Document [original]

Dugleetal. Systematic Reviews (2023) 12:199

https://doi.org/10.1186/s13643-023-02366-3

PROTOCOL

Peer support interventions inmaternal

andchild healthcare delivery insub-Saharan

Africa: protocol forarealist review

Gordon Dugle1, John Antwi2 and Wilm Quentin3,4*

Abstract

Background Peer support has been proposed as a promising policy intervention for addressing adverse maternal

and child healthcare (MCH) outcomes in sub-Saharan Africa (SSA). Existing reviews on peer support largely draw

on evidence from high-income countries or focus on single services like breastfeeding, nutrition or postnatal care.

In contrast, this review aims to provide a comprehensive overview of the empirical literature on peer support inter-

ventions across various MCH services in sub-Saharan Africa. Specifically, we aim to understand how, why, for whom,

and in what circumstances different forms of MCH peer support interventions contribute to improving healthcare

outcomes in sub-Saharan Africa.

Methods This review follows five iterative steps for undertaking realist reviews (1) defining the review scope; (2)

developing initial programme theories; (3) searching for evidence; (4) selecting and appraising evidence; and (5)

extracting, analysing and synthesising evidence. Four databases–Cochrane Library, PubMed, CINAHL, and EMBASE–

were repeatedly searched between March and June 2021. From a large volume of records retrieved from the database

and citation search, 61 papers have been selected for review. We will conduct a second search of the same database

covering June 2021 to the present before the final extraction and synthesis. The final list of selected papers will be

imported into NVivo 12 software and organised, extracted, analysed and synthesised iteratively to examine and illus-

trate the causal links between contexts, mechanisms and outcomes of MCH peer support interventions in SSA. We

have drawn on the existing literature on peer support in healthcare generally to develop initial programme theories.

We will then use the empirical literature on MCH peer support interventions in SSA, inputs from a stakeholders’ work-

shop in Ghana and a conference presentation to refine the initial programme theory.

Discussion The review will develop an explicit theory of peer support intervention in healthcare delivery and pro-

vide insights for developing evidence-informed policy on the intervention. Drawing lessons from the different

national contexts and diverse areas of MCH in SSA, the review will provide an analytically generalizable programme

theory that can guide intervention design and implementation. While focusing on MCH peer support interventions

in SSA, the review contributes to evolving conversations on the use of theory for health policy planning and complex

intervention design and implementation globally.

Trial registration PROSPERO registration ID: CRD42 02342 7751.

Keywords Peer support, Maternal and child healthcare, Realist review, Complex intervention, Sub-Saharan Africa

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Systematic Reviews

*Correspondence:

Wilm Quentin

[email protected]

Full list of author information is available at the end of the article

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Background

Adverse outcomes in maternal and child healthcare

(MCH) remain critical national and global health pri-

orities. Although most developed countries have made

significant progress in MCH over the last two decades,

much of the world’s adverse outcomes occur in Sub-Saha-

ran Africa (SSA). Progress reports on the Millennium

Development Goals (MDGs) and Sustainable Develop-

ment Goals (SDGs) have consistently pointed to persis-

tent adverse outcomes in SSA [1–4]. For instance, the

World Health Organization (WHO) estimates that about

66% of the world’s maternal deaths occur in SSA [3], and

under-five mortality in 2020 was twice as high in SSA (72

deaths per 1000 live births) than the global average [5].

Peer support has emerged as a policy intervention for

promoting effective and sustainable MCH delivery over

the last two decades. Peer support broadly refers to ongo-

ing social and practical assistance provided by non-pro-

fessionals to help people manage their health conditions,

respond to particular healthcare needs, and/or contribute

to overall well-being. It includes recurring interactions

between people such as family members, neighbours,

friends, or other associates but excludes incidental inter-

actions and formal relationships like contacts between

patients and service providers [6, 7]. Policy-makers and

scholars have suggested that peer support is a promising

intervention for promoting physical, mental and social

well-being [8, 9].

