these can compensate for the rigidity of public welfare [14], e.g. through a focus on linking clients to these services. Availability of platforms for cross-sectoral cooperation – such as open preschools in this case – also influence the feasibility of implementing social innovations focused on community outreach. The social context in the form of vulnerable groups with heterogeneous needs further influences the transfer process, where flexible approaches to meeting recipients’ needs could be seen as a strategy for connecting demand and supply in social innovation.
Few previous studies have explored the process itself in informal adaptation of paraprofessional support, and previous research has tended to focus on how informally adapted interventions are received [32] or how interventions can be systematically adapted through involvement of community members or stakeholders [30, 33, 35]. Our process differed from these mainly due to the fact that the ownership of the intervention, and thus its contextualization, resided with a different organization than the research project. Understanding the process of adapting social innovations outside the formalized structures of academia can shed light on the role of the third sector in cross-contextual transfer of knowledge and practices. This knowledge is important as a large portion of social innovations are implemented by actors such as non-governmental organizations [36].
Comparison to Philani’s five pillars
While adaptations of parental support interventions can allow for reaching new groups and increase retention, the positive effects cannot be assumed to remain if core elements are changed or replaced [37]. This is a potential risk when interventions are adapted informally, and it is important to clarify these before changing the intervention’s content or how it is delivered. While not articulated as the core of the model per se, the five pillars of the Philani model describe its fundamental operational priorities [19]. To understand the extent to which the model was adapted, our results can be interpreted in relation to these.
The first pillar is a careful recruitment process. This includes recruitment of women who can act as role models in the community, as well as a careful selection after an initial evaluation. A sub-theme in our analysis was trustful relationships as a key to sustaining engagement, where participants expressed how the ability to instill a sense of trust was fundamental to achieve good peer support, and a personal quality to consider when recruiting. The ability to build trust can be seen as one way of acting as a role model, even if it does not regard motherhood per se. The sub-theme matching a heterogeneous target group with diversity among peer supporters described how responding to heterogeneity in the Swedish setting was a prerequisite for building this trust. This matching necessitated an adaptation of how recruitment was undertaken, without challenging the careful selection process itself. The possibility of selecting potential peer supporters after initial internal evaluation was not discussed during the workshops or interviews. The need to match high cultural and linguistic diversity may however limit the possibility of choosing a large number of candidates. Strong legal protection in Sweden also prevents dismissal of candidates shortly after employment [38].
The second pillar is appropriate training. In the South African setting this consists of six weeks of training, preparing for the range of tasks that the peer supporter may perform in the role of a health and social worker. To ensure that the training received by the peer supporters is appropriate, it must naturally correspond to the tasks and challenges they are likely to face in the field. The South African setting presents challenges such as a high burden of HIV [39] and undernutrition [40]. In the Swedish context, the prominent challenges were described as social isolation, marginalization, unemployment and barriers to accessing social services, requiring a focus on the social determinants of health. This mirrors how bridging social gaps in child health has previously been framed in urban areas in Sweden, such as by the Commission for a Socially Sustainable Malmö [23]. Meeting social needs by linking to the right services requires a good knowledge of the structure of Swedish society and what types of support and opportunities are available within both public and civic sectors, which are important aspects to consider in training. Peer supporters must also have an understanding of why e.g. participation in early childhood education makes a difference to children's development, if they are to empower families in their decision-making. The training provided within the adapted Philani model was structured to cover these aspects.
The third pillar is home-based, action-orientated health intervention, which represents both what is done during meetings, how it is done and where. Home-visiting may be a viable strategy to recruit clients and maintain their engagement in a setting where they cluster together geographically, as is the case where the Philani model is developed [41]. The sub-theme target group defined by social exclusion in our analysis described how recipients of the model in Sweden were defined based mainly on individual characteristics rather than primarily on the basis of living in a disadvantaged geographical area. This has implications for how these families are reached in the Swedish context, as addressed within the sub-theme reaching the hard-to-reach through multiple arenas. When peer supporters cannot rely on spatial delimitations, their strategies for initiating contact with potential clients must be multi-faceted and rely on their own understanding of the social environments of the target group. This represents a shift in the level on which decisions are made, as peer supporters cannot be assigned a well-defined geographical area by a supervisor.
