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6 Home Visiting: Essential Guidelines for Home Visits and Engaging With Families

• Published: August 2008
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Home visiting has a long history in education, family and child welfare, and physical and mental health services. Home visits are critical in serving children and youth from birth to high school and in addressing issues ranging from programs for pre-school children through school system concerns. Educational organizations rely on home visits to address a wide range of issues related to student behaviors such as attendance, discipline, physical or mental challenges, drug or alcohol abuse, depression, or antisocial activities. Other home visits focus on student characteristics relating specifically to school performance, such as risk for school failure among pre-school children or low academic achievement among school-aged children. This chapter presents information relevant for school social workers and others who provide services to school-aged students and their families. It begins with providing information on the prevalence of home visiting and a brief review of program outcomes. It then includes guidelines for home visiting, specific information for preparing for a home visit, and a framework and strategies to guide the actual home visit. Additional resources are provided to illustrate the various types of programs, purposes, and outcomes of home visitation.

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Home visiting

A home visit is one of the essential parts of the community health services because most of the people are found in a home. Home visit fulfils the needs of individual, family and community in general for nursing service and health counselling. A home visit is considered as the backbone of community health service. A home visit is a family –nurse contact which allows the health worker to assess the home and family situation in order to provide the necessary nursing care and health-related activities. Read less

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• 1. HOME VISITING Introduction A home visit is one of the essential parts of the community health services because most of the people are found in a home. Home visit fulfils the needs of individual, family and community in general for nursing service and health counselling. A home visit is considered as the backbone of community health service. A home visit is a family –nurse contact which allows the health worker to assess the home and family situation in order to provide the necessary nursing care and health-related a ctivities. Definition A home visit is defined as the process of providing the nursing care to patients at their doorsteps. It requires technical skills, resourcefulness, judgment, relationships. It is defined as providing the services to family at their door step to maintain the health & to reduce the mortality & morbidity in family. Principle  .When carrying out the home visit, the community health nurse should follow certain basic principles which are as follow:  The home visit should have a purpose and objectives.  The home visit should be planned according to priority.  The purpose of the home visit should be clear, regular, and flexible according to the needs of the family.  First of all, introduce yourself, your institution, your purpose, of a home visit, and collects facts about an individual, family environment.  Establish a good interpersonal relationship between families and be polite, courage, friendly.  Carefully listen the family and understand the others person view.  Health education, nursing care should be scientific.  Use safe technical skills and scientific nursing procedures.  Involve whole family members as much as possible during nursing care.  The nurse and family member must develop a positive interpersonal relationship in their work to achieve present goals.  Evaluate your own work periodically.  Make a note of important facts about the home visit in your diary.  Thanks to the family members and individual for good response.
• 2. Purposes  To find out needs of individual, family and community in relation to health, socio- economic and cultural aspects.  To provide domiciliary midwifery as care for pregnant, delivery, and puerperal mother and infant.  To give care to the sick, to a postpartum mother and her newborn with the view teach a responsible family member to give subsequent care.  To assess the living condition of the patient and his family and their health practices in order to provide the appropriate health teachings.  To provide basic health services for minor ailments. (i.e. injury, boils, abrasions)  To provide counseling on family planning, immunization, nutrition.  To give health teaching regarding the prevention and control of diseases.  To establish a close relationship between the nurses and the public for promotion of health.  To make use of an inter-referral system and to promote the utilization of community services. Steps of home visiting Home visit refers to meeting the health needs of people at doorsteps. The steps of home visiting are as follow: 1.Facts findings 2.Data finding 3.Planning action with individual or family 4. Action and health education 5.Follow through 6. Evaluation of services 7. Explain the use of home visiting bag 1. Facts findings: Facts findings are the first steps during home visiting. It helps to study the clinical and other records to get an understanding of what has to be done which is given below:
• 3. Prepare a map of the area to be visited and i.e. location, house, road, temples etc., prepare family folders. Collect information of the family member i.e. number of family member, occupation, education, date of birth, religion, income, past history, present illness, use of family planning, immunization etc. Use technical skills and nursing procedure. Establish an interpersonal relationship, be polite and courage, show the interest towards the family. Identify the needs of individual, family members Discuss the problem with the family members and find out the possible solutions to problems. 2. Data findings: After completing the fact finding the process of analysis begins. The data of the members should be honest and based on facts and not an opinion. The personal, emotional, spiritual aspects should be involved which are taken together constitute the usual health problem.the problem and facts should show exact problems and what he is expected to do. Discuss the point step by step and examine the matter critically. Then only comes to the conclusions. Do not jump and do not make hasty conservation. After that, the nurse helps the family to plan and use local and outside resources. 3. Planning actions with family: It is the most important in all our work and relationships. Make good and realistic objectives and plan how we are going to achieve those objectives. First priority should be given to essential basic need such as hunger, then only for personal hygiene or safe water or sanitation. That’s why planning is very important and it should be based on the condition of the family, home environmental and local resources available in a family in order to be practical. Planning should also be based upon short term or long term objectives of the family. Some alternatives plan or suggestions are also helpful. Do respect the individual’s ideas, suggestion or solution. Good planning always leads to doing a good action and achieve objectives. 4. Action and health education: After planning, a formal home visit should be done to solve the problem. On the first visit, CHN should introduce herself and explain the purpose of her visit. The talk should be informal, giving plenty of opportunities to ask a question and provide a platform for discussion. The action and health education should be as per family time schedule. Find out what is the best time for teaching them. For example, if they are drying food in a yard, then you should teach about food storage, and help them for proper drying. This help to provide effective teaching as you are helping them, it also builds good interpersonal relationships. Emphasis should be given on practical more often than theoretical. 5. Follow through:
• 4. It is one of the most important steps of a home visit. Follow up for those which were already planned and implement to find out how far the objectives are fulfilled. It also helps to find out how far the instruction, suggestion, and actions were followed. Appreciate if they have done well and if not done properly, find out the cause. It gives ideas for planning for next visit. 6. Evaluation of service: For evaluation services, review each family record periodically and answer the following question.  What is the immediate problem/need?  What is the total problem?  List the difficulties and hindering factors in the situation?  List the helpful and supporting factors e.g. coping ability of family, availability of local resources?  What has been done about the immediate problem?  What plans are being made and what actions are being taken to deal with the underlying cause of a problem?  How did the personal respond to your visit?  What changes took place?  Have you made effective use of man, material, and measures?  How far the visit has been useful?  What is the attitude of individual, family and community?  Do you need guidance, counseling, and discussion with your superior? The result of community health service is not always seen immediately, it takes time. Knowledge is changed but attitude, habit and behavior change is difficult, but once changed, it has a permanent effect. 7. Explain the home visiting back: It is also one of the essential steps of home visiting. The major objective of health care services in the home is to help people with their health problems and work with them towards keeping the family healthy. The purpose of the bag is to carry out necessary equipment to perform nursing care in the home. E.g. performing minor dressing, conducting delivery etc. It saves times and effort in the performance of a nursing procedure.
• 5. `Frequency of Home Visit Making decision regarding frequency of visit is a matter of judgment. It will depend upon the extent of health problems of the family In no case clinic visit by the family are substitute to family visit by the community health nurse family visits are basis of priorities available time and work lord, health agency’s policies and facilities available. Priorities are established on the following guidelines  Visits in response to the need felt by the family such as mother in labour, acute and serious illness etc.  Visit to premature infants and infants with defects  Regular visits to post natal mother and antenatal mother  Visits to chronically ill patients  Supervisory visits to infants, toddler, and eligible couple  Collection of family information and investigations.  Information, education, counselling and guidance purposes Advantage  It helps to develop an interpersonal relationship between family members and the nurses. Community health nurse assess the individual and family member in their own environment.  It gives an opportunity to observe the background of the family member and their relationship.  It helps in the basic understanding of physical and emotional needs of individual and to guide them.  It helps to gain more knowledge and become realistic as a family member are more relaxed in their own surroundings.  It also gives an opportunity to find out new health problems References  Tuitui, Roshani and. Dr. Suwal S.N. A Textbook of Community Health Nursing.
• 6. Kathmandu: Vidyarthi Prakashan(P) Ltd, 2007.  Gulani K K ,community health nursing principles and practice, kumar publication,2017,  https://tr.scribd.com/document/233132586/Diagnostic-Exam-2  https://ja.scribd.com/presentation/113589897/Community-Health-Nursing  fac.ksu.edu.sa/sites/default/files/home_visit.ppt  nursestopicks.blogspot.com/

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Impacts of Home Visiting Programs on Young Children’s School Readiness

Grace Kelley, PhD, Erika Gaylor, PhD, Donna Spiker, PhD SRI International, Center for Education and Human Services, USA January 2022 , 2nd rev. ed.

Introduction

Home visiting programs are designed and implemented to support families in providing an environment that promotes the healthy growth and development of their children. Programs target their services to families and caregivers in order to improve child development, enhance school readiness, and promote positive parent-child interactions. Although programs differ in their approach, populations served and intended outcomes, high-quality home visiting programs can provide child development and family support services that reduce risk and increase protective factors.    Home visiting programs addressing school readiness are most effective when delivered at the community level, through a comprehensive early childhood system that includes the supports and services that ensure a continuum of care for all family members across the early years.  School readiness includes the readiness of the individual child, the school’s readiness to support children, and the ability of the family and community to support early child development, health, and well being. In addition to home visiting services, appropriate referrals to community services, including to preschool programs, offer a low-cost universal approach that increases the chances of early school success. This comprehensive approach to home visiting as a part of a broad early childhood system has been identified as an effective strategy to help close the gap in school readiness and child well-being associated with poverty and early childhood adversity. 1,2 

Home visitation is a type of service-delivery model that can be used to provide many different kinds of interventions to target participants. 3,4 Home visiting programs can vary widely in their goals, clients, providers, activities, schedules and administrative structure. They share some common elements, however. Home visiting programs provide structured services:

• in a home a  ;
• from a trained service provider;
• in order to alter the knowledge, beliefs and/or behaviour of children and caregivers or others in the caregiving environment, and to provide parenting support. 5

Home visits are often structured to provide consistency across participants, providers, and visits and to link program practices with intended outcomes. A visit protocol, a formal curriculum, an individualized service plan, and/or a specific theoretical framework can be the basis for activities that take place during home visits. Services are delivered in the living space of the participating family and within their ongoing daily routines and activities. The providers may be credentialed or certified professionals, paraprofessionals, or volunteers, but typically they have received some form of training in the methods and topical content of the program so that they are able to act as a source of expertise and support for caregivers. 6 Finally, home visiting programs are attempting to achieve some change on the part of participating families—in their understanding (beliefs about child-rearing, knowledge of child development), and/or actions (their manner of interacting with their child or structuring the environment, ability to provide healthy meals, engage in prenatal health care)—or on the part of the child (change in rate of development, health status, etc.). Home visiting also may be used as a way to provide case management, make referrals to existing community services including early intervention for those with delays and disabilities, or bring information to parents or caregivers to support their ability to provide a positive and healthy home environment for their children. 3,4,7

Data about the efficacy of home visiting programs have been accumulating over the past several decades. The federal Maternal, Infant, and Early Childhood Home Visiting (MIECHV) program launched in the U.S. in 2012 and its accompanying national Mother and Infant Home Visiting Program Evaluation (MIHOPE)  (which included 4 models - Early Head Start’s Home-based option, Healthy Families America, Nurse-Family Partnership, and Parents as Teachers), and the Home Visiting Evidence of Effectiveness (HoMVEE) reviews has contributed much new data about program features, implementation, and impacts. 8-12 More of the research has  used randomized controlled trial (RCT) or quasi-experimental designs, with multiple data sources and outcome measures, and longitudinal follow-up. These studies, along with older reviews,  and recent meta-analyses have generally found that home visiting programs produce a limited range of significant effects and that the effects produced are often small. 4,13,14 Nevertheless, a review of seven evidence-based home visiting models showed all seven to have at least one study with positive impacts on child development and school readiness outcomes. 13 Detailed analyses, however, sometimes reveal important program effects. For example, certain subsets of participants may experience long-term positive outcomes on specific variables. 15,16 These results and others suggest that in assessing the efficacy of home visiting programs, it is important to include measures of multiple child and family outcomes at various points in time and to collect enough information about participants to allow for an analysis of the program effects on various types of subgroups. Averaging effects across multiple studies is currently seen as an inadequate approach to understanding what works for whom. 17

Other difficulties when conducting or evaluating research in this area include ensuring the equivalency of the control and experimental groups in randomized controlled trials (RCTs), 18 controlling for participant attrition (which may affect the validity of findings by reducing group equivalence) and missed visits (which may affect validity by reducing program intensity), 19 documenting that the program was fully and accurately implemented, and determining whether the program’s theory of change logically connects program activities with intended outcomes.