Various peer support programmes in SSA have

emerged to address maternal, newborn and child health-

care gaps. Examples include the Kenyan Mentor Mother

Programme established in 2012 as part of the country’s

national strategy for preventing mother-to-child trans-

mission of HIV and syphilis. In addition, the mothers-

2mothers (M2M) programme, which started in South

Africa in 2001, has quickly expanded to nine other SSA

countries (namely, Angola, Ghana, Lesotho, Kenya,

Malawi, Mozambique, Tanzania, Uganda and Zambia).

M2M uses women living with HIV as social support

and mentors to help HIV-positive pregnant women stay

healthy and prevent mother-to-child transmissions.

While policy and scholarly interests in peer support

in MCH are growing, there is less clarity on how, why,

for whom, and in what circumstances peer support is

effective (or not). Existing reviews on the effect of peer

support in specific MCH areas like nutrition [10], breast-

feeding [11–13], and postnatal care [14] have focused

exclusively on high-income countries. Reviews that have

included evidence from low- and middle-income coun-

tries have only evaluated the effect of peer support on

(exclusive) breastfeeding [15–17]. However, MCH com-

prises a wide range of services for promoting health and

avoiding morbidity and mortality of mothers (women of

childbearing age), infants, children and adolescents [18].

It ranges from antenatal care for mothers and growth

monitoring in children to sexual education for adoles-

cents. Yet, no review has explored peer support across

this diverse set of MCH services (e.g., breastfeeding,

family planning, antenatal care and postnatal care). This

limits our understanding of the processes by which peer

support for different MCH services improves delivery

outcomes across a range of national and local conditions.

Recent discussions in research and policy circles

acknowledge that peer support interventions are con-

text-bound programmes as they vary in terms of design,

scope of activities and the broader social structures

within which they are developed and implemented [8, 9,

14]. This understanding of peer support interventions as

context-bound aligns closely with the realists’ position

that interventions will work in certain contexts but not in

others [11, 19]. Accordingly, we aim to undertake a realist

review to examine and illustrate how, why, for whom, and

in what circumstances different forms of peer support

interventions contribute to improving MCH outcomes in

SSA.

The review is intended as an initial step towards a

transdisciplinary research project on developing, imple-

menting and evaluating health-related peer support

interventions. The project–still at a conceptual stage–

aims to foster transformational advances in the gen-

eration and use of research and evidence to inform the

development and implementation of peer support inter-

ventions in healthcare across national, regional and

global levels. The project will be led by this review team

together with other academics and practitioners from

diverse disciplinary backgrounds involved in developing

and implementing peer support interventions in health-

care. The findings of this review will inform the next

stage of the project.

Methods

Realist review

Realist review or synthesis (used here interchangeably)

is a theory-driven method of synthesising evidence and

is rooted in the realist philosophy [20–22]. Conduct-

ing a realist review of evidence about a phenomenon

(in this case MCH peer support interventions in SSA)

involves addressing the general question: ‘What works

for whom in what circumstances and in what respects,

and how?’ [23]. Proponents of realist review argue that

traditional methods of review often focus on examining

the effectiveness of interventions (i.e., whether inter-

ventions work or not) without developing our under-

standing of how, why, and when they work (or not) [22,

24]. The realist review method fills this gap by applying

a configurational lens to develop an explanatory theory

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of how, why, for whom, and in what circumstances

interventions work [21, 22, 25]. It lends itself to a con-

text (c) + mechanism (M) = outcome (O) configuration

heuristic for explaning causation [21, 22]. While other

forms of reviews may examine the context, mechanism

and outcome elements of interventions in isolation,

arealist synthesis applies configurational thinking to

explore their interface [22].

Realist review is underpinned by the idea that pro-

grammes or interventions are theories [22, 26, 27]. The

configurational approach used by realists enables a more

reflexive and iterative examination and illustration of

programme theories underlying complex interventions

[27–29]. Therefore, the unit of analysis in realist reviews

is programme theory, but a C + M = O configuration heu-

ristic is commonly applied to guide data analyses and

syntheses. This means that evidence is analysed and syn-

thesised to produce causal explanations for why, how, for

whom and in what circumstances outcomes come about.