Changing the focus of the model from promoting health behaviors within the family, as in South Africa, to a strong focus on linking to existing services, as described in Sweden, marked a further shift away from a home-based intervention, demonstrated by the emphasis on Swedish peer supporters physically accompanying mothers to appointments and activities. A factor not discussed during workshops or interviews was how individualistic norms may affect the use of the home as an arena for interventions. Sweden has traditionally been described as a deeply individualistic society despite a strong emphasis on collective solutions [42], where individualistic values are particularly strong in the private sphere [43]. This could have a negative impact on the possibility of contacting families by seeking them out in their homes.
The choice to prioritize improvements in social conditions over direct health intervention was described as necessitated by the outer context in Sweden – both the needs of the community and the widespread availability of preventive and curative health services, where the latter were something the peer supporters had to complement rather than compete with, by prioritizing linking. This ability to complement public systems, sometimes compensating for their inability to meet diverse needs and minority preferences, has been highlighted in previous research on the role of the third sector in welfare [14]. The internal context of the organization, in terms of stakeholders' professional expertise, which was principally in integration, social sustainability and education issues, also influenced the decision to prioritize social determinants. This very central change in what the intervention was formulated to achieve thus partly emanated from the inner context of the implementing organization itself and may not be fully applicable to other actors in Sweden.
The fourth pillar is in-the-field supervision and support. Supervision was not addressed directly by workshop participants and only mentioned in passing during interviews. However, the sub-theme matching a heterogeneous target group with diversity among peer supporters in our analysis identifies considerations to take into account. The need for diversity in language skills and cultural competencies of the peer supporters require corresponding competences of the person providing supervision in the field if they are to have a comprehensive understanding of how meetings with clients are conducted. This may complicate adherence to the fourth pillar when it is adapted to fit a multicultural setting. Accordingly, peer supporters in the adapted intervention are not supervised in the field but instead have weekly group meetings with a project coordinator.
The fifth pillar is monitoring and performance feedback. Measuring standardized clinical outcomes such as breastfeeding rates or HIV treatment fidelity in the target population allows for straightforward evaluation of the effectiveness of the intervention at the recipient and provider level. The data collected within this study mainly concerned strategic considerations, and while monitoring in the Swedish setting was not described directly, some considerations touch upon potential challenges. An intervention aimed at improving social conditions in a broad sense may require a range of outcome measures to give a representative picture of what has been achieved. Another potential barrier to systematic monitoring is flexibility on the level of the provider-recipient interaction. The more flexible an intervention is in relation to the number of problems it is intended to address, the more difficult it may be to monitor and quantitatively evaluate its success [44]. The sub-theme responding to heterogeneous needs points towards this challenge, as participants agreed on the importance of peer supporters tailoring their work to individual needs. In the adapted intervention, the monitoring takes place through registration of digital forms. These include both pre-set response options and free-text fields for reporting field activities, with the pre-set options being continuously reviewed and updated to reflect the activities being reported.
Our analysis of the contextualization process thus suggests adaptations of the five pillars of the Philani model. While core elements such as careful recruitment, appropriate training and supervision were contextualized while still remaining relevant, the intervention content centered on a home-based health intervention was modified to a large extent to respond to needs in the context at hand. In line with its philosophy in its original context, the model implemented in Sweden did however emphasize empowerment of pregnant women and mothers of young children as a key to overcoming barriers to their own and their children’s health and wellbeing, by building on strengths within the community, harnessing peer supporters understanding of the local context and their target group and using trustful relationships to engage and retain supported mothers.