Research Context

Because home visiting programs differ in their goals and content, research into their efficacy must be tailored to program-specific goals, practices, and participants. (See also chapter by Korfmacher and coll. ) In general, home visiting programs can be grouped into those seeking medical/physical health outcomes and those seeking parent-child interaction and child development outcomes. The target population may be identified at the level of the caregiver (e.g., teen mothers, low-income families) or the child (e.g., children with disabilities). Some programs may have broad and varied goals, such as improving prenatal and perinatal health, nutrition, safety, and parenting. Other programs may have narrower goals, such as reducing the incidence of child abuse and neglect. Program outcomes may focus on adults or on children; providers frequently cite multiple goals (e.g., improved child development, parent social-emotional support, parent education). 10  

In this chapter, we focus on the effectiveness of home visiting programs in promoting developmental, cognitive, and school readiness outcomes in children. The majority of home visiting services and research have focused on the period prenatally through 2 to 3 years and thus have not measured long-term impacts on school readiness and school achievement, but some of the more recent studies have done follow up into elementary school. However, most of the available studies have examined the impact on these outcomes indirectly through changes in parenting practices and precursors to successful school success (i.e., positive behaviour outcomes including self-regulation and attention).

Key Research Questions

Key research questions include the following:

• What are the short-term and long-term benefits experienced by participating families and their children relative to nonparticipating families, particularly for children’s school readiness skills and parenting to support child development?
• What factors influence participation and nonparticipation in the program?
• Do outcomes differ for different subgroups?

Research Results

Recent advances in program design, evaluation and funding have supported the implementation of home visiting as a practical intervention to improve the health, safety and education of children and families, mitigating the impact of poverty and adverse early childhood experiences. 3 Although program approaches and quality may vary, there are common positive effects found on parenting knowledge, beliefs, and/or behaviour and child cognitive, language, and social-emotional development. In order to achieve the intended outcomes, programs need to have clearly defined interventions and outcome measures, with a process to monitor quality. 20  Recent research has begun to focus on how measures to assess quality can be used to monitor programs and program improvement efforts. 21,22  

A review of seven home visiting program models across 16 studies conducted over a decade ago that included rigorous evaluation components and measured child development and school readiness outcomes concluded positive impacts on young children’s development and behaviour. Six models showed favourable effects on primary outcome measures (e.g., standardized measures of child development outcomes and reduction in behaviour problems). 23 Only studies with outcomes using direct observation, direct assessment, or administrative records were included. More recent reviews also show relatively small effects on developmental outcomes, but authors noted that “modest effect sizes in studies concerning developmental delay can result in important population-level effects given the high proportion of children in low-income families (nearly 20%) meeting criteria for early intervention services”. 3  A rigorous review conducted more recently in 2018 identified 21 home visiting models that met criteria of being an evidence-based model. 11 That review concluded that 12 of the models had evidence for favorable impacts on child development and school readiness outcomes. Recent and continuing research has been focusing on families with infants and toddlers living in poverty who are at higher risk for adverse early childhood experiences (ACES) that can lead to lifelong negative effects on physical and emotional health, and  educational success. 3,24 For example, the Adverse Childhood Experiences study indicates that traumatic experiences in early childhood can have lifelong impacts on physical and mental health. Data from this study indicate that children with 2 or more adverse experiences are more likely to repeat a grade. Home visiting programs can mitigate the effects of toxic stress, enhancing parenting skills and creating more positive early childhood experiences. 24,25 This research points to the importance of targeted home visiting programs to families who are experiencing stress and a recent meta-analysis of home visiting with such families indeed shows decreases in both social-emotional problems and stressful experiences. 26  

Problems identified in earlier reviews completed in the 1990s still plague this field, however, including that many models have limited rigorous research studies. In many of the studies described in previous and more recent reviews and meta-analyses, programs struggled to enroll, engage, and retain families. When program benefits are demonstrated, they usually accrued only to a subset of families originally enrolled in the programs, they rarely occurred for all of a program’s goals, and the benefits were often quite modest in magnitude. 27    The generally small effects on outcomes averaged across studies have led researchers to call for precision home visiting research to look at what works for whom. 17,28 (Also see chapter by Korfmacher and coll .).

Research into the implementation of home visiting programs has documented a common set of difficulties across programs in delivering services as intended. (See also Paulsell chapter ) First, target families may not accept initial enrollment into the program. Two studies that collected data on this aspect of implementation found that one-tenth to one-quarter of families declined invitations to participate in the home visiting program. 29,30 In another study, 20 percent of families that agreed to participate did not begin the program by receiving an initial visit. 19 Second, families may not receive the full number of planned visits. Evaluation of the Nurse Family Partnership model found that families received only half of the scheduled number of visits. 31 Evaluations of the Hawaii Healthy Start and the Parents as Teachers programs found that 42 percent and 38 percent to 56 percent of scheduled visits respectively were actually conducted. 29,32 Even when visits are conducted, the planned curriculum and visit activities may not be presented according to the program model, and families may not follow through with the activities outside of the home visit. 33,34 Recent research has begun to examine how technical assistance and training supports delivered to home visiting program supervisors and home visitors can improve model fidelity. 35 (See Paulsell chapter. )  In a review of home visiting research in the 1990s, Gomby, Culross, and Berman 27 found that between 20 percent and 67 percent of enrolled families left home visitation programs before the scheduled termination date. More recent studies continue to show a persistent problem with families leaving the program and not engaging in visits as intended by program developers. For example, in the MIHOPE evaluation, about 28% of families left MIHOPE home visiting programs within six months, while about 55% were still receiving about two visits per month after a year. 9 With only about half of families remaining after one year, many families were only receiving half of the intended number of visits. 8 Studies of Early Head Start also show that families with the greatest number of risk factors are the most likely to drop out which was also observed in the recent MIHOPE study. 36  

The assumed link between parent behaviour change and improved outcomes for children has received mixed research support. In other words, even when home visitation programs succeed in their goal of changing parent behaviour, these changes do not always appear to produce significantly better child outcomes in the short term, but in some cases appear to have an impact in the long term. 37,38  Examples include a study of the Home Instruction Program for Preschool Youngsters (HIPPY) model with low-income Latino families showing changes in parenting practices and better third-grade math achievement and positive impacts on both math and reading achievement in fifth grade. 39,40 Earlier evaluations of HIPPY found mixed results regarding program effectiveness. In some cohorts, program participants outperformed nonparticipants on measures of school adaptation and achievement through second grade, but these results were not replicated with other cohorts at other sites.

Both older and more recent reviews of home visiting programs described above included only studies using rigorous designs and measurement and a number of models show significant impacts on child development and school readiness outcomes. The Early Head Start model used a RCT design to study the impact of a mixed-model service delivery (i.e., center-based and home-visiting) on developmental outcomes at 2- and 3-year follow-up. Overall, there were small, but significant gains on cognitive development at 3 years, but not 2 years. More recent Early Head Start evaluations find positive impacts at ages 2 and 3 on cognition, language, attention, behaviour problems, and health and on maternal parenting, mental health, and employment outcomes, with better attention and approaches toward learning and fewer behavior problems at age 5 than the control group, but no differences on early school achievement. 41 Nonexperimental follow-up showed, however, that those children who went on to attend preschool after EHS did have better early school achievement. Studies of the Nurse Family Partnership model followed children to 6 years and found significant program effects on language and cognitive functioning as well as fewer behaviour problems in a RCT study. 42 In addition, evaluations of Healthy Families America have shown small, but favourable effects on young children’s development. 43,44  

Home visiting programs focusing on supporting parents’ abilities to promote children’s development explicitly appear to impact children’s development positively. One meta-analysis found that programs that taught parent responsiveness and parenting practices found better cognitive outcomes for children. 4 A meta-analysis of RCTs found that the most pronounced effect for parent-child interactions and maternal sensitivity can be improved in a shorter period of time, where effects of interventions on child development may take longer to emerge. 45 Several studies find longer-term impacts on parenting and associated positive effects for child outcomes. In a RCT of a New York Healthy Families America program, the program reduced first grade retention rates and doubled the number of first graders demonstrating early academic skills for those participating in the program. 2 And at least one recent longitudinal study of Parents as Teachers found positive school achievement and reduced disciplinary problems in early elementary school along with increased scores on parent measures of interactions, knowledge of child development, and family support. 46

Other studies were unable to document program impacts on parenting and home environment factors that are predictive of children’s early learning and development through control group designs. An evaluation of Hawaii’s Healthy Start program found no differences between experimental and control groups in maternal life course (attainment of educational and life goals), substance abuse, partner violence, depressive symptoms, the home as a learning environment, parent-child interaction, parental stress, and child developmental and health measures. 43 However, program participation was associated with a reduction in the number of child abuse cases.   

Other models show mixed impacts. A 1990’s RCT evaluation of the Parents as Teachers (PAT) program also failed to find differences between groups on measures of parenting knowledge and behaviour or child health and development. 32 Small positive differences were found for teen mothers and Latina mothers on some of these measures. However, another RCT study with the Parents as Teachers Born to Learn curriculum did find significant effects on cognitive development and mastery motivation at age 2 for the low socioeconomic families only. 47  Furthermore, a more recent RCT in Switzerland found that children receiving the PAT program had improved adaptive behavior and enhanced language skills at age 3 with the most high-risk children also having reductions in problem behaviours. 48 A randomized controlled trial of Family Check-Up demonstrated favourable impacts on at risk toddlers’ behaviour and positive parenting practices. 49

Randomized controlled trials (RCTs) have also shown that programs are more likely to have positive effects when targeted to the neediest subgroups in a population. For example, in the Nurse Family Partnership model children born to mothers with low psychological resources had better academic achievement in math and reading in first through sixth grade compared to their control peers (i.e., mothers without the intervention with similar characteristics). 50,51 (See also updated information in the Donelan-McCall & Olds chapter ).

The largest RCT of a comprehensive early intervention program for low-birth-weight, premature infants (birth to age three), the Infant Health and Development Program, included a home visiting component along with an educational centre-based program. 52 At age three, intervention group children had significantly better cognitive and behavioural outcomes and improved parent-child interactions. The positive outcomes were most pronounced in the poorest socioeconomic group of children and families and in those who participated in the intervention most fully. In follow-up studies, improvements in cognitive and behavioural development were also found at age 8 and 18 years for those in the heavier weight group. 53 The Chicago Child-Parent  Center Program also combined a structured preschool program with a home visitation component. This program found long-term differences between program participants and matched controls. Participating children had higher rates of high-school completion, lower rates of grade retention and special education placement, and a lower rate of juvenile arrests and impacts lasting into adulthood. 54-56 Another example showing more intensive programming has larger impacts is the Healthy Steps evaluation showing significantly better child language outcomes when the program was initiated prenatally through 24 months. 57 Early Head Start studies cited earlier also show that combining home visiting with later preschool attendance will yield better school readiness impacts than home visiting alone. Finally, there is a need to look at how home visiting could be beneficial for improving school outcomes when combined with a preschool program as in a recent study with families in Head Start programs that found reduced need for educational and mental health services in third grade. 58 These studies suggest that a more intensive intervention involving the child directly may be required for larger effects on school readiness to be seen with home visiting as one part of a more comprehensive approach.

Conclusions

Research on home visitation programs has not been able to show that these programs alone have a strong and consistent effect on participating children and families, but modest effects have been repeatedly reported for children’s early development and behaviour and parenting behaviours and discipline practices. Programs that are designed and implemented with greater rigour seem to provide better results. Home visitation programs also appear to offer greater benefits to certain subgroups of families, such as low-income, single, teen mothers.