Thus, realist reviews are configurational evidence synthe-

ses as opposed to the aggregative nature of synthesis in

conventional systematic reviews. This review follows five

iterative steps recommended by various realist scholars:

(1) defining the review scope; (2) developing initial pro-

gramme theories; (3) searching for evidence; (4) select-

ing and appraising evidence; and (5) extracting, analysing

and synthesising evidence [21, 22, 26, 30, 31].

Defining thereview scope

We first conducted a preliminary search of the litera-

ture with the aim of obtaining an overview of the litera-

ture on peer support in healthcare broadly and MCH

in particular. We reviewed two categories of evidence

retrieved from Google Scholar in March 2021: (1) empir-

ical papers published between 2020 and 2021; and (2)

review/conceptual papers published anytime. We used

the search theme ‘peer support in healthcare’. The search

was informal and not based on structured selection cri-

teria as we aimed to undertake an exploratory review of

the literature on peer support in healthcare. We progres-

sively reviewed the most current and conceptual papers

retrieved to understand the range of candidate theories of

peer support in healthcare broadly and develop a frame-

work for our substantive review. The preliminary search

guided our substantive review in the following ways: (1)

defining the review questions and scope; (2) identifying

initial (candidate) programme theories; (3) developing

a literature search, appraisal and selection strategy for

the substantive review; and (4) conceptualising the data

extraction and synthesis framework. The realist review

questions that emerged from the preliminary search

were:

(1) What are the causal mechanisms (‘why?’) that

explain the effects of peer support interventions on

MCH outcomes in SSA?

(2) How do the characteristics of peers and interven-

tion target group (‘for whom’) influence these mech-

anisms and resulting outcomes?

(3) What is the influence of contextual factors (‘what

circumstances’) on these mechanisms?

We draw on Pratley’s concept of MCH as encompass-

ing ‘care utilization (obstetric care, ante- and/or perinatal

care, delivery in a health facility), reproductive behav-

iours (utilization of modern contraceptives, birth spac-

ing and ideal family size and/or number of children),

women’s health outcomes (anaemia, nutritional status

and exposure to violence) and child health outcomes

(nutritional status, diarrhoea, immunization status and

lower respiratory infections)’ [32]. We look at the physi-

cal, mental and social well-being of mothers and chil-

dren across the wide range of promotive, preventive,

curative, rehabilitative and palliative health services they

need [33]. This aligns with the broad range of indicators

contained in the United Nation’s SDGs 3.1 and 3.2 that

serve as measures of improvements in maternal and child

health outcomes by 2030.

We operationalise context, mechanism and outcomes

in this review as follows. Context here refers to the sali-

ent conditions within which peer support interventions

in MCH in SSA are embedded. We analyse contexts at

two levels: micro and macro. We consider the micro con-

text as the characteristics of peers and intervention target

groups, such as their demographic structures and norms.

We consider the macro context as the broader institu-

tional structure (environment) within which the groups

and interventions operate. Examples include the wider

national health policy and socio-cultural settings of spe-

cific groups and their interventions. Analysing the micro

and macro contexts enables us to distil specific features

of individual interventions alongside broader political,

social, cultural and economic factors in different coun-

tries. We suggest that doing so allows the generation of

findings, conclusions and recommendations that have

both theoretical and practical implications beyond the

SSA setting.

Given that realist research ‘begins with the researcher

positing the potential processes through which a pro-

gramme may work as a prelude to testing them’ [23],

mechanism is considered the pivot around which real-

ist research revolves [22, 26]. We use mechanisms here

in relation to the underlying processes or ways by which

peer support interventions bring about intended/unin-

tended outcomes in maternal and child healthcare in

SSA [21, 23, 24]. We examine and illustrate how and why

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various mechanisms are indicative of outcome patterns

across different MCH services (e.g., breastfeeding, fam-

ily planning, antenatal care and postnatal care) and SSA

countries.

