The home visit communication skills inventory: Piloting a tool to measure community health worker fidelity to training in rural South Africa

Community-based home visiting programs using community health workers (CHWs) have become popular modes of delivering health care services, especially in settings where health workers are overburdened and resources are limited. Yet, little is known about the processes that shape effective implementation in low-resource settings, and whether these processes adhere to home visitors' training. This study used the newly-developed Home Visit Communication Skills Inventory (HCSI) to explore the delivery of a CHW program in rural South Africa. Routine home visits from CHWs to their maternal care clients were audio-recorded with consent, and later transcribed and translated into English. The HCSI, devised and piloted using existing frameworks and program-specific training components, consisted of 21 items covering domains related to active listening, active delivery, and active connecting, and was used to score English transcripts of the home visits. The HCSI was used to generate general frequencies and aggregate scores for each CHW. Eighty-four home visits by 14 CHWs showed a diverse application of communication skills. Active listening and active delivery were common, with fewer instances of active connecting observed. Practices disaggregated by CHW showcased varying strengths by an individual. In reviewing visit characteristics, longer average visit duration was significantly correlated with the presence of multiple types of active connecting skills. While technical skills were widely observed, fewer CHWs engaged in more complex "connecting" skills. The HCSI is a feasible, low-cost, and practical way to describe home visit fidelity among CHWs. Audio-based checklists can be used to describe fidelity to a model in the absence of additional supervisory resources.