These conclusions support recent attention to use of research designs that look at more differentiation of the program models and components to match the needs of the families aimed at improving child development and other outcomes. Precision home visiting uses research to identify what aspects of home visiting work for which families in what circumstance, resulting in programs that target interventions to the needs of particular families. 17  

Future research needs to examine the role of evidence-based home visiting within a more comprehensive system of services across the first five years of life.  It can be an initial cost -effective strategy to build trusting relationships and support early positive parenting that will improve children’s development over the long run because families will have increased likelihood of enrolling their children in preschool programs and use other needed child and family supports. 

Furthermore, efficacy research needs to include longitudinal designs and simultaneously include cost-benefit studies to demonstrate the long-term cost savings that will build public support for both early home visiting programs and a more comprehensive early childhood system. 

The recent Covid-19 pandemic brought to light the disparities and inequities of our early childhood service systems (as well as our later education systems). This state of affairs also has reinforced the benefit of more authentic participatory approaches in research and evaluation to identify what works and for whom.  Research and evaluation that includes various stakeholders, from those who are affected by an issue to those that fund the programs, promises to provide insights and perspectives that can strengthen the impact of home visiting programs. 

Implications

Programs that are successful with families at increased risk for poor child development outcomes tend to be programs that offer a comprehensive focus—targeting families’ multiple needs—and therefore may be more expensive to develop, implement, and maintain. In their current state of development, home visitation programs alone do not appear to represent the low-cost solution to child health and developmental problems that policymakers and the public have hoped for for decades. However, as the field continues to research more precision approaches that match program components to child and family needs, add the needed assistance and professional development supports to ensure model fidelity, and incorporate home visiting programs within a comprehensive early childhood system across the first five years of life, more consistent and positive results for participating target families are to be expected.

For high risk families with multiple challenges and levels of adversity, home visiting programs can serve to encourage families to take advantage of preschool programs available to them and their children and increase their participation in other family support programs during the preschool through 3 rd grade years 59 to further support school readiness outcomes. 

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Gomby DS, Culross PL, Behrman RE. Home visiting: Recent program evaluations-analysis and recommendations. Future Child . 1999;9(1):4-26.

Condon EM. Maternal, Infant, and Early Childhood Home Visiting: A Call for a Paradigm Shift in States' Approaches to Funding. Policy, Politics, & Nursing Practice . 2019;20(1):28-40.

Duggan AK, McFarlane EC, Windham AM, Rohde CA, Salkever DS, Fuddy L, Rosenberg LA, Buchbinder SB, Sia CC. Evaluations of Hawaii's Healthy Start Program. Future Child . 1999;9(1):66-90.

Olds DL, Henderson CR, Jr., Kitzman HJ, Eckenrode JJ, Cole RE, Tatelbaum RC. Prenatal and infancy home visitation by nurses: Recent findings. Future Child . 1999;9(1):44-65.

Korfmacher J, Kitzman H, Olds DL. Intervention processes as predictors of outcomes in a preventive home visitation program. Journal of Clinical Child & Adolescent Psychology . 1998;26(1):49-64.

Wagner MM, Clayton SL. The Parents as Teachers Program: Results from two demonstrations. Future Child. 1999;9(1):91-115.

Baker AJL, Piotrkowski CS, Brooks-Gunn J. The Home Instruction Program for Preschool Youngsters (HIPPY). Future Child . 1999;9(1):116-133.

Hebbeler KM, Gerlach-Downie SG. Inside the black box of home visiting: A qualitative analysis of why intended outcomes were not achieved. Early Childhood Research Quarterly . 2002;17:28-51.

Chen W-B, Spiker D, Wei X, Gaylor E, Schachner A, Hudson L. Who gets what? Describing the non‐supervisory training and supports received by home visiting staff members and its relationship with turnover. American Journal of Community Psychology . 2019;63:298-311.

Roggman L, Cook G, Peterson CA, Raikes H. Who drops out of Early Head Start home visiting programs? Early Education & Development . 2009;19:574-579.

Caughy MO, Huang K, Miller T, Genevro JL. The effects of the Healthy Steps for Young Children Program: Results from observations of parenting and child development. Early Childhood Research Quarterly . 2004;19(4):611-630.

Minkovitz CS, Strobino D, Mistry KB, Scharfstein DO, Grason H, Hou W, Ialongo N, Guyer B. Healthy steps for young children: Sustained results at 5.5 years. Pediatrics . 2007;120(3):658-668.

Nievar A, Brown AL, Nathans L, Chen Q, Martinez-Cantu V. Home visiting among inner-city families: Links to early academic achievement. Early Education and Development. 2018;29(8):1115-1128.

Nievar MA, Jacobson A, Chen Q, Johnson U, Dier S. Impact of HIPPY on home learning environments of Latino families. Early Childhood Research Quarterly. 2011;26:268-277.

Love JM, R. C-C, Raikes H, Brooks-Gunn J. What makes a difference: Early Head Start evaluation findings in a developmental context. Monographs of the Society for Research in Child Development . 2013;78((1):vii-viii):1-173.

Olds DL, Kitzman H, Cole R, Robinson J, Sidora K, Luckey DW, Henderson CR Jr, Hanks C, Bondy J, Holmberg J. Effects of nurse home-visiting on maternal life course and child development: Age 6 follow-up results of a randomized trial. Pediatrics . 2004;6(6):1550-1559.

Caldera D, Burrell L, Rodriguez K, Crowne SS, Rohde C, Duggan A. Impact of a statewide home visiting program on parenting and on child health and development. Child Abuse and Neglect. 2007;31(8):829-852.

Landsverk J, Carrillo T, Connelly CD, et al. Healthy Families San Diego clinical trial: Technical report. San Diego, CA: The Stuart Foundation, The California Wellness Foundation, State of California Department of Social Services: Office of Child Abuse Prevention; 2002.

Rayce SB, Rasmussen IS, Klest SK, al. e. Effects of parenting interventions for at-risk parents with infants: a systematic review and meta-analyses. BMJ Open 2017.

Lahti M, Evans CBR, Goodman G, Schmidt MC, LeCroy CW. Parents as Teachers (PAT) home-visiting intervention: A path to improved academic outcomes, school behavior, and parenting skills. Children and Youth Services Review. 2019;99:451-460.

Drotar D, Robinson J, Jeavons L, Lester Kirchner H. A randomized, controlled evaluation of early intervention: The Born to Learn curriculum. Child: Care, Health & Development. 2009;35(5):643-649.

Schaub S, Ramseier E, Neuhauser A, Burkhardt SCA, Lanfranchi A. Effects of home-based early intervention on child outcomes: A randomized controlled trial of Parents as Teachers in Switzerland. Early Childhood Research Quarterly. 2019;48:173-185.

Shaw DS, Dishion TJ, Supplee L, Gardner F, Arnds K. Randomized trial of a family-centered approach to the prevention of early conduct problems: 2-year effects of the family check-up in early childhood. Journal of Consulting and Clinical Psychology. 2006;74(1):1-9.

Olds DL, Kitzman H, Hanks C, Cole R, Anson E, Sidora-Arcoleo K, Luckey DW, Henderson CR Jr, Holmberg J, Tutt RA, Stevenson AJ, Bondy J. Effects of nurse home visiting on maternal and child functioning: Age-9 follow-up of a randomized trial. Pediatrics . 2007;120(4):e832-e845.

Kitzman HJ, Olds DL, Cole RE, Hanks CA, Anson EA, Arcoleo KJ, Luckey DW, Knudtson MD, Henderson CR Jr, Holmberg JR. Enduring effects of prenatal and infancy home visiting by nurses on children: Follow-up of a randomized trial among children at age 12 years. Archives of Pediatric Adolescent Medicine . 2010;164(5):412-418.

Gross RT, Spiker D, Haynes CW, eds. Helping low birth weight, premature babies . Stanford, CA: Stanford University Press; 1997.

Mallik S, Spiker D. Effective early intervention programs for low birth weight premature infants: Review of the Infant Health and Development Program (IHDP). In: Tremblay RE, Barr RG, Peters RD, eds. Encyclopedia on early childhood development [online]. Montreal, Quebec: Centre of Excellence for Early Childhood Development; 2016.

Reynolds AJ, Temple JA, Robertson DL, Mann EA. Long-term effects of an early childhood intervention on educational achievement and juvenile arrest: A 15-year follow-up of low-income children in public schools. JAMA . 2001;285(18):2339-2346.

Reynolds AJ, Richardson BA, Hayakawa M, Englund MM, Ou S-R. Multi-site expansion of an early childhood intervention and school readiness. Pediatrics . 2016;138(1):1-11.

Reynolds AJ, Temple JA, Ou S-R, Arteaga IA, White BAB. School-based early childhood education and age-28 well-being: Effects by timing, dosage, and subgroups. Science . 2011;333(6040):36-364.

Johnston BD, Huebner CE, Anderson ML, Tyll LT, Thompson RS. Healthy steps in an integrated delivery system: Child and parent outcomes at 30 months. Archives of pediatrics & adolescent medicine. 2006;160(8):793-800.

Bierman KL, Welsh J, Heinrichs BS, Nix RL. Effect of preschool home visiting on school readiness and need for services in elementary school: A randomized clinical trial. JAMA Pediatrics . 2018;172(8):e181029-e181029.

Magnuson K, Schindler HS. Parent programs in pre-k through third grade. Future Child . 2016;26(2):207-223.

Note: a Services are brought to the family and settings may include the family’s home, or another mutually agreed upon location such as community center, park, or public library. More recently, due to the pandemic, programs have relied on virtual methods or conducting a home visit remotely via digital devices.   

How to cite this article:

Kelley G, Gaylor E, Spiker D. Impacts of Home Visiting Programs on Young Children’s School Readiness. In: Tremblay RE, Boivin M, Peters RDeV, eds. Spiker D, Gaylor E, topic eds. Encyclopedia on Early Childhood Development [online].  https://www.child-encyclopedia.com/home-visiting/according-experts/impacts-home-visiting-programs-young-childrens-school-readiness . Updated: January 2022. Accessed May 18, 2024.

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Home Visitor’s Online Handbook

All Head Start programs are authorized by the Improving School Readiness through Head Start Act of 2007. The Act describes the general scope and design of Head Start and Early Head Start programs. Section 636 states the purpose of Head Start as promoting the school readiness of low-income children by enhancing their cognitive, social, and emotional development. This takes place in a learning environment that supports children's growth in language, literacy, mathematics, science, social and emotional functioning, creative arts, physical skills, and approaches to learning. It is accomplished through the provision of health, educational, nutritional, social, and other services to low-income children and their families that are determined to be necessary based on family needs. 

The Head Start Program Performance Standards (HSPPS) define the specific regulations for all programs serving infants, toddlers, preschoolers, and pregnant women. They also include the requirements for the home-based program option. As described in the HSPPS, home visits and group socializations are guided by a research- and home-based curriculum that is aligned with the Head Start Early Learning Outcomes Framework: Ages Birth to Five .

The HSPPS are referenced throughout the Home Visitor's Online Handbook to help you become familiar with the unique and comprehensive approach of the Head Start and Early Head Start home-based program option. Your own program will further define this information within its own procedures and protocols. In addition, this handbook relates research on the efficacy of home-based programs, strategies for best practices, video examples for reflection, resources, and wisdom from your colleagues shared in the Voices from the Field video series.

Terminology for the name of the person who conducts home visits in the home-based option varies from program to program. You may be called a home visitor, family advocate, or an infant/toddler educator. In this handbook, we use the term "home visitor." The terms "parent" and "family" are used interchangeably throughout, except where the law and regulations require the work be done with parents. This represents all of the people who may play both a parenting role in a child's life and a partnering role with Head Start and Early Head Start staff. This includes fathers; mothers; expectant parents; grandparents; kith and kin caregivers; lesbian, gay, bisexual, and transgender (LGBT) parents; guardians; teen parents; and families with diverse structures that include multiple co-parenting relationships.