A fundamental feature of a realist synthesis is that ‘it is

able to explain the complex signature of outcomes’ [23].

As discussed above, peer support groups naturally oper-

ate in different contexts and are underpinned by varied

mechanisms. This suggests that the patterns of outcomes

characterising different interventions may vary according

to their underlying contexts and mechanisms. In health

policy analysis, outcomes represent improvements,

changes or impacts for targeted individuals, groups or

populations attributable to the intervention under study

[32, 34, 35]. In this review, we refer to outcomes as the

intended and unintended results or impacts of peer sup-

port interventions. Specifically, we examine the nature

and form of outcomes that different interventions gener-

ate at two levels: organisational and societal. By organi-

sational level outcomes, we look at the improvements

in the capacity and functionality of national health sys-

tems and healthcare organisations/providers to deliver

MCH attributable to the intervention. We conceptualise

societal-level outcomes to include the intended and unin-

tended impacts of MCH peer support interventions for

targeted individuals and groups or populations.

Developing initial programme theories

Realist reviews often involve identifying initial (candi-

date) theories that potentially explain the CMO con-

figuration of the intervention under study. They then

proceed to ‘interrogate the existing evidence to find out

whether and where these theories are pertinent and pro-

ductive’ [21]. A programme theory is an overarching

framework of how interventions are expected to work

and what outcomes they are anticipated to create [22,

23]. The sources for eliciting initial programme theories

are varied, namely, ‘documents, programme architects,

practitioners, previous evaluation studies and social

science literature’ [23]. Programme theories are often

unique to individual settings or interventions contain-

ing well-defined metrics of outcomes against which the

programme could be evaluated [23]. However, the inter-

vention under review in this article falls into this category

as it involves peer support across different areas of MCH

within the diverse national/local social structures of SSA

countries. In such complex realist research contexts, the

initial programme theory can be one that is rooted in the

theoretical literature [30, 36, 37]. Pawson and Tilley refer

to this approach to elicitation of initial programme the-

ory as drawing on ‘substantive theory’ [23].

Drawing on the understanding that substantive theories

represent ‘well-established theories within a particular

field that help to explain why things happen the way they

do’ [38], we based our elicitation of initial programme

theories from our exploratory review of the broader lit-

erature on peer support. While exploring the literature

on peer support in healthcare retrieved through a Google

Scholar search conducted in March 2021 (see further

explanation in “Defining the review scope” section), we

paid attention to how scholars have attempted to hypoth-

esise the realist question of ‘What works for whom in

what circumstances and in what respects, and how?’ [23]

(i.e., CMO configurations) in the broader discussion of

peer support as interventions in healthcare contexts. We

found two overarching programme theories with poten-

tial explanatory value for MCH peer support interven-

tions in SSA: social support and resource-based theories.

Figure1 shows the hypothesised CMO configurations of

these initial programme theories.

Social support theory is perhaps the most domi-

nant programme theory of how peer support interven-

tions are thought to promote improvement in health

outcomes. The underlying principles of social support

theory centre on the availability of social relationships

for promoting health and well-being among people and

communities [39–41]. This is implicit in both conceptual

[10–14, 42] and empirical [43–46] literature on peer sup-

port in healthcare. Scholars frequently link peer support

in healthcare to improved health and well-being attain-

able through four main mechanisms, namely, emotional,

instrumental, appraisal and informational supportive

functions [8, 40]. For example, peer support interven-

tions are thought to promote emotional health through

acceptance, encouragement and compassion [11, 47],

instrumental support like financial assistance [8, 40],

and informational support including the sharing of use-

ful guidance and advice that facilitate healthy behaviours

such as the appropriate use of drugs [6, 45].

The hypothesis is that peer support promotes health

and well-being (outcome) through emotional, instru-

mental, appraisal and informational supportive functions

(mechanisms). The fundamental context underlying this

hypothesis is the availability of social support established

by health policy and local community social structures.