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Home Visitor Orientation and Training

Home Visitors must complete orientation within 3 months (90 days) of hire/grant award, depending on previous experience. A checklist should record progress toward completion and be maintained as a part of the local personnel file. Documentation of all orientation steps should be provided upon request of the KDHE MCH Program Consultant during monitoring visits.

Requirements Before Service

Prior to conducting visits with families, a home visitor will:

• Review the local agency MCH aid to local application to better understand the services, partnerships, and home visiting plan submitted to KDHE
• Review local policies and procedures regarding home visiting
• Review MCH Manual
• Complete Basic Home Visitor Online Training *See Details Below in Initial Training
• Understand education, information, and resources/materials shared during visits
• Receive orientation to community partners, services, and resources
• Shadow 3 visits conducted by an experienced home visitor (to be determined by supervisor and KDHE MCH program consultant)
• Conduct at least 1 visit accompanied by the Home Visiting Program Supervisor

Initial Training

All program staff must complete the Kansas Basic Home Visitation Training, developed in partnership between KDHE and the Kansas Head Start Association. The training includes two parts – online and face to face.

Online Training (Part 1), KS-TRAIN course ID# 1043474

• Must be completed within 30 days of hire AND prior to providing services
• Required for all regardless of profession/credential because content is specific to home visiting services

Also required before moving on to Part 2:

Abuse and Neglect, KS-TRAIN course ID# 1043466 HIPAA Awareness Module 1, KS-TRAIN course ID# 1047429

Healthcare or Public Health Workforce should complete:

HIPAA: Allowable Disclosures and Safeguards Module 2, KS-TRAIN course ID# 1072478 HIPAA: Right to Access and Documentation Module 3,     KS-TRAIN course ID# 1072486

Face to Face Training (Part 2)

• Must be completed (Level 1, 1 ½ days) within nine (9) months of hire
• Does not need to be completed prior to conducting home visits
• Only offered once every 6 to 9 months depending on need/potential attendance. If the training is not offered within the first 9 months of hire, the home visitor must notify the KDHE MCH Program Contact and plan to attend a future scheduled training.
• Topics covered include: Home visiting models, best practices and beliefs, confidentiality, taking care of yourself, dealing with stress, role of the home visitor, trust and respect, tools, listening skills, power of words, negative consequence of rescuer, boundaries, home visitor safety, understanding cultures, poverty, family in community and community resources, documentation.
• Must be completed within six (6) months of hire
• Home Visiting 101: This module is an introduction into home visiting and its importance for children, parents and families.
• Home Visiting 102: In this module the Home Visitor will explore the daily activities of a family support professional and describe skills that can improve a family support professional’s effectiveness.
• Home Visiting 103: This module describes qualities and behaviors that are essential to family support professionals.
• Every home visitor is required to keep updated on their certification on MHFA.
• The certification is valid for three years.
• Local agencies may build training fees associated with MHFA in the MCH grant budget.

Fall Regional Home Visiting Training

All Home Visitors are required to attend this annual training administered by KDHE.

Other Continuing Education Options

• A half day Level 2 of the Face to Face Training above is available if MCH Home Visitors would like to attend. It is designed for more intensive home visiting programs, such as Parents as Teachers or Early Head Start, but has valuable topics including: Ethical principles of home visitation, family systems, building a healthy self-reliance and interdependence, empowerment model, six principles of empowerment assessment, home visitor professional development
• Consider attending quality conferences and events such as the Governor’s Public Health Conference, Governor’s Conference for Prevention of Child Abuse and Neglect, and Kansas Public Health Association Conference.
• KS-TRAIN . KS-TRAIN maintains records of all trainings completed through that site.
• Public Health Connections
• Institute for the Advancement of Family Support Professionals
• The MCH Navigator is an online learning portal for MCH professionals funded by the Federal Maternal and Child Health Bureau, which provides free foundational and essential training/education for those working to improve the health of women, infants, and families. NOTE: The MCH Navigator does not provide certificates or records of completion, so it is important to document the course and date completed OR capture a screen shot of the completion page for each course.

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The outcomes of nurse practitioner (NP)-Provided home visits: A systematic review

Zainab toteh osakwe.

a Adelphi University College of Nursing and Public Health, 1 South Avenue, Garden City, New York 11530, United States

Sainfer Aliyu

b Washington Hospital Center. 110 Irving Street, NW. Washington, DC 20010, United States

Olukayode Ayodeji Sosina

c Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, Baltimore, MD 21205, United States

Lusine Poghosyan

d Columbia University, School of Nursing, 560W 168th St, New York, New York 10032, United States

With the shortage of primary care providers to provide home-based care to the growing number of homebound older adults in the U.S. Nurse Practitioners (NPs) are increasingly utilized to meet the growing demand for home-based care and are now the largest type of primary care providers delivering home-visits.

The purpose of this study was to systematically examine the current state of the evidence on health and healthcare utilization outcomes associated with NP-home visits.

Five Databases (PubMed, EMBASE, Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library) were systematically searched to identify studies examining NP-home visits. The search focused on English language studies that were published before April 2019 and sought to describe the outcomes associated with NP-home visits. We included experimental and observational studies.  Quality appraisal was performed with the Kmet, Lee & Cook tool, and results summarized qualitatively. The impact of NP-home visits on clinical (functional status, quality of life [QOL]), and healthcare utilization (hospitalization, Emergency department(ED) visits) outcomes was evaluated.

Results/Discussion

A total of 566 citations were identified; 7 met eligibility criteria and were included in the review. The most commonly reported outcomes were emergency department (ED) visits and readmissions. Given the limited number of articles generated by our search and wide variation in intervention and outcomes measures. NP-home visits were associated with reductions in ED visits in 2 out of 3 studies and with reduction in readmissions in 2 out of 4 studies.

Published studies evaluating the outcomes associated with NP-home visits are limited and of mixed quality. Limitations include small sample size, and variation in duration and frequency of NP-home visits. Future studies should investigate the independent effect of NP-home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.

Introduction

Over two million older adults in the United States are homebound and have great difficulty living in their home independently. 1 Homebound older adults have medical and psychiatric illness, higher functional limitations, symptom burden and mortality compared to non-homebound older adults. 1 , 2 , 3 , 4 These individuals also have poor clinical outcomes, including high hospitalization and emergency room visits. 5 , 6 Despite being a fragile population, many homebound patients have inconsistent access to office-based care, often only receiving care for medical emergencies. 5 , 7 Because of their multiple chronic co-morbidities and functional impairments, homebound patients are among the most costly group of patients in the U.S healthcare system accounting for more that 30 percent of Medicare expenditure. 8 , 9 , 10 , 11

A few modes of “home-based” healthcare services have been developed to meet the needs of homebound patients, from home health care which provides episodic skilled nursing, therapy and home health aide services, 12 to the provision of primary care at home. 13 Home-based medical care (HBMC) is one of such services. HBMC provides primary, urgent or palliative care to homebound patients by bringing the provider into the home. 14 Nurse practitioners (NPs) and physicians are the most common providers of HBMC services in the U.S. 15 Common models of HBMC are home-based primary care (HBPC), home based palliative care and transitional care programs. In HBPC, healthcare providers (e.g., physicians, NPs, and physician assistants) and interdisciplinary care team provide comprehensive longitudinal in-home medical care to homebound. 16 , 17 In home-based palliative care, the focus is on symptom control and entails the provision of consultative palliative care in collaboration with the patient's primary care provider. 18 In transitional care programs, patients transitioning from the hospital to the home setting receive transitional care home visits by a master's prepared advanced practice nurses such as clinical nurse specialist, more recent forms of the transitional care programs utilize NPs. 19 , 20 A growing body of evidence has demonstrated that HBMC programs lead to reduction in hospitalizations, 30‐day readmissions, and potentially preventable hospitalizations. 20 , 21 , 22 , 23 , 24

While the outcomes of HBMC have been shown to be positive, there is currently a national shortage of providers in the U.S, 25 in part due to the escalating primary care physician shortage. 26 , 27 As a result, there has been an increasing reliance on other health care providers such as physician assistants and NPs to reduce barriers in access to HBMC. Current evidence points to high utilization of NP-home visits. In 2013, NPs made 1.1 million home visits making them the largest provider of home visits and the most common provider of home visits to rural residents in the U.S. 28 , 29 This number nearly doubled to 2 million NP-home visits in 2016. 30 , 31 Many homebound patients who receive home visits from an NP, physician or physician assistant also receive Medicare Home Healthcare services, which provides skilled nursing, therapy or home health aide services. For decades, long standing federal regulations in the U.S that govern the services that NPs can provide, have restricted the autonomy of NPs in meeting patient care needs of homebound patients who receive Medicare Home Healthcare services. Although NPs were recognized by Medicare and Medicaid as primary care providers, NPs were not been able to order, certify or re-certify Medicare Home Healthcare —a service utilized by about 3 million Medicare beneficiaries each year. 12 , 32

More recently, amidst the COVID-19 pandemic, the Home Health Care Planning Improvement Act (S. 296/H.R. 2150), was included in the Coronavirus Aid, Relief, and Economic Security Act or the “CARES Act” (H.R. 748). 33 This bill now permanently authorizes NPs to order Medicare Home Healthcare services for Medicare patients consistent with state scope-of-practice law governing NP practice. Allowing NPs to order, certify and re-certify Medicare Home Healthcare services increases practice autonomy for NPs and expands access to home healthcare for vulnerable homebound patients. 31 , 32

Despite the growing utilization in the delivery of varied modes of HBMC, very little is known about outcomes associated with NP-provided care. While studies of HBPC report positive outcomes, patient outcomes are not delineated by provider type (physician or NP), making it hard to precisely estimate the impact of the NP role. 21 , 34 , 35 Studies of transitional care have focused on the post-acute care population transitioning from one setting to another, with NPs providing transitional care supplemental to the care delivered by the primary care providers. 20 , 36 Although substantial evidence has shown that NPs provide quality of care similar to that of physicians, 37 , 38 even with medically complex patients 39 most of these studies have focused on acute care 40 or ambulatory care, 41 , 42 and these findings are not generalizable to care provided in a patient's home environment which presents unique challenges. 34

Because NPs are more likely to serve in low income, minority, and rural areas and to accept Medicaid insurance when compared to physicians, 43 increased practice independence for NPs in HBMC has the potential to address physician shortage and extend care to underserved populations in the U.S. Nevertheless, lack of evidence about the outcomes associated with NP-home visits restricts the optimal utilization of the growing NP workforce to meet the increasing demand for HBMC. 44 , 45

The use of NP-home visits has particularly gained national and policy interest. A current Medicare demonstration program, Independence at Home (IAH), tests the effectiveness of delivering primary care in the home by an interdisciplinary team led by physicians or NPs. The IAH demonstration showed that patients who receive HBPC had fewer 30-day readmissions, hospitalizations, and emergency department visits. 46 , 47 In light of IAHs success, there is a clear need to assess and quantify the specific contributions of NPs reflected in patient outcomes. With the growing aging population, the utilization of NPs in the delivery of HBMC is expected to increase. An understanding of the health and healthcare utilization outcomes associated with NP-home visits will inform efforts to expand access to HBMC for vulnerable homebound older adults in the U.S.

Therefore, guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, 48 we performed a review of the literature to examine the relationship between NP-home visits and health and healthcare utilization outcomes of homebound older adults.

Search strategy

With the assistance of a medical librarian, searches were conducted in the following electronic databases: PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature (CINAHL), and Cochrane Central Register of Clinical Trials to identify studies investigating the outcomes of NP- home visits.  The search procedure developed for PubMed was carefully replicated to retrieve studies from EMBASE, CINAHL and Cochrane. Initially, broad categories of search terms were chosen, including the following: “nurse practitioner”, “advanced practice nursing”, “advanced practice nurse”, “nurse clinician,” in combination with “house,” “home care services,” “home health nursing,” “transitional care,” “house call,” “home visit,” “home based,” “home care,” “home health,” “home healthcare,” “transitional care,” “transitional health care,” “aged,” “middle aged,” “elderly seniors” and “senior citizen.” Medical subject heading (MESH), key words and truncated search terms were used when available to capture all relevant articles in a database. The search was conducted without date restriction. Reference list of included articles were screened for additional relevant articles. The complete lists of search strategies for each database are listed in Appendix A.