The hypothetical view is that the availability of peer sup-

port is sufficient for improved health and well-being to

happen. This relates closely to the Ubuntu philosophy

of Africa. Ubuntu is an African philosophy or ethic that

views and approaches life and all its social dimensions

like MCH, more as shared rather than individualistic

citizenship [48–50]. Our focus on SSA, therefore, reveals

an interesting opportunity to examine whether/how the

prevalence of peer support may be shaped by indigenous

socio-cultural contexts like the Ubuntu philosophy. This

enables us to explore a quality dimension of the social

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support hypothesis. For instance, what contexts and

mechanisms are most positive in promoting the health

and well-being of mothers and children? As we highlight

in “Defining the review scope” section, addressing this

question requires exploring multiple dimensions of con-

texts (across micro and macro levels) and mechanisms

(component interventions and sequence of steps).

The literature also reveals a resource-based theory

of peer support in healthcare. For instance, Kåks and

Målqvist [14] suggest that peer support interventions

in high-income countries are complementary pathways

to bridging access and coverage gaps. The overall view

is that due to financial and human resource constraints,

policy-makers and state-led healthcare organisations

are increasingly integrating peer support groups into

national health policy and service delivery programmes

[11, 42]. Accordingly, the use of peer support groups in

health service delivery helps to save governments the cost

of wages and compensation that would be required to

employ skilled health personnel. Additionally, peer sup-

port groups are seen as resources for filling staffing gaps

in health service delivery [13, 42, 51, 52]. It is argued that

the growing turnover of skilled health workforce globally

presents peer support as a complementary source of lay/

voluntary human resources for various health services

[12, 13, 45]. Therefore, the hypothesis is that the integra-

tion of peer support interventions into national health

policy and practice (mechanism) is considered to provide

complementary financial and human resources needed

to address delivery gaps (outcome) arising from resource

constraints on governments and health systems (context).

The above hypothesis resonates with resource-based

theories about the possession, utilisation and exchange

of resources in classical economics [53, 54], management

studies [55, 56], social psychology [57, 58] and sociology

literature [59, 60]. Broadly, the resource-based theory

in management studies and the social sciences gener-

ally proposes that firms engage in resource dependence,

exchange or complementarity because they lack the

needed resources to grow and become competitive [61,

62]. Given persistently limited budgetary allocations for

health services and general fiscal constraints in SSA [63],

critical analyses of emerging evidence on peer support

interventions are needed to enhance our understanding

of operational questions on (1) how to effectively inte-

grate peer support resources into mainstream national

health systems; (2) how to adapt the integration to local

health priorities, given differences in social contexts

within countries; and (3) how to sustain the integration.

This exploratory theorising is intended to highlight

candidate programme theories that will be expanded

during the iterative cycle of theory generation and refine-

ment. Findings from the empirical review, brainstorming

by the review team (via virtual meetings, phone calls and

email discussions, stakeholders workshop with experts

and practitioners and insights from a conference presen-

tation (see “Refining the initial programme theory” sec-

tion) will be used to refine the initial programme theory.

By drawing on substantive theory to elicit our initial pro-

gramme theory, the refined theory underlying MCH peer

support interventions in SSA can be transferable to other

health services or geographic settings.

Searching forevidence

Following the preliminary search described in “Defin-

ing the review scope” section, we purposively con-

ducted a database search for relevant studies using a

three-heading search criterion: (1) mechanism–peer

Fig. 1 Initial programme theories of MCH peer support interventions

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support; (2) context–sub-Saharan Africa; and (3)

outcome–maternal and child healthcare. Four data-

bases–Cochrane Library, PubMed, CINAHL, and

EMBASE–were searched between 10th March and 3rd

June 2021. The search strategy involved various com-

binations of terms related to the three-heading search

criterion. Search entries and word truncations were

based on the requirements of each database (see Addi-

tional file1 for the search entries and outputs of each

database). The search was limited to studies published

in the English language.