Eligibility criteria

To be included in the review, studies must have met the following criteria: target patient population was (a) older adults ≥ 65; (b) the study investigated patient outcomes associated with NP- home visits, (c) qualitative or quantitative study design, and (d) from peer-reviewed journals published in English through April 30, 2019. Excluded from this review were review articles, editorials, case reports or case studies, reports published as abstracts or commentaries . Because we sought to obtain a comprehensive understanding of the current state of evidence about the outcomes of NP-home visits, studies were not excluded based on study design. Studies were also not excluded based on location/country. Relevant articles were imported to Endnote, reference management software (Endnote X9; Thomas Reuters) and duplicates were deleted.

Study selection

Fig. 1 provides the details of the search process. Two reviewers (SA and ZO) independently screened titles and abstracts of articles to determine whether inclusion criteria were met. Full text articles were reviewed independently by the same reviewers (SA and ZO), and references of those articles were searched for potentially relevant publications. All disagreements were resolved by consensus.

Flow diagram of the process of study selection.

Data extraction

The following information was collected from each study: first author's name, publication year, study design, study objective, number of NP-home visits, characteristics of the study sample, including sample size, mean age and sex of participants, race/ethnicity of sample and study setting (country and/or area in which the study was conducted) and outcome variables. All data were entered in an Excel (Microsoft Corp., Redmond, VA) document.

Quality appraisal

The quality appraisal instrument developed by Kmet, Lee & Cook 49 was used to assess the quality of the selected studies. This is a validated tool containing individual checklists to assess the quality of qualitative and quantitative studies and consists of 14 criteria scored on a 3-point scale (2 = yes, 1 = partially, 0 = no). Following the guidelines of the tool, “non-applicable” was applied when criteria were not applicable to a study design. Items that met the “non-applicable” criteria were marked and excluded from the calculation of the summary score. The scores were then summed and divided by the total number of items to obtain a summary score for each paper. The summary score was then converted into a percentage of the maximum possible score. Studies were determined to be of high quality if they scored > 75%, unclear quality if they scored 55%−75%, and of low quality of they scored < 55%. Two reviewers (SA and ZO) independently appraised each study. Discrepancies were resolved by discussion between the 2 reviewers, and in consultation with a third reviewer (KS).

In total, 566 article titles and abstracts were screened for study relevance. After applying the eligibility criteria and removing duplicates, 484 articles were excluded by reviewing titles and abstracts. The remaining 39 articles were obtained for full text review out of which, 7 peer-reviewed studies of various designs met inclusion criteria and were selected for the review: 2 randomized control trial (RCT), 50 , 51 3 quasi-experimental, 52 , 53 , 54 1 observational study 55 and 1 mixed methods study. 56 A flowchart with details on the literature search and search results is shown in Fig. 1 .

Characteristics of included studies

Table 1 provides a description of each included study. The study samples represent data from 1748 participants who received NP-home visits. Five studies were conducted in the U.S. and the remaining 2 were conducted in Canada, 52 and in the UK. 54 Mean age of study participants ranged from 66.1 to 81.4 years. The model of NP-home visits varied across the included studies; 3 studies were based on HBPC, 52 , 53 , 56 while 2 studies were based on the TCM, 50 , 55 and 1 study was based on an in-home comprehensive geriatric assessment (CGA) program. 51 The in-home CGA is conducted to assess the medical, psychological and functional abilities of older adults. 57 In all studies, the NP role during home visits included medication management, patient education, and coordination of care. The impact of NP-home visits on healthcare utilization (ED visits, hospitalizations, and readmission) was the most frequently reported outcome 50 , 52 , 53 , 54 , 55 , 56 Study period across the included studies ranged from 2 months 52 to 36 months. 51

Summary of Physician Involvement in NP-Home Visits.

Characteristics of included studies.

NP* = Nurse Practitioner.

HBPC†* = Home based primary care.

TCM†** = Transitional care mode.

Participant recruitment varied across studies. Two studies recruited hospitalized patients, 50 , 55 another 3 recruited community dwelling participants. 51 , 52 , 53 In 2 studies, participants had specific diagnosis such as chronic obstructive pulmonary disease (COPD), 54 and post Coronary artery bypass grafting (CABG) surgery. 55 One study specifically utilized NPs with specialty training in geriatrics. 51

Unsurprisingly, we found that most studies conducted in the U.S. reported a physician oversight, 55 consultation 51 or collaboration with the physician for medication management, 50 although only the NP made home visits. Of the 2 RCTs, 1 compared NP-home visits to case management and physician office visits, 50 the second study compared NP-home visits to medical and social services. 51 One of the quasi-experimental studies compared the NP-home visit intervention to participants receiving care in a hospital setting, 54 another recruited patients receiving home care services. 52

Quality assessment of included studies

Based on the quality assessment tool, 4 studies were of high quality, 2 studies were of unclear quality, and 1 study was of low quality. Quality scores ranged from 54%−100% (mean score 77%). Overall, all the articles had clearly stated aims, main outcomes, and findings. Of the 7 studies, three of the studies did not control for potential confounders (42.8%, n  = 7) and one study (14.2%, n  = 7) did not provide a rationale for including the covariates in multivariate analyses.

Impact of NP home-visits on emergency department (ED) visits

One RCT 50 and 2 quasi-experimental studies 52 , 53 examined the effect of NP-home visits on ED visits. Two studies reported a reduction in ED visits. 52 , 53 Coppa et al. tested the impact of NP-home visits on ED visits and reported significant reductions in the ED visits by 35.56% and 23.7% after implementation of the HBPC program after with 6 months ( p  = 0.001) and 12 months ( p  = 0.001) before the program was implemented. 53 Although the patients received NP-home visits, the visits were only supplemental to visits provided by the patient's primary care providers, therefore, patients in the study still received care from primary care physicians. A Canadian study by Tung et al. compared the number of ED visits among home care patients who received NP home-visits with home care patients who received usual medical care from family physician offices or community outreach medical teams. Participants in the intervention group received at least one home visit from the NP for assessment, treatment or a procedure. The authors found that patients who received NP-home visits had less ED visits at 2 weeks ( p  = 0.0005) and 4 weeks ( p  = 0.0055) compared to those receiving usual care. However, there was no significant difference in the number of ED visits between the 2 groups at the 8 week period ( p  = 0.800). 52 Enguidanos et al. conducted a brief transition intervention for older adults using a RCT designed to examine the impact of the NP intervention on 6 month-service utilization among patients enrolled from one managed care medical center. The NP also contacted the patient's PCP when medication problems were identified. Usual care was described as standard medical care combined with case management services. Patients assigned to the intervention group had half as many ED visits compared with the usual care group (mean=0.50, SD=1.2 versus mean =0.99, SD=2.5; P  = 0.096); however the decrease was not statistically significant. 50

Impact of NP home-visits on hospitalizations

Two RCTs reported the effect of NP-home visits on hospitalizations. 50 , 51 Stuck et al. conducted a 3-year RCT to test the effect of annual in-home CGA on the rate of hospitalization among community dwelling older adults, they found no statistically significant difference between participants who received annual in-home CGA from a geriatric specialty-NP and the usual care group. The usual care group received medical and social services. The mean length of stay per hospitalization was 6.3 days in the intervention group and 5.1 days in the control group ( p  = 0.7) . 51 Enguidanos et al. found no difference in days spent in the hospital in patients who received NP-home visits compared to patients who received usual care ( p  = 0.514), patients enrolled in the usual care received all medical services, including disease senior case management. 50

Impact of NP home-visits on readmission

Four studies including 1 RCT, 50 1 quasi experimental study, , 53 1 observational study 55 and 1 mixed methods study 56 evaluated the impact of NP-home visits on hospital readmissions. Hall et al. found that patients who received NP-home visits post CABG surgery had a significant decrease in all-cause hospital readmissions compared to patients who did not receive NP-home visits. Patients in the intervention group received 2 NP-home visits in the first week to 10 days after discharge from the hospital. Each home visit involved physical examination, medication reconciliation and medication changes under the supervision of the operating surgeon. Six of the 156 patients who received the NP-home visits (3.85%) and 18 of the 156 controls (11.54) were readmitted ( p  = 0.023). 55 Coppa et al., also found a 59.42% decrease in readmissions at 6 months ( p  = 0.001) after enrollment in the HBPC intervention led by a NP, however the result was not sustained at the 12 month-interval ( p  = 0.087). 53

Enguidanos and colleagues 50 evaluated the impact of NP intervention on care transitions among older adults and found no change in readmission rates at 6 months following enrollment in the study ( p  = 0.526). Ornstein and colleagues examined the impact of NP-home visits in a transitional care program embedded within a HBPC program; while the 30-day readmission decreased from 16.6% to 15.8%, it did not reach statistical significance. 56

Impact of NP home-visits on quality of life

One quasi-experimental study 54 assessed quality of life. Health related quality of life (HRQoL) was assessed differently in both studies. A UK study by Ansari et al., compared patients with exacerbation of COPD managed at home by an NP to a hospital cohort of patients with COPD exacerbation managed in an acute care hospital. In this study, COPD -specific quality of life was assessed with St George's Respiratory Questionnaire (SGRQ); a disease-specific questionnaire, which measures health status and perceived wellbeing in persons living with COPD. At recovery, the total SGRQ score decreased for patients who received NP-home visits, it did not reach significance ( p  = 0.06), however, improvement in the activity domain was significant ( p  < 0.05).

Impact of NP home-visits on functional status and nursing home admission

The analysis was based on 1 RCT conducted in 1995. 51 In this study, geriatric specialty NPs provided annual in-home CGA with follow up visits to community dwelling older adults 75 years or older . The odds of dependency in basic activity of daily living was significantly lower in the intervention group compared to the control group (adjusted odds ratio, 0.4; 95% CI, 0.2–0.8; p  = 0.02). Additionally, 9 people in the intervention group (4%) and 20 people in the control group (10%) were permanently admitted to nursing homes ( P  = 0.02).

We conducted a systematic review to assess existing evidence about NP- home visits and how they affect the outcomes of older adults. In this review spanning almost 3 decades, we found only 7 published studies. Studies varied considerably in terms of study design, delivery of intervention, and study outcomes. Given the small number of studies and their methodological limitations, overall evidence of the relationship between NP-home visits and patient outcomes is limited. While we attempted to identify the outcomes associated with autonomous NP-home visits, this was particularly challenging, as we excluded studies where the NP and physicians provided home visits to the same patients.

Similar to a systematic review by Stall and Colleagues, 21 which evaluated the outcomes of HBPC, in this review the most common outcomes were related to healthcare utilization (ED utilization, hospitalizations and readmissions). Many of the studies we identified were based on the TCM and largely enrolled a post-acute care population. Although prevention of acute care utilization is an important goal of HBMC. The use of NP-home visits among homebound older adults extends beyond transitional care purposes; to prevent healthcare utilization post discharge, 58 but fill a critical access gap, by meeting the ongoing healthcare needs in the home environment.

In studies examining the effect of NP-home visits on readmissions, 1 high quality observational study 55 found that a home transition program, which involved NP-home visits for patients post CABG-surgery significantly, reduced 30-day readmission. One additional study found a decrease in readmissions at 6 months, yet the results were not sustained at 1 year, 53 the 2 remaining articles found no effect. 50 , 56 Therefore, the results do not conclusively demonstrate that NP-home visits will lead to reductions in readmissions.

Emergency department utilization was another common outcome examined in the reviewed studies. Although results for ED utilization were promising, more evidence is needed to fully understand the impact of NP-home visits on the rate of ED utilization among older adults. Two of the 3 studies in our review showed that use of NP-home visits could lead to reduction in ED visits. One study found decrease in ED visits at 2 and 4 weeks; however this association was not consistently significant at 8 weeks; this study did not control for comorbidities. 52 A second study found reductions in ED utilization at 6 months and 1 year, although it had a small sample size, and there was no comparison group. 53

Overall, research on the effect of NP-home visits on health and healthcare utilization outcomes is limited and inconclusive. Study design and methodological rigor varied across studies; hence, it was challenging to compare outcomes across studies. Most of the studies did not find associations that reached statistical significance, 50 , 52 , 54 , 56 though this may be due to the fact that they were insufficiently powered. Intervention characteristics included in the studies also varied including intensity of home visit, use of specialty NPs across studies, this made synthesis of study measures and outcomes difficult. The comparison groups were inconsistent and none of the studies directly compared NP-home visits to home visits by other healthcare providers such as physicians or physician assistant. Although, the RCTs compared an intervention with “usual care,” specific details of usual care were not clearly provided.