The initial search generated a large volume of

records. We also manually searched the reference lists

of the studies selected for inclusion and some identi-

fied systematic review papers for additional evidence.

We used the Preferred Reporting Items for Systematic

Reviews and Meta-Analysis (PRISMA) flowchart to

depict the number of records identified, included and

excluded (see Fig.2). In fulfilment of requirements to

address the development of review protocols, we have

attached a PRISMA-P checklist in Additional file 2.

We will conduct a second search covering June 2021

to the present using the procedure described above

before the final extraction and synthesis.

Selecting andappraising evidence

We followed iterative steps to filter and appraise the evi-

dence generated from the search so far, as summarised

in Fig.2. First, GD imported records from the database

search into Endnote × 9 reference management software.

Then, he removed duplicates using the software’s ‘find

duplicates’ tool. Second, to ensure consistency, only GD

screened the remaining records according to the inclu-

sion and exclusion criteria. Following discussions within

the review team, we considered only peer-reviewed arti-

cles on primary studies for inclusion in the review. There

were no restrictions on the type of research design and

publication date. GD manually screened 19,166 titles

and excluded papers that were either not healthcare-

related (10,979 titles) or were grey literature (2,012) such

as blogs, conference presentations, dissertations, gov-

ernment documents and reports of ongoing interven-

tions. Subsequently, the remaining 6175 abstracts were

screened and records removed that were conceptual/

review articles (60 titles), were conducted in other set-

tings than SSA (5,701 titles) or did not focus on MCH

(343 titles).

At the full-text screening stage, 13 articles were

removed, including study protocols (9) and reports of

ongoing MCH peer support projects (3) (see Additional

Fig. 2 PRISMA flow diagram of literature search and appraisal process

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file3 for the list of screened studies). GD then applied the

‘relevance criteria’ recommended for realist review. Rel-

evance thinking draws on the idea that the review team

may limit their inclusion/ exclusion criteria to evidence

containing data that is of use to the programme theory

under development [25, 64, 65]. In traditional system-

atic reviews, researchers evaluate the quality of identified

studies using structured appraisal tools like Evidence-

Based Management guidelines, the Cochrane risk-of-

bias tool and the Quality Appraisal of Reliability Studies

checklist. A fundamental limitation of such a one-size-

fits-all approach is the potential to exclude relevant evi-

dence [66]. Through discussions within the review team,

we agreed on the final list of selected studies based on

two assessment questions: ‘Does the research address the

theory under test?’ [22] and ‘Is this study good enough to

provide evidence that will contribute to the synthesis?’

[25]. All 61 papers selected from the first search were

found to be relevant. We will apply the same selection

criteria in our planned second search.

Extracting, analysing andsynthesising evidence

Data extraction andinitial coding

The extraction and synthesis of our final set of selected

studies will be conducted in an iterative process

described below. Two reviewers (GD and JA) will inde-

pendently read and code the data. To ensure consistency,

JA will concentrate on extracting a range of the study

characteristics of the selected articles using a predesigned

Microsoft Excel spreadsheet. This includes authorship,

publication date, study setting, scope, aims, design and

methods. GD will import papers selected for the review

into the NVivo 12 software and then undertake repeated

and close reading of the papers to code the data.

To develop an in-depth understanding of the differ-

ent categories of contexts, mechanisms and outcomes,

data will be coded under three parent nodes: context,

mechanism and outcome. Child nodes (themes) under

each parent note will be the basic categories of the con-

texts, mechanisms and outcomes across different MCH

services and SSA countries. This enables us to develop

an overview of the lists of contexts, mechanisms and

outcomes reported in the empirical literature selected

for review. In line with our realist lens, coding from the

onset will be based on keywords, metaphors and lines

of reasoning that address the review questions [67]. This

involves close reading of the full text to identify themes

from codes and realign emergent themes as the extrac-

tion progresses using the node hierarchies in NVivo (i.e.,

‘parent’ and ‘child’ nodes). At the end of the data extrac-

tion and coding, a codebook will be generated, which will

be reviewed independently by all members of the review

team to ensure patterns occurring in the data are not

missed.