While beyond the scope of this review, analysis of the included studies points to known barriers to autonomous NP-provided care in the home setting prior to the implementation of the CARES Act. Of the 7 studies, studies conducted in the U.S captured the presence of physician oversight, supervision or collaboration although the NPs provided the home visits (Supplemental Table 1). In efforts to examine the unique outcomes of NP-home visits, we attempted to exclude studies that describe NP-home visits that involved physician co-management; this presented a challenge predominantly for studies conducted in the U.S. where state scope-of- practice restrictions on NPs vary across the country and many states require collaboration with a physician. 59 Notably, in this review, studies conducted outside the U.S did not mention any form of physician consultation or oversight.

Strengths and limitations

Findings from this review are supported by rigorous methods including the use of a medical librarian in developing the search strategy, independent selection of studies by 2 reviewers, and quality appraisal conducted by 2 reviewers, and validated by a 3rd reviewer.

This systematic review has certain limitations. First, the paucity of published studies related to NP- home visits limits the ability to draw conclusions. Second, studies that met our inclusion criteria had varied study designs and patient samples, and duration and frequency of NP home-visit varied across studies. Third, our restriction to studies published in English may have also excluded some relevant papers. We may have also missed articles in the literature search due to other variations in terminology describing NPs particularly for studies conducted outside the U.S., where other terms may capture the role of an NP. Finally, there is a possibility of publication bias, as we did not include unpublished findings such as conference proceedings or dissertation results. Notwithstanding these limitations, our findings present the state of the literature assessing NP-home visits and point to important future directions for continued investigation.

Implications for practice and future research

The use of NP-home visits is widely recognized and has gained national interest, 28 , 60 yet few studies have assessed the outcomes of NP-home visits. This is the first study to our knowledge to systematically review the evidence of the impact of NP-home visits on the outcomes of homebound older adults. Our findings indicate that the effect of NP-home visits on health and healthcare utilization outcomes is mixed at best, with only half of the studies reviewed reported positive findings on reducing ED utilization. We identified gaps in the evidence that future research could address.

Future studies should directly compare NP-home visits to home visits provided by other health care providers or teams. While RCTs investigating the effect of NP-home visits may be difficult given the patient population and the complexity of the intervention, researchers should consider observational studies that use robust risk adjustment and modeling approaches to create more defined comparison groups. Future research should also identify larger samples of patients receiving NP-home visits or use large datasets such as nationwide Medicare data to ensure sufficient statistical power to identify associations.

Clinical outcomes were underrepresented in the results generated by our systematic review; the most commonly reported outcomes were related to health care utilization. Although health care utilization (hospitalizations, readmission and ED visits) is an important indicator of high-quality HBMC, 21 other outcomes such as functional status or medication adherence are also important patient outcomes to be evaluated. Future studies should also identify patient-level factors, for example, level of comorbidity that may be associated with likelihood to receive NP- home visits, such studies will inform policy and clinical practice decisions about what subgroups of patients benefit most from NP-home visits. In the U.S, racial and ethnic minorities and rural populations tend to have poorer access, satisfaction, and health outcome;s 61 , 62 researchers should consider subgroup analysis of these understudied groups in future work. Doing so will inform the development of future targeted interventions.

While expanding the independence of NPs in the delivery of HBMC is a topic of ongoing debate 32 ; based on our review, little research informs such discussion. This gap in evidence is critical given the expected increase in the homebound older adults as the current population ages and growing reliance on NP-home visits. Future studies should investigate the independent effect of NP- home visits on the health outcomes of older adults using large and nationally representative data with more rigorous study design.

Acknowledgments

We would like to acknowledge Ms. Karen Sorenson, Research and Education Librarian, Albert Einstein College of Medicine, New York for her appreciated assistance with the literature search for this systematic review. We thank Dr. Yamnia I. Cortes for a careful read and helpful comments.

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Home > Books > Healthcare Access - New Threats, New Approaches

Home Visitation by Community Health Workers

Submitted: 27 December 2022 Reviewed: 02 February 2023 Published: 28 March 2023

DOI: 10.5772/intechopen.110354

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Community health workers are faced with challenges in the community during home visits. The re-engineering of primary health care services in South Africa brought a new cadre of community health workers that relieved the extra workload of primary health care nurses of conducting home visits as one of the activities. The findings of the study conducted in the Tshwane District culminated in the challenges of community, logistical, occupational, human resource, and managerial in nature. The CHWs stated the need for respect and acceptance by the community during home visits, improved planning related to delegation of households by Outreach Leaders and provision of material resources, and the support by managers for career development through training and education for various disease prevention. This indicated that the training of community health workers needs to be formalized and in-service education related to home visits should be planned, structured, and supported by the Department of Health.

• community health workers
• primary health care

Author Information

Hilda kawaya *.

• University of Pretoria, Gauteng College of Nursing (GCON) SG Lourens Campus, Pretoria, South Africa

*Address all correspondence to: [email protected], [email protected], [email protected]

1. Introduction

This chapter defines home visits, community health worker and primary health care, the overview of home visits, the purpose of home visits, the historical perspective of home visits, the process of home visits, the advantages and disadvantages of home visits, challenges encountered by community health workers (CHWs) during home visits from a South African perspective, and report from the study done in 2020 by CHWs in the Tshwane district.

2. Definition of home visits

A home visit is a formal interaction between a nurse and an individual’s place of residence designed to provide nursing care related to the identified need.

3. Definition of community health worker

Community health worker means an individual with an in-depth understanding of the community culture and language, who has received standardized job-related training, which is of shorter duration than health professionals, and whose the primary goal is to provide culturally appropriate health services to the community. CHW is an individual employed by the state, allocated at a PHC facility by a nongovernmental entity, and receives a stipend for the services rendered in the community.

4. Primary health care

Primary health care is health care based on scientifically evidence-based care by socially acceptable standards, which is universally accessible to individuals and their families at a cost the community and the country can afford by being self-reliant and by self-determination. PHC is rendered to individuals and families who are residents of the area surrounding the community clinic by health workers.

5. Overview of home visits

Families and individuals visit the primary health care (PHC) clinic daily and/or monthly to be assessed for acute and chronic ailments as well as monitor compliance. Noncompliance to treatment will warrant that the community health worker (CHW) visits the individual more frequently to establish the reasons for clinic nonattendance and noncompliance to treatment regimens [ 1 ]. CHW programs are designed to target hard-to-reach communities that are more than 5 km from a health facility or in the lowest socioeconomic areas [ 2 ]. The PHC clinics provide preventive, promotive, curative, and rehabilitative services to the community within a 5-km radius. Currently, the clinics consult with the ward-based outreach teams to allocate CHWs to do home visits to individuals who default on treatment and are noncompliant with treatment. CHWs are responsible for home visits to make sure that vulnerable groups are getting adequate care and are not missed in the health system. CHWs are currently paid stipends by the Department of Health and through nongovernmental organizations [ 3 ].

Currently, an estimated 5482 PHC outreach teams are caring for the uninsured population of South Africa, and the teams are required to reach 84% of the total population who are based in rural areas, informal urban settlements, and townships [ 4 ]. In the financial year 2014/2015, it was estimated that there were 86 teams in Tshwane covering 46 wards, with 39 trained team leaders and 217 CHWs [ 5 ]. The services are available, accessible, and affordable [ 6 ], and are provided at homes, schools, and other public and private institutions because health care is a right for all citizens. The role of the CHWs among others is to do home visits [ 7 ]. Home visit services originated in Great Britain, dating back to the 1850s, and focused on improving health and hygiene in families with young children. The families were visited for the continuation of nursing care and support. According to the study [ 8 ], home visits offer a viable strategy to avoid challenges associated with obtaining health from clinics, which include difficulty in scheduling clinic appointments, long waiting lines, and expensive transport.

The evaluation of the effectiveness of the home-visit program for high-risk pregnant women [ 9 ] found that at least one visitation during pregnancy was effective in preventing preterm births. Participating in the home-visit program reduced the risk of adverse outcomes in a disadvantaged population [ 10 ]. It was found that home visits are part of larger programs that might have positive effects on individuals, including exercise programs, improved assessment methods by medical professionals, or fall prevention [ 11 ]. Skilled health workers do home visits, but in areas where there is a lack of health providers, trained community members, called CHWs, are used instead. These workers are trained to perform basic preventative and curative care and to assist families in seeking necessary care at a healthcare facility.

The role of CHWs in Lesotho dates to 1979 when the country embraced primary health care (PHC) and improved the efforts to reach underserved and remote areas [ 12 ]. The CHWs’ scope ranges from core roles of disease prevention, early detection of ill-health, community advocacy, outreach services, and assisting in accessing services through referrals and home visits. The CHWs understand their roles and responsibilities regarding health promotion. However, the changes in disease burden have resulted in a shift in roles and this is affecting their health promotion practice and experience. You et el. [ 13 ] reported that the outcomes of health workers doing home visits for at-risk mothers in the United States are less effective compared to nurses, who are better suited to enhance and determine physical and psychological health, and decrease the use of emergency medical services. Bheekie and Bradley [ 14 ] reported that home visiting has been demonstrated as being effective when mounted by professionals, but low and middle-income countries (LMICs), such as South Africa, cannot afford nurses and will not be able to train the personnel necessary to render such support until at least by the year 2050.

In 2010, the South African National Department of Health (NDoH) launched a national PHC initiative to strengthen health promotion, disease prevention, and early disease detection called reengineering of primary health care (rPHC) to provide preventive and health-promoting community-based PHC model [ 15 ]. A key component of rPHC is the use of ward-based outreach teams (WBOTS) staffed by generalist CHWs to do home visits and provide care to families and communities [ 16 , 17 ]. CHWs are a core in the community-based PHC model and the complex contextual challenges they face during home visits and the development of skills in community care need specific attention [ 18 ]. Health facilities are challenged by limited staffing, resources, infrastructure, and access to PHC clinics is affected by distance, financial constraints, and transport availability.

6. The purpose of home visits

The purpose of the home visit is to have face-to-face contact at an individual’s home, with a healthcare professional. The home visit allows an assessment of the home environment and family situation to provide for healthcare-related activities. It is done to reduce the defaulter rate and to enhance compliance with treatment [ 7 ]. Home visits provide opportunities for professional development, as well as improve the life orientation skills of healthcare students [ 19 ].

7. Historical perspective

Globally, home visits were intended to improve health and hygiene in families with young children [ 7 ]. A home visit is vital to reducing maternal and infant morbidity and mortality [ 20 ]. A healthcare project in Egypt recommended four home visits to women and their infants during the postnatal period within 24 h of delivery, on day 4 after birth, on day 7 after birth, and a clinical visit on day 40 [ 21 ]. American Indian and Alaska Native people have used informal home visits as a traditional cultural practice to take care of and address the needs of young children and families and improved outcomes in these areas [ 22 ].

Salami and Brieger [ 23 ] stated that the benefits of home visits by trained community health workers can change newborn practices. Rotheram-Borus et al. [ 8 ] confirmed that at least one visitation during pregnancy would reduce the risk of preterm births. Health workers during their home visits were able to keep track of non-facility-based births, which were not recorded officially and affected the calculations of infant mortality [ 24 ]. Trainees in medicine can gain experience and confidence in making house calls by doing structured home visits [ 25 ]. The focus of home visits expanded to other areas such as care of the elderly. The authors further reported that home visits are proposed to be an essential component of general practice care in the provision of comprehensive person-centered care for the elderly.

Home visits are an integral part of primary care provided by family physicians and medical assistants to homebound elderly individuals living in private households, and not by communities [ 26 ]. Preventative home visits may have a positive effect on healthcare costs by decreasing nursing home admission, hospitalizations, and the length of stay in hospitals [ 27 ]. Home visiting services are part of the national health systems in most countries in Western Europe, where services are voluntary and free to all families [ 7 ].

The role of professional nurses’ in home visits as stated by Grant et al. [ 17 ] reported that health facilities faced the challenge of limited staffing and resources. The shortage of nurses at PHC clinics made their role to conduct home visits compromised. Wells et al. [ 28 ] agreed that, to prevent diseases and promote health, the role of community nurses was to conduct home visits irrespective of work overload. However, it is important to recognize that the clinical proficiency of the nurse performing the home visits had a heavy influence on visits due to their experience, which assists them to diagnose challenges and refer to relevant healthcare providers [ 29 ].

In the study by Bheekie and Bradley [ 14 ], the establishment of district management teams (DMT) to improve the primary health system increases life expectancy, decreases child and maternal mortality, combats HIV and AIDS, and decreases the tuberculosis burden. The effective use of CHWs is by allocating them to 250 families each, to address health problems. The PHC outreach team consists of a professional nurse, an environmental officer, a health promoter, and six CHWs in a municipal ward who work together with the designated nurses at the clinic to provide comprehensive care to this population, from health promotion to the treatment of minor ailments [ 30 ]. According to Kane et al. [ 31 ], more than five million CHWs are active globally and are known for their effectiveness and importance in providing services to communities [ 32 ]. CHWs are trained government workers allocated at facilities and the community recognizes them as health professionals and an extension of the formal health system.

Kok et al. [ 33 ] stated that CHWs had their origins in China in the 1920s and were precursors to the “barefoot doctors” movement in the 1950s, they indicated that CHWs’ are groups of health workers who work outside health facilities directly with people in their homes, neighborhoods, communities, and other nonclinical spaces where health and diseases are produced. Zulliger et al. [ 34 ] regarded CHWs as health workers conducting functions related to health care delivery; trained in some way in the context of the intervention and having no formal professional or paraprofessional certificate or degree in tertiary education. The role of CHWs is to conduct household profiling, screening, and health education through supervision by the professional nurse team leader [ 29 ]. In South Africa, CHWs are expected to assess health needs; facilitate service access; provide community-based information, education, and psychosocial support; deliver basic health care; and support community campaigns [ 35 ]. PHC training package identifies 12 roles that are to be performed by the CHWs working in PHC, which are home-based care, counseling, support and stress relief, health promotion and education at a household level, referral to relevant departments, initiative and support home-based projects, liaison between NDoH and the community, mobilization against diseases and poor health through campaigns, Directly Supervised Treatment Support (DOTS), screening of health-related clinic cards for compliance or default, assessment of health status for all family members and giving advice, weighing infants and babies and recording in “Road to Health” card, and providing prevention of mother-to-child transmission of HIV/AIDS [ 4 ].

Kelly et al. [ 36 ] reported that the NDoH was developing a policy framework to regulate the role of CHWs and their working conditions and further asserts that shifting tasks and care responsibilities from professionals is necessary to meet the needs of the health care service. CHWs are trained to accompany HIV individuals on ART and do routine home visits to monitor side effects and appointment reminders [ 37 ]. The role of CHWs is to collaborate with community leaders in providing basic health and environmental service in rural areas, create a link between the facility and the community, and are paid salaries by the Ministry of Health [ 38 ]. In the paper by Ref [ 39 ], the role of CHWs in countries has contributed to better outcomes; however, in South Africa, the health outcomes are suboptimal in areas of maternal and child health. Home visits by CHWs during pregnancy can play a role in improving thermal care, early and exclusive breastfeeding, and hygienic cord care practices in different settings [ 22 ].

At the international conference on primary health care at Alma-Ata in 1978 where a declaration of “Health for All” by the year 2000 was made by the representatives, CHWs’ role in providing PHC was highlighted [ 32 ]. The World Health Organization (WHO) has identified five key elements to achieving this goal: reducing exclusion and social disparities in health (universal coverage reforms); principles of equity, access, empowerment, community self-determination, and inter-sectoral collaboration. Universal health coverage (UHC) is aspired by most countries in terms of rights to health care, financial protection, and utilization of healthcare services on an equitable basis. UHC indicates equity of access and financial risk protection [ 40 ] and community care is a crucial contribution that is affordable with running costs of less than one dollar per capita per year [ 41 ]. The recent Astana Declaration (2018) has emphasized the critical role of PHC in advancing UHC. The potential contribution of CHWs to supporting UHC is commendable [ 42 ].

UHC, broadly, means that all people receive the health services they need, including health initiatives designed to promote better health, prevent illness, and provide treatment, rehabilitation, and palliative care of sufficient quality to be effective while at the same time ensuring that the use of these services does not expose the individual to financial hardship. The District Health System (DHS) in South Africa provides an equitable, efficient, and effective health system based on the principles of the PHC approach. The National Health Insurance (NHI) systems and the DHS model are key elements of UHC in South Africa. The DHS depicts a set of activities such as community involvement, integrated and holistic healthcare delivery, intersectoral collaboration, and a strong “bottom-up” approach to planning, policy development, and management. NHI aims to provide funds that will improve access to health services for all South Africans [ 43 ] and to rectify the public-private funding inequality. NHI includes rPHC, which focuses on the prevention of diseases, including three streams of municipal ward-based PHC outreach teams, school health teams, and district-based clinical specialist teams [ 29 ]. In terms of cost, a preliminary policy paper issued by the government estimated that NHI will cost R255 billion per year by 2025 if implemented as planned over 15 years [ 44 ]. To achieve the principles of PHC, together with inclusion in the NHI and UHC, the employment of CHWs commenced.

The health services in which CHWs work often present preconditions or limitations to function [ 33 ]. The challenges found in the study of CHWs in Lesotho are demotivation because of inconsistent incentives, lack of supplies, community attitude, increased workload, gaps in training, and lack of standardized reporting tools [ 11 ]. CHWs work in an environment where trust and confidentiality play a cornerstone in social relationships. CHWs interact with other family members during home visits and discussing confidential information seemed to be challenging if family members were present and could lead to unwanted disclosure of sensitive information [ 17 ]. Families failed to obtain medications due to transportation and financial problems [ 29 ]. Transport is identified as a challenge in the study of workers in Malawi [ 38 ]. Management apathy around allowances for CHWs in Kenya is a source of feelings of devaluation and of not having control over one’s work sphere [ 31 ].

Other barriers included the lack of career prospects for CHWs, lack of formal recognition as government employees of the health system (even though the stipend is paid through the government pay system), low incentives, and delayed payments [ 45 ]. CHWs preferred better financial recognition for their work, an increase in stipend, and proof of their work for prospects, raincoats, Christmas hampers, and tokens to help mitigate financial constraints [ 46 ]. The CHWs mentioned their role in solving social issues in the community, but the stipend did not match the extra work they did on top of health issues. Working in the community allows opportunities to channel their values and beliefs into concrete actions with opportunities for self-actualization [ 31 ]. A perceived lack of personal safety was found to affect motivation to work at locations and into people resigning. Young female health workers felt unsafe, scared of substance abuse among young men, violent assaults, verbal abuse, accusations, and were afraid of contracting infections [ 22 ].

Climate, environmental challenges, and the need to cover large distances hampered CHWs’ performance of their duties. It was reported that the CHWs’ had difficulties in reaching communities because of flooding [ 33 ]. A study done in Uganda for the visitation of mothers during prenatal and postnatal by Village Health Teams proved that the teams could not navigate large geographical areas in some cases and had low incentives for Village Health Teams to travel long distances [ 47 ]. Traditionally in Jordan, women are not supposed to leave the house for 40 days post-delivery, mothers preferred that the home visit should be conducted by a female CHW in the presence of a family member to enhance a sense of security [ 19 ].

8. Advantages of home visits

It provides an assessment window into the household characteristics.

The nurse obtains the full picture of the home environment the individuals reside in.

Identification of the influence of the environment on the individual’s health.

It allows the CHW to view the individuals’ relationship with family members and the community.

It is an opportunity for a CHW to view the individual’s performance of activities of daily living.

It gives the CHW a perspective to plan and evaluate interventions in a natural setting.

It allows a CHW to recognize unidentified health and social needs.

9. Disadvantages of home visits

A stigma attached to the family’s self-perspective of incompetence.

It is not cost-effective for a health worker to travel to one individual and see them at home unlike seeing them at the clinic and achieving the goal of consulting twenty individuals in a day.

10. The process of home visits, a home visitation program

The home visitation program in South Africa is structured by the outreach team leaders who allocate different individuals to a specific CHW to visit the homes in a particular month. The nursing process approach of assessment, diagnosing, planning, implementation, evaluation documentation, and termination is utilized by following the outlined steps to explain the program [ 48 ].

10.1 Step 1

Initiation of the home visit whereby the CHW introduces themself to establish rapport.

10.2 Step 2

Conduct a preliminary assessment by r eviewing the individual’s history and documentation to determine the health care needs related to biological, psychological, environmental, sociocultural, behavioral, and health system determinants of health.

10.3 Step 3

Formulate a diagnosis based on the assessment.

10.4 Step 4

Plan to review the previous interventions made and their results. Prioritize the needs and identify those that need immediate attention. Develop goals and objectives for the visit and determine the levels of care involved. Consider the individual’s circumstances and consent related to the visit and time of visits. Identify appropriate interventions to address problems. Mobilize resources, supplies, and equipment. Plan for evaluation of the home visit.

10.5 Step 5

Implementation of the plans made by priority and dealing with any distractions.

10.6 Step 6

Evaluate the response to the interventions, short-term and long-term outcomes, the quality of planning and implementation of the home visit, and the quality of care.

10.7 Step 7

Document the individuals’ assessment, interventions, individuals’ responses to care, outcomes of interventions, plans of care, and the individual’s health status at discharge.

10.8 Step 8

Plan for termination on the first visit, inform the individual about the number of visits and their duration, review the goals and objectives, and make referrals where necessary.

11. Challenges encountered by community health workers

Below are narrative perspectives of community health workers from the study done by the author.

11.1 Community challenges

Community challenges emerged as the first perceived challenge by the CHWs. Various challenges from the community posed a problem in accessing the community members during home visits. This included community access, animosity, mistrust, noncompliance to treatment, nonrecognition, acceptance, and public environmental health.

11.1.1 Community access

The CHWs were faced with difficulty in accessing members of the community during the day and the attitude they received from community members hampered access. CHWs reported that when going to visit individuals at homes, they meet people in the street calling them names and swearing at them and when they reach the designated homes individuals will chase them away or send dogs after them. The CHWs are required to map 250 household registrations as part of the workload for the area that is allocated to them. All the households should be captured and followed up to reach all members of the designated community linked to the PHC clinic.

11.1.2 Community animosity and mistrust

CHWs mentioned that data capturing included registration of the water meter reading, which led to the community members asking questions about the relation of meter checking to health and illness. CHWs were faced with mistrust and resentment from the community due to the belief that their roles were not in support of community needs. The lack of respect from the community has been seen to demotivate CHWs [ 45 ].

Several factors undermining the work of CHWs, as stated in the study by Mhlongo and Lutge [ 32 ], were different perceptions of the CHW roles, lack of knowledge and skills, and lack of stakeholders and community support.

11.1.3 Community noncompliance with treatment

Individuals with chronic conditions, TB, and HIV default to treatment and are not compliant with taking the medication. Follow-up is done to monitor compliance with treatment. Home visits are conducted to follow up with defaulters of treatment and to encourage compliance with treatment. The individuals are traced back to their addresses to keep them on track with and to comply with the treatment prescribed.

11.1.4 Nonrecognition and acceptance by the community

The CHWs reported that the clinic does not provide uniforms but only name tags. The uniform that they wear was provided by the NGO before being transferred to the clinics. The lack of uniform and name tags make the community not recognize and accept the workers as professionals and they are given a bad attitude. In the study about the role of CHWs [ 46 ], it was reported that the workers asked for “branded” goods, such as t-shirts, hats, or ID cards, to identify them as part of the health team. The provision of branded goods would prevent them from being viewed with suspicion by the community.