Elicitation ofCMO configurations andprogramme theory

Realist reviewers use retroduction to formulate CMO

configurations and elicit programme theories. ‘Retroduc-

tion refers to the identification of hidden causal forces

that lie behind identified patterns or changes in those

patterns’ [68]. The fundamental question guiding realist

reviewers’ elicitation of CMO configurations and pro-

gramme theories is about the causal powers of the inter-

vention within the given contexts in which it is developed

and implemented. In this case, how is it that peer support

intervention for different MCH services can produce

observable outcomes in given conditions? Elicitation of

CMO configurations and programme theories will be

based on our three specific review questions:

(1) What are the causal mechanisms (‘why?’) that

explain the effects of peer support interventions on

MCH outcomes in SSA?

(2) How do the characteristics of peers and interven-

tion target group (‘for whom’) influence these mech-

anisms and resulting outcomes?

(3) What is the influence of contextual factors (‘what

circumstances’) on these mechanisms?

Memo writing is considered an effective tool for care-

fully constructing theoretical arguments in realist

research [69, 70]. ‘Memos are informal analytic notes

about the data and the theoretical connections between

categories [in this case context-mechanism-outcome]’

[71]. They represent the researchers’ thoughts and inter-

pretations of the developing theory [67]. During this ini-

tial coding, GD will write memos to document ideas and

thoughts on the CMO configurations and programme

theories emerging from the evidence. This will involve

annotating and taking notes of observed configurations

and their underlying programme theories and examples

of the contexts, mechanisms and outcomes illustrat-

ing them. Memo writing will follow an iterative process

as the data analysis proceeds; initial ideas and thoughts

of CMO configurations and programme theories will be

revised as new patterns and insights emerge from further

analysis of the evidence.

A memo will be written for every observable CMO

configuration and its underlying programme theory

found in the data. The memos will define the specific

outcomes of MCH peer support interventions and the

contexts and mechanisms driving them. Each observ-

able CMO configuration will then be linked to the rel-

evant initial programme theory defined in “Developing

initial programme theories” section. If the configuration

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projects a new programme theory, the memo will high-

light how this potentially provides grounds for refuting

or refining the initial programme theories. Each memo

will be linked to the source document(s) informing its

development to allow other members of the review team

to check.

The codebook generated alongside the memos written

during the initial coding of data will be independently

reviewed by the review team members. We will then hold

several rounds of discussions to brainstorm and agree on

the CMO configuration themes and related programme

theories, which will be further refined through the steps

detailed in “Refining the initial programme theory” sec-

tion. The discussions leading to the development of CMO

configuration themes and related programme theories

will pay attention to projecting a constant comparative

analysis of the generative causality between the different

MCH services and national settings.

Refining theinitial programme theory

Realist scholars believe that the question about the causal

powers of interventions within given contexts cannot be

adequately addressed by using only observable evidence

[68, 72]. We will combine the views and experiences of

practitioners and the interpretations and expertise of

scholars to cross-examine, support, refute, or refine

CMO configurations and programme theories emerg-

ing from the evidence reviewed [27, 72]. This approach

aligns with the realists’ view that establishing multiple

sources of reasoning to develop programme theories–

such as intervention elements, participant responses,

interpretation of the original researcher or interpreta-

tion of reviewers–is crucial for demonstrating theoretical

relevance and rigour [22, 28]. Specifically, we will refine

the initial programme theories and their take-up in the

reviewed literature through three steps [26].