11.1.5 Public environmental health

The CHWs assist with the cleaning of the home, such as dirty windows, and open windows for fresh air before commencing with procedures. The unsafe and unkempt environment in the community leads to CHWs to extend their scope of work by cleaning the household and referring the challenges to the social development ministry.

11.2 Logistical challenges

The government should devise a means of providing the CHW programs with transport and absorb them to be permanent employees with all benefits. CHW programs tend to be unsustainable at scale when there is poor planning, vague and/or extensive CHW scopes of work, lack of community and health system buy-in, resource scarcity, inadequate training, low incentives to the CHWs, and poor supervision [ 45 ].

11.2.1 Ineffective planning and delegation

The concept of walking the distance from house to house and to and from the clinic to report and clock out poses a challenge even though it is structured daily. The CHW program should be planned so that CHWs report weekly to the OTLs at a designated area in the clinic. The CHW should draw a monthly schedule and submit it to the manager for approval.

11.2.2 Lack of transport

The CHWs walk distances to individuals’ homes after they have reported at the clinic and at the end of the home visit go back to the clinic to clock out. The clinic does not provide transport for CHWs. They are not allowed in government vehicles as they do not have indemnity. Weather conditions and the fact that the CHWs are contract workers also mitigate the challenge of transport. CHWs in other areas did not access formal modes of transport and instead walked to and from their allocated area of work.

11.3 Occupational challenges

The scope of practice of CHWs does not include aspects of mental health and domestic abuse and cannot intervene when faced with situations. The CHWs refer the matters beyond their control to the police and social workers because it is not covered in their training.

11.3.1 Exposure to ethical-legal risks

The CHWs gave information about this insufficient training, which causes distress when dealing with individuals. Other health topics were not covered in their training, which made them frustrated. The insufficient training given to CHWs will lead them to be involved in legal cases and can be found to have violated ethical issues.

11.3.2 Exposure to psychological risks

The CHWs have trouble dealing with emotions and would be brave in front of individuals not to expose their sadness in seeing children with terminal conditions. They cry privately when they reach their homes. They pray daily not to meet dangerous individuals in the community. The CHWs experience emotional stress of coping with difficult circumstances of being scared to venture into the community. Exposure to sick individuals causes emotional distress and frustration.

11.3.3 Exposure to safety risks in the community

The CHWs mentioned that the nurses at the clinic will give referrals to trace individuals who defaulted treatment of TB, others are XDR or MDR individuals, and end up being exposed to health risks of contracting diseases because of insufficient information given to them about the individual status.

The lack of face masks when visiting homes can lead to workers contracting airborne diseases. There were concerns about CHW’s safety, identification, debriefing, and risk of contracting diseases [ 29 ].

11.3.4 Insufficient equipment and resources

The CHWs reported challenges of limited resources of having to carry blood pressure machines to different homes on certain days. Lack of data on cell phones to call the OTLs or to summon the ambulance when faced with emergencies during home visits. The cell phones issued had a short lifespan. The lack of material resources creates a challenge and financial burden for community workers, which can lead to feelings of frustration and spending their own money to counter the limited resources [ 47 ].

11.3.5 Working relationship problems with clinic staff

The lack of medical aid to consult when ill poses a challenge to CHWs and this is seen by the clinic staff, making CHWs queue like any other individual visiting the facility.

The lack of support from clinic staff leads to stress and frustration [ 29 ]. Managers reported that the CHW’s workload was very heavy and their working conditions are difficult and mentioned the lack of space, stationery, and equipment.

11.4 Human resources challenges

The human resource department in the clinics does not include CHWs in the skill professional development plan. The CHWs reported no opportunities to improve their skills and see growth in their chosen job and the reluctance of the clinic to include them during in-service training.

11.4.1 Inadequate opportunities for personal development and promotion

The CHWs have no opportunities for promotion from one level to the other, they remain in one category. There should be a growth pathway for CHWs to ensure that the persons with experience can achieve higher levels of employment and mentor the newer applicants in the program [ 4 ]. In South Africa, the Human Resource for Health Strategy estimated that the critical need gap persists with a shortage of over three thousand formally qualified CHWs and over two thousand qualified home-based caregivers [ 45 ].

11.4.2 Inadequate training and education

The CHWs reported that there is inadequate training when they observed that other CHWs were performing the same skill differently. Peer training is encouraged in areas that were not covered in the CHW course. Conducting more in-service education will make sure that the acquired skills and knowledge are not lost forever [ 37 ]. Formalization of CHWs’ training about procedures done during home visits will bring job satisfaction. It was recommended that the training of the CHWs should be incorporated into the Expanded Public Works Programme (EPWP) training strategy, which will enable the CHWs to obtain a formal qualification that is aligned with national standards [ 4 ]. The general training of CHWs as generalist health workers is ideal, but program-specific training is effective and ensures that core knowledge and skills are effectively relayed [ 49 ].

11.4.3 Unconducive conditions of service

The CHWS sign a contract every year and they have been in the temporary position for more than five years. The CHWs expressed anger and frustration when narrating the aspect of stipends and signing contracts of employment every year. The gifts received from employers helped mitigate financial requests [ 46 ]. CHWs reflected negatively on the fact that they earned a meager stipend whilst they needed to cover their transport to and from their allocated area of work and that they worked a normal workday of 8 hours duration [ 4 ] and asserted to the review of the remuneration package to be aligned with labor law in the country.

11.5 Management challenges

The CHWs mentioned that managers are not supporting them in terms of training, shortage of resources, and engaging with the department to transfer their posts to permanent employees.

11.5.1 Inconsistent training

Training of CHWs is not the same; some CHWs have done 10-day courses, and others 59- or 69-day courses, which included HIV counseling and irregular one-off training sessions without opportunities to refresh knowledge which has been reported to demotivate and reduce CHW performance in other LMICs [ 50 ]. CHWs refused to conduct certain tasks when they had not been invited to be trained because the training was given to those who were favored and was attached to financial gain [ 33 ].

11.5.2 Lack of managerial support and recognition

It was perceived that the challenges of being contract workers and not having enough resources are ongoing. There is an indication that managers are not supporting in terms of the shortage of resources and engaging with the department to transfer their posts to permanent employees. Managers questioned CHW’s role perceived by the community as professionals, because of limited training. The managers wanted a planned strategy for CHWs, including career progression and professional regulation, and were concerned about security risk, space, and logistical support. The managers think that CHWs need to be selected based on some criteria, such as education more than matriculation [ 29 ].

12. Conclusion

The chapter focused on the definitions of home visits, community health workers and primary health care, overview, the purpose of home visits, historical perspective, advantages and disadvantages, the process of home visits, the challenges perceived by CHWs regarding home visits in the Tshwane district, which were that of community, logistical, occupational, human resource, and managerial.

Acknowledgments

I want to thank the community health workers in the Tshwane District, SG Lourens Nursing College management, supervisors Prof MM Moagi and Prof MD Peu for their guidance and support, and the Department of Health Region C, supervisors of Community Health Workers, Outreach Team Leaders, and Facility managers of the sub-district clinics.

Conflict of interest

The author declares no conflict of interest.

Additional information

Parts of this book chapter are taken from the dissertation titled “Challenges Community Health Workers Perceived Regarding Home Visits in the Tshwane District,” authored by Hilda Kawaya, which is available on the University of Pretoria repository platform, dated December 2020. The dissertation has not been peer-reviewed and has not been published.

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Chiefs' Harrison Butker blasted for commencement speech encouraging women to be homemakers

Kansas City Chiefs kicker Harrison Butker has aggravated one of the internet's biggest culture wars by telling a class of college graduates that one of the “most important” titles a woman can hold is homemaker.

During a commencement speech last weekend at Benedictine College, a Catholic liberal arts school in Atchison, Kansas, the NFL player railed against abortion, Pride month and Covid-19 lockdown measures.

Drawing the most viral backlash this week, however, was a section of his speech in which he addressed the female graduates specifically — telling them that it’s women who have had “the most diabolical lies” told to them.

“How many of you are sitting here now, about to cross this stage, and are thinking about all the promotions and titles you are going to get in your career? Some of you may go on to lead successful careers in the world,” Butker said. “But I would venture to guess that the majority of you are most excited about your marriage and the children you will bring into this world.”

The criticisms that followed took aim at Butker as well as the NFL.

"Hey @NFL — If you want to continue to grow your female fan base and any other marginalized group (straight white men are already watching your product), come get your boy," wrote Lisa Guerrero, a former NFL sideline reporter and now an investigative journalist for "Inside Edition."

He went on to tell the graduates that his wife would agree that her life “truly started when she began living her vocation as a wife and as a mother.” It is her embrace of this role, he said, that made his own professional success possible.

Butker’s comments share similarities with some of the more extreme ideas around gender roles that have gained traction in communities that promote “ tradwife ” lifestyles or other relationship dynamics that center on traditional gender roles .

“Listen, there’s nothing wrong with his wife being a homemaker. Homemakers are wonderful, that’s not the point,” filmmaker Michael McWhorter, known by his more than 6 million TikTok followers as TizzyEnt, said in a video response. “The point is he seemed to be acting as if you should be ashamed if you don’t want to be a homemaker, or, ‘I know what you really want to do is just stay home and have babies.’"

The speech was the latest incident to add fuel to the flames of this increasingly vocal cultural battle, much of which is playing out online. While many prominent right-wing men have voiced such beliefs before, they’re usually confined to internet forums, podcasts and other online communities where these ideologies thrive.

A spokesperson for Butker did not immediately respond to a request for comment.

Benedictine College and the Kansas City Chiefs did not immediately respond to a request for comment.

A spokesperson for the NFL told People Magazine that Butker "gave a speech in his personal capacity" and his "views are not those of the NFL as an organization."

"The NFL is steadfast in our commitment to inclusion, which only makes our league stronger," a spokesperson told the publication.

Butker, who is teammates with Chiefs tight end Travis Kelce, further drew surprise and criticism when he quoted Kelce’s girlfriend, Taylor Swift, whose monumental career success as a global pop star has inspired college courses .

“As my teammate’s girlfriend says, ‘familiarity breeds contempt,’” he said, drawing murmurs from the crowd as he used the “Bejeweled” lyric as an analogy for why Catholic priests should not become “overly familiar” with their parishioners.

In the days since his speech, a Change.org petition for the Chiefs to dismiss Butker for “discriminatory remarks” has garnered nearly 19,000 signatures.

“These comments reinforce harmful stereotypes that threaten social progress,” the petition stated. “They create a toxic environment that hinders our collective efforts towards equality, diversity and inclusion in society. It is unacceptable for such a public figure to use their platform to foster harm rather than unity.”

Those who criticized Butker’s speech online include actor Bradley Whitford as well as DJ and rapper (and self-proclaimed Swiftie ) Flavor Flav .

But his speech was also lauded by some on the religious right, including conservative sports media personalities such as Clay Travis and Jason Whitlock , who defended Butker’s statements toward women.

“Not a word Harrison Butker says here should be remotely controversial. He’s 100% correct,” former NFL wide receiver T.J. Moe posted on X . “Those trying to convince women that being assistant VP of lending & intentionally childless at age 40 is more fulfilling than making a family and home are evil.”

Sports and culture commentator Jon Root also posted that Butker “exposed the lies that the world has been telling women.” Women, he wrote, are wrongly encouraged to climb the corporate ladder, view children as a “burden” and see marriage as “not worth pursuing.”

Still, a deluge of viewers online took issue with his attitude toward women and the LGBTQ community. Many women also rejected the premise that they would be happier staying at home in lieu of paid work, even if they do have a husband and children.

“I am moved. I actually had no idea that my life began when I met my husband,” neurosurgeon Betsy Grunch, known as Ladyspinedoc on TikTok, said sarcastically in a TikTok video . “It did not begin when I graduated magna cum laude from the University of Georgia with honors. It certainly did not begin when I graduated with a 4.0 GPA, Alpha Omega Alpha, from medical school. And I had no idea that it did not begin when I completed my residency in neurosurgery.”

Angela Yang is a culture and trends reporter for NBC News.