First, we will convene a stakeholders’ workshop in

Ghana to discuss our findings with and generate inputs

from a wide range of experts including policy-makers,

health directors, representatives of peer support groups

and civil society organisations, and nurses/midwives. This

will provide an opportunity to compare the emerging

programme theory and the experiences of practitioners

and policy-makers. Further details on the stakeholders

and the workshop will be included in the final review for

readers to check. Second, we will present our findings at

an international conference which will enable us to gen-

erate fresh ideas and suggestions for further refinement

of the programme theory. Third, the review team will dis-

cuss the refined programme theory emerging from the

previous steps and link it back to the substantive theory

in the existing literature described in the “Developing

initial programme theories” section. The final output of

the review will be a more refined programme theory with

explanatory value for peer support interventions beyond

MCH and SSA contexts.

Discussion

Our focus on SSA resonates with emerging calls from

scholars and policy-makers for attention to social and

institutional peculiarities in developing and evaluating

peer support interventions [9, 11, 15]. These calls for

attention to context require a review method that sys-

tematically explains ‘what works for whom, in what cir-

cumstances, in what respects and how’ [22]. Using realist

review methodology enables us to examine the context-

mechanism-outcome configurations of different forms of

MCH peer support interventions in SSA. Given the large

volume of literature on peer support in healthcare, we

concentrate on MCH to achieve an in-depth synthesis of

evidence and explication of theory. In reviewing the liter-

ature on different forms of MCH, we consider our review

to provide generalizable practical and theoretical lessons

on peer support interventions in other health services.

As explained in previous sections, persistent adverse out-

comes and access gaps peculiar to MCH in resource-con-

strained settings like SSA further justify our review focus.

The review is considered to articulate an explicit pro-

gramme theory of peer support intervention in health-

care delivery and provide insights for developing

evidence-informed policy on the intervention. First, by

drawing lessons from the different national contexts and

diverse areas of MCH, our review has the potential to

provide a generalizable programme theory that can guide

intervention design and implementation. While focusing

on SSA, we aim to contribute to evolving conversations

on the use of theory for health policy planning and inter-

vention design and implementation globally. Second,

we hope the review identifies practical ways of develop-

ing effective and sustainable peer support initiatives. We

expect our findings to highlight some latent and unique

properties of the SSA story, which we term reverse inno-

vation [73], that health policy-makers and leaders in non-

SSA settings like high-income countries may draw on to

develop creative peer support interventions.

Abbreviations

CMO Context-Mechanism-Outcome

HIV Human Immunodeficiency Virus

MCH Maternal and Child Healthcare

MDGs Millennium Development Goals

PRISMA Preferred Reporting Items for Systematic Reviews and

Meta-Analysis

PRISMA-P Preferred Reporting Items for Systematic Reviews and Meta-Anal-

ysis Protocols

SDGs Sustainable Development Goals

SSA Sub-Saharan Africa

WHO World Health Organization

Page 9 of 10

Dugleetal. Systematic Reviews (2023) 12:199

Supplementary Information

The online version contains supplementary material available at https:// doi.

org/ 10. 1186/ s13643- 023- 02366-3.

Additional file1.

Additional file2.

Additional file3.

Acknowledgements

Not applicable

Authors’ contributions

The authors agreed to publish a protocol paper. GD is the principal investiga-

tor and WQ is the supervisor of the review. JA contributed to the conceptu-

alisation of the review. GD drafted the protocol. All other authors reviewed

the draft protocol and provided extensive suggestions for revision. All authors

read and approved the final manuscript.

Funding

Open Access funding enabled and organized by Projekt DEAL. We did not

receive any funding for the conduct, authorship or publication of this review.

Availability of data and materials

All data generated or analysed in this review are included in this article and its

supplementary information files.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Author details

1 School of Business, SD Dombo University of Business and Integrated

Development Studies, Box UY 36, Wa, Ghana. 2 School of Business, University

for Development Studies, Post Office BOX 1350, Tamale, Ghana. 3 Depar tment

of Healthcare Management, Technische Universität Berlin, Berlin, Germany.

4 German West-African Centre of Global Health and Pandemic Prevention

(G-WAC), Kwame Nkrumah University of Science and Technologies, Kumasi,

Ghana.

Received: 30 May 2023 Accepted: 11 October 2023